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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: altered mental status
HPI(4): Mr. ___ is a ___ man well known to me with
vascular dementia and a recent admission for AMS d/t urinary
tract infection who presents with a UTI. His wife last noticed
him normal two days ago. Yesterday, the ___ staff called to
report he was complaining of shoulder pain, more confused. This
was a similar presentation to his previous UTI. Patient is
currently unable to give a review of systems, though tells me he
is in no pain. His previous urine culture on ___ grew a
pan-sensitive E. coli.
In the ED afebrile, HR 56, BP 170/76, RR 18, O2sat 96% on RA.
CBC
normal. UA shows large leuks, pos nitrates, many bacteria, and
31
WBC. BMP normal. Trop 0.02. LFTs normal. Patient was given 1 gm
ceftriaxone and admitted to medicine.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
Abdominal aortic aneurysm
Peripheral vascular disease
Dementia
First degree AV block
Diabetes
Penile implant
Depression
HTN
OSA- uses O2 at night
Nocturnal urination/neurogenic bladder
History of TIA and white matter disease on MRI brain
BPH
CAD: CABG (LIMA-LAD, SVG-Ramus, SVG-RPLV) in ___.
Social History:
___
Family History:
Mother DM ___, Father dementia
Physical ___:
EXAM(8)
VITALS: 96.7 144/84 45 20 95
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: S1, S2, ___ precordial murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
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, appropriate affect
discharge exam:
110/69 50 18 96% RA
lying in bed, comfortable
oriented to person, place, hospital
lungs clear to auscultation, normal respiratory effort
cv soft systolic murmurs appreciated
abdomen soft, NT, ND, NABS
ext without edema
Pertinent Results:
Admission labs:
Blood cultures x 2 negative.
I personally reviewed the chest x-ray, which showed no
consolidations, and a left lung nodule.
___ 11:00AM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-141
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
___ 11:00AM ALT(SGPT)-12 AST(SGOT)-17 CK(CPK)-59 ALK
PHOS-47 TOT BILI-0.4
___ 11:00AM LIPASE-34
___ 11:00AM CK-MB-2 cTropnT-0.02*
___ 11:00AM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-3.8
MAGNESIUM-2.3
___ 11:00AM WBC-5.2 RBC-4.52* HGB-13.6* HCT-41.4 MCV-92
MCH-30.1
MCHC-32.9 RDW-13.2 RDWSD-44.3
___ 11:00AM NEUTS-57.6 ___ MONOS-10.9 EOS-3.3
BASOS-0.8 IM ___ AbsNeut-2.97 AbsLymp-1.39 AbsMono-0.56
AbsEos-0.17 AbsBaso-0.04
Urine tests:
___ 11:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:00AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 11:00AM URINE RBC-6* WBC-31* BACTERIA-MANY* YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 11:00AM URINE MUCOUS-RARE*
Urine culture -
ecoli, resistant only to ampicillin
blood cultures negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. alfuzosin 10 mg oral DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
6. Donepezil 10 mg PO QHS
7. Lactulose 30 mL PO DAILY
8. Lisinopril 2.5 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Namenda XR (MEMAntine) 28 mg oral DAILY
11. Senna 17.2 mg PO QHS
12. Simvastatin 20 mg PO QPM
13. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
14. Ascorbic Acid ___ mg PO DAILY
15. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. alfuzosin 10 mg oral DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Bisacodyl 10 mg PR QHS:PRN constipation
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
8. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) DAILY
9. Lactulose 30 mL PO DAILY
10. Lisinopril 2.5 mg PO DAILY
11. Namenda XR (MEMAntine) 28 mg oral DAILY
12. Senna 17.2 mg PO QHS
13. Simvastatin 20 mg PO QPM
14. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
15. HELD- Donepezil 10 mg PO QHS This medication was held. Do
not restart Donepezil until off ciprofloxacin
16. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until heart rate increases, in ___ throughout hospitalization
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Acute encephalopathy
Vascular dementia
Coronary artery disease
Bradycardia
Discharge Condition:
tolerating diet
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with chest pain//evaluate for infiltrate
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
With patient status post median sternotomy and CABG. Heart size remains
mildly enlarged. The thoracic aorta is diffusely calcified and mildly
tortuous, as seen previously. Mediastinal and hilar contours are
unremarkable. 2.1 x 2.0 cm rounded opacity in the left midlung field is
unchanged. No focal consolidation, pleural effusion, or pneumothorax is
present. Mild degenerative changes are noted in the thoracic spine.
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Persistent 2.1 cm left midlung field rounded opacity for which dedicated
chest CT imaging is recommended.
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Urinary tract infection, site not specified
temperature: 97.5
heartrate: 56.0
resprate: 18.0
o2sat: 96.0
sbp: 170.0
dbp: 76.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ male with vascular dementia and a
toxic-metabolic encephalopathy caused by a UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Epinephrine / Xylocaine / Novocaine / Ampicillin / aspirin
Attending: ___.
Chief Complaint:
dysuria, increased urinary frequency, chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ MDS, polycythemia ___, s/p splenectomy and splenorenal
shunt, h/o stroke with dizziness and right ___ weakness, with
history of UTIs presenting with dysuria and increased urinary
frequency x5 days. Patient developed these symptoms five days
prior, and had UA checked from ___ (date
___ trace leuks, trace protein, otherwise negative) and no
intervention was made at that time. However, her dysuria and
urinary frequency (without hematuria) have persisted and
worsened
over the last few days, with new chills developing on the night
prior to admission. Denies any fever, back pain. She does have
mild nausea and headache, but no vomiting, diarrhea or abdominal
pain. Has been off of coumadin since ___ due to plt <70.
Denies any sick contacts.
Last UTI from beginning of ___ was treated with course of
nitrofurantoin. Last interferon injection was more than 2 months
ago. s/p flu vaccine ___.
ED course:
11:57 0 99.0 81 149/87 16 96%
Today 17:36 4 98.6 86 146/88 18 97% RA
Today 18:43 3 98.6 86 146/88 17 97% RA
meds
16:08 Acetaminophen 1000 mg PO
ED evaluation: "Patient has elevated WBC count w/ left shift and
11% bandemia. Although at baseline she has a leukocytosis, this
marks an increase from baseline and in the setting of chills and
general malaise we are concerned she could have an occult
infection. We would like to admit her overnight and will send
her
urine for culture. We did not plan to empirically cover her with
broad spectrum abx as she does not have a clear source and is
not
showing evidence of deteriation to sepsis at this time. "
Review of Systems: As per HPI. Additionally, patient continues
to
have chronic dizziness, relieved when laying/resting. She does
use a walker at baseline for ambulation, and hasn't really been
out of the house in the last year except for doctors' visits.
All
other systems negative.
Past Medical History:
MYELODYSPLASTIC SYNDROME
h/o UTIs
HYPERTENSION
POLYCYTHEMIA ___
--asplenic for decades and is in the burned
out phase of PCV with significant leukocytosis, cytopenias with
regards to both anemia and thrombocytopenia and marrow that
shows
significant fibrosis
ESSENTIAL THROMBOCYTOSIS
L1 FRACTURE
chronic dizziness of unclear etiology
anxiety
Cerebrovascular accident x2 (___)
Remote gastrointestinal bleed secondary to esophageal varices
complicated by splenorenal shunt status post splenectomy
Bilateral total knee replacement
Social History:
___
Family History:
Hypertension in multiple family members. Half-brother diagnosed
with leukemia at advanced age.
Physical Exam:
vitals:
GEN: NAD
HEENT: PERRL, EOMI, MMM, oropharynx clear, no cervical ___: CTAB, no wheezes, rales or rhonchi.
CV: RRR, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, non-tender, not distended. No
suprapubic tenderness.
EXTR: Warm, well perfused. No edema. 2+ pulses.
BACK: no CVA tenderness b/l
NEURO: alert and orientedx3, motor grossly intact in UE and ___
bilaterally
Pertinent Results:
___ 02:00PM BLOOD WBC-40.1*
RBC-5.22 Hgb-12.9 Hct-43.8 MCV-84 MCH-24.7* MCHC-29.5* RDW-18.5*
Plt Ct-75*
___ 06:10AM BLOOD WBC-44.2* RBC-4.80 Hgb-11.9* Hct-40.9
MCV-85 MCH-24.8* MCHC-29.1* RDW-18.5* Plt Ct-41*
___ 02:00PM BLOOD Neuts-86* Bands-11* Lymphs-1* Monos-0
Eos-2 Baso-0 ___ Myelos-0 NRBC-1* Other-0
___ 02:00PM BLOOD Plt Smr-VERY LOW Plt Ct-75*
___ 02:38PM BLOOD ___ PTT-31.6 ___
___ 06:10AM BLOOD Plt Ct-41*
___ 02:00PM BLOOD Glucose-105* UreaN-15 Creat-0.8 Na-139
K-3.9 Cl-101 HCO3-20* AnGap-22*
___ 06:10AM BLOOD Glucose-85 UreaN-20 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-27 AnGap-13
___ 06:10AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
___ 01:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:50PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 01:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:50PM URINE Mucous-RARE
___ 01:50PM URINE CastHy-1*
urine culture results pending
CXR ___
Final Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Chills, sweats, myalgia.
COMPARISON: ___.
FINDINGS: Frontal and lateral views of the chest were obtained.
There has
been interval decrease in previously seen right pleural
effusion. There is
persistent blunting of the left costophrenic angle. No definite
focal
consolidation is seen. The cardiac, mediastinal, and hilar
contours are
stable. Aortic calcifications are seen. There are surgical
clips in the
upper abdomen. Moderate-to-severe compression of the L1
vertebral body is
grossly stable as compared to lumbar spine radiographs from
___.
IMPRESSION: No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Propranolol 20 mg PO DAILY:PRN palpitations
5. Ranitidine 150 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Prochlorperazine 10 mg PO DAILY PRN nausea
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Prochlorperazine 10 mg PO DAILY PRN nausea
6. Propranolol 20 mg PO DAILY:PRN palpitations
7. Ranitidine 150 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
urinary tract infection
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: Chills, sweats, myalgia.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There has
been interval decrease in previously seen right pleural effusion. There is
persistent blunting of the left costophrenic angle. No definite focal
consolidation is seen. The cardiac, mediastinal, and hilar contours are
stable. Aortic calcifications are seen. There are surgical clips in the
upper abdomen. Moderate-to-severe compression of the L1 vertebral body is
grossly stable as compared to lumbar spine radiographs from ___.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSURIA
Diagnosed with DYSURIA, MYALGIA AND MYOSITIS NOS, UNSPEC VIRAL INFECTION
temperature: 99.0
heartrate: 81.0
resprate: 16.0
o2sat: 96.0
sbp: 149.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | The patient was admitted overnight for observation. She was
started on nitrofurantoin for treatment of presumed UTI. The
following morning she feels much better. She has not had any
chills. She has not had a fever while here. Her dysuria is
improving. She will be discharged home on Bactrim for 5 days
(previous issues with macrobid not being covered by insurance).
She will contact Dr. ___ Dr. ___ her symptoms do not
resolve or if they get worse. Total time spent on discharge
activities less than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of CHF, pulmonary hypertension
+/- COPD on 4L nasal cannula O2 at home, presenting for
shortness of breath and fatigue.
Per the patient and her daughter, patient has been feeling more
short of breath and tired over past week since getting a "cold"
last week. States that last week she developed nasal congestion
and a cough productive of scant greenish sputum. During this
time she also noticed weight gain (236 lbs on ___ compared to
about ~216 pounds at recent baseline) and increased swelling of
her lower extremities. Complained of fatigue which because much
worse over the weekend prior to presentation. She denied any
fevers, chills, chest pain or pressure, abdominal pain/cramping
or any other concerning symptoms during this time. No recent
medication changes. She has continued to adhere to her low
sodium diet.
Patient's health has been poor since a hospitalization last
___ at ___. During this admission she was
diagnosed with and treated for CHF. In addition, several
pulmonary problems were identified at this admission. She has
been told that she has COPD and also that she likely has
pulmonary hypertension. She has been trying to get to ___ to
see Dr. ___ for assessment of her pulmonary
hypertension and possible treatment.
After that admission, she was discharged home on supplemental
O2:4L O2 via nasal cannula at rest and increases to 5L nasal
cannula O2 with exertion. She closely monitors her O2
saturations at home and is usually 87-90% at rest and routinely
drops sats to the mid-70s% with exertion. She denies any
symptoms associated with these desat events.
In the ED initial vitals were: T 97.2, HR 87, BP 149/70, RR 25,
O2 96% on NRB after presenting with O2 88% on 5L NC. Placed on
BiPAP, but did not tolerate it and then back to 6L NC. Triggered
initially for VS criteria, stabilized with supplemental O2.
EKG: Rate ___, sinus, Rightward axis, LBBB.
Labs/studies notable for: VBG 7.46/33/___; Na=127; WBC=13.6;
Tpn-T<0.01; proBNP=7993.
Patient was given: Furosemide 40mg IV x 2 (at 14:28 and then
22:36), Foley was placed.
Reported output from time in ED to floor arrival is
approximately 4650 cc (2800 cc, then 1850 cc).
On the floor, patient still feels short of breath and tired but
improved compared to prior.
Soon after arrival to the floor, patient desatted to mid-70s%
with moving in bed and was triggered for hypoxia. She was placed
on non-rebreather but did not tolerate it and had increased
coughing. Nasal cannula restarted at 6 LPM and O2 sats improved
to 88-90% with rest.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension
2. CARDIAC HISTORY:
- CHF (unknown EF)
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- COPD, on home O2 4L at rest, 5L with exertion
- Pulmonary Hypertension
- Hypothyroidism
- Hypertension
- Dry macular degeneration
- b/L TKA
- Lung nodule incidentally noted on CT in ___, PET
reportedly negative
- Pelvic Organ Prolapse with pessary, E2 ring
Social History:
___
Family History:
+PBC (sister)
+MI (presumed, father)
___ (mother, sister)
Physical Exam:
==============
ADMISSION EXAM
==============
VS: T=97.1 BP=158/98 HR=105 RR=24 O2 sat=90% 5L
GENERAL: Elderly, plethoric woman in NAD. Oriented x3. Mood,
affect appropriate. Speaking in full sentences with mildly
hoarse voice.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 13-cm.
CARDIAC: RRR, S1/S2 without murmurs. ?S3 gallop.
LUNGS: Crackles to midlung b/L. Scant diffuse wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. 2+ to 3+ ___ edema. LLE>RLE.
SKIN: Warm and dry. No stasis dermatitis, ulcers, scars, or
xanthomas.
PULSES: Distal pulses palpable and symmetric
==============
DISCHARGE EXAM
==============
VS: T 97.4-98.1 BP 111-139/53-76 HR ___ RR ___ O2 88-92% on
5L
I/Os: ___
Wt: 99.7 kg <- 97.7kg <- 98.7kg <- 98.6 kg
GENERAL: Elderly Caucasian female, NAD, sitting up in bed and
taking humidified O2. In NAD.
HEENT: Sclerae anicteric.
NECK: h/o moderate TR. Supple, JVP approximately 16cm H2O while
sitting up in bed.
CARDIAC: Regular rate and rhythm, S1/S2 without murmurs, soft S4
best heard at the apex.
LUNGS: Crackles to midfields bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pitting ___ edema up to knees bilaterally.
Stable.
SKIN: Warm and dry. No new rashes or lesions.
Pertinent Results:
================
ADMISSION LABS
================
___ 11:40AM BLOOD WBC-13.6* RBC-4.64 Hgb-13.4 Hct-42.2
MCV-91 MCH-28.9 MCHC-31.8* RDW-13.8 RDWSD-46.4* Plt ___
___ 11:40AM BLOOD Neuts-80.1* Lymphs-8.4* Monos-8.7 Eos-1.6
Baso-0.4 Im ___ AbsNeut-10.91* AbsLymp-1.15* AbsMono-1.19*
AbsEos-0.22 AbsBaso-0.05
___ 11:40AM BLOOD ___ PTT-29.8 ___
___ 11:40AM BLOOD Plt ___
___ 11:40AM BLOOD Glucose-151* UreaN-21* Creat-0.9 Na-127*
K-4.8 Cl-90* HCO3-22 AnGap-20
___ 03:57AM BLOOD CK(CPK)-792*
___ 11:40AM BLOOD proBNP-7993*
___ 11:40AM BLOOD cTropnT-<0.01
___ 10:22PM BLOOD Calcium-9.4 Phos-3.1 Mg-2.0
___ 03:52PM BLOOD ___ pO2-93 pCO2-33* pH-7.46*
calTCO2-24 Base XS-0
___ 02:55PM URINE Color-Straw Appear-Clear Sp ___
___ 02:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
================
KEY INTERIM LABS
================
___ 03:57AM BLOOD CK(CPK)-792*
___ 03:57AM BLOOD CK-MB-10 MB Indx-1.3 cTropnT-<0.01
___ 03:57AM BLOOD TSH-3.0
================
DISCHARGE LABS
================
___ 06:55AM BLOOD WBC-11.0* RBC-4.59 Hgb-13.5 Hct-41.6
MCV-91 MCH-29.4 MCHC-32.5 RDW-13.7 RDWSD-45.6 Plt ___
___ 06:55AM BLOOD Glucose-105* UreaN-22* Creat-0.8 Na-133
K-3.8 Cl-94* HCO3-27 AnGap-16
___ 06:55AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.0
================
MICROBIOLOGY
================
BLOOD CULTURE (___): No growth x2
================
DIAGNOSTICS
================
___
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Left Atrium - Volume: *60 ml < 40 ml
Left Atrium - ___ Volume/BSA: 29 ml/m2 <= 34 ml/m2
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: *5.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: 65% >= 55%
Left Ventricle - Stroke Volume: 46 ml/beat
Left Ventricle - Cardiac Output: 3.98 L/min
Left Ventricle - Cardiac Index: *1.90 >= 2.0 L/min/M2
Right Ventricle - Diastolic Diameter: *5.8 cm <= 4.0 cm
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI:18
Aortic Valve - LVOT diam:1.8 cm
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.50
Mitral Valve - E Wave deceleration time: 182 ms 140-250 ms TR
___ (+ RA = PASP): *69 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. IVC dilated
(>2.1cm) with <50% decrease with sniff (estimated RA pressure
(>=15 mmHg).
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Markedly dilated RV cavity.
Severe global RV free wall hypokinesis. Abnormal septal
motion/position consistent with RV pressure/volume overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS. ___
(1+) MR.
___ VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Moderate
[2+] TR. Severe PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 65%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is markedly dilated with severe
global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild posterior leaflet mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension (flying-W sign in pulmonic valve Doppler signal
suggests precapillary etiology of pulmonary hypertension). There
is no pericardial effusion.
IMPRESSION: cor pulmonale
___ UP EXT VEINS US
FINDINGS:
There is normal compressibility, flow, and augmentation of the
left 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.
___ (PORTABLE AP)
FINDINGS:
AP portable upright view of the chest. There is mild elevation
of right hemidiaphragm. The heart appears at least moderately
enlarged. There is hilar congestion and probable mild
interstitial pulmonary. No large effusion is seen. No
pneumothorax. Bony structures are intact. No free air below
the right hemidiaphragm.
IMPRESSION:
Cardiomegaly, congestion and mild pulmonary edema.
===============
CARDIAC STUDIES
===============
RIGHT HEART CATH (___):
Pressures:
- RA mean 10
- RV 99 systolic (EDP 13)
- PA 100/30 (mean 56)
- PCW mean 8
Oximetry:
- Ao 90% sat
- PA 67% sat
Cardiac output:
- CO 5.93 fick
- CI 2.9 fick
Resistances:
- PVR 8.1 ___
Nitric oxide:
- RA mean 5
- PA ___ (mean 45)
- PCW mean 7
IMPRESSIONS:
1. Significant, systemic level precapillary pulmonary
hypertension (mPAP 56, PVR 8.1 ___.
2. Elevated RA pressure, greater than PCWP.
3. Normal cardiac output and index.
4. In response to inhaled oxygen, there was no significant
change in pulmonary hemodynamics.
5. In response to inhaled nitric oxide, there was small,
technically nonsignificant decrease in mPAP (to
mPAP 45). RAP also encouragingly decreased compared to baseline
RAP measurement.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amlodipine-benazepril ___ mg oral BID
2. Labetalol 100 mg PO BID
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Eye Vitamin and Minerals (vit A-vit C-vit E-zinc-copper) Dose
is Unknown oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Magnesium Citrate 160 mg PO Frequency is Unknown
8. Furosemide 40 mg PO DAILY
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation DAILY
11. PredniSONE 5 mg PO DAILY
12. Estring (estradiol) 2 mg vaginal Q3MOS
13. LORazepam 0.25 mg PO BID:PRN anxiety
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, dyspnea
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NU BID
RX *fluticasone 50 mcg/actuation 1 spray intranasal twice a day
Disp #*1 Spray Refills:*0
3. Sildenafil 20 mg PO TID
RX *sildenafil 20 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*5
4. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Eye Vitamin and Minerals (vit A-vit C-vit E-zinc-copper) 1
pill ORAL DAILY
6. Magnesium Citrate 160 mg PO DAILY:PRN constipation
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, dyspnea
8. Estring (estradiol) 2 mg vaginal Q3MOS
9. Labetalol 100 mg PO BID
10. Levothyroxine Sodium 175 mcg PO DAILY
11. LORazepam 0.25 mg PO BID:PRN anxiety
12. Omeprazole 20 mg PO DAILY
13. PredniSONE 5 mg PO DAILY
14. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation DAILY
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Pulmonary hypertension
Right heart failure
Heart failure with preserved ejection fraction, acute-on-chronic
exacerbation
SECONDARY:
Hypertension
Chronic obstructive pulmonary disease
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: CHEST (PORTABLE AP)
INDICATION: ___ with hx of CHF and dyspea // ?Pulmonary edema
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. There is mild elevation of right
hemidiaphragm. The heart appears at least moderately enlarged. There is
hilar congestion and probable mild interstitial pulmonary. No large effusion
is seen. No pneumothorax. Bony structures are intact. No free air below the
right hemidiaphragm.
IMPRESSION:
Cardiomegaly, congestion and mild pulmonary edema.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with L>R leg swelling // please eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, 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: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with SOB // Evaluate for ILD
TECHNIQUE: DIFFUSE LUNG DISEASE PROTOCOL
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 25.4 cm; CTDIvol = 14.7 mGy (Body) DLP = 372.2
mGy-cm.
2) Spiral Acquisition 4.3 s, 34.0 cm; CTDIvol = 19.3 mGy (Body) DLP = 657.6
mGy-cm.
3) Spiral Acquisition 4.0 s, 31.5 cm; CTDIvol = 20.5 mGy (Body) DLP = 644.6
mGy-cm.
Total DLP (Body) = 1,674 mGy-cm.
COMPARISON: ___
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No thyroid gland visualized
suggesting previous thyroidectomy. No supraclavicular or axillary adenopathy.
No gross breast masses.
UPPER ABDOMEN: This study was not designed to evaluate the subdiaphragmatic
organs. Small sliding hiatus hernia/epiphrenic diverticulum (the latter being
statistically less likely). No adrenal lesions. Atherosclerotic changes of
the abdominal arterial vasculature. Incompletely imaged splenic arterial
aneurysm measuring approximately 14 mm in diameter.
MEDIASTINUM: There are multiple subcentimeter mediastinal lymph nodes, most
likely reactive in nature, but unchanged compared to prior.
HILA: Transverse cardiomegaly. No pericardial effusion. Moderate aortic
annular calcification. Mild aortic valve calcification. Mild left coronary
artery calcification. Moderate calcification of the thoracic aortic arch and
supra-aortic vessels.
PLEURA: No pleural effusion.
LUNG:
-PARENCHYMA: Suture material seen in the left lung base suggesting previous
wedge resection/biopsy. Mild apical pleural-parenchymal scarring. Diffuse
central and peripheral interstitial thickening, ground-glass, architectural
distortion and bronchiectasis. More focal bronchiolectasis also seen in the
right upper lobe (4, 104) lung bases bilateral: Right (4, 168) and left (4,
182). Suspected interspersed normal lung seen in the right lung base (4,
146). Air trapping present for example in the right upper lobe (4, 114). Two
indeterminate pulmonary nodules: One in the left upper lobe measuring 9 mm in
average diameter (4, 86) and one in the right upper lobe measuring 6 mm in
diameter (4, 51). These nodules appear similar compared to prior imaging done
___.
-AIRWAYS: Major airways are patent to the subsegmental level.
-VESSELS: Enlargement of the pulmonary artery measuring 32 mm in diameter
suggestive of pulmonary arterial hypertension.
CHEST CAGE: Spondylotic changes of the thoracic spine. No lytic/destructive
bony lesions.
IMPRESSION:
1. Diffuse chronic/ fibrotic interstitial lung disease with a mild apical
basal gradient, but involving the central and peripheral lung zones having the
imaging appearance of chronic hypersensitivity pneumonitis.
2 . indeterminate pulmonary nodules measuring 9 mm and 6 mm respectively
(stable since ___.
Reactive mediastinal adenopathy unchanged.
Splenic arterial aneurysm measuring approximately 14 mm in diameter.
RECOMMENDATION(S): Evidence of previous lung biopsy/wedge resection of the
left lower lobe and correlation with the pathology result advised.
2 indeterminate pulmonary nodules for which either six-month CT follow-up or
PET-CT may be performed.
Dedicated imaging of the splenic arterial aneurysm may be performed if
clinically warranted.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 97.2
heartrate: 87.0
resprate: 25.0
o2sat: 96.0
sbp: 149.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | ___ woman with a history of CHF, COPD on home O2, and
hypothyroidism presented with progressive dyspnea and hypoxemia
in the setting of volume overload and elevated BNP consistent
with CHF exacerbation.
# CORONARIES: Unknown
# PUMP: HFpEF (LVEF 65% based on echo ___
# RHYTHM: Sinus
=============
ACTIVE ISSUES
=============
# CHF EXACERBATION: Diuresed to euvolemia. Stably net even on
20mg PO torsemie prior to discharge. O2 requirement at baseline
at discharge (___).
- 2L fluid restriction
- 2 g/day low sodium diet
- PRELOAD: Torsemide 20mg PO daily
- NHBK: Labetalol 100mg BID
- AFTERLOAD: Amlodipine 5mg daily
# PULMONARY HTN: Very severe, with RV pressure 99 systolic.
V/Q low probability for pulmonary embolus, CT non-con with
findings of nonspecific interstitial lung disease. Started on
sildenafil 20mg TID in-house, tolerated well. Rheumatology
markers (including ___, myositis antibodies)
were pending at discharge.
- Home on baseline O2 (4L at rest, 5L with activity).
- Sildenafil 20mg TID as above.
# NEW-ONSET AFIB: Less than 24 hours duration, rates well
controlled with verapamil. Anticoagulated with apixaban.
Spontaneously resolved ___, has been in NSR since. Likely
transient Afib in setting of active diuresis and fluid shifts,
held off on further AV blockade + anticoagulation thereafter.
# ACUTE-ON-CHRONIC HYPERCAPNIC/HYPOXIC RESPIRATORY FAILURE:
Likely multifactorial with COPD, pulmonary HTN, and acute
decompensated CHF. Patient on baseline level of oxygen ___ NC
at home). Desats with even minimal exertion, suggesting very
low pulmonary reserve. ___ of LLE showed no e/o DVT, V/Q ___
low probability for pulmonary embolus.
- Supplemental O2 via NC
=====================
CHRONIC/STABLE ISSUES
=====================
# COPD: On home ___, though patient had slightly increased
dyspnea, and increased sputum production. No wheezing on exam.
- Duonebs q.6H standing
- Albuterol neb q.4H PRN
- Supplemental O2 for goal sat 88-90%
- Prednisone 5 mg PO daily
# LEUKOCYTOSIS: To a peak of 14.5, decreased to 11 prior to
discharge. Afebrile and no localizing symptoms other than nasal
congestion. Possible etiologies may include steroids (patient on
prednisone) vs. stress response.
# HTN:
- Labetalol 100mg BID
- 5mg amlodipine for BP control
- Hold amlodipine-benzapril
# HYPOTHRYOIDISM: s/p thyroidectomy. TSH 3.0 (WNL).
- Home levothyroxine
===================
TRANSITIONAL ISSUES
===================
# CODE: Full (presumed)
# CONTACT: ___ (___) ___
___ (dtr) ___ (work)
# ATRIAL FIBRILLATION, TRANSIENT: Had one episode of atrial
fibrillation lasting < 24h, with rates well controlled with
verapamil. If recurrent, consider long term anticoagulation.
# UPCOMING APPOINTMENTS: Pt has a follow-up appointment with
Dr. ___ on ___. Consider scheduling an appointment with
the patient's outpatient pulmonologist thereafter.
# FOLLOW-UP SERVICES:
- Please consider pulmonary rehabilitation.
# MEDICATION CHANGES:
- Added sildenafil 20mg TID
- Added torsemide 20mg PO daily
- Adding 5mg amlodipine daily.
- Held amlodipine-benzapril given good pressures on amlodipine.
# PENDING LABS:
- Slceroderma Ab, Sjogren's Ab, anti-RNP, pneumonitis
hypersensitivity profile, ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Septra DS / Lipitor / Pravachol / Combivent / Lisinopril /
insect stings
Attending: ___
Chief Complaint:
Disequilibrium, AMS
Historian: husband ___ patient had trouble giving coherent
history.
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Ms. ___ is a ___ F with a ___ body dementia
(neurologist Dr. ___, mild cervical spondylosis, CAD s/p
CABG, CHF, CKD, and T1DM c/b neuropathy and retinopathy presents
with the worst headache of her life, confusion, and
disequilibrium.
She was in her USOH until ___ at 10am after coming home from a
walk with her health aides. At that time, her husband noticed
that she was more fatigued than usual after a walk. At lunch
time, she had a left-sided toothache. Shortly thereafter, the
tooth pain resolved, and she had a left frontal headache that
was
non-radiating and non-pulsatile. She does not have a history of
headaches, and this was the worst HA of her life. The patient
had
trouble qualifying and quantifying the pain. She took 1000mg
tylenol without relief. HA worst at onset and then gradually got
better and resolved within four hours. No
exacerbating/alleviating factors. No associated aura, N/V, F/C,
pain with eye movements, photophobia, phonophobia, vision
changes, tearing, neck pain.
She presented to the ___ ED, where labs (type
unknown) and NCHCT were reportedly normal (images unavailable;
ED
called to get images, but the weekend staff were unable to help
with this). She was given 600mg of ibuprofen, but her headache
has nearly resolved at that time.
That evening, her husband noticed that she was "cloudy;" namely,
she was slow to respond and had confusion about how to take her
Advair. The following morning, she was still confused, and she
thought she saw horses in the hallway. Additionally, she became
irritable and agitated. She declined to drink water all day, and
she repeatedly wanted to leave the ED. She was also unsteady on
her feet without falls or leaning to one direction.
Additionally,
she spilled cereal with her spoon in the morning.
At baseline, she does not manage her finances, manage her
medications, go/find places on her own, or cook. She is fully
oriented. She gets help with dressing herself and with cleaning
after BM (able to urinate independently). She also uses a cane
at
baseline. Per her husband, she is currently different from her
baseline in that she is agitated (normally calm and cooperative)
and more confused than at baseline.
Of note, she was seen by the neurology consult team (Dr.
___, Dr. ___ in ___ for AMS and R arm/leg
weakness as well as speech difficulties. She was noted to have L
hemispheric epileptiform discharges, but and AED was not started
because no seizure was captured, and it was felt that an AED
could contribute to her confusion.
At the time of interview, she denies HA or tooth pain. She did
note disequilibrium with sitting up in bed. ROS is also neg for
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. Incontinent of urine at
baseline.
On general review of systems, the patient reports intermittent
SOB at rest/with exertion but denies cough, sputum production
CP,
F/C, or wheezing. Urine incontinence at baseline. The pt denies
recent fever or chills. No night sweats or recent weight loss
or
gain. Denies cough. 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:
___ body dementia
Mild cervical spondylosis
CAD s/p CABG (___)
CHF
CKD stage IV
T1DM c/b neuropathy, retinopathy
Macular degeneration
UC
Recurrent cholecystitis/cholangitis
Cholecystectomy (___)
Social History:
___
Family History:
Denies. No history of stroke, aneurysm, cerebral hemorrhage.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Note: exam limited by patient's AMS and intermittently poor
cooperation.
Vitals: 98.2F 59 159/53 18 100%RA
General: Awake, intermittently uncooperative with exam,
intermittently agitated, NAD.
HEENT: NC/AT
Neck: Supple, neg Kernig and Brudzinski, no carotid bruits
appreciated. No nuchal rigidity.
Pulmonary: CTAB
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
MSK: no TMJ TTP, no jaw claudication, no posterior cervical or
occipital TTP, no cervical muscle spasm noted, no temperal TTP,
temporal arteries not palpated
Neurologic:
-Mental Status: Alert, oriented to first name ___ name
for surname, "___," ___ Registered ___, recall
___ with categ prompts, ___ with MC prompts). Spells WORLD
forward but not backwards. Speech fluent, called pen "pencil"
and
pen tip "pin" but able to name thumb, fingernail.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Saccadic intrusions.
V: Initially R>L facial sensation in V1-3 (but not
reproducible).
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. ?Subtle RUE parietal
drift.
No adventitious movements, such as tremor, noted. MMT testing
was
extremely limited by cooperation: deltoids 4+/5 ___, bic/trip 4
R,
tric 4+ left, bic 5 left, wrist ext 4+ ___, grip 4 L and 4+ R,
finger extension ___, IOs 4+ ___. IP ___ ___,
___ ___.
-Sensory: When attempting to test sensation, pt initially said
R>L UE sensation. Could not be reproduced on repeat questioning.
When asked ___ LT same or different, she said, "Yes, same or
differnet." When asked about pinprick in ___, she said they were
different "because they were made out of batteries. Subtle R
parietal drift as above. Remainder of sensation testing
deferred.
-DTRs: 1+ bic/tric/brachioradialis, 2+ patella, absent ankles
Plantar response was flexor bilaterally.
-Coordination: Had difficulty understanding F2N (kept touching
different fingers when asked to touch her nose). Declined to do
H2S testing. Foot tap ok. Did not understand how to do finger
tap. No truncal ataxia (but subjective dyseequilibrium).
-Gait: Difficulty getting out of bed/into bed. Narrow-based,
normal stride and arm swing.
DISCHARGE PHYSICAL EXAM:
MS: She remains unaware of where she is or the date, has some
difficulty
comprehending complex commands.
CN: EOMI, ___ 3 mm, no facial asymmetry, VFF tongue and palate
are normal.
Motor: Exam limited by her cooperation but at least ___ in all
muscle groups.
Pertinent Results:
IMAGING:
1. CXR: no acute cardiopulm process
2. NCHCT: ventriculomegaly and cortical atrophy;
ventriculomegaly
may be out of proportion to atrophy but stable since ___
3. MRI: Only limited MR ___ images were obtained only as the
patient could not cooperate with the exam given the altered
mental status. Partially visualized are dilated ventricles and
sulci.
LABS ON ADMISSION:
___ 02:15PM BLOOD WBC-7.5 RBC-3.59* Hgb-11.2 Hct-33.8*
MCV-94 MCH-31.2 MCHC-33.1 RDW-13.2 RDWSD-45.6 Plt ___
___ 02:15PM BLOOD Neuts-66.2 ___ Monos-6.2 Eos-3.1
Baso-0.5 Im ___ AbsNeut-4.99 AbsLymp-1.79 AbsMono-0.47
AbsEos-0.23 AbsBaso-0.04
___ 02:15PM BLOOD ___ PTT-30.2 ___
___ 02:15PM BLOOD Plt ___
___ 02:15PM BLOOD Glucose-204* UreaN-24* Creat-1.2* Na-141
K-4.7 Cl-104 HCO3-29 AnGap-13
___ 02:15PM BLOOD ALT-31 AST-30 AlkPhos-97 TotBili-0.4
___ 02:15PM BLOOD Lipase-30
___ 02:15PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.4 Mg-2.0
___ 02:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:20PM BLOOD Glucose-193* Lactate-1.1
CSF:
___ 11:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-5* Polys-0
___ ___ 11:00PM CEREBROSPINAL FLUID (CSF) TotProt-22
Glucose-118
DIACHARGE LABS:
___ 06:15AM BLOOD WBC-7.8 RBC-3.06* Hgb-9.6* Hct-28.8*
MCV-94 MCH-31.4 MCHC-33.3 RDW-13.2 RDWSD-45.6 Plt ___
___ 03:52PM BLOOD WBC-6.0 RBC-3.28* Hgb-10.0* Hct-31.1*
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.3 RDWSD-45.7 Plt ___
___ 06:40AM BLOOD WBC-9.0 RBC-3.63* Hgb-10.9* Hct-34.0
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.2 RDWSD-45.1 Plt ___
___ 06:15AM BLOOD Plt ___
___ 03:52PM BLOOD PTT-29.4
___ 03:52PM BLOOD Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-170* UreaN-21* Creat-1.2* Na-143
K-3.8 Cl-107 HCO3-32 AnGap-8
___ 06:40AM BLOOD Glucose-318* UreaN-20 Creat-1.1 Na-140
K-4.1 Cl-102 HCO3-27 AnGap-15
___ 06:15AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9
___ 06:40AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
___ 07:40AM BLOOD CRP-0.9
SED RATE 2 (< OR = 30 mm/h)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fluticasone 50 mcg/actuation nasal BID
2. Donepezil 10 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Apriso (mesalamine) .75 grams oral DAILY
5. Ursodiol 300 mg PO BID
6. Valsartan 80 mg PO DAILY
7. Rosuvastatin Calcium 5 mg PO DAILY
8. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
9. Lorazepam 0.25 mg PO DAILY:PRN agitation
Discharge Medications:
1. Donepezil 10 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Rosuvastatin Calcium 5 mg PO DAILY
4. Ursodiol 300 mg PO BID
5. Valsartan 80 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Furosemide 20 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Metoprolol Tartrate 50 mg PO QPM
11. Metoprolol Tartrate 100 mg PO QAM
RX *metoprolol tartrate [Lopressor] 100 mg 1 tablet(s) by mouth
daily in the morning Disp #*30 Tablet Refills:*3
12. Apriso (mesalamine) .75 grams oral DAILY
13. fluticasone 50 mcg/actuation nasal BID
14. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
15. Lorazepam 0.25 mg PO DAILY:PRN agitation
16. Calcitriol 0.25 mcg PO EVERY OTHER DAY
17. Glargine 10 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
18. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
19. Glucose Gel 15 g PO PRN hypoglycemia protocol
20. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
___ Body dementia
Secondary diagnosis:
Hypertension
Diabetes type I
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman with altered mental status, evaluate for
infarct.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformatted images were acquired.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 8.0 s, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Comparison is made to head CT ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
are severely enlarged out of proportion to the sulci, stable from the prior
study. Periventricular white matter hypodensities are nonspecific, but most
likely sequela of chronic small vessel disease. The basal cisterns are patent
and there is preservation of gray-white matter differentiation.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, and middle ear cavities are clear. There opacification of the left
mastoid air cells. The visualized portion of the orbits are unremarkable.
Air dense calcifications within the cavernous carotid arteries and vertebral
arteries bilaterally.
IMPRESSION:
1. No acute intracranial process.
2. Enlarged ventricles out of proportion to sulci, unchanged from prior,
findings could represent normal pressure hydrocephalus in the appropriate
clinical setting.
Radiology Report
INDICATION: ___ with CHF, CAD p/w AMS // r/o pneumo
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. Multiple fractured
median sternotomy wires are again noted. No acute osseous abnormalities, old
healed left anterior rib fractures are noted. Surgical clips in the right
upper quadrant suggest prior cholecystectomy.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI scout IMAGES
INDICATION: ___ year old woman with worse headache of life, AMS,
disequilibrium. // ?Sentinel bleed ?Ischemic event
TECHNIQUE: Only the scout images of the brain were acquired. The patient had
altered mental status and could not cooperate during the scan. The study had
to be aborted at that point.
COMPARISON: Prior head CT from ___.
FINDINGS:
The scout images demonstrate dilated ventricles, unchanged compared to the
prior CT.
IMPRESSION:
Only limited MR scout images were obtained only as the patient could not
cooperate with the exam given the altered mental status. Partially visualized
are dilated ventricles and sulci.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.2
heartrate: 59.0
resprate: 18.0
o2sat: 100.0
sbp: 159.0
dbp: 53.0
level of pain: 0
level of acuity: 2.0 | A/P: Ms. ___ is a ___ F with a ___ body dementia
(followed by neurologist Dr. ___, mild cervical
spondylosis, CAD s/p CABG, CHF, CKD, and T1DM c/b neuropathy and
retinopathy who presented with the worst headache of her life,
confusion, and disequilibrium. Initial concerns were for SAH, vs
infectious process.
#NEURO: confusion altered mental status and headache. She was
transferred from ___ where head CT was performed
and found no acute intracranial process. On arrival LP done to
evaluate for xanthocromia in ED only 5 RBCs found, otherwise
unremarkable. CT head w/o contrast repeated, found with enlarged
ventricles out of proportion to sulci, unchanged from prior,
findings. Otherwise no acute intracranial process noted. Planned
for MRI/A head and neck, which was not tolerated, so did not
reattempt. CT c-spine was ordered given bilateral weakness on
exam but she was unable to tolerate. ESR/CRP checked to evaluate
for temporal arteritis. However, these were within normal
limits. Utox was also checked and negative. She was monitored on
cvEEG for 24 hours, no seixure activity recorded.
Of note during this admission she was given seroquel which
caused a paradoxical effect, and was added to her allergy list.
#CV: Hypertension. We continued her home furosemide, metoprolol,
crestor, valsartan, ASA 325. She developed hypertension to the
180s during her course, so her home metoprolol was increased to
100mg qAM and 50mg qPM. she was advised to visit her PCP for
further monitoring.
#PULM: Asthma. We have continued her home advair, Flonase,
fluticasone. She was given albuterol nebs.
#GI: Continued her home ursodiol, home mesalamine
#RENAL: Known histiry of CKD. We have trended her
creatininewhile in house.
#ID: To rule out infectious causes of AMS UA and CXR obtained
which were negative.
#ENDO: Known history of DM type I. Continued on glatgine 10
units qhs, as well as ISS, which was managed by the ___
___ during this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / Simvastatin
Attending: ___.
Chief Complaint:
Acute Coronary Syndrome (ST-Elevations without elevated cardiac
enzymes, Unstable Angina, ST-Elevation ACS)
Hyperlipidemia
Hypertension
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Percutaneous Coronary Intervention
with Drug-Eluting Stent to mid-Left Anterior Descending Artery
on ___ ___.
History of Present Illness:
___ y/o male with h/o HTN and HL presenting with chest discomfort
x1 day. Patient reports he noticed a burning chest discomfort
yesterday morning which came on with exertion (walking ___ yards)
and immediately improved with rest. Occurred consistently
throughout the day. Patient reports he had the same symptoms at
rest this morning while sitting at his desk. He works at ___
___ and simply presented himself for evaluation when symptoms
became intolerable.
Had a stress test ___ years ago which was unremarkable per
patient.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, joint pains, cough, hemoptysis, black stools or
red stools. S/he denies recent fevers, chills or rigors. Hhe
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
Hypertension
Dyslipidemia
Vertigo
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: BP=145/99 HR=80 RR=16 SaO2=97% on RA
General: NAD, Pleasant and Cooperative
HEENT: NCAT, EOMI, PERRL, MMM
Neck: No JVD, carotid bruits, or lymphadenopathy
CV: RRR, no MRG
Lungs: CTAB, no crackles or wheeze
Abdomen: Soft, ND, NT, +BS, no masses or organomegaly
Ext: No pitting edema in extremities
Neuro: A+Ox3, motor grossly intact
Skin: No skin lesions
PULSES: ___ pulses
DISCHARGE PHYSICAL EXAM:
VS: 98.0 133/75 85 18 96%RA 700:2700
General: well appearing, NAD
CV: RRR no murmurs
LUNGS: clear bilaterally
EXT: no edema
SKIN: warm and dry
PSYCH: A+Ox3
Pertinent Results:
___ 10:30AM cTropnT-<0.01
___ 04:15PM cTropnT-<0.01
======================================
Electrocardiogram ___ @ 14:41 =
NSR, ST Elevations in II, III, aVF and reciprocal depressions in
aVL
======================================
Cardiac Catheterization & Endovascular Procedure Report ___
Patient Name ___, ___
MRN ___
Study Date ___
Study Number ___
Date of Birth ___
Age ___ Years
Gender Male
Race
Height 170 cm (5'7'')
Weight 73 kg (161 lbs)
BSA 1.84 M2
Procedures:
1- Catheter placement, R radial artery with Slender sheath.
2- Coronary Angiography.
3- Successful PTCA and stenting of the mid RCA and placement of
3.5x16 mm Premier drug-eluting stent with excellent result.
4- Removal of the R radial sheath and placement of T-Band with
adequate hemostasis.
Indications:
1- CAD, native vessels.
2- Unstable angina.
3- Transients upsloping ST segment concerning for evolving acute
myocardial injury.
Staff
Diagnostic Physician ___, MD, MPH
Technologist ___, CVT
Nurse ___, RN
Technologist ___, RTR
Fellow ___, MD
___ ___, MD
___: Local
Specimens: None
Catheter placement via , 5 ___
Coronary angiography using 5 ___
Hemodynamic Measurements (mmHg)
Baseline
SiteSysDiasMeanHR
___
Contrast Summary
Contrast Total (ml): Optiray (ioversol 320 mg/ml)110
Radiation Dosage
Effective Equivalent Dose Index (mGy) 574.148
Radiology Summary
Total Runs
Total Fluoro Time (minutes) 10.8
Medication Log
Start-StopMedicationAmountComment
04:02 ___ Lidocaine 1% Subcut2 ml
04:03 ___ Nitroglycerine bolus (IA) IA200 mcg
04:03 ___ Diltiazem bolus (IA) IA500 mcg
04:11 ___ Bivalirudin bolus IV55 mg
04:15 ___ Bivalirudin drip IV127.5 mg per hr
04:24 ___ Nicardipine bolus (IC) IC200 mcg
04:27 ___ Nicardipine bolus (IC) IC200 mcg
04:27 ___ Nitroglycerine bolus (IC) IC100 mcg
04:33 ___ Nicardipine bolus (IC) IC200 mcg
04:33 ___ Nitroglycerine bolus (IC) IC100 mcg
Materials
ManufacturerItem Name ___
TERUMO TR BAND (LARG)
MERIT MEDICALLEFT HEART KIT
___ MEDICAL PROD & s CUSTOM STERILE KIT(STERILE
PACK)
TYCO ___ 320200ml
CORDIS JR 5 SUPER TORQUE5fr
CORDIS JL 3.5 SUPER TORQUE5fr
___ SCIENTIFMAGIC TORQUE .035 180cm.035in
COOK J WIRE 260cm.035in
TERUMO GLIDESHEATH SLENDER5Fr
___ P-PACKS ___ (INDEFLATORS)
___ ___ WIRE180CM
CORDIS JR 46 fr
___ MEDICAL PROD & ___ 24050ml
MEDTRONICEXPORT AP6fr
___ SCIENTIFAPEX RX 12mm2.0mm
___ SCIENTIFPREMIER RX 16mm3.5mmlot # ___
MEDTRONICNC SPRINTER RX 12mm3.5mm
Findings
ESTIMATED blood loss: <30 cc
Hemodynamics (see above): Normal systemic arterial blood
pressure.
Coronary angiography: right dominant
LMCA: Patent.
LAD: Proximal 60% focal lesion at a bend with haziness.
LCX: 60% mid lesion just proximal to the takeoff of a large OM
branch.
RCA: Mid with hazy tubular 99% with TIMI 2 flow beyond
(particularly into the RPDA). The AM (originates from the
diseased segment) had 80% ostial.
Interventional details
Decision to treat the culprit (mid RCA) with PTCA and stenting
and addreww the LAD and LCX lesion later.
Utilizing the Slender sheath (R radial artery), ___ JR4 guide
provided adequate support. Crossed with short ___ with ease
and passed the Export catheter then predilated with 2.0x12 mm
balloon at 12 ATM. We then deployed a 3.5x16 mm Premied
drug-eluting stent at 12 ATM, postdilated with 3.5x12 mm NC
balloon at 22 ATM with excellent result.
Final angiography showed excellent result with 0% residual
stenosis within the stent, TIMI 3 flow, and no apparent
dissection or distal emboli.
The R radial sheath was then removed and T-Band placed with
adequate hemostasis.
The patient stated he felt "much better" and his chest felt
"clear" at the end of the procedure.
Potential for Radiation Injury
This patient underwent a procedure performed under fluoroscopic
(X-ray) guidance. Procedures involving lengthy exposures to
X-rays may cause damage to the skin and/or hair. These adverse
effects may be increased if one has had previous (especially
recent) radiation exposure to the same skin area. Radiation
injury to the skin can take many forms, including an area of
redness, blistering, hair loss, or ulceration. These effects may
appear after a few weeks or even after several months. If an of
these occur on the side and back of the torso (or elsewhere),
please contact the Interventional Cardiology Section at
___ to arrange further evaluation.
0 If this box is checked, this patient received a prolonged
exposure to X-rays and should be monitored more closely to see
if
any skin or hair changes occur.
Assessment & Recommendations
1. Three vessel CAD with the culprit being the mid RCA>
2. Successful PTCA and stenting of the mid RCA and placement of
3.5x16 mm Premier drug-eluting stent with excellent result.
3. Removal of the R radial sheath and placement of T-Band with
adequate
4. ASA 325 mg po daily x3 months then 81 mg daily indefinitely.
5. Clopidogrel (received loading dose of 600 mg poi in the ED).
Continue with 75 mg po daily x minimum of 12 months.
6. Consider stress testing to risk stratify the LAD and LCX
lesion versus proceed with FFR of these lesions. Will decide
in the outpatient setting.
7. Global CV risk reduction strategies.
8. ___ with me in the office in3-4 weeks with non-imaging
symptom-limited ETT in preparation for cardiac rehab.
9. Global CV risk reduction strategies and post PCI care per
___ service while in-house.
=
=
================================================================
Echocardiogram ___
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.4 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: 0.31 >= 0.29
Left Ventricle - Ejection Fraction: 60% >= 55%
Left Ventricle - Lateral Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *13 < 13
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 0.75
Mitral Valve - E Wave deceleration time: *279 ms 140-250 ms
TR Gradient (+ RA = PASP): *26 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous
mitral valve leaflets. Mild MVP. Normal mitral valve supporting
structures. ___ of the mitral chordae (normal variant). No
resting LVOT gradient. No MS. ___ (1+) MR. ___ (>250ms)
transmitral E-wave decel time. LV inflow pattern c/w impaired
relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular ejection fraction is normal
(LVEF = 60%). However, there is focal hypokinesis of the
inferior free wall, posterior wall, and anterior wall. 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 leaflets are mildly thickened.
The mitral valve leaflets are myxomatous. There is mild
posterior leaflet mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Electronically signed by ___, MD, Interpreting
physician ___ ___ 10:12
========================================================
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Chest pain.
COMPARISONS: ___.
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.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with INTERMED CORONARY SYND, HYPERTENSION NOS
temperature: 97.6
heartrate: 83.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 96.0
level of pain: 2
level of acuity: 2.0 | ___, a ___ yo M with PMHx HTN and Dyslipidemia,
presenting with worsening chest pain with exertion x1 day, was
found to have ST-elevations in II, III, and aVF and negative
troponins and a 99% stenosis of the mid-RCA. He was discharged
s/p DES to mid-RCA on coronary artery disease medications.
# ACS/CAD: Patient with HTN/Dyslipidemia presented with
exertional chest discomfort, negative troponins, ST elevations
in II, III, and aVF EKG with aVL reciprocal changes, and was
found to have three vessel disease per cath, loaded with
clopidogrel s/p DES of mid-RCA. He was started on CAD
medication (Clopidogrel 75mg PO Daily, ASA 325 mg po daily x3
months then 81 mg daily indefinitely per interventional
cardiology recommendations, rosuvastatin 2.5mg daily lowest dose
to allow for minimal myalgias as patients has history of
statin-associated myalgias, and metoprolol succinate ER 50mg PO
Daily). Echocardiogram showed good ejection fraction and
hypokinesis of RCA territory. ___ was consulted and recommended
home with no services. Cardiology recommends work restrictions
of "stay off wrist for 2 weeks, may resume work in 1 week, may
do jury duty".
# HTN: Hypertension has been borderline in outpatient setting,
being 150/85 on ___. During his hospital stay, his blood
pressures was often in SBP 140s-150s. He was given metoprolol
as above and we would have had a low threshold for starting an
ACE inhibitor.
# Dyslipidemia: On ___, lipid panel showed total
cholesterol 252, Triglycerides 1421, HDL 60, LDL 164. Numerous
lipid medications (pravastatin, simvastatin, atorvastatin,
gemfibrozil and niacin) were started and stopped in outpatient
setting due to side effects. He has a diet with a lot of
"pastries and cold cuts" and his PCP has counseled him in this
regard. He was started on low-dose rosuvastatin as above with
Coenzyme Q10 OTC. Nutrition gave Mr. ___ their
recommendations.
# Code Status: Full Code, Mr. ___ filled in a HCP form
designating his wife ___ reachable @ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
___ y/o male transferred from OSH with CT demonstrating C2 type
II odontoid with left lateral mass fracture with concern for
extension into vertebral foramen.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient reports falling down 4 steps on the morning of ___
while helping his wife with the vacuum cleaner. He states that
he fell backward and hit his head on the doorknob and landed on
his right side. He denies loss of consciousness. Initially,
patient took Percocet and tried icing his neck,
alternating with topical analgesia cream.
On the morning of ___, patient reports that his pain
persisted. He presented to and OSH, where a CT spine
demonstrated C2 type II odontoid fracture with lateral mass
fracture with concern for extension into vertebral foramen.
Patient was transferred to ___ for a higher level of care. In
ED, CTA head and neck were obtained. The neurosurgical spine
service was consulted.
Past Medical History:
-CVA in ___ with residual left weakness and spasticity
-Pre-diabetes
-Chronic pancreatitis in ___
-S/p Roux-en-Y longitudinal pancreaticojejunostomy, partial
pancreatic resection, open cholecystectomy, drainage
peripancreatic abscess (___)
-S/p TURP
-S/p hernia repair
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Examination
O: T: 98.6 BP: 160/82 HR: 86 R 16 O2Sats 98% on RA
Gen: WD/WN, comfortable, NAD. Hard cervical collar in place.
HEENT: Pupils: equal and reactive EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused, right wrist splint in place
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Cranial Nerves: face symmetric with tongue deviation towards
right
Motor:
D B T WE WF IP Q H AT ___ G
R 4 5 5 n/a n/a 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 4 4 4
*Right biceps weakness ___ shoulder pain
*Left ___ weakness at baseline
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 * 2 0
Left ___ 2 0
*Unable to assess brachioradialis fracture ___ wrist splint
Toes downgoing bilaterally
Spasticity throughout
Clonus on left ___
Negative ___.
Discharge Physical Examination: unchanged from admission
Pertinent Results:
___ 03:20PM GLUCOSE-112* UREA N-12 CREAT-0.7 SODIUM-133
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-31 ANION GAP-9
___ 03:20PM WBC-4.3# RBC-3.17* HGB-10.9* HCT-32.3*
MCV-102*# MCH-34.3*# MCHC-33.7 RDW-13.8
___ 04:46PM ___ PTT-31.1 ___
___ CTA Head and Neck:
1. No acute hemorrhage or mass effect. Hypodensity in right
parietal
subcortical white matter may be from prior infarct (2:22).
2. Type III C2 dense fracture. Encroachment on the left
vertebral artery
(3:188). No dissection.
3. No aneurysm. Patent intracranial vessels.
___ Plain Films Right Shoulder and Hand: Volar angulated
boxer's fracture.
___ Thoraco-lumbar Spine: No acute fracture or
malalignment in the thoracolumbar spine.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 5 mg PO DAILY
2. Baclofen 10 mg PO TID
3. BuPROPion (Sustained Release) 100 mg PO BID
4. Clonazepam 0.5 mg PO TID anxiety
5. Creon 12 1 CAP PO TID W/MEALS
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Ropinirole 2 mg PO TID
9. Enalapril Maleate 20 mg PO DAILY
10. Fexofenadine 60 mg PO BID
11. Temazepam 15 mg PO HS:PRN insomnia
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Baclofen 10 mg PO TID
3. BuPROPion (Sustained Release) 100 mg PO BID
4. Clonazepam 0.5 mg PO TID anxiety
5. Creon 12 1 CAP PO TID W/MEALS
6. Enalapril Maleate 20 mg PO DAILY
7. Fexofenadine 60 mg PO BID
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
9. Pantoprazole 40 mg PO Q24H
10. Ropinirole 2 mg PO TID
11. Temazepam 15 mg PO HS:PRN insomnia
12. Acetaminophen 650 mg PO Q6H:PRN fever or pain
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *Oxecta 5 mg 1 tablet(s) by mouth every four (4) hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
C2 Type II odontoid fracture with lateral mass fracture
Right hand Boxer's 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
RIGHT HAND AND SHOULDER RADIOGRAPHS PERFORMED ON ___
COMPARISON: Outside hospital right hand radiograph.
CLINICAL HISTORY: Right boxer's fracture, assess severity and displacement.
Right shoulder pain. Assess for fracture.
FINDINGS: Three views of the right hand again demonstrate an acute fracture
through the neck of the fifth metacarpal with slight volar angulation of the
distal fracture fragment. No additional fractures in the right hand.
Degenerative changes at the basal joint. Vascular calcifications noted.
Three views of the right shoulder demonstrate no fracture or dislocation. No
significant degenerative joint disease and soft tissues appear normal.
IMPRESSION: Volar angulated boxer's fracture.
Radiology Report
CTA HEAD AND NECK, ___
INDICATION: ___ man with C2 fracture, type 3, disrupting the left
vertebral artery foramen. Evaluate for vertebral artery injury.
COMPARISON: Cervical spine CT performed at ___ on ___.
TECHNIQUE: Following a non-contrast head CT, axial multidetector CT images of
the head and neck were obtained during intravenous contrast administration,
with multiplanar maximal intensity projection reformatted images, volume
rendered three-dimensional reformatted images, and curved reformatted images.
FINDINGS:
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage, edema, or
mass effect. The ventricles and sulci are normal in size and configuration.
Subcentimeter foci of low density in bilateral basal ganglia and corona
radiata are nonspecific, but most compatible with sequela of chronic small
vessel ischemic disease in a patient of this age. Mucosal thickening is noted
in some of the mastoid air cells bilaterally.
CTA NECK: There is a three-vessel aortic arch. The left vertebral artery is
dominant. There is an approximately 40% narrowing of the left vertebral artery
at the level of the disrupted left C2 transverse foramen. However, there is
no evidence of a dissection flap or large intramural hematoma within the left
vertebral artery. The right vertebral artery appears normal. The right
common, internal carotid and vertebral arteries appear normal. There is a
small focus of calcified plaque in the proximal left internal carotid artery,
without evidence of a hemodynamically significant stenosis. The distal
cervical internal carotid arteries measure 4.5 mm in diameter on the right and
4.3 mm in diameter on the left.
Mild bronchiectasis is noted in the imaged upper lungs.
The cervical spine is better assessed on the preceding dedicated cervical
spine CT from ___, which demonstrates a type 3 odontoid
fracture with disruption of the left transverse foramen.
HEAD CTA: The intracranial left vertebral artery is widely patent. The
non-dominant right vertebral artery is hypoplastic distal to the origin of the
posterior inferior cerebellar artery. There is no evidence of intracranial
arterial stenosis or aneurysm.
IMPRESSION:
1. No evidence of acute intracranial abnormalities. Foci of low density in
the basal ganglia and corona radiata are nonspecific, but could represent
sequela of chronic small vessel ischemic disease in a patient of this age.
2. Type 3 odontoid fracture with disruption of the left transverse foramen.
The left vertebral artery demonstrates approximately 40% narrowing at the
level of the disrupted foramen, without evidence of a dissection flap or large
intramural hematoma. MRA with fat-suppressed axial T1-weighted images would
be more sensitive for detecting small intramural hematoma, if clinically
indicated.
3. No evidence of intracranial arterial stenosis or aneurysm.
Radiology Report
THORACOLUMBAR SPINE RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Midline thoracolumbar spine pain with tenderness to
percussion, status post fall. Assess for fracture or malalignment.
FINDINGS: A total of six views were provided including AP, lateral and
swimmer's lateral views of the thoracolumbar spine. The thoracic spine aligns
normally and there is no definite sign of compression fracture. Please note
there is limited evaluation at the level of the cervicothoracic junction,
though this level is clearly assessed on the same day CT of the cervical spine
performed at outside hospital. Degenerative disc disease is partially imaged
in the lower C-spine, better obtained on the outside hospital CT scan. There
are five non-rib-bearing lumbar-type vertebral bodies. Clips are noted
projecting over L1. Excreted contrast in the bilateral renal collecting
systems is noted secondary to prior contrast injection. The lumbar spine
aligns normally. No compression fracture or significant degenerative disease
is seen.
IMPRESSION: No acute fracture or malalignment in the thoracolumbar spine.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: C2 FX, RIGHT BOXER FX
Diagnosed with FX C2 VERTEBRA-CLOSED, FX METACARPAL NECK-CLOSE, FALL ON STAIR/STEP NEC
temperature: 98.6
heartrate: 86.0
resprate: 16.0
o2sat: 98.0
sbp: 160.0
dbp: 82.0
level of pain: 4
level of acuity: 2.0 | Patient was transferred from OSH to ___ on ___ after CT
scan revealed minimally displaced C2 type II dens fracture with
left lateral mass fracture that was concerning for extension
into the vertebral foramen. Upon arrival to ___, neurosurgery
spine service as consulted. Patient was found to be in hard
cervical collar with right hand splint. Mr. ___ had no
neurological deficits beyond his baseline. A CTA head and neck
was obtained that demonstrated intact vasculature. Patient was
assessed by the acute care service and found to have no injuries
beyond his cervical spine and hand fractures.
Patient was admitted to neurosurgical service on ___ for
observation. He was placed in an Aspen collar. Patient's pain
was well managed.
On ___, patient was given instructions on appropriate
c-collar wear. His gait was noted to be unsteady, a ___ consult
was placed. As patient reported social alcohol use, thiamine
and folate were started. Orthopaedics service was contacted
regarding instructions for follow-up care.
On ___, patient was in good condition. ___ evaluation
yielded recommendation for discharge home with cane. Mr. ___
was discharged to self care with instructions to wear his Aspen
collar at all times for 8 weeks. He is to follow-up with Dr.
___ in 8 weeks with repeat CT C-Spine. He is to follow-up in
2 weeks with Dr. ___ for evaluation of his right
hand Boxer's fracture. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast- Oral and IV Dye / sulfa
Attending: ___
Chief Complaint:
Arm and neck pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with TAVR in ___ c/b CHB s/p pacemaker,
h/o HFpEF, transferred from ___ for NSTEMI.
In the past few days she has had mild exertional dyspnea, some
neck and arm pain but no chest pain. Her weight increased by 5
pounds at the same time. She has not had any palpitations,
lightheadedness, or unusual heartburn/indigestion.
She presented to ___ on ___ and echocardiogram showed an
EF of ~0.30-0.35 with anteroapical hypokinesis and a possible
increase in PASP to ~73 mm Hg + RAP. It also showed normal
function of the ___ 3 aortic prosthesis. Her troponin was
elevated, and her ECG showed a RBBB with some increase in ST
depression. She was then transferred to ___ for further care.
At ___ ER, EKG showed ST depressions laterally in the setting
of a right bundle branch block. An echocardiogram was performed
and the ___ ejection fraction was noted to have decreased
from 50% in ___ to 30% today. Patient was also noted to have
moderate dysfunction of the right ventricle. Labs notable for
Trop-T: 1.02 >0.83, CK-MB: 16, proBNP: 8540. She got 1 dose of
40
mg of IV Lasix at 8 AM and was given full dose of aspirin,
atorvastatin, and placed on a heparin drip. She is followed by
Atrius and they were consulted and agreed with admission for
cardiac catheterization.
On arrival to the floor, patient endorses HPI as above.
Currently
chest pain free. States she is breathing comfortably.
Past Medical History:
Osteoarthritis, localized, knee
Bursitis, subacromial/subdeltoid
Hypertension, essential
Hyperlipidemia
Obesity, morbid
BMI 40.0-44.9, adult
Aortic stenosis
S/P TKR (total knee replacement)
Gastropathy
Pseudophakia, right eye
Diabetes mellitus type 2, uncomplicated - per daughter this was
mild and transient but never required treatment
Severe aortic stenosis by prior echocardiogram
Chronic Diastolic congestive heart failure
Hypertensive heart disease with congestive heart failure
Class 2 obesity due to excess calories without serious
comorbidity with body mass index (BMI) of 39.0 to 39.9 in adult
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Gen: NAD. Sitting up in bed comfortably.
HEENT: JVP at ___
Card: RRR, no MRG, S1 and S2+
Pulm: Bibasilar crackles
Abd: Soft, non-distended, non-tender, no organomegaly, BS+
Ext: Warm, well perfused without cyanosis, clubbing or edema
Pertinent Results:
ADMISSION LABS:
===============
___ 12:30PM BLOOD WBC-8.7 RBC-3.60* Hgb-8.0* Hct-28.7*
MCV-80* MCH-22.2* MCHC-27.9* RDW-20.3* RDWSD-56.0* Plt ___
___ 12:30PM BLOOD ___ PTT-55.3* ___
___ 12:30PM BLOOD CK-MB-16* MB Indx-6.1* proBNP-8540*
___ 12:30PM BLOOD CK(CPK)-262*
___ 12:30PM BLOOD Calcium-8.7 Phos-5.4* Mg-2.4
___ 12:30PM BLOOD Glucose-87 UreaN-24* Creat-1.2* Na-135
K-7.5* Cl-99 HCO3-23 AnGap-13
INTERVAL LABS:
==============
___ 06:27AM BLOOD WBC-7.4 RBC-3.76* Hgb-8.4* Hct-30.5*
MCV-81* MCH-22.3* MCHC-27.5* RDW-20.7* RDWSD-58.6* Plt ___
___ 06:27AM BLOOD ___ PTT-48.9* ___
___ 06:27AM BLOOD Glucose-99 UreaN-23* Creat-1.1 Na-145
K-3.9 Cl-102 HCO3-29 AnGap-14
DISCHARGE LABS:
===============
___ 06:30PM BLOOD Glucose-132* UreaN-27* Creat-1.2* Na-142
K-3.8 Cl-98 HCO3-30 AnGap-14
___ 06:30PM BLOOD Calcium-8.7 Phos-5.1* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. Multivitamins 1 TAB PO DAILY
3. Aspirin 81 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Amiodarone 200 mg PO DAILY
7. Digoxin 0.0625 mg PO Q48H
8. Torsemide 10 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Potassium Chloride 10 mEq PO DAILY
11. TraMADol 50 mg PO BID:PRN Pain - Moderate
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. ALPRAZolam 0.25 mg PO BID:PRN anxiety
4. Amiodarone 200 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Digoxin 0.0625 mg PO Q48H
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Potassium Chloride 10 mEq PO DAILY
12. TraMADol 50 mg PO BID:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic HF with borderline ejection fraction
Type II non-ST elevation MI
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 new oxygen requirement// Reason for new
oxygen requirement
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
A left chest wall dual lead pacemaker is present as well as a TAVR. There is
no focal consolidation, pleural effusion or pneumothorax identified. Streaky
retrocardiac opacities on the lateral view likely reflect atelectasis. The
degree of pulmonary edema has decreased since prior. The size of the cardiac
silhouette is enlarged but unchanged. Multilevel degenerative changes are
seen in the thoracic spine.
IMPRESSION:
Interval decrease in extent of pulmonary edema. Streaky retrocardiac
opacities likely reflect atelectasis however superimposed aspiration/pneumonia
would be hard to exclude in the proper clinical context.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 97.6
heartrate: 71.0
resprate: 20.0
o2sat: 97.0
sbp: 143.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ woman with TAVR in ___ c/b CHB
s/p pacemaker, h/o HFpEF, transferred from ___ for NSTEMI
and concern for newly reduced EF.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year-old m with h/o stage IV lung cancer on C1D5
carboplatin/pemetrexed presenting to ED with fever to 101.2 and
worsening respiratory distress. Mr. ___ started
chemotherapy this past ___. Patient called his oncologist
last night regarding fever to 100.4 last night and was asked to
come in, but felt well enough to stay home at that time. This
morning he developed worsening fever to 101.2 and worsened
dyspnea, so he came into the ED. In the ED he noted worsening
of his breathing and cough. Of note, he had pneumonia in
Feburary for which he was treated with augmentin and
azithromycin as an outpatient. He otherwise has been doing well
except for four days of constipation.
.
On arrival to the ED vital signs were 100.6 109 130/74 16 88%
ra. Physical exam was significant for diffuse rhonchi
throughout. CXR showed pneumonia, but could not exclude a small
pneumothroax, so he underwent CTA to eval for pneumothorax and
PE, which showed pneumonia and lung cancer. In the ED he
received 3L IVF, cefepime, levofloxacin, vancomycin, and
albuterol/atrovent nebulizer treatments. On transfer patient's
vitals are: 117 125/64 29 90% on NRB.
.
On arrival to the MICU, patient reports his symptoms are much
improved from earlier today. His breathing feels more
comfortable now and his cough is improving. Patient had
headache in ED, which has now resolved.
Past Medical History:
1. History of nonsmall cell lung cancer - started
carboplatin/premetrexed on ___.
2. Hypertension
3. Hyperlipidemia
4. Elevated uric acid levels on allopurinol
5. h/o low back pain (now resolved)
6. BPH
Social History:
___
Family History:
No family members with lung cancer. No other cancers in the
family. No medical problems that patient knows of.
Physical Exam:
Admission exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diffuse rhonchi b/l, worse on left than right
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 grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, gait deferred.
Discharge exam:
Vitals: 97.8, 128/64, 84, 20, 92% on 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diffuse rhonchi b/l, worse on left than right
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: condom cath on with yellow urine output.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, gait deferred.
Psych: pleasant, calm, appropriate
Pertinent Results:
Labs on Admission:
------------------
___ 09:15AM BLOOD WBC-14.7* RBC-6.02 Hgb-18.0 Hct-54.2*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.5 Plt ___
___ 09:15AM BLOOD Neuts-92.2* Lymphs-5.9* Monos-1.0*
Eos-0.5 Baso-0.4
___ 09:15AM BLOOD ___ PTT-28.5 ___
___ 09:15AM BLOOD Glucose-150* UreaN-21* Creat-1.0 Na-137
K-4.5 Cl-98 HCO3-23 AnGap-21*
___ 09:15AM BLOOD Calcium-10.0 Phos-3.4 Mg-2.1
___ 09:22AM BLOOD ___ pO2-37* pCO2-39 pH-7.43
calTCO2-27 Base XS-1
___ 09:22AM BLOOD Lactate-3.1*
Pertinent micro:
-----------------
___ URINE URINE CULTURE-NEGATIVE INPATIENT
___ SPUTUM GRAM STAIN-SPARSE COMMENSAL
RESPIRATORY FLORA; RESPIRATORY CULTURE-FINAL INPATIENT
___ SPUTUM GRAM STAIN-INADEQUATE SPECIMEN;
RESPIRATORY CULTURE-FINAL INPATIENT
___ MRSA SCREEN MRSA SCREEN-NEGATIVE INPATIENT
___ URINE URINE CULTURE-NEGATIVE EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-NEGATIVE EMERGENCY WARD
Pertinent imaging:
-------------------
___ CTPA
No acute aortic pathology or pulmonary embolism. Bilateral
parenchymal opacification with consolidation and ground-glass
opacities is unchanged from five days prior. Supervening
infection cannot be excluded given the degree of opacification.
Unchanged right lower lobe nodule.
Discharge labs:
----------------
___ 08:15AM BLOOD WBC-4.9 RBC-5.02 Hgb-14.7 Hct-43.5 MCV-87
MCH-29.3 MCHC-33.8 RDW-14.4 Plt ___
___ 07:00AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-138
K-4.6 Cl-103 HCO3-26 AnGap-14
___ 07:00AM BLOOD Calcium-9.8 Phos-3.0 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Atenolol 50 mg PO DAILY
Hold for SBP < 100, HR < 60
4. Benzonatate 100 mg PO TID:PRN cough
5. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
6. Dexamethasone 4 mg PO Q12H
For 3 days following chemo
7. Finasteride 5 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP < 100
10. Ondansetron 8 mg PO Q8H:PRN nausea
For 3 days following chemo
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Simvastatin 20 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Benzonatate 100 mg PO TID:PRN cough
5. Finasteride 5 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Simvastatin 20 mg PO DAILY
11. Tamsulosin 0.4 mg PO HS
12. Levofloxacin 750 mg PO DAILY Duration: 5 Days
End date ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*4 Tablet Refills:*0
13. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
RX *sodium chloride [Saline Nasal] 0.65 % 2 sprays in each
nostril as needed for dry nose Disp #*1 Bottle Refills:*0
14. Home Oxygen
___ continuous via NC pulse dose for portability
Diagnosis: lung cancer
15. Suction machine
with yankauar for oral secretions
Dx: lung cancer
16. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing or sob
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inhaled every
six hours Disp #*1 Unit Refills:*0
17. Bisacodyl 10 mg PO DAILY Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
18. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
19. Polyethylene Glycol 17 g PO TID:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth up to
three times daily Disp #*90 Packet Refills:*0
20. Senna 2 TAB PO BID Constipation
RX *sennosides [senna] 8.6 mg 2 tabs by mouth two times a day
Disp #*120 Tablet Refills:*0
21. Nebulizer
Home nebulizer machine
Diagnosis: pneumonia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Lung cancer
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 shortness of breath. Evaluate for evidence
of consolidation or pneumothorax
COMPARISON: Multiple prior chest radiographs most recent on ___. Chest
CT from ___.
TECHNIQUE: Portable upright chest radiograph.
FINDINGS: Nearly complete opacification of the left hemithorax is of
increasing density since the recent prior CT. A large area of opacity in the
inferior segment of the right upper lobe as well as more patchy right middle
lobe involvement were better assessed in recent chest CT from ___
and similar in appearance allowing for difference in techniques. Widespread
opacification of the left mid to lower lung is increasingly dense, however.
There is no evidence of pneumothorax. The cardiomediastinal contours are
stable.
IMPRESSION: Similar extensive alveolar opacities in the inferior segment of
the right upper lobe and right middle lobe as well as increased confluent
opacification of the left mid to lower lung.
The overall appearance suggests severe worsening multifocal pneumonia
superimposed on known malignancy.
Radiology Report
INDICATION: Cough and fever. Evaluate for pulmonary embolism.
___.
TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed
with 100 mL Omnipaque intravenous contrast. Images are presented for display
in the axial plane at 2.5 mm and 1.25 mm collimation. A series of multiplanar
information images are submitted for review.
CT CHEST WITH CONTRAST: The thoracic aorta is normal in caliber without
evidence of dissection and with mild atherosclerotic calcifications along its
course. Pulmonary arterial vasculature is well visualized to the subsegmental
level without filling defect to suggest pulmonary embolism. No pathologically
enlarged axillary, mediastinal, or hilar lymph nodes are identified, ranging
up to 10 mm in the right hilum. Aortic valve and coronary artery
calcifications are of unknown hemodynamic significance. There is no pleural
or pericardial effusion. No nodules are seen in the thyroid gland.
Lung window images demonstrate diffuse bilateral ground glass opacities with
areas of more confluent opacification in all lobes, unchanged from ___,
five days prior. This is compatible with the patient's known diagnosis of
mucinous bronchoalveolar carcinoma. Supervening infection cannot be excluded
on this study given the degree of opacification. A 14 x 12 mm right lower lobe
nodule (2:83) unchanged, previously 12 x 14 mm. Airways remain patent to the
subsegmental levels.
This study is not tailored for subdiaphragmatic evaluation. No abnormality is
seen in the imaged upper abdomen.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Bilateral parenchymal opacification with consolidation and ground-glass
opacities is unchanged from five days prior. Supervening infection cannot be
excluded given the degree of opacification.
3. Unchanged right lower lobe nodule.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED
temperature: 100.6
heartrate: 109.0
resprate: 16.0
o2sat: 88.0
sbp: 130.0
dbp: 74.0
level of pain: 5
level of acuity: 1.0 | Mr. ___ is a ___ year old gentleman with recently
diagnosed stage IV lung cancer on his first cycle of
carboplatin/pemetrexed who presented with fever and respiratory
distress.
# Sepsis:
Patient met SIRS criteria with fever, tachycardia, leukocytosis,
and tachypnea. Most likely source thought to be pulmonary given
cough, respiratory distress, and possible pneumonia superimposed
on lung cancer as seen on imaging. No evidence of UTI on UA.
No complaints to suggest GI etiology and no evidence of skin
infection. The patient was started on vancomycin/cefepime for
HCAP given recent IV chemotherapy administration. IVF was
bolused as necessary to maintain MAP and cultures were followed
for growth. Once his respiratory status improved and afebrile,
he was transitioned to levaquin. He was transferred to the
oncology service, where levaquin was continued without
recurrence of fever or septic signs or symptoms.
.
# Respiratory distress:
Patient with some dyspnea at baseline, but had new hypoxia and
tachypnea on presentation. No evidence of PE or pneumothorax on
CTA and EKG without evidence of cardiac ischemia. Thought to be
pneumonia superimposed on lung cancer. This was treated as
above, patient was given symptomatic treatment, and he was
continued on nebulizer treatments. His overall oxygenation
improved with treatment of his pneumonia. However, his baseling
lung parenchyma is so poor, it was presumed that he will likely
not recover his baseline oxygenation ability. He was stable for
several days on 4L of O2 via nasal cannula, and he was
discharged on home oxygen, suctioning, and nebs.
.
# Hematuria:
Likely secondary to traumatic foley. Burning pain at the tip of
the urethra improved with pyridium and topical lidocaine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Primary diagnoses
1. Upper GI bleed
2. Orthostatic hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presents for evaluation of a near syncopal episode. Patient
states he was on a date yesterday and when going to pay for the
check, he suddenly got weak and fell to the ground. He was
caught by a waiter. He denies losing consciousness. No tongue
biting/lip biting, loss of urine. Did not hit his head. No
preceding cp, sob, ha prior to falling. No confusion afterwards.
Denies f/c, cp, sob, abd pain, n/v/d, dysuria.
Of note, patient reports that yesterday he slipped and fell
down stairs. Again, denies LORC or headstrike. Has had bleeding
on bridge of nose since. Also with ED admission 2 weeks ago
while in ___ for pre-syncopal episode. He states he was
with his family and told he looked weak so he was brought in to
the ED where he was observed overnight with a negative work-up
and sent home.
In the ED, initial vitals were: 120 140/93 20 100% RA
- Labs were significant for cr 2.1, wbc 10 with 80% pmns, cbc
normal, plt normal, negative trop
- Imaging revealed no acute intrathroacic process in cxr, ct
head negative, ekg without signs of ischemia.
While in the ED, patient had 3 episodes of coffee ground
emesis.
- The patient was given 2L IV NS, iv zofran 4 mg x 1, iv
pantoprazole 40 mg x 1, octreotide infusion.
- Seen by GI who recommended keeping npo, iv ppi bid, and
trending crit overnight with further plans pending.
Vitals prior to transfer were: 110 176/94 19 100% RA
Upon arrival to the floor, patient reports feeling thirsty but
otherwise well. Denies focal symptoms or current pain. He does
report one black tarry stool 1.5 hours ago. Denies history of
any other recent nausea, no prior hematochezia or melena. No
nsaid intake.describe it further even with prompting of various
psychiatric conditions. He does report having a history of
hallucinations. Last colonoscopy ___ years ago at ___ and
reportedly normal.
Denies major surgeries. Denies hx of cirrhosis or liver
problems.
Past Medical History:
Unknown psychiatric disease
Social History:
___
Family History:
Father deceased with history of heart condition,
cancer and stroke. Mother is ___ and healthy. Sister is ___ and
healthy.
Physical Exam:
Initial Exam:
PHYSICAL EXAM:
Vitals: 98 129/99 100 20 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Tachy 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
Discharge Exam:
Physical Exam:
Vitals: T 98.2 BP 110s-140s/70s-90s ___ 20 96% RA
General: AAOx3, comfortable appearing, in NAD
HEENT: NCAT, EOMI Sclera anicteric, MMM.
Neck: supple
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender.
GU: no foley
Ext: WWP. No edema.
Neuro: alert, oriented, MAE.
Psych: Pressured speech, redirectable
Pertinent Results:
Initial labs
___ 03:10PM BLOOD WBC-10.0 RBC-5.96 Hgb-16.1 Hct-48.6
MCV-82 MCH-27.0 MCHC-33.1 RDW-13.4 RDWSD-39.1 Plt ___
___ 03:10PM BLOOD Plt ___
___ 03:10PM BLOOD Glucose-134* UreaN-44* Creat-2.1*# Na-137
K-4.3 Cl-96 HCO3-22 AnGap-23*
___ 03:10PM BLOOD ALT-39 AST-23 AlkPhos-145* TotBili-0.5
___ 03:10PM BLOOD Lipase-35
___ 03:10PM BLOOD cTropnT-<0.01
___ 03:10PM BLOOD Albumin-5.3*
Discharge labs
___ 09:29AM BLOOD WBC-4.7 RBC-4.01* Hgb-11.0* Hct-32.8*
MCV-82 MCH-27.4 MCHC-33.5 RDW-13.3 RDWSD-39.6 Plt ___
___ 09:29AM BLOOD Plt ___
___ 09:29AM BLOOD Glucose-106* UreaN-19 Creat-1.0 Na-138
K-3.3 Cl-103 HCO3-25 AnGap-13
___ 09:29AM BLOOD Calcium-8.3* Phos-1.8* Mg-1.7
Imaging:
CXR: FINDINGS: There is bibasilar atelectasis without definite
focal consolidation. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are stable.. No
displaced fracture is identified. Evidence of DISH is seen
along the thoracic spine.
IMPRESSION: No acute cardiopulmonary process.
CT head w/o contrast: FINDINGS: There is no evidence of
infarction, hemorrhage, edema, or mass. The ventricles and sulci
are normal in size and configuration. There is no evidence of
fracture. There is a mucous retention cyst in the left
maxillary sinus. The remaining visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. IMPRESSION:
No acute intracranial process.
CT abdomen w/contrast: Final read pending.
Micro: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. RISperidone 3 mg PO QHS
2. ClomiPRAMINE 225 mg PO QHS
Discharge Medications:
1. ClomiPRAMINE 225 mg PO QHS
2. RISperidone 3 mg PO QHS
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
4. Outpatient Physical Therapy
Orthostatic Hypotension: ICD___
Please evaluate and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleeding
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 tachycardia, recent falls // eval for
infection, rib injury
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is bibasilar atelectasis without definite focal consolidation. No
pleural effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are stable.. No displaced fracture is identified. Evidence of
DISH is seen along the thoracic spine.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, poor historian // eval for bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 802.73 mGy-cm
COMPARISON: CTA head and neck dated ___ and MR head dated ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. There is a mucous retention cyst in the
left maxillary sinus. The remaining visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
Radiology Report
INDICATION: ___ year old man with UGIB, looking for paraesophageal hernia and
anatomic abnormalities. Please page GI-west for any questions. // With PO
contrast as well.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Total exam DLP: 1128 mGy.cm
COMPARISON: None.
FINDINGS:
LOWER CHEST: Atelectasis is seen at the lung bases bilaterally. No pleural or
pericardial effusions. Small sized hiatal hernia.
ABDOMEN:
HEPATOBILIARY: Liver demonstrates homogeneous attenuation with no focal mass
lesion. No intra or extrahepatic ductal dilatation. The hepatic vasculature
is patent. Cholelithiasis with no CT features of acute cholecystitis.
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 not bulky in appearance, however measures approximately
15 cm in the CC dimension. No focal splenic mass lesion.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: No dilatation of the renal collecting system. Within both kidneys,
largest on the left measuring up to 11 mm, are cysts. No perinephric
abnormality.
GASTROINTESTINAL: The stomach is normal in appearance. Oral contrast was
administered and is seen to the mid small bowel. Within the abdomen, the
small bowel are mildly prominent, however nondilated. No bowel wall
thickening or bowel obstruction. No free air free fluid. As mentioned above
there is a small hiatal hernia with no inflammatory stranding or
paraesophageal/ perigastric free fluid.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Cholelithiasis.
2. Small hiatal hernia.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 5:05 ___, shortly after discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with SYNCOPE AND COLLAPSE, GASTROINTEST HEMORR NOS
temperature: 97.4
heartrate: 120.0
resprate: 20.0
o2sat: 100.0
sbp: 140.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | ___ who presented to ED with pre-syncope, with scant coffee
ground emesis in the ED and reports of melena, currently
hemodynamically stable. EGD showed evidence of submucosal fundal
bleed and antral ulcer. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
black hair dye / novocaine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Dialysis catheter placement
History of Present Illness:
___ ESRD, IgA nephropathy, HTN, pulmonary edema, due to start
dialysis this ___, who is coming to the MICU for acute
renal
failure after presenting to ___ ED for dyspnea and "feeling
fluid on my lungs."
Medical hx notable for hospitalization in ___ for hypertensive
urgency i/s/o medication noncompliance treated with nitro gtt
and
initiation of nifepdine. He had acute kidney injury at the time
as well with a creatinine that peaked at 3.0. Since then, his
creatinine has not returned to baseline and the deterioration of
his kidney function has increased. Patient was being planned in
outpatient setting to transition to RRT, with planned admission
for placement of a tunneled dialysis catheter and dialysis on
___ with hopes to bridge to transplant.
Approximately 2 weeks prior to presentation, patient developed
impaired concentration as well as cognitive difficulties
believed
to be secondary to hyperuricemia per his outpatient nephrology.
2
days prior to presentation, patient noticed increased swelling
in
his lower extremities and abdomen. Within 24 hours, patient
subsequently developed dyspnea and feeling as though he had
"fluid in his lungs". Dyspnea is positional, worse while laying
supine and improved when upright. Associated with reduced urine
output over that time period, though patient states he is still
producing urine. No hematuria/dysuria. Endorses constipation.
Endorses pruritus and intermittent muscle pain as well as lower
abdominal pain of mild severity
In the ED, initial vitals were: T: 97.8, HR: 89, BP: 169/102,
RR: 16, PO2: 100% RA
- Exam notable for: Ill appearance,e facial plethora, bilateral
rales/ronchi, systolic murmur, 2+ ___ edema
- Labs notable for: Cr of 18.3, pH of 7.27/32/41. Bicarb of 15.
UA positive for opiates
- Imaging was notable for:
Renal US: New fluid investing the bilateral kidneys, likely
representing ascites
CT A/P: Ascites, trace pleural effusion
CXR: Prominent pulmonary vasculature
- Patient was given: Lasix 100 mg IV once, sevelamer
Upon arrival to the ICU, patient reports continued dyspnea but
is
otherwise feeling well. He was started on a nitro gtt for HTN
and
redosed w/ lasix 160.
Review of systems was negative except as detailed above.
Past Medical History:
IgA nephropathy: CKD V from IGA nephropathy, biopsy diagnosed in
___.
Social History:
___
Family History:
No FH of renal disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VITALS: Reviewed in MetaVision.
GENERAL: Facial plethora, otherwise well appearing comfortable
HEENT: JVP 12 cm
CARDIAC: RRR, no rmg
PULMONARY: Reduced breath sounds at bases, crackles throughout
ABDOMEN: NTND
EXTREMITIES: 2+ non-pitting edema
NEURO: NO Asterixis
DISCHARGE PHYSICAL EXAM
=========================
VITALS: 24 HR Data (last updated ___ @ 759)
Temp: 98.6 (Tm 99.6), BP: 172/97 (143-186/81-111), HR: 64
(64-81), RR: 18, O2 sat: 97% (95-100), O2 delivery: Ra, Wt:
181.88 lb/82.5 kg
GENERAL: In NAD.
HEENT: PERRL, MMM.
NECK: R tunneled cath w/o erythema.
CARDIAC: RRR, soft systolic ejection murmur over LL sternal
border.
PULMONARY: CTAB, no crackles/wheezing/rhonchi.
ABDOMEN: Soft, NTND. No shifting dullness, no fluid shift.
EXTREMITIES: Trace bilateral ___ edema.
SKIN: No ecchymoses or petechiae.
Pertinent Results:
___ 09:09PM BLOOD WBC-8.9 RBC-2.60* Hgb-7.5* Hct-22.3*
MCV-86 MCH-28.8 MCHC-33.6 RDW-13.3 RDWSD-41.1 Plt ___
___ 06:12AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Target-OCCASIONAL
Schisto-1+* Tear Dr-OCCASIONAL
___ 11:56PM BLOOD ___ PTT-31.4 ___
___ 09:09PM BLOOD Glucose-107* UreaN-208* Creat-18.3*#
Na-135 K-4.2 Cl-92* HCO3-16* AnGap-27*
___ 09:09PM BLOOD ALT-17 AST-17 CK(CPK)-574* AlkPhos-81
TotBili-0.3
___ 09:09PM BLOOD Lipase-76*
___ 09:09PM BLOOD cTropnT-0.04* ___
___ 09:09PM BLOOD Albumin-3.5 Calcium-7.8* Phos-10.1*
Mg-2.4
___ 10:20AM BLOOD calTIBC-244* Ferritn-250 TRF-188*
___ 04:54AM BLOOD Hapto-85
___ 01:20AM BLOOD ___ pO2-41* pCO2-32* pH-7.27*
calTCO2-15* Base XS--10 Intubat-NOT INTUBA
___ 12:10AM BLOOD Lactate-0.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Calcium Carbonate 1000 mg PO TID
3. Vitamin D ___ UNIT PO DAILY
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
5. Minoxidil 2.5 mg PO BID
6. NIFEdipine (Extended Release) 30 mg PO QPM
7. NIFEdipine (Extended Release) 90 mg PO DAILY
8. Torsemide 40 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Calcium Acetate ___ mg PO TID W/MEALS
RX *calcium acetate 667 mg 3 tablet(s) by mouth Three times a
day Disp #*30 Tablet Refills:*2
2. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
3. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*2
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR
5. Torsemide 80 mg PO 4X/WEEK (___)
6. Atorvastatin 10 mg PO QPM
7. Calcium Carbonate 1000 mg PO TID
8. Ferrous Sulfate 325 mg PO DAILY
9. Minoxidil 2.5 mg PO BID
10. NIFEdipine (Extended Release) 30 mg PO QPM
11. NIFEdipine (Extended Release) 90 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13.Outpatient Lab Work
ICD 10: N18.6
Please obtain CBC, Na, K, Cl, CO3, BUN, Cr on ___.
Fax results to:
Dr. ___
___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Acute on chronic renal failure
SECONDARY DIAGNOSIS
====================
Hypertension
Thrombotic microangiopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: History: ___ with bilateral flank pain and new LLQ abdominal pain
in the setting of ESRD (not on dialysis).// hydronephrosis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Comparison to ultrasound ___
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Bilateral kidneys
are again demonstrated to be diffusely echogenic. No focal lesions are
demonstrated.
Right kidney: 10.0 cm
Left kidney: 10.4 cm
The bladder is moderately well distended and normal in appearance.
There is small perinephric ascites bilaterally, as well as small-moderate
intra-abdominal ascites .
IMPRESSION:
1. Redemonstration of echogenic kidneys compatible with chronic medical renal
disease. No stones or hydronephrosis are visualized.
2. New fluid investing the bilateral kidneys, likely representing ascites.
There is small-moderate intra-abdominal ascites layering near the bladder.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: +PO contrast; History: ___ with ESRD, p/w abdominal pain+PO
contrast// bowel perforation? Abscess?
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 6.2 s, 49.1 cm; CTDIvol = 14.6 mGy (Body) DLP = 713.8
mGy-cm.
Total DLP (Body) = 714 mGy-cm.
COMPARISON: Ultrasound ___
FINDINGS:
LOWER CHEST: Visualized lung fields demonstrate trace the pleural effusions
with solid and ground-glass opacities which likely represents atelectasis .
There is a 4 mm left lower lobe sub solid nodule (series 2, image 5).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. There is a moderate stool
burden demonstrated within the transverse and descending colon, without focal
abnormality. The appendix is within normal limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is at
least moderate, low-density ascites.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly 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: There is mild diffuse anasarca.
IMPRESSION:
1. Mild-moderate intra-abdominal low-density ascites. Prominent stool burden
within the transverse and descending colon, without free intraperitoneal air
or definite sign of perforation. No findings suspicious for intra-abdominal
or intrapelvic abscess. No hydronephrosis or obstructing renal stones.
2. Bilateral trace pleural effusions with overlying atelectasis, as well as
diffuse anasarca.
3. 4 mm left lower lobe sub solid nodule is likely a component of atelectasis.
Findings are amenable to follow-up on repeat CT.
Radiology Report
INDICATION: ___ year old man with acute renal failure// Will require
hemodialysis
COMPARISON: Chest x-ray dated ___.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
25mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 24 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 4 mg of Zofran
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 0.1 minutes, 8 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right 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 tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the ___ wire through which the catheter was
threaded into the right side of the heart with the tip in the right atrium.
The sheath was then peeled away. The catheter was sutured in place with 0 silk
sutures. ___ subcuticular Vicryl sutures and Steri-strips were also used to
close the venotomy incision site. Final spot fluoroscopic image demonstrating
good alignment of the catheter and no kinking. The tip is in the right atrium.
The catheter was flushed and both lumens were capped. Sterile dressings were
applied. The patient tolerated the procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing 23 cm
dialysis catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The
tip of the catheter terminates in the right atrium. The catheter is ready for
use.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS PORT
INDICATION: ___ year old man with leg edema, L>R// ? DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None available.
FINDINGS:
There is normal compressibility and flow of the bilateral common femoral,
femoral, and popliteal veins. Normal color flow is demonstrated in the
posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea, Leg swelling
Diagnosed with Recurrent and persistent hematuria w oth morphologic changes
temperature: 97.8
heartrate: 89.0
resprate: 16.0
o2sat: 100.0
sbp: 169.0
dbp: 102.0
level of pain: 4
level of acuity: 2.0 | MICU COURSE
===========
Mr. ___ was admitted to the MICU with acute renal failure. A
tunneled dialysis line was placed and he received a hemodialysis
session. He tolerated HD well and was called out to the floor.
___ year old male with ESRD from IgA nephropathy, HTN, and
pulmonary edema who presented with dyspnea and sensation of
fluid on his lungs, admitted to ___ with acute renal failure
complicated by uremia and anion gap metabolic acidosis, started
on dialysis urgently via tunneled dialysis line. His hospital
course was complicated by anemia and thrombocytopenia with
likely thrombotic microangiopathy.
ACUTE ISSUES
==============
#Acute on chronic renal Failure
#Anion gap metabolic acidosis
#Uremia
ESRD is due to IgA nephropathy and poorly controlled
hypertension. HD was urgently initiated in the setting of his
metabolic derangement secondary to renal failure. He had a
tunneled dialysis catheter placed by ___ on ___ and initiated on
HD. He received three successive sessions of dialysis and then
placed on a MWF schedule, with plans to start outpatient
dialysis at ___ on ___. He was continued on
calcium acetate while inpatient.
#Volume Overload
#Dyspnea
Anasarctic on admission with BNP>41000 in the setting of renal
failure, TTE in ___ without significant cardiac dysfunction. In
addition to dialysis, he was diuresed with improvement in
dyspnea and volume overload. He was discharged euvolemic, and
started torsemide on non HD days.
#Hypertension
BP acutely elevated in the setting of volume overload, briefly
required nitro gtt while in MICU, transitioned to home blood
pressure medications before floor transfer. He was continued on
home nifedipine, minoxidil and clonidine patch. After
consultation with his outpatient nephrologist, he was started on
losartan additionally.
# Anemia/Thrombocytopenia
# Thrombotic microangiopathy
Initially presented with low Hgb and platelet count, assumed to
be ___ renal disease. The patient was having intermittent
epistaxis but no other signs of bleeding or clotting. His
labwork reflected a mixed picture for hemolysis, including
schistocytes on smear but normal haptoglobin/coags. He had a
Doppler US of his legs without signs of DVT. Hematology
evaluated him and felt the picture was consistent with TMA. He
received 2u pRBC during his hospitalization. He was continued on
iron supplementation, and he receives outpatient Aranesp. He
will have repeat labs as an outpatient and have Hematology
follow up.
TRANSITIONAL ISSUES
===================
[] Patient has labwork for ___ which will be sent to his
outpatient nephrologist. Please review as he required two
transfusions this hospitalization.
[] Patient had labile blood pressure inpatient. He may require
further titration as an outpatient to SBP <160.
[] A 4 mm left lower lobe sub solid nodule was visualized on
___ CT A/P. Will need repeat CT.
NEW MEDICATIONS: Losartan 50 mg, calcium acetate, nephrocaps
HOLD/STOPPED MEDICATIONS: None |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
TEE on ___
History of Present Illness:
___ with PMHx of non-ischemic cardiomyopathy (EF 35%), Afib, and
CHB (s/p PPM in ___ -> upgraded to ICD in ___ -> recently
upgraded to BiV ICD in ___ p/w 1 day of left flank pain and
diffuse abdominal pain.
Pt was discharged from the hospital on ___ after being admitted
from ___ for upgrade of ICD to a BiV ICD. Initial attempt
to remove the PPM by EP was unsuccessful and resulted in pacer
pocket hematoma. Cardiac surgery was consulted and were able to
successfully place an epicardial LV lead by left thoracotomy and
exchange the generator to a ___ CRT-D
(model ___, serial no ___ on ___.
He has since completed his post-operative antibiotics and was
seen in Cardiology wound clinic yesterday (___) for follow up.
At that time, he reported that he has been experiencing a vague
epigastric discomfort that started on ___. He describes the
pain as dull, constant, and located in the L > R lower abdomen.
Also describes point tenderness to low back on the left side
that also started yesterday. Able to tolerate dinner last
night. Drank only water this morning and took Pradaxa. Did not
take any other morning medications.
In the ED, initial vitals were: Tm 99.1, 74, 128/78, 18, 100% RA
- Exam was notable for point tenderness to posterior ribs, left
back. minimal abdominal pain to deep palpation diffusely.
- EKG: Afib w/ 3rd degree block, 100% ventricular pacing with
RBBB morphology of QRS.
- Labs revealed: H/H 11.7/36.9, Chem 7 WNL, LFts elevated (AST
113 > ALT 46, ALP 85, TBili 1.8), UA: negative
- Imaging showed: CT A/P showed several low-attenuation regions
in the left kidney c/f multiple renal infarcts versus
pyelonephritis; perinephric stranding present, particularly
inferiorly.\
- Patient was started on a heparin gtt.
On the floor, patient reports ongoing ___ left flank pain,
worse with inspiration. He denies chest or arm pain.
Past Medical History:
- Familial cardiomyopathy
- Complete heart block (s/p PPM in ___ -> upgraded to VVI ICD
in ___ -> upgraded to BiV ICD in ___ -- epicardial LV lead,
___ CRT-D, Model ___, Serial ___
___
- Chronic atrial fibrillation (s/p DCCV in ___
- Atrial flutter (s/p ablation in ___
- Recurrent ventricular tachycardia
- Pacemaker induced cardiomyopathy
Social History:
___
Family History:
Familial cardiomyopathy; mother died at age ___. 2 Brothers with
cardiomyopathy. Pt denies any history of sudden death. Also
h/o strokes in brother and mother.
Physical Exam:
ADMISSION:
Vital Signs: T 99.0, 122/75, 70, 18, 97%RA
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 except at left base where there are crackles
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE:
Vital Signs: T98.1 BP 115/68 HR ___ RR 18 98% on RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; well healing scar in left axilla from recent procedure.
Lungs: Clear except at left base where there are crackles
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
=============
___ 12:40PM BLOOD WBC-9.0 RBC-3.97* Hgb-11.7* Hct-36.9*
MCV-93 MCH-29.5 MCHC-31.7* RDW-13.7 RDWSD-46.2 Plt ___
___ 12:40PM BLOOD Neuts-73.6* Lymphs-11.7* Monos-12.6
Eos-0.8* Baso-0.7 Im ___ AbsNeut-6.63*# AbsLymp-1.05*
AbsMono-1.13* AbsEos-0.07 AbsBaso-0.06
___ 06:35PM BLOOD ___ PTT-43.6* ___
___ 12:40PM BLOOD Glucose-91 UreaN-18 Creat-0.9 Na-136
K-4.7 Cl-98 HCO3-27 AnGap-16
___ 12:40PM BLOOD ALT-46* AST-113* CK(CPK)-155 AlkPhos-85
TotBili-1.8*
___ 12:40PM BLOOD cTropnT-<0.01
___ 12:49AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:50PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:50PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
LABS AT DISCHARGE:
================
___ 08:05AM BLOOD WBC-12.2* RBC-3.78* Hgb-11.3* Hct-35.3*
MCV-93 MCH-29.9 MCHC-32.0 RDW-14.1 RDWSD-47.6* Plt ___
___ 08:05AM BLOOD Glucose-67* UreaN-18 Creat-0.9 Na-138
K-4.3 Cl-98 HCO3-29 AnGap-15
___ 08:05AM BLOOD ALT-35 AST-43* AlkPhos-102 TotBili-2.1*
MICRO:
=====
URINE CULTURE (Final ___: NO GROWTH.
BLOOD CULTURES ___: No growth at time of discharge.
IMAGING:
=======
___ TEE:
The left atrium and right atrium are normal in cavity 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. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Overall left ventricular systolic function is
mildly depressed. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 40 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: No ___ SEC or thrombus. No ASD/PFO. No
source of embolism identified.
ECHO (___):
IMPRESSION: No echocardiographic evidence for cardiac souce of
embolus identified. The patient appears to be ventricularly
paced. There is no atrial activity arguing for either sinus
nodal arrest or atrial fibrillation as underlying
supraventricular rhythm. Mild global left ventricular systolic
dysfunction. There is a non-cardiac structure compression the ___
___ which may be a hiatal hernia. If clinically indicated
a chest CT could identify this structure further.
Compared with the prior study (images reviewed) of ___,
no significant change.
CXR (___):
No evidence of rib fracture. Pacemaker and ICD leads are
unchanged in
position.
CT A/P (___):
Several low-attenuation regions in the left kidney, the largest
of which involve the lower pole and measures approximately 4.3 x
2.7 x 3.1cm. No definite capsular enhancement is seen, however,
findings raise concern for multiple renal infarcts versus
pyelonephritis. Perinephric stranding, particularly inferiorly.
Of note, patient urinalysis does not indicate infection. The
patient also has a history of atrial fibrillation which raises
concern for renal infarct. Further characterization could be
obtained with MRI. If not obtained, recommend follow-up in one
month to exclude underlying mass.
Indeterminate 8 mm hypodensity in the left lobe of the liver
could be further assessed with ultrasound or MRI on a non
emergent basis.
ECG: Afib w/ 3rd degree block, 100% ventricular pacing with RBBB
morphology of QRS.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO QHS
5. Spironolactone 25 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO QHS
5. Spironolactone 25 mg PO BID
6. Acetaminophen 1000 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Multiple renal infarcts likely d/t cardiac emboli during
interruption of anticoagulation
- Indirect hyperbilirubinemia NOS
Secondary diagnosis:
-Familial cardiomyopathy
-Complete heart block (s/p PPM in ___ -> upgraded to VVI ICD in
___ -> upgraded to BiV ICD in ___ -- epicardial LV lead,
___ CRT-D, Model ___, Serial ___ ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PA and lateral chest radiographs
INDICATION: Left back pain
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ PA and lateral chest radiographs
FINDINGS:
Lungs are fully expanded and clear. No pleural abnormalities. Severe
cardiomegaly and cardiomediastinal hilar silhouettes are unchanged. Pacemaker
and ICD leads are unchanged in position. No evidence of displaced rib
fracture.
IMPRESSION:
No evidence of rib fracture. Pacemaker and ICD leads are unchanged in
position.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with LUQ pain, elevated LFTsNO_PO
contrast // Sourse of LUQ pain
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 6.7 mGy (Body) DLP = 362.5
mGy-cm.
Total DLP (Body) = 381 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST:
Partially imaged heart is enlarged. Pacer wires are seen extending into the
right atrium right ventricle trace left pleural effusion is seen. There is
minimal bibasilar atelectasis. No pericardial effusion is seen.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely low in attenuation, suggesting fatty
infiltration. 8 mm hypodensity in the left lobe of the liver in series 2,
image 29 is not well evaluated on this study. Assessment for focal
intrahepatic lesions is suboptimal given fatty infiltration. The portal vein
is patent. Tubular vascular structure in the anterior left lobe of the liver
on series 2, image ___ represent arterial venous shunt. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are several low-attenuation regions in the left kidney, the
largest of which involve the lower pole and measures approximately 4.3 x 2.7
cm on coronal image 31. Additional wedge-shaped hypodense region is seen
laterally in the interpolar region and a smaller area of hypodensity is seen
in the upper pole the left kidney. No definite capsular enhancement is seen,
however, findings raise concern for multiple renal infarcts versus
pyelonephritis. There is perinephric stranding, particularly inferiorly. Of
note, patient urinalysis does not indicate infection. The patient also has a
history of atrial fibrillation which raises concern for renal infarct. No
hydronephrosis is seen.
GASTROINTESTINAL: The stomach is collapsed. No bowel obstruction or bowel
wall thickening is seen. Retrocecal appendix is normal in caliber.
PELVIS: The urinary bladder is unremarkable. Very trace pelvic free fluid is
noted.
REPRODUCTIVE ORGANS: Prostate gland appears mildly enlarged.
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: 1 .1 cm sclerotic focus in the medial right iliac bone on series 2,
image 58 most likely represents a bone island.
IMPRESSION:
1. Several low-attenuation regions in the left kidney, the largest of which
involve the lower pole and measures approximately 4.3 x 2.7 cm.31. No
definite capsular enhancement is seen, however, findings raise concern for
multiple renal infarcts versus pyelonephritis. Perinephric stranding,
particularly inferiorly. Of note, patient urinalysis does not indicate
infection (query any recent antibiotic?). The patient also has a history of
atrial fibrillation which raises concern for renal infarct.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 98.3
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 78.0
level of pain: 5
level of acuity: 2.0 | ___ with PMHx of non-ischemic cardiomyopathy (EF 35%), Afib, and
CH(s/p PPM in ___ -> upgraded to ICD in ___ -> recently
upgraded to BiV ICD in ___ p/w 1 day of left flank pain and
found to have renal hypodensities on CT concerning for renal
infarcts.
# Left flank pain/renal infarcts:
Patient presented with one day of left flank and diffuse
abdominal pain. He was found to have new hypodensities in left
kidney on CT concerning for renal infarcts secondary to embolic
shower. Patiient was started on a heparin gtt and underwent
cardiac echo to look for cardiac thrombus. TEE on ___
demonstrated no thrombus. Patient had not received pradaxa from
___ to ___ during ICD upgrade so unclear if embolic phenomena
represents true treatment failure on pradaxa. After talking with
the patient's cardiologist, Dr. ___ home dose of
Pradaxa was resumed. Patient's abdominal pain was improving and
the patient remained hemodynamically stable at the time of
discharge.
# AFib:
As noted above, patient initially started on heparin gtt until
TEE ruled out cardiac thrombus. Discontinued Heparin gtt on ___
at which point the patient was restarted on Pradaxa as per
outpatient cardiologist, Dr. ___.
# Systolic CHF:
EF 35-40%, s/p recent upgrade from PPM to BiV ICD, the placement
of which was complicated by hematoma of the pacer pocket. No
evidence of heart failure exacerbation on this admission. His
CHF regimen was maintained as follows:
- Lisinopril 5 mg PO DAILY
- Metoprolol Succinate XL 25 mg PO QHS
- Spironolactone 25 mg PO BID
- ASA 81mg qday
# Elevated LFTs and TBili:
Elevated during last admission as well. Differential includes
resolving hematoma (especially with AST predominance) versus
hepatic or biliary process. Favor former diagnosis given time
course and no acute hepatobiliary findings on CT. Patient with
isolated elevated tbili in the past, raising suspicion for
___ disease. LFTs downtrending at time of discharge.
# Indeterminate 8 mm hypodensity in the left lobe of the liver:
Consider further assessed with ultrasound or MRI on a non
emergent basis. Deferred during this hospitalization.
TRANSITIONAL ISSUES:
- Please monitor for complete resolution of abdominal pain.
- Further characterization of renal hypodensities could be
obtained with MRI, which was not obtained during this
hospitalization. Recommend follow-up in one month to exclude
underlying mass.
Indeterminate 8 mm hypodensity in the left lobe of the liver
could be further assessed with ultrasound or MRI on a non
emergent basis.
- Patient with indirect hyperbilirubinemia, also noted in past
and may represent ___ syndrome. Further evaluation at ___
___.
# CODE STATUS: Full Code
# CONTACT: ___ (sister, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Bactrim DS / Sulfa (Sulfonamide Antibiotics) /
Keflex
Attending: ___.
Chief Complaint:
Fever
Atered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of chronic pain, COPD, and hld
who presents after being found down with AMS, dyspnea, and
fever.
The patient is a poor historian, but states that about a week
ago she started to feel unwell and was having increased cough,
at times coughing up blood. She also reports having decreased
appetite. On ___, her air conditioning was turned off by
mechanics (unclear why), and for the next few days the patient's
home became "unbearable" and extremely hot. On the morning of
presentation the ED, the patient states she woke up extremely
sweaty. She went to have a bowel movement, and briefly passed
out. She woke up, and went to get some cold water to pour on
herself, and does not remember what happened after that.
She was found on the floor by EMS with AMS and dyspnea. When
asked about the possibility of taking extra of her medications,
the patient states "I don't think so." Denies having
purposefully taken extra medications. Medications normally
managed by granddaughter, who is currently in ___. Patient
is able to recount most of her medications accurately.
Vital signs notable for tachycardia, febrile to 105. Exam per ED
is notable for pinpoint pupils, appears to be hallucinating with
reaching for objects - not comatose - not agitated delirium.
EKG: QRS widened at 154 with terminal R.
In the ED, VS: 105.1 113 150/74 18 95%.
Delirious on exam, with hallucinations.
Notable labs: WBC 12.4 Hgb 17.8 Hct 54.2 Plt 281
136 / 98 /21 /
------------ 188
4.2 / ___ / 1.2\
Lactate 3.4
CXR showed no acute cardiopulmonary process.
Head CT - no acute intercranial process.
EKG with widened QRS 154
Received 2L IVF, Bicarb gtt, tylenol, ceftriaxone, ativan
Attempted LP, but largest spinal needle and not adequate, pt
declines further attempts.
Consults: Toxicology
Recommendations: stop bicarb, as pt clinically improving. No
physostigmine at this time, monitor core temp, cont infectious
workup
On arrival to the FICU, patient remained somewhat confused, but
was alert and oriented x3. Still had O2 requirement, but
temperature at 99.4, and patient reported feeling much better.
Past Medical History:
-IVDU - heroin quit > 20+ years
-Hepatitis B and C
-Legal blindness due to congenital rubella
-Intermittent falls with a left ankle fracture
in ___ requiring multiple surgeries (x8)
-chronic lower extremity edema,
-endometrial cancer status post TAH/BSO in ___
-morbid obesity
-asthma, and chronic bronchitis
-deep venous thrombosis and pulmonary embolism during pregnancy
in ___
- L5-S1 disc herniation with radiculopathy and chronic low back
pain.
- Recurrent UTIs- last in ___ for which she took antibiotic for
it (uncertain what type)
- Recurrent sinusitis
- IBS - with last flare in mid ___
Social History:
___
Family History:
Pt was adopted and does not know family history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vitals: T: 100.2 (rectal) BP: 121/73 P: 87 R: 13 O2: 91% 2L
GENERAL: drowsy, but oriented x3. Poor concentration, tangental.
NAD
HEENT: pupils 4mm, reactive to light. No lymphadenopathy. NCAT.
NECK: unable to appreciate JVP due to body habitus. Supple
LUNGS: Decreased air flow, but no wheezes or rhonchi
CV: distant heart sounds. RRR, no murmurs appreciated
ABD: obese , bsx4, mildly tender to palpation in RLQ
EXT: pitting edema to knees, chronic venous stasis changes
SKIN: rash on upper torso with small erythematous vesicles,
improving per patient
DISCHARGE PHYSICAL EXAM:
==========================
Vitals: 98.5, 104/48, 77, 18, 100% on RA
GENERAL: Alert and oriented x 3, tangential but redirectable
HEENT: PERRL. No lymphadenopathy. NCAT.
NECK: Supple, no LAD
LUNGS: Clear to auscultation bilaterally
CV: Distant heart sounds. RRR, no murmurs appreciated
ABD: obese, +BS, non-tender, non-distended
EXT: pitting edema to knees, chronic venous stasis changes
NEURO: No focal deficits
Pertinent Results:
ADMISSION LABS:
===============
___ 09:50PM BLOOD WBC-12.4* RBC-6.18* Hgb-17.8* Hct-54.2*
MCV-88 MCH-28.8 MCHC-32.8 RDW-15.6* RDWSD-46.5* Plt ___
___ 09:50PM BLOOD Neuts-63.1 ___ Monos-4.0*
Eos-0.2* Baso-0.6 Im ___ AbsNeut-7.82* AbsLymp-3.94*
AbsMono-0.50 AbsEos-0.02* AbsBaso-0.08
___ 09:50PM BLOOD ___ PTT-34.2 ___
___ 09:50PM BLOOD Glucose-188* UreaN-21* Creat-1.2* Na-136
K-4.2 Cl-98 HCO3-22 AnGap-20
___ 09:50PM BLOOD Albumin-4.3 Calcium-9.7 Phos-1.9*# Mg-1.7
___ 09:50PM BLOOD ALT-14 AST-26 CK(CPK)-78 AlkPhos-45
TotBili-0.7
___ 10:36PM BLOOD ___ pO2-35* pCO2-34* pH-7.38
calTCO2-21 Base XS--3
___ 10:02PM BLOOD Lactate-3.4*
___ 10:36PM BLOOD O2 Sat-67
DISCHARGE LABS:
===============
___ 07:40AM BLOOD WBC-9.6 RBC-5.21* Hgb-14.9 Hct-47.4*
MCV-91 MCH-28.6 MCHC-31.4* RDW-14.7 RDWSD-49.1* Plt ___
___ 07:40AM BLOOD Glucose-102* UreaN-20 Creat-0.8 Na-139
K-4.1 Cl-103 HCO3-26 AnGap-14
___ 07:40AM BLOOD Calcium-9.1 Phos-4.9* Mg-2.1
___ 03:35PM BLOOD Lactate-1.3
IMAGING:
========
CT Head (___):
Technically limited exam due to body habitus and head
positioning, without evidence for acute intracranial
abnormalities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Docusate Sodium 100 mg PO QHS constipation
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
5. Morphine SR (MS ___ 10 mg PO Q12H
6. Multivitamins 1 TAB PO DAILY
7. Topiramate (Topamax) 150 mg PO BID
8. Amitriptyline 75 mg PO QAM
9. Amitriptyline 150 mg PO QHS
10. ClonazePAM 1 mg PO TID
11. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain
12. Erythromycin 0.5% Ophth Oint 1 cm BOTH EYES Q4-6H as needed
13. Fluconazole 150 mg PO ONCE repeat if symptoms persist after
complete 10 days
14. nystatin 100,000 unit/gram topical apply under arms BID PRN
15. bismuth subsalicylate unknown strength oral PRN indigestion
16. Calcium Carbonate 500 mg PO PRN indigestion
17. Loratadine 10 mg PO 30 MINUTES BEFORE BEDTIME PRN nasal
congestion
18. Mucinex (guaiFENesin) 600 mg oral as needed
19. Cinnamon (cinnamon bark) unknown strength oral as needed to
help digest sugars
20. biotin unknown strength oral DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Amitriptyline 75 mg PO QAM
3. Amitriptyline 150 mg PO QHS
4. ClonazePAM 1 mg PO TID
5. Morphine SR (MS ___ 10 mg PO Q12H
6. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain
7. Topiramate (Topamax) 150 mg PO BID
8. biotin 0 strength ORAL DAILY
9. Bismuth Subsalicylate 0 strength ORAL PRN indigestion
10. Calcium Carbonate 500 mg PO PRN indigestion
11. Cinnamon (cinnamon bark) 0 strength ORAL AS NEEDED to help
digest sugars
12. Docusate Sodium 100 mg PO QHS constipation
13. Erythromycin 0.5% Ophth Oint 1 cm BOTH EYES Q4-6H as needed
14. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
RX *fluticasone [Flovent HFA] 220 mcg 2 puffs INH twice a day
Disp #*1 Inhaler Refills:*5
15. Fluconazole 150 mg PO ONCE repeat if symptoms persist after
complete 10 days Duration: 1 Dose
RX *fluconazole 150 mg 1 tablet(s) by mouth Once Disp #*2 Tablet
Refills:*1
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Loratadine 10 mg PO 30 MINUTES BEFORE BEDTIME PRN nasal
congestion
18. Mucinex (guaiFENesin) 600 mg oral as needed
19. Multivitamins 1 TAB PO DAILY
20. nystatin 100,000 unit/gram topical apply under arms BID PRN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heat stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with fever and altered mental status. Evaluate
for acute cardiopulmonary process.
TECHNIQUE: Portable frontal chest x-ray was obtained.
COMPARISON: Multiple prior chest radiographs with direct comparison made to
study from ___.
FINDINGS:
Study is limited due to underpenetration but no overt consolidation is
identified. The cardiomediastinal silhouette is unchanged. There is no
pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ women with fever, altered mental status, evaluate for
acute intracranial process.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.8 cm; CTDIvol = 53.2 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: No prior head CT. Sinus CT from ___ is available for
correlation.
FINDINGS:
There is mild streak artifact through the posterior fossa and lower cerebrum
due to the patient's body habitus with prominent soft tissues of the neck, as
well as tilted head positioning.
There is no evidence of acute hemorrhage, edema, or mass effect. Gray/white
matter differentiation appears grossly preserved. Ventricles and sulci are
age appropriate.
No osseous abnormalities seen. The included paranasal sinuses are well
aerated. The mastoids are underpneumatized bilaterally with minimal air
cells. Middle ear cavities and bilateral mastoid antra are patent.
IMPRESSION:
Technically limited exam due to body habitus and head positioning, without
evidence for acute intracranial abnormalities.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Fever
Diagnosed with ALTERED MENTAL STATUS , FEVER, UNSPECIFIED
temperature: 105.1
heartrate: 113.0
resprate: 18.0
o2sat: 95.0
sbp: 150.0
dbp: 74.0
level of pain: nan
level of acuity: 2.0 | Ms. ___ is a ___ year old F with PMH of COPD, who presented to
the ED after being found down by EMS, with symptoms mostly
consistent with heat stroke.
# Toxic/metabolic encephalopathy due to hyperthermia and UTI:
# Severe nonexertional hyperthermia:
Most likely heat stroke due to excessive heat in patient's
apartment. Patient's cental A/C unit broken, and portable A/C
unit wasn't working well, with reported temperatures above 100
Degrees F in her home. When she went to have a bowel movement,
she briefly passed out. She was found on the floor by EMS with
AMS and dyspnea. Patient had temperature 105 degrees, pinpoint
pupils, hallucinations, and QRS widened at 154 with terminal R
on admission. Initial concern for TCA overdose given medication
list and Toxicology was consulted, but patient began to self
resolve with supportive care in the ICU and Toxicology did not
feel symptoms were consistent with TCA overdose. With supportive
care she improved to her baseline functional and mental status
with no additional fevers. Her home air conditioning unit was
being repaired while she was in the hospital.
# Concern for urinary tract infection, resolved:
Patient has history of recurrent UTIs. Most recently
pan-sensitive e.coli and klebsiella. Urine culture from this
admission only growing mixed flora, unlikely to be true
infection. Does have leukocytosis, but is relvatively stable
since ___. Held further antibiotics. If she were to have
symptoms of UTI as an outpatient she can be prescribed
antibiotics if appropriate.
# Dyspnea:
Patient has history of COPD and is current smoker, but does not
use home O2. On arrival to the ICU she required ___ satting in
low ___, and was satting in low ___. Her O2 requirement quickly
improved and she remained on room air without issues for the
remainder of the hospitalization. Patient was noted to have
increased HgB levels suggestive that of lower oxygenation at
baseline. She reported not using Flovent at home because she
felt her breathing had been fine recently. She was provided with
a refill of Flovent and encouraged to resume taking it.
# Chronic pain from foot fracture:
Patient takes amitryptiline morphine, oxycontin, oxycodone. No
signs of drug overdose. After confirming her home medications,
they were slowly resumed without complications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Erythromycin Base / Nsaids / azithromycin / ACE
Inhibitors / metoclopramide
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH ESRD on HD with recently thrombosed AV fistula,
recurrant PNAs, HTN, CHF (EF 30%), possible lupus anticoagulant,
retroperitoneal hemorrhage while anticoagulated, hodgkins s/p
chemo and mediastinal radiation in ___ who presents today with
dyspnea on exertion. Pt state Pt had large (650cc with blood) R
sided pl effusion drained at ___ last ___.
Since that time pt having increased SOB, (cannot lie flat,
dyspneic when standing, cannot walk more then 5 feet). Pt has
subjective fevers/chills/dry cough, but has never recorded a
fever. He has never coughed anything up. He presents today to
___ instead ___ because he would like to
"finally figure out why he gets pulmonary effusions."
Of note, patient had L pleural effusion in ___ which required
multiple drainages and eventually a talc pleurodesis. This has
not been a problem for the patient since ___ until this most
recent episode.
In the ED, initial vitals were 98.8 107 134/83 20 100% RA. Pt
recieved 1g ceftriaxone, 1g vancomycin. CXR notable for
bilateral pleural effusions and mild pulmonary edema. He was
seen by his nephrologist to evaluate a left sided fistula graft.
Nephrology dialysis is aware of the patient and
On the floor, patient with stable vital signs, afebrile.
Past Medical History:
1. ESRD. Anuric. Dialysis ___.
2. Hypertension.
3. Hodgkin's disease s/p chemotherapy with ___ (Doxorubicin,
Etoposide, Vinblastine) and radiation.
4. Guillain ___ - reportedly as a result of chemo treatment -
left him with numbness below the waist.
5. Depression with one prior psych hospitalization.
6. H/o suicidal attempt with narcotics overdose.
8. Back pain - right flank pain requiring chronic narcotics (as
per pt). Unknown etiology.
9. Hypothyroidism.
10. Gout.
11. Chronic anemia
12. Neuropathy, worse in right leg.
13. peptic ulcer disease
14. lupus anticoagulant, intermediate anticardiolipin with right
IJ thrombus (___), on warfarin prior to ___ RP hemorrhage
15. systolic heart failure: EF 35%
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father s/p
renal transplant ?hypertensive nephropathy. Mother with
depression and alcohol dependence. Two sons with renal
dysplasia. No history of deafness or cystic kidney disease.
Physical Exam:
ADMISSION PE:
Vitals: 98.3, 146/109, 110, 18, 99 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP elevated 10cm, no LAD
CV: tachy, reg rhythm, normal S1 + S2 appreiable splitting, no
murmurs, rubs, gallops
Lungs: decreased breath sounds at the bilateral bases, no
wheezes, rales, rhonchi, unable to appreciate dullness to
percussion
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, gait deferred.
DISCHARGE PE:
Vitals: 97.4, 119/75, 84, 20, 94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP elevated 10cm, no LAD
CV: tachy, reg rhythm, normal S1 + S2 appreiable splitting, no
murmurs, rubs, gallops
Lungs: decreased breath sounds at the bilateral bases, no
wheezes, rales, rhonchi, unable to appreciate dullness to
percussion
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, gait deferred.
Pertinent Results:
ADMISSION LABS:
___ 12:35PM BLOOD WBC-8.8 RBC-2.78* Hgb-8.4*# Hct-26.8*
MCV-97 MCH-30.3 MCHC-31.3 RDW-14.0 Plt ___
___ 12:35PM BLOOD Neuts-86* Bands-0 Lymphs-9* Monos-4 Eos-0
Baso-1 ___ Myelos-0
___ 12:35PM BLOOD Glucose-77 UreaN-52* Creat-8.4*# Na-132*
K-5.0 Cl-92* HCO3-24 AnGap-21*
___ 12:35PM BLOOD Calcium-8.7 Phos-5.9* Mg-2.3
___ 12:44PM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 07:20AM BLOOD Glucose-117* UreaN-56* Creat-8.7*#
Na-131* K-4.0 Cl-90* HCO3-28 AnGap-17
___ 07:20AM BLOOD Iron-35*
___ 07:20AM BLOOD calTIBC-164* Ferritn-___* TRF-126*
MICRO:
Blood Cultures Pending at discharge
STUDIES/IMAGING:
___ CXR:
PA and lateral views of the chest provided. Implanted device
projects over
the anterior chest wall. Vascular stents in the right axilla
noted. Extensive
calcification in the mediastinum likely corresponds with lymph
nodes. There
are small bilateral pleural effusions with mild pulmonary edema.
The heart is
top-normal in size. The mediastinal contour is unremarkable.
There is no
pneumothorax. The bony structures are intact.
IMPRESSION:
Mild pulmonary edema, small bilateral effusions.
___ TTE:
The left atrium is normal in size. The left ventricular cavity
size is top normal/borderline dilated. There is moderate
regional left ventricular systolic dysfunction with inferior,
inferolateral and basal inferoseptal hypokinesis. The remaining
segments contract normally (LVEF = ___. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, posteriorly-directed jet of mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with moderate reigonal and
global systolic dysfunction, c/w mixed cardiomyopathy. Mild
ischemic mitral regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
CT Chest
FINDINGS:
The thyroid gland is unremarkable. Multiple nonspecific mildly
prominent
mediastinal lymph nodes measure up to 12 mm in short axis (3,
24). Additional
coarsely calcified lymph nodes are scattered throughout the
anterior
mediastinum and AP window. There are no pathologically enlarged
supraclavicular, or axillary lymph nodes.
There is stable mild cardiomegaly with multichamber enlargement
and dense
coronary artery calcification. There is no pericardial effusion
or
calcification. The main pulmonary artery and thoracic aorta are
normal
caliber. Diffuse low attenuation of the blood within the heart
suggests
anemia.
Respiratory motion partially obscures fine detail in the lungs.
There is a
recurrent moderate nonhemorrhagic right pleural effusion. Wisps
of higher
attenuation in the fluid posteriorly may be due to loculating
septae or
pleural thickening. Chronic circumferential left pleural
thickening is
unchanged. There is associated partial right lower lobe passive
and linear
atelectasis. Additional areas of linear atelectasis versus
scarring are noted
bilaterally. There is no endobronchial lesion.
Images of the upper abdomen are unremarkable. Bilateral axillary
vascular
stents and an implanted left anterior chest wall loop recorder
are noted.
There are no lesions in the chest cage worrisome for infection
or malignancy.
Chronic deformity of a left posterior rib is unchanged since at
least ___.
IMPRESSION:
Recurrent moderate nonhemorrhagic right pleural effusion, which
may be further
assessed with ultrasound and pleural sampling for possible
bacterial and
cytologic causes. The effusion results in partial right lower
lobe passive
atelectasis.
Nonspecific mildly prominent mediastinal lymph nodes. Coarsely
calcified,
prevascular mediastinal nodes, most commonly due, in this
location to treated
lymphoma or infection.
Stable cardiomegaly with multichamber enlargement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nephrocaps 1 CAP PO DAILY
2. ClonazePAM 0.5 mg PO QD AT 16:00 anxiety
3. Escitalopram Oxalate 10 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
5. Lactulose 30 mL PO Q8H:PRN constipation
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Metoprolol Succinate XL 25 mg PO HS
8. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
9. TraZODone 100 mg PO HS
10. DiphenhydrAMINE 50 mg PO Q6H:PRN itch
11. Pantoprazole 40 mg PO Q24H
12. Benzonatate 100 mg PO TID
13. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm
Discharge Medications:
1. Benzonatate 100 mg PO TID
2. ClonazePAM 0.5 mg PO QD AT 16:00 anxiety
3. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm
4. DiphenhydrAMINE 50 mg PO Q6H:PRN itch
5. Escitalopram Oxalate 10 mg PO DAILY
6. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO HS
9. Nephrocaps 1 CAP PO DAILY
10. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
11. Pantoprazole 40 mg PO Q24H
12. TraZODone 100 mg PO HS
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
14. Lactulose 30 mL PO Q8H:PRN constipation
15. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Pleural Effusion of Unknown Origin
- Congetive Heart Failure
- End Stage Renal Disease
Secondary Diagnosis:
- Chronic Pain
- Depression
- Hypothyroid
- Peptic Ulcer Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with pmh pleural effusion p/w sob // eval effusion
COMPARISON: Prior exam dated ___.
FINDINGS:
PA and lateral views of the chest provided. Implanted device projects over
the anterior chest wall. Vascular stents in the right axilla noted. Extensive
calcification in the mediastinum likely corresponds with lymph nodes. There
are small bilateral pleural effusions with mild pulmonary edema. The heart is
top-normal in size. The mediastinal contour is unremarkable. There is no
pneumothorax. The bony structures are intact.
IMPRESSION:
Mild pulmonary edema, small bilateral effusions.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with history of end-stage renal disease and right
internal jugular vein thrombosis presenting with shortness of breath, dyspnea
on exertion and recurrent pleural effusion. Evaluate for primary lung
pathology as no rCHF on TTE.
TECHNIQUE: Non-contrast chest CT was performed acquiring sequential axial
images from the thoracic inlet through the adrenal glands. Thin section axial,
coronal, sagittal and axial MIP's were also obtained.
DOSE: 454.0 mGy
COMPARISON: Outside CT scan dated all ___.
FINDINGS:
The thyroid gland is unremarkable. Multiple nonspecific mildly prominent
mediastinal lymph nodes measure up to 12 mm in short axis (3, 24). Additional
coarsely calcified lymph nodes are scattered throughout the anterior
mediastinum and AP window. There are no pathologically enlarged
supraclavicular, or axillary lymph nodes.
There is stable mild cardiomegaly with multichamber enlargement and dense
coronary artery calcification. There is no pericardial effusion or
calcification. The main pulmonary artery and thoracic aorta are normal
caliber. Diffuse low attenuation of the blood within the heart suggests
anemia.
Respiratory motion partially obscures fine detail in the lungs. There is a
recurrent moderate nonhemorrhagic right pleural effusion. Wisps of higher
attenuation in the fluid posteriorly may be due to loculating septae or
pleural thickening. Chronic circumferential left pleural thickening is
unchanged. There is associated partial right lower lobe passive and linear
atelectasis. Additional areas of linear atelectasis versus scarring are noted
bilaterally. There is no endobronchial lesion.
Images of the upper abdomen are unremarkable. Bilateral axillary vascular
stents and an implanted left anterior chest wall loop recorder are noted.
There are no lesions in the chest cage worrisome for infection or malignancy.
Chronic deformity of a left posterior rib is unchanged since at least ___.
IMPRESSION:
Recurrent moderate nonhemorrhagic right pleural effusion, which may be further
assessed with ultrasound and pleural sampling for possible bacterial and
cytologic causes. The effusion results in partial right lower lobe passive
atelectasis.
Nonspecific mildly prominent mediastinal lymph nodes. Coarsely calcified,
prevascular mediastinal nodes, most commonly due, in this location to treated
lymphoma or infection.
Stable cardiomegaly with multichamber enlargement.
Anemia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with PLEURAL EFFUSION NOS, SHORTNESS OF BREATH, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS
temperature: 98.8
heartrate: 107.0
resprate: 20.0
o2sat: 100.0
sbp: 134.0
dbp: 83.0
level of pain: 8
level of acuity: 2.0 | ASSESSMENT AND PLAN: ___ with hx of End Stage Renal Disease on
hemodialysis, recurrant pneumonias, hypertension, CHF (EF 30%)
who presents with dyspnea on exertion and dry cough x 1 week
with recent thoracentesis of R pleural effusion at ___
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo female with a history of non small cell lung cancer who is
admitted with pneumonia. The patient states starting last night
she has been having fevers up to 103 and chills. She also has
had
an increased cough. She denies any nausea, vomiting, shortness
of
breath, sore throat, diarrhea, dysuria, or rashes. Of note she
last received chemotherapy yesterday with carboplatin and
premetrexed.
In the ED she was found to be febrile to 103.5 and hypotensive
to
95/61. A chest x-ray showed a new pneumonia. She was started on
cefepime and vanc. She was also given IV Fluids and
hydrocortisone as well as Tylenol, ibuprofen, and omeprazole.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- Stage IV non-small-cell lung cancer, adenocarcinoma of the
lung (EGFR wild-type, ALK FISH negative, ROS1 FISH negative,
KRAS
G12C mutation and PD-L1 IHC 22C3 TPS 90%).
1. Status post 2 cycle/doses of pembrolizumab 200 mg on ___
and ___
2. Status post 3 cycles of carboplatin and pemetrexed on
___ and ___.
PAST MEDICAL HISTORY:
- h/o mycosis fungoides (___)
- hypertension
- irritable bowel syndrome
- diverticulosis
- hyperlipidemia
- osteoarthritis
Social History:
___
Family History:
Father: colon cancer, heart disease
Paternal grandmother: esophageal cancer
Mother: ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: T 96 BP 114/69 HR 68 RR 20 O2 97%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: Decreased breath sounds diffusely.
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
DISCHARGE PHYSICAL EXAM:
VITALS: 97.8PO 106 / 60 70 118
GENERAL: pleasant, appears younger than stated age, in NAD
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: Decreased breath sounds diffusely.
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.:
Pertinent Results:
LABORATORY ANALYSIS:
WBC: 10.1*. RBC: 3.76*. HGB: 10.7*. HCT: 32.4*. MCV: 86. RDW:
22.1*. Plt Count: 470*.
Neuts%: 92.0*. Lymphs: 2.9*. MONOS: 2.8*. Eos: 1.4. BASOS: 0.2.
Na: 131*. K: 3.8. Cl: 95*. CO2: 21*. BUN: 21*. Creat: 0.8. Ca:
8.7. Mg: 1.5*. PO4: 2.9.
Alb: 3.3*. AST: 76* (Slightly Hemolyzed specimen; Hemolysis
falsely elevates this test). ALT: 86*. Alk Phos: 222*. Total
Bili: 0.6. Alb: 3.3*.
IMAGING:
Chest X-ray:
1. New patchy ill-defined opacity within the lateral right mid
lung field which may reflect an area of pneumonia.
2. Persistent patchy lateral opacity in the right lung base
which
could reflect an area of rounded atelectasis, better assessed on
the previous CT.
3. Increased opacification in the left lung base could reflect
worsening atelectasis, but infection in this area is also not
excluded.
4. Similar appearance of laterally loculated moderate left
pleural effusion and trace right pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
2. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
3. FoLIC Acid 1 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. PredniSONE 10 mg PO DAILY
7. Prochlorperazine 10 mg PO Q12H:PRN Nausea
8. LORazepam 0.5 mg PO Q12H:PRN Nausea, Anxiety
9. Ondansetron 8 mg PO Q8H:PRN Nausea
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*4
Tablet Refills:*0
2. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
3. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
4. FoLIC Acid 1 mg PO DAILY
5. LORazepam 0.5 mg PO Q12H:PRN Nausea, Anxiety
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea
8. PredniSONE 10 mg PO DAILY
9. Prochlorperazine 10 mg PO Q12H:PRN Nausea
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Community Acquired Pneumonia
Non-small cell lung cancer
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// pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Cardiac silhouette size appears mildly enlarged but unchanged. Mediastinal
and hilar contours are similar. The pulmonary vasculature is not engorged. A
moderate pleural effusion on the left demonstrates some loculation laterally,
as seen previously, not substantially changed in the interval. Trace right
pleural effusion is also unchanged. Patchy left basilar opacity may reflect
atelectasis, slightly worse in the interval. There is a persistent patchy
right basilar lateral opacity, unchanged, as seen on the previous CT, possibly
an area of rounded atelectasis. New patchy ill-defined opacities however seen
within the right lateral midlung field, which may reflect infection. No
pneumothorax is identified. There are no acute osseous abnormalities.
IMPRESSION:
1. New patchy ill-defined opacity within the lateral right mid lung field
which may reflect an area of pneumonia.
2. Persistent patchy lateral opacity in the right lung base which could
reflect an area of rounded atelectasis, better assessed on the previous CT.
3. Increased opacification in the left lung base could reflect worsening
atelectasis, but infection in this area is also not excluded.
4. Similar appearance of laterally loculated moderate left pleural effusion
and trace right pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Pneumonia, unspecified organism
temperature: 103.5
heartrate: 115.0
resprate: 14.0
o2sat: 98.0
sbp: 102.0
dbp: 43.0
level of pain: 0
level of acuity: 2.0 | ___ yo female with a history of non small cell lung cancer who is
admitted for fevers.
# FEVER
# ?COMMUNITY ACQUIRED PNEMONIA
Pt presented with fever to 103 in the ED after getting
chemotherapy with cisplatin/pemetrexed 1 day PTA. CXR showing
new patchy ill-defined opacity in the later R mid-lung field
possibly reflecting area of pna. Pt otherwise denied symptosm
of cough or sputum production. CBC at baseline with no
neutropenia. However, given her NSCLC and possible degree of
immunosuppression from chemo/steroids, pt was treated with
Cefepime/azithro->levaquin for completion of 5-day course for
CAP. She was afebrile and HDS with BP's in the low 100's
systolic, and no symptoms of orthostasis on discharge.
# NON-SMALL CELL LUNG CANCER
Pt received C3 carboplatin and pemetrexed on ___. Pt's
Oncologist Dr. ___ and he said Dr. ___ will follow-up
with pt next week (she has f/u apt scheduled on ___.
Continued home folic acid, Ativan, omeprazole, Zofran,
Compazine, and vitamin D. Mild tranaminitis, possibly due to
chemotherapy, ongoing, continue to monitor.
#PE: diagnosed in ___ Continue lovenox.
#HX of PERICARDITIS/PERICARDIAL EFFUSION: d/x in ___.
Continued home prednisone 10mg. Pt also got stress-dose
hydrocort in the ED for soft BP's but this was not continued as
pt otherwise appeared well and BP's remained stable in the high
90's-low 100's range. |
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 s/p explant of necrotic pancreatic allograft with
vascular repair
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, washout
___: PICC line placement
___: Opening of abdominal incision
History of Present Illness:
___ POD 11 exploratory laparotomy pancreatic allograft
explant and simple arterial repair now with 48 hours of
persistent abdominal pain associated with nausea, small volume
clear emesis leading to ED presentation with hypotension,
peritonitis, leukocytosis, KUB with sliver of free air under
left
hemidiaphragm, and non-contrast CT with free air and free fluid
___ the mid abdomen.
Pt reports crampy abdominal pain starting ___ days prior with an
uneventful clinic visit ___ (documentation unavailable at time
of consultation) progressing to ___ pain with ambulation and
rising from a supine position. Denies fevers or chills. No
abdominal distention. Maintaining flatus and
nonbloody/melenotic
stool, last just prior to presentation. Pt reports pain on ride
from ___ worse with any bumps.
Pertinent history, cadaveric pancreas transplant with enteric
drainage for DM1 (___), LDRT (___) recently with LGIB,
necrotic
allograft with suppurative vascular injury requiring exploratory
laparotomy, pancreatic autograft explant and debridement with 2
layer repair of native enterotomy from anastomotic takedown as
well as primary repair of left common iliac suppurative
arteriotomy. Uncomplicated post-operative course with exception
of urinary retention. Seen ___ clinic 2 days prior to
presentation
with symptoms consistent with constipation.
At time of consultation, patient ___ no acute distress, afebrile
but hypotension responsive to fluids, generalized peritonitis
with WBC 14.2, Hct 30, Cr 3.9, KUB with free air, ncCTAP with
free air and fluid ___ mid-abdomen. Vancomycin/Zosyn
administered.
Operative intervention offered and risks/benefits/complications
discussed ___ depth with patient and family. Consent signed ___
Emergency Department. Plan for emergent exploration.
Past Medical History:
S/P sequential living kidney(brother) and cadaveric pancreas
Transplant ___ ___ end organ dz from DM
___ s/p pancreatic transplant
Gastroparesis
Hypercholesterolemia
HTN
Osteopenia
.
___: Exploratory laparotomy, transplant pancreatectomy
and repair of iliac artery.
Social History:
___
Family History:
Father died at age ___ of acute MI. Mother is alive with hx of
breast cancer. He has one brother with diabetes who had a
pancreatic transplant, and one brother and one sister who are
both healthy.
Physical Exam:
VS: T 97.6, HR 86, BP 88/46, RR 16, SaO2 94ra%
GEN: NAD, A/Ox3
HEENT: EOMI, MMM
CV: RRR, no M/R/G
PULM: CTAB
BACK: no CVAT
ABD: soft, midline staples intact, minimal drainage from
inferior
aspect of wound, staple line erythema without fluctuance,
warmth, tenderness.
PELVIS: DRE - normal tone, no stool ___ rectal vault, no BRBPR
EXT: WWP, femoral pulses symmetrical 1+ bilaterally, distal
pulses intact
Pertinent Results:
Labs on Admission: ___
WBC-14.2* RBC-3.34* Hgb-10.0* Hct-30.3* MCV-91 MCH-30.0
MCHC-33.1 RDW-15.2 Plt ___ PTT-28.6 ___
Glucose-309* UreaN-49* Creat-3.9*# Na-129* K-4.6 Cl-88* HCO3-22
AnGap-24*
ALT-14 AST-17 AlkPhos-109 TotBili-0.4
Lipase-8
Albumin-1.7* Calcium-7.0* Phos-6.1*# Mg-1.5*
.
___ 6:00 am PERITONEAL FLUID (Taken ___ OR)
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ SHORT CHAINS AND SINGLY.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___) ON
___ AT
08:48 AM.
FLUID CULTURE (Final ___:
MIXED BACTERIAL FLORA.
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..
ENTEROCOCCUS SP.. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
VIRIDANS STREPTOCOCCI.
MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 4 R
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringenes, and C.septicum.
None of
these species was found.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 2 mg PO Q12H
2. Mycophenolate Sodium ___ 720 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using NPH Insulin
5. PredniSONE 5 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Carvedilol 6.25 mg PO BID
8. NexIUM (esomeprazole magnesium) 40 mg oral Daily
9. Furosemide 20 mg PO 3X/WEEK (___)
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
11. Pravastatin 10 mg PO QPM
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Calcium Carbonate 500 mg PO DAILY
15. Docusate Sodium 100 mg PO BID
16. Vitamin D 400 UNIT PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Senna 8.6 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 6.25 mg PO BID
3. PredniSONE 5 mg PO DAILY
4. Ampicillin-Sulbactam 3 g IV Q6H
End date ___
RX *ampicillin-sulbactam 3 gram 3 grams IV every 6 hours Disp
#*20 Vial Refills:*0
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
Take separately from immunosuppressants
7. Mycophenolate Sodium ___ 720 mg PO BID
Please continue to hold until advised to restart with the
transplant clinic
8. Vitamin D 400 UNIT PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Pravastatin 10 mg PO QPM
11. Glargine 10 Units Breakfast
Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth every night Disp #*20
Tablet Refills:*0
13. Vancomycin Oral Liquid ___ mg PO Q6H
continue until ___
PO Vanco has been been delivered to ___ 10
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Omeprazole 40 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY
18. Tacrolimus 0.5 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
intra-abdominal abscess
C.diff
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: Abdominal pain, rule out free air
TECHNIQUE: Upright and supine views of the abdomen and pelvis were obtained.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
There is a small amount of intraperitoneal free air below the left
hemidiaphragm. Bowel gas pattern is nonobstructive. There is some enteric
contrast seen within the ascending colon. Surgical clips are noted in the left
lower quadrant. Midline skin staples are present.
IMPRESSION:
Small amount of pneumoperitoneum. Nonobstructive bowel gas pattern.
Radiology Report
INDICATION: ___ with pancreatectomy, worsening abdominal pain and renal
failure, evaluate for abdominal catastrophe
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis was obtained
without the administration of IV contrast . Coronal and sagittal reformatted
images were also generated for review.
DOSE: 978 mGy-cm
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
Evaluation of intra-abdominal soft tissues structures is somewhat limited
without the administration of IV contrast.
LOWER CHEST: There are small bilateral pleural effusions with adjacent
compressive atelectasis. Coronary artery calcifications are noted. There is no
pericardial or pleural effusion.
LIVER: The liver demonstrates homogeneous attenuation. Within the limitations
of this noncontrast enhanced study, no focal liver lesion is identified. The
gallbladder is unremarkable. There is no intrahepatic biliary ductal
dilatation.
PANCREAS: The pancreas is severely atrophic. There is no peripancreatic
stranding.
SPLEEN The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The native kidneys are severely atrophic. There is nonspecific
perinephric stranding. The transplanted kidney is in the right lower quadrant
and appears within expected limits on a noncontrast examination. A 1.4 cm cyst
is noted in the interpolar region of the kidney.
GI TRACT: The stomach is unremarkable. The small bowel is mostly collapsed
and unremarkable. In the mid lower abdomen, there is a fluid collection
measuring approximately 7.9 x 3.4 x 6.2 cm with scattered foci of air
concerning for infected collection. Adjacent to this collection are surgical
staples which may reflect the prior enterotomy site. The colon is mostly
collapsed and unremarkable. The appendix is not visualized but there are no
secondary signs of appendicitis.
VASCULAR: The aorta is normal in caliber without aneurysmal dilatation.
Vessel patency cannot be assessed on this noncontrast enhanced study.
RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph
node enlargement. There is a small amount of perihepatic and perisplenic
fluid. There are multiple foci of free air in the peritoneum, the largest
collection is seen in the left upper quadrant, increased compared to prior
study.
PELVIC CT: There is a 6.3 x 4.0 x 3.8cm collection within the pelvis with
multiple foci of gas concerning for another pocked of infected fluid. The
urinary bladder and distal ureters are unremarkable. No pelvic wall or
inguinal lymph node enlargement is seen. There is no pelvic free fluid.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is
present.
IMPRESSION:
Pneumoperitoneum, increased since prior study, as well as two gas containing
collections in the abdomen and pelvis concerning for infected fluid possibly
from enterotomy breakdown.
NOTIFICATION: Initial findings were reviewed with Dr. ___ from
transplant surgery by ___ at 4:20am in person. Patient was subsequently
taken to the operating room.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with renal and pancreatic transplant s/p R IJ
placement // Right IJ placement Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has received a right
internal jugular vein catheter. The course of the catheter is unremarkable,
the tip of the catheter projects over the right atrium. No complications,
notably no pneumothorax. The patient also has received a nasogastric tube.
The course of the tube is unremarkable.
The lung volumes have decreased, mild fluid overload is present but no overt
pulmonary edema is seen. Moderate atelectasis in the retrocardiac lung
regions. No larger pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with renal transplant // re-evaluate for R IJ
loaction. Pulled back 2cm
COMPARISON: ___, 12:47
IMPRESSION:
As compared to the previous radiograph, the right internal jugular vein
catheter has been pulled back. The tip of the catheter now projects over the
cavoatrial junction. No complications, notably no pneumothorax.
The lung volumes remain low. Unchanged course of the nasogastric tube.
Moderate cardiomegaly with mild pulmonary edema. Retrocardiac atelectasis is
constant.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p ex-lap w pO2 of 55 on room air, 76 on 4L NC.
// pulm edema? pleural effusions? interval change
IMPRESSION:
As compared to the recent radiograph from earlier the same date, there has
been minimal change in the appearance of the chest except for slight worsening
of left retrocardiac opacification, likely representing a combination of
atelectasis and pleural effusion. ,
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man ___ s/p exlap/washout w desats, also pulled NGT
// interval change, gastric distention
COMPARISON: ___
IMPRESSION:
As compared to the previous image, the nasogastric tube has been removed. The
right internal jugular vein catheter is in unchanged position. Unchanged left
retrocardiac atelectasis and minimal left pleural effusion. Unchanged normal
appearance of the right lung. Borderline size of the cardiac silhouette.
Overall low lung volumes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man who just ripped out his R IJ central line. No
external bleeding or subQ hematoma. // bleeding into chest? also just
interval change as still intermittent o2 req
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Heart size and mediastinum are stable but there is interval development of
pulmonary edema associated with bilateral pleural effusion. No pneumothorax is
seen.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with PICC. // Pt had a left ___
___ Contact name: ___: ___ Pt had a left ___
___
IMPRESSION:
The left subclavian PICC line extends to the lower portion of the SVC. The
pulmonary edema has essentially cleared. Small layering pleural effusion with
compressive atelectasis is seen on the left.
NOTIFICATION: ___, a venous access nurse.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: ___ h/o LRRT PAK in ___ c/b failed pancreas p/w enterovascular
fistula s/p exlap debridement now POD11 with free air s/p ex-lap, wash out
with persistent leaukocytosis despite antibiotics and > 500 cc JP drain output
daily. POD 9 from washout // Please assess for areas of abscess.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without
intravenous contrast administration .Coronal and sagittal reformations were
performed and submitted to PACS for review. Oral contrast was administered.
DOSE: DLP: 1046 mGy-cm (abdomen and pelvis).
COMPARISON: CT abdomen and pelvis dated ___.
CTA dated ___.
FINDINGS:
LOWER CHEST: The small left pleural effusion and adjacent compressive
atelectasis have both increased since ___. The left pleural effusion is
now moderate in size and the entire left lower lobe is collapsed. The small
right pleural effusion and adjacent compressive atelectasis are overall stable
since ___. Coronary vascular calcifications are again noted.
Hypoattenuation of the blood pool is again seen and suggests anemia. The heart
is mildly enlarged. There is no pericardial effusion.
ABDOMEN:
Evaluation of the soft tissues and organs is limited without the use of
intravenous contrast.
HEPATOBILIARY: A 1.5 x 0.9-cm hypodensity in the inferior tip of the right
lower lobe (Segment 6) is new since ___ and is likely secondary to
retractor positioning during the interval washout procedure, although an
infection cannot be completely excluded (Series 2, Image 32; Series 601b,
Image 37). Otherwise, the liver demonstrates homogenous attenuation
throughout. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is non-distended and within normal limits, without
stones or gallbladder wall thickening. Perihepatic ascites has minimally
increased since ___. Perisplenic ascites is stable. Fluid in the paracolic
gutters has essentially resolved.
PANCREAS: The pancreas is severely atrophic. There is no peripancreatic
stranding.
SPLEEN: The spleen is normal in size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The native kidneys are severely atrophic with non-specific mild
perinephric stranding bilaterally, unchanged from the prior exam. The
transplanted kidney resides in the right lower quadrant and appears normal in
size without stones or hydronephrosis. Several tiny pockets of air are now
visualized in the transplanted kidney, new since ___ (Series 2, Images 73,
74, and 76), concerning for pyelonephritis in the setting of rising
leukocytosis (although reflux or post-foley etiology are possible as well).
Small, non-dependent bubbles of air are demonstrated in the anterior bladder
lumen, also new since ___ (Series 2, Image 84; Series 601b, Image 21). There
is slight irregularity of the anterior bladder wall with increased adjacent
stranding in the fat without evidence of a clear fat plane, suggesting a
possible vesiculo-cutaneous fistula (Series 2, Image 83; Series 602b, Image
49-50). There is no air in the bladder wall. The cyst in the upper pole of the
transplanted kidney is unchanged (Series 601b, Image 27).
GASTROINTESTINAL: Surgical drains are unchanged in position. Surgical clips
are again seen in the region of the prior enterotomy site. The small bowel is
otherwise unremarkable with normal caliber, wall thickness, and enhancement.
The colon and rectum are unremarkable. The previously described mid-abdominal
fluid collection with pockets of air is improved since ___, smaller in size
and now without air, reflecting likely post-operative changes (Series 2, Image
61).
RETROPERITONEUM: There is no evidence of retroperitoneal or mesenteric
lymphadenopathy.
VASCULAR: The previously described entero-vascular fistula on CT dated ___
cannot be assessed on this non-contrast study. There is no abdominal aortic
aneurysm. Atherosclerosis involving the abdominal aorta, bifurcation, and
iliac branches are re-demonstrated.
PELVIS: The previously described fluid collection with multiple foci of gas in
the pelvis has resolved since ___. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES: There is no suspicious lytic or sclerotic bony lesion.
Moderate anasarca in the visualized sub-cutaneous tissue is stable. Anterior
abdominal wall skin staples are present. Possible vesiculo-cutaneous fistula
that cannot be excluded as described under the Urinary section.
IMPRESSION:
1. New air in the transplant kidney, more concerning for emphysematous
pyelonephritis in the setting of persistent, rising leukocytosis without other
definite cause. Associated non-dependent air in the bladder lumen, also new
since ___. Differential includes recent bladder instrumentation / Foley
placement. Correlate with urine culture.
2. Possible vesiculo-cutaneous fistula, new since ___, which may also
contribute to leukocytosis. Correlate clinically.
3. Increased, now moderate left pleural effusion and compressive atelectasis
since ___. Stable small right pleural effusion with compressive
atelectasis.
4. No evidence of abscess in the abdomen or pelvis on this non-contrast study.
Interval resolution of the possible pelvic fluid collection since ___ and
significant interval improvement of the mid-abdominal fluid collection since
___, likely representing post-operative changes.
5. 1.5-cm hypodensity in the right hepatic lobe is new since ___, likely
from retractor positioning, although infection cannot be excluded.
6. Overall stable or minimally improved ascites as well as moderate anasarca.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ from the referring team on the telephone on ___ at 2:24
___, 2 minutes after discovery of the findings.
The renal and bladder findings were discussed by Dr. ___ with Dr.
___ from the referring team on the telephone on ___ at 4:34
___, 1 minute after discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Weakness, Constipation
Diagnosed with PERFORATION OF INTESTINE, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.6
heartrate: 92.0
resprate: 16.0
o2sat: 94.0
sbp: 88.0
dbp: 46.0
level of pain: 8
level of acuity: 2.0 | ___ y/o male who presents with Abdominal pain s/p explant of
necrotic pancreatic allograft with vascular repair on ___.
Exam demonstrated peritonitis and imaging demonstrated concern
for a small amount of free air with a fair bit of free fluid and
possible pelvic abscess
concerning for an enteric leak. He was taken to the operating
room with Dr ___.
At the time of surgery the midline incision was reopened, and
upon entry to the
abdomen, there was a large amount of purulent ascites that was
foul smelling. There was no evidence of succus or bile tinged
fluid. Fluid was all yellow to cream ___ color and was cloudy.
There was also evidence of inflammatory response to his recent
exploration and infection with a fibrinous rind on much of the
small bowel ___ the pelvis. There was no evidence of bowel
perforation, no leakage or succus upon examination of the bowel.
A JP drain was placed, and the patient was closed primarily.
___ the ED the patient had been hypotensive which was responsive
to fluids. He was still hypotensive ___ the OR, and after the
case was complete, he was kept intubated and transferred to the
ICU on pressors. He did receive a bolus and albumin post op for
continued low BPs. The Pressors were weaned down as the day
progressed.
He was extubated on POD1. The dilaudid was given as
intermittentent IV, however patient did complain of some visual
hallucintations.
He was started on insulin drip for poorly controlled blood
sugars, and was followed by the ___ consult attending. He was
transitioned to long acting and sliding scale insulin when
appropriate.
Culture was sent of the abdominal purulent drainage. The patient
had received Vanco and Zosyn ___ the ED prior to surgery, and
both were continued for 4 days. Fluconazole was added on POD 3,
Zosyn was stopped after 4 days, and after ID consultation,
Unasyn was started with a planned course through ___
___ addition to the Fluconazole.
Blood and urine cultures were collected on several days post op,
but there was no growth on either culture sets. The peritoneal
fluid was finally speciated (Mixed flora reported initially) to
Klebsiella and enterococcus.
On POD 2 the patient was noted to have increasing delirium. The
NG tube and central line placed during OR were both self
discontinued by the patient. Transplant kidney function was
stable, antibitotics were continued for resolving sepsis, and
the patient was taken off of the narcotic pain medications that
had been used post op.
Patient was transferred once more oriented to the regular
surgical floor on POD 2. Mental status was a bit slow to
resolve, but by POD 4, he was oriented, but still anxious and
having occasional visual hallucinations.
He was placed on a hydrocortisone stress dose taper schedule.
Tacro and MMF were initially held for the septic picture. The
tacro was restarted on POD 4, with subsequent daily levels and
Tacro dosing per level. It has been recommended to hold the MMF
until ___, 2 weeks following surgery.
Steroid pulse was expedited, and on POD 7 he will return to home
dose Prednisone of 5 mg daily.
Due to the need for long term antibiotics (plan per ID is
through ___ a PICC line was placed on ___.
Patient was noted to be having multiple loose stools daily. A C
Diff was sent on ___, and found to be positive. He was started
on PO Vanco. Leukocytosis to 25 was noted on ___, (15 the day
prior), unsure if this was a result of the C Diff infection,
repeat CBC on the following day revealed the WBC not really
decreasing. A JP drain cell count was sent, ANC was 141.
After the WBC was still not below 20 by ___, a CT of the
abdomen and pelvis was obtained. There was no evidence of
abscess ___ the abdomen or pelvis on this non-contrast study.
There is interval resolution of the possible pelvic fluid
collection since ___ and significant interval improvement of
the mid-abdominal fluid collection.
The JP drain was removed and site was sutured. He was discharged
home with IV ___ services on ___. Per ID, his course
of antibiotics will be Unasyn until ___, po vanc for C.diff
until ___. He will return to office for an appointment ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Iodine Containing Agents
Classifier / Nickel / Bee Pollens / Shellfish Derived / NSAIDS
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of DMII and
asthma who presented to the ED on ___ with a chief complaint
of chest pain. She awoke on ___ with pleuritic pain in the
left substernum radiating into L arm, shoulder and back. The
pain was responsive to nitro/morphine in the ED, is worse when
she moves her left arm, and is reproducible on exam. She relates
several prior episodes of similar chest pain over the last year.
In the ED, initial vitals were 97.8 93 ___ ra. She
had two negative troponins and an equivocal non-imaging exercise
stress test with non-specific EKG changes (0.5-1 mm sloping
upsloping/horizontal ST segment depression seen in the
inferolateral leads at peak exercise and in early recovery )in
the setting of baseline ST-T abnormalities. Her pain was treated
with morphine 4mg IV x 3.
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for the presence of
worsenign dyspnea on exertion over the last year and worsening
lower extremity edema. Cardiac ROS is notable for the absence of
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
Diabetes well controlled
Asthma
Glaucoma
Hiatal hernia
Charcot foot left
Social History:
___
Family History:
Mother with early CAD died of ischemic CHF at age ___. Father
with CAD at an advanced age. Sister with MIs beginning in late
___. 5 of 11 siblings passed of cardiovascular related
complications.
Physical Exam:
VS: T=97.9.BP=132/77.HR=86.RR=20.O2 sat=100% on RA
GENERAL: well appearing woman, talkative/conversant, pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVD at level of the clavicle
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.
EXTREMITIES: trace edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
Admission:
___ 12:30PM BLOOD WBC-7.8 RBC-3.51* Hgb-9.8* Hct-30.2*
MCV-86 MCH-27.8 MCHC-32.3 RDW-14.0 Plt ___
___ 12:30PM BLOOD Glucose-101* UreaN-20 Creat-0.8 Na-143
K-4.2 Cl-109* HCO3-25 AnGap-13
___ 12:30PM BLOOD cTropnT-<0.01
___ 02:21PM BLOOD D-Dimer-4763*
___ 10:46PM BLOOD cTropnT-<0.01
Discharge:
Pertinent:
CTA of chest:
Unremarkable CT angiogram of the chest without evidence of acute
aortic
syndrome or pulmonary embolism.
ETT:
Probable non-anginal symptoms with non-specific EKG changes
in the setting of baseline ST-T abnormalities. Poor exercise
tolerance.
STRESS MIBI:
EXERCISE RESULTS
RESTING DATA
EKG: SINUS
HEART RATE: 85 BLOOD PRESSURE: 120/60
PROTOCOL MODIFIED ___ - TREADMILL /
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
0 ___ 1.0 8 97 134/60 ___
1 ___ 1.7 10 108 158/50 ___
TOTAL EXERCISE TIME: 5.75 % MAX HRT RATE ACHIEVED: 63
SYMPTOMS: NONE
INTERPRETATION: ___ yo woman with HTN, HL and DM was referred to
evaluate an atypical chest discomfort following a ETT revealing
nonspecific ST segment changes and atypical symptoms. The
patient
completed 5.75 minutes of a modified ___ protocol representing
a poor
exercise tolerance for her age; ~ ___ METS. The patient
requested that
the test be stopped due to lower leg discomfort and low back
pain. Due
to the limited hemodynamic response and orthopedic limitations,
lack of
symptoms and nonspecific ST segment changes noted during
exercise, the
patient was administered 0.4 mg Regadenson IV bolus over 20
seconds. No
chest, back, neck or arm discomforts were reported during
exercise or
during the administration of the Regadenson. Post-infusion,
1-1.5 mm
horizontal/downsloping ST segment depression was noted
inferiorly and in
leads V3-V6. These ST segment changes resolved slowly following
the
administration of 75 mg Aminophylline and were absent by 10
minutes
post-infusion. The rhythm was sinus with no ectopy noted in
exercise or
during the Regadenson infusion. As noted, a limited hemodynamic
response
was noted with exercise.
IMPRESSION: Poor exercise tolerance with test stopped due to
orthopedic
limitation (see above); coverted to pharmacological stress test.
No
anginal symptoms with ischemic ST segment changes. Nuclear
report sent
separately.
RADIOPHARMACEUTICAL DATA:
31.6 mCi Tc-99m Sestamibi Stress ___
HISTORY: ___ year old male with atypical chest pain.
SUMMARY OF EXERCISE DATA FROM THE EXERCISE LAB:
Exercise protocol: Modified ___, converted to Regadenson
Exercise duration: 5.75 min
Reason exercise terminated: lower leg discomfort and low back
pain
Resting heart rate: 85
Resting blood pressure: 120/60
Peak heart rate: 108
Peak blood pressure: 170/64
Percent max predicted HR: 63%
Symptoms during exercise: No anginal symptoms.
ECG findings: 1-1.5 mm horizontal/downsloping ST segment
depression was noted
inferiorly and in leads V3-V6. These ST segment changes resolved
slowly
following the administration of 75 mg Aminophylline and were
absent by 10
minutes post-infusion.
IMAGING METHOD:
Stress perfusion images was obtained with Tc-99m sestamibi.
Tracer was injected 45 minutes prior to obtaining images.
This study was interpreted using the 17-segment myocardial
perfusion model.
Imaging Protocol: gated SPECT
INTERPRETATION:
Left ventricular cavity size is witin normal limits.
Stress perfusion images reveal uniform tracer uptake throughout
the myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 53%.
IMPRESSION: Normal cardiac perfusion scan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 35 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
2. Ferrous Gluconate 325 mg PO DAILY
3. Lisinopril 30 mg PO DAILY
4. Gabapentin 600 mg PO QID
5. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
6. Cetirizine *NF* 10 mg Oral qd
7. Omeprazole 20 mg PO DAILY
8. travoprost *NF* 0.004 % ___ daily
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
10. Azopt *NF* (brinzolamide) 1 % ___ daily
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
12. Tretinoin 0.025% Cream 1 Appl TP QHS
13. Meclizine 25 mg PO Q8H:PRN dizziness
14. Psyllium 1 PKT PO TID:PRN constipatin
15. DiphenhydrAMINE 25 mg PO Q6H:PRN allergic symptoms
16. Probiotic *NF* (lactobacillus rhamnosus GG) 10 billion cell
Oral daily
17. prednisoLONE acetate *NF* 1 % ___ daily
patient may take their own
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Azopt *NF* (brinzolamide) 1 % ___ daily
3. Cetirizine *NF* 10 mg Oral qd
4. Ferrous Gluconate 325 mg PO DAILY
5. Gabapentin 600 mg PO QID
6. Lisinopril 30 mg PO DAILY
7. Psyllium 1 PKT PO TID:PRN constipatin
8. Tretinoin 0.025% Cream 1 Appl TP QHS
9. Glargine 35 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
10. DiphenhydrAMINE 25 mg PO Q6H:PRN allergic symptoms
11. Meclizine 25 mg PO Q8H:PRN dizziness
12. Omeprazole 20 mg PO DAILY
13. prednisoLONE acetate *NF* 1 % ___ daily
14. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
15. Probiotic *NF* (lactobacillus rhamnosus GG) 10 billion cell
Oral daily
16. travoprost *NF* 0.004 % ___ daily
17. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
18. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
19. Nitroglycerin SL 0.3 mg SL PRN chest pain
please call your cardiologist or seek medical attention if you
require this medication
RX *nitroglycerin 0.4 mg 1 tab sublingually daily Disp #*20
Tablet Refills:*0
20. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with chest pain radiating to the arm and back.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: None available.
FINDINGS:
No focal consolidation, pleural effusion or pneumothorax is detected. Heart
and mediastinal contours are within normal limits.
IMPRESSION:
No acute findings.
Radiology Report
TYPE OF THE EXAM: MR angiogram of the chest.
REASON FOR THE EXAM AND MEDICAL HISTORY: ___ lady with chest pain
radiating to back and arm and hypotension, aortic dissection or pulmonary
embolism was queried by the emergency room staff.
PRIOR EXAMINATIONS: CT of the abdomen and pelvis without contrast dated
___.
MR angiogram of the chest was performed secondary to history of prior allergic
contrast reaction from iodine-containing contrast.
TECHNIQUE: Multiplanar, multisequence MRA of the chest was obtained pre- and
post-administration of contrast. 22 mL of intravenous Gadavist was injected
without any complication). Cardiac gating and multiplanar cine images were
obtained for evaluation of the thoracic aorta.
FINDINGS:
There is no abnormal dilation of the aorta or dissection. There is a common
origin of the right brachiocephalic artery and left common carotid artery from
the aortic arch. The left and right subclavian arteries, common carotid
arteries, the proximal internal carotid arteries, and visualized vertebral
arteries demonstrate normal caliber and appearance.
Although this study was not tailored for evaluation of the infra-abdominal
aorta and the mesenteric vessels, the celiac artery, superior mesenteric, and
bilateral renal arteries are well visualized in the post-contrast coronal
images and demonstrate normal caliber without aneurysmal dilatation,
dissection, or significant stenosis.
Evaluation of the pulmonary artery demonstrates patent main pulmonary artery
and branches up to the subsegmental level without evidence of pulmonary
embolus.
Heart is normal in size. There is no pericardial effusion.
There is no evidence of lung consolidation or large nodule. No evidence of
axillary, supraclavicular, or mediastinal lymphadenopathy. Thyroid gland is
unremarkable in morphology and enhancement pattern. No evidence of focal liver
lesions. The gallbladder and common bile duct are unremarkable. There is no
evidence of abnormal marrow signal in the axial T1 images.
IMPRESSION:
Unremarkable CT angiogram of the chest without evidence of acute aortic
syndrome or pulmonary embolism.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 97.8
heartrate: 93.0
resprate: 16.0
o2sat: 100.0
sbp: 211.0
dbp: 86.0
level of pain: 9
level of acuity: 2.0 | Ms. ___ is a ___ year old man with a history of DM, Asthma,
glaucoma and GERD who presented with chest pain.
# Chest Pain: Her symptoms were atypical and ACS was thought to
be of low likelihood. However, she had several risk factors
making her high risk for coronary artery disease. Her risk
factors included a family history of early CAD and a personal
history of DM. SHe uderwent a ETT non-specific which yielded
non-specific results. Due to a contrast allergy, an imaging
stress test was performed which was negative. During the stress
portion of her MIBI, ST depressions were noted laterally. In
conjunction with her ECG which demonstarted possible LVH, the
changes were thought to be related to LVH with a plan to further
evaluate with an echocardiogram as an outpatient. During
admission she was treated with ASA 325 daily, atorva 80mg, low
dose beta blocker, and ACE. At discharge, her aspirin was
decreased to 81mg, atorva decreased to 80 for lipids not to
goal. Beta-blocker was stopped. She was discharged on her home
lisinopril and given a script for nitro for recurrent chest pain
as this relieved her symptoms.
# Asthma/Allergic Rhinitis: PRN albuterol and antihistamines
were continued.
# DM/Diabetic Neuropahty: Humalog/Glargine and gabapentin were
continued.
# Glaucoma: Azopt, prednisolone, and travatan were continued.
# Acne: Tretinoin was continued.
# GERD: High dose PPI with protonix was given serious dyspepsia
while Ms. ___ was on ASA previously. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough, fever, hypoxia
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
Mr. ___ is a ___ male with a w/PMH of
hypocellular MDS, ___ a MUD PBSCT ___ requiring a second
transplant (now Day 706) from the same donor for graft failure
with a course complicated by cGVHD (gut mainly) on prednisone.
He was admitted for fever, cough, and associated hypoxia found
to
have new GGO and concern of atypical infx. Patient initiated on
levaquin, underwent bronchoscopy on ___, awaiting results. ID
consulted for further recs. Patient also noted for weight loss
and anorexia, will consult nutrition for further recs.
Past Medical History:
PAST ONCOLOGIC HISTORY:
--___ presented to PCP with fatigue and a 30-lb weight
loss over previous ___ years. On exam, he was noted to have
splenomegaly. Labs showed anemia with a Hgb/Hct of 11.1/32.9
and
PLT of 95,000. WBC was 7.1 with 34% neutrophils, 10%
lymphocytes, 5% monocytes, 9% eosinophils, 11% bands, 7%
myelocytes, 17% metamyelocytes, 2% promyelocytes, 1% blasts and
8% nucleated RBCs. Further work up was negative for BCR-ABL in
the peripheral blood. Cytogenetics on the peripheral blood
showed deletion of chromosome 12p. HIV was negative, uric acid
was 5.2.
--___ Bone marrow biopsy showed markedly hypocellular
with mild dyspoeisis but without significant fibrosis. Repeat
bone marrow biopsy was similar. Based on these findings, the
most likely diagnosis was hypoplastic MDS.
--___ underwent myeloablative MUD allo SCT but had graft
failure.
--___ underwent a second transplant with TLI and ATG
conditioning. His hospital course was complicated with
persistent graft failure for which he remained in the hospital
for over four months ___ through ___. White cells
engrafted, but had poor engraftment of platelets and RBCS
requiring ongoing transfusions.
--___ chimerism study reveals 100% donor cells
--___ bmbx shows extremely hypocellular marrow with
extensive fibrosis.
--___ - ___. Still with poor RBC/PLT engraftment,
concern that it is due to ABO mismatch. Underwent plasma
exchange x9 to remove anti-B antibodies.
--___: tacrolimus stopped after being tapered over previous
few months
--___: Diffuse pain and numbness of all extremities started
--___: seen by Dr. ___ in neuro-oncology who noted
decreased vibratory sensation in lower extremities.
--___: admitted for extremity pain. Methylpred
increased from 10mg to 20mg and gabapentin started. Pain
improved.
--___: Noted to have elevated LFTs in clinic -> admitted,
given 40mg IV methylpred for possible GVHD, stopped voriconazole
and gabapentin. LFTs improving.
--___: admitted with recurrent extremity pain
OTHER PAST MEDICAL HISTORY:
-hemorrhoids
-Respiratory bronchiolitis interstitial lung disease
-Gout
Social History:
___
Family History:
He has three children who are healthy. He has three sisters and
two brothers. One sister has heart disease requiring stent
placement. Father had emphysema. Mother with "sugar" problem and
hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD, thin
VITAL SIGNS: 98.2 119/65 100 20 96%RA
HEENT: MMM, no OP lesions or thrush
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: nonlabored, bibasilar crackles no wheeze
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
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 and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE PHYSICAL EXAM:
Tm: 98.3 F HR: 84 BP: 113/60 RR: 18 02sat: 95% RA
I/O: 1000/1000
GEN: Non-toxic appearing, pleasant, conversive. Thin.
Eyes: Anicteric. EOMI. PERRL.
HENT: Normocephalic, atraumatic. MMM. OP with palatal petechiae,
no OP leasions.
Lungs: + cough. Able to complete full sentences without dyspnea.
B/l bases with crackles. No wheezing.
CV: RRR. Normal S1/S2. No murmur or gallops.
GI: NABS. Soft, nd, nt.
Ext: 2+ radial and pedal pulses bilaterally. No ___ edema.
Skin: WWP. No rashes or lesions
Pertinent Results:
___ 06:20AM BLOOD WBC-6.7 RBC-3.07* Hgb-11.0* Hct-31.1*
MCV-101* MCH-35.8* MCHC-35.4 RDW-14.7 RDWSD-53.8* Plt Ct-71*
___ 11:55AM BLOOD WBC-12.3*# RBC-3.56* Hgb-12.7* Hct-35.7*
MCV-100* MCH-35.7* MCHC-35.6 RDW-14.3 RDWSD-52.1* Plt Ct-93*
___ 06:20AM BLOOD Neuts-57.8 ___ Monos-7.5 Eos-0.9*
Baso-0.1 Im ___ AbsNeut-3.88 AbsLymp-2.14 AbsMono-0.50
AbsEos-0.06 AbsBaso-0.01
___ 11:55AM BLOOD Neuts-61.5 ___ Monos-8.8 Eos-1.3
Baso-0.2 Im ___ AbsNeut-7.57*# AbsLymp-3.40 AbsMono-1.09*
AbsEos-0.16 AbsBaso-0.03
___ 06:20AM BLOOD Glucose-92 UreaN-24* Creat-0.9 Na-133
K-3.7 Cl-98 HCO3-26 AnGap-13
___ 11:55AM BLOOD UreaN-23* Creat-1.0 Na-133 K-4.3 Cl-94*
HCO3-24 AnGap-19
___ 06:20AM BLOOD ALT-15 AST-26 LD(LDH)-121 AlkPhos-74
TotBili-0.6
___ 11:55AM BLOOD ALT-18 AST-30 LD(LDH)-212 AlkPhos-90
TotBili-0.9
___ 06:20AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.0 Mg-2.1
___ 11:55AM BLOOD TotProt-6.6 Albumin-4.4 Globuln-2.2
Calcium-9.1 Phos-2.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Dronabinol 2.5 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
5. Lorazepam 0.5 mg PO Q4H:PRN anxiety
6. Pantoprazole 40 mg PO Q24H
7. Pyridoxine 50 mg PO DAILY
8. Ursodiol 300 mg PO BID
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Gabapentin 100 mg PO TID
11. Morphine SR (MS ___ 30 mg PO Q12H
12. PredniSONE 15 mg PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Pentamidine-Inhalation 300 mg IH EVERY 4 WEEKS
15. Fluconazole 400 mg PO Q24H fungal prophylaxis
16. Benzonatate 100 mg PO TID:PRN cough
17. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Benzonatate 100 mg PO TID:PRN cough
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Dronabinol 2.5 mg PO BID
5. Fluconazole 400 mg PO Q24H fungal prophylaxis
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 100 mg PO TID
8. Lorazepam 0.5 mg PO Q4H:PRN anxiety
9. Morphine SR (MS ___ 30 mg PO Q12H
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Pantoprazole 40 mg PO Q24H
12. PredniSONE 15 mg PO DAILY
13. Pyridoxine 50 mg PO DAILY
14. Ursodiol 300 mg PO BID
15. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
16. Pentamidine-Inhalation 300 mg IH EVERY 4 WEEKS (___)
FOR INHALATION ONLY
*Admin/Prep Precautions*
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
MDS
___ MUD allo
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 fever, cough
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: CT chest and chest radiograph ___
FINDINGS:
Cardiac, mediastinal and hilar contours are within normal limits with the
heart size within normal limits. The pulmonary vasculature is not engorged.
Ill-defined nodular and patchy opacities are noted bilaterally, most
pronounced in the lung bases. No pleural effusion or pneumothorax is
identified. No acute osseous abnormalities detected.
IMPRESSION:
Ill-defined nodular and patchy opacities, predominantly in a bibasilar
distribution, concerning for infection.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ man with AML status post alloSCT p/w pnia, still on
___ // evaluate lung parenchyma
TECHNIQUE: Multidetector helical scanning of the chest was reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: Total DLP (Body) = 214 mGy-cm.
COMPARISON: Noncontrast chest CT ___, chest CT ___
FINDINGS:
Visualized portion of the thyroid gland is unremarkable.
Thoracic aortic and dates mi calcifications, but is without aneurysmal
dilation. Main pulmonary artery is normal in caliber. Heart size is normal,
without pericardial effusion. Coronary artery calcifications are again noted.
No evidence of axillary, supraclavicular, and mediastinal or hilar
lymphadenopathy within the limitations of this noncontrast study.
Airways are patent to the subsegmental levels. Mild centrilobular emphysema
is noted predominantly in the lung apices, and unchanged. Again seen are
innumerable ___ opacities predominantly in the lung bases bilaterally.
This appears worse compared to the prior study on ___, particularly in
the right middle lobe (6:272), and is concerning for atypical infection. Of
note, there is a 1.7 x 1.8 cm heterogeneous-appearing, partially ground-glass
opacity in the right lower lobe (6:166) that is new, and likely a component of
underlying infectious process. No large consolidation. No pleural effusions.
No pneumothorax.
Limited images of the upper abdomen demonstrate no gross abnormalities.
Incidental note is made of a 2.0 cm accessory spleen.
Osseous structures are diffusely mottled and sclerotic in appearance, which is
unchanged from at least ___. No acute fractures. Mild to moderate
degenerative changes are noted predominantly in the lower thoracic spine.
IMPRESSION:
1. New 1.7 x 1.8 cm partially-ground-glass right lower lobe opacity in
addition to worsening bibasilar ___ opacities is concerning for
atypical infection superimposed on a background of bronchiolitis.
2. Mild bi-apical centrilobular emphysema.
NOTIFICATION: Preliminary findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 2:27 ___, 1 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with likely atypical infx on levo // evaluate
for improvement while on ABX
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSAGE: TOTAL DLP 218.9mGy-cm
COMPARISON: Chest CT scans since ___ most recently ___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not pathologically enlarged and
there are no soft tissue abnormalities in the chest wall suspicious for
malignancy. This study is not designed for subdiaphragmatic diagnosis but
shows normal size adrenal glands, chronic all hyper attenuation of the liver
and the enlarged spleen.
Sub cm hypodensities in both lobes of the thyroid are too small to warrant
further imaging evaluation. Atherosclerotic calcification is mild in head and
neck vessels, present also in coronaries at least in the left anterior
descending and circumflex branches. Aortic valvular calcification is
moderate, hemodynamically indeterminate. Aorta and central pulmonary arteries
are normal size. There is no pericardial or pleural abnormality.
Mediastinal lymph nodes are not enlarged and hilar contours do not suggest
adenopathy.
The profusion of bronchial wall thickening and bronchiolar nodulation,
primarily in the lower lungs, which worsened considerably between ___
and ___ has subsequently improved slightly. The new region of
irregular and heterogeneous peribronchial infiltration in the superior segment
is unchanged, 4:158- 180, and a second smaller lesion, 4:207, is less
pronounced, and there are no new lung lesions.
Heterogeneous sclerosis and demineralization of the entire chest cage is
unchanged since at least ___ and there are no pathologic fractures.
.
IMPRESSION:
Because the findings of diffuse small bronchial inflammation increased from
___ and have subsequently improved, I doubt this is due to non
infectious bronchiolitis obliterans although there may be a physiologic
component of small airway obstruction. Instead I suspect either blossoming of
a chronic viral infection or non-tuberculous mycobacteria. The right lower
lobe lesion new on ___ could be the same or a different pathogen, but
it has not worsened.
Coronary atherosclerosis. Hemodynamically indeterminate aortic valvular
calcification. Clinical correlation advised.
RECOMMENDATION(S): Clinical assessment of aortic valvular calcification and
coronary atherosclerosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ILI, Fever
Diagnosed with Fever, unspecified
temperature: 100.6
heartrate: 127.0
resprate: 24.0
o2sat: 96.0
sbp: 126.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with a w/PMH of hypocellular
MDS, ___ a MUD PBSCT ___ requiring a second transplant (now
Day 706) from the same donor for graft failure with a course
complicated by cGVHD (gut mainly) on prednisone. He was admitted
for pneumonia with associated hypoxia.
#PNA with hypoxia: The etiology is most likely viral with
superimposed bacterial pneumonia, but could also be a primary
atypical bacterial or fungal agent. Continues with 02 sats
mainly
in the upper ___. Flu PCR and Urine legionella is negative. RVP
PCR is neg. His IgG is > 1700.
-Continue levaquin at this point as the distribution of
infection
on imaging and sxs with preceding rhinorrhea seem more
atypical-completed 7d course prior to discharge
-QTC ___ to monitor while on levaquin/fluconazole
-Chest CT w/o contrast ___ concerning for atypical infection
superimposed on a background of bronchiolitis, repeat consistent
with same however RLL may be atypical vs something else? But
noted with improvement overall
-Bronch ___ AM, result pending, NTD
-Repeat sputum bacterial/fungal cx pending
-Aspergillus Ag; b glucan negative (LDH wnl so less likely to be
PCP; last received pentamidine ___
-Send CMV PCR VL given h/o CMV viremia (last VL in ___ ND)
-continues with tessalon pearles prn
-continues atrovent prn to albuterol for cough
-will need follow up PFTs while inhouse-indeterminated due to
infection currently
-Patient to be d/c home with f/u next ___ or sooner if issues
arise
#Decreased Hb abd plts from baseline since admission: ? due to
infection, query if this is a viral process which can lead to
cytopenias. LDH and bilirubin wnl, unlikely to be hemolysis.
-haptoglobin and retic stable
#Constipation: BM x ___ yesterday, no acute issue. Denies
abdominal
pain/cramping or nausea. Encourage pt to take stool reg as
needed at home.
#cGVHD manifested as weight loss, anorexia, and skin changes
with
recent endoscopy not revealing active GVHD (chronic
inflammation and inactive gastritis). Prednisone was
decreased to 15 mg daily on ___. Of note, has had 5lbs weight
loss since admission. Patient has had some decreased appetite
here and does not like food here, refused nutrition consult.
Encourage pt to have parent bring food in from home
-Continue prednisone 15mg daily
-Continue dronabinol for appetite stimulation
-Continue PPI for GI PPX while on chronic steroids
#Dry Eyes: Initiated artificial tears/ointment to help with dry
eyes + warm compresses. consulted optho for further evaluation,
rec continuing with intervention as noted above.
#MDS ___ 2 transplants, 24 months from his first and 22 months
from his second matched unrelated donor allogeneic stem cell
transplant (same donor for both): D+ 705 from second transplant.
His last PRBC transfusion was on ___ and platelet
transfusion
was on ___. Bone marrow done ___ hypocellular with
fibrosis present Chimerism was 100% donor.
-Chimerism peripheral blood 100% donor
-Previous chimerisms 100%
#H/O Peripheral Neuropathy: continue opoid and gabapentin
#PPX:
-Continue Acyclovir, Fluconazole
-Pentamidine was last given ___.
-Received IV IgG on ___
-Ursodiol
FEN: Regular diet
DVT PROPHYLAXIS: Heparin 5000 units SC BID (hold if plts < 50K)
ACCESS: PIV
CODE STATUS: Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___
Chief Complaint:
Partial Small Bowel Obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ woman with history of multiple
bowel resections and other abdominal surgeries (see ___) with
multiple SBOs who presents with abdominal pain and found with a
recurrent SBO. The patient is unable to provide much history,
however as per resident history and the chart it appears that
the patient was most recently admitted in ___ for a partial
SBO which was managed conservatively.
In the ED her initial vitals were 95.9, 85, 167/79, 20, 98%.
Given she was noted with a significantly elevated lactate, she
underwent CT of the abdomen, IV fluids, IV
ciprofloxacin/metronidazole. The patient apparently refuses a
NGT. The ACS consult team saw her in the ED, and felt again that
conservative management was safer for the patient.
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomiting, - Diarrhea, + Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
Past Medical History:
PMH: ___ disease, HTN, CKD stage II-III, colon Ca T1nO,
Cholelithiasis, ventral hernia, h/o multiple SBO, lumbar spinal
stenosis, OA, depression, gout
PSH: sigmoid colectomy ___, cholecystectomy, ventral hernia
repair x2 (___)
Social History:
___
Family History:
Son - stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 97.9, 120/50, 76, 20, 97%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Markedly Tympanic and distended, + high-pitch BS, - CVAT
EXT: - CCE
NEURO: Awake/Alert, Non-Focal
DISCHARGE EXAM:
Vitals: Tm 98.8 Tc 97.3 BP 119-152/54-80 HR 90-105 RR 20 SpO2
97 RA
I/Os: 1350 | 450 Foley, BMx2
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple
CARDIAC - regular rate & rhythm, normal S1/S2
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - multiple well-healed surgical scars, faint and rare
bowel sounds, soft but moderately distended, mildly tender to
palpation in RLQ, no rebound tenderness to palpation, large
ventral hernia
EXTREMITIES - 1+ edema to knees bilaterally warm,
well-perfused, no cyanosis, clubbing
SKIN - without rash
NEUROLOGIC - A&Ox1 (to self only), CN II-XII grossly normal,
normal sensation. Gait assessment deferred
Pertinent Results:
ADMISSION LABS:
___ 08:00AM PLT COUNT-207
___ 08:00AM NEUTS-83.1* LYMPHS-10.5* MONOS-5.3 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-9.02* AbsLymp-1.14* AbsMono-0.58
AbsEos-0.07 AbsBaso-0.02
___ 08:00AM WBC-10.9*# RBC-4.08# HGB-11.5# HCT-39.3#
MCV-96 MCH-28.2 MCHC-29.3* RDW-19.3* RDWSD-66.9*
___ 08:00AM ALBUMIN-3.9
___ 08:00AM proBNP-344
___ 08:00AM LIPASE-78*
___ 08:00AM ALT(SGPT)-84* AST(SGOT)-154* ALK PHOS-112*
TOT BILI-1.2
___ 08:00AM GLUCOSE-259* UREA N-45* CREAT-1.5* SODIUM-139
POTASSIUM-7.9* CHLORIDE-95* TOTAL CO2-23 ANION GAP-29*
___ 08:20AM LACTATE-5.3* K+-5.6*
___ 08:34AM ___ PO2-31* PCO2-54* PH-7.36 TOTAL
CO2-32* BASE XS-2
___ 09:03AM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 09:03AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.5
LEUK-NEG
PERTINENT LABS:
___ 12:53PM LACTATE-5.8*
___ 04:58PM LACTATE-3.3* K+-4.7
___ 01:12AM BLOOD Lactate-2.9*
___ 05:37AM BLOOD Lactate-2.5*
___ 12:54PM BLOOD Lactate-2.4*
___ 06:10PM BLOOD Lactate-4.0*
___ 01:49AM BLOOD Lactate-3.8*
___ 07:24AM BLOOD Lactate-4.0*
___ 01:22PM BLOOD Lactate-3.9*
___ 01:08AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:29AM BLOOD CK-MB-2 cTropnT-0.01
DISCHARGE LABS:
___ 05:44AM BLOOD WBC-4.1 RBC-2.68* Hgb-7.7* Hct-26.5*
MCV-99* MCH-28.7 MCHC-29.1* RDW-19.3* RDWSD-69.3* Plt ___
___ 05:44AM BLOOD Glucose-123* UreaN-12 Creat-1.0 Na-143
K-4.0 Cl-110* HCO3-22 AnGap-15
___ 05:44AM BLOOD ALT-22 AST-41* AlkPhos-87 TotBili-0.9
___ 05:44AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9
MICRO:
Blood Culture, Routine (Final ___: NO GROWTH
IMAGING:
CHEST (PA & LAT) Study Date of ___ 8:26 AM
IMPRESSION:
No acute cardiopulmonary process. Large hiatal hernia is again
seen.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 8:56 AM
IMPRESSION:
1. Dilated loops of small bowel, measuring up to 4.1 cm, with
small bowel
fecalization concerning for an early or partial small bowel
obstruction.
Transition point is not definitively identified.
2. Multilevel moderate degenerative changes in the spine with
stable chronic deformity of the right hip.
3. Bilateral renal cysts.
4. Large hiatal hernia.
CT CHEST W/O CONTRAST Study Date of ___ 9:35 AM
IMPRESSION:
1. Large hiatal hernia. No evidence of mediastinal mass or
fluid collection.
2. Multiple pulmonary nodules, the largest measuring up to 7 mm
in the right middle lobe.
3. Please refer to same day CT abdomen and pelvis for full
description of
subdiaphragmatic findings.
RECOMMENDATION(S): If patient is low risk, initial follow-up CT
Chest is
recommended as ___ months, then at ___ months if no change
for pulmonary nodules. If patient is high risk, follow-up is
recommended with CT chest CT 3 to six-month, then at ___
months, and 24 months if no change.
ABDOMINAL FILM ___:
1. Limited study due to underpenetration. No evidence of
gross pneumoperitoneum or obstruction.
2. Large hiatal hernia hiatal hernia, nearly 50% of the stomach
is located in the chest on recent CT
DECUBITUS FILM ___:
Limited as the anterior abdomen is incompletely visualized, but
there is no free intraperitoneal air within these limitations.
RIGHT UPPER EXTREMITY ULTRASOUND ___:
Very limited exam due to difficulty with patient cooperation.
No evidence of thrombus in the right internal jugular and right
subclavian veins. The other deep veins could not be assessed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO QHS
3. Docusate Sodium 200 mg PO BID
4. Duloxetine 20 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Lorazepam 1 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Mirtazapine 15 mg PO QHS
10. Omeprazole 40 mg PO DAILY
11. PredniSONE 10 mg PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN Pain
13. Senna 8.6 mg PO BID:PRN constipation
14. Cyanocobalamin 1000 mcg IM/SC 1X/MONTH
15. Ferrous Sulfate 325 mg PO DAILY
16. Lactulose 15 mL PO BID:PRN Constipation
17. Nitroglycerin Patch 0.2 mg/hr TD Q24H
18. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Duloxetine 20 mg PO DAILY
3. Lactulose 15 mL PO BID:PRN Constipation
4. Mirtazapine 15 mg PO QHS
5. Omeprazole 40 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. PredniSONE 10 mg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Allopurinol ___ mg PO DAILY
10. Carbidopa-Levodopa (___) 1 TAB PO QHS
11. Levothyroxine Sodium 150 mcg PO DAILY
12. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
do not take if you are sleepy
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Lorazepam 1 mg PO DAILY:PRN anxiety
please do not take if your are sleepy.
15. Ferrous Sulfate 325 mg PO DAILY
16. Cyanocobalamin 1000 mcg IM/SC 1X/MONTH
17. Furosemide 40 mg PO DAILY
18. Miconazole Powder 2% 1 Appl TP TID:PRN fungal skin infection
RX *miconazole nitrate [Miconazorb AF] 2 % Apply to rash on
inner thigh/under belly three times daily Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# recurrent Partial Small Bowel Obstruction
# Chronic lactic acidemia of unknown etiology
# pulmonary nodules, incidentally noted
secondary:
# ___ disease
# hypertension
# CKD stage II-III
# colon ca s/p sigmoid colectomy ___
# s/p cholecystectomy ___
# s/p ventral hernia repair ___
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 multiple surgeries, frequent obstructions; c/o
abd pain // CXR: eval for consolidation
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiographs from ___,
___
FINDINGS:
Patient is slightly rotated to the right. The heart is moderately enlarged.
The mediastinal contours unchanged since prior exams. A large hiatal hernia
is redemonstrated. Lung volumes remain low. There is moderate compressive
atelectasis. No definite consolidation is noted. No pulmonary edema or
pneumothorax.
IMPRESSION:
No acute cardiopulmonary process. Large hiatal hernia is again seen.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: NO_PO contrast; History: ___ with history of colon carcinoma
status post sigmoid colectomy, history of multiple small bowel obstructions,
ventral hernia repair x2, now with worsening abd painNO_PO contrast // eval
for obstruction
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 50.5 cm; CTDIvol = 19.5 mGy (Body) DLP = 984.1
mGy-cm.
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: The exam is somewhat limited by lack of intravenous contrast.
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas appears atrophic, without evidence of focal lesions or
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a 2.3 x 2.8 cm hypodense lesion in the right lower renal pole and a
2.1 x 1.5 cm hypodense lesion in the left upper renal pole, likely cysts.
There is no evidence of hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: A large hiatal hernia is redemonstrated. There are dilated
loops of small bowel, measuring up to 4.1 cm, with small bowel fecalization,
concerning for an early or partial small bowel obstruction. A transition
point is not definitively identified. There is mesenteric stranding and
edema, particularly in the right anterior mid to lower abdomen. Patient
status post sigmoid colectomy. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Multilevel moderate degenerative changes are seen in the spine. There
is a grade 1 anterolisthesis of the L3-L4 vertebral level. There is mild
retrolisthesis but the T12-L1 vertebral level. A chronic deformity of the
right hip is unchanged since prior exam. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: A large ventral hernia is again noted containing much of the
small and large bowel.
IMPRESSION:
1. Dilated loops of small bowel, measuring up to 4.1 cm, with small bowel
fecalization concerning for an early or partial small bowel obstruction.
Transition point is not definitively identified. Mesenteric stranding/edema
centered on the right.
2. Multilevel moderate degenerative changes in the spine with stable chronic
deformity of the right hip.
3. Large hiatal hernia.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: History: ___ with a/f level above the diaphragm in the L chest
// eval for abscess
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal reformations.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 31.6 cm; CTDIvol = 19.5 mGy (Body) DLP = 617.0
mGy-cm.
Total DLP (Body) = 617 mGy-cm.
COMPARISON: CT chest with contrast from ___
FINDINGS:
The thyroid is normal. Supraclavicular, axillary, mediastinal and hilar lymph
nodes are not enlarged. Calcified subcarinal lymph nodes are incidentally
noted, likely from prior granulomatous infection. Aorta and pulmonary arteries
are normal size. Vascular calcifications are seen along the aortic arch.
Cardiac configuration is normal but has rightward shift due to a large hiatal
hernia, stable compared to multiple prior exams. Coronary calcifications are
noted. There is no mediastinal mass or fluid collection.
A 2 mm and 7 mm pulmonary nodules are seen in the right middle lobe. A 3 mm
nodule is seen in the right lower lobe. Mild dependent atelectasis is noted.
There is no pleural effusion or pneumothorax.
Limited views of the abdomen are remarkable for a large hiatal hernia,
diastasis of the anterior abdominal wall, and cholecystectomy. Please refer
to same day CT abdomen and pelvis for full description of subdiaphragmatic
findings.
Multilevel moderate degenerative changes are seen in the spine. No evidence
of osseous or lytic lesions concerning for malignancy.
IMPRESSION:
1. Large hiatal hernia. No evidence of mediastinal mass or fluid collection.
2. Multiple pulmonary nodules, the largest measuring up to 7 mm in the right
middle lobe.
3. Please refer to same day CT abdomen and pelvis for full description of
subdiaphragmatic findings.
RECOMMENDATION(S): If patient is low risk, initial follow-up CT Chest is
recommended as ___ months, then at ___ months if no change for pulmonary
nodules. If patient is high risk, follow-up is recommended with CT chest CT 3
to six-month, then at ___ months, and 24 months if no change.
Radiology Report
INDICATION: ___ with h/o ventral hernia c/b multiple SBO in ___
requiring repair, prior sigmoid colectomy for colon adenocarcinoma T1n0, HTN,
and CKD who p/w abdominal pain in the setting of a partial SBO, now advancing
diet slowly to soft regular diet and nectar thickened liquids per S+S, and
tolerating well. Worsening pain. Evaluate for perforation or small bowel
obstruction.
TECHNIQUE: Single supine AP abdominal radiograph
COMPARISON: Radiograph from ___ and CT abdomen pelvis from ___.
FINDINGS:
There is study is limited due to underpenetration and technique. Large hiatal
hernia is seen. There are no abnormally dilated loops of small or large bowel
in the abdomen.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structure evaluation is limited.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Limited study due to underpenetration. No evidence of gross
pneumoperitoneum or obstruction.
2. Large hiatal hernia hiatal hernia, nearly 50% of the stomach is located in
the chest on recent CT
Radiology Report
INDICATION: ___ year old woman with elevated lactate in setting of partial
SBO. // free air? Please send portable x-ray.
TECHNIQUE: Left lateral decubitus abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Limited as the anterior abdomen is incompletely visualized. There is no free
intraperitoneal air within these limitations. There are no abnormally dilated
loops of large or small bowel.
IMPRESSION:
Limited as the anterior abdomen is incompletely visualized, but there is no
free intraperitoneal air within these limitations.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman with ___ woman with h/o ventral hernia c/b
multiple SBO requiring repair, prior sigmoid colectomy for CRC, HTN, and CKD
found to have partial SBO on CT scan // ? venous thrombosis in R upper
extremity. Patient's arm has been swollen relative to L.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
Very limited exam due to difficulty with patient cooperation. There is normal
flow with respiratory variation in the right subclavian vein.
The right internal jugular vein is patent, show normal color flow and
compressibility. The right cephalic vein is patent with normal
compressibility and vascular flow. The right axillary, brachial, and basilic
veins are unable to be visualized due to difficulty with patient cooperation.
IMPRESSION:
Very limited exam due to difficulty with patient cooperation. No evidence of
thrombus in the right internal jugular and right subclavian veins. The other
deep veins could not be assessed.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:08 ___, 5 minutes after discovery
of the findings.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified intestinal obstruction
temperature: 95.9
heartrate: 85.0
resprate: 20.0
o2sat: 98.0
sbp: 167.0
dbp: 79.0
level of pain: unable
level of acuity: 2.0 | Ms. ___ is an ___ woman with PMH ___, h/o ventral
hernia c/b multiple SBO requiring repair, prior sigmoid
colectomy for CRC, HTN, and CKD, who presented on ___ w/
worsening abdominal pain and was found to have partial SBO on CT
scan, treated medically. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Penicillins
Attending: ___.
Chief Complaint:
Dyspnea and weight gain
Major Surgical or Invasive Procedure:
___- Right heart catheterization
History of Present Illness:
___ with hx of pulmonary HTN
(unable to tolerate PAH therapy), pulmonary venoocclusive
disease
on slow steroid wean, HFpEF, COPD on ___ NC at baseline, h/o
DVT/PE on warfarin, who is presenting with shortness of breath
and weight gain.
She presents with dyspnea and a 30 pound weight gain since
hospital stay two months ago, despite aggressive home diuresis.
She has had progressive dyspnea on exertion. She also reports
being hypoxic on exertion when checking her O2 sats. She
reports
feeling like her legs are heavy and increasing in size. She has
pain in her upper and lower back that she feels is weight
related. She denies fever, chills, CP, abd pain, nausea,
vomiting, diarrhea, cough worse than baseline.
The pt's ___ called the pt's Pulmonologist Dr. ___
gaining
over 6 lbs in 3 days and confirming that she is now 30 lbs over
discharge weight. Her oxygen has been stable at 5LNC while at
rest. Dr. ___ admission for IV diuresis. She has
been taking 80mg torsemide BID at home, but despite this has
been
continuing to gain weight.
Past Medical History:
1. Atrial fibrillation
2. DVT/PE
3. Sarcoidosis
4. Hypertension
5. Depression
6. Gout
7. hypokalemia
8. fibromyalgia
9. anxiety
10. NSTEMI in ___
Social History:
___
Family History:
No family history of arrhythmia or sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=============================
VS: 98.2, BP 137 / 83, HR 77, RR 18, 95 5L
GENERAL: ___ female sitting up in bed eating
dinner,
NAD, pleasant, obese appearing with possible cushingoid features
HEENT: Normocephalic atraumatic. Oropharynx is clear.
NECK: Her JVP was difficult to appreciate.
CARDIAC: RRR, no murmur heard
LUNGS: Crackles at the bases bilaterally, no significant wheezes
ABDOMEN: Soft, non-tender, non-distended, obese
EXTREMITIES: Warm, well perfused. She has pitting edema of the
thighs and knee area.
SKIN: No significant skin lesions or rashes.
PULSES: radial pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
=============================
24 HR Data (last updated ___ @ 550)
Temp: 98.1 (Tm 98.5), BP: 138/72 (109-144/58-84), HR: 82
(75-94), RR: 20 (___), O2 sat: 92% (92-96), O2 delivery: 5L,
Wt: 292.11 lb/132.5 kg
Dry Weight: 132 kg
GENERAL: ___ female, NAD, pleasant
HEENT: Normocephalic atraumatic.
NECK: Nadir of JVP at level of clavicle
CARDIAC: RRR, no murmur heard
LUNGS: Crackles at the bases bilaterally, no significant wheezes
ABDOMEN: Soft, non-tender, non-distended, obese
EXTREMITIES: Warm, well perfused. No appreciable pitting edema
Pertinent Results:
ADMISSION LABS
=================
___ 10:15AM BLOOD WBC-11.1* RBC-4.70 Hgb-13.1 Hct-41.0
MCV-87 MCH-27.9 MCHC-32.0 RDW-18.6* RDWSD-58.1* Plt ___
___ 10:15AM BLOOD ___ PTT-24.4* ___
___ 10:15AM BLOOD Glucose-109* UreaN-41* Creat-1.4* Na-146
K-4.2 Cl-99 HCO3-33* AnGap-14
___ 06:36AM BLOOD ALT-23 AST-21 AlkPhos-72 TotBili-0.3
___ 10:15AM BLOOD CK-MB-5 proBNP-267*
___ 02:05PM BLOOD cTropnT-0.02*
___ 05:50PM BLOOD ___ pO2-53* pCO2-72* pH-7.38
calTCO2-44* Base XS-13
DISCHARGE LABS
================
___ 12:35PM BLOOD Glucose-142* UreaN-55* Creat-1.7* Na-140
K-4.5 Cl-91* HCO3-33* AnGap-16
___ 12:35PM BLOOD Cholest-234*
___ 12:35PM BLOOD Triglyc-93 HDL-94 CHOL/HD-2.5 LDLcalc-121
IMAGING
=================
___ CT CHEST
IMPRESSION:
1. Unchanged dilatation of the main pulmonary artery up to 42 mm
in keeping
with given history of pulmonary arterial hypertension. A
background of
bilateral upper lobe predominant smooth interlobular septal
thickening appears
slightly improved compared to ___ along with minimal
mosaic
parenchymal attenuation. Please note that these findings are
entirely
nonspecific and can be seen in the setting of mild interstitial
edema, though
these findings have been reported in the setting of pulmonary
___
disease, which would require a biopsy for definitive diagnosis.
2. Unchanged left upper lobe anterior segment bronchial atresia
with
associated air trapping.
3. No suspicious focal consolidation or pulmonary nodularity.
___ CARDIAC CATH
1. Severe pulmonary HTN with normal left-sided filling pressures
and preserved cardiac output/index
___ TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is
moderately dilated with depressed free wall contractility. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Dilated, hypokinetic right
ventricle. At least moderate pulmonary hypertension. Abnormal
septal motion consistent with volume/pressure overload.
Hyperdynamic left ventricular systolic function.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Compared with the prior study (images reviewed) of ___,
the image quality is worse; the overall findings are likely
similar (severe pulmonary artery hypertension seen prevoiusly,
but today's study may have suboptimally assessed).
___ CXR
1. Mild pulmonary vascular congestion and enlargement of the
cardiomediastinal
silhouette suggesting mild volume overload without frank
pulmonary edema. No
focal consolidation.
2. Coarsened interstitial markings and central adenopathy are
likely
attributable to underlying sarcoidosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
2. Allopurinol ___ mg PO DAILY
3. Amitriptyline 25 mg PO QHS
4. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY
5. Gabapentin 600 mg PO TID
6. HydrALAZINE 25 mg PO TID
7. Lisinopril 20 mg PO DAILY
8. PARoxetine 20 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Warfarin 3 mg PO DAILY16
12. Amiodarone 100 mg PO DAILY
13. Calcium Carbonate 500 mg PO TID W/MEALS
14. Ferrous Sulfate 325 mg PO DAILY
15. PredniSONE 20 mg PO DAILY
16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
17. Torsemide 80 mg PO BID
18. Alendronate Sodium 70 mg PO QMON
19. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Warfarin 4 mg PO DAILY16
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Alendronate Sodium 70 mg PO QMON
4. Allopurinol ___ mg PO DAILY
5. Amiodarone 100 mg PO DAILY
6. Amitriptyline 25 mg PO QHS
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate 500 mg PO TID W/MEALS
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY
11. Gabapentin 600 mg PO TID
12. HydrALAZINE 25 mg PO TID
13. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
14. Lisinopril 20 mg PO DAILY
15. PARoxetine 20 mg PO DAILY
16. PredniSONE 20 mg PO DAILY
Please decrease dose to 15mg daily starting ___
RX *prednisone 5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
17. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
18. Tiotropium Bromide 1 CAP IH DAILY
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Severe pulmonary hypertension
Chronic right-sided heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with SOB, evaluate for acute process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs dating back to ___,
most recently ___, and CT of the chest dated ___.
FINDINGS:
There is persistent mild pulmonary vascular congestion and enlargement of the
cardiomediastinal silhouette. There is no pleural effusion, focal
consolidation, or pleural effusion. An implantable cardiac monitoring device
is noted in the subcutaneous tissues of the left anterior chest, unchanged.
Prominent central adenopathy and coarsened interstitial markings are similar
to prior studies and likely attributable to underlying sarcoidosis.
IMPRESSION:
1. Mild pulmonary vascular congestion and enlargement of the cardiomediastinal
silhouette suggesting mild volume overload without frank pulmonary edema. No
focal consolidation.
2. Coarsened interstitial markings and central adenopathy are likely
attributable to underlying sarcoidosis.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with pulmonary hypertension// ?PVOD change
TECHNIQUE: Axial helical multi detector CT images were acquired of the chest
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes as well as axial MIPS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.1 s, 35.1 cm; CTDIvol = 14.5 mGy (Body) DLP = 484.6
mGy-cm.
2) Spiral Acquisition 5.3 s, 20.4 cm; CTDIvol = 14.3 mGy (Body) DLP = 274.6
mGy-cm.
Total DLP (Body) = 770 mGy-cm.
COMPARISON: Noncontrast CT and CTA examinations of the chest dating from ___ through ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The visualized thyroid is
unremarkable. There is no axillary lymphadenopathy. The soft tissues of the
visualized lower neck and chest wall are otherwise grossly unremarkable.
UPPER ABDOMEN: Although this study is not tailored for subdiaphragmatic
analysis, the visualized upper abdomen is grossly unremarkable.
MEDIASTINUM: There is no mediastinal lymphadenopathy.
HILA: There is no gross hilar lymphadenopathy given confines of a noncontrast
examination.
HEART and PERICARDIUM: The heart is borderline in size. There is no
pericardial effusion.
PLEURA: Pleural surfaces are clear without effusion or pneumothorax.
LUNG:
1. PARENCHYMA: Mild diffuse smooth interlobular septal thickening with
bilateral upper lobe predominance appears slightly less prominent than on the
prior examination from ___, and there remains a minimal background
of mosaic parenchymal attenuation. Otherwise there is no focal consolidation
or suspicious focal pulmonary nodularity.
2. AIRWAYS: There is stable bronchial atresia within the left upper lobe of
the anterior segment, with associated air trapping in the anterior segment of
the left upper lobe. The remainder of the central airways are patent.
3. VESSELS: The the thoracic aorta is normal caliber with mild
atherosclerotic calcification. The main pulmonary artery is enlarged
measuring up to 42 mm in maximal diameter, intervally unchanged.
CHEST CAGE: The thoracic cage is intact without acute fracture or suspicious
focal bone lesion. There are mild multilevel degenerative changes of the
thoracic spine.
IMPRESSION:
1. Unchanged dilatation of the main pulmonary artery up to 42 mm in keeping
with given history of pulmonary arterial hypertension. A background of
bilateral upper lobe predominant smooth interlobular septal thickening appears
slightly improved compared to ___ along with minimal mosaic
parenchymal attenuation. Please note that these findings are entirely
nonspecific and can be seen in the setting of mild interstitial edema, though
these findings have been reported in the setting of pulmonary ___
disease, which would require a biopsy for definitive diagnosis.
2. Unchanged left upper lobe anterior segment bronchial atresia with
associated air trapping.
3. No suspicious focal consolidation or pulmonary nodularity.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 97.6
heartrate: 90.0
resprate: 20.0
o2sat: 90.0
sbp: 117.0
dbp: 58.0
level of pain: 4
level of acuity: 2.0 | ___ with hx of pulmonary HTN, pulmonary venoocclusive disease on
prednisone, HFpEF, DVT/PE, COPD on ___ NC at baseline, who
presented with shortness of breath and weight gain of 30 pounds
over 2 months. Initially suspected to be ___ to volume overload
and treated with aggressive diuresis without response. More
consistent with weight gain in the setting of increased intake
during prednisone course. Underwent right heart cath that showed
normal LV filling pressures and CT chest for evaluation of
disease evolution on steroids with mild improvement. Was
discharged home at new dry weight of 132kg.
#CHRONIC RIGHT SIDED HEART FAILURE:
#WEIGHT GAIN
Initially presented with 30 pound weight gain, edema, and
vascular congestion on CXR, despite aggressive torsemide
uptitrating as outpatient. Her low BNP was suspected to be
falsely low due to obesity. Had modest UOP after 80mg IV Lasix
bolus in the ER, with lytes checked that were subsequently
stable. Received aggressive diuresis with Lasix drip +
metolazone with little output and subsequent ___, so diuresis
was held. Underwent right heart cath with PCWP of 13, indicating
euvolemia at a dry weight of 132kg. Ultimately weight gain was
suspected to be in setting of recent course of prednisone for
presumed sarcoid-related PVOD and increased intake. She was
continued on lisinopril 20mg daily and hydralazine 25mg TID,
discharged on torsemide 40mg daily.
# SEVERE PULMONARY HTN,
# ACUTE ON CHRONIC HYPOXIC RESPIRATORY FAILURE:
Multifactorial due to COPD, likely pulmonary venoocclusive
disease, prior DVT/PE. Improved during hospital course and
remained on home ___ O2, though would desat to the ___
without symptoms sporadically. She had a CT chest which showed
Unchanged dilatation of the main pulmonary artery and slightly
improved bilateral upper lobe predominant smooth interlobular
septal thickening compared to ___ along with minimal
mosaic parenchymal attenuation. She was continued on her home
regimen of Advair BID, Prednisone 20mg, Tiotropium, Bactrim for
PJP ppx, calcium, vitamin D. Dr. ___ was involved in her care
throughout her hospital course. Prednisone to decrease to 15mg
daily ___
# ATRIAL FIBRILLATION:
Remained on home amiodarone and warfarin which was increased to
4mg daily for subtherapeutic INR
# IRON DEFICIENCY:
Continue home iron
# GOUT:
Continued home allopurinol
# FIBROMYALGIA:
Continue home amitriptyline, gabapentin, paroxetine, and
hydrocodone-acetaminophen
TRANSITIONAL ISSUES
=====================
- Dry weight- 132kg.
- Discharged on torsemide 40mg daily
- Cr 1.7 at discharge
- Warfarin increased to 4mg daily given subtherapeutic INR
- Please check INR & BMP ___ and fax results to Dr. ___
___ ___ INR, 1.3 ___, creatinine 1.7.
- Will need to decrease prednisone to 15mg daily starting ___
- Ambulatory O2 saturation at discharge 80-85% on 5L NC
- Please continue dietary counseling regarding intake
particularly while on steroids
- Lipid panel pending at discharge. Please follow-up and
consider whether statin therapy indicated |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Oxycodone
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization x 3
History of Present Illness:
This is an ___ M with CAD s/p CABG,
diastolic Heart failure, PAD, CKD with Unstable angina (negative
trop x 3) who is transferred from ___ for consideration of
cardiac cath given positive stress test.
On ___, he experienced SSCP with exertion (using his
walker) which lasted ___ minutes and remitted with NTG, however
it returned 15 minutes later, again lasted several minutes and
remitted with NTG. There was no diaphoresis, nausea, radiation
to jaw or arm. He was concerned about his symptoms and thus went
to ___ for evaluation.
At ___, is trop was 0.02 -> 0.02 -> 0.02. He underwent a nuclear
regedenason stress test which showed no anginal symptoms but
demonstrated reduced tracer uptake in the inferolateral and
apical region. Calculated LVEF was 36%.
Currently, he reports feeling well. The history is obtained from
him and his daughter who is present at bedside. We discussed is
current status and the potential need for intervention. The
patient and his daughter indicated that he would not want
cardiac surgery, but that he would be okay with PCI. We also
discussed his code status, and he indicated "I have lived a good
life, let me go if it is my time." He also indicated that he
would be willing to reverse his code status for a procedure with
the goal of relieving his symptoms.
He reports not being particularly functional at home, and does
not generally walk outside. He uses a walker at home, but does
not generally get pain/dyspnea with exertion except for today.
When he needs to go to appointments, he has to go by ambulance
from him. His daughter takes care of him at home ~24 hours
except when she is at work.
Past Medical History:
- Coronary artery disease
* s/p CABG in ___ at ___ (___ LIMA to LAD, SVG to OM, Ramus)
- HFnEF
- Peripheral artery disease
* s/p L external iliac artery stent in ___ for infected left
fourth toe ulcer
* ___, left hallux amputation with good healing.
* R carotid bruit
- Hypertension
- Hyperlipidemia
- Chronic kidney disease (baseline cr 1.9)
- Prostate CA s/p chemo/XRT
- Gout
Social History:
___
Family History:
- Sister had CAD
- Brother died suddenly ?MI
Physical Exam:
ADMISSION:
=============
Vitals: T 97.7 BP 147/71 HR 59 RR 18 SaO2 98% on RA
GENERAL: Limited ___ speaking, but comfortable, appropriate
HEENT: EOMI, MMM
CARDIAC: RRR, no m/r/g
LUNG: CTAB
ABDOMEN: Soft, nontender
EXTREMITIES: Chronic venous stasis changes. 1+ pulses in DPs, 1+
in bilat femoral arteries. Missing left hallux.
NEURO: A&Ox3. Moving all four extremities. Follows commands.
DISCHARGE:
==============
Vitals: 97.7 62 (60-70s) 153/70 (130-150/50-70s) 18 97% RA
GENERAL: Limited ___ speaking, laying comfortably in bed
HEENT: sclera anicteric MMM
CARDIAC: RRR, no m/r/g
LUNG: CTAB anteriorly. no w/r/r
ABDOMEN: Soft, nontender, somewhat distended, NT, no
rebound/guarding
EXTREMITIES: distal pulses doplerable
NEURO: alert and conversant. Moving all four extremities.
Follows commands.
Pertinent Results:
ADMISSION:
=============
___ 10:32PM ___ PTT-29.6 ___
___ 10:32PM PLT COUNT-137*
___ 10:32PM WBC-7.0 RBC-3.81* HGB-11.6* HCT-33.4* MCV-88
MCH-30.6 MCHC-34.9 RDW-14.6
___ 10:32PM CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-2.1
___ 10:32PM GLUCOSE-99 UREA N-32* CREAT-1.8* SODIUM-139
POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-20* ANION GAP-17
DISCHARGE:
=============
___ 12:45PM BLOOD WBC-7.4 RBC-3.45* Hgb-10.5* Hct-31.4*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.9 Plt ___
___ 04:00AM BLOOD ___ PTT-31.8 ___
___ 12:45PM BLOOD Glucose-106* UreaN-24* Creat-2.0* Na-136
K-5.2* Cl-102 HCO3-22 AnGap-17
___ 04:00AM BLOOD CK-MB-10 MB Indx-5.8
___ 12:45PM BLOOD Calcium-8.7 Phos-2.6* Mg-2.7*
CARDIAC ENZYMES:
==================
___ 01:16AM BLOOD CK-MB-25* cTropnT-0.23*
___ 07:00AM BLOOD CK-MB-96* cTropnT-1.08*
___ 07:10PM BLOOD CK-MB-82* cTropnT-1.93*
___ 07:07AM BLOOD CK-MB-38* cTropnT-2.22*
___ 03:40PM BLOOD CK-MB-9 cTropnT-2.61*
___ 04:00AM BLOOD CK-MB-10 MB Indx-5.8
STUDIES/IMAGING:
==================
CARDIAC CATH ___
Findings
ESTIMATED blood loss: <60 cc
Hemodynamics (see above): Stage II hypertension (SBP as high as
205 mmHg). Mildly elevated left-sided filling pressure (LVEDP 14
mmHg).
Coronary angiography: right dominant
LMCA: Stump occluded.
LAD: Smaller vessel with 70% focal beyond the LIMA touchdown.
LCX: Occluded.
RCA: Diffusely diseased throughout with mild luminal
irregularities and distal segment with 80% distal segment.
The RPDA has 70% focal at mid segment.
SVG-RI: Diffusely diseased mid segment with hazy focal 80%.
This graft feeds a relatively large size lower pole of the
RI. It also retrogradely feeds the upper pole of the RI and
a second OM.
SVG-OM: Sequential lesions with 60% proximal, 80% mid and 90%
distal. This graft feeds the OM (?4) and retrogradely the
OM3 and the AV groove LCX.
LIMA-LAD: Patent, tortuous.
Other: Markedly tortuous L SC and relatively unfolded aorta
making the diagnostic procedure very difficult. We had to
switch to R CFA access for the intervention.
Assessment & Recommendations
1. Severe three vessel (native) disease.
2. Severe graft disease.
3. Successful stenting of the SVG-OM and placement of three
non-overlapping stents as described above.
4. ASA 81 mg daily indefinitely.
5. Clopidogrel 75 mg daily x12 months minimum.
6. Return to cath lab ___ (renal function permitting) to
treat the SVG-RI and distal RCA.
7. Post discharge -P-MIBI to assess the native LAD lesion
(distal to LIMA touchdown), if clinically indicated.
8. Best Med Rx (with antihypertensives for goal BP <150/90 mmHg
and potent statin.
CARDIAC CATH ___
Assessment & Recommendations
1. Severe three vessel (native) disease.
2. Severe graft disease.
3. Successful stenting of the SVG-OM and placement of three
non-overlapping stents as described above.
4. ASA 81 mg daily indefinitely.
5. Clopidogrel 75 mg daily x12 months minimum.
6. Return to cath lab ___ (renal function permitting) to
treat the SVG-RI and distal RCA.
7. Post discharge -P-MIBI to assess the native LAD lesion
(distal to LIMA touchdown), if clinically indicated.
8. Best Med Rx (with antihypertensives for goal BP <150/90 mmHg
and potent statin.
CARDIAC CATH ___
Hemodynamics (see above): Stage II hypertension. SBP as high as
190 mmHg.
Coronary angiography: right dominant
LMCA: Not engaged.
LAD: Not engaged.
LCX: Not engaged.
RCA: Mid RPDA with tubular lesion tapers to 90%. Distal RCA
with long 70%, tapers to 80% distally.
SVG-RI: proximal 40% focal. Mid graft with tubular 80%. The
rest of the RCA has mild-to-moderate (___) diffuse
luminal irregularities including 30% ostial (normal
pressure tracing throughout).
SVG-OM: Not engaged.
LIMA-LAD: Not engaged.
1- Successful staged PCI of the RPDA and distal RCA and
deployment of drug-eluting stents.
2- Successful staged PCI to the SVG-RI and deployment of a
drug-eluting stent.
3- Successful deployment of ___ AngioSeal to the L CFA access
4- Dual antiplatelet therapy (ASA 81 mg daily and Clopidogrel
75 mg daily) for minimum of 12 months then ASA indefinitely.
5- Global CV risk reduction strategies.
6- Patient will need follow up evaluation R CFA disease noted
on cath. Consider referral to vascular medicine clinic with
R DEI-CFA arterial duplex.
7- Follow up with Dr. ___ cardiologist.
ULTRASOUND ___
IMPRESSION: Essentially normal examination without evidence of
pseudoaneurysm or hematoma. However, apparent bidirectional
flow in the right common femoral artery is noted and while of
unclear clinical significance may be followed up with repeat
ultrasound if patient continues to have symptoms.
EKG ___
Sinus rhythm. Compared to the previous tracing of earlier this
date there has been improvement in the anterior ST segment
abnormality and resolution of the anterolateral ST segment
elevation.
EKG ___
Baseline artifact. Sinus arrhythmia. Predominantly lateral ST-T
wave
abnormalities. Since the previous tracing of ___ the rate is
faster.
QRS voltage is less prominent in the limb leads and more
prominent in the
lateral precordial leads. Clinical correlation is suggested
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Febuxostat 80 mg PO DAILY
5. PredniSONE 5 mg PO DAILY Gout
6. Losartan Potassium 100 mg PO DAILY HTN
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q6H:PRN pain
10. Docusate Sodium 100 mg PO BID
11. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
constipation
12. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Febuxostat 80 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY HTN
RX *losartan 100 mg 1 tablet(s) by mouth dailt Disp #*14 Tablet
Refills:*0
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. PredniSONE 5 mg PO DAILY Gout
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
12. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q24H Disp #*14
Tablet Refills:*0
13. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*14
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Unstable anginga
CAD
SECONDARY DIAGNOSIS:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Status post catheterization with right femoral access and audible
bruit on post-cath check. Evaluate for pseudoaneurysm.
COMPARISON: None.
TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound evaluation of
the right groin.
FINDINGS: The right common femoral vein is compressible and shows normal
color flow and spectral Doppler waveforms. The right common femoral artery
shows normal spectral waveform, but has apparent bidirectional flow of unclear
significance. No definite pseudoaneurysm is detected and there is no
hematoma.
IMPRESSION: Essentially normal examination without evidence of pseudoaneurysm
or hematoma. However, apparent bidirectional flow in the right common femoral
artery is noted and while of unclear clinical significance may be followed up
with repeat ultrasound if patient continues to have symptoms.
Updated results telephoned to ___ by ___ at 11:50 am,
___, 2 hours after discovery.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by UNKNOWN
Chief complaint: UNKNOWN-CC
Diagnosed with CHEST PAIN NOS
temperature: 97.8
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 143.0
dbp: 95.0
level of pain: 0
level of acuity: nan | ___ M with CAD (s/p CABG in ___, PVD, gout who presented to ___
with unstable angina (ruled out for MI) and had a positive
nuclear stress who was referred for consideration of cardiac
cath.
#) UNSTABLE ANGINA: Pt transferred from an OSH after presenting
with chest pain. He had 3 sets of cardiac enzymes that were
negative but had a positive stress test. He underwent an initial
cardiac catherization that showed severe 3 vessel disease and
severe graft disease. He had 2 DES and 1BMS stent placed in the
SVG-OM. After returning to the floor he had severe chest pain
that required a nitro drip. He was urgently taken back to the
cath lab for a re-look which was clean. During this period his
cardiac enyzmes trended up, with no EKG changes. He returned to
the Cath lab 3 days later with placement of ___ to his
rPDA, dRCA, SVG-RAMUS. His Atorvastatin was increased and he was
started on plavix.
#) R groin bruit: During patient's post catheterization check,
he was noted to have a bruit in his right groin. An ultrasound
was performed that found no aneurysm or hematoma, but
bidirectional flow. He should have outpatient vascular studies
#) GOUT: No flare currently, but per notes has severe disease
and unable to wean from prednisone. He was continued on
prednisone and febuxostat
#) HYPERTENSION: Well controlled. Treated with losartan,
metoprolol, Amlodipine 10 mg PO/NG DAILY
#) BPH: Continue tamsulosin
#) GERD: Continue omeprazole
# Code: DNR/DNI (confirmed with patient and daughter/HCP)
# Emergency Contact: ___ (___/___) ___
It was recommended that he go to rehab, but family declined. He
is going home with ___ and visiting nurse. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Phenazopyridine
Attending: ___.
Chief Complaint:
Acute on chronic back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female hx. osteoporosis with multiple compression
fractures and spinal surgeries, lumbar radiculopathy, HTN, HLD,
COPD presenting with c/o acute on chronic back pain.
Patient received L3/L4 epidural injection for chronic low back
pain ___. Patient reports good relief after receiving
injections, however next day she was bending over to take
something out of the fridge when she experienced sudden onset
low back pain. Says she felt a 'snap' in her low back. Had
intense pain that radiated down the back of both legs to behind
her calfs. Tried her home vicodin without relief. For the last
___ weeks the patient has also had problems with urinary
retention. Says she often has the urge to go but will only be
able to produce a dribbling stream. Denies frequency/burning or
irritation. Denies urinary incontinence. She said these symptoms
started prior to her acute onset back pain. She reported these
symptoms to her PCP who, concerned for cord compression,
referred her to the ED.
Patient initially presented to ___ where plain films
demonstrated stable chronic compression fractures. Given
reported new urinary retention and concern for cord compression,
she was transferred to the ___ ED for urgent MRI.
In the ED initial vitals were: 98.2 72 124/72 18 97% RA.
- Labs were significant for CBC with macrocytic anemia,
otherwise normal, unremarkable chem-7, u/a with trace leuks and
bacteria. MRI was obtained which showed multiple old compression
fractures with no abnormal cord signal, as well as enhancing
foci in L1, L5, S1 vertebral bodies concerning for metastasis.
- Patient was given ativan 0.5mg IV, morphine 5mg IV x3. Patient
then developed an oxygen requirement (90% on RA) and underwent
CXR that showed a left pleural effusion, was administered
levofloxacin x1 and admitted.
On the floor patient says pain is currently ___, says only
thing that helped was morphine which 'took the edge off'.
Otherwise has no complaints. She has had no fevers/chills, no
headache, no dyspnea or cough, no numbness/tingling or weakness.
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:
COPD/Asthma
HLD
PUD
GERD
Osteoporosis with multiple compression fractures, s/p L3
vertebroplasty
T11 compression fracture s/p decompressive laminectomy (___)
spinal stenosis with lumbar radiculopathy
severe AS as per ECHO ___ - peak grad 79, mean 44, ___ 0.8
cm
Social History:
___
Family History:
denies significant
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - 98.8 139/50 gr 68 20 97% RA
GENERAL: awake, alert, NAD, ambulating independently
HEENT: EOMI, PERRLA, OMM no lesions
CARDIAC: RRR, S1/S2, ___ harsh systolic murmur LUSB
LUNG: crackles in left base otherwise clear
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: CN II-XII intact, strength ___ in UE and ___ b/l, gait
intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Vitals- 98.6, 106/42, 64, 18, 95%RA
General- Alert, oriented, NAD, kyphotic but can ambulate
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Decreased breath sounds in L lung base
CV- ___ systolic murmur loudest at LUSB, radiating to carotids
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- Foley intact, making good, clear urine output
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
LABS
====
___ 05:15PM GLUCOSE-89 UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-27 ANION GAP-11
___ 05:15PM estGFR-Using this
___ 05:15PM WBC-6.3 RBC-2.98* HGB-9.9* HCT-30.2* MCV-101*
MCH-33.3* MCHC-32.9 RDW-12.3
___ 05:15PM NEUTS-54.2 ___ MONOS-3.6 EOS-0.5
BASOS-0.6
___ 05:15PM PLT COUNT-182
___ 05:15PM ___ PTT-28.6 ___
___ 04:13PM URINE HOURS-RANDOM
___ 04:13PM URINE HOURS-RANDOM
___ 04:13PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 04:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 04:13PM URINE MUCOUS-RARE
MICROBIOLOGY
=========
NONE
RADIOLOGY
=======
___ - MR SPINE ___ CONTRAST
1. Multilevel thoracic spondylosis with compression deformities
as detailed above without evidence of cord compression or
abnormal spinal cord signal, or significant spinal canal or
neural foraminal narrowing. 2. Multilevel spondylosis and
chronic compression fractures within the lumbar spine as
detailed above, with moderate to severe L3-L4 spinal canal
narrowing. 3. Suspicious foci within the L1 and S1 vertebral
bodies, as well as the right ilium, concerning for neoplasm. 4.
T11 and T12 post laminectomy changes with 3.1 cm fluid
collection within the post-laminectomy sites.
___ - CHEST XRAY PA & LAT
Left pleural effusion. Chronically elevated hilus with adjacent
lymph nodes or mass. Further evaluation with comparison to prior
studies. If none are available dedicated chest CT is
recommended.
___ - CT CHEST W/ CONTRAST
Centrally cavitated spiculated left upper lobe mass with
adjacent soft tissue structures extending into the mediastinum
and the portopulmonary window as well as along the left upper
lobe bronchus and left pulmonary artery. The mass is highly
suspicious for lung cancer and must be further worked up with
PET-CT and biopsy. Multiple ipsilateral and contralateral
pulmonary nodules. Left pleural effusion with moderate extent.
Upper lobe predominant centrilobular pulmonary emphysema and
moderate chronic airways disease.
___ - LEFT TIBIAL/FIBULA XRAY AP & LAT
Mild osteopenia, particularly subarticular around the knee
joint, is
physiologic for a patient of this age. There are no bone lesions
suspicious for malignancy
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. TraZODone 50 mg PO HS:PRN sleep
2. Omeprazole 20 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Gabapentin 900 mg PO TID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
6. Docusate Sodium 100 mg PO BID
7. Methocarbamol 750 mg PO TID
8. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 900 mg PO TID
4. Omeprazole 20 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
7. TraZODone 50 mg PO HS:PRN sleep
8. Methocarbamol 750 mg PO TID
9. Acetaminophen 1000 mg PO Q8H
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BEDTIME
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
14. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
15. Polyethylene Glycol 17 g PO BID
16. Senna 17.2 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on chronic back pain secondary to compression fracture
Probable malignancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR thoracic, lumbar spine.
INDICATION: *** CODE CORD *** History: ___ with known L spine fracture now
with worse pain and urinary retention // eval cord/nerve root injury
TECHNIQUE: MRI of the thoracic and lumbar spine were obtained without
administration of intravenous contrast.
COMPARISON: None.
FINDINGS:
Thoracic Spine: There is a dextro curvature and mildly exaggerated kyphosis
related to multiple chronic compression fractures it is all most prominent at
T11 with greater than 50% loss of height. There is also loss of vertebral body
height at T7, T8, T10 and T12. There is no increased STIR signal to suggest
acute fracture. Alignment in the sagittal plane appears relatively
well-maintained. Laminectomy changes are noted at T11 and T12, with a 1.1 AP
x 0.8 TV x 3.1 SI cm fluid collection in the laminectomy sites eccentric to
the right. Disc protrusions noted at T4-T5 through T8-T9, without significant
spinal canal or neural foraminal narrowing. The thoracic spinal cord and
conus medullaris have normal morphology and signal intensities. The
paraspinal soft tissues are normal.
Lumbar spine: Chronic compression fractures of L1 and L4 with greater than
50% loss of vertebral body height. Compression deformities also noted of L3
with approximately 50% loss of height. Kyphoplasty changes noted at L2 with
mild loss of vertebral body height. There is also mild loss of height at L1
and L5. No increased STIR signal is identified to suggest an acute fracture.
Is relatively well maintained. Bone marrow is diffusely heterogeneous with
suspicious foci of T1 hypointensity and increased STIR signal within the L1
vertebral body measuring approximately 0.9 cm the and S1 vertebral body
measuring approximately 2.9 cm. A suspicious 1.4 cm focus is also noted within
the right ilium. Type 1 endplate degenerative changes noted L5 inferior
endplate.
T12-L1: Disk bulge with endplate spurring without significant spinal canal or
neural foraminal narrowing.
L1-L2: Disk bulge eccentric to the left and bilateral facet arthrosis without
significant spinal canal or neural foraminal narrowing.
L2-L3: Disk bulge with endplate spurring, ligamentum flavum thickening,
bilateral facet arthrosis contribute to mild to moderate spinal canal and mild
bilateral neural foraminal narrowing.
L3-L4: Disk bulge with endplate spurring the, ligamentum flavum thickening,
and bilateral facet arthrosis contribute to moderate to severe spinal canal
and moderate left-greater-than-right neural foraminal narrowing.
L4-L5: Disk bulge with annular tear eccentric to the right, ligamentum flavum
thickening, and bilateral facet arthrosis contribute to mild-to-moderate
spinal canal, and mild right and moderate left neural foraminal, narrowing.
L5-S1: Disk bulge, ligamentum flavum thickening, bilateral facet arthrosis
result in mild spinal canal and no significant neural foraminal narrowing.
The conus medullaris and cauda equina have normal morphology and signal
intensities. The conus medullaris terminates at L1 level.
The paraspinal soft tissues are normal.
A small to moderate left pleural effusion is noted.
IMPRESSION:
1. Multilevel thoracic spondylosis with compression deformities as detailed
above without evidence of cord compression or abnormal spinal cord signal, or
significant spinal canal or neural foraminal narrowing.
2. Multilevel spondylosis and chronic compression fractures within the lumbar
spine as detailed above, with moderate to severe L3-L4 spinal canal narrowing.
3. Suspicious foci within the L1 and S1 vertebral bodies, as well as the right
ilium, concerning for neoplasm.
4. T11 and T12 post laminectomy changes with 3.1 cm fluid collection within
the post-laminectomy sites.
Radiology Report
CLINICAL INDICATION: Dyspnea. Evaluate for pneumonia.
COMPARISON: Thoracic spine radiographs performed 12 hours prior.
FRONTAL AND LATERAL VIEWS OF THE CHEST: Elevated left hilus with adjacent
focal opacity. There is a moderate left pleural effusion. The aortic knob is
calcified. There is mild cardiomegaly. No pneumothorax is identified. There
are breast calcifications. Compression fractures and prior vertebroplasty are
seen on the prior radiographs of the thoracic spine performed 12 hours
earlier.
IMPRESSION: Left pleural effusion. Chronically elevated hilus with adjacent
lymph nodes or mass. Further evaluation with comparison to prior studies. If
non are available dedicated chest CT is recommended.
COMMENT: ___ discussed recommendations with ___ at 0841 ___.
Radiology Report
COMPUTED TOMOGRAPHY OF THE THORAX
INDICATION: Back pain, suspicious spinal lesions and new left pleural lesion,
evaluate for effusion.
COMPARISON: No comparison available at the time of dictation.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
FINDINGS: Moderately enlarged thyroid with multiple mixed density nodules (3,
5) that could be further worked up with ultrasound. Massive bilateral breast
calcifications. Mild-to-moderate coronary calcifications. Aortic and mitral
valve calcifications. No pericardial effusion. Calcified granulomas in the
spleen. No evidence of adrenal lesions. Atheromatous plaque in the
descending aorta.
As known from the lateral chest x-ray, there are multiple vertebral collapses
and status post vertebroplasty.
Moderate bilateral centrilobular emphysema.
In the left upper lobe (5, 80) an irregularly shaped soft tissue density mass
with potential central cavitation is visualized. The maximum diameter of the
mass is 4.5 cm. The mass has irregular margins and multiple spiculations as
well as pleural tags. Medially to the mass (5, 89) a soft tissue density,
likely neoplastic or lymphatic, extends towards the mediastinum and into the
aortopulmonary window (5, 97). The mass also has broad-based contact with the
pulmonary artery and the left upper lobe bronchus. In addition, there is
increased lymphatic tissue at the level of the left hilus (5, 119).
The left lung additionally shows parenchymal nodules with maximum diameter of
approximately 7-8 mm, for eg, on series 5, image 39, image 60, and image 56.
A contralateral nodule is seen in the apex of the right lower lobe (5, 89).
Other right lung nodules are visualized, for eg, in the right upper lobe (5,
83). There is evidence of bronchial wall thickening and bronchial wall
irregularities, likely reflecting chronic airways disease, as well as of a
moderate left-sided pleural effusion, combined to dorsal atelectasis.
No evidence of enlarged lymph nodes in the posterior mediastinum.
IMPRESSION: Centrally cavitated spiculated left upper lobe mass with adjacent
soft tissue structures extending into the mediastinum and the aortopulmonary
window as well as along the left upper lobe bronchus and left pulmonary
artery. The mass is highly suspicious for lung cancer and must be further
worked up with PET-CT and biopsy.
Multiple ipsilateral and contralateral pulmonary nodules.
Left pleural effusion with moderate extent.
Upper lobe predominant centrilobular pulmonary emphysema and moderate chronic
airways disease.
The information was added to the radiology dashboard.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFTTIB/FIB (AP AND LAT) LEFTi
INDICATION: ___ year old woman with lung mass concerning for cancer //
evaluate for fracture, metastatic lesion
COMPARISON: There no prior conventional radiographic images of this region. .
IMPRESSION:
Mild osteopenia, particularly subarticular around the knee joint, is
physiologic for a patient of this age. There are no bone lesions suspicious
for malignancy
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with LUMBAGO
temperature: 98.3
heartrate: 66.0
resprate: 22.0
o2sat: 96.0
sbp: nan
dbp: nan
level of pain: 10
level of acuity: 1.0 | Ms ___ is a ___ year old female with history of osteoporosis
with multiple compression fractures, HTN, HLD, COPD presenting
with c/o acute on chronic back pain in the setting of a recent
trauma.
# Acute on chronic back pain: The acute onset of the patient's
pain with activity made an exacerbation or recurrence of one of
her compression fractures most likely, given her known DJD and
history of multiple compression fractures. Given her history of
urinary retention, we decided to obtain an MRI of her spine
which confirmed multilevel chronic compression fractures with no
evidence of spinal cord compression but did show suspicious foci
of signal abnormality within the L1 and S1 vertebral bodies,and
right ilium, concerning for neoplasm. It therefore became
unclear if her current symptoms were secondary to
osteoporotic-related compression fractures or pathologic
fractures secondary to a potential metastatic malignancy. While
waiting to further work-up her MRI lesions, we maintained her on
standing tylenol 1g TID, naproxen BID, oxycodone ___ PRN, and
achieved adequate pain control. Physical therapy also evaluated
her and recommended xrays of her left leg giving complaints of
pain, which were normal,as well as discharge to a rehabilitation
facility.
# Urinary retention: As above, her symptoms were initially
concerning for cord compression but MRI was negative. Patient
had no symptoms of UTI. Per prior notes, patient has had urinary
retention in the past thought due to chronic narcotic use.
Patient reports oxycodone recently discontinued, though it is
unclear if this was for urinary retention. Foley was initially
placed but removed after MRI ruled out cord compression. We also
sent a urinalysis and urine culture, both of which were
unremarkable. Her urinary retention ultimately resolved with out
further intervention. Most likely it is related to continued
opiate use. If symptoms persist, PCP could consider outpatient
urodynamic studies or further evaluation for micrometastasis to
the cord cauda equina as other likely explanations for her
symptoms.
# Concern for malignancy: As above, MRI of her spine showed
multiple vertebral enhancements concerning for metastatic
malignancy. Patient denied blood in her stool, weight loss,
night sweats, or other concerning symptoms, though on discharge
endorsed she 'always had a suspicion' she might have cancer
because of hemoptysis she had a few weeks ago, especially given
her extensive smoking history. On admission patient also
complained of mild dyspnea and a CXR showed a moderate left
pleural effusion. Given that her findings were new, we performed
a chest CT with contrast which showed a centrally cavitated
spiculated left upper lobe mass. Together, these findings were
very concerning for malignancy, and it was recommended that
tissue biopsy be obtained for further evaluation. However, the
patient strongly declined all further work-up, indicating clear
understanding of the risks involved including death, and
reaffirmed her decision with multiple members of our team. She
drew on experiences involving her brother who was diagnosed with
cancer but suffered significant side effects from chemotherapy
and radiation and eventually died despite treatment.We offered
both palliative care and social work consults this admission and
she refused those as well. Looking forward, she said she will
plan to discuss these findings with her PCP on discharge. Her
PCP was notified of the findings and discussions with the
patient.
# Hypoxia: As explained above, patient endorsed mild dyspnea on
presentation, and CXR showed moderate left pleural effusion. She
was given 1 dose levofloxacin in the ED but given lack of
fevers, leukocytosis, or cough, we felt pneumonia was less
likely, discontinued antibiotics, and maintained her on her home
bronchodilators and incentive spirometer, which resolved her
symptoms by her second hospital day.
# Asthma/COPD: This was not active during her hospital course,
and she did not require any PRN treatments
# GERD: No symptoms during hospital course. We continued her
home omeprazole
TRANSITIONAL ISSUES
1. She should consider further work-up of chest mass (biopsy,
PET-CT) if within goals of care. Please discuss further with
your PCP as you plan regarding the findings we commmunicated to
you. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Syncopal fall
Major Surgical or Invasive Procedure:
___ - LINQ implantable loop recorder placement
History of Present Illness:
___ is a ___ male who presents to ___ on
___ with a moderate TBI. He was playing badminton and felt
lightheaded and dizzy and fell to the ground striking his head.
Reportedly he had LOC for
30 seconds. Patient reports similar syncopal episodes in the
past
after long periods of exercise, which were worked up by his PCP.
He was brought to ___ where ___ & MRI were done which revealed
R frontal contusion, L occipital fracture with small overlying
hematoma, and small bilateral temporal SDH. He was transferred
to
___ for Neurosurgical evaluation. Upon eval patient reports
headache, dizziness, nausea, denies visual changes, weakness,
numbness, difficulty ambulating, confusion.
Past Medical History:
Seasonal Allergies
Hx of syncopal events after exercise- reportedly TTE negative
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
Physical Exam:
O: T:99.8 BP: 110/70 HR:66 RR:16 O2 Sat:96% on RA
GCS upon Neuro___ Evaluation:
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL ___
Neck: soft non tender
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
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
ON DISCHARGE:
He is awake, alert, and cooperative with the exam. He is
oriented to self, location, and date. PERRL, EOMI. ___. Speech
fluent, comprehension intact. No pronator drift. He moves all
extremities with ___ strength. Sensation is intact to light
touch.
Pertinent Results:
Please refer to OMR for pertinent results.
Medications on Admission:
1. Multivitamin
2. Antihistamine
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4gm acetaminophen daily
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth two times daily
Disp #*6 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours as
needed for pain Disp #*15 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. Multivitamins 1 TAB PO DAILY
7.Outpatient Physical Therapy
Vestibular physical therapy
8.Rolling walker
Dx: Traumatic brain injury
Px: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right frontal contusion
Occipital bone fracture
Bilateral subdural hematoma
Bradycardia
BPPV
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 WITHOUT CONTRAST
INDICATION: ___ year old man with R frontal contusion, bilateral small
temporal SDH, Occipital SDH, L occipital fx// interval change, please complete
at 0600 AM ___
TECHNIQUE: Axial images of the head were obtained without contrast with
sagittal and coronal reformats.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___.
FINDINGS:
In comparison to noncontrast CT head from ___, again noted is a
obliquely oriented occipital bone fracture which is nondisplaced. Again seen
are an occipital subdural hematoma as well as small bilateral temporal
subdural hematomas, unchanged compared to prior. There has been interval
evolution of right frontal intraparenchymal contusion with increase in
surrounding edema, but overall stability of contusion. Subtle apparent change
in the ventricular size is thought to be within normal limits.
IMPRESSION:
Overall stable compared to prior study of ___ with slight evolution of
frontal contusion as described above. No new hemorrhage is seen.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 7:01 am, 10 minutes after
discovery of the findings.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: SDH, Transfer
Diagnosed with Syncope and collapse, Other fracture of occiput, right side, init, Traum subdr hem w LOC of unsp duration, init, Fall on same level, unspecified, initial encounter
temperature: 99.8
heartrate: 66.0
resprate: 16.0
o2sat: 96.0
sbp: 110.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ year old male who suffered a TBI after a
syncopal fall.
# TBI:
Patient was evaluated in the ED and due to occipital bone
fracture and frontal contusion, patient was admitted to the
Neuro Step Down Unit for continued monitoring. He was started on
Keppra x7 days for seizure prophylaxis. Repeat CT Head on ___
showed evolving right frontal contusion. He continued to be
neurologically intact and no further repeat imaging was
indicated. Patient does exhibit concussion symptoms including
dizziness and nausea.
# Bradycardia:
Patient was bradycardic to ___, with heart rate maximum ~60.
Medicine and Cardiology were consulted for further evaluation of
bradycardia/syncope. EKG showed sinus bradycardia. Orthostatic
vital sign check was negative. AM cortisol was normal. ECHO was
normal. EP placed LINQ Implantable loop recorder and patient
will follow up with EP as an outpatient.
# Dizziness
Patient was diagnosed with BPPV. ___ maneuvers were
performed inpatient by physical therapy. Outpatient vestibular
physical therapy was recommended once cleared by home physical
therapy.
# Dispo
Patient was evaluated by physical therapy, initially it was
recommended he go to acute rehab on ___ however, the patient
refused. He remained inpatient and worked with ___ daily until he
was cleared for discharge home with home ___ on ___. His pain
was well controlled with oral medications. He was tolerating a
diet and ambulating with a rolling walker. His vital signs were
stable and he was afebrile. He was discharged home with home
services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Streptomycin
Attending: ___.
Chief Complaint:
Chest pain/fever/chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo ___ speaking F with HTN and mild AS presented to the
ED with chest pain. Via interpreter, she reports about a week of
intermittent chest pain, described as dull left sided chest pain
radiating to her shoulders, neck and arms. She also describes
some lower abdominal and groin pain since yesterday, along with
nausea and non-bloody emesis. She does not feel these pains are
exertional or related to meals. She denies dyspnea, bowel
symptoms or urinary symptoms.
In the ED, initial vitals 102.9 92 141/00 20 100%. She received
IV levoflox for pneumonia and tylenol for fever. Given LFTs an
abdominal ultrasound was performed which was fairly
unremarkable. Vitals on transfer 99.2 81 96/52 27 96.
Currently, she feels well and is without complaint. She denies
abdominal pain or chest pain at this time.
Past Medical History:
- Hypertension
- Multinodular goiter
- Blindness
- Gastritis
- Aortic stenosis
- Osteoarthritis
- Insomnia
- Pre-diabetes
- Varicose veins
- Hemorrhoids
Social History:
___
Family History:
Non-contributory to chest pain
Physical Exam:
PHYSICAL EXAM ON ADMISSION ___:
VS 98.4 105/69 67 18 98%
GENERAL - Calm, pleasant cooperative, NAD, speaking ___
pionting to abdomen, Well-appearing overweight and elderly
woman.
HEENT - NC/AT, EOMI, sclerae anicteric, OP clear, MMM
NECK - supple, no thyromegaly or dyssymetry of thyroid, no JVD
HEART - regular rate and rhythm, nl S1-S2, ___ holosystolic
murmur heard best at RUSB, no R/G.
LUNGS - No respiratory distress or use of abdominal muscles.
Clear to auscultation bilaterally except for right lower lobe
fine crackles
ABDOMEN - NABS, soft, moderately tender to palpation in lower
quadrants, no ___ sign no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema in lower extremities bilaterally.
Varicosities noted on lower extremities
SKIN - no rashes or lesions, mutiple nevi noted on neck
NEURO - AAOx3 . CNII-XII grossly intact. Speech coherent,
cognition intact.
PSYCH: Appropriate affect
SKIN: No rashes or lesions visible on exposed regions
PHYSICAL EXAM ON DISCHARGE ___:
Vitals: Tm 102.9 T 98.2 BP 119/54 P ___ RR 18 POx 97% RA
GENERAL - Calm, pleasant cooperative, NAD, speaking ___
pionting to abdomen, Well-appearing overweight and elderly
woman.
HEENT - NC/AT, EOMI, sclerae anicteric, OP clear, MMM
NECK - supple, no thyromegaly or dyssymetry of thyroid, no JVD
HEART - regular rate and rhythm, nl S1-S2, ___ holosystolic
murmur heard best at RUSB, no R/G.
LUNGS - No respiratory distress or use of abdominal muscles.
Clear to auscultation bilaterally except for right lower lobe
fine crackles
ABDOMEN - NABS, soft, moderately tender to palpation in lower
quadrants, no ___ sign no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema in lower extremities bilaterally.
Varicosities noted on lower extremities
SKIN - no rashes or lesions, mutiple nevi noted on neck
NEURO - AAOx3 . CNII-XII grossly intact. Speech coherent,
cognition intact.
PSYCH: Appropriate affect
SKIN: No rashes or lesions visible on exposed regions
Pertinent Results:
LABS:
___ 04:40PM BLOOD ___ PTT-31.2 ___
___ 04:40PM BLOOD Neuts-90.5* Lymphs-7.0* Monos-2.0 Eos-0.4
Baso-0.2
___ 04:40PM BLOOD WBC-10.2# RBC-5.20 Hgb-15.1 Hct-45.6
MCV-88 MCH-29.0 MCHC-33.1 RDW-13.7 Plt ___
___ 06:05AM BLOOD WBC-10.6 RBC-4.88 Hgb-14.2 Hct-43.2
MCV-88 MCH-29.2 MCHC-33.0 RDW-13.7 Plt ___
___ 05:40AM BLOOD WBC-6.3 RBC-4.72 Hgb-13.8 Hct-41.4 MCV-88
MCH-29.2 MCHC-33.3 RDW-14.0 Plt ___
___ 05:40AM BLOOD ___ PTT-30.6 ___
___ 04:40PM BLOOD Glucose-125* UreaN-10 Creat-0.7 Na-137
K-3.6 Cl-97 HCO3-32 AnGap-12
___ 06:05AM BLOOD Glucose-98 UreaN-11 Creat-0.6 Na-139
K-3.7 Cl-102 HCO3-30 AnGap-11
___ 05:40AM BLOOD Glucose-115* UreaN-9 Creat-0.5 Na-142
K-3.8 Cl-108 HCO3-27 AnGap-11
___ 04:40PM BLOOD Lipase-26
___ 04:40PM BLOOD ALT-92* AST-48* AlkPhos-140* TotBili-3.6*
DirBili-0.8* IndBili-2.8
___ 06:05AM BLOOD ALT-70* AST-32 AlkPhos-117* TotBili-2.6*
___ 05:40AM BLOOD ALT-47* AST-18 LD(LDH)-172 CK(CPK)-40
AlkPhos-102 TotBili-1.3
___ 06:05AM BLOOD Calcium-8.3* Phos-1.3*# Mg-1.9
___ 05:40AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9
___ 04:40PM BLOOD Albumin-4.4
___ 04:40PM BLOOD proBNP-1183*
___ 04:40PM BLOOD cTropnT-<0.01
___ 04:42PM BLOOD Lactate-1.4
___ 04:40PM BLOOD HCV Ab-NEGATIVE
___ 04:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:05AM BLOOD Hapto-201*
URINE:
___ 05:40PM URINE RBC-7* WBC-71* Bacteri-FEW Yeast-NONE
Epi-7 TransE-2
___ 05:45PM URINE RBC-2 WBC-16* Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
___ 05:40PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-7.0 Leuks-LG
___ 05:45PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-MOD
___ 05:40PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:45PM URINE Color-Yellow Appear-Clear Sp ___
MICROBIOLOGY:
___ 4:40 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___
___ 8:10AM.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 5:20 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
GRAM NEGATIVE ROD #2.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
RODS.
Urine culture pending
RADIOLOGY:
CXR ___:
IMPRESSION: Mild bibasilar patchy airspace opacities may
reflect infection, aspiration, or atelectasis. A lateral view
would help to evaluate for small effusions.
LIVER U/S ___:
1. No focal liver lesion detected with limited acoustic window.
2. Simple-appearing cyst in the right renal upper pole measuring
2 cm.
3. Cholelithiasis without evidence for cholecystitis.
4. Mild fullness in the right renal collecting system
CXR ___:
Mild-to-moderate cardiomegaly is stable. Bibasilar opacity
larger on the left side has increased on the right. Likely
atelectasis, superimposed infection is also probably present.
There is no pneumothorax or pleural effusion. There are
mild-to-moderate degenerative changes in the thoracic spine.
Mediastinal and hilar contours are unchanged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.25-0.5 mg PO HS:PRN insomnia
Please monitor and hold for sedation, RR<12 or AMS
2. Atenolol 25 mg PO DAILY
3. Ranitidine 300 mg PO DAILY
4. Amlodipine 5 mg PO DAILY
Please hold for SBP <110
5. ammonium lactate *NF* 12 % Topical BID
Apply to legs and back twice a day
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2 sprays in each nostril
7. Hydrocortisone (Rectal) 2.5% Cream ___ID
apply to affeted area
8. Polyethylene Glycol 17 g PO DAILY constipation
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. ginkgo biloba *NF* Uncertain Oral daily
11. Glucosamine Relief *NF* (glucosamine sulfate 2KCl) 1,000 mg
Oral daily
12. Milk of Magnesia 30 mL PO DAILY
13. Fish Oil (Omega 3) Dose is Unknown PO BID
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.25-0.5 mg PO HS:PRN insomnia
Please monitor and hold for sedation, RR<12 or AMS
2. Atenolol 25 mg PO DAILY
3. Ranitidine 300 mg PO DAILY
4. Amlodipine 5 mg PO DAILY
Please hold for SBP <110
5. ammonium lactate *NF* 12 % Topical BID
Apply to legs and back twice a day
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2 sprays in each nostril
7. Hydrocortisone (Rectal) 2.5% Cream ___ID
apply to affeted area
8. Polyethylene Glycol 17 g PO DAILY constipation
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. ginkgo biloba *NF* Uncertain Oral daily
11. Glucosamine Relief *NF* (glucosamine sulfate 2KCl) 1,000 mg
Oral daily
12. Milk of Magnesia 30 mL PO DAILY
13. Fish Oil (Omega 3) Dose is Unknown PO BID
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
Please hold for SBP <110
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2 sprays in each nostril
4. Hydrocortisone (Rectal) 2.5% Cream ___ID
apply to affeted area
5. Lorazepam 0.25-0.5 mg PO HS:PRN insomnia
Please monitor and hold for sedation, RR<12 or AMS
6. Polyethylene Glycol 17 g PO DAILY constipation
7. Ranitidine 300 mg PO DAILY
8. ammonium lactate *NF* 12 % Topical BID
Apply to legs and back twice a day
9. Fish Oil (Omega 3) 0 mg PO BID
10. ginkgo biloba *NF* 0 mg ORAL DAILY
11. Glucosamine Relief *NF* (glucosamine sulfate 2KCl) 1,000 mg
Oral daily
12. Milk of Magnesia 30 mL PO DAILY
13. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Weeks
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice each day
Disp #*19 Tablet Refills:*0
14. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gram negative bacteremia with E.coli and Klebsiella
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Fevers.
COMPARISON: ___.
FINDINGS: Mild bibasilar patchy airspace opacities are new since ___. The cardiophrenic angles are blunted. Presence of small effusions is
difficult to ascertain without a lateral projection. Cardiomegaly is
moderate. The aorta is tortuous.
IMPRESSION: Mild bibasilar patchy airspace opacities may reflect infection,
aspiration, or atelectasis. A lateral view would help to evaluate for small
effusions.
Radiology Report
INDICATION: ___ female with elevated liver enzymes.
COMPARISON: None available.
TECHNIQUE: Transabdominal ultrasound examination of the right upper quadrant
was performed.
FINDINGS: Acoustic window is limited and therefore evaluation of the liver
parenchyma is suboptimal, but no focal liver lesions are detected. The
gallbladder contains a small layering stone and is otherwise normal. There is
no intra- or extra-hepatic biliary ductal dilation. Visualized portions of
the pancreas are unremarkable. A 2 x 1.9 x 1.8 cm cyst is seen in the upper
pole of the right kidney. There is mild fullness of the right renal
collecting system. The main portal vein is patent with hepatopetal flow.
IMPRESSION:
1. No focal liver lesion detected with limited acoustic window.
2. Simple-appearing cyst in the right renal upper pole measuring 2 cm.
3. Cholelithiasis without evidence for cholecystitis.
4. Mild fullness in the right renal collecting system.
Findings discussed with ___ by ___ by phone at 9:04 p.m.
on ___.
Radiology Report
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Hypertension, mild AS, chest and abdominal pain and GNR
bacteremia.
Comparison is made with prior study ___.
Mild-to-moderate cardiomegaly is stable. Bibasilar opacity larger on the left
side has increased on the right. Likely atelectasis, superimposed infection
is also probably present. There is no pneumothorax or pleural effusion.
There are mild-to-moderate degenerative changes in the thoracic spine.
Mediastinal and hilar contours are unchanged.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: N/V/CHEST PAIN
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 102.9
heartrate: 92.0
resprate: 20.0
o2sat: 100.0
sbp: 141.0
dbp: 0.0
level of pain: 13
level of acuity: 2.0 | ___ yo ___ speaking F with HTN and mild AS, hypertension,
blindness, multinodular goiter, hyperlipidemia, prediabetes who
presented to the ED with chest pain, complaining of abdominal
pain and found to have GNR bactermia.
#E. Coli and Klebsiella Septicemia: Patient with ___ positive
blood cultures ( E. Coli and Klebsiella) drawn in the ED in
anaerobic bottles in setting of fever and tachypnea. GI source
suspected given patient's abdominal pain and elevated LFTs. (
see below) RUQ U/S unremarkable except for stones. Pulmonary
source possible given prolonged cough equivocal CXR and slight
crackles at RLB on lung exam. Urinary source unlikely given
negative urine culture. The patient was initially on IV cefepime
and subsequently transitioned to PO ciprofloxacin. She will
complete a 2 week course of antibiotic treatment.
# Elevated LFTs/RUQ/Abdominal pain
LFTs showed slight transaminitis with mixed hyperbilirubinemia.
The bilirubin appears to be out of proportion to her
transaminitis, which may suggests a resolving cholestatic
process given down trending LFTs. RUQ ultrasound shows
cholelithiasis without evidence for cholecystitis. Hepatitis
serologies unremarkable. Tylenol level undetecteble. Hemolysis
labs unremarkable. It is quite possible the patient passed a
stone, and translocated some bacteria as the potential source of
her bacteremia. Given her age, would not recommend at
cholecystectomy at this time. Would recheck LFTs at PCP follow
up.
# Chest pain: Unclear etiology of her pain, which is unlikely to
be cardiac (normal ecg, negative enzymes, non-exertional) and is
more likely to be musculoskeletal given the reproducibility of
the pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
___: Right trochanteric femoral nail
History of Present Illness:
___ s/p mechanical fall in ___ parking lot, landing on
right side. Immediate right hip pain and inability to
weightbear. No head strike or LOC. Taken to ___
where imaging revealed a R hip fracture for which she was
transferred to ___ for further evaluation.
Past Medical History:
- Lung cancer s/p Chemo XRT at ___, Dx at ___
- COPD
- HTN
- Osteoporosis
- Depression
- Anxiety
Social History:
___
Family History:
No Known Significant Inheritable Disorder
Physical Exam:
EXAM ON ADMISSION:
Vitals: 98.3 69 98.3 18 95% RA
General: elderly female in NAD.
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
Knee mild-moderate tenderness to palpation
+pain with logroll
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
+DP pulse, foot warm and well-perfused
========================
EXAM ON DISCHARGE:
AFVSS
GEN: NAD, AAOx3 at time of discharge
RLE: ___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
+DP pulse, foot warm and well-perfused
Pertinent Results:
___ 07:25AM BLOOD WBC-5.3 RBC-3.26*# Hgb-9.8*# Hct-29.4*
MCV-90 MCH-30.0 MCHC-33.2 RDW-13.1 Plt ___
___ 07:35AM BLOOD WBC-4.5 RBC-3.69* Hgb-10.8* Hct-33.5*
MCV-91 MCH-29.1 MCHC-32.1 RDW-12.8 Plt ___
___ 11:30PM BLOOD Glucose-138* UreaN-8 Creat-0.5 Na-123*
K-4.1 Cl-96 HCO3-21* AnGap-10
___ 06:10AM BLOOD Glucose-115* UreaN-10 Creat-0.6 Na-126*
K-4.0 Cl-93* HCO3-24 AnGap-13
___ 02:50PM BLOOD Glucose-120* UreaN-13 Creat-0.6 Na-127*
K-4.5 Cl-92* HCO3-24 AnGap-16
___ 07:50AM BLOOD Glucose-127* UreaN-8 Creat-0.5 Na-129*
K-3.8 Cl-97 HCO3-24 AnGap-12
___ 07:25AM BLOOD Glucose-94 UreaN-6 Creat-0.4 Na-131*
K-3.9 Cl-96 HCO3-27 AnGap-12
___ 07:35AM BLOOD Glucose-89 UreaN-6 Creat-0.4 Na-131*
K-3.7 Cl-95* HCO3-26 AnGap-14
Bilateral hip XR ___:
Postoperative changes of the proximal left femur. Acute
angulated intertrochanteric right femur fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Alendronate Sodium Dose is Unknown PO DAILY
8. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every six (6) hours Disp #*50
Tablet Refills:*0
2. Escitalopram Oxalate 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 50 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
4. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*0
5. Enoxaparin Sodium 30 mg SC QHS
Start: Today - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 30 mg/0.3 mL 30 mg SQ qday Disp #*14 Syringe
Refills:*0
6. Multivitamins 1 CAP PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Ipratropium Bromide MDI 2 PUFF IH QID
11. Albuterol Inhaler ___ PUFF IH Q6H SOB
12. Alendronate Sodium 5 mg PO DAILY
Continue previous home dose of alendronate sodium on discharge
13. FoLIC Acid 1 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right femur intertrochanteric fracture. Anticipate that rehab
stay will not exceed 30 days.
Discharge Condition:
Mental Status: Alert and oriented, sometimes confused.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST, SINGLE VIEW: ___
HISTORY: ___ female with hip fracture.
COMPARISON: ___ and film from earlier the same day.
FINDINGS: Single supine view of the chest. When compared to prior exams,
there has been no significant interval change. There is left mid to upper
lung scarring, which is unchanged from prior with superior retraction of the
left hilum. Lungs are clear of consolidation or overt pulmonary edema.
Enlarged central pulmonary arteries are again noted. The cardiomediastinal
silhouette is unchanged, difficult to assess accurately given slight rotation.
Lower thoracic vertebral body compression deformity is again noted.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
PELVIS AND BILATERAL HIP FILMS AND RIGHT FEMUR FILMS: ___
HISTORY: ___ female with hip fracture on the right.
COMPARISON: Pelvis and left hip films from ___.
FINDINGS: Since prior, postoperative changes seen at the proximal left femur
traversing previously seen intertrochanteric left hip fracture. Extensive
heterotopic ossification seen traversing the fracture site. There is no
evidence of hardware complication. Femoroacetabular joint is anatomically
aligned.
On the right, there is an acute intertrochanteric femoral fracture with varus
angulation. The femoroacetabular joint remains anatomically aligned. There
is no distal right femoral fracture.
Old left superior and inferior pubic rami fractures are noted; however, these
have occurred since prior exam. Degenerative changes seen in the lumbar
spine. Atherosclerotic calcifications are noted.
IMPRESSION: Postoperative changes of the proximal left femur. Acute
angulated intertrochanteric right femur fracture.
Radiology Report
STUDY: Right hip, ___.
CLINICAL HISTORY: Patient with right hip fracture ORIF.
FINDINGS: Comparison is made to previous study from ___.
Several fluoroscopic images of the right hip from the operating room
demonstrate interval placement of a short intramedullary rod with proximal pin
fixating an intertrochanteric fracture of the right proximal femur. There is
improved anatomic alignment. There are no signs for hardware-related
complications. Please refer to the operative note for additional details.
Radiology Report
HISTORY: COPD, lung cancer status post resection, now with rales on clinical
exam.
TECHNIQUE: Single frontal portable radiograph was obtained with patient in an
upright position.
COMPARISON: Comparison is made to radiographs dated ___.
FINDINGS:
Redemonstrated is left mid-upper lung scarring, with associated superior
retraction of the left hilum. There is a vague opacification noted over the
left mid lung, which may be consistent with a developing consolidation There
is no pleural effusion, pneumothorax, or overt pulmonary edema. The heart is
normal in size. The mediastinal contours are otherwise normal.
Redemonstrated is a lower thoracic vertebral body compression deformity.
IMPRESSION:
Vague opacification seen in the left mid lung, concerning for an developing
pneumonia.
Findings were conveyed by Dr. ___ to Dr. ___ telephone at 11:33 am
on ___, at the time of discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R HIP FX, R Knee pain, Transfer
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL
temperature: 98.3
heartrate: 69.0
resprate: 18.0
o2sat: 95.0
sbp: 98.3
dbp: nan
level of pain: 5
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Right femur intertrochanteric fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for Right transfemoral fixation nail,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate.
She was noted on postoperative day 1 to be hyponatremic to 123
and had altered mental status. She was repleted orally and with
normal saline. Medicine was also consulted. Over the next few
days her sodium gradually rose and was atable at 131 at the time
of her discharge. She is encouraged to eat heartily following
discharge.
Altered mental status was noted with patient asking whether
someone was present when someone clearly was not. Medicine
service noted her waxing and waning delirium and recommended no
narcotic pain medicines or benzodiazepines, maintenance of a
regular sleep-wake cycle with minimum interruptions. The
patient was AAOx3 on exam prior to discharge.
A chest x-ray was conducted on ___ to assess for possible lung
pathology in the context of PMH including COPD and lung cancer
s/p resection and a physical exam that noted few diffuse rales.
The CXR demonstrated "vague opacification seen in the left mid
lung, concerning for an developing pneumonia." The patient was
afebrile with stable vital signs. Her temperature was 98.5 at
the time of discharge. The findings were discussed with the
team and were judged to be non-concerning for acute pathology.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is Weight-bearing as tolerated in the
Right lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
___:
1. Anterior cervical diskectomy and fusion, C6-7, using Globus
anterior structural allograft, plate and screw system.
2. Microscopic dissection.
3. Morselized bone graft.
History of Present Illness:
___ year old male presented to ___ by ambulance s/p
mechanical trip and fall on uneven pavement outside of ___ this evening. He reports falling forward and hitting
his
nose on the ground but there was no loss of consciousness. At
___ ED he was found to have a left humerus fracture and and
unstable C6-7 fracture. He is currently complaining of pain in
his left arm with motion, but otherwise no current complaints.
Past Medical History:
PMH: DM2, HTN, Crohn's
PSH: tonsils, circumcision
Social History:
___
Family History:
N/C
Physical Exam:
=== ADMISSION PHYSICAL EXAM === (per trauma surgery consult note
in ED)
Vitals: T 96.3, HR 74, BP 147/80, RR 18, O2 96ra
Gen: a&o x3, nad; c-collar in place, no midline tenderness
CV: rrr, no murmur
Resp: cta bilat, no chest wall tenderness or crepitus
Abd: soft, NT, ND, +BS
Extr: warm, 2+ pulses; pain with motion of LUE, able to move
hand
and fingers; sensation and strength intact
=== DISCHARGE PHYSICAL EXAM ===
Vitals: T 98.0, HR 61, BP 124/40, RR 18, 99%RA
Gen: Alert, no acute distress
HEENT: Sclera anicteric. MMM. Echymosis around eyes R>L, with
some R eye swelling as well. Anisicoria: R pupil 2mm, very
minimally reactive. L eye 3mm-->2 mm with light (per patient at
baseline). Extraocular movements grossly intact. Neck brace in
place.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Ext: LUE with brace in place. Swelling in LUE extending to
forearm, nonpitting. Echymoses in L antecubital fossa.
Compression glove on L hand. Bilateral lower with no pedal
edema, warm and well perfused.
Skin: per above
Neuro: LUE in brace; moving RUE and bilateral lower legs.
Pertinent Results:
==== ADMISSION LABS ===
___ 05:08PM BLOOD WBC-7.8 RBC-2.90* Hgb-8.8* Hct-26.0*
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.1 RDWSD-42.8 Plt ___
___ 05:08PM BLOOD Glucose-125* UreaN-28* Creat-1.3* Na-132*
K-4.2 Cl-96 HCO3-26 AnGap-14
=== PERTINENT LABS DURING HOSPITAL STAY ===
___ 06:20AM BLOOD WBC-6.0 RBC-2.38* Hgb-7.2* Hct-22.0*
MCV-92 MCH-30.3 MCHC-32.7 RDW-13.4 RDWSD-45.1 Plt ___
___ 02:38PM BLOOD Neuts-81.9* Lymphs-10.1* Monos-6.8
Eos-0.4* Baso-0.4 Im ___ AbsNeut-6.70* AbsLymp-0.83*
AbsMono-0.56 AbsEos-0.03* AbsBaso-0.03
___ 02:38PM BLOOD Glucose-254* UreaN-35* Creat-1.6* Na-132*
K-4.0 Cl-101 HCO3-21* AnGap-14
___ 02:38PM BLOOD CK-MB-3 cTropnT-0.02*
___ 02:38PM BLOOD ALT-25 AST-42* LD(LDH)-191 AlkPhos-49
TotBili-0.6
___ 10:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
___ 02:57PM BLOOD Glucose-234* Lactate-3.5*
___ 02:57PM BLOOD freeCa-1.11*
=== MICROBIOLOGY ===
___ MRSA SCREEN (Final ___: No MRSA isolated.
___ C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
=== IMAGING ===
___ HUMERUS A/P:
IMPRESSION:
Obliquely oriented fracture through the mid-diaphysis of the
left humerus with 1 shaft width of displacement. Nondisplaced
fracture component extending to the proximal diaphysis.
Sclerosis of the humeral head suggesting avascular necrosis.
___ CT HEAD:
IMPRESSION:
No acute intracranial process.
Bilateral nasal bone and nasal septal fracture and fracture
through the
frontal process of the maxilla on the right.
___ CTA NECK:
IMPRESSION:
1. No evidence of vascular injury with the cervical spinal
fractures better visualized on the dedicated CT C-spine.
2. A 0.9 cm hyperdense extra-axial mass with a focus of
calcification anterior to the left temporal lobe a, likely
representing a small meningioma.
___ SHOULDER & HUMERUS:
IMPRESSION:
Obliquely oriented displaced left humeral fracture, with some
improvement in alignment but persistent 13 mm posterior
displacement of the distal fragment.
___ MR NECK:
IMPRESSION:
1. Fracture through the C6 inferior endplate extending in to the
C6-7 disc space resulting in widening of the disc space and
increased angulation at this level with no significant spinal
canal stenosis. At C6-7 there is focal tear of the anterior
longitudinal ligament, ligamentum flavum strain and high-signal
in the interspinous space suggestive of interspinous ligamentous
injury. No additional sites of ligamentous injury are seen.
2. Normal appearance of the spinal cord.
3. Right C6 pedicle fracture better seen on the prior CT.
___ LEFT ELBOW:
IMPRESSION:
Limited by overlying splint material. Within that limitation no
fracture or dislocation of the elbow is seen.
___ CTA CHEST:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Small left apical ground-glass opacity may be inflammatory.
2 mm left
upper lobe nodule. Follow-up can be performed if clinically
indicated in ___ months.
3. Moderate bibasilar atelectasis and small bilateral pleural
effusions.
4. Mild cardiomegaly. Coronary artery atherosclerosis is
severe.
___ CT HEAD:
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Fracture of bilateral nasal bones and nasal septum is
re-demonstrated.
___ C-SPINE:
IMPRESSION:
No previous images. There is an anterior fusion at C6-C7 with
no evidence of hardware-related complication. The vertebra and
intervertebral disc spaces are somewhat difficult to assess on
the lateral view, with generalized osteopenia and apparent
widespread narrowing with calcification in the anterior
longitudinal ligament. No prevertebral soft tissue swelling is
identified.
Of incidental note is calcification in the region of the carotid
bifurcation bilaterally.
___ CXR
Bibasilar patchy consolidations new relative to prior
examination performed ___ possibly atelectasis
although infectious etiology cannot be excluded.
___ Gleno humeral shoulder xray
** wet read** Compared to the study of ___ spiral
fracture of the midshaft of the left humerus is re-
demonstrated. There is posterior and lateral
displacement of the distal fracture fragment approximately ___
shaft width.There is no significant angulation. No appreciable
callus formation is seen.
===DISCHARGE LABS===
___ 06:00AM BLOOD WBC-8.7 RBC-2.37* Hgb-7.2* Hct-22.0*
MCV-93 MCH-30.4 MCHC-32.7 RDW-13.0 RDWSD-44.3 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-114* UreaN-30* Creat-1.1 Na-138
K-3.6 Cl-103 HCO3-25 AnGap-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Gabapentin 200 mg PO TID
3. Atenolol 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. BuPROPion 150 mg PO BID
6. Mirtazapine 7.5 mg PO QHS
7. Nateglinide 60 mg PO BID BEFORE BREAKFAST AND DINNER
8. Aspirin 81 mg PO DAILY
9. Lialda (mesalamine) 1500 mg oral DAILY
10. Terazosin 5 mg PO QHS
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. BuPROPion 150 mg PO BID
3. Gabapentin 200 mg PO TID
4. Lisinopril 30 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Terazosin 5 mg PO QHS
7. Aspirin 81 mg PO DAILY
8. Lialda (mesalamine) 1500 mg oral DAILY
9. Mirtazapine 7.5 mg PO QHS
10. Nateglinide 60 mg PO BID BEFORE BREAKFAST AND DINNER
11. Docusate Sodium 100 mg PO BID
12. Pravastatin 10 mg PO QPM
13. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
To continue for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
1. Hyperextension injury with fracture dislocation, C6-7, in the
setting of diffuse idiopathic skeletal hyperostosis.
2. Left humerus spiral fracture
3. Fracture of bilateral nasal bones and nasal septum
SECONDARY DIAGNOSES
====================
Hypertension
Crohn's Disease
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with s/p fall, L shoulder/humerus pain // ?fracture, ?ICH
TECHNIQUE: Multiple views of the left shoulder and humerus.
COMPARISON: None.
FINDINGS:
Exam is slightly limited due to technique. There is apparent sclerosis
identified at the superior aspect of the humeral head raising the possibility
of underlying avascular necrosis. The humeral head contour is preserved.
Small well corticated calcific density inferior to the acromion appears
chronic. Moderate degenerative changes are noted at the acromioclavicular
joint. Glenohumeral joint is anatomically aligned.
There is an obliquely oriented fracture through the mid diaphysis of the left
humerus. There is 1 shaft width of posterior displacement. Nondisplaced
fracture component extends to the proximal diaphysis.
Included portion of the left hemi thorax and soft tissues are unremarkable.
IMPRESSION:
Obliquely oriented fracture through the mid-diaphysis of the left humerus with
1 shaft width of displacement. Nondisplaced fracture component extending to
the proximal diaphysis.
Sclerosis of the humeral head suggesting avascular necrosis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with s/p fall, L shoulder/humerus pain // ?fracture, ?ICH
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Gray-white matter differentiation is
preserved. Ventricles and sulci are prominent compatible with global volume
loss. Basilar cisterns are patent. Atherosclerotic calcifications noted
within the intracranial ICAs and vertebral arteries bilaterally.
There are bilateral comminuted and displaced nasal bone fractures. There is
also nasal septal fracture. Fracture seen involving the frontal process of
the maxilla on the right. Skull and extracranial soft tissues are otherwise
unremarkable. Mucosal thickening is noted within the ethmoid air cells and
sphenoid sinuses. Other included paranasal sinuses and mastoids are
essentially clear.
IMPRESSION:
No acute intracranial process.
Bilateral nasal bone and nasal septal fracture and fracture through the
frontal process of the maxilla on the right.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with s/p fall, L shoulder/humerus pain // ?fracture, ?ICH
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 963 mGy-cm.
COMPARISON: ___.
FINDINGS:
There is an acute fracture through the right pedicle of C6 (02:55) which
extends through the transverse foramen (2: 56) containing the vertebral artery
at this level. There is also a lucency through the anterior flowing
osteophytes at the C6-7 level with widening of the intervertebral disc space
which is new since ___.
No other acute fracture is identified.
No other fracture identified. Anterolisthesis of C4 on C5 is chronic. There
is anterior osseous bridging at this the C4, C5, and C6 levels. Large
anterior osteophytes also seen at C2-3 and C3-4.
IMPRESSION:
1. Acute nondisplaced fracture through the right pedicle of C6 extending to
the transverse foramen.
2. Acute fracture through the bridging anterior osteophyte at C6-7 with
widening of the intervertebral disc space, a 2 column injury in this patient
with DISH, new since ___.
RECOMMENDATION(S): CTA neck should be considered to evaluate for underlying
vascular injury.
Radiology Report
EXAMINATION: DX SHOULDER AND HUMERUS
INDICATION: History: ___ with splinted humeral fx? // reduced?
reduced?
TECHNIQUE: Left shoulder two views and left humerus two views
COMPARISON: Left shoulder radiographs dated ___ at 17:43
FINDINGS:
Compared with study of 6 hours prior, there is now a splint overlying the left
upper extremity. Again seen is the obliquely oriented fracture through the mid
diaphysis of the left humerus. Alignment is somewhat improved now with 13 mm
of posterior displacement compared with 22 mm prior.
IMPRESSION:
Obliquely oriented displaced left humeral fracture, with some improvement in
alignment but persistent 13 mm posterior displacement of the distal fragment.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: ___ male with c-spine fracture. Evaluate vascular
injury.
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of 70 mL of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered, curved reformatted
and segmented images were generated. This report is based on interpretation of
all of these images.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
4) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
5) Spiral Acquisition 4.6 s, 35.8 cm; CTDIvol = 35.2 mGy (Head) DLP =
1,260.3 mGy-cm.
Total DLP (Head) = 1,290 mGy-cm.
COMPARISON: CT C-spine from ___.
FINDINGS:
There is minimal atherosclerosis of the aortic arch. There is atherosclerotic
calcification in the bilateral cavernous carotid arteries. There is
atherosclerotic calcification of bilateral V4 vertebral artery segments.
Otherwise, the carotid and vertebral arteries and their major branches are
patent with no evidence of high grade stenoses. No evidence for dissection is
seen.
Atherosclerotic calcification of the bilateral carotid bulbs is seen. By
NASCET criteria, there is less than 50 percent stenosis of the right ICA and
less than 50 percent stenosis of the left ICA.
A 0.9 cm hyperdense extra-axial mass with a focus of calcification is noted in
the anterior left temporal lobe. Multi
Degenerative changes are seen in the cervical spine. The previously described
fractures are again seen and better visualized on the prior study. There is
minimal mucosal thickening of the ethmoids
IMPRESSION:
1. No evidence of vascular injury with the cervical spinal fractures better
visualized on the dedicated CT C-spine.
2. A 0.9 cm hyperdense extra-axial mass with a focus of calcification anterior
to the left temporal lobe a, likely representing a small meningioma.
Radiology Report
INDICATION: History: ___ with unstable cspine fx // r/o impingement
TECHNIQUE: Supine frontal radiograph of the chest
COMPARISON: ___
FINDINGS:
Supine positioning accentuates normal heart size and pulmonary vascular
markings. There is bibasilar atelectasis. No focal consolidation, large
pleural effusion or pneumothorax.
IMPRESSION:
No acute process.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ male with unstable cspine fracture. Rule out
impingement.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: CT C-spine ___ and ___.
FINDINGS:
There is stable grade 1 anterolisthesis of C4 on C5. Flowing anterior
syndesmophytes are seen throughout the cervical and upper thoracic spine.
There is widening of the C6-7 disc space with focal increased angulation at
this level. STIR hyperintense signal is noted in the inferior endplate of the
C6 vertebral body, extending into the disc space. There is focal disruption
of the anterior longitudinal ligament at this level. The posterior
longitudinal ligament is intact. There is focal buckling of the ligamentum
flavum with a focus of increased T2/STIR hyperintense signal at C6-7. In
addition, increased STIR signal is noted in the interspinous space at C6-7.
The right C6 pedicle fracture is better visualized on the prior CT. Trace
prevertebral edema is noted at the level of the lower cervical spine.
Vertebral body heights are preserved. The visualized portion of the spinal
cord is preserved in signal and caliber. There is loss of intervertebral disc
height and signal throughout the cervical spine. Within the limits of this
noncontrast study there is no evidence of infection or neoplasm. The
visualized portion of the posterior fossa, cervicomedullary junction,
paranasal sinuses and lung apicesare preserved. Hypertrophic changes are
noted at C1-2
At C2-3 there is disc osteophyte complex, ligamentum flavum thickening and
facet arthropathy resulting in mild spinal canal and moderate left neural
foraminal stenosis.
At C3-4 there is central disc protrusion, facet arthropathy and ligamentum
flavum thickening results in moderate to severe spinal canal stenosis and
severe bilateral neural foraminal stenosis.
At C4-5 there is uncovering of the disc and facet arthropathy resulting in
moderate right neural foraminal, mild left neural foraminal and L canal
stenosis.
At C5-6 there is bilateral facet arthropathy results in mild-to-moderate
bilateral neural foraminal stenosis.
At C6-7 there is ligamentum flavum infolding and facet hypertrophy with no
significant spinal canal or neural foraminal stenosis.
At C7-T1 there is no spinal canal or neural foraminal stenosis.
Minimal fluid is noted layering in the posterior nasopharynx
IMPRESSION:
1. Fracture through the C6 inferior endplate extending in to the C6-7 disc
space resulting in widening of the disc space and increased angulation at this
level with no significant spinal canal stenosis. At C6-7 there is focal tear
of the anterior longitudinal ligament, ligamentum flavum strain and
high-signal in the interspinous space suggestive of interspinous ligamentous
injury.
No additional sites of ligamentous injury are seen.
2. Normal appearance of the spinal cord.
3. Right C6 pedicle fracture better seen on the prior CT.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with elbow pain, humeral fx s/p injury // eval for
fx/injury eval for fx/injury
TECHNIQUE: Left Elbow, 3 views.
COMPARISON: None available
FINDINGS:
Overlying splint material obscures fine detail. No fracture or dislocation is
identified around the elbow. The mid humeral fracture is partially visualized
at the superior aspect of the image. There is a prominent olecranon spur at
the expected attachment of the triceps tendon.
IMPRESSION:
Limited by overlying splint material. Within that limitation no fracture or
dislocation of the elbow is seen.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with altered mental status // R/O ICH
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, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect or
large territorial infarction. Ventricles and sulci are quite prominent
compatible with age-related atrophy. Periventricular and subcortical white
matter hypodensities are nonspecific but may reflect chronic microvascular
ischemic disease. The basal cisterns are patent. Gray-white matter
differentiation is preserved.
The partially imaged paranasal sinuses, mastoid air cells and middle ear
cavities are grossly clear. Fracture of bilateral nasal bones and nasal
septum is re- demonstrated.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Fracture of bilateral nasal bones and nasal septum is re- demonstrated.
Radiology Report
INDICATION: ___ year old man with new onset hypotension // PTX? PNA?
TECHNIQUE: Portable
COMPARISON: No prior
FINDINGS:
Low lung volumes with minimal subsegmental atelectasis in the lung bases. No
interstitial edema. No pneumothorax. The cardiomediastinal silhouette is
unremarkable. No significant pleural effusions.
IMPRESSION:
No pneumothorax or pneumonia.
Radiology Report
INDICATION: ___ year old man s/p mechanical fall, with unstable spinal
fracture, now with altered mental status and hypotension // rule out PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: mGy-cm
COMPARISON: None
FINDINGS:
There is some heterogeneous enhancement of the thyroid without definite focal
nodule. The esophagus is patulous but otherwise grossly normal. Scattered
lower paratracheal lymph nodes are noted measuring up to 7 mm in short axis
but these are not pathologically enlarged by CT size criteria. There are
prominent left hilar nodes measuring 0.8 x 1.8 cm and 1.3 x 0.8 cm (3:99),
less than 1 cm short axis diameter.
Heart size is mildly enlarged without pericardial effusion. There are
atherosclerotic calcifications of the coronary arteries. The thoracic aorta
and great vessels are normal in caliber with minimal scattered
atherosclerosis. The main pulmonary arteries normal in caliber. The
pulmonary arteries are well opacified to the subsegmental level without
evidence of pulmonary embolism.
There is no pneumothorax. Small area of ground-glass opacification of the
left apex may be inflammatory (series 3, image 41). There is a 1.8 cm gas
containing cyst in the lingula (3:128), 2 mm left upper lobe nodule (3:62),
and calcified granuloma in the right upper lobe (3:75).
There is moderate atelectasis of the lung bases and small bilateral
nonhemorrhagic pleural effusions.
UPPER ABDOMEN: This study is not designed for evaluation of the
subdiaphragmatic structures however the partially visualized solid organs and
stomach are grossly normal. There is small amount of perihepatic ascites
OSSEOUS STRUCTURES: Known fractures of the cervical spine are not appreciated
on this study. There is no worrisome blastic or lytic lesion in the partially
imaged thoracic spine.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Small left apical ground-glass opacity may be inflammatory. 2 mm left
upper lobe nodule. Follow-up can be performed if clinically indicated in ___
months.
3. Moderate bibasilar atelectasis and small bilateral pleural effusions.
4. Mild cardiomegaly. Coronary artery atherosclerosis is severe.
RECOMMENDATION(S): Followup suggested if clinically appropriate in ___
months.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: ACDF C6-C7.
TECHNIQUE: 2 lateral views of the cervical spine obtained in the OR without
radiologist present.
COMPARISON: MRI cervical spine ___
FINDINGS:
The 2 available images show the mid to lower cervical spine. Bulky anterior
osteophytes with fusion seen along the mid cervical spine extending from C4
through C6. Surgical screws are seen positioned at what appears to be the
C6-C7 disc space. Please see the operative report for further details.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man s/p C6-7 ACDF // AP and Lateral xrays eval
Hardware, ACDF AP and Lateral xrays eval Hardware, ACDF
IMPRESSION:
No previous images. There is an anterior fusion at C6-C7 with no evidence of
hardware-related complication. The vertebra and intervertebral disc spaces
are somewhat difficult to assess on the lateral view, with generalized
osteopenia and apparent widespread narrowing with calcification in the
anterior longitudinal ligament. No prevertebral soft tissue swelling is
identified.
Of incidental note is calcification in the region of the carotid bifurcation
bilaterally.
Radiology Report
INDICATION: ___ male with leukocytosis postoperatively.
COMPARISON: Chest radiograph performed ___.
FINDINGS:
Single upright portable AP chest radiograph demonstrates a patchy
consolidations within the lung bases bilaterally, right greater than left,
newly apparent relative to prior examination performed ___.
Blunting of bilateral costophrenic angles may reflect small pleural effusions.
Cardiomediastinal and hilar contours are within normal limits. Bibasilar
atelectasis is moderate. Imaged osseous structures are without an acute
abnormality. Upper abdomen is unremarkable.
IMPRESSION:
Bibasilar patchy consolidations new relative to prior examination performed ___ possibly atelectasis although infectious etiology cannot be
excluded.
Radiology Report
INDICATION: ___ year old man with L spiral humeral fracture managed non op //
assessment of evolution of fracture
TECHNIQUE: Three views of the left humerus and shoulder
FINDINGS:
There is a moderately displaced oblique fracture of the midshaft of the left
humerus with minimal angulation. Fragments are minimally changed in position
since ___. There is equivocal inferior subluxation of the
humeral head from the glenoid which may reflect positioning with no specific
images obtained of the shoulder
IMPRESSION:
Little interval change in displaced and slightly angulated midshaft left
humeral fracture
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Shoulder injury
Diagnosed with FX HUMERUS SHAFT-CLOSED, FX C6 VERTEBRA-CLOSED, UNSPECIFIED FALL, NASAL BONE FX-CLOSED, FX MALAR/MAXILLARY-CLOSE
temperature: 96.3
heartrate: 74.0
resprate: 18.0
o2sat: 96.0
sbp: 147.0
dbp: 80.0
level of pain: 10
level of acuity: 2.0 | === SUMMARY ===
___ y/o male with PMH notable for HTN, DM, Crohn's disease who
presented on ___ with a mechanical fall injuring his face,
neck, and left arm. Work-up revealed L spiral humerus fracture
as well as C6-7 cervical fractures (C6 R pedicle, and C6-7
osteophyte fx with increased intervertebral disc space, and a
focal tear of the anterior longitudinal ligament with
interspinous ligamentous injury), bilateral nasal bone and nasal
septal fractures and fracture through the frontal process of the
maxilla on the right.
=== ACUTE ISSUES ===
#SICU: Patients hospital stay was notable for transfer to SICU
on ___ (pre-op) in the setting of hypotension and AMS.
Initially hypotensive with SBP in ___, had a line placed and
became hypertensive to 190s/90s. BP subsequently normalized to
132/45. CTA chest - negative for PE, CT scan of the head no
intracranial process, has been having loose dark stools that
were found to be guiac positive. Hct was stable at 23.
#Leukocytosis: Patient was transferred to the medical service
for WBC of 16. Was afebrile with no localizing signs of
infection. CXR was performed and compared to CXR in ___ with no
marked change noted in RLL process. C diff was negative in ___
and UA ___ was bland. WBC improved to 8.7 with no interventions
and was consequently felt to represent reactive demargination in
the setting of post surgical stress.
#Hyperglycemia: Patient was additionally transferred to the
medical service for hyperglycemia with blood sugars to mid ___.
This improved with adjustment of insulin sliding scale and
initiation of glargine 10u qhs. Home glipizide was held.
#Hypertension: Patient was additionally transferred to the
medical service for HTN to 190s, otherwise asymptomatic. This
improved with re-initation of home BP medications.
___ on CKD: Patient with diabetic nephropathy. Creatinine
baseline around 1.0 elevated to peak 1.6 in setting of
hypotensive episode on ___ and was downtrending to 1.1 at time
of discharge.
#Anemia: Hgb 8.8 at admission. At 7.2 at time of discharge. No
evidence of bleed noted and no blood was transfused.
# S/S: mild baseline dysphagia for which he is followed by ENT
at ___. Evaluated by s/s earlier in hospital stay who
recommended Regular; Diabetic/Consistent Carbohydrate
Consistency: Pureed (dysphagia); Thin liquids. Of note, they
noted that dysphagia would be worse post op days ___.
Recommended TID oral care and aspiration precautions as follows:
Sit fully upright for all PO intake, small bites/sips, use
repeat swallows if sensation of residue in the throat.
# BPH: Foley removed post op and outpatient terazosin restarted
with no issues with urination at time of discharge.
# Unstable C6-C7 Fracture: Patient was evaluated by neurosurgery
and taken to the operating room for anterir cervical discectomy
and fusion on ___. AP/Lateral C-spine films were completed
___ which showed appropriate placement of the vertebral body
screws. Patient was subsequently kept in hard c-collar (Aspen
collar) at all times with q4h neurochecks.
# Left humerus spiral fracture: Patient was evaluated in ED for
fracture which was managed nonoperatively during hospital stay.
Patient was evaluated by orthopedic surgery in house. He is to
remain in ___ Brace until follow-up. He can use a sling
for comfort.
# Facial fractures: Bilateral nasal bone and nasal septal
fractures and fracture through the frontal process of the
maxilla on the right. Managed non operatively per acute care
surgery recommendations. Patient has plastic surgery follow up
scheduled.
=== CHRONIC ISSUES ===
# Crohn's disease: No flares for last ___ years. Mesalamine was
continued.
# Psych: Home Bupropion (Sustained Release) 150 mg PO QAM was
continued.
# Peripheral neuropathy: Home Gabapentin 300 mg PO/NG QHS was
continued.
# CAD: continued home Pravastatin 10 mg PO QPM
# GERD: continued home Omeprazole 20 mg PO DAILY
# Bowel regimen: Docusate Sodium 100 mg PO BID and Senna 8.6 mg
PO/NG BID.
=== TRANSITIONAL ISSUES ===
****No NSAIDS per neurosurgery****
#) Unstable C6-C7 Fracture: Patient to be kept in hard collar at
all times until follow-up. Patient has follow up scheduled with
Neurosurgery. Please follow up to ensure that patient makes it
to this appointment.
#) Left humerus spiral fracture: Managed nonoperatively. Ortho
recommends follow-up in 1 week with Dr. ___. Pt. to not lift
or carry anything with left arm. Sling for comfort. Maintain
in ___ brace until follow-up.
#) Facial fractures: Managed nonopertively during hospital stay.
Patient to follow up with plastic surgery. Please ensure that
patient makes it to this appointment.
#) Dysphagia: Patient with mild baseline dysphagia for which he
is followed by ENT at ___. Evaluated by s/s earlier in hospital
stay who recommended Regular; Diabetic/Consistent Carbohydrate
Consistency: Pureed (dysphagia); Thin liquids. Of note, they
noted that dysphagia can be worse post op days ___. Recommended
TID oral care and aspiration precautions as follows: Sit fully
upright for all PO intake, small bites/sips, use repeat swallows
if sensation of residue in the throat. Please monitor for
worsening dysphagia and intervene as clinically warranted.
#) Anemia: Patient admitted with hgb 8.8 and was 7.2 at time of
discharge. No evidence of bleed. Please perform CBC on ___
and transfuse if clinically warranted.
#) DVT Prophylaxis: Continue lovenox 40mg SC Daily for 4 weeks.
# CODE: Full code, confirmed.
# CONTACT: HCP ___ (___) |
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, right facial droop
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
___ ___ M with a h/o RH M with a h/o stroke
treated with tPA in ___ (right facial droop and right
hemiparesis, no residual deficits on discharge from ___,
bradycardia s/p pacemaker placement, Afib on dabigatran who
presents from his assissted living facility after the onset of
right facial droop and right sided weakness and altered mental
status occurring sometime between 1pm and 1:40pm today. The
patient was reportedly in his usual state of health, which is
relatively independent (does not need many services at his
assissted living facility), when he was noted to have these
symptoms while eating lunch. The report of events is not
entirely
clear, the patient may have had a seizure at the facility, but
it
is not clear whether this occured before or after the onset of
the right sided weakness. EMS was called and he was brought to
___. He was noted to have an episode of staring, right arm
tightness and lip smacking noted en route. Upon evaluation in
the
ED I witnessed a seizure which started with eye deviation and
head version to the right and proceeded to full body
convulsions.
He was given 2mg ativan and the spell abated after roughly 1.5
minutes. The patient was then intubated for airway protection in
the ED.
Unable to obtain ROS ___ obtundation
Past Medical History:
bradycardia s/p pacemaker placement
ischemic stroke ___ treated with tPA
Afib on dabigatran
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals:
98.0 ___ 72 ___ 100%
GEN: eyes closed, unresponsive
HEENT: Blood from mouth over right chin, anicteric
NECK: Supple
RESP: coarse airway sounds prior to intubation
CV: irregularly irregular
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS: (prior to intubation)
Eyes closed, does not open eyes to voice or noxious stim. He
does
grimace. Does not follow commands or attend to examiner.
CN: (exam following intubation and sedation, off propofol for
short time)
II:
PERRLA 4 to 2mm and brisk.
Unable to elicit VOR, weak corneal on right, intact on left.
Cough present.
Motor/Sensory:
There is symmetric low tone in the BUE, mildly increased tone
symetrically in the BLE
There are initially some purposely movements of the right arm
against gravity. Both legs withdrawal to light noxious
stimulation. Unable to examine left arm prior to sedation.
Following intubation when off propofol for a short time there is
grimace to noxious stimuli in BUE, but no withdrawal. There is
withdrawal vs. triple flexion to noxious of BLE with better
strength on the left.
Reflexes are 2+ and symmetric, toes are upgoing ___
~~~~~~~~~~~~~~~~~~~~~~~~~~~
DISCHARGE EXAM
MS: A&O to self, month, ___, able to follow simple commands
without difficulty. Language was fluent with no paraphasic or
neologistic errors.
Motor:
There is symmetric low tone in the BUE, mildly increased tone
symetrically in the BLE.
Delt Bic Tri WrE WrF FFl FE IO IP Quad Ham TA
L 5 4+ 5 5 4+ ___ 4+ 5 ? 5
R 5 ___- ___ ___ 5 5
Sensation: Intact to light touch in all without any distribution
of deficit.
Reflexes are 2+ and symmetric, toes are up on right, mute on
left
Pertinent Results:
___ 02:00PM BLOOD WBC-8.4 RBC-4.94 Hgb-15.5 Hct-45.3 MCV-92
MCH-31.4 MCHC-34.2 RDW-15.1 Plt ___
___ 02:00PM BLOOD ___ PTT-42.7* ___
___ 09:44AM BLOOD ___ PTT-145.3* ___
___ 12:52PM BLOOD ___ PTT-107.3* ___
___ 04:13PM BLOOD ___ PTT-39.7* ___
___ 01:54AM BLOOD Glucose-115* UreaN-9 Creat-0.7 Na-141
K-3.6 Cl-109* HCO3-25 AnGap-11
___ 01:54AM BLOOD ALT-48* AST-56* CK(CPK)-74 AlkPhos-104
TotBili-0.9
___ 02:00PM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.8 Mg-2.1
___ 01:54AM BLOOD %HbA1c-5.3 eAG-105
___ 01:54AM BLOOD Triglyc-60 HDL-44 CHOL/HD-2.2 LDLcalc-42
___ 09:23PM BLOOD Phenyto-16.4
___ 02:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 02:59AM BLOOD Type-ART Temp-37.0 Rates-/14 Tidal V-460
PEEP-5 FiO2-40 pO2-188* pCO2-41 pH-7.41 calTCO2-27 Base XS-1
Intubat-INTUBATED Vent-SPONTANEOU
___ 02:10PM BLOOD Glucose-135* Na-142 K-4.2 Cl-103
calHCO3-23
CTA ___
CT head: No evidence of hemorrhage. Atrophy. Right parietal bone
sclerosis
could be due to Paget's disease but clinical correlation
recommended to
exclude bony metastatic disease. Comparison with prior imaging
would be
helpful. Bone scan can be helpful for better assessment if no
prior studies are available.
Somewhat limited normal CT perfusion of the head. No significant
abnormality on CT angiography of the head and neck.
LENIs ___ - unremarkable for any DVT or other thrombosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Tolterodine 1 mg PO BID
4. Magnesium Oxide 400 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain, fever >101
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever >101
2. Atorvastatin 10 mg PO DAILY
3. Apixaban 5 mg PO BID
4. LeVETiracetam 1000 mg PO BID
5. QUEtiapine Fumarate 25 mg PO BID:PRN agitation
6. Magnesium Oxide 400 mg PO DAILY
7. Tolterodine 1 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
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: CTA HEAD AND NECK WITH PERFUSION
INDICATION: History: ___ with ams, facial droop, seizure // eval bleed
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of cc 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: 3912 mGy-cm; CTDI: 310 mGy
COMPARISON: None.
FINDINGS:
CT of the head shows no evidence of hemorrhage. Brain atrophy seen. Small
vessel disease noted. Note is made of cortical thickening and sclerosis of the
right parietal bone predominantly limited to the external table.
CT perfusion imaging demonstrates slightly delayed mean transit time in the
left cerebral hemisphere MPRAGE impressions twelfth normal blood flow and
blood volume appears artifactual.
CT angiography of the neck demonstrates no evidence of occlusion or stenosis
in the carotid or vertebral arteries. Extensive degenerative changes are
identified.
CT angiography of the head shows no evidence of vascular occlusion stenosis or
aneurysm > 3 mm in size in the arteries of the anterior or posterior
circulation
IMPRESSION:
CT head: No evidence of hemorrhage. Atrophy. Right parietal bone sclerosis
could be due to Paget's disease but clinical correlation recommended to
exclude bony metastatic disease. Comparison with prior imaging would be
helpful. Bone scan can be helpful for better assessment if no prior studies
are available.
Somewhat limited normal CT perfusion of the head. No significant abnormality
on CT angiography of the head and neck.
Radiology Report
INDICATION: Status post intubation. Evaluate positioning of the endotracheal
tube.
TECHNIQUE: Single semi-upright AP view of the chest.
COMPARISON: Chest radiograph from ___.
FINDINGS:
An endotracheal tube is in satisfactory position approximately 4 cm from the
carina. An enteric tube courses below the diaphragm with the tip out of the
field of view. A new retrocardiac opacity is present, and may represent
atelectasis. There may be a component of a small left pleural effusion.
There is no right pleural effusion. The lungs are otherwise clear. There is
no pulmonary edema or pneumothorax. The mediastinal contours are normal. The
heart is mildly enlarged, and unchanged. A left-sided cardiac device and its
wires are also unchanged.
IMPRESSION:
1. Satisfactory position of the endotracheal tube.
2. New retrocardiac opacity, which is presumably atelectasis. Aspiration or
pneumonia cannot be completely excluded. There may be a tiny left pleural
effusion. Attention on followup radiographs is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke // NG tube placement. NG tube
placement.
IMPRESSION:
In comparison with the study of there has been placement of ___, the a
nasogastric tube that extends well into the stomach with the side hole distal
to the esophagogastric junction. Retrocardiac opacification is consistent with
volume loss in the left lower lobe and some associated pleural effusion. Mild
atelectatic changes are seen on the right.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with seizure/stroke. // left lower extremity
swelling?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
of the lower extremity veins bilaterally.
COMPARISON: Bilateral leg ultrasound ___
FINDINGS:
There is normal compressibility, flow and augmentation of bilateral common
femoral, femoral, and popliteal veins. Visualization of the calf veins is
limited bilaterally. No DVT is seen in the right calf veins which are only
partially visualized. The left calf veins could not be identified.
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 either leg. Note is made of
limited visualization of the calf veins bilaterally.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with prior strokes, sz. pulled his ng, requiring
replacement. // eval ng replacement eval ng replacement
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
The transesophageal drainage tube has been partially withdrawn, now ending at
the gastroesophageal junction, and needs to be advanced 12 cm. Increasing
opacification at the base the right lung is concerning for possible
aspiration, transforming into pneumonia. Heterogeneous consolidation of the
left lung base is unchanged, for another likely focus of aspiration. Small
pleural effusions are presumed. Upper lungs are clear. Heart size is normal.
No pneumothorax.
Transvenous right atrial and right ventricular pacer leads follow their
expected courses, unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recently placed NGT, s/p self dc'ed NGT 2
hours ago. // NGT placement NGT placement
COMPARISON: Chest radiographs since ___ most recently ___, through 18:43.
IMPRESSION:
NG tube ends in mildly distended upper stomach. Mild cardiomegaly is chronic.
Aeration of the lung bases is compromised, by atelectasis reflecting elevation
of the diaphragm. Pneumonia is not excluded of course. Pleural effusions are
presumed, but not substantial in size. There is no pneumothorax.
Transvenous right atrial and right ventricular pacer leads follow their
expected courses.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: STROKE
Diagnosed with OTHER CONVULSIONS, SEMICOMA/STUPOR, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ ___ M with a h/o RH M with a h/o stroke
treated with tPA in ___ (right facial droop and right
hemiparesis, no residual deficits on discharge from ___,
bradycardia s/p pacemaker placement, Afib on dabigatran who
presents from his assisted living facility after the onset of
right facial droop and right sided weakness and altered mental
status occurring sometime between 1pm and 1:40pm. It is not
clear whether these symptoms preceded or followed reported
seizure activity. He was witness to have a seizure in the ED
with head version and eye deviation to the right followed by
generalized convulsions, perhaps stronger on the right than
left. Initial exam was limited by seizure followed by sedation
and intubation, however in the brief exam prior to the seizure
he did not appear to have any syndrome indicating ischemia of a
large vascular territory. ___ and CTA head and neck did not
show any evidence of hemorrhage or vessel cut off. DDx includes
ischemic stroke with secondary seizure activity vs. primary
seizure with resulting right sided ___ paralysis. He was not
a candidate for IV tPA due to treatment with dabigitran.
He was loaded with dilantin (20mg/kg) and admitted to the ICU.
Continuous EEG showed mild encephalopathy and intermittent L
slowing/FIRDA. He was extubated the next morning with no
complications. Dilantin 100TID was transitioned to Keppra
1000bid. UA showed 20WBCs and 74 RBCs. He was started on a 7 day
course of ceftriaxone. EEG was discontinued. He was initially
treated with a heparin gtt secondary to not being able to
swallow dabigitran while intubated. He failed his swallow study
so he was transitioned to apixaban because it can be
administered via an NG tube. He was transferred to the floor
with no complications.
On the floor he passed Speech/Swallow eval and was able to take
adequate feeds without any signs of aspiration. He was
discharged to acute rehab on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Chloroquine
Attending: ___.
Chief Complaint:
mechanical fall down 10 steps with head strike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male who BIBEMS complains of
FALL. he tripped and fell down 10 concrete stairs this
morning, landed on his face. Per EMS: no LOC and slow to
respond. Denies other complaints.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS 99.7 84 139/56 16 98 RA
Gen: Well appearing, in no acute distress
CV: RRR
Pulm: CTAB
GI: Soft, NTND
HEENT: facial abrasions/lacerations described, midface
stable, no malloclusion
no cspine tenderness
Extr/Back: no hip or pelvic tenderness
Skin: left zygoma and forehead abrasions, deep upper lip
laceration 1cm dose not cross ___ border
Neuro: Speech fluent, ___ strength in all extremities, sensation
intact throughout
Pertinent Results:
___ 08:10AM BLOOD WBC-5.4 RBC-4.40* Hgb-12.9* Hct-39.4*
MCV-90 MCH-29.3 MCHC-32.7 RDW-12.9 RDWSD-42.2 Plt ___
___ 08:10AM BLOOD ___ PTT-27.1 ___
___ 08:10AM BLOOD UreaN-15 Creat-1.2
___ 08:10AM BLOOD estGFR-Using this
___ 08:10AM BLOOD Lipase-35
___ 08:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:14AM BLOOD pH-7.44
___ 08:14AM BLOOD Glucose-101 Lactate-1.3 Na-137 K-5.9*
Cl-103 calHCO3-24
IMAGING
CXR (___)
IMPRESSION:
No acute cardiopulmonary process.
Head CT (___)
IMPRESSION:
No sequela of acute trauma. No acute territory infarct or
intracranial
hemorrhage.
CT max/face (___)
IMPRESSION:
A small left frontal subgaleal hematoma. No evidence of
maxillofacial
fracture.
CT c-spine (___)
IMPRESSION:
1. No acute fracture, malalignment, or prevertebral soft tissue
abnormality of
the cervical spine.
2. Please note, if there is high clinical concern for
ligamentous injury, MRI
may be more sensitive if there are no contraindications.
Right hand XR (___)
IMPRESSION:
No acute fracture or dislocation.
Left knee XR (___)
IMPRESSION:
No acute fracture or dislocation.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. irbesartan 300 mg oral daily
3. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. irbesartan 300 mg oral daily
4. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical fall with headstrike
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Tripped and fall down 10 steps
TECHNIQUE: Portable supine AP view of the chest
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
Heart size is mildly enlarged. Aorta is tortuous. Mediastinal and hilar
contours are otherwise unremarkable. Cephalization of pulmonary vasculature
is likely due to supine positioning. No pulmonary edema, focal consolidation,
large pleural effusion or pneumothorax is present. No acute osseous
abnormality is present.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: Evaluate for traumatic injury in a patient status post fall.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 20.0 cm; CTDIvol = 45.1 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
mass effect. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is a small mucous retention cyst in
the left maxillary sinus. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are otherwise clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
No sequela of acute trauma. No acute territory infarct or intracranial
hemorrhage.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: Evaluate for traumatic injury in a patient status post fall.
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 2.9 s, 23.0 cm; CTDIvol = 26.0 mGy (Head) DLP = 599.2
mGy-cm.
Total DLP (Head) = 599 mGy-cm.
COMPARISON: None.
FINDINGS:
SOFT TISSUES: There is a 7 mm left frontal subgaleal hematoma. There is no
fluid collection or other soft tissue abnormality.
MAXILLOFACIAL BONES: The maxillofacial bones are intact, without fracture.
The zygomatico-maxillary complex is intact. The lateral pterygoid plates are
intact.
MANDIBLE: The mandible is without fracture or temporomandibular joint
dislocation. The temporomandibular joints are symmetric, without significant
degenerative change.
DENTITION: There are no dental fractures.Ossific fragment within the floor of
the left maxillary sinus in the expected location ___ ___ represent
residual root. There is no remarkable periodontal disease, periapical
lucency, or odontogenic abscess.
SINUSES: There is a small mucous retention cyst in the left maxillary sinus
and mild mucosal thickening in the right maxillary sinus. The paranasal
sinuses are otherwise intact and clear. The ostiomeatal units are patent. The
mastoid air cells and middle ear cavities are clear.
NOSE: There is no nasal bone fracture. Nasopharyngeal soft tissues are
unremarkable. There is no nasal septal hematoma.
ORBITS: The orbits, including the laminae papyracea, are intact. The globes
are intact with non-displaced lenses and no intraocular hematoma. There is no
preseptal soft tissue edema. There is no retrobulbar hematoma or fat
stranding.
Allowing for imaging technique optimized for the face, the limited included
portion of the brain is grossly unremarkable.
IMPRESSION:
A small left frontal subgaleal hematoma. No evidence of maxillofacial
fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: Evaluate for traumatic injury in a patient status post fall.
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 6.1 s, 23.8 cm; CTDIvol = 37.3 mGy (Body) DLP = 890.3
mGy-cm.
Total DLP (Body) = 890 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no acute fracture or malalignment of the cervical spine. Is not
dental ossification of the nuchal ligament posterior to the C5 and C6 spinous
processes. Multilevel degenerative spondylosis is identified, most prominent
at is C5-C6 where a prominent posterior disc protrusion and thickening of
ligamentum flavum results in a mild to moderate spinal canal narrowing,
effacing the ventral thecal sac. Uncovertebral facet arthropathy results in
moderate right and mild left neural foraminal narrowing. There is no
prevertebral soft tissue swelling.Incidental note is made of bilateral
retropharyngeal courses of the cervical internal carotid arteries.
IMPRESSION:
1. No acute fracture, malalignment, or prevertebral soft tissue abnormality of
the cervical spine.
2. Please note, if there is high clinical concern for ligamentous injury, MRI
may be more sensitive if there are no contraindications.
Radiology Report
INDICATION: History: ___ fall ___ steps
TECHNIQUE: Left knee, three views
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is present. Moderate degenerative changes
are seen primarily involving the medial and patellofemoral compartments with
degenerative spurring. There is a small suprapatellar joint effusion. No
concerning lytic or sclerotic osseous abnormality is detected. No radiopaque
foreign body is visualized.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
INDICATION: History: ___ with fall
TECHNIQUE: Right hand, three views
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is present. Subchondral lucency involving
the ulnar aspect of the base of the proximal phalanx of the small finger
likely reflects a subchondral cyst. Joint spaces are maintained. Minimal
degenerative spurring is seen at the first CMC joint. No radiopaque foreign
body or soft tissue calcification is present.
IMPRESSION:
No acute fracture or dislocation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with Concussion without loss of consciousness, initial encounter, Unspecified injury of head, initial encounter, Laceration without foreign body of lip, initial encounter, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ presented after a mechanical fall with head strike.
His head and c-spine CT did not show any acute abnormality. He
also complained or right arm and left knee pain but the Xrays
did not show any abnormalities. The CT scan and Xray of his face
did not show any evidence of maxillofacial fracture. Due to
slowness to respond on initial presentation, he was seen by the
neurocognitive team who recommended he followup as an
outpatient. His pain was controlled, he was ambulating, voiding
and he was discharged home with followup instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
facial drooping
Major Surgical or Invasive Procedure:
Lumbar Puncture (___)
PICC line placement (___)
History of Present Illness:
___ w/protein S deficiency on coumadin presents for LP. Pt had
erythema migrans and positive Lyme titers in ___ and was
treated with 21 days of doxycycline. However, he continued to
have symptoms including fever and last few weeks had developed
Right facial numbness and drooping. MRI ___ showed enhancement
of Right facial nerve and trigeminal nerve consistant with Lyme
disease. He went to see neurologist on ___ who recommended
starting ceftriaxone for neuro-Lyme and LP but LP delayed due to
therapeutic INR. Pt received his third dose of CTX today.
.
In ED pt had LP, cell count indicates viral meningitis; all
viral titers/lyme antibody pending. Gram stain NEGATIVE for
organisms.
.
On arrival to floor pt reports sx improved since starting CTX.
Facial droop now intermittent, mostly resolved. But lack of
taste on right side on tongue. Overall he feels at his recent
baseline. He would like to go home. He had not planned on
being admitted. He was told by outpatient providers to have LP
done in ED and to return home and to follow plan for outpt IV
abx daily at ___ and then to have PICC line placed as
an outpatient on ___, to start home infusion CTX on
___.
.
ROS: + as above, otherwise reviewed and negative
Past Medical History:
Childhood asthma
Seasonal allergies
L knee surgeries for torn ACL
Protein S Deficiency
Social History:
___
Family History:
Father had a blood clot. M. grandfather with pancreatic cancer.
Physical Exam:
AVSS
PAIN: 4
General: nad, speeking in full sentences
HEENT: op clear
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: wwp, no e/c/c
Skin: no rash
Neuro: strength intact, alert, follows commands, answering
questions appropriately, no facial droop
Discharge Day Exam:
VS: 97/3, 126/723, 58, 16, 100% on RA
Pain: ___
Gen: NAD, comfortable, lying in bed, converstant
HEENT: anicteric, MMM
Neck: no LAD, no nuchal rigidity
CV: RRR, no murmur
Lungs: CTAB/L
And: soft, NT, ND NABS
Ext: WWP, no edema, RUE ___ site with dressing C/D/I
Neuro: AAOx3, fluent speech, no facial droop
Pertinent Results:
Bloodwork:
___ 04:11PM CEREBROSPINAL FLUID (CSF) WBC-81 RBC-9*
POLYS-0 ___ ___ 04:11PM CEREBROSPINAL FLUID (CSF) WBC-73 RBC-2*
POLYS-0 ___ ___ 08:10PM WBC-6.9 RBC-4.56* HGB-13.5* HCT-40.3 MCV-88
MCH-29.5 MCHC-33.3 RDW-13.0
___ 08:10PM PLT COUNT-259
___ 11:11AM BLOOD ___ PTT-39.6* ___
___ 06:50AM BLOOD CRP-12.1*
___ 06:50AM BLOOD ESR-27*
.
Outpatient MR ___ ___
IMPRESSION:
Asymmetric abnormal enhancement of the right facial nerve in its
intracanalicular portion and distally. Given asymmetric
enhancement of the right trigeminal nerve as well, this would
support Lyme disease as underlying cause in patient with this
history.
.
.
PCXR (___)
FINDINGS: There has been placement of a right-sided PICC line
with distal lead tip at the distal SVC. The heart size is
within normal limits. There are no pneumothoraces. There are
parenchymal lung sutures within the right upper lobe.
.
CSF Studies
___ 04:11PM CEREBROSPINAL FLUID (CSF) WBC-73 RBC-2* Polys-0
___ ___ 04:11PM CEREBROSPINAL FLUID (CSF) WBC-81 RBC-9* Polys-0
___ ___ 05:22PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1
CONVERTING ENZYME-PND
___ 04:11PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
___ 04:11PM CEREBROSPINAL FLUID (CSF) BORRELIA BURG___
ANTIBODY INDEX FOR CNS INFECTION-PND
___ Gram stain: no organisms, no polys
___ Culture: no growth to date, final PENDING
.
___ Flow Cytometry: PENDING
___ 04:11PM CEREBROSPINAL FLUID (CSF) IPT-PND
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
2. Warfarin 11.25 mg PO DAILY16
3. Enoxaparin Sodium 100 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
4. Metadate ER (methylphenidate) 10 oral daily
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
2. Enoxaparin Sodium 100 mg SC Q12 HOURS Start: ___, First
Dose: Next Routine Administration Time
3. Warfarin 15 mg PO DAILY16 Duration: 3 Days
start on ___
4. CeftriaXONE 2 gm IV DAILY
RX *ceftriaxone 2 gram 2 grams IV daily Disp #*24 Unit
Refills:*0
5. Nicotine Patch 21 mg TD DAILY
6. Heparin Flush (10 units/ml) 5 mL IV DAILY each lumen on days
medications NOT administered
each lumen on days medications NOT administered
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
5 ml IV daily Disp #*24 Syringe Refills:*0
7. Heparin Flush (10 units/ml) 5 mL IV DAILY after medication
infusion
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
5 ml IV daily Disp #*24 Syringe Refills:*0
8. Sodium Chloride 0.9% Flush 10 mL IV DAILY before AND after
every medication administration
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 10 ml IV
twice daily Disp #*48 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Presumed Neuro Lyme / Lyme Meningitis
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: Patient with PICC line placed.
FINDINGS: There has been placement of a right-sided PICC line with distal
lead tip at the distal SVC. The heart size is within normal limits. There
are no pneumothoraces. There are parenchymal lung sutures within the right
upper lobe.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: +LYME TITER
Diagnosed with LYME DISEASE
temperature: 97.6
heartrate: 77.0
resprate: 16.0
o2sat: 100.0
sbp: 154.0
dbp: 95.0
level of pain: 0
level of acuity: 3.0 | ___ w/protein S deficiency on Coumadin, recent Lyme diagnosis,
s/p course of doxycycline, then developed persistent symptoms,
including facial droop, with imaging c/w neuro-Lyme, started on
IV ceftriaxone as outpatient, admitted after seeking LP in the
ED.
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Verapamil / Lisinopril / Cozaar / tramadol / acetaminophen /
ibuprofen
Attending: ___.
Chief Complaint:
Alcohol Detoxification
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of alcohol abuse, HTN, HLD, DM2 and
hemochromatosis who presents to the ED with request of alcohol
detox.
The patient has had a long history of alcohol abuse with 3
detoxifications in the past, most recently 2 weeks ago at ___.
He has been trying to cut back his drinking and would like
assistance with a detox program. He normally drinks ___ vodka
drinks per ___, with binges of around 12 drinks on weekends. He
has not successfully been abstinent for the past few years--he
went to a alcohol cessation program at ___ ___ years
ago but he only remained sober for 3 days. He has never had
seizures or DTs with his withdrawals. His last drink was at 2am
this morning. He denies other drug use. Denies any falls or
trauma recently. ROS is only positive for poor PO intake (has
been eating lots of Ramen noodles) and no BM for several days.
Otherwise having mild nausea and tremors.
In the ED, initial vitals: 96.5 154 114/80 16 99% RA.
Labs were notable for: alcohol level of 395, creatinine 1.3
(baseline 0.9), positive anion gap with bicarb of 24, elevated
LFTs up from baseline with ALT 101, AST 180, Tbili 1.6, lipase
of 156, negative urine tox screen, negative UA, lactate of 3.2.
CXR showed atelectasis but no findings concerning for pneumonia.
He was given:
___ 03:44 IV Diazepam 20 mg
___ 03:59 IV Thiamine 100 mg
___ 03:59 IVF 1000 mL NS 1000 mL
___ 04:27 IV Metoclopramide 10 mg
___ 05:11 IV FoLIC Acid 1 mg
___ 05:12 IVF 1000 mL NS 1000 mL
___ 05:25 IV Magnesium Sulfate 4 gm
___ 07:22 IV Diazepam 10 mg
___ 07:22 IVF 1000 mL NS 1000 mL
___ 07:57 IV Diazepam 10 mg
___ 09:13 IV Diazepam 10 mg
Given his high diazepam requirments and ongoing tachycardia he
was admitted to the ICU for phenobarbital protocol. On transfer,
vitals were: afebrile 122 132/84 17 95% Nasal Cannula.
On arrival to the MICU the patient is comfortable without acute
complaints.
Past Medical History:
EtOH abuse, no known hx of DTs or seizures
HTN
HLD
DM2
Hemochromatosis, compound heterozygosity for the ___ mutation
and the H63D mutation in HFE, last with phlebotomy several
months ago
Cervical DJD
Social History:
___
Family History:
Brother - lung ca
Mother - DM, MI
Father - DM, HTN, Prostate ca
Sister - DM
Physical ___:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 117 134/96 21 94% on RA
GENERAL: Alert, oriented, no acute distress; mild tremor of
outstretched hands
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAMINATION:
VS 98.7 ___ 14 94%RA
Gen: Alert, oriented, fidgety, mild tremor with outstretched
arms, tongue tremulous
HEENT: MMM, no JVD
LUNGS: CTAB
CV: RRR, S1 and S2, no m/r/g
ABD: Soft, BS+, NT, ND
EXT: WWP, mild tremor with out stretched arms
Pertinent Results:
==ADMISSION LABS==
___ 03:30AM BLOOD WBC-8.0# RBC-4.24* Hgb-14.6 Hct-41.4
MCV-98 MCH-34.4* MCHC-35.3 RDW-13.9 RDWSD-50.4* Plt ___
___ 03:30AM BLOOD Neuts-49.1 ___ Monos-10.2 Eos-1.1
Baso-0.4 Im ___ AbsNeut-3.93 AbsLymp-3.13 AbsMono-0.82*
AbsEos-0.09 AbsBaso-0.03
___ 03:30AM BLOOD ___ PTT-28.0 ___
___ 03:30AM BLOOD Glucose-183* UreaN-10 Creat-1.3* Na-132*
K-4.8 Cl-90* HCO3-23 AnGap-24*
___ 03:30AM BLOOD Albumin-4.3 Calcium-8.7 Phos-2.8 Mg-1.2*
___ 03:30AM BLOOD ALT-101* AST-180* AlkPhos-124
TotBili-1.6* DirBili-0.5* IndBili-1.1
___ 03:30AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:41AM BLOOD Lactate-3.2* K-4.3
___ 03:30AM BLOOD Lipase-156*
==DISCHARGE LABS==
___ 02:38AM BLOOD WBC-4.5 RBC-3.46* Hgb-11.8* Hct-34.4*
MCV-99* MCH-34.1* MCHC-34.3 RDW-13.8 RDWSD-50.6* Plt ___
___ 02:38AM BLOOD ___ PTT-28.4 ___
___ 02:38AM BLOOD Glucose-143* UreaN-7 Creat-1.0 Na-137
K-4.3 Cl-101 HCO3-22 AnGap-18
___ 02:38AM BLOOD Calcium-8.0* Phos-1.3* Mg-1.5*
___ 02:38AM BLOOD ALT-76* AST-135* AlkPhos-101 TotBili-2.0*
___ 02:45AM BLOOD Lactate-1.5
==IMAGING==
CHEST XRAY ___
No acute cardiopulmonary process. New atelectasis of most
likely right middle lobe (less likely right lower lobe). No
definitive consolidation to suggest infection demonstrated.
RUQ US ___
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
Note that ultrasound is insensitive to detection of focal
lesions in the liver secondary to diffuse increased
echogenicity.
2. Cholelithiasis. No cholecystitis.
3. Possible tiny angiomyolipoma within the right kidney.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 80 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO QHS
3. Hydrochlorothiazide 25 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Codeine Sulfate 30 mg PO TID:PRN head/neck pain
7. Aspirin 81 mg PO DAILY
8. Magnesium Oxide 800 mg PO DAILY
9. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO QHS
4. Thiamine 100 mg PO DAILY
5. Codeine Sulfate 30 mg PO TID:PRN head/neck pain
6. Diltiazem Extended-Release 360 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Magnesium Oxide 800 mg PO DAILY
9. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Alcohol Detoxification
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Diabetes Mellitus, Type II
Hemochromatosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with tachycardia // eval for consolidation
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
The cardiomediastinal and hilar contours are normal. There is no pleural
effusion or pneumothorax. Lung volumes are low, but there is no focal
consolidation concerning for pneumonia. New right middle lobe opacities
located medially and giving the decrease in the position of the minor fissure
might represent atelectasis potentially of right middle lobe or of right lower
lobe. No other focal consolidations demonstrated.
Pulmonary vasculature is within normal limits. The upper abdomen is
unremarkable.
IMPRESSION:
No acute cardiopulmonary process. New atelectasis of most likely right middle
lobe (less likely right lower lobe). No definitive consolidation to suggest
infection demonstrated.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with transaminitis, hemochromatosis, ETOH // ?
acute pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___ and GU ultrasound from ___.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass given limitations of the diffusely echogenic
liver. The main portal vein is patent with hepatopetal flow. There is no
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD is not
visualized.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: 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 13 cm.
KIDNEYS: The right kidney measures 10.5 cm. The left kidney measures 10.3 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. 6 mm echogenic focus in the mid polar region of the right kidney
may represent a tiny AML. There is no evidence stones, or hydronephrosis in
the kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination. Note that ultrasound is insensitive to
detection of focal lesions in the liver secondary to diffuse increased
echogenicity.
2. Cholelithiasis. No cholecystitis.
3. Possible tiny angiomyolipoma within the right kidney.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ETOH
Diagnosed with Tachycardia, unspecified, Alcohol dependence with withdrawal, unspecified
temperature: 96.5
heartrate: 154.0
resprate: 16.0
o2sat: 99.0
sbp: 114.0
dbp: 80.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ presented to the hospital for alcohol detoxification. He
was admitted to the intensive care unit and started on
phenobarbital. Approximately 20 hours after admission to the
ICU, he requested to leave. The medical team explained that it
would be recommended for him to remain in the hospital and
explained that leaving would be against medical advice. He
related that he understood this and still wished to leave the
hospital. The risks of leaving the hospital were explained
(including seizures, delirium tremens, death) and he was
encouraged to return in the event of a seizure, excessive
tremors, or other concerning symptoms.
# Alcohol Abuse/Withdrawal: Pt presented requesting alcohol
detoxification. He had recently attempted detox at ___ 2
weeks ago. On admission to the intensive care unit, patient
with tachycardia, tremors, and nausea consistent with
withdrawal. Requests detox and seems motivated to quit drinking.
He was started on the phenobarbital protocol. He got IVF as
needed. He was also started on IV thiamine and oral folate and
multivitamin. Approximately 20 hours after admission to the
intensive care unit, the pt requested to leave. The medical
team explained that he was still displaying signs of active
alcohol withdrawal and that remaining in hospital would be
recommended. He endorsed an understanding of the risks of
leaving including resuming alcohol abuse, seizures, delirium
tremens, and death if he has a seizure and is not found. He was
advised to return to the hospital if he has seizures, DTs,
tremors, or other concerning symptoms.
# Anion Gap Metabolic Acidosis with Metabolic Alkalosis: Patient
with lactic acidosis to 3.2 on admission. He has had persistent
elevated lactate in past admissions, attributed to metformin use
in setting of liver dysfunction and intermittent hypovolemia.
Also has metabolic alkalosis which could be due to vomiting vs.
dehydration with increased aldosterone stimulation. His lactate
was 1.5 on discharge.
# Transaminitis: On admission the patient had a mild
transaminitis. This was stable and likely alcohol related but
may also be related to hemochromatosis. He had an elevated
bilirubin, which may have been the result of a hemolyzed
laboratory specimen. He had a RUQ US showing steatosis and
cholelithiasis without evidence of cholecysitis.
# ___: On admission, patient with mild ___, likely prerenal. He
was given IVF and his valsartan was held. On discharge, his
creatinine was back to baseline (1.0).
# Hyponatremia: On admission the pt had a sodium of 132. This
likely represented hypovolemic hyponatremia and was 137 on
discharge.
# HTN: On HCTZ, diltiazem, valsartan and metoprolol at home.
Valsartan and HCTZ were held in the setting of ___. Diltiazem
was held given boardline BPs. The pt's ___ resolved prior to
admission to ___ and valsartan were resumed on discharge. The
pt's BP was 150s/110s on discharge, so diltiazem was resumed.
# DM2: Had been on metformin the patient says his PCP wants to
restart it. However, given lactic acidosis and renal failure,
held in hospital and will not be started on discharge.
TRANSITIONAL ISSUES
- Pt left hospital against medical advice.
- Pt should follow up with primary care physician within ___ week.
- Pt should have ongoing care for alcohol detoxification and
abstinence.
- Possible liver steatosis seen on ___ ultrasound. This finding
may require additional work up.
- Possible tiny angiomyolipoma within the right kidney seen on
RUQ US. This finding may require further work up.
- Recommended that pt take daily multivitamin.
- Code: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Right tibia IM nail
History of Present Illness:
___ presents as transfer from OSH complaining of R leg pain.
Patient was playing soccer at around 7PM yesterday evening when
he was "tackled hard" and experienced immediate onset of RLE
pain. He was taken initially to ___ where ED
workup revealed a R midshaft tib/fib fracture and at that time
he was transferred to ___ for further workup. He denies any
other symptoms at this time.
Past Medical History:
Denies
Social History:
___
Family History:
Non contributory
Physical Exam:
Afebrile, Vital signs stable
Gen: no actue distress
Musculoskeletal:
___
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
RLE splint intact
Pertinent Results:
___ RLE Post reduction 2 views:
The distal tibial fracture shows near full shaft-width posterior
displacement of the major distal fragment, with slight anterior
apex angulation, but no medial or lateral displacement.
The fibular fracture shows near full shaft-width lateral and
posterior
displacement of the major distal fragment, with slight anterior
apex
angulation and approximately 15-20 mm overriding of the fracture
fragments.
Assessment of the knee and ankle joints is limited, but the
joints appear
grossly congruent. ? small cyst at the base of the anterior
process of the calcaneus. The anterior process itself appears
irregular or fragmented, of indeterminate acuity, but ? old.
___ 12:00AM GLUCOSE-112* UREA N-12 CREAT-1.1 SODIUM-142
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-26 ANION GAP-10
___ 12:00AM WBC-12.9*# RBC-4.92 HGB-13.3* HCT-39.9*
MCV-81* MCH-26.9* MCHC-33.2 RDW-13.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 325 mg PO DAILY Duration: 6 Weeks
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily as needed for constipation symptoms. Disp #*14 Capsule
Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ to 6 hours as
needed for pain control. Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right tib/fib 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
HISTORY: Tib-fib fracture post-reduction.
RIGHT LOWER LEG, TWO VIEWS.
A splint is in place, obscuring fine bony detail. Allowing for this, there
are fractures of the distal diaphyses of both the tibia and fibula.
The distal tibial fracture shows near full shaft-width posterior displacement
of the major distal fragment, with slight anterior apex angulation, but no
medial or lateral displacement.
The fibular fracture shows near full shaft-width lateral and posterior
displacement of the major distal fragment, with slight anterior apex
angulation and approximately 15-20 mm overriding of the fracture fragments.
Assessment of the knee and ankle joints is limited, but the joints appear
grossly congruent. ? small cyst at the base of the anterior process of the
calcaneus. The anterior process itself appears irregular or fragmented, of
indeterminate acuity, but ? old.
Radiology Report
HISTORY: ORIF right tibia.
Fluoroscopic assistance provided to the surgeon in the OR without the
radiologist present. Four spot views obtained. These demonstrate hardware in
relation to the right tibia as well as tibial and fibular fractures. Fluoro
time recorded as 137.7 seconds on the electronic requisition. Correlation
with real-time findings and, when appropriate, conventional radiographs is
recommended for full assessment.
Radiology Report
INDICATION: Known right lower extremity displaced fracture.
COMPARISON: Right lower extremity radiograph ___.
FINDINGS: Frontal and lateral views of the right lower extremity. The patient
is status post reduction of distal transverse right tibial and fibular
fractures. There is more anatomic alignment with persistent lateral
displacement of the distal fracture fragments. The talar dome is smooth.
Overlying cast material somewhat obscures bony material. There are no
additional fractures identified. The hip and knee are intact. There is no
suprapatellar joint effusion.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: R TIB/FIB FX
Diagnosed with PAIN IN LIMB
temperature: 99.5
heartrate: 80.0
resprate: 14.0
o2sat: 100.0
sbp: 135.0
dbp: 68.0
level of pain: 10
level of acuity: 3.0 | The patient was transferred to the emergency department from OSH
and was evaluated by the orthopedic surgery team. The patient
was found to have a right tib/fib fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibia IM nail, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with outpatient ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right lower extremity, and will be discharged on 325 ECASA for 6
weeks for DVT prophylaxis. The patient will follow up in two
weeks per routine with Dr. ___. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma MCC:
post L third-seventh rib fx
lat L fifth-seventh ribs fx
L anterior first and second rib fx
comminuted displaced L mid-clavicular
Major Surgical or Invasive Procedure:
scalp laceration (staples applied)
History of Present Illness:
___ yo M with h/o HTN, and chronic knee pain on nightly
Percocet ___ per night, presenting on ___
following a motorcycle accident. The patient was a helmeted
driver of a ___ when he lost control, and hit a pole. The
patient and bystanders denied LOC. To note chest CT indicates
non
displaced posterior Left ___ rib fractures, lateral ___ rib
fractures, Left anterior 1,2 rib fractures, and comminuted
displaced mid clavicule fracture, and left pneumothorax. APS was
consulted for assistance with poorly controlled pain on Dilaudid
PCA at 0.24 mg IVPCA.
Past Medical History:
HTN
PSH:
Gastric bypass ___ ago)
Hernia repair ___ ago)
Cholecystectomy ___ ago)
Mult knee surgery
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___
Constitutional: Comfortable
HEENT: left 4cm scalp laceration
left scapular and upper chest wall tendernerss
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds,
Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Physical examination upon discharge: ___:
General: Sling left arm, NAD
HEAD: staples left parietal
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: left arm in sling, localized tenderness left shoulder,
+CSM fingers left hand
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 05:25AM BLOOD WBC-6.7 RBC-3.31*# Hgb-9.6*# Hct-30.4*
MCV-92 MCH-29.0 MCHC-31.6* RDW-13.1 RDWSD-43.3 Plt ___
___ 05:27AM BLOOD Hct-33.7*
___ 07:52PM BLOOD WBC-11.0* RBC-4.42* Hgb-13.0* Hct-40.8
MCV-92 MCH-29.4 MCHC-31.9* RDW-13.0 RDWSD-43.8 Plt ___
___ 05:25AM BLOOD Plt ___
___ 07:52PM BLOOD ___ PTT-23.2* ___
___ 05:27AM BLOOD Glucose-107* UreaN-19 Creat-0.8 Na-140
K-4.6 Cl-105 HCO3-27 AnGap-13
___ 07:52PM BLOOD UreaN-17 Creat-0.9
___ 07:52PM BLOOD Lipase-37
___ 05:27AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.1
___ 05:27AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.1
___ 07:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: chest x-ray:
Known left pneumothorax better seen on trauma CT scan as are the
numerous
additional fractures.
___: cat scan of the c-spine:
1. No acute fracture or mal-alignment of the cervical spine.
2. Partially visualized left pneumothorax.
___: cat scan of the head:
. Left parietal subgaleal hematoma and laceration without
underlying
fracture.
2. No acute intracranial process.
___: cat scan of the chest:
1. Multiple non-displaced left rib fractures described above
with associated moderate left pneumothorax.
2. Comminuted left mid-clavicular fracture.
3. No traumatic injury in the abdomen or pelvis.
___: chest x-ray:
1. Moderate left apical pneumothorax, lateral left extrapleural
hematoma, and small dependent left pleural effusion.
2. Confluent opacity at left lung base, which could represent
pulmonary
contusion or aspiration in the appropriate clinical setting
___: x-ray of left clavicle:
Unchanged appearances of a displaced mid-clavicular fracture.
___: chest x-ray:
No detectable left pneumothorax, pigtail pleural drainage
catheter unchanged in position. Consolidation at the base of
the left lung has worsened since ___, conceivably
atelectasis, but now raising some concern for pneumonia. Right
lung is grossly clear. Heart size is normal. Left pleural
thickening persists,, at the site of several left lateral and
anterolateral rib fractures, perhaps loculated hemothorax, but
there is no appreciable pleural effusion.
___: chest x-ray:
As compared to the previous radiograph, the appearance of the
left-sided rib fractures has not changed. In the interval, the
left pigtail catheter has been removed from the pleural space.
There is no appreciable pneumothorax on the current image.
Minimal atelectasis at the left lung bases. Unchanged
appearance of the right lung.
Medications on Admission:
Oxycodone 5mg x6-8qhs
Lorazepam ___ qd
mirtazepam ?mg qd
mult. vit
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
discontinue tylenol when you resume your percocet
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*2
3. Gabapentin 300 mg PO TID
for 3 weeks, last dose ___
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*63 Capsule Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) apply to left side of chest
once a day Disp #*12 Patch Refills:*0
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN
breakthrough pain
inc. interval dose between doses to ___ hours, then 8 hours,
then discontinue resume home percocet
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*80 Tablet Refills:*0
7. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*1
8. Gabapentin 300 mg PO BID
start ___ for 1 week, then discontinue
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*14 Capsule Refills:*0
9. Morphine SR (MS ___ 15 mg PO TID
45 mg TID x 7 days
30 mg TID x 7 days
15 mg TID x 7 days, then d/c
RX *morphine 15 mg 3 tablet(s) by mouth three times a day Disp
#*126 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma:
posterior left third-seventh rib fracture
lat Left fifth-seventh ribs fracture
Left anterior first and second rib fracture
comminuted displaced L mid-clavicular
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with MVC chest pain*** WARNING *** Multiple patients with
same last name! // eval ? ptx
TECHNIQUE: Single supine view of the chest.
COMPARISON: Correlation made to same day chest CT.
FINDINGS:
Increased lucency projecting over the cardiac silhouette on the left abutting
the diaphragm is compatible with patient's pneumothorax. Posterior left third
rib fracture is noted. Left lateral rib fracture is also suspected. The
cardiomediastinal silhouette is within normal limits. The lungs are otherwise
clear. Surgical clips seen in the right upper quadrant.
IMPRESSION:
Known left pneumothorax better seen on trauma CT scan as are the numerous
additional fractures.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ male involved in a motorcycle crash with a posterior
head laceration and left scapular pain. The patient also has hypotension and
diffuse abdominal tenderness to palpation. Please evaluate for traumatic
injury.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute vascular territorial infarction, hemorrhage,
edema or mass. Ventricles and sulci are normal in size and configuration for
the patient's age.
There is left parietal subgaleal hematoma with overlying staples (series
2:image 21). No underlying fracture is seen.
The visualized paranasal sinuses, mastoid air cells and middle ear cavities
are clear. The globes are intact.
IMPRESSION:
1. Left parietal subgaleal hematoma and laceration without underlying
fracture.
2. No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ male involved in a motorcycle crash with a posterior
head laceration, left scapular pain, hypotension and diffuse tenderness to
palpation on physical exam. Please evaluate for traumatic injury.
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 786 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment of the cervical spine is maintained. No acute fracture is seen, and
there is no prevertebral soft tissue swelling. There is no significant spinal
canal stenosis. Mild disc height loss is seen at C5-C6 and C6-C7.
The visualized thyroid gland is unremarkable, and a partially visualized left
pneumothorax is seen.
IMPRESSION:
1. No acute fracture or malalignment of the cervical spine.
2. Partially visualized left pneumothorax.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: ___ male involved in a motorcycle crash. The patient had
a posterior head laceration, left scapular pain, hypotension and diffuse
enters to palpation on this exam. Evaluate for traumatic injury.
TECHNIQUE: MDCT acquired axial images of the chest, abdomen, and pelvis were
obtained after administration of 130 mL Omnipaque intravenous contrast.
Enteric contrast was not given. Coronal and sagittal reformats were prepared
and reviewed.
DOSE: Total DLP (Body) = 1,910 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST: The heart and great vessels are unremarkable. The thoracic aorta is
of normal caliber and course. There is no mediastinal hematoma. There is no
pericardial effusion. Is no supraclavicular axillary lymphadenopathy. There
are no mediastinal or hilar lymph nodes are pathologic large by CT size
criteria. There is a 8 mm hypodense nodule within the posterior right thyroid
lobe (series 2:image 9).
There is a moderate left pneumothorax with associated atelectasis seen in the
left upper and lower lobes. No pleural effusion is seen. No pulmonary
laceration or contusion is noted. The airways are patent to the subsegmental
level.
ABDOMEN: The liver is intact without focal lesion of signs of acute injury.
There is no intrahepatic or extrahepatic biliary dilation. The hepatic veins
and main portal veins are patent. The spleen is intact and normal in size.
The patient is status post cholecystectomy. The pancreas, and adrenals are
unremarkable. The kidneys enhance symmetrically and excrete contrast promptly
without focal lesion or hydronephrosis. Left parapelvic cysts are noted.
There is no evidence of renal or collecting system injury. The abdominal
aorta is normal in course and caliber with widely patent major branches. No
lymphadenopathy, free air, or free fluid.
The patient is status post gastric bypass surgery.
PELVIS: The small bowel is unremarkable with sutures reflective of prior
bowel surgery noted. There is no ileus or obstruction. There is no evidence
or bowel or mesenteric injury. The colon is unremarkable. The appendix is
not definitively seen, though there are no secondary findings to suggest
appendicitis. The bladder is unremarkable. There is no pelvic free fluid.
BONES: There are nondisplaced fractures of the posterior left third-seventh
ribs (series 3:image 40, 49, 59). There are also nondisplaced fractures
through the lateral left fifth-seventh ribs (series 3:image 64, 82).
Fractures of the left anterior first and second rib are also seen. A
comminuted mildly displaced left mid-clavicular fracture is noted. A midline
fat-containing anterior hernia is noted. A lipoma is noted in the right lower
quadrant abdominal anterolateral musculature (series 2:image 186).
IMPRESSION:
1. Multiple non-displaced left rib fractures described above with associated
moderate left pneumothorax.
2. Comminuted left mid-clavicular fracture.
3. No traumatic injury in the abdomen or pelvis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 10:01 ___, 10 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ s/p single vehicle MCC, helmeted; no LOC; +scalp lac s/p
staple closure, L post rib fx, small PTX // Interval assesment
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___.
FINDINGS:
There is a moderate-sized left pneumothorax with an overlying mid clavicular
fracture and a fracture of the posterior third rib, visualized on the prior
CT. There is a localized hematoma of the left lateral chest wall. There are
linear opacities at the right lung base. There is a more confluent
opacification at the left lung base. Small left pleural effusion. Heart size
is normal. The mediastinal and hilar contours are normal. The pulmonary
vasculature is normal.
IMPRESSION:
1. Moderate left apical pneumothorax, lateral left extrapleural hematoma, and
small dependent left pleural effusion.
2. Confluent opacity at left lung base, which could represent pulmonary
contusion or aspiration in the appropriate clinical setting.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old man S/P MVC, L ribs and clavicle fractures and ptx
s/p pigtail placement pls perform @ 0500 // Evaluate for ptx change, please
do tomorrow AM @ 0500 Evaluate for clavicle fx interval change
IMPRESSION:
In comparison with the study of ___, the chest tube remains in place and
there is no evidence of pneumothorax. Little overall change in the appearance
of the heart and lungs.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L pneumothorax, now s/p chest tube placement
// chest tube placement chest tube placement
IMPRESSION:
In comparison with the earlier study of this date, there has been placement of
a pigtail catheter on the left with resolution of the pneumothorax. Left
basilar opacification again is consistent with atelectasis and possible small
he fusion. The right lung is essentially
In the left clavicular fracture is again seen, though the localized hematoma
of the left lateral chest wall it is less prominent given the change in
patient obliquity.
Radiology Report
EXAMINATION: CLAVICLE LEFT
INDICATION: ___ year old man with displaced clavicular fx ___ trauma, needs
dedicated clavicular films // displaced clavicular fx
TECHNIQUE: Two views left clavicle.
COMPARISON: Chest radiograph ___ and ___
FINDINGS:
A left apical chest drain is in-situ, this is better evaluated on the
dedicated chest radiograph. There is a fracture through the mid clavicle with
superior displacement of the medial fragment by more than 1 shaft's width.
This is unchanged in appearance compared to the prior chest radiograph.
IMPRESSION:
Unchanged appearances of a displaced midclavicular fracture.
Radiology Report
INDICATION: ___ y/o M s/p L pigtail placement on ___ // interval change-
please obtain film at 6:00 AM
TECHNIQUE: Chest portable
FINDINGS:
In comparison with the study of ___, the chest tube remains in good
position and there is no evidence of pneumothorax. There is increasing left
and right lower lobe atelectasis. There is a small left-sided effusion that
is stable. No interstitial pulmonary edema. The heart is stable in size.
IMPRESSION:
There is increasing left and right lower lobe atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest tube in place // Evolution of
pneumothorax Evolution of pneumothorax
COMPARISON: Prior chest radiographs ___ through ___ at 04:48.
IMPRESSION:
No detectable left pneumothorax, pigtail pleural drainage catheter unchanged
in position. Consolidation at the base of the left lung has worsened since
___, conceivably atelectasis, but now raising some concern for
pneumonia. Right lung is grossly clear. Heart size is normal. Left pleural
thickening persists,, at the site of several left lateral and anterolateral
rib fractures, perhaps loculated hemothorax, but there is no appreciable
pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left Rib fxs, recent left PTX // Eval for
PTX
COMPARISON: ___, 11:05
IMPRESSION:
As compared to the previous radiograph, the appearance of the left-sided rib
fractures has not changed. In the interval, the left pigtail catheter has
been removed from the pleural space. There is no appreciable pneumothorax on
the current image. Minimal atelectasis at the left lung bases. Unchanged
appearance of the right lung.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with TRAUM PNEUMOTHORAX-CLOSE, FX MULT RIBS NOS-CLOSED, FX CLAVICLE SHAFT-CLOSED, MV COLLIS NOS-MOTORCYCL, OPEN WOUND OF SCALP
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was admitted to the hospital after the motor-cycle
he was driving hit a pole. Upon admission, he was reporting
left shoulder/left upper back pain. He sustained a laceration to
his scalp which was stapled in the emergency room. Upon
admission, the patient was made NPO, given intravenous fluids,
and underwent imaging. On cat scan imaging, he was reported to
have non-displaced posterior left ___ rib fractures, lateral ___
rib fractures, left anterior 1,2 rib fractures, comminuted
displaced mid clavicle fracture, and a left pneumothorax.
Because of the extent of his rib fractures, the Acute Pain
service was consulted. A pain regimen was designed to meet the
patient's needs.
The Orthopedic service was consulted regarding management of the
left mid-clavicular fracture. No operative intervention was
indicated and a sling was applied for support. The patient was
noted to have a left pneumothorax and a pigtail catheter was
placed on ___ with resolution of the pneumothorax. The
patent's pulmonary status was closely monitored and his oxygen
saturation remained stable. The pig-tail catheter was removed
on ___ with no appreciable pneumothorax identified.
The patient's vital signs remained stable and he was afebrile.
He was tolerating a regular diet and voiding without difficulty.
Prior to discharge, the Acute pain service provided
recommendations for out-patient pain management which included
weaning down the narcotic pain medication. A tapering schedule
for the MS contin was outlined. A follow-up appointment was
made for staple removal in the acute care clinic. Discharge
instructions were reviewed with the patient and his wife at the
time of discharge. The patient conveyed a clear understanding
of the plan and the narcotic wean. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
lower abdominal pain
Major Surgical or Invasive Procedure:
___:
US-guided placement of ___ pigtail catheter into the right
lower quadrant fluid collection
___:
1. Laparoscopic converted to open ileocolectomy with primary
ileocolic anastomosis.
2. Drainage of pelvic and right upper quadrant abscesses.
History of Present Illness:
Otherwise healthy ___ presents to the ___ ED with the
complaint of RLQ abdominal pain. The pain began yesterday
evening, initially dull in quality and ___, and
progressed today to sharp, constant localized RLQ abdominal
pain. He also endorses loss of appetite, and denies fever,
chills, chest pain, SOB, N/V, dysuria, diarrhea or BRBPR.
Past Medical History:
No past medical history
Social History:
___
Family History:
Non-contribuatory
Physical Exam:
ADMISSION PHYSICAL EXAM
T:99.5, HR:73, BP:129/86, RR:16 SO2: 100% RA
Gen: uncomfortable, not in acute distress
HEENT: wnl
CV:RRR, normal S1/S2, no m/r/g
Pulm: CTAB, non-labored
Abd: mildly tender to palpation of right lower quadrant, soft,
nondistended, no guarding or peritonitis
DISCHARGE PHYSICAL EXAM:
VS: T: 98.5 PO BP: 130/78 HR: 68 RR: 18 O2: 97% Ra
GEN: A+Ox3, NAD
HEENT: normocephalic, atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, mildly distended, appropriately tender at incision.
Midline incision with staples OTA, well-approximated no s/s
infection. RLQ JP with moderate amount of serosanguinous
drainage in bulb. JP drain site with no s/s infection.
EXT: wwp, +1 edema b/l, no erythema or induration
Pertinent Results:
___ 03:45PM WBC-11.4* RBC-4.82 HGB-14.6 HCT-43.2 MCV-90
MCH-30.3 MCHC-33.8 RDW-13.3 RDWSD-43.9
___ 03:45PM NEUTS-87.9* LYMPHS-6.2* MONOS-3.9* EOS-0.7*
BASOS-0.6 IM ___ AbsNeut-9.99* AbsLymp-0.71* AbsMono-0.44
AbsEos-0.08 AbsBaso-0.07
___ 03:45PM ALT(SGPT)-12 AST(SGOT)-18 ALK PHOS-61 TOT
BILI-0.7
___ 03:45PM LIPASE-16
IMAGING:
___ ABD & PELVIS WITH CONTRAST
Acute appendicitis likely complicated by perforation.
Appendicoliths (x2) in the proximal appendix. No fluid
collection, free air or CT evidence for peritonitis.
___- CT ABD & Pelvis WITH PO CONTRAST
1. Re-demonstrated is perforated appendicitis, with a
significant increase in nonhemorrhagic free fluid, with the
largest volume in the right lower quadrant and pelvis. There is
associated extensive peritoneal enhancement, compatible with
peritonitis. Peripheral enhancement surrounding the largest
portion of the collection in the pelvis is likely reflective of
inflamed peritoneum surrounding fluid, as opposed to a discrete
fluid collection. There are small locules of gas adjacent to
the ascending colon, which may be extraluminal.
2. Dilated, fluid-filled proximal small bowel with likely mild
bowel wall thickening distally is probably related to ileus and
secondary bowel wall inflammation with possible partial
obstruction related to the diffuse peritonitis.
3. Trace bilateral pleural effusions with subjacent passive
atelectasis are new.
___: CXR:
The tip of the nasogastric tube projects over the stomach.
Dilated small bowel loops are seen in the upper abdomen.
___: Portable Abdominal x-ray:
Moderate proximal small bowel dilatation. In the early
postoperative course findings are most suggestive of ileus,
although partial obstruction is not excluded. Short-term
follow-up radiographs may be helpful to reassess.
Microbiology:
___ 9:25 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. RARE GROWTH.
Reported to and read back by ___ (___) AT
8AM ___.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 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---- =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*8 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
hold for loose stool
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Take with food
5. MetroNIDAZOLE 500 mg PO Q8H
do NOT drink alcohol while taking this medication
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*12 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated appendicitis with multiple abdominal abscesses
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
INDICATION: ___ with RLQ pain, no appetite// Please evaluate for appendicitis
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) = 499 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Imaged lung bases are clear.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. Main portal vein is patent. Mild
periportal edema likely reflects aggressive hydration. There is no
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas appears normal.
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 and duodenum appear normal. Small bowel loops
demonstrate no signs of ileus, obstruction, or wall thickening. The colon and
rectum are within normal limits. In the right lower abdomen, the appendix is
dilated to 16 mm in diameter, with mucosal hyperemia. Two large
appendicoliths measure 13 and 15 mm, one lodged at the base of the appendix
(2:42, 2:44), and the second within the proximal lumen. There is
periappendiceal fat stranding, a significant volume of free fluid without
discrete drainable fluid collection. The wall of the appendix appears
discontinuous raising concern for perforation (601:24, 02:43). There is no
free air. No CT signs of peritonitis.
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 normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: No evidence of thrombophlebitis region inflammation the right
abdomen. 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 appendicitis likely complicated by perforation. Appendicoliths (x2) in
the proximal appendix. No fluid collection, free air or CT evidence for
peritonitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 6:00 pm, immediately after discovery of
the findings.
Radiology Report
INDICATION: ___ year old man with hx of perforated appendicites// Acute
increase in abdominal pain
TECHNIQUE: Upright, left lateral decubitus and supine frontal views of the
abdomen/pelvis.
COMPARISON: CT abdomen and pelvis ___.
IMPRESSION:
Small bowel loops are borderline in caliber measuring up to 3 cm and large
bowel is distended to a maximum caliber of 7.5 cm and air filled. Findings
are suggestive of an ileus. There is no frank evidence of obstruction. There
is no pneumatosis or free air.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ year old man s/p perforated appendicitis, still feeling
horrible, fevers, low grade temp,// Does he have a collection? An abscess?
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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 6.5 s, 1.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
15.0 mGy-cm.
3) Spiral Acquisition 15.3 s, 52.5 cm; CTDIvol = 10.1 mGy (Body) DLP =
515.3 mGy-cm.
Total DLP (Body) = 546 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Trace bilateral pleural effusions are new. There is subjacent
passive atelectasis. No 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 is top-normal in size, measuring 13 cm SI dimension.
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 numerous mildly
dilated small bowel loops extending into the pelvis, where the becomes
decompressed and there is mild wall thickening/hyperemia of the ileum. This
is likely ileus in the setting of diffuse peritonitis. The colon and rectum
are within normal limits. The appendix remains dilated, fluid-filled and
hyperemic, with extensive adjacent phlegmonous change. There is now moderate
volume free fluid in the lower abdomen and pelvis, with peritoneal enhancement
suggestive of peritonitis. This fluid is not definitely within a discrete
abscess, but likely reflects fluid in the setting of peritonitis (5:71). The
largest component of fluid is present just anterior to the rectum and measures
8.1 x 4.1 x 3.7 cm (series 5, image 72). There may be a tiny locules of fluid
outside of the bowel in the right lower quadrant (5:49, 6:27).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
moderate free fluid in the pelvis as described previously.
REPRODUCTIVE ORGANS: The prostate gland and seminal vesicles are within normal
limits.
LYMPH NODES: Mesenteric lymph nodes are increased in number, likely reactive
to peritonitis. 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: There is mild anasarca.
IMPRESSION:
1. Re-demonstrated is perforated appendicitis, with a significant increase in
nonhemorrhagic free fluid, with the largest volume in the right lower quadrant
and pelvis. There is associated extensive peritoneal enhancement, compatible
with peritonitis. Peripheral enhancement surrounding the largest portion of
the collection in the pelvis is likely reflective of inflamed peritoneum
surrounding fluid, as opposed to a discrete fluid collection. There are small
locules of gas adjacent to the ascending colon, which may be extraluminal.
2. Dilated, fluid-filled proximal small bowel with likely mild bowel wall
thickening distally is probably related to ileus and secondary bowel wall
inflammation with possible partial obstruction related to the diffuse
peritonitis.
3. Trace bilateral pleural effusions with subjacent passive atelectasis are
new.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED DRAINAGE CATHETER PLACEMENT
INDICATION: ___ year old man with perforated appendicitis here fluid
collection in pelvis// drainage of pelvic fluid
COMPARISON: CT abdomen and pelvis ___
PROCEDURE: Ultrasound-guided placement of a drainage catheter into the right
lower quadrant
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during the
key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via ultrasound.
Approximately 50 cc of clear yellow fluid was drained with a sample sent for
cell count and differential, and microbiology evaluation. The catheter was
secured by a StatLock. The catheter was attached to bag. Sterile dressing was
applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of
19 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited preprocedure ultrasound showed a moderate amount of complex fluid in
the right lower quadrant, which was targeted for ultrasound-guided drainage.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the right
lower quadrant. Samples was sent for cell count, differential, and
microbiology evaluation.
Radiology Report
INDICATION: ___ year old s/p lap appy, NGT places// is NGT in the right place?
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
FINDINGS:
The tip of the nasogastric tube projects over the left upper quadrant. The
lung apices are not included on this radiograph however the visualized lungs
there is left basilar atelectasis and a probable small left pleural effusion.
No large pneumothorax. The size of the cardiac silhouette is within normal
limits. The visualized upper abdomen is notable for multiple dilated small
bowel loops.
IMPRESSION:
The tip of the nasogastric tube projects over the stomach.
Dilated small bowel loops are seen in the upper abdomen.
Radiology Report
INDICATION: ___ y/o M POD ___ s/p open R hemicolectomy for perforated
appendicitis, now w/ nausea/emesis// eval for ileus
TECHNIQUE: Abdominal radiographs, two views.
COMPARISON: CT from ___.
FINDINGS:
Drain projects over the right lower quadrant. There has apparently been an
interval surgery with a staple line in the right lower quadrant. Proximal
small bowel is dilated up to 5.5 cm. Small bowel is aerated but less dilated
in the right lower quadrant. There is air and even mild distension of the
sigmoid arguing alternatively for ileus, however. Air is also present in the
transverse colon. No evidence of free air. Vertical staple line is present.
IMPRESSION:
Moderate proximal small bowel dilatation. In the early postoperative course
findings are most suggestive of ileus, although partial obstruction is not
excluded. Short-term follow-up radiographs may be helpful to reassess.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with Right lower quadrant pain
temperature: 98.8
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 88.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ presented to ___ on ___ with lower
abdominal pain. Admission abdominal/pelvic CT revealed acute,
perforated appendicitis with 2 appendicoliths seen in the
proximal appendix. WBC was elevated at 11.4. He was admitted
to the General Surgical Service, originally for non-operative
management. He was made NPO, received IV fluids for hydration
and IV antibiotics (Ciprofloxacin/metronidazole)
On HD1, he was advanced to a clear liquid diet, which he was
unable to tolerate secondary to nausea.
Due to lack of improvement, with the patient remaining nauseous
with continuous abdominal pain, unable to tolerate clear
liquids, and a low grade temperature, a repeat abdominal CT
abdomen/pelvis was performed which revealed a pelvic collection.
The patient had a pelvic drain placed by interventional
radiology to drain the pelvic collection.
On HD8, due to the lack of improvement even with the drain in
place, the patient was consented for surgery and was taken to
the operating room where he underwent a laparoscopic
appendectomy converted to an open ileocolectomy with primary
ileocolic anastomosis and drainage of pelvic and right upper
quadrant abscesses. This procedure went well (reader, please see
operative notes for details). After a brief, uneventful stay
in the PACU, the patient arrived on the floor on IV fluids, with
a nasogastric tube in place for gastric decompression, two JP
drains, one in right up quadrant and one in the right pelvis,
and a dilaudid PCA for pain control. The patient was
hemodynamically stable.
Post operatively, patient was immediately feeling better. On POD
#1, the nasogastric tube was discontinued, he was gradually
advanced to clears, his IV fluids were discontinued when oral
intake of fluids was adequate. On POD #2, he was gradually
advanced to a regular diet as tolerated, converted to oral pain
medications, and the pelvic JP drain was removed. The patient
had an episode of emesis and was backed down to clear liquids,
then diet was re-advanced later to regular.
When tolerating a diet, the patient was converted to oral pain
medication and antibiotics (ciprofloxacin/metronidazole) with
continued good effect. Antibiotics were to continue for 10 days
post operatively. The patient voided without problem. During
this hospitalization, the patient ambulated early and actively
participated in the plan of care. The patient received
subcutaneous heparin during this stay.
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. Patient was discharged with one JP drains in place,
instructions and teaching on drain management, with a follow up
appointment at the Acute Care Surgery Clinic established. He
verbalized an understanding and agreement with the discharge
plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Abdominal pain and constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: ___
_
________________________________________________________________
PCP:
Name: ___.
Location: ___
Address: ___, ___
Phone: ___
Fax: ___
GI at ___: ___ MD
_
________________________________________________________________
HPI:
___ with h/o long standing constipation, with h/o pelvic
inflammatory disease c/b sepsis in ? ___ c/b persistent GI sx
consisting of abdominal pain, constipation, distension, gas who
presents with worsening constipation for weeks. Patient reports
that she has not completedly moved her bowels x 1.5w. She
reports that she has had multiple episodes of liquid stool but
has never had that sensation of complete emptying. She reports a
sensation of hard stool within her rectum but is unable to pass
this. She reports a sensation of needing to vomit and nausea but
has been unable to vomit. She also has abdominal spasms
radiating from the RLQ to the LUQ and to the rectum which occur
without triggers. With the severe abdominal bloating and
distension which is even noticed by her co-workers she has the
constant sensation of abdominal heaviness. She reports that she
has taken multiple doses of different laxatives- as much as 8
senna tablets for the past few days without success.
+ rectal pain - as though there is a cinder block in her rectum-
___ pain not worsened by stooling. She has been on a gluten
free diet for 4 weeks without any effect. She has ___ b/l lQ
and b/l upper quadrants which is unchanged with food. No blood
in stool.
Patient reports that she went to see her primary care doctor,
who referred her for urgent CAT scan to rule out obstruction.
On examination the patient's abdomen is distended and
tympanitic. She does have active bowel sounds. She is diffusely
tender without guarding or rebound. Per rectum the patient has a
large quantity of stool which is heme negative.
In ER: (Triage Vitals:6 97.5 79 124/80 16 100% RA )
Meds Given:
Ondansetron 2mg/mL-2mL ___ ___
___ 18:19 Morphine 5 mg Vial [class 2] ___ ___
___ 19:05 DiphenhydrAMINE 50mg/mL Vial ___ ___
___ given:1 LNS
Radiology Studies: abdominal CT scan
.
PAIN SCALE: ___ location:
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[-] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[+]Anorexia [ ]Night sweats
[+ ] __4___ lbs. weight loss over the past month
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ +] Nausea [-] Vomiting [+] Abd pain [+] Abdominal
swelling [ ] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[ ] Dysuria [+ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[ ] Joint pain [ ] Jt swelling [+] Mild Back and neck pain
which improves with mineral ice [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[+] Depression. [-]Suicidal Ideation [ ] Other:
ALLERGY:
Compazine -> anxiety
[+ ]Medication allergies [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
anxiety disorder
urinary retention of unclear etiology
pelvic inflammatory disease with sepsis at the end of ___?
EGD and Colonoscopy in ___ -diagnosed with gastritis
and irritable bowel syndrome.
Uriniary retention- straight cathed herself q ___ hours last
time 6 weeks ago- ___. S/p treatment of a UTI
Social History:
___
Family History:
The patient's mother has COPD/emphysema,lung cancer and type 2
diabetes. The patient's father is healthy. There is no family
history of celiac disease, irritable bowel syndrome, or
colorectal cancer
Physical Exam:
1. VS Tm T P BP RR O2Sat on ____ liters O2 Wt, ht, BMI
GENERAL:
Nourishment
Grooming
Mentation
2. Eyes: [X] WNL
PERRL, EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [X] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[] Regular [] Tachy [] S1 [] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
2+ DPP pulses b/l
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [x]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
nabs, tender to moderate palpation in LLQ, suprapubic tenderness
with radiation to the rectum with palpation, RUQ tenderness.
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
Rectal:
Scant amount of liquid brown/clear stool. No hard stool
appreciated.
8. Neurological [X] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [X] WNL
[X] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
Pertinent Results:
___ 05:00PM BLOOD WBC-4.8 RBC-4.37 Hgb-13.4 Hct-39.2 MCV-90
MCH-30.7 MCHC-34.3 RDW-12.9 Plt ___
___ 05:00PM BLOOD Neuts-59.1 ___ Monos-5.4 Eos-1.4
Baso-1.1
___ 06:50AM BLOOD Glucose-95 UreaN-3* Creat-0.7 Na-143
K-3.7 Cl-111* HCO3-27 AnGap-9
___ 06:25AM BLOOD Creat-0.8 Na-140 K-3.5 Cl-107
___ 05:00PM BLOOD Glucose-82 UreaN-10 Creat-0.8 Na-140
K-4.2 Cl-102 HCO3-24 AnGap-18
___ 05:00PM BLOOD ALT-11 AST-22 TotBili-0.4
___ 05:00PM BLOOD Lipase-22
___ 06:50AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.8
___ 06:25AM BLOOD Mg-1.7
.
UCX <10,000 organisms
.
CT scan abdomen:
IMPRESSION:
1. No evidence of obstruction.
2. No evidence of appendicitis, colitis, or other infectious or
inflammatory
process in the abdomen or pelvis.
3. 2.6 cm likely physiologic ovarian cyst, given the patient's
age.
.
KUB5/4:
IMPRESSION:
Air seen throughout non-dilated loops of colon without signs for
small bowel
obstruction.
.
KUB ___
IMPRESSION: Non dilated loops of small and large bowel with
multiple air fluid
levels are likely related to the patient's cathartic bowel
preparation. There
is no ileus, obstruction or free air.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO Q8H:PRN constipation
2. Align *NF* (bifidobacterium infantis) 4 mg Oral daily
3. Multivitamins 1 TAB PO DAILY
4. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral tid
5. BuPROPion (Sustained Release) 150 mg PO QHS
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QHS
2. Polyethylene Glycol 17 g PO Q8H:PRN constipation
3. Bisacodyl 10 mg PO/PR BID:PRN constipation
RX *bisacodyl 5 mg 2 tablet,delayed release (___) by mouth
daily Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Align *NF* (bifidobacterium infantis) 4 mg Oral daily
6. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral tid
7. Multivitamins 1 TAB PO DAILY
8. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 40 mg/0.6 mL 40-80mg by mouth four times a day
Disp #*1 Bottle Refills:*0
9. linaclotide *NF* 145 mcg Oral daily
resume your previously prescribed dose
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8hrs Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with abdominal distention and clinical concern for
obstruction.
TECHNIQUE: MDCT acquired axial images were obtained from the lung bases to
the pubic symphysis after administration of intravenous contrast material.
Coronal and sagittal reformats prepared and reviewed.
COMPARISON: None available.
FINDINGS:
The lower chest is unremarkable.
ABDOMEN: The liver enhances homogeneously and is without focal abnormality.
The gallbladder and biliary tree appear normal. The pancreas, spleen, and
adrenal glands appear normal. The kidneys enhance normally and excrete
contrast symmetrically. The stomach, duodenum, and abdominal loops of small
and large bowel are of normal caliber, without wall thickening, or associated
mass. The appendix is normal. There are several radiodense pills throughout
the colon. There is no ascites, fluid collection, or pneumoperitoneum.
The portal, splenic, and mesenteric veins are patent. The abdominal aorta is
not enlarged and its main branches are patent. There is no retroperitoneal,
periportal, or mesenteric lymphadenopathy.
PELVIS: The rectum and sigmoid are normal. The bladder, uterus, and adnexae
are normal. A 2.6 cm likely physiologic cyst is seen in the left ovary.
There is no pelvic free fluid or mass. There is no pelvic or inguinal
lymphadenopathy.
MUSCULOSKELETAL: There are no lytic or sclerotic osseous lesions concerning
for malignancy.
IMPRESSION:
1. No evidence of obstruction.
2. No evidence of appendicitis, colitis, or other infectious or inflammatory
process in the abdomen or pelvis.
3. 2.6 cm likely physiologic ovarian cyst, given the patient's age.
Radiology Report
STUDY: Abdomen supine and erect films, ___.
CLINICAL HISTORY: ___ woman with severe constipation, now with
worsening abdominal gas and nausea. Evaluate for small bowel obstruction.
FINDINGS: Comparison is made to CT scan from ___.
There is air seen throughout the colon, which is not dilated. There are no
dilated loops of small bowel. There is free air in the abdomen. Slight
scoliosis of lower lumbar spine. Hip joint spaces are preserved.
IMPRESSION:
Air seen throughout non-dilated loops of colon without signs for small bowel
obstruction.
Radiology Report
HISTORY: Evaluation for obstruction and ileus. Patient with constipation,
abdominal pain and vomiting after bowel prep.
COMPARISON: Abdominal radiograph ___.
FINDINGS: Upright and supine frontal abdominal radiographs demonstrate
nondilated loops of small and large bowel with prominent gas in the splenic
flexure. There are multiple air-fluid levels. No free intraperitoneal air is
identified. Compared to the prior radiograph of ___ there is little change
in the bowel gas pattern.
IMPRESSION: Non dilated loops of small and large bowel with multiple air fluid
levels are likely related to the patient's cathartic bowel preparation. There
is no ileus, obstruction or free air.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: ABD PAIN, RECTAL PAIN
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA, UNSPECIFIED CONSTIPATION
temperature: 97.5
heartrate: 79.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 80.0
level of pain: 6
level of acuity: 3.0 | ___ yo F with h/o bacterial overgrowth presents with constipation
and ileus.
# Ileus, constipation: Unclear underlying cause, but has been a
chronic issue for the patient for which she follows with GI.
Suspect colonic dysmotility/motility issue. Pt was not taking
any opioid pain medication prior to admission and did not have
signs of UTI, PID, or bowel obstruction. She underwent a CT scan
that revealed constipation and gas but did not reveal any
evidence of obstruction. She was initially started on an
aggressive bowel regimen and reported the passing of some very
small amounts of liquid stool. She then was advanced to a
regular diet and developed abdominal pain with nausea and
vomiting. She was then made NPO. KUB did not reveal any evidence
of obstruction. The GI service was consulted. On ___ her
symptoms improved and an aggressive bowel regimen was undertaken
including golytely x2L, miralax x2, dulcolax x2, colace, MOM
without effect. Narcotics were discontinued. Pt also developed
vomiting after eating and taking go lytely prep. KUB was
repeated on ___ and revealed again non dilated loops of small
and large bowel with multiple air fluid levels related to her
bowel prep, no obstruction or free air noted. On ___, pt
reported that her nausea and vomiting had improved. Of note, she
expressed frustration with her hospitalization and throughout
and her hospital course with seemingly lack of improvement
despite aggressive bowel regimen. The patient desired to be
discharged on ___, fearing consequences at work with continued
admission. Her diet was advanced and she continued to pass
flatus during her hospitalization as well as on day of
discharge. The GI service recommended a gastrografin enema on
the day of DC, but pt requested to be discharged and to complete
this as an outpatient. Despite having periods of vomiting on
occasion, imaging x3 did not reveal any obstruction and upon
discussion with the radiology service, there were never any
distended loops of small or large bowel and there was no
apparent large solid stool, or stool balls present causing
obstruction. It appears that pt has very slow colonic treatment
and that continued very aggressive bowel regimen with golytely
etc would just lead to distention of the small bowel and pt
developing more bloating/gas. Therefore, pt appeared to be able
to transition her care to the outpatient setting and this was
also her request. The GI service recommended the gastrografin
enema to be complete as an outpatient which the pt agrees to,
and to continue at least BID miralax, daily dulcolax, and to
fill her prescription that she reports is at the pharmacy for
her linaclotide previously prescribed, as well as colace. She
was also given simethicone. The Gi service also recommended ___
markers to help to clarify bowel transit in the outpatient
setting.
She will follow up with her PCP and primary gastroenterologist
upon DC.
.
# Mood, anxiety: Continued wellbutrin. Gave prn ativan during
admission.
# Nausea: PRN ativan, zofran. Pt was provided with a
prescription for zofran upon DC.
FEN: regular
DVT PPx: heparin
CODE: FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet / aspirin
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomitting
Major Surgical or Invasive Procedure:
___ ex-lap, LOA, reinforcement of bladder hitch repair
History of Present Illness:
___ year old female s/p recent left oophrectomy c/b ureteral
transection s/p
ex-lap, ureteral reimplanation and psoas hitch now here w/
nausea/vomiting and abdominal pain. She reports having nausea
and
vomiting over the last 2 weeks that is acutely worsening. She is
tolerating only minimal po. Her last bm was nearly week ago
however she did attempt an enema yesterday with a small amount
of
stool passage. He reports severe cramping, intermittent but
diffuse abdominal pain that has also been worsening. She denies
any fevers/chills, chest pain or SOB. She does report being seen
recently in the ED for dysuria however this resolved and she did
develop some hematuria today.
Past Medical History:
URINARY TRACT INFECTION
Laparoscopic oophorectomy ___
Hysterectomy for fibroids ___
C-Section ___
Social History:
___
Family History:
No family history currently on file.
Physical Exam:
PE: upon admission: ___:
97.8 ___ 18 100%
NAD, Alert and oriented x3
Sinus tachy
Unlabored respirations
Abd soft, mildly distended, diffuse tenderness to light
palpation, +tympany, no rebound or gaurding, old midline
incision
is healing well
Ext wwp no edema
Pertinent Results:
___ 06:40AM BLOOD WBC-6.6 RBC-3.43* Hgb-10.6* Hct-31.0*
MCV-90 MCH-30.9 MCHC-34.2 RDW-13.9 Plt ___
___ 07:05AM BLOOD WBC-11.1* RBC-3.37* Hgb-10.3* Hct-29.6*
MCV-88 MCH-30.5 MCHC-34.7 RDW-13.7 Plt ___
___ 10:30PM BLOOD WBC-11.4* RBC-4.32 Hgb-13.3 Hct-37.8
MCV-87 MCH-30.8 MCHC-35.2* RDW-13.8 Plt ___
___ 10:30PM BLOOD Neuts-69.1 ___ Monos-6.6 Eos-1.5
Baso-0.2
___ 06:40AM BLOOD Plt ___
___ 03:00AM BLOOD ___ PTT-42.1* ___
___ 06:40AM BLOOD Glucose-105* UreaN-6 Creat-0.3* Na-137
K-3.8 Cl-103 HCO3-27 AnGap-11
___ 10:30PM BLOOD Glucose-131* UreaN-13 Creat-0.6 Na-137
K-8.9* Cl-101 HCO3-22 AnGap-23*
___ 06:40AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.8
___ 02:09AM BLOOD K-3.8
___: cat scan of abdomen and pelvis:
. High-grade closed loop small bowel obstruction. Small bowel
is mildly
hyperemic without evidence of pneumatosis, portal venous gas or
free air.
2. Moderate to large volume intra-abdominal and pelvic ascites,
not seen on renal ultrasound from ___, likely reactive in the
setting of a high-grade obstruction.
3. Left double-J ureteral stent appears well positioned. No
evidence of
hydronephrosis.
Medications on Admission:
lisinopril 40mg', metoprolol XL 50mg', omeprazole
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
hold for increased sedation, resp. rate <8
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
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 AND PELVIS WITH CONTRAST.
INDICATION: ___ with diffuse abdominal pain, vomiting, history of prior
ureteral injury s/p repair.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE:
This study involved 4 CT acquisition phases with dose indices as follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
4) Spiral Acquisition 4.2 s, 45.5 cm; CTDIvol = 5.9 mGy (Body) DLP = 269.5
mGy-cm.
Total DLP (Body) = 276 mGy-cm.
IV Contrast: 130 mL Omnipaque
COMPARISON: Comparison is made to Outside Hospital Ct from ___ and
renal ultrasound from ___.
FINDINGS:
LOWER CHEST: The lung bases are clear. There is no pericardial or pleural
effusion.
ABDOMEN:
HEPATOBILIARY: Subcentimeter hypodensity at the dome of the liver is too small
to characterize. The liver otherwise enhances homogeneously and is without
focal lesions. The gallbladder is decompressed and normal. There is no intra
or extrahepatic biliary duct dilation.
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 enhance and excrete contrast symmetrically. A double-J
left ureteral stent is in appropriate position. There is no hydronephrosis.
No focal renal lesions seen.
GASTROINTESTINAL: Oral contrast is seen within the stomach. The small bowel
is fluid-filled and dilated up to 3.7 cm with two transition point in the mid
abdomen (series 2, image 39, 43). Dilated small bowel on either side of the
transition point, raising the concern for a closed loop obstruction. Bowel
wall is mildly hyperenhancing. Distal small bowel is completely collapsed.
Portions of colon are stool-filled well descending and transverse colon are
completely collapsed. Appendix not visualized but no secondary signs of
appendicitis within the right lower quadrant. There is moderate volume
intra-abdominal ascites not identified on prior renal ultrasound although seen
on CT scan from ___, likely relates to high-grade obstruction.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in
the abdominal aorta and great abdominal arteries.
PELVIS: Postsurgical changes from hitch procedure in the pelvis. The bladder
is relatively decompressed with a small amount of IV contrast layering
posteriorly. No extraluminal contrast is seen. There is no evidence of
pelvic or inguinal lymphadenopathy. There is large volume pelvic free fluid.
BONES AND SOFT TISSUES:
A well-circumscribed lytic lesion with sclerotic borders in the right femoral
neck, is likely degenerative.
Abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. High-grade closed loop small bowel obstruction. Small bowel is mildly
hyperemic without evidence of pneumatosis, portal venous gas or free air.
2. Moderate to large volume intra-abdominal and pelvic ascites, not seen on
renal ultrasound from ___, likely reactive in the setting of a high-grade
obstruction.
3. Left double-J ureteral stent appears well positioned. No evidence of
hydronephrosis.
NOTIFICATION: Findings discussed in person with the surgical team by Dr.
___ on ___ at 01:55, 10 minutes after they were made.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 97.8
heartrate: 118.0
resprate: 18.0
o2sat: 100.0
sbp: 194.0
dbp: 128.0
level of pain: 10
level of acuity: 2.0 | ___ year old female who had a ureteral injury at an outside
hospital a couple of months ago. She presented here and had a
ureteral reimplantation
with a psoas hitch done by the Urology team approximately a
month ago.
She now presents with a high grade small bowel obstruction, as
well as a low density fluid collection in the pelvis.
On ___, the patient was taken to the operating room where she
underwent an exploratory laparotomy, lysis of adhesions, and
bladder hitch repair. The operative course was stable with
minimal blood loss. At the close of the procedure, ___
drain was placed into the pelvis. After the surgery, the patient
experienced mild nausea which was relieved with the placement of
a ___ tube. She required additional intravenous fluids
for a diminished urine output. During her post-operative course
she was noted to have an elevated blood pressure which was
treated with oral anti-hypertensive agents. The ___
tube was removed on POD #2. The patient was started on clear
liquids and advanced to a regular diet. Her vital signs
remained stable and she was afebrile. The patient was discharged
home on POD # 6 in stable condition. A follow-up appointment
was scheduled in the acute care clinic. Out-patient follow-up
visit with Urology was recommended. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None this admission
Recently:
___: Aortic valve replacement 25 mm ___ Biocor
Epic tissue valve.
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of aortic
stenosis, hyperlipidemia, hypertension, and pituitary adenoma.
She underwent aortic valve replacement on ___ with Dr.
___. Her postoperative course was notable for a sensation of
heaviness of her right upper extremity. Neurology consulted
and CTA of head and neck was negative. Her symptoms resolved
prior to discharge with plan to an outpatient MRI. She was
discharged to rehab on postoperative day five. She had been
overall doing well at rehab, with the exception of fatigue and
mild dyspnea on exertion. On morning of ___, she developed
palpitations with associated shortness of breath. She was noted
to be orthostatic, and AM doses of both furosemide and
metoprolol tartrate were held. As the day progressed, she felt
more fatigued and symptoms persisted. Her heart rate was
irregular and elevated to 120-150s, prompting transfer to ___
ED. In the ED, an EKG demonstrated an irregular rhythm,
consistent with atrial
fibrillation. She received IV metoprolol tartrate 5mg and PO
metoprolol tartrate 12.5mg, and was admitted to cardiac surgery
for further management.
Past Medical History:
Aortic Stenosis
Back Pain
Hyperlipidemia
Hypertension
LAFB
Osteoarthritis
Pituitary Adenoma
Skin Cancer
Social History:
___
Family History:
Father - myocardial infarction in his ___, died of MI at ___.
Mother - multiple MIs, died at age ___.
Brother - CABG at age ___.
Daughter - breast cancer.
Daughter - autoimmune hepatitis and positive lupus.
Physical Exam:
Admission PE: Vital Signs
T 97.6 AF 100 R 20 96/70 98% RA
Weight: 178 pounds Height: 64"
General: Awake, alert in NAD
Skin: Warm, dry, intact, sternal incision clean/dry/intact - no
click
Chest: Lungs clear bilaterally, diminished at bases
Heart: Irregular, tachy
Abdomen: Normal BS, soft, non-distended, non-tender
Extremities: Warm, well-perfused; trace bilateral edema
Neuro: Grossly intact
Pulses:
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Discharge PE:
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: CTA [x] No resp distress []
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema
Left Lower extremity Warm [x] Edema
Pulses:
DP Right:+ Left:+
___ Right:+ Left:+
Skin/Wounds: Dry [x]intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
Pertinent Results:
___ 10:45AM BLOOD WBC-11.4* RBC-3.81* Hgb-11.2 Hct-35.0
MCV-92 MCH-29.4 MCHC-32.0 RDW-14.0 RDWSD-47.0* Plt ___
___ 10:45AM BLOOD Glucose-115* UreaN-20 Creat-0.9 Na-142
K-4.7 Cl-105 HCO3-23 AnGap-14
___ 10:45AM BLOOD WBC-11.4* RBC-3.81* Hgb-11.2 Hct-35.0
MCV-92 MCH-29.4 MCHC-32.0 RDW-14.0 RDWSD-47.0* Plt ___
___ 10:45AM BLOOD ___ PTT-25.5 ___
___ 10:45AM BLOOD Glucose-115* UreaN-20 Creat-0.9 Na-142
K-4.7 Cl-105 HCO3-23 AnGap-14
___ 05:08AM BLOOD UreaN-22* Creat-0.9 K-4.6
___ ___ F ___ ___
Radiology Report MR HEAD W/O CONTRAST Study Date of ___
2:47 ___
___ FA8 ___ 2:47 ___
MR HEAD W/O CONTRAST Clip # ___
Reason: ___ year old woman with history of CVA after CABG, exam
was scheduled for ___, but patient is now inpatient.
UNDERLYING MEDICAL CONDITION:
___ year old woman with history of CVA after CABG, exam was
scheduled for ___, but patient is now inpatient.
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with history of CVA after CABG,
exam was
scheduled for ___, but patient is now inpatient.// ___ year old
woman with
history of CVA after CABG, exam was scheduled for ___, but
patient is now
inpatient.
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 of ___, MRI
pituitary of ___, MRI head and MRA head neck of ___.
FINDINGS:
No evidence of acute infarct or intracranial hemorrhage.
Partially visualized is a large pituitary macroadenoma with
invasion into the right cavernous sinus encasing the right
internal carotid artery, with extension and mass effect along
the right ventral aspect of the pons, overall unchanged from
prior examination. A small left posterior fossa meningioma
along the petrous apex is poorly evaluated on today's
examination. No additional intracranial mass lesions
identified.
The major intracranial flow voids are preserved. The paranasal
sinuses are essentially clear. The orbits are unremarkable
noting bilateral lens
replacements. No significant fluid signal is seen in the
mastoid air cells.
IMPRESSION:
1. No evidence of acute infarct or intracranial hemorrhage.
2. Allowing for technical differences no gross interval change
in large
pituitary macroadenoma with invasion into the right cavernous
sinus and mass effect along the ventral aspect of the pons.
3. A known left posterior fossa meningioma is poorly visualized.
4. Additional findings as described above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
2. Furosemide 20 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. Ranitidine 150 mg PO BID
6. Venlafaxine XR 37.5 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Rivaroxaban 20 mg PO DINNER
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Metoprolol Tartrate 12.5 mg PO BID
7. Ranitidine 150 mg PO BID
8. Venlafaxine XR 37.5 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Rapid atrial fibrillation
Secondary:
Aortic Stenosis s/p AVR (tissue) ___
Back Pain
Hyperlipdiemia
Hypertension
LAFB
Osteoarthritis
Pituitary Adenoma
Skin Cancer
Vertigo
Past Surgical History:
___, LLE
Left knee replacement
Right knee replacement
Right hip replacement
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema - trace
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with afib// eval chf
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___.
FINDINGS:
Median sternotomy wires are intact and aligned. The cardiomediastinal
silhouette is stable. Compared to the prior study, opacities at the bilateral
bases, right greater than left, have improved, likely reflecting atelectasis.
Otherwise, the lungs appear clear. No pleural effusion or pneumothorax.
IMPRESSION:
Interval improvement of bibasilar atelectasis. No evidence of pulmonary
edema.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with history of CVA after CABG, exam was
scheduled for ___, but patient is now inpatient.// ___ year old woman with
history of CVA after CABG, exam was scheduled for ___, but patient is now
inpatient.
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 of ___, MRI pituitary of ___, MRI head and MRA head neck of ___.
FINDINGS:
No evidence of acute infarct or intracranial hemorrhage. Partially visualized
is a large pituitary macroadenoma with invasion into the right cavernous sinus
encasing the right internal carotid artery, with extension and mass effect
along the right ventral aspect of the pons, overall unchanged from prior
examination. A small left posterior fossa meningioma along the petrous apex
is poorly evaluated on today's examination. No additional intracranial mass
lesions identified.
The major intracranial flow voids are preserved. The paranasal sinuses are
essentially clear. The orbits are unremarkable noting bilateral lens
replacements. No significant fluid signal is seen in the mastoid air cells.
IMPRESSION:
1. No evidence of acute infarct or intracranial hemorrhage.
2. Allowing for technical differences no gross interval change in large
pituitary macroadenoma with invasion into the right cavernous sinus and mass
effect along the ventral aspect of the pons.
3. A known left posterior fossa meningioma is poorly visualized.
4. Additional findings as described above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Palpitations
Diagnosed with Paroxysmal atrial fibrillation
temperature: 97.6
heartrate: 100.0
resprate: 20.0
o2sat: 98.0
sbp: 96.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted through the emergency department when
she presented from rehab with palpitations and telemetry
revealed atrial fibrillation with a rapid ventricular response.
The electrophysiology service saw her in consultation and
recommended anticoagulation with apixaban, which was started.
Her ventricular rates responded to titration of metoprolol, so a
rate control strategy was initiated with a plan for elective
cardioversion in several weeks. She converted to sinus rhythm on
___ and remained in sinus rhythm. She had a head MRI which she
was scheduled for as an outpatient which revealed no infarct or
bleed. She was seen in consultation by the physical therapy
service and was recommended to return to rehab for help with
strengthening. She was discharged back to ___ on ___
___ on ___ in good condition with all appointments for
follow up. |
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 distention
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, extensive lysis of adhesions,
reduction of internal hernia.
History of Present Illness:
___ yo M with history of stab wound to abdomen as a ___ year
old child presents with 9 days of abdominal bloating. He was
seen
at ___ where he was admitted for 5 days, discharged
2 days ago, and was treated with NPO, NGT and enemas. He says he
was able to have 2 BM's with enemas, but still felt bloated at
the time of discharge. He never vomited, but was treated with
NGT
shortly after symptoms developed. Denies fevers, chills, and no
abdominal pain. Not passing gas currently.
Past Medical History:
PMH: "Back spasms" occasionaly, not on meds for this. Did have a
colonoscopy at age ___ which found some "polyps", was told to
repeat in ___ years (is due).
PSH: stab wound treated with local exploration as above.
Social History:
___
Family History:
non-contributory
Physical Exam:
Gen: NAD, AAOx3
HEENT: NCAT, no neck masses, anicteric
CV: RRR no M/G/R
P: CTAB no W/R/R
Abd: appropriately tender, non-distended, well healing wound.
Ext: no C/C/E
TLD: none
Pertinent Results:
CT ab/pel ___: Closed loop small bowel obstruction with two
transitions points in close proximity in the lower mid abdomen
(601b:23). Proximally, there is upstream small bowel
obstruction. Small amount of free fluid within the abdomen
pelvis. No evidence of ischemia or perforation.
___ 03:45PM WBC-5.9 RBC-4.39* HGB-14.4 HCT-43.2 MCV-98
MCH-32.8* MCHC-33.3 RDW-12.6 RDWSD-45.6
___ 03:45PM NEUTS-60 BANDS-0 ___ MONOS-8 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-3.54 AbsLymp-1.89
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.00*
___ 03:45PM GLUCOSE-116* UREA N-22* CREAT-1.1 SODIUM-138
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-30 ANION GAP-14
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*120 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Closed loop bowel obstruction with an internal hernia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ w/ prior abd surgery here w/bloating, recent
discharge for bowel obstruction // ? obstruction, ileus
TECHNIQUE: ABDOMEN (SUPINE AND ERECT)
COMPARISON: None available.
FINDINGS:
There are multiple loops of dilated small bowel with multiple air-fluid levels
in the small bowel in the right mid and lower abdomen, concerning for small
bowel obstruction. The stomach is distended with air fluid level. There is a
paucity of colonic gas and gas in the rectum. No definite free
intraperitoneal air is identified.
IMPRESSION:
Multiple loops of dilated small bowel and air-fluid levels concerning for
small bowel obstruction. CT of the abdomen can be obtained for further
evaluation.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 6:43 ___, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: History: ___ with abdominal distention, evidence of obstruction
on KUB
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
4) Spiral Acquisition 4.8 s, 52.0 cm; CTDIvol = 14.8 mGy (Body) DLP = 770.1
mGy-cm.
Total DLP (Body) = 782 mGy-cm.
COMPARISON: Abdominal x-ray ___ at 14:31.
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 an 8 mm hypodensity in hepatic segment 6 (2:31) that is too small to
characterize, but statistically likely represents a cyst. A 1.5 cm simple
cyst in the caudate lobe is also noted. No other focal hepatic lesions are
identified. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a 2.0 cm simple cyst in the lower pole of the right kidney. There is
no evidence of concerning focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: An enteric tube terminates in the stomach. There are
multiple abnormally dilated loops of small bowel measuring up to 4.3 cm in
diameter, compatible with a small bowel obstruction. There appears to be two
adjacent transition points in the lower mid abdomen (___:23) with an
intervening dilated segment of small bowel with associated mesenteric edema,
concerning for a closed loop obstruction. The distal ileum is collapsed. No
evidence of ischemia or perforation. Colonic loops are collapsed. A small
amount of simple free fluid is seen within the abdomen and pelvis.
PELVIS: Bladder is well distended and appears unremarkable. Distal ureters
are within normal limits. Small amount of free fluid is seen within the
pelvis.
REPRODUCTIVE ORGANS: Prostate gland appears enlarged.
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. The bilateral iliac branches are diffusely prominent, but there is
no focal aneurysmal dilation.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Dextroconvex scoliosis of the lumbar spine. There are bilateral L5 pars
defects with grade 1 anterolisthesis of L5 on S1 with endplate degenerative
changes at this level.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Closed loop small bowel obstruction with two transitions points in close
proximity in the lower mid abdomen (___:23). Proximally, there is upstream
small bowel obstruction. Small amount of free fluid within the abdomen
pelvis. No evidence of ischemia or perforation.
NOTIFICATION: Updated findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 9:14 ___, 2 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ male with history of SBO post ex-lap found to have internal
hernia through enteroentero adhesion evaluate NG tube position.
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: ___ abdominal radiograph.
FINDINGS:
NG tube terminates at the distal GE junction with side port in the distal
esophagus. Surgical staples overlie the abdomen and pelvis. There is a
single dilated loop of small bowel likely postsurgical in etiology. There is
no gross pneumoperitoneum. Air can be seen in the rectum.
IMPRESSION:
1. NG tube terminates at the distal GE junction with side port in the distal
esophagus. Recommend advancement.
2. No gross pneumoperitoneum.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with Unspecified intestinal obstruction
temperature: 98.8
heartrate: 76.0
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ was transferred to ___ from ___ on ___ after
failing conservative management of the SBO. CT Ab/Pel at that
time showed a closed loop obstruction, and he was taken
emergently to the OR for exploratory laparatomy, lysis of
adhesions, and reduction of internal hernia. For more details,
see operative report. The patient was taken from the OR to the
PACU in stable condition with NGT, PCA, and foley catheter in
place. He was then taken to the surgical floor. On POD1, the
foley catheter was remove and he voided without difficulty. A
KUB on POD1 showed the NGT possibly past the pylorus, and the
tube was pulled back 6cm. The NGT output then decreased, and the
tube was removed on POD2. The patient's diet was then slowly
advanced from sips of clear fluids to a regular diet. He was
discharged ___ eon ___ tolerating a regular diet, pain well
controlled on oral medications, reporting normal bowel function
and voiding, and ambulating without difficulty. All of his
Questions were answered to his satisfaction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Morphine / Oxycodone / simvastatin
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with history of asthma, DMII, newly
diagnosed pericardial effusion on stress echo, obesity s/p
hemicolectomy and gastric bypass presenting with dyspnea.
Symptoms started last week including cough, dyspnea, and
fatigue. Denies any infectious symptoms including URI sx, fever,
or chills. Pt went to ___ 5 days ago, was kept
overnight and treated with nebs and prednisone 40mg until today.
Pt was seen by PCP today, ___ 91% on RA with improvement to
96% on 2L NC. Pt was noted to have conversational dyspnea. She
was send to ED for cardiology consult and further ___ effusion.
In the ED, initial vitals were: 98.6 81 142/90 18 98% 4L.
- Labs were significant for: H&H 10.___, proBNP 36, glucose 217
otherwise normal chem7, trops x2 negative. lactate 2.
- Imaging revealed: CXR with streaky retrocardiac opacity most
likely atelectasis. Bedside echocardiogram with pericardial
effusion but no tamponade physiology.
Cardiology recommended echocardiogram in am and consulting them
once done.
- The patient was given nebs, solumedrol 125mg, 2L NS, and her
home medications as she was initially placed in observation.
Vitals prior to transfer were: 70 130/63 18 93% Nasal Cannula.
Upon arrival to the floor, VS are 97.5 131/71 94 20 95%2L.
Pt reports improvement of her symptoms.
Past Medical History:
*S/P HEMICOLECTOMY
*S/P HEMORHOIDECTOMY
*S/P HERNIORRHAPHY
*S/P RNY GASTRIC BYPASS
ANEMIA
BACK PAIN
COLONIC POLYPS
CORONARY ARTERY DISEASE
DEPRESSION
DIABETES MELLITUS
ELEVATED LFTS
HEALTH MAINTENANCE
MARIJUANA USE
NEUROPATHY
OSTEOARTHRITIS
PANIC ATTACK
PREMENSTRUAL SYNDROME
REACTIVE AIRWAY DISEASE
SEVERE MORBID OBESITY
TREATMENT PLAN UPDATE
HEALTH MAINTENANCE
PERICARDIAL EFFUSION
H/O BORDERLINE PERSONALITY DISORDER
h/o Obstructive Sleep Apnea
Social History:
___
Family History:
Family history is significant for a sister with breast cancer,
maternal grandmother with lung cancer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: 97.5 131/71 94 20 95%2L.
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. pulses < 10
Lungs: diffuse wheezes, prolonged expiratory phase
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
PHYSICAL EXAM ON DISCHARGE
Vitals: 98.4 ___ ___ 18 97%RA ___ 91% o/n)
Curr: 98.4 161/91 99 18 97%RA
Peak flow prior to neb: 350
Amb sat: 90%
Gen: obese female, NAD, AAOx3, breathing comfortably on RA
CV: RRR no mrg
Lung: diffuse wheezing, improved from admission. Good air
movement
GU: no foley
Extrem: no cce
Neuro: grossly fROM
Pertinent Results:
LABS ON ADMISSION
------------------
___ 04:25PM BLOOD WBC-7.1 RBC-4.40 Hgb-10.3* Hct-33.0*
MCV-75* MCH-23.3* MCHC-31.2 RDW-17.4* Plt ___
___ 04:25PM BLOOD Glucose-217* UreaN-14 Creat-0.6 Na-138
K-4.3 Cl-102 HCO3-25 AnGap-15
___ 04:25PM BLOOD Calcium-9.2 Phos-2.8 Mg-2.0
PERTINENT LABS
---------------
___ 05:05AM BLOOD Calcium-8.8 Phos-4.3# Mg-2.3 Iron-14*
___ 05:05AM BLOOD calTIBC-402 Ferritn-8.4* TRF-309
IMAGING
---------
___ Cardiovascular ECG ___ ___
Sinus rhythm. Non-specific ST segment changes. Low voltage.
Compared to the previous tracing no change.
TRACING #2
Read by: ___
___ Axes
Rate PR QRS QT/QTc P QRS T
68 134 88 420/434 57 12 36
___ Cardiovascular ECHO ___ ___.
Findings
This study was compared to the report of the prior study (images
not available) of ___.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: Small to moderate pericardial effusion. Effusion
circumferential. No RA or RV diastolic collapse.
GENERAL COMMENTS: Right pleural effusion.
Conclusions
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is a small
to moderate sized pericardial effusion. The effusion appears
circumferential. No right atrial or right ventricular diastolic
collapse is seen.
Compared with the report of the prior study (images unavailable
for review) of ___, the findings are similar (heart rate is
now higher).
___ Imaging CHEST (PA & LAT) ___
FINDINGS:
Mild enlargement of the cardiac silhouette is unchanged. The
mediastinal and hilar contours are within normal limits.
Pulmonary vasculature is normal. Streaky retrocardiac opacity
likely reflects atelectasis. No focal consolidation, pleural
effusion or pneumothorax is present. Moderate
multilevel degenerative changes are again seen in the thoracic
spine.
IMPRESSION: Streaky retrocardiac opacity most likely reflective
of atelectasis.
___ Cardiovascular ECG ___ ___
Sinus rhythm. Diffuse low voltage. Compared to the previous
tracing
of ___ no change.
TRACING #1
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 126 88 ___ 65 -2 37
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 225 mg PO BID Pain
2. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
5. Docusate Sodium 100 mg PO BID
6. Clonazepam 2 mg PO TID
7. Duloxetine 120 mg PO DAILY
8. ARIPiprazole 10 mg PO QHS
9. Baclofen ___ mg PO DAILY:PRN spasms
10. ChlorproMAZINE 200 mg PO QHS
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. GlyBURIDE 5 mg PO DAILY
13. MethylPHENIDATE (Ritalin) 20 mg PO QAM
14. MethylPHENIDATE (Ritalin) 10 mg PO QPM
15. Pravastatin 40 mg PO QPM
16. Naproxen 220 mg PO Q12H:PRN pain
17. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough
Discharge Medications:
1. ARIPiprazole 10 mg PO QHS
2. Baclofen ___ mg PO DAILY:PRN spasms
3. ChlorproMAZINE 200 mg PO QHS
4. Clonazepam 2 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 120 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Lisinopril 40 mg PO DAILY
9. MethylPHENIDATE (Ritalin) 20 mg PO QAM
10. MethylPHENIDATE (Ritalin) 10 mg PO QPM
11. Pravastatin 40 mg PO QPM
12. Pregabalin 225 mg PO BID Pain
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 Neb soln IH
q6h:prn Disp #*25 Vial Refills:*0
14. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 Neb IH q6h;prn
Disp #*25 Vial Refills:*0
15. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
16. GlyBURIDE 5 mg PO DAILY
17. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
18. PredniSONE 60 mg PO DAILY
Day 1 (___) Prednisone 60
Day ___: 40mg
Day ___: 20mg
Day 6+ 10mg until seen by Dr. ___
___ dose - DOWN
RX *prednisone 20 mg ___ tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
19. Prescription
Spacer:
Use as directed
20. Prescription
Nebulizer Machine
ICD-9 code:___
21. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Acute exacerbation of COPD
Secondary:
- Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with severe dyspnea
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Mild enlargement of the cardiac silhouette is unchanged. The mediastinal and
hilar contours are within normal limits. Pulmonary vasculature is normal.
Streaky retrocardiac opacity likely reflects atelectasis. No focal
consolidation, pleural effusion or pneumothorax is present. Moderate
multilevel degenerative changes are again seen in the thoracic spine.
IMPRESSION:
Streaky retrocardiac opacity most likely reflective of atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Asthma exacerbation, Dyspnea
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION, WHEEZING
temperature: 98.6
heartrate: 81.0
resprate: 18.0
o2sat: 98.0
sbp: 142.0
dbp: 90.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with history of asthma, DMII, newly
diagnosed pericardial effusion on stress echo, obesity s/p
hemicolectomy and gastric bypass, and CAD presenting with
dyspnea.
BRIEF HOSPITAL COURSE:
=======================
# ACUTE ASTHMA EXACERBATION: Patient presented with subacute
cough, dyspnea, and fatigue. Peak flow on admission 300. On
admission, diffusely wheezing, pulsus negative, JVD flat. Given
history of pericardial effusion, patient evaluted by
echocardiogram for percardial effusion which revealed small to
moderate pericardial effusion, no concern for cardiac tamponade
physiology. Patient treated with prednisone 60mg and nebulizer
with improvement in symptoms, improvement of oxygenation to 97%
on room air, and peak flow improvement to 400, however with
continued wheezing on exam, albeit with good air movement.
Patient advised to discontinue marijuana smoking, and continue
nebulizers and MDI with spacers. Patient with periodic
ambulatory desaturations while hosptialized. Patient discharged
with plans for slow taper of prednisone until follow up with Dr.
___. Consider also repeat sleep study given
desaturations noted overnight.
# IRON DEFICIENCY ANEMIA: Patient noted to have severe iron
deficiency during hospitalization. Repleted with IV ferric
gluconate. Please repeat CBC.
# PERICARDIAL EFFUSION: Given history of pericardial effusion,
patient evaluted by echocardiogram for percardial effusion which
revealed small to moderate pericardial effusion, no concern for
cardiac tamponade physiology. Recommend outpatient cardiology
work-up and repeat TTE in one year.
# HAND PAIN: Patient complaining of hand pain. Describes as
intermittent through the day, particular problems in the AM,
needs to faciliate opening hand with other hand. Family history
of rheumatoid arthritis, consider work up as outpatient.
# DEPRESSION: Patient continued on home dose medications.
# HYPERTENSION: Patient continued on home dose antihypertensives
TRANSITIONAL ISSUES
=====================
[] PCP/PULM: Please follow up acute asthma exacerbation.
Consider extending or discontinuing prednisone
[] PCP: ___ CBC
[] PCP: ___ repeat sleep study given desaturations
overnight
[] CARDS: Patient with small to moderate pericardial effusion.
Please workup as outpatient. Repeat TTE in one year
[] PCP: ___ hand pain, consider early rheumatoid arthritis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
Coronary angiogram ___
History of Present Illness:
Mr. ___ is a ___ yo man with H/O CAD s/p CABG ___ with
multiple PCIs (before and after CABG), ESRD on HD, hypertension,
and type 2 diabetes mellitus on insulin presenting with 3 days
of epigastric pain associated with emesis and diaphoresis. He
declined an interpreter for this interview multiple times. The
pain was not associated with exertion and not typical for his
angina. He initially attributed this to antibiotics he has been
taking for the past 2 weeks. He noted that with his past MIs, he
had "big pain" and did not feel like his recent symptoms. He
denied any exertional dyspnea, paroxysmal nocturnal dyspnea,
orthopnea, lower extremity edema. He had blood red blood per
rectum occasionally at home from his hemorrhoids, but none
recently. He denied any fevers, chills, night sweats, or
productive cough.
In the ED initial vitals were: T 97.4 HR 72 BP 149/58 RR 16 SaO2
99% on RA. EKG showed T wave inversion in leads I, aVL, V2-V5.
Labs/studies notable for: troponin-T 0.37, 0.38, 0.39, CK-MB 1,
Cr 5.1. CXR had airspace opacities in right lower lung that
might represent developing pneumonia. Patient was given ASA 243
mg, heparin gtt, ceftriaxone and azithromycin.
After arrival to the cardiology ward, the patient denied any
current chest pain or epigastric pain like he was having before
admission.
Past Medical History:
1. CAD RISK FACTORS
-Hypertension
-Diabetes Mellitus, Insulin requiring
-Hyperlipidemia
2. CARDIAC HISTORY
CAD
-NSTEMI ___ treated with ___ ___ treated with off-pump CABG ___ (LIMA-LAD,
___, SVG-D)
-NSTEMI ___ treated with PTCA ___ touchdown, ___
___.
-Acute ischemic mitral regurgitation, improved after ___
stenting
3. OTHER PAST MEDICAL HISTORY
-Diabetic foot ulcer Left foot
-End-Stage Renal Disease on HD
-Anemia of Chronic Disease
-Glaucoma
-Latent Tuberculosis treated with INH/B6 x 9 months
-Obstructive Sleep Apnea
-Peripheral Arterial Disease
-Meningioma
-Hemorrhoids
Social History:
___
Family History:
No FH of early CV disease, DM, hypertension. Father with
multiple strokes.
Physical Exam:
On admission
GENERAL: Elderly black man sitting up in bed in no acute
distress.
VS: T 97.8 PO BP 152/70 left arm supine HR 61 RR 18 SaO2 97% on
RA
HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP at 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line, increased intensity. Regular rate and rhythm. Normal S1,
S2. No murmurs, rubs, or gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
CTAB--no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Left heel with necrotic ulcer without purulent
drainage, mild tenderness.
NEURO: CN II-XII intact. Strength ___ x4 extremities. Sensation
Intact to Light Touch x4 extremities.
SKIN: No rashes
PULSES: Radial and DP pulses 1+
At discharge
GENERAL: Elderly male sitting in bed in no acute distress.
24 HR Data (last updated ___ @ 817) Temp: 98.2 (Tm 98.4),
BP: 133/56 (98-159/45 thigh-91), HR: 69 (59-70), RR: 18 (___),
O2 sat: 93% (93-98), O2 delivery: A
Wt: 137.57 lb/62.4 kg
HEENT: Mucous membranes moist.
NECK: JVP 7 cm.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
CTAB. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No hepatomegaly. No
splenomegaly. Normoactive bowel sounds.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. LUE with AV fistula with palpable thrill. Left
heel with necrotic ulcer without purulent drainage, mild
tenderness. Right wrist access site with bandage.
NEURO: Alert and conversant, moving all extremities
SKIN: No rashes
PULSES: Radial pulses 2+ bilaterally
Pertinent Results:
___ 01:50AM BLOOD WBC-9.1 RBC-3.73* Hgb-10.2* Hct-33.4*
MCV-90 MCH-27.3 MCHC-30.5* RDW-15.3 RDWSD-49.1* Plt ___
___ 07:50AM BLOOD ___ PTT-95.6* ___
___ 01:50AM BLOOD Glucose-252* UreaN-30* Creat-5.1* Na-139
K-4.1 Cl-98 HCO3-29 AnGap-12
___ 01:50AM BLOOD cTropnT-0.37*
___ 07:50AM BLOOD cTropnT-0.38*
___ 09:17AM BLOOD cTropnT-0.39*
___ 06:15PM BLOOD CK-MB-1 cTropnT-0.38*
ECG ___ 23:19:32
Sinus rhythm. Probable left atrial enlargement. LVH with
secondary repolarization abnormality
CXR ___
Median sternotomy wires are intact. The cardiac silhouette is
mildly enlarged and stable. Patchy airspace opacities at the
right lung base are present and may represent developing
pneumonia in the appropriate clinical setting. There is no
pleural effusion, or pneumothorax. The mediastinal contour
stable.
IMPRESSION: Right lower lung airspace opacities may represent
developing pneumonia in the appropriate clinical setting.
Coronary angiogram ___
LM: The left main coronary artery had 40% distal.
LAD: The left anterior descending coronary artery was calcicifed
with 60-70% diffuse mid with retrograde filling of the LIMA.
Circ: The circumflex coronary artery was occluded proximally at
the location of prior stent. Collaterals were present.
RCA: The right coronary artery was occluded mid. Collaterals
were present.
LIMA-LAD: A left internal mammary artery to the LAD was not
engaged, as known atretic from prior study.
___: A saphenous vein graft to the OM was with widely patent
stents.
SVG-Diagonal: A saphenous vein graft to the Diagonal was widely
patent.
FINDINGS:
Three vessel coronary artery disease (similar to prior).
Patent ___ and SVG-Diagonal.
No clear culprit lesion identified.
DISCHARGE LABS
___ 06:13AM BLOOD WBC-6.1 RBC-3.44* Hgb-9.6* Hct-30.8*
MCV-90 MCH-27.9 MCHC-31.2* RDW-15.7* RDWSD-50.7* Plt ___
___ 03:58AM BLOOD ___ PTT-52.5* ___
___ 06:13AM BLOOD Glucose-164* UreaN-24* Creat-5.0*# Na-140
K-4.4 Cl-98 HCO3-28 AnGap-14
___ 06:13AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Prasugrel 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 25 mg PO BID
5. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Cinacalcet 30 mg PO DAILY
7. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
8. Lisinopril 40 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. CeFAZolin 2 g IV POST HD (___)
2. CeFAZolin 3 g IV POST HD (SA)
3. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
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. Cinacalcet 30 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Lisinopril 40 mg PO DAILY
11. Prasugrel 10 mg PO DAILY
12. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
-Non-ST segment elevation myocardial infarction
-Coronary artery disease, native and arterial conduit
-Prior coronary artery bypass surgery
-Left heel ulcer
-Type 2 diabetes mellitus, on insulin
-End-stage renal disease on hemodialysis
-Hypertension
-Hyperlipidemia
-Glaucoma
-Anemia of chronic disease
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 nauea, emesis, ekg changes, epigastric pain//
?pna ?pulm edema ?pnx
COMPARISON: Multiple prior chest radiographs most recently dated ___
FINDINGS:
PA and lateral views of the chest provided.
Median sternotomy wires are intact. The cardiac silhouette is mildly enlarged
and stable. Patchy airspace opacities at the right lung base are present and
may represent developing pneumonia in the appropriate clinical setting. There
is no pleural effusion, or pneumothorax. The mediastinal contour stable.
IMPRESSION:
Right lower lung airspace opacities may represent developing pneumonia in the
appropriate clinical setting.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Epigastric pain
Diagnosed with Acute ischemic heart disease, unspecified
temperature: 97.4
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 149.0
dbp: 58.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a ___ yo man with H/O CAD with NSTEMI treated with
DES to ___ ___, NSTEMI treated with CABGx3 ___, NSTEMI treated
with DES to SVG->OM1 ___, ESRD on HD, hypertension, type 2
diabetes mellitus on insulin presenting with 3 days of
epigastric pain associated with emesis and diaphoresis. He was
found to have NSTEMI based on elevated troponin-T and underwent
coronary angiography ___ which showed patent vein grafts and no
change underlying CAD.
ACUTE ISSUES
# NSTEMI, CAD. s/p ___ ___, CABG ___ (LIMA-LAD, ___,
SVG-D), ___. He presented with post-prandial
epigastric pain with diaphoresis and emesis, T wave inversions
on EKG, elevated troponin-T peaked at 0.39 (ESRD but above last
troponin 0.17 in ___, consistent with NSTEMI. He was started
on a heparin gtt. Coronary angiography ___ showed three
vessel coronary artery disease (similar to prior, with known
atretic LIMA-LAD), patent ___ and SVG-Diagonal, and no clear
culprit lesion identified. He was continued on home aspirin,
prasugrel (to be continued through ___ with
anticipation of lifelong DAPT per outpatient cardiologist if no
bleeding issues), carvedilol, amlodipine, and lisinopril.
# Left heel ulcer: This did not appear grossly infected this
admission, continued outpatient cefazolin post-HD (2 gm ___ and
___ and 3 gm ___ with end date ___.
CHRONIC ISSUES
# Hypertension: Continued home carvedilol, lisinopril,
amlodipine.
# Type 2 diabetes mellitus on insulin: Continued glargine 10
units at breakfast, insulin sliding scale.
# ESRD on HD ___: Previously on peritoneal dialysis,
catheter removed in setting of bacterial peritonitis in ___
and transitioned to hemodialysis. Continued home cinacalcet,
sevelamer. Received HD ___.
# Anemia of renal disease: Chronic normocytic anemia with Hgb
10.2 on presentation, unchanged from baseline.
# Glaucoma: Continued home latanoprost drops.
TRANSITIONAL ISSUES
[] On HD ___, last HD on ___
[] Continued cefazolin ___ post HD, on antibiotic course
through ___ as outpatient for left heel ulcer. Cefazolin 2 g on
___ and ___ and Cefazolin 3 g on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
___ Complaint:
Found Down
Major Surgical or Invasive Procedure:
-Intubation
-PICC line placement
-Tracheostomy and PEG tube ___
History of Present Illness:
Primary Care Physician: ___ Complaint: Found down
Reason for MICU transfer: Shock
HISTORY OF PRESENT ILLNESS:
___ with h/o IDDM was brought to an OSH after she was found
unresponsive by her husband. Per report, she was initially
found to be unresponsive around 4 am, but her husband did not
call until she did not wake up until later that afternoon
(around 3pm). Per report, she was noted to be diaphoretic and
her ___ was 13 when EMS arrived. She was given glucagon (per
report) and they attempted intubation.
She was subsequently intubated on arrival to the OSH ED. Her
vital signs were Tm 102.2, HR 118-140, BP 99/75-160/98. LP with
+WBCs with left shift. She was given vancomycin/ceftrixaone out
of concern for bacterial meningitis. Flagyl was also added for
concern for aspiration given the findings of an infiltrate on
CXR. She also received propofol, lorazepam, dilaudid, and ASA
PR. She did not have additional episodes of hypoglycemia; per
report her ___ on arrival was 113.
In the ED, initial vitals: 111 ___ 100% on the vent.
She was given acyclovir. On exam, there was note of chemosis
and proptosis of her eyes. She had normal IOP (right 19/left
17). There was report of increased optic nerve diameter on the
left. Neurology was consulted who recommended continued therapy
for bacterial and viral mengingitis. They will continue to
follow and feel she likely will require EEG monitoring when less
sedated. Ophthamology was consulted who recommended
erythromycin ointment and to keep the lids closed. A TSH was
obtained and returned wnl. During her ED course, her SBP
dropped to ___ systolic and she was started on levophed. On
transfer, vitals were: 99.8 110 121/72 16 100% on the Vent.
On arrival to the MICU, the patient is intubated and sedated.
She does not withdraw to pain. She is noted to have
intermittent right sided twitching in her right upper and lower
extremities. No spontaneous movements were noted on the left
side.
Past Medical History:
- Bipolar
- PTSD
- Psychiatry ___
- Non compliant with medical follow up
- Alcoholism
- Periodic drug use
- IDDM Type II (Metformin) - HISS / Lantus / Metformin A1c <6%
Social History:
___
Family History:
Unknown and not relevant to critical illness.
Physical Exam:
ADMISSION PHYSICAL EXAM
99.8 110 121/72 16 100% on the Vent
General- Intubated and sedated.
HEENT- Proptosis (L > R), chemosis, small pupils, L seems
slightly more reactive than right. Injected sclera.
Neck- Stiff, but difficult to fully assess given mental status.
CV- RRR, nl s1s2, no m/r/g
Lungs- Good air entry, scattered expiratory ronchi
Abdomen- S/NT/ND, NABS,
GU- Foley draining clear yellow urine
Ext- WWP, no CCE, DP 2+ b/l
Neuro- Intubated and sedated. Does not follow commands and or
respond to voice. Does not withdraw to pain. Low amplitude/low
frequency rhthymic movements in RUE/RLE.
DISCHARGE PHYSICAL EXAM
Tm 100 HR 50-100 BP ___ RR ___ 100% 30% FiO2
General: Trach in place on trach collar, unresponsive, triple
flexion to noxious stimuli but not clearly withdrawing, no
sedation
HEENT: B/l proptosis, chemosis, tongue macerated; pupils similar
in size 3-4mm but not reactive to light. Eyes with discordant
downward gaze left eye slightly laterally and downward deviated
more than right, poor dentition, bottom teeth extracted
CV: RRR; no m/r/g
Lungs: CTA B/L, moving air well and symmetrically
Abd: soft, NTND
Extremity: no edema
Neuro: intact cough and gag, vestibulo-occular reflex, extensor
posturing spontaneously, upgoing babinski, triple flexion
Pertinent Results:
ADMISSION LABS
___ 09:40PM BLOOD WBC-5.4 RBC-3.80* Hgb-10.1* Hct-32.8*
MCV-86 MCH-26.5* MCHC-30.7* RDW-15.6* Plt ___
___ 09:40PM BLOOD Neuts-81.6* Lymphs-13.8* Monos-3.8
Eos-0.4 Baso-0.4
___ 09:40PM BLOOD Plt ___
___ 09:40PM BLOOD Glucose-128* UreaN-12 Creat-0.7 Na-145
K-3.0* Cl-110* HCO3-21* AnGap-17
___ 02:11AM BLOOD ___ PTT-27.3 ___
___ 09:40PM BLOOD CK(CPK)-1098*
___ 09:40PM BLOOD cTropnT-0.07*
___ 02:11AM BLOOD Calcium-6.0* Phos-3.1 Mg-0.9*
___ 02:11AM BLOOD Triglyc-80
___ 02:11AM BLOOD Osmolal-293
___ 09:40PM BLOOD TSH-2.9
___ 12:59AM BLOOD Type-ART Temp-37.7 Rates-16/ Tidal V-500
PEEP-5 FiO2-50 pO2-140* pCO2-49* pH-7.30* calTCO2-25 Base XS--2
Intubat-INTUBATED
___ 09:51PM BLOOD Lactate-2.4*
___ 12:59AM BLOOD O2 Sat-98
___ 09:16AM BLOOD freeCa-0.88*
PERTINENT REPORTS:
MRI HEAD ___ : Diffuse abnormality in bilateral cerebral
hemispheres involving both the white matter and the gray matter
as well as the middle cerebellar peduncle. Findings could
reflect hypoglycemic encephalopathy or hypoxic injury. No large
territorial infarction is noted.
MRI Head and cavernous sinuses with contrast ___: There is
diffuse sinus opacification with fluid levels in the maxillary
and sphenoid sinuses as previously noted. Although bilateral
superior ophthalmic veins are mildly prominent, no filling
defects are seen in the cavernous sinuses. Bilateral mastoid
fluid is seen. There is mild soft tissue swelling in the left
frontal region which may be related to trauma.
CT Head ___ IMPRESSION:
1. No acute intracerebral hemorrhage.
2. Progressive hypodensities throughout the bilateral cerebral
hemispheres. There is increaesed edema, loss of grey white
contrast, and swlling. As suggested on prior MR examination,
these findings could reflect changes associated with
hypoglycemic encephalopahty, diffuse infarction, or hypoxic
injury.
Last EEG ___
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of continuous focal slowing and continuous
periodic lateralized epileptiform discharges over the left
hemisphere. These findings are indicative of a highly
potentially epileptogenic focal structural lesion in the left
hemisphere. The right hemisphere shows less severe slowing with
no posterior dominant rhythm and rare right frontal central
sharp waves, indicating potentially epileptogenic focal cerebral
dysfunction in the right hemisphere as well. This is
etiologically nonspecific. No clinical or electrographic
seizures are present. Compared to the prior day's recording, the
left hemisphere periodic lateralized epileptiform discharges are
less prominent, and are also reactive, disappearing during
periods of stimulation.
MICROBIOLOGY:
- OSH BCx Negative Final
- OSH CSF Cx Negative Final
- OSH CXF HSV PCR and Culture Pending ___, will recieve a
14 day course of Acyclovir prior to results
- MRSA screen +
- No growth on multiple blood cxs, sputum cxs, urine cxs at
___
DISCHARGE LABS
___ 04:00AM BLOOD WBC-5.7 RBC-2.84* Hgb-7.5* Hct-24.1*
MCV-85 MCH-26.5* MCHC-31.2 RDW-16.2* Plt ___
___ 04:00AM BLOOD Glucose-201* UreaN-8 Creat-0.4 Na-145
K-3.6 Cl-104 HCO3-28 AnGap-17
___ 04:00AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.4*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 20 mg PO DAILY
2. TraZODone Dose is Unknown PO Frequency is Unknown
3. Aripiprazole Dose is Unknown PO Frequency is Unknown
4. ClonazePAM Dose is Unknown PO Frequency is Unknown
5. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN Pain or Fever
2. Acyclovir 500 mg IV Q8H Duration: 3 Days
first day ___, 2 week course, last day ___. Ampicillin 2 g IV Q4H Duration: 3 Days
first day ___, 2 week course, last day ___. CeftriaXONE 2 gm IV Q 12H Duration: 3 Days
first day ___, 2 week course, last day ___. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Docusate Sodium (Liquid) 100 mg PO BID constipation
7. Morphine Sulfate ___ mg IV Q4H:PRN pain/grimacing
8. Scopolamine Patch 1 PTCH TD Q72H
9. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
10. Bromocriptine Mesylate 1.25 mg PO TID
11. LeVETiracetam Oral Solution 500 mg PO BID
12. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN dry
eyes/corneal abrasions
13. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Coma
- Anoxic Brain Injury
- Hypoxic respiratory failure
- Ventilator dependent
Chronic:
- Bipolar
- PTSD
- Diabetes Mellitus (Insulin Dependent Type II)
- Alcoholism
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound - can participate in ___
Followup Instructions:
___
Radiology Report
TECHNIQUE: MRI of the brain without gad. MRV using 2D time-of-flight.
HISTORY: Woman with chemosis and proptosis concerning for cavernous sinus
thrombosis. There is opacification of the paranasal sinuses with fluid levels
in the maxillary and sphenoid sinuses as well as the frontal sinus. Bilateral
mastoid opacification is also seen.
There are foci of slow diffusion in bilateral supratentorial white matter as
well as in the basal ganglion and the hippocampus and the middle cerebellar
peduncles. There is relatively poor visualization of the right MCA which
could be technical, but recommend correlation with intracranial MRA. MRV of
the brain demonstrates no evidence for dural venous sinus thrombosis. There
is cupping of the optic disks which could reflect papilledema. To the extent
that it can be evaluated, the superior ophthalmic veins are not enlarged.
Diffuse sinus opacification is seen.
IMPRESSION: Diffuse abnormality in bilateral cerebral hemispheres involving
both the white matter and the gray matter as well as the middle cerebellar
peduncle. Findings could reflect hypoglycemic encephalopathy or hypoxic
injury. No large territorial infarction is noted.
To further evaluate for the possibility of possible orbital mass or cavernous
sinus thrombosis, would recommend dedicated mr of the cavernous sinuses.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess reposition ET tube.
Comparison is made with prior study performed five hours earlier.
ET tube tip is in appropriate position 3 cm above the carina. There are no
other acute interval changes.
Radiology Report
COMPARISON: Outside CT of the head ___.
TECHNIQUE: Axial MDCT images were obtained through the brain without IV
contrast. Multiplanar coronal, sagittal and thin section bone algorithm
reconstructed images were generated.
FINDINGS: There is no evidence of hemorrhage, edema, or mass effect.
Relative ___ of the right lenticular nucleus is of unclear etiology
and may have been present on the outside CT. The insular ribbons are
preserved. The ventricles and sulci are normal in size and configuration. The
basal cisterns are patent. There is poor grey white differentiation which
could be related to hypoglycemia.
There is no fracture. There is opacification of several bilateral mastoid air
cells. The middle ear cavities are clear. There is partial opacification
with air-fluid levels of the sphenoid, partially visualized maxillary, and
ethmoid air cells.
IMPRESSION: ___ of the right lenticular nucleus is concerning for
ischemic infarct. Further evaluation by MR is recommended.
These results were telephoned to ___ by ___ at 10:30 a.m.,
___.
Radiology Report
TECHNIQUE: MRI of the cavernous sinus without and with gadolinium.
HISTORY: Possible cavernous sinus thrombosis.
FINDINGS: There is diffuse sinus opacification with fluid levels in the
maxillary and sphenoid sinuses as previously noted. Although bilateral
superior ophthalmic veins are mildly prominent, no filling defects are seen in
the cavernous sinuses. Bilateral mastoid fluid is seen. There is mild soft
tissue swelling in the left frontal region which may be related to trauma.
IMPRESSION: No definite evidence for cavernous sinus thrombosis is seen.
Other brain changes were detailed on the prior MRI of the brain from the same
day.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with altered mental status.
Placement of the ET tube.
AP radiograph of the chest was compared to ___.
The ET tube tip is 8 cm above the carina, slightly above clavicular head and
should be advanced approximately 2 to 3 cm. NG tube tip is in the stomach.
Heart size and mediastinum are stable. There is progression of the left lower
lobe atelectasis and remaining left lung consolidation. Pleural effusion is
most likely present. There is no definitive pneumothorax seen. The right
internal jugular line tip is at the level of mid SVC.
Radiology Report
REASON FOR EXAMINATION: New PICC line placement.
Portable AP radiograph of the chest was reviewed with no prior studies
available for comparison.
The ET tube tip is too high, approximately 10 cm above the carina and should
be advanced for several centimeters. The right internal jugular line tip is
at the level of low SVC. The right PICC line tip is at the level of mid SVC.
There is left retrocardiac opacity most likely representing a combination of
atelectasis and pneumonia. Small pleural effusion is noted. The right lung
is essentially clear. There is no evidence of pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluation of endotracheal tube placement.
COMPARISON: ___.
FINDINGS: The endotracheal tube has been advanced and is now approximately 6
cm from the carina, the other monitoring and support devices are in constant
position. Unchanged small left pleural effusion with subsequent atelectasis
on the left. No new parenchymal opacity. Unchanged appearance of the cardiac
silhouette with slightly improving ventilation in the retrocardiac lung areas.
No pneumothorax.
Radiology Report
HISTORY: Question meningitis, found down now with new anisocoria. Evaluate
for bleeding.
COMPARISON: Prior head CT and brain MRI from ___ (under different
MRN ___.
TECHNIQUE: Contiguous axial CT images were obtained through the brain without
IV contrast. Sagittal, coronal both italic further reconstructions were
generated.
Total exam DLP: 1026 mGy-cm.
CTDI: 64 mGy-cm.
FINDINGS:
There is no evidence of hemorrhage, mass or shift of normally midline
structures. The ventricles and sulci are normal in size and configuration.
Patchy hypodensities are again seen throughout the bilateral cerebral
hemispheres. Allowing for differences in technique these appear somewhat more
prominent on today's examination, as compared to prior head CT from ___. There is increased mass effect with diffuse effacement of sulci and loss
of grey white contrast.
No fracture is identified. Moderate amount of fluid is seen in the bilateral
maxillary sinuses, ethmoidal air cells, sphenoid sinuses and frontal sinuses
bilaterally. There is moderate opacification of the mastoid air cells
bilaterally. Small amount of fluid is seen in the left middle ear cavity.
The right middle ear cavity is clear. There is no evidence of bone
destruction.
IMPRESSION:
1. No acute intracerebral hemorrhage.
2. Progressive hypodensities throughout the bilateral cerebral hemispheres.
There is increaesed edema, loss of grey white contrast, and swlling. As
suggested on prior MR examination, these findings could reflect changes
associated with hypoglycemic encephalopahty, diffuse infarction, or hypoxic
injury.
Additional findings discussed with ___ by ___ via telephone
on ___ at 3:34 AM.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Anoxic brain injury, evaluation for endotracheal tube placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the endotracheal tube has
been slightly advanced, the tube projects approximately 6 cm above the carina.
Advancement by another 1-2 cm would be necessary. The nasogastric tube has
been substantially pulled back, the tip now projects over the mid esophagus.
The tube needs to be advanced by at least 25 cm. There is no evidence of
complication, notably no pneumothorax. Unchanged left lower lung opacities,
likely atelectatic in origin. No cardiomegaly.
At the time of dictation and observation, 1:04 p.m., on the ___, the referring physician, ___, was paged for notification.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Anoxic brain injury, intubated.
Comparison is made with prior study, ___.
Cardiomediastinal contours are unchanged. Left lower lobe opacities have
markedly improved. There are no new lung abnormalities. The right lung is
grossly clear. There is no pneumothorax or large effusion. Right PICC tip is
in the low SVC. ET tube is in standard position. NG tube tip is in the
stomach, but the sideport is in the distal esophagus and should be advanced at
least 6 cm for more standard position.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Brain injury, tracheostomy tube, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
tracheostomy tube. The tip of the tube is in correct position and no evidence
of pneumothorax. Minimal positional blunting of the left diaphragmatic
contour. Right PICC line is in unchanged position. No nasogastric tube is
seen. No pneumonia, no pulmonary edema, no pneumothorax.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: FOUND DOWN
Diagnosed with SEMICOMA/STUPOR
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ with history of DM and alcholism who was found down
unresponsive at home for >12 hours admitted to MICU and found to
have profound hypoglycemic / Anoxic brain injury without
evidence of neurologic recovery.
# Encephalopathy/Coma: Hypoglycemic vs anoxic brain injury
likely from being down at home for roughly 12 hours. Unclear
definite precipitant wither anoxia vs hypoglycemia but
regardless showed profound irreversible brain injury with EEG,
MRI findings and neurologic physical examination findings
showing profoundly poor progrnosis. She was intubated and after
sedation was discontinued for >5 days showed no arousability and
no signs of neurologic recovery. MRI and CT Head with extensive
loss of architecture and loss of grey-white matter border.
Decerebrate postruting on exam and without response to noxious
stimuli indicate poor prognosis for neurologic recovery. She was
treated empirically for meningitis with Vancomycin / Ceftriaxone
/ Ampicillin and Acyclovir. Vancomycin was discontinued after
CSF Cx returned negative. BCx and CSF Cx negative final. HSV PCR
pending during stay at ___ and it was determined that result
would return to OSH in 21 days, well after completion of a 14
day empiric course with Acyclovir. Continuous EEG monitoring did
not reveal seizure activity though on physical exam patient with
evidence of seizure like activity so Keppra started. Neurology
followed during MICU course and agreed with poor prognosis and
little hope of neuro recovery. After extensive discussion about
GOC and prognosis, decision was made by the family to pursue a
tracheostomy and PEG tube placement, which occurred on ___.
Pt was unable to tolerate trach mask overnight and requires
intermitternt CMV overnight however can be maintained on trach
collar for a period of time during the day. In addition, pt with
heavy nasal/oral secretions which improved with removal of NGT,
starting Bromocriptine and diuresis.
# Autonomic instability: During MICU admission patient with
periods of hypertensive urgency, tachycardia, diaphoresis,
tachypnea and excessive mouth secretions. Thought likely
neurologic in origin from sympathetic storm ___
hypothalamic/insular involvement by anoxic brain injury.
Initially treated with Propofol with improvement in symptoms
though this was discontinued and Morphine used to treat with
good effect. Scopolamine patch also started for excessive
secretions.
# Fevers: Patient has had daily low grade fevers to 100s-101.
She has been on empiric broad spectrum coverage for nearly two
weeks has had multiple negative cultures and CXRs, remained
hemodynamically stable and with improving WBC count. Thought
central fevers from neurologic process, unlikely infectious and
she was treated symptomatically with tylenol.
# Hypoxic Respiratory Failure: Intubated after suffering
anoxic/hypoglycemic brain injury. Mental status intractible
barrier to extubation. Tracheostomy and PEG tube placed on
___ after family discussion requested that aggressive care
be continued. Given that LOS fluid balance was +15L near time of
discharge (albeit with significant insensible loses from nasal
secretions), decision was made to start diuresis. Lasix ___
IV prn which helped with both secretions and weaning ventilator
requirement.
#DM: Chronic, Insulin dependent DM II, on Metformin and Lantus
at home without Sulfonylurea or other hypglycemic agents.
Hypoglycemic to teens when found down so possibly suffered brain
injury as a result of hypoglycemia. ___ slightly hyperglycemic
___ 200s) during this admission while on tube feeds. Started on
regular insulin sliding scale and home Lantus was uptitrated for
control of ___ while on tube feeds. She was treated with Regular
Insulin Sliding Scale given continuous tube feeds with the
epectation that insulin would be changed to Humalog if changing
to bolus dosing.
# Psych: Chronic, stable. Patient with history of Bipolar
disorder. Held Trazodone, Abilify and Klonopin during admission.
No longer indicated given current mental status.
# UTI: E coli UTI at OSH, sensitive to ceftriaxone, treated
empirically with CTX for meningitis anyway which covered UTI
with resolution of pan-sensitive E.Coli UTI.
# Thrombocytosis: Increasing plateletes during admission thought
likely to medication effect, this was monitored and she showed
no signs of thrombosis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Port-a-cath placed by interventional radiology ___.
History of Present Illness:
___ yo female with h/o breast ca with liver metastasis presenting
with worsening abd pain x 1 week. Notes increased ruq pain with
associated n/v(nbnb)/diarrhea. Denies fevers, chills, recent
change in diet or known sick contacts(although she does work
with children). States the pain feels like previous episodes
related to her tumors, but that this episode was much worse.
She is on her second cycle of xeloda(finished ___ and is
planned to start taxol next ___.
Pertinent ROS noted above. rest of review wnl
Past Medical History:
breast ca
migraines
nephrolithiasis
Social History:
___
Family History:
hypertension
Physical Exam:
Admission Exam
Vitals Temp: 98.2 HR 82 BP 134/74 ___ 100RA
GEN: Patient lying comfortably in bed nad a+ox3
HEENT: MMM oropharynx clear
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: crackles noted at the bases bilaterally
ABD: soft distended with ttp of the ruq no rebound/guarding.
EXTR: no ___ edema good pedal pulses bilaterally
DERM: no rashes, ulcers or petechiae
neuro: cn ___ grossly intact non-focal
PSYCH: normal affect and mood
discharge exam:
VS 98.8 124/72 67 20 98% RA
otherwise unchanged
Pertinent Results:
___ 01:30PM BLOOD WBC-8.5 RBC-4.18* Hgb-11.6* Hct-37.5
MCV-90 MCH-27.8 MCHC-31.0 RDW-16.5* Plt ___
___ 01:30PM BLOOD ___ PTT-33.7 ___
___ 01:30PM BLOOD Glucose-113* UreaN-11 Creat-1.0 Na-139
K-4.3 Cl-101 HCO3-28 AnGap-14
___ 01:30PM BLOOD ALT-16 AST-36 AlkPhos-273* TotBili-0.9
___ 01:30PM BLOOD Lipase-21
___ 01:30PM BLOOD Albumin-3.9
___ 01:41PM BLOOD Lactate-1.4
Head CT:
No evidence of acute disease. Non-contrast study, as performed
here, is insensitive for small metastases.
abdominal u/s ___:
1. Innumerable echogenic metastatic lesions within the liver. No
evidence of intra- or extra-hepatic ductal dilatation.
2. Cholelithiasis without evidence of cholecystitis.
MRI of head ___:
Normal MRI of the head, specifically without evidence of
metastatic disease.
Atrius CT abd ___:
IMPRESSION:
Hepatomegaly with extensive metastatic disease throughout the
liver. Compared to the prior study, there has been interval
increase in size of the liver compatible with worsening
metastatic disease. Of note, and ___, the liver measured
18 cm in cephalocaudad dimension. On the current study it
measures 26 centimeters.
Medications on Admission:
Gabapentin 300 mg Oral Capsule TAKE 1 CAPSULE AT BEDTIME
Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) 1 CAPSULE
EVERY MORNING on empty stomach
Prochlorperazine Maleate 10 mg Oral Tablet 1 TABLET EVERY
MORNING and also EVERY 6 hours if needed for nausea
Capecitabine (XELODA) 500 mg Oral Tablet take one po in the AM
and two po in the ___ x 14 days followed by a ___etirizine 10 mg Oral Capsule one qhs prn Dr ___
___ Medications:
1. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
2. morphine 15 mg Tablet Sig: One (1) Tablet PO every ___ hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. ondansetron HCl 4 mg Tablet Sig: ___ Tablets PO Q8H (every 8
hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
4. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for nausea: do not drive while taking this
medication as it can make you very drowsy. do not drink alcohol
with this medication as it can be very dangerous.
Disp:*30 Tablet(s)* Refills:*0*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Disp:*30 Powder in Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: metastatic breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HEAD CT
HISTORY: Increasing abdominal pain and vomiting. Patient with stage IV
breast cancer. Question edema or mass effect.
COMPARISONS: None available.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no evidence for intra- or extra-axial hemorrhage. There
is no mass effect, hydrocephalus or shift of the normally midline structures.
The gray-white differentiation appears preserved. Surrounding soft tissue
structures are unremarkable. The visualized paranasal sinuses and mastoid air
cells appear clear.
IMPRESSION: No evidence of acute disease. Non-contrast study, as performed
here, is insensitive for small metastases.
Radiology Report
INDICATION: Evaluation of the patient with history of breast cancer with
metastases to the liver with right upper quadrant pain.
COMPARISON: None available.
FINDINGS:
Innumerable echogenic foci, some with hypoechoic halos are visualized
throughout the liver consistent with multiple hepatic metastases.
Additionally, large masses protrude both from the right and left lobes of the
liver and are incompletely imaged. There is no intra- or extra-hepatic ductal
dilatation with the common bile duct measuring 4 mm. The portal vein is
patent with appropriate hepatopedal flow. Cholelithiasis is noted with no
wall edema or pericholecystic fluid. Main portal vein is patent with
hepatopetal flow.
Bilateral kidneys are normal without evidence of hydronephrosis or stones with
the right kidney measuring 10.3 cm and the left kidney measures 9.3 cm. The
visualized portions of the aorta and inferior vena cava are normal. The
spleen is normal at 10.3 cm. The pancreas is not well visualized.
IMPRESSION:
1. Innumerable echogenic metastatic lesions within the liver. No evidence of
intra- or extra-hepatic ductal dilatation.
3. Cholelithiasis without evidence of cholecystitis.
Radiology Report
The MR exam could not be completed as the patient was in pain and unable to
maintain the required position in the scanner. All efforts to improve the
patient's comfort level were unsuccessful. The ordering physician was
notified.
Radiology Report
INDICATION: ___ female with metastatic breast cancer. Assess for CNS
involvement.
COMPARISON: None available for comparison.
TECHNIQUE: Sagittal T1 and axial T1, T2, FLAIR, gradient echo, and diffusion
with ADC map images were obtained without contrast. Following IV
administration of gadolinium, sagittal MP-RAGE and axial T1 spin echo
sequences were acquired.
FINDINGS: The cerebral sulci, ventricles, and extra-axial CSF-containing
spaces have normal size and configuration. There is no shift of the midline
structures. The gray-white matter differentiation of the brain parenchyma is
well preserved. A solitary left subcortical white matter abnormality is
nonspecific and may represent early changes with small vessel ischemic
disease. There is no evidence of acute infarction, intracranial hemorrhage,
space-occupying lesion or mass effect. No abnormal leptomeningeal or
parenchymal enhancement is identified. There is a partial empty sella. No
abnormality is noted with regard to basal ganglia, brainstem and
craniocervical junction. Flow voids of the major intracranial vessels are
preserved. The visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
Normal MRI of the head, specifically without evidence of metastatic disease.
Radiology Report
INDICATION: ___ year old woman with metastatic breast CA, needs port placed
for chemotherapy. Please place single-lumen port and leave accessed.
RADIOLOGISTS: Dr. ___ (fellow) performed the procedure. Dr.
___ (attending physician) supervised throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
200 mcg of fentanyl and 2 mg of Versed throughout the total intraservice time
of 55 minutes during which the patient's hemodynamic parameters were
continuously monitored.
PROCEDURE: Written informed consent was obtained from the patient after
explaining the risks, benefits and alternatives of the procedure. The patient
was brought to the angiographic suite and laid supine on the table. The right
neck and chest were prepped and draped in a sterile fashion. A preprocedural
huddle and timeout were performed per ___ protocol.
Patent right internal jugular vein was accessed with a micropuncture needle
under ultrasound and fluoroscopic guidance. Hard copy images of ultrasound
were obtained. A micropuncture wire was placed into the IVC. A skin ___ was
performed and the needle was exchanged for a micropuncture sheath. A ___
wire was then advanced down the IVC.
Attention was now directed to the right anterior chest wall, four
fingerbreadths below the venotomy site. Skin incision was made after
anesthetizing the site with 1% lidocaine. A pocket was created at that site
using blunt dissection after administering 1% lidocaine with epinephrine. A
tunneling device was used to tunnel the tubing of the port from the anterior
chest wall to the venotomy site. After appropriate measurements were
obtained, a peel-away sheath was introduced. The tubing was cut to 12 cm of
intravascular length. The tubing and connections were checked. No leaks were
observed. The tube was inserted through the peel-away sheath. The port was
affixed to the anterior chest wall, utilizing 0 Prolene sutures. The skin
pocket was closed utilizing ___ subcutaneous and ___ subcuticular sutures.
The venotomy site was closed utilizing ___ Vicryl suture. Dermabond was
applied on the pocket and the venotomy site. Sterile dressings were applied.
The port was accessed and found to be withdrawing and flushing easily. A
single image of the chest confirmed satisfactory port tube positioning as well
as postoperative changes in the right upper quadrant. Sterile dressings were
applied. The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Successful uncomplicated placement of power-injectable
single-lumen port with the tip in the right atrium. The port is accessed and
ready to use.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN GENERALIZED, NAUSEA, DEHYDRATION, SECOND MALIG NEO LIVER
temperature: 98.2
heartrate: 102.0
resprate: 16.0
o2sat: 99.0
sbp: 121.0
dbp: 87.0
level of pain: 8
level of acuity: 3.0 | TRANSITIONAL ISSUES:
[ ] f/u blood cultures
___ yo woman with PMH of metastatic breast CA on Xeloda with
liver metastasis presenting with abdominal pain, nausea and
vomiting most likely due to progressive malignancy. Her symptoms
were managed medically and patient was started on
carboplatin/taxol. She had a portacath placed while she was
in-house.
# Abdominal pain/Nausea: tenderness to palpation in RUQ, most
likely due to progressive malignancy and ?liver capsule
distension. RUQ U/S negative for biliary obstruction,
cholecystitis (though +cholelithiasis). Patient's pain was
initially managed with IV morphine with good control, and she
was transitioned to PO morphine when her nausea improved. For
her nausea, she was started on dexamethasone with good effect,
and used zofran and ativan prn as well.
# Transaminitis: Patient had normal LFTs on admission but her
LFTs worsened during the hospitalization. Thought to be possibly
due to tumor involvement of her liver. She was treated with
Carboplatin AUC 2 on ___ and her LFTs improved. Compazine was
discontinued for possible hepatic toxicity. Patient was
discharged OFF compazine.
# Metastatic Breast CA: Progressive despite Xeloda. She was
given Taxol on ___ given significant disease progression on
Xeloda. She also received carboplatin on ___. She had MRI of
brain which did not show any metastases. She had portacath
placed during this hospitalization for further outpatient
chemotherapy and tolerated it well.
# GERD: continued home omeprazole 20mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Polysubstance overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ hx migraine/tension headaches, HLD who
presented as a transfer from ___ with polysubstance
overdose. Patient was found down in a pile of urine by his
mother with several empty pill bottles around him. Of note, he
has prescriptions for lamictal, klonipin, tramadol, and
duloxetine. At 7PM last night he presented to OSH hypertensive
to 130s, tachypneic to ___, and hypertensive to SBP 170s. He was
noted to have rotary nystagmus. Urine tox was positive for
benzos and marijuana, CT head negative, serum ETOH negative. EKG
at OSH at 7pm, sinus tach at 140, PR 88, QRS 110, QTc 580. Due
to concern for serotonin syndrome he received 2L NS, 1 g Mg, and
a total of 30 mg IV valium at OSH. He was transferred to ___
for ICU admission.
In the ED, initial vitals: 98.6 87 143/111 18 95% RA
Patient was noted to be AAOx1, hallucinating, intermittently
agitated, with dry axillae, dilated pupils, rotary nystagmus.
Labs were notable for:
WBC 13.6 H/H 14.4/42.1 Plts 191
Na 140 K 4.3 Cl 106 HCO3 19 BUN 9 Cr 0.9 Glc 101
Lactate 2.2
ALT 31 AST 73 AP 75 T bili 0.5 Alb 4.4
Urinalysis showed few bacteria, 10 RBCs, 1 WBC, neg leuks,
large blood, trace protein.
Urine tox screen was negative for benzos, barbs, opiates,
cocaine, amphetamines, methadone, oxycodone.
Serum tox was negative for ASA, ETOH, APAP, Benzos, barbs,
TCAs.
VBG: ___.
Patient received 1L NS.
Toxicology consulted in the ED and recommended EKGs q1h.
On arrival to the MICU, vital signs were stable. He was
experiencing visual hallucinations but said he was overall
comfortable.
Review of systems:
(+) Per HPI
Past Medical History:
- Microtia s/p reconstruction ___, pt is deaf in the right ear
- Right clavicular fracture
- Dyslipidemia
- Vit D Deficiency
- Eczema
- Headache tension and migraine
- ___ Tib/fib fracture ORIF ___
Social History:
___
Family History:
Father diabetic. Denies family history of
depression, anxiety, addiction.
Physical Exam:
ADMISSION
Vitals: 97.8 Bp 156/96 P 90 96RA
GENERAL: lying flat with eyes wide open
HEENT: + nystagmus, pupils dilated, abrasions on forehead
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds absent, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: large blister noted on L foot plantar side
NEURO: visual hallucinations; says the month is "nocabra";
Babinski downgoing and no myoclonus but seems hypersensitive to
me touching his extremities; no muscle rigidity but has
difficulty following commands
discharge:
VS: 97.9 128/98 62 18 98RA
Gen: NAD
HEENT: NCAT, oropharynx clear, no LAD
CV: RRR, no mrg
Resp: CTA ___
Abd: soft, nt, nd
Ext: no CCE
Neuro: AOx3
Pertinent Results:
ADMISSION
___ 12:20AM BLOOD WBC-13.6* RBC-5.17 Hgb-14.4 Hct-42.1
MCV-81* MCH-27.9 MCHC-34.2 RDW-13.4 RDWSD-39.4 Plt ___
___ 12:20AM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-140
K-4.3 Cl-106 HCO3-19* AnGap-19
___ 12:20AM BLOOD Albumin-4.4 Calcium-9.1 Phos-2.9 Mg-2.2
___ 12:23AM BLOOD Lactate-2.2*
DISCHARGE:
___ 06:04AM BLOOD WBC-9.0 RBC-5.35 Hgb-14.9 Hct-43.8 MCV-82
MCH-27.9 MCHC-34.0 RDW-13.2 RDWSD-38.6 Plt ___
___ 07:20AM BLOOD Glucose-93 UreaN-18 Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
___ 07:20AM BLOOD CK(CPK)-1495*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ClonazePAM 1 mg PO BID
2. QUEtiapine Fumarate 25 mg PO QHS
3. Duloxetine 60 mg PO QHS
4. TraMADOL (Ultram) 50 mg PO TID
5. LaMOTrigine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain, fever
2. Naproxen 500 mg PO Q12H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Toxic ingestion
Rhabdomyolysis
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 polysubstance overdose, found with foam in
his mouth // aspiration pna? aspiration pna?
IMPRESSION:
No comparison. Moderate platelike atelectasis at the left lung basis. No
other parenchymal abnormalities. Borderline size of the cardiac silhouette.
No pleural effusions. Healed right clavicular fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Overdose, Transfer
Diagnosed with Poisoning by oth synthetic narcotics, accidental, init, Poisn by selective serotonin reuptake inhibtr, acc, init, Poisoning by benzodiazepines, accidental, init
temperature: 98.6
heartrate: 87.0
resprate: 18.0
o2sat: 95.0
sbp: 143.0
dbp: 111.0
level of pain: uta
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with history of
depression, anxiety, alcohol use disorder, who presented as a
transfer from ___ with polysubstance overdose,
admitted to ___ MICU, found to have rhabdomyolysis, now
improved and called out to the floor, now medically stable for
discharge to a psychiatric facility.
# Polysubstance overdose: Patient presented with mild agitated
delirium s/p polysubstance abuse s/p benzo loading at OSH with
mild tachycardia and HTN. On presentation to ___ ED he had no
clonus or hyperreflexia to suggest 5-HT syndrome; although given
the patient is on duloxetine and tramadol, this remains on the
differential; additionally pt is s/p benzo loading which may
mask symptomatology. Patient's clinical features with
tachycardia, flushing, prolonged QTc may mimic TCA overdose (and
patient has a history of filling amitriptyline rx in ___
however, TCA in serum tox negative. Lamotrigine may cause
nystagmus, seizures, tachycardia, prolonged QTc, hypokalemia.
Duloxetine + tramadol may cause serotonin syndrome, which could
cause hyperthermia. Ddx includes neuroleptic malignant syndrome
(NMS), anticholinergic toxicity, malignant hyperthermia,
intoxication from sympathomimetic agents, sedative-hypnotic
withdrawal, meningitis, and encephalitis. Also of note patient
is on Seroquel, whose overdose can cause anticholinergic
symptoms as well as drowsiness.
After speaking with toxicology, we at first obtained EKG's q1h
to monitor QRS and QTc. These remained normal. Home meds were
held. Psychiatry was consulted as this was likely a suicide
attempt and recommended obtaining an EEG to rule out seizure
activity, which was normal. Low dose Haldol for agitation was
also recommended. LFT's obtained to rule out liver injury which
showed Alt of 98. Overall, main toxidrome was likely a
combination of anticholinergic toxidrome possibly ___
amitriptyline and seroquel, which can mimic TCA toxicity.
Medically stable for discharge to psychiatric facility.
- Responds well to redirection, haloperidol 5mg PO/IM/IV.
- Outstanding issue - psych needs to clarify home psych meds.
- Being screened for inpatient psych, pt would like to go to
___.
- ___ scale
# Acute encephalopathy: resolved. Likely toxic/metabolic
encephalopathy from drug overdose. CT head negative. Infectious
workup unrevealing.
# Immobilization rhabdomyolysis in the setting of ingestion: now
resolved with IVF.
# Leukocytosis: Resolved-mild, likely stress-related. Infectious
work-up negative.
# Foot blisters: Significant left plantar foot blister as well
as lateral right foot blisters likely from unconscious episode.
Pt had left foot blister drained in FICU with sterile technique.
#Medical Clearance: Patient is medically stable for discharge
to a psychiatric facility.
Discussed with BEST team regarding CK. Patient's CK has cleared
from over 15,000 to less than 1500 with minimal treatment. He
exhibits no evidence of Kidney dysfunction, has robust urine
output. AT this point, I would no longer treat him nor would I
repeat a lab value, as it is expected to decrease by ~50% each
day until it reaches a normal value of 300-500. Given this, he
is MEDICALLY CLEARED FOR DISCHARGE and there is NO
contraindication to discharge medically. A repeat value today
would have little value, as it is expected to decrease by nearly
50% every 24 hours, and he has no evidence of kidney
dysfunction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine / Nitroglycerin
Attending: ___.
Chief Complaint:
RLE Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M w/ hx of AFib (on Coumadin), CAD s/p CABG x3 in ___,
and DM2 c/b neuropathy who is ___ s/p R leg deep and
superficial
fasciotomy releases on ___ in ___, in the
setting of compartment syndrome ___ hematoma due to
gastrocgnemius tear. The patient states that he stepped on a
rock in a bad way leading to the muscle tear and resulted in his
leg growing to 2x the size of the right leg and felt "like
marble". MRI showed large hematoma. He is on coumadin for Afib
and had an INR of 3.0 during his hospitalization there so
coumadin was held and reversed with Vitamin K. Surgery was
performed ___ after which he received Cefazolin x3 days and was
started on enoxaparin for warfarin bridge though he hasn't
restarted his coumadin. He required 1 u PRBCs
post-operatively. He remained on strict bedrest and RLE
elevation for 7 days and was transported back to the US ___
with a flight nurse. He denies f/c but states that he feels like
the skin in his right leg is being stretched leading to some
numbness/tingling above that from his baseline neuropathy.
In the ED, initial vital signs were: 97.2 80 162/72 18 97%RA.
Ortho consult was called with plan to observe in ED for IV abx
and ___ in AM but failed observation status with ongoing pain and
concern for early wound infection in a diabetic so admitted to
medicine for ongoing IV abx, ___, and have the orthopedic team
follow on the floor
On Transfer Vitals were: 98.3 77 137/71 20 98% RA.
Review of Systems:
(+)
(-) fever, chills, night sweats, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea. As per HPI
otherwise negative.
Past Medical History:
PAF s/p surgical PVI, MAZE, and ___ ligation in ___, on
coumadin
CAD s/p CABG x3
DM2 (on insulin)
DM neuropathy
Hyperlipidemia
Hypertension
GERD
Gout
CABG x3
R leg superficial and deep posterior fasciectomies on ___
Mild venous insufficiency in left leg from SVG harvesting
Social History:
___
Family History:
Dad with CAD, Mom with DM, Brother with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.1 149/82 66 18 98%RA
General: Well appearing, friendly, talkative man sitting up in
bed in NAD
HEENT: PERRL, sclera anicteric, MMM
CV: RRR, normal S1/S2, no m/r/g
Lungs: CTAB
Abdomen: Soft, nontender, nondistended, normal BS
Ext: Warm, well perfused, 2+ pulses bilaterally, venous stasis
changes present, 1+ ___ edema bilaterally R slightly > L. 10 cm
surgical wound over anterior R shin with surrounding erythema
and taut sutures, tender to palpation. Full ROM bilaterally.
Neuro: AAOx3, sensory exam equal and intact in BLE. Full
strength in ___ bilaterally. Motor and sensory exam otherwise
grossly intact.
DISCHARGE PHYSICAL EXAM:
Vitals- Not recorded
General: Well appearing, friendly, talkative man sitting up in
bed in NAD
HEENT: PERRL, sclera anicteric, MMM
CV: RRR, normal S1/S2, no m/r/g
Lungs: CTAB
Abdomen: Soft, nontender, nondistended, normal BS
Ext: Warm, well perfused, 2+ pulses bilaterally, venous stasis
changes present, 1+ ___ edema bilaterally R slightly > L. 10 cm
surgical wound over anterior R shin with reduced erythema and
taut sutures, tender to palpation. Full ROM bilaterally.
Neuro: AAOx3, sensory exam equal and intact in BLE. Full
strength in ___ bilaterally. Motor and sensory exam otherwise
grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 07:38PM GLUCOSE-140* UREA N-26* CREAT-1.2 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
___ 07:38PM WBC-6.4 RBC-3.88*# HGB-12.2*# HCT-36.2*#
MCV-93 MCH-31.3 MCHC-33.6 RDW-15.1
___ 07:38PM NEUTS-67.9 ___ MONOS-7.0 EOS-3.7
BASOS-1.2
___ 07:38PM ___ PTT-42.7* ___
INTERVAL LABS:
___ 05:40AM BLOOD WBC-6.5 RBC-3.88* Hgb-11.8* Hct-36.2*
MCV-93 MCH-30.5 MCHC-32.7 RDW-14.5 Plt ___
___ 05:40AM BLOOD ___ PTT-45.9* ___
___ 05:40AM BLOOD Glucose-99 UreaN-22* Creat-1.2 Na-139
K-4.7 Cl-100 HCO3-30 AnGap-14
___ 05:40AM BLOOD CK(CPK)-45*
___ 05:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:40AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.9
PERTINENT LABS:
___ 06:10AM BLOOD WBC-5.6 RBC-3.87* Hgb-11.9* Hct-35.5*
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.7 Plt ___
___ 06:10AM BLOOD ___ PTT-46.0* ___
___ 06:10AM BLOOD Glucose-125* UreaN-20 Creat-1.2 Na-138
K-4.5 Cl-98 HCO3-31 AnGap-14
___ 06:10AM BLOOD Calcium-9.3 Phos-3.4 ___
MICRO: NONE
IMAGING: ___ Tib/fib XR
AP and lateral views of the right tibia and fibula were
provided. Two tiny
surgical clips are noted within the soft tissues medially along
the mid calf.
The tibia and fibula are intact without fracture or bony
erosion. The right
knee and ankle joints articulate normally. No soft tissue gas.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Aspirin 162 mg PO DAILY
3. Vitamin D3 (cholecalciferol (vitamin D3)) 4,000 unit oral
daily
4. Cyanocobalamin 1000 mcg PO DAILY
5. Avodart (dutasteride) 0.5 mg oral qhs
6. Gabapentin 600 mg PO HS
7. NIFEdipine CR 60 mg PO QHS
8. Furosemide 20 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Nasonex (mometasone) 50 mcg/actuation nasal DAILY:PRM
allergies
11. Metoprolol Tartrate 12.5 mg PO BID
12. Atorvastatin 40 mg PO HS
13. Allopurinol ___ mg PO DAILY
14. glimepiride 2 mg oral daily
15. quiniDINE Gluconate E.R. 324 mg PO Q8H
16. Multivitamins 1 TAB PO DAILY
17. Astepro (azelastine) 0.15 % (205.5 mcg) nasal daily:PRN
allergies
18. Cialis (tadalafil) 20 mg oral PRN sexual activity
19. Eye Drops (tetrahydrozoline;<br>tetrahydrozoline-zinc) 0.05
% ophthalmic daily:PRN allergies
20. Warfarin 4 mg PO DAILY16
21. HumaLOG Mix ___ KwikPen (insulin lispro protam-lispro) 100
unit/mL (75-25) subcutaneous qhs
22. Enoxaparin Sodium 100 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 162 mg PO DAILY
3. Atorvastatin 40 mg PO HS
4. Cyanocobalamin 1000 mcg PO DAILY
5. Enoxaparin Sodium 100 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg subcutaneous injection twice a
day Disp #*21 Syringe Refills:*0
6. Ferrous Sulfate 325 mg PO DAILY
7. Furosemide 20 mg PO BID
8. Gabapentin 600 mg PO HS
9. Metoprolol Tartrate 12.5 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. NIFEdipine CR 60 mg PO QHS
12. Pantoprazole 40 mg PO Q24H
13. quiniDINE Gluconate E.R. 324 mg PO Q8H
14. Warfarin 4 mg PO DAILY16
15. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
16. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides 8.6 mg 8.6 mg by mouth BID:PRN constipation Disp
#*60 Tablet Refills:*0
17. Astepro (azelastine) 0.15 % (205.5 mcg) nasal daily:PRN
allergies
18. Avodart (dutasteride) 0.5 mg oral qhs
19. Cialis (tadalafil) 20 mg oral PRN sexual activity
20. Eye Drops (tetrahydrozoline;<br>tetrahydrozoline-zinc) 0.05
% ophthalmic daily:PRN allergies
21. glimepiride 2 mg ORAL DAILY
22. HumaLOG Mix ___ KwikPen (insulin lispro protam-lispro) 100
unit/mL (75-25) subcutaneous qhs
23. Nasonex (mometasone) 50 mcg/actuation nasal DAILY:PRM
allergies
24. Vitamin D3 (cholecalciferol (vitamin D3)) 4,000 unit oral
daily
25. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN leg
pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg 1 tablet(s) by
mouth Q4H:PRN pain Disp #*12 Tablet Refills:*0
26. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Leg cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RIGHT TIBIA AND FIBULA RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam dated ___.
CLINICAL HISTORY: Right leg pain status post fall, fasciotomy, evaluate for
fracture.
AP and lateral views of the right tibia and fibula were provided. Two tiny
surgical clips are noted within the soft tissues medially along the mid calf.
The tibia and fibula are intact without fracture or bony erosion. The right
knee and ankle joints articulate normally. No soft tissue gas.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg swelling
Diagnosed with PAIN IN LIMB
temperature: 97.2
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 162.0
dbp: 72.0
level of pain: 2
level of acuity: 2.0 | ___ y/o M w/ hx of AFib (on Coumadin), CAD s/p CABG x3 in ___,
and DM2 c/b neuropathy who is ___ s/p R leg deep and
superficial fasciotomy releases on ___ in ___,
in the setting of compartment syndrome ___ hematoma due to
gastrocnemius tear, now with concern for post-surgical
cellultis.
#Cellulitis: Continued pain with swelling and erythema at wound
site concerning for post-surgical wound cellulitis. Likely mild
infection without spread away from wound site, no leukocytosis
or fever. Initially treated with cefazolin in ED and transition
to cephalexin 500mg q6h for 10 day course (day ___ prior to
discharge. Pain managed with Percocet ___ tab q4h prn for
pain. Orthopedics followed during admission recommending ___ for
suture removal ___, f/u with ortho in 2 weeks as outpt.
#RLE Compartment syndrome/hematoma: Hematoma formed after
gastrocnemius tear in ___ leading to compartment syndrome
released by fasciotomy in ___. On admission to ___, CK 45
and no current concern for compartment syndrome per ortho.
Orthopedics followed recommending ambulation as tolerated,
elevation with ice for comfort when resting, no
contraindictation to restarting warfarin, suture removal as
above. Discharged home with home ___.
#Chest pain: Likely musculoskeletal given association with
reaching and reproducibility. Given CAD hx, EKG and cardiac
biomarkers were obtained which were negative.
#Paroxysmal Afib: Stable during admission with NSR rate ___ on
quiniDINE Gluconate E.R. 324 mg PO Q8H, NIFEdipine CR 60 mg PO
QHS. Continued patient on enoxaparin 100mg BID started in ___
to bridge to warfarin. INR 1.2 at discharge.
#DM2: Held home glimepiride and humalin. Stable on HISS with FSG
QACHS.
#CAD: Stable on Aspirin 162 mg PO DAILY, Metoprolol Tartrate
12.5 mg PO BID, Atorvastatin 40 mg PO HS.
#Venous insufficiency: Stable on furosemide 20 mg PO BID
#GERD: Stable on pantoprazole 40 mg PO Q24H
#Peripheral neuropathy: Stable on gabapentin 600 mg PO qhs
#BPH: Replaced dutasteride with finasteride qhs for formulary
reasons during admission, restarted on dutasteride on d/c.
#Gout: Stable on allopurinol
#Seasonal allergies: Held azelastine, eye drops during admission
#Vit deficiencies: Stable on cyanocobalamin, Vitamin D3, MVI,
iron
TRANSITIONAL ISSUES:
-___ should remove sutures ___
-F/u with ortho in 2 weeks as outpt
-Discharged on enoxaparin bridge which should be discontnued
after INR becomes therapeutic on warfarin dose. Patient should
follow up with PCP regarding INR follow up.
-Patient should continue cephalexin through ___
# Code Status: Full code (confirmed)
# Contact: Partner ___ ___ is first call, HCP is
son ___ in ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fentanyl / Midazolam / Heparin Agents
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with morbid obesity from which she is home bound,
psoriasis, seronegative spondyloarthropathy on chronic
prednisone and sulfasalazine, and history of atypical chest pain
with limited workup due to habitus who presents for evaluation
of chest pain. Pt living at facility since discharge from
hospitalization for cellulitis and has been essentially bed
bound. Pt sent in today due to complaint of chest pain. Pt says
that she typically gets pain in the pectoral area from use of
her muscles to shift around. Today she experienced pain that was
in the usual location but worse in severity than before. Pt also
with multiple other complaints including headache, lower
abdominal pain, nausea, and feeling short of breath.
Pt describes her chest pain as pressure as if an elephant is
sitting her chest. She says that it improves when she lies on
her L side. No dyspnea currently. Reports nausea. Lower
abdominal pain, located at site of hematoma from fundaparinux
injections.
In ED, pt hemodynamically stable. Workup notable for nl ECG, and
negative troponin. CXR negative. D-dimer checked and elevated at
650. Pt unable to get CTA in ED due to her body habitus, ___
dopplers done which showed no DVT's.
Pt also noted to have findings concerning for abdominal wall
cellulitis. Pt given pain meds and clindamycin and admitted for
furhter care.
ROS: negative except as above
Past Medical History:
-seronegative spondylopathy on chronic immunosuppresion
-Psoriasis
-Morbid obesity
-Hypertension
-Hyperlipidemia
-chronic intertriginous eruptions
-OSA
-OA
-Migraines
-h/o Glaucoma
-?h/o DVT (per pt)
-diverticulosis and hemorrhoids
-Kidney stones
Social History:
___
Family History:
Father - ___ disease
Mother - ___
Physical ___:
Admission Exam:
Vitals: 98.8 148/63 87 18 96%RA
Gen: uncomfortable appearing, shifting around
HEENT: NCAT
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, obese, lower abdominal hematoma with mild surrounding
erythema w/o warmth or tenderness
Ext: non-pitting edema
Neuro: alert and oriented x 3, no focal deficits
Discharge Exam:
AFVSS
Alert, NAD
NC/AT
RRR, no m/r/g
CTA B
Abd obese, soft, BS present; stable hematoma in mid-lower
abdomen
CN ___ grossly intact, ___ strength in BUE's
Pertinent Results:
___ 06:15PM BLOOD WBC-12.1* RBC-3.79* Hgb-10.3* Hct-32.0*
MCV-85 MCH-27.2 MCHC-32.1 RDW-16.8* Plt ___
___ 06:15PM BLOOD Neuts-79.0* Lymphs-14.7* Monos-4.5
Eos-1.5 Baso-0.3
___ 06:15PM BLOOD ___ PTT-32.3 ___
___ 06:15PM BLOOD Glucose-106* UreaN-11 Creat-0.6 Na-141
K-4.5 Cl-103 HCO3-28 AnGap-15
___ 07:00PM BLOOD D-Dimer-650*
___ 06:15PM BLOOD HCG-<5
___ 09:10AM BLOOD WBC-10.5 RBC-3.69* Hgb-9.9* Hct-31.1*
MCV-84 MCH-26.9* MCHC-31.9 RDW-16.4* Plt ___
___ 09:10AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-143 K-4.0
Cl-102 HCO3-29 AnGap-16
___ 09:10AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.6
___ 06:15PM BLOOD cTropnT-<0.01
___ 12:30AM BLOOD cTropnT-<0.01
___ 09:10AM BLOOD cTropnT-<0.01
___ 09:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:20PM URINE UCG-NEGATIVE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Blood Cx: NGTD
ECG - Sinus rhythm. Compared to the previous tracing of ___
no change.
CXR - FINDINGS:
The cardiac, mediastinal and hilar contours appear stable. There
is no pleural effusion or pneumothorax. Streaky opacity
projecting over the left mid lung suggests minor scarring or
atelectasis. Otherwise, the lungs remain clear.
IMPRESSION: No evidence of acute cardiopulmonary disease.
BLE U/S - IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins. Non visualization of the calf veins due the
patient's body habitus.
Abdominal U/S - IMPRESSION: Nonvascularized cystic mass within
the left lower quadrant correlating with the patient's palpable
abnormality and pain. Findings likely represent an
injection-site hematoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gabapentin 1200 mg PO TID
5. HydrOXYzine 25 mg PO Q6H:PRN itch
6. Ibuprofen 800 mg PO Q8H:PRN pain
7. Metoprolol Tartrate 25 mg PO DAILY
8. Nifedical XL (NIFEdipine) 120 oral DAILY
9. Omeprazole 20 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
11. PredniSONE 14 mg PO DAILY
12. Aspirin 325 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Ferrous Sulfate 325 mg PO DAILY
16. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
17. Escitalopram Oxalate 10 mg PO DAILY
18. Meclizine 25 mg PO Q8H:PRN dizziness
19. Multivitamins 1 TAB PO DAILY
20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
21. Cyanocobalamin 1000 mcg PO DAILY
22. Ascorbic Acid ___ mg PO DAILY
23. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 10 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Gabapentin 1200 mg PO TID
9. HydrOXYzine 25 mg PO Q6H:PRN itch
10. Ibuprofen 800 mg PO Q8H:PRN pain
11. Metoprolol Tartrate 25 mg PO DAILY
12. Nifedical XL (NIFEdipine) 120 oral DAILY
13. Omeprazole 20 mg PO DAILY
14. PredniSONE 14 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. Ascorbic Acid ___ mg PO DAILY
17. Cyanocobalamin 1000 mcg PO DAILY
18. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
19. Meclizine 25 mg PO Q8H:PRN dizziness
20. Multivitamins 1 TAB PO DAILY
21. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
22. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
23. Zinc Sulfate 220 mg PO DAILY
24. Fondaparinux 10 mg SC DAILY
25. SulfaSALAzine_ 1000 mg PO TID
26. Ciprofloxacin HCl 500 mg PO Q12H
Take for a 7 day course (last day ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Active:
- Hematoma
- Atypical chest pain
- Urinary tract infection
Chronic:
- Seronegative spondyloarthropathy
- Psoriasis
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 RADIOGRAPHS
INDICATION: Chest pain and shortness of breath.
TECHNIQUE: Chset, AP upright and lateral.
COMPARISON: Radiographs from ___, and CT from ___.
FINDINGS:
The cardiac, mediastinal and hilar contours appear stable. There is no pleural
effusion or pneumothorax. Streaky opacity projecting over the left mid lung
suggests minor scarring or atelectasis. Otherwise, the lungs remain clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: History: ___ with concern for PE // eval for DVT please obtain
Left and Right
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. The calf veins are not
visualized due to the patient's body habitus
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Non visualization of the calf veins due the patient's body habitus.
Radiology Report
EXAMINATION: Focused left lower quadrant ultrasound examination.
INDICATION: ___ year old woman with erythema and subcutaneous nodule at site
of Fondaparinoux injections, concerning for abscess // Eval for underlying
abscess
TECHNIQUE: Focused grayscale and Doppler ultrasound images were acquired over
the left lower quadrant in the region of the patient's palpable abnormality.
COMPARISON: None available.
FINDINGS:
Within the subcutaneous tissues of the left lower quadrant there is a 2.2 x
2.5 x 3.0 cm noncompressible complex cystic lesion without evidence of
intrinsic or peripheral vascular flow.
IMPRESSION:
Nonvascularized cystic mass within the left lower quadrant correlating with
the patient's palpable abnormality and pain. Findings likely represent an
injection-site hematoma.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NEC
temperature: 97.3
heartrate: 78.0
resprate: 18.0
o2sat: 96.0
sbp: 132.0
dbp: 64.0
level of pain: 8
level of acuity: 2.0 | ___ yo F with morbid obesity, seronegative spondyloarthropathy,
chronic atypical chest pain, psoriasis who was admitted with
multiple complaints including chest pain and abdominal pain with
only focal pathology evidence is abdominal subcutaneous lesion
consistent with most likely hematoma
# Chest Pain
Patient has history of chronic atypical chest pain which has
been attributed to musculoskeletal in nature. Pain is
reproducible on palpation which further supports musculoskeletal
origin. She has been seen by cardiology in the past though her
obesity has been limiting in diagnostic evaluation of coronary
artery disease. Imaging modalities are limited by both poor
image quality and/or increased radiation dose. She is also at
high risk for cardiac catheterization due to her size as well.
Given that, she has been treated empirically for CAD given her
comorbidities though has not been known to have CAD/MI in the
past. She is on medical management including ASA, Atorvastatin
and Metoprolol. On admission there were no symptoms suggestive
of ACS and Trops negative x3. Regarding PE, the patient had an
elevated D-Dimer which is non-specific. Additionally, she was on
therapeutic dosing of Fondaparinaux while at rehab which further
reduces her risk for DVT or PE. LENIs also negative for DVTs
bilaterally. CXR was negative for acute cardiopulmonary process.
Given the above her symptoms were thought most likely MSK in
nature.
# Urinary Tract Infection: UCx grew e.coli, and pt endorsed some
bladder spasms. Will tx with ciprofloxacin x 7 days.
# Breast Pain
She does have focal tenderness to palpation in a discrete area
of left breast. No mass appreciated. However, pt does report a
prior history of breast discharge. This was discussed at length
with the patient. She will f/u with her PCP (Dr. ___
regarding this and will benefit from an outpatient breast
ultrasound.
# Abdominal lesion
Ultrasound consistent with hematoma from site of Fondaparinaux
injections. Remained stable off antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Perforated Appendicitis with Large Appendiceal Abscess
Major Surgical or Invasive Procedure:
___ Image Guided Drain Placement
History of Present Illness:
___ who presents with ___ days of abdominal pain, nausea and
overall malaise. Evaluated at ___ over the weekend
and treated with cipro/flagyl for presumed diverticulitis.
Patient endorses initial improvement in symptoms, until ___
when she began to deteriorate. Her WBC increased on repeat eval
at ___ today and she was sent to the ED for further evaluation.
She reports nausea, dry heaving, no frank emesis. She reports
diarrhea since starting abx on ___, which she describes as
liquid, orange in color, BMx3/day for the last three days. She
denies pain with urination, denies urinary frequency, denies
blood in her urine, denies flank pain. Denies fevers and chills.
Denies HA. Denies shortness of breath or congestion, reports
lingering cough s/p URI a few weeks ago. She has never had a
colonoscopy.
Past Medical History:
Hypertension
Migraines
Obesity
Basal cell carcinoma s/p Mohs
Social History:
___
Family History:
Mother - DM
Father - COPD, ___ disease
Sister - brain aneurysm age ___
Sister - HTN, CVA, melanoma
Brother - DM
Daughter - asthma
Physical Exam:
General: well appearing, NAD
HEENT: normocephalic, atraumatic, no scleral icterus
Resp: breathing comfortably on room air
CV: regular rate and rhythm on monitor
Abdomen: soft, appropriately tender, but improved from
admission, drain in place draining cloudy, purulent appearing
fluid.
Extremities: Warm and well perfused
Medications on Admission:
butalbital-aspirin-caffeine 40-325-40 q6h prn migraine,
labetalol
400 mg bid, HCTZ 25 mg daily, ASA 81 mg daily, fluticasone 2
sprays each nostril daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth three times a day Disp #*100 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth twice a day Disp #*22 Tablet Refills:*0
3. Aspirin EC 81 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Labetalol 400 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with nausea, lower abdominal pain, failed
outpatient tx for presumed diverticulitis // please evaluate lower abdomen
for diverticulitis vs. abscess vs. colitis, please eval appendix
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technqiue.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 718 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: The bases of lungs are clear.
ABDOMEN: Multiple hypodense lesions are seen throughout the liver, with the
largest in the right hepatic lobe measuring 2.1 cm x 2.7 cm, series 2, image
19 likely secondary to biliary hamartomas. There is no intrahepatic biliary
ductal dilatation. The gallbladder is normal without evidence of stones, or
wall thickening. The spleen is homogeneous and normal in size. A calcified
granuloma is seen along the superior aspect of the spleen. The adrenal glands
bilaterally are normal. The kidneys bilaterally are normal without evidence
of focal solid or cystic lesions concerning for malignancy. The pancreas is
normal without evidence of focal lesions, or pancreatic ductal dilatation.
The stomach appears to be unremarkable.
Within the deep right pelvis, there is a large abscess, with air-fluid levels,
measuring 8.9 cm x 8.1 cm by 8.9 cm, replacing the appendix. The ascending
colon demonstrates mild thickening, consistent with colitis. Inflammatory
changes are seen surrounding the abscess. The remainder the bowel is
unremarkable.
CT pelvis: The urinary bladder is normal. Within the pelvis, bilateral tubal
ligation clips are seen. There is a small amount of pelvic free fluid. There
is no pelvic wall or inguinal lymphadenopathy, however prominent lymph nodes
are seen surrounding the large collection, for example the largest node in the
right hemipelvis, series 2, image 55 measuring 1.3 cm x 0.9 cm.
Osseous structures: No lytic or blastic lesions concerning for malignancy are
identified. T11 hemangioma.
IMPRESSION:
1. Large abscess, with air-fluid levels in the deep right pelvis, measuring up
to 9 cm, replacing the appendix. There is extensive surrounding soft tissue
inflammatory changes and mild adjacent colitis. Findings are consistent with
perforated appendicitis.
2. Multiple hypodense lesions seen throughout the liver, measuring up to 3 cm,
likely cysts and biliary hamartomas.
Radiology Report
EXAMINATION: CT-guided drain placement
INDICATION: ___ year old woman with perforated appendicitis, needs drain into
abscess // perforated appendicitis, needs drain
COMPARISON: CT abdomen pelvis ___
PROCEDURE: CT-guided drainage of pelvic collection.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 150 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 7.5 s, 23.1 cm; CTDIvol = 13.9 mGy (Body) DLP = 303.5
mGy-cm.
4) Stationary Acquisition 6.9 s, 1.4 cm; CTDIvol = 71.0 mGy (Body) DLP =
102.2 mGy-cm.
Total DLP (Body) = 414 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 17
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Large pelvic abscess is identified in the right pelvis in the expected
location compared to recent CT. There is loss of fat plane between this
collection and the cecum. There is fat stranding surrounding the collection.
Multiple calcified uterine fibroids artery. Contrast is in the bladder from
recent CT scan. No new findings compared to prior.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
pelvic collection. Samples was sent for microbiology evaluation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with AC APPEND W PERITONITIS, HYPERTENSION NOS
temperature: 98.0
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 93.0
dbp: 63.0
level of pain: 6
level of acuity: 3.0 | The patient was admitted to the hospital for perforated
appendicitis with large associated appendiceal abscess. She was
initially kept NPO, started on IVF, and initiated on IV
antibiotics. An Image guided drain was placed in Interventional
Radiology on ___ and the fluid was sent for cultures. The
drain had immediate drainage of 300 ml of purulent appearing
fluid. The patient had relief of her pain and remained afebrile.
She was transitioned to PO augmentin. The patient was discharged
on hospital day 3. At the time of discharge, her pain had
improved dramatically, she was out of bed to ambulate, and she
was urinating and stooling normally and her pain was controlled
on oral pain medication. She was discharged with home health
services and plan to follow up with Dr. ___ in general
surgery clinic in 2 weeks. She was discharged on PO Augmentin,
course ending on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / doxycycline
Attending: ___.
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ G2P1, 17 weeks preg presents with fever and cough.
USOH until last ___ night when developed palpitations and on
___ developed fever. The fever led to chills and these
progressed over several days. She was seen by PCP and thought to
have viral syndrome, but then was sent to ED at ___ on
___, had a CXR which was prelim read as neg and sent home
with
presumed viral syndrome. On review of CXR by PCP ___ day or so
later, wwas actually thought to have an infiltrate. ___ started
on azithromycin, today is on day 2. Fever and chills progressed,
and cough has progressed even more over the last few days, now
productive of white sputum, so sent to ED. Reports f/c, HA with
fevers. Denies ___, orthopnea, PND, ___ trauma, h/o clots,
stasis,
recent abx (other than Z-pack as above), chest pain, abd pain,
diarrhea, rash, dysuria, urgency. Sick contact ___ son (___ months
old) who had fever and cough and loose stool. No recent travel.
Fever responds quite well to APAP.
Presented to ED, ___ ED 101, 101/66. CXR with progressive
multifocal pna. Given CTX and 1L NS and admitted to medicine.
She feels like her breathing is unchanged since presentation to
ED. Fever coming back on now. Has not been eating much last few
days.
ROS: positive or negative as above, otherwise negative ___ 12
systems
Past Medical History:
GERD
eczema
thyroid nodule
Gaucher's carrier
Social History:
___
Family History:
father ___ (died)
otherwise reviewed and non-contributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
Constitutional: VS reviewed, tachycardic and hypoxemic
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: tachycardic, JVP 8cm
Resp: bronchial BS RLL, LLL
GI: sntnd, NABS, gravid
GU: no foley
MSK: no obvious synovitis
LAD: subgmental non-tender LAD
Ext: wwp, neg edema ___ BLEs
Skin: no rash grossly visible
Neuro: A&O grossly, DOWB intact, MAEE, no facial droop
Psych: normal affect, pleasant
DISCHARGE PHYSCIAL EXAM:
VS:
Gen: young woman ___ NAD, pleasant, EWOB.
Eyes: anicteric, non-injected
HEENT: MMM, grossly nl OP
Chest: Bilateral rales, but good movement throughout. No
wheezes. EWOB, speaking ___ full sentences
CV: RRR nl S1/S2, +flow murmur, intact peripheral pulses.
Back: no midline spinous process tenderness, no CVAT.
Abd: soft, NT/ND, NABS, gravid uterus
GU: ni suprapubic tenderness, no IUC
Ext: WWP, no edema
Neuro: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout, normal gait
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 06:56PM BLOOD WBC-5.3 RBC-4.00 Hgb-11.5 Hct-34.2 MCV-86
MCH-28.8 MCHC-33.6 RDW-14.3 RDWSD-44.9 Plt ___
___ 06:56PM BLOOD Neuts-87* Bands-0 Lymphs-10* Monos-1*
Eos-0 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-4.61
AbsLymp-0.53* AbsMono-0.05* AbsEos-0.00* AbsBaso-0.00*
___ 06:56PM BLOOD Glucose-81 UreaN-5* Creat-0.6 Na-130*
K-4.3 Cl-94* HCO3-21* AnGap-15
___ 06:56PM BLOOD ALT-33 AST-61* AlkPhos-223* TotBili-0.3
___ 06:35PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIOLOGY:
___ 6:50 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:01 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:53 am URINE Source: ___.
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, ___
infected patients the excretion of antigen ___ urine may
vary.
___ 5:54 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..
___ 6:30 pm SPUTUM Source: Induced.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
___ 9:21 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Time Taken Not Noted ___ Date/Time: ___ 10:36 pm
BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:10 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 3:15 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Time Taken Not Noted ___ Date/Time: ___ 2:05 pm
Blood (CMV AB) CHEM # ___.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results
Time Taken Not Noted ___ Date/Time: ___ 2:05 pm
Blood (EBV) CHEM # ___.
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE BY EIA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
___ most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
___ 9:07 pm SPUTUM Source: Expectorated.
ADD ON LEGIONELLA CULTURE PER ___ (___)
___.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Pending):
IMAGING:
- RUQUS ___. Cholelithiasis. No biliary dilation.
2. Normal hepatic parenchyma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate Dose is Unknown PO QID:PRN gerd
2. Azithromycin 250 mg PO Q24H
3. Vitamin D 1000 UNIT PO DAILY
4. Prenatal Multi (prenatal ___ acid) ___ mg-mcg
oral DAILY
5. Omega-3 (omega 3-dha-epa-fish oil) 350 mg-235 mg- 90 mg-597
mg oral DAILY
Discharge Medications:
1. Azithromycin 500 mg PO DAILY Duration: 4 Doses
Last dose ___
RX *azithromycin 500 mg 1 tablet(s) by mouth DAILY Disp #*5
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H
Last dose ___ ___
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*22 Tablet Refills:*0
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 PUFF
INH Q6H PRN Disp #*1 Inhaler Refills:*1
4. Calcium Carbonate 500 mg PO QID:PRN gerd
5. Omega-3 (omega 3-dha-epa-fish oil) 350 mg-235 mg- 90 mg-597
mg oral DAILY
6. Prenatal Multi (prenatal ___ acid) ___
mg-mcg oral DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Multifocal Pneumonia
Acute Hypoxemic Respiratory Failure
Transaminitis
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 loss of breath sound LLL. Patient is
pregnant and must be shielded// r/o pleural effusion
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
Re-demonstration of a large left lower lobe opacity, consistent with
pneumonia, which now obscures the left heart border. New from prior, there is
opacity of the right lower lobe. Lung volumes are normal. There is no
appreciable pleural effusion. No pneumothorax. Cardiac borders are now
obscured, however the cardiomediastinal silhouette appears stable in size.
IMPRESSION:
Large left lower lobe opacity and new right lower lobe opacity, highly
concerning for multifocal pneumonia.
No appreciable pleural effusion.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Pneumonia and D compensating hypoxemia. Query fluid overload.
17 weeks in pregnancy.
COMPARISON: Prior studies from ___.
FINDINGS:
Extent of opacification involving the left mid to lower lung has increased.
This may include a developing pleural effusion, more extensive consolidation
or both. A right lower lobe consolidation appears similar. There is no
pleural effusion on the right. No pneumothorax.
IMPRESSION:
Worsening left lower lung opacification. If substantial pleural effusion
component is clinical concern then decubitus radiography might be of some
value.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with elevated alk phos// evaluation for
obstruction
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. There is bilateral, right greater
than left pleural effusions.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
Possible trace pericholecystic fluid, difficult to re-demonstrate,
nonspecific.
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: 11.8
KIDNEYS: Limited views of the kidneys show no hydronephrosis. Apparent mild
increased echogenicity of the right kidney is likely due to technique.
Right kidney: 11.0
Left kidney: 11.5
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Normal hepatic parenchyma.
2. No cholelithiasis or gallbladder wall thickening. No intrahepatic or
extrahepatic biliary dilation.
3. There are bilateral-right greater than left pleural effusions.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with ___ pregnancy, rising LFTs// ? biliary
dilation, hepatic parenchymal changes.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___.
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: 2 mm
GALLBLADDER: Cholelithiasis. Slightly without gallbladder wall thickening due
to decompression.
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: 12.1 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis. No biliary dilation.
2. Normal hepatic parenchyma.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Productive cough
Diagnosed with Pneumonia, unspecified organism, Dyspnea, unspecified
temperature: 100.5
heartrate: 128.0
resprate: 24.0
o2sat: 96.0
sbp: 101.0
dbp: 66.0
level of pain: 7
level of acuity: 2.0 | ___ is a ___ G2P1 18 week pregnant woman
admitted with hypoxic respiratory failure ___ the setting of
multifocal pneumonia.
# Hypoxemic respiratory failure: CXR on admission demonstrated
multifocal pneumonia. Patient admitted to medical ward after
outpatient antibiotic failure. However, she quickly developed
escalating oxygen requirements necessitating transfer to the ICU
for high flow nasal canula. There, she was able to be weaned to
oximizer. Given concurrent pregnancy and complicated course, ID
and OB were consulted. She was initially treated with
ceftriaxone, vancomycin, and levofloxacin (despite levofloxacin
as class C medication given her disease severity). MRSA
negative, vancomyicn stopped. After 3 days of treatment ID
recommended continued use of CTX and change of levofloxacin to
high dose azithromycin. Sputum culture and blood cultures
ultimately negative. HIV, strep pneumo negative. Respiratory
viral panel, mycoplasma, RVP, G/G, EBV, CMV were all negative.
Transferred out of the ICU after weaned to nsal canulla. On the
floor, weaned of oxygen at rest, but still had ambulatory
desaturations. for elevated LFTs, CTX transitioned early to
cefpodoxime and antibiotics converted to orals on day prior to
discharge. She was discharged with intent to follow-up a ___s recommended by ID.
# Elevated LFTs
# Elevated Alk Phosphatase: AP noted to be elevated ___ ICU.
RUQUS without ductal dilation or parenchymal changes. After
transfer out of ICU, LFTs subsquently rose. CTX changed to
cefpoxidime early as a result as ceftriaxone can cause biliary
sludging. LFTs were elevated at time of discharge, however,
obstetrics did not think LFTs represented acute fatty liver of
pregnancy of HELLP given normal BP and normal other blood work.
RUQUS was unremarkable. Felt possibly related to prior
ceftriaxone use. Discharged with intent to have LFTs rechecked
at PCP appointment on ___. Discharge LFTs (___):
ALT: 86 AST: 81 AP: 431
# Pregnancy: 17 weeks at admission to hospital. OB performed
daily Doppler and her prenatal viatmins were continued.
# GERD: Home calcium carbonatewere continued PRN |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Vicodin /
Ciprofloxacin / Keflex / Codeine / OxyContin / Clindamycin
Attending: ___.
Chief Complaint:
Fever, chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMH diabetes and psoriatic arthritis on Infliximab,
methotrexate, prednisone taper who p/w ~5 day hx of fevers (to
103), B/L rib pain, and chills. Pt was on cruise in ___ and
returned 4d ago. During the cruise, she had an allergic reaction
on her face to a spa facial, resolved after about a week. ___
days after, her rigors and fever started. Also noted pain in B/L
ribs recently. Has a h/o CP that her cardiologist has attributed
to costochondritis. Her last dose of infliximab was 4 weeks ago,
was scheduled for next dose on day of admission but cancelled
due to fevers. She saw her PCP in clinic yesterday, who was
concerned about infection given the rigors, fever, and
immunosuppressive meds, and wanted her to get cultures and
abdominal CT to r/o abdominal abscess. Of note, the patient
underwent liver biopsy one month ago at ___ after she had
developed liver "problems" when on MTX previously, biopsy was
normal per pt. this time. Endorses recent weight gain from
prednisone, about 50 pounds over the past year.
In the ED, initial VS: 98.8 81 106/67 16 96% RA. On exam, she
was TTP in ribs, LLQ, knee and hand joints. Abdominal CT w/
contrast and CTA chest showed no PE or PNA, increased central
lymphadenopathy of undetermined significance, no abscess. She
was noted to desaturate to the high ___ on room air and so was
admitted to medicine. VS at transfer: 98.7 78 134/67 17 95% 3L
NC. She was given 1L NS in the ED.
Overnight, her O2 requirement started to increase to the point
that she was persistent hypoxemic to low ___ on a 40% ventimask.
ABG showed 7.43/42/68. ID was consulted as there was concern
for PCP ___. She was started on bactrim 2 DS TID for PCP
treatment, increased to prednisone 30 mg BID (from her 2.5 mg a
day taper dose). She was then admitted to the MICU for
persistent hypoxemia.
In the MICU, there was suspicion for volume overload causing her
hypoxemia in addition to possible infection. She was started on
IV lasix 20mg BID and continued on the bactrim/prednisone
regimen. Her hypoxemia improved. She no longer required
ventimask and was transferred back to the medicine floor. On the
floor, she did not complain of SOB but did complain of continued
chest wall tenderness and pain in her joints. She denied fever,
chills, night sweats, or LOA. She was mainly concerned about
being on a higher dose of prednisone, as it took her a long time
to be weaned down to 2.5mg per day.
Past Medical History:
-Psoriatic arthritis, currently treated with Humira, MTX, and
prednisone
-Methotrexate liver toxicity
-Hyperthyroidism s/p ablation
-DM, controlled with diet/exercise
-hypertension
-hyperlipidemia
-atrial flutter (___)
-OSA
-macular degeneration
Past GI History:
-rectal bleed: suspected hypoperfusion ischemic ___
-hemorrhoids
-diverticulosis
-IBS
-___ esophagus (EGD ___
-cholelithiasis
Past MSK/Neurologic history:
-R ulnar nerve transposition
-lumbar disc disease
-frontal lobe dysfunction w/ early frontotemporal atrophy
possibly secondary to neurodegenerative process: Neuropsych
testing ___ demonstrated mild deficits in attention and
executive function; average intellectual functions
-TIA, amaurosis fugax
-vertigo
-migraine headaches
Past Surgical History:
-L5-S1 fusion with L5 laminectomy (___)
-C5-C7 cervical spinal fusion with anterior instrumentation
(___)
-Lumbar L3-5 vertebrectomy with fusion, anterior spacers, and
autograft, bone morphogenic protein and allograft (___)
-Posterior lumbar fusion and revision laminectomy (___),
complicated by dural tear patched with Duragen and Tisseel, as
well as pseudomeningocoele and subdural hematoma
-hemorrhoidectomy ___
-Bilateral rotator cuff tear/repair (R ___, L ___
Social History:
___
Family History:
Patient has 3 sons and 3 grandsons. Family history of mental
illness/alcoholism (both parents), denied history of lung
problems.
Heart disease: twin sister developed CHF at ___(extensive smoking
history and HTN), father d. MI at ___, son had MI at ___.
Cancer: maternal aunt and grandmother had breast cancer in their
___. Maternal uncle had penile cancer. Paternal grandmother
had breast cancer in her ___.
Diabetes: Twin sister, sister (d. ___), maternal aunt.
"Kidney nephrosis": twin sister awaiting renal transplant,
sister's son had episode of anuria and swelling at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - satting 94% on 2L NC
Gen - well nourished, non-toxic appearing elderly woman in NAD
HEENT - NCAT, MMM, EOMI, PERRL, sclera anicteric, conjunctiva
pink, OP clear
CV - RRR, no m/g/r, normal S1 and S2, PMI nondisplaced
Resp - poor inspiratory effort (secondary to chest wall pain),
bibasilar crackles, no wheezes or rhonchi
Abd - s, nd, nt, no organomegaly, normoactive BS
Ext - WWP, no e/c/c, 2+ peripheral pulses
Neuro - CN II-XII intact, ___ strength, no sensory deficits,
normal finger-to-nose test
Skin - erythematous, dry skin on face and neck
DISCHARGE PHYSICAL EXAM:
Vitals - 98.4, 98/46, 57, 18, 94% on 2L NC
Gen - well nourished, non-toxic appearing elderly woman in NAD
HEENT - NCAT, MMM, EOMI, PERRL, sclera anicteric, conjunctiva
pink, OP clear
CV - RRR, no m/g/r, normal S1 and S2, PMI nondisplaced
Resp - normal inspiratory effort, mild crackles in R middle
lobe, no wheezes or rhonchi
Abd - s, nd, nt, no organomegaly, normoactive BS
Ext - WWP, no e/c/c, 2+ peripheral pulses
Neuro - CN II-XII intact, ___ strength, no sensory deficits,
normal finger-to-nose test
Skin - erythematous, dry skin on face and neck is stable
Pertinent Results:
ADMITTING LABS:
___ 04:00PM BLOOD WBC-6.9 RBC-3.94* Hgb-13.0 Hct-38.6
MCV-98 MCH-33.1* MCHC-33.8 RDW-15.0 Plt ___
___ 04:00PM BLOOD Neuts-57.2 ___ Monos-10.3 Eos-2.5
Baso-0.7
___ 04:00PM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-143
K-3.9 Cl-105 HCO3-30 AnGap-12
___ 04:00PM BLOOD ALT-23 AST-24 AlkPhos-27* TotBili-0.3
___ 08:35AM BLOOD LD(LDH)-389*
___ 04:00PM BLOOD Lipase-14
___ 04:00PM BLOOD proBNP-202
___ 04:00PM BLOOD Albumin-4.3
___ 11:05AM BLOOD Type-ART Temp-38.9 FiO2-40 pO2-68*
pCO2-42 pH-7.43 calTCO2-29 Base XS-2 Intubat-NOT INTUBA
RELEVANT LABS:
___ 04:12PM BLOOD Lactate-1.4
___ 08:35AM BLOOD LD(LDH)-389*
___ 11:05AM BLOOD Type-ART Temp-38.9 FiO2-40 pO2-68*
pCO2-42 pH-7.43 calTCO2-29 Base XS-2 Intubat-NOT INTUBA
___ 04:12PM BLOOD Lactate-1.4
___ 12:45PM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-NEGATIVE
___ 08:35AM BLOOD B-GLUCAN-NEGATIVE
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-9.6 RBC-4.16* Hgb-14.1 Hct-41.3
MCV-99* MCH-33.8* MCHC-34.0 RDW-15.1 Plt ___
___ 06:50AM BLOOD Glucose-107* UreaN-17 Creat-1.1 Na-135
K-4.1 Cl-101 HCO3-24 AnGap-14
___ 06:50AM BLOOD LD(LDH)-325*
PERTINENT MICRO/PATH:
DIPSTICK
U
R
I
N
A
L
Y
S
ISBloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks
___ 18:10 NEGNEGTRNEGNEGNEGNEG7.5TR
___ 4:30 pm 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.
___ 3:54 pm SPUTUM Source: Induced.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
___ 6:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:53 am Blood (EBV) EBVP ADDED TO ___.
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___:
Test canceled and patient credited due to a prior EBV
panel sent on
___ indicating evidence of past infection (EBV
VCA-IgG positive,
EBNA IgG positive and EBV VCA-IgM negative). A repeat
panel is
unlikely to detect EBV reactivation. Serum will be held
for 3 months.
For any questions, contact the Microbiology Medical
Director.
___ VIRUS EBNA IgG AB (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ VIRUS VCA-IgM AB (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 12:45 pm Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
NOT FOR USE IN DIAGNOSTIC PROCEDURES.
FOR RESEARCH USE ONLY..
This test has been validated by the Microbiology
laboratory at ___.
___ 6:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 8:35 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
PERTINENT IMAGING:
CHEST (PA & LAT)Study Date of ___ 1:49 ___
IMPRESSION: No evidence of acute cardiopulmonary infectious
process.
CT ABD & PELVIS WITH CONTRAST and CTA CHESTStudy Date of
___ 7:52 ___
IMPRESSION:
1. No evidence of pulmonary embolus or acute aortic syndrome.
2. Borderline central lymphadenopathy, of uncertain clinical
significance,
slightly increased in size since ___ exam.
3. Cholelithiasis without evidence of acute cholecystitis.
4. A 12 x 10 mm left adnexal cyst, stable since ___ exam,
which can be
further assessed with pelvic ultrasound exam on non-emergent
basis.
ECHO ___
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. PredniSONE 5 mg PO QOD Duration: 1 Doses Start: ___. PredniSONE 2.5 mg PO QOD Duration: 14 Days Start: After 5 mg
tapered dose.
3. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral TID:PRN
migraine
4. Valsartan 40 mg PO DAILY
hold for SBP<100
5. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
apply to back, legs, other areas as directed by patient
6. Methotrexate 15 mg PO 1X/WEEK (MO)
7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
8. Infliximab Dose is Unknown IV Q4WEEKS
9. Pravastatin 40 mg PO HS
10. Multivitamins 1 TAB PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Hold for SBP<100
12. oxyCODONE-acetaminophen *NF* ___ mg Oral Q6H:PRN pain
13. Oxymorphone HCl 20 mg PO DAILY:PRN pain
Hold for sedation, RR<10
14. esomeprazole magnesium *NF* 40 mg Oral daily
15. Cal-Citrate *NF* (calcium citrate-vitamin D2) 250-100
mg-unit Oral daily
16. Aspirin 81 mg PO DAILY
17. traZODONE 100 mg PO HS
18. Levothyroxine Sodium 100 mcg PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
apply to back, legs, other areas as directed by patient
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pravastatin 40 mg PO HS
7. PredniSONE 5 mg PO QOD Duration: 1 Doses
8. traZODONE 100 mg PO HS
9. Vitamin D 1000 UNIT PO DAILY
10. butalbital-acetaminophen-caff *NF* 50 mg ORAL TID:PRN
migraine
11. Cal-Citrate *NF* (calcium citrate-vitamin D2) 250-100
mg-unit Oral daily
12. Esomeprazole Magnesium *NF* 40 mg ORAL DAILY
13. Methotrexate 15 mg PO 1X/WEEK (MO)
14. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H:PRN pain
15. Oxymorphone HCl 20 mg PO DAILY:PRN pain
16. PredniSONE 2.5 mg PO QOD Duration: 14 Days
after completing course of 5mg every other day
17. Infliximab 0 mg IV Q4WEEKS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
1. Hypoxemia
2. Fever
3. Hypotension
Secondary diagnoses:
1. psoriatic arthritis
2. diabetes mellitus
3. paroxysmal atrial fibrillation
4. GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Acute hypoxemia in patient on Remicade for psoriatic arthritis
with leukocytosis and concern for atypical pneumonia.
COMPARISON: Chest radiographs from ___ and ___. CTA of
the chest, abdomen, and pelvis from ___.
FINDINGS: A bedside AP radiograph of the chest demonstrates new pulmonary
edema as well as engorgement of the mediastinal vasculature, consistent with
acute exacerbation of congestive heart failure. In addition there may be
consolidation of the left lower lobe obscuring the descending aortic contour.
There is no pneumothorax or pleural effusion. The heart size is top normal.
IMPRESSION: Acute decompensated congestive heart failure with consolidation
of the left lower lobe which may represent underlying pneumonia, new since the
CTA obtained ___.
Radiology Report
AP CHEST 4:07 ___
HISTORY: Hypoxia.
IMPRESSION: AP chest compared to ___:
Lung volumes are appreciably lower today accounting in part for some of the
apparent increase in caliber of the already widened mediastinum, which is
probably stable mediastinal venous engorgement presumably due to volume
overload. I doubt there is pulmonary edema. Small right pleural effusion is
new or newly apparent. No pneumothorax. Bilateral infrahilar opacification
is probably atelectasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED
temperature: 98.8
heartrate: 81.0
resprate: 16.0
o2sat: 96.0
sbp: 106.0
dbp: 67.0
level of pain: 6
level of acuity: 3.0 | Primary Reason for Admission:
___ year old female with a past medical history of psoriatic
arthritis on infliximab, methotrexate, and prednisone presenting
with fevers, now with persistent hypoxemia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
PEG tube ___
History of Present Illness:
___ is an ___ year old man with vascular dementia,
CAD s/p CABG and stents (still on DAPT), PAD, DM2,
hypothyroidism, UC, who presented after a fall.
The patient has had diarrhea for a day, then an episode of
shingles (was started on valacyclovir), then became increasingly
weak and confused with difficulty walking. On the morning of
presentation, he fell out of bed and hit his head on the ground.
___ revealed a small left-sided SDH w/o mass effect.
He was admitted to neurosurgery, but given no indication for
operative management, and also rapid worsening of ___,
hyponatremia, anemia, and metabolic encephalopathy, he was
promptly transferred to medicine for ongoing care.
Past Medical History:
vascular dementia
CAD s/p stents and CABG (at ___
PVD
type 2 diabetes, on insulin
hypothyroid
ulcerative colitis
hypothyroidism
h/o giant cell arteritis
___
Social History:
___
Family History:
Patient unable to provide ___
Physical Exam:
On Admission ___:
Physical Exam:
O: T: <96 BP: 144/61 HR: 55 RR: 16 O2 Sat: 99% RA
GCS at the scene: unknown
GCS upon Neurosurgery Evaluation: 13
Time of evaluation: ___ @ 1420
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[x]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[x]5 Localizes to painful stimuli
[ ]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Right pupil surgical. Left 3-2mm reactive.
Neck: supple
Neuro:
Mental Status: Awake and alert. Uncoorperative with exam, not
following commands.
Orientation: Oriented to person.
Language: Speech is dysarthric and perseverative.
Cranial Nerves:
I: Not tested
II: Right pupil surgical. Left pupil 3-2mm.
III, IV, VI: Unable to formally assess, but patient tracks
examiner. EOMs appear intact without nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XII: Could not assess, not following commands.
Motor:
Patient not following commands. Unable to assess pronator drift
or formal motor. Moves all extremities antigravity.
Sensation: Intact to light touch
ON DISCHARGE
============
VS: Reviewed in OMR
HEENT: NC/AT, anicteric sclera, MMM CV: RRR, S1/S2, no murmurs,
gallops, or rubs
CHEST: Scabbed over rash in the upper right chest (approximately
the T5 dermatome).
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Rectal area
erythematous with light brown stool. Approximately 4cm sacral
pressure ulcer with mild erythema around the edge. No
fluctuance, drainage, or purulence.
EXTREMITIES: No cyanosis, clubbing, or edema. Elbows without
erythema or swelling bilaterally. right elbow ROM moderately
limited by pain.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric. R pupil with cataract, L pupil small and minimally
reactive.
DERM: Warm and well perfused, BLEs with chronic venous stasis
changes, bilateral calcaneal dressings c/d/i
Pertinent Results:
ADMISSION
=========
___ 10:00AM ___ PTT-35.5 ___
___ 10:00AM WBC-6.1 RBC-3.19* HGB-10.1* HCT-31.1* MCV-98
MCH-31.7 MCHC-32.5 RDW-13.7 RDWSD-49.5*
___ 10:00AM NEUTS-61.1 ___ MONOS-14.1* EOS-2.3
BASOS-0.5 IM ___ AbsNeut-3.71 AbsLymp-1.31 AbsMono-0.86*
AbsEos-0.14 AbsBaso-0.03
___ 10:00AM CRP-43.8*
___ 10:00AM T4-7.3 FREE T4-1.3
___ 10:00AM TSH-10*
___ 10:00AM ALT(SGPT)-20 AST(SGOT)-46* ALK PHOS-113 TOT
BILI-0.3
___ 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:25PM GLUCOSE-144* UREA N-31* CREAT-1.5*
SODIUM-132* POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-17* ANION
GAP-12
DISCHARGE
=========
___ 07:30AM BLOOD WBC-6.8 RBC-3.18* Hgb-9.7* Hct-31.9*
MCV-100* MCH-30.5 MCHC-30.4* RDW-15.5 RDWSD-57.4* Plt ___
___ 07:30AM BLOOD Glucose-165* UreaN-49* Creat-1.2 Na-133*
K-5.2 Cl-96 HCO3-26 AnGap-11
MICROBIOLOGY
============
___ Urine Culture: ESCHERICHIA COLI. >100,000 CFU/mL
AMPICILLIN------------ <=2 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---- =>16 R
Blood Culture ___ and ___: No Growth
___ 5:41 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
IMAGING:
CT Head w/o Contrast ___: Acute left hemispheric subdural
hematoma without significant mass effect.
CT Spine w/o Contrast ___:
1. No acute fracture or malalignment.
2. Moderate to severe cervical spondylosis.
CT Abdomen and Pelvis with Contrast ___:
1. Bilateral pleural effusions, minimal on the left, trace on
the right,
without focal consolidation.
2. Cholelithiasis without definite evidence of acute
cholecystitis.
3. Wall thickening of the cecum, descending, and rectosigmoid
colon with
mucosal enhancement without significant pericolonic stranding to
indicate
active inflammation, concordant with history of ulcerative
colitis.
4. Compression fracture of the T12 vertebral body of unknown
chronicity but new since ___. Recommend clinical correlation
for point tenderness.
5. Moderate bilateral fat containing inguinal hernia, with small
volume of
fluid on the right.
6. Ill-defined 1.2 cm hypodense focus associated with the neck
of the
pancreas, incompletely characterized but cystic in appearance,
could represent a side branch IPMN, or possibly choledochal
cyst. This can be further evaluated on MRCP in 6 months to ___
year if clinically warranted.
CTA Chest ___:
1. Bilateral pleural effusions, cardiomegaly, and interlobular
septal
thickening with ground-glass opacities consistent with pulmonary
edema.
2. No focal consolidations identified to suggest pneumonia.
3. No evidence of pulmonary embolism or aortic abnormality.
4. Essentially unchanged partially visualized L1 compression
fracture is
better characterized on CT abdomen pelvis from ___.
CT Head without Contrast ___:
1. Unchanged left subdural hematoma measuring up to 5 mm in
maximal thickness. No new intracranial hemorrhage or acute
large major infarct.
Xray Elbow ___:
Possible fracture without substantial displacement involving the
tip of the coronoid process of the ulna. No joint effusion
found.
Xray Shoulder ___:
No evidence of fracture. Mild acromioclavicular degenerative
change.
CXR ___:
Interstitial abnormality is unchanged cardiomediastinal
silhouette is stable. Small left pleural effusion stable. No
pneumothorax. NG tube projects below the left hemidiaphragm.
G-Tube Placement ___
Successful placement of a 16 ___ MIC gastrostomy tube. The
catheter should not be used for 24 hours.
CT Head ___:
The hyperattenuating component of a left hemispheric subdural
hematoma has
decreased in size. The overall size of the left hemispheric
subdural fluid
collection has minimally increased, reflecting increased chronic
blood
products or the development of a superimposed subdural hygroma.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough, diarrhea, AMS work up. Evaluate for
pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___ and ___.
FINDINGS:
The lungs are expanded. There is no focal consolidation. Sternotomy wires
are again noted and the cardiomediastinal silhouette is stable. There is no
pleural effusion or pneumothorax. Multilevel degenerative changes of the
thoracic spine are present.
IMPRESSION:
No evidence of acute thoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with altered mental status. Evaluate for
intracranial hemorrhage.//
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 10.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
501.7 mGy-cm.
Total DLP (Head) = 1,304 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
Acute left hemispheric subdural hematoma without measuring up to 5 mm in
thickest diameter, without significant mass effect (02:19). The basal
cisterns are patent. Otherwise, there is no evidence of territorial
infarction, edema,or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes.
Prominent calcifications of the imaged distal vertebral arteries are noted,
overall similar to the previous study.
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.
IMPRESSION:
Acute left hemispheric subdural hematoma without significant mass effect.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:03 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with history of UC, here with bright
red blood, mild abdominal distention, altered mental statusNO_PO contrast//
Colitis?
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 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 23.7 mGy (Body) DLP =
1,258.2 mGy-cm.
Total DLP (Body) = 1,274 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Bilateral pleural effusions are noted, minimal on the left, trace
on the right, without evidence of focal consolidation. Coronary
calcifications are demonstrated. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver overall demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is a slightly
prominent common bile duct without evidence of intrahepatic ductal dilatation.
A 4 mm stone is seen near the neck of the gallbladder (02:29). Mild
enhancement of the gallbladder wall is noted. The gallbladder is not
abnormally distended and demonstrates no definite signs of active
inflammation. There is mild intrahepatic biliary ductal dilatation, and the
extrahepatic bile duct is prominent at 9 mm diameter, which is within normal
limits for patient's age.
PANCREAS: Ill-defined 1.2 cm hypodense focus associated with the neck of the
pancreas is incompletely characterized, may represent a cyst (02:27).
Otherwise, 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: Focal thickening of the left adrenal gland is noted (02:20).
Otherwise, the adrenal glands are normal.
URINARY: Bilateral cortical hypodensities measuring up to 2.3 cm in the left
kidney are most consistent with simple cysts. A cortical defect in the
inferior pole of the right kidney may reflect sequela of previous inflammatory
insult or intervention (601:42). Otherwise, the kidneys are of unremarkable
with normal nephrogram. There is no hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: A small hiatal hernia is noted. Otherwise, the stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout.
There is wall thickening involving the cecum, descending colon, and
rectosigmoid colon associated with mucosal enhancement, without significant
pericolonic stranding to indicate active inflammation, concordant with
reported history of ulcerative colitis. There is no evidence of bowel
obstruction, free fluid, or pneumoperitoneum.
PELVIS: The urinary bladder is distended. The distal ureters are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: Several prominent but not pathologically enlarged mesenteric,
retroperitoneal, and inguinal lymph nodes are noted. There is no pelvic
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Scattered mild-to-moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Wedge compression deformity of the T12 vertebral body with
well-corticated fragment is consistent with compression fracture, new since
___ but of unknown chronicity(602:37). Multilevel degenerative changes with
prominent anterior osteophytes involving the thoracolumbar spine. Moderate
bilateral fat containing inguinal hernia, with small volume of fluid on the
right.
IMPRESSION:
1. Bilateral pleural effusions, minimal on the left, trace on the right,
without focal consolidation.
2. Cholelithiasis without definite evidence of acute cholecystitis.
3. Wall thickening of the cecum, descending, and rectosigmoid colon with
mucosal enhancement without significant pericolonic stranding to indicate
active inflammation, concordant with history of ulcerative colitis.
4. Compression fracture of the T12 vertebral body of unknown chronicity but
new since ___. Recommend clinical correlation for point tenderness.
5. Moderate bilateral fat containing inguinal hernia, with small volume of
fluid on the right.
6. Ill-defined 1.2 cm hypodense focus associated with the neck of the
pancreas, incompletely characterized but cystic in appearance, could represent
a side branch IPMN, or possibly choledochal cyst. This can be further
evaluated on MRCP in 6 months to ___ year if clinically warranted.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with s/p fall w/ headstrike// ?fracture
?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 5.8 s, 22.8 cm; CTDIvol = 22.8 mGy (Body) DLP = 518.5
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
Total DLP (Body) = 578 mGy-cm.
COMPARISON: CT cervical spine ___.
FINDINGS:
Alignment is normal. No fractures are identified.Moderate to severe multilevel
degenerative changes with intervertebral disc space narrowing and
calcifications, vertebral body height loss, endplate sclerosis, and anterior
and posterior osteophytes are demonstrated, most pronounced at C4-5 through
C7-T1. There is moderate to severe multilevel central canal narrowing due to
a combination of posterior osteophytes and disc bulging, most pronounced at
C4-5, C5-6, and C6-7. Additionally, mild to moderate multilevel neural
foraminal stenosis is seen due to uncovertebral spurring and facet
hypertrophy. There is no prevertebral soft tissue swelling.
There is no evidence of infection or neoplasm.Mild atherosclerotic
calcifications of the carotid bifurcations are noted bilaterally.Imaged
thyroid gland demonstrates dense peripherally calcified right thyroid nodule
measuring up to 14 mm, as seen previously. Scarring within the lung apices is
unchanged.
IMPRESSION:
1. No acute fracture or malalignment.
2. Moderate to severe cervical spondylosis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with L SDH s/p fall on Plavix/aspirin// Eval for
interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.8 mGy-cm.
2) Sequenced Acquisition 3.0 s, 12.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
560.8 mGy-cm.
3) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
186.9 mGy-cm.
4) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
186.9 mGy-cm.
Total DLP (Head) = 1,308 mGy-cm.
COMPARISON: Noncontrast head CT dated ___
FINDINGS:
Limited examination due to patient motion, within this limitation, there is a
grossly unchanged appearance of left hemispheric subdural hematoma measuring
about 5 mm in thickness, without significant midline shift. The basal
cisterns are again patent. Unchanged prominence of the ventricle and sulci.
No evidence acute large territorial infarction or hemorrhage. Again seen are
calcifications of the carotid siphons, and imaged distal vertebral arteries.
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.
IMPRESSION:
Unchanged appearance left hemispheric subdural hematoma without significant
midline shift.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with CAD s/p CABG and stent, vascular dementia,
holding anticoagulation in setting of fall with headstrike and subdural
hematoma. Now somnolent and worse right-sided weakness.// Any evidence of new
bleed?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 1422 MGy-cm
COMPARISON: CT head dated ___.
FINDINGS:
There is no evidence of acute large territorial infarction. A subdural
hematoma overlying the left cerebral convexity is not significantly changed,
measuring 5 mm in maximum thickness. There is prominence of the ventricles
and sulci suggestive of involutional changes. There are periventricular and
subcortical hypodensities, which may represent small vessel ischemic 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. Unchanged left subdural hematoma measuring up to 5 mm in thickness.
2. No new hemorrhage is demonstrated.
Radiology Report
INDICATION: ___ year old man with type 2 diabetes, cad s/p cabg, vascular
dementia, ulcerative colitis, now with no BM for several days and confusion//
Stool burden?
TECHNIQUE: Supine and upright portable radiographs of the abdomen were
obtained.
COMPARISON: Correlation with CT abdomen and pelvis from ___.
FINDINGS:
The large bowel is predominantly gas-filled and mildly distended in some
segments with the sigmoid colon appearing the most distended measuring 6.5 cm
in diameter. Air is seen distally into the rectum. There is only a small
amount of stool. There is gas within the small bowel. There is no evidence
of pneumatosis or pneumoperitoneum.
There is mild left basal atelectasis and possibly a small effusion.
IMPRESSION:
The colon is predominantly gas-filled with a small amount of stool. The
appearance is consistent with colonic ileus.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITHOUT CONTRAST
INDICATION: ___ man with CAD s/p CABG and stent, giant cell arteritis, and
ulcerative colitis presents after fall in setting of diarrhea (5 BMs per day
on ___ and ___, frankly bloody stool on presentation to ED with rising CRP.
KUB shows significant gas and question of inflammatory ileus.// Any
intra-abdominal bleeding or hematoma? Any possible cause for ileus?
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 15.4 s, 53.0 cm; CTDIvol = 17.2 mGy (Body) DLP =
887.2 mGy-cm.
Total DLP (Body) = 901 mGy-cm.
COMPARISON: Previous enhanced CT abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with associated
bibasal atelectasis. There are multivessel coronary calcifications. There is
bilateral gynecomastia. Heart is mildly enlarged
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. Cholelithiasis is again noted. There is no evidence of acute
cholecystitis.
PANCREAS: The pancreas appears unremarkable. The previously identified
hypodensity in the neck, likely an IPMN, is not well-defined on this study.
There is no pancreatic ductal dilatation. There is no significant
peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There are bilateral
renal cysts. There are persistent nephrograms probably associated with recent
contrast injection, suggesting some degree of renal insufficiency. There is
no hydronephrosis. There is no nephrolithiasis.
GASTROINTESTINAL: The sigmoid colon and rectum are diffusely thickened as
better demonstrated on the previous enhanced CT. There is now mild gaseous
distension of the proximal sigmoid and descending colon, where the wall
previously appeared mildly thickened. This is likely related to ileus. There
is no pneumatosis or pneumoperitoneum. Mild diverticulosis of the proximal
colon is noted. The small bowel is not dilated. Small bilateral fat
containing inguinal hernias with trace fluid, left greater than right, very
similar to the prior study.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable aside
from prostate enlargement.
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: No aggressive bone lesions are demonstrated. There is a moderate
anterior wedge compression fracture of the T12 vertebral body with
approximately 40% anterior height loss, unchanged from ___ and
not present on a lumbar spine MRI from ___, but otherwise age
indeterminate.
SOFT TISSUES: There are bilateral fat containing inguinal hernias. Both
contain a trace of fluid. There is otherwise no ascites. There is no
retroperitoneal or pelvic hematoma.
IMPRESSION:
1. No evidence of intra-abdominal bleeding.
2. Inflammatory changes in the distal colon and rectum are again demonstrated.
No evidence of bowel obstruction or perforation.
Radiology Report
INDICATION: Rabbi ___ is an ___ man with T2D, CAD s/p CABG, vascular
dementia, ulcerative colitis, hypothyroidism, and recent VZV diagnosis and
diarrhea who presents after a fall with headstrike in the setting of
progressive weakness and confusion, found to have acute left subdural
hemorrhage without mass effect.// interval change in ileus
TECHNIQUE: Portable abdominal radiograph
COMPARISON: ___
FINDINGS:
There is some decrease in small bowel distension. Otherwise, study is
unchanged.
There is no free intraperitoneal air.
IMPRESSION:
Persistent mild ileus but with some improvement.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with recent dobhoff placement// two step dobhoff
placement-- thanks!
TECHNIQUE: Three sequential AP radiographs of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There are postsurgical changes from CABG. There has been interval placement of
a Dobbhoff enteric tube, which terminates in the proximal body of the stomach
on the third radiograph. There is a new hazy opacity in the left lung base,
which silhouettes the left hemidiaphragm and most likely represents a
combination of a pleural effusion and atelectasis. Additional patchy opacities
in the left lung base may represent aspiration pneumonitis or developing
pneumonia. The right lung is clear. The cardiomediastinal silhouette is stable
in appearance. There are no acute osseous abnormalities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with desaturation while on oxygen
supplementation.// ?pneumonia, aspiration ?pneumonia, aspiration
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Opacification of the left lower lobe developed between ___ and
___. Mediastinal shift has increased slightly since then. Findings
point to left lower lobe atelectasis but pneumonia is not excluded. There is
an accompanying small left pleural effusion. Right lung is clear. Right
pleural effusion is tiny. Heart size top-normal. No pulmonary edema.
Feeding tube ends in the upper stomach.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man here with ___, now with hypoxia concerning for
aspiration vs. PNA, and persistent somnolence.// evaluate for acute
intracranial pathology, has known SDH, ?expansion?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.6 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT head without contrast from ___
FINDINGS:
There is no evidence of acute major vascular territorial infarction,new
intracranial hemorrhage,edema,or mass. A previously demonstrated 5 mm left
cerebral convexity subdural hematoma is unchanged since ___.
There is prominence of the ventricles and sulci suggestive of involutional
changes. The ill-defined periventricular subcortical white matter
hypodensities are nonspecific but likely due to chronic sequela of
small-vessel ischemic disease. There is no midline shift. Atherosclerotic
calcifications are seen in both carotid siphons.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Unchanged left subdural hematoma measuring up to 5 mm in maximal thickness.
No new intracranial hemorrhage or acute large major infarct.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ is an ___ man with T2D, CAD s/p CABG, vascular
dementia, ulcerative colitis, hypothyroidism, and recent VZV diagnosis and
diarrhea who presents after a fall with headstrike in the setting of
progressive weakness and confusion, found to have acute left subdural
hemorrhage without mass effect, now transferred from neurosurgery to medicine
for further management. Likely UC flare causing diarrhea and orthostasis >
fall > subdural hematoma but also considering stroke given son's report of
"slurring words." // PE, pneumonia, fluid overload?
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) = 415 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Patient is status post CABG with expected postsurgical
changes. The heart is mildly enlarged. The pericardium, and great vessels
are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass. A nasogastric tube is
demonstrated and courses throughout the mediastinal esophagus, terminating
within the stomach.
PLEURAL SPACES: Bilateral pleural effusions are demonstrated, small on the
right, and small to moderate on the left. No pneumothorax.
LUNGS/AIRWAYS: Interlobular septal thickening with areas of ground-glass
opacities are visualized bilaterally predominantly perihilar in distribution.
No focal consolidations are identified. The airways are patent to the level
of the segmental bronchi bilaterally.
BASE OF NECK: A 2 cm partially calcified right thyroid nodule is demonstrated.
No supraclavicular lymphadenopathy is identified.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No worrisome osseous abnormality is seen. A partially visualized L1
compression fracture is re-demonstrated and better characterized on CT abdomen
pelvis from ___.
IMPRESSION:
1. Bilateral pleural effusions, cardiomegaly, and interlobular septal
thickening with ground-glass opacities consistent with pulmonary edema.
2. No focal consolidations identified to suggest pneumonia.
3. No evidence of pulmonary embolism or aortic abnormality.
4. Essentially unchanged partially visualized L1 compression fracture is
better characterized on CT abdomen pelvis from ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dobhoff placement// confirm dobhoff
placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT scan dated ___
FINDINGS:
The tip of the feeding tube projects over the stomach. The visualized lungs
are clear although a small left pleural effusion is suspected. The size of
the cardiac silhouette is within normal limits. Apparent healed right
posterior eighth rib fracture.
IMPRESSION:
The tip of the Dobhoff tube extends to the stomach.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with s/p fall SDH c/b UTI and TME. Now with R
hand edema and pain. Evaluate for DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the right subclavian vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with toxic metabolic encepathology with increased
cough yesterday after eating.// ? Aspiration PNA ? Aspiration PNA
IMPRESSION:
Comparison to ___. No relevant change is noted. Borderline size
of the cardiac silhouette. Minimal left pleural effusion and retrocardiac
atelectasis. The remaining lung parenchyma is normal. No evidence of
pneumonia. No pulmonary edema. Stable alignment of the sternal wires.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with doboff. Possible displacement// check doboff
location.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The patient's head obscures the left lung apex. There is a layering left
pleural effusion, likely not significantly changed since prior. A small right
pleural effusion is also noted. No right pleural effusion.
The Dobhoff extends into the distal stomach.
Radiology Report
EXAMINATION: Right shoulder radiographs, three views.
INDICATION: New right arm pain.
COMPARISON: None.
FINDINGS:
Acromioclavicular degenerative changes are mild including small inferiorly
pointing osteophytes. Glenohumeral joint is preserved in with. There is no
evidence of fracture, dislocation or lysis.
IMPRESSION:
No evidence of fracture. Mild acromioclavicular degenerative change.
Radiology Report
EXAMINATION: Right elbow radiographs, three views.
INDICATION: Status post fall with subdural hemorrhage. Query fracture. New
right arm pain.
COMPARISON: Prior study from ___.
FINDINGS:
Despite lack of a joint effusion, two view suggests the possibility of a very
small fracture along the tip of the coronoid process the proximal ulna,
although not well characterized. Very small calcifications along each
epicondyle of the distal humerus suggests sequela of mild enthesopathy.
IMPRESSION:
Possible fracture without substantial displacement involving the tip of the
coronoid process of the ulna. No joint effusion found.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old man with dementia and dobhoff placed for tube
feeds.// Dobhoff placement.
IMPRESSION:
In comparison with the study of ___, there has been placement of a
Dobhoff tube. The tube extends at least to the upper stomach were crosses the
lower margin of the image, and the opaque tip cannot be seen. To determine the
precise position of the tube, repeat study could be obtained with the upper
margin of the casette at the level of the carina.
No change in the appearance of the heart and lungs, except for better
visualization of the left hemidiaphragm, suggesting some decrease in volume
loss and pleural fluid at the base.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with vascular dementia and encephalopathy with
new fever and cough// ? Aspiration Pneumonia
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Interstitial abnormality is unchanged cardiomediastinal silhouette is stable.
Small left pleural effusion stable. No pneumothorax. NG tube projects below
the left hemidiaphragm
Radiology Report
INDICATION: ___ year old man with vascular dementia and Subdural hematoma with
failed speech and swallow evaluation. Need for g-tube placement for
nutrition/hydration.// G-Tube placement for nutrition
COMPARISON: Abdominal x-ray ___
TECHNIQUE: OPERATORS: Dr. ___ and
Dr. ___ resident performed the procedure.
ANESTHESIA: 1 drug sedation was provided by administrating divided doses of
50mcg of fentanyl. 1% lidocaine was injected in the skin and subcutaneous
tissues overlying the access site.
MEDICATIONS:
CONTRAST: 50 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 5.9 minutes, 51 mGy
PROCEDURE: 1. Placement of a 16 ___ MIC gastrostomy tube placement.
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.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A ___ wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
After tract dilation utilizing a 10 mm Mustang balloon, a 16 ___ MIC
gastrostomy catheter was advanced over the wire into position. The catheter
was secured by instilling 5 ml of dilute contrast into the balloon in the
stomach after confirming the position of the catheter with a contrast and air
injection. The catheter was then flushed, capped and secured to the skin with
0-silk sutures. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a 16 ___ MIC gastrostomy tube.
IMPRESSION:
Successful placement of a 16 ___ MIC gastrostomy tube. The catheter should
not be used for 24 hours.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SDH after a fall 4 weeks ago. Repeat CT for
evaluation of resolution prior to restarting antiplatelet agents.// Subdural
Hematoma Monitoring
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.3 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Noncontrast head CTs between ___ and ___
FINDINGS:
The hyperattenuating component of a left hemispheric subdural hematoma has
decreased in size. The overall size of a left hemispheric subdural fluid
collection has minimally increased, measuring up to 1.0 cm from the inner
table, previously 0.8 cm, reflecting additional chronic blood products or the
development of a superimposed subdural hygroma. No midline shift. Otherwise,
no evidence of new intracranial hemorrhage. No evidence of large territorial
infarction, edema, or mass. The ventricles and sulci are prominent,
consistent with involutional change.
There is no evidence of fracture. Nonspecific partial opacification of the
left mastoid air cells and middle ear cavity. Nonspecific partial
opacification of dependent right mastoid air cells. Left lens replacement
noted. The 4 segment and carotid siphon calcifications are noted.
IMPRESSION:
The hyperattenuating component of a left hemispheric subdural hematoma has
decreased in size. The overall size of the left hemispheric subdural fluid
collection has minimally increased, reflecting increased chronic blood
products or the development of a superimposed subdural hygroma.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Slurred speech
Diagnosed with Nontraumatic acute subdural hemorrhage, Weakness, Hypothermia, initial encounter, Altered mental status, unspecified, Exposure to other specified factors, initial encounter
temperature: 94.3
heartrate: 60.0
resprate: 18.0
o2sat: 99.0
sbp: 144.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | HOSPITAL SUMMARY
================
___ is an ___ year old man with a history of T2DM, CAD
s/p CABG, PAD s/p stent, vascular dementia, ulcerative colitis,
hypothyroidism, and recent VZV diagnosis and recent viral
enteritis, s/p fall with SDH. Hospital course was complicated by
UTI, urinary retention, ___, anemia, ileus, heel and decubitus
ulcers, metabolic encephalopathy, and dysphagia (now s/p G
tube). After a prolonged hospital course he was discharged to
rehab.
ACUTE ISSUES
============
# Fall
# SDH:
# Metabolic encephalopathy:
# Dysphagia
Neurosurgery evaluated the patient, decided on no operative
intervention, and advised serial imaging and outpatient follow
up. Neurologic exam remained stable, SBP was maintained <160.
Repeat CT head ___ stable and will see neurosurgery for
another repeat scan in one month. Safe to discharge on
aspirin/Plavix but will only restart aspirin as PVD stent placed
years ago.
Despite stable SDH, his mental status waxed and waned while
inpatient, likely secondary to metabolic encephalopathy,
followed by a worsening hospital delirium. EEG was not
concerning for seizure activity, and home Keppra was stopped per
outpatient neurologist's request.
He was followed closely by speech and swallow this admission,
and was kept NPO with hydration/nutrition via NG tube. PEG was
then placed, when it became apparent he would not improve
quickly. As his mental status improved he was able to take in
pureed foods, although he remains an aspiration risk with
liquids, even if nectar thick.
# Pressure Ulcers:
Bilateral calcaneal and sacral ulcers developed during this
admission. Wound care followed the patient, he was placed on an
air mattress with frequent turning, moved OOB to chair 3x daily.
# R arm pain:
Patient intermittently reported pain and around IV site on R
hand. R UE venous duplex negative for DVT. Right elbow xray with
possible small fracture of the ulnar coronoid process. Talked to
orthopedics. They think there might just be microscopic fracture
or tendonitis. No intervention necessary and no restrictions.
Tylenol and lidocaine patches were used for pain control.
# Hyponatremia:
Patient with hypovolemic hyponatremia on arrival. Fluctuating
sodium this admission, resolved with titration of free water
flushes.
# HTN:
Continued home atenolol. Initially restarted lisinopril but
given ___ and ___ stopped this medication.
# ___:
Patient with pre-renal ___ on arrival, likely due to GI
losses from presumed viral gastroenteritis. This resolved with
fluids.
# UTI:
___ Cx +ve for E. Coli w/ resistance to bactrim. Completed 7
day course of Antibiotics (___). Blood Cultures: No
Growth (Final)
# Zoster:
Completed a course of valcycliovir treatment. Originally with
vesicular rash in T5-6 dermatome, does not cross midline.
Lesions are now scabbed over and non-infective.
# Normocytic iron deficiency anemia:
# Reported history of GI bleeding
The patient had anemia on arrival, which appeared to worsen
initially, but he was probably just hemoconcentrated in the
setting of hypovolemia. Hgb steadily rose thereafter throughout
his hospitalization, simply from the iron in his tube feeds.
He reportedly was noted to have a bloody stool in the ED,
which would not be explained by his clinically quiescent UC.
There was no recurrence of this and significance is unclear.
# Urinary retention:
Bladder scan and straight cath PRN. Tamsulosin cannot be
crushed and given through a PEG, so he was started on terazosin
# Hypothyroid
# Sick euthryoid syndrome:
Continued home levothyroxine Levothyroxine Sodium 50 mcg
PO/NG 4X/WEEK (___), and Levothyroxine Sodium 25 mcg
PO/NG 3X/WEEK (___)
# Obstructive Sleep Apnea:
Nocturnal desaturation likely sequela of mixed obstructive
/central process. Could consider CPAP, although it's unclear if
the patient would tolerate this.
# Ulcerative Colitis:
UC at baseline. Continued home sulfasalazine Having loose
stools, but these are likely due to his tube feeds.
#Ileus
Patient had no BM for many days after admission and KUB
showed dilated bowel loops. GI suggested suppositories and
treatment of intercurrent illnesses. Ileus has resolved.
# Gout:
Continued colchicine, prednisone. Uric acid 4.1 on ___.
# Diabetes:
Held home glipizide, linagliptin, and tresiba 20u daily. Was
on lantus 15u daily with ISS. Restarted home regimen on
discharge.
# PVD:
Was on Plavix/aspirin, stopped Plavix on discharge as stent
placed many years ago.
# T12 COMPRESSION FRACTURE
Seen on CT A/P, unknown chronicity. No point tenderness. As
this would suggest underlying osteoporosis, bone density testing
would be a consideration.
# Non-displaced fracture of coronoid process of R ulna
Possible fracture of right elbow without substantial
displacement involving the tip of the coronoid process of the
ulna. No need for orthopedic intervention, have been managing
with pain control.
TRANSITIONAL ISSUES
===================
Discharge Cr: 1.2
Discharge Hgb: 9.7
[ ] Patient will need intensive physical therapy as tolerated
[ ] Continue to monitor sacral and calcaneal pressure ulcers for
signs of infection; Ensure wound care is being followed as
outlined in page 1 of discharge paperwork
[ ] Patient having intermittent bouts of diarrhea. Would closely
titrate bowel regiment to ___ soft stools daily while on tube
feeds. On banana flakes for fiber
[ ] Repeat ___ ___ with no evidence of midline shift
associated with a chronic subdural hematoma. Case discussed with
the attending of record. Dr. ___ decided safe to
restart ASA/Plavix. On discussion with outpatient PCP and
neurologist, the decision was made to stop Plavix and continue
aspirin at this time
[ ] Follow up with neurosurgery in one month with a NCHCT. He
can call ___ to make this appointment.
[ ] Consider outpatient sleep study/CPAP for concern for apneic
episodes
[ ] Chronic T12 compression fracture on imaging - may need
osteoporosis workup outpatient, on chronic prednisone 1mg daily.
[ ] 1.2 cm side branch IPMN, or possibly choledochal cyst. This
can be further evaluated on MRCP in 6 months to ___ year, if
clinically warranted (i.e. if he is doing well enough that he
would be a candidate for a Whipple, should the scan show
anything concerning for cancer).
[ ] s/p ___ PEG tube. Interventional radiology (___) follow up
scheduled
[ ] Consider repeat swallow evaluation as mental status improves
[ ] Will need continued bladder scans and straight
catheterizations as needed; started on terazosin 2mg daily,
which can be increased as tolerated.
[ ] Restarted home diabetes regimen on discharge with glipizide,
linagliptin, and tresiba 20u daily. Will need to monitor sugars
and adjust as needed based on glycemic control
# CODE: full code, confirmed
# CONTACT: Dov (son and HCP) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
hydralazine
Attending: ___.
Chief Complaint:
Foul smelling discharge from foot ulcer
Major Surgical or Invasive Procedure:
___: bedside debridement
___: right lower extremity angiogram
___: R ___ bypass
___: R TMA (Podiatry)
History of Present Illness:
Mr. ___ is a ___ with hx R foot diabetic foot
ulcer/infection, CVA, CAD (c/b vfib arrest during cath in
___, CKD, HTN, and T2DM c/b neuropathy presenting to ED with
increased bleeding, foul purulent discharge, wound dehiscence at
site chronic right foot ulcer. Recently had area sutured by
podiatry 1 week ago. Denies fevers or chills.
In the ED, Exam notable for large deep ulcer open to
tendons/fascia between ___ and ___ toes, foul smelling drainage,
1.5 cm surrounding erythema worst on ___ toe, minimal TTP, some
sutures still in place. Podiatry was consulted and excised skin
edges to bleeding borders and the plantar and proximal aspects
were sutured with ___ prolene. Wound cx sent. Labs notale for
WBC 15, K+ 5.2. Lactate 1.8. He was started on vanc/zosyn.
He was recently admitted ___ for N&V and, while here,
Podiatry performed I&D and partial closure of diabetic foot
ulcer; however, on day of discharge, podiatry came to change his
dressing and noted wound dehiscence. They recommended 10 days of
Augmentin and a wound care ___. Reviewing his chart, micro data
returned on ___ (2 days after discharge) showing MRSA. For
reasons unknown, the podiatry office cancelled his follow up
visit with them on ___. He is now being admitted to medicine per
Podiatry for IV Abx.
On the floor, pt feels well and has no complaints. His R foot is
s/p debridement by podiatry in ER. He does not have any pain.
Past Medical History:
- Hypertension
- Hyperlipidema
- Type 2 diabetes with HbA1C 8.6% in ___
- CAD s/p cath in ___ with 60% stenoses of LAD and LCx
- VFib arrest during cath in ___
- CVA in ___, and ___ with residual right-sided
hemiparesis
- CKD stage III with baseline Cr 1.5
- Nephrolithiasis
- Erectile dysfunction
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Vitals: 98.5/98.3 83 135/72 18 96%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes, poor dentition
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: R TMA, incision appears c/d/i, R: p/p/d/d
L:p/p/d/d
PULSES: 2+ DP pulses bilaterally via doppler
NEURO: CN II-XII intact. Residual right sided weakness s/p CVA.
SKIN: warm and well perfused, no rashes
Pertinent Results:
___ 05:25AM GLUCOSE-295* UREA N-39* CREAT-1.3*
SODIUM-132* POTASSIUM-6.8* CHLORIDE-103 TOTAL CO2-18* ANION
GAP-18
___ 05:25AM estGFR-Using this
___ 05:25AM WBC-15.0*# RBC-3.70* HGB-10.4* HCT-30.2*
MCV-82 MCH-28.1 MCHC-34.4 RDW-12.7
___ 05:25AM NEUTS-90.7* LYMPHS-5.7* MONOS-3.3 EOS-0.1
BASOS-0.2
___ 05:25AM PLT COUNT-445*#
___ 05:15AM LACTATE-1.8 K+-5.2*
___ 06:45AM BLOOD WBC-6.5 RBC-3.51* Hgb-9.9* Hct-28.7*
MCV-82 MCH-28.1 MCHC-34.4 RDW-13.8 Plt ___
___ 06:15AM BLOOD WBC-5.8 RBC-3.26* Hgb-9.2* Hct-26.5*
MCV-81* MCH-28.2 MCHC-34.6 RDW-13.7 Plt ___
___ 06:30AM BLOOD WBC-5.9 RBC-3.07* Hgb-8.8* Hct-25.3*
MCV-82 MCH-28.5 MCHC-34.6 RDW-13.7 Plt ___
___ 06:30AM BLOOD WBC-6.8 RBC-3.32* Hgb-9.3* Hct-27.3*
MCV-82 MCH-27.9 MCHC-33.9 RDW-13.6 Plt ___
___ 05:05PM BLOOD WBC-8.3 RBC-3.29* Hgb-9.1* Hct-27.2*
MCV-83 MCH-27.6 MCHC-33.5 RDW-13.7 Plt ___
___ 08:58PM BLOOD WBC-6.7 RBC-3.38* Hgb-9.4* Hct-28.3*
MCV-84 MCH-27.7 MCHC-33.1 RDW-13.8 Plt ___
___ 05:50AM BLOOD WBC-9.6 RBC-3.05* Hgb-8.4* Hct-25.2*
MCV-83 MCH-27.6 MCHC-33.5 RDW-13.9 Plt ___
___ 06:17AM BLOOD WBC-8.4 RBC-2.88* Hgb-8.0* Hct-23.8*
MCV-82 MCH-27.6 MCHC-33.5 RDW-13.8 Plt ___
=====================
Imaging:
Right foot CXR (___)
Soft tissue ulceration along the superior portion of the first
and second
right post without radiographic evidence of osteomyelitis.
RLE angiogram (___)
1. Patent bilateral renal arteries.
2. Patent abdominal aorta without any signs of aneurysmal
dilation or occlusion.
3. Bilateral iliac arterial segments are patent.
4. The right common femoral artery, SFA, and profunda femoris
are all patent.
5. The right popliteal artery is patent.
6. The right anterior tibial artery has a long-segment occlusion
proximally. It is patent in the distal lower leg and is of
great caliber for bypass.
7. The right peroneal artery is occluded.
8. The right ___ has a short-segment occlusion proximally but is
then patent throughout and is of excellent caliber for a bypass.
9. The right DP is patent and is of excellent caliber for a
bypass.
==============================================
Microbiology:
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain or fever
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
7. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID
8. GlipiZIDE 10 mg PO BID
9. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain or fever
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
8. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*30 Suppository Refills:*0
9. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID
10. GlipiZIDE 10 mg PO BID
11. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
12. Minocycline 100 mg PO BID Duration: 3 Days
RX *minocycline 100 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
non-healing traumatic RLE wound
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: FOOT 2 VIEWS RIGHT
INDICATION: ___ year old man with open ulcer of R foot between ___ and ___
toes // ? osteomyelitis ? osteomyelitis
TECHNIQUE: Right foot, three views.
COMPARISON: Right foot radiograph dated ___.
FINDINGS:
A soft tissue defect is noted overlying the right first and second toes. No
osteolysis or periosteal new bone formation is detected. No subcutaneous
emphysema is identified. Extensive vascular calcifications are noted.
IMPRESSION:
Soft tissue ulceration along the superior portion of the first and second
right post without radiographic evidence of osteomyelitis. CT SCANNING COULD
REVEAL DEMINERALIZATION OR PERIOSTEAL REACTION INDICATIVE OF EARLY
OSTEOMYELITIS NOT APPARENT ON THIS STUDY.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with PVD, R tibial dz // please assess veins for
possible bypass
TECHNIQUE: Grey scale and measuring evaluation was performed on the bilateral
upper extremity basilic and cephalic veins for vein mapping.
COMPARISON: None.
FINDINGS:
The bilateral basilic and cephalic veins are patent in the upper extremities.
There is no intraluminal thrombus. Specific measurements of each vein along
its course is provided in the scanned in sheet.
IMPRESSION:
Patent bilateral cephalic and basilic veins.
Radiology Report
EXAMINATION: VENOUS DUP LOWER EXT BILATERAL
INDICATION: ___ year old man with PVD, R tibial dz // pls assess veins
TECHNIQUE: Grey scale and measurement evaluation was performed on the
bilateral lower extremity greater and lesser saphenous veins.
COMPARISON: None.
FINDINGS:
The greater and lesser saphenous veins are patent bilaterally in the lower
extremities. There is no evidence of intraluminal thrombus. Specific
measurements can be found in the scanned in sheet, with measurements provided
throughout the course of each vein.
IMPRESSION:
Patent bilateral greater and lesser saphenous veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p RLE angio, R distal bypass, R TMA, with SOB
// ?acute process
COMPARISON: None available
FINDINGS:
Low lung volumes injury the cardiac silhouette and bronchovascular structures.
With this limitation in mind, heart size is normal. Aorta is mildly tortuous.
Lungs and pleural surfaces are essentially clear.
IMPRESSION:
Limited chest radiograph demonstrating no acute cardiopulmonary radiographic
abnormality. If symptoms persist, repeat radiograph with improved inspiratory
level may be helpful for more complete assessment.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Foot pain
Diagnosed with DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, ABN REACT-PROCEDURE NEC
temperature: 98.5
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 150.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with right diabetic foot infection who was
admitted to the ___ on ___.
Of note, patient is status post I&D on ___ with wound
cultures growing MRSA and corynebacterium. He was started on
Vanc/Zosyn for empiric coverage of suspected polymicrobial foot
infection. Podiatry debrided this right foot wound in the ED and
applyed a wound vac.
ABI/PVR on admission ealier this month showing significant right
lower extremity tibial disease. He therefore taken to the
endovascular suite and runderwent right lower extremity
angiogram on ___. Angiogram confirmed severe tobial-peroneal
disease. The right anterior tibial artery had a long-segment
occlusion proximally with distal reconstitution. The right
peroneal artery was occluded. The right ___ has a short-segment
occlusion proximally but was then patent throughout. The patient
tolerated the procedure well without complications and was
brought to the post-anesthesia care unit in stable condition.
Post-operatively, he did well without any groin swelling.
Vein mapping showed adequate caliber GSV conduit for lower
extremity bypass. Wound cultures were positive for MRSA. He was
transition from Vanc/zosyn to PO minocycline on ___. He
remained inhospital for scheduled bypass on ___. He underwent a
R ___ bypass which he tolerated well. Please see operative
note for further details. His wound was carefully observed after
his bypass with the hopes that establishing better vascular
supply would be able to heal the wound. Unfortunately, the skin
and the ___ toe continued to not look viable. It was decided
that the best course at this time would be a TMA which was done
by Podiatry on ___. He tolerated the procedure well, he
received 1U PRBC intra-op with a stable Hct post-op. Please see
operative note for further details. Physical Therapy worked with
the patient and recommended rehab. His minocycline was
disctoninued on ___ and his vancomycin was discontinued on
___. He will continue a course of oral minocycline at rehab for
a total of 5 days of post-op antibiotics from his TMA. He wast
stable for discharge on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Acute on chronic dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx of ___ disease, frontal lobe dementia, chronic
dizziness, IBS who presents with severe dizziness. She awoke
this morning at 5AM and while doing leg exercises in bed, she
experienced severe dizziness, with general lightheadedness and
no vertigo.
She has a longstanding ___ history of similar dizziness of
unclear etiology, and has been extensively investigated
previously, followed by neurology. This episode differed in that
it was more severe and lasted for hours (usually resolves within
an hour) so she presented to the ED.
In the ED, initial VS were: 96.0 84 124/68 20 98%. Her dizziness
was more severe than usual. UA negative, lytes wnl, CXR without
events. CBC reflected leukopenia and thrombocytopenia (slightly
worse than her baseline). Transfer vitals: 98.1 74 103/58 19
100% RA.
On arrival to the floor, patient feeling well. Reports that her
dizziness resolved in the ED around 4PM. She now complains of a
right frontal headache and requesting tylenol. Also reports ___
weeks of daily to BID loose stools with intermittent
constipation.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, BRBPR, melena, hematochezia,
dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Hypercholesterolemia
2. Gastroesophageal reflux disease
3. Depression
4. Dementia, frontal lobe vs. ___
5. Headaches
6. Chronic dizziness, followed by Dr. ___ Neuro
7. h/o Bradycardia
8. Cervical spondylosis
9. Osteoarthritis
10. h/o Chronic leukopenia and thrombocytopenia , bone marrow
unreveling
11. Cataracts
12. Chronic hearing loss
13. Chronic constipation
14. Chronic Venous Insufficiency
15. History of Syphilis
16. S/P Hysterectomy
17. Parkinsons disease
18. Gait disorder
Social History:
___
Family History:
Non contributary
Physical Exam:
ADMISSION PHYSICAL EXAM:
---------
VS: 97.7; 122/66; 78; 18; 100%RA
Orthostatics:
-SITTING 129/76 74 100/RA
-STANDING 148/94 83 98/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, R. eye cataract, anicteric sclera, pink
conjunctiva, dry MM, 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
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ throughout
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
-----
GENERAL: NAD
HEENT: AT/NC, EOMI, R. eye cataract, anicteric sclera, pink
conjunctiva, dry MM, 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
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___,
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
-----------
___ 10:40AM BLOOD WBC-2.3* RBC-4.13* Hgb-12.4 Hct-37.9
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.7 Plt Ct-69*
___ 10:40AM BLOOD Neuts-40.8* Lymphs-44.7* Monos-7.1
Eos-5.9* Baso-1.5
___ 10:40AM BLOOD Glucose-120* UreaN-13 Creat-0.6 Na-141
K-3.7 Cl-106 HCO3-26 AnGap-13
___ 10:40AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
___ 12:45PM URINE Color-Straw Appear-Clear Sp ___
___ 12:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
DISCHARGE LABS:
---------
NONE DRAWN ON THE DAY OF DISCHARGE.
IMAGING:
-------
CXR ___
FINDINGS: AP and lateral views of the chest. Improved
inspiration seen on
the current exam. The lungs are clear without focal
consolidation or
effusion. Again seen is relative elevation of the left
hemidiaphragm. The
cardiomediastinal silhouette is top normal, likely accentuated
by technique.
Aorta is tortuous. No acute osseous abnormality is identified.
IMPRESSION: No definite acute cardiopulmonary process.
MICRO:
----
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Fluocinonide 0.05% Cream 1 Appl TP BID
4. Hydrocortisone (Rectal) 2.5% Cream ___ID
5. Omeprazole 40 mg PO DAILY
6. Tolterodine 4 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
9. Carbidopa-Levodopa CR (___) 1 TAB PO 5X/DAY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. Hydrocortisone (Rectal) 2.5% Cream ___ID
5. Omeprazole 40 mg PO DAILY
6. Tolterodine 4 mg PO DAILY
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
8. Fluocinonide 0.05% Cream 1 Appl TP BID
9. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY
10. Docusate Sodium 100 mg PO BID
11. Outpatient Physical Therapy
Outpatient ___, evaluate and treat 3x/week, for total 9 sessions.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
----------
VIRAL GASTROENTERITIS
DIZZINESS
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, TWO VIEWS: ARPIL 23, ___
HISTORY: ___ female with hypotension.
COMPARISON: ___.
FINDINGS: AP and lateral views of the chest. Improved inspiration seen on
the current exam. The lungs are clear without focal consolidation or
effusion. Again seen is relative elevation of the left hemidiaphragm. The
cardiomediastinal silhouette is top normal, likely accentuated by technique.
Aorta is tortuous. No acute osseous abnormality is identified.
IMPRESSION: No definite acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with DIARRHEA, VERTIGO/DIZZINESS
temperature: 96.0
heartrate: 84.0
resprate: 20.0
o2sat: 98.0
sbp: 124.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | ___ PMHx of ___ disease, chronic dizziness, gait
disturbance who presented with dizziness, which had resolved by
the time of her arrival on the floor.
ACTIVE ISSUES:
---------
# ACUTE ON CHRONIC DIZZINESS: SELF-RESOLVED. Metabolic and
infectious workup revealed a normal UA, lactate, and
electrolytes. CBC reflected leukopenia and thrombocytopenia at
her baseline. Placement was not possible in the ED so the
patient was admitted to medicine for case management and
further evaluation. Orthostatics on the floor were negative.
Her telemetry was unremarkable. Patient was discharged hours
after arrival on the floor, in the morning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / miconazole
/ Ilotycin
Attending: ___
___ Complaint:
Fever, UTI symptoms
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ PMH schizo-affective disorder, sarcoidosis,
obesity and diabetes who presents to the ED with a CC of
persistent UTI symptoms and fever. She had been previously seen
in the ED on ___ for UTI and was prescribed nitrofurantoin x5d.
She was seen in clinic for follow up on ___, and was ntoed to
have hematuria. On ___ she called her PCPs office to state she
was having fevers as high as 102 and persistent UTI symptoms so
an appointment was made for her to see a physician ___ at noon.
She went to her appointment ___ and was referred to the ED for
further workup and management.
In the ED her initial VS were 98.2 106 122/88 16 97% RA. Tmax in
ED was 102.9. Her exam was notable for not responding to
questions and having tremor of all 4 limbs. Given her AMS and
fevers, and LP was attempted but was unsuccessful. She also had
a CTU done that showed retroperitoneal lymphadenopathy but no
evidence of pyelonephritis. She was also found to have an
elevated lactate to 2.6. She was given 5L IVF, APAP 1000mg, CTX
1g, Vanc, Cipro, lorazepam 1mg IV.
On arrival to the MICU, her VS are T 98.4, HR 66, BP 85/52, 95%
on 2LNC. She is speaking slowly and having difficulty performing
a review of systems. When asked if she has any urinary symptoms
she says she isn't sure. When asked if she is feeling
lightheaded she says I don't know. Further review of systems was
deferred out of concern that patient was not mentating well due
to hypotension and may need central access.
Past Medical History:
DM2 on insulin
Schizoaffective disorder
Sarcoidosis on prednisone 5mg and MTX q ___
HTN
HLD
Depression
Social History:
___
Family History:
Mother - anxiety, HTN, IBS, polymyalgia rheumatic
Father - HTN, CLL
MGF - stroke
PGF - stroke
PGM - breast cancer, Alzheimer's disease, Crohn's disease
Physical Exam:
ADMISSION PHYSICAL:
VITALS: T98.4, HR 66, BP 85/52, RR 23, 95% on 4L NC
GENERAL: somnolent, wakes to sternal rub and then falls back to
sleep
HEENT: injected sclera, PERRL, EOMI, MMM
LUNGS: CTAB, no wheezes, ronchi, crackles appreciated
CV: RRR, no murmurs, rubs, gallops
ABD: NABS, soft, NT, ND, no rebound or guarding
EXT: wwp, no clubbing cyanosis or edema
NEURO: AAOx3, but somnolent, not participating in exam, awakes
to sternal rub and will briefly answer questions appropriately
but then falls back to sleep
DISCHARGE PHYSICAL:
VS: Reviewed in metavision.
I/Os: Reviewed in metavision.
PHYSICAL EXAM:
General: Well-appearing woman laying back in bed
HEENT: AT/NC, EOMI, PERRL-A, no JVD, no LAD appreciated
Cardiac: RRR, s1+s2 normal, no m/g/r appreciated
Pulm: Lungs CTAB
Abd: +BS, soft, non-tender, non-distended
Ext: Pulses present, no discoloration/edema
Neuro: No motor/sensory deficits elicited
Pertinent Results:
ADMISSION LABS:
___ 03:03PM LD(LDH)-257*
___ 03:03PM HAPTOGLOB-63
___ 03:03PM WBC-7.5 RBC-4.36 HGB-13.7 HCT-40.6 MCV-93
MCH-31.4 MCHC-33.7 RDW-13.2 RDWSD-44.5
___:03PM PLT COUNT-102*
___ 03:03PM ___ 03:03PM RET AUT-4.2* ABS RET-0.18*
___ 06:20AM ___ PO2-59* PCO2-53* PH-7.31* TOTAL
CO2-28 BASE XS-0 INTUBATED-NOT INTUBA
___ 06:20AM LACTATE-1.0
___ 05:59AM GLUCOSE-122* UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-20* ANION GAP-14
___ 05:59AM ALT(SGPT)-19 AST(SGOT)-28 LD(LDH)-279* ALK
PHOS-52 TOT BILI-0.2
___ 05:59AM cTropnT-<0.01
___ 05:59AM CALCIUM-6.8* PHOSPHATE-3.4 MAGNESIUM-1.6
___ 05:59AM TSH-1.8
___ 05:59AM T4-6.6 T3-74*
___ 05:59AM CORTISOL-199.1*
___ 05:59AM WBC-11.0* RBC-4.05 HGB-12.8 HCT-38.2 MCV-94
MCH-31.6 MCHC-33.5 RDW-13.5 RDWSD-45.7
___ 05:59AM NEUTS-66 BANDS-0 LYMPHS-8* MONOS-21* EOS-4
BASOS-1 ___ MYELOS-0 AbsNeut-7.26* AbsLymp-0.88*
AbsMono-2.31* AbsEos-0.44 AbsBaso-0.11*
___ 05:59AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 05:59AM PLT SMR-LOW* PLT COUNT-80*
___ 05:59AM ___ PTT-28.2 ___
___ 03:17AM ___ PO2-64* PCO2-50* PH-7.30* TOTAL
CO2-26 BASE XS--1
___ 03:17AM LACTATE-1.0
___ 03:17AM O2 SAT-89
___ 12:02AM LACTATE-1.8
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE UHOLD-HOLD
___ 07:45PM URINE COLOR-DkAmb* APPEAR-Clear SP ___
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100*
GLUCOSE-300* KETONE-10* BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 07:45PM URINE RBC-2 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 07:45PM URINE HYALINE-6*
___ 07:45PM URINE MUCOUS-MANY*
___ 07:37PM LACTATE-2.6*
___ 07:15PM GLUCOSE-172* UREA N-12 CREAT-1.2* SODIUM-136
POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-29 ANION GAP-13
___ 01:20PM WBC-11.0* RBC-4.63 HGB-14.8 HCT-44.1 MCV-95
MCH-32.0 MCHC-33.6 RDW-13.5 RDWSD-46.5*
___ 01:20PM NEUTS-63.9 LYMPHS-9.3* MONOS-19.9* EOS-5.3
BASOS-0.4 IM ___ AbsNeut-7.06* AbsLymp-1.02* AbsMono-2.19*
AbsEos-0.58* AbsBaso-0.04
___ 01:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL
___ 01:20PM PLT SMR-LOW* PLT COUNT-135*
DISCHARGE LABS:
___ 12:56AM BLOOD WBC-8.5 RBC-4.02 Hgb-12.7 Hct-36.6 MCV-91
MCH-31.6 MCHC-34.7 RDW-13.0 RDWSD-42.5 Plt Ct-96*
___ 12:56AM BLOOD Plt Ct-96*
___ 12:56AM BLOOD Glucose-250* UreaN-15 Creat-0.8 Na-140
K-3.5 Cl-106 HCO3-23 AnGap-11
___ 12:56AM BLOOD ALT-20 AST-20 AlkPhos-55 TotBili-0.2
___ 12:56AM BLOOD Albumin-2.8* Calcium-7.7* Phos-2.6*
Mg-2.1
IMAGING:
CT a/p: IMPRESSION:
1. New retroperitoneal and mesenteric lymphadenopathy with
associated mild
mesenteric stranding. These findings are nonspecific, however
suspicious for
lymphoma.
2. No urolithiasis or hydronephrosis.
MICRO:
___ 4:54 pm URINE Site: NOT SPECIFIED
CHEM ___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
___ 1:09 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 4 mg PO DAILY
2. OLANZapine 5 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. amLODIPine 2.5 mg PO DAILY
6. metHOTREXate sodium 25 mg/mL injection 1X/WEEK
7. TraZODone 100 mg PO QHS
8. FoLIC Acid 1 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Ezetimibe 10 mg PO DAILY
11. Divalproex (EXTended Release) 1000 mg PO QHS
12. Levothyroxine Sodium 112 mcg PO DAILY
13. Cyanocobalamin 500 mcg PO DAILY
14. GlipiZIDE XL 10 mg PO DAILY
15. Omeprazole 20 mg PO BID
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY
18. NPH 25 Units Breakfast
NPH 18 Units Bedtime
Insulin SC Sliding Scale using aspart Insulin
19. Fluconazole 150 mg PO 1X/WEEK (WE)
20. Nystatin Ointment 1 Appl TP DAILY
21. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
3. Cyanocobalamin 500 mcg PO DAILY
4. Divalproex (EXTended Release) 1000 mg PO QHS
5. Ezetimibe 10 mg PO DAILY
6. Fluconazole 150 mg PO 1X/WEEK (WE)
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. GlipiZIDE XL 10 mg PO DAILY
10. NPH 25 Units Breakfast
NPH 18 Units Bedtime
Insulin SC Sliding Scale using aspart Insulin
11. Levothyroxine Sodium 112 mcg PO DAILY
12. metHOTREXate sodium 25 mg/mL injection 1X/WEEK (WE)
13. Nystatin Ointment 1 Appl TP DAILY
RX *nystatin 100,000 unit/gram apply small amount to affected
area daily Disp #*15 Gram Gram Refills:*0
14. OLANZapine 5 mg PO QHS
15. Omeprazole 20 mg PO BID
16. PredniSONE 4 mg PO DAILY
17. Simvastatin 20 mg PO QPM
18. TraZODone 100 mg PO QHS
19. HELD- amLODIPine 2.5 mg PO DAILY This medication was held.
Do not restart amLODIPine until you are told to do so by your
primary care doctor
20. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you are told to do so by your
primary care doctor
21. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you are told to do so by your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Polypharmacy
Secondary Diagnosis:
- Sarcoidosis
- Schizo-affective disorder
- Hypothyroidism
- GERD
- OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with new central line// please assess RIJ
placement Contact name: ___: ___ please assess RIJ
placement
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lung volumes have improved substantially and pulmonary vasculature no longer
looks as engorged. Mediastinal veins however are still distended, but there
is no other mediastinal widening.. Heart size top-normal. No appreciable
pleural effusion.
Right jugular line ends in the upper right atrium. \
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea, Fever
Diagnosed with Fever, unspecified, Altered mental status, unspecified, Diarrhea, unspecified
temperature: 98.2
heartrate: 106.0
resprate: 16.0
o2sat: 97.0
sbp: 122.0
dbp: 88.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ PMH schizo-affective disorder, sarcoidosis,
obesity and diabetes who presents to the ED with fevers and
hypotension. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, bilateral tubo-ovarian abscess
Major Surgical or Invasive Procedure:
___ drainage of abscess
History of Present Illness:
Ms. ___ is a ___ yo G2P0 who presents to the ED as a transfer
from ___ with bilateral TOAs seen on
imaging.
Patient reports that she developed lower abdominal cramping pain
and LLQ pain approximately 2 weeks ago. She thought this was the
start of her period and reports LMP ___. Menses were somewhat
abnormal for her as she reports usually the first ___ days are
heavy and painful, but this time she had spotting for first 4
days and then heavy and painful menses. She notes that she did
not have a period in ___, but had a normal one in ___.
Negative pregnancy test. When her pain worsened and did not
resolve, she presented to ___ ED where she
was diagnosed with a UTI and given ciprofloxacin x 3 days. They
then called her after she had finished the antibiotics and was
told that she needed to take macrobid for 7 days. She started
this medication, but the pain did not improve so she
re-presented to ___ on ___.
There she underwent CT ab/pel and pelvic ultrasound, which
revealed bilateral tubo-ovarian abscesses. She was then
transferred to ___ ED for GYN evaluation.
She currently reports that she has bilateral lower quadrant
pain, R > L with radiation down her legs bilaterally, again R >
L. She describes this pain as "crampy." She states that
previously she was "doubled over" with ___ pain, but she
received IV morphine at ___, which has improved her
pain significantly. She currently reports no pain, but some
discomfort in bilateral
lower quadrants. She also reports a feeling of fullness and
bloating. She has no vaginal bleeding since cessation of her
menses, but does report creamy, foul-smelling discharge. Denies
fevers, chills, CP, SOB. Reports decreased appetite, but denies
nausea/vomiting.
Past Medical History:
POB: G2P0
- TAB x 1 with D&C, 7 wk
- SAB x 1, early ___ tri
PGYN:
LMP ___
History of menorrhagia and dysmenorrhea
Currently sexually active with one male partner. No
contraception. Does not use condoms.
History of chlamydia ___ years ago, treated, but partner not
treated to her knowledge (different partner than current).
Normal Pap last year, denies h/o abnormal Paps.
PMH: denies
PSH: D&C
Social History:
smokes 7 cigarettes/day, drinks socially on the weekends (max 2
drinks at a time), smokes marijuana daily. She lives in ___
and is visiting her sister in ___ for the summer because
her living situation in ___ became too stressful. Denies
feeling depressed, "just stressed." She is currently not
working. Sexually active in a monogamous relationship. Does not
use contraception.
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding, incision
c/d/i
Ext: no TTP
Pertinent Results:
___ 01:00PM HBsAg-NEGATIVE
___ 01:00PM HIV Ab-NEGATIVE
___ 01:00PM HCV Ab-NEGATIVE
___ 03:25AM URINE UCG-NEGATIVE
___ 03:25AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 03:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 03:25AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-2
___ 03:15AM GLUCOSE-103* UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
___ 03:15AM CRP-37.0*
___ 03:15AM WBC-18.8* RBC-4.71 HGB-13.6 HCT-41.0 MCV-87
MCH-28.9 MCHC-33.3 RDW-13.5
___ 03:15AM NEUTS-78.8* LYMPHS-14.9* MONOS-5.2 EOS-0.7
BASOS-0.5
___ 03:15AM PLT COUNT-526*
___ 03:15AM ___ PTT-29.0 ___
Medications on Admission:
ibuprofen PRN for menstrual cramps
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
3. Clindamycin 450 mg PO Q6H
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth four times a
day Disp #*168 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral tubo-ovarian abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with bilateral TOAs // please evaluate b/l
TOAs for ___ drainage
TECHNIQUE: PELVIS, NON-OBSTETRIC
COMPARISON: Outside reference scans. Ultrasound and CT
FINDINGS:
Anteverted uterus is present at measures 6.7 x 2.6 x 4.0 cm. The endometrium
is normal. In the cul-de-sac a tubular collection is present with low level
echoes. In view of the patient's symptoms cyst thought to represent a
tubo-ovarian abscess. Both ovaries are normal.
Potential transvaginal drainage was made. NC approach is made through the
posterior fornix then close proximity to the tubo-ovarian abscess is possible.
These findings were discussed with the patient. Transvaginal drainage under
ultrasound guidance was a recommended in preference to a trans gluteal
approach under CT.
IMPRESSION:
Tubo-ovarian abscess in posterior cul-de-sac. Transvaginal approach for
drainage should be straight forward
Radiology Report
INDICATION: ___ year old woman presenting with abdominal pain and found to
have b/l ___ // please drain b/l ___
TECHNIQUE: US OVARIAN CYST DRAINAGE;VAG APPROACH
COMPARISON: PELVIC ULTRASOUND OF SAME DAY 40 STABILITY. CT AND ULTRASOUND
FROM ___.
FINDINGS:
Prior to Procedure a routine was it explained to the patient and potential
complications discussed. Written informed consent was obtained. A time-out
was taken. Conscious sedation was used throughout the procedure and the
patient's condition monitored by the attending nurse.
Patient was placed in lithotomy position. Procedure was performed under
aseptic conditions throughout. Vagina was cleansed and the posterior
cul-de-sac which offered the best opportunity for drainage was cleansed and
local anesthesia was applied . With direct ultrasound guidance a 20 gauge
long spinal needle was placed into the collection which was in a swollen tube.
Approximately 15 cc of pus was removed. The tube was irrigated on
approximately 5 occasions with saline until the returning fluid was clear.
Evaluation cough further abscesses was performed but nothing drainable could
be otherwise identified. Patient tolerated procedure well. A condition.
Will be monitored by the nursing staff and when appropriate sent back to the
floor.
The pus wassent away for culture
IMPRESSION:
Successful drainage of right tubo-ovarian abscess
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with FEM PELV INFLAM DIS NOS, SALPINGO-OOPHORITIS NOS
temperature: 96.4
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 112.0
dbp: 36.0
level of pain: 7
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology service
after presenting as a transfer from ___ with
bilateral tubo-ovarian abscess. She was started on IV gentamycin
and clindamycin for 48 hours. Her pain was initially controlled
with IV dilaudid and she was transitioned to PO tylenol, motrin
and oxycodone. She had ___ drainage of the the R tube on ___
and had ~15cc of purulent discharge. Please see the operative
report for full details.
Her pain was controlled wit PO tylenol, motrin and oxycodone.
Patient tested positive for gonorrhea and was counseled on how
it was important for her partner to also get treatment. On day
of discharge, she was transitioned to PO clindamycin 450mg QID
for ___y HD #2, she was tolerating a regular diet, ambulating
independently, and pain was controlled with oral medications.
She was then discharged home in stable condition with outpatient
follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Clavulanic Acid
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP ___:
A limited/partial cholangiogram was obtained due to the clinical
concern for cholangitis. No evidence of overt filling defects.
Gallbladder was opacified. No sphincterotomy done given patient
on Eliquis.
Stent placement: A 10 ___, 7 cm straight plastic biliary
stent was placed successfully.
Impressions: Successful ERCP with stent placement as described
above.
Recommendations: Repeat ERCP in 4 weeks for stent removal and
reevaluation.
History of Present Illness:
Mr. ___ is an ___ male with history of A. fib on
anticoagulation, peripheral vascular disease s/p bypass
graft ___ years ago, chronic kidney disease, who is transferred
from ___ with concern for cholangitis.
Patient states that he initially came to the hospital due to 2
weeks of weakness and difficulty with walking with cramps. Also
endorsed shoulder blade pain that lasted around ___s indigestion. He was concerned that he was having an MI, and
he
presented to the ED at ___. On presentation to
the Ed, he had elevated LFTs with an AST of 514, ALT of 564, and
a bilirubin of 3.54. Lipase is normal at 28. CT of the abdomen
and pelvis showed evidence of cholelithiasis. Also of note
showed a 1 cm hyperenhancing lesion in the right lobe of the
liver most likely representing a cavernous hemangioma. An
abdominal ultrasound showed gallbladder wall thickening and
submucosal edema with mobile gallstones measuring up to 4 mm.
Findings were concerning for acute cholecystitis. Given
patient's
multiple medical comorbidities, was felt that further evaluation
by advanced endoscopy was warranted. Therefore patient was
transferred to ___ for further workup and management.
Patient was seen in the ED of ___ by the surgery team
as well as the vascular surgery team given his lower extremity
weakness. He was felt by both teams been no immediate surgical
intervention.
Past Medical History:
- Paroxysmal AFib, on Eliquis and amiodarone.
- Peripheral vascular disease s/p Aortobifemoral bypass graft
approximately ___ years ago.
- Right bundle branch block.
- Hypertension.
- Hyperlipidemia.
- Chronic kidney disease (baseline creatinine seems to be
around 1.6 and 1.7).
- PTSD from ___ War.
PAST SURGICAL HISTORY:
1. Aortobifemoral bypass graft approximately ___ years ago.
2. Ventral incisional hernia repair.
3. Left hip replacement.
4. Excision of basal cell carcinoma from face.
Social History:
___
Family History:
Positive for hypertension and heart disease.
Physical Exam:
Discharge:
___ ___ Temp: 97.9 PO BP: 142/62 HR: 77 RR: 18 O2 sat: 95%
O2 delivery: Ra
GENERAL: NAD
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM.
GU: No suprapubic fullness or tenderness to palpation
SKIN: No rashes or ulcerations noted
Pertinent Results:
___ 09:30PM GLUCOSE-111* UREA N-26* CREAT-2.0* SODIUM-140
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16
___ 09:30PM ALT(SGPT)-333* AST(SGOT)-164* ALK PHOS-139*
TOT BILI-1.6*
___ 09:30PM CK-MB-5 cTropnT-0.07*
___ 09:30PM CALCIUM-8.2* PHOSPHATE-4.2 MAGNESIUM-1.6
___ 09:30PM WBC-9.3 RBC-3.40* HGB-11.5* HCT-34.8*
MCV-102* MCH-33.8* MCHC-33.0 RDW-14.8 RDWSD-55.8*
___ 09:30PM PLT COUNT-146*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. TraZODone 12.5 mg PO QHS:PRN insomnia
8. Aspirin 81 mg PO DAILY
9. Calcium Carbonate 500 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. melatonin 3 mg oral QHS
12. Multivitamins 1 TAB PO DAILY
13. Senna 8.6 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H cholangitis Duration: 6
Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth q8hours Disp #*18
Tablet Refills:*0
3. Amiodarone 100 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Calcitriol 0.25 mcg PO DAILY
8. Calcium Carbonate 500 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. melatonin 3 mg oral QHS
12. Multivitamins 1 TAB PO DAILY
13. Senna 8.6 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. TraZODone 12.5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Possible cholangitis, s/p ERCP with stent placement.
Lower extremity weakness and pain, history of peripheral
vascular disease.
Hypoxic respiratory distress, resolved.
Nocturnal hypoxia.
Troponemia, mild, no chest pain.
Atrial fibrillation, with history of stroke.
Hypertension.
Chronic kidney disease stage III.
Discharge Condition:
Alert and oriented. Ambulatory. Independent of ADLs.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with hypoxia/tachypnea// acute process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is subtle increase in opacity at the lateral left lung base may be due
to atelectasis, but infection is not excluded in the appropriate clinical
setting. No large pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are stable. Hilar contours are slightly more
prominent which may indicate central pulmonary vascular engorgement without
overt pulmonary edema.
IMPRESSION:
Subtle increase in opacity at the lateral left lung base could be due to
atelectasis or pneumonia.
Hilar contours are slightly more prominent, which may indicate central
pulmonary vascular engorgement, without overt pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.0
heartrate: 47.0
resprate: 27.0
o2sat: 91.0
sbp: 167.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | SUMMARY/ASSESSMENT: Mr. ___ is an ___ male with
history of A. fib on anticoagulation, peripheral vascular
disease status post bypass graft ___ years ago, chronic kidney
disease, who is transferred from ___ with concern for
cholangitis, now s/p ERCP with stent placement. Following the
procedure, patient developed acute shortness of breath requiring
nonrebreather briefly. He was given Lasix 20 mg IV once. He was
weaned from O2, however has required O2 at night while sleeping. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of IDDM1, hemorrhagic CVA ___ years ago and residual
aphasia and right ___ transferred from ___
for c/o urinary tract infection and hyperglycemia. History is
taken from records as patient is aphasic.
Per ED report, patient has been having fevers, abdominal pain
and vomiting today at her ___. She was
referred to ___ where u/a was grossly
positive, CT abd/pelv showed evidence of cystitis but no pyelo.
Cr 1.7. She had leukocystosis and a nitrite positive UA with WBC
TNTC. She was given vanc and zosyn as well as 2L IVF and sent
here.
In the ED, initial vital signs were 99.0 94 120/70 16 95% RA.
Infectious workup was initiated with CXR, UA, BCx. CT abd/pelvis
from ___ uploaded. Labs notable for WBC 15 with 86%
neutrophils, Cr 1.3 (baseline 1.1-1.6). Hemoglobin at baseline,
lactate normal.
On the floor, the patient is aphasic and unable to participate
in the history. She does sometimes nod yes or no to questioning
and says no to if she is having any pain. She does make
gestures to her right lower leg, however and seems to ask for
medications.
Review of Systems:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Diabetes Mellitus type 1 (dx at age ___, hx of hypoglycemic
episodes
CVA (hemorrhagic) at 27 with residual aphasia and Right
hemiparesis, tracheostomy post CVA now recannulated during
recent ___ admission
Blindness in one eye
History of aspiration pneumonia
Depression
Hyperthyroidism
Anemia ___ hct ___
HTN
Gastroparesis
LV dysfunction
C. diff
Social History:
___
Family History:
healthy brother/sister. Maternal family history of DM.
Physical Exam:
ADMISSION EXAM:
===============
Vitals- 97.9 124/77 hr 90 16 99% RA
___: awake, alert, aphasic but answers questions with
nodding
HEENT: left eye blind, right eye tracks, OMM no lesions
Neck: supple, no JVD, previously tracheostomy scar
CV: CTABL
Lungs: RRR, no m/r/g
Abdomen: soft, nontender, nondistended
GU: no foley
Ext: WWP, no c/c/e, hyperflexed RLE
Neuro: dense right hemiparesis, RUE and RLE spastic
Skin: stage 1 pressure ulcers on heels b/l
DISCHARGE EXAM:
===============
VS - 98.3 137/86 95 98%RA
___: awake, alert, aphasic but answers questions with
nodding
HEENT: left eye blind, right eye tracks, OMM no lesions
Neck: supple, no JVD, old tracheostomy scar
CV: RRR, no r/g/m (previously noted ___ systolic murmur LUSB not
appreciated this AM)
Lungs: CTA b/l
Abdomen: soft, nontender, nondistended
GU: no foley
Ext: WWP, no c/c/e, hyperflexed RLE
Neuro: dense right hemiparesis, RUE and RLE spastic, seen moving
___ & LL extremities
Skin: stage 1 pressure ulcers on heels b/l covered this AM
Pertinent Results:
ADMISSION LABS:
===============
___ 02:00PM PLT COUNT-237
___ 02:00PM NEUTS-85.8* LYMPHS-8.1* MONOS-5.2 EOS-0.4
BASOS-0.5
___ 02:00PM WBC-15.1*# RBC-3.63* HGB-10.7* HCT-32.6*
MCV-90 MCH-29.5 MCHC-32.9 RDW-12.9
___ 02:00PM estGFR-Using this
___ 02:00PM GLUCOSE-36* UREA N-12 CREAT-1.3* SODIUM-143
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-28 ANION GAP-10
___ 02:19PM LACTATE-1.1
DISCHARGE LABS:
===============
___ 07:50AM BLOOD WBC-5.8 RBC-3.64* Hgb-10.7* Hct-33.0*
MCV-91 MCH-29.3 MCHC-32.4 RDW-12.6 Plt ___
___ 07:50AM BLOOD Glucose-127* UreaN-16 Creat-1.3* Na-140
K-4.0 Cl-104 HCO3-28 AnGap-12
___ 07:50AM BLOOD Mg-1.8
MICROBIOLOGY:
=============
Urine Cx ___, ___:
*) Klebsiella:
-Resistant: Ampicillin
-Intermediate: Ampicillin/Sulbactam, Nitrofurantoin
-Sensitive: Amoxicillin/clavulanate, AztreonamCefazolin, CTX,
Cefepime, Cipro, Ertapenem, Gentamicin, Imipenem, Levaquin,
Bactrim
*) Proteus:
-Resistant: Cipro, Levaquin, Gentamicin, Nitrofurantoin, Bactrim
-Sensitive: Amoxicillin/clavulanate, Ampicillin,
Ampicillin/Sulbactam, Aztreonam, Cefazolin, CTX, Cefepime,
Ertapenem
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING:
========
___ Imaging CHEST (PORTABLE AP)
FINDINGS: As compared to the previous radiograph, the lung
volumes have
slightly increased, reflecting improved ventilation. Although
minimal
atelectasis might be present at the lung bases, there is no
clear sign of
pneumonia. No pleural effusion. Scoliosis with subsequent
asymmetry of the rib cage. Moderate cardiomegaly without
pulmonary edema. No pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 200 mg PO BID
2. Glargine 5 Units Breakfast
Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN severe pain
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Milk of Magnesia 30 mL PO DAILY:PRN constipation
6. Acetaminophen 650 mg PO Q6H:PRN pain/fever
7. Bisacodyl 10 mg PR HS:PRN constipation
8. Prochlorperazine 25 mg PR Q12H:PRN nausea/vomiting
9. Ferrous Sulfate 325 mg PO BID
10. Simvastatin 20 mg PO QHS
11. Docusate Sodium 100 mg PO BID
12. Baclofen 15 mg PO TID
13. Lorazepam 0.5 mg PO BID
14. Amlodipine 10 mg PO DAILY
15. Calcium Carbonate 500 mg PO DAILY
16. Sertraline 75 mg PO DAILY
17. Aspirin 81 mg PO DAILY
18. Ascorbic Acid ___ mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Baclofen 15 mg PO TID
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Glargine 5 Units Breakfast
Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Labetalol 200 mg PO BID
9. Lorazepam 0.5 mg PO BID
RX *lorazepam 0.5 mg 1 tablet by mouth twice a day Disp #*6
Tablet Refills:*0
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
12. Simvastatin 20 mg PO QHS
13. Sertraline 75 mg PO DAILY
14. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*30 Tablet Refills:*0
15. Acetaminophen 650 mg PO Q6H:PRN pain/fever
16. Ascorbic Acid ___ mg PO BID
17. Ferrous Sulfate 325 mg PO BID
18. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN severe pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*6 Tablet Refills:*0
19. Prochlorperazine 25 mg PR Q12H:PRN nausea/vomiting
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: UTI
Secondary: Type I Diabetes
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
CHEST RADIOGRAPH
INDICATION: Fever, rule out pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
slightly increased, reflecting improved ventilation. Although minimal
atelectasis might be present at the lung bases, there is no clear sign of
pneumonia. No pleural effusion. Scoliosis with subsequent asymmetry of the
rib cage. Moderate cardiomegaly without pulmonary edema. No pneumothorax.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Hyperglycemia, UROSEPSIS
Diagnosed with URIN TRACT INFECTION NOS, IDDM W SPEC MANIFESTATION
temperature: 99.0
heartrate: 94.0
resprate: 16.0
o2sat: 95.0
sbp: 120.0
dbp: 70.0
level of pain: 13
level of acuity: 3.0 | ___ w/ hx of IDDM1, hemorrhagic CVA ___ years ago and residual
aphasia and right ___ transferred from ___
for urinary tract infection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Demerol / Penicillins / red dye
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with HTN, HLD, T2DM, sarcoidosis who
initially presented to her PCP with fevers, cough, and difuse
body aches, found to have T101.2, O2 sat 86% and LLL rales now
admitted to ___ for LLL PNA. Patient transferred to MICU
overnight for tachycardia and hypoxia.
Patient notes that 4 days prior to presentation she developed a
non-productive cough. This progressively worsened and was
accompanied by subjective fevers, labored breathing at rest and
shortness of breath with exertion. Patient further reports
feeling dizzy while standing, decrease ___ appetite leading to
less po intake. Patient further endorses constipation for 4 days
with no BM, no abdominal pain or pain with urination. Patient
further denied any CP/palpitations/abdominal pain.
___ the ED, initial vitals: 103.1 121 135/71 28
- Labs notable for: WBC 12.6 and negative rapid flu test
- Imaging notable for: CXR showing LLL PNA
-Patient given 3L NS and levaquin 750mg
On the medical floor, patient was noted to be persistently
tachycardic with HR ___ 120s, also tachypneic with RR ___ ___.
She received an additional 1L LR and 1L NS. She was broadened to
vanc/cefepime. Subsequently on the early morning of ___, given
persistent tachypnea and report of feeling tired from breathing,
she was transferred to the MICU for tachycardia and hypoxia.
Patient notes that 4 days prior to presentation she developed a
non-productive cough. This progressively worsened and was
accompanied by subjective fevers, labored breathing at rest and
shortness of breath with exertion. Patient further reports
feeling dizzy while standing, decrease ___ appetite leading to
less po intake. Patient further endorses constipation for 4 days
with no BM, no abdominal pain or pain with urination. Patient
further denied any CP/palpitations/abdominal pain.
Past Medical History:
Sarcoidosis
HTN
HLD
T2DM
Social History:
___
Family History:
Mother Lung cancer
Father CAD
Son UC
Brother DM
Sister ___
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 102.6 156/72 126 38 94(4L)
GENERAL: Sitting upright, tachypneic, ___ moderate distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: LLL with inspiratory rhonchi, egophany
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No lesions.
NEURO: A&O x3
ACCESS: PIVs
DISCHARGE EXAM:
===============
VITALS: 97.9 134 / 83 94 20 92% ra
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: LLL with rhonchi. otherwise clear
CV: Regular tachycardia, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no cyanosis or clubbing
NEURO: A&O x3
Pertinent Results:
ADMISSION LABs:
===============
___ 11:20AM BLOOD WBC-12.6*# RBC-4.79 Hgb-11.5 Hct-37.7
MCV-79* MCH-24.0* MCHC-30.5* RDW-14.1 RDWSD-40.1 Plt ___
___ 11:20AM BLOOD Neuts-81.7* Lymphs-8.9* Monos-8.8
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.24*# AbsLymp-1.12*
AbsMono-1.11* AbsEos-0.00* AbsBaso-0.03
___ 11:20AM BLOOD Glucose-267* UreaN-12 Creat-1.1 Na-132*
K-4.6 Cl-95* HCO3-22 AnGap-20
___ 11:20AM BLOOD Calcium-8.9 Phos-2.4* Mg-1.7
___ 11:52AM BLOOD Lactate-2.5*
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-3.5* RBC-4.44 Hgb-10.9* Hct-34.8
MCV-78* MCH-24.5* MCHC-31.3* RDW-14.3 RDWSD-40.6 Plt ___
___ 07:10AM BLOOD Glucose-225* UreaN-12 Creat-0.7 Na-143
K-3.9 Cl-104 HCO3-25 AnGap-18
___ 07:10AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
PERTINENT LABS:
===============
___ 06:13AM BLOOD ___ Temp-37.3 Rates-/28 O2 Flow-4
pO2-58* pCO2-34* pH-7.41 calTCO2-22 Base XS--1 Intubat-NOT
INTUBA
___ 01:00AM BLOOD Lactate-1.7
___ 06:13AM BLOOD Lactate-0.9
___ 05:38AM BLOOD proBNP-210
MICRO
======
Test Result Reference
Range/Units
S. PNEUMONIAE ANTIGENS, Not Detected Not Detected
URINE
___ 10:12 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 11:44 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Final ___:
HEAVY GROWTH Commensal Respiratory Flora.
___ and ___ Blood Cx: NGTD
IMAGING
=======
___ CXR:
IMPRESSION:
1. Left lower lobe pneumonia with small left pleural effusion.
Followup
radiographs after treatment are recommended to ensure resolution
of these
findings.
2. Bibasilar subsegmental atelectasis.
___ CXR:
IMPRESSION:
Comparison to ___. Stable appearance of the left
lower lobe
pneumonia, but progression of the retrocardiac atelectasis.
Mild improvement of the atelectasis at the right lung basis. No
pleural effusions. Borderline size of the cardiac silhouette
without pulmonary edema.
___ CXR:
IMPRESSION:
Left lower lobe consolidation appears to be minimally improved
radiographically. Heart size and mediastinum are stable. No
appreciable
pleural effusion. No appreciable pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO EVERY OTHER DAY
2. Hydroxychloroquine Sulfate 200 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Pregabalin 300 mg PO BID
6. Ranitidine 150 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Januvia (sitaGLIPtin) 100 mg oral DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Diltiazem Extended-Release 360 mg PO DAILY
11. DULoxetine 90 mg ORAL DAILY
12. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 5 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
2. Aspirin 81 mg PO EVERY OTHER DAY
3. Diltiazem Extended-Release 360 mg PO DAILY
4. DULoxetine 90 mg ORAL DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Hydroxychloroquine Sulfate 200 mg PO BID
7. Januvia (sitaGLIPtin) 100 mg oral DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Pregabalin 300 mg PO BID
11. Ranitidine 150 mg PO BID
12. Vitamin D ___ UNIT PO DAILY
13. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until your PCP says it is OK
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Community acquired pneumonia
Hypoxemic respiratory failure
SECONDARY DIAGNOSES:
Hypertension
Sarcoidosis
Anemia
Type 2 Diabetes
Neuropathy
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 fevers, cough sent from clinic for T101.2,
tachycardia and possible left lower lobe rales, concern for pneumonia
TECHNIQUE: PA and lateral views of the chest provided.
COMPARISON: Chest radiograph ___
FINDINGS:
Focal opacification of the left lower lobe is concerning for pneumonia.
Linear opacities in the lingula and right lung base are compatible with areas
of subsegmental atelectasis. A small left pleural effusion is noted. The
cardiac and mediastinal contours are unchanged and the heart size within
normal limits. The pulmonary vasculature is not engorged. No pneumothorax is
present. There are no acute osseous abnormalities visualized.
IMPRESSION:
1. Left lower lobe pneumonia with small left pleural effusion. Followup
radiographs after treatment are recommended to ensure resolution of these
findings.
2. Bibasilar subsegmental atelectasis.
RECOMMENDATION(S):
Follow-up radiographs are recommended after treatment to ensure resolution of
these findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with LLL pneumonia with worsening hypoxia and
tachycardia // Please assess for interval change Please assess for
interval change
IMPRESSION:
Comparison to ___. Stable appearance of the left lower lobe
pneumonia, but progression of the retrocardiac atelectasis. Mild improvement
of the atelectasis at the right lung basis. No pleural effusions. Borderline
size of the cardiac silhouette without pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with LLL pneumonia with worsening hypoxia and
tachycardia // interval change? interval change?
IMPRESSION:
Left lower lobe consolidation appears to be minimally improved
radiographically. Heart size and mediastinum are stable. No appreciable
pleural effusion. No appreciable pneumothorax.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ILI
Diagnosed with Sepsis, unspecified organism, Pneumonia, unspecified organism
temperature: 103.1
heartrate: 121.0
resprate: 28.0
o2sat: 96.0
sbp: 135.0
dbp: 71.0
level of pain: 10
level of acuity: 2.0 | ___ with HTN, HLD, T2DM, sarcoidosis admitted to MICU for
fevers, cough, tachycardia and O2 Sat 86%, found to have LLL PNA
on CXR.
#Community acquired pneumonia: On admission on ___, patient
met ___ SIRS criteria with fever, tachycardia, and tachypnea
with suspected pneumonia c/w sepsis. s/p 4L IVF ___ MICU, BPs
were 120-140s and patient was mentating well. No risk factors
for HCAP, however, given worsening tachypnea and tachycardia,
the patient was broadened to vanc/cefepime ___, subsequently
to CTX/azithromycin ___ ___ the MICU. Final sputum culture
showed heavy growth of commensal flora, GPC ___ pairs on gram
stain, strep pneumo antigen negative, viral panel negative, and
flu negative. WBC count downtrended to 3.5 from 13 with O2 sats
>90% on RA after weaning from ___ of O2. She was discharged to
complete a 10-day course of ABX with Cefpodoxime 400mg BID.
#Tachycardia: Resolved on discharged (mostly ___ ___,
improved from 120s-130s ___ the days before. Likely secondary to
pneumonia and fever as detailed above.
#Anemia: Hypochromic and microcytic. Iron studies WNL. As she
has known pulmonary sarcoid, etiology may be secondary to anemia
of chronic disease. H/H stable (10.5-11.5). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
incontinence, acute renal failure, spinal cord compression,
progressive metastatic renal cell CA
Major Surgical or Invasive Procedure:
1.) Attempted PICC line placement in interventional radiology
History of Present Illness:
ATTENDING ADMISSION NOTE
Date: ___
Time: ___
___________________________________________________
PCP: ___. ONC: ___
.
CC: cord compression with incontinence, acute renal failure,
progressive metastatic RCC
__________________________________________________
HPI: ___ yo M with metastatic renal CA s/p IL-2 and Avastin,
Sunitinib with recent cord compression s/p T8 laminectomy and
radiation on ___ and C6 Corpectomy and C5-7, anterior fusion on
___, recent admission in ___ for pain control. He presented
to the ___ this evening, accompanied by his wife and family
friend with a chief complaint of decrease PO intake, abdominal
distention. He has been followed closely by the palliative care
service and recently reported new rib pain.
In ER: (Triage Vitals: 96.8 121 144/63 18 98% RA). ___ course
was significant for foley placement with 1L urine output.
consults called: code spine called-- seen by neurosurgery,
neurology, social work. Meds Given: morphine 5mg, lorazepam 4
mg, dexamethasone, ceftriaxone, Fluids given: 1L NS, Radiology
Studies: CT torso with progression of disease, MRI spine (very
limited study) suggestive of thoracic cord compression but given
the progression of disease on CT, he was deeemed not to be a
surgical candidate.
PAIN SCALE: unable to assess currently but appears comfortable
___________________________________________________
REVIEW OF SYSTEMS: patient sedated- unable to answer questions
Past Medical History:
- presented to ___ in ___ c/o abdominal pain and gross
hematuria. CT scan performed and showed a 14-cm tumor on his
left kidney.
- ___: underwent a radical left nephrectomy which showed a
14 x 14 x 10 cm tumor that was of clear cell type, firm and
nuclear grade ___. There was evidence of tumor thrombus
extending into a large muscular vein at the hilum of the
kidney. His left adrenal gland was removed and was negative for
tumor. ___ hilar lymph nodes, ___ paraaortic lymph nodes and a
small bowel lymph node obtained was negative for malignancy.
- ___: suffered a traumatic work-related fall (fell 25
feet off a ladder). Standard trauma x-rays and a nonenhanced CT,
showed the presence of new pulmonary nodules.
- ___ CT TORSO: innumerable pulmonary metastases, bulky
mediastinal lymphadenopathy.
- ___: FNA right upper lobe lung nodules showed malignant
cells consistent with metastatic clear cell carcinoma of the
kidney
___: Started on IL-2; received 10 out of 14 doses, first
week was complicated by encephalopathy and the second week was
complicated by renal failure, transaminitis and Staph
epidermitis bacteremia s/p Vancomycin
- ___ chest CT, no evidence of progression of metastatic
disease
- ___ CT TORSO: progression of disease
- ___: Started Avastin 10mg/kg q2 weeks; CT ___ showed
stable disease
- ___: Cyberknife to subcarinal mass; 2400 cGy in 3
fractions. Avastin on hold.
- ___: Restarted Avastin every 2 weeks.
- ___: Admitted for severe neck pain, MRI showed
degenerative disc disease. Avastin on hold.
- ___: CT with disease progression in lytic lesions, slight
progression of chest disease
- ___: Avastin resumed 10mg/kg q2 weeks.
- ___: Admitted to ___ with progressive disease
and worsening pain, started on Sunitinib on ___ at a dose of
37.5 mg daily for 4 weeks on, 2 weeks off.
- ___: started cycle 2 of Sunitinib
- ___: presented with RLE weakness and found to have cord
compression at T8; underwent laminectomy on ___. Admitted
___.
___ MRI: new mass lesion in the right petrous apex
and clivus in close proximity to the right sixth cranial nerve.
- ___: radiation to T5-T9, C2-T3, right clivus.
- ___: C6 Corpectomy and C5-7 anterior fusion
- ___: admitted, palliative care again involved in
pain mgmt
.
PAST MEDICAL HISTORY:
GERD
s/p appendectomy at age ___ 25ft fall; suffered bilateral calcaneal fractures,
bilateral tibial fractures, L2 fracture
s/p IVC filter
Depression
Anxiety
Social History:
___
Family History:
Mother had breast cancer but died of alcohol abuse. His brother
also has alcoholic liver disease.
Physical Exam:
#ADMISSION PHYSICAL EXAM:
Exam very limited by patient sedated
T 98.0 P ___ BP 114/69 RR 15 O2Sat 97% RA
GENERAL: sleeping comfortably, does not respond to verbal
stimuli, light touch
Neck: C-collar in place
Respiratory: Lungs CTA anteriorly
Cardiovascular: Reg, S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted.
Genitourinary: foley in place
ACCESS: [x]PIV
Per neurology/neurosurgery exam in ___, patient has myoclonus,
decreased tone in UE bilaterally, and increased tone in ___
bilaterally all consistent with
UMN pattern of weakness in ___
#DISCHARGE PHYSICAL EXAM:
VITALS not done, patient CMO.
GENERAL: sleeping comfortably, does not respond to verbal
stimuli, light touch
Neck: C-collar removed for comfort
Respiratory: Lungs with coarse breath sounds anteriorly, fine
crackles
Cardiovascular: Reg, S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted.
Genitourinary: foley in place
ACCESS: [x]PIV
Pertinent Results:
#ADMISSION LABS:
___ 03:20PM WBC-7.6 RBC-3.59* HGB-9.0* HCT-28.3* MCV-79*
MCH-25.0* MCHC-31.7 RDW-20.1*
___ 03:20PM NEUTS-79.4* LYMPHS-10.8* MONOS-8.9 EOS-0.6
BASOS-0.2
___ 03:20PM PLT SMR-NORMAL PLT COUNT-215
___ 03:20PM GLUCOSE-126* UREA N-41* CREAT-3.7*#
SODIUM-136 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23*
___ 03:20PM CALCIUM-10.3 PHOSPHATE-5.9*# MAGNESIUM-2.5
___ 03:32PM LACTATE-1.8
___ 04:28PM URINE HOURS-RANDOM CREAT-118 SODIUM-31
POTASSIUM-37 CHLORIDE-30
___ 04:28PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 04:28PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:28PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE
EPI-0
PERTINENT LABS:
___ 07:35AM BLOOD WBC-6.4 RBC-4.33* Hgb-11.3* Hct-34.5*
MCV-80* MCH-26.2* MCHC-32.9 RDW-19.4* Plt ___
___ 07:20AM BLOOD WBC-5.7# RBC-4.45* Hgb-11.6* Hct-36.2*
MCV-81* MCH-26.1* MCHC-32.1 RDW-19.4* Plt ___
___ 07:33AM BLOOD WBC-3.6* RBC-3.76* Hgb-10.0* Hct-30.1*
MCV-80* MCH-26.7* MCHC-33.3 RDW-18.9* Plt Ct-95*
___ 08:55AM BLOOD WBC-4.5 RBC-3.85* Hgb-10.3* Hct-31.5*
MCV-82 MCH-26.7* MCHC-32.7 RDW-18.2* Plt ___
___ 07:35AM BLOOD WBC-3.6* RBC-3.47*# Hgb-9.4*# Hct-28.1*#
MCV-81* MCH-27.0 MCHC-33.4 RDW-18.1* Plt ___
___ 08:00AM BLOOD WBC-2.9*# RBC-2.63*# Hgb-6.6*# Hct-20.5*#
MCV-78* MCH-25.1* MCHC-32.2 RDW-20.1* Plt Ct-91*#
___ 07:35AM BLOOD Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:33AM BLOOD Plt Ct-95*
___ 08:55AM BLOOD Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD ___ PTT-30.7 ___
___ 05:45PM BLOOD ___ PTT-29.1 ___
___ 08:00AM BLOOD Plt Smr-LOW Plt Ct-91*#
___ 07:20AM BLOOD Glucose-82 UreaN-10 Creat-0.8 Na-136
K-4.3 Cl-100 HCO3-23 AnGap-17
___ 07:33AM BLOOD Glucose-71 UreaN-13 Creat-0.8 Na-142
K-3.6 Cl-106 HCO3-23 AnGap-17
___ 08:55AM BLOOD Glucose-79 UreaN-17 Creat-1.0 Na-142
K-3.9 Cl-107 HCO3-24 AnGap-15
___ 07:35AM BLOOD Glucose-72 UreaN-25* Creat-1.2# Na-144
K-3.7 Cl-108 HCO3-28 AnGap-12
___ 08:00AM BLOOD Glucose-95 UreaN-38* Creat-2.5*# Na-143
K-4.0 Cl-107 HCO3-23 AnGap-17
___ 07:20AM BLOOD ALT-33 AST-639* AlkPhos-171* TotBili-0.5
___ 07:35AM BLOOD AlkPhos-97 TotBili-0.2
___ 05:45PM BLOOD LD(LDH)-905*
___ 07:20AM BLOOD Albumin-3.4* Calcium-9.9 Phos-2.4*
Mg-1.5*
___ 07:33AM BLOOD Calcium-9.3 Phos-2.3* Mg-1.8
___ 08:55AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.6
___:35AM BLOOD Calcium-8.9 Phos-2.8# Mg-1.9
___ 08:00AM BLOOD Calcium-8.7 Phos-5.1* Mg-2.3
___ 05:45PM BLOOD Hapto-253*
___ 03:32PM BLOOD Lactate-1.8
#MICROBIOLOGY/PATH:
___ 3:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:28 pm URINE Site: NOT SPECIFIED
CHEM # ___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
___ 1:35 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
#RADIOLOGY:
___ CT torso: (PRELIM!!!) 1. Since ___ and ___, there is significant interval progression of diffuse
metastatic disease including chest wall masses, mediastinal
lymphadenopathy and extensive bony metastases involving the
ribs,the shoulder, pelvic girdles, ribs, sternum and thoracic
and lumbar spine and proximal femurs. 2. Metastatic disease to
the sacral neural foramina likely explaining the patient's
urinary incontinence. 3. The innumerable pulmonary nodules have
slightly decreased. 4. Perivesical fat stranding, likely
inflammatory and possible due to cystitis.
___ MRI spine: (PRELIM!!!) Exam aborted due to agitated
patient. On the very limited provided sequences, extensive
metastatic disease, most pronounced at T2 and T11 with
encroachment on the spinal cord, and an unchanged fluid
collection at the thoracic laminectomy site are again seen.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Calcium Carbonate 500 mg PO BID
2. Clonazepam 0.5 mg PO TID
3. Afinitor *NF* (everolimus) 10 mg Oral daily
4. Dexamethasone Dose is Unknown PO Q8H
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 600 mg PO QAM, Q AFTERNOON
7. Gabapentin 900 mg PO HS
8. HYDROmorphone (Dilaudid) ___ mg PO Q2H:PRN pain
9. Levothyroxine Sodium 150 mcg PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Senna 2 TAB PO DAILY:PRN constipation
12. Sertraline 100 mg PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO MWF
14. Methadone 50 mg PO TID
Discharge Medications:
1. HYDROmorphone (Dilaudid) 3 mg/hr SC INFUSION INFUSION
PCA Dose: ___3mg______
Lockout Interval: 10 minutes 1 hour limit:__21mg/hr______
2. Dilaudid PCA
Dilaudid PCA - Subcutaneous Infusion
Concentration: 30mg/ml
PCA dose: 3mg
Lockout: 10minutes
Basal rate: 3mg/hr
Dispense: 200ml
3. dexamethasone *NF* 4mg [4mg/ml] Oral Q8H pain, chronic
steroid dosing
administer 1mL (ie- 4mg) every 8 hours
RX *dexamethasone 0.5 mg/5 mL 4mg [4mg/mL] by mouth every eight
(8) hours Disp ___ Milliliter Refills:*0
4. methadone *NF* 50mg [50mg/mL] sub lingual Q8H
administer 1mL (i.e.- 50mg) every 8 hours
5. dexamethasone *NF* 4mg [4mg/mL] Oral Q8H pain, chronic
steroid dosage Reason for Ordering: Wish to maintain
preadmission medication while hospitalized, as there is no
acceptable substitute drug product available on formulary.
administer 1mL (i.e. - 4mg) every 8 hours
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
spinal cord compression
Secondary Diagnosis:
Metastatic Renal Cell Carcinoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
MRI OF THE CERVICAL, THORACIC, AND LUMBAR SPINE
REASON FOR EXAM: ___ male with metastatic renal cell carcinoma,
presenting with urinary retention and fecal incontinence. Evaluate for cord
compression.
COMPARISON: MRI of the spine dated ___.
TECHNIQUE: Three-plane localizer images and attempted sagittal T2-weighted
images were acquired through the spine. However, the patient was unable to
tolerate the exam and it was terminated.
FINDINGS: Limited exam. There is again extensive metastatic disease, which
is most pronounced at the T11 level. There is interval increase in the
compression of the vertebral body at this level and further retropulsion of
material, bone, tumor, or both, in the spinal canal. These changes produce
spinal cord compression. The severity of cord compression is difficult to
evaluate on this limited study. Numerous other metastatic foci, including to
the right lung apex, several ribs, and numerous vertebral bodies are
visualized but not well evaluation. Fluid collection at the laminectomy site
is again seen.
IMPRESSION: Severely limited exam, which was terminated due to patient
agitation. Extensive metastatic disease is again visualized throughout the
spine and thorax.
Interval increase in retropulsed material and cord compression at T11. Study
interpretation as cord compression was confirmed in the neurology consult
note.
Radiology Report
INDICATION: ___ man with metastatic renal cell carcinoma and urinary
retention. Please assess for progression of disease.
TECHNIQUE: Contiguous MDCT images through the chest, abdomen and pelvis were
performed without intravenous or oral contrast. Multiplanar reformations
provided.
COMPARISON: CT of the torso from ___ and MRI of the C-, T-, and
L-spine from ___.
CT OF THE CHEST: Overall, there is a stable to minimally decreased size of
the pulmonary metastatic nodules since ___. There are no new pulmonary
nodules. However, there has been interval increase in the chest wall masses.
For example, there is a right apical mass (target lesion) which currently
measures 5.8 x 5.2 cm (S601b, 33), previously 4.0 x 3.0 cm.
There is no pericardial and no pleural effusion. There is a prominent
subcarinal lymph node which contains metallic clips.
CT OF THE ABDOMEN: Assessment of the multiple previously seen hypoattenuating
liver lesions is not possible without intravenous contrast. The gallbladder
is normal. The pancreas is atrophic. The spleen is normal. The patient is
status post left radical nephrectomy. The right kidney appears normal. There
is no intraperitoneal free air or free fluid. The stomach, small and large
bowel are normal. There is no significant atherosclerotic calcification of the
abdominal aorta. An infrarenal IVC filter is seen.
CT OF THE PELVIS: A Foley catheter is seen in the urinary bladder.
Perivesical fat stranding is seen, likely inflammatory and possible due to
cystitis. The seminal vesicles and prostate gland are normal.
BONES: There are multiple large chest wall and rib metastases, all of which
are progressed from the prior study. For example, a previously 4.2 x 2.9 cm
measuring posterior sixth rib mass has increased to 5.0 x 4.2 cm. There is
metastatic disease to the left scapula. There is a pathologic fracture of the
sternum, new from prior. Innumerable metastases are seen to the vertebral
bodies of the thoracic and lumbar spine with progression both since the torson
CT from ___ and since the total spine MRI from ___. A
reference lesion, at the T11 vertebral body has progressed, with the vertebral
body now completely collapsed due to a pathologic fracture - this is new since
___. There is a new T6 through T9 laminectomy. Large metastases are
seen at the pelvis, the largest involves the iliac crest on the left side with
a large associated soft tissue component with the entire complex measuring
about 13 x 7 cm, progressed from about 3.1 x 2.9 cm. Metastases are also seen
at the sacral ala involving the sacral neural foramina which has progressed
since the previous study from ___.
IMPRESSION:
1. Significant interval progression of metastatic disease burden in the chest
wall, spine and bony skeleton. Metastatic disease to the sacrum involving the
neural foramina likely accounts for the patient's symptom of urinary
incontinence.
2. Pulmonary nodules are stable to marginally decreased in size.
3. Perivesical fat stranding, likely due to cystitis.
4. New pathological sternal fracture.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: INCONTINENCE W/ BACK PAIN
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, RETENTION URINE UNSPECIFIED, SECONDARY MALIG NEO BONE, MYELOPATHY IN OTH DIS
temperature: 96.8
heartrate: 121.0
resprate: 18.0
o2sat: 98.0
sbp: 144.0
dbp: 63.0
level of pain: 9
level of acuity: 2.0 | []BRIEF CLINICAL HISTORY:
Assessment: ___ yo M with metastatic renal CA s/p IL-2 and
Avastin, Sunitinib with recent cord compression s/p T8
laminectomy and radiation,s/p C6 Corpectomy and C5-7, anterior
fusion on ___ now with progressive disease, thoracic cord
compression with urinary and fecal incontinence, urinary
retention, acute renal failure.
[]ISSUES:
#Home Hospice needs: Patient to go home with hospice for CMO
care. He is DNR/DNI/CMO. His only current PO meds are
dexamethasone, synthroid, and sertraline. There is a concern
for aspiration with pills, so his only critical med that needs
to be converted is dexamethasone; he has been taking long term
and we want to avoid adrenal crisis with abrubt cessation. The
hospice liason is working on a concentrated liquid formation of
dexamethasone. He will be sent home with dex and dilaudid and
methadone. Plan tentatively for dispo today or ___. The
IV nurse team and the interventional radiology teams both
attempted PICC placement and were unsuccessful. The plan is to
send him home with a subcutaneous PCA.
# metastatic RCC: progression of disease (particularly rib,
spine lesions, chest wall, mediastinum) despite everolimus and
with new cord lesions/pathologic fracture and cord compression,
functional status is likely to be very limited. The patient and
family was seen by palliative care during a family meeting where
Dr. ___ was present. They presented to the patient that the
only option is radiation therapy, chemo and surgery are no
longer viable options.
# spinal cord compression: His presentation and very limited
imaging is consistent with thoracic cord compression. Given his
progression of metastatic RCC elsewhere, he was deeemed not to
be a surgical candidate and he was admitted primarily for
palliation. Given his urinary retention, a foley was placed.
Patient will receive palliative XRT for stabilization of lower
thoracic spine lesion. He received his first dose of palliative
thoracic spine XRT on ___ with the plan for a ___ut
he refused further treatments after the ___ session. Patient
originally has need to be in hard cervical collar until after 3
months from his cervical operation (around ___ however, he
is now CMO and has it removed.
# Acute renal failure: resolved. initially pre-renal in
etiology.
Patient's Cr 0.8 on ___.
# Anemia: chronic, HCT 20.5 on morning after admission, down
from 28, likely ___ hemodilution. Improved s/p 2 units of blood
on admission, with Hct ~31.
# UTI: patient w/ ua initially that was suggestive of UTI.
Culture demonstrated staph aureus coag negative. All antibiotics
stopped on ___ once patient became CMO.
# Depression/anxiety: cont sertraline if patient tolerates PO.
# Hypothyroid: cont levothyroxine if patient tolerates PO.
# FEN: Regular diet if patient tolerates PO.
# PPX: PO diet
#CODE STATUS:
DNR/DNI/CMO
[]TRANSITIONAL ISSUES:
1.) Patient is CMO.
2.) Patient is taking steroids and must continue taking them as
prescribed. It there is a clinical indication to stop, he MUST
be slowly tapered off the steroids to prevent adrenal crisis.
3.) Patient may remove c-collar for comfort with the
understanding that his neck will be unstable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough, abdominal bloating
Major Surgical or Invasive Procedure:
Paracentesis x 2
History of Present Illness:
___ male patient with history of HIV positive (CD4 count
762, viral load 22) on Genvoya, presenting to the ED as a
referral from his primary care where he presented for evaluation
of persistent cough, abdominal bloating, frequency of stool and
change in urine stream.
His symptoms first began in the third week of ___ when he
developed a cough and shortness of breath. It was a dry cough.
His shortness of breath was worse with movement. He had a CXR on
___ which was negative but he was started on abx for
treatment of possible PNA. He completed 5 days of this but he is
not sure of the medication's name. ? Azithromycin. He continued
to feel poorly and re-presented on ___ at which time his
CXR did show PNA. He took 5 days of levaquin but still felt
poorly. 5 days prior to presentation he noticed abdominal
bloating. This prompted him to go to his PCP's office who
referred him to the ED.
He has had decreased volumes of urine since his abdominal
bloating began. He does not reports dysuria. He think he has
gained 15 lbs. He has some shortness of breath when laying flat
but this slowly resolves when laying down. It hurts to lay on
his
back. He has not had fevers or chills. No sick contacts.
No rashes or changes in his skin. He has not noticed a change in
his cough or breathing. He has a cat. He does not have nausea or
vomiting.
Pt reports 15 pound weight gain in past 2 weeks but per PCP it
was 8 lbs.
In ER: (Triage Vitals:0 |100.0 |124 |153/89 |17 |97% RA )
Meds Given: None
Fluids given: None
Radiology Studies: CXR/RUQ/CT- torso
Consults called: None
.
PAIN SCALE: ___
______________________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [+]DOE
CARDIAC: [-] chest tightness
GI: [ +] frequent small firm stools
GU: [+] Per HPI
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:
Prostate cancer- s/p brachytherapy in ___
HIV
Vasculitis- pt does not recognize this diagnosis and denies ever
being treated for this
Chronic pain
Amphetamine abuse now sober for 2 months
Avoidant personality disorder
Dysthymia
H/o primary VZV, h/o reactivation in around ___
Social History:
___
Family History:
Mother died at ___ from "natural causes". She did not go to the
doctor very often. Father ___ alive and well. One of his 8
siblings died but he is not sure of the cause.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.6 PO 142 / 89 105 18 96 Ra
CONS: NAD, comfortable appearing
HEENT: ncat anicteric MMM
CV: s1s2, tachy, rrr no m/r/g
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
++ Distended abdomen
MSK:no c/c/e 2+pulses
GU: No foley
SKIN: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
DISCHARGE EXAM:
Gen - Sitting in chair by bedside. NAD. Able to walk around with
ease
Eyes - EOMI, PERRL
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normal bowel sounds , minimally distended
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION LABS
--------------
___ 07:10AM BLOOD WBC-11.1* RBC-5.03 Hgb-14.3 Hct-44.5
MCV-89 MCH-28.4 MCHC-32.1 RDW-17.7* RDWSD-55.8* Plt ___
___ 03:00PM BLOOD WBC-10.8* RBC-4.94 Hgb-14.3 Hct-44.3
MCV-90 MCH-28.9 MCHC-32.3 RDW-17.3* RDWSD-55.3* Plt ___
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD Glucose-84 UreaN-13 Creat-0.9 Na-136
K-4.5 Cl-97 HCO3-27 AnGap-12
___ 07:10AM BLOOD ALT-91* AST-108* AlkPhos-233*
TotBili-1.7*
___ 03:00PM BLOOD ALT-84* AST-133* AlkPhos-188* TotBili-1.2
___ 07:00AM BLOOD calTIBC-211* Ferritn-313 TRF-162*
___ 03:00PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 03:00PM BLOOD Smooth-NEGATIVE
___ 07:00AM BLOOD AFP-2.3
___ 03:00PM BLOOD ___
___ 03:00PM BLOOD PEP-BASED ON I IgG-1335 IgA-193 IgM-72
IFE-NO MONOCLO
___ 03:00PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 03:00PM BLOOD HCV Ab-NEG
___ 07:00AM BLOOD QUANTIFERON-TB GOLD-PND
IMAGING
-------
CXR ___:
PA and lateral views of the chest provided. Lung volumes are
low with
bibasilar atelectasis noted. No large effusion or pneumothorax.
No overt
signs of pneumonia or edema. Heart size difficult to assess.
Mediastinal
contour is normal. Bony structures are intact.
CT torso ___:
1. Attenuated right portal vein and anterior and posterior
branches of the
right portal vein suggestive of right portal vein thrombosis.
2. Moderate volume ascites.
3. Interval progression of splenomegaly measuring up to 21 cm in
craniocaudal length. Wedge shaped heterogeneity in the upper
and lower splenic poles are thought to reflect infarcts. there
is no lymphadenopathy.
4. Centrilobular and ___ opacities in the periphery of
the upper lobes bilaterally are nonspecific and can be seen in
the context of
infectious/inflammatory bronchiolitis.
RUQ ultrasound ___:
1. No evidence of biliary pathology.
2. 2.4 cm echogenic right hepatic lesion corresponds to area of
hypodensity seen on prior CTA aorta study from ___, and likely represents a hemangioma. This could be
confirmed on multiphase CT or MRI.
3. Splenomegaly, spleen measures 22.2 cm. Moderate ascites.
TTE ___:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional/global systolic
function. Indeterminate diastolic parameters to assess diastolic
function. Trivial aortic regurgitation.
EGD ___:
Normal duodenum
Varices in the distal esophagus
Congestion, petechiae, and mosaic mucosal pattern in the stomach
fundus and stomach body compatible with portal hypertensive
gastropathy
Paracentesis ___:
1. Technically successful ultrasound guided therapeutic
paracentesis.
2. 4.75 L of fluid were removed.
MICROBIOLOGY
------------
___ 9:05 am PERITONEAL FLUID PERITONEAL FLUID.
ADDON ACID FAST CULTURE & SMEAR, FUNGAL CULTURE PER
___
(___) ___ ___.
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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST CULTURE (Pending):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 11:30 am SPUTUM Site: INDUCED Source: Induced.
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 CLIA standards.
.
Test done at ___ Mycobacteriology
Laboratory..
Time Taken Not Noted Log-In Date/Time: ___ 7:16 am
SPUTUM INDUCED.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
MTB Direct Amplification (Final ___:
CANCELLED. PATIENT CREDITED.
Specimen received less than 7 days from previous
testing.
___ 12:50 pm SPUTUM INDUCED.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Final ___:
CANCELLED. PATIENT CREDITED.
Specimen received less than 7 days from previous
testing.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Blood culture x 2: NGTD
DISCHARGE LABS
--------------
WBC: 15.6
Hgb: 15.1
Plt: 266
127 | 92 | 13
---------------< 92
5.2 | 25 | 1
ALT
106 --> 122 --> 128 --> 130 --> 179 --> 158 --> 143 --> 150
AST
118 --> 132 --> 146 --> 153 --> 214 --> 186 --> 148 --> 155
Alk Phos:
304 --> 335
Bili
2.2
Reports - Reviewed
MRCP ___. No evidence of biliary obstruction. No discrete hepatic
mass.
Marked splenomegaly. Stable moderate ascites.
2. Stable thrombosis involving the right portal vein and its
branches. Thrombosis involving the middle and right hepatic
veins with possible extension into the suprahepatic IVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN
2. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 2 tablet(s) by mouth twice a day
Disp #*50 Tablet Refills:*0
2. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral DAILY
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Portal vein thrombosis: Budd Chiari Syndrome
Hyponatermia: Due to water-pills
Bronchiolitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with SOB, weight gain// eval for pleural effusion/PNA
COMPARISON: Prior from ___
FINDINGS:
PA and lateral views of the chest provided. Lung volumes are low with
bibasilar atelectasis noted. No large effusion or pneumothorax. No overt
signs of pneumonia or edema. Heart size difficult to assess. Mediastinal
contour is normal. Bony structures are intact.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with transamnitis// eval for biliary pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CTA aorta from ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. A 1.9 x 1.8 x 2.4 cm echogenic lesion in the right lobe
corresponds to area of hypodensity seen on prior CTA aorta study from ___, and likely represents a hemangioma. There is no new focal
liver mass. The main portal vein is patent with hepatopetal flow. There is
moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Spleen is enlarged, measuring 22.2 cm.
KIDNEYS: Limited views of the right and left kidneys show no hydronephrosis.
The right kidney measures 12.6 cm in length and the left kidney measures 14.0
cm in length.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No evidence of biliary pathology.
2. 2.4 cm echogenic right hepatic lesion corresponds to area of hypodensity
seen on prior CTA aorta study from ___, and likely represents a
hemangioma. This could be confirmed on multiphase CT or MRI.
3. Splenomegaly, spleen measures 22.2 cm. Moderate ascites.
Radiology Report
EXAMINATION: CT chest, abdomen and pelvis
INDICATION: History: ___ with large volume ascites over last 5 days.//
Neoplastic process? Cause for massive ascites with no liver disease?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the chest, 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 7.5 s, 0.5 cm; CTDIvol = 63.2 mGy (Body) DLP =
31.6 mGy-cm.
2) Spiral Acquisition 8.8 s, 69.6 cm; CTDIvol = 22.6 mGy (Body) DLP =
1,573.4 mGy-cm.
3) Spiral Acquisition 1.2 s, 9.1 cm; CTDIvol = 19.3 mGy (Body) DLP = 176.1
mGy-cm.
Total DLP (Body) = 1,781 mGy-cm.
COMPARISON: Ultrasound dated ___ and CT dated ___
FINDINGS:
CHEST:
LOWER NECK: The thyroid gland is partially included in the field of view.
Dystrophic calcifications are noted in the inferior aspect of the left thyroid
lobe.
AIRWAYS/LUNGS:
The airways are patent to the subsegmental level.
Note is made of scattered centrilobular and ___ opacities in the
periphery of the upper lobes bilaterally. There is no focal airspace
consolidation. Areas of subsegmental atelectasis are noted in the right
middle lobe, lingula and bilateral lung bases.
PLEURA: There is trace bilateral pleural effusions.
LYMPH NODES and MEDIASTINUM: No pathologically enlarged mediastinal, hilar, or
axillary lymph nodes.
HEART and VASCULATURE: The heart is not enlarged. No pericardial effusion.
CHEST WALL: unremarkable
BONES: No aggressive bony lesions.
ABDOMEN:
HEPATOBILIARY:
There is no morphologic evidence of cirrhosis. There is slight heterogeneous
appearance of the right hepatic lobe which appears attenuated compared to the
left lobe. The right portal vein is attenuated and appears to contain
heterogeneous internal filling defects (series 2, image 54). The anterior and
posterior branches of the right portal vein are also attenuated and not well
visualized. The left portal vein and main portal vein are adequately
opacified and patent.
Previously noted lesion in segment 8 is less clearly seen on the current
examination (series 2, image 39) but corresponds to an echogenic lesion seen
on the most recent ultrasound and likely represents a hepatic hemangioma.
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 significantly enlarged measuring 21 cm in craniocaudal
length, previously 17 cm. Wedge shaped heterogeneity in the upper and lower
splenic poles are thought to reflect infarcts.
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.
Subcentimeter cortical hypodensity in the lower right kidney is too small to
characterize. There is no hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is moderate volume ascites.
REPRODUCTIVE ORGANS: Brachytherapy seeds are again noted in the prostate.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted.
Attenuated right portal vein as well as anterior and posterior branches of the
right portal vein as described above concerning for portal vein thrombosis.
There are no filling defects within the left and main portal vein. The
splenic vein is patent. SMV is suboptimally opacified by contrast.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Attenuated right portal vein and anterior and posterior branches of the
right portal vein suggestive of right portal vein thrombosis.
2. Moderate volume ascites.
3. Interval progression of splenomegaly measuring up to 21 cm in craniocaudal
length. Wedge shaped heterogeneity in the upper and lower splenic poles are
thought to reflect infarcts. there is no lymphadenopathy.
4. Centrilobular and ___ opacities in the periphery of the upper lobes
bilaterally are nonspecific and can be seen in the context of
infectious/inflammatory bronchiolitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:50 pm, 10 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with splenomegaly, splenic infarcts, ascites and
low grade temp.// Please evaluate for SBP and etiology of ascites.
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 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 3.06 L of clear, straw-colored fluid were removed. Fluid
samples were submitted to the laboratory for chemistry, cell count,
differential, culture, and cytology.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3.06 L of fluid were removed.
Radiology Report
INDICATION: ___ year old man with new ascites, portal vein thrombosis// Please
perform large-volume paracentesis, therapeutic
TECHNIQUE: Ultrasound guided therapeutic paracentesis
COMPARISON: Paracentesis ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 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 4.75 L of clear, straw-colored fluid were removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
IMPRESSION:
1. Technically successful ultrasound guided therapeutic paracentesis.
2. 4.75 L of fluid were removed.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with LFT abnormalities, ascites, portal vein
thrombosis// Please eval for HIV cholangiopathy, other gall bladder/bile duct
abnormalities
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT ABDOMEN AND PELVIS FROM ___
FINDINGS:
Lower thorax: Partially imaged lung bases show subsegmental atelectasis and
small pleural effusions.
Liver: Liver demonstrates normal parenchymal morphology. There is no evidence
of hepatic steatosis. Few areas of arterial hyper enhancement with no
definite correlate on the portal venous phase likely represent transient
hepatic intensity defects. Air chain 80 postcontrast with relative
___ of the right hepatic lobe is likely secondary to portal vein
and hepatic vein thrombus (described below) the. No suspicious liver lesion
seen. There is moderate ascites.
Biliary: The gallbladder is normally distended without evidence of wall
thickening. No intra or extrahepatic biliary dilatation.
Pancreas: Pancreas shows homogeneous signal intensity and enhancement. No
evidence of pancreatic ductal dilatation or focal masses.
Spleen: Markedly enlarged measuring 19.6 cm without evidence of focal lesions.
2.6 cm accessory spleen seen near the splenic hilum.
Adrenal Glands: Normal size and shape bilaterally.
Kidneys: Both kidneys are normal in size and show symmetric enhancement. Few
small T2 hyperintense nonenhancing lesions in bilateral cortices are in
keeping with simple cysts. No suspicious renal mass identified. There is no
hydronephrosis.
Gastrointestinal Tract: The stomach and visualized bowel loops are within
normal limits.
Lymph Nodes: No retroperitoneal or mesenteric lymphadenopathy.
Vasculature: No evidence of abdominal aortic aneurysm. Conventional aortic
branches patent. Again seen is the non opacification of the right portal vein
and its branches. Filling defects are also seen involving the right and
middle hepatic veins with possible extension into the IVC (series 1703 image
86).
Osseous and Soft Tissue Structures: No abnormal marrow signal. No soft tissue
abnormality.
IMPRESSION:
1. No evidence of biliary obstruction. No discrete hepatic mass. Marked
splenomegaly. Stable moderate ascites.
2. Stable thrombosis involving the right portal vein and its branches.
Thrombosis involving the middle and right hepatic veins with possible
extension into the suprahepatic IVC.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Other ascites
temperature: 100.0
heartrate: 124.0
resprate: 17.0
o2sat: 97.0
sbp: 153.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with well controlled HIV on Genvoya who
presented on ___ with two months of cough, shortness of
breath not improved with two courses of antibiotics along with
ascites. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Compazine
Attending: ___.
Chief Complaint:
back pain and numbness and tingling in thighs
Major Surgical or Invasive Procedure:
LAMINECTOMY T3-T7 with Dural Repair on ___ with Dr. ___
___ of Present Illness:
___ who has had 1 month of mid back pain and 2 weeks of
tingling/numbness in her thighs and a belt like ring around the
abdomen at the level of the umbilicus. During these two weeks,
she's also noted some weakness in her legs with them giving out
on her from time to time requiring the use of a cane for
ambulation. She was seen by her PCP today for this issue and
sent to neurology her at ___. Ultimately, she was sent to the
ER for further evaluation and likely admission. On arrival, she
reports the same issues as above. Denies fevers or chills.
Denies bladder or bowel dysfunction. She denies prior spine
issues or surgeries apart from some numbness/tingling in the
upper extremities for which she's been treated on gabapentin
with good relief.
Past Medical History:
HLD, hypothyroid; gallbladder removal.
Social History:
lives alone in ___ retired. Non-smoker, no alcohol, no
drug use.
Physical Exam:
PHYSICAL EXAMINATION:
General: NAD, AOx3; responds to questions appropriately, appears
comfortable.
Vitals: see OMR; VSS
Spine exam:
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 3 5 5 5 5
R 5 ___ ___ 5 4 5 5 5 5
- Patient displays ___ weakness in hip flexion on L and ___ hip
flexion on R
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl*
* with the exception of T10 around the abdomen - belt like with
diminished sensation to light touch
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
Pertinent Results:
___ 06:44AM BLOOD WBC-6.2 RBC-2.84* Hgb-8.2* Hct-25.2*
MCV-89 MCH-28.9 MCHC-32.5 RDW-13.6 RDWSD-44.3 Plt ___
___ 05:54AM BLOOD WBC-7.9 RBC-3.29* Hgb-9.6* Hct-29.0*
MCV-88 MCH-29.2 MCHC-33.1 RDW-13.6 RDWSD-43.9 Plt ___
___ 04:55PM BLOOD WBC-6.1 RBC-3.78* Hgb-11.0* Hct-32.9*
MCV-87 MCH-29.1 MCHC-33.4 RDW-13.8 RDWSD-43.8 Plt ___
___ 04:55PM BLOOD Neuts-59.7 Lymphs-18.9* Monos-9.0
Eos-11.4* Baso-0.5 Im ___ AbsNeut-3.67 AbsLymp-1.16*
AbsMono-0.55 AbsEos-0.70* AbsBaso-0.03
___ 06:44AM BLOOD Plt ___
___ 05:54AM BLOOD Plt ___
___ 04:55PM BLOOD Plt ___
___ 04:55PM BLOOD ___ PTT-31.9 ___
___ 06:44AM BLOOD Glucose-99 UreaN-11 Creat-0.5 Na-141
K-3.8 Cl-106 HCO3-22 AnGap-17
___ 05:54AM BLOOD Glucose-118* UreaN-16 Creat-0.6 Na-142
K-4.8 Cl-108 HCO3-26 AnGap-13
___ 04:55PM BLOOD Glucose-121* UreaN-14 Creat-0.6 Na-144
K-4.3 Cl-108 HCO3-25 AnGap-15
___ 05:54AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9
___ 01:56AM BLOOD CRP-5.4*
___ 02:47PM BLOOD WBC-6.7 RBC-2.88* Hgb-8.4* Hct-25.0*
MCV-87 MCH-29.2 MCHC-33.6 RDW-13.1 RDWSD-41.3 Plt ___
___ 02:47PM BLOOD Plt ___
___ 02:47PM BLOOD Glucose-113* UreaN-13 Creat-0.4 Na-137
K-4.5 Cl-100 HCO3-26 AnGap-16
___ 02:47PM BLOOD Calcium-8.6 Phos-3.5 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Gabapentin 300 mg PO BID
3. Levothyroxine Sodium 175 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Diazepam 5 mg PO BID:PRN pain/ spasm
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Gabapentin 300 mg PO BID
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Thoracic spinal canal mass, extradural.
2. Progressive thoracic spinal cord injury.
3. Thoracic spinal cord compression.
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: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: *** CODE CORD *** History: ___ with T3-T7 phlegmon, spine is
requesting a C spine MRI as wellIV contrast to be given at radiologist
discretion as clinically needed// eval for any phlegmon, e/o cord compression
eval for any phlegmon, e/o cord compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: MRI thoracic and lumbar spine with without contrast (MRI: Cord
compression) ___.
FINDINGS:
Cervical alignment is anatomic. Vertebral body heights are preserved. There
is no suspicious marrow lesion of the cervical spine. Known upper to mid
thoracic epidural mass contiguous with a right prevertebral component
resulting in compression of the thoracic cord is better described prior MRI
thoracic and lumbar spine of the same day. Degenerative loss of disc height
and signal is mild at C5-C6 and C6-C7.
The visualized posterior fossa is unremarkable. There is no abnormal signal
of the cervical cord.
C2-C3 through C4-C5: There is no significant spinal canal or neural foraminal
narrowing.
C5-C6: A right central protrusion minimally narrows the spinal canal.
Uncovertebral facet arthropathy results in mild bilateral neural foraminal
narrowing.
C6-C7: A central protrusion with intervertebral osteophytes results in mild
spinal canal narrowing. Uncovertebral and facet arthropathy results in no
significant neural foraminal narrowing.
C7-T1: Unremarkable.
The visualized prevertebral and paraspinal soft tissues demonstrates no gross
abnormality.
IMPRESSION:
1. No evidence of mass lesion or infectious process of the cervical spine. No
cervical cord signal abnormality.
2. Minimal degenerative changes most prominent at C5-C6 where there is mild
spinal canal narrowing and neural foraminal narrowing.
3. Please refer to separate report of same day thoracic and lumbar spine MRI
for additional details regarding a thoracic epidural mass lesion compressing
the thoracic cord with prevertebral components.
Radiology Report
INDICATION: T3-T7 laminectomy
COMPARISON: Chest radiograph from ___
IMPRESSION:
Two lateral views of the thoracolumbar spine have been submitted for
dictation. On the second image, there is a posterior marker at the level of a
mid thoracic vertebral body, possibly T8; however localizing landmarks are
difficult to ascertain. No significant compression deformities are seen.
Please refer to the operative note for additional details.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: ___ year old woman with thoracic spine mass s/p laminectomy T3-6//
Alignment post op Alignment post op
IMPRESSION:
Three views of the postoperative chest show physiologic alignment of the
thoracolumbar spine after surgery.
Mild pulmonary edema is present.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, Leg weakness
Diagnosed with Weakness
temperature: 98.1
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 126.0
dbp: 81.0
level of pain: 5
level of acuity: 3.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.Hospital course was otherwise unremarkable.On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old man with atrial fibrillation on
warfarin, CKD stage III, and multiple myeloma who is presenting
with lower extremity weakness.
The patient shares that today before dinner time he got up and
felt his legs were weak and could not support him. He fell back
on the couch. He shares he also generally feels weak, but
emphasizes that it was his legs that gave out. He did not feel
lightheaded or dizzy. He has had no fevers, and felt chills two
nights ago. He said he had cough once, and attributed it to a
tickle in his throat. He does say that over the past few days he
has felt short of breath with exertion.
In the ED, initial VS were: 99.9 90 150/80 18 98% RA. Exam in
the
ED not documented. Labs were notable for Hb 8.7, WBC 8.6,
platelet 159, Cr 1.9 (baseline 1.6), K 5.4, Na 136, glucose 112,
lactate 1.4, flue negative. CXR showed left posterior opacity
concerning for pneumonia in the correct clinical setting. EKG
was
paced with no signs of ischemia. He was given ceftriaxone and
azithromycin.
On arrival to the floor, patient reports the above. He says he
feels fine, but wants to know why he feels weak. He feels his
urination is normal, as are his bowel movements. He has no back
pain and no groin numbness or tingling. He is not currently on
chemotherapy for myeloma, and has not been on it for over a
year.
His daughter adds that about three weeks ago he had the flu and
diarrhea. He was treated at his facility and did not require
hospitalization. She said he took a while to recover from that,
and is just getting back to normal. She also says that he often
will not drink as much water as he should, and has suffered from
dehydration before.
Past Medical History:
· HTN
· Mult. myeloma ___ IgG kappa, active but stable no
chemo presently ___ ___ ___
· Peripheral neuropathy secondary to chemo
· Cataracts?
· Prostate CA-
· Hernia
· ___ months.
· Esophageal Tear r/t hemoptysis
· Gait d/o
· Hyperlipidemia
· MOCA ___ and same score ___, ___ ___
___, Mini Cog ___ word recall and clock okay ___ ___
___
· Burn and abrasion
· Afib and carotid stenosis Dr ___ normal non
ischemic pharmacological stress test
· basal cell nodular ca left temple-final excision by ___ at
___ ___ and squamous cell CA
· PPM ___ dR ___ bradycardia/ HAS
DEFIBRILLATOR
· Left eye clot (?retinal vein), getting steroid injections
· Chronic panick attacks (on Xanax)
· diverticulosis and has had frequent low grade diverticultitis
(doing better ___ GI Dr ___
· ___ HYPERTROPHIC CARDIOMYOPATHY, mod LVH, marked ___
___ noted
· Moderate dilated ascending aorta 4.4cm ___
· HISTORY OF BLADDER CANCER; negative on ___ surveillance with
dr ___
___ History:
___
Family History:
Significant for CAD in his dad; cancer in mother
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.0 159/84 59 18 95 Ra
GENERAL: NAD, lying in bed, pale
HEENT: pale mucosa
NECK: no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: LLL with rales, breathing comfortably on room air with no
accessory muscle use, no coughing noted while in the room
ABDOMEN: nondistended, large 7x7 hernia to left of umbilicus -
nontender and reducible. nontender abdomen
EXTREMITIES: 1+ ankle edema bilaterally, BLE warm
NEURO: A&Ox3, BLE ___ at quads/hamstrings, ___ plantar and
dorsiflexion
RECTAL: rectal tone intact, dried stool in underwear
DISCHARGE PHYSICAL EXAM
VS: Temp: 98.1 PO BP: 127/68 HR: 65 RR: 18 O2 sat: 96% O2
delivery: RA
GENERAL: NAD, lying in bed
HEENT: pale mucosa
NECK: no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: LLL with rales, breathing comfortably on room air with no
accessory muscle use
ABDOMEN: nondistended, large hernia to left of umbilicus -
nontender and reducible. nontender abdomen
EXTREMITIES: 1+ ankle edema bilaterally, BLE warm
NEURO: A&Ox3, able to lift both legs against gravity
Pertinent Results:
ADMISSION LABS
--------------
___ 08:17PM BLOOD WBC-8.6 RBC-3.08* Hgb-8.7* Hct-27.6*
MCV-90 MCH-28.2 MCHC-31.5* RDW-20.3* RDWSD-66.1* Plt ___
___ 08:17PM BLOOD ___ PTT-34.9 ___
___ 08:17PM BLOOD Glucose-112* UreaN-30* Creat-1.9* Na-136
K-5.4 Cl-100 HCO3-21* AnGap-15
DISCHARGE LABS
--------------
___ 08:00AM BLOOD WBC-6.3 RBC-2.99* Hgb-8.5* Hct-27.3*
MCV-91 MCH-28.4 MCHC-31.1* RDW-20.4* RDWSD-67.7* Plt ___
___ 08:00AM BLOOD ___ PTT-36.1 ___
___ 08:00AM BLOOD Glucose-82 UreaN-28* Creat-1.7* Na-138
K-3.9 Cl-103 HC___ AnGap-12
CXR ___
Mild obscuration of the left hemidiaphragm with posterior
opacity on lateral view which could represent LLL pneumonia in
the appropriate clinical setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Senna 8.6 mg PO BID:PRN Constipation - First Line
3. azelastine 0.15 % (205.5 mcg) nasal BID
4. Mirtazapine 7.5 mg PO QHS
5. Fenofibrate 134 mg PO DAILY WITH MEAL
6. Warfarin 1.5 mg PO DAILY16
7. Triamterene-HCTZ (37.5/25) 1 CAP PO 3X/WEEK (___)
8. Carvedilol 100 mg PO BID
9. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 3 Doses
2. Cefpodoxime Proxetil 400 mg PO Q12H
3. Polyethylene Glycol 17 g PO DAILY
4. Carvedilol 50 mg PO BID
5. ___ MD to order daily dose PO DAILY16
6. azelastine 0.15 % (205.5 mcg) nasal BID
7. Fenofibrate 134 mg PO DAILY WITH MEAL
8. Ferrous Sulfate 325 mg PO DAILY
9. Mirtazapine 7.5 mg PO QHS
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Simvastatin 40 mg PO QPM
12. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO 3X/WEEK (___)
This medication was held. Do not restart Triamterene-HCTZ
(37.5/25) until you are instructed to restart it by your doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
pneumonia
neuropathy
dehydration
acute on chronic kidney failure
Secondary:
hypertension
atrial fibrillation
history of complete heart block s/p pacemaker
history of GI bleed
history of bladder cancer
multiple myeloma
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 weakness, malaise// r/o infx process
COMPARISON: Multiple chest radiographs the most recent dated ___.
FINDINGS:
PA and lateral views of the chest provided.
There is re-demonstration of a right pectoral pacemaker with the single lead
terminating over the expected position of the right ventricle, unchanged from
prior.
The left hemidiaphragm is slightly obscured which may correlate with posterior
opacity demonstrated on lateral projection and could represent pneumonia in
the appropriate clinical setting. There is no effusion, or pneumothorax. The
heart is mildly enlarged. The mediastinal contour stable. Imaged osseous
structures are intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
Mild obscuration of the left hemidiaphragm with posterior opacity on lateral
view which could represent LLL pneumonia in the appropriate clinical setting.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fatigue, Weakness
Diagnosed with Pneumonia, unspecified organism, Weakness, Chronic kidney disease, unspecified
temperature: 99.9
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 150.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is an ___ year old man with recent history of flu 3
weeks ago and diarrhea, a background history of atrial
fibrillation on warfarin, CKD stage III, and multiple myeloma
who presented with weakness, found to have pneumonia and
dehydration.
#Neuropathy
#Weakness
Patient seems to have gradually been experiencing weakness over
the past few days, with worsening weakness with attempting to
stand on day of admission. On exam, his legs are strong and
rectal tone is intact, so unlikely spinal process. His ___
"weakness" likely ___ neuropathy from MM treatment (patient has
numbness, tingling and impaired sensation from the shins
downwards) iso recent diarrhea prior to admission, pneumonia,
and dehydration from not drinking much fluid at home. Blood and
sputum cultures did not grow any bacteria. ___ and OT were
consulted and recommended discharge to rehab. Given vague
symptoms, his beta blocker dose was reduced as well.
#LLL pneumonia
CXR showed LLL opacity c/f pneumonia. No signs of respiratory
distress; however, infection likely contributed to his weakness
as noted above. Flu negative currently, but reportedly positive
3 weeks ago. He was started on ceftriaxone/azithromycin, day 1
___ -> switched to cefpodoxime + azithromycin and should
continue for a 5 day course (-___)
#Normocytic Anemia
___ be insufficient synthesis given multiple myeloma. Iron
studies suggest component of iron deficiency anemia (low Tsat).
This can be followed up as an outpatient. Patient does not
remember date of last colonoscopy.
#HTN
Takes carvedilol 100mg BID and triamterene-HCTZ MWF at home.
Carvedilol was decreased to 50mg BID, since high doses of BB can
cause weakness and fatigue. His home triamterene-HCTZ was
stopped in setting of normotension.
___ on Stage III CKD
Baseline creatinine 1.6-1.7 increased to 1.9. Improved with
fluids
#Atrial fibrillation
CHADS2VASC=3. S/p PPM for complete heart block in ___.
Discharge INR 3.1. Continue to adjust dosing in setting of
antibiotics.
#Multiple myeloma
Patient says has not been treated with chemotherapy for over a
year per his choice given prior side effects. He obtained care
at ___ however, he had refused further chemotherapy
given side effects.
TRANSITIONAL ISSUES
------------------- |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pravastatin / Fenofibrate / lisinopril / oxybutinin
Attending: ___
Chief Complaint:
Dyspnea, NSTEMI
Major Surgical or Invasive Procedure:
Coronary Angiography and Right heart catheterization
History of Present Illness:
Ms. ___ is an ___ year old woman, with prior history of aortic
stenosis s/p bioprosthetic AVR in ___, CAS s/p CABG (LIMA to
LAD) in ___, ___ type II s/p PPM, IDDM, HTN, HLD, who
initially presented on ___ to orthopedics for a mechanical
fall, found to have a left IT femoral fracture, underwent
intertronchancteric femoral nailing, now presenting with
increased dyspnea. Patient being admitted to ___ service for
management of effusions, NSTEMI management.
Patient reports that about 5 days prior to her admission,
patient was found to have increased dyspnea. She currently is at
rehab center at ___ after discharge from
her surgical intervention for left femoral IT fracture, however
given increasing dyspnea, patient was then transferred to ___
___ for further evaluation. Patient was initially evaluated
for PE with CTA, which was negative. Patient was on lovenox
prophylaxis after her hip fracture, however initial O2 sats were
noted to be in the ___. Patient was not having any increased
chest pain. Post operatively, it was demonstrated that patient
had increased her weight. Per family, her weight was 121 lbs pre
surgery, and then in rehab went as high as 135 lbs. Her lower
extremity edema was somewhat intermittently improved, however
still notable. During her stay at rehab, patient was also having
worsening nausea/vomiting, and did have several episodes of
biliary emesis.
Patient was initially seen at ___. CTA was notable for no
pericardial effusion, moderate pleural effusions bilaterall, L >
R, and cardiomegaly with coronary artery calcifications. Her
pacer was also in place. Reportedly, patient also underwent a
bedside echo which showed "marked wall motion abnormalities, and
elevated pressures". Her BNP was found to be elevated, and she
was given Lasix prior to transfer to ___. Patient was found to
have positive troponin to 0.101, no chest pain. She was given 20
mg IV Lasix, 162 aspirin, 1 gram vanco, 1 gram cefepime.
Notably, patient was discharged on ___ from the orthopedics
service after let hip IT nailing. Discharge summary was not
notable for any specific intraoperative or postoperative
complications, and patient was discharged on enoxaparin 30 mg
daily, oxycodone 2.5-5 mg daily for plan for lovenox x 4 weeks.
During hospital stay, cardiology was consulted for risk
stratification. As noted in OMR, patient has been progressively
followed for worsening aortic stenosis, and at that time her
symptoms were well controlled. She was noted to have extensive
cardiac history, however at that time no evidence of
decompensated CHF, and therefore recommended to continue
aspirin, metoprolol, losartan for cardiac medications. Hospital
course also complicated with hyperglycemia for which ___
consulted, and insulin management. PPM was also interrogated at
that time, which showed normal pacer function, and no
programming changes. 100% ventricular pacing, with < 1% of
Atrial pacing.
In the ED initial vitals were: 0 98.6 93 115/73 22 99% Nasal
Cannula
Upon transfer, vitals: 0 88 108/47 25 100% Nasal Cannula
EKG: V-paced.
Labs/studies notable for: Hgb 10.3, Hct 34.5, Sodium 135, K
6.5, BUN 98, Bicarb 19, BUN 26, Cr 0.9. Glucose 188. Trop-T:
0.11. MB 5, CK 91, Ca 8.7, Mg 1.7, Phosph 4.1. INR 1.1.
Repeat K: 6.3.
Patient was given:
___ 14:00 PO Aspirin 162 mg
___ 14:59 IV Heparin 3400 Units
___ 14:59 IV Heparin
REVIEW OF SYSTEMS:
Per HPI
Past Medical History:
CARDIAC HISTORY:
1. Aortic stenosis, status post aortic valve replacement with a
21-mm ___ tissue valve on ___.
2. Coronary artery disease status post bypass graft with a LIMA
to the LAD at the time of her aortic valve replacement.
3. Mobitz II AVB s/p pacemaker ___
Other Past Medical History:
IDDM
Hypertension
Hyperlipidemia
H/o colon cancer
Osteoporosis
Rectal Cancer ___ s/p low anterior resection and adjuvant
chemotherapy
Seborrheic Keratosis
PAST SURGICAL HISTORY:
CABG and AVR (see above) ___
Rectal Cancer s/p low anterior resection ___
Appendectomy
Social History:
___
Family History:
2 siblings with CABG
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 98.1 114/68 90 60 100% on 3L.
Patient is on 3L of O2. No tachypnea noted at this time.
Conversing well.
General: Patient has supple, no cervical lymphadenopathy. Her
JVD mildly elevated, JVP 9 cm.
Cardiac: S1, Firm S2, diastolic murmur, non radiating. Loudest
in left upper sternal border.
Lungs: There is crackles in the bilateral bases. No other
adventitial sounds heard.
Abdomen: Soft, non tender, non distended. There is no
hepatomegaly appreciated.
Extremities: There is 2+ pitting lower extremity edema, L > R.
2+ ___ pulses.
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.1, 135/170, 89, 20, sat 97 on ra
___ Wt 52kg <- 53.5
General: well appearing, sitting comfortably in bed
HEENT: oral mucosa moist
Cardiac: S1, Firm S2, low systolic murmur, non radiating.
Loudest in left upper sternal border.
Lungs: mild R base crackles clear w/ inspiration, non-labored
breathing
Abdomen: Soft, non tender, non distended.
Extremities: trace nonpitting edema bilaterally
Pertinent Results:
ADMISSION LABS
====================
___ 02:14PM BLOOD WBC-8.3# RBC-3.38* Hgb-10.3* Hct-34.5#
MCV-102* MCH-30.5 MCHC-29.9* RDW-18.6* RDWSD-70.2* Plt ___
___ 02:14PM BLOOD Neuts-78.3* Lymphs-12.5* Monos-8.0
Eos-0.1* Baso-0.5 Im ___ AbsNeut-6.48* AbsLymp-1.03*
AbsMono-0.66 AbsEos-0.01* AbsBaso-0.04
___ 02:14PM BLOOD ___ PTT-27.6 ___
___ 02:14PM BLOOD Glucose-188* UreaN-26* Creat-0.9 Na-135
K-6.5* Cl-98 HCO3-19* AnGap-25*
___ 02:14PM BLOOD CK-MB-5 ___
___ 02:14PM BLOOD cTropnT-0.11*
___ 09:09PM BLOOD CK-MB-5 cTropnT-0.13*
___ 03:57AM BLOOD CK-MB-4 cTropnT-0.12*
___ 02:14PM BLOOD Calcium-8.7 Phos-4.1 Mg-1.7
___ 11:40PM URINE Color-Straw Appear-Clear Sp ___
___ 11:40PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:40PM URINE RBC-59* WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT/DISCHARGE LABS
=========================
___ 07:58AM BLOOD WBC-4.5 RBC-3.17* Hgb-9.7* Hct-31.5*
MCV-99* MCH-30.6 MCHC-30.8* RDW-18.0* RDWSD-66.1* Plt ___
___ 06:35AM BLOOD Glucose-57* UreaN-22* Creat-0.9 Na-140
K-3.9 Cl-99 HCO3-25 AnGap-20
___ 06:35AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.9
___ 05:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
IMAGING/REPORTS
=========================
UNILAT LOWER EXT VEINS LEFT Study Date of ___ 6:50 ___
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 FEMUR (AP & LAT) LEFT Study Date of ___
7:28 ___
FINDINGS: AP pelvis and AP and lateral views of the left femur
were provided. 2 clips are noted in the lower pelvis. The bony
pelvic ring appears intact. The SI joints appear grossly
symmetric. The right hip aligns normally with mild loss of
right hip joint space and mild acetabular spurring. There is a
left femoral IM rod with a gamma nail traversing the
intertrochanteric fracture of the left femoral neck. Alignment
is near anatomic. No signs of hardware failure. Vascular
calcification noted. Mild degenerative changes at the left knee
noted. No definite joint effusion at the left knee.
IMPRESSION: Left hip fracture status post ORIF with near
anatomic alignment and no signs of hardware failure.
Portable TTE (Complete) Done ___ at 4:22:36 ___
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. LV
systolic function appears mildly-to-moderately depressed (LVEF =
40%) secondary to extensive apical hypokinesis and
pacing-induced dyssynchrony. The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated
with focal hypokinesis of the apical free wall. A bioprosthetic
aortic valve prosthesis is present. The prosthetic aortic valve
leaflets are thickened. The transaortic gradient is higher than
expected for this type of prosthesis. The mitral valve leaflets
are mildly thickened. There is severe mitral annular
calcification. There is moderate functional mitral stenosis
(mean gradient 10 mmHg) due to mitral annular calcification.
Moderate to severe (3+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. [Due to acoustic shadowing, the severity
of tricuspid regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
left ventricular ejection fraction is reduced; mitral
regurgitation and tricuspid regurgitation are increased; mitral
stenosis now moderate.
___ Cardiovascular C.CATH
Impressions:
1. Severe native three vessel coronary artery disease (worst in
the LAD and RCA).
2. Patent LIMA onto a severely diseased heavily calcified LAD.
3. Significant bioprosthetic aortic valve stenosis with
echocardiographic evidence of AVR regurgitation.
4. Labile filling pressures, with marked rise in mean PCW and PA
pressures between baseline and post angiographic reassessment,
with moderate left ventricular diastolic heart failure and
moderate-severe pulmonary hypertension measured after LIMA
angiography.
5. No hemodynamic evidence of significant anatomic mitral
stenosis given equalization of LVEDP and PCW at end diastole,
with most of the transmitral (mean) gradient of 14 mm Hg (with
calculated MVA 1.0 cm2)driven by the V wave.
Recommendations
1. Routine post-TR Band care.
2. RFA and RBV sheaths to be removed in Holding Area.
3. Consult Cardiac Surgery and Structural Heart Team regarding
redo CABG+AVR vs. valve-in-valve TAVR with option for post-TAVR
PCI of the LAD and/or RCA.
4. Reinforce secondary preventative measures against CAD,
NSTEMI, and diastolic heart failure.
CXR ___
In comparison to ___, mild cardiomegaly is
accompanied by a new
pulmonary vascular congestion and minimal interstitial edema as
well as small bilateral pleural effusions. No definite focal
areas of consolidation are identified to suggest acute
pneumonia, but follow-up radiographs after diuresis may be
helpful for more complete assessment of the lungs if clinical
suspicion persists. Compression deformity at the T8 vertebral
body level is similar to prior CT of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Losartan Potassium 25 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H
6. Calcium Carbonate 500 mg PO QID:PRN heart burn
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 30 mg SC Q24H
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID:PRN constipation
14. Glargine 32 Units Breakfast
Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Furosemide 40 mg PO DAILY
Please start on ___. Metoprolol Tartrate 25 mg PO BID
4. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
To be completed on ___. Glargine 32 Units Breakfast
Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Acetaminophen 650 mg PO Q6H
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
10. Calcium Carbonate 500 mg PO QID:PRN heart burn
11. Docusate Sodium 100 mg PO BID
12. Losartan Potassium 25 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
Please start this medication on ___. Omeprazole 20 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Aortic Stenosis
SECONDARY DIAGNOSIS: Acute diastolic CHF exacerbation, NSTEMI,
Diabetes
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: ___ year old woman with L femur fx
COMPARISON: Prior exam is dated ___
FINDINGS:
AP pelvis and AP and lateral views of the left femur were provided. 2 clips
are noted in the lower pelvis. The bony pelvic ring appears intact. The SI
joints appear grossly symmetric. The right hip aligns normally with mild loss
of right hip joint space and mild acetabular spurring. There is a left
femoral IM rod with a gamma nail traversing the intertrochanteric fracture of
the left femoral neck. Alignment is near anatomic. No signs of hardware
failure. Vascular calcification noted. Mild degenerative changes at the left
knee noted. No definite joint effusion at the left knee.
IMPRESSION:
Left hip fracture status post ORIF with near anatomic alignment and no signs
of hardware failure.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with LLE swelling > RLL. recent hip surgery //?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 (PA AND LAT)
INDICATION: ___ h/o of aortic stenosis s/p bioprosthetic AVR in ___, CAS s/p
CABG (LIMA to LAD) in ___, Mobitz type II s/p PPM, IDDM, HTN, HLD, now
presenting with increased dyspnea and elevated cardiac enzymes, concerning for
NSTEMI with decompensated CHF now with cough and vomiting episode //
evaluation for PNA
IMPRESSION:
In comparison to ___, mild cardiomegaly is accompanied by a new
pulmonary vascular congestion and minimal interstitial edema as well as small
bilateral pleural effusions. No definite focal areas of consolidation are
identified to suggest acute pneumonia, but follow-up radiographs after
diuresis may be helpful for more complete assessment of the lungs if clinical
suspicion persists. Compression deformity at the T8 vertebral body level is
similar to prior CT of ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, NSTEMI, Transfer
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Heart failure, unspecified
temperature: 98.6
heartrate: 93.0
resprate: 22.0
o2sat: 99.0
sbp: 115.0
dbp: 73.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ year old woman, with prior history of aortic
stenosis s/p bioprosthetic AVR in ___, CAS s/p CABG (LIMA to
LAD) in ___, ___ type II s/p PPM, IDDM, HTN, HLD, now
presenting with increased dyspnea and elevated cardiac enzymes,
concerning for NSTEMI with decompensated CHF and concerning
aortic valve stenosis of artificial valve.
#Aortic Valve Stenosis/Acute diastolic CHF exacerbation: Patient
presented with new SOB, pulmonary edema, ___ edema and elevated
proBNP. It was suspected that she had an exacerbation in the
setting of possible new NSTEMI and worsening aortic stenosis and
aortic insufficiency. The cardiac surgery team was consulted and
deemed that the patient was high risk for surgery. TAVR team was
consulted and patient will need outpatient work up. The patient
was diursed with 20mg of IV Lasix and put out well. She was
switched to PO Lasix 20mg daily. However had CXR that showed
pulmonary edema on ___. She was given 20mg BID on ___ and
will be increased to Lasix 40mg daily on ___. She was
continued on metoprolol tartrate 25mg BID and will need to be
switched to ___. Patient was restarted on losartan on day of
discharge.
# NSTEMI: patient presented with elevated troponin and new
hypokinesis concerning for NSTEMI. She may have had a
perioperative event or a missed event post operatively. She
underwent cardiac catheterization that showed significant
disease but no interveneable lesion (see attached report).
Recommended continued medical management. She was continued on
ASA, atorvastatin and metoprolol.
# Left Femoral IT fracture: Patient now s/p IT nailing, ortho
consulted in ED and patients fracture and repair were stable.
Recommended continuing lovenox and outpatient follow up. Lovenox
40mg daily for DVT prophylaxis in setting of recent procedure.
Will complete 4 weeks of therapy post initial hospital discharge
on ___. Follow up with ortho as outpatient.
#Cough- patient reported cough after having episode of nausea
and vomiting. Repeat CXR showed pulmonary edema and vascular
congestion. No evidence of pneumonia.
# Hematuria: per family, has intermittent hematuria, noted to
have elevated RBC on initial UA, however on repeat UA hematuria
had resolved. Will need outpatient work up.
#Nausea/Vomiting: Limited x1 likely in setting of constipation.
Has had this happen prior per family. Abdomen was distended not
no rebound. She had two bowel movements her symptoms resolved.
Continue bowel regimen at rehab.
# IDDM: Controlled, HgbA1c 6.2%. Patient having low blood sugars
after limited nausea and vomiting x1. Blood sugars down to ___
on AM of ___, AM lantus decreased form 32 to 20U. If blood
sugars increasing can titrate back to home dose of insulin.
# GERD: Continued omeprazole 20 mg daily
# T8 Vertebral Compression: without fracture, previously known.
Will need outpatient follow up.
# Glaucoma: stable. Continued on brimonidine 0.15% BID both
eyes
# Macrocytic Anemia: Patient with new MCV 102, likely
concentrated in the setting of other previous MCV normal.
Patient will need outpatient work up.
# CODE: Full
# CONTACT: ___ ___ daughter, HCP, ___
___
TRANSITIONAL ISSUES
=====================
-patient will need cardiology follow up and outpatient TAVR
evaluation
-check chem 7 ___ to evaluate electrolytes and kidney
function
-PO Lasix increased to 40mg on ___ as CXR showed pulmonary
edema, recheck lytes and if elevated Cr consider dropping down
to 20mg daily
- lovenox to be continued for 30 days post orthopedics
operation, to be completed on on ___ (4 weeks after prior
discharge per orthopedic recs)
- blood sugars decreased on day of discharge likely in setting
of limited PO intake from nausea. Symptoms improved and appetite
increasing. Lantus decreased to 20U qAM. Consider increasing
lantus back to home regimen of 32UqAM or 6UqPM.
- give dose of metoprolol tartrate 25mg on ___ at ___ and
switch to metoprolol succinate 50mg daily at ___
- further work up of macrocytic anemia
- follow up for stable T8 vertebral compression
- further work up of intermittent hematuria, will need urology
follow up
- discharge weight 52.8kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
aspirin / ibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug)
Attending: ___.
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
CEA - ___
History of Present Illness:
The patient is a ___ yo RH M with PMHx MI ___ s/p CABG
(___), T2DM (insulin-dependent), HTN, HLD and OSA who was
transferred to ___ ED ___ after presenting to an OSH with RUE
numbness and weakness. He received tPA (infusion completed at
22:30) at the OSH.
Pt reports having an acute onset of R arm numbness and weakness
around 20:00. He had drank ~6 beers and was singing karaoke when
symptoms occurred. He also had slurred speech but attributed
this
to drinking.
His wife was with him and brought his to the OSH ED. At the ED,
he had an unremarkable NCHCT and was administered IV tPA
(infusion completed at 22:30) and transferred to ___ for
further management.
At the time of my assessment, he reports worsening RUE weakness
and resolution of RUE numbness. He reports a mild word finding
difficulty but no issues with speech comprehension.
On neurologic review of systems, the patient chronic gait
instability due to R foot drop. Pt denies headache or
lightheadedness. Denies loss of vision, blurred vision,
diplopia,
vertigo, tinnitus, hearing difficulty, or dysphagia. Denies
bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
MI ___ s/p CABG (___)
T2DM, insulin-dependent
HTN
HLD
OSA
Right foot drop
Appendectomy
Rotator cuff surgery (___)
Hearing loss (L>R)
Social History:
___
Family History:
+heart disease. No family history of stroke or neurologic
disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: Afebrile 83 141/88 18
General: NAD, obese
HEENT: NCAT, no oropharyngeal lesions
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Skin: Chronic skin changes in ___ B/L
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Inattentive and recalls a tangential history. Speech is
fluent without paraphasic errors. Intact repetition and verbal
comprehension. Content of speech demonstrates decreased naming
of
low frequency objects (cannot name hammock or cactus on stroke
cards). Normal prosody. Mild dysarthria. No apraxia. No evidence
of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. Slight R NLFF but activates symmetrically. Palate
elevation symmetric. SCM strength ___ bilaterally. Tongue
midline.
- Motor - Normal bulk and tone. No drift in LUE. No tremor or
asterixis in LUE.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 4+ 5
R 1 ___ 4+ 3 4+ 5 5 5 0 5
- Sensory - No deficits to light touch or pin bilaterally in the
upper extremities. Decr sensation to pinprick in lower
extremities in a stocking distribution.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally on the L. Unable to assess on the R ___ weakness.
HTS
intact in B/L ___.
- Gait - Deferred.
PHYSICAL EXAM ON DISCHARGE
alert and oriented x3
PERRL
Motor - Normal bulk and tone. No drift in LUE.
Delt Bic Tri Grip IP Quad Ham AT ___
L 5 5 5 ___ ___ 5
R 3 4 4 ___ 5 0 0 5
incision- c/d/i, steri strips
Pertinent Results:
RELEVANT LABS
STUDIES
CTA Head and Neck
No intracranial hemorrhage. No intracranial arterial occlusion,
dissection, or aneurysm. Severe stenosis of the Left internal
carotid artery 1 cm above the carotid are artery bifurcation.
Mild to moderate stenosis of the right internal carotid artery
at
the same level.
.
MRI Brain
1. Acute infarction centered within the left frontal cortex,
extending to the pre and postcentral gyrus and the centrum
semiovale corresponding to the MCA territory. No evidence of
hemorrhagic conversion.
2. Paranasal sinus disease as described.
The distribution and appearance of the multiple strokes were
consistent with watershed territory infarct.
.
Echocardiogram ___
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. 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. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
.
Carotid ultrasound ___
Right ICA less than 40% stenosis
Left ICA 60-69% stenosis
___
1. Expected post left endarterectomy changes with interval
resolution of left carotid bulb atheroma and stenosis. No
evidence of complication.
2. Infarct at the left frontal cortex and posterior left centrum
semi ovale, better characterized on prior MR of the head. No
___ acute intracranial abnormality.
3. Atherosclerosis and luminal stenosis at the right carotid
bulb measuring less than 50 percent by NASCET criteria.
4. Atherosclerosis with in the bilateral vertebral artery
origins.
5. Patent intracranial and neck vasculature without evidence of
thrombosis or dissection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Humalog ___ 74 Units Breakfast
Humalog ___ 74 Units Dinner
2. Amlodipine 10 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Glargine 32 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Lisinopril 40 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Clopidogrel 75 mg PO DAILY
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. Docusate Sodium 100 mg PO BID
9. Ezetimibe 10 mg PO DAILY
10. GlipiZIDE 10 mg PO DAILY
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Glucose Gel 15 g PO PRN hypoglycemia protocol
13. Heparin 5000 UNIT SC TID
14. HydrALAzine 10 mg IV Q6H:PRN SBP>160
15. Amlodipine 10 mg PO DAILY
16. Hydrochlorothiazide 25 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left MCA stroke
Left Carotid Stenosis
Diabetes
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 neck WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ year old man s/p L CEA with word finding difficulties and new
profound right sided weakness // evaluate for ich versus 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: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 55.8 mGy (Head) DLP =
1,003.4 mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
5) Spiral Acquisition 5.6 s, 44.2 cm; CTDIvol = 35.5 mGy (Head) DLP =
1,569.4 mGy-cm.
Total DLP (Head) = 2,603 mGy-cm.
COMPARISON: ___ noncontrast head MRI.
___ noncontrast head CT.
___ contrast-enhanced head and neck CTA.
___ noncontrast head CT.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is loss of gray-white matter differentiation within the lateral left
frontal cortex and left posterior centrum semi ovale hypodensity consistent
with sites of subacute infarction better characterized on prior MR. ___ is
no evidence of hemorrhage, mass, or mass effect. The ventricles and
extra-axial spaces are unremarkable. The orbits, calvarium, and soft tissues
are unremarkable. The paranasal sinuses and mastoid air cells are clear.
CTA HEAD:
There is mild calcific atherosclerosis of the left carotid siphon without
significant stenosis. The bilateral posterior communicating arteries are
visualized. There is normal flow in the intracranial vasculature without
evidence of occlusion, dissection, or aneurysm. The dural venous sinuses are
patent. There are focal short segment stenoses of the left V4 segment
vertebral artery at its mid portion and at its anastomosis with the basilar
artery.
CTA NECK:
There is interval resolution of previously described left carotid bulb and
noncalcific atherosclerosis with patent lumen and no evidence of stenosis by
NASCET criteria. There is subcutaneous emphysema marginating the left carotid
sheath extending superficially to the lateral skin surface consistent with
post endarterectomy surgical changes.
There is calcific and noncalcific atherosclerosis at the right carotid bulb
with approximately 29% stenosis by NASCET criteria.
There is calcific atherosclerosis at the right vertebral artery origin. There
is calcific and noncalcific atherosclerosis with stenosis at the origin of the
left vertebral artery. There is no significant abnormality within the V2 or V3
segment bilateral vertebral arteries.
There is mild calcific atherosclerosis of the visualized aortic arch.
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. There are multilevel degenerative changes of the cervical spine
without acute fracture or osseous lesion. Soft tissue density is noted within
the right external auditory canal which may represent cerumen. There are
postsurgical changes related to prior sternotomy noted.
IMPRESSION:
1. Expected post left endarterectomy changes with interval resolution of left
carotid bulb atheroma and stenosis. No evidence of complication.
2. Infarct at the left frontal cortex and posterior left centrum semi ovale,
better characterized on prior MR of the head. No new acute intracranial
abnormality.
3. Atherosclerosis and luminal stenosis at the right carotid bulb measuring
less than 50 percent by NASCET criteria.
4. Atherosclerosis with in the bilateral vertebral artery origins.
5. Patent intracranial and neck vasculature without evidence of thrombosis or
dissection.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ male with stroke. Evaluate for vascular occlusion.
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: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
5) Spiral Acquisition 5.5 s, 43.5 cm; CTDIvol = 35.4 mGy (Head) DLP =
1,541.0 mGy-cm.
Total DLP (Head) = 2,572 mGy-cm.
COMPARISON: ___ outside noncontrast head CT.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no hemorrhage, mass. There is suggested loss of gray-white
differentiation left superior frontal gyrus versus artifact. The ventricles
and extra-axial spaces are normal. There is periventricular white matter
hypodensity which is nonspecific but likely represents chronic microvascular
white matter change. The orbits and calvarium are unremarkable. There is
mild mucosal thickening and partial opacification of the bilateral ethmoid air
cells. There remainder of the paranasal sinuses and mastoid air cells are
clear.
CTA HEAD:
There is mild calcific atherosclerosis of the left carotid siphon without
significant stenosis. The bilateral posterior communicating arteries are
visualized. There is normal flow in the intracranial vasculature without
evidence of occlusion, dissection, or aneurysm. The dural venous sinuses are
patent. There are focal short segment stenoses of the left V4 segment
vertebral artery at its mid portion and at its anastomosis with the basilar
artery (see65___:5).
CTA NECK:
There is calcific and non calcific atherosclerosis of the left carotid bulb
with maximal residual luminal patency measuring 2.2 mm at the maximum stenosis
(see5:164) versus 3.8 mm any more cephalad internal carotid artery
(see5:187)consistent with approximately 42% stenosis stenosis by NASCET
criteria.
There is calcific and noncalcific atherosclerosis at the right carotid bulb
with residual luminal patency measuring 3.5 mm at the maximum stenosis
(see5:168) versus 4.6 mm at the more cephalad internal carotid artery
(see5:191) consistent with approximately 24% stenosis by NASCET criteria.
There is calcific atherosclerosis with severe luminal stenosis at the right
vertebral artery origin (see5:90). There is calcific and noncalcific
atherosclerosis with severe luminal stenosis at the origin of the left
vertebral artery (see5:90). There is no significant abnormality within the V2
or V3 segment bilateral vertebral arteries.
There is mild calcific atherosclerosis of the visualized aortic arch.
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. There are multilevel degenerative changes of the cervical spine
without acute fracture or osseous lesion. Soft tissue density is noted within
the right external auditory canal which may represent cerumen. Postsurgical
changes related to prior sternotomy noted.
IMPRESSION:
1. Patent intracranial and neck vasculature without evidence of dissection,
occlusion, or aneurysm.
2. Short segment mild stenoses of the left V4 segment vertebral artery which
is nonspecific and may be seen with intracranial atherosclerosis.
3. Atherosclerosis and luminal stenosis at of the bilateral carotid bulbs,
left greater than right as described, measuring less than 50% by NASCET
criteria.
4. Atherosclerosis with severe luminal stenosis at the bilateral vertebral
artery origins.
5. Findings concerning for left frontal gyrus infarct versus artifact as
described. Recommend clinical correlation. If clinically indicated, MRI of
the brain may be obtained for further evaluation.
6. Paranasal sinus disease as described.
RECOMMENDATION(S): Findings concerning for left frontal gyrus infarct.
Recommend clinical correlation. If clinically indicated, MRI of the brain may
be obtained for further evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke // ?PNA
COMPARISON: No comparison
IMPRESSION:
Status post CABG. Normal size of the cardiac silhouette. Normal hilar and
mediastinal contours. No pneumonia, no pulmonary edema, no pleural effusions.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ male with right upper extremity weakness. 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.
___ contrast-enhanced CTA of the neck and head.
___ outside noncontrast head CT.
FINDINGS:
Lateral left frontal cortex, left pre and postcentral gyrus, and left centrum
semi ovale restricted diffusion. There is correlate FLAIR signal
hyperintensity and no evidence of a hemorrhage.
There is a focus of FLAIR signal hyperintensity with central CSF signal, at
the subcortical white matter of the right frontal cortex consistent with
remote infectious inflammatory or ischemic process. The ventricles and
extra-axial spaces are normal. The vascular flow voids are preserved. The
orbits, calvarium, and soft tissues are unremarkable. There is mild right
ethmoid sinus mucosal thickening. The mastoid air cells are clear.
IMPRESSION:
1. Acute infarction centered within the left frontal cortex, extending to the
pre and postcentral gyrus and the centrum semiovale corresponding to the MCA
territory. No evidence of hemorrhagic conversion.
2. Paranasal sinus disease as described.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with likely left sided stroke status post tPA,
now with acute change in mental status and waxing/waning neuro exam. Evaluate
for intracranial hemorrhage.
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 16.0 s, 16.6 cm; CTDIvol = 53.8 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: ___ contrast head and neck CTA.
FINDINGS:
There is no CT evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. Atherosclerotic
vascular calcifications are noted of bilateral vertebral and cavernous
portions of internal carotid arteries.
Ethmoid sinus mucosal thickening is present. There is no evidence of
fracture. The visualized portion of the mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
Soft tissue density is noted within the right external auditory canal which
may represent cerumen.
IMPRESSION:
1. No intracranial hemorrhage.
2. Paranasal sinus disease as described.
Radiology Report
EXAMINATION: ___
Department of Radiology
Study: Carotid Series Complete
Reason: ___ year old male with left ICA stenosis.
Findings:
Duplex evaluation was performed of bilateral carotid arteries. On the right
there is moderate calcified plaque plaque in the ICA. On the left there is
moderate calcified plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 72/24, 85/24, and 66/17cm/sec. CCA peak systolic
velocity is 62cm/sec. ECA peak systolic velocity is 96cm/sec. The ICA/CCA
ratio is 1.4 . These findings are consistent with less than 40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively 128/37, 159/26, and 115/26 cm/sec. CCA peak systolic
velocity 66cm/sec. ECA peak systolic velocity is 107cm/sec. The ICA/CCA ratio
is 2.4. These findings are consistent with 60-69% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression:
Right ICA less than 40% stenosis.
Left ICA 60-69 % stenosis.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, STATUS POST ADMINISTRATION OF TPA (RTPA) IN A DIFFERENT FACILITY WITHIN THE LAST 24 HOURS PRIOR TO ADMISSION TO CURRENT FACILITY
temperature: nan
heartrate: 83.0
resprate: 18.0
o2sat: nan
sbp: 141.0
dbp: 88.0
level of pain: 13
level of acuity: 1.0 | Multiple MCA territory strokes and L ICA stenosis.
MRI showed multiple acute strokes in a watershed territory
between ACA and MCA. His CTA showed around 42% stenosis of left
ICA but appeared more significant on personal review. Carotid US
showed R ICA at 60-69% stenosis with L ICA<40%. Given the
characteristic appearance of his MRI, Neurosurgery was consulted
for consideration of CEA even though stenosis appeared
borderline. Prior to surgery his neuro exam was as follows:
Slower activation of the right face on smile, mildly dysarthric,
___ right deltoid weakness and dysmetria on finger to nose with
RUE. Patient went for carotid endarterectomy on ___.
Regarding his other risk factors:
His HbA1C returned at 8.3 showing suboptimal glycemic control
which he will need to follow up with his primary care provider
___. Patient reported that he was unable to afford his dose of
humalog ___ and ___ was consulted to explore alternatives.
They suggested starting glipizide 10mg daily (to be started
after operation), and adjustment of insulin regimen. He was
discharged on Lantus 40u QAM, 30u QPM and a sliding scale.
His LDL returned at 119 which required starting Atorvastatin
80mg daily. Triglycerides were in the 500s - with greater than
5:1 ratio with HDL which was only in the ___. He was already on
Ezetimibe 10mg daily. His diet was modified to 1500
calories/day. Repeat ___ level was 502. If the repeat level is
still grossly elevated, the patient may benefit from starting
Niacin. Starting this medication can discussed by PCP.
He will need follow up with a stroke neurologist in 3 months -
however the patient lives in ___ and may wish to find
a local neurologist there by PCP ___.
He underwent a carotid endarterectomy on ___ with Dr. ___.
The procedure was uncomplicated. He was extubated in the OR.
Patient was transferred to the PACU post operatively.
Immediately after the procedure it was noted that the patient
had expressive aphasia and worsened right upper extremity
weakness compared to pre-operative exam. A stat CTA was
preformed which revealed expected post operative changes and no
___ stroke or intracranial abnormality. Overnight patient's exam
slowly improved back to baseline.
He was evaluated by physical therapy and occupational therapy
who recommended discharge to rehab.
He was discharged to rehab on ___ in stable condition with
instructions for follow up. At time of discharge his pain was
well controlled. He was tolerating an advanced diet. He was
ambulating with assistance. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Clogged GJ tube
Major Surgical or Invasive Procedure:
GJ-tube check ___
History of Present Illness:
___ w/ history of prior sigmoid volvulus s/p sigmoid
colectomy recently admitted with SMA syndrome for which he
underwent an exploratory laparotomy, duodenal release of SMA
syndrome, and placement of a GJtube now seen in consultation for
a clogged Jtube noted at rehab this morning. Mr. ___
postoperative course was uncomplicated and he was discharged to
rehab on ___. Since that time, he has been tolerating Jtube
feeds without issue until this morning when staff at his
facility
were unable to flush or instill feeds via the Jtube. ___
was instilled without improvement in Jtube function, at which
time he was transferred to ___ for further workup and
evaluation.
Past Medical History:
Past Medical History:
Tendonitis of shoulders
IBS
Pre-asthma
Past Surgical History:
Appendectomy at ___ y/o
R inguinal hernia repair ___ y/a, repair of recurrence ___ y/a
with mesh
Social History:
___
Family History:
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam
Vital: 97.9 79 132/73 15 98% RA
Gen: NAD, comfortable
CV: RRR
R: clear ___
Abd: well healing surgical incision with staples in place, no
erythema or discharge, appropriately tender to palpation, no
rebound/guarding, GJ in place without erythema or drainage
Ext: no c/c/e
Discharge Physical exam
Vital: T: 97.7 BP: 121/53 HR: 41 RR:8 O2sat:96%Ra
Gen: NAD, comfortable
CV: RRR, normal S1, S2
Pulmonary: clear to auscultation bilaterally
Abd: well healing surgical incision with staples in place, no
erythema or discharge, appropriately tender to palpation, no
rebound/guarding, GJ in place without erythema or drainage
Ext: warm and well perfused
Pertinent Results:
___ 01:00AM GLUCOSE-88 UREA N-26* CREAT-0.9 SODIUM-146
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-34* ANION GAP-15
___ 01:00AM estGFR-Using this
___ 01:00AM WBC-5.1 RBC-3.47* HGB-11.4* HCT-33.8* MCV-97
MCH-32.9* MCHC-33.7 RDW-13.2 RDWSD-47.2*
___ 01:00AM NEUTS-74.5* LYMPHS-17.6* MONOS-5.3 EOS-1.2
BASOS-0.2 IM ___ AbsNeut-3.81 AbsLymp-0.90* AbsMono-0.27
AbsEos-0.06 AbsBaso-0.01
___ 01:00AM PLT COUNT-441*
___ 08:12PM URINE HOURS-RANDOM
___ 08:12PM URINE UHOLD-HOLD
___ 08:12PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 08:12PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-8.0
LEUK-LG*
___ 08:12PM URINE RBC-3* WBC-95* BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 08:12PM URINE AMORPH-RARE*
___ 08:12PM URINE MUCOUS-RARE*
Radiology Report
INDICATION: ___ year old man with SMA syndrome s/p GJ placement now clogged//
please replace GJT.
COMPARISON: Abdominal x-ray dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
and Dr. ___, Interventional Radiology fellow performed the
procedure. Dr. ___ supervised the trainee during any key
components of the procedure where applicable and reviewed and agrees with the
findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
0mcg of fentanyl and 0.25 mg of midazolam throughout the total intra-service
time of 8 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: 20 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 1.2 minutes, 5 mGy
PROCEDURE: 1. MIC GJ tube Check.
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.
A scout image of the abdomen was obtained. Images demonstrate an 18 ___ GJ
catheter with distal tips in the jejunum. The catheter was then flushed, and
contrast injection into the jejunal lumen demonstrated brisk flow into jejunal
loop. Subsequent flushing with normal saline clear contrast from jejunal
loop. Our attention was then turned to the gastric lumen. Contrast was
flushed into gastric lumen and contrast was seen delineating the rugal folds.
Both lumens were flushed without encountering any resistance. A Glidewire was
then advanced into the to jejunal port and seen to traverse freely into the
jejunum. The tube was then capped and left in place, previously secured to
the skin with 0-silk sutures. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Functional 18 ___ MIC GJ tube.
IMPRESSION:
Successful check of 18 ___ MIC GJ tube. The catheter can be used
immediately.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: gtube eval
Diagnosed with Mech compl of gastrointestinal prosth dev/grft, init, Exposure to other specified factors, initial encounter
temperature: 98.5
heartrate: 86.0
resprate: 16.0
o2sat: 98.0
sbp: 122.0
dbp: 65.0
level of pain: 3
level of acuity: 3.0 | The patient presented to the Emergency Department on ___. He
was sent to the ED following a clogged GJ-tube that staff at his
facility were unable to flush or instill feeds to. Given
findings, the patient was admitted into the hospital and planed
for a GJ-tube replacement by interventional radiology. On ___
he was taken to interventional radiology for GJ-tube
check/replacement. While on interventional radiology they were
able to flush the GJ-tube and there was no need for replacement.
Neuro: The patient was alert and oriented throughout
hospitalization.
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, and early ambulation were encouraged
throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO for the procedure
and 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: M
Service: MEDICINE
Allergies:
Penicillins / codeine / ibuprofen
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH poorly controlled T1DM c/b diabetic
retinopathy, gastroparesis, and ESRD on HD MWF, HFpEF(50%), DVT
___ on apixaban, PUD with duod ulcer ___ EGD,
poorly-controlled HTN presents for hyperglycemia (FSBG 436) and
nausea. Repeatedly hospitalized for hypertensive emergency,
hyperglycemia, nausea vomiting, DKA most recently on ___.
Pt minimally engaging with me during my encounter with him.
Re cough: endorsing cough without sputum production as well as
sweating and subjective fevers. Uncertain of sick contacts but
multiple hospitalizations recently. Endorses sore throat. Denies
dyspnea.
Re home med compliance: uncertain of what meds he is taking or
not but endorses adherence with blister packs, saying he takes
what is in them. Declining to answer what frequency he might
miss
doses. Unclear whether taking apixaban as directed.
Re back pain: chronic, for several months, lower back, no
trauma.
No change. MRI from ___ without acute pathology.
DC summary from ___ reviewed and summarized as follows:
Admitted with numerous issues similar to the above, incl hypoxia
on NRB requiring urgent HD for volume overload, as well as HTN
with likely poor med adherence. Chronic pain issues were
addressed, w/ pt reporting 4 months of LBP for which likely
taking unprescribed dilaudid; pall care consulted to see pt but
he was sleeping whenever they tried to see him and a meaningful
evaluation was never performed. Pt to be linked into chronic
pain
management outpatient though no records in OMR of having been to
appt. It was discussed to avoid IV dilaudid inpatient though he
got PO; no opiates on DC. Numerous social barriers noted as
contributing to repeated admissions incl poor support at home,
blindness, poor adherence and losing HD slot for nonadherence
(partially contributing to this was his frequent absence d/t
hospital admission); blister packs started, in order to assist
with his meds.
In ED:
VS: afebrile, HR 112 --> 104 (max 128), BP 230/110 --> 170/100,
RR 24 --> 16, 96% RA initially then 97% on 2L NC (though never
recorded as hypoxic)
Labs: glu 464 --> 255; wbc 10.8, hb 7.7 (b/l), BMP significant
for Cr 5.9, BUN 23, glu 365, trop 0.40 (b/l), VBG 7.50, bcb 36
Imaging: CXR read as mild pulm edema
Received: Haldol 5mg IM; insulin 10u then 3u; nifedipine 60
extended release PO, ___, Zofran, cyclobenzaprine 10 PO
Consult: none
ED course with patient initially resistant to care, refusing PO
but then allowing US IV placement for admission and in agreement
to allow medical intervention in the event of admission
Past Medical History:
- ESRD on HD MWF, followed by Dr. ___. At one point, concern
was for immunologic disease and was on mycophenolate then
tacrolimus,
however renal biopsy showed DM glomerulosclerosis
- T1DM
- Diabetic retinopathy
- Gastroparesis
- Presumed ___ tear
- PUD
- HTN
- Vitreous hemorrhage
- Hx hypoglycemic seizures
Social History:
___
Family History:
Multiple family members with insulin-dependent diabetes
Physical Exam:
EXAM:
VITALS: Afebrile and vital signs significant for HTN, now on 2L
with saturation in high ___ on attempt to wean on floor arrival
GENERAL: Alert, mildly ill appearing
EYES: Anicteric, pupils equally round, some dependent edema in
right lid
ENT: Patient deferring oropharyngeal exam
CV: Heart regular, no murmur, no S3, no S4. Patient refusing
positioning necessary to evaluate JVD. No ___ edema
RESP: Lungs clear to auscultation though poor participation in
exam. Breathing is non-labored. Intermittent dry cough noted
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted; right TLC without exudate,
erythema
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
___ ___ Temp: 98.4 PO BP: 183/109 HR: 90 RR: 18 O2 sat:
95%
O2 delivery: RA FSBG: 387
GENERAL: Alert, mildly ill appearing. Did not wake up / respond
to questions. Refused exam.
EYES: Anicteric, pupils equally round, some dependent edema in
right lid
CV: refused
RESP: refused
GI: refused
SKIN: No rashes or ulcerations noted. Face swollen.
PSYCH: non-responsive, refusing to speak.
Pertinent Results:
Admission Labs:
glucose 464 --> 255; wbc 10.8, hb 7.7 (b/l), BMP significant
for Cr 5.9, BUN 23, glu 365, trop 0.40 (b/l), VBG 7.50, bcb 36
Imaging: CXR read as mild pulm edema
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. CARVedilol 50 mg PO BID
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
5. Cyclobenzaprine 10 mg PO Q8H:PRN back spasm pain, thigh
muscle spams
6. Doxazosin 4 mg PO HS
7. HydrALAZINE 75 mg PO Q8H
8. Losartan Potassium 100 mg PO DAILY
9. Metoclopramide 5 mg PO Q8H:PRN indigestion
10. Minoxidil 2.5 mg PO 3X/WEEK (___)
11. NIFEdipine (Extended Release) 90 mg PO BID
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Valproic Acid ___ mg PO Q8H:PRN mood disturbance
14. Vitamin D ___ UNIT PO DAILY
15. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
16. Pen Needle (pen needle, diabetic) 29 gauge x ___
miscellaneous QID
17. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Glargine 9 Units Breakfast
Glargine 4 Units Bedtime
Humalog 4 Units Breakfast
Humalog 2 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Apixaban 2.5 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 50 mg PO BID
5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
6. Cyclobenzaprine 10 mg PO Q8H:PRN back spasm pain, thigh
muscle spams
7. Doxazosin 4 mg PO HS
8. HydrALAZINE 75 mg PO Q8H
9. Losartan Potassium 100 mg PO DAILY
10. Metoclopramide 5 mg PO Q8H:PRN indigestion
11. Minoxidil 2.5 mg PO 3X/WEEK (___)
12. NIFEdipine (Extended Release) 90 mg PO BID
13. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
14. Pantoprazole 40 mg PO Q12H
15. Pen Needle (pen needle, diabetic) 29 gauge x ___
miscellaneous QID
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Valproic Acid ___ mg PO Q8H:PRN mood disturbance
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hyperglycemia
Hypertension
Hypoxemic respiratory failure due to volume overload
ESRD
Lower back pain
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with cough and hyperglycemia// PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Dual-lumen projected over right atrium. Cardiothoracic ratio remains
enlarged.
Lung volumes remain diminished with bronchovascular crowding. Central venous
congestion, with suggestion of mild pulmonary edema. No lobar pneumonia.
IMPRESSION:
Mild pulmonary edema suspected. No lobar pneumonia.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hyperglycemia
Diagnosed with Type 1 diabetes mellitus with hyperglycemia, Type 1 diabetes w diabetic autonomic (poly)neuropathy, Gastroparesis, Long term (current) use of insulin
temperature: 98.9
heartrate: 109.0
resprate: 16.0
o2sat: 95.0
sbp: 220.0
dbp: 127.0
level of pain: 10
level of acuity: 2.0 | SUMMARY/ASSESSMENT:
___ with PMH poorly controlled T1DM c/b diabetic
retinopathy, gastroparesis, and ESRD on HD MWF, HFpEF(50%), DVT
___ on apixaban, PUD with duod ulcer ___ EGD,
poorly-controlled HTN presents for hyperglycemia (FSBG 436) and
nausea, also found to be hypertensive and mildly hypoxemic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left Foot Pain
Major Surgical or Invasive Procedure:
___ L ___ toe amputation
___ R ___ toe arthroplasty
History of Present Illness:
Mr. ___ is a ___ with PMHx LRRT ___ due to
hypertensive/diabetic nephropathy), HTN, IDDM, with hx of foot
ulcers presenting with an ulceration to ___ webspace of left
foot.
The patients wife noticed on ___ the patients foot was
ulcerated with redness, swelling, and warmth. Patient endorses
some chills, feels hot. Patient follows closely with podiatry.
He did have the dorsal ulceration to the left fifth toe debrided
___ ___ clinic yesterday. He has a similar dorsal ulceration
to his right fifth toe as well (covering both of these dorsal
ulcerations with betadine soaked gauze). Both of these
ulcerations appear healthy. The left foot has significant
swelling, redness and warmth that extends to the dorsal foot up
to the ankle. ROS otherwise negative.
Patient recently admitted from ___ to ___ with neutropenic
fever and aphthous stomatitis. Neutropenia thought to be
secondary to MMF as it improved with discontinuation. WBC
improved so on ___ he was restarted on MMF
___ the ED, initial vitals were: 98.8 95 198/80 18 100% RA
- Exam notable for: blanching redness to the left foot
- Labs notable for:
12.0
9.3 >---< 164
36.7 N:81.7 L:6.2 M:10.8 E:0.8 Bas:0.1 ___: 0.4
136 101 29
-------------< 63 AGap=13
4.2 26 1.4
Lactate:1.2
Ca: 9.7 Mg: 1.9 P: 1.9
- Imaging was notable for: Foot AP/LAT/OB Left
1. Bony destruction cortical regularity along the distal
lateral aspects of the proximal phalanx at the IP joint of the
fifth digit (small toe) which is new as compared to left foot
radiograph ___ and is concerning for nosteomyelitis.
2. Significant soft tissue swelling of the fifth digit without
evidence of subcutaneous gas.
3. Moderate to severe degenerative changes of the left foot as
detailed above are grossly unchanged.
- Patient was given: 500CC normal saline, Zosyn, Vanco (Ordered
but not given yet)
Renal Consult: "This is a ___ male with a PMHx of CKD
secondary to diabetic nephropathy s/p LRRT on ___ with
Banff 1A acute rejection treated with steroids now on
prednisone/tacrolimus presenting for foot ulcer/cellulitis. We
will await labs for further recommendations. Agree with broad
spectrum coverage with vancomycin/zosyn at this time. If no need
for admission to surgical service, then patient should be
admitted to ET under Dr. ___
Podiatry Consult:"Patient evaluated. L sub ___ toe ulcer with
exposed tendon. No purulence. bone is covered. -will f/u labs
and Xrays"
Plan to admit to transplant medicine.
Upon arrival to the floor, patient reports his foot lesions are
not painful. He denies any known vascular disease and states
that per his outpatient podiatrist, his ulcers are due to his
underlying diabetes. he denies any fevers, chills, or systemic
systems. He states that his apthous ulcers have completely
resolved. He reports full compliance with his medications.
Past Medical History:
Essential Hypertension
Type 2 Diabetes
Diabetic Neuropathy
Hyperlipidemia
Anemia of CKD
LRRT ___, due to hypertensive/diabetic nephropathy
per
Pt, complicated by Banff 1A rejection ___ ___
Neutropenic Fever
Aphthous stomatitis
Social History:
___
Family History:
Mother: DM, HTN, CKD
Father: DM
___: DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vital Signs: T 100.2 BP 179/89 HR85 RR18 98% RA
General: pleasant, 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-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: well perfused, left foot is wrapped with multiple layers of
dressing that are clean, dry, and intact without and erythema
extending up to the exposed skin. (did not remove bandages per
patient request). Neuro: CNII-XII intact, ___ strength
upper/lower extremities, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred.
DISCHARGE PHYSICAL EXAM:
=========================
Vital Signs: 98.3
PO 153 / 86 70 18 95 Ra
General: pleasant, well appearing
HEENT: No icterus. MMM.
CV: RRR, no m/r/g.
Lungs: Non-labored, CTAB.
Abdomen: Soft, NDNT including over RLQ transplant site
Ext: Surgical dressings CDI. No stigmata on endocarditis.
Neuro: Normal mental status.
Pertinent Results:
LABS:
======
___ 06:50PM BLOOD WBC-9.3# RBC-4.34* Hgb-12.0* Hct-36.7*
MCV-85 MCH-27.6 MCHC-32.7 RDW-13.6 RDWSD-42.2 Plt ___
___ 06:02AM BLOOD WBC-9.7 RBC-4.06* Hgb-11.3* Hct-34.8*
MCV-86 MCH-27.8 MCHC-32.5 RDW-13.8 RDWSD-42.8 Plt ___
___ 05:36AM BLOOD WBC-6.8 RBC-4.14* Hgb-11.4* Hct-35.3*
MCV-85 MCH-27.5 MCHC-32.3 RDW-13.3 RDWSD-41.5 Plt ___
___ 05:47AM BLOOD WBC-3.6* RBC-4.36* Hgb-11.9* Hct-37.1*
MCV-85 MCH-27.3 MCHC-32.1 RDW-13.1 RDWSD-41.0 Plt ___
___ 05:50AM BLOOD WBC-5.2 RBC-4.30* Hgb-12.2* Hct-36.2*
MCV-84 MCH-28.4 MCHC-33.7 RDW-13.3 RDWSD-41.4 Plt ___
___ 05:44AM BLOOD WBC-5.0 RBC-4.31* Hgb-12.1* Hct-36.5*
MCV-85 MCH-28.1 MCHC-33.2 RDW-13.2 RDWSD-40.7 Plt ___
___ 06:50PM BLOOD Neuts-81.7* Lymphs-6.2* Monos-10.8
Eos-0.8* Baso-0.1 Im ___ AbsNeut-7.57*# AbsLymp-0.57*
AbsMono-1.00* AbsEos-0.07 AbsBaso-0.01
___ 06:15AM BLOOD Neuts-67.4 Lymphs-14.7* Monos-13.1*
Eos-4.2 Baso-0.6 AbsNeut-2.43# AbsLymp-0.53* AbsMono-0.47
AbsEos-0.15 AbsBaso-0.02
___ 06:02AM BLOOD ___ PTT-28.6 ___
___ 05:36AM BLOOD ___ PTT-28.8 ___
___ 05:50AM BLOOD ___ PTT-29.5 ___
___ 05:44AM BLOOD ___ PTT-30.1 ___
___ 06:50PM BLOOD Glucose-63* UreaN-29* Creat-1.4* Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
___ 06:02AM BLOOD Glucose-153* UreaN-20 Creat-1.4* Na-141
K-4.3 Cl-103 HCO3-25 AnGap-17
___ 05:50AM BLOOD Glucose-144* UreaN-34* Creat-1.4* Na-140
K-4.6 Cl-104 HCO3-23 AnGap-18
___ 05:44AM BLOOD Glucose-153* UreaN-30* Creat-1.3* Na-140
K-4.5 Cl-103 HCO3-26 AnGap-16
___ 06:50PM BLOOD Calcium-9.7 Phos-1.9* Mg-1.9
___ 06:02AM BLOOD Albumin-3.9 Calcium-9.1 Phos-2.8 Mg-1.9
___ 05:50AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0
___ 05:44AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0
___ 06:02AM BLOOD CRP-193.8*
___ 06:02AM BLOOD tacroFK-3.8*
___ 05:36AM BLOOD tacroFK-5.3
___ 05:38AM BLOOD tacroFK-8.8
___ 06:15AM BLOOD tacroFK-5.9
___ 08:04AM BLOOD tacroFK-6.7
___ 05:50AM BLOOD tacroFK-8.2
___ 05:44AM BLOOD tacroFK-6.4
___ 07:04PM BLOOD Lactate-1.2
Foot XR ___:
IMPRESSION:
1. Bony destruction cortical regularity along the distal lateral
aspects of the proximal phalanx at the IP joint of the fifth
digit (small toe) which is new as compared to left foot
radiograph ___ and is concerning for osteomyelitis.
2. Significant soft tissue swelling of the fifth digit without
evidence of
subcutaneous gas.
3. Moderate to severe degenerative changes of the left foot as
detailed above are grossly unchanged.
___ R foot XR:
IMPRESSION:
1. Status post interval right fifth proximal phalanx
arthroplasty at the PIP joint, with expected postsurgical
changes.
2. Other chronic findings are notable for increased sclerosis
and osteophytes at the first MTP joint arthroplasty compared to
___. Other degenerative changes are similar to before.
___ L foot XR:
IMPRESSION:
___ comparison with the study of ___, there has been
resection of most of the phalanges of the fifth digit with a
small residual. Otherwise, little change.
___ L toe (summarized):
- Acute osteo focal with overlying soft tissue with acute
inflammation and granulation tissue formation
___ Tissue Micro:
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
TISSUE (Final ___:
BETA STREPTOCOCCUS GROUP B. RARE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
MIXED BACTERIAL FLORA.
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, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. HydrALAZINE 25 mg PO QPM
3. Labetalol 200 mg PO QAM
4. Labetalol 400 mg PO QHS
5. Multivitamins 1 TAB PO LUNCH
6. NIFEdipine CR 90 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. Rosuvastatin Calcium 20 mg PO QPM
9. Sodium Bicarbonate 650 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Atovaquone Suspension 1500 mg PO DAILY
12. biotin 5000 mcg oral DAILY
13. Tacrolimus 4 mg PO Q12H
14. Mycophenolate Mofetil 250 mg PO BID
15. Glargine 42 Units Breakfast
Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone ___ dextrose,iso-os 2 gram/50 mL 2 g intravenous
Daily Disp #*28 Intravenous Bag Refills:*0
2. Tacrolimus 5 mg PO Q12H
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Atovaquone Suspension 1500 mg PO DAILY
5. biotin 5000 mcg oral DAILY
6. HydrALAZINE 25 mg PO QPM
7. Glargine 42 Units Breakfast
Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Labetalol 200 mg PO QAM
9. Labetalol 400 mg PO QHS
10. Multivitamins 1 TAB PO LUNCH
11. Mycophenolate Mofetil 250 mg PO BID
12. NIFEdipine CR 90 mg PO DAILY
13. PredniSONE 5 mg PO DAILY
14. Rosuvastatin Calcium 20 mg PO QPM
15. Sodium Bicarbonate 650 mg PO BID
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Osteomyelitis of left fifth toe
Diabetic foot ulcer
SECONDARY DIAGNOSIS
===================
Status post kidney transplant on immunosuppression
Acute on chronic renal failure
Insulin-dependent diabetes mellitus
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ w/dorsal and plantar ulceration to the left ___ toe, please
evaluate for bony involvement, subq gas
TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs
of left foot
COMPARISON: Left foot radiograph ___
FINDINGS:
There is erosive change, bony destruction, and cortical irregularity along the
distal and lateral aspect of the proximal phalanx of the fifth digit (smallest
toe) which is new as compared to left foot radiograph ___. There
is significant soft tissue swelling around the fifth digit (smallest toe).
There is no subcutaneous gas.
Patient is status post resection of the distal phalanx of the fourth toe.
There is ankylosis across the PIP joint of the fourth toe. There are moderate
degenerative changes at the PIP and MTP joints of the big toe. There also
degenerative changes noted at the talonavicular joint and a large spur off of
the anterior superior aspect of the talus, unchanged from ___.
Calcaneal spurs are again noted. Calcifications overlying the Achilles tendon
are unchanged and likely represent prior injury.
No acute fractures or dislocation are seen.
IMPRESSION:
1. Bony destruction cortical regularity along the distal lateral aspects of
the proximal phalanx at the IP joint of the fifth digit (small toe) which is
new as compared to left foot radiograph ___ and is concerning for
osteomyelitis.
2. Significant soft tissue swelling of the fifth digit without evidence of
subcutaneous gas.
3. Moderate to severe degenerative changes of the left foot as detailed above
are grossly unchanged.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old man s/p L ___ digit amputation// s/p L ___ digit amp
s/p L ___ digit amp
IMPRESSION:
In comparison with the study of ___, there has been resection of most of
the phalanges of the fifth digit with a small residual. Otherwise, little
change.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man s/p R ___ PIPJ arthroplasty// post op
TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs
of the right foot. Obtained portably.
COMPARISON: Right foot radiograph ___
FINDINGS:
The patient is status post interval right fifth PIP joint arthroplasty with
associated soft tissue swelling.
No acute fractures or dislocation is detected.
Previous arthroplasty site at the first proximal phalanx is notable for
increased sclerosis and osteophyte at the proximal phalanx base. As before,
the first ray sesamoids have been resected and 2 soft tissue anchors are seen
in relation to the distal first metatarsal. Small ossific fragments are
again noted near the distal first metatarsal, increased along the tibial side
of the metatarsal head.
Extensive degenerative changes in the midfoot, tibiotalar joint, and calcaneal
spurring are similar to before. Small areas of lucency in the fourth and
fifth proximal phalanx bases are unchanged. Fusion of first IP and second PIP
joints is again noted.
Dystrophic and vascular calcifications in the lower calf is unchanged.
IMPRESSION:
1. Status post interval right fifth proximal phalanx arthroplasty at the PIP
joint, with expected postsurgical changes.
2. Other chronic findings are notable for increased sclerosis and osteophytes
at the first MTP joint arthroplasty compared to ___. Other
degenerative changes are similar to before.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Foot pain
Diagnosed with Pain in left foot
temperature: 98.8
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 198.0
dbp: 80.0
level of pain: 2
level of acuity: 3.0 | ___ with h/o liver related renal transplant ___ ___ on
tacrolimus/MMF/prednisone (MMF restarted ___ after holiday due
to neutropenic fever), IDDM c/b foot ulcers, admitted from
___ clinic for osteomyelitis of left ___ toe. He underwent
bedside debridement followed by amputation of the toe without
complication, and was treated with IV antibiotics with
Ceftriaxone with guidance from ID. Plan for a ___nd will follow-up with ___ clinic with Dr. ___.
He remained hemodynamically stable with no signs of sepsis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HTN, hypothyroidism, and depression referred by PCP ___/
acute SOB, dyspnea since ___. Saw PCP for same day sick
visit and was sent to ___ from there. Denies chest
pain, sob, fever, chills, cough. Reports having suicidal
thoughts ___ past two weeks. States she feels like a demon is
inside of her telling her she is worthless. Currently she wants
to live. No plan and no intent on carrying out suicide attempt.
___ the past has been hospitalized for depression.
The patient presented to ___ on ___ given her ongoing
symptoms. At ___ were significant for sats ___ on RA, SBP
___, afebrile. Labs were significant for no leukocytosis, H/H
15.6/47.9, BUN/Cr 35/5.0, TSH 95, Free T4 0.5, positive UA. CTA
chest negative for PE but showed reticulonodular pattern
bilaterally with small left lower lobe infiltrate. CT abd/pelvis
negative for acute pathology. L femoral CVL placed. She was
given 4L IVF, 400mcg IV levothyroxine, 8mg IV dexamethasone, 1g
IV vancomycin, ertapenem, and started on norepi gtt. She was
then transferred to ___ for further care.
At ___, initial vitals: 98.0 68 109/68 20 95% Nasal Cannula.
Labs were significant for bicarb 19 w/ anion gap of 15, BUN/Cr
___, VBG ___ with SVO2 62, lactate 1.1. She was
given 1L NS and continued on the norepi gtt. On transfer, vitals
were: 98.0 71 94/64 20 94% Nasal Cannula.
On arrival to the MICU, Patient is alert and oriented x3. She
endorses chest tightness/wheezing, dry cough, and
lethargy/fatigue. She denies chest pain, nausea, vomiting,
diarrhea, dysuria. She denies medication non-compliance, EtOH,
or illicit drug use. She has a 30 pack year smoking history and
quit just a few days ago ___ the setting of her respiratory
illness.
Past Medical History:
BACKACHE NOS
ESSENTIAL (PRIMARY) HYPERTENSION
HYPOTHYROIDISM, UNSPECIFIED
OTHER FATIGUE
PURE HYPERCHOLESTEROLISM
Depression
Social History:
___
Family History:
Father passed away from MI, alcoholic
Mother alive and well at ___
No major history of heart disease, cancer, or lung disease ___
the family.
Physical Exam:
=============================
ADMISSION EXAM:
=============================
Vitals: T:98.8 BP:128/57 (on levo) P: 73 R:18 O2: 95% on 4L
GENERAL: fatigued appearing but alert and oriented x3, NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: good air entry but diffusely rhonchorous bilaterally;
faint expiratory wheezing bilaterally.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or other lesions.
NEURO: face symmetric, motor grossly intact.
=============================
DISCHARGE EXAM:
=============================
Vitals: T 97.6 BP 116/77 HR 71 RR 16 94% RA
GENERAL: AOx3, lying ___ bed, ___ NAD
HEENT: EOMI. MMM.
CARDIAC: RRR, no m/r/g.
LUNGS: Clear to auscultation, mild expiratory wheezing
ABDOMEN: BS+, soft, NT, mildly distended.
EXTREMITIES: No peripheral edema.
SKIN: Warm, well-perfused, no rashes.
NEUROLOGIC: AOx3. No focal deficits.
PSYCH: Flat affect but more engaged today.
Pertinent Results:
=========================
ADMISSION LABS:
=========================
___ 10:08PM BLOOD WBC-8.8 RBC-4.71 Hgb-13.9 Hct-44.9 MCV-95
MCH-29.5 MCHC-31.0* RDW-15.0 RDWSD-52.5* Plt ___
___ 10:08PM BLOOD Neuts-89.1* Lymphs-8.0* Monos-2.4*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.82* AbsLymp-0.70*
AbsMono-0.21 AbsEos-0.00* AbsBaso-0.02
___ 10:08PM BLOOD ___ PTT-27.8 ___
___ 10:08PM BLOOD Glucose-138* UreaN-30* Creat-3.4* Na-138
K-4.4 Cl-104 HCO3-19* AnGap-19
=========================
PERTINENT RESULTS:
=========================
LABS:
=========================
___ 10:08PM BLOOD TSH-13*
___ 10:08PM BLOOD Free T4-1.3
___ 05:34AM BLOOD Cortsol-6.9
___ 05:40AM BLOOD Cortsol-7.3
___ 07:10AM BLOOD Cortsol-1.7*
=========================
MICROBIOLOGY:
=========================
___ 04:06AM BLOOD HCV Ab-NEGATIVE
___ 04:06AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
==========================
Sputum Culture (Final ___:
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. MODERATE GROWTH.
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
=========================
IMAGING:
=========================
CXR (___): Bandlike opacity at the left base may represent
atelectasis or residual pneumonia.
=========================
DISCHARGE LABS:
=========================
___ 07:35AM BLOOD WBC-8.1 RBC-4.48 Hgb-13.3 Hct-41.6 MCV-93
MCH-29.7 MCHC-32.0 RDW-14.6 RDWSD-49.8* Plt ___
___ 07:35AM BLOOD Glucose-81 UreaN-19 Creat-0.8 Na-140
K-4.3 Cl-103 HCO3-29 AnGap-12
___ 07:35AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Atorvastatin 40 mg PO QPM
3. BuPROPion 100 mg PO BID
4. ClonazePAM 1 mg PO TID:PRN anxiety
5. Gabapentin 300 mg PO TID:PRN pain
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Mirtazapine 15 mg PO QHS
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. BuPROPion 100 mg PO BID
3. ClonazePAM 1 mg PO TID:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth Three times a day Disp
#*18 Tablet Refills:*0
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Mirtazapine 15 mg PO QHS
RX *mirtazapine 15 mg 1 tablet(s) by mouth At bedtime Disp #*14
Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
7. Lisinopril 40 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
a day Disp #*60 Capsule Refills:*1
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth Twice a day Disp
#*60 Tablet Refills:*1
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 gram by mouth Daily
Refills:*0
11. Simethicone 40-80 mg PO QID:PRN abd cramping
Do not take within 4 hours of taking your Synthroid
RX *simethicone [Gas-X] 80 mg 1 tab by mouth Every 6 hours Disp
#*60 Tablet Refills:*1
12. PredniSONE 10 mg PO ASDIR
4 ___ up)
RX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*50 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
==============
PRIMARY:
==============
Septic shock
Community acquired pneumonia
COPD Exacerbation
==============
SECONDARY:
==============
Adrenal insufficiency
Hypothyroidism
Acute kidney injury
Depression
Anxiety
Hypertension
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with LLL pneumonia at OSH with hypotension //
eval for pulmonary edema, pneumonia
TECHNIQUE: single portable semi upright view of the chest
COMPARISON: None.
FINDINGS:
Cardiomediastinal silhouette is within normal limits. Increased opacification
at the left base could represent atelectasis or residual pneumonia. Opacities
at the right base likely represent atelectasis. The lungs are otherwise
clear. There is no large effusion or pneumothorax.
IMPRESSION:
Bandlike opacity at the left base may represent atelectasis or residual
pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Pneumonia, Transfer
Diagnosed with Sepsis, unspecified organism, Pneumonia, unspecified organism
temperature: 98.0
heartrate: 68.0
resprate: 20.0
o2sat: 95.0
sbp: 109.0
dbp: 68.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ y/o woman with history of hypertension,
hypothyroidism, and depression who presented from an outside
hospital with shock from suspected pneumonia versus urinary
tract infection, and subsequently found to have low morning
cortisol.
====================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Niacin / Chantix Starting Month Pak / Metformin
Attending: ___
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with MMP, including Afib/Aflutter on Coumadin, ___ /
apical hypertrophic cardiomyopathy, dementia NOS with mood
disturbance, DM2 on insulin, hx of recurrent UTI's, COPD,
ILD/pulmonary fibrosis, presents from home with 2 days of
increasing somnolence.
.
Patient unable to provide history, denies any complaints on my
interview. HPI is obtained from private aide at bedside and in
speaking with daughter (HCP) ___ via phone.
.
Patient was noted to be more lethargic x 2 days, less verbal and
less interactive. No noted fevers. No new cough, abdominal
pain, diarrhea or malodorous urine noted. Still with good
appetite. No constipation, last BM on day of presentation. Per
daughter, patient typically does NOT have urinary symptoms with
UTI, only lethargy/somnolence.
.
Daughter also notes some increased abdominal girth, concerned
for volume overload / ___ flare. Also concerned that patient
may be oversedated, as patient is on many psychiatric
medications, and was recently admitted to inpatient GeriPsych in
___ with medication adjustment. Was seen in f/u by Psychiatry
as outpatient in ___, but did not taper back medications.
Aide reports that patient now appears to be back to her baseline
mental status, alert but confused.
.
In ED patient had stable VS. Labs showed normal WBC,
unremarkable Chem-7, but did have elevated BNP of 1500. UA was
grossly positive. CXR did show evidence of volume overload, so
patient received 1 gram IV Ceftriaxone and 20mg IV Lasix.
.
ROS: 10-point ROS negative except as noted above in HPI.
.
Past Medical History:
- dementia
- Aflutter / Afib, on Coumadin
- Apical Hypertrophic Cardiomyopathy
- diastolic CHF
- DM2, on insulin
- HLD
- HTN
- COPD, no home O2
- ILD / pulmonary fibrosis
- Hypothyroidism
- Spinal stenosis
- Hemorrhoids
- h/o lung nodule
- Depression
- Hx of thrombocytopenia
- Tobacco abuse
- bilateral lumbar radiculopathy
Social History:
___
Family History:
per prior DC summary
"significant for CAD"
Physical Exam:
Admission Physical Exam:
VS: 98.3, 152/54, 100, 16, 96% on RA
Pain: zero/10
Gen: NAD, lying in bed comfortably
HEENT: anicteric, MMM
CV: irreg irreg, no murmur
Pulm: bibasilar rales, but comfortable
Abd: soft, NT, ND, NABS
Ext: trace edema at ankles, warm
Skin: no jaundice, no erythema
Neuro: AAOx3 ___ "BI," "___," fluent speech
Psych: calm, non-agitated
Pertinent Results:
Admission Labs:
10.3
5.8 >-------< 168
32.4
133 / 95 / 24
---------------< 235
3.7 / 26 / 1
Lactate 1.1
BNP - 1544
UA - nitrite POSITIVE, large leuks, >182 WBC's, many bacteria, 2
epi's.
Microbiology:
Blood cultures ___ x 1 set, ___ x 2 sets) - NEG
___ 11:10 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------------ <=2 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
Imaging:
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with confusion, drowsiness; decreased
lasix,
crackles b/l on exam. Eval for pulm edema, PNA.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs of ___, ___hest of ___.
FINDINGS:
There are diffusely increased interstitial lung markings due to
underlying
fibrotic changes, previously described as NSIP on the CT chest
of ___.
However, compared with the radiograph from ___, there
are increased
bilateral hazy opacities, raising the concern for pulmonary
edema. Heart size
is top normal. No confluent focal consolidation or pneumothorax
is
identified.
IMPRESSION:
1. Increased bilateral hazy opacities diffusely raises the
concern for
pulmonary edema. No confluent focal consolidation.
2. Diffused increased interstitial lung markings are also
attributed to
underlying fibrotic changes, described as NSIP on the CT chest
of ___.
EKG - NSR, no significant ST changes, non-specific T wave
changes.
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old woman with dementia, dCHF, DMII,
admitted w UTI
mild CHF exac. Now w cough. // re-assess pulm edema, r/o
infiltrate
re-assess pulm edema, r/o infiltrate
IMPRESSION:
As compared to ___, the pre-existing
manifestations of
relatively severe predominantly interstitial pulmonary edema
have only
minimally decreased in severity. Moderate cardiomegaly
persists. No new
focal parenchymal opacities indicating the presence of
pneumonia.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Digoxin 0.0625 mg PO 3X/WEEK (___)
3. Divalproex (EXTended Release) 750 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Furosemide 20 mg PO 4X/WEEK (___)
7. Furosemide 40 mg PO 3X/WEEK (___)
8. GlipiZIDE XL 10 mg PO DAILY
9. Glargine 20 Units Bedtime
10. Lactulose 15 mL PO DAILY:PRN constipation
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Lorazepam 0.5 mg PO QHS
13. Lorazepam 0.5 mg PO BID:PRN anxiety
14. Metoprolol Succinate XL 25 mg PO BID
15. Omeprazole 40 mg PO DAILY
16. RISperidone 1 mg PO QHS
17. RISperidone 0.5 mg PO DAILY
18. Spironolactone 25 mg PO DAILY
19. TraZODone 50 mg PO QHS
20. TraZODone 25 mg PO TID:PRN anxiety
21. Warfarin 5 mg PO DAILY16
22. Docusate Sodium 100 mg PO BID
23. Vitamin D 1000 UNIT PO DAILY
24. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
25. Multivitamins 1 TAB PO DAILY
26. Hydrocortisone Oint 1% 1 Appl TP DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Digoxin 0.0625 mg PO 3X/WEEK (___)
3. Divalproex (EXTended Release) 750 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Ezetimibe 10 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
8. GlipiZIDE XL 10 mg PO DAILY
9. Hydrocortisone Oint 1% 1 Appl TP DAILY
10. Glargine 22 Units Bedtime
11. Lactulose 15 mL PO DAILY:PRN constipation
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Lorazepam 0.5 mg PO QHS
14. Lorazepam 0.25 mg PO BID:PRN anxiety
15. Metoprolol Succinate XL 25 mg PO BID
16. Omeprazole 40 mg PO DAILY
17. RISperidone 1 mg PO QHS
18. RISperidone 0.5 mg PO DAILY
19. Spironolactone 25 mg PO DAILY
20. TraZODone 25 mg PO TID:PRN anxiety
21. Vitamin D 1000 UNIT PO DAILY
22. Warfarin 5 mg PO DAILY16
23. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
24. Multivitamins 1 TAB PO DAILY
25. TraZODone 25 mg PO QHS:PRN INSOMNIA
Discharge Disposition:
Home With Service
Facility:
___
___:
# metabolic encephalopathy
# urinary tract infection, pansensitive Ecoli
# acute on chronic diastolic CHF
SECONDARY DIAGNOSES:
# dementia
# neurocognitive disorder with mood instability
# DM type II, uncontrolled with complications
# HTN
# atrial fibrillation/ flutter
# hypothyroidism
# COPD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with confusion, drowsiness; decreased lasix,
crackles b/l on exam. Eval for pulm edema, PNA.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs of ___, ___ and CT chest of ___.
FINDINGS:
There are diffusely increased interstitial lung markings due to underlying
fibrotic changes, previously described as NSIP on the CT chest of ___.
However, compared with the radiograph from ___, there are increased
bilateral hazy opacities, raising the concern for pulmonary edema. Heart size
is top normal. No confluent focal consolidation or pneumothorax is
identified.
IMPRESSION:
1. Increased bilateral hazy opacities diffusely raises the concern for
pulmonary edema. No confluent focal consolidation.
2. Diffused increased interstitial lung markings are also attributed to
underlying fibrotic changes, described as NSIP on the CT chest of ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dementia, dCHF, DMII, admitted w UTI
mild CHF exac. Now w cough. // re-assess pulm edema, r/o infiltrate
re-assess pulm edema, r/o infiltrate
IMPRESSION:
As compared to ___, the pre-existing manifestations of
relatively severe predominantly interstitial pulmonary edema have only
minimally decreased in severity. Moderate cardiomegaly persists. No new
focal parenchymal opacities indicating the presence of pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion, Fatigue
Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS
temperature: 97.6
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 147.0
dbp: 52.0
level of pain: 0
level of acuity: 3.0 | ___ yo F with PMH including dementia NOS with mood disturbance,
Afib/Aflutter on Coumadin, dCHF / apical HCM on Lasix, DM2 on
insulin, COPD, ILD, recurrent UTI's, now presenting with
lethargy x 2 days, likely due to UTI, and also with evidence of
mild volume overload / dCHF flare.
# metabolic encephalopathy:
Multifactorial etiology, addressed underlying causes as below.
Mental status returned to baseline by the day prior to
discharge. Daughter and personal caregiver confirmed.
# UTI, pansensitive Ecoli:
Patient without urinary symptoms, but per daughter, patient
typically without urinary symptoms, only subtle changes in
mental status with UTI. Prior culture data with E. coli
resistant to fluoroquinolones only. Received IV ceftriaxone in
ED and per aide, mental status improved. She was subsequently
switched to po cipro and completed a five day course.
# dCHF, acute on chronic
# apical HCM
# Afib / Aflutter
Based on crackles on exam, elevated BNP and pulmonary congestion
on CXR, patient with mild CHF flare. Received 1 dose of IV
Lasix 20mg in ED. HR elevated, but missed ___ dose of
beta-blocker. On the medical floor, she was given her home dose
oral lasix, and I/O were monitored closely. She was continued on
her home beta-blocker, digoxin, and spironolactone. Digoxin
level was within therapeutic range. During her hospital course,
her po intake was poor especially when she was more somnolent.
This contributed to mild hypovolemia, and her lasix was held. It
was restarted at the time of discharge at a reduced dose, and
she will need close f/u of her volume status, renal function and
electrolytes. She was maintained on warfarin with close
monitoring INR given interaction with antibiotics.
# dementia/cognitive decline with mood disturbance NOS
Pt had a recent GeriPsych admission ___. Daughter is
concerned about ___ from multiple psychiatric
medications, although somnolence on admission was at least
partially due to acute infection from UTI. SHe is followed by
psychiatrist Dr. ___ at ___, last seen in
___ after her GeriPsych admission. Contacted Dr ___
___ consulted psychiatry regarding optimizing her psychiatric
meds, given the tenuous balance between sedation and agitation
in this patient. She was maintained on her regimen of Depakote,
Ativan, Trazodone, and risperidone, with minor adjustments in
dosing and timing of administration to reflect the med list in
Dr ___ note from ___. Mental status gradually
returned to baseline. During the last 24hrs of her
hospitalization, pt was alert, interactive, pleasantly confused
with short term memory loss, eating, and ambulating with walker.
# DM2, uncontrolled with complications
No recent A1C, last was 8.2% in ___. She was continued on
insulin glargine and covered with HISS. Also continue home
glipizide.
# COPD
# ILD
No acute issues. Stable on room air throughout her
hospitalization.
- continue PRN albuterol inhaler
.
# Hypothyroidism
- continue home levothyroxine dose
.
DVT PPx: Coumadin
Code Status: DNR, ok to intubate for reversible causes of
respiratory failure
. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Rectal pain, draiange
Major Surgical or Invasive Procedure:
___: Exam under anesthesia, drainage of abscess, ___
placement
History of Present Illness:
The patient is a ___ woman who last week underwent
placement of setons on the right side. At that time, we did not
have imaging, and the left side was actually probed but did not
have a lot of symptoms per the patient report, and we could not
really probe into the cavity. However, she presented with more
pain now on the left side. The imaging did show extension of
abscesses and fistula on the left in a full horseshoe fashion.
Risks and benefits including but not limited to infection,
bleeding, need for more procedures were discussed. The patient
understood and agreed to proceed with surgery.
Past Medical History:
IRON DEFICIENCY ANEMIA
CROHN'S DISEASE - GI Dr. ___, last seen in ___.
Symptoms since age ___, confirmed on colonoscopy in ___.
Currently controlled on "nothing", using alternative methods
(diet, previously on herbs though not at present).
Vitamin D Deficiency
H/O C-Diff Enterocolitis
H/O OSTEOPENIA BMD nl ___
H pylori s/p treatment ___
Social History:
___
Family History:
Mother: Alive and well.
Father: Alive and well.
Cancer History: Grandmother, brain cancer; grandfather, colon
cancer.
Coronary Artery Disease History: Grandfather.
Physical Exam:
VS: Please see flowsheets in POE
GEN: WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: normal excursion, no respiratory distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
PELVIS: shotty left inguinal adenopathy
EXT: WWP, no CCE
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 12:35PM BLOOD WBC-10.5* RBC-4.37 Hgb-11.2 Hct-36.2
MCV-83 MCH-25.6* MCHC-30.9* RDW-13.2 RDWSD-40.0 Plt ___
___ 12:35PM BLOOD Neuts-83.4* Lymphs-11.1* Monos-4.4*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-8.79*# AbsLymp-1.17*
AbsMono-0.46 AbsEos-0.04 AbsBaso-0.02
___ 12:35PM BLOOD ___ PTT-30.2 ___
___ 12:35PM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-140 K-3.9
Cl-100 HCO3-25 AnGap-15
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman with rectal pain// Please do fistula protocol.
Concern for fistula or abscess in setting of crohn's disease
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 5 mL Gadavist.
COMPARISON: Enterography ___, MR pelvis ___
FINDINGS:
RECTUM:
There is a complex transsphincteric perianal fistula arising from the
posterior 6 o'clock position approximately 2.4 cm above the anal verge (series
7, image 53). This tract branches into right and left secondary limbs.
Right-sided tract extends transphincterically from the 6 o'clock to 8 o'clock
position with tertiary branching anterior and posterior tracts extending
inferiorly and exiting out of the gluteal cleft. Posterior right-sided tract
contains a ___. These tracts are composed of granulation tissue.
Left-sided limb extends anterolaterally ending in multiple rim enhancing
multiloculated fluid collections. Largest fluid collections measure 1.1 x 1.8
cm in the left ischioanal fossa (series 7, image 43) and 2.0 x 1.2 cm adjacent
to the left vaginal wall (series 7, image 43). More superior fluid collection
exerts mass effect with secondary thickening of the left vaginal cuff with a
tract extending through the vaginal mucosa (series 7, image 38-34). Another
notable T1 hyperintense smaller fluid collection containing proteinaceous
debris is located between the vaginal introitus and inferior rectum measuring
1.2 x 0.7 cm (series 6, image 49). Overall severity has worsened since both
___ and since the most recent prior enterography. For example the right
sided tracts are new since that time and left-sided fluid collections are more
complex.
There is an additional intrasphincteric fistula arising from the 11 o'clock
anterior position just above the anal verge comprised of granulation tissue in
extending anteriorly to the perineum (series 7, image 62-64).
UTERUS AND ADNEXA:
The uterus is anteverted and measures 8.6 x 4.4 x 4.9 cm.
The endometrium is normal in thickness for age and measures 7 mmd.
The junctional zone is not thickened.
The right ovary is visualized and appears within normal limits.
The left ovary is visualized and appears within normal limits.
There is a small amount of free fluid in the pelvis. There is also edema
tracking along the left pelvic sidewall which is likely reactive.
LYMPH NODES: There are prominent bilateral obturator lymph nodes with the
largest on the left measuring 0.9 cm.
BLADDER AND DISTAL URETERS: The bladder is partially distended and
unremarkable.
VASCULATURE: Pelvic vasculature is patent.
OSSEOUS STRUCTURES AND SOFT TISSUES: There is an unchanged nonaggressive
appearing lesion most likely low grade chondroid lesion in the right femoral
head. No additional bony lesions are seen. Edema in the anterior left
sacroiliac joint is likely degenerative.
IMPRESSION:
1. Complex transsphincteric fistula arising from 6 o'clock position with left
and right secondary limbs.
2. Left-sided limb ends in a complex multiloculated abscess with the largest
liquified components measuring 1.8 x 1.1 inferiorly in the ischioanal fossa
and 1.2 x 2.0 cm superiorly at the level of the left vaginal cuff.
3. Superior collection causes secondary inflammation of the left vaginal wall
with fistulous extension through the vaginal mucosa.
4. Right-sided limbs composed of granulation tissue with a ___.
5. Second anterior intrasphincteric fistula arising just above the anal verge
composed of granulation tissue.
6. Enlarged pelvic sidewall lymphadenopathy, likely reactive.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Rectal pain
Diagnosed with Other specified diseases of anus and rectum
temperature: 98.9
heartrate: 108.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 75.0
level of pain: 10
level of acuity: 3.0 | ___ is a ___ year-old woman with a history of
Crohn's disease who presented with concerns of increasing
perirectal pain and drainage following an EUA and ___
placement several days prior. A MRI was obtained which showed
extension of a perirectal abscess. She was admitted on ___
for pain control and pre-operative planning. The patient was
brought to the operating room where they underwent an EUA,
drainage of abscess and ___ placements. The patient tolerated
the procedure without complications. She was discharged to home
the evening of POD#0. On POD#0 the patient was tolerating a
regular diet, pain was well controlled on an oral pain regimen,
and they had regular flatus/BMs. The patient was discharged from
the hospital in stable condition with follow up in clinic in ___
weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / clarithromycin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ woman with a history of mild cerebral
palsy who presents with abdominal pain and burning. This is her
third presentation for the same problem in the last week. She
reports symptoms began on ___ when she developed abdominal
pain, nausea, vomiting, and diarrhea. She presented to the ED
where her labs were normal, VS were stable, diarrhea and
vomiting had resolved and she was discharged home after
tolerating PO. She returned on ___ reporting weakness, joint
stiffness, abdominal pain, diarrhea, nausea and vomiting. CT
abdomen done at the time did not reveal any acute process or
structural abnormalities to which her pain could be attributed,
labs were again unremarkable. She was discharged with diagnosis
of likely viral gastroenteritis.
On day of admission, she called the ___
service reporting burning in addition to pain and they referred
her back to the ED. She reports that she began to experience
burning at the same location as her abdominal pain. She
describes the pain as constant, diffuse but more intense in the
LLQ, ___. She also reports dark stools and some bright red
blood on toilet paper.
Prior to the onset of her syptoms, she reports she was in her
usual state of health. She denies any new foods or exposures.
Denies any recent life events aside from death of her boyfriend
in ___.
In the ED, initial VS were: 98.1 62 ___ 100%. She had
guaiac positive stool. She received morphine and 1L NS.
On arrival to the floor, she reports that pain continues ___
and is worse when pressure is applied on it even though the
burning gets better with pressure to the area. She reports not
having nausea and vomiting for the last 48 hours. Her last loose
stool was yesterday morning. She reports fever to ___ at
home that resolved with ibuprofen. She denies dizziness,
lightheadedness, CP, SOB, rash, arthralgias, or vision changes.
She has not had a period since having a D&C in ___ and has not
been sexually active since ___, when her boyfriend passed
away.
Past Medical History:
CP: does not require assist device, not on medication
MVP
Social History:
___
Family History:
Adopted. Mother is from ___.
no history of GI disorder to her knowledge
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.1 F, BP 81/51, HR 56, R 18, ___ 99% RA
GENERAL - Pleasant, ___ woman in NAD,
sleeping comfortably and easily arousable.
HEENT - Sclera anicteric, MMM, OP clear, PERRL
NECK - No lymphadenopathy, supple, soft
LUNGS - CTA bilat, no wheezes, ronchi, crackles.
HEART - RRR, normal S1 and S2. No murmurs, rubs, or gallops.
ABDOMEN - Soft, non distended, with tenderness throughout but
worse on LLQ. No rebound or guarding. +BS. no masses or HSM.
RECTAL EXAM - Normal rectal tone, no hemorrhoids or fissures. No
mass appreciated in the rectum. No stool obtained during exam.
EXTREMITIES - Warm, well perfused. No edema. 2+ peripheral
pulses.
SKIN - no rashes or lesions
NEURO - A&Ox3, CNs ___ intact, full motor strength
throughout, intact RAM and ___. No tremor or asterixis.
DISCHARGE PHYSICAL EXAM:
VS - Temp 98.4 F, BP ___, HR ___, R 18, ___ 99% RA
GENERAL - Pleasant, ___ woman in NAD,
sleeping comfortably and easily arousable.
HEENT - Sclera anicteric, MMM, OP clear, PERRL
NECK - No lymphadenopathy, supple, soft
LUNGS - CTA bilat, no wheezes, ronchi, crackles.
HEART - RRR, normal S1 and S2. No murmurs, rubs, or gallops.
ABDOMEN - Soft, non distended, with tenderness throughout but
worse on LLQ. No rebound or guarding. +BS. no masses or HSM.
RECTAL EXAM ___ ___- Normal rectal tone, no hemorrhoids or
fissures. No mass appreciated in the rectum. No stool obtained
during exam.
EXTREMITIES - Warm, well perfused. No edema. 2+ peripheral
pulses.
SKIN - no rashes or lesions
NEURO - A&Ox3, CNs ___ intact, full motor strength
throughout, intact RAM and ___. No tremor or asterixis.
Pertinent Results:
___ 02:35AM BLOOD ___
___ Plt ___
___ 09:00AM BLOOD ___
___ Plt ___
___ 02:35AM BLOOD ___
___
___ 02:35AM BLOOD ___
___
___ 02:35AM BLOOD ___
___ 02:35AM BLOOD ___
___ 02:35AM BLOOD ___
___ 02:41AM BLOOD ___
___ 12:24PM URINE ___ Sp ___
___ 12:24PM URINE ___
___
___ 12:24PM URINE ___
___ TransE-<1
___ TVUS: FINDINGS: On transabdominal imaging, the uterus
measures 6.5 x 2.9 x 4.5 cm. An endovaginal exam was performed
for better visualization of the endometrium and adnexa. The
endometrium is thin and somewhat difficult to visualize
measuring 2 mm. The uterus is normal in appearance. No
suspicious adnexal mass is identified. The ovaries could not be
visualized. Multiple loops of bowel are seen within the pelvis.
No free fluid is visualized. IMPRESSION: Normal appearing
uterus. The ovaries were not identified.
Radiology Report
HISTORY: ___ female with left lower quadrant abdominal pain.
COMPARISON: Abdomen and pelvic CT ___.
FINDINGS:
On transabdominal imaging, the uterus measures 6.5 x 2.9 x 4.5 cm. An
endovaginal exam was performed for better visualization of the endometrium and
adnexa. The endometrium is thin and somewhat difficult to visualize measuring
2 mm. The uterus is normal in appearance. No suspicious adnexal mass is
identified. The ovaries could not be visualized. Multiple loops of bowel are
seen within the pelvis. No free fluid is visualized.
IMPRESSION:
Normal appearing uterus. The ovaries were not identified.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN LLQ
temperature: 98.1
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 105.0
dbp: 75.0
level of pain: 7
level of acuity: 3.0 | ___ woman with a history of mild cerebral palsy who presents
with abdominal pain and burning for the last 7 days with normal
labs and CT abdomen, found to have guaiac+ stool in the ED and
admitted for further workup.
# Abdominal pain: LLQ pain with guaiac+ stool is most
consistent with diverticulitis. However, CT abdomen done on
___ for similar complaint was normal without signs of
diverticuli. Resolved n/v/d makes it also less likely to be a
gastroenteritis in the setting of continued pain. PID is also
unlikely as patient has not been sexually active since ___.
Pelvic pathology such as ovarian cyst, torsion, or malignancy
must be considered and transvaginal US would better evaluate
these structures. Peptic ulcer disease cannot be ruled out at
this time but less likely as pain is stronger in LLQ, not in the
epigastric region, and NSAID use has been minimal. Would
consider an EGD as she has never had one before and now has
guaiac + stool. Hepatobiliary causes less likely in the setting
of normal LFTs. Pancreatitis is also less likely in setting of
normal lipase. Meckel's diverticulum is unlikely as she is ___
and CT did not show any signs of acute process. Pelvic US
unremarkable for pathology/structual lesions, UA negative. No
signs of active bleeding, worsening pain in conjuction with lack
of BM suggests that may be cause.
Patient had no futher stools while in house to ___; Hb/Hct
stable throughout admission without stigmata of bleeding. She
was started on PPI for one month or until EGD done as an
outpatient. She did not require pain medications aside from
tylenol. Given recent daily NSAID use, recommend strongly
against any further use given side effect profile and likely GI
bleed.
NSAIDS were stopped, and patient was placed on a bowel regimen
upon discharge.
# Cerebral Palsy: stable, no issues during this admission
# MVP: stable, no issues at this time.
>>Transitional Issues:
- ___ with new PCP
- ___ with outpatient GI for w/u of abdominal pain
- WBC low upon discharge however has been low in the past,
recommend recheck with PCP next week |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ ex-lap, Right colectomy
History of Present Illness:
HPI: ___ was on a cruise in ___ when she experienced some
right sided abdominal pain and distension 3 days ago. The pain
subsided and the cruise physician suspected it may be
gallbladder
related. The pain recurred the next day and resolved again.
They then docked in ___ and proceeded to make their way
home.
This was when the pain was the most severe, where she
experienced
abdominal pain with every step while walking. The flight from
___ to ___ was uneventful and she had no complaints of
pain. She went to bed around 8pm last evening and then awoke at
3am with the same share recurrent right sided pain. She denies
nausea and emesis. She has been having normal BMs and passing
flatus. She does feel distended and uncomfortable. She has had
one episdoe of an SBO in ___ treated conservatively. She is
currently on Tarceva for metastatic bony lesions from her NSCLC.
Past Medical History:
1. NSCLCA - Stage 1A s/p VATS in ___, RLL lesion benign
appearing on CT, stable with repeat.
2. Acoustic neuroma (Dx ___ yrs) - stable per recent f/u MRI ___. SBO - treated conservatively ___.
4. Hypothyroidism
5. Colon Polyp
6. Internal hemorrhoids.
7. Enuresis ___ yrs)
.
PSH:
1. s/p VATS assisted left lower lobectomy for a stage IA
adenocarcinoma of the lung with flexible bronchoscopy; ___. Cervical mediastinoscopy with lymph node biopsies of 4L, 4R,
7 LN stations; Flexible bronchoscopy. ___. TAHBSO in ___ for fibroids
4. ovarian cyst excision
5. removal of a thyroid cyst
6. cataract removal OD
7. 2x Achilles tendon surgeries
Social History:
___
Family History:
non-contributory, No hx of seizures in the family
Physical Exam:
PHYSICAL EXAMINATION: ___ admission examination
Temp: 98.6 HR: 75 BP: 120/82 Resp: 18 O(2)Sat: 96 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, diffuse ttp L>R
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Pertinent Results:
___ 06:25AM BLOOD WBC-3.8* RBC-3.21* Hgb-10.1*# Hct-31.8*
MCV-99* MCH-31.4 MCHC-31.7 RDW-12.7 Plt ___
___ 01:31AM BLOOD WBC-6.0# RBC-3.99* Hgb-12.8 Hct-39.6
MCV-99* MCH-32.1* MCHC-32.5 RDW-12.8 Plt ___
___ 01:31AM BLOOD Neuts-74.9* Lymphs-16.2* Monos-6.8
Eos-1.7 Baso-0.4
___ 06:25AM BLOOD Plt ___
___ 09:20AM BLOOD Glucose-115* UreaN-6 Creat-0.6 Na-143
K-4.0 Cl-109* HCO3-27 AnGap-11
___ 01:31AM BLOOD ALT-51* AST-49* AlkPhos-60 TotBili-0.9
___ 06:40AM BLOOD Calcium-8.1* Phos-4.1# Mg-1.7
EKG: ___:
Sinus rhythm. Left atrial enlargement. Poor R wave progression
in
leads V1-V4 raises the possibility of old anteroseptal
myocardial infarction.
There are diffuse ST-T wave changes in leads II, III, aVF and
V3-V6 which
raises the possibility of myocardial ischemia. Compared to the
previous
tracing of ___ ST-T wave abnormalities are new. Clinical
correlation is suggested
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. High-grade cecal volvulus, dilated up to 10 cm with the
"beak" in the
right upper quadrant below the liver edge. The cecum points
towards the left upper quadrant. Distal small bowel loops are
dilated to 2.7 cm. Moderate amount of simple free fluid in the
pelvis and throughout the abdomen.
2. Diffuse sclerotic metastatic disease, progressed since
___.
3. Bibasilar atelectatic changes.
Medications on Admission:
Tarceva 150mg qday, Levoxyl 75mcg daily, metoprolol 12.5mg
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Erlotinib 150 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
hold for systolic blood pressure <110, hr <60
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Docusate Sodium 100 mg PO BID
HOLD FOR DIARRHEA
Discharge Disposition:
Home
Discharge Diagnosis:
volvulos
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with abdominal pain.
TECHNIQUE: Contiguous MDCT images through the abdomen and pelvis were
performed after the administration of intravenous contrast. Axial, coronal,
and sagittal reformats were acquired.
COMPARISON: CT of the torso from ___.
FINDINGS:
CT OF THE ABDOMEN:
There are bibasilar atelectatic changes (right greater than left). There are
no focal hepatic lesions. Hyperenhancing focus in segment V/VI is unchanged
likely a perfusion artifact. The gallbladder is normal. There is mild
periportal edema. The pancreas, spleen, both adrenal glands and kidneys are
normal. There is no retroperitoneal or mesenteric lymphadenopathy. The
portal venous, systemic venous and systemic arterial system of the abdomen and
pelvis are normal. Small esophageal hiatal hernia. There is a cecal volvulus
with the beak in right upper quadrant just below the liver edge (series 602B,
image 13). The cecum projects towards the left upper quadrant and is dilated
to 10 cm. The distal ileum small bowel loops are fluid filled and dilated to
2.7 cm. There is moderate amount of free fluid in the pelvis and surrounding
the liver with Hounsfield unit measurements 15 consistent with simple fluid.
CT OF THE PELVIS:
The urinary bladder is normal. No pelvic lymphadenopathy.
BONES: There are diffuse pelvic and spinal sclerotic metastases from
patient's known history of lung cancer, progressed since ___. No
acute compression fractures are seen.
IMPRESSION:
1. High-grade cecal volvulus, dilated up to 10 cm with the "beak" in the
right upper quadrant below the liver edge. The cecum points towards the left
upper quadrant. Distal small bowel loops are dilated to 2.7 cm. Moderate
amount of simple free fluid in the pelvis and throughout the abdomen.
2. Diffuse sclerotic metastatic disease, progressed since ___.
3. Bibasilar atelectatic changes.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with VOLVULUS OF INTESTINE, SECONDARY MALIG NEO BONE, HX-BRONCHOGENIC MALIGNAN
temperature: 98.6
heartrate: 75.0
resprate: 18.0
o2sat: 96.0
sbp: 120.0
dbp: 82.0
level of pain: 9
level of acuity: 3.0 | The patient was admitted to the acute care with right sided
abdominal pain and distention. Upon admission, she was made NPO,
given intravenous fluids, and underwent imaging. She was
reported to have a cecal volvulus. The initial EKG showed
diffuse ST changes in the inferior and leads V3-V6. A
___ tube was placed for gastric decompression. Because
of these findings, she was taken to the operating room for a an
exploratory laparotomy and right colectomy. The operative
course was stable. A thoracic epidural catheter was placed for
post-operative management. She was extubated after the
procedure and monitored in the recovery room. She required
additional intravenous fluids in the recovery room for a
decreased blood pressure.
The post-operative course was uneventful. The patient's vital
signs were closely monitored and electrolytes repleted. The
epidural catheter was pulled on POD #1 after premature
disconnection of the line. The ___ tube was removed
after the gastric secretions had decreased. She was maintained
on oral analgesia for management of the incisonal pain. She was
started on clear liquids POD #3 and advanced to a regular diet
on POD # 4. On POD #4, she began experiencing bouts of
diarrhea. A c.diff culture was sent and reported as negative.
Stool cultures were pending upon discharge. Repeat EKG prior to
discharge continues to show poor r wave progression, but the st
changes in V3-6 have resolved.
Her vital signs have remained stable and she has been afebrile.
She is preparing for discharge home with instructions to
follow-up in the acute care clinic in 1 week for staple removal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right pneumothorax
Major Surgical or Invasive Procedure:
___ Pigtail catheter placement by interventional
pulmonary.
History of Present Illness:
___ old female in usual state of health who reported having
sudden onset right chest pain with difficulty breathing 10 days
ago with some spontaneous
improvement. However, symptoms did not fully resolve so she saw
her PCP 3
days ago whereupon CXR demonstrated a right pneumothorax. She
was referred
to ___ where the pneumothorax appeared stable over 4
hours and she
was discharged home. Follow-up CXR today showed persistent
pneumothorax, so she was referred to ___ ED for tube
thoracostomy.
Past Medical History:
PAST MEDICAL HISTORY:
Mitral valve prolapse (takes antibiotics prior to dental
procedures), history right breast cancer in ___ status-post
right mastectomy and chemotherapy/radiation therapy
PAST SURGICAL HISTORY:
Right mastectomy with pedicled latissimus flap reconstruction
___, laparoscopic cholecystectomy ___
Social History:
___
Family History:
Mother with breast cancer. Denies other family history of
cancer. Denies family history of lung disease
Physical Exam:
VITAL SIGNS STABLE
GENERAL: No acute distress; alert and fully oriented
CARDIAC: Regular rate and rhythm; normal S1 and S2; no
appreciable murmurs
CHEST: Pigtail catheter site clean, dry, and intact with
dressing in place; no drainage or surrounding erythema
PULMONARY: Clear to auscultation bilaterally
ABDOMEN: Soft, non-tender, non-distended; no palpable masses
EXTREMITIES: No swelling or edema bilaterally
Pertinent Results:
Radiology:
Chest X-ray ___:
FINDINGS: A new pigtail catheter has been placed and projects
over the right hemithorax. There is a small residual right
apical pneumothorax but markedly decreased. Irregularity along
the superior margin of the right pleural surface suggests that a
bleb may be the etiology, although a discrete bleb is not
visualized. The lungs appear otherwise clear. There are no
pleural effusions or pneumothorax. The cardiac, mediastinal and
hilar contours appear unchanged.
IMPRESSION: Small residual right apical pneumothorax, but
markedly decreased following chest tube placement
Chest X-ray ___:
Small right pneumothorax is unchanged. Right apical pigtail
catheter is in
unchanged position. Cardiac size is top normal. The lungs are
grossly clear. There is no pleural effusion or left pneumothorax
Chest X-ray ___: Following 1-hour clamp trial
Minimal right apical pneumothorax is unchanged and right apical
pigtail
catheter is in unchanged position. Cardiomediastinal contours
are unchanged. Right lower lobe atelectasis has resolved. The
left lung is clear
Chest X-ray ___: Following 6-hour clamp trial
Volume of the right apical pneumothorax is little changed over
the past 24
hours with the lung apex at the level of the third posterior rib
and no
appreciable pleural effusion anteriorly placed. Pigtail drainage
catheter is unchanged in position. Lungs are clear aside from
linear atelectasis at the left base and the heart is normal
size. Normal mediastinal and hilar
contours
Medications on Admission:
None
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every ___ hours as needed for pain: do not drive on narcotics.
Disp:*60 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): taking while taking percocet to prevent
constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right spontaneous pneumothorax.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Followup of known pneumothorax status post chest tube placement.
COMPARISONS: Outside radiograph from ___ from earlier on the same
day.
TECHNIQUE: Chest, AP upright.
FINDINGS: A new pigtail catheter has been placed and projects over the right
hemithorax. There is a small residual right apical pneumothorax but markedly
decreased. Irregularity along the superior margin of the right pleural
surface suggests that a bleb may be the etiology, although a discrete bleb is
not visualized. The lungs appear otherwise clear. There are no pleural
effusions or pneumothorax. The cardiac, mediastinal and hilar contours appear
unchanged.
IMPRESSION: Small residual right apical pneumothorax, but markedly decreased
following chest tube placement.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Patient with spontaneous pneumothorax with PICC tail
catheter in place.
Comparison is made with prior study performed a day before.
Small right pneumothorax is unchanged. Right apical pigtail catheter is in
unchanged position. Cardiac size is top normal. The lungs are grossly clear.
There is no pleural effusion or left pneumothorax.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST.
REASON FOR EXAM: Assess for pneumothorax, chest tube clamp.
Comparison is made with prior study performed six hours earlier.
Minimal right apical pneumothorax is unchanged and right apical pigtail
catheter is in unchanged position. Cardiomediastinal contours are unchanged.
Right lower lobe atelectasis has resolved. The left lung is clear.
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: Right apical pneumothorax.
IMPRESSION: PA and lateral chest compared to ___ and through 28 at
3:07 p.m.:
Volume of the right apical pneumothorax is little changed over the past 24
hours with the lung apex at the level of the third posterior rib and no
appreciable pleural effusion anteriorly placed. Pigtail drainage catheter is
unchanged in position. Lungs are clear aside from linear atelectasis at the
left base and the heart is normal size. Normal mediastinal and hilar
contours.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: PNEUMOTHORAX
Diagnosed with OTHER PNEUMOTHORAX
temperature: 98.0
heartrate: 58.0
resprate: 18.0
o2sat: 100.0
sbp: 110.0
dbp: 38.0
level of pain: 1
level of acuity: 2.0 | Given the relatively long duration that the patient's right
pneumothorax had presumably been in place, it was determined
unlikely to resolve without intervention. Therefore she
underwent placement of a right-sided apical pig-tail catheter
for evacuation of her pneumothorax performed by the
interventional pulmonary team at bedside. Post-placement film
demonstrated significant resolution with only a small residual
apical pneumothorax.
The patient did well overnight and had good oxygen saturations
on room air. The following morning a repeat chest X-ray remained
unchanged as compared to previously, and a trial-clamp of the
tube was performed. After 1 and 6-hour intervals repeat chest
X-rays were performed, both of which remained stable: the
patient's right lung was well-inflated with only a tiny remnant
of an apical pneumothorax. It was determined appropriate at that
time to remove the pigtail cathetera and the patient was
discharged home after several more hours of monitoring.
At the time of discharge she had no pain issues, was saturating
well on room air, was ambulating independently without shortness
of breath or chest pain, and had remained hemodynamically stable
and afebrile through-out the entirety of her hospital stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Motor vehicle crash.
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of right medial malleolar
fracture.
History of Present Illness:
___ MVC vs tree passenger, intubated in ED agitation,
sustaining Grade III liver laceration, hepatic subcapsular
hematoma, R renal laceration, R mandibular condyle fracture, L
wrist fracture, and R ankle fracture.
Past Medical History:
None.
Social History:
___
Family History:
- Mother: Healthy
- Father: DVT after knee surgery s/p warfarin x 6 months, no
recurrence
- No other family history of clotting or miscarriages
Physical Exam:
Physical Exam on admission:
Temp: afeb BP: 120 to 180/P Resp: 31 O(2)Sat: 100 Normal
Constitutional: Immob but agitated
HEENT: Facial abrasions. Blood in OP
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Rectal: Heme Negative, Normal prostate
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: GCS 13
Psych: Agitated uncoop
___: No petechiae
On discharge: ___:
vital signs: t=96.2, bp=126/78, hr=81, resp. rate 18, oxygen
saturation 98% rooom air
General: NAD
CV: ns1m s2m -s3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: Cast left arm, +CSM fingers left, bruising right forearm,
+ radial right, lower ext: air cast rigth foot, + dp, left
foot: +dp, no calf tenderness
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 02:15AM BLOOD Glucose-171* UreaN-13 Creat-1.1 Na-142
K-3.7 Cl-104 HCO3-23 AnGap-19
___ 02:15AM BLOOD ___ PTT-26.0 ___
___ 01:00PM BLOOD PTT-58.1*
___ 12:50AM BLOOD PTT-58.9*
___ 05:00AM BLOOD ___ PTT-59.3* ___
___ 10:35AM BLOOD PTT-52.1*
___ 02:15AM BLOOD WBC-14.9* RBC-5.04 Hgb-14.9 Hct-43.3
MCV-86 MCH-29.5 MCHC-34.3 RDW-12.3 Plt ___
___ 05:38PM BLOOD WBC-5.4 RBC-4.28* Hgb-12.8* Hct-35.9*
MCV-84 MCH-29.8 MCHC-35.6* RDW-12.3 Plt ___
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 04:50 18.7*1 1.8*
.
CT Torso:
IMPRESSION:
1. Large liver laceration centered within the right hepatic lobe
with an associated small subcapsular liver hematoma. No evidence
of active extravasation. 2. Likely right lower pole renal
laceration, extending to but not definitely violating the
collecting system. There is an associated small subcapsular
right renal hematoma. 3. Hyperdense right adrenal lesion
measuring up to 3.7 cm is likely a hematoma, especially given
the adjacent hepatic and right kidney injuries. However, an
underlying adrenal mass cannot be excluded, and followup CT with
adrenal protocol should be performed after the patient has fully
recovered. 4. Bilateral dependent consolidative opacities are
most consistent with aspiration in the setting of intubation. 5.
ET tube ends in the proximal right mainstem bronchus. Recommend
withdrawing by 5 cm for appropriate positioning. 6. Tiny right
pleural effusion.
.
CT head:
Minimally displaced fracture through the right mandibular
condyle.
.
L Wrist plain film:
Minimally displaced fractures through the distal radius, with
intra-articular extension.
.
R ankle plain film:
Displaced intra-articular fracture through the medial malleolus
with associated widening of the medial ankle mortise.
.
CT sinus/mandible: IMPRESSION: Comminuted right mandibular
condyle fracture. The mandibular condyle remains appropriately
positioned within the glenoid fossa. No additional fractures.
.
___ CTA PE protocl:
IMPRESSION:
1. Right main arterial pulmonary embolism without evidence of
right heart
strain.
2. Linear defect through the left hemidiaphragm could be
congenital or the
result of traumatic injury or could represent a CT artifact.
Medications on Admission:
none
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): To be given until INR
therapeutic on coumadin, goal INR ___.
Disp:*20 injection* Refills:*0*
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take 2 tablets for a total of 4 mg every day at the same
time until ___. At that time the ___ clinic will contact
you to adjust dose, goal INR ___.
Disp:*60 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
___, draw ___ and fax results to the ___
___ at ___ at ___. Goal INR ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
s/p MVC:
Injuries:
Grade III liver laceration
Sub-capsular hepatic hematoma
Right renal laceration w/ subcapsapular hematom
Right mandibular fracture, minimally displaced
Left distal radius fracture
Right medial malleolar fracture
Secondary:
Right main artery pulmonary embolism
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: Status post MVC, car into tree. Evaluate for trauma.
COMPARISON: None.
AP CHEST, ONE VIEW: A trauma board slightly limits evaluation of these
radiographs. The endotracheal tube extends into the proximal portion of the
right mainstem bronchus. Lung volumes are low. The lungs are clear. There
are no pleural effusions. No pneumothorax is seen. The cardiac and
mediastinal contours are normal. An NG tube passes below the level of the
left hemidiaphragm, curling superiorly within the gastric cardia. The bony
thorax is intact.
AP PELVIS, ONE VIEW: No fracture or dislocation. A left femoral catheter is
noted.
IMPRESSION:
1. No acute cardiac or pulmonary process.
2. ET tube ends within the proximal right main stem bronchus and should be
withdrawn by 6 cm for appropriate positioning.
3. Bony pelvis is grossly intact.
Pertinent findings were discussed with Dr. ___ by Dr. ___ at
2:33 a.m. via telephone on the day of the study.
Radiology Report
INDICATION: Status post MVC, car into tree. Now with altered mental status.
Evaluate for trauma.
TECHNIQUE: MDCT axial images were acquired through the cervical spine without
the administration of intravenous contrast material. Multiplanar reformations
were performed.
COMPARISON: None.
FINDINGS: There is no acute cervical spine fracture. As noted on the
accompanying head CT, there is a minimally displaced fracture through the
right mandibular condyle (3:5). There is no prevertebral soft tissue edema or
hematoma. Note is made of an ET tube and an oro/nasogastric tube. There are
no pathologically enlarged cervical lymph nodes. The thyroid gland is grossly
unremarkable. Bilateral dependent consolidative opacities in the lung apices
could relate to aspiration during intubation. The visualized portions of the
lung apices are otherwise clear. The imaged aspects of the mastoid air cells
are well aerated. This study was not optimized for evaluation of the
intracranial contents. Limited evaluation of the posterior fossa is
unremarkable.
IMPRESSION:
1. No acute cervical spine fracture or malalignment.
2. Minimally displaced fracture through the right mandibular condyle.
Further evaluation is recommended with a dedicated maxillofacial CT.
Radiology Report
INDICATION: Status post trauma, MVC into tree. Now with altered mental
status. Evaluate for acute intracranial process.
TECHNIQUE: Sequential axial images were acquired through the head without the
administration of intravenous contrast material. Multiplanar reformations
were performed.
COMPARISON: None.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of
normally midline structures, hydrocephalus, or acute large vascular
territorial infarction. The ocular globes are intact. The visualized
portions of the paranasal sinuses and mastoid air cells are well aerated.
There is a minimally displaced fracture through the right mandibular condyle
(3:9). No additional fractures are identified.
IMPRESSION:
1. No acute intracranial process.
2. Minimally displaced fracture through the right mandibular condyle.
Radiology Report
INDICATION: Status post MVC, car into tree. Now with altered mental status.
Evaluate for trauma.
TECHNIQUE: MDCT axial images were acquired from the thoracic inlet through
the lesser trochanters following infusion of 130 cc of intravenous contrast
material. Subsequently, rapid axial images were acquired through the pelvis
after infusion of 500 cc of water-soluble contrast material into the bladder
via a Foley catheter. Multiplanar reformations were performed.
COMPARISON: None.
CHEST CT: There are bilateral consolidative dependent opacities, most
consistent with aspiration in the setting of recent intubation. There is also
minimal bilateral dependent atelectasis. The lungs are otherwise clear. The
airways are patent to the subsegmental levels bilaterally. There is a tiny
right pleural effusion. No pneumothorax is seen.
The heart and great vessels are grossly normal. There is no pericardial
effusion. No pathologically enlarged mediastinal, hilar, or axillary lymph
nodes are seen. The visualized portion of the thyroid gland is normal. The
endotracheal tube ends in the proximal right mainstem bronchus (2:17).
ABDOMEN CT: An ill-defined 8.8 x 3.0 x 5.7 cm hypodense region centered
within the right hepatic lobe (2:44, 300B:30) is consistent with a liver
laceration. There is also a small subcapsular liver hematoma along the
inferior portion of the right hepatic lobe (300B:39). There is no evidence of
active extravasation. There is no intrahepatic biliary duct dilatation. The
portal vein is patent and appears intact. The gallbladder is unremarkable.
The spleen is grossly normal. The pancreas is unremarkable. The left adrenal
gland and kidney are grossly normal. A 3.7 x 2.0 x 2.3 cm hyperdense lesion
is seen within the expected area of the right adrenal gland, possibly an
adrenal hematoma or mass. A linear hypodensity in the anterior aspect of the
right lower renal pole could be a laceration, extending near but not
definitely violating the collecting system (2:69). There is a small
subcapsular right renal hematoma, not significantly compressing the parenchyma
(2:68, 300B:38). The kidneys secrete contrast symmetrically. The ureters are
grossly unremarkable.
An NG tube is seen entering the stomach, ending within the gastric cardia.
The stomach, small bowel, and colon are grossly normal. The appendix is
unremarkable. There may be a small quantity of free fluid in the right
paracolic gutter, likely hemorrhagic material (2:72). There is no free air in
the abdomen. No pathologically enlarged abdominal lymph nodes are seen. The
abdominal aorta is normal in caliber and its main branches are patent.
PELVIS CT: The bladder is unremarkable, without evidence of perforation. A
Foley catheter is noted within the inferior aspect of the bladder. There is
no free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes
are seen. Minimal stranding in the left inguinal region likely relates to
recent femoral line placement. The left femoral line extends to the upper
left external iliac vein.
BONE WINDOW: No fractures are identified. There are no suspicious lytic or
blastic lesions.
IMPRESSION:
1. Large liver laceration centered within the right hepatic lobe with an
associated small subcapsular liver hematoma. No evidence of active
extravasation.
2. Likely right lower pole renal laceration, extending to but not definitely
violating the collecting system. There is an associated small subcapsular
right renal hematoma.
3. Hyperdense right adrenal lesion measuring up to 3.7 cm is likely a
hematoma, especially given the adjacent hepatic and right kidney injuries.
However, an underlying adrenal mass cannot be excluded, and followup CT with
adrenal protocol should be performed after the patient has fully recovered.
4. Bilateral dependent consolidative opacities are most consistent with
aspiration in the setting of intubation.
5. ET tube ends in the proximal right mainstem bronchus. Recommend
withdrawing by 5 cm for appropriate positioning.
6. Tiny right pleural effusion.
Radiology Report
INDICATION: Status post MVC, now with absent radial pulse. Please evaluate
for fracture.
COMPARISON: None.
LEFT WRIST, THREE VIEWS: There is a minimally displaced, obliquely oriented
distal radial fracture with intra-articular extension. An additional fracture
line is seen along the ulnar aspect of the distal radius, also with
intra-articular extension. There is possibly a chip fracture from the ulnar
styloid process. No dislocation. Soft tissue swelling is seen at the wrist
joint.
IMPRESSION:
1. Minimally displaced fractures through the distal radius, with
intra-articular extension.
2. Possible ulnar styloid chip fracture.
Radiology Report
INDICATION: Right ankle swelling, evaluate for fracture. The patient is
status post MVC, car into tree.
COMPARISON: None.
RIGHT ANKLE, THREE VIEWS: There is a displaced fracture of the medial
malleolus with intra-articular extension into the tibiotalar joint. The
medial ankle mortise is widened. No additional fracture or dislocation. Soft
tissue swelling is seen surrounding the ankle.
TIBIA/FIBULA, FOUR VIEWS: No fractures are seen aside from the aforementioned
medial malleolar fracture.
IMPRESSION: Displaced intra-articular fracture through the medial malleolus
with associated widening of the medial ankle mortise.
Radiology Report
INDICATION: MVC, car versus tree. Right mandibular condylar fracture seen on
head and C-spine CT. Further evaluate condylar fracture and assess for
additional fractures.
TECHNIQUE: MDCT axial images were acquired through the facial bones without
the administration of intravenous contrast material. Multiplanar reformations
were performed.
COMPARISON: CT C-spine from ___.
FINDINGS: There is a comminuted, obliquely oriented fracture through the
inferior aspect of the right mandibular condyle (401A, 121, 2:73). No
additional fractures are seen. The mandibular condyles are appropriately
positioned within the glenoid fossae. The paranasal sinuses and mastoid air
cells are well aerated. The ostiomeatal units are patent bilaterally. The
lamina papyracea and cribriform plates are intact. The bony nasal septum
deviates to the left. Note is made of an orogastric tube and endotracheal
tube. The orbits are grossly normal.
IMPRESSION: Comminuted right mandibular condyle fracture. The mandibular
condyle remains appropriately positioned within the glenoid fossa. No
additional fractures.
Radiology Report
CHEST RADIOGRAPH
INDICATION: ETT placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the previously
malpositioned endotracheal tube has been re-positioned. The right main
bronchus is now free, the tip of the tube projects 4.2 cm above the carina.
The tube could be advanced by 1 cm. No evidence of complications, notably no
pneumothorax. No visible rib fractures. The course and position of the
orogastric tube is unremarkable.
Radiology Report
RIGHT ANKLE
INDICATION: Post-surgical control.
FINDINGS: Three fluoroscopic views are provided of the right ankle, where an
ORIF has been performed. The two screws appear to be correctly positioned.
Radiology Report
INDICATION: ___ man with recent surgery and tachycardia, evaluate for
PE protocol.
COMPARISON: CT of the chest, abdomen, and pelvis on ___.
TECHNIQUE: MDCT images were acquired through the chest with IV contrast.
Standard soft tissue algorithms, thin sections and multiplanar reformations
were obtained and reviewed.
FINDINGS:
There is a pulmonary embolism in the right main pulmonary artery extending
into the right upper and lower lobe arteries. No evidence of right heart
strain is noted. The left pulmonary artery shows no evidence of embolism.
The partially imaged thyroid gland is unremarkable. There is no axillary or
mediastinal lymphadenopathy by CT size criteria. Soft tissue in the anterior
mediastinum is consistent with remnant thymic tissue. The heart is
unremarkable. The aorta is normal in caliber throughout. The airways are
patent down to the subsegmental level. There is mild right greater than left
bibasilar atelectasis. There are trace non-hemorrhagic effusions bilaterally.
The lungs are otherwise clear.
Although this examination was not intended for subdiaphragmatic evaluation, a
linear defect is noted through the left hemidiaphragm (3:109 and 601B:19).
The partially imaged abdomen shows central hypodensity within the liver
consistent with known liver laceration.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or blastic lesions or
fractures.
IMPRESSION:
1. Right main arterial pulmonary embolism without evidence of right heart
strain.
2. Linear defect through the left hemidiaphragm could be congenital or the
result of traumatic injury or could represent a CT artifact.
These findings were communicated via telephone to ___, M.D. at 11:39
a.m. on ___.
Gender: M
Race: UNABLE TO OBTAIN
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with HEAD INJURY UNSPECIFIED, FX DISTAL RADIUS NEC-CL, FX ANKLE NOS-CLOSED, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ passenger of MVC vs tree, presented to ___ ED via
ambulance. Following completion of the primary survey, the
patient was intubated for extreme agitation. After completion of
the secondary survey and imaging studies, the following injuries
were identified: Grade III liver laceration, hepatic subcapsular
hematoma, right renal laceration, right mandibular condyle
fracture, left distal radius fracture, and right medial
malleolar fracture.
The patient was admitted to the Trauma Surgical ICU under the
care of the Acute Care Surgery team, for ventilator management
and close monitoring. The following details the evaluation and
management course for each of his injuries:
Liver and renal lacerations:
The patient's hematocrit was checked serially and remained
stable. He initially had a mild amount of hematuria on
presentation, however, this proceeded to clear. He maintained
good urine output throughout his stay.
Right mandibular condyle fracture:
The ___ service was consulted and advised his fracture to be
non-operative at this time. He was instructed to stay on a soft
diet. He will follow up with ___ in clinic 1 week
post-discharge.
Left distal radius fracture:
The left wrist fracture was determined to be non-operative by
the Orthopedic Surgery service, and he was fitted into a cast.
He was maintained non-weight bearing on his left upper
extremity.
Right medial malleolar fracture:
On ___ the patient underwent ORIF of his right medial
malleolar fracture by the Orthopedic Surgery service. He was
maintained non-weight bearing on his right lower extremity. He
was evaluated by the physical therapy service, who recommended
rehab, and will follow up with the Orthopedic Surgery service in
1 week. He had an air cast applied to his right foot on ___.
This will remain in place until he returns for follow-up visit
with ortho.
Following his operation for ORIF of his ankle fracture, the
patient was weaned from the ventilator and successfully
extubated. He remained stable from a neurologic, hemodynamic,
and respiratory standpoint, and was thus transferred to the
floor on HD1/POD0.
On HD2/POD1, the patient was noted to be febrile and
tachycardic. A CTA PE protocol demonstrated a right main
pulmonary artery pulmonary embolus, without right heart strain.
He was begun on a heparin drip, titrated to PTT 50-60. The
Hematology service was consulted and did not recommend any
immediate hypercoagulable workup. They instead recommended a
heparin gtt with subsequent 6 months of coumadin on discharge.
His heparin drip was discontinued on ___ and he was started on
coumadin with bridging with lovenox. His family members have
received instruction in the adminstration of lovenox. He has
been set up with the ___ clinic here and will meet
with his PCP next week. He will have monitoring of his ___
by ___ services.
His vital signs are stable. He continues to get mild shortness
of breath when ambulating. He has been maintained on rooom air
with an oxygen satuation of 98%. He is tolerating a regular
diet and he is afebrile. He is voiding without difficulty. He
is preparing for discharge home with ___ services for monitoring
of his ___. He will continue on lovenox and coumadin as
instructed with follow-up in the ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Dilantin Kapseal / Depakote / Tegretol / Codeine / Phenobarbital
/ Penicillins
Attending: ___.
Chief Complaint:
increased seizure frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This a ___ year-old right-handed man with a history of
intractable complex partial epilepsy who is well known to the
Neurology department of the ___
___.
He presents to the ___ ED today following a prolonged seizure
that he sustained while at a hotel in ___. The patient was
scheduled to arrive for an elective EMU admission today, but
arrived early by EMS given his prolonged seizure at night. His
seizures typically consist of an aura that consists of sharp
pain
in either his right or left temporal region, followed by
rhythmic
shaking of his right upper +/- lower extremity during which he
does not respond to stimuli and his eyes are closed, but is
largely aware of his surroundings and comprehends commands.
He was most recently hospitalized here in ___ in
___ where he had two stints in the ICU as he
required large amounts of benzodiazepines to control his
seizures. He was on an ativan drip at one point, from which he
was slowly weaned to scheduled ativan IV, and then PO. He did
not
require intubation at that time. His seizures were ultimately
controlled, and he was initiated on the ___ diet, which in
conjunction with a AED regimen of vimpat 200 TID, keppra 1g q6h,
lamictal ___, ativan 6mg q6h, and felbamate
___.
In the interim, he was doing well initially. His seizures were
under control, but was experiencing increased side effects of
AEDs including excessive sleepiness, gait instability with
falls,
blurry vision and generalized fatigue particularly after the
second/third/fourth medication doses of the day. He describes a
debilitating blurry vision that starts on the left eye and then
progresses to both eyes. He also describes a sensation,
particularly towards the end of the day, when his legs "become
jello", and occasionally experiences tremors of both lower
extremities when they are weak. His seizure frequency was about
2/week at this time, and they were well controlled by VNS swipes
and 1mg of sublingual ativan that his wife would give him. There
were attempts to lower his lamictal and ativan dose slightly.
These did not interfere with seizure control, and yet, he still
complained of feeling dysfunctional.
Approximately ___ months ago, he self discontinued his ___
diet for fear that it would worsen his metabolic profile. He
describes today how several members of his family have coronary
artery disease, and he didn't want to take on the same risk.
Also, he notes that his wife would go out of her way to prepare
___ meals for him, and would not enjoy those meals herself.
He
did not want to put her through that. More recently, he has had
a
few life stressors. Hishome ___ was discontinued due to
insurance
issues. His mother's health has been poor and was recently
diagnosed with a heart condition ("heart got plugged"), and his
sister was diagnosed with cancer. In this setting, his seizure
frequency has worsened from approxoimately 2/week to 2/day. He
was hospitalized ___ for partial status at an OSH. Had prolonged
partial seizures requiring 4 mg of sublingual ativan at home.
This seizure described as sudden onset, nonresponsive shaking on
right side with spread to both sides. Seizure started slowing
down after 3 mg, then began responding after another mg. 911 was
called and he was taken to ___ where he had
further seizures and required 14 mg of Ativan to stop them. His
Felbatol was increased by 600 mg on ___ and he was
discharged.
Since discharge, he has had more seizures.
Following his clinic visit yesterday, he went to a nearby hotel
to stay the night prior to coming in for an elective admission
this morning. At about 11PM, while sleeping, he developed
another
one of his typical seizures. EMS was called as it did not break
with multiple doses of sublingual ativan. He was taken to an OSH
ED, and subsequently transferred to the ___ ED on request of
his wife. Per report, he required a total of 16mg of ativan to
break his seizure. At this time, he is awake (though expectedly
drowsy), and is able to provide a history himself.
Past Medical History:
-intractable complex partial epilepsy and likely secondary
generalized seizures since ___, s/p cortical sectioning of
epileptic area of lower sensory motor strip ___, s/p left VNS
___, with VNS replaced ___.
-chronic headaches
-sinusitis
-viral meningitis at age ___
-L4-5 disc herniation s/p left L4-5 hemilaminectomy, median
facetectomy and L4-5 diskectomy ___
-GERD
-HLD
-sleep apnea
-depression
-tonsillectomy
-s/p vasectomy
-benign hematuria, kidney stones (thought to be ___ topamax)
-hx of PE in ___, s/p ~6 months of Coumadin
Social History:
___
Family History:
Mother living, age ___ with a history of MI and uterine
cancer. Father died at age ___ of a stroke and MI
Physical Exam:
Physical Exam:
VS: HR 68, BP 128/105, afebrile, RR 12, 98% on RA
General: Awake, alert and oriented. Cooperative, NAD
HEENT: NC/AT, no conjunctival icterus noted, MMM, no lesions
noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: Obese, soft, NT/ND, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, drowsy but arousable. Oriented to self,
___, ___. No paraphasic errors or anomia noted.
Makes two errors when recalling ___ backwards. Speech is slow,
and has delayed reaction times. Comprehension intact, follows
midline and appendicular commands well. Very mild dysarthria.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Visual acuity is ___ OD, ___
OS.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing grossly intact
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 5 5 ___ 5 5 5 5 5
R 5 5 5- 5- 5 5- 4+ 5 4+ 4+ 5
-Sensory: No deficits to light touch throughout
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was downgoing bilaterally.
-Coordination: No intention tremor, no dysmetria on FNF
bilaterally.
-Gait: Deferred
Pertinent Results:
___ 11:00AM CHOLEST-181
___ 11:00AM %HbA1c-5.8 eAG-120
___ 11:00AM TRIGLYCER-187* HDL CHOL-62 CHOL/HDL-2.9
LDL(CALC)-82 ___
___ 10:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:10AM GLUCOSE-101* UREA N-16 CREAT-0.6 SODIUM-143
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15
___ 04:10AM estGFR-Using this
___ 04:10AM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-1.9
___ 04:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:10AM WBC-9.0 RBC-3.92* HGB-12.1* HCT-37.3* MCV-95
MCH-30.8 MCHC-32.5# RDW-14.5
___ 04:10AM NEUTS-64.0 ___ MONOS-4.6 EOS-1.8
BASOS-0.3
___ 04:10AM PLT COUNT-254
EEG ___:
IMPRESSION: This video-EEG monitoring session captured one
prolonged
clinical event on the evening of ___ at around 10pm. During
this
episode, the patient had low-amplitude rhythmic movements of the
right
upper extremity and appeared less responsive on video. EEG
showed beta
activity and sharp morphologies in the left anterior temporal
region,
but these findings were also present at other times nearly
continuously,
and could be consistent with a breach rhythm from a skull defect
in this
area. It was therefore difficult to be certain about any
electrographic
correlate with the clinically observed event. No frank
spike-and-slow-wave discharges were seen. The background was a
normal
alpha rhythm during wakefulness.
EEG ___:
IMPRESSION: This video EEG monitoring session captured no
symptomatic
pushbutton activations or electrographic seizures. As before, a
breach
rhythm with interictal sharp waves was seen in the left temporal
region
suggestive of a focus of epileptogenesis and a skull defect in
that
area. The background was a normal alpha rhythm during
wakefulness.
Medications on Admission:
Atorvastatin 40 daily
Celexa 40 daily
Zetia 10 daily
Felbatol ___
Vimpat 200 TID
Lamictal ___
Keppra 1000mg QID
Ativan 4 QID
Metoprolol XL 50 daily
Nexium 20 daily
Zantac 300 daily
Aspirin 81 mg daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QNOON ().
5. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. lacosamide 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO PRN DAILY () as needed for titrate to 1BM /2 days.
15. felbamate 400 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
16. felbamate 400 mg Tablet Sig: Three (3) Tablet PO NOON (At
Noon).
17. felbamate 400 mg Tablet Sig: 4.5 Tablets PO QPM (once a day
(in the evening)).
18. clobazam 5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
Disp:*240 Tablet(s)* Refills:*0*
19. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
20. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Intractable epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST, ___.
COMPARISON: ___ radiograph.
FINDINGS: Vagal nerve stimulator remains in place. Right PICC has been
removed since the prior radiograph. Allowing for accentuation by apical
lordotic projection, cardiomediastinal contours are within normal limits
without change. Lungs and pleural surfaces are clear.
Radiology Report
CHEST PORT LINE PLACEMENT ___ AT 9:51
CLINICAL INDICATION: ___ with new PICC line, check location.
Comparison to prior study ___ at 9:32.
Portable semi-erect chest film ___ at 9:51 is submitted.
IMPRESSION:
Interval placement of a right subclavian PICC line with its tip appearing to
be looped in the proximal superior vena cava. Repositioning was recommended
and communicated to the IV nurse by Dr. ___ at 12:30 p.m. by phone on
___. A vagus nerve stimulator remains in place overlying the left upper
chest. Cardiomediastinal contours are stable. Lungs remain well inflated and
clear. No pneumothorax.
Radiology Report
CHEST PORT LINE PLACEMENT ___ AT 12:54
CLINICAL INDICATION: Reposition of PICC line. Check location.
Comparison to prior study dated ___ at 9:51.
Portable semi-erect chest film ___ at 12:54 is submitted.
IMPRESSION:
1. Right subclavian PICC line now has its tip in the mid SVC. A vagal nerve
stimulator remains in place. The lungs are well inflated and clear. Overall
cardiac and mediastinal contours are stable.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P SEIZURE
Diagnosed with GRAND MAL STATUS
temperature: 95.6
heartrate: 64.0
resprate: 14.0
o2sat: 97.0
sbp: 141.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Neuro:
Mr. ___ was admitted to the neurology service on ___ due to
increased seizure frequency as well as symptoms of AED toxicity
including blurry vision, sleepiness, lower extremity weakness
with gait instability and falls. He was connected to LTM and had
multiple typical events of R arm jerking usually lasting 30
minutes to 1.5 hours. He was treated with IV ativan prn for
these episodes. EEG showed intermittent sharp waves over the
left temporal region but did not show any correlation during his
clinical episodes of arm shaking. His standing ativan was slowly
tapered down and finally discontinued. In the meantime he was
started on clobazam and titrated up to 20mg BID. He was
continued on the rest of his home AED's (Felbatol
___, Vimpat 200 TID Lamictal ___, Keppra
1000mg QID). His seizure activity gradually decreased over the
course of his admission and by the time of his discharge he had
been seizure free for 48 hours. He will follow up with Dr.
___ in clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Left knee injury
Major Surgical or Invasive Procedure:
left knee closed reduction
History of Present Illness:
___ student at ___ was walking home this evening
(possible etoh tonight) when he came upon a large group of men
who took his belongings and assaulted him. He recalls being on
the ground and someone calling the police. He was hit in the
left knee. In ED was noted to have left knee deformity, and XR
showed an anterior knee dislocation for which ortho was
consulted.
The patient was noted to have strong and symmetric DP and ___
pulses bilaterally (both before and after closed reduction). No
numbness/sensory changes, no weakness.
Past Medical History:
Anxiety
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge physical exam:
AVSS
NAD, A&Ox3
LLE: Knee with moderate swelling, TTP, ___ Brace, Fires
___. SILT s/s/dp/sp/tibial
distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
___ 03:30AM GLUCOSE-116* UREA N-13 CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15
___ 03:30AM WBC-20.9*# RBC-4.53* HGB-13.2* HCT-38.4*
MCV-85 MCH-29.1 MCHC-34.4 RDW-14.5
___ 03:30AM PLT COUNT-380
Medications on Admission:
Clonazepam 1mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H prn pain
Do not exceed 4g/day.
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Do not drink alcohol, drive, or use heavy machinery while
taking.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
3. ClonazePAM 1 mg PO BID
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left knee anterior dislocation s/p closed reduction
2. Complete rupture of ACL.
3. Sprain and likely partial tear of PCL.
4. Vertical tear of the posterior horn of the lateral meniscus.
5. Avulsed fibular collateral ligament with a small avulsion
fracture of fibular head.
6. Anterior medial femoral condyle and posterior medial tibial
plateau contusions.
7. Large joint effusion and extensive soft tissue edema.
8. Findings suspicious for rupture of the arcuate ligament at
the posterior lateral corner.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: History: ___ with trauma and left knee pain // fracture
TECHNIQUE: AP and lateral views of the left main
COMPARISON: None
FINDINGS:
There is no definite acute fracture identified. There is posterior dislocation
of the femur with regard to the tibia. No suspicious focal lytic or sclerotic
lesion is identified. No soft tissue calcification or radio-opaque foreign
body seen.
IMPRESSION:
No definite evidence of fracture. Posterior dislocation of the femur with
regard to the tibia. Consider CTA of the lower extremity to evaluate for
vascular injury.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with knee reduction // post reduction fracture
TECHNIQUE: The AP and lateral view of the left knee
COMPARISON: Knee radiographs on ___
FINDINGS:
There has been reduction of a left knee dislocation and the left knee no
appears to be in anatomic alignment. Small avulsed bone fragments adjacent to
the fibula is consistent with acute fracture. There is a small joint
effusion. No suspicious osseous lesions are seen.
IMPRESSION:
Status post reduction of a left knee dislocation in anatomic alignment. Small
a it vulsed bone fragments adjacent to the head of the fibula is consistent
with acute fracture. Small joint effusion.
Radiology Report
EXAMINATION: CTA LOWER EXT W/ANDW/O C AND RECONS LEFT
INDICATION: ___ year old man with posterior knee dislocation // vascular
injury
TECHNIQUE: MDCT images were obtained from the mid thigh through the mid
tibia. IV contrast was administered. Sagittal and coronal reformatted images
were acquired and reviewed.
DOSE: DLP: 765mGy-cm
COMPARISON: Knee radiographs on ___
FINDINGS:
Extensive soft tissue stranding involving the distal thigh and proximal left
lower leg is consistent with recent left knee dislocation. A linear calcific
density seen adjacent to the fibular head is consistent with a small avulsed
fracture. No additional fractures are identified. No suspicious osseous
lesions are seen. There is a small to moderate left knee effusion.
CTA: The popliteal artery is patent and shows no evidence of stenosis or
occlusion. The trifurcation is normal appearing. There is no evidence of
arterial injury.
IMPRESSION:
1. Small avulsed fracture involving the left fibular head.
2. No evidence of arterial injury.
3. Extensive soft tissue stranding as well as small to moderate left knee
effusion is consistent with recent left knee dislocation.
Radiology Report
EXAMINATION: MR KNEE W/O CONTRAST LEFT
INDICATION: ___ year old man with s/p anterior dislocation - assess for
multiligamentous injury.
TECHNIQUE: Multiplanar images of the LEFT knee were performed without the
administration of intravenous contrast using a routine MR knee protocol.
COMPARISON: The radiographs dating ___.
FINDINGS:
Medial meniscus: The posterior horn of the lateral meniscus demonstrates
increased signal, without discrete tear.
Lateral meniscus: There is a vertically oriented longitudinal tear in the
posterior horn of the medial meniscus extending to both the tibial and femoral
articular surfaces, with the peripheral component remaining attached to the
ligament of Wrisberg, consistent with a ___ rip.
Anterior cruciate ligament: There is complete rupture of the ACL with fluid
and disorganized fibers filling the expected location of the ACL.
Posterior cruciate ligament: The PCL is heterogeneous with thickening at the
distal insertion. This appearance is consistent with at least a sprain and
likely a partial tear.
Medial collateral ligament: The MCL remains in tact with normal signal, but
has surrounding edema, consistent with a grade 2 injury.
Lateral collateral ligamentous complex: The iliotibial band remains in tact.
The fibular collateral ligament is avulsed with a small fragment of the
fibular head. The biceps femoris is intact, but the distal insertion is
poorly visualized and included in the area of edema at the fibular head
avulsion. At least a portion of the biceps femoris is avulsed with the
fibular fracture. The popliteal tendon is intact. On the sagittal images,
there is nonvisualization of the capsule in the posterolateral corner with
appearances suspicious for injury to the arcuate ligament.
Extensor mechanism: Normal
___ cyst: None
Joint effusion: There is a large effusion with heterogeneity which could be
on the basis of debris, blood products, or loose bodies.
Patellofemoral articular cartilage: Normal
Medial articular cartilage: The cartilage overlying the anterior medial
femoral condyle contusion is attenuated in thickness and edematous in signal.
Lateral compartment cartilage: Normal
Marrow: Focal marrow edema is seen along the anterior medial tibial plateau
and posterior medial femoral condyle secondary to impaction injury. Extensive
edema is also present at the point of fibular head avulsion.
Additional findings: There is extensive subcutaneous edema and edema
surrounding the muscles, which remain in tact. Vascular structures are not
assessed on this noncontrast evaluation.
IMPRESSION:
1. Complete rupture of ACL.
2. Sprain and likely partial tear of PCL.
3. Vertical tear of the posterior horn of the lateral meniscus.
4. Avulsed fibular collateral ligament with a small avulsion fracture of
fibular head.
5. Anterior medial femoral condyle and posterior medial tibial plateau
contusions.
6. Large joint effusion and extensive soft tissue edema.
7. Findings suspicious for rupture of the arcuate ligament at the posterior
lateral corner, the capsule is not well visualized in this area.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Assault, L Knee injury
Diagnosed with LOWER LEG INJURY NOS, ASSAULT NEC
temperature: 97.9
heartrate: 70.0
resprate: 16.0
o2sat: 98.0
sbp: 130.0
dbp: 74.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an anteriorly dislocated left knee which was closed
reduced while in the ED. He was noted to have strong and
symmetric DP and ___ pulses bilaterally (both before and after
closed reduction). No numbness/sensory changes, no weakness. He
was admitted to the orthopedic surgery service. The patient
underwent CTA which showed no evidence of vessel disruption and
an MRI which showed significant injuries to the left knee. He
was initially treated with IV pain medication which was
transitioned to PO pain medications. The patient's home
medications were continued throughout this hospitalization. He
was placed in ___ Brace for immobilization and evaluated
by Physical Therapy who recommended discharge to home. At the
time of discharge the patient's pain was well controlled with
oral medications and the patient was voiding/moving bowels
spontaneously.
The patient is PWB 50% in the LLE with ___ Brace locked in
extension. The patient will follow up with Dr. ___. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute renal failure, hypernatremia, hyperkalemia
Major Surgical or Invasive Procedure:
EGD with biopsy
History of Present Illness:
___ w/hx of CVA (left sided weakness), HTN and dementia
presenting from the nursing care facility with concerns for
abnormal labs. Patient was found to be hyperkalemic. Patient has
been not taking in good p.o. He has been spitting his pills and
food back out when he is given them. He also had one episode of
vomiting earlier today, nonbilious nonbloody. He is afebrile and
otherwise well. No increased lethargy noted in nursing facility
notes. Patient is minimally verbal, and therefore unable to
obtain history from patient.
In the ED, He was chewing on his IV, refusing treatments, he was
noted to be incontinent of urine but refusing foley. Per report,
he was behaving in such manner at the rehab as well. Initial vs
were: T 95.6 P 83 BP 127/70 R 16 O2 sat. 98%RA. EKG was notable
for peaked lateral T waves, no ST elevations/depressions.
Patient was given Calcium Gluconate, Dextrose, Insulin,
Kayexalate, and 2 L fluid and then admitted.
On the floor, patient was calmly resting in bed, without any
apparent distress. Vitals were HR of 52, BP of 125/83, SpO2 of
98% on room air. He was minimally verbal.
Review of sytems: could not be performed due to patient's
inability to speak.
Past Medical History:
#Stage III CKD - Creatinine 1.4 in ___
#CVA (Left-sided weakness)
#Hypertension
#Hyperlipidemia
Social History:
___
Family History:
unable to obtain as pt nonverbal.
Physical Exam:
On Admission:
Vitals: T: Afebrile, SBP 120s, HR 55, RR 12 99%on2L
General: Elderly, thin male laying in bed frequently moving.
Alert, doesn't follow commands or answer questions.
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Breathing comfortably, CTAB
CV: RRR, no MRG
Abdomen: +BS, soft NTND
Ext: warm, 2+ pulses, no clubbing, cyanosis or edema
Large stage III malodourous ulcer on right heel with green
discharge.
Neuro: Oriented to self, unable to follow commands, partly due
to language barrier, CNII-XII intact grossly, but weak on left
side.
Discharge Physical Exam:
Physical exam:
vitals: 98, 128/64, 67, 18, 97 RA
general: comfortable today. sitting and interacting
HEETN: NC AT
CV: RRR
lungs: ctab
abdomen: soft, NTTP, no guarding
extremities: no swelling, pulses 2+
Pertinent Results:
___ 02:10PM PLT COUNT-449*
___ 02:10PM NEUTS-81.6* LYMPHS-14.9* MONOS-2.4 EOS-0.7
BASOS-0.3
___ 02:10PM WBC-11.6* RBC-5.13 HGB-14.9 HCT-48.0 MCV-94
MCH-29.1 MCHC-31.0 RDW-13.7
___ 02:10PM estGFR-Using this
___ 05:40PM URINE HYALINE-3*
___ 05:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG
___ 05:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:12PM ___ PTT-25.7 ___
___ 09:12PM PLT COUNT-370
___ 09:12PM CALCIUM-10.1 PHOSPHATE-7.2*# MAGNESIUM-3.2*
___ 09:12PM GLUCOSE-106* UREA N-235* CREAT-10.4*
SODIUM-176* POTASSIUM-5.2* CHLORIDE-135* TOTAL CO2-17* ANION
GAP-29*
___ Renal US
No evidence of hydronephrosis. Atrophic echogenic kidneys,
likely reflective of chronic renal disease.
ECG
Probable sinus rhythm with atrial premature beats. Left anterior
fascicular
block. Voltage criteria for left ventricular hypertrophy.
Isolated
ventricular premature beats. Non-specific ST-T wave changes. No
significant
change compared with previous tracing of ___.
Read by: ___.
___ Axes
Rate PR QRS QT/QTc P QRS T
75 ___ -___ -23
EGD:
Impression: Stenosis of the lower esophagus (dilation)
Small hiatal hernia
Erythema and few nodules in the stomach antrum (biopsy)
Erythema and erosions in the duodenum compatible with duodenitis
Otherwise normal EGD to third part of the duodenum
EGD gastric biopsy
Stomach, antrum, biopsy:
- Antral mucosa with chronic active gastritis.
- no h pylori
Discharge labs:
___ 05:05AM BLOOD WBC-4.6 RBC-2.96* Hgb-8.6* Hct-25.6*
MCV-87 MCH-28.9 MCHC-33.4 RDW-15.5 Plt ___
___ 02:10PM BLOOD Neuts-81.6* Lymphs-14.9* Monos-2.4
Eos-0.7 Baso-0.3
___ 05:05AM BLOOD Glucose-91 UreaN-11 Creat-1.5* Na-139
K-3.9 Cl-108 HCO3-24 AnGap-11
___ 05:05AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.6
Medications on Admission:
Hydrocodone-tylenol ___ mg po prn for dressing change
Folic acid 1 mg po daily
Vitamin B12 500 mcg po daily
Vitamin C 500 mg po daily
Plavix 75 mg po daily
MVI daily
Amlodipine 5 mg po daily
Ramipril 10 mg po daily
Aggrenox ___ mg po bid
Baclofen 10 mg po daily
Namenda 10 mg po daily
Tylenol ___ mg po daily
Simvastatin 20 mg po daily
Ranitidine 150 mg po qhs
Senna qhs
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig:
One (1) Cap PO BID (2 times a day).
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 days.
11. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 18 days.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) esophageal stricture
2) dehydration
3) acute kidney injury
4) dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Renal failure.
COMPARISONS: None available.
FINDINGS:
Right kidney measures 9.5 cm. Left kidney measures 8 cm. There is no
evidence of hydronephrosis, renal calculi, or renal masses bilaterally. The
kidneys appear atrophic and display diffusely increased echogenicity.
IMPRESSION:
No evidence of hydronephrosis. Atrophic echogenic kidneys, likely reflective
of chronic renal disease.
Radiology Report
PORT LINE PLACEMENT
CLINICAL INDICATION: A ___ with new right PICC line, check position.
No comparison studies. Please note that comparison to old films can be
helpful to detect subtle interval change.
Portable AP upright chest film of ___ at 10:35 a.m. is submitted.
IMPRESSION:
1. Right subclavian PICC line has its tip in the mid superior vena cava. No
pneumothorax. No evidence of focal airspace consolidation to suggest
pneumonia. No pleural effusions. Overall, the cardiac and mediastinal
contours are within normal limits. Note is made of an elevated left
hemidiaphragm as well as elevation of the left scapula and possible
subluxation of the left glenohumeral joint. The chronicity of these findings
is uncertain and therefore clinical correlation is advised. Spinal fusion
hardware overlies the mid cervical spine.
2. A 3-cm rounded opacity in the left paraspinal area abutting the left
hemidiaphragm is seen. The significance of this finding is uncertain,
although it is possible that it could represent a hiatal hernia. However,
further characterization with PA and lateral chest film, when the patient is
clinically stable, would be advised. Results entered into Critical Results
Dashboard on ___ at 1:05pm.
Radiology Report
PORTABLE AP CHEST FILM ___ at 15:44
CLINICAL INDICATION: ___ with new nasogastric tube placement.
COMPARISON: Comparison made to prior study dated ___ 11:00.
A single portable semi-erect chest film ___ at 15:44 is submitted.
IMPRESSION:
1. Right subclavian PICC line with its tip in the proximal to mid superior
vena cava. Interval placement of a nasogastric tube which has a portion
coiled within the pharynx, the tip at the gastroesophageal junction and side
port within the mid esophagus. Repositioning is advised.
2. The left hemidiaphragm remains elevated. The more rounded left paraspinal
opacity is not as well seen on the current examination, again favoring that
this most likely corresponded to a hiatal hernia, but PA and lateral imaging
would still be advised once the patient is clinically stable.
3. Lungs appear well inflated and without focal airspace consolidation,
pulmonary edema, pleural effusions or pneumothorax.
4. Spinal fusion hardware overlies the mid cervical spine.
The results of this examination were called to the patient's nurse, ___, in
the ICU on ___ and 4:20 p.m.
Radiology Report
PORTABLE AP CHEST FILM
CLINICAL INDICATION: ___ with repositioned nasogastric tube, check
location.
Comparison is made to the prior study of ___ at 15:44.
PORTABLE AP CHEST FILM ___ at 16:02 is submitted. The left lateral
hemithorax is not included on the current examination.
IMPRESSION:
1. Nasogastric tube still has its tip at the gastroesophageal junction and
the side port in the mid esophagus. Repositioning is advised. The house
staff is aware.
2. Left hemidiaphragm remains somewhat elevated. The more rounded opacity at
the left paraspinal region abutting the left diaphragm is again seen, and
although may represent a hiatal hernia, imaging with a PA and lateral study to
further characterize this finding would be advised. Lungs appear grossly
clear. No pneumothorax. Right subclavian PICC line has its tip in the
proximal superior vena cava. Overall, cardiac and mediastinal contours are
likely stable given patient rotation on the current study.
Radiology Report
INDICATION: Poor p.o. intake and altered mental status. Evaluate for
Dobbhoff placement.
COMPARISON: None.
NASOINTESTINAL TUBE PLACEMENT: The patient arrived to the radiology
department without a Dobbhoff in place. Several attempts were made to place a
Dobbhoff, but were unsuccessful. The Dobbhoff was seen within the main stem
bronchi upon several attempts. The patient was unable to cooperate with the
exam and the procedure was stopped.
IMPRESSION: Unsuccessful placement of a nasointestinal tube.
Gender: M
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: ABNORMAL LABS
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOKALEMIA, HYPEROSMOLALITY, HYPERTENSION NOS
temperature: 95.6
heartrate: 83.0
resprate: 16.0
o2sat: nan
sbp: 127.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ M from Nursing Care with a PMH of CKD - Stage
III, (last Cr. 1.4) who was found to be hyperkalemic,
hypernatremia and in acute renal failure at nursing facility,
had been spitting pills, not drinking, and had an episode of
non-bilious,non-bloody vomiting.
#. Acute renal failure - evidence of creatinine at 1.4 4 months
ago. The etiology of the renal failure was likely pre-renal,
given reports of poor PO intake and highly elevated sodium.
Patient was seen by the renal consult and hemodialysis was
deferred. Renal ultrasound did not show any sign of
hydronephrosis. The patient was given fluids for several days
and his creatinine trended down from 10 to his baseline. He
began producing appropriate amounts of urine and we were
satisfied that his kidney function was appropriate.
#Hyperkalemia - evidence of peaked T-waves on EKG. Patient was
given calcium gluconate and insulin as well as kayexalate on the
floor. His hyperkalemia was likely caused by acute renal
failure. Hyperkalemia resolved with fluid resuscitation and
resumption of normal urine output.
#Hypernatremia - likely related to overall dehydration. His free
water fluid deficit was approximately 7 L on admission. He was
given ___ with goal of lowering his serum sodium by 10 over 24
hours. His electrolytes were monitored q6h to avoid
overcorrecting. He was then changed to D5W for correction. His
sodium fell to normal levels and his mental status improved.
Once he was tolerating food, we stopped fluids and watched his
sodium and other electrolytes to see if he could maintain normal
electrolytes wtih just PO food and hydration. He was successful
and we discharged him.
#HTN: the patient was consistently normo/hypotensive while on
our service and his antihypertensives were held. Once his blood
pressures are consistently above 140, we would like his
medications to be slowly restarted given his history of stroke.
\
#ESBL UTI - the patient was found to have ESBL UTI, and so he
was started on meropenem. He received 10 of 14 days of the
medications, and should continue the medication for 4 more days.
He is also to take flagyl for another 18 days after discharge.
# CDIFF- the patient developed CDIFF while in the ICU. The
patient will continue flagyl until 2 weeks following the
cessation of meropenem.
# Dementia: Patient has known baseline dementia. The patient
came in more obtunded than his description, which we attributed
to hypernatremia. With the resolution of his hypernatremia, the
patient became more alert and interactive. We spoke with the
daughter, who agreed that he was closer to his baseline at that
point.
#.Goals of Care - per discussion with family members, he was
minimally interactive at rehab for quite some time. Patient
remained DNR/ DNI. Decision made not to place PEG tube. After
two family meetings, it was decided that the patient would be
rehydrated and he would be sent to a nursing home. Patient's
daughter was informed given severe dementia and aphasia that the
odds of patient developing this issue again are extremely high,
even with excellent nursing care, and that given he is at the
end of his life each intervention should be carefully considered
in the context of the goals we hope to achieve in caring for
him. His daughter expressed understanding of this and did have
"do not hospitalize" status discussed with her though she has
not elected to make this his status as yet. Weight on discharge
is 127 pounds.
# Code: DNR/DNI (discussed with HCP)
___ issues:
-if patient develops systolic blood pressure greater than 140,
please restart home antihypertensives.
-discharge weight 127 lbs |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male, previously healthy, who
presented to an OSH ED this morning with back pain, found to
have concerning CTA findings. He reports having back pain for
the past ___ days, which started on his flight to ___ 4
days ago and has waxed and waned since. Reports it as a dull
pain that is occasionally sharp in his lower back, and to his
left. Not improved with heat or ice. Not positional. On the
morning of presentation the back pain was worsened prompting him
to go to the ED. He had a CT scan which was initially read as
negative and was discharged home with Percocet. However he was
called back in because the final read was concerning for SMA
dissection. The OSH CT scanner was apparently out of order so he
was transferred to our ED for further imaging. CTA here showed
"Focal narrowing of the proximal SMA with eccentric thrombus and
surrounding fat stranding. No intramural hematoma. Findings are
nonspecific but can be seen in the setting of vasculitis versus
a focal vascular injury. 2. Normal appearance of the bowel
without evidence of ischemia."
Vascular surgery was consulted and recommmended aspirin but no
other treatment at this time. If he were to develop symptoms,
they recommend steroids.
In the ED, initial vitals: 98.4 65 131/71 18 97% ra
Imaging: See HPI
Patient was given: morphine, NS and ASA
On the floor, Patient reports L lower back pain that he says is
worse with eating. He noticed this after the ED doctor asked him
this question. Denies bloody stools, abdominal pain, chest pain
or shortness of breath. Denies fever, chills, joint pain or
swelling or rash. He says he was prescribed pain medication and
a medrol dose pack in the ED but never filled the prescription.
ROS:
Please refer to HPI for pertinent positives and negatives. 10
point ROS is otherwise negative.
Past Medical History:
Hyperlipidemia
?cholangitis in ___ resulting in lap chole
Social History:
___
Family History:
grandmother died of aortic aneurysm
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 98.2 61 133/81 18 96% RA
General: AAOx3, comfortable appearing, in NAD
HEENT: NCAT, EOMI. Sclera anicteric. MMM. OP clear.
Neck: supple, no JVD.
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM.
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: CNs II-XII intact. MAEE. Grossly normal strength and
sensation.
DISCHARGE EXAM:
===============
Vitals: 97.7, 130/70, 60, 18, 96-98%RA
General: AAOx3, comfortable appearing, in NAD
HEENT: NCAT, EOMI. Sclera anicteric. MMM.
Neck: supple, no JVD.
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM.
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: MAEE. Grossly normal strength and sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 02:30PM GLUCOSE-99 UREA N-16 CREAT-1.0 SODIUM-136
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11
___ 02:30PM estGFR-Using this
___ 02:30PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-60 TOT
BILI-0.7
___ 02:30PM cTropnT-<0.01
___ 02:30PM ALBUMIN-3.9
___ 02:30PM CRP-11.2*
___ 02:30PM WBC-9.5 RBC-4.85 HGB-14.4 HCT-40.8 MCV-84
MCH-29.6 MCHC-35.3* RDW-14.1
___ 02:30PM NEUTS-70.9* ___ MONOS-6.5 EOS-2.3
BASOS-0.5
___ 02:30PM PLT COUNT-188
___ 02:30PM ___ PTT-31.8 ___
OTHER PERTINENT LABS:
=====================
___ 05:15AM BLOOD Lipase-37
___ 05:15AM BLOOD Triglyc-306* HDL-29 CHOL/HD-7.6
LDLcalc-129
___ 02:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 02:36PM BLOOD ANCA-NEGATIVE B
___ 05:15AM BLOOD CRP-12.6*
___ 02:36PM BLOOD ___
___ 02:30PM BLOOD CRP-11.2*
___ 01:11PM BLOOD PEP-AWAITING F IgG-600* IgA-204 IgM-59
IFE-PND
___ 02:30PM BLOOD C3-158 C4-43*
___ 02:30PM BLOOD HCV Ab-NEGATIVE
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 9 < OR = 20 mm/h
___
THIS TEST WAS PERFORMED AT:
___ ___
___
CARDIOLIPIN ANTIBODIES (IGG, IGM)
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGG) <14 GPL
Value Interpretation
----- --------------
< or = 14 Negative
15 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGM) <12 MPL
Value Interpretation
----- --------------
< or = 12 Negative
13 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
Test Result Reference
Range/Units
COMMENT See Below
The antiphospholipid antibody syndrome (APS) is a
clinical-pathologic correlation that includes a clinical
event(e.g. thrombosis, pregnancy loss, thrombocytopenia)
and persistent positive antiphospholipid antibodies
(IgM or IgG ACA ___ MPL/GPL, IgM or IgG anti-b2GPI
antibodies or a lupus anticoagulant). The IgA isotype
has been implicated in smaller studies, but has not yet
been incorporated into the APS criteria. International
consensus guidelines suggest waiting at least 12 weeks
before retesting to confirm antibody persistence.
Reference J Thromb Haemost ___: 4; 295
THIS TEST WAS PERFORMED AT:
___ ___
___
___ 13:11
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG) Results Pending
IMAGING:
========
___ CTA:
IMPRESSION:
1. Short segment luminal narrowing (~40%) of the proximal SMA
with eccentric thrombus and extensive surrounding fat stranding.
No intramural hematoma. Findings are nonspecific but can be
seen in the setting of vasculitis versus a focal vascular
injury.
2. Normal appearance of the bowel without evidence of ischemia
___ CTA:
IMPRESSION:
1. No significant change in short segment narrowing of the
proximal SMA with surrounding fat stranding and findings
compatible with intramural edema. This most likely represent
vasculitis.
DISCHARGE LABS:
===============
___ 06:01AM BLOOD WBC-12.4* RBC-5.22 Hgb-16.0 Hct-43.2
MCV-83 MCH-30.6 MCHC-37.0* RDW-13.8 Plt ___
___ 06:01AM BLOOD Glucose-130* UreaN-14 Creat-1.0 Na-137
K-5.2* Cl-101 HCO3-25 AnGap-16
___ 06:01AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 10 mg PO QPM
Discharge Medications:
1. Rosuvastatin Calcium 10 mg PO QPM
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN back pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0
7. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
8. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*0
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
11. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-vasculitis
Secondary:
-hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ with abdominal pain, OSH NCCT scan concerning for SMA
dissection.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis before contrast and after the administration of IV contrast in the
arterial and portal venous phase. Axial images were interpreted in
conjunction with coronal and sagittal reformats. Oral contrast was not
administered. MIP images were also obtained. 3D images were acquired on a
separate workstation.
DLP: 3056 mGy-cm
COMPARISON: None available.
FINDINGS:
CHEST: There is minimal dependent atelectasis. There is no pericardial or
pleural effusion.
ABDOMEN: The liver enhances homogeneously and is without focal lesions. The
portal venous system is patent. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent.
The spleen and adrenal glands are unremarkable. The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric nephrograms. There are no focal renal lesions.
There is no hydronephrosis. The ureters are normal in caliber and course to
the bladder.
The distal esophagus is normal without a hiatal hernia. The stomach is under
distended. The small and large bowel are normal in caliber and without
evidence of wall thickening. Bowel wall enhances normally. The appendix is
well-visualized and normal. Colonic diverticulosis is present without evidence
of diverticulitis.
CTA: There is mild (~40%) luminal narrowing and fat stranding surrounding a
short segment of the proximal superior mesenteric artery just distal to its
takeoff. There is no intramural hematoma seen on non contrast CT. No definite
intimal flap is seen. The narrowed segment measures approximately 2.5 cm with
normal caliber and appearance of the SMA distally (series 4A, image 66).
Delayed images demonstrate eccentric hypodense intraluminal thrombus along the
wall of the vessel (series 4B, image 269). Scattered retroperitoneal lymph
nodes in the region of stranding are present, none of which are pathologically
enlarged. The remainder of the vessels are patent and normal in appearance.
The left hepatic artery arises from the left gastric artery. The right
hepatic artery arises from the celiac trunk. There is one renal artery
bilaterally.
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.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. There are bilateral L5 pars defects with minimal anterolisthesis.
IMPRESSION:
1. Short segment luminal narrowing (~40%) of the proximal SMA with eccentric
thrombus and extensive surrounding fat stranding. No intramural hematoma.
Findings are nonspecific but can be seen in the setting of vasculitis versus a
focal vascular injury.
2. Normal appearance of the bowel without evidence of ischemia.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 4:53 ___, minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with suspected vasculitis // assess for
progression of disease
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous and
delayed phase images were acquired through abdomen and pelvis
Oral contrast was not administered
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DLP: 3065.3 mGy-cm (abdomen and pelvis.
IV Contrast: 130 mL of Omnipaque
COMPARISON: CTA abdomen pelvis from ___.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is no calcium burden in the
abdominal aorta and great abdominal arteries. Again seen is eccentric
narrowing of the proximal superior mesenteric artery for approximately 2 cm
with significant
surrounding fat stranding in this region. Delayed images again demonstrate
eccentric hypodense intramural abnormality, likely representing edema within
the wall (series 604, image 63). These findings, not typical for a dissection,
are unchanged from the prior study and likely represent vasculitis. .
Scattered retroperitoneal nodes are present in this area though not enlarged
by CT criteria and unchanged from the prior study. The most prominent lymph
node is a celiac axis node measuring 2.1 x 1.6 cm. The remainder of the
intra-abdominal vessels are unremarkable. The right hepatic artery arises from
the celiac trunk and the left hepatic artery arises from the left gastric.
There is no accessory renal artery on the right and a single renal artery on
the left.
LOWER CHEST:
The lung bases are clear. The visualized heart and pericardium are
unremarkable.
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 main portal vein is patent. Patient is
status post cholecystectomy.
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: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits.
Appendix has normal caliber without evidence of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate gland is unremarkable.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. There mild degenerative changes at
L5-S1 with there is grade 1 anterolisthesis and disc space narrowing.
Abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No significant change in short segment narrowing of the proximal SMA with
surrounding fat stranding and findings compatible with intramural edema. This
most likely represent vasculitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, Transfer
Diagnosed with AC VASC INSUFF INTESTINE
temperature: 98.4
heartrate: 65.0
resprate: 18.0
o2sat: 97.0
sbp: 131.0
dbp: 71.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ male, previously healthy, who
presented to an OSH ED this morning with back pain, found to
have CTA concerning for SMA vasculitis.
# SMA vasculitis: Large vessel vasculitides including ___
can affect the branches of the aorta, though vasculitis of small
and medium vessels such as polyarteritis nodosa or microscopic
polyangiitis would more typically involve the SMA. Mesenteric
vasculitis can be seen with other rheumatologic diseases such as
SLE which would be less likely to present in a ___ year old male.
PAN is associated with hepatitis B. CRP was elevated at 11.2.
Hepatitis serologies, complement, ___ were sent and were
negative. Rheumatology was consulted for assistance in deciding
on steroid treatment. Heme/onc was consulted for the question of
anticoagulation and deferred to vascular. Vascular surgery
recommended repeating the CT scan as it was uncertain whether
there was thrombus vs. a filling defect on the first image.
Second CTA showed wall edema and no evidence of clot. Decision
was made to start on prednisone 60mg daily with plan to follow
up with rheumatology regarding a taper. Bactrim prophylaxis,
calcium/vitamin D and omeprazole were started for PCP
prophylaxis, osteoporosis prevention and gastric protection
respectively. Hypercoagulable workup including antiphospholipid,
anticardiolipin and lupus anticoagulant were negative.
Vasculitis labs that returned during hospitalization were also
negative. SPEP and beta 2 microglobulin were pending at
discharge.
# Back pain: No red flag symptoms on history. Likely
musculoskeletal in origin. Could be related to SMA finding,
especially since pain is worse post-prandially. Nothing in
history to raise suspicion for occult infection or abscess. He
was treated with oxycodone, lidocaine patch, acetaminophen and
ibuprofen.
# Hyperlipidemia: Continue rosuvastatin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right facial abscess
Major Surgical or Invasive Procedure:
I&D of right facial abscess with ENT ___
History of Present Illness:
___ F PMHx HTN, DMII p/w R facial swelling.
Patient reports a "pimple" ~ 2 weeks ago which over the last
week
___ particular began to swell with increasing pain and ___ the
last
few day fevers and chills.
She presented initially to OSH where a CT was performed and she
was found to have 5.8 x 3.7 x 6 cm multiloculated abscess ___ the
soft tissues right side of the face extending to and abutting
the
lateral wall of the right maxillary sinus anteriorly posteriorly
abutting the angle of the mandible. No bone destruction.
She was brought to ___ ED for evaluation by ENT.
She denies difficulty breathing though she endorses trismus. No
pooling of saliva. Still able to swallow without difficulty.
No dyspnea or chest pain. No abdominal pain. No tooth pain. No
identified trauma or bug bites. No history of prior.
___ the ED:
- Initial vital signs were notable for:
100.6, 100, 134/82, 18, 99% RA
- Exam notable for:
R facial abscess
- Labs were notable for:
Leukocytosis with left shift
- Studies performed include:
5.8 x 3.7 x 6 cm multiloculated abscess ___ the soft tissues
right
side of the face extending to and abutting the lateral wall of
the right maxillary sinus anteriorly posteriorly abutting the
angle of the mandible. No bone destruction.
- Patient was given:
Fentanyl & IV tylenol
Zosyn & Vancomycin
Insulin
- Consults:
ENT (see recs below)
Upon arrival to the floor, she gives the above history.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
HTN
DM
HLD
Social History:
___
Family History:
DMII
HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
___ 0128 Temp: 97.9 PO BP: 149/88 HR: 86 RR: 18 O2 sat: 96%
O2 delivery: RA
GEN: appears uncomfortable
HEENT: EOMI, MMM, erythema and edema along lower jaw reaching
almost to level of amxilla. Aarea of drainage from R inferior
face and cluster of pustules with surrounding duskiness and
nodularity.
Oral Cavity/Oropharynx: Mucous membranes are moist and pink,
tongue without lesions. Good dentition.
DISCHARGE PHYSICAL EXAM:
===================
VITALS:
24 HR Data (last updated ___ @ 2350)
Temp: 98.3 (Tm 98.3), BP: 148/88 (137-148/84-90), HR: 69
(69-79), RR: 18, O2 sat: 99% (98-100), O2 delivery: RA
GEN: appears uncomfortable
HEENT: EOMI, MMM, improving erythema and edema. Bandage covering
drainage site of abscess, when peeled wick is ___ place with
sero-sanguinous drainage.
Oral Cavity/Oropharynx: Mucous membranes are moist and pink,
tongue without lesions. Good dentition. Right side of interior
mouth appears swollen.
Pertinent Results:
___ 05:40PM GLUCOSE-242* UREA N-14 CREAT-0.6 SODIUM-137
POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-22 ANION GAP-19*
___ 05:40PM estGFR-Using this
___ 05:40PM WBC-14.8* RBC-4.50 HGB-13.0 HCT-39.6 MCV-88
MCH-28.9 MCHC-32.8 RDW-11.5 RDWSD-37.0
___ 05:40PM NEUTS-79.3* LYMPHS-13.2* MONOS-6.2 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-11.73* AbsLymp-1.95 AbsMono-0.91*
AbsEos-0.02* AbsBaso-0.04
___ 05:40PM PLT COUNT-336
==============
DISCHARGE LABS
=================
___ 07:45AM BLOOD WBC-7.6 RBC-4.69 Hgb-13.6 Hct-41.6 MCV-89
MCH-29.0 MCHC-32.7 RDW-11.9 RDWSD-37.8 Plt ___
___ 07:45AM BLOOD Glucose-219* UreaN-13 Creat-0.9 Na-142
K-3.9 Cl-103 HCO3-25 AnGap-14
___ 07:45AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.0
==================
OTHER PERTINENT LABS
==================
___ 08:01AM BLOOD %HbA1c-12.4* eAG-309*
==============
MICROBIOLOGY
=================
___ 7:28 pm SWAB Source: facial wound R.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 11:16 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
=================
IMAGING
=================
___ CT HEAD W AND WITHOUT CONTRAST
IMPRESSION:
1. No evidence of intracranial pathology.
2. Please see separate CT neck report for full description of
findings
related to inflammatory change ___ the right facial subcutaneous
fat.
___ CT NECK W AND WITHOUT CONTRAST
IMPRESSION:
1. Patient is status post incision and drainage of a right
facial abscess
with extensive surrounding inflammatory changes. The abscess
cavity is now
open to the skin surface, and contains packing material. It
appears
contiguous with ill-defined posterior abscess cavity margins,
which are
similar ___ extent compared to the previous exam.
2. Prominent right level 1B and 2A lymph nodes, likely
reactive.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Discharge Medications:
1. Cephalexin 500 mg PO QID
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*37 Capsule Refills:*0
2. GlipiZIDE 5 mg PO BID
RX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*130
Tablet Refills:*0
4. Atorvastatin 20 mg PO QPM
5. Lisinopril 30 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right facial abscess
Uncontrolled type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/ AND W/O CONTRAST Q1212 CT HEAD
INDICATION: ___ year old woman with facial abscess s/p I D// Please evaluate
for evolution of facial abscess
TECHNIQUE: Contiguous axial images of the brain were obtained before and
after the intravenous administration of Omnipaque contrast agent. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
2) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 1,495 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of large territory infarction, edema, hemorrhage or mass
effect. The ventricles and sulci are normal in size and configuration.
There is soft tissue stranding and edema seen in the right superficial buccal
subcutaneous fat subcutaneous, in the sub-zygomatic region (2:1).
There is no gross evidence of acute fracture. The ethmoid, sphenoid, and
frontal sinuses are clear. There is a small mucous retention cyst in the left
maxillary sinus (2:6). The middle air cavities are unremarkable. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of intracranial pathology.
2. Please see separate CT neck report for full description of findings
related to inflammatory change in the right facial subcutaneous fat.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT
INDICATION: ___ year old woman with facial abscess s/p I D// Please evaluate
for evolution of facial abscess
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.8 s, 30.2 cm; CTDIvol = 10.8 mGy (Body) DLP = 325.4
mGy-cm.
Total DLP (Body) = 325 mGy-cm.
COMPARISON: CT of the neck soft tissues dated ___..
FINDINGS:
Aero digestive tract: There is no mass.
Neck lymph nodes: There are prominent reactive lymph nodes, measuring upwards
of 1 cm in station 2A (3:68). There also prominent lymph nodes at level 1 B
there is no retropharyngeal adenopathy.
Extra nodal tumor spread: There are no findings suggestive of extra nodal
extension.
Deep neck muscles, masticator space: Patient is status post I&D of a right
facial abscess in the buccal superficial subcutaneous soft tissue surrounding
inflammatory changes. Packing material is visualized with a track open to the
surface of the skin (03:56). Inflammatory changes involve the adjacent
superficial musculature platysma. The extent of the lobular deep margin
appears grossly similar to the previous examination, and appears in
communication with the dominant abscess cavity.
Bones, skull base:
Minimal degenerative change including posterior osteophytes, most prominently
at C5-C6. The disc osteophyte results in likely moderate spinal canal
narrowing at this level (series 301, image 154) with mild-to-moderate right
neural foraminal narrowing. No suspicious osseous lesions.
Vessels: There is no vascular thrombosis.
Brachial Plexus: There is no brachial plexus contact or invasion.
Thyroid, salivary glands: There is no mass.
Other findings: There are no lung nodules.
IMPRESSION:
1. Patient is status post incision and drainage of a right facial abscess
with extensive surrounding inflammatory changes. The abscess cavity is now
open to the skin surface, and contains packing material. It appears
contiguous with ill-defined posterior abscess cavity margins, which are
similar in extent compared to the previous exam.
2. Prominent right level 1B and 2A lymph nodes, likely reactive.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by AMBULANCE
Chief complaint: Abnormal CT, R Facial swelling
Diagnosed with Cutaneous abscess of face
temperature: 100.6
heartrate: 100.0
resprate: 18.0
o2sat: 99.0
sbp: 134.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | ====================
PATIENT SUMMARY:
====================
Ms. ___ presented with a right facial abscess that initially
started as a pimple about 2 weeks prior to presentation. She
went to an OSH where CT showed multiloculated facial abscess.
Transferred to ___ for ENT consult. At ___ abscess was
incised and drained and she was started on broad spectrum abx.
Wound culture grew MSSA. She was followed by ENT and OMFS during
admission who felt no surgical indication. She was transitioned
to Keflex. Course c/b A1c 12.4 revealing uncontrolled T2DM. She
was seen by the ___ DM team and started on glipizide ___
addition to ISS. Will go home on glipizide and metformin. Will
f/u with PCP regarding diabetes ___ and possible insulin needs.
====================
TRANSITIONAL ISSUES:
====================
#discharge Cr: 0.9 (baseline 0.6)
#stopped meds: none
#changed meds: metformin restarted at discharge at lower dose of
500 mg PO BID for two days (___) with plan to increase
back to 1000 mg PO BID starting on ___
#new meds: cephalexin 500 mg PO QID (ends ___, glipizide 5
mg PO BID
[ ] F/u blood sugars: Found to have A1c 12.4 this admission.
Started on glipizide. Restarted home metformin at discharge with
plan to increase back to former dose (see above). Also provided
glucometer, test strips and lancets. Please continue to follow
blood sugars and consider need for insulin and/or referral to
endocrinologist
[ ] Facial abscess: found to have multiloculated facial abscess,
s/p I&D. Will be going home on cephalexin for total 14 day
course (end date ___
[ ] Follow-up appointment with ENT pending at time of discharge.
If appointment is not made within ___ days, can call
___ to make this appointment.
[ ] Wound care recs per ENT (will be carried out by patient's
daughter and ___: Daily wick changes until ENT follow-up. To
change, cut a 2 inch piece of 1" iodinated wick and insert into
the drainage site on the right face using the back end of a
cotton swab. Secure with a folded gauze and tape.
[ ] Found to have very mild ___ this admission thought to be
from minimal PO intake, which was improving at time of
discharge. Please check CMP ___ 1 week (___) and ensure Cr has
normalized.
#code status: full
#contact: daughter ___
====================
ACUTE ISSUES:
====================
# R Facial multiloculated abscess
Reported first noticing "pimple" two weeks prior to admission
that progressed to inflamed, tender abscess. Presented to OSH
where CT showed multiloculated right facial abscess so she was
transferred to ___ for work up with ENT. At ___ she denied
any trauma, bite or other structural insult. ENT was consulted,
and she underwent I and D and intermittent milking of abscess
with wick ___ place. She was started on broad spectrum IV abx
pending final wound cx results. Seen by ___ given c/f possible
massiteric space firmness, but per OMFS no intraoral
involvement. She had a repeat CT ___ showing "abscess cavity
now open to the skin surface, and contains packing material. It
appears contiguous with ill-defined posterior abscess cavity
margins, which are similar ___ extent compared to the previous
exam." Wound cx resulted with MSSA, so she was transitioned to
cephalexin ___ for total 14 day course with end date ___. Her
blood cultures on day of discharge were NGTD. She will go home
with ___ to assist with dressing changes, and her daughter who
is a ___ will also assist with keeping the wound clean. She will
follow up with ENT as an outpatient (ENT to schedule).
# Poorly controlled T2DM
She has a history of DM and was on metformin at home. She and
family reported that she used to check BG at home but not ___
months-years and does not have home glucomter. A1c 12.4% this
admission. Her home metformin was held on admission and she was
started on insulin. ___ was consulted as her diabetes was
poorly controlled and likely contributed to her large facial
infection and admission. She was started on glipizide at low
dose and uptitrated to 5mg BID on day of discharge. She will be
discharged on metformin 500mg BID x 2 days and will then go back
to home metformin 1000mg BID. She has f/u with PCP for further
counseling and mangagement of her blood sugars. She is also
going home with glucometer, test strips, and lancets, which she
and her children report knowing how to use.
___
Cr 0.6 on admission --> peaked at 1.1. Likely pre renal because
of NPO
status for imaging/ procedures. Improved with PO intake.
Creatinine on discharge was 0.9.
====================
CHRONIC ISSUES:
====================
#HTN: continued home lisinopril |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Abdominal pain, fevers
Major Surgical or Invasive Procedure:
___ Successful CT-guided placement of an ___ pigtail
catheter into the collection. Samples were sent for microbiology
evaluation.
History of Present Illness:
Mr. ___ is a ___ presenting with 3 weeks of abdominal
discomfort and fevers to 103. He was in his normal state of
health until 3 weeks ago when he started to have vague lower
abdominal pain while in ___. At that time, he presented to
an ED in ___ where he underwent a CT scan and was told he
had gastroenteritis. The following day he returned home to
___ with worsening pain and was admitted to ___
___. No repeat imaging was completed, but he was discharged
with 10 days of antibiotics (Cipro/flagyl). Despite antibiotics,
he began having fever and chills to 103. He denies any symptoms
of nausea or vomiting, but has had episodes of loose stools. He
has only mild lower abodminal and pelvic discomfot. He saw his
PCP last ___ regarding these high fevers and was prescribed
another course of PO antibiotics (Cipro/flagyl). WBC levels were
checked in the outpatient setting which had showed resolving
leukocytosis last week. However, over this past weekend, he
started having high grade fevers and was found to have
leukocytosis to 15 this morning. He was therefore referred to
the ED for further evaluation.
Past Medical History:
PMH: none
PSH: none
Social History:
___
Family History:
Grandmother-lymphoma, HTN
Aunt- colitis
Physical ___:
Admission Physical Exam:
Vitals: 99.9 83 128/81 18 100% RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.6, 80, 132/90, 18, 99 RA
Gen: Alert, sitting at edge of bed eating lunch with mom at
bedside.
HEENT: no deformity. PERRL, EOMI. Mucus membranes pink, moist.
Neck supple. Trachea midline.
CV: RRR
Pulm: clear to auscultation bilaterally
ABd: Soft, non-tender, non-distended. Normoactive bowel sounds x
4 quadrants.
Skin: warm and dry.Left gluteal JP drain to bulb suction with
serosanguinous.
Ext: no edema, 2+ ___ pulses.
Neuro: A&Ox3. Follows commands, moves all extremities equal and
strong. Speech is clear and fluent.
Pertinent Results:
___ 04:55AM BLOOD WBC-7.7 RBC-3.63* Hgb-11.5* Hct-33.2*
MCV-92 MCH-31.7 MCHC-34.6 RDW-12.2 RDWSD-40.6 Plt ___
___ 04:50AM BLOOD WBC-7.9 RBC-3.80* Hgb-11.9* Hct-35.7*
MCV-94 MCH-31.3 MCHC-33.3 RDW-12.1 RDWSD-42.0 Plt ___
___ 10:00AM BLOOD WBC-14.7* RBC-4.07* Hgb-12.8* Hct-37.8*
MCV-93 MCH-31.4 MCHC-33.9 RDW-12.1 RDWSD-41.5 Plt ___
___ 04:50AM BLOOD ___ PTT-30.7 ___
___ 04:55AM BLOOD Glucose-104* UreaN-5* Creat-0.8 Na-134
K-3.6 Cl-100 HCO3-26 AnGap-12
___ 04:50AM BLOOD Glucose-66* UreaN-7 Creat-0.9 Na-141
K-4.2 Cl-103 HCO3-24 AnGap-18
___ 10:00AM BLOOD Glucose-88 UreaN-8 Creat-0.8 Na-140 K-3.9
Cl-103 HCO3-28 AnGap-13
___ 10:00AM BLOOD ALT-25 AST-24 AlkPhos-89 TotBili-0.3
___ 04:55AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.7
___ 04:50AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
___ CT Abd/Pelvis
Bowel wall thickening of the sigmoid colon with adjacent fat
stranding and
small locules of extraluminal air are concerning for
perforation, possibly
from diverticulitis. A 4.4 x 4.7 x 4.1 cm peripherally
enhancing fluid
collection seen inferior to the sigmoid colon is compatible with
abscess
formation.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
Do not exceed 4 grams per 24 hours
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 13 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*26 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 13 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*39 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Take lowest effective dose.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. Docusate Sodium 100 mg PO BID
hold for diarrhea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ with 3 weeks of bilat lower abd pain, urge to defecate+PO
contrast // eval for 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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 689 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 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. The appendix is
normal. There is bowel wall thickening with surrounding stranding at the
sigmoid colon and small locules of extraluminal air. A more discrete 4.4 x
4.7 x 4.1 cm complex fluid collection is seen extending inferior from the
___ inflammation, anterior to the rectum, compatible with abscess
formation (2:67). A few scattered diverticula are seen proximal to the region
of inflammation.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy
although scattered borderline retroperitoneal lymph nodes are identified.
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:
Bowel wall thickening of the sigmoid colon with adjacent fat stranding and
small locules of extraluminal air are concerning for perforation, possibly
from diverticulitis. A 4.4 x 4.7 x 4.1 cm peripherally enhancing fluid
collection seen inferior to the sigmoid colon is compatible with abscess
formation.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 2:55 ___, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with 4.4 x 4.7 x 4.1 cm complex intra-abdominal
fluid collection // Request for abscess drainage
COMPARISON: Comparison is made to CT from ___.
PROCEDURE: CT-guided drainage of pericolonic collection.
OPERATORS: Dr. ___, radiology trainees and Dr. ___,
___ radiologist. Dr. ___ supervised the trainee during the
key components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 23 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: 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.
SEDATION: Moderate sedation was provided by administering divided doses of 4
mg Versed and 250 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Preprocedure images demonstrate a fluid collection between the rectum and
sigmoid. The sigmoid is abnormally thickened with surrounding stranding.
There are sigmoid diverticula present.
Periprocedural images demonstrate appropriate location of the a wire and
catheter.
Postprocedure images demonstrate decompression of the abscess cavity, and
appropriate position of the pigtail catheter.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples was sent for microbiology evaluation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Peritoneal abscess
temperature: 99.9
heartrate: 83.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 81.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
Service on ___ with abdominal pain and fevers despite a
course multiple courses ciprofloxacin and metronidazole. He had
a CT scan of his abdomen that showed bowel wall thickening in
the sigmoid colon with adjacent fat stranding concerning for a
perforation along with an enhancing fluid collection compatible
with abscess formation. He was taken to interventional radiology
and had a CT guided placement of an 8 ___ pigtail catheter. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / shellfish derived
Attending: ___.
Chief Complaint:
Rectal pain
Major Surgical or Invasive Procedure:
Exam under anesthesia, Botox injection
History of Present Illness:
___ hx of ___ disease, currently on Humira, presents with
rectal pain and swelling. She reports that symptoms started two
weeks ago when she noticed discomfort with bowel movements.
Since then the pain has increased. Pain is sharp and
continuous, worsened by bowel movements and by sitting for long
periods. Pain is diffuse along her sacrum toward her perineum,
left greater
than right sided. She also noticed purulent discharge when
wiping after bowel movements and on underwear. Has also noted
fevers to 103 at home this past ___, none since. Denies prior
perianal abscesses. Tolerating PO, denies nausea or vomiting.
Also denies BRBPR or melena. Last bowel movement today. ___
disease diagnosed in ___. Was initially on pentasa, until last
year,
then started Humira. Has ___ bowel movements daily. Soft,
formed, non-bloody. Reports that last colonoscopy was in ___
and is due for one again in the near future. No ___ flares
recently. Her typical manifestations are bloody bowel movements
and abdominal pain. Typically has right colonic symptoms. Is
followed at ___.
Past Medical History:
___, HTN
Social History:
___
Family History:
No family members with ___, ulcerative colitis, or colon
cancer
Physical Exam:
Gen: NAD
HEENT: NCAT, anicteric, no neck masses
CV: RRR
Pulm: no respiratory distress
Abd: S/NT/ND
Rectal: Posterior midline anal fissure
TLD: None
Pertinent Results:
___ 07:26AM BLOOD WBC-5.5 RBC-4.84 Hgb-13.5 Hct-40.5 MCV-84
MCH-27.9 MCHC-33.3 RDW-13.7 RDWSD-41.6 Plt ___
___ 07:26AM BLOOD Neuts-42.2 ___ Monos-6.7 Eos-1.6
Baso-0.2 Im ___ AbsNeut-2.33 AbsLymp-2.70 AbsMono-0.37
AbsEos-0.09 AbsBaso-0.01
___ 07:26AM BLOOD Glucose-113* UreaN-7 Creat-0.8 Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
___ 04:30PM BLOOD ALT-65* AST-41* AlkPhos-95 TotBili-0.3
___ 07:26AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8
Medications on Admission:
Humira, Valsartan 80'
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain or fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*60 Tablet Refills:*0
2. Psyllium Powder 1 PKT PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
4. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of Crohn's disease with purulent rectal drainage.
Evaluate for source of infection or abscess.
TECHNIQUE: Multiplanar and multisequence T1 and T2 weighted images were
acquired through the pelvis before after the uneventful intravenous
administration of 10 mL of Gadavist contrast.
COMPARISON: None.
FINDINGS:
In the low rectum, approximately 41 mm from the anal verge, there is a short
interloop fistula which is confined to the rectal wall on the right. It
originates at approximately 10 o'clock (5, 17), extends 15 mm in the cranial
caudal dimension, and then reenters through the mucosa at approximately 12
o'clock. It is approximately 5 mm in width. There is a small amount of fluid
within this fistula. There is some surrounding enhancement, suggesting active
inflammation.
No other fistula or sinus track is identified. No discrete drainable abscess
is identified.
The ischiorectal fossa, ischioanal fossa, and anal sphincter are within normal
limits. There is no significant scarring or thinning of the musculature.
The remainder of the rectum and intrapelvic bowel loops are normal. There are
no focal inflammatory changes. The uterus, cervix, and vaginal canal are
normal. The endometrium is thin and homogeneous, measuring 2 mm. The ovaries
are not discretely visualized. No adnexal masses are identified. The bladder
is unremarkable without focal thickening or evidence of a mass.
There is no pelvic or inguinal lymphadenopathy. No free fluid is identified
in the pelvis.
There are no concerning osseous lesions. The soft tissues are unremarkable.
IMPRESSION:
Short intraloop fistula in the low right rectum which is confined to the
rectal wall, as described above.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abscess, Rectal pain
Diagnosed with Other specified diseases of anus and rectum
temperature: 97.8
heartrate: 89.0
resprate: 16.0
o2sat: 99.0
sbp: 174.0
dbp: 87.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ was admitted to ___ for an exam under anesthesia
for a presumed rectal abscess. For more details, see operative
report. She was taken from the OR to the PACU in stable
condition. She was soon moved to the surgical floor. She
tolerated a regular diet, and her pain was well controlled with
oral pain medication. She was discharged home with instructions
to take Metamucil daily and follow up with Dr. ___ in 2
weeks. All of her questions were answered to her satisfaction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Fever, wound drainage
Major Surgical or Invasive Procedure:
___: ___ guided lumbar puncture
History of Present Illness:
___ yo female patient s/p craniotomy and resection of WHO Grade
II meningioma on ___. She returns after a fall at home and
fever with wound drainage and found to have a UTI and
hyponatremia.
Past Medical History:
HTN
Scoliosis
Family History:
Non-contributory
Physical Exam:
Exam on admission:
PHYSICAL EXAM:
O: T: 102.2 BP: 152/77 HR: 88 R 16 O2Sats 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 3-2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. LUE tremulous with
activity. LUE and LLE 4+/5, rest ___ throughout. Unable to fully
supinate LUE; no downward drift or further pronation.
Sensation: Intact to light touch
Wound: Small area just anterior to right pole of incision with
drainage noted. Nothing expressible.
---------------
Discharge Exam:
---------------
General:
Afebrile, AVSS
___ 0757 Temp: 98.4 PO BP: 151/72 HR: 71 RR: 16 O2 sat: 96%
O2 delivery: RA
Bowel Regimen: [x]Yes
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 3-2mm
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [x]Yes - Left pronation
Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___+4+4+5
IPQuadHamATEHLGast
___
Left5 5 5 5 5 5
Wound:
[ ]Incision - 3 staples added to far right incision. Mild
erythema/edema inferior to staples. No active or expressible
drainage.
Labs:
___ 04:40AM BLOOD WBC: 7.6 RBC: 2.72* Hgb: 8.6* Hct: 25.5*
MCV: 94 MCH: 31.6 MCHC: 33.7 RDW: 14.4 RDWSD: 48.2* Plt Ct: 256
___ 04:40AM BLOOD Glucose: 103* UreaN: 9 Creat: 0.6 Na: 136
K: 3.7 Cl: 101 HCO3: 24 AnGap: 11
___ 04:40AM BLOOD ___: 16.3* PTT: 60.2* ___: 1.5*
Pertinent Results:
Please see OMR for pertinent results.
Medications on Admission:
- Acetaminophen 325-650 mg PO Q4H:PRN fever or pain
- Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Heparin IV Sliding Scale
No Initial Bolus
Start infusion with rate of: 1150 units/hr
Therapeutic/Target PTT Range: 60 - 99.9 seconds
4. Sodium Chloride 3 gm PO TID
5. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 6 Days
6. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
fever; wound drainage
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: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with fever s/p craniotomy.
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: ___ brain MRI and noncontrast head CT and ___ outside hospital noncontrast head CT
FINDINGS:
Status-post right frontoparietal craniotomy and meningioma resection.
The resection cavity is minimally decreased in size, measuring approximately
4.5 x 4.1 cm, previously 4.8 x 4.2 cm. There is a large air collection within
the surgical cavity. Contents in the inferior dependent portion of the
resection cavity demonstrate increased intrinsic T1 signal hyperintensity
consistent with blood products. No evidence of slowed diffusion. Hyperintense
signal on diffusion-weighted imaging does not correspond well with findings on
other sequences and is likely due to susceptibility artifact from the air
collection and surgical hardware. Vasogenic edema adjacent to the resection
cavity has significantly decreased since the prior examination, making less
likely the possibility of abscess and parenchymal infection.
Leptomeningeal enhancement most prominent lateral and inferior to the
resection cavity has increased. Interval decrease in subdural pneumocephalus,
but increase in subdural fluid which does not completely suppress on FLAIR
imaging and does not demonstrate slow diffusion. The increase in fluid and
the signal intensity characteristics are worrisome for infection involving the
subdural space. Note, however that there is minimal enhancement associated
with these collections.
Enhancing soft tissue with slow diffusion along the medial aspect of the
resection cavity, adjacent to the superior sagittal sinus, is not
significantly changed and concerning for residual meningioma.
No evidence of infarction. No evidence of new hemorrhage. The ventricles and
sulci are enlarged, consistent with involutional change. Small incidental
probable Tornwaldt cyst. Bilateral lens replacements.
IMPRESSION:
1. Increased leptomeningeal enhancement highly concerning for meningitis.
2. While increased subdural fluid collections the could reflect the presence
of a dural defect, sequela of dural or leptomeningeal infection should be
considered.
3. The resection cavity is minimally decreased in size. No findings to
specifically suggest abscess formation.
4. The persistent presence of gas within the resection cavity likely reflects
the presence of a dural defect.
5. Enhancing soft tissue medial to the resection cavity, adjacent to the
superior sagittal sinus, reflects residual meningioma.
NOTIFICATION: The findings were discussed with ___, N.P. by
___, M.D. on the telephone on ___ at 9:54 am, approximately
60 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: Fever workup, rule out PNA
IMPRESSION:
No comparison. Lung volumes are low. Severe scoliosis with subsequent
asymmetry of the ribcage. Minimal pleural effusions, seen on the lateral
radiograph only and occupying the posterior parts of the costophrenic sinuses.
No pneumonia. No pulmonary edema.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman s/p surgery with BLE redness and tenderness//
r/o DVTs
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.
Left peroneal vein demonstrates noncompressibility, which is strongly
suggestive of a deep vein thrombosis. Additionally, there is limited
evaluation of the right calf veins due to poor penetration.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Left perennial vein demonstrates noncompressibility, which is strongly
suggestive of a focal deep vein thrombosis.
2. Limited evaluation of the right calf veins due to poor penetration.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:12 pm, less than 5
minutes after discovery of the findings.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ POD#22 from R frontal crani for resection, re-admitted after
falls with fevers and wound drainage, MRI concerning for meningitis. On
heparin gtt for DVT, stopped at 10:15 today, appreciate assistance to LP to
mimimize attempts and time off heparin.// CSF for culture
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A pre-procedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L5-S1.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 22 gauge, 12 cm spinal needle was inserted into
the thecal sac. The opening pressure was 31 cm H2O. There was good return of
clear CSF. 12 mls of CSF were collected in 4 tubes and sent for requested
analysis.
COMPARISON: None.
FINDINGS:
Degenerative changes of the lower lumbar spine.
12 mls of CSF were collected in 4 tubes. The opening pressure was 31 cm H2O.
IMPRESSION:
1. Lumbar puncture at L5-S1 without complication.
2. Opening pressure of 31 cm H2O.
I, Dr. ___ supervised the trainee during the key components
of the above procedure and I reviewed and agree with the trainee's findings
and dictation.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc// r dl picc 48cm ping iv ___
Contact name: ping, ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the right PICC line projects over the upper right atrium,
approximately 1 cm beyond the cavoatrial junction.
Bibasilar opacities left greater than right likely reflect pleural fluid and
subjacent atelectasis. Superimposed pneumonia would be hard to exclude in the
proper clinical context. No pneumothorax or pulmonary edema. The size of the
cardiac silhouette is enlarged but unchanged.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with newly placed PICC, has been pulled back
since last x-ray, please evaluate PICC placement// Evaluate PICC placement
Contact name: ___: ___ Evaluate PICC placement
IMPRESSION:
Right PICC line tip is at the level of lower SVC. Heart size and mediastinum
are stable. There is vascular congestion/mild to moderate interstitial
pulmonary edema. Bilateral pleural effusions are most likely present. No
pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT, s/p Fall, Transfer
Diagnosed with Urinary tract infection, site not specified
temperature: 102.2
heartrate: 88.0
resprate: 16.0
o2sat: 96.0
sbp: 152.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ yo female patient s/p craniotomy and resection of WHO Grade
II meningioma on ___. She returns after a fall at home and
fever with wound drainage and found to have hyponatremia.
#Fever
Given wound drainage a brain MRI was done to assess for abscess,
which was concerning for meningitis. Interventional radiology
was consulted and she underwent ___ guided LP. Heparin drip was
held and INR was reversed prior to LP. Infectious disease was
consulted and she was started on empiric vancomycin and
cefazolin. Per ID recommendation, she was transitioned to
Bactrim PO for a total 10 day antibiotic course.
#Hyponatremia
On admission lab work revealed Na of 126. The patient was
started on Salt tabs and repeat labs showed improvement to
normonatremia.
#Left peroneal DVT
The patient complained of lower extremity pain, therefore LENIs
were ordered which revealed LLE peroneal DVT. She was started on
heparin drip on ___. Bridge to Coumadin was started on ___.
#Anemia
The patient's hemoglobin and hematocrit were found to be low
upon presentation, but stabilized throughout admission without
intervention.
At the time of discharge to acute rehab patient was in stable
condition, voiding independently, ambulatory, and with adequate
pain control. She was given instructions to follow up with Dr.
___, as scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Acetaminophen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy.
History of Present Illness:
___ with one day of generalized, periumbilical abdominal pain
which began yesterday afternoon and somewhat focused on the
right side. Pain is constant and has progressed over the past 24
hours. Pain is worse with eating. ROS also positive for
decreased appetite, no nausea or emesis.
Past Medical History:
PMH: Myalgias, tendonitis
PSH: None
Social History:
___
Family History:
non-contributory
Physical Exam:
___ HR79 BP116 RR18 Pox100RA
GEN: AAOx3, NAD
HEART: RRR S1S2
PULM: CTAB
AB: soft, ND, mild TTP over incisions, non-saturated dressings
over incisions
EXT: peripheral pulses intact bilaterally
Pertinent Results:
___ 10:36AM BLOOD WBC-6.7 RBC-4.31 Hgb-13.5 Hct-39.8 MCV-92
MCH-31.3 MCHC-33.9 RDW-12.6 Plt ___
___ 07:34PM BLOOD ___ PTT-31.5 ___
___ 10:36AM BLOOD UreaN-13 Creat-0.7 Na-141 K-3.5 Cl-102
HCO3-30 AnGap-13
CT AB/PELVIS ___
IMPRESSION:
Mildly dilated enhancing appendix, measuring 8 mm with no
definite periappendiceal fat stranding, abdominal free fluid, or
intra-abdominal abscess formation. Findings consistent with
early appendicitis.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute, nonperforated appendicitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with 36 hr abdominal pain right lower quadrant
greater than left lower quadrant.
COMPARISON: CT abdomen and pelvis ___.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after administration of oral contrast and 130 cc of Omnipaque.
Multiplanar reformatted images in the coronal and sagittal planes were
generated.
DLP: 440.60mGy-cm
FINDINGS:
The lung bases are clear. The included heart and pericardium are normal.
Abdomen: The liver enhances homogeneously without focal lesions. The
gallbladder is normal without radiopaque gallstones. There is no intra or
extrahepatic biliary duct dilation. The portal vein is patent. The adrenal
glands, spleen, and pancreas are unremarkable. The kidneys display symmetric
nephrograms and excretion of contrast. The ureters are normal in caliber
along their course to the bladder. There are no perinephric abnormalities.
The distal esophagus is normal without a hiatal hernia. Oral contrast extends
from the stomach through the small bowel. The stomach is normal. The small
bowel is normal in caliber without focal wall thickening or evidence of
obstruction. The large bowel is normal in caliber without obstructive mass
lesion or wall thickening.
The appendix is enhancing and mildly dilated measuring 8 mm in the transverse
dimension (4:60); (6:19). There is no definite periappendiceal fat stranding.
There is no free fluid or intra-abdominal abscess formation. There is no
appendicolith or associated cecal wall thickening. Findings are consistent
with early appendicitis.
The abdominal aorta is normal in caliber without aneurysmal dilation. The
major branches off of the abdominal aorta are patent. There are no enlarged
retroperitoneal or mesenteric lymph nodes.
Pelvis: The bladder is well distended and normal. The uterus, and rectum are
unremarkable. There are bilateral follicular cysts in the adnexa. There is
no pelvic free fluid. There are no pathologically enlarged pelvic sidewall or
inguinal lymph nodes. There are no inguinal hernias.
Osseous structures: There are no concerning lytic or sclerotic bony lesions.
IMPRESSION:
1. Mildly dilated enhancing appendix, measuring 8 mm with no definite
periappendiceal fat stranding, abdominal free fluid, or intra-abdominal
abscess formation. Findings consistent with early appendicitis.
Critical findings were given by telephone to Dr. ___ by Dr. ___
on ___ at 140PM, 10 minutes after they were made. The patient was sent
from the CT scanner to the emergency department.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: APPY
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.7
heartrate: 76.0
resprate: 16.0
o2sat: 97.0
sbp: 117.0
dbp: 70.0
level of pain: 2
level of acuity: 2.0 | The patient was admitted to the Acute Care Surgery Service on
___ after undergoing a laparoscopic appendectomy. Please
see the separately dictated operative note for details of
procedure. The patient was extubated and transferred to the
hospital floor for further post-operative care. The
post-operative course was uneventful and the patient was
discharged to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
___: Right chest wall pigtail catheter insertion
History of Present Illness:
___ Yo f presents today as trauma for fall from standing. This
morning, pt was walking and fell down 2 steps backwards. No LOC.
No headstrike. No blood thinners. Pt fell on R chest/back. After
the fall, patient complained of 8 out
of 10 rib pain associated with shortness of breath. Patient
without any other complaints including headache, neck pain,
belly pain, extremity injuries. Paramedics arrived and found
patient hypoxic to 85% and placed on 6 L nasal cannula with
improvement, felt subcutaneous emphysema on the right.
Past Medical History:
___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 97.6 HR: 70 BP: 125/75 Resp: 24 O(2)Sat: 95
Constitutional: Uncomfortable. On NRB.
Speaking
full sentences
Chest: Clear to auscultation on the left
Diminished
on the right
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nontender, Nondistended, Soft
GU/Flank: No costovertebral angle tenderness or C/T/L spine
ttp
Extr/Back: No cyanosis, clubbing or edema.
Palpable
crepitus on the right lower ribs, laterally.
No BUE or BLE ttp, scaphoid ttp
Skin: No rash, Warm and dry
Discharge Physical Exam:
VS: T: 99.2 PO BP: 139/84 HR: 65 RR: 20 O2: 95% RA
GEN: A+Ox3, NAD
HEENT: atraumatic
CV: RRR, no m/r/g
PULM: diminished lung sounds at right base, otherwise CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CXR:
Slightly displaced fractures of the right posterior ___ and ___
ribs.
Moderate right apical and anterior pneumothorax.
Subcutaneous emphysema along the right chest wall and neck.
___: CXR:
1. Interval placement of right thoracostomy catheter with
interval decrease or resolution of the previous right
pneumothorax.
2. The linear density projecting over the left upper lung zone
probably
represents an extracorporeal object and less likely reflects a
pneumothorax. If clinically concerning, a short-term follow-up
radiograph may be obtained.
___: CXR:
Previously seen right pneumothorax is not definitely visualized.
___: Right Shoulder x-ray:
1. No evidence of acute fracture or dislocation involving the
right shoulder.
2. Redemonstration few mildly displaced right-sided rib
fractures, unchanged from prior study.
3. Small sclerotic foci overlying the right humeral head and
projecting under the coracoid process as described above, likely
representing bone islands or possibly loose bodies.
4. Similar position of a right pleural pigtail catheter, without
definite
evidence of pneumothorax identified.
5. Stable appearance of subcutaneous emphysema overlying the
right
supraclavicular region.
___: CXR:
Trace right apical pneumothorax, not apparent on chest
radiograph ___ at 15:15 but decreased in size from the radiograph at
04:56. No signs of tension pneumothorax. Stable positioning of
right thoracostomy catheter.
___: CT Chest:
1. Status post placement of right pleural pigtail catheter with
residual small
right-sided pneumothorax noted. Extensive subcutaneous
emphysema is seen in the right chest wall.
2. Small right hemothorax.
3. Lower lobe opacities are seen which may be due to combination
of
atelectasis and aspiration.
4. Multiple left-sided pulmonary nodules are seen measuring up
to 5 mm.
5. Mild centrilobular emphysema.
6. Bilateral adrenal thickening greater on the right,
nonspecific.
NOTIFICATION: 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.
Medications on Admission:
-Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID
-Levothyroxine Sodium 100 mcg PO DAILY
-PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Take with food
4. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
7. Senna 8.6 mg PO BID:PRN Constipation
8. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye)
BID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
Discharge Disposition:
Home
Discharge Diagnosis:
-Posterior-lateral right 6 & 7th rib fractures, anterior ___ &
6th rib fractures
-Right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: TRAUMA #3 (PORT CHEST ONLY)
INDICATION: History: ___ with right chest wall crepitance// assess for pt
TECHNIQUE: Portable AP view of the chest.
COMPARISON: None
FINDINGS:
Slightly displaced fractures of the right posterior ___ and 7th ribs with
subcutaneous emphysema along the right chest wall and base of the neck.
Moderate size right apical and anterior pneumothorax with basilar atelectasis.
There is no focal consolidation or pleural effusion. Cardiomediastinal
silhouette is within normal limits.
IMPRESSION:
Slightly displaced fractures of the right posterior ___ and 7th ribs.
Moderate right apical and anterior pneumothorax.
Subcutaneous emphysema along the right chest wall and neck.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 5:15 am, 2 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with rt PTX, s/p pigtail placement// interval
assessment
TECHNIQUE: Portable chest AP.
COMPARISON: Chest radiograph obtained less than an hour prior.
FINDINGS:
An apically oriented thoracostomy catheter projects over the right upper lung
zone. Lungs are expanded. The previously noted right pneumothorax is no
longer evident. Anterior component of pneumothorax would not be appreciated.
A thin linear density along the left upper lung zone probably reflects and
extracorporeal object and less likely represents a pneumothorax, as lung
markings are seen extending superior to this line. There is no focal
consolidation or large pleural effusion. Again seen are the mildly displaced
fractures of the posterior right ribs, largely unchanged. Subcutaneous air
along the right chest wall and base of the neck is again noted.
Cardiomediastinal silhouette is largely unchanged.
IMPRESSION:
1. Interval placement of right thoracostomy catheter with interval decrease
or resolution of the previous right pneumothorax.
2. The linear density projecting over the left upper lung zone probably
represents an extracorporeal object and less likely reflects a pneumothorax.
If clinically concerning, a short-term follow-up radiograph may be obtained.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ yo f presents today as trauma for fall from standing. R
pigtail placed in ED for R pneumothorax. Needs repeat CXR for follow up.//
interval eval
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Multiple prior chest radiographs, most recently on ___
at 05:37
FINDINGS:
Compared with chest radiograph performed earlier on same day, there is no
significant change in positioning of a right pigtail catheter. A previously
seen right pneumothorax is not seen. There is mild bibasilar atelectasis,
similar to prior. Cardiomediastinal silhouette is stable. There is
subcutaneous emphysema over the right supraclavicular region. Multiple mildly
displaced right-sided rib fractures are again seen.
IMPRESSION:
Previously seen right pneumothorax is not definitely visualized.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ F s/p fall from standing on RT side, + crepitus and subq
emphysema on RT side, hypoxic, CXR w/ R PTX s/p R pigtail placement// interval
assessment
COMPARISON: Chest radiographs ___
FINDINGS:
PA and lateral views of the chest provided.
Right anterolateral approach thoracostomy catheter is unchanged in position.
There is trace right apical pneumothorax, not apparent on chest radiograph ___ at 15:15 but decreased in size from the earlier radiograph at
04:56. Small right pleural effusion and mild right basilar atelectasis are
new. Multiple right posterior rib fractures are re-demonstrated, without
increased displacement. Right neck subcutaneous emphysema is unchanged.
The left lung is clear. Cardiomediastinal and hilar contours are otherwise
normal.
IMPRESSION:
Trace right apical pneumothorax, not apparent on chest radiograph ___ at 15:15 but decreased in size from the radiograph at 04:56. No signs of
tension pneumothorax. Stable positioning of right thoracostomy catheter.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA RIGHT
INDICATION: ___ F s/p fall from standing on RT side, + crepitus and subq
emphysema on RT side, hypoxic, CXR w/ R PTX s/p R pigtail placement. Now with
right shoulder pain. Evaluation for fracture/dislocation.
TECHNIQUE: Frontal, internal rotation, and axillary views of the right
shoulder.
COMPARISON: Comparison to chest radiograph from ___.
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
Mild degenerative change at the acromioclavicular and glenohumeral joints.
Few mildly displaced right-sided rib fractures are again noted. There is a
small sclerotic focus overlying the right humeral head measuring 1.2 cm,
likely compatible with bone island or loose body. A small sclerotic focus
projecting under the coracoid process measures 8 mm, likely representing a
bone island or loose body. Right pleural pigtail catheter remains in similar
position, extending to the right lung apex. No definite pneumothorax
identified. Subcutaneous emphysema is again demonstrated over the right
supraclavicular region, similar in appearance to prior study.
IMPRESSION:
1. No evidence of acute fracture or dislocation involving the right shoulder.
2. Redemonstration few mildly displaced right-sided rib fractures, unchanged
from prior study.
3. Small sclerotic foci overlying the right humeral head and projecting under
the coracoid process as described above, likely representing bone islands or
possibly loose bodies.
4. Similar position of a right pleural pigtail catheter, without definite
evidence of pneumothorax identified.
5. Stable appearance of subcutaneous emphysema overlying the right
supraclavicular region.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman s/p fall with right pneumothorax and chest tube
placement// Eval for R shoulder/scapular pain, confirm location of chest tube,
assess for any other injuries
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Chest x-ray and shoulder x-ray performed earlier same day.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits based on an unenhanced
scan. No pericardial effusion is seen. Mild coronary artery calcifications
are seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: There is a right pleural pigtail catheter terminating
anteriorly in the upper pleural space. There is associated extensive
subcutaneous emphysema is seen in the right chest wall. Punctate residual
right pneumothorax is seen (series 3, image 45 and 74). There is small right
hemothorax
LUNGS/AIRWAYS: Multiple small pulmonary nodules are seen in the right lung
largest measuring 5 mm (series 3, image 108). There is mild centrilobular
emphysema. Lower lobe opacities are seen. The central airways are patent to
the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen demonstrates
bilateral adrenal thickening greater on the right for which traumatic etiology
and hematoma could be considered. Multiple hepatic cysts.
BONES: Posterior-lateral right 6 and 7 displaced rib fractures are again seen.
There are undisplaced fractures of the anterior fifth and 6 ribs
IMPRESSION:
1. Status post placement of right pleural pigtail catheter with residual small
right-sided pneumothorax noted. Extensive subcutaneous emphysema is seen in
the right chest wall.
2. Small right hemothorax.
3. Lower lobe opacities are seen which may be due to combination of
atelectasis and aspiration.
4. Multiple left-sided pulmonary nodules are seen measuring up to 5 mm.
5. Mild centrilobular emphysema.
6. Bilateral adrenal thickening greater on the right, nonspecific.
NOTIFICATION: 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: CHEST (PA AND LAT)
INDICATION: ___ y/o F with right rib fractures, right pneumothorax, now s/p
right chest tube removal// please obtain a 4 hour post-pull film- Obtain x-ray
today (___) at 13:00
COMPARISON: Chest radiograph ___, chest CT ___
FINDINGS:
PA and lateral views of the chest provided.
Patient is status post interval removal of right chest tube. There is no
pneumothorax. Mildly displaced mid posterior right rib fractures and right
neck subcutaneous emphysema are unchanged. Small bilateral pleural effusions
and compressive atelectasis are unchanged. Cardiomediastinal and hilar
contours are normal.
IMPRESSION:
No pneumothorax, status post interval removal of right chest tube.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoxia, s/p Fall
Diagnosed with Unspecified abdominal pain, Fall same lev from slip/trip w/o strike against object, init
temperature: 97.6
heartrate: 70.0
resprate: 24.0
o2sat: 95.0
sbp: 125.0
dbp: 75.0
level of pain: 8
level of acuity: 1.0 | Ms. ___ is a ___ Yo f who presented to ___ s/p mechanical
fall down 2 stairs backwards, onto her right chest and back. On
physical exam, chest wall crepitus was noted and imaging
revealed a right pneumothorax. The patient was hypoxic on
arrival and o2 was uptitrated to 100% NRB to assist with
improving the size of the pneumothorax. An emergent right chest
tube was placed as per the trauma surgery team for thoracic
decompression. Postprocedural x-ray confirmed appropriate
positioning with no significant complications. The patient was
admitted to the trauma surgery team for additional management.
The chest tube was initially placed to suction and then later to
waterseal. Interval chest x-rays were obtained. On HD3, the
right chest tube was removed and post-pull cxr was stable with
no pneumothorax seen.
Pain was managed with oxycodone, acetaminophen, and toradol.
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.
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: SURGERY
Allergies:
Lisinopril / Shellfish Derived
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with 3 history of of generalized abdominal
pain described as achy in nature. Pain associated with eating
and acutely worsened after a big meal of rice and beans
yesterday. Patient became nauseated and was spitting out small
volumes of bilious fluid all day. She last had a normal bowel
movement the day before yesterday and had no difficulty passing
flatus at present. She had not had recent travels out of this
country and had not experienced fever or chills. She has
multiple abdominal scars which she claims were operations she
had when she was a child and did not recall what procedures they
were.
Past Medical History:
Hypertension, MR, mild aortic stenosis, hyperlipidemia,
trigeminal neuralgia, osteoarthritis
Social History:
___
Family History:
NC
Physical Exam:
Vitals: T 97, HR 65, BP 155/81, RR 18, SaO2 100% on RA
Gen: NAD, well-appearing.
Neuro: Alert & oriented x3. Moving all extremities spontaneously
___: RRR, normal S1/S2. Grade II systolic ejection murmur.
Chest: Clear to auscultate bilaterally, no crackles/wheezing
___: Midline surgical scar. Normoactive bowel sounds, soft,
non-tender, non-distended, no rebound/guarding
Ext: Warm, well-perfused. Palpable distal pulses.
Pertinent Results:
___ 04:45AM BLOOD WBC-4.9 RBC-4.57 Hgb-13.6 Hct-42.1 MCV-92
MCH-29.8 MCHC-32.3 RDW-13.3 Plt ___
___ 03:25AM BLOOD WBC-5.0 RBC-4.76 Hgb-13.9 Hct-43.0 MCV-90
MCH-29.3 MCHC-32.5 RDW-13.3 Plt ___
___ 03:25AM BLOOD Neuts-67.8 ___ Monos-7.5 Eos-1.8
Baso-0.6
___ 04:45AM BLOOD Plt ___
___ 03:25AM BLOOD Plt ___
___ 04:45AM BLOOD Glucose-110* UreaN-7 Creat-0.7 Na-139
K-3.6 Cl-100 HCO3-28 AnGap-15
___ 04:45AM BLOOD ALT-18 AST-26 AlkPhos-76 Amylase-102*
TotBili-0.2
___ 04:45AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.7
___: cat scan of abdomen and pelvis:
Findings consistent with early/partial small bowel obstruction
with transition point in the left lower quadrant of the abdomen,
raising the possibility of adhesion
Medications on Admission:
Artificial Tears Eye Drops
ONE DROP TOPICAL ___
___ 160 mg tablet
1 Tablet(s) by mouth daily
EpiPen 0.3 mg/0.3 mL (1:1,000) injection,auto-injector
1 injection IM anaphylaxis
Lipitor 20 mg tablet
1 (One) Tablet(s) by mouth once a day
ProAir HFA 90 mcg/actuation aerosol inhaler
2 puffs(s) orally every 6 hours as needed
SteriLid Topical Foam
Tegretol XR 200 mg tablet,extended release
Trimo-San Jelly 0.025 %-0.01 % vaginal
one applicatorfull per vagina twice a week
Vitamin D3 400 unit tablet
1 Tablet(s) by mouth DAILY (Daily)
acetaminophen 500 mg tablet
2 (Two) Tablet(s) by mouth three times a day
amlodipine 10 mg tablet
1 (One) Tablet(s) by mouth once a day
fluticasone 50 mcg/actuation Nasal Spray, Susp
2 spray(s) to each nostril daily
hydrochlorothiazide 25 mg tablet
1 Tablet(s) by mouth daily
metoprolol tartrate 25 mg tablet
2 tablet(s) by mouth daily Take 1 tablets in AM Take 1 tablet in
___
omeprazole 20 mg tablet,delayed release
1 Tablet(s) by mouth daily
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Acetaminophen 650 mg PO Q8H:PRN pain
3. Atorvastatin 20 mg PO DAILY
4. Carbamazepine 200 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Valsartan 160 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Partial 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 ABD AND PELVIS WITH CONTRAST
INDICATION: ___ woman presenting with 24 hr history of intermittent
abdominal pain and no bowel movement for 2 days. Evaluate for bowel
obstruction.
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained
after administration of 130 mL Omnipaque intravenous contrast. Enteric
contrast was not given. Coronal and sagittal reformats prepared and reviewed.
DOSE: DLP: 385.28 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
CHEST:
Aside from bibasilar dependent atelectasis, there is no abnormality in the
imaged portion of the lower chest.
ABDOMEN:
The liver enhances homogeneously, without concerning focal lesion. The patient
is status post cholecystectomy. The gallbladder and central intrahepatic bile
ducts are chronically dilated. The pancreas is normal, without focal lesion or
duct dilation. The spleen is normal in size, without focal lesion. The adrenal
glands are normal. The kidneys enhance normally and excrete contrast briskly.
There are no solid renal lesions or hydronephrosis.
The stomach, duodenum, and proximal jejunum are filled with fluid. The
proximal small bowel is minimally dilated. There is a relatively gradual
transition point in the left lower quadrant of the abdomen, where there are
several loops of small bowel with hyperemic, thickened walls (602b:46),
however this is likely due to collapse of these loops. There is some
fecalization of small bowel contents. There is stool and air in the colon.
There is no intra- or retroperitoneal lymphadenopathy. There is no ascites,
fluid collection, or pneumoperitoneum. The tortuous abdominal aorta is normal
caliber. There is moderate atherosclerotic disease. There is calcified plaque
at the origin of the celiac trunk, causing stenosis (602b:48). The portal vein
and IVC are patent.
PELVIS:
The urinary bladder is without wall thickening or mass. The rectum is
unremarkable. There is no pelvic mass. There is no free fluid. There is no
pelvic or inguinal lymphadenopathy. The uterus is normal in size and
enhancement. No adnexal abnormality bilaterally. There is a pessary within
the vaginal vault.
BONES AND SOFT TISSUES:
There is no acute fracture. There are no destructive osseous lesions
concerning for malignancy or infection. There are multilevel degenerative
changes of the spine. There are no soft tissue masses.
IMPRESSION:
Findings consistent with early/partial small bowel obstruction with transition
point in the left lower quadrant of the abdomen, raising the possibility of
adhesion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Constipation, Dizziness, Nausea
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 97.9
heartrate: 59.0
resprate: 16.0
o2sat: 99.0
sbp: 194.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | The patient presented to the Emergency Department on ___
and was admitted to the Acute Care Surgery service for
management of partial small bowel obstruction. She was made NPO
and received IV fluids. An NG tube was not placed as she had
return of bowel function (passed flatus) when she arrived to the
floor and her nausea and vomiting had improved. She had a bowel
movement overnight, and on HD2, she was started on a diet and
tolerated it well without nausea or vomiting. Home medications
were restarted once she tolerated POs. She had elevated blood
pressures, which was controlled with resumption of her home
metoprolol.
During her hospital course, vital signs were routinely
monitored. Electrolytes were repleted as needed. She had no
respiratory, hematologic, renal, or infectious issues. She
received subcutaneous heparin and was encouraged to ambulate.
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 required no pain
control. 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:
simvastatin
Attending: ___.
Chief Complaint:
ACUTE PANCREATITIS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH prostate cancer, HTN, osteoporosis in USOH yesterday
morning - ate typical breakfast, had normal BM, went swimming.
Approximately noon, began to experience typical heartburn
symptoms with burning epigastric/mid-sternal pain and
acid-brash. Approximately 3pm developed nausea, vomiting, and
diffuse mid/upper abdominal pain. Symptoms persisted through
the afternoon eating with recurrent emesis ("like clockwork")
every 30 minutes - emesis initially consisted of food materials,
then largely bile only with small flecks of blood. Endorses
subjective mild fever, warmth.
Denies sick contacts. Drank 1 glass of white wine the night
prior to onset of symptoms. Denies recent headache, visual
change, speech difficulty, sore throat, lymphadenopathy, cough,
shortness of breath, chest pain, palpitations, dysuria,
diarrhea, rash, focal numbness/weakness, myalgias/arthralgias,
weight loss.
Past Medical History:
Prostate cancer (untreated)
Hypertension
Osteoporosis
Colonoscopy ___ with 4mm polyp
GERD
Social History:
___ immigrant, works as ___. Married, lives
in ___. Smokes ___ cigarettes daily. Rare EtOH.
Physical Exam:
98.6 126/59 51 16 97 RA
GEN: Awake and alert, in NAD
HEENT: Anicteric, dry mucous membranes
NECK: Supple, JVP not elevated, no lymphadenopathy
CHEST: Clear to auscultation bilaterally without rales or wheeze
COR: S1 S2 bradycardic regular without M/R/G
ABD: Soft, mildly distended, hypoactive bowel sounds, minimally
tender to palpation in epigastrium, no masses or palpable
organomegaly. Well-healed appendectomy scar.
EXTREM: No C/C/E. No foot ulcers.
NEURO: Detailed and fluent historian, CNII-XII intact, no
pronator drift, no asterixis.
PSYCH: Calm, pleasant, appropriate
DISCHARGE
WELL APPEARING
NO WHEEZES
SOFT ABDOMEN NON TENDER NO GUARDING OR TENDERNESS
Pertinent Results:
___ 11:06AM LACTATE-3.0*
___ 11:06AM WBC-18.0* RBC-6.30* HGB-18.8* HCT-56.7*
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.9* RDWSD-47.6*
___ 11:06AM PLT COUNT-215
___ 11:06AM LIPASE-1158*
___ 11:06AM ALT(SGPT)-128* AST(SGOT)-103* ALK PHOS-77 TOT
BILI-1.5
___ 11:06AM GLUCOSE-154* UREA N-27* CREAT-1.2 SODIUM-143
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-28 ANION GAP-24*
___ 04:47PM LACTATE-1.8
___ 04:45PM GLUCOSE-117* UREA N-23* CREAT-1.0 SODIUM-143
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13
CT abdomen/pelvis ___
1. Extensive peripancreatic stranding with focal pancreatic
body enlargement and hypoenhancement is concerning for acute
interstitial edematous pancreatitis. There is no gross
pancreatic mass or ductal dilatation, however component of
pancreatic necrosis cannot be excluded, particularly within the
inferior body. Given the focality of the pancreatic
abnormality, consider short interval follow-up with MRCP, which
will also assess for the presence of necrosis. Inflammatory
change of the fourth portion of the duodenum is likely reactive
to the adjacent pancreatitis.
2. Multiple 4 mm bilateral lung nodules. By ___ society
guidelines, if patient is at higher risk for malignancy,
follow-up CT at 12 months may be performed.
Abdominal ultrasound ___
IMPRESSION:
1. Gallbladder filled with stones and sludge without specific
evidence of
cholecystitis.
2. No CBD or intrahepatic biliary ductal dilation.
3. Diffusely hypoechoic pancreatic head and body, compatible
with known
pancreatitis, better evaluated on same-day CT abdomen and
pelvis.
4. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
___ 05:58AM BLOOD WBC-7.7 RBC-4.69 Hgb-13.9 Hct-42.3 MCV-90
MCH-29.6 MCHC-32.9 RDW-13.8 RDWSD-45.7 Plt ___
___ 05:58AM BLOOD UreaN-11 Creat-0.7
___ 06:15AM BLOOD Glucose-119* UreaN-17 Creat-0.7 Na-140
K-3.5 Cl-106 HCO3-25 AnGap-13
___ 07:27AM BLOOD Lipase-155*
Wet Read by ___ on ___ ___ 8:54 ___
The study is somewhat limited by patient motion. There is no
intra or
extrahepatic bile duct dilation. No filling defect is seen
within the common
bile duct or the main pancreatic duct to suggest a stone.
Gallstones are seen
within the gallbladder. Mild pericholecystic fluid is likely
related to
pancreatitis without specific evidence for acute cholecystitis.
Acute interstitial pancreatitis appears similar to ___.
No evidence
for hemorrhage or definite necrosis. No acute peripancreatic
fluid
collection. Minimal dilation of the duct of Wirsung without
filling defect
and without dilation of the remainder of the main pancreatic
duct is a normal
variant. No evidence of portal vein thrombus or arterial
pseudoaneurysm.
Intrahepatic periportal edema is noted.
Hepatic steatosis.
Medications on Admission:
1. melatonin 1 mg oral QHS
2. Amlodipine 5 mg PO DAILY
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
4. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
5. Omeprazole 20 mg PO DAILY:PRN heartburn
6. Creon 12 3 CAP PO QAC:PRN (?)dyspepsia - patient states that
he rarely takes this medication
7. Naproxen 500 mg PO prn - patient states that he has not been
taking this recently
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Cholelithiasis
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 nausea, vomiting, no bowel movement.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS. Oral
contrast was not administered.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
4) Spiral Acquisition 4.9 s, 53.5 cm; CTDIvol = 7.2 mGy (Body) DLP = 383.8
mGy-cm.
Total DLP (Body) = 398 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: A 4 mm right lower lobe pulmonary nodule, 4 mm lingular nodule
(2:4) and two 4 mm left lower lobe pulmonary nodules are identified (2:3,7).
Aortic valve calcifications and a small hiatal hernia are noted.
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. There is a small amount of pericholecystic
fluid, but the gallbladder is otherwise unremarkable.
PANCREAS: There is significant peripancreatic stranding and focal hypodensity
of the pancreatic body which is enlarged (2:27, 601b:21), concerning for
interstitial edematous pancreatitis. A component of pancreatic necrosis is
not excluded, particularly within the inferior pancreatic body. There is no
gross mass lesion or ductal dilatation. No peripancreatic fluid collections
identified.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: 8 mm left adrenal gland nodule is incompletely characterized, but
statistically likely an adenoma. The right adrenal gland is unremarkable.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Multiple bilateral simple renal cysts are identified. The largest of these
measures 5.0 x 4.4 cm in the right lower renal pole (___:36 and 2:40). There
is no perinephric abnormality.
GASTROINTESTINAL: There is enhancement and inflammatory change of the fourth
portion of the duodenum, likely reactive to the adjacent pancreatitis. Small
bowel loops otherwise demonstrate normal caliber, wall thickness and
enhancement throughout. Diverticulosis of the sigmoid colon is noted, without
evidence of wall thickening and fat stranding. The appendix is not directly
visualized, but there are no secondary findings of appendicitis. No
mesenteric lymphadenopathy by CT size criteria.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild to moderate
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: The prostate is enlarged and heterogeneous.
BONES AND SOFT TISSUES: Mild degenerative changes of the lower lumbar spine,
most pronounced at L5-S1, are noted. There is no fracture. Abdominal and
pelvic wall is within normal limits.
IMPRESSION:
1. Extensive peripancreatic stranding with focal pancreatic body enlargement
and hypoenhancement is concerning for acute interstitial edematous
pancreatitis. There is no gross pancreatic mass or ductal dilatation, however
component of pancreatic necrosis cannot be excluded, particularly within the
inferior body. Given the focality of the pancreatic abnormality, consider
short interval follow-up with MRCP, which will also assess for the presence of
necrosis. Inflammatory change of the fourth portion of the duodenum is likely
reactive to the adjacent pancreatitis.
2. Multiple 4 mm bilateral lung nodules. By ___ guidelines,
if patient is at higher risk for malignancy, follow-up CT at 12 months may be
performed.
RECOMMENDATION(S): 1. Given the focality of the pancreatic abnormality,
consider short interval follow-up with MRCP, which will also assess for the
presence of necrosis.
2. Bibasilar 4 mm lung nodules. By ___ society guidelines, if patient
is at higher risk for malignancy, follow-up CT at 12 months may be performed.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ man with pancreatitis, evaluate for gallstones.
TECHNIQUE: Gray scale and color Doppler ultrasound images of the abdomen were
obtained and reviewed.
COMPARISON: Same-day CT abdomen and pelvis ___.
FINDINGS:
LIVER: The liver is diffusely echogenic. There is an area of focal fatty
sparing near the gallbladder fossa. The contour of the liver is smooth. There
is no focal liver mass. The main portal vein is patent with hepatopetal flow.
There is trace ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: Stones and sludge fill the gallbladder, which demonstrates
minimal wall edema, likely secondary to pancreatitis, and is otherwise
unremarkable.
PANCREAS: The imaged portion of the pancreatic head and body appear is mild
lead diffusely hypoechoic, compatible with edema in the setting of
pancreatitis, better evaluated on same-day CT.
SPLEEN: Normal echogenicity, measuring 8.9 cm.
KIDNEYS: Limited sagittal views of the right kidney demonstrate no evidence
hydronephrosis.
RETROPERITONEUM: The visualized portions of the aorta and the IVC are within
normal limits.
IMPRESSION:
1. Gallbladder filled with stones and sludge without specific evidence of
cholecystitis.
2. No CBD or intrahepatic biliary ductal dilation.
3. Diffusely hypoechoic pancreatic head and body, compatible with known
pancreatitis, better evaluated on same-day CT abdomen and pelvis.
4. Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
Radiology Report
EXAMINATION: MR abdomen
INDICATION: ___ year old man with acute pancreatitis c/f stone // are there
stones or filling defects in the ducts?
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet as per the pancreas MRCP portal.
Intravenous contrast: Gadavist 6 cc.
COMPARISON: CT and ultrasound abdomen dated ___
FINDINGS:
Lower Thorax: Mild bilateral dependent atelectasis. No large pleural
effusions.
Liver: The liver parenchyma demonstrates heterogeneous signal characteristics.
There is signal loss on the out of phase sequence to suggest to mild
steatosis. No solid masses. The contours are smooth.
Biliary: No intra- or extra-hepatic duct dilatation. The common bile duct is
not dilated. The gallbladder appears slightly contracted and there is
pericholecystic fluid and cholelithiasis; however, these findings are likely
related to secondary inflammatory changes from the pancreas as opposed to
acute cholecystitis. There is no choledocholithiasis.
Pancreas: In the body of the pancreas, there is an ill-defined region of
heterogeneous increased T2 signal. The pancreas enhances normally. There is
no evidence of necrosis or hemorrhage. A 1.3 cm AP x 1.0 cm TV x 1.4 cm SI
well-circumcised focus of fluid inferior pancreatic body/tail is consistent
with small acute peripancreatic fluid collection (3:16; 4:25). The portal
vein is patent. There are no splenic artery pseudoaneurysms.
Spleen: The spleen is grossly unremarkable.
Adrenal Glands: On series 4, image 22, there is a 4 mm mildly T2 hyperintense
nodule on the lateral limb of the left adrenal gland. There is signal
drop-out on the out of phase sequence consistent with microscopic fat.
Kidneys: Multiple bilateral simple appearing cysts. The largest cyst arises
from the lower pole of the right kidney and measures approximately 5.2 cm. In
the interpolar region of the right kidney there is a 9 mm lesion which is
bright on the T1 and T2 weighted sequences in keeping with a proteinaceous
cyst. There are no solid masses. No hydronephrosis or hydroureter.
Gastrointestinal Tract: The visualized portion of the GI tract is of normal
caliber throughout. No focal abnormalities are identified.
Lymph Nodes: No adenopathy by size criteria
Vasculature: The visualized portion of the abdominal vasculature is patent
without any significant areas of narrowing or dilatation.
Osseous and Soft Tissue Structures: No concerning osseous lesions.
IMPRESSION:
1. Imaging findings are most in keeping with interstitial edematous
pancreatitis with small acute peripancreatic fluid collection as described.
2. No choledocholithiasis.
3. Mild hepatic steatosis.
4. Left adrenal nodule with microscopic fat is consistent with an adenoma.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pancreatitis now with SOB // pulm edema?
infiltrate?
TECHNIQUE: Portable chest
COMPARISON: None.
FINDINGS:
The heart is upper limits normal in size. The aorta is mildly tortuous.
There is mild pulmonary vascular redistribution. There is volume loss at both
bases. An early infiltrate can't be excluded in the lower lobes due to the
mild volume loss
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with ACUTE PANCREATITIS
temperature: 99.4
heartrate: 96.0
resprate: 16.0
o2sat: 96.0
sbp: 146.0
dbp: 74.0
level of pain: 3
level of acuity: 3.0 | ___ PMH HTN, prostate cancer, osteoporosis admitted with severe
pancreatitis, suspect gallstone-induced. Initially with anion
gap/lactic acidosis, hemoconcentration, suspected contraction
alkalosis, mild renal insufficiency - improved s/p IVF
resuscitation. BISAP score 2 upon presentation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Seroquel / Milk of Magnesia
Attending: ___.
Chief Complaint:
Confusion, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a past medical history
significant for hypothyroidism, obesity, osteoporosis,
hypertension, hyperlipidemia, and severe psychiatric disease who
is admitted with dizziness and confusion. Patient called ___
today complaining of fatigue, not feeling herself, more anxious
and psychiatrically unstable. She was seen for an episodic
visit during which time she had a sodium level checked; it
returned at 123, which is much lower than her baseline in the
130s. Ms. ___ was subsequently sent to the ED for further
evaluation.
Ms. ___ has a ___ history of SIADH, which
historically has been attributed to her psychiatric medications
and primary polydipsia. She tries to fluid restrict herself,
but says that over the last few days has drank much more
frappuccinos (they were on sale at Stop and Shop) than usual.
Her zoloft was also recently increased from 100mg QD to 125mg
QD. Ms. ___ complains of feeling more "confused" but cannot
pinpoint exactly what this means. She endorses a poor memory at
baseline, but something is now "off." Moreover, she is unsteady
on her feet. No problems walking, but will sometimes "miss ___
step." She recently fell onto the sink, which she says never
happens.
In the ED, intial vitals were: 97.2 HR: 60 BP: 145/66 Resp: 16
O(2)Sat: 95. A non-contrast head CT was performed to rule out
various etiologies of gait instability such as NPH, which
showed: "No intracranial hemorrhage or large territorial
infarction." Upon recheck on the floor, patient's sodium was
127. She was comfortable and with complaints described above.
ROS: Patient denies chest pain, abdominal pain, nausea,
vomiting, diarrhea, fever, chills, or dysuria. She says she has
some chronic shortness of breath with her asthma. She has had a
chronic sinus infection for months and has pain in the temporal
region and on top of her head.
Past Medical History:
--Schizophrenia
--Depresion
--Anxiety
--GERD
--Psychogenic polydipsia
--Left shoulder replacement
--Asthma
--Hypothyroidism
--Osteoporosis
--Hyperlipidemia
--Insomnia
--S/p ASD repair ___
--S/p L hip replacement ___
--S/p multiple R leg fractures ___
Social History:
___
Family History:
Patient's mother is in her ___ and still bowls.
Maternal: Grandmother died of lung cancer and mother is survivor
of lung cancer.
Siblings: She has two brothers and one sister, all of whom are
deceased.
Physical Exam:
Admission PE:
VS: 99, ___, 72, 18, 96% on RA
GENERAL: Very pleasant woman, discolaration of her face (from
thorazine), no acute distress
HEENT: Mucous membranes slightly dry, but not overly so
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, ___ systolic murmur
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: No edema bilaterally
NEURO: A&O x3, some trouble with FNF but patient says it is
difficult without glasses, Romberg negative (was positive before
and patient says she feels better doing this exam now), gait
within normal limits while walking across hospital room
Discharge PE:
Tm 99.0 Tc 98.8 BP 148/71 (127-158/58-71) HR 67 (61-72) RR
20 Sat 96% RA
Gen: Alert, awake, comfortable, NAD, conversant, pleasant
HEENT: NC/AT, EOMI, PEERLA
Chest: Clear to auscultation bilaterally
Cardiovascular: RRR, normal S1/S2, III/VI SEM loudest at ___
Abdominal: Soft, NT/ND, BS+
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, lip smacking during coversation,
CN II-XII intact, Strength ___, DTRs 2+, light touch preserved
in U/L extremeties bilatearlly. Proprioception intact. No
pronator drift. Rapid alternative movements, finger-nose-finger
intact and equal bilaterally. On gait with eyes open without
cane, is steady. Mild instability with eyes closed.
Psych: pleasant, cooperative, NAD
Pertinent Results:
Admission labs:
___ 09:20PM SODIUM-129* POTASSIUM-3.4 CHLORIDE-93*
___ 07:35PM SODIUM-127* POTASSIUM-3.9 CHLORIDE-91*
___ 01:10PM URINE HOURS-RANDOM UREA N-507 CREAT-68
SODIUM-50 POTASSIUM-93 CHLORIDE-69 TOTAL CO2-7.0
___ 01:10PM URINE HOURS-RANDOM
___ 01:10PM URINE HOURS-RANDOM
___ 01:10PM URINE OSMOLAL-487
___ 01:10PM URINE UHOLD-HOLD
___ 01:10PM URINE GR HOLD-HOLD
___ 01:10PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:04AM GLUCOSE-99
___ 09:04AM UREA N-14 CREAT-0.8 SODIUM-123* POTASSIUM-4.6
CHLORIDE-87* TOTAL CO2-30 ANION GAP-11
___ 09:04AM estGFR-Using this
___ 09:04AM CALCIUM-9.5 MAGNESIUM-1.8
___ 09:04AM VIT B12-984*
___ 09:04AM OSMOLAL-257*
___ 09:04AM TSH-2.1
___ 09:04AM T3-75* FREE T4-1.4
___ 09:04AM VALPROATE-79
___ 09:04AM WBC-3.5* RBC-4.05* HGB-12.7 HCT-36.5 MCV-90
MCH-31.2 MCHC-34.7 RDW-13.2
___ 09:04AM PLT COUNT-___: No intracranial hemorrhage or large
territorial infarction.
Discharge labs:
___ 05:50AM BLOOD WBC-3.1* RBC-3.73* Hgb-11.5* Hct-33.8*
MCV-91 MCH-30.8 MCHC-34.0 RDW-13.3 Plt ___
___ 03:25PM BLOOD Na-129* K-4.4 Cl-95*
___ 10:30AM BLOOD Na-128* K-4.2 Cl-94*
___ 05:50AM BLOOD Glucose-97 UreaN-13 Creat-0.6 Na-130*
K-4.1 Cl-95* HCO3-27 AnGap-12
___ 04:10AM BLOOD Na-130* K-4.5 Cl-94*
___ 11:50PM BLOOD Na-131* K-3.6 Cl-94*
___ 09:20PM BLOOD Na-129* K-3.4 Cl-93*
___ 07:35PM BLOOD Na-127* K-3.9 Cl-91*
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Alendronate Sodium 70 mg PO QSUN
4. Aspirin 81 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Cetirizine *NF* 10 mg Oral QD
7. Divalproex (DELayed Release) ___ mg PO QHS
8. Docusate Sodium 100 mg PO BID
9. Flunisolide Inhaler *NF* 29 mcg Inhalation 2 puffs qd
10. Gabapentin 600 mg PO TID
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Lisinopril 5 mg PO QHS
13. Lorazepam 1 mg PO TID
14. Metoprolol Succinate XL 25 mg PO HS
15. Montelukast Sodium 10 mg PO QAM
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO BID
18. Risperidone 16 mg PO HS
19. Senna 1 TAB PO BID
20. Sertraline 125 mg PO QAM
21. Simvastatin 40 mg PO DAILY
22. traZODONE 200 mg PO HS:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Alendronate Sodium 70 mg PO QSUN
4. Aspirin 81 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Divalproex (DELayed Release) ___ mg PO QHS
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 600 mg PO TID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Lisinopril 5 mg PO QHS
11. Lorazepam 1 mg PO TID
12. Metoprolol Succinate XL 25 mg PO HS
13. Montelukast Sodium 10 mg PO QAM
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO BID
16. Risperidone 16 mg PO HS
17. Senna 1 TAB PO BID
18. Sertraline 100 mg PO QAM
19. Simvastatin 40 mg PO DAILY
20. traZODONE 200 mg PO HS:PRN insomnia
21. Cetirizine *NF* 10 mg Oral QD
22. Flunisolide Inhaler *NF* 29 mcg Inhalation 2 puffs qd
23. Lidocaine 5% Patch 2 PTCH TD DAILY pain
please apply one to affected upper extremity and one to affected
lower extremity.
RX *lidocaine 5 % (700 mg/patch) apply 1 patch daily Disp #*7
Transdermal Patch Refills:*0
24. BusPIRone 10 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Headache, blurry vision, generalized weakness, and abnormal neuro
exam.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Axial images were interpreted in
conjunction with coronal, sagittal, and thin slice bone algorithm reformats.
COMPARISON: Multiple prior head NECTs, most recently ___.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. The ventricles and sulci are prominent, compatible with age
related volume loss. Mild white matter hypodensities in the left centrum
semiovale is compatible with chronic small vessel ischemic disease. The basal
cisterns appear patent and there is preservation of gray-white matter
differentiation.
No fracture is identified. Opacification of few ethmoidal air cells is
similar to prior. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are otherwise clear. The visualized portions of the
globes are unremarkable.
IMPRESSION: No intracranial hemorrhage or large territorial infarction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FATIGUE/WEAKNESS
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, ALTERED MENTAL STATUS , VERTIGO/DIZZINESS
temperature: 97.2
heartrate: 60.0
resprate: 16.0
o2sat: 95.0
sbp: 145.0
dbp: 66.0
level of pain: 3
level of acuity: 3.0 | This is a ___ woman with a past medical history
significant for hypertension, hyperlipidemia, psychiatric
disease, and hypothyroidism who is admitted with confusion and
unsteadiness, likely in the setting of hyponatremia.
# hyponatremia: The patient has history of hyponatremia, likely
secondary to underlying medication effect (from SSRIs), as well
as psychogenic polydipsia in the past. The patient did report
having fatigue, but neuro exam was nonfocal, though she did have
some difficulty with balance. Her urine lytes and serum osms
were c/w SIADH; likely in the setting of increasing her free
water intake, as well as increasing her dose of her SSRI a month
ago. Renal was consulted in the ED, and it was thought that her
imbalance was not related to her hyponatremia and said that
hypertonic saline was not necessary. Instead the patient was
fluid restricted, and her sodium gradually trended up at a slow
rate, with goal of 8 meq over the course of 24 hours.
The patient was set up with follow up within one week of
discharge. She was instructed to have her sodium checked at
this PCP ___. The importance of free water restriction
was also emphasized and the patient was instructed not to drink
excess free water, as this would drive down her sodium.
Finally, her sertraline dose was reduced from 125 mg to 100 mg;
she had follow up scheduled with her psychopharmacist two days
after discharge.
# shoulder pain: The patient reports having chronic shoulder
pain, which was why she started taking high dose Ibuprofen
starting the week prior to presentation. The patient was
advised to stop taking Ibuprofen and was instead given lidocaine
patches to help with her pain.
# confusion: It is likely that the patient's confusion and
imbalance was related to her low sodium levels. Head CT was
negative for any acute process. TSH and RPR were within normal
limits, as was B12. The patient was ambulating without any
difficulty and ___ was not needed to evalaute her.
# psychiatric disease: The patient's sertraline was decreased to
100 mg daily. She has outpatient follow up with
psychopharmacist. While in patient, she was continued on her
home fluoxetine, gabapentin, divalproex, lorazepam, risperdal,
trazodone, ativan.
# chronic sinusitis: The patient was continued on her
fluticasone.
# HTN: The patient was continued on her lisinopril and
metoprolol.
# HLD: The patient was continued on her home statin.
# hypothyroidism: The patient was continued on her home
levothyroxine; TSH was within normal limits.
# GERD: Continued omeprazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neutropenic Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a h/o triple negative Stage IA breast
cancer on C4D11 of DDAC who was referred to the ED for
neutropenic fevers to 101.4 and odynophagia. She had a sore
throat on the morning of admission and increasing fever recorded
at home. She called her heme/onc NP who referred her to the ED
for admission. Ms. ___ endorses sore throat, worse on right.
No pain in the floor of her mouth. She also has a mild headache
associated with mild nausea. She denies any abdominal pain,
urinary symptoms, or diarrhea. She says her son is sick with a
sore throat, was at the doctor today as well and strep was
negative. In the ED, the patient was HD stable and started on
Vanc/Cefepime, and per on-call onc recs, will get neupogen daily
once admitted until WBC is greater than 10K. On arrival to the
floor, the patient was anxious about her medications; states she
does not want to take Zofran as it causes her constipation and
still feels discomfort from mouth pain.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Triple negative breast cancer Stage IA, T1cN0M0
-___: self palpated mass in left breast, diagnostic imaging
confirmed. Biopsy revealed invasive ductal carcinoma, grade 3,
ER positive 20%, PR negative, HER2 negative by IHC and FISH.
-___: s/p left breast excision by Dr. ___. Final
pathology revealed a 1.5cm, grade 3, IDC, negative LVI, clean
lymph nodes (___). Repeat hormone staining showed ER negative
(<1%), PR negative, HER2 negative, 2 margins were involved
-___: re-excision revealed no residual carcinoma
-___: developed post-op hematoma which was evacuated by Dr.
___ on ___: initiate adjuvant chemotherapy DDAC
PAST MEDICAL HISTORY:
Hypothyroidism during pregnancy
Social History:
___
Family History:
There is no breast or ovarian cancer. There is a paternal first
cousin, the daughter of a paternal uncle, who developed brain
cancer and died at age ___.
Physical Exam:
ON ADMISSION:
==================
VS: Tc 98.4 BP 102/60 HR 77 RR 18 SaO2 100% on RA
General: Chronically ill appearing woman in NAD.
HEENT: MMM, posterior oropharynx mildly hyperemic, no evidence
of thrush.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy
CV: RRR, normal S1/S2.
PULM: Nonlabored breathing, CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: A&Ox3, CN II-XII intact. ___ motor strength of the
proximal and distal upper and lower extremities; 2+ patellar
reflexes, toes downgoing bilaterally.
ON DISCHARGE:
===================
VS: Tc 98.3 BP 110/65 HR 82 RR 18 SaO2 98% on RA
General: Chronically ill appearing woman in NAD.
HEENT: Alopecia, MMM, posterior oropharynx mildly hyperemic
without exudate, no evidence of thrush.
LYMPH: No cervical lymphadenopathy
CV: RRR, normal S1/S2.
PULM: Nonlabored breathing, CTAB.
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: WWP, no edema.
NEURO: A&Ox3, CN II-XII intact. Motor and sensory exam grossly
intact.
Pertinent Results:
LABS ON ADMISSION:
========================
___ 01:10AM BLOOD WBC-1.4* RBC-3.25* Hgb-8.9* Hct-27.0*
MCV-83 MCH-27.4 MCHC-33.0 RDW-20.0* RDWSD-59.7* Plt ___
___ 01:10AM BLOOD AbsNeut-0.56*
___ 07:25PM BLOOD Neuts-74* Bands-0 ___ Monos-4*
Eos-1 Baso-1 Atyps-1* ___ Myelos-0 AbsNeut-0.44*
AbsLymp-0.12* AbsMono-0.02* AbsEos-0.01* AbsBaso-0.01
___ 07:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 01:10AM BLOOD Plt ___
___ 07:25PM BLOOD Glucose-114* UreaN-9 Creat-0.6 Na-136
K-3.5 Cl-102 HCO3-24 AnGap-14
LABS ON DISCHARGE:
=========================
___ 06:19AM BLOOD WBC-14.3*# RBC-2.83* Hgb-7.9* Hct-23.3*
MCV-82 MCH-27.9 MCHC-33.9 RDW-19.8* RDWSD-56.1* Plt ___
___ 06:19AM BLOOD Neuts-91* Bands-1 Lymphs-5* Monos-2*
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-13.16*
AbsLymp-0.72* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.14*
___ 06:19AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-OCCASIONAL
Polychr-OCCASIONAL Ovalocy-OCCASIONAL Tear Dr-OCCASIONAL
___ 06:19AM BLOOD Plt Smr-LOW Plt ___
___ 06:19AM BLOOD Glucose-80 UreaN-9 Creat-0.6 Na-139 K-3.6
Cl-101 HCO3-28 AnGap-14
___ 06:19AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY Constipation
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO DAILY
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth once a
day Disp #*14 Capsule Refills:*0
3. Polyethylene Glycol 17 g PO DAILY Constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by
mouth once a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Neutropenic fever
Mucositis
Breast cancer
Leukocytosis
Anemia
Secondary Diagnosis:
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with neutropenic fever // ? pna
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Right chest wall Port-A-Cath is again noted. Lungs are clear. There is no
consolidation, effusion, or edema. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Neutropenia, unspecified
temperature: 101.4
heartrate: 48.0
resprate: 16.0
o2sat: 97.0
sbp: 129.0
dbp: 80.0
level of pain: 5
level of acuity: 2.0 | Mrs. ___ is a ___ with triple negative Stage IA breast
cancer s/p L lumpectomy on C4D11 of ddAC who presents with
neutropenic fever to 101.4 and odynophagia. We continued her on
IV vancomycin/cefepime until her ANC > 1500 and she was afebrile
for > 24hrs. Her infectious workup was negative to date with
blood cultures from ___ pending on discharge. She continued to
complain of mild sore throat and received one dose of IM
penicillin G. Her throat swab results are pending on discharge.
She was also started on Filgrastim with improvement in her
counts. She declined oral analgesia, narcotics, and anti-nausea
medications given concern for mucositis, but was agreeable to
have IV omeprazole to help with nausea.
# Neutropenic Fever: On admission, she presented with febrile
neutropenia with nadir ANC of 440 and Tmax 101.4F on C4D11 of
DDAC. The patient was treated with IV vancomycin/cefepime until
her ANC > 1500 and she was afebrile > 24 hours. Given her son
was sick with a sore throat, she was treated with IM PCN G x 1
dose. Her strep, flu, and urine cultures were all negative; to
date no growth on blood cultures. She received neupogen until
her WBC >8.0, upon discharge her ANC was ___.
# Breast Cancer: Triple negative L breast cancer Stage IA,
T1cN0M0. s/p lumpectomy of left breast in ___. Patient was
continued on Lupron and prn Zofran for nausea. She will have
outpatient follow-up with her primary oncologist on ___ for
cycle 3 of chemotherapy.
# Mucositis: Grade ___. Patient offered pain medications,
topical viscous lidocaine, clotrimazole troches, and sialagogues
but declined. On discharge, her oral pain was improved since
admission.
# Constipation: Colace/Senna.
# Anxiety: Lorazepam. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Duragesic
Attending: ___
Chief Complaint:
Hemoptysis, Confusion
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ with a PMHx of tracheobronchial malacia,
fibromyalgia, systemic lupus (?on Plaquenil), who is being
transferred from ___ with hyponatremia and
hemoptysis.
Pt has a long-standing history of chronic pain, fibromyalgia,
LBP, migraines and L knee pain. 5d prior to admission, she
slipped on ice and fell backwards, ___ on her flexed LLE. She
developed pain in her L ankle, limiting her motion. There was no
LOC or head strike. Pt did not experience any cardiac sx prior
to fall. 3d PTA, she attempted to stand from the floor, and
exeprienced bilateral knee pain, worse on the left.
In terms of her respiratory status, pt has a hx of TBM sp 3
failed pulmonary stents, complicated by recurrent MRSA PNA. She
was scheduled to see thoracic surgery and underwent a CT scan on
___. This showed an inflammatory opacity in the RUL, which may
represent early infection. Over the past week, she has been
having a worsened cough (compared to pt's chronic cough),
productive for foul-tasting sputum, Tm 99.9 and worsening
dyspnea (exertional and at rest). She presented to her PCP 3d
prior with knee pain and underwent L knee XR (wnl per pt) and
was prescribed levofloxacin for her respiratory sx. Per PCP, ___
knee was thought to have meniscal tear and pt was scheduled for
MRI.
On day of admission, pt was coughed up two quater-sized "globs"
of bright red (dark per ED hx) blood. She subsequerntly coughed
up green/grey phlegm. She has had no further episodes of
hemoptysis. Of note, pt was previously admitted ___ for
hemoptysis and was found to have PNA.
During the past several days, she reports feeling "parched" and
drinking up to 16 cans of seltzer per day. At the same time, she
has had poor PO intake.
In addition, pt reports having scratched her arms as an
emotional reaction to the anniversary of her mother's death.
Finally, she reports CP, which is L-sided, non-radiating,
constant x 2d, pleuritic and reproducible. Pain is not worsened
with exertion and not relived with rest.
On day of admission, she reported feeling dizzy, lightheadedness
and seeing "hallucinations" when she closed her eyes.
In the emergency department at ___, initial VS: T 97.3, P 75, BP
112/60, R 16, O2 Sat 99%RA. Pt was noted to have a sodium level
of 121, K 3.1, HCT 36, LFTs wnl, flu swab negative, TnI <0.046.
A CT scan of the head showed paranasal sinus disease. An x-ray
of the chest was unremarkable. She received oxycodone 10mg x 2,
imitrex ___, toradol 30mg IM, donnatol 10mg, Vistaril 50mg,
Maalox, Viscous lidocaine, and ASA 325mg po x 1. She was
transferred to ___ for further care.
In the ___ ED intial vitals were: T 97.0 P 80 BP 118/60 R 18
O2 Sat 97% on 2L. Labs were significant for HCT 31.9, Na 119, K
3.2, lactate 1.2, UA negative. CTA chest showed no acute
process. Pt received metoclopramide 10mg IV and hydromorphone
2.125mg IV total prior to admission. She also received 2L NS at
125cc/hr.
On the floor, pt reports feeling a migraine headache.
Review of Systems:
(+) night sweates
(-) chills, vision changes, rhinorrhea, congestion, sore throat,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- TBM Y-stent placed in ___ with Dr. ___ it was
removed few days later due to severe intractable cough; per pt
she had 2 additional trials of stent placement BWH, both
complicated by PNA
- Raynaud's
- SLE
- Chronic Pain, notable for knee and abdominal pain in the past
- Fibromyalgia
- Anxiety/Insomnia/Depression/PTSD
- Hypertension
- GERD
- Peripheral Neuropathy
- h/o Migraines
- Surgical history: s/p cholecystectomy, s/p TAH-BSO, s/p breast
reduction
Social History:
___
Family History:
Brother - ___
Strong hx br ca, MI
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals - T: 97.3 BP: 112/60 HR: 75 RR: 16 02 sat: 99% on RA
GENERAL: Obese female in NAD, A+Ox3, occasional cough
(potentially exhagerrated)
HEENT: ATNC, pupils constricted, anicteric sclera, pink
conjunctiva, patent nares, Dry MM, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs; reproducible
costochondral ttp
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, +BS, mild ttp in RLQ and LLQ bl, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis or
clubbing; trace pitting edema. L ankle with lateral effusion and
ttp. Medial L knee with ttp. Drawer and reverse drawer sign
negative. Small effusion in L knee. Preserved ROM in L knee and
ankle. Mild ttp on lateral distal fibula.
PULSES: 2+ DP and radial pulses bilaterally
NEURO: CN II-XII intact; strength ___ in all extremities;
sensation intact to LT
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
GENERAL: NAD, A+Ox3
HEENT: NCAT, PERRL
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs; reproducible
costochondral ttp
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, +BS, non-tender, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES PULSES: 2+ DP and radial pulses bilaterally
NEURO: CN II-XII intact; strength ___ in all extremities;
sensation intact to LT
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
admission labs
___ 11:31PM BLOOD WBC-4.8# RBC-3.79* Hgb-10.7* Hct-31.9*
MCV-84 MCH-28.4 MCHC-33.6 RDW-14.0 Plt ___
___ 11:31PM BLOOD Neuts-61.6 ___ Monos-11.0
Eos-4.2* Baso-0.3
___ 11:31PM BLOOD Glucose-110* UreaN-5* Creat-0.6 Na-119*
K-3.2* Cl-79* HCO3-28 AnGap-15
___ 11:31PM BLOOD CK(CPK)-224*
___ 11:31PM BLOOD Mg-1.5* Iron-PND
OTHER LABS:
___ 06:45AM BLOOD WBC-3.8* RBC-3.81* Hgb-10.7* Hct-32.5*
MCV-85 MCH-28.2 MCHC-33.1 RDW-14.3 Plt ___
___ 02:08AM BLOOD WBC-3.6* RBC-3.59* Hgb-10.5* Hct-32.2*
MCV-90 MCH-29.2 MCHC-32.5 RDW-14.5 Plt ___
___ 05:06AM BLOOD WBC-3.3* RBC-3.30* Hgb-9.4* Hct-29.4*
MCV-89 MCH-28.6 MCHC-32.2 RDW-14.4 Plt ___
___ 06:04AM BLOOD WBC-4.2 RBC-3.60* Hgb-10.3* Hct-32.8*
MCV-91 MCH-28.5 MCHC-31.3 RDW-14.7 Plt ___
___ 06:45AM BLOOD Glucose-94 UreaN-5* Creat-0.5 Na-123*
K-3.6 Cl-83* HCO3-28 AnGap-16
___ 09:00AM BLOOD Na-125* K-3.4 Cl-88*
___ 11:59AM BLOOD Glucose-94 UreaN-6 Creat-0.5 Na-131*
K-4.0 Cl-94* HCO3-30 AnGap-11
___ 03:08PM BLOOD Na-130* K-4.2 Cl-95*
___ 11:10PM BLOOD Na-130* K-3.9 Cl-94*
___ 02:08AM BLOOD Glucose-117* UreaN-8 Creat-0.6 Na-131*
K-4.1 Cl-96 HCO3-25 AnGap-14
___ 05:06AM BLOOD Glucose-105* UreaN-8 Creat-0.5 Na-132*
K-4.2 Cl-98 HCO3-25 AnGap-13
___ 11:00AM BLOOD Na-131* K-4.0 Cl-97
___ 03:01PM BLOOD Na-130* K-4.0 Cl-97
___ 12:12AM BLOOD Na-132* K-4.2 Cl-100
___ 06:04AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-135
K-4.3 Cl-101 HCO3-24 AnGap-14
___ 11:31PM BLOOD CK(CPK)-224*
___ 11:31PM BLOOD Mg-1.5* Iron-73
___ 06:45AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.8
___ 11:59AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9
___ 02:08AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.0
___ 05:06AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.0 Iron-34
___ 06:04AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1
___ 11:59AM BLOOD Cortsol-10.4
___ 03:08PM BLOOD TSH-0.79
___ 11:31PM BLOOD Osmolal-241*
___ 03:08PM BLOOD Osmolal-263*
___ 11:31PM BLOOD calTIBC-400 VitB12-GREATER TH Ferritn-32
TRF-308
___ 05:06AM BLOOD calTIBC-346 Ferritn-30 TRF-266
radiology:
CTA CHEST ___
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Several foci of ground glass opacification in the right upper
lobe without
evidence of a solid mass.
3. Incidentally noted asymmetric and prominent left axillary
lymph nodes
measuring up to 1.2 cm.
4. Incidentally noted mild pneumobilia of unknown etiology.
LEFT ANKLE PLAIN FILMS ___
IMPRESSION: No acute fracture or dislocation.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ClonazePAM 0.5 mg PO TID
2. ClonazePAM 1 mg PO QHS
3. Estradiol 1 mg PO DAILY
4. Pregabalin 100 mg PO BID:PRN pain
5. Hydrochlorothiazide 50 mg PO DAILY
6. Fluoxetine 60 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Amitriptyline 50 mg PO HS
9. Sumatriptan Succinate 100 mg PO BID:PRN migraine
10. flunisolide 25 mcg (0.025 %) nasal 2 puff bid
11. Morphine SR (MS ___ 30 mg PO Q8H
12. Prochlorperazine 10 mg PO Q8H:PRN nausea/migraine
13. Atenolol 100 mg PO DAILY
14. NexIUM (esomeprazole magnesium) 40 mg oral bid
15. Methocarbamol 1000 mg PO QID:PRN pain
16. Levalbuterol Neb 0.63 mg/3 mL inhalation tid prn SOB
17. Mupirocin Ointment 2% 1 Appl TP TID
18. Provigil (modafinil) 100 mg oral bid prn
19. Hydroxychloroquine Sulfate 400 mg PO DAILY
20. Fluocinonide 0.05% Cream 1 Appl TP BID
21. OLANZapine 5 mg PO BID
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
23. Acetaminophen-Caff-Butalbital ___ TAB PO DAILY:PRN migraine
24. Ketorolac 60 mg IM Frequency is Unknown
25. Chlorpheniramine-Hydrocodone Dose is Unknown PO Q12H:PRN
severe cough
26. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
27. Levofloxacin 500 mg PO Q24H
28. oxyCODONE-acetaminophen ___ mg oral Q3H PRN Pain
29. Gabapentin 600 mg PO HS
30. Bisacodyl 10 mg PO DAILY:PRN constipation
31. Senna 8.6 mg PO BID:PRN constipation
32. modafinil 600 mg oral HS
33. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO DAILY:PRN migraine
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
3. Amitriptyline 50 mg PO HS
4. Atenolol 100 mg PO DAILY
5. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN severe cough
6. ClonazePAM 0.5 mg PO TID
7. ClonazePAM 1 mg PO QHS
8. flunisolide 25 mcg (0.025 %) nasal 2 puff bid
9. Fluocinonide 0.05% Cream 1 Appl TP BID
10. Fluoxetine 60 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Hydroxychloroquine Sulfate 400 mg PO DAILY
13. Levofloxacin 750 mg PO DAILY Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Methocarbamol 1000 mg PO QID:PRN pain
16. Morphine SR (MS ___ 30 mg PO Q8H
17. Mupirocin Ointment 2% 1 Appl TP TID
18. Pregabalin 100 mg PO BID:PRN pain
19. Prochlorperazine 10 mg PO Q8H:PRN nausea/migraine
20. Sumatriptan Succinate 100 mg PO BID:PRN migraine
21. Docusate Sodium 200 mg PO BID
22. Estradiol 1 mg PO DAILY
23. Ketorolac 60 mg IM Q8H:PRN pain
24. Levalbuterol Neb 0.63 units INHALATION TID PRN SOB SOB
25. NexIUM (esomeprazole magnesium) 40 mg oral bid
26. OLANZapine 5 mg PO BID
27. oxyCODONE-acetaminophen ___ mg oral Q3H PRN Pain
28. Provigil (modafinil) 100 mg oral bid prn
29. Gabapentin 600 mg PO HS
30. modafinil 600 mg ORAL HS
31. Senna 8.6 mg PO BID:PRN constipation
32. Bisacodyl 10 mg PO DAILY:PRN constipation
33. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Hyponatremia
Secondary diagnoses:
Tracheobronchomalacia
SLE
Fibromyalgia
Anxiety/Insomnia/Depression/PTSD
Hypertension
GERD
Peripheral Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female tracheobronchomalacia and hemoptysis for two
days, evaluate for fistula or other acute process.
COMPARISON: CT neck/chest from ___.
TECHNIQUE: Axial MDCT images through the lungs during rapid administration of
intravenous contrast, with multiplanar reformats including oblique MIPs.
DLP: 688 mGy-cm
FINDINGS:
CTA CHEST: Pulmonary arteries are well opacified to the subsegmental level
without filling defect to suggest pulmonary embolism. There is no aneurysm or
dissection in the thoracic aorta.
CT CHEST: Thyroid enhances homogeneously. Trachea is midline and the
tracheobronchial tree is patent to the subsegmental level. Multiple prominent
left axillary lymph nodes measure up to 1.2 cm (2:59). In the right axilla,
there are fewer lymph nodes which are much smaller. There is no mediastinal or
hilar lymphadenopathy.
Several small areas of ground glass opacification are noted in the right upper
lobe in proximity to the minor fissure, largest measuring 9x7 mm (2:73,
601b:30). Background lung parenchyma is otherwise normal. No pleural effusion
or pneumothorax.
Heart is of normal size and there is no pericardial effusion.
Limited view of the upper abdomen is notable for several tiny scattered
locules of air in the biliary tree.
Bones do not show lesions concerning for infection or malignancy.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Several foci of ground glass opacification in the right upper lobe without
evidence of a solid mass.
3. Incidentally noted asymmetric and prominent left axillary lymph nodes
measuring up to 1.2 cm.
4. Incidentally noted mild pneumobilia of unknown etiology.
Radiology Report
HISTORY: Left ankle pain. Evaluate for fibular fracture.
COMPARISON: No relevant comparisons available.
LEFT ANKLE, THREE VIEWS: There is no acute fracture or dislocation. A linear
lucency with sclerosis in the distal fibula could represent an old fracture.
The joint spaces are preserved without significant degenerative change. The
ankle mortise is congruent. No radiopaque foreign body or soft tissue
calcification. There is no significant soft tissue edema.
IMPRESSION: No acute fracture or dislocation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HEMOPTYSIS
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, HEMOPTYSIS, UNSPECIFIED, SYST LUPUS ERYTHEMATOSUS, HYPERTENSION NOS
temperature: 97.0
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 118.0
dbp: 60.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ with a PMHx of tracheobronchial malacia,
fibromyalgia, systemic lupus (on Plaquenil), who was transferred
from ___ with hyponatremia and hemoptysis.
# Hemoptysis:
Pt is followed by Dr. ___ in ___, ___), as
well as by Dr ___ at ___. Previously hemoptysis occurred in
setting of MRSA PNA. Pt reported SOB and had evidence of an
inflammatory RUL lesion on CT scan, though this was subtle and
not thought to represent PNA. She had recently been started on
levofloxacin by her PCP and completed ___ 7d course during this
admission. Pt had no leukocytosis or report of fever. CT did not
show pulmunary embolus. Sputum Cx showed Commensal Respiratory
Flora and sparse yeast. Dr. ___ with ENT did not feel urgent
need for inpatient evaluation and asked patient to keep upcoming
outpatient appointment. Pt did not have further episodes of
hemoptysis during hospital stay and improved shortness of
breath.
# Hyponatremia:
Pt presented with hyponatremia of 119, Uosm 257, UNa<10. She
reported poor PO intake and copious intake of free water and
these are likely the contributing etiologies. Overall, given
Na<10 and FeNa 0.1, this was most consistent with hypovolemic
hyponatremia associated with poor po intake. Although pt
reported copious water intake and this may have be playing a
role, Uosm were >100 (?volume-driven siADH). She was initially
given NS IVF. Renal service was consulted. There was high
suspicion of psychogenic polydipsia and advised against NS or
hypertonic fluids, so NS was discontinued. Na was trended and as
she was correcting relatively quickly, so free water was given
to slow rapid correction. Thiazides were discontinued. She was a
given one dose of DDAVP. She had no changes in mental status and
no seizures during hospital stay. TSH and cortisol were normal.
Her sodium slowly improved an was normal at 135 upon discharge.
# Anemia:
Stable and chronic. Likely ACD. Low normal iron stores and
adequate Vitamin B12 stores (___). stable throughout.
# Hypokalemia:
Likely ___ albuterol use. DDx included diuretic abuse, though
much less likely given low UNa and UCl. Thiazides were held and
potassium repleted.
# L ankle sprain:
Pt has L ankle effusion and ttp over L fibula. According to ___
criteria, obtained a L ankle XR which did not show frcature.
# L knee pain:
Exam most consistent with L medial meniscal tear. Currently
undergoing workup including imaging by PCP. Will continue f/up
with PCP
# CP:
Pt presents with atyical cp, most consistent with
costochondritis. EKG showed no ischemic changes. Trend CE x 2
which were normal. no chest pain upon 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:
fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. ___ is an ___ year old male with a pmh significant for
metastatic prostate cancer as well as cecal cancer who presents
from clinic with 3 weeks of fatigue, found to have ARF and
pneumonia.
He discontinued his anti-androgen therapy at home approximately
three weeks ago, so that he could run a road race. Since that
time he has felt "terrible." He has been very fatigued, feels
dehydrated, and has had a decreased appettite.
He denies any fever, chills, cough, shortness of breath. He has
had pain in his right ribs/chest for several weeks which he
attributes to bony disease. He was seen by Dr. ___ today to
assess his symptoms and was found to have a creatinine of 1.7
(baseline 1.1) and WBC of 14.7. He was sent to the ED for
management and hydration with plan for admission to the OMED
service.
In ED/Clinic, initial vitals were: 96.0 87 105/39 18 94% RA
Labs were significant for WBC of 14.7, Na 132->128, creatinine
1.7->1.5, and lactate of 2.7.
Patient was given ceftriaxone 1g, azithromycin 500mg, oxycodone
5mg
Patient underwent a CXR which shows a RLL pneumonia
Final vitals prior to transfer were 99.9 94 96/51 16 93% NC
Access - PIV
IVF - 1L NS
Review of Systems:
(+) Per HPI
(-) Denies fever, 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 cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
Metastatic prostate cancer
cecal ca s/p radical prostatectomy ___, cecal resection ___,
arthritis
anemia
Social History:
___
Family History:
No spinal disease
Physical Exam:
Physical Examination:
VS: 98.5 122/48 82 18 91%RA
GEN: elderly man, standing in doorway in street clothes with
many food stains
HEENT: MMM, anicteric
CARDIAC: Normal rate, somewhat distant heart sounds, soft SEM
LUNG: decreased breath sounds at the right base with crackles
halfway up the lung field, with left basilar crackles; no
wheezing
GI: +BS, soft, NT/ND
NEURO: No gross deficits on exam
SKIN: No rash
Pertinent Results:
==================================
Labs
==================================
___ 01:55PM BLOOD WBC-14.7*# RBC-3.86* Hgb-12.1* Hct-36.0*
MCV-93 MCH-31.5 MCHC-33.7 RDW-14.4 Plt ___
___ 07:35AM BLOOD WBC-7.5 RBC-3.58* Hgb-10.6* Hct-33.7*
MCV-94 MCH-29.6 MCHC-31.5 RDW-15.3 Plt ___
___ 12:50PM BLOOD Neuts-92.4* Lymphs-4.5* Monos-2.7 Eos-0.3
Baso-0.2
___ 12:50PM BLOOD ___ PTT-33.8 ___
___ 01:55PM BLOOD UreaN-74* Creat-1.7* Na-132* K-3.5 Cl-95*
HCO3-21* AnGap-20
___ 07:00PM BLOOD Glucose-112* UreaN-53* Creat-1.2 Na-135
K-3.5 Cl-101 HCO3-22 AnGap-16
___ 07:35AM BLOOD Glucose-103* UreaN-25* Creat-0.9 Na-135
K-4.5 Cl-101 HCO3-26 AnGap-13
___ 01:55PM BLOOD ALT-27 AST-37 AlkPhos-75 TotBili-1.4
___ 09:10AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.7*
___ 12:50PM BLOOD Calcium-7.7* Phos-2.0* Mg-2.2
___ 01:55PM BLOOD PSA-13.2*
___ 10:26PM BLOOD Lactate-2.7*
==================================
Radiology
==================================
CHEST (PA & LAT)Study Date of ___ 9:41 ___
FINDINGS: The heart is at the upper limits of normal size. The
mediastinal
and hilar contours appear within normal limits. There is
extensive
opacification of the right lower lung, mostly involving the
right lower lobe,
which is largely consolidated perhaps with a right middle lobe
component of
opacification. The left lung remains clear. There is no
definite pleural
effusion or pneumothorax.
IMPRESSION: Extensive opacification in the right lower lung
most consistent
with pneumonia. Follow-up radiographs are recommended within
eight weeks in
order to show resolution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. bicalutamide 50 mg oral daily
2. Ascorbic Acid ___ mg PO DAILY
3. calcium-magnesium-zinc 333-133-5 mg oral daily
4. Vitamin D 3000 UNIT PO DAILY
5. Niacin SR 1000 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO Frequency is Unknown
7. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 7 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
2. bicalutamide 50 mg oral daily
3. Ascorbic Acid ___ mg PO DAILY
4. calcium-magnesium-zinc 333-133-5 mg oral daily
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Niacin SR 1000 mg PO DAILY
7. Vitamin D 3000 UNIT PO DAILY
8. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pneumonia
acute renal failure
hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Weakness. Question pneumonia.
COMPARISONS: Scout view from CT performed on ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is at the upper limits of normal size. The mediastinal
and hilar contours appear within normal limits. There is extensive
opacification of the right lower lung, mostly involving the right lower lobe,
which is largely consolidated perhaps with a right middle lobe component of
opacification. The left lung remains clear. There is no definite pleural
effusion or pneumothorax.
IMPRESSION: Extensive opacification in the right lower lung most consistent
with pneumonia. Follow-up radiographs are recommended within eight weeks in
order to show resolution.
Radiology Report
INDICATION: Metastatic prostate cancer with point tenderness in the back.
COMPARISON: Chest radiograph ___.
TWO VIEWS THORACIC SPINE
There are moderate degenerative changes of the thoracic spine. There are
multilevel osteophytes. No compression fracture is definitively identified.
There is consolidation at the right lung base, which is best evaluated on the
recent chest radiograph.
IMPRESSION:
1. Right lower lobe pneumonia.
2. No definite compression fracture. If there is concern for an osseous
lesion, however, MRI would be recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 96.0
heartrate: 87.0
resprate: 18.0
o2sat: 94.0
sbp: 105.0
dbp: 39.0
level of pain: nan
level of acuity: 3.0 | Dr. ___ is an ___ year old male with a pmh significant for
metastatic prostate cancer as well as cecal cancer who presents
from clinic with 3 weeks of fatigue, found to have ARF and
pneumonia.
1. Bacterial Pneumonia: given hyponatremia he was checked for
urine legionella but this was negative. He was treated with
ceftriaxone, azithromycin, switch to cefpodoxime at discharge.
He did not produce sputum for a culture. He required oxygen on
admission to keep o2 sat >90, but often would not keep it on. By
discharge he is low ___ o2 sat on room air and is comfortable
walking around. his hyponatremia resolved with IV fluids.
2. Acute renal failure: Likely due to volume depletion. He was
given 1L in the ED. Creatinine returned to baseline.
hyponatremia and anion gap acidosis also resolved. At discharge
he is eating and drinking well
3. Loose Stool: resolved, may be antibiotic related. c diff
negative.
4. home safety: patient lives alone and while here displayed odd
behaviors (saying inappropriate things, emotional lability,
lying naked in bed, disheveled with extensive food stains on
clothes) that brought into question whether he is safe to live
alone. He was seen by ___ and seems safe to continue living
independently. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceclor / Sulfa (Sulfonamide Antibiotics) /
Combigan / tramadol / Zofran / citalopram
Attending: ___.
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
___ with PMHx of Afib (not on AC), HTN, recent hospitalization
for BRBPR ___ s/p attempted ___ embolization c/b ___
dissection presents as a transfer for GI evaluation after p/w
one
episode of BRBPR.
In terms of prior hospitalization, she presented to OSH ED with
2
epsisodes of BRBPR. Hgb was 10.9 from 13.6 baseline. CTA showed
active sigmoidal extravasation and diverticulosis, and she was
transferred to ___. Here ___ angiography ___ showed active
extravasation but embo was not completed given complication of
___ dissection. Sigmoidoscopy ___ showed blood clots and
diverticuli but no active bleeding. Overall her BRBPR was felt
to
be diverticular in setting of recent NSAID use. Her bleeding
resolved and she was discharged with Hgb 10.0 on ___. She was
also discharged with a 3d of Macrobid for UTI and 5d of
clindamycin for LUE cellulitis.
Pt states that after her hospitalization she was home doing well
with no bleeding. She has not been taking ASA or NSAIDs. Then
yesterday she had 1 episode of stool mixed with blood, very
small
amount. Therefore she represented to OSH ED. She denies any
dizziness, CP, palpitations, dyspnea, fatigue. In total she has
had 4 episodes of blood mixed with stool in last 24h. Currently
denies dysuria, suprapubic tenderness. Also endorses LUE pain,
erythema, hardness along the vein that is overall stable to
improved.
In the ED:
- Initial vital signs: 96.4 98 169/99 18 96% RA
- Exam: Rectal exam with normal rectal tone. ___ pink stool,
external hemorrhoids without bleeding or without exquisite
firmness, guaiac positive
- Labs: Hgb 9.9, otherwise WNL; Chem rel. WNL; UA: 56 WBC, few
bact
- Studies:
LUE US: 1. Completely occlusive thrombus within the left
cephalic
vein at the antecubital fossa, compatible with superficial
thrombophlebitis. 2. No evidence of deep vein thrombosis in the
left upper extremity.
- Meds:
___ 01:36 IVF NS ___ Started
___ 03:07 PO/NG Fosfomycin Tromethamine 3 g ___
___ 03:08 IVF NS 500 mL ___ Stopped (1h ___
___ 03:43 PO Acetaminophen 650 mg ___
- Consults:
GI:
-If evidence of recurrent bleed, please make NPO for possible
sigmoidoscopy
-Trend Hgb per primary team
-Volume resuscitate as appropriate
-Maintain active T&S
-Maintain 2 large bore IVs
- ED Course: @ 05:03 pt with episode of BM with scant amount of
bright red blood
ROS: Complete ROS obtained and is otherwise negative.
Past Medical History:
-Atrial fibrillation (not on anticoagulation)
-Basal cell carcinoma
-Hyperlipidemia
-Hypertension
-Idiopathic gastroparesis
-Gastritis
-Chronic low back pain
-Prior history of nephrolithiasis in the ___
-OSTEOPOROSIS
-LACTOSE INTOLERANCE
-Diverticulosis c/b BRBPR
Social History:
___
Family History:
She has no family history of inflammatory arthritis or
connective tissue disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ 0553 Temp: 98.0 PO BP: 177/88 R Sitting HR: 85
RR: 16 O2 sat: 97% O2 delivery: RA
GENERAL: Thin appearing elderly female, alert and interactive.
In
no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
Tachy
MM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. BACK: No spinous
process tenderness. No CVA tenderness.
ABDOMEN: Soft, NT, ND to deep palpation in all four quadrants.
RECTAL: deferred given exam done in ED
GI: Witnessed BM with tiny flecks of blood mixed with loose
stool
EXTREMITIES: No edema. 5 cm segment of induration along vein
within antecubital fossa, non-tender
cephalic vein within the antecubital fossa
SKIN: WWP
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Gait is
normal. AOx3.
DISCHARGE PHYSICAL EXAM
Temp 98.4 BP 131/73 HR 97 RR 16 SaO2 95% Ra
GENERAL: Thin appearing elderly female, alert and interactive.
In
no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
Tachy
MM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. BACK: No spinous
process tenderness. No CVA tenderness.
ABDOMEN: Soft, NT, ND to deep palpation in all four quadrants.
RECTAL: deferred given exam done in ED
EXTREMITIES: No edema. 5 cm segment of palpable cord along vein
within antecubital fossa
GU: Serpiginous, scarlet red lesion over right lateral mons
pubis
and right labia majora with well-demarcated borders
SKIN: WWP
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Gait is
normal. AOx3
Pertinent Results:
ADMISSION LABS
___ 12:24AM BLOOD WBC-9.6 RBC-3.36* Hgb-9.9* Hct-31.4*
MCV-94 MCH-29.5 MCHC-31.5* RDW-14.1 RDWSD-47.9* Plt ___
___ 12:24AM BLOOD Glucose-96 UreaN-22* Creat-0.9 Na-143
K-4.4 Cl-107 HCO3-24 AnGap-12
___ 10:15AM BLOOD Calcium-9.5 Phos-2.8 Mg-1.9
NOTABLE LABS
___ 12:24AM BLOOD WBC-9.6 RBC-3.36* Hgb-9.9* Hct-31.4*
MCV-94 MCH-29.5 MCHC-31.5* RDW-14.1 RDWSD-47.9* Plt ___
___ 06:13PM BLOOD WBC-10.7* RBC-3.55* Hgb-10.3* Hct-33.8*
MCV-95 MCH-29.0 MCHC-30.5* RDW-14.0 RDWSD-49.4* Plt ___
___ 06:20AM BLOOD WBC-9.7 RBC-3.50* Hgb-10.3* Hct-33.2*
MCV-95 MCH-29.4 MCHC-31.0* RDW-14.4 RDWSD-50.1* Plt ___
___ 05:45AM BLOOD WBC-9.9 RBC-3.13* Hgb-9.2* Hct-29.9*
MCV-96 MCH-29.4 MCHC-30.8* RDW-14.5 RDWSD-50.6* Plt ___
DISCHARGE LABS
___ 05:45AM BLOOD WBC-9.9 RBC-3.13* Hgb-9.2* Hct-29.9*
MCV-96 MCH-29.4 MCHC-30.8* RDW-14.5 RDWSD-50.6* Plt ___
___ 05:45AM BLOOD Glucose-86 UreaN-23* Creat-0.8 Na-147
K-4.1 Cl-113* HCO3-23 AnGap-11
___ 05:45AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9
___ 11:27PM URINE Blood-SM* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 11:27PM URINE RBC-4* WBC-56* Bacteri-FEW* Yeast-NONE
Epi-<1
MICROBIOLOGY
__________________________________________________________
___ 11:27 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-- <=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
IMAGING & PROCEDURES
___ Colonoscopy
High residual material throughout. Multiple attempts were made
to irrigate the colon but the mucosa could not be visualized
adequately.
Normal mucosa in the whole colon and 10 cm into the terminal
ileum.
LUE US ___
1. Completely occlusive thrombus within the left cephalic vein
at the
antecubital fossa, compatible with superficial thrombophlebitis.
2. No evidence of deep vein thrombosis in the left upper
extremity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Levobunolol 0.5% 1 DROP BOTH EYES DAILY
3. Lidocaine 5% Ointment 1 Appl TP TID
4. Methocarbamol 500 mg PO QHS:PRN Muscle Spasm
5. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Trandolapril 2 mg PO BID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Miconazole 2% Cream 1 Appl TP BID
RX *miconazole nitrate 2 % twice a day Refills:*0
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Levobunolol 0.5% 1 DROP BOTH EYES DAILY
5. Lidocaine 5% Ointment 1 Appl TP TID
6. Methocarbamol 500 mg PO QHS:PRN Muscle Spasm
7. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
8. Simvastatin 20 mg PO QPM
9. Vitamin D 400 UNIT PO DAILY
10. HELD- Trandolapril 2 mg PO BID This medication was held. Do
not restart Trandolapril until discussion with your primary care
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=====
Hematochezia
Superficial thrombophlebitis
Tinea Cruris
Secondary
========
Atrial fibrillation
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: History: ___ with LUE erythema swelling and cor dlike structure//
DVT? Thrombophlebitis?
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: Upper extremity ultrasound dated ___.
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, and basilic veins are patent,
compressible and show normal color flow and augmentation.
There is completely occlusive thrombus along a 5 cm segment of the left
cephalic vein within the antecubital fossa.
IMPRESSION:
1. Completely occlusive thrombus within the left cephalic vein at the
antecubital fossa, compatible with superficial thrombophlebitis.
2. No evidence of deep vein thrombosis in the left upper extremity.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified, Urinary tract infection, site not specified
temperature: 96.4
heartrate: 98.0
resprate: 18.0
o2sat: 96.0
sbp: 169.0
dbp: 99.0
level of pain: 0
level of acuity: 2.0 | ___ with PMHx of Afib (not on AC), HTN, recent hospitalization
for BRBPR ___ s/p attempted ___ embolization c/b ___
dissection presents as a transfer for GI evaluation after she
presented with another episode of hemtochezia in the outpt
setting.
# Hematochezia
# Hx of diverticular bleed
Patient presented after a bloody bowel movement at home
described by patient as having blood in the toilet bowl, blood
mixed with stool and some blood coating stool. On day of
presentation she had witnessed BM x 2 with small flecks of blood
mixed with loose stool. Given recurrent nature of bleed and
recent flex sig without evaluation of entire extent of colon, it
was decided that patient would undergo colonoscopy by GI consult
service. She was prepped with MoviPrep and underwent colonoscopy
___. This showed adherent residue, but otherwise normal mucosa
to the ileum. It was advised that if patient has repeat
bleeding, she should be evaluated by colorectal surgery to
consider sigmoidectomy. She was counseled on a high fiber diet
and increased PO fluids to avoid constipation. She remained
hemodynamically stable throughout her hospitalization, with
stable hemoglobin.
# Hx of UTI:
# Pyuria
Recent E.coli UTI ___ s/p 3d course macrobid. She was found to
have pyuria on a repeat UA obtained this admission.
Pan-sensitive E. coli on urine culture from ___. She was not
treated for UTI this admission since she was asymptomatic.
# Tinea Cruris.
Ms. ___ reported several days of itching
over her right labia. She denieed associated vaginal discharge
or
bleeding. On review of record she has a history of atrophic
vaginitis and recurrent yeast infections. Appearance of this
rash
most consistent with tinea cruris. Started on miconazole 2%
cream BID for 2 weeks (___) and assess for interval healing
in the outpatient setting.
# Superficial thrombophlebitis.
Recent LUE cellulitis in setting of IV line s/p 5d course of
clindamycin. Now with continued erythema. LUE US shows
completely
occlusive thrombus along a 5 cm segment of the left cephalic
vein
c/w superficial thrombophlebitis. Exam notable for palpable
cord. Managed with warm packs Q6H, arm elevation. Avoided NSAIDs
and anticoagulation given concern for GIB as above. Itchiness
and pink discoloration almost resolved by discharge.
# Atrial fibrillation:
Hx of Afib, not on AC given history of ocular hemorrhage.
CHADsVASC 4. Continued on home diltiazem. She reported
palpitations on night of ___ but otherwise asymptomatic. Rates
in the ___ inhouse with relative hypotension at night (SBPs
___ so maintained at current dose. Consider increase in
once daily dosing versus twice daily dosing as clinically
indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Dilaudid (PF) / Haldol / VAC Drape
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of UC s/p takedown of ileal J-pouch anal anastamosis
and completion proctectomy with end ileostomy (___) p/w abd
pain and no ostomy output overnight.
Past Medical History:
-Ulcerative colitis s/p total colectomy with temporary ileostomy
(___)
-Depression
-Anxiety
-Peripheral neuropathy
Social History:
___
Family History:
Mother with vitiligo, brother with autoimmune pancreatitis. No
UC or other IBD.
Physical Exam:
98.4 94 110/62 18 100% on RA
Gen - NAD, AAOx3
CV - RRR, nml S1/S2, no M/R/G
Resp - CTAB, no W/R/R
Abd - S, NT/ND, ostomy in place, gas + stool in bag
Ext - no C/C/E, WWP
Pertinent Results:
Admission Labs
___ 02:40AM BLOOD WBC-11.6* RBC-4.59* Hgb-13.9* Hct-42.0
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.7 Plt ___
___ 02:40AM BLOOD Neuts-74.8* Lymphs-16.3* Monos-4.9
Eos-3.4 Baso-0.6
___ 02:40AM BLOOD Glucose-86 UreaN-25* Creat-1.1 Na-137
K-4.1 Cl-101 HCO3-28 AnGap-12
___ 02:56AM BLOOD Lactate-0.8
Discharge Labs
___ 08:25AM BLOOD WBC-7.6 RBC-4.48* Hgb-13.9* Hct-41.2
MCV-92 MCH-31.1 MCHC-33.9 RDW-14.5 Plt ___
___ 08:25AM BLOOD Glucose-80 UreaN-13 Creat-0.8 Na-138
K-4.1 Cl-102 HCO3-26 AnGap-14
___ 08:25AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.8
Admission Imaging
___ 4:___BD & PELVIS WITH CONTRAST
IMPRESSION: High-grade partial small-bowel obstruction with a
transition
point in the deep pelvis near an apparent small bowel
anastomosis.
___ 4:09 AM
XR ABDOMEN (SUPINE & ERECT)
IMPRESSION: Non-specific bowel gas pattern. Fecalized material
projects over the pelvis. This patient does not have normal
rectum and therefore this is an abnormal finding. Subsequent CT
shows a high grade SBO with fecalized small bowel in the pelvis.
Medications on Admission:
CITALOPRAM [CELEXA] 20 mg tablet - two tablets by mouth once
daily
ETHYL CHLORIDE 100 % Topical Spray - use as directed for weekly
injection once a week
ONDANSETRON [ZOFRAN ODT] 4 mg disintegrating tablet - 1 tablet
by mouth every eight (8) hours as needed (please do not exceed
32 mg of zofran in 24 hours)
OXYCODONE 5 mg tablet - 1 tablet by mouth q 4 to 6 hours prn
TRAZODONE 100 mg tablet - 1 tablet by mouth at bedtime
TRETINOIN - Dosage uncertain
VIT B COMPLEX - Dosage uncertain
CALCIUM CARBONATE-VITAMIN D3 - 500 mg (1,250 mg)-200 unit tablet
- 1 tablet by mouth twice a day
GARLIC - Dosage uncertain
LOPERAMIDE [LO-PERAMIDE] 2 mg tablet - ___ tablet(s) by mouth
twice a day as needed for loose/frequent output from ileostomy
MULTIVITAMIN - 1 tablet by mouth once a day
OMEGA-3 FATTY ACIDS - Dosage uncertain
ZINC [CHELATED ZINC] 50 mg tablet - 1 tablet(s) by mouth daily
Discharge Medications:
Home meds only (no new presciptions given)
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: History of obstruction and Crohn's disease, decreased stomach
output.
FINDINGS: Supine and upright abdominal radiographs were obtained. A paucity
of bowel gas limits evaluation. There ___ large amount of fecalized material
in the pelvis. There is no free abdominal air. Lung bases are clear.
IMPRESSION: Non-specific bowel gas pattern. Fecalized material projects over
the pelvis. This patient does not have normal rectum and therefore this is an
abnormal finding. Subsequent CT shows a high grade SBO with fecalized small
bowel in the pelvis.
Radiology Report
INDICATION: Crohn's disease, decreased stool output.
COMPARISON: ___.
TECHNIQUE: MDCT data were acquired through the abdomen and pelvis after the
administration of oral and intravenous contrast. Images were displayed in
multiple planes.
FINDINGS: The visualized lung bases are clear. The liver enhances
homogeneously. A stable subcentimeter hypodensity in segment VI is too small
to characterize but likely a cyst. The main portal veins are patent. There
is no intra- or extra-hepatic biliary dilatation. The gallbladder is normal.
The pancreas and spleen enhance homogeneously. Adrenal glands are normal.
The kidneys enhance symmetrically and excrete contrast promptly. There is no
mesenteric or retroperitoneal adenopathy.
There is a high-grade small-bowel obstruction with a transition point in the
deep pelvis. Fecalized small bowel loops measuring up to 3.9 cm course into
the deep pelvis to a transition zone just beyond a small bowel staple
line(2:68). Small bowel distal to this point is mostly decompressed but a
small amount of fluid is seen distally. There is fecal material in the ostomy
bag. This patient has had a total colectomy followed by a J-pouch and then a
resection of this J-pouch and creation of an end ileostomy. The origin of the
staple line around the transition point is not obvious from the most recent
operative note note. There is a small amount of free pelvic fluid.
Bladder and prostate are normal. There is no inguinal or pelvic adenopathy.
BONE WINDOWS: There are no concerning lytic or sclerotic bone lesions.
IMPRESSION: High-grade partial small-bowel obstruction with a transition
point in the deep pelvis near an apparent small bowel anastomosis.
Findings discussed with Dr ___ at 8am on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 99.0
heartrate: 125.0
resprate: 18.0
o2sat: 98.0
sbp: 120.0
dbp: 82.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ presented to the ED with a 1-day hx of low/no ostomy
output and abdominal pain. His history, exam, and imaging (CT
and XR) were concerned for small bowel obstruction. He was made
NPO and started on IVF and pain medication. He was transferred
to the floor and did well overnight. He never vomited and did
not require an NGT. On the morning of HD2, he was found to have
a large amount of stool and gas in his ostomy bag. His diet was
advanced to clears and then regular, both which he tolerated
well. His pain was greatly reduced; he was hemodynamically
stable throughout his hospital course. This evening he
expressed readiness to be discharged, and he was D/C'ed home in
good condition without restiction. He should follow-up with his
primary care doctor as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Crixivan
Attending: ___.
Chief Complaint:
Shortness of breath, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with HIV (CD4 of 9, ___
complicated by neuropathy, not on HAART, with recent admission
for aspiration pneumonia ___ - ___ with hypotension requiring
ICU care initially treated with vancomycin and Zosyn,
transitioned to Meropenem to complete an 11 day total course. He
was discharged last ___ and was notably still orthostatic
on discharge. He also continued to have mild dyspnea on
discharge and never fully reached his baseline prior to the
pneumonia.
He describes severe lightheadedness on standing which makes it
difficult for him to walk and this is further complicated by his
continued dyspnea especially with exertion. He noted that he was
taking in large amounts of fluids during his prior
hospitalization, but his fluid intake decreased on discharge. He
denies headache, vision changes, ___ weakness or numbness,
palpitations, or syncope. Regarding his dyspnea, he feels it is
stable since discharge, but worse than baseline. He denies
cough, wheezing, chest pain, feves, chills, nausea, vomiting,
sore throat, or upper respiratory symptoms.
He notes that he was supposed to be seen by ___ and ___ on
___, but his ___ did not come until ___ and they found
him to be profoundly orthostatic and recommended that he go to
the ED.
In the ED he was afebrile with BP ___ and was noted to be
orthostatic (no vitals provided). Given his poor venous access,
a R subclavian triple lumen was placed. He was bolused 1L NS
with increase in BP to 110/76. He was given emperic Meropenum,
Vancomycin, and Bactrim. Labs were notable for leukopenia (3.2)
and stable chronic renal failure with cr of 2.5 (baseline
2.2-2.8) and normal lactate.
Of note, he is not currently on HAART, but has follow up
scheduled with Dr. ___ and
he plans to start a regimen at his next appointment. He is
currently prescribed Bactrim three times per week, but has been
taking daily.
Overnight, he complains of lightheadedness on standing and
shortness of breath with minimal exertion. He is otherwise
without complaints. On ROS, he denies chest pain, shortness of
breath at rest, leg pain or swelling, wheezing, cough, fevers,
chills, nausea, vomiting, abdominal pain, diarrhea,
constipation, dysuria, hematuria, or blood per rectum.
Past Medical History:
- HIV (diagnosed in ___ via PCP ___
- History of PCP, ___, MAC, CMV retinitis, CMV pancreatitis,
enterobacter sepsis, wasting syndrome
- HIV neuropathy
- Hypertension
- Chronic renal insufficiency
- Hepatitis B
- Nephrolithiasis ___ crixivan ___ yrs ago
- PTX ___ pentamidine
- Depression
Past Surgical History:
- Right nephrectomy (kidney donor for brother) ___
- Retinal implants bilaterally
Social History:
___
Family History:
Father killed, died of head trauma at age ___. Mother died of
stomach CA at age ___. 2 brothers deceased from DM1 (one of which
had juvenile DM and received a kidney from pt). 1 brother alive
at ___ with DM1.
Physical Exam:
Admission physical exam:
Vitals: T:98.1 BP:109/71 P:80 R: 18 O2: 100% RA
General: Elderly appearing AA male in NAD
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: No edema
Discharge physical exam:
Vitals: Tc/m 98.2/98.4 HR 87 (70s-80s) BP 111/74
(110s-120s/70s-80s) RR 18 O2 100%RA
General: Pleasant man in NAD
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no rales or ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Neuro: CNII-XII intact bilaterally, full strength and sensation
throughout, normal gait
Ext: No edema
Pertinent Results:
Admission labs:
___ 04:52PM BLOOD WBC-3.2* RBC-3.59* Hgb-11.5* Hct-34.1*
MCV-95 MCH-32.0 MCHC-33.6 RDW-15.4 Plt ___
___ 04:52PM BLOOD Neuts-45.3* Lymphs-43.0* Monos-8.9
Eos-2.2 Baso-0.7
___ 04:52PM BLOOD Glucose-81 UreaN-32* Creat-2.5* Na-138
K-5.0 Cl-115* HCO3-16* AnGap-12
___ 10:00AM BLOOD Albumin-2.4* Calcium-7.4* Phos-3.0 Mg-2.1
___ 10:00AM BLOOD ALT-58* AST-41* LD(LDH)-178 AlkPhos-269*
TotBili-0.3
___ 04:20AM BLOOD ___ pO2-98 pCO2-29* pH-7.32*
calTCO2-16* Base XS--9
___ 05:21PM BLOOD Lactate-0.9
Discharge labs:
___ 07:12AM BLOOD WBC-1.8* RBC-3.23* Hgb-10.3* Hct-31.3*
MCV-97 MCH-31.8 MCHC-32.8 RDW-15.2 Plt ___
___ 04:59AM BLOOD Neuts-53.7 ___ Monos-5.9
Eos-16.1* Baso-0.4
___ 07:12AM BLOOD Glucose-84 UreaN-20 Creat-2.1* Na-135
K-5.3* Cl-114* HCO3-17* AnGap-9
___ 07:12AM BLOOD Calcium-7.6* Phos-3.1 Mg-2.2
___ 04:20AM BLOOD Lactate-0.6
Micro:
___ Immunology (CMV) CMV Viral Load-FINAL
CMV Viral Load (Final ___:
CMV DNA detected, less than 600 copies/mL.
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
___ MRSA SCREEN MRSA SCREEN-FINAL
___ URINE URINE CULTURE-FINAL no growth
___ SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ URINE URINE CULTURE-FINAL no growth
Studies:
___ CHEST (PORTABLE AP)
FINDINGS: Frontal view of the chest was obtained. A right
subclavian central catheter terminates in the lower SVC.
Metallic clips overlie the right upper quadrant. The heart is
of normal size with normal cardiomediastinal contours. Vague
bibasilar opacities are nonspecific but may represent infection.
No pleural effusion or pneumothorax.
IMPRESSION: Vague bibasilar opacities, which may represent
infection in the appropriate clinical setting.
___ CHEST (PORTABLE AP)
FINDINGS: Single portable view of the chest compared to
previous exam from ___. Right subclavian line is
seen with catheter tip in the lower SVC. There is no visualized
pneumothorax. Previously seen right PICC and left subclavian
lines are no longer seen. Cardiomediastinal silhouette is within
normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: ___ right subclavian line with tip in the lower
SVC. No pneumothorax.
___ ECG
Sinus rhythm. Normal ECG. Since the previous tracing of ___
limb lead
voltage is now more prominent. Otherwise, unchanged.
Pending results:
___ 04:04PM BLOOD HIV GENOTYPING-PND
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
INPATIENT
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Omeprazole 20 mg PO BID
3. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry/itchy eyes
5. Quetiapine Fumarate 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES BID:PRN dry/itchy eyes
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Omeprazole 20 mg PO BID
4. Quetiapine Fumarate 25 mg PO QHS:PRN insomnia
5. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Sepsis
Secondary diagnoses:
- HIV/AIDS, CD4 of 9, VL 75K
- Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ male with new right subclavian line. Question
placement.
FINDINGS: Single portable view of the chest compared to previous exam from
___. Right subclavian line is seen with catheter tip in the
lower SVC. There is no visualized pneumothorax. Previously seen right PICC
and left subclavian lines are no longer seen. Cardiomediastinal silhouette is
within normal limits. Osseous and soft tissue structures are unremarkable.
IMPRESSION: New right subclavian line with tip in the lower SVC. No
pneumothorax.
Radiology Report
INDICATION: ___ male with HIV with shaking chills and recent
pneumonia. Evaluate for pneumonia.
COMPARISONS: Multiple prior chest radiographs, most recently of ___.
FINDINGS: Frontal view of the chest was obtained. A right subclavian central
catheter terminates in the lower SVC. Metallic clips overlie the right upper
quadrant. The heart is of normal size with normal cardiomediastinal contours.
Vague bibasilar opacities are nonspecific but may represent infection. No
pleural effusion or pneumothorax.
IMPRESSION: Vague bibasilar opacities, which may represent infection in the
appropriate clinical setting.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: WEAKNESS
Diagnosed with HYPOTENSION NOS, SHORTNESS OF BREATH
temperature: 97.5
heartrate: 98.0
resprate: 16.0
o2sat: 98.0
sbp: 89.0
dbp: 72.0
level of pain: 0
level of acuity: 1.0 | ___ with HIV/AIDS (last CD4: 9, VL: 75K, ___ not on ARVs)
admitted with orthostatic hypotension, transferred to ICU with
hypotension refractory to 4L NS and tachycardia in the setting
of positive blood cultures concerning for sepsis.
# Sepsis: Patient initially admitted to medicine for orthostasis
and dyspnea (below), but developed rigors (without fevers) and
hypotension with tachycardia. He was given 4L NS IVF and started
emperically on vancomycin and meropenem prior to transfer to the
ICU. He was given an additional 2.5L with stabilization of his
blood pressure and improvement of his tachycardia. Blood
cultures ___ bottles) returned positive for pan-sensitive
coagulase negative staph. He did not have any further rigors or
temperature spikes. He was well enough for transfer to the
floor. SBPs remained in the 100s-130s on the floor and patient
was feeling much better. He remained stable following
discontinuation of antibiotics (___). CMV DNA detected
in his blood, but at a very low level. ID was not concerned
about this and did not recommend treatment.
# Dyspnea: Recent admission for multifocal pneumonia treated
with 11 days total of Vanc/Zosyn then Miropenem. Repeat CXR in
the ED revealed improvement in RML infiltrate from prior on ___.
In the abscence of clear source of infection without fever,
chills, nausea, vomiting, or cough on admission. Patient does
not have clinical signs of heart failure. He was thought to
simply be recovering from severe pneumonia. PE though on the
differential was felt to be less likley given that he is not
tachycardic or hypoxemic. Emperic antibiotics were initially
deferred given lack of symtpoms, above, but later in his
hospital course were initiated given concern for sepsis (above).
His chest x-ray is much improved from prior admission.
Dyspnea improved throughout admission, and he is satting 100% on
RA by discharge.
# Orthostatic hypotension: Patient has documented orthostasis
from prior admission that did not resolve prior to discharge. He
notes good PO fluid intake on last admssion, but this decreased
since discarge home. He is likely volume depleted given that he
improved with fluid bolus in the ED. This is likely complicated
by his underlying HIV neuropathy which may also be contributing
to orthostasis. Hematocrit is stable since discharge making
acute blood loss an unlikely explanation for orthostasis. He was
given IV fluids in the ED with reported improvment and had
negative orthostatic blood pressures prior to discharge.
# HIV/AIDS: CD4 9 on ___, VL 75k. He is not on HAART
currently, but will follow up with ID at ___. He is on bactrim
prophyliaxis, and ID felt that he did not need additional
prophylaxis. HIV genotyping was sent and Dr. ___
follow up on this result and make sure it gets to ___ to his
outpatient ID doctor.
# CKD: Creatinine 2.1, which appears to be his stable baseline
since ___. He ___ started on a low potassium, low phos diet.
# Depression: Stable. Continued bupropion (Sustained Release)
150 mg PO QAM.
# GERD: Stable. Continued home omeprazole 20 mg PO BID.
# Prophylaxis: Subcutaneous heparin, ppi, bowel regimen
# Code: FULL
# Contact: Girlfriend, ___ ___
# ___ issues:
- HIV genotyping was sent and Dr. ___ (___) will
follow up on this result and make sure it gets to ___ to his
outpatient ID
- Mycolytic blood cultures pending at discharge, no growth |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / cefpodoxime / cefuroxime / Amoxicillin
Attending: ___.
Chief Complaint:
Hypernatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with history of Alzheimer's disease, CAD, HTN,
___, Afib on Coumadin, CVA with L residual weakness, COPD on 2L
NC, residing at rehab who presents after abnormal labs. Patient
has had poor p.o. intake for the last few days and routine labs
this morning showed sodium 166, BUN 60, creatinine 1.1. Her
rehab placed IV for hydration, but patient became agitated and
pulled out. Given hypernatremia, she was sent to the ED from
rehab. At her baseline, she is alert, disoriented, cannot follow
simple commands; however, she was more lethargic and difficult
to arouse, which is a change. In the ED, attempted to talk to
patient with ___ interpreter but she is nonconversant.
In ED initial VS: T 98.8 HR 70 BP 124/62 RR 16 99% 2L NC
Exam: Eyes closed, responds to painful stimuli, NAD, nonverbal
CV: Irregularly irregular, no murmurs
HEENT: Dry mucous membranes
Abdomen: Positive BS, soft, nondistended nontender
Back: No bruising on flanks
___: No edema, warm, well perfused
Neuro: PERRLA, responds to painful stimuli, moving bilateral
hands equally, unable to follow commands
GU Brown stool, guaiac negative
Labs significant for: Na+ 171, osm 368, INR 3.2, Cr 1.1
Patient was given: 1L NS at 200 mL/h
Imaging notable for: CXR: No focal consolidation to suggest
pneumonia
Consults: None
VS prior to transfer: T 98.8 HR 72 BP 107/82 RR 16 94% 2L NC
On arrival to the MICU, patient initially agitated during foley
insertion then calm, arousable to voice.
REVIEW OF SYSTEMS: Unable to obtain
Past Medical History:
A. fib/flutter on Coumadin
COPD on 2L NC
HTN
Alzheimer's
Osteoarthritis
Peripheral vascular disease
Chronic ___ edema
History of CVA (___) with mild residual left-sided weakness
___
Social History:
___
Family History:
Reviewed with family, none pertinent to this hospitalization
Physical Exam:
ADMISSION EXAM
VITALS: T afebrile HR 80 BP 117/54
GENERAL: calm, arousable to voice, asleep, not responding to
commands w ___ phone interpreter
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash or breakdown
NEURO: no notable contractures, clonus. 1+ patellar reflexes;
1+ brachial reflexes
DISCHARGE EXAM
Vitals: 97.2, 110 / 65, HR 60, RR 18, 97 RA
GENERAL: in bed, somewhat lethargic and resting comfortably
HEENT: MMM
LUNGS: equal chest rise, normal respiratory effort
CV: regular rhythm, normal rate, 2+ radial pulses
ABD: Soft, non-tender
EXT: Warm, no edema
NEURO: Unable to assess due to mental status, does not answer
questions appropriately
Pertinent Results:
ADMISSION LABS
___ 09:35PM BLOOD WBC-12.2*# RBC-4.35# Hgb-13.5# Hct-44.5#
MCV-102*# MCH-31.0 MCHC-30.3* RDW-13.6 RDWSD-51.4* Plt ___
___ 09:35PM BLOOD Neuts-74.0* Lymphs-17.2* Monos-7.4
Eos-0.9* Baso-0.2 Im ___ AbsNeut-9.04* AbsLymp-2.11
AbsMono-0.91* AbsEos-0.11 AbsBaso-0.03
___ 09:35PM BLOOD ___ PTT-32.6 ___
___ 09:35PM BLOOD Glucose-139* UreaN-62* Creat-1.1 Na-171*
K-4.2 Cl-131* HCO3-28 AnGap-12
___ 09:35PM BLOOD Osmolal-368*
___ 12:40AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:40AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:40AM URINE RBC-8* WBC-5 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:40AM URINE Mucous-RARE*
___ 12:40AM URINE Hours-RANDOM Creat-95 Na-39
___ 12:40AM URINE Osmolal-557
PERTINENT LABS
___ 12:50AM BLOOD Glucose-135* UreaN-63* Creat-1.1 Na-171*
K-4.3 Cl-133* HCO3-26 AnGap-12
___ 11:15AM BLOOD Na-158*
IMAGING
___ CXR
No focal consolidation to suggest pneumonia.
MICROBIOLOGY
Blood and urine cultures negative
DISCHARGE LABS
___ 05:48AM BLOOD WBC-4.4 RBC-2.94* Hgb-9.0* Hct-26.9*
MCV-92 MCH-30.6 MCHC-33.5 RDW-13.9 RDWSD-45.4 Plt ___
___ 05:48AM BLOOD ___
___ 05:48AM BLOOD Glucose-99 UreaN-6 Creat-0.4 Na-144 K-3.4
Cl-110* HCO3-25 AnGap-9*
___ 05:48AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Voltaren (diclofenac sodium) 1 % topical Q4H:PRN
4. Famotidine 20 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Donepezil 10 mg PO QHS
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
11. Hiprex (methenamine hippurate) 1 gram oral BID
12. Ferrous Sulfate 325 mg PO BID
13. Levothyroxine Sodium 62.5 mcg PO DAILY
14. Trimethoprim 100 mg PO Q24H
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, SOB
16. Cranberry-Probiotics-Vitamin C (cranberry conc-C-bacillus
coag) 450-30-50 mg-mg-million oral BID
17. Docusate Sodium 100 mg PO BID
18. Lactulose 30 mL PO BID:PRN constipation
19. nystatin 100,000 unit/gram topical DAILY
20. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
21. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Bisacodyl ___AILY:PRN constipation
2. Warfarin 1 mg PO DAILY16
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Donepezil 10 mg PO QHS
8. Famotidine 20 mg PO DAILY
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, SOB
10. Levothyroxine Sodium 62.5 mcg PO DAILY
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypernatremia
Hypoglycemia
End stage dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypernatermia and leukocytosis.// evaluate for
pneumonia
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
No focal consolidation, pleural effusion, evidence of pneumothorax is seen.
The cardiac and mediastinal silhouettes are stable. Right sided calcified
granuloma is re-demonstrated.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R DL Power PICC 47cm ___
___ Contact name: ___: ___ R DL Power PICC 47cm ___
___
IMPRESSION:
Comparison to ___. Patient has received the new right-sided PICC
line. The course of the line is unremarkable, the tip of the line projects
over the lower SVC. No complications, notably no pneumothorax. Normal size
of the heart. No pleural effusions. No pulmonary edema.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abnormal sodium level, Lethargy
Diagnosed with Abn lev enzymes in specimens from female genital organs
temperature: 98.8
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 124.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ year old ___ speaking woman with
advanced Alzheimer's dementia, CAD, HFpEF and atrial
fibrillation on warfarin, reported COPD on 2L, and CVA with
residual left sided weakness, admitted with hypernatremia in the
setting of
poor oral intake.
#Hypernatremia
Developed hypernatremia the setting of poor/no oral intake. She
lives at facility, but her daughter usually is the one who feeds
her, and she was in ___ during this time. Na was 171 at
admission, and was treated with IV D5W and frequent lab checks.
Renal was consulted to assist in safe lowering of sodium. She
normalized her sodium prior to discharge. Her PO intake remains
poor, and is best when done with assistance of her family
members. It was discussed with family that lack of appetite is
the end process of dementia, and they are aware. They know that
a feeding tube is not indicated and not within goals of care.
They would like to continue to try to hydrate her via PO means
as best they can, but they were made aware via multiple meetings
at the ultimate inevitability of future dehydration.
#Severe Malnutrition Nutrition
#Goals of care
Per daughter, she usually takes thickened liquids and pureed or
soft foods, with 1:1 feeding. PEG/Feeding tube neither
indicated nor within goals of care. Patient takes very little
PO in. She does best with her daughter's assistance.
#Alzheimers dementia
End stage, patient is non-verbal. Home donepezil was continued
#Elevated INR - coagulopathy
#A-Fib
INR in ___ range on admission. Warfarin was reduced to 1mg
daily, with last INR of 2.2. Would recommend to recheck INR in
___ days.
#H/o CVA and CAD
Continued home Aspirin and Atorvastatin
#GERD
Continued home Famotidine
#Macrocytic anemia
No sign of active bleeding. Likely contribution from
nutritional causes, as well as anemia of chronic disease.
#COPD
Per documentation patient was on ___ prior to admission, but
was on room air and breathing comfortably this admission.
Nebulizers were continued.
#Recurrent Urinary Tract Infections:
She had been on methenamine, trimethoprim, and cranberry prior
to admission. These were stopped as she did not reliably take
her pills.
#Hypothyroidism
On levothyroxine
#Polypharmacy
Patient was on multiple medications that may not benefit
mortality or quality of life at her age and with her mental
status. Many meds were discontinued.
TRANSITIONAL ISSUES
==========================
- Multiple family discussions were had regarding that her lack
of appetite and dehydration is a sign of the natural progression
of dementia into its latter stages. The family decided to make
patient DNR/DNI, and MOLST was completed. Despite aspiration
risk, family would like to continue to try to feed the patient.
Family would still like the patient to be hospitalized when she
becomes dehydrated again. If admitted in the future for
dehydration, recommend early goals of care conversations with
family.
- INR 2.2 at discharge, recommend to recheck in ___ days, adjust
warfarin as needed
- Recommend to check serum chemistries including sodium in ___
days
- Nutrition plan: eating for comfort with pureed diet; family
aware of aspiration risk, and she was made DNR/DNI for this
reason
- Polypharmacy: We discontinued many medications that are
unlikely to benefit morbidity and mortality at her age. Please
consider discontinuing more with time. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Vancomycin Analogues / Imodium A-D /
Ciprofloxacin / Penicillins / clindamycin
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with complicated Crohn's
disease, well known to our service who presents with fevers to
103 at rehab. She was most recently discharged to ___
on ___ after an admission for fever, and on workup was found
to have c.diff infection and ongoing fistulous disease. Her last
operation was in late ___ when she underwent sigmoid
colectomy, colostomy, ___, small bowel resection for
enterotomy and
she has had multiple image-guided drainage procedures for
intraabdominal abscesses. Care during her last admission
included IV antibiotic therapy for known fistulae and
intraabdominal abscesses, as well as oral vancomycin therapy for
c.diff in coordination with ID. She was followed by the wound
care and ostomy care teams for management of her sacral
decubitus ulcers, her midline colocutaneous fistula, and her
colostomy. She was continued on TPN with ongoing improvement in
her oral intake. Ms. ___ had initially been d/c'ed home on
___ with services and readmitted the following day after a
fall, CT was negative, care was coordinated and she had been
discharged to rehab and was doing well until 2 days ago.
Over the past 2 weeks at rehab, her PO intake improved, TPN was
stopped on ___, and she continued to be followed by ID with
ongoing antibiotic therapy (ertapenem, fluconazole, PO vanco).
On ___ in the evening the patient had rigors, chills, and
sweats and was found to have a fever to 103, cultures were sent.
She had some low grade temperatures from ___ as well, some
cultures
were sent, and IV flagyl and PO bactrim were added. She was
planning to have a CT scan performed as an outpatient at ___
in the context of a WBC count of ___ at rehab prior to the
onset of fevers. She was sent to the ED for fever workup and CT
scan after she spiked to 103 last evening and 101.4 again this
morning. Her WBC on arrival was 11.9 with 94% neutrophils.
Per the patient, her midline wound has been improving, with
decreased stool output and has been essentially dry for 3 days
managed with dry gauze, but again began oozing feculent output
this morning. Her ostomy output has been thicker, and she has
occasional fecal incontinence from her anus. Her setons remain
in place and continue to drain. Her sacral decubitus ulcer
continues
to improve and is being managed well. The patient has no
dysuria, no frequency, no cough, shortness of breath, cold
symptoms. Her abdominal pain has been stable, with no worsening
discomfort, nausea, or vomiting. She has been drinking ensures
daily, taking in grilled cheese, soup, peanut butter,
vegetables, and is eating better than ever, and weaned down from
TPN to off.
She is being admitted to the ___ service for ongoing fever
workup and culture surveillance.
Past Medical History:
PMH: Crohn's disease with arthralgias, erythema nodosum,
perineal drainage; ocular inflammation, anxiety
PSH: ileocolic resection (___), s/p multiple abscess drainage,
___ placements, tonsillectomy, hernia repair,
excision of benign tumors of right arm/leg (___)
Social History:
___
Family History:
Brother and sister with Crohn's disease. Mother died of cervical
cancer. Father died of laryngeal cancer.
Physical Exam:
Vitals: Tmax: 98.4 T: 98.7 HR:83 BP: 119/60 RR:18 SpO2: 99 RA
Gen:Cachetic female in NAD.
CV:RRR. No m/r/g
Resp:CTAB, good airmovement
Abd: Soft, nontender, nondistended. Normoactive bowel sounds.
Mid abdominal wound is contracted peripherally with central
granulation tissue. There is a coloplast ___ one piece
drainable pouch covering the wound. The abdominal wound is
producing loose feculent material. There are no signs of skin
infection around the wound. The stoma which is to the left of
the wound is pink, retracted, with intact mucocutaneous and
peristomal skin intact. There is an ostomy pouch over this site
and it is also producing loose feculent material. Perianal
fistulas appear clean with no signs of infection. There is a
Mepiplex dressing over the coccyx/sacrum with no signs of
infection.
Extr: no c/c/e
Pertinent Results:
___ 02:55PM ___ PTT-31.1 ___
___ 01:51PM LACTATE-1.7
___ 01:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
___ 01:40PM URINE RBC-1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:00PM GLUCOSE-110* UREA N-10 CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
___ 01:00PM estGFR-Using this
___ 01:00PM WBC-11.9* RBC-3.66* HGB-9.6* HCT-30.4* MCV-83
MCH-26.2* MCHC-31.6 RDW-18.0*
___ 01:00PM NEUTS-94.5* LYMPHS-3.1* MONOS-1.7* EOS-0.6
BASOS-0.2
___ 01:00PM PLT COUNT-215
Medications on Admission:
prednisone 15mg', diazepam 5'' prn, famotidine 20', dilaudid
prn, vanco PO, erta IV, fluc IV, flagyl IV, bactrim PO, SQH, TPN
stopped ___
Discharge Medications:
1. Diazepam 5 mg PO Q12H:PRN anxiety
2. Famotidine 20 mg PO DAILY
3. PredniSONE 15 mg PO DAILY
4. Fluconazole 400 mg IV Q24H
5. Meropenem 500 mg IV Q6H
6. Vancomycin Oral Liquid ___ mg PO Q6H
7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
8. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fevers
Malnutrition
Failure to Thrive
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Fever after recent resection. History of Crohn's disease.
COMPARISON: ___.
TECHNIQUE: Chest, AP upright and lateral.
FINDINGS: A PICC line terminates in the superior vena cava. The cardiac,
mediastinal and hilar contours appear unchanged. The lungs appear clear. The
are no pleural effusions or pneumothorax. Bony structures are unremarkable.
IMPRESSION: No evidence of acute disease.
Radiology Report
INDICATION: ___ female with Crohn's status post partial colectomy
with fevers for three days. Rule out abdominal abscess.
COMPARISONS: CT of the abdomen and pelvis from ___.
TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with IV
contrast. Multiplanar reformations were obtained and reviewed.
FINDINGS:
The partially imaged lungs are clear. The partially imaged heart is
unremarkable.
CT ABDOMEN: The liver, spleen, both adrenals, both kidneys, pancreas and
gallbladder are unremarkable. A small hypodensity in the spleen (2:19) is too
small to accurately characterize but unchanged.
The remnant small and large bowel loops appear unremarkable. Again noted are
multiple fistulous and sius traces in the perianal region extending into the
left obturator internus, inferior to the stoma and subjacent to the umbilicus.
A left obturator collection fistulized to the colon measures 1.9 x 2.1 cm. A
peristomal collection measures 1.9 x 2.9 cm and the subumbilical collection
fistulized to the colon measures 4 mm x 4 mm. These are all unchanged
compared to the previous examination. No significantly dilated loops of bowel
are present. The rectum and sigmoid colon appear unremarkable.
CT OF THE PELVIS:
The uterus and both adnexa are unremarkable as well. The bladder is well
distended. Setons are noted in the perianal region. No pelvic or inguinal
lymphadenopathy or pelvic free fluid is present.
BONES: There are no suspicious bone lesions.
IMPRESSION: Stable complex fistulous disease; superimposed infectious process
is not excluded, however.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, REGIONAL ENTERITIS NOS
temperature: 99.8
heartrate: 94.0
resprate: 22.0
o2sat: 97.0
sbp: 117.0
dbp: 55.0
level of pain: 4
level of acuity: 3.0 | General Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment of fevers of unknown origin as high as
103 while at rehabilitation. Her hospital course is as follows.
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. A chest x-ray done when
she presented to the ED was unremarkable and showed clear lungs.
GI/GU/FEN: The patient was evaluated by a nutritionist. She is
on a regular diet with ensure plus drinks twice daily and ensure
pudding at dinner. She was also restarted on TPN for decreased
oral nutrition. The patient has tolerated her Regular diet and
TPN. She has been voiding appropriately. Output from the fistula
has decreased. The fistula and ostomy have both produced loose
feculent material during this hospitalization. Electrolytes were
carefully monitored and replaced.Patient continued home
famotidine for GERD prophylaxis.
ID:Patient was seen by infectious disease and restarted on Po
vancomycin, IV fluconazole, and IV meropenem. Patient was
afebrile while in house. WBC has dropped from 11.9 at time of
admission to 7.3. An abdominal/pelvic CT scan showed stable
fistulous disease. A left obturator collection fistulized to the
colon measures 1.9 x 2.1 cm. A peristomal collection measures
1.9 x 2.9 cm and the subumbilical collection fistulized to the
colon measures 4 mm x 4 mm. These are all unchanged
compared to the previous examination. The patient was discharged
with instructions to continue antibiotics(PO vancomycin, IV
fluconazole, IV meropenem) until her followup appointment with
Dr. ___. Wound/ostomy nurse was consulted and followed
wound care. Blood cultures were no growth to date. Cdiff PCR was
negative.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, 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: ___.
Major Surgical or Invasive Procedure:
___ Bedside Tracheostomy Exchange, Bronchoscopy
___ Flexible Bronchoscopy and tracheostomy exchange
Pertinent Results:
ADMISSION LABS
=====================
___ 10:50AM BLOOD WBC-13.6* RBC-3.08* Hgb-9.8* Hct-32.4*
MCV-105* MCH-31.8 MCHC-30.2* RDW-19.7* RDWSD-75.2* Plt ___
___ 10:50AM BLOOD Neuts-53.7 ___ Monos-15.4*
Eos-5.7 Baso-0.4 Im ___ AbsNeut-7.27* AbsLymp-3.19
AbsMono-2.08* AbsEos-0.77* AbsBaso-0.06
___ 10:50AM BLOOD ___ PTT-36.5 ___
___ 10:50AM BLOOD Glucose-255* UreaN-12 Creat-1.0 Na-139
K-5.4 Cl-102 HCO3-28 AnGap-9*
___ 03:56AM BLOOD ALT-9 AST-19 LD(LDH)-190 AlkPhos-87
TotBili-0.3
___ 10:50AM BLOOD CK-MB-2 ___
___ 10:50AM BLOOD cTropnT-0.12*
___ 06:03PM BLOOD cTropnT-0.12*
___ 10:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
___ 11:31AM BLOOD ___ pO2-50* pCO2-70* pH-7.22*
calTCO2-30 Base XS-0
___ 06:21PM BLOOD Lactate-1.8
___ 11:31AM BLOOD O2 Sat-72
INTERVAL LABS
======================
___ 02:56AM BLOOD WBC-6.8 RBC-2.09* Hgb-6.5* Hct-21.6*
MCV-103* MCH-31.1 MCHC-30.1* RDW-19.0* RDWSD-70.3* Plt ___
___ 08:35AM BLOOD Cortsol-11.1
___ 04:09PM BLOOD ___ Temp-36.7 PEEP-8 FiO2-30 pO2-30*
pCO2-38 pH-7.46* calTCO2-28 Base XS-1 Intubat-INTUBATED
MICROBIOLOGY
=====================
Multiple sets of blood cultures with no growth to date
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
MRSA SCREEN (Final ___: No MRSA isolated.
___ 10:34 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
___ 6:24 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): BUDDING YEAST.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
RESPIRATORY CULTURE (Final ___:
~1000 CFU/mL Commensal Respiratory Flora.
YEAST. 10,000-100,000 CFU/mL.
IMAGING
=========================
___ CXR
Mild pulmonary edema and small bilateral pleural effusions,
slightly improved in the interval. Bibasilar airspace opacities
may reflect atelectasis, though aspiration or infection is
difficult to exclude in the correct clinical setting.
___ CT ABDOMEN
1. Interval improved pulmonary edema, now mild, and bilateral
moderate pleural effusions.
2. Right middle lobe and left lung apex ill-defined opacities
worrisome for infection.
3. Scattered ground-glass pulmonary nodules are noted, some
which appear new and may be infectious or inflammatory in
etiology.
4. Other previously noted patchy ill-defined opacities in the
lower lobes and right upper lobe on prior CT exam are improved
or resolved.
5. Distended stomach and large bowel loops, but no evidence of
ileus or bowel obstruction.
6. Anasarca and trace ascites.
7. Cholelithiasis.
8. Dilated esophagus with fluid-filled distention distally
suggests esophageal dysmotility.
___ KUB
1. Similar gaseous distension of the stomach and large bowel
without dilated loops of small bowel as seen on CT performed
___.
2. A gastrostomy tube overlies the stomach.
___. The tracheostomy tube is in overall appropriate position
terminating in the mid trachea with balloon inflated. The
posterior lip abuts the posterior tracheal wall. No
subcutaneous emphysema.
2. Ground-glass opacities in the left lung apex, which may
represent
infectious or inflammatory process.
___ RENAL US
1. No hydronephrosis of either the right or left kidney.
Collapsed bladder.
2. Trace ascites.
3. Limited images demonstrate fluid within bilateral patent
processus
vaginalis, with mesentery/a bowel loop within the right inguinal
hernia.
DISCHARGE LABS
=====================
___ 06:00AM BLOOD WBC-6.9 RBC-2.47* Hgb-7.7* Hct-26.5*
MCV-107* MCH-31.2 MCHC-29.1* RDW-20.9* RDWSD-76.5* Plt ___
___ 06:00AM BLOOD Glucose-274* UreaN-22* Creat-1.2 Na-141
K-4.5 Cl-106 HCO3-27 AnGap-8*
___ 06:00AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ascorbic Acid ___ mg PO DAILY
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Famotidine 20 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. PredniSONE 1 mg PO DAILY
9. Senna 17.2 mg PO QHS
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
11. SulfaSALAzine ___ 1000 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Vitamin D 1600 UNIT PO DAILY
14. Alphagan P (brimonidine) 0.1 % ophthalmic (eye) BID
15. Colchicine 0.6 mg PO DAILY
Start: Upon Arrival
16. Artificial Tears GEL 1% ___ DROP BOTH EYES Q6H:PRN eye
dryness
17. Aspirin 81 mg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD QAM Right ribs
19. Multivitamins W/minerals Chewable 1 TAB PO DAILY
20. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
21. Apixaban 5 mg PO BID
22. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
23. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
2. Metoprolol Tartrate 25 mg PO Q6H
3. Terazosin 2 mg PO QHS
4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Alphagan P (brimonidine) 0.1 % ophthalmic (eye) BID
6. Apixaban 5 mg PO BID
7. Artificial Tears GEL 1% ___ DROP BOTH EYES Q6H:PRN eye
dryness
8. Ascorbic Acid ___ mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
12. Famotidine 20 mg PO BID
13. FoLIC Acid 1 mg PO DAILY
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QAM Right ribs
16. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
17. Multivitamins W/minerals Chewable 1 TAB PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
19. PredniSONE 1 mg PO DAILY
20. Senna 17.2 mg PO QHS
21. SulfaSALAzine ___ 1000 mg PO DAILY
22. Thiamine 100 mg PO DAILY
23. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
24. Vitamin D 1600 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses
====================
Ventilator associated pneumonia
Atrial fibrillation
Atrial flutter with rapid ventricular response
Acute on chronic Hypoxemic and Hypercapnic Respiratory Failure
Secondary diagnoses
=====================
Acute tubular necrosis
Dementia
Acute on chronic heart failure with preserved ejection fraction
Ileus
Malpositioned tracheostomy
Acute on Chronic macrocytic Anemia
Deep venous thrombosis
Type II diabetes
Coronary artery disease
Ulcerative colitis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with sob // eval for pna
TECHNIQUE: Portable AP view of the chest
COMPARISON: Chest radiograph ___ and ___
FINDINGS:
Tracheostomy tube is in unchanged position. A right-sided PICC tip terminates
at the SVC/right atrial junction. Patient is status post median sternotomy
and CABG. Cardiac silhouette size is mildly enlarged, as seen previously.
Mediastinal and hilar contours are not substantially changed. There is mild
pulmonary edema, slightly improved in the interval, with continued small
bilateral pleural effusions. Patchy opacities in lung bases may reflect areas
of atelectasis. Evaluation of the left apex is limited due to the patient's
chin obscuring this region. No right-sided pneumothorax. No acute osseous
abnormality.
IMPRESSION:
Mild pulmonary edema and small bilateral pleural effusions, slightly improved
in the interval. Bibasilar airspace opacities may reflect atelectasis, though
aspiration or infection is difficult to exclude in the correct clinical
setting.
Radiology Report
EXAMINATION: CT chest, abdomen and pelvis without contrast.
INDICATION: History: ___ with history of CHF, prior pneumonia, tracheostomy,
presenting from rehab with increased ventilatory requirement and secretions,
also has very distended abdomen, has G-tube and prior history of ileus -please
perform CT abdomen with p.o. contrast through G-tube, no IV contrast, please
perform dry CT chest to evaluate for pneumonia or pulmonary edema // please
perform CT abdomen with p.o. contrast through G-tube, no IV contrast, please
perform dry CT chest to evaluate for pneumonia or pulmonary edema
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis without intravenous contrast. Coronal and sagittal reformats were
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.2 s, 72.1 cm; CTDIvol = 24.8 mGy (Body) DLP =
1,787.5 mGy-cm.
Total DLP (Body) = 1,788 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___. CT chest dated ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Status post CABG. The heart is mildly enlarged. There
is decreased attenuation of the blood pool relative to myocardium suggestive
of anemia. There are dense triple coronary artery calcification. There is a
partially visualized subclavian approach central venous catheter with tip
terminating in the right atrium. There is no pericardial effusion. Thoracic
aorta is normal in caliber without intramural hematoma. Mild atherosclerotic
calcifications. Main pulmonary artery is normal caliber.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma. Esophagus is patulous with the
distal aspect appearing fluid-filled.
PLEURAL SPACES: There are bilateral moderate pleural effusion, right greater
than left, increased in size from the previous CT study. Right basilar chest
tube has been removed. No pneumothorax.
LUNGS/AIRWAYS: There is a tracheostomy tube visualized with tip terminating at
the T3 level, in standard position. The airways are patent to the level of
the segmental bronchi bilaterally. Ill-defined opacities in the left lung
apex and right middle lobe are nonspecific but may reflect an infectious
process. Other additional patchy ill-defined opacities in the lower lobes and
right upper lobe on prior exam appear interval improved or resolved. There is
interval improvement in mild pulmonary edema. Scattered nodular opacities in
both lungs are noted. For example in the right lower lobe there is an
unchanged 5 mm nodule (series 2, image 38) and in the left upper lobe there is
a 7 mm ground-glass nodule not seen previously (series 2, image 28), findings
which are nonspecific may be secondary to infection or inflammation.
Ground-glass and mild interstitial abnormality in the right apex is improved.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration within the limitation of an
unenhanced scan.There is no perihepatic free fluid. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. There is a 5 mm stone
visualized at the dependent portion of the gallbladder. There is no evidence
of 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 lesion or laceration within the limitation of an unenhanced
scan.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are bilateral renal low-attenuation cystic lesions, poorly
characterized at the current study measuring up to 1.7 cm in the right renal
lower pole and 2.1 cm in the left renal lower pole. There is bilateral renal
pelvis fullness, right greater than left with mild fullness of the left
ureter. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. There is a PEG tube
visualized in appropriate position. The stomach is mildly dilated but grossly
unremarkable. Small bowel loops demonstrate normal caliber. The colon and
rectum are distended but otherwise unremarkable. The appendix is normal.
There is no evidence of mesenteric injury.
There is trace free fluid in the abdomen.
PELVIS: The urinary bladder demonstrates a thickened wall which may be
secondary to chronic outlet obstruction. There is trace free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged measuring 4.9 cm transverse
dimension.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: There is a chronic T12 vertebral body compression deformity. There is
no acute fracture. No focal suspicious osseous abnormality. There are
moderate multilevel degenerative changes of the thoracolumbar spine. Intact
median sternotomy wires.
SOFT TISSUES: There are moderate bilateral inguinal fat and ascites containing
hernias. There is diffuse anasarca.
IMPRESSION:
1. Interval improved pulmonary edema, now mild, and bilateral moderate pleural
effusions.
2. Right middle lobe and left lung apex ill-defined opacities worrisome for
infection.
3. Scattered ground-glass pulmonary nodules are noted, some which appear new
and may be infectious or inflammatory in etiology.
4. Other previously noted patchy ill-defined opacities in the lower lobes and
right upper lobe on prior CT exam are improved or resolved.
5. Distended stomach and large bowel loops, but no evidence of ileus or bowel
obstruction.
6. Anasarca and trace ascites.
7. Cholelithiasis.
8. Dilated esophagus with fluid-filled distention distally suggests esophageal
dysmotility.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK
INDICATION: ___ year old man with trach in place, recently 3 trach changes.
P/w c/f cuff leak, has high Ppeaks. Bedside bronch just completed // Eval
trach position
TECHNIQUE: MDCT acquired helical axial images were obtained from the thoracic
inlet through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 23.4 cm; CTDIvol = 16.5 mGy (Body) DLP = 359.9
mGy-cm.
Total DLP (Body) = 375 mGy-cm.
COMPARISON: CT C-spine ___, CT chest ___. CT
chest, abdomen and pelvis ___.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect. A tracheostomy is again noted, terminating in the mid
trachea (series 5, image 49), with the posterior lip abutting the posterior
trachea (series 6, image 38). Secretions are seen superior to the tracheal
balloon with an otherwise patent trachea inferiorly. The trachea balloon
abuts the wall of the trachea circumferentially (series 5 image 46). No
subcutaneous emphysema is demonstrated.
The salivary glands are grossly without mass or adjacent fat stranding. The
right lobe of the thyroid gland contains a calcified nodule measuring 1.2 cm,
which is stable. There are scattered prominent but nonenlarged
supraclavicular nodes measuring up to 0.7 cm in the short axis (series 4,
image 46), which are unchanged.
No pneumothorax bilaterally. There is pleuroparenchymal scarring at the
bilateral lung apices. Several left apical ground-glass nodules measuring up
to 4 mm (series 4, image 60, 65) are unchanged from most recent prior study.
There are no osseous lesions. There is degenerative change including
multilevel spondylolisthesis of the cervical spine which is likely chronic and
degenerative in nature. No fractures. A right-sided internal jugular central
catheter terminates below the level of the study, at least within the SVC.
Sternotomy changes are noted along the superior sternum.
IMPRESSION:
1. The tracheostomy tube is in overall appropriate position terminating in the
mid trachea with balloon inflated. The posterior lip abuts the posterior
tracheal wall. No subcutaneous emphysema.
2. Ground-glass opacities in the left lung apex, which may represent
infectious or inflammatory process.
Radiology Report
INDICATION: ___ year old man with distended abdomen who p/w hypercarbic resp
failure // Eval for ileus
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT torso from ___.
Abdominal radiograph from ___
FINDINGS:
A gastrostomy tube terminates in the stomach which is distended with air as
seen on prior CT. There is diffuse gaseous distention of large bowel colon
without dilation small bowel loops which measure up to 7.8 cm, similar to
prior CT given differences in technique. No evidence of gross free
intraperitoneal air although assessment is limited on supine radiographs.
Osseous structures are notable for degenerative changes in the spine.
IMPRESSION:
1. Similar gaseous distension of the stomach and large bowel without dilated
loops of small bowel as seen on CT performed ___.
2. A gastrostomy tube overlies the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ is a ___ year-old male with hx dementia, dysphagias/p
PEG, CAD s/p CABGx4 and stents, HFpEF, T2DM, and recenthospitalization for
pneumonia with subsequent trach placement ___, who presented from
___ with several days of increased ventilatory requirements
iso 3 trach exchanges consistent with hypercarbic respiratory failure and also
with increasing abdominal distention. // elevated peak, desynchronize
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiograph and chest CT dated ___.
FINDINGS:
Tracheostomy and sternotomy wires again noted. Right-sided PICC line is noted
in standard position. Cardiomediastinal silhouette is unchanged. Mild
pulmonary edema appears improved when compared to the prior radiograph.Again
seen are bibasilar opacities which may reflect areas of atelectasis or
infection. There are bilateral, mild-to-moderate pleural effusions, grossly
unchanged. There is no pneumothorax.
IMPRESSION:
1. Bibasilar patchy opacities may reflect atelectasis or infection in the
correct clinical setting.
2. Improving, mild pulmonary edema.
3. Mild-to-moderate bilateral pleural effusions appears worse on the right.
Radiology Report
INDICATION: ___ year old man with abdominal distension, increasingly difficult
to ventilate // Obstruction? Ileus?
TECHNIQUE: Supine abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph dated ___ and ___.
FINDINGS:
Gaseous distention of multiple loops of small bowel measuring up to 2.7 cm.
Interval decrease of gaseous distension of the colon.
There is no free intraperitoneal air.
Moderate multilevel degenerative changes of the lower thoracic and lumbar
spine.
Patient is status post median sternotomy with the two visualized inferior
sternal wires remain intact.
Surgical clips are demonstrated in the left upper quadrant. A partially
visualized gastrostomy tube is again demonstrated in the left upper quadrant.
IMPRESSION:
1. Interval decrease of gaseous distension of the colon.
2. Gaseous distension of multiple small bowel loops measuring up to 2.7 cm is
unchanged from prior.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ is a ___ year-old male with hx dementia, dysphagias/p
PEG, CAD s/p CABGx4 and stents, HFpEF, T2DM, and recenthospitalization for
pneumonia with subsequent trach placement ___, who presented from
___ with severaldays of increased ventilatory requirements in
setting of 3 trach exchanges consistent with hypercarbic respiratory failure
and also with increasing abdominal distention and urinary retention. //
?Renal abnormality
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT torso ___.
FINDINGS:
The right kidney measures 10.7 cm. The left kidney measures 10.9 cm.
There is no hydronephrosis, stones, or masses of the right kidney. Simple
appearing right renal cysts measure up to 1.7 cm. The left kidney is not well
visualized, but there is no left hydronephrosis. A cyst of the left kidney is
not well visualized.
The bladder is decompressed, limiting evaluation.
Trace perihepatic and right perirenal ascites.
Limited images demonstrate fluid within bilateral patent processes vaginalis,
with mesentery/bowel loop within a right inguinal hernia.
IMPRESSION:
1. No hydronephrosis of either the right or left kidney. Collapsed bladder.
2. Trace ascites.
3. Limited images demonstrate fluid within bilateral patent processus
vaginalis, with mesentery/a bowel loop within the right inguinal hernia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoxia
Diagnosed with Pneumonia, unspecified organism
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | ___ is a ___ year-old male with hx dementia, dysphagia
s/p PEG, CAD s/p CABGx4 and stents, HFpEF, T2DM, and recent
hospitalization for pneumonia with subsequent trach placement on
___, who presented from his rehab facility with several
days of increased ventilatory requirements iso 3 trach exchanges
consistent with hypercarbic respiratory failure and also with
increasing abdominal distention and inability to tolerate tube
feeds. He was found to have a VAP here and was treated for 7
days with antibiotics. He underwent multiple trach exchanges
with improvement in his trach function and positioning. He also
had evidence of ATN and oliguria which was resolving at the time
of discharge. He was undergoing intermittent diuresis for volume
overload. In addition he had intermittent periods of atrial
flutter and atrial fibrillation with rates up to the 130s at
time. He was improving and discharged back to his facility.
TRANSITIONAL ISSUES
===========================
[ ] Status post tracheostomy exchange to Portex Blue-line #7.
Post-bronch showed good placement and we did not have issues
with high peak pressures after the trach was exchanged. Continue
regular trach care and wean from ventilator to trach collar as
tolerated.
[ ] Anticoagulation: Apixaban 5 BID restarted ___ (had been on
heparin gtt during hospitalization). Getting treatment for acute
DVT from prior hospitalization. Needs lifelong a/c if he can
tolerate for his atrial fibrillation
[ ] Continue to titrate insulin to target blood glucose <180
[ ] Patient with ongoing evidence of volume overload. Would
continue gentle diuresis at rehab as tolerated. Tolerates 20mg
IV Lasix at a time and monitor kidney function with diuresis.
[ ] Continue bolus feeding of tube feeds. He does not tolerate
continuous feeds.
[ ] Terazosin started for urinary retention.
[ ] Metoprolol at 25mg q6 on discharge. Per discussion with
cardiology, ok to tolerate HR ranges from 60-130s.
[ ] Platelets had been downtrending in the few days prior to
discharge. Please repeat within 3 days of discharge to ensure
they are improving/stable.
[ ] Family is very involved in his care and should be alerted
about any major change in his medications or clinical status.
#Code status: Full code
#Contact: HCP son ___ ___
ACUTE ISSUES
===================
#Acute on chronic Hypoxemic and Hypercapnic Respiratory Failure
#VAP
CO2 on VBG in ED 70. CT with RML and left lung apex opacities
and scattered ground
glass pulmonary nodules c/f pneumonia. Treatment for VAP
initiated in ED with IV cefepime. He is s/p 7 day course of
ceftazadime for VAP treatment.
#Trach mal-positioning. Issues with intermittent blockage of the
tracheostomy and impingement on the posterior tracheal wall. The
tracheostomy was changed to a Portex perfit 7.0, followed by
___ 7.0 XLT and then a #7 Uniperc trach. IP consulted since
despite the Uniper #7, he was still having intermittent blockage
of the tracheostomy. Bedside bronch showed that the Uniperc
trach was impinging on the posterior tracheal wall, and was
intermittently occluded by the posterior tracheal wall. IP
exchanged for a Portex blue-line 7.0. Repeat examination showed
that this trach was nicely sitting in the lumen of the trachea.
Please note that during bronchoscopy we did notice a large clot
completely plugging up the RML. IP evacuated this clot, there
was some oozing which was easily controlled with topical saline
and diluted epi. Will follow up with IP as outpatient.
# Ileus and abdominal distension. Has had ongoing issues with
inability to tolerate TF and ileus. KUB here showing distension
of multiple small bowel loops. Standing reglan was trialed with
some improvement and QTc was closely monitored. Converting his G
tube to a GJ tube was also considered to allow for venting but
after discussion with his son, we transitioned to bolus feeding
and he tolerated this well. The reglan was stopped prior to
discharge. Discharged on bolus tube feeds Two Cal HN; Full
strength 240ml QID with venting after each bolus.
#Hx Atrial flutter (CHAD2VASc 5: age, CHF, vascular, diabetes)
Hx of AF rates ___ to 130s, anticoagulated with apixaban 5mg BID
at home. His rhythm varied during this admission, intermittently
in atrial flutter with variable block, also in atrial
fibrillation. Cardiology was consulted to assist with rate and
rhythm control strategies. His metoprolol dose was titrated down
to 12.5mg q6h given soft blood pressures. Cardiology recommended
against the use of amiodarone. At the time of discharge his
rates ranged from the ___. After discussion with
cardiology, we determined that the risk of tachycardia induced
cardiomyopathy is low with intermittently being in the 130s and
thus we tolerated the intermittent periods of rapid aflutter.
Increased metoprolol to 25mg q6 on discharge.
# Oliguria
Renal consulted per HCP's request. Oliguria most likely d/t ATN
from pre-renal/low renal perfusion in the setting of infection
on admission. Renal U/S didn't not show hydronephrosis. Cr was
stable throughout admission. Renal recommended gentle diuresis
given he appeared volume overloaded. Started on terazosin with
concern for BPH iso urinary retention but was making urine on
discharge without needing straight cath
# Acute on Chronic macrocytic Anemia
No obvious signs of bleeding. Hb lowest at 6.5, requiring 1u
pRBC. Baseline anemia thought to be chronic due to inflammation
and nutritional status.
# Thrombocytopenia:
Plt downtrending from ___ (165->147), and 111 on discharge.
Likely BM suppression, less concerned for HIT. Will need to
recheck in 3 days
# HFpEF
Sig history of CAD with prior 4-vessel CABG in ___ and stent
placement ___. Troponins appear chronically in 0.10 range, most
likely d/t a component of renal disease. Pt appeared fluid
overloaded on exam and was receiving gentle diuresis with 20mg
IV Lasix at a time, usually once or twice per day. Patient needs
ongoing diuresis at rehab, while closely monitoring his renal
function.
CHRONIC ISSUES
============================
# LLE DVT, distal femoral. Hx of DVT during last admission, on
apixaban at home. Was on heparin gtt while in the ICU given need
for procedures but transitioned back to his home apixaban prior
to discharge.
# Dysphagia, s/p PEG. TF plan as above.
# Dementia. Minimally interactive at baseline.
# Type II diabetes. Continued on standing insulin and sliding
scale.
# Hypertension. Previously on atenolol on prior admits. Was not
on at rehab. Here intermittently with soft pressures requiring
pressors briefly.
# CAD. s/p CABG in ___ and stent in ___. Continued ASA 81mg
# Ulcerative colitis. Continued home Sulfazsalzaine and
prednisone
# Hypothyroid
# Sick euthryoid syndrome. Continued home levothyroxine 50mg
daily at 3AM
# Gout. Held home colchicine.
#Hx of rejected corneal graft. Continued home Dorzolamide
2%/Timolol 0.5%, Lumigan (bimatoprost)0.01%, Alphagan P
(brimonidine) 0.1% |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
groin pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMH NASH cirrhosis s/p hernia repair
on ___ (Dr. ___, who now presents with pain, redness, and
swelling of his left groin. Patient is a somewhat limited
historian secondary to hepatic encephalopathy. States that
swelling began following the surgery, and has been getting
worse. Also has noticed increased pain and bruising around his
groin and into his scrotum. Patient first reports that he has
not had a bowel movement in over a week. However, on further
questioning reports that he is having regular bowel movements.
Takes lactulose at home, and states that there has not been any
problems. No fevers or chills. No urinary symptoms.
In the ED, initial vitals: 97.9, 73, 103/50, 18, 98% RA
- Exam notable for: Left groin grossly swollen and ecchymotic.
Firm and painful to touch. Scrotum grossly swollen, penis
retracted with ecchymosis to area
No asterixis
- Labs notable for:
CBC: WBC 9.8, Hgb 15.3, Plt 66
Lytes:
128 / 92 / 23
--------------99
5.3 \ 26 \ 1.0
___: 25.2 PTT: 42.6 INR: 2.3
Lactate:1.4
Repeat K 4.8
- Imaging notable for CT pelvis w/ contrast showing mixed
density fluid tracking from the left pelvis into the left
hemiscrotum with surrounding stranding. This may represent
postoperative change with associated hemorrhage.
- Patient given:
___ 13:36 IV Morphine Sulfate 2 mg
___ 20:18 IV Morphine Sulfate 2 mg
___ 20:18 PO/NG Furosemide 80 mg
___ 20:18 PO/NG Lactulose 15 mL
___ 20:18 PO Pravastatin 80 mg
___ 20:18 PO/NG Spironolactone 100 mg
___ 21:34 PO Nadolol 20 mg
___ 22:13 IV Morphine Sulfate 2 mg
- Vitals prior to transfer: 98.0, 65, 102/48, 18 , 98% RA
On arrival to the floor, pt reports that his pain is somewhat
improved with his pain medications
REVIEW OF SYSTEMS: Per HPI
Past Medical History:
- Cirrhosis with NASH
- portal venous thrombosis, on coumadin
- ascites
- inguinal and ventral hernia s/p repair
- Ventral hernia repair.
- ___ - Laparoscopic left indirect inguinal hernia repair
with mesh and laparoscopic incarcerated ventral hernia repair
with mesh.
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.0, 65, 102/48, 18 , 98% RA
General: Alert, oriented, no acute distress, somewhat slowed
response to questions
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender, some tenderness to palpation around
surgical wounds, otherwise nontender
GU: Large firm groin mass extending into L scrotum with
ecchymosis. Tender to palpation
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL EXAM
Vitals: 99.3, 94-105/56-69, 61-79, ___, 94-96% RA
GENERAL: Pleasant, cooperative, AOx3, NAD, no asterixis
HEENT: Moist mucous membranes, good dentition. Oropharynx is
clear.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, non distended, mildly tender to
deep palpation in all four quadrants
GU: Large left scrotal mass, purpuric, tense and tender to
palpation, does not appear improved compared to previous exam
EXTREMITIES: No clubbing, cyanosis, or edema
Pertinent Results:
ADMISSION LABS
----------------
___ 01:00PM BLOOD WBC-9.8# RBC-4.36* Hgb-15.3 Hct-44.3
MCV-102* MCH-35.1* MCHC-34.5 RDW-13.1 RDWSD-49.3* Plt Ct-66*#
___ 01:00PM BLOOD Neuts-69.8 Lymphs-9.9* Monos-15.5*
Eos-3.4 Baso-0.7 Im ___ AbsNeut-6.87* AbsLymp-0.97*
AbsMono-1.53* AbsEos-0.33 AbsBaso-0.07
___ 01:00PM BLOOD ___ PTT-42.6* ___
___ 01:00PM BLOOD Glucose-99 UreaN-23* Creat-1.0 Na-128*
K-5.3* Cl-92* HCO3-26 AnGap-15
___ 06:20AM BLOOD ALT-37 AST-51* AlkPhos-187* TotBili-6.7*
___ 06:20AM BLOOD Albumin-3.1* Calcium-8.4 Phos-4.3 Mg-2.0
MICROBIOLOGY
-----------------
___ 1:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
---------
CT PELVIS WITH CONTRAST (___): Mixed density fluid tracking
from the left pelvis into the left hemiscrotum with surrounding
stranding. This may represent postoperative change with
associated hemorrhage. Infection/reaction to mesh is not
excluded; correlation with infectious symptoms is recommended.
LIVER/GALLBLADDER ULTRASOUND (___): 1. Cirrhosis with
sequela of portal hypertension, including splenomegaly. 2.
Patent main portal vein and left portal vein. Anterior and
posterior right portal veins are chronically occluded.
DUPLEX DOPPLER ABDOMINAL ULTRASOUND (___): 1. Cirrhosis
with sequela of portal hypertension, including splenomegaly. 2.
Patent main portal vein and left portal vein. Anterior and
posterior right portal veins are chronically occluded.
SCROTAL ULTRASOUND (___): Symmetric blood flow to both
testicles without evidence of current torsion.
Testicles appear symmetrically heterogeneous bilaterally with
scattered small
hyperechoic regions within the testes of unclear clinical
significance.
Differential diagnosis may include small intratesticular
lipomas, possibly
related to microlithiasis, granulomatous orchitis. Correlate
with any history
of symptoms of systemic disease to exclude lymphoproliferative.
Recommend
follow-up ultrasound in 6 weeks for further assessment, to
assess stability.
Possible soft tissue hematoma in the soft tissue of the
superolateral left
scrotum. Superinfection not excluded, although the region does
not appear
hypervascular.
No drainable fluid collection seen.
DISCHARGE/INTERVAL LABS
___ 07:50AM BLOOD WBC-4.4 RBC-3.98* Hgb-13.6* Hct-40.9
MCV-103* MCH-34.2* MCHC-33.3 RDW-12.9 RDWSD-49.3* Plt Ct-68*
___ 07:50AM BLOOD ___ PTT-33.6 ___
___ 07:50AM BLOOD Glucose-88 UreaN-18 Creat-0.9 Na-131*
K-4.0 Cl-90* HCO3-27 AnGap-18
___ 07:50AM BLOOD ALT-39 AST-58* LD(LDH)-280* AlkPhos-232*
TotBili-3.9*
___ 07:50AM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.1 Mg-2.1
___ 06:20AM BLOOD Osmolal-276
___ 08:25AM URINE Hours-RANDOM UreaN-775 Creat-88 Na-23
Cl-<20
___ 08:25AM URINE Osmolal-461
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO BID
2. Lactulose 30 mL PO BID
3. Nadolol 20 mg PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
5. Pravastatin 80 mg PO QPM
6. Spironolactone 100 mg PO BID
7. Warfarin 7.5 mg PO DAILY16
8. Ascorbic Acid ___ mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
3. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Ascorbic Acid ___ mg PO DAILY
5. Lactulose 30 mL PO BID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Nadolol 20 mg PO DAILY
8. Pravastatin 80 mg PO QPM
9. Warfarin 7.5 mg PO DAILY16
10.Outpatient Lab Work
INR, AST/ALT/Alkaline Phosphatase/Total bilirubin, CHEM-7
ICD-9 code: ___.5
Fax to ___, MD: ___
11.Outpatient Lab Work
INR, AST/ALT/Alkaline Phosphatase/Total bilirubin, CHEM-7
ICD-9 code: ___
Fax to ___, MD: ___
12.Outpatient Lab Work
INR, AST/ALT/Alkaline Phosphatase/Total bilirubin, CHEM-7
ICD-9 code: ___
Fax to ___, MD: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Seroma, hyponatremia
SECONDARY: ___ cirrhosis, status post hernia repair surgery on
___, portal vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: Please do abdominal ultrasound with doppler. eval for ascites,
portal thrombosis
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: CT of the abdomen dated ___. And MR ___
dated ___.
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. Common bile
duct is not well seen.
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema.
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 cm.
Kidneys: Limited views the right kidney are grossly unremarkable.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is approximately 30 cm/sec.
The left portal vein is patent. The anterior and posterior right portal veins
are not well seen.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
IMPRESSION:
1. Cirrhosis with sequela of portal hypertension, including splenomegaly.
2. Patent main portal vein and left portal vein. Anterior and posterior right
portal veins are chronically occluded.
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: Mr. ___ is a ___ with ___ cirrhosis s/p hernia repair on
___ (Dr. ___, and portal vein thrombosis on Coumadin (temporarily on
hold), who now presents with pain, redness, and swelling of his left groin
thought to be a seroma ___ to hernia repair surgery, admitted for
hyponatremia. concern for venous congestion and ischemia // please get duplex
ultrasound
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 2.2 x 3.0 x 4.8 cm.
The left testicle measures: 3.3 x 3.1 x 4.1 cm.
The testicular echogenicity is symmetrically heterogeneous bilaterally with
scattered small echogenic foci which do not shadow. Findings could be related
to microlithiasis, small intratesticular lipomas, granulomatous orchitis may
also be in the differential diagnosis.
Vascularity is normal and symmetric in the testes and epididymides.
Bilateral epididymal cysts are seen, measuring 1.2 x 0.9 x1.3 cm on the right
and 0.7 x 0.7 x 0.7 cm on the left.
Small to moderate simple appearing left hydrocele is seen.
In the soft tissue of the superolateral left scrotum, there is an avascular
heterogeneously hypoechoic region measuring at least 3.6 x 3 cm, most likely
representing a hematoma.
IMPRESSION:
Symmetric blood flow to both testicles without evidence of current torsion.
Testicles appear symmetrically heterogeneous bilaterally with scattered small
hyperechoic regions within the testes of unclear clinical significance.
Differential diagnosis may include small intratesticular lipomas, possibly
related to microlithiasis, granulomatous orchitis. Correlate with any history
of symptoms of systemic disease to exclude lymphoproliferative. Recommend
follow-up ultrasound in 6 weeks for further assessment, to assess stability.
Possible soft tissue hematoma in the soft tissue of the superolateral left
scrotum. Superinfection not excluded, although the region does not appear
hypervascular.
No drainable fluid collection seen.
RECOMMENDATION(S): Follow-up scrotal ultrasound in 6 weeks to assess
stability of testicular findings
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval, Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.9
heartrate: 73.0
resprate: 18.0
o2sat: 98.0
sbp: 103.0
dbp: 50.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ y/o M with PMHx of NASH cirrhosis s/p
laprascopic ventral and inguinal hernia repair on ___ and
portal vein thrombosis on Coumadin, who presents with pain,
redness, and swelling of his left groin thought to be a seroma
secondary to hernia repair surgery, found to have hyponatremia
to 128. Patient was evaluated by surgery with CT pelvis and
scrotal ultrasound showing a relatively large firm mass in the
region of his inguinal hernia repair that likely represents a
seroma; Hgb/Hct and WBC were stable making hematoma and
infection unlikely. Patient will have close follow-up with
surgery on ___ and was cleared for discharge by Dr. ___.
Patient's Coumadin was initially held out of concern for scrotal
hematoma (and the need for possible surgical intervention); it
was restarted without bridging on discharge. Regarding his
hyponatremia, the patient was initially treated with albumin
(diuretics held for the first 48 hours). His home diuretics
(spironolactone and furosemide at reduced dosing) were restarted
prior to discharge and Na remained stable (discharge Na was
131). He otherwise remained asymptomatic and clinically stable
during this hospital stay.
TRANSITIONAL ISSUES
-------------------
[]Will need repeat labs (Chem7, LFTs, and INR) on ___
[]Reduced Furosemide from 80 mg BID to 40 mg daily;
Spironolactone reduced from 100 mg BID to ___ mg daily.
[]Restarted home Coumadin dosing without bridging on discharge.
Indication for anticoagulation is portal vein thrombosis. INR on
day of discharge is 1.5. Patient to have repeat INR on ___.
[]Will need close exam for worsening of scrotal mass given slow
recovery and concern for possible superinfection of seroma.
# CODE STATUS: FULL CODE
# CONTACT: HCP: ___. Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Purulent drainage from R lateral foot ulcer
Major Surgical or Invasive Procedure:
___ R ___ Metatarsal Head Resection
History of Present Illness:
Mr. ___ is a ___ quadraplegic and chronic right foot ulcer
who presents with worsening of his chronic ulcer over the past
week. He reports that he has been having increased redness of
the area. He saw his podiatrist last week who was able to drain
pus from the wound and sent it for culture. Inflammatory markers
were checked and were mildly elevated. He was sent to Urgent
Care for ceftriaxone which he received on ___. The patient
was referred to the ED for further evaluation. He denies fevers,
chills, or pain. He has deep feeling and can tell something is
going on but has no surface sensory abilities.
In the ED, initial vital signs were 97.6 69 91/55 16 97%. Labs
were notable for HCT 38.4%. The patient was seen by Podiatry who
thought that no acute intervention was necessary and
broad-spectrum
antibiotics by mouth would suffice.
On the floor, the patient was without complaint.
Past Medical History:
# C7 Quadriplegic, since ___ diving accident
- sensory and motor dysfunction from mid-chest down, partial
sensory
disturbance in arms and hands.
- w/c dependent
- personal assistant am & pm for ADL
- condom urinary catheter
- Hoyer lift,
# HTN controlled
# Obesity
# Sacral decub Stage I (buttocks)
# Cellulitis L arm ___
# Anemia
# Hx constipation, uses Miralax supp q3d
Social History:
___
Family History:
neg for GERD,PUD,stomach cancer, celiac sprue, IBD,IBS, Colon
cancer, colon polyps or HNPCC associated malignancies. No
history of liver disease
Physical Exam:
ADMISSION EXAM
--------------------
VS: 97.4 56 159/87 16 100RA
GENERAL: NAD, well-appearing, non-toxic
HEENT: MMM
NECK: Supple neck
CARDIAC: RRR, S1/S2
LUNG: Generally CTA b/l
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Ulceration on the lateral aspect of the right foot
under the ___ metatarsal, no evidence of drainage, mild erythema
of the foot, no warmth
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
VS: 97.9 120/71 55 18 99 RA
GENERAL: NAD, well-appearing, non-toxic
HEENT: MMM
NECK: Supple neck
CARDIAC: RRR, S1/S2
LUNG: Generally CTA b/l
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Ulceration on the lateral aspect of the right foot
is in c/d/i dressing. Lateral L hand also has area of skin
breakdown with eschar. No warmth. Chronic skin changes but no
erythema.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION LABS
___ 01:10PM BLOOD WBC-6.4 RBC-4.60 Hgb-12.8* Hct-38.4*
MCV-84 MCH-27.9 MCHC-33.4 RDW-14.9 Plt ___
___ 07:13AM BLOOD ___ PTT-31.1 ___
___ 01:10PM BLOOD Glucose-93 UreaN-12 Creat-0.5 Na-135
K-4.2 Cl-102 HCO3-23 AnGap-14
___ 01:10PM BLOOD Calcium-10.2 Phos-3.0 Mg-2.4
___ 06:10AM BLOOD CRP-5.5*
___ 01:20PM BLOOD Lactate-1.2
MICROBIOLOGY
___ Gram Stain: No PMN, no organisms. Culture pending.
___ Swab: Coag + Staph Aureus, Coag - Staph Aureus,
culture still pending
___ Blood Cx: PENDING
IMAGING
___ EKG
Baseline artifact. Sinus bradycardia. Early R wave progression.
No previous tracing available for comparison.
___ MRI R Foot
Signal changes involving the distal end of the fifth metatarsal
which are compatible with osteomyelitis. Minimal signal change
at the base of the fifth toe proximal phalanx may be reactive or
represent very early changes of osteomyelitis.
___ Tissue - Pathology
PENDING
___ X-Ray R Foot
There has been resection of the distal fifth metatarsal. There
is a soft tissue defect and soft tissue gas consistent with the
recent surgery. Overlying bandage material partially limits fine
bony detail. There is generalized demineralization. There are
degenerative changes of the first MTP
joint and of the talonavicular joint.
DISCHARGE LABS
___ 07:13AM BLOOD WBC-6.1 RBC-4.36* Hgb-12.6* Hct-37.4*
MCV-86 MCH-28.9 MCHC-33.7 RDW-15.1 Plt ___
___ 06:13AM BLOOD Glucose-99 UreaN-13 Creat-0.7 Na-136
K-4.3 Cl-105 HCO3-23 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO QID:PRN spasm
2. Bisacodyl 10 mg PR QHS:PRN constipation
Discharge Medications:
1. Baclofen 10 mg PO QID:PRN spasm
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Moxifloxacin 400 mg OTHER DAILY Duration: 10 Days
RX *moxifloxacin 400 mg 1 tablet(s) by mouth daily Disp #*11
Tablet Refills:*0
*****Due to nonavailability of moxifloxacin at accessible
pharmacies, antibiotic regimen transitioned to TMP-SMX and
cephalexin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Osteomyelitis of ___ Metatarsal Head
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: MR FOOT ___ CONTRAST RIGHT
INDICATION: ___ with R lateral foot ulcer, purulent drainage, x-ray with ?
osteo but wound does not probe to bone // r/o osteo
TECHNIQUE: Multiplanar T1, inversion recovery sequences in addition to pre
and post contrast fat suppressed T1 weighted sequences were acquired on a 1.5
Tesla magnet.
COMPARISON: There are no prior studies for comparison.
FINDINGS:
The distal end of the fifth metatarsal appears diminutive suggesting previous
surgery. There is abnormal low signal intensity at the distal end of the fifth
metatarsal on T1 weighted images, with associated marrow edema which tracks
into the distal shaft. A similar pattern of increased signal is seen on
post-contrast images extending from the distal end of the fifth metatarsal
into the mid to distal shaft. There is surrounding soft tissue edema and
enhancement.
There is very minimal marrow edema at the base of the fifth toe proximal
phalanx, with minimal if tiny loss of signal on T1 (series 5, image 19).
No acute fracture is seen. There is some degenerative change at the first
tarsometatarsal joint. No drainable fluid collection.
Muscles appear diffusely relatively atrophic.
IMPRESSION:
Signal changes involving the distal end of the fifth metatarsal which are
compatible with osteomyelitis. Minimal signal change at the base of the fifth
toe proximal phalanx may be reactive or represent very early changes of
osteomyelitis.
NOTIFICATION: Findings were discussed with Dr. ___ by telephone at 13:50
on ___ at time of interpretation.
Radiology Report
INDICATION: ___ year old man s/p ___ metatarsal resection // Assess s/p foot
surgery
COMPARISON: MRI from ___.
IMPRESSION:
There has been resection of the distal fifth metatarsal. There is a soft
tissue defect and soft tissue gas consistent with the recent surgery.
Overlying bandage material partially limits fine bony detail. There is
generalized demineralization. There are degenerative changes of the first MTP
joint and of the talonavicular joint.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT FOOT ULCER, OSTEOMYLITIS
Diagnosed with CELLULITIS OF FOOT, HYPERTENSION NOS
temperature: 97.6
heartrate: 69.0
resprate: 16.0
o2sat: 97.0
sbp: 91.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ with history of quadriplegia and chronic
right foot ulcer. He presented with new erythema and drainage
from his ulcer associated with mild inflammatory marker
elevation and radiographic findings concerning for osteomyelitis
of ___ metatarsal head.
ACTIVE ISSUES
1. Osteomyelitis: MRI confirmed osteomyelitis of ___ metatarsal
head, area underlying chronic right foot ulcer. Given
unremarkable imaging in ___, this infection was most likely
acute vs. acute-on-chronic. Outpatient culture grew MSSA and
inpatient wound swabs were growing both coat + and coat - staph
at time of discharge. Patient had received two doses of
ceftriaxone as an outpatient; given chronicity of ulcer, he was
broadened to pip-tazo as an inpatient. He underwent
uncomplicated resection of ___ metatarsal head by Podiatry on
___. The Podiatry team reported that they saw no evidence of
involvement of surrounding bones intraoperatively. Patient was
discharged on a course of moxifloxacin, to complete a total of
two weeks of antibiotics (d1 = ___. Unfortunately, his
pharmacy and other pharmacies in his neighborhood did not have
moxifloxacin in stock; given his preference to stick with ___
pharmacy, we agreed to complete antibiotic course with TMP-SMX
and cephalexin. Patient will follow-up with outpatient
Podiatrist in 1 week.
2. L Hand Skin Breakdown: Patient had an eschar on L medial
hand, in an area without sensation that he often pushes off of
for transfers. He was seen by wound care and OT, who recommended
a wound care regimen, splint, and additional training in
transfers to minimize trauma. He will have ___ sessions of home
OT for further management.
3. Labile Blood Pressures: Patient's systolic blood pressures
ranged from 80-160, most likely due to his spinal cord injury.
He remained asymptomatic and did not require treatment.
CHRONIC ISSUES
1. Quadriplegia: C7 level. Continued home suppositories,
baclofen, condom cath.
TRANSITIONAL ISSUES
- Patient set up with Visiting Nurse services for wound care
- Patient was seen by OT for splint for left medial hand for
area of eschar/skin break down from transfering. He will have
___ visits with home OT to continue to work on transfering in a
safe way
- Follow-up with Podiatry next week
- Follow-up pending cultures |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cc: fever, weakness
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Patient is an ___ y/o male with recent diagnosis of metastatic
cholangiocarcinoma after presentation with 3 weeks of painless
jaundice. He is s/p ERCP with stent placement but had
persistant left sided intrahepatic bile duct dilation, and this
was not felt to be amenable to ___ percutaneous drainage. There
was a question of cholangitis the last admission so he was given
IV antibiotics and discharged with unasyn.
He returned today for removal of plastic stents and placement of
metal stents, but he went to ___ because he got lost; he
was dizzy when he went to the bathroom and "felt to knees" so he
was referred to the ED. They felt that he was dehydrated on
account of being NPO and gave him IV fluids and he was referred
for inpatient hospitalization prior to ERCP.
He states that he has done well since last ERCP - his jaundice
completely resolved and he has a "reasonable" appetite. He is
not walking much. ___ abdominal pain/n/v. He had a temperature
to 101 in the ED, given Tylenol, blood cultures sent. He denies
fevers at home, ___ dysuria, cough.
Past Medical History:
Cholangiocarcinoma: Brushings show adenocarcinoma with mets to
lung
Atrial fibrillation: Picked up by his PCP at visit after last
discharge; put on full dose aspirin and metoprolol
SIADH
Prostate Ca s/p prostatectomy
HTN
Hypothyroid s/p partial thyroidectomy
Osteoporosis s/p laminectomy and L4-5 fusion
nephrolithiasis
Social History:
___
Family History:
___ GI malignancy
Physical Exam:
ADMISSION EXAM:
AF 77 127/57 Pox 99% on RA
Gen: Appeared improved from last time I saw him - jaundiced
resolved, appears to have more fullness in face, pleasant, NAD
Lung: CTA B
CV: RRR
Abd: Nabs, soft, nt/nd
Ext: ___ edema
DISCHARGE EXAM:
Vital Signs: 98.4 176/75 78 18 96%RA
I/O: ___
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, ___ m/r/g
CHEST: improved TTP over the left lateral chest wall
PULM: CTA B
GI: S/NT/ND, BS present
EXT: ___ edema
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 12:20PM BLOOD WBC-13.5* RBC-3.65*# Hgb-11.5*#
Hct-34.0*# MCV-93 MCH-31.5 MCHC-33.8 RDW-15.5 RDWSD-53.0* Plt
___
___ 12:20PM BLOOD Neuts-86.6* Lymphs-4.3* Monos-7.7
Eos-0.4* Baso-0.4 Im ___ AbsNeut-11.64* AbsLymp-0.58*
AbsMono-1.04* AbsEos-0.06 AbsBaso-0.06
___ 12:20PM BLOOD ___ PTT-28.0 ___
___ 12:20PM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-126*
K-4.3 Cl-92* HCO3-25 AnGap-13
___ 12:20PM BLOOD ALT-55* AST-68* AlkPhos-285* TotBili-1.5
___ 12:20PM BLOOD Lipase-27
Discharge Labs:
___ 06:50AM BLOOD WBC-19.6* RBC-3.54* Hgb-11.1* Hct-31.9*
MCV-90 MCH-31.4 MCHC-34.8 RDW-14.9 RDWSD-49.0* Plt ___
___ 06:50AM BLOOD Na-124*
___ 07:15AM BLOOD ALT-48* AST-49* AlkPhos-289* TotBili-1.1
___ 07:15AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.0
CBC Trend:
___ 12:20PM BLOOD WBC-13.5* RBC-3.65*# Hgb-11.5*#
Hct-34.0*# MCV-93 MCH-31.5 MCHC-33.8 RDW-15.5 RDWSD-53.0* Plt
___
___ 07:05AM BLOOD WBC-28.0*# RBC-3.18* Hgb-10.1* Hct-29.0*
MCV-91 MCH-31.8 MCHC-34.8 RDW-15.6* RDWSD-52.8* Plt ___
___ 06:35AM BLOOD WBC-24.2* RBC-3.70* Hgb-11.6* Hct-33.4*
MCV-90 MCH-31.4 MCHC-34.7 RDW-15.4 RDWSD-51.5* Plt ___
___ 06:20AM BLOOD WBC-17.4* RBC-3.29* Hgb-10.2* Hct-30.1*
MCV-92 MCH-31.0 MCHC-33.9 RDW-15.3 RDWSD-51.5* Plt ___
___ 06:35AM BLOOD WBC-19.4* RBC-3.64* Hgb-11.4* Hct-32.9*
MCV-90 MCH-31.3 MCHC-34.7 RDW-15.3 RDWSD-50.8* Plt ___
___ 06:20AM BLOOD WBC-19.0* RBC-3.59* Hgb-11.2* Hct-32.5*
MCV-91 MCH-31.2 MCHC-34.5 RDW-15.0 RDWSD-50.0* Plt ___
___ 07:00AM BLOOD WBC-20.0* RBC-3.52* Hgb-11.0* Hct-31.8*
MCV-90 MCH-31.3 MCHC-34.6 RDW-14.9 RDWSD-49.7* Plt ___
___ 07:15AM BLOOD WBC-14.8* RBC-3.46* Hgb-10.9* Hct-31.3*
MCV-91 MCH-31.5 MCHC-34.8 RDW-15.1 RDWSD-49.8* Plt ___
___ 06:50AM BLOOD WBC-19.6* RBC-3.54* Hgb-11.1* Hct-31.9*
MCV-90 MCH-31.4 MCHC-34.8 RDW-14.9 RDWSD-49.0* Plt ___
Electrolyte Trend:
___ 12:20PM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-126*
K-4.3 Cl-92* HCO3-25 AnGap-13
___ 07:05AM BLOOD Glucose-101* UreaN-13 Creat-0.5 Na-127*
K-4.9 Cl-92* HCO3-26 AnGap-14
___ 06:35AM BLOOD Glucose-109* UreaN-9 Creat-0.5 Na-123*
K-4.3 Cl-89* HCO3-26 AnGap-12
___ 07:05PM BLOOD Glucose-117* UreaN-14 Creat-0.5 Na-123*
K-3.5 Cl-89* HCO3-24 AnGap-14
___ 06:20AM BLOOD Glucose-103* UreaN-13 Creat-0.5 Na-125*
K-4.5 Cl-91* HCO3-25 AnGap-14
___ 06:35AM BLOOD Glucose-83 UreaN-9 Creat-0.5 Na-126*
K-4.7 Cl-88* HCO3-25 AnGap-18
___ 06:20AM BLOOD Glucose-90 UreaN-8 Creat-0.4* Na-124*
K-4.3 Cl-87* HCO3-25 AnGap-16
___ 07:00AM BLOOD Glucose-110* UreaN-6 Creat-0.4* Na-121*
K-4.2 Cl-85* HCO3-27 AnGap-13
___ 07:30PM BLOOD Na-123*
___ 07:15AM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-125*
K-4.6 Cl-87* HCO3-28 AnGap-15
___ 06:50AM BLOOD Na-124*
Other Labs:
___ 06:35AM BLOOD Osmolal-257*
___ 12:34PM BLOOD Lactate-2.1*
Urine Studies:
___ 12:34PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:34PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
___ 12:34PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 03:19PM URINE Hours-RANDOM Creat-172 Na-<20 K-30
___ 03:19PM URINE Osmolal-556
___ 07:17PM URINE Hours-RANDOM Creat-51 Na-<20
___ 07:17PM URINE Osmolal-359
___ 05:19AM URINE Hours-RANDOM Na-72
___ 05:19AM URINE Osmolal-338
Micro Data:
Blood Cx x 1 NEGATIVE
URINE CULTURE (Final ___: <10,000 organisms/ml.
C.Diff NEGATIVE
RUQ U/S (___) - IMPRESSION:
1. Unchanged intrahepatic biliary ductal dilatation, worse in
the left lobe. Known cholangiocarcinoma is not well evaluated on
this examination.
2. Heterogeneity of the left lobe of the liver is better
evaluated on the prior MR. ___ fluid collection or abscess.
3. ___ evidence of cholecystitis.
4. Small bilateral pleural effusions are partially imaged.
CT Chest (___) - IMPRESSION:
Previously seen ground-glass opacity in the left upper lobe has
completely resolved.
New mild pulmonary edema and bilateral pleural effusions.
Heterogeneous large thyroid mass should be evaluated with
ultrasound and any suspicious areas sampled histologically.
Mediastinal and right hilar lymph nodes have slightly increased
in size since the prior concerning for malignant involvement,
either from subdiaphragmatic or possible thyroid malignancy.
CT A/P (___) - IMPRESSION:
1. Improvement of the predominantly left intrahepatic biliary
ductal dilation, with fluid density structures seen in the left
lobe measuring 5.1 x 5.5 cm and 3.5 x 3.3 cm as above. They
remain incompletely characterized but given the biliary
pathology may represent bilomas.
2. Nonvisualized left portal vein, middle hepatic vein, and left
hepatic vein, suspicious for continued thrombosis/occlusion.
This finding was better characterized on the recent MRI from ___.
3. ___ other collection or source of leukocytosis identified.
L Hip Films - IMPRESSION: ___ acute bony injury seen.
Rib Films - FINDINGS: Lung volumes are within normal limits.
The trachea is deviated to the left, consistent with the known
large thyroid nodule. The cardiomediastinal contour is
unchanged. There is atelectasis at the left lung base with a
small left pleural effusion. The known right-sided pleural
effusion is not clearly seen. ___ pneumothorax. There are mildly
displaced fractures to the left sixth and seventh ribs
laterally, there may also be a fracture through the left eighth
rib although this is not clearly seen. ___ additional fracture
seen. Biliary stents in the right upper quadrant incompletely
visualized. Oral contrast material is seen in the small bowel.
IMPRESSION: At least 2 left lateral rib fractures as described.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Imipramine 20 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Alendronate Sodium 70 mg PO QMON
4. Aspirin 325 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Durable Medical Equipment
1 adult rolling walker
Dx: impaired mobility
Prognosis: guarded
Length of need: indefinite
2. Alendronate Sodium 70 mg PO QMON
3. Imipramine 20 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Senna 8.6 mg PO BID:PRN constipation
7. Aspirin 325 mg PO DAILY
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
10. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch as needed daily Disp #*15
Patch Refills:*0
11. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
Use caution with the medication as it causes drowsiness.
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth every 6
hours as needed Disp #*10 Capsule Refills:*0
12. Acetaminophen ___ mg PO Q8H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours as
needed Disp #*30 Tablet Refills:*0
13. Sodium Chloride 1 gm PO BID
RX *sodium chloride 1 gram 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangiocarcinoma
Thyroid Mass
Leukocytosis
Fever
Hyponatremia
Fall with rib 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: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with history of metastatic cholangiocarcinoma
presents with leukocytosis and fever // ? abscess/ choleysititis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MR ___.
FINDINGS:
LIVER: Similar to the prior study, the hepatic parenchyma in the left lobe of
the liver is heterogeneous without a focal fluid collection seen. Large simple
hepatic cysts in segment 4 and the left lobe of the liver measure up to 5.5
cm. The main portal vein is patent with hepatopetal flow. There is ___
ascites.
BILE DUCTS: Intrahepatic biliary ductal dilatation is mild in the right lobe
and moderate on the left, unchanged. The CHD measures approximately 7 mm,
however contains a biliary stent which extends into the right lobe of the
liver.
GALLBLADDER: The gallbladder contains sludge. ___ stones or evidence of
cholecystitis.
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 9.7 cm.
KIDNEYS: Limited views of the right kidney show ___ hydronephrosis.
Small bilateral pleural effusions are incidentally noted.
IMPRESSION:
1. Unchanged intrahepatic biliary ductal dilatation, worse in the left lobe.
Known cholangiocarcinoma is not well evaluated on this examination.
2. Heterogeneity of the left lobe of the liver is better evaluated on the
prior MR. ___ fluid collection or abscess.
3. ___ evidence of cholecystitis.
4. Small bilateral pleural effusions are partially imaged.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis
INDICATION: ___ year old man with pancreatic cancer, presented for ERCP for
stent exchange but found to have fever and leukocytosis, now s/p ERCP with
stent exchange but still with persistent leukocytosis. // please evaluate for
any possible sources of leukocytosis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 69.6 cm; CTDIvol = 5.7 mGy (Body) DLP = 391.8
mGy-cm.
Total DLP (Body) = 392 mGy-cm.
COMPARISON: MRI from ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: Re- demonstration of predominantly left-sided intrahepatic
biliary ductal dilation, with transition near the hepatic hilum compatible
with the patient's known underlying cholangiocarcinoma. Overall, the degree
of intrahepatic biliary ductal dilation has improved. Two fluid density
structures are seen in the left lobe measuring 3.5 x 3.3 cm and 5.1 x 5.5 cm.
Although these are incompletely characterized, given the biliary duct
pathology the differential includes biloma is versus hepatic cysts. There are
metallic stents seen within the right anterior and right posterior
intrahepatic ducts, coursing within the common bile duct and terminating at
the level of the ampulla. There is only mild right-sided intrahepatic biliary
ductal dilation. The gallbladder contains gallstones without wall thickening
or surrounding inflammation.
The left portal vein is not visualized, and likely thrombosed. Similarly, the
middle and left hepatic veins are not well visualized, and again are likely
thrombosed. This finding was better depicted on the recent MRI.
There is infiltrative soft tissue densities seen extending along the hepatic
hilum and reaching the celiac trunk. This is concerning for tumoral
extension/involvement at this level.
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: Visualized small and large bowel loops are unremarkable in
appearance.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Degenerative changes are seen in the lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Improvement of the predominantly left intrahepatic biliary ductal dilation,
with fluid density structures seen in the left lobe measuring 5.1 x 5.5 cm and
3.5 x 3.3 cm as above. They remain incompletely characterized but given the
biliary pathology may represent bilomas.
2. Nonvisualized left portal vein, middle hepatic vein, and left hepatic vein,
suspicious for continued thrombosis/occlusion. This finding was better
characterized on the recent MRI from ___.
3. No other collection or source of leukocytosis identified.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
TECHNIQUE: CT chest with IV contrast
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 69.6 cm; CTDIvol = 5.7 mGy (Body) DLP = 391.8
mGy-cm.
Total DLP (Body) = 392 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: ___
FINDINGS:
MEDIASTINUM: Large heterogeneous mass contiguous with the left thyroid gland
with central necrosis and focal calcifications measuring 6 x 5.2 cm is similar
in size. There is substantial mass effect on the trachea which is deviated to
the right. The left common carotid and left subclavian artery are also dated
however remain patent. No invasion of the adjacent clavicle or sternum.
Right lower paratracheal lymph node series 3, image 17 has increased in size
now measuring 12 mm in short axis previously 6 mm. Sub carinal lymph node has
also increased now measuring 7 mm previously 3 mm. Right hilar lymph node now
measuring 12mm.
HEART AND GREAT VESSELS: The aorta and pulmonary arteries are normal in size.
No large central filling defects in the pulmonary arteries. The heart size is
normal and there is no pericardial effusion. Mild atherosclerotic
calcifications of the thoracic aorta and of the coronary arteries.
PLEURA: There is no pneumothorax. Small to moderate bilateral nonhemorrhagic
effusions are new. No pleural nodularity or enhancement.
LUNGS AND TRACHEOBRONCHIAL TREE: The airways are patent. Previously seen
ground-glass opacity in the left upper lobe has completely resolved.
Pre-existing millimetric solid pulmonary nodules in the right upper lobe
series 4, image 42 and 156 are stable in appearance punctate calcified
granuloma in the left upper lobe. Mild interlobular septal thickening and
dependent opacities in the lung bases can be mild edema.
BONES AND CHEST WALL: There are no destructive focal osseous or chest wall
lesions concerning for malignancy within the imaged thoracic skeleton.
Multilevel degenerative changes are moderate to severe. Healing rib fractures
on the right unchanged.
UPPER ABDOMEN: Please refer to the separate CT report of the abdomen and
pelvis.
IMPRESSION:
Previously seen ground-glass opacity in the left upper lobe has completely
resolved.
New mild pulmonary edema and bilateral pleural effusions.
Heterogeneous large thyroid mass should be evaluated with ultrasound and any
suspicious areas sampled histologically.
Mediastinal and right hilar lymph nodes have slightly increased in size since
the prior concerning for malignant involvement, either from subdiaphragmatic
or possible thyroid malignancy.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: ___ year old man with fall, with L hip and rib pain // please
evaluate for any e/o traumatic injury
TECHNIQUE: AP pelvis, two views left hip.
COMPARISON: CT abdomen and pelvis performed earlier on the same date.
FINDINGS:
The bones diffusely demineralized which limits sensitivity for detecting
fracture, nonetheless no fracture is seen. Excreted contrast material seen
within the bladder. Numerous surgical clips are seen in the bladder. There
are mild degenerative changes in the bilateral hip joints. Degenerative
changes in the lower lumbar spine are more severe. Enthesophytes along the
pelvic brim. No destructive lytic or sclerotic bone lesion seen.
IMPRESSION:
No acute bony injury seen.
Radiology Report
EXAMINATION: RIB UNILAT, W/ AP CHEST LEFT
INDICATION: ___ year old man with fall, with L hip and rib pain // please
evaluate for any e/o traumatic injury
TECHNIQUE: AP chest, four views left ribs
COMPARISON: CT chest abdomen and pelvis ___
FINDINGS:
Lung volumes are within normal limits. The trachea is deviated to the left,
consistent with the known large thyroid nodule. The cardiomediastinal contour
is unchanged. There is atelectasis at the left lung base with a small left
pleural effusion. The known right-sided pleural effusion is not clearly seen.
No pneumothorax. There are mildly displaced fractures to the left sixth and
seventh ribs laterally, there may also be a fracture through the left eighth
rib although this is not clearly seen. No additional fracture seen. Biliary
stents in the right upper quadrant incompletely visualized. Oral contrast
material is seen in the small bowel.
IMPRESSION:
At least 2 left lateral rib fractures as described.
NOTIFICATION: Findings discussed with Dr. ___ by telephone at 16:13 on ___ within 5 min of discovery by Dr. ___.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Presyncope, Presyncope
Diagnosed with Syncope and collapse
temperature: 100.2
heartrate: 87.0
resprate: 18.0
o2sat: 97.0
sbp: 147.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ y/o male with recent diagnosis of cholangiocarcinoma with
presumed metastases to the lung admitted to medicine service
after presenting for planned ERCP, found to have fever and now
with elevated WBC. Infectious work up largely negative. S/p ERCP
with stent exchange. Hospital course c/b persistently elevated
WBC as well as downtrending Na. Course also c/b mechanical fall
with 2 rib fractures.
#Fever, Leukocytosis
The patient presented for planned procedure and was noted to be
febrile with elevated WBCs. Fever resolved without intervention.
The patients white blood cell count peaked at 28. Infectious
work up including blood cultures, urine culture and C. diff were
negative. Tbili did rise slightly to 1.7 prior to ERCP and then
normalized following stent exchange. WBC remained elevated, and
CT torso was ordered. CT torso showed known malignant disease in
thyroid and chest, fluid collections in the liver c/w biloma vs.
hepatic cyst. D/w ERCP re: hepatic findings, who felt that these
represented hepatic cysts and that there was nothing to do about
them at this time. Started empiric ciprofloxacin given ___ other
localizing source of infection other than slight bump in Tbili
prior to ERCP. WBC downtrended slightly (19->14) for one day,
but then uptrended to 19 again on the day of discharge. Pt
remained afebrile and well-appearing. After multiple discussions
with patient and his family, given his goals to maximize quality
time at home, patient was d/c'ed home with close outpt ___ for
repeat WBC. Of note, given persistently high WBC with ___ fever
or localizing s/s, this raises the question of non-infectious
process (? inflammation from underlying malignancy).
# Hyponatremia: Patient with history if SIADH. On fluid
restriction. Na had slowly improved, but then began to downtrend
despite ongoing fluid restriction. Consulted renal, who agreed
that SIADH was likely etiology. Recommended increasing fluid
restriction and encouraging Ensure with meals. Sodium improved
with this but then decreased again slightly on the day of
discharge(125->124). Discussed with renal, who recommended
starting salt tabs. Given goals of care as above, pt was d/c'ed
with close PCP ___ for repeat Na testing.
# Cholangiocarcinoma: Presumed metastatic to lungs. Not getting
treated but does see an oncologist closer to home. S/p ERCP with
stent exchange. Tbili downtrended as above.
# Thyroid Mass: Seen on prior imaging as well. Discussed this
finding with patient's family. Given his goals of care as above,
will not pursue further testing of this mass at this time.
# Fall: Pt with mechanical fall while in hospital, with imaging
showing rib frx. Seen by trauma surgery, who recommended pain
control, IS. Added lidocaine patch for better pain control.
Prior to planned discharge, pt was noted to be quite unsteady
with ___, so decision was made to stay for an additional night
for repeat ___ eval. On repeat eval, patient had noted
improvement in his unsteadiness. Pt and wife were taught
techniques to minimize fall risk. ___ also discussed pt's
unsteadiness on stairs with pt, and pt's dtr planning to help pt
get back into home after discharge. Of note, while working with
___, patient was noted to be orthostatic by VS (but reported
minimal associated symptoms).
# HTN: Pt with very labile BPs (170's - 180's while in bed;
however, low 100's when working with ___. Given increased fall
risk as well as goals of maximizing quality time at home, will
hold off on treatment at this time.
# Atrial fibrillation: Paroxysmal. Continued home metoprolol.
Aspirin was held for ERCP and resumed prior to discharge.
# Hpothyroidism: Continued synthroid.
# GOALS OF CARE: While patient has multiple medical issues, his
main goals at this
time are to go home to spend as much quality time with his
family as possible. I discussed his multiple active issues with
him and his wife prior to discharge. We discussed his fall as
well as his unsteadiness and increased risk to fall at home. We
also discussed his sodium issues and his leukocytosis. Finally,
we discussed his presumably 2 malignant processes. At this
point, pt feels strongly about being discharged home. He also
expressed understanding that remaining in the hospital carries
it own risks, including further deconditioning. Will also
arrange close PCP ___ for repeat Na and WBC. Encouraged patient
to discuss hospice option further with his PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
___ ___
Major Surgical or Invasive Procedure:
___ CT-guided biopsy of lung nodule
History of Present Illness:
___ yo male with a history of esophageal cancer who is admitted
with worsening dyspnea. The patient reports worsening shortness
of breath over the last week but increasing severity today where
he can not walk but a few feet. He denies any fevers or cough.
He states otherwise he has been feeling well and denies any sore
throat, chest pain or palpitations, nausea, diarrhea, dysuria,
or rashes. The patient is unsure of his medications but there is
a note in the ED records indicating he may have been started in
metoprolol in the last couple of weeks. Of note he does have a
PEG tube but does not use it for much.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Mr. ___ has a history of episodes of food impaction for which
he
underwent dilation of the esophagus in ___. He had
increasing difficulty swallowing, and was seen in the emergency
department on ___ in ___. An EGD was performed
on ___ and food bolus was removed at that time.
There was an esophageal stricture near the GE junction as well
as
evidence of hiatal hernia and active esophagitis.
Subsequently, a CT of the chest on ___ showed
multiple bilateral pulmonary nodules, the largest of which was
2.2 cm. There was also a nonspecific 1 cm left adrenal lesion
seen.
On ___, the patient underwent attempted dilation
of the esophagus and high-grade stricture was noted. There was
induration/mucosal ulceration and findings were considered
suspicious for malignancy. Biopsies were performed with
pathology showing at least intramucosal adenocarcinoma.
EUS was performed here at ___ on ___. Findings
revealed on T stage an exophytic esophageal mass in the lower
third of the esophagus, involving the mucosa, submucosa, and
muscularis propria with evidence of invasion beyond the
muscularis layer T3 by EUS criteria. A lymph node was noted in
the paraesophageal mediastinum 37 cm from the incisors,
measuring
2.4 cm. It was hypoechoic and homogeneous with poorly defined
borders. It was not sampled because the aspirating needle would
have had to first traverse the primary esophageal lesion risking
contamination by this lesion. It was considered very suspicious
on imaging characteristics. A second enlarged paraesophageal
lymph node was also noted that was suspicious for malignancy,
endoscopic ultrasound stage T3, N1, Mx. Pathology from the
patient's biopsy was reviewed at ___ and read as moderately
differentiated adenocarcinoma, at least intramucosal in the
sample. With note, the malignant glands were infiltrating
within
the lamina propria. No submucosa was present to evaluate for
deeper invasion. A PET-CT was obtained on ___. The study revealed multiple lung nodules, none of which
revealed significant FDG uptake. There were considered
compatible with granulomas. Malignancy could not be completely
excluded. Within the lower thoracic esophagus, there was mural
thickening with abnormal FDG uptake seen. There was also
irregular lobulation of the urinary bladder. Further
examination
with cystoscopy was recommended.
Receiving onc care at ___, per pt s/p chemo/RT which
completed ___ (per reports 6 cycles of chemo).
PAST MEDICAL HISTORY:
COPD
HTN
HL
BPH
CKD (Cr 1.5)
Atrial fibrillation (on coumadin)
Diabetes type II
Pulmonary nodules
S/p PEG ___
Social History:
___
Family History:
Brother had lung cancer. Mother had a tongue cancer, father had
lung cancer.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
General: NAD
VITAL SIGNS: T 97.7 BP 124/60 HR 80 RR 20 O2 93% on 4L
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly, G tube in
place.
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
PHYSICAL EXAM ON DISCHARGE:
VS: 97.9 136/68 62 16 97%3L
General: Man lying in bed in NAD, pleasant
HEENT: NCAT, MMM, no OP lesions
CV: RRR, no murmurs/rubs/gallops, normal S1S2
PULM: Lungs sound much improved, still some bronchial breath
sounds throughout. Bandage at biopsy site on back c/d/i.
ABD: Soft, NTND, no masses or hepatosplenomegaly, G tube in
place.
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented x3, strength and sensation grossly
intact in bilateral upper and lower limbs
Pertinent Results:
LABS ON ADMISSION:
___ 10:55PM WBC-7.4 RBC-3.35* HGB-9.9* HCT-30.9* MCV-92
MCH-29.6 MCHC-32.0 RDW-14.4 RDWSD-48.5*
___ 10:55PM NEUTS-75.5* LYMPHS-6.5* MONOS-10.2 EOS-6.6
BASOS-0.4 IM ___ AbsNeut-5.62 AbsLymp-0.48* AbsMono-0.76
AbsEos-0.49 AbsBaso-0.03
___ 10:55PM ___ PTT-33.8 ___
___ 10:55PM GLUCOSE-122* UREA N-30* CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
___ 10:55PM ALT(SGPT)-28 AST(SGOT)-28 LD(LDH)-289* ALK
PHOS-102 TOT BILI-0.2
___ 10:55PM ALBUMIN-3.4* CALCIUM-9.3 PHOSPHATE-3.4
MAGNESIUM-2.1
___ 10:55PM proBNP-1450*
___ 11:16PM LACTATE-1.5
___ 10:55PM CEA-9.1*
___ 10:55PM ___
LABS ON DISCHARGE:
___ 07:20AM BLOOD WBC-9.1 RBC-3.52* Hgb-10.5* Hct-32.6*
MCV-93 MCH-29.8 MCHC-32.2 RDW-14.5 RDWSD-48.5* Plt ___
___ 07:20AM BLOOD Glucose-99 UreaN-44* Creat-1.1 Na-139
K-4.4 Cl-101 HCO3-31 AnGap-11
___ 07:20AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1
OTHER LABS:
___ 07:10AM BLOOD %HbA1c-7.2* eAG-160*
___ 07:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 07:00AM BLOOD HCV Ab-NEGATIVE
MICROBIOLOGY:
UCx ___: contamination
Tissue culture ___: no growth
UCx ___: contamination
BCx ___: no growth
PATHOLOGY:
Lung biopsy ___: "Metastatic adenocarcinoma consistent with
esophageal origin, see note."
IMAGING:
CXR ___:
Severe fibrosing interstitial pulmonary abnormality may have
improved over the past week suggesting a reversible component of
what, given the appropriate clinical history could be a
chemotherapy related pulmonary drug toxicity. Small left
pneumothorax is no larger, stable of the lung base bases, but
smaller at the apex.
Heart is normal size. No right pneumothorax or appreciable
pleural effusion. Multiple pulmonary nodules noted.
CXR ___:
In comparison with the study of ___, there is a small
postprocedure pneumothorax. The area of increased opacification
in the right mid zone has slightly decreased, whereas the
opacification at the left base appears more prominent than on
the earlier study, both of which probably represent multifocal
pneumonia. Nodular opacifications were much better seen on the
CT scan of ___.
CT guided biopsy ___:
1. Successful CT-guided biopsy of a left lower lobe lung nodule.
2. Tiny left basilar pneumothorax was identified during the
procedure.
TTE ___:
CONCLUSIONS: Mild global left ventricular dysfunction (LVEF
40-45%). Mild diastolic dysfunction. Mild mitral regurgitation
and mild pulmonary artery systolic pressure. The aortic valve is
moderately thickened without aortic stenosis. The ascending
aorta is mildly dilated (3.8 cm).
Chest CTA ___:
1. No pulmonary embolism. Limited evaluation the distal
subsegmental branches to the bilateral lower lobes due to
adjacent lung parenchymal abnormality.
2. Interval progression of pulmonary metastases, with bilateral
spiculated pulmonary nodules measuring up to 2.5 cm appearing
larger or new since prior from ___.
3. Mild interval progression of minimal mediastinal
lymphadenopathy.
4. New diffuse, peripheral/subpleural pulmonary fibrosis and
scarring, may relate to radiotherapy. Differential includes
diffuse lymphangitic spread of malignancy or sequelae of
repeated aspiration.
5. Severe thoracic aortic mixed atherosclerotic disease.
6. Severe centrilobular emphysema worst at the lung apices.
7. New subcentimeter soft tissue density nodules along the
anterior chest wall within the subcutaneous fat are nonspecific,
however concerning for soft tissue metastases given history of
malignancy.
8. 2.7 cm posterior gastric fundal diverticulum.
Appropriately-positioned percutaneous gastrostomy tube.
CXR ___:
Evidence of pulmonary nodules, better assessed on CT. New
lateral right mid lung and bilateral lower lung opacities are
worrisome for multifocal
pneumonia.
Radiology Report
INDICATION: ___ with 3 weeks progressive DOE without fever or, history of
esophageal cancer with known lung mets , evaluate for pulmonary embolism ,
further delineation of opacities on CXR, differential of multifocal PNA vs
worsening tumor burden (clinically this is most likely).
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 10.6 mGy (Body) DLP =
5.3 mGy-cm.
2) Spiral Acquisition 4.5 s, 35.1 cm; CTDIvol = 13.6 mGy (Body) DLP = 478.0
mGy-cm.
Total DLP (Body) = 483 mGy-cm.
COMPARISON: CT Chest ___ from outside facility.
FINDINGS:
CTA THORAX: The aorta and major thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the chest without evidence of
intramural hematoma or dissection. There is severe mixed atherosclerotic
disease of the thoracic aorta, primarily affecting the aortic arch and
descending thoracic aorta. A 1.2 cm focal irregularity along the left
superolateral wall of the aortic arch (series 3, image 59) may represent
irregular plaque. Major aortic arch branch vessels are heavily calcified but
patent, and otherwise unremarkable. The pulmonary artery is normal in
caliber, and is well opacified to subsegmental levels. There is no evidence
of intraluminal filling defect in the main, right, left, lobar, or segmental
pulmonary dural branches, however evaluation of the more distal segmental and
subsegmental pulmonary arterial branches to the lower lobes bilaterally is
limited in the presence of significant lung parenchymal abnormality. No
arteriovenous malformation is identified.
CT THORAX: The partially imaged thyroid is within normal limits. The
esophagus is grossly unremarkable on this examination. There is moderate
coronary artery and cardiac valvular calcification. Heart and pericardium are
otherwise unremarkable. There is no pericardial effusion. Mediastinal lymph
nodes measure up to 9 mm in short axis at the right lower paratracheal station
(series 2, image 43). High right paratracheal nodes are not pathologic
enlarged individually, but increased in number and prominent (for example see
series 2 images 13 and 31). Left peribronchial nodes measure up to 10 mm in
short axis, and are unchanged since ___ (series 2, image 60).
Major airways are patent to subsegmental levels bilaterally, although the
distal subsegmental bronchial tree to the lower lobes bilaterally is limited
in assessment. An irregular lingular nodule is slightly larger since prior,
now with 22 x 20 mm, previously 21 x 16 mm (series 3, image 126). A 4 mm
lingular nodule appears new (series 3, image 139). More inferiorly in the
lingular, 7- and 3 mm nodules also appear new (series 3, image 147 and 149).
A left lung base 25 x 22 mm nodule is larger, previously 19 mm, and now abuts
the pleural surface (series 3, image 168). A nodule at the left lung apex is
larger, now 5 mm, previously 1-2 mm (series 3, image 29). Additional
ipsilateral upper pole nodules are new or larger (for series 3, image 77). A
right upper lobe 13 x 12 mm spiculated nodule appears larger, previously 9 mm
in ___ (series 3, image 82). Superior segment of the right lower
lobe and right middle lobe 12- and 7 mm nodules, respectively, are new or
significantly larger (series 3, image 100). A previously 7 mm nodule in the
inferior right middle lobe is now 12 mm (series 3, image 133). A previously
10 mm right lung base nodule is now 12 mm (series 3, image 155).
New since prior exam diffuse, subpleural/peripheral predominant interstitial
abnormality, consistent with fibrosis and scarring. Background severe
centrilobular emphysema is most conspicuous at the lung apices there is no
pleural effusion or pneumothorax.
A small, approximately 2.7 x 2.3 cm gastric diverticulum arises from the
posterior fundus (series 2, image 97). A percutaneous gastrostomy tube is
seen in appropriate position with the balloon inflated in the distal gastric
body. Right parapelvic cysts are partially imaged. Otherwise, the partially
imaged upper abdominal solid and hollow viscous organs are within normal
limits.
MUSCULOSKELETAL: Multiple subcentimeter soft tissue density nodules are seen
in the subcutaneous fat along the anterior chest wall, new since prior (for
example see series 2, image 70). These are nonspecific, however in the
setting of malignancy concerning for metastasis. There is mild multilevel
thoracic spine degenerative change. Vertebral body heights are preserved, and
alignment is normal. No concerning focal lytic or sclerotic osseous lesions
are seen.
IMPRESSION:
1. No pulmonary embolism. Limited evaluation the distal subsegmental branches
to the bilateral lower lobes due to adjacent lung parenchymal abnormality.
2. Interval progression of pulmonary metastases, with bilateral spiculated
pulmonary nodules measuring up to 2.5 cm appearing larger or new since prior
from ___.
3. Mild interval progression of minimal mediastinal lymphadenopathy.
4. New diffuse, peripheral/subpleural pulmonary fibrosis and scarring, may
relate to radiotherapy. Differential includes diffuse lymphangitic spread of
malignancy or sequelae of repeated aspiration.
5. Severe thoracic aortic mixed atherosclerotic disease.
6. Severe centrilobular emphysema worst at the lung apices.
7. New subcentimeter soft tissue density nodules along the anterior chest wall
within the subcutaneous fat are nonspecific, however concerning for soft
tissue metastases given history of malignancy.
8. 2.7 cm posterior gastric fundal diverticulum. Appropriately-positioned
percutaneous gastrostomy tube.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:25 AM, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT-guided lung biopsy
INDICATION: ___ year old man with ___ yo male with a history of esophageal
cancer who is admitted with worsening dyspnea. Among other findings, CT shows
"Interval progression of pulmonary metastases, with bilateral spiculated
pulmonary nodules measuring up to 2.5 cm appearing larger or new since prior
from ___ // Please perform CT-guided biopsy of growing lung
nodules, ideally on ___. Thank you.
COMPARISON: CTA chest ___
PROCEDURE: CT-guided lung biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a left lateral decubitus/left anterior oblique
position on the CT scan table. Limited preprocedure CTscan of the intended
biopsy area was performed. Based on the CT findings an appropriate position
for the biopsy was chosen. The site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the
lesion. An 18 gauge core biopsy device with a 22 mm throw was used to obtain
2 core biopsy specimens, which were sent for pathology ___ cores) and
microbiology ___ core).
The procedure was tolerated well. A tiny pneumothorax was identified during
the procedure. The size of the pneumothorax did not increased during
subsequent fluoroscopic imaging or on the postprocedure scan.
DOSE: Total DLP (Body) = 2,019 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
0.5 mg Versed and 25 mcg fentanyl throughout the total intra-service time of
22 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Severe aortic atherosclerotic disease and coronary artery calcifications are
present. Multiple scattered lung nodules which were seen on prior are again
identified. Apical predominant severe centrilobular emphysema with peripheral
interstitial/fibrotic changes. Small nodular densities are again seen in the
anterior chest wall. Gastric diverticulum is noted adjacent to the fundus.
Partially visualized right kidney cyst. Partially visualized gastrostomy
tube.
Tiny left basilar pneumothorax was identified during the procedure. On
subsequent procedural and postprocedure scans, there is no increase in size of
the pneumothorax.
IMPRESSION:
1. Uncomplicated CT-guided biopsy of a left lower lobe lung nodule.
2. Tiny left basilar pneumothorax was identified during the procedure.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 11:15 AM, 10 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with tiny left basilar pneumothorax identified
during CT-guided biopsy morning of ___ // eval for PTX eval for PTX
IMPRESSION:
In comparison with the study of ___, there is a small postprocedure
pneumothorax. The area of increased opacification in the right mid zone has
slightly decreased, whereas the opacification at the left base appears more
prominent than on the earlier study, both of which probably represent
multifocal pneumonia. Nodular opacifications were much better seen on the CT
scan of ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with tiny left basilar pneumothorax identified
during CT-guided biopsy morning of ___ // eval for changes in known
pneumothorax eval for changes in known pneumothorax
IMPRESSION:
Compared to prior chest radiographs since ___, most recently ___
and ___.
Severe fibrosing interstitial pulmonary abnormality may have improved over the
past week suggesting a reversible component of what, given the appropriate
clinical history could be a chemotherapy related pulmonary drug toxicity.
Small left pneumothorax is no larger, stable of the lung base bases, but
smaller at the apex.
Heart is normal size. No right pneumothorax or appreciable pleural effusion.
Multiple pulmonary nodules noted.
Gender: M
Race: UNKNOWN
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, Pneumonia, Transfer
Diagnosed with Dyspnea, unspecified
temperature: 98.4
heartrate: 75.0
resprate: 18.0
o2sat: 93.0
sbp: 139.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ year-old male with a history of esophageal cancer who is
admitted with worsening dyspnea.
# Hypoxemia: On admission, the patient patient required ___ NC
at rest with more required for ambulation. He had no
supplemental oxygen requirement at home before this admission.
His CT on admission showed subpleural ground-glass opacities and
fibrosis which were new from a PET-CT done in ___. In
addition, the CT showed enlarging nodules which have been
present since late ___, see "lung nodules" below. His new
interstitial pulmonary disease was certainly the cause of his
hypoxia, but the etiology of the fibrosis is unclear. Many
processes were considered, including malignancy-related vs.
radiation/chemo toxicity vs. other inflammatory process.
Infectious etiologies were unlikely based on lack of other
symptoms. The distribution of the interstitial disease suggested
against chronic aspiration or pulmonary edema.
We initially consulted interventional pulmonology to do a
biopsy, but they stated that the area of interest could not be
biopsied bronchoscopically and the patient would require a VATS
for a tissue diagnosis. We elected not to proceed with a
VATS/wedge biopsy given the high morbidity of this procedure and
the patient's age and comorbid conditions. Therefore we elected
to treated the patient with a course of empiric steroids in the
case that the subpleural changes are related to radiation injury
or another inflammatory etiology that may be steroid-responsive.
We started the patient on empiric prednisone 60mg daily on
___. After several days the patient felt symptomatically
better, and CXR ___ showed possible improvement in his
interstitial disease. However, his oxygen requirement did not
decrease with steroids by the time of discharge.
We discharged the patient on 60mg prednisone daily. We set up
home oxygen for him. In addition, we started him on omeprazole
40mg daily for GI prophylaxis and Bactrim SS daily for PCP
prophylaxis, as we anticipate a long course of steroid
treatment. We set the patient up with a follow-up appointment
with Dr. ___, who is a pulmono___ specializing in
interstitial lung disease. Dr. ___ will determine the
patient's steroid course. The patient was discharged to home
with ___ and home ___ on ___.
#Lung nodules: The patient's CT scan on admission showed
interval progression of nodules concerning for pulmonary
metastases. The patient had a CT-guided biopsy of one of these
nodules on ___. The pathology report returned on the day of
discharge and showed "Metastatic adenocarcinoma consistent with
esophageal origin." The patient and his family were informed
that he had confirmed metastatic cancer. Dr. ___ was also
informed of the results. Possible therapeutic options may be
explored at scheduled oncology follow-up visit.
#Pneumothorax: The patient had a small left basilar pneumothorax
during his CT-guided lung biopsy on ___, which did not
increase on post-procedure CT. He did not have any symptoms from
the pneumothorax. He had follow-up xrays the evening after the
procedure and the following morning, which showed no increase in
size of the pneumothorax. No further intervention was required.
#Type 2 DM: chronic. The patient was on 20U lantus QHS at home
plus glimepiride and sitagliptin. A1c was measured at 7.2 during
this admission. We initially held the patient's oral
antidiabetics and placed him on his home lantus plus a
postprandial Humalog sliding scale. His fingerstick blood
glucose values were elevated, which required increasing his
lantus. Once we started empiric prednisone for his interstitial
pulmonary disease, his fingersticks were labile, ranging from 55
to >500 in one 24-hour period. We consulted the ___ diabetes
specialists, who placed the patient on morning NPH insulin in
addition to his evening lantus. ___ monitored his response
and adjusted the doses on the day of discharge. The patient was
discharged on 18 units of NPH at breakfast, 36 units of glargine
at bedtime, an increased dose of his home glimepiride 4mg daily,
and the same dose of his Januvia 25mg daily. Importantly, his
diabetes regimen will need to be adjusted once he begins his
tapering his steroids. ___ left her contact
information if there are any questions, see "Transitional
Issues" below.
#Esophageal Cancer: ongoing. The patient's last treatment in
___ see "oncologic history" above. The patient was in
surveillance at the time of admission. As described above,
during this admission he had a CT-guided biopsy of growing known
pulmonary nodule, which showed metastatic esophageal cancer. We
informed the patient and his family of this diagnosis. The
patient was given a follow-up appointment with our ___
clinic, but he will also need to follow-up with his established
oncologist in ___.
#Atrial Fibrillation: chronic. The patient's INR was 3.0 on
admission. His warfarin was held without bridging starting
___ given the anticipated need for a biopsy. After the
patient's lung nodule biopsy on ___, we restarted the
patient's home home warfarin 8mg without a bridge. The dose was
confirmed with the patient's PCP ___. We discharged the
patient with instructions for next INR draw to be on ___ to
be followed up by his PCP. During this admission, we continued
the patient's home metoprolol tartrate 12.5mg BID for rate
control.
#Hyperlipidemia: chronic. We continued the patient's home
simvastatin during this admission.
#Psych: We continue the patient's home sertraline during this
admission.
***TRANSITIONAL ISSUES:***
[ ] steroids to be tapered after Pulmonary followup with Dr.
___
[ ] further insulin titration will be needed based on reported
home FSBG, especially when steroids are titrated
[ ] patient to discuss treatment options for his metastatic
malignancy with oncologist after discharge
[ ] if there are questions about the patient's new insulin
regimen, please call his ___ provider ___ NP at
___
___
___
___: wife
Phone number: ___ |
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 stroke, sp TPA at OSH
Major Surgical or Invasive Procedure:
TPA administration.
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 5 min
Time/Date the patient was last known well: 8:50 AM
___ Stroke Scale Score: 6
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: TPA was already
given at OSH at 9:58am
___ Stroke Scale score was 6
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 2
4. Facial palsy: 1
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 1
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
Reason for Consultation: code stroke, sp TPA at OSH
HPI: The patient is a ___ year old RH man with a history of
smoking who was on his way to work today when he came to a road
block impeding his journey to work. He stopped and called his
boss from his cell phone, but noted that he had difficulty using
the phone and his L hand seemed clumsy. He spoke on the phone
with his boss but noted his speech was slurred and sounded like
a drunk person. His boss asked him if he did any drugs since his
speech was slurred, and he said "no." Someone came to pick him
up and they found him sitting on the side of the road, wrapping
his cell phone in plastic wrap, non responsive. They drove him
to ___. EMS noted L sided weakness and at ___
tele-stroke was called which initially had a NIHSS of 8, which
improved to a 5. TPA was given for difficulty describing the
stroke card, L facial droop, L sided drift and sensory loss. He
was also noted to have variable attention and would at times be
inattentive to the exam. Labs were drawn and were notable for an
elevated Trop-I to 2.29 and a low K of 2.5. Some K was given
prior to transfer. Cards was consulted there and EKG showed
possible ST elevations. He was transferred here for further
post-TPA care and further cardiology evaluation.
The patient states that for the last week he has had chest and
back pain. He states that it felt like muscle soreness and his
chest hurt when to takes a deep breath. He also endorsed
vomiting this week, although his wife at the bedside denies
this. Denies any fever. He states this started after he dug a
deep hole to bury his cat last ___, who had to be put down
because of liver
failure. He has had a stressful week and also lost his
grandmother this week.
On neurologic review of systems, the patient denies
headache,lightheadedness, or confusion. Endorses initially
slurred speech as above, denies word finding
difficulty. Denies changes in vision. Denies muscle weakness,
although did note L arm clumsiness when dialing his phone.
Denies loss of sensation.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies current chest
pain although had chest pain earlier this week. Endorses
vomiting this week as above.
Past Medical History:
Bilateral optic atrophy
Social History:
___
Family History:
His mother has hereditary ___ Atrophy type 1 - this is
inherited in an autosomal dominant fashion. She had a possible
stroke in her ___ with unclear symptoms
Mr. ___
___ grandfather has bilateral optic atrophy
Maternal grandmother had ovarian cancer and is still living. She
had two miscarriages in her first trimester.
Maternal great aunt had a MI at age ___ and died
Father has hyperlipidemia.
Patient's paternal uncle has hyperlipidemia.
His mother's sister has a recessive gene for cystic fibrosis.
His mother's brother has a hx of a gunshot wound.
___ does not have any siblings or children.
Physical Exam:
Admission Exam:
VS 99.0 114 134/78 89 18 100%
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
CV: RRR, + systolic murmur
Neurologic Examination:
- Mental Status -
Awake, alert, at times inattentive and stares off blankly ahead,
other times will answer examiners questions. Able to relate
history although often pauses and requires several attempts to
answer a question. Names all stroke card objects (although only
on the R half of the page, names other objects when card is
turned upside down), describes stroke picture. Speech is fluent
although he does not have a large amount of spontaneous verbal
output, he will speech in complete sentances sometime when
prompted. No dysarthia, no paraphasic errors. ++ L sided
neglect.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (4mm to 3mm). Visual fields show a
dense L visual field cut without blink to threat on that side.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus, EOMI although he neglects the L and has
difficulty getting all the way over, but with encouragement can
look fully to the L.
V. facial sensation was intact, muscles of mastication with full
strength
VII. Mild L UMN facial droop.
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
L arm pronation and drift. L leg drifts down as well. With
encouragement, able to elicit ___ strength on the L although he
is neglectful of that side.
Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas
L 5 5 ___ 4+* 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
*appears effort related
- Sensation -
Decreased responsiveness to pinch on the L arm, intermittently
states he has decreased sensation on the L side, but able to
tell
when his L leg is being touched. Unable to preform extinction to
DSS due to inattention.
- DTRs -
slightly hyperreflexic on the L arm with L toe upgoing
- Cerebellar -
Dysmetria with L hand ___ be related to optic ataxia or
- Gait -
deferred
Discharge Exam:
Mild LT sided neglect, full strength throughout.
Pertinent Results:
___ TTE
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with focal apical akinesis with a small aneurysm. A
pedunculated, wide based, mildly mobile 1.4cm echogenic mass
seen in the apex c/w a THROMBUS. 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.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and apical aneurysm/akinesis with likely
apical wide-based pedunculated/mobile mass most c/w a THROMBUS.
No valvular pathology or pathologic flow identified. No atrial
septal defect or patent foramen ovale identified.
___ CTA Head/neck
1. Study limited secondary to poor contrast bolus.
2. Loss of gray-white matter differentiation in the right MCA
territory,
consistent with an acute infarction which is seen on the
subsequently
performed MRI.
3. Decreased in size and caliber of the terminal right M2 and M3
branches of the right MCA consistent with thrombus or slow flow,
also seen on the
subsequently performed MRI.
4. Normal CTA of the neck.
___ MR ___
1. Evolving right MCA infarction with no evidence of hemorrhage.
___ CT Head
1. Evolving right MCA territory infarct.
2. No hemorrhagic conversion. Linear hyperdensity in the right
frontal lobe appears to correspond to linear FLAIR signal
hyperintensity on MR from the day prior, and again likely
reflects a thrombosed distal vessel or small area of spared
cortex.
___ CT Head
1. Continued evolution of right MCA territory infarct with
minimally increased effacement of right lateral ventricle.
2. Grossly stable approximately 2 mm right to left midline
shift.
3. No definite hemorrhagic conversion identified. Recommend
clinical
correlation and attention on followup imaging.
4. Grossly stable possible thrombosed right distal MCA
distribution vessels as described.
___ CT Head
1. Continued evolution of right MCA territory infarct without
definite
hemorrhagic conversion. Recommend clinical correlation and
attention on
followup imaging.
2. Continued effacement of the right lateral ventricle.
3. Stable 2 mm right to left midline shift.
___ CT Head
1. Evolving right MCA territory infarction.
2. No evidence of hemorrhage or new infarction.
___ EEG
IMPRESSION: This is an abnormal continuous video-EEG monitoring
study due to the presence of continuous focal slowing over the
right hemisphere,
particularly in the right temporal region. This finding suggests
a structural lesion on the right side. No epileptiform
discharges or electrographic seizures were seen. Background
activity over the left hemisphere was normal.
___ EEG
IMPRESSION: This is an abnormal continuous video-EEG monitoring
study due to the presence of continuous focal slowing over the
right hemisphere,
particularly in the right temporal region. This finding suggests
a structural lesion on the right side. No epileptiform
discharges or electrographic seizures were seen. Background
activity over the left hemisphere was normal.
LAB RESULTS:
1. CBC:
___ 05:42AM BLOOD WBC-8.6 RBC-4.42* Hgb-13.9 Hct-41.8
MCV-95 MCH-31.4 MCHC-33.3 RDW-13.7 RDWSD-47.4* Plt ___
___ 06:30AM BLOOD WBC-6.6 RBC-4.47* Hgb-14.0 Hct-42.6
MCV-95 MCH-31.3 MCHC-32.9 RDW-13.7 RDWSD-47.9* Plt ___
___ 06:27AM BLOOD WBC-7.5 RBC-4.26* Hgb-13.6* Hct-41.4
MCV-97 MCH-31.9 MCHC-32.9 RDW-14.0 RDWSD-49.3* Plt ___
___ 09:15AM BLOOD WBC-7.6 RBC-4.51* Hgb-14.3 Hct-43.6
MCV-97 MCH-31.7 MCHC-32.8 RDW-14.0 RDWSD-49.1* Plt ___
___ 06:38AM BLOOD Hct-UNABLE TO
___ 01:27AM BLOOD WBC-9.0 RBC-4.37* Hgb-13.9 Hct-41.5
MCV-95 MCH-31.8 MCHC-33.5 RDW-13.8 RDWSD-47.3* Plt ___
___ 06:05AM BLOOD WBC-10.2* RBC-4.46* Hgb-14.0 Hct-42.6
MCV-96 MCH-31.4 MCHC-32.9 RDW-13.8 RDWSD-47.5* Plt ___
___ 10:31AM BLOOD WBC-9.3 RBC-4.43* Hgb-14.1 Hct-42.0
MCV-95 MCH-31.8 MCHC-33.6 RDW-13.6 RDWSD-46.7* Plt ___
___ 03:08AM BLOOD WBC-9.1 RBC-4.12* Hgb-13.0* Hct-39.0*
MCV-95 MCH-31.6 MCHC-33.3 RDW-13.4 RDWSD-46.0 Plt ___
___ 02:53AM BLOOD WBC-10.3* RBC-3.99* Hgb-12.6* Hct-37.7*
MCV-95 MCH-31.6 MCHC-33.4 RDW-13.3 RDWSD-45.9 Plt ___
___ 01:55AM BLOOD WBC-11.9* RBC-3.95* Hgb-12.6* Hct-37.3*
MCV-94 MCH-31.9 MCHC-33.8 RDW-13.8 RDWSD-48.1* Plt ___
___ 03:30AM BLOOD WBC-10.2* RBC-3.94* Hgb-12.4* Hct-37.6*
MCV-95 MCH-31.5 MCHC-33.0 RDW-13.9 RDWSD-48.6* Plt ___
___ 01:10PM BLOOD WBC-12.6* RBC-4.35* Hgb-13.7 Hct-40.3
MCV-93 MCH-31.5 MCHC-34.0 RDW-13.4 RDWSD-45.6 Plt ___
___ 01:10PM BLOOD Neuts-92.3* Lymphs-4.7* Monos-2.3*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.64* AbsLymp-0.59*
AbsMono-0.29 AbsEos-0.00* AbsBaso-0.02
2. COAGS
___ 04:07AM BLOOD ___
___ 12:34PM BLOOD PTT-35.2
___ 05:42AM BLOOD Plt ___
___ 05:42AM BLOOD ___ PTT-72.0* ___
___ 11:05PM BLOOD PTT-59.1*
___ 01:38PM BLOOD PTT-46.6*
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-63.6* ___
___ 11:05PM BLOOD ___ PTT-82.2* ___
___ 02:05PM BLOOD PTT-80.5*
___ 06:27AM BLOOD Plt ___
___ 06:27AM BLOOD ___ PTT-89.2* ___
___ 05:50PM BLOOD ___ PTT-69.3* ___
___ 09:15AM BLOOD Plt ___
___ 09:15AM BLOOD ___ PTT-51.5* ___
___ 09:15AM BLOOD ___ PTT-51.5* ___
___ 06:38AM BLOOD ___ PTT-28.7 ___
___ 02:40AM BLOOD PTT-71.4*
___ 08:16PM BLOOD ___ PTT-63.1* ___
___ 10:11AM BLOOD ___ PTT-84.1* ___
___ 01:27AM BLOOD Plt ___
___ 01:27AM BLOOD ___ PTT-42.9* ___
___ 05:09PM BLOOD ___ PTT-57.5* ___
___ 06:05AM BLOOD ___ PTT-98.8* ___
___ 12:09AM BLOOD PTT-85.6*
___ 05:45PM BLOOD PTT-74.0*
___ 10:31AM BLOOD Plt ___
___ 10:31AM BLOOD PTT-62.9*
___ 09:27PM BLOOD PTT-56.7*
___ 03:25PM BLOOD PTT-57.3*
___ 09:42AM BLOOD PTT-57.1*
___ 03:08AM BLOOD Plt ___
___ 03:08AM BLOOD ___ PTT-58.5* ___
___ 05:36PM BLOOD ___ PTT-66.7* ___
___ 11:25AM BLOOD ___ PTT-70.0* ___
___ 02:53AM BLOOD Plt ___
___ 02:53AM BLOOD ___ PTT-78.6* ___
___ 09:00PM BLOOD ___ PTT-66.1* ___
___ 04:00PM BLOOD ___ PTT-57.8* ___
___ 09:16AM BLOOD ___ PTT-51.9* ___
___ 01:55AM BLOOD ___ PTT-52.7* ___
___ 03:30AM BLOOD Plt ___
___ 07:47PM BLOOD ___ PTT-27.0 ___
___ 01:10PM BLOOD ___ PTT-24.1* ___
3. SPECIAL TESTS
___ 07:47PM BLOOD FacVIII-182
___ 07:47PM BLOOD VWF AG-213* VWF ___
___ 02:04PM BLOOD ProtSFn-135
___ 07:47PM BLOOD ProtCFn-120
___ 07:47PM BLOOD Lupus-NEG
4. CHEMISTRY
___ 04:07AM BLOOD Glucose-95 UreaN-14 Creat-1.0 Na-134
K-4.8 Cl-98 HCO3-24 AnGap-17
___ 05:42AM BLOOD Glucose-99 UreaN-14 Creat-0.8 Na-137
K-4.6 Cl-101 HCO3-25 AnGap-16
___ 06:30AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-138
K-4.8 Cl-102 HCO3-25 AnGap-16
___ 06:27AM BLOOD Glucose-86 UreaN-19 Creat-0.9 Na-135
K-4.8 Cl-101 HCO3-22 AnGap-17
___ 06:27AM BLOOD Glucose-86 UreaN-19 Creat-0.9 Na-135
K-4.8 Cl-101 HCO3-22 AnGap-17
___ 09:15AM BLOOD Glucose-99 UreaN-20 Creat-0.9 Na-138
K-4.5 Cl-102 HCO3-27 AnGap-14
___ 06:38AM BLOOD Glucose-91 UreaN-22* Creat-1.0 Na-137
K-5.7* Cl-102 HCO3-23 AnGap-18
___ 12:45PM BLOOD Na-139 K-4.3 Cl-102
___ 01:27AM BLOOD Glucose-114* UreaN-19 Creat-0.9 Na-137
K-4.1 Cl-100 HCO3-25 AnGap-16
___ 05:09PM BLOOD Na-136 K-4.1 Cl-101
___ 11:30AM BLOOD Na-137 K-4.0 Cl-100
___ 06:05AM BLOOD Glucose-95 UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
___ 12:09AM BLOOD Na-139 K-4.0 Cl-103
___ 05:45PM BLOOD Na-139 K-4.0 Cl-100
___ 01:10PM BLOOD ALT-44* AST-34 CK(CPK)-193 AlkPhos-67
TotBili-0.5
5. CARDIAC
___ 07:47PM BLOOD CK(CPK)-171
___ 03:30AM BLOOD CK(CPK)-146
___ 01:10PM BLOOD CK-MB-3
___ 01:10PM BLOOD cTropnT-0.40*
___ 07:47PM BLOOD CK-MB-3 cTropnT-0.34*
___ 03:30AM BLOOD CK-MB-3 cTropnT-0.30*
___ 12:11AM BLOOD cTropnT-0.14*
___ 08:26AM BLOOD CK-MB-1 cTropnT-0.08*
___ 04:07AM BLOOD Calcium-10.2 Phos-4.1 Mg-2.3
___ 05:42AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.3
___ 06:30AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.3
___ 06:27AM BLOOD Calcium-10.0 Phos-3.7 Mg-2.3
___ 09:15AM BLOOD Calcium-10.3 Phos-3.5 Mg-2.4
___ 06:38AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.9
___ 01:27AM BLOOD Calcium-9.6 Phos-5.2* Mg-2.5
___ 06:05AM BLOOD Calcium-10.0 Phos-5.2*# Mg-2.5
___ 10:31AM BLOOD Calcium-9.8 Phos-3.6 Mg-2.6
___ 03:08AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.4
___ 02:53AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.4
___ 11:47PM BLOOD Calcium-9.0 Phos-2.7 Mg-2.3
___ 01:55AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.4
___ 03:30AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.6 Cholest-189
___ 01:10PM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.2* Mg-2.3
___ 01:10PM BLOOD %HbA1c-5.3 eAG-105
___ 03:30AM BLOOD Triglyc-148 HDL-39 CHOL/HD-4.8
LDLcalc-120
___ 07:47PM BLOOD Homocys-4.8
___ 06:30AM BLOOD Osmolal-283
___ 02:04PM BLOOD C3-184* C4-17
___ 01:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
SED RATE BY MODIFIED 31 H
SM ANTIBODY <1.0 NEG
SCL-70 ANTIBODY <1.0 NEG
SJOGREN'S ANTIBODY (SS-A) <1.0 NEG <1.0 NEG AI
SJOGREN'S ANTIBODY (SS-B) <1.0 NEG <1.0 NEG AI
RNP ANTIBODY <1.0 NEG
B2 GLYCOPROTEIN I (IGG)AB <9
PROTEIN S ANTIGEN, FREE 123
Antithrombin Antigen, P ___
LIPOPROTEIN (a) 25 <75 nmol/L
Risk Category
Optimal < 75 nmol/L
Moderate 75 - 125 nmol/L
High > 125 nmol/L
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DiphenhydrAMINE 25 mg PO Q6H:PRN itching/allergies
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Lisinopril 5 mg PO DAILY
4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching/allergies
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right middle cerebral artery stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Exam: Mildly inattentive,flat affect. Full strength.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ male with stroke. Evaluate for aneurysm or
dissection.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
5) Spiral Acquisition 5.1 s, 40.0 cm; CTDIvol = 31.8 mGy (Head) DLP =
1,271.5 mGy-cm.
Total DLP (Head) = 2,190 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is loss of gray-white matter differentiation in the right MCA territory.
There is no evidence of no evidence of hemorrhage, or mass. The ventricles
and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
Please note study is limited secondary to poor contrast bolus. There is
decrease in size and caliber of the terminal right M2 and M3 branches of the
right MCA. The remainder of the vessels of the circle of ___ and their
principal intracranial branches appear normal without stenosis, occlusion or
aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
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. Study limited secondary to poor contrast bolus.
2. Loss of gray-white matter differentiation in the right MCA territory,
consistent with an acute infarction which is seen on the subsequently
performed MRI.
3. Decreased in size and caliber of the terminal right M2 and M3 branches of
the right MCA consistent with thrombus or slow flow, also seen on the
subsequently performed MRI.
4. Normal CTA of the neck.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old man with R MCA stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT and CTA from ___
FINDINGS:
There is T2/FLAIR hyperintense signal in the right frontoparietal gyri with
associated gyral swelling. Associated slow diffusion is seen in the right MCA
distribution. There is no evidence of hemorrhage or midline shift. Mild
effacement of the right lateral ventricle is seen from mass effect. FLAIR
hyperintense signal is seen in the distal right MCA branches, likely secondary
to slow flow.
The visualized orbits, paranasal sinuses and mastoid air cells are normal.
IMPRESSION:
1. Evolving right MCA infarction with no evidence of hemorrhage.
NOTIFICATION:
The results of this study were discussed by Dr. ___ by telephone with
nurse ___ at 9:10 am.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: 24 hour followup in a ___ man with stroke status post
tPA.
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 10.0 s, 17.5 cm; CTDIvol = 47.6 mGy (Head) DLP =
833.6 mGy-cm.
Total DLP (Head) = 846 mGy-cm.
COMPARISON: MR head and CTA head and neck from ___.
FINDINGS:
There is evolution of the right MCA territory infarct seen on MR from the day
prior. There is no definite hemorrhagic conversion. A linear hyperdensity in
the right frontal lobe (03:23) appears to correspond to a linear FLAIR signal
hyperintensities seen on MR from the day prior, and again likely reflect
distal MCA branch thrombus or a small area of spared cortex. There is no
shift of normally midline structures.
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. Evolving right MCA territory infarct.
2. No hemorrhagic conversion. Linear hyperdensity in the right frontal lobe
appears to correspond to linear FLAIR signal hyperintensity on MR from the day
prior, and again likely reflects a thrombosed distal vessel or small area of
spared cortex.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 11:32 on ___, approximately 5 minutes
after discovery.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with known acute to subacute right MCA infarct.
Evaluate for infarct extend.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal sagittal reformats were then produced.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___ 10:05 noncontrast head CT.
___ noncontrast brain MRI.
FINDINGS:
There is continued evolution of right MCA territory infarct involving right
frontoparietal region. Involved area appears slightly more hypodense, with
minimally increased effacement of right lateral ventricle. There is grossly
stable approximately 2 mm of right to left midline shift. There is no definite
hemorrhagic conversion. Linear hyperdensities are again noted in the
distribution of distal right MCA branches (see ___ on current exam
in ___ on ___ 10:05 exam).
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. Continued evolution of right MCA territory infarct with minimally increased
effacement of right lateral ventricle.
2. Grossly stable approximately 2 mm right to left midline shift.
3. No definite hemorrhagic conversion identified. Recommend clinical
correlation and attention on followup imaging.
4. Grossly stable possible thrombosed right distal MCA distribution vessels as
described.
RECOMMENDATION(S): No definite hemorrhagic conversion identified. Recommend
clinical correlation and attention on followup imaging.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with R MCA stroke, evaluate for interval change
TECHNIQUE: Contiguous axial images from skull base to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.9 cm; CTDIvol = 47.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
There is no significant interval change to the evolving right MCA territory
infarct involving the right frontoparietal region. There is unchanged
effacement of the right lateral ventricle. Minimal 2 mm leftward shift of
midline structures also unchanged. There is no evidence of hemorrhagic
conversion. Grossly stable linear hyperdensities in the distribution of the
distal right MCA branches suggestive of thrombosed distal right MCA vessels
are again seen.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Continued evolution of right MCA territory infarct without definite
hemorrhagic conversion. Recommend clinical correlation and attention on
followup imaging.
2. Continued effacement of the right lateral ventricle.
3. Stable 2 mm right to left midline shift.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST
INDICATION: ___ year old man with recent R MCA infarct // evaluate for edema.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: 1343 m-Gy
COMPARISON: CT head without contrast dated ___.
FINDINGS:
There is no evidence of hemorrhagic conversion. There has been further
evolution of large right MCA territory infarction. There is mild right-sided
mass effect. This exam is partially limited by motion. There are no new
areas of infarction.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Evolving right MCA territory infarction.
2. No evidence of hemorrhage or new infarction.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with recent RT MCA stroke now with flat affect
and inattention. // Please assess for interval change/acute process.
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: CT head without contrast of ___, portable head CT of
___.
FINDINGS:
Re-identified is right hemispheric MCA territory infarct with with diffuse
sulcal effacement and mass effect resulting in approximately 3 mm leftward
midline shift at the level of the caudate heads. There is effacement of the
right lateral ventricle, similar appearance to prior exam. The ventricles
remain patent. Mild crowding of the perimesencephalic cisterns is unchanged
from prior exam, otherwise the basilar cisterns are patent.
There is no new acute territorial infarct. There is no evidence for
hemorrhagic transformation. The visualized paranasal sinuses are essentially
clear. The orbits are unremarkable. The mastoid air cells are well
pneumatized, but demonstrate trace fluid.
IMPRESSION:
1. Expected evolution of right MCA territory infarct.
2. No evidence of hemorrhagic transformation or new territorial infarct.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, FACIAL WEAKNESS, STATUS POST ADMINISTRATION OF TPA (RTPA) IN A DIFFERENT FACILITY WITHIN THE LAST 24 HOURS PRIOR TO ADMISSION TO CURRENT FACILITY
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ year old ___ man with a history of smoking,
who presented with an episode of confusion, found to have L
sided weakness at OSH with an NIHSS 8 which improved to 5, s/p
tPA at OSH. At OSH, the patient was also noted to have troponin
elevation to 2.29. He has a right MCA stroke due to LV thrombus
with left apical akinesis and aneurysm of unknown etiology.
# Neuro:
The patient was monitored initially in the ICU post-tPA, and
then continued in the ICU due to the risk of significant
cerebral edema. He did develop some edema with slight midline
shift on subsequent CT scans, but his exam improved daily. He
was on Mannitol for treatment of cerebral edema. He
simultaneously developed SIADH, so the mannitol treatment
ultimately kept his Na stable in the 130s. He is on a fluid
restriction of 750ml daily. He should have chemistries checked
twice a week and tailor accordingly. Cardiac risk factors
assessed A1C=5.3, LDL=120 (targeted therapy as below per
cardiology section).
On history, the patient's mother and maternal grandfather both
have bilateral optic atrophy, and his mother tested positive for
a mutation in OPA1, which causes autosomal dominant optic
atrophy. Mr. ___ has a history of bilateral optic atrophy
(and pale optic nerves on exam) but has never been tested for
OPA1. Therefore, we recommended that the patient follow up with
a neurogeneticist for continued care.
# CV:
The etiology of the left apical akinesis and aneurysm with LV
thrombus was initially unknown, with a broad differential
diagnosis. Cardiology was consulted. The patient was treated
with a heparin gtt for thrombus. He was started on a statin (LDL
of 120), BB, and ACE for management of cardiac risk factors and
to promote remodeling. An extensive autoimmune and vasculitis
workup was sent, which were negative for ___, ANCA, SM,
Scleroderma, Ro, LA, RNP, ___, cardiolipin and Beta2 glycoprotein
antibodies, and his homocysteine, Factor VIII, Protein C,
Protein S function, Protein S antigen, antithrombin, and
apolipoprotein A were all normal, though his VW was slightly
elevated. His troponins trended down. Therefore, the patient was
treated for presumed coronary artery disease with a bridge to
warfarin treatment for long term anticoagulation. The patient
was instructed to follow up coordination of his warfarin
treatment in the outpatient setting. Cardiology recommended
starting him on aspirin 81mg daily for suspected CAD. However,
aspirin 81mg daily was not started due to the risk of
hemorrhagic transformation in the setting of a large right MCA
infarct and already being on anti-coagulation with warfarin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / amlodipine / enalapril / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___.
Chief Complaint:
Acute Hepatitis
Major Surgical or Invasive Procedure:
Liver biopsy (___)
History of Present Illness:
___ year old female with PMHx hypertension, hyperlipidemia, DM II
diet controlled, with newly developed severe hepatitis. She was
in her usual state of health until the end of ___ when she
noticed her urine becoming darker and experiencing flu like
symptoms (upper respiratory symptoms with increased fatigue).
Her husband was also experiencing URI symptoms. She had labs
drawn on ___ which showed an ALT of 1200, AST 700. Total
bilirubin was normal at that time. However most recent labs at
___ have shown a bilirubin up to 6.3 with persistent elevation
in ALT/AST and a normal INR.
Patient has taken Benadryl but has not taken Tylenol. She
previously was on atorvastatin for ?years with recent increase
in dose, but this was stopped when her initial LFT's were noted
to be elevated. No new medications. No recent illnesses except
that mentioned above.
Evaluation at ___ is notable for negative hepatitis
serologies, negative AMA. Patient does have positive ___ with
titer of 1:320, and positive anti-smooth muscle antibody at 26
(reference range <20). Ferritin is elevated at 1,943. Alpha 1
anti-trypsin slightly elevated at 230 (reference range
83-199)Serum copper pending, CMV IgG/IgM pending,
Immunoglobulins pending. Hepatitis E virus studies pending. Of
note, on ___ at ___ INR was 1.1, ___ was 12.4.
In the ED, initial VS were 95.4, 79, BP 157/85, RR 16, Pulse Ox
100% on RA.
Labs were notable for normal chemistry panel and CBC, ALT 1266,
AST 793, Alk Phos 351, Lipase 141, Total bilirubin 6.2, direct
bilirubin 4.8. Albumin 4.3. Lactate 2.1. UA unremarkable.
Preliminary Report of RUQ US showed patent hepatic vasculature.
NO evidence of portal vein thrombosis.
On arrival to the floor, patient has no complaints. Denies
fevers, chills, night sweats, vomiting, diarrhea, chest pain,
chest pressure, lower extremity edema. Denies altered mental
status or pruritus.
Past Medical History:
DM II Diet Controlled
Hyperlipidemia
s/p thyroid surgery (thyroid nodule)
Hypertension
Tobacco Dependence
Obesity
Social History:
___
Family History:
Family history of cirrhosis, although all of cases were thought
to be secondary to EtOH, HTN, DM.
Denies history of autoimmune disorders
Physical Exam:
ADMISSION:
VS: 98.2, 133/70, 73, 20, 100% on RA.
GENERAL: Pleasant, laying in bed, does not appear in any acute
distress, breathing non-labored.
HEENT: EOMI, PERRL, icteric sclera.
NECK: supple neck, no elevated JVD.
CARDIAC: RRR, S1/S2, no murmurs.
LUNG: CTAB, no wheezes, rales, rhonchi,
ABDOMEN: soft, non-tender, non-distended, no rebound or
guarding, ___ sign negative.
EXTREMITIES: No lower extremity edema.
PULSES: 2+ DP pulses bilaterally
NEURO: Moving all extremities with purpose. No asterixis.
SKIN: Difficult to appreciate jaundice given dark baseline
complexion.
DISCHARGE
VS: 97.6, 131/72, 53, 18, 100% on RA
I/O 860/BRP; 200/BRP
GEN: NAD
HEENT: EOMI, PERRL, icteric sclera.
NECK: supple neck, no elevated JVD.
CARDIAC: RRR, S1/S2, no murmurs.
LUNG: CTAB, no wheezes, rales, rhonchi,
ABDOMEN: soft, non-tender, non-distended, no rebound or
guarding, ___ sign negative, RUQ dressing C/D/I
EXTREMITIES: WWP, No lower extremity edema.
NEURO: Moving all extremities with purpose. No asterixis.
Pertinent Results:
ADMISSION
___ 10:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-6.0
LEUK-NEG
___ 10:17PM LACTATE-2.1*
___ 10:17PM LIPASE-141*
___ 10:17PM LIPASE-141*
___ 10:17PM ALT(SGPT)-1266* AST(SGOT)-793* ALK PHOS-351*
TOT BILI-6.2* DIR BILI-4.8* INDIR BIL-1.4
___ 10:17PM GLUCOSE-161* UREA N-22* CREAT-0.9 SODIUM-140
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-26 ANION GAP-18
___ 10:29AM ___ PTT-34.7 ___
___ 10:29AM WBC-7.4 RBC-3.91 HGB-11.7 HCT-35.4 MCV-91
MCH-29.9 MCHC-33.1 RDW-15.1 RDWSD-49.3*
___ 10:29AM CALCIUM-9.5 PHOSPHATE-4.3 MAGNESIUM-1.9
PERTINENT
___ 05:35AM BLOOD WBC-11.4*# RBC-3.75* Hgb-11.1* Hct-33.9*
MCV-90 MCH-29.6 MCHC-32.7 RDW-15.3 RDWSD-50.2* Plt ___
___ 05:35AM BLOOD Glucose-271* UreaN-29* Creat-0.9 Na-135
K-3.5 Cl-97 HCO3-26 AnGap-16
___ 10:29AM BLOOD ALT-1241* AST-845* LD(LDH)-485*
AlkPhos-315* TotBili-7.0*
___ 05:10AM BLOOD ALT-1112* AST-643* AlkPhos-333*
TotBili-7.8*
___ 05:35AM BLOOD ALT-843* AST-326* AlkPhos-284*
TotBili-7.0*
___ 06:38AM BLOOD %HbA1c-6.4* eAG-137*
___ 05:10AM BLOOD 25VitD-13*
DISCHARGE
___ 05:40AM BLOOD WBC-10.8* RBC-3.74* Hgb-11.2 Hct-33.9*
MCV-91 MCH-29.9 MCHC-33.0 RDW-15.4 RDWSD-50.6* Plt ___
___ 05:40AM BLOOD ___ PTT-28.9 ___
___ 05:40AM BLOOD Glucose-178* UreaN-29* Creat-0.8 Na-138
K-3.7 Cl-101 HCO3-24 AnGap-17
___ 05:40AM BLOOD ALT-785* AST-299* AlkPhos-271*
TotBili-5.2*
MICRO:
-Blood culture (___): pending
PATH:
-Liver biopsy (___): Liver, core needle biopsy:
1. Severe lobular and moderate portal mixed inflammation
comprised of neutrophils, lymphocytes, scattered plasma cells
and rare eosinophils; perivenular hepatocyte dropout/parenchymal
collapse with central-to-central and foci of central-to-portal
bridging necrosis are present.
2. Prominent lobular regeneration and frequent apoptotic
hepatocytes seen.
3. Minimal large droplet steatosis; no ballooning degeneration
or intracytoplasmic hyaline identified.
4. Lobular, predominantly perivenular, and foci of periportal
ceroid laden macrophages.
5. Trichrome stain highlights hepatocyte dropout/parenchymal
collapse with areas of bridging necrosis; no advanced fibrosis
is identified but staging is deferred at this time due to the
marked inflammatory changes.
6. Iron stain shows mild iron deposition within Kupffer cells.
7. A reticulin stain is in progress and any additional findings
will be reported in an addendum.
IMAGING:
RUQ U/S (___): IMPRESSION: Patent hepatic vasculature. No
evidence of portal vein thrombosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 200 mg PO BID
2. irbesartan 300 mg oral DAILY
3. Levothyroxine Sodium 125 mcg PO 6X/WEEK (___)
4. Levothyroxine Sodium 250 mcg PO 1X/WEEK (MO)
5. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. irbesartan 300 mg oral DAILY
3. Labetalol 200 mg PO BID
4. Levothyroxine Sodium 125 mcg PO 6X/WEEK (___)
5. Levothyroxine Sodium 250 mcg PO 1X/WEEK (MO)
6. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by
mouth daily Disp #*60 Tablet Refills:*0
7. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] Use as
directed four times a day Disp #*1 Package Refills:*0
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
10 Units before bedtime Disp #*3 Syringe Refills:*3
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 8
Units QID per sliding scale Disp #*3 Syringe Refills:*3
RX *lancets [FreeStyle Lancets] 28 gauge AS DIR four times a day
Disp #*100 Each Refills:*3
8. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
9. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth qAM Disp #*40 Tablet
Refills:*0
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
11. Vitamin D ___ UNIT PO 1X/WEEK (MO)
RX *ergocalciferol (vitamin D2) [Drisdol] 50,000 unit 1
capsule(s) by mouth qMON Disp #*4 Capsule Refills:*0
12. Glucose Tab ___ TAB PO PRN hypoglycemia
RX *dextrose ___ Tablets by mouth As Needed Disp #*120
Unspecified Refills:*1
13. GlipiZIDE XL 2.5 mg PO DAILY Duration: 30 Days
RX *glipizide 2.5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
14. Outpatient Lab Work
Please check AST, ALT, t bili, alk phos, albumin, Chem-10 (Na,
K, Cl, HCO3, BUN, Cr, glucose, Ca, Mg, PO4)
ICD-10: K75.4, Autoimmune hepatitis
Please fax results to ___, MD - ___. Pen Needle (pen needle, diabetic) 32 gauge x ___
Subcutaneous As Needed
To be used with insulin pen
RX *pen needle, diabetic [Pen Needle] 32 gauge X ___ Use
Needles for Insulin Injection As needed Disp #*2 Package
Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Autoimmune hepatitis
-Type 2 diabetes mellitus on insulin
SECONDARY DIAGNOSES:
Hypothyroidism
Hypertension
Hyperlipidemia
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 jaundice // Eval for portal vein thrombus,
obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: 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 10.0 cm.
The hepatic vasculature is patent.
IMPRESSION:
Patent hepatic vasculature. No evidence of portal vein thrombosis.
Radiology Report
INDICATION: ___ year old woman with new transaminitis, lab work c/f autoimmune
hepatitis // Please perform non-targeted liver biopsy
COMPARISON: Comparison is made to ultrasound performed on the same day.
PROCEDURE: Ultrasound-guided non-targeted liver biopsy.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the right
hepatic lobe was performed and a suitable approach for non targeted liver
biopsy was determined. No other abnormalities were identified on the limited
imaging.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound
guidance, a 16 gauge core biopsy needle was then advanced into the liver and a
single core biopsy sample was obtained and placed in formalin. The skin was
then cleaned and a dry sterile dressing was applied. There was no immediate
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 10
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated non-targeted liver biopsy.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Fatigue, Jaundice
Diagnosed with Inflammatory liver disease, unspecified
temperature: 95.4
heartrate: 79.0
resprate: 16.0
o2sat: 100.0
sbp: 157.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | ___ female with PMHx hypertension, hyperlipidemia, DM II diet
controlled, with newly developed severe hepatitis, with elevated
transaminases and bilirubin c/f autoimmune hepatitis.
# Acute Hepatitis, likely autoimmune: Patient presents with 10
day history of progressive transaminitis with subsequent
hyperbilirubinemia. She received an extensive outpatient
work-up; positive tests include ___ at 1:320, elevated
anti-smooth muscle antibody at 26 (reference range <20),
elevated alpha-1-antitrypsin at 230 (reference range 83-199),
and elevated ceruloplasmin at 71 (reference range ___, copper
at 245 (reference range 80-155). Viral hepatitis studies, CMV
are negative. Lab work consistent with autoimmune hepatitis.
Patient was admitted for expedited liver biopsy. She underwent
biopsy on ___ pathology consistent with autoimmune
hepatitis. She was initiated on prednisone 60mg; she was
transitioned to 40mg qd at discharge. In addition, due to
anticpated extended prednisone course, she was started on
Bactrim SS ppx, calcium supplementation, vitamin D
supplementation, and protonix. Upon further review of history,
patient had recently had a dose increase of her atorvastatin to
40mg qd, which was a possible precipitant for her autoimmune
hepatitis. This medication was discontinued and she was
counseled to avoid statins in the future. Labs pending at
discharge include immunoglobulins and TPMT. She will follow up
with Dr. ___ ___ ___.
# Type II DM: patient with known T2DM as outpatient; diet
controlled. In the setting of prednisone initiation, patient's
blood sugars became significantly elevated. HbA1C 6.4%. She was
initiated on the insulin sliding scale. ___ was consulted,
and she was started on 10u lantus qHS, Humalog ISS, and
glipizide 2.5mg qAM to take with her prednisone. ___ was set up
for insulin teaching. She will follow up with her PCP for
continued management of her T2DM.
# Hypertension: She was continued on her home anti-HTN:
labetalol 200 mg PO BID, HCTZ 25 mg PO daily, irbesartan 300 mg
PO daily.
# Hypothyroidism: She was continued on her home levothyroxine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is ___ with history of CAD s/p CABG in ___ (___->LAD,
SVG->diag->OM, SVG->PDA) and s/p NSTEMI in ___ with DES x3
to RCA and POBA to D2 as well as hypertension and DM who
presents with chest pain. Since her last presentation patient
reports intermittent episodes of throat pain that she states
usually occurs after eating something she "has no business
eating." It is usually resolved with antacids. On day of
presentation she reported repeated episodes throughout the day
lasting minutes. She states that as soon as the Tums would wear
off, the pain would recur. Additionally, the quality of the pain
on day of admission was reminiscent of her prior cardiac event
which prompted her to come to the ED for evaluation.
She states that the pain was associated with SOB but did not
change with exertion. There was no pleuritic nature to it and it
was reproducible. She states that she has been battling a URI
illness all week and has a cough because of it. Denied fevers or
chills. No orthopnea, PND ___ edema.
In the ED, initial vitals were 71 ___ 98%RA Labs and
imaging significant for Hct 35 and Cr 1.5 - both near baseline.
Patient was chest pain free while in ED and thus was not
anticoaagulated however did receive aspirin 325mg. Patient was
then admitted for work-up of chest pain and rule out MI. Vitals
on transfer were HR 54 BP160/91 RR12 99%ra.
On arrival to the floor, patient states that she is very anxious
about being in the hospital again however denies CP currently.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
CABG in ___: CAD s/p CABG ___ (___->LAD, SVG->diag->OM,
SVG->PDA)
Cath: ___
-- LIMA to LAD patent.
-- SVG to the diagonal and OM occluded.
-- SVG to the PDA was occluded.
-- Old 80% LAD lesion and 100% D1 occlusion.
-- circumflex moderately diseased,
-- RCA had serial 80% lesions --> 3 stents placed in the RCA.
PCI: RCA PCI in ___
.
3. OTHER PAST MEDICAL HISTORY:
-prior CVA without residual deficit
-glaucoma
-arthritis
-history of heart block and dual chamber pacemaker placement in
___
- diastolic CHF
- PVD
- Vertigo
- HRN
- Hypothyroidism
- Depression/Anxiety
Social History:
___
Family History:
Her son, ___, had a history of diabetes, hypertension,
hyperlipidemia, status post anterior ST elevation MI with a
drug-eluting stent to the proximal LAD in ___. He had an
ICD implanted in ___ for a nonsustained VT in the
setting of low EF (20%). He presented on ___ after
syncope and ICD shocks for rapid monomorphic VT with cycle
length 210, right bundle-branch block configuration, right
superior axis. There may have been 12 occurrences. During VT
ablation in the EP lab, he had a non-clinical VT for which
shocked. He had a PEA arrest from which he recovered but never
regained normal function. He died ___ following a
prolonged neurological vegetative state.
Family history also significant for coronary artery disease.
Physical Exam:
Admission Physical Exam:
VS- 98.2 187/100 65 18 100%RA Wt 135.4lbs
Gen: Pleasant, anxious, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP
CV: RRR. normal S1S2. no mrg
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: Obese, NABS. Soft, NT, ND. No HSM.
EXT: WWP, NO CCE. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Non-focal
Discharge Physical Exam:
t = 98.1-98.2, bp = 124/79 - 128/73, pulse = 60, rr = 18, O2
sat= 96-100 on RA
GENERAL: Elderly AA female, lying in bed in no apparent
distress.
HEENT: NCAT. Sclera anicteric. MMM.
NECK: Supple. Nondistended JVD.
CARDIAC: RRR. No audbile murmurs, rubs, or gallops. No S3 or S4,
no thrills or lifts.
LUNGS: Unlabored respirations, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, nondistended. Nontender to palpation.
EXTREMITIES: Warm extremities. No edema present.
Pertinent Results:
Labs on Admission:
___ 09:50PM BLOOD WBC-8.3 RBC-3.96* Hgb-12.2 Hct-35.6*
MCV-90 MCH-30.8 MCHC-34.2 RDW-14.9 Plt ___
___ 09:50PM BLOOD Neuts-66.7 ___ Monos-5.2 Eos-0.9
Baso-0.4
___ 09:50PM BLOOD ___ PTT-29.8 ___
___ 09:50PM BLOOD Glucose-225* UreaN-47* Creat-1.5* Na-138
K-4.7 Cl-101 HCO3-28 AnGap-14
___ 09:50PM BLOOD cTropnT-<0.01
___ 03:14AM BLOOD CK-MB-3 cTropnT-0.02*
___ 09:02AM BLOOD CK-MB-3 cTropnT-0.02*
___ 09:02AM BLOOD Calcium-10.0 Phos-2.9 Mg-2.5
Labs on Discharge:
___ 07:15AM BLOOD ___-7.7 RBC-4.12* Hgb-12.1 Hct-36.5
MCV-89 MCH-29.3 MCHC-33.1 RDW-14.7 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-138* UreaN-50* Creat-1.5* Na-137
K-5.0 Cl-99 HCO3-30 AnGap-13
___ 07:15AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.5
Admission EKG: Vpaced 67bpm
CXR (___): FINDINGS: Frontal and lateral views of the
chest were obtained. The heart is normal size with stable
cardiomediastinal contours. The lungs are clear. No focal
consolidation, pleural effusion, or pneumothorax. No pulmonary
edema. Dual-lead left chest wall pacer, midline sternotomy
wires, and CABG clips are similar to prior.
IMPRESSION: No acute cardiopulmonary process.
Echocardiogram (___):
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with infero-lateral hypokinesis extending in to the
apex. No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. 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. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared to prior study from ___, no change.
Medications on Admission:
The Preadmissions Medication list may be inaccurate and require
further investigation.
1. Lisinopril 20 mg PO DAILY
hold for sbp < 100
2. Atenolol 50 mg PO DAILY
hold for sbp < 100 and hr < 60
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for sbp < 100
5. GlyBURIDE 10 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO HS
8. Torsemide 5 mg PO DAILY
hold for sbp < 100
9. Felodipine 1.25 mg PO DAILY
hold for sbp < 100
10. Carvedilol 25 mg PO BID
hold for sbp < 100 and hr < 60
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Felodipine 1.25 mg PO DAILY
hold for sbp < 100
3. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
hold for sbp < 100
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Torsemide 5 mg PO DAILY
hold for sbp < 100
7. GlyBURIDE 10 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO HS
9. Aspirin 325 mg PO DAILY
10. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease, Hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with neck pain, which is anginal equivalent.
Evaluate for pulmonary edema.
COMPARISONS: Multiple prior chest radiographs, most recently of ___.
FINDINGS: Frontal and lateral views of the chest were obtained. The heart is
normal size with stable cardiomediastinal contours. The lungs are clear. No
focal consolidation, pleural effusion, or pneumothorax. No pulmonary edema.
Dual-lead left chest wall pacer, midline sternotomy wires, and CABG clips are
similar to prior.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS
temperature: nan
heartrate: 71.0
resprate: 24.0
o2sat: 98.0
sbp: 110.0
dbp: 79.0
level of pain: 9
level of acuity: 2.0 | ___ with history of CAD s/p CABG in ___ (___->LAD,
SVG->diag->OM, SVG->PDA) and s/p NSTEMI in ___ with DES x3
to RCA and POBA to D2 as well as hypertension and DM who
presents with throat and chest pain. During this
hospitalization, troponins were stable. Medical management of
her CAD and anginal symptoms was optimized.
# CAD: Extensive CAD history with recent NSTEMI in ___ with
DES to RCA. Symptoms on presentation (throat pain) are atypical
for CAD, but prior NSTEMI had similar symptoms, making this
concerning for an anginal equivalent. Troponins were <0.01,
0.02, 0.02. Given her relatively stable troponins and her
complicated cardiac anatomy, the decision was made to optimize
medical management of CAD. She was continued on aspirin 325 mg
and Plavix 75mg. She is also on Carvedilol 12.5mg BID,
Lisinopril 20mg, and Imdur 90mg. Throughout this
hospitalization, we attempted to better control the patient's
hypertension on admission (180s/100s).
# PUMP: TTE on date of discharge showed LVEF of 40-45%, largely
unchanged from previous TTE in ___. Was euvolemic on exam.
# RHYTHM: History of complete heart block s/p PPM. The patient
was monitored on telemetry throughout the admission.
# Hypertension: Blood pressure was elevated on admission to
180s/100s. Patient had a good deal of anxiety on admission. She
was unclear on which medications she had been taking most
recently. By discharge, pressures had come down to 120s/80s.
Hypertension medication regimen includes: Carvedilol 12.5mg BID,
Felodipine 1.25 mg, Lisinopril 20mg. Discontinued outpatient
atenolol 50mg (to simplify beta blocker regimen). Also increased
Isosorbide Mononitrate 60mg to 90mg.
# Chronic Kidney Disease - Creatinine was elevated throughout
admission, but close to baseline of 1.3-1.5. Renally toxic
medications were avoided.
# DM - Home medications were held during admission and the
patient was on Insulin Sliding Scale. She will be discarghed on
home meds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Drainage from right hip incision site
Major Surgical or Invasive Procedure:
Surgical washout of right hip- ___
Surgical washout of right hip- ___
History of Present Illness:
Patient is a ___ male with history of CAD s/p DES ___ mid LAD
___, severe AS, who presents s/p right hip fracture repair on
___ with increased wound dehiscence.
.
The patient had been doing well at home since discharge from
rehab. He was ambulating more but then noticed his surgical
wound was opening up about 2 days ago. His home nurse monitored
it closely but it became more erythematous and then developed
purulent discharge so he was sent ___ for further evaluation.
There was up to 4cm of erythema and purulent drainage. He
denies confusion, fevers, dyspnea, chest pain, lower extremity
swelling or palpitations, cough. These symptoms have not caused
significant amount of pain or decreased his ability to ambulate.
Of note the patient only speaks ___, so the history was
obtained with his daughter who speaks fluent ___.
.
___ the ED, initial VS- T- 99.8, HR- 76, BP- 137/65, RR- 16, SaO2
97% on RA. Orthopedics was consulted and recommended imaging to
rule out osteomylitis. ___ addition, they recommended admission
to medicine because of his significant medical history with
plans for surgical washout today.
.
On the floor this morning, vital signs were T- 98.3 (Tmax 98.6),
HR- 82, BP- 151/80, RR 18, SaO2- 98% on RA. The patient denies
any fevers, chills or pain and reports feeling well. Review of
systems below was obtained.
.
REVIEW OF SYSTEMS:
Denies fevers, 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:
Severe/Critical Aortic Stenosis Valve area 1.1 ___ ___ ECHO
CAD -DES to mid-LAD ___
Complete heart block s/p PPM ___ ___ dual chamber)
HTN
BPH
Thalassemia
-acute right intertrochanteric fracture-s/ repair ___
Social History:
___
Family History:
Multiple family members with CAD
Physical Exam:
VS - Temp 98.3 F, BP 148/73 , HR 76 , R 12 , O2-sat 97 % RA
GENERAL - Alert, interactive, well-appearing male ___ NAD
HEENT - PERRLA, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur ___
the second intercostal space which radiates to the carotids.
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses.2.1 cm x 0.5-1
cm areas of slight purulent drainage with surrounding erythema
from right hip surgical site.No significant limitation to
internal/external rotation of the right hip. No fluctuance by
surgical site and no tenderness ___ the area.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred
Pertinent Results:
___ 12:50 pm SWAB SUPERFICIAL RIGHT HIP.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 10:34PM BLOOD WBC-6.3 RBC-4.81 Hgb-10.9* Hct-36.3*#
MCV-76* MCH-22.7* MCHC-30.0*# RDW-18.3* Plt ___
___ 07:28AM BLOOD WBC-5.0 RBC-4.71 Hgb-10.6* Hct-35.4*
MCV-75* MCH-22.6* MCHC-30.0* RDW-18.1* Plt ___
___ 01:44PM BLOOD WBC-5.1 RBC-4.52* Hgb-10.4* Hct-34.0*
MCV-75* MCH-22.9* MCHC-30.5* RDW-17.9* Plt ___
___ 06:10AM BLOOD WBC-6.8 RBC-4.57* Hgb-10.0* Hct-35.0*
MCV-77* MCH-21.9* MCHC-28.6* RDW-17.8* Plt ___
___ 06:35AM BLOOD WBC-5.2 RBC-4.48* Hgb-10.0* Hct-33.9*
MCV-76* MCH-22.3* MCHC-29.5* RDW-17.9* Plt ___
___ 10:34PM BLOOD Neuts-70.4* ___ Monos-5.4
Eos-4.3* Baso-0.3
___ 07:28AM BLOOD ___ PTT-30.8 ___
___ 06:35AM BLOOD ___ PTT-31.7 ___
___ 06:35AM BLOOD ESR-25*
___ 10:34PM BLOOD Glucose-111* UreaN-17 Creat-0.7 Na-136
K-6.9* Cl-103 HCO3-24 AnGap-16
___ 07:28AM BLOOD Glucose-107* UreaN-14 Creat-0.6 Na-139
K-3.9 Cl-102 HCO3-28 AnGap-13
___ 01:44PM BLOOD Glucose-124* UreaN-12 Creat-0.7 Na-138
K-3.8 Cl-103 HCO3-28 AnGap-11
___ 06:10AM BLOOD Glucose-121* UreaN-10 Creat-0.7 Na-137
K-4.2 Cl-101 HCO3-29 AnGap-11
___ 06:35AM BLOOD Glucose-114* UreaN-14 Creat-0.8 Na-138
K-3.6 Cl-100 HCO3-29 AnGap-13
___ 06:35AM BLOOD ALT-19 AST-18 AlkPhos-132* TotBili-0.8
___ 07:28AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.3
___ 06:35AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
___ 06:35AM BLOOD CRP-45.4*
___ 10:49PM BLOOD Lactate-1.1 K-3.6
___ 07:05AM BLOOD WBC-4.9 RBC-4.38* Hgb-9.8* Hct-33.0*
MCV-75* MCH-22.5* MCHC-29.8* RDW-17.4* Plt ___
___ 05:24AM BLOOD WBC-4.9 RBC-4.20* Hgb-9.4* Hct-32.0*
MCV-76* MCH-22.5* MCHC-29.6* RDW-17.1* Plt ___
___ 07:05AM BLOOD ___ PTT-30.3 ___
___ 05:24AM BLOOD ___ PTT-28.1 ___
___ 07:05AM BLOOD Glucose-117* UreaN-16 Creat-0.7 Na-136
K-4.2 Cl-99 HCO3-31 AnGap-10
___ 05:24AM BLOOD Glucose-114* UreaN-14 Creat-0.8 Na-140
K-4.0 Cl-102 HCO3-28 AnGap-14
___ 07:05AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
___ 05:24AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.3
___ 07:10AM BLOOD WBC-6.1 RBC-3.90* Hgb-8.7* Hct-29.2*
MCV-75* MCH-22.3* MCHC-29.8* RDW-17.2* Plt ___
___ 07:10AM BLOOD Glucose-117* UreaN-12 Creat-0.7 Na-136
K-3.8 Cl-99 HCO3-31 AnGap-10
___ 07:10AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
Chest X-ray- ___
IMPRESSION:
1. Stable appearance of right hip hardware without radiographic
evidence of loosening or malpositioning.
2. Nonobstructive right lower quadrant hernia containing a loop
of colon.
Medications on Admission:
1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO at bedtime.
5. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous QPM
(once a day ___ the evening)) for 4 weeks: continue until ___
___.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on narcotics for pain control.
7. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Dyspepsia.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
15. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
ONCE (Once) for 1 doses.
16. Alendronate
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) inj Subcutaneous
DAILY (Daily) for 4 weeks.
Disp:*28 Syringes* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ml PO twice a day as needed for dyspepsia.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. alendronate Oral
16. nafcillin 2 gram Recon Soln Sig: Two (2) gm Intravenous
every four (4) hours for 4 weeks.
Disp:*168 units* Refills:*0*
17. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every ___ hours
as needed for pain: Do not drink alcohol or drive while on this
medication.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary- Wound infection
Secondary- Aortic stenosis
CAD
Complete heart block s/p PPM ___ ___ dual
chamber)
HTN
BPH
Thalassemia
Right intertrochanteric fracture-s/p repair ___
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
PICC LINE PLACEMENT
INDICATION: IV access needed for antibiotics.
The procedure was explained to the patient. A timeout was performed.
RADIOLOGIST: Dr. ___ (resident) performed
the procedure.
Dr. ___ attending radiologist was present and supervised the procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the right basilic
vein was punctured under direct ultrasound guidance using a micropuncture set.
Hard copies of ultrasound images were obtained before and immediately after
establishing intravenous access. A peel-away sheath was then placed over a
guidewire and a single lumen PICC line measuring 40 cm in length was then
placed through the peel-away sheath with its tip positioned in the SVC under
fluoroscopic guidance. Position of the catheter was confirmed by a
fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4 ___
single lumen PICC line placement via the right basilic venous approach. Final
internal length is 40 cm, with the tip positioned in SVC. The line is ready
to use.
Radiology Report
INDICATION: ___ male with recent hip replacement with evidence of
slight infection. Question hardware displacement or effusion.
COMPARISON: ___.
FINDINGS: Single AP view of the pelvis and two coned-down views of the right
hip demonstrate similar configuration of a dynamic compression device and
interlocking screws fixating the right hip, without ___ lucency to
indicate hardware complication. Since ___, skin staples have been
removed. There is no new fracture. Left hip appears within normal limits.
No pubic symphyseal or SI joint diastasis. Lower lumbar spine spondylosis is
moderate. Bowel gas pattern is nonobstructive. Note is made of unusual
configuration of a loop of colon overlying the right lower quadrant,
suggestive of a large nonobstructing colon containing hernia. No abnormal
soft tissue calcifications.
IMPRESSION:
1. Stable appearance of right hip hardware without radiographic evidence of
loosening or malpositioning.
2. Nonobstructive right lower quadrant hernia containing a loop of colon.
Radiology Report
INDICATION: Left PICC placement.
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: ___.
FINDINGS: The new left PICC terminates in the region of the left internal
jugular vein. The cardiac pacer leads terminate in the region of the right
atrium and ventricle. There is no pneumothorax. Bilateral low lung volumes
are noted. The cardiomediastinal silhouette is within normal limits.
IMPRESSION: Left-sided PICC terminates in the left internal jugular vein.
Findings were discussed with ___ (IV nurse) by phone at 4:24 p.m. on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT HIP WOUND DEHISANCE
Diagnosed with OTHER POST-OP INFECTION, DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, ABN REACT-PROCEDURE NOS, HYPERTENSION NOS, AORTIC VALVE DISORDER, CARDIAC PACEMAKER STATUS
temperature: 99.8
heartrate: 76.0
resprate: 16.0
o2sat: 97.0
sbp: 137.0
dbp: 65.0
level of pain: 4
level of acuity: 3.0 | ASSESSMENT AND PLAN:
___ male with pmhx of CAD s/p DES ___ mid LAD ___, severe AS,
who presents s/p right hip fracture repair ___ with
increased wound dehiscence with purulent drainage and erythema.
.
#Right surgical site dehiscence- On admission, drainage and
erythema are consistent with underlying infection, possibly even
osteomyelitis. Prior to admission, he was afebrile but had
increased purulent drainage over the preceding 2 days.
Orthopedics evaluated the patient and recommended surgical
washout, which was performed on ___. They found a
collection of pus deep ___ the wound, near the hardware.
Cultures were taken and the patient was started on vancomycin
1250mg q12 hours. He also received a few doses of unasyn prior
to culture information. Given location of wound, ID was
consulted and recommended a 4 week course of antibiotics.
Cultures grew back staph aureus (methicillin sensitive), so the
patient will be treated with naficillin 2gm q4hr for 4 weeks
(last day ___. PICC line placed on left side on ___ but
patient has PPM there so it was pulled back to a midline. ___
placed right PICC on ___ and left midline was discontinued
shortly thereafter. Patient underwent second surgical washout
on ___, which was without complication. Cultures from the
washout grew out proteus for which patient will be treated with
Ciprofloxacin. The patient had fever of 101.0 (asymptomatic)
the evening of the procedure with no fevers afterwards. Blood
cultures were sent and were negative for growth. Ortho
recommended antibiotics and lovenox. ID performed OPAT and the
patient will send weekly CBC w/diff, BMP, LFTs, ESR/CRP and
vancomycin troughs to the ___ clinic (fax number (___.
ID will follow the patient on discharge. As mentioned, there
are no systemic signs of infection and looked clinically well.
Blood cultures had no growth at the time of discharge.
#Aortic stenosis/CAD- The patient has known history of severe
AS. During this admission, he had no signs of heart failure or
cardiac symptoms, including shortness of breath, chest pain,
syncope. He does endorse dyspnea on exertion which is chronic
but denies dyspnea at rest. He is not on Plavix because he
completed ___fter stent placement. He was continued
on home simvastatin, lisinopril, and metoprolol succinate, and
ASA 81mg daily while ___ the hospital.
#BPH- Stable. Prior to previous hospitalization, the patient
had been on doxazosin and finasteride, however he was only
discharged on finasteride. Per the family, none of their
physicians (including cardiologist) made this change so the
patient was resumed on doxazosin during this admission, which he
will continue on discharge.
#Anemia- At recent baseline with no signs of bleeding, including
no melena or hematoma at surgical site. Microcytic, likely
related to history of thalassemia. Hct was stable while ___ the
hospital.
#Hypertension- continued home anti-hypertensives (lisinopril and
metoprolol succinate)
# CODE:Full code (confirmed) |