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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R foot infection
Major Surgical or Invasive Procedure:
___: R foot I&D w/ debridement
History of Present Illness:
___ w/PVD, DM s/p RLE SFA-DP bypass ___ who presents
with a R foot infection and postive bone scan from OSH. Pt is
closely followed by Dr ___, and Dr. ___,
___. He states that he saw Dr. ___ ___. He reports
that ongoing discussions were had re: a bone scan vs. MRI. He
reports that he underwent a bone scan on ___ and his PCP
called this morning with the results and discussed with them
that he needs IV abx. His wife called the on call pager this
morning re: ___ treatment/plan for the bone scan results. He
reports of experiencing nightly fever and chills. He denies
current N/F/V/C, SOB, CP. He presents today for IV abx and
possible debridement of R foot.
Past Medical History:
PMH: DM, HTN, HLD, PVD
PSH: RLE SFA-DP bypass (___), R ___ digit amputation (___),
multiple b/l foot debridements, RLE angio (___), PTA AT/pop
(___), R foot debridement (___)
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission PE:
V:99 93 119/57 18 100%
Gen: NAD, AAOx3, pleasant, cooperative
___: ___: ___, CRT <3 secs, warm, dorsal
hyperpigmentation/erythema. R lateral base of ___ met
hyperkeratotic wound decreased in size since LCV with no
malodor, streaking, undermining, probe or tracking.
Discharge PE:
VSS, afebrile
GEN - NAD
___: Dressings c/d/i, cap refill immediate, digits WWP
Pertinent Results:
___ 07:40AM BLOOD WBC-5.9 RBC-3.98* Hgb-9.5* Hct-30.9*
MCV-78* MCH-23.9* MCHC-30.8* RDW-15.3 Plt ___
___ 06:35AM BLOOD WBC-6.1 RBC-4.07* Hgb-9.8* Hct-31.8*
MCV-78* MCH-24.1* MCHC-30.8* RDW-15.3 Plt ___
___ 06:50AM BLOOD WBC-4.7 RBC-4.18* Hgb-10.3* Hct-32.4*
MCV-78* MCH-24.5* MCHC-31.7 RDW-15.1 Plt ___
___ 08:20AM BLOOD WBC-5.2 RBC-4.22* Hgb-10.4* Hct-33.5*
MCV-79* MCH-24.6* MCHC-31.0 RDW-15.1 Plt ___
___ 07:35AM BLOOD WBC-4.1 RBC-3.83* Hgb-9.1* Hct-30.1*
MCV-78* MCH-23.8* MCHC-30.4* RDW-15.1 Plt ___
___ 07:28AM BLOOD WBC-5.7 RBC-3.98* Hgb-9.7* Hct-31.2*
MCV-78* MCH-24.2* MCHC-31.0 RDW-15.1 Plt ___
___ 03:30PM BLOOD WBC-6.3 RBC-4.13* Hgb-10.2* Hct-33.0*
MCV-80* MCH-24.7* MCHC-30.9* RDW-15.2 Plt ___
___ 03:30PM BLOOD Neuts-68.7 ___ Monos-6.2 Eos-1.3
Baso-0.5
___ 07:40AM BLOOD Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:50AM BLOOD Plt ___
___ 08:20AM BLOOD Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:28AM BLOOD Plt ___
___ 03:30PM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-157* UreaN-20 Creat-1.2 Na-128*
K-4.7 Cl-95* HCO3-26 AnGap-12
___ 06:35AM BLOOD Glucose-156* UreaN-19 Creat-1.1 Na-134
K-4.5 Cl-98 HCO3-26 AnGap-15
___ 06:50AM BLOOD Glucose-144* UreaN-23* Creat-1.2 Na-136
K-4.6 Cl-99 HCO3-27 AnGap-15
___ 08:20AM BLOOD Glucose-227* UreaN-21* Creat-1.1 Na-133
K-4.7 Cl-97 HCO3-28 AnGap-13
___ 07:35AM BLOOD Glucose-164* UreaN-24* Creat-1.2 Na-136
K-4.7 Cl-99 HCO3-27 AnGap-15
___ 07:28AM BLOOD Glucose-225* UreaN-21* Creat-1.2 Na-136
K-4.8 Cl-98 HCO3-28 AnGap-15
___ 03:30PM BLOOD Glucose-108* UreaN-22* Creat-1.1 Na-138
K-4.5 Cl-99 HCO3-29 AnGap-15
___ 08:20AM BLOOD ALT-47* AST-24 LD(LDH)-137 AlkPhos-69
TotBili-0.3
___ 07:28AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7
___ 06:35AM BLOOD CRP-91.6*
___ 03:38PM BLOOD Lactate-1.9
___ 1:17 pm SWAB RIGHT DORSAL DEEP TISSUE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 1:17 pm TISSUE RIGHT DORSAL DEEP TISSUE AND BONE.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
Reported to and read back by ___ @ 13:11 ON
___.
STAPH AUREUS COAG +. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ ___ M ___ ___
Radiology Report MR FOOT ___ CONTRAST RIGHT Study Date of
___ 10:09 AM
___. SURG FA2 ___ 10:09 AM
MR FOOT ___ CONTRAST RIGHT Clip # ___
Reason: eval; + bone scan ___ ___
Contrast: GADAVIST Amt: 11
*** UNAPPROVED (PRELIMINARY) REPORT ***
EXAMINATION: MR FOOT ___ CONTRAST RIGHT
INDICATION: ___ year old man DM, PVD chronic ulceration R foot
___ met base
recently underwent a bone scan @ ___ and was positive.
TECHNIQUE: Imaging performed at 1.5 Tesla using the extremity
coil. Sequences include multiplanar localizer, coronal STIR,
coronal T1 nonfat sat, axial T1, axial STIR, coronal T1 fat-sat
pre and postcontrast, axial T1 post-contrast fat-sat, sagittal
T1 fat-sat post-contrast, and coronal subtraction images..
COMPARISON: Foot radiographs ___.
FINDINGS:
There is marked marrow signal abnormality enhancement in
metatarsals 2 through 5, the medial, middle, and lateral
cuneiforms, and the cuboid and navicular bones. There is a small
amount of fluid extending from the calcaneocuboid joint with an
overlying soft tissue defect but no clear fistulous tract
connecting these two entities. A small amount of fluid is also
seen between the base of the third and fourth metatarsals. There
is no clear focal bone marrow signal abnormality seen to suggest
osteomyelitis, but this is not excluded. At the level of the
cuboid, the peroneus brevis is not well seen.
The visualized tendons and ligaments are otherwise unremarkable.
Edema in the soft tissues surrounding the midfoot is also
present. No masses are seen.
IMPRESSION:
Marked multifocal bone marrow signal abnormality throughout the
midfoot, suggestive of Charcot arthropathy. A small focus of
osteomyelitis is not excluded. Right foot radiographs are
recommended to assess for additional
___ ___ ___ ___
Radiology Report FOOT AP,LAT & OBL RIGHT Study Date of
___ 6:15 ___
___. SURG FA2 ___ 6:15 ___
FOOT AP,LAT & OBL RIGHT Clip # ___
Reason: ?changes consistent with charcot neuroarthropathy vs OM
UNDERLYING MEDICAL CONDITION:
___ year old man with right foot infection
REASON FOR THIS EXAMINATION:
?changes consistent with charcot neuroarthropathy vs OM
Final Report
INDICATION: Right foot infection.
TECHNIQUE: 3 non standing views of the right foot.
FINDINGS:
Since similar exam ___ there has developed extensive
bone destruction involving the adjacent proximal portions of the
third and fourth metatarsals and probably the adjacent distal
portion of the third cuneiform bone. Exam is otherwise
unchanged with amputation of the second toe and possibly a
portion of the proximal fifth metatarsal. Dorsal soft tissue
swelling is little changed. Extensive vascular calcifications.
Normal mineralization and the lack the generalized
demineralization in the face of this apparent infection
suggests ischemia and is consistent with neuropathic
osteoarthropathy. Normal joints.
IMPRESSION:
Short interval bone destruction highly suggestive of
osteomyelitis.
___ Imaging CHEST PORT. LINE PLACEM ___
___. Unread
___ ___ ___ ___
Pathology Report Tissue: SOFT TISSUE, DEBRIDEMENT Procedure Date
of ___
Report not finalized.
Logged in only.
PATHOLOGY # ___
SOFT TISSUE, DEBRIDEMENT
Medications on Admission:
ASA 81', Plavix 75', levothyroxine 125', lisinopril 10',
metformin 1000'', simvastatin 40', lantus 44', metoprolol 12.5''
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Glargine 44 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
4. Levothyroxine Sodium 125 mcg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Metoprolol Tartrate 12.5 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Vancomycin 1000 mg IV Q 8H
RX *vancomycin 1 gram 1 g IV every eight (8) hours Disp #*42
Vial Refills:*2
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
q4h;prn Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R foot infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR FOOT ___ CONTRAST RIGHT
INDICATION: ___ year old man DM, PVD chronic ulceration R foot ___ met base
recently underwent a bone scan @ ___ and was positive.
TECHNIQUE: Imaging performed at 1.5 Tesla using the extremity coil. Sequences
include multiplanar localizer, coronal STIR, coronal T1 nonfat sat, axial T1,
axial STIR, coronal T1 fat-sat pre and postcontrast, axial T1 post-contrast
fat-sat, sagittal T1 fat-sat post-contrast, and coronal subtraction images..
COMPARISON: Foot radiographs ___.
FINDINGS:
There is marked marrow signal abnormality enhancement in metatarsals 2 through
5, the medial, middle, and lateral cuneiforms, and the cuboid and navicular
bones. There is a small amount of fluid extending from the calcaneocuboid
joint with an overlying soft tissue defect but no clear fistulous tract
connecting these two entities. A small amount of fluid is also seen between
the base of the third and fourth metatarsals. Cortical discontinuity at the
base of the third and fourth metatarsals raises the question of fracture.
Within this area of extensive marrow abnormality, no focally pronounced bone
marrow signal abnormality is identified to suggest osteomyelitis, but
osteomyelitis is not excluded. At the level of the cuboid, the peroneus
brevis is not well seen, of uncertain significance. The visualized tendons and
ligaments are otherwise unremarkable. Edema in the soft tissues surrounding
the midfoot is also present. No masses are seen.
IMPRESSION:
Extensive, pronounced, multifocal bone marrow signal abnormality throughout
the midfoot. This appearance is nonspecific, but in the setting of diabetes,
multiFocal marrow edema is consistent with Charcot arthropathy. Superimposed
osteomyelitis is not excluded. Soft tissue edema without gross fluid
collection suggestive of abscess.
There are possible fractures, at least at the base of the third and fourth
metatarsals, and possibly elsewhere. Right foot radiographs are recommended to
assess for additional findings.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 4:31 ___, 20 minutes after discovery of the
findings.
Radiology Report
INDICATION: Right foot infection.
TECHNIQUE: 3 non standing views of the right foot.
FINDINGS:
Since similar exam ___ there has developed extensive bone destruction
involving the adjacent proximal portions of the third and fourth metatarsals
and probably the adjacent distal portion of the third cuneiform bone. Exam is
otherwise unchanged with amputation of the second toe and possibly a portion
of the proximal fifth metatarsal. Dorsal soft tissue swelling is little
changed. Extensive vascular calcifications. Normal mineralization and the
lack the generalized demineralization in the face of this apparent infection
suggests ischemia and is consistent with neuropathic osteoarthropathy. Normal
joints.
IMPRESSION:
Short interval bone destruction highly suggestive of osteomyelitis.
Radiology Report
INDICATION: ___ year old man with PICC. // Pt had a left picc,48cm ___
___ Contact name: ___: ___
TECHNIQUE: semi upright AP chest
COMPARISON: Chest radiographs ___ through ___
FINDINGS:
New left PICC line terminates in the mid SVC. Prior right PICC line has been
removed. There is no pneumothorax. Lung volumes are slightly low with
atelectasis at the lung bases. There is no pleural effusion. The heart is not
enlarged. The mediastinal and hilar contours are normal.
IMPRESSION:
New left PICC line terminates in the mid SVC.
NOTIFICATION: The findings were telephoned to ___ by ___ at 1:45 pm,
___, 5 min after discovery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Foot pain
Diagnosed with OSTEOMYELITIS NOS-FOOT
temperature: 99.0
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 119.0
dbp: 57.0
level of pain: 5
level of acuity: 3.0 | The patient presented to Emergency Room ___. After thorough
evaluation, it was deemed necessary to admit the patient to the
podiatric surgery service. He underwent an MRI and xray to his
right foot to determine the cause for his pain, erythema, and
swelling. Patient was kept NPO with IVF at midnight for an
incision and drainage with debridement for bone sample on
___. Pt was evaluated by anesthesia and taken to the
operating room. There were no adverse events in the operating
room; please see the operative note for details. Afterwards, pt
was taken to the PACU in stable condition, then transferred to
the ward for observation.
He was left off of antibiotics to ensure thfor best culture
results. ID was consulted and their recommendations were
followed. After his procedure he was placed on IV antibiotics.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled with IV pain medication
that was then transitioned into an entirly oral pain medication
regimen on a PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. Urine output remained
adequate throughout the hospitalization. The patient received
subcutaneous heparin throughout admission.
Cultures were positive on his bone samples concluding that the
OSH bone scan, MRI, and xray had been positive for
osteomyelitis. ID chose to treat him with IV antibiotics for 6
weeks.
The patient was subsequently discharged to home on POD2. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prempro / Clindamycin / Iodine / Latex / Prevacid / "multiple
chemical sensitivities" / Nickel / Iodinated Contrast Media - IV
Dye / Percocet
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of morbid obesity,
allergic rhinitis, seborrheic dermatitis, contact dermatitis,
lactose intolerance and anxiety who presented with shortness of
breath and urticaria.
Patient reports that 6 days prior to admission she had right ear
pain, mild light headedness, HA, and subjective temperature.
Then 3 days prior to admission she developed a pruritic rash
around her thighs that improved with Allegra. She was seen by
her PCP the day prior to admission who thought her rash was
likely urticarial ___ viral illness. She was told to treat her
rash with allegra 180mg BID and Benadryl ___ daily qHS.
Later that night, she was at home and felt labored breathing and
noticed a worsening of the rash on her arms and legs so she
called EMS and presented to the ED.
In the ED, initial VS were T 98.1, HR 90, BP 170/89, RR 16, Sat
95%RA.
Exam notable for CTA b/l and no ___ calf tenderness
Labs showed trop 0.02-0.03, normal CK and MB, repeat trop neg.
Imaging showed EKG without acute changes and CXR without acute
processes.
Received ASA 324mg and diphenhydramine 25mg x2. Patient was
noted to have intermittent exacerbation of her rash and perioral
and periorbital (L>R) swelling. She felt her voice change and
she couldn't talk but was able to swallow water without issue.
She was given IV Solumedrol 125mg, famotidine 40mg and
diphenhydramine 25mg. She was not given epinephrine because
vitals were stable. Decision was then made to admit to medicine
for further management.
On arrival to the floor, patient reports pruritic rash under her
armpits, behind his knees, around her neck, and on her palms.
She denies itching/tingling of lips/tongue/palate, edema of
lips/tongue, metallic taste, itching or congestion of nose,
itching or tightness of throat, shortness of breath, chest
tightness, wheezing, nausea, abdominal pain, vomiting, diarrhea,
dysphagia, feeling ___ or dizziness, chest pain, palpitations,
difficulty hearing, urinary or fecal incontinence, periorbital
itching, or tearing.
She reports generalized sensitivity to the environment, noting
that she has a history of turning "beet red" when exposed to
chemicals like strong perfumes. She also notes having hives in
the past that responded to treatment with Benadryl. She denies
any new soaps, lotions, clothes, or exposures.
Of note, patient reports she has had increased anxiety over the
past few weeks after the sudden death of her sister in
___.
Past Medical History:
Past Medical History: Abnormal CPK and Pap Smear, Allergic
Rhinitis, Anxiety, Benign Positional Vertigo, Patellofemoral
Syndrome, Bilateral Knee Pain, Colon Polyp, Constipation,
Depression, Cirrhosis, Gastritis, GERD, H. Pylori, Lactose
Intolerance, Microscopic Hematuria, Obesity, Seborrheic
Dermatitis, Stress Incontinence, Syncope, Tremor, Mild LVH,
Osteoarthritis, Sleep Apnea, Chemical Sensitivities, Macular
Hole
Bilaterally, and Cataracts.
Social History:
___
Family History:
Osteoporosis, DM, HTN, Thalassemia, Bipolar, Non-Hodgkin's
lymphoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 98.0 159/90 102 20 93 RA
GENERAL: morbidly obese woman, sitting comfortably on side of
bed, alert and awake, breathing comfortably and speaking in full
sentences, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition, OP clear without evidence of edema or
erythema, nontender supple neck
HEART: tachycardic, regular rhythm, nml S1/S2, no murmurs,
gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: obese, +BS, non-distended, non-tender, no
rebound/guarding
EXTREMITIES: WWP, no cyanosis, clubbing or edema, moving all 4
extremities with purpose
SKIN: urticarial lesions on posterior thighs L>R, armpits L>R,
back, and neck
DISCHARGE PHYSICAL EXAM:
=========================
VS: 97.8 162/63 99 20 92%RA
GENERAL: morbidly obese woman, fidgety and scratching her arms
and legs, alert and awake, breathing comfortably and speaking in
full sentences, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition, OP clear without evidence of edema or
erythema, nontender supple neck
HEART: tachycardic, regular rhythm, nml S1/S2, no murmurs,
gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: obese, +BS, non-distended, non-tender, no
rebound/guarding
EXTREMITIES: WWP, no cyanosis, clubbing or edema, moving all 4
extremities with purpose
SKIN: urticarial lesions on bilateral thighs L>R, armpits L>R,
forearms, back, neck, and palms of hands
Pertinent Results:
ADMISSION LABS:
=================
___ 02:00AM BLOOD WBC-8.8 RBC-4.56 Hgb-12.7 Hct-40.2 MCV-88
MCH-27.9 MCHC-31.6* RDW-13.8 RDWSD-44.3 Plt ___
___ 02:00AM BLOOD Neuts-56.6 ___ Monos-6.5 Eos-1.7
Baso-0.3 Im ___ AbsNeut-4.95 AbsLymp-2.99 AbsMono-0.57
AbsEos-0.15 AbsBaso-0.03
___ 02:00AM BLOOD Glucose-162* UreaN-19 Creat-0.6 Na-136
K-4.2 Cl-100 HCO3-23 AnGap-17
___ 02:00AM BLOOD CK(CPK)-190
___ 02:00AM BLOOD CK-MB-6
___ 02:00AM BLOOD cTropnT-0.02*
___ 05:59AM BLOOD cTropnT-0.03*
___ 12:16PM BLOOD cTropnT-<0.01
___ 03:40AM URINE Color-Straw Appear-Clear Sp ___
___ 03:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
NOTABLE LABS:
=============
___ 02:00AM BLOOD cTropnT-0.02*
___ 05:59AM BLOOD cTropnT-0.03*
___ 12:16PM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD CK-MB-6
DISCHARGE LABS:
================
___ 06:40AM BLOOD WBC-12.6* RBC-4.59 Hgb-13.4 Hct-39.6
MCV-86 MCH-29.2 MCHC-33.8 RDW-13.7 RDWSD-42.5 Plt ___
___ 06:40AM BLOOD Glucose-212* UreaN-27* Creat-0.6 Na-135
K-4.2 Cl-95* HCO3-24 AnGap-20
___ 06:40AM BLOOD ALT-40 AST-19 AlkPhos-72 TotBili-0.7
___ 06:40AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.1
MICRO:
=======
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
=========
___ Imaging CHEST (PA & LAT)
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine 60 mg PO QHS
2. Fexofenadine 180 mg PO BID:PRN allergy
3. Lisinopril 10 mg PO DAILY
4. LORazepam 0.5 mg PO DAILY:PRN anxiety
5. Meclizine 12.5 mg PO Q6H:PRN vertigo
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Psyllium Powder 1 PKT PO TID:PRN constipation
8. Naproxen 500 mg PO Q8H:PRN Pain - Mild
9. DiphenhydrAMINE ___ mg PO QHS
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
RX *cetirizine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
3. PredniSONE 30 mg PO DAILY Duration: 1 Dose
This is dose # 1 of 3 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
4. PredniSONE 20 mg PO DAILY Duration: 2 Doses
This is dose # 2 of 3 tapered doses
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
5. PredniSONE 10 mg PO DAILY Duration: 1 Dose
This is dose # 3 of 3 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*1 Tablet
Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID PRN Disp
#*60 Tablet Refills:*0
7. Fexofenadine 60 mg PO BID allergy
8. LORazepam 0.5 mg PO QHS:PRN anxiety
9. Naproxen 500 mg PO Q12H:PRN Pain - Mild
10. DiphenhydrAMINE ___ mg PO QHS
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. DULoxetine 60 mg PO QHS
13. Lisinopril 10 mg PO DAILY
14. Meclizine 12.5 mg PO Q6H:PRN vertigo
15. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
====================
Acute Urticaria
Anxiety
SECONDARY DIAGNOSES:
====================
Obstructive sleep apnea
Depression
Morbid obesity
Seborrheic dermatitis
Hypertension
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 hx of shortness of breath// eval for PNA or ptx
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Shortness of breath
temperature: 98.1
heartrate: 90.0
resprate: 16.0
o2sat: 95.0
sbp: 170.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with history of morbid obesity,
allergic rhinitis, seborrheic dermatitis, contact dermatitis,
lactose intolerance and anxiety who presented with dyspnea and
urticarial after a viral infection.
#Urticaria:
Her acute urticaria was thoughout mostly likely ___ to a viral
illness v environmental exposure. She had no recent medication
changes, no signs of vasculitis. She was given Benadryl and
allergra in the ED. She was then noticed to have perioral and
periorbital edema without anaphylaxis and was given IV
solumedrol and famotidine x1 and admitted to medicine for
further management. She was continued on Benadryl and allergra
and started on a prednisone taper. On HD2, she was noted to have
continued pruritus. Famotidine was started and she was also
started on cetirizine for symptom relief and to reduce the
amount of Benadryl administered. During this admission, she was
hemodynamically stable without any signs or symptoms of
anaphylaxis. She was discharged home to complete her prednisone
taper and to follow-up with an Allergist/Immunologist.
#Dyspnea:
Pt also noted to have dyspnea upon admission, which was thought
to be due to anxiety. Troponins .02 --> .___ --> <.01 and her EKG
was w/o ischemic changes. Etiology was thought not to be cardiac
given no angina or dyspnea at baseline and reassuring EKG as
well as very low troponin.
#Anxiety:
Per patient, she has been more anxious than baseline over the
past few weeks since the sudden death of her sister in
___. She usually takes duloxetine and Ativan PRN at
home. Her home medications were continued and she was monitored
for signs/symptoms of oversedation given concurrent benzo and
Benadryl use. The patient remained alert and awake and
hemodynamically stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine
Attending: ___.
Chief Complaint:
Peripheral edema, dyspnea on exertion
Major Surgical or Invasive Procedure:
R chest tunneled line CVL (___)
History of Present Illness:
Ms. ___ is a ___ y/o F with PMhx of OSA (on CPAP),
fibromyalgia, obesity (s/p RNYGB ___ c/b afferent limb
obstruction s/p subtotal gastrectomy and small bowel resection
now with short gut syndrome (on TPN ___ years), p/w bilateral leg
edema for 1 day and
shortness of breath. Pt reports that she has never had any edema
before and that concerned her enough to come to the ED.
She says the edema started suddenly two nights ago and extended
from her feet to her groin; she also noted edema in her arms
bilaterally. She endorses diffuse pain associated with the
edema. She also endorses dyspnea and fatigue after walking up a
half
flight of stairs. She can lay flat without coughing; she denies
waking up coughing at night. She had an exercise stress test and
echocardiogram done at ___ 2 weeks ago, which the patient
reports were within normal limits.
She also had a TTE at ___ ___ and records show a
normal EF 65%, no diastolic dysfunction, no large valvular
regurg, no pericardial effusions.
ROS: Positive diarrhea for many years ___ short gut syndrome),
anxiety/depression. Reports history of DVT that was due to picc
line (completed course of LMWH). 3-week history of focal R chest
pain, for which she has been taking Tylenol. Negative for cough,
fevers, chills, left-sided chest pain, abdominal pain, dysuria,
constipation, dizziness, pain behind calves, recent travel,
recent immobilization, or changes to vision/hearing.
Past Medical History:
Obesity (s/p Roux-en-Y gastric bypass c/b afferent limb
obstruction now s/p multiple stomach and small bowel resections)
Short gut syndrome
Depression
Fibromyalgia
Insomnia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.2 71 101/64 18 96%RA
Physical exam:
General: Well-appearing, tearful
HEENT: Sclera non-icteric, EOMs intact, PERRLA. JVP <5cm from
sternal border.
Card: RRR, faint systolic ejection murmur.
Pulm: CTAB. Reproducible R-sided pain over 3rd rib.
Abdominal: Soft, non-tender, non-distended. Multiple well-healed
scars, including a large midline scar.
Extremities: 2+ pitting edema over lower extremities ___. No
pitting edema in UE, but patient was TTP diffusely over
extremities. 2+ DP and radial pulses ___
Neuro: AOx3, moving all 4 extremities spontaneously.
DISCHARGE PHYSICAL EXAM
Physical exam: 98.2 106/69 62 18 99%RA
General: Well-appearing, in no acute pain or distress
HEENT: Sclera non-icteric, EOMs intact
Card: RRR, faint systolic ejection murmur. No rubs or gallops
Pulm: CTAB. No wheezes, rales, or rhonchi
Abdominal: Soft, non-tender, non-distended
Extremities: 2+ pitting edema over lower extremities ___ up to
knees, mildly tender to palpation
Neuro: AOx3, moving all 4 extremities spontaneously.
Pertinent Results:
ADMISSION LABS
___ 12:13AM BLOOD WBC-9.9 RBC-3.03*# Hgb-9.6*# Hct-29.9*
MCV-99*# MCH-31.7 MCHC-32.1 RDW-13.4 RDWSD-48.1* Plt ___
___ 12:13AM BLOOD Ret Aut-2.1* Abs Ret-0.06
___ 12:21AM BLOOD Glucose-78 UreaN-18 Creat-0.7 Na-141
K-3.6 Cl-107 HCO3-22 AnGap-12
___ 12:21AM BLOOD ALT-37 AST-42* AlkPhos-117* TotBili-0.4
___ 12:21AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-570*
___ 12:21AM BLOOD Albumin-2.9* Calcium-7.9* Phos-3.8 Mg-1.6
Iron-49
___ 03:56PM BLOOD Triglyc-75 HDL-33* CHOL/HD-2.0 LDLcalc-18
LDLmeas-14
DISCHARGE LABS
___ 06:10AM BLOOD WBC-5.7 RBC-2.73* Hgb-8.8* Hct-29.0*
MCV-106* MCH-32.2* MCHC-30.3* RDW-14.8 RDWSD-57.8* Plt ___
___ 06:10AM BLOOD Glucose-79 UreaN-15 Creat-0.5 Na-145
K-5.1 Cl-110* HCO3-24 AnGap-11
___ 06:10AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.2
___ 06:34AM BLOOD calTIBC-220* Ferritn-88 TRF-169*
___ 06:34AM BLOOD Triglyc-86
MICROBIOLOGY
Urine Culture (___): Mixed bacterial flora likely contaminant
IMAGING
CXR (___): Heart size upper limit of normal. No acute
cardiopulmonary process
LENIS (___): No evidence of DVT. Extensive SC edema b/l
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q4H nausea
2. LORazepam 1 mg PO Q8H:PRN anxiety
3. Cetirizine 10 mg PO QAM:PRN allergies
4. Mirtazapine 30 mg PO QHS
5. Zolpidem Tartrate 10 mg PO QHS
6. Tizanidine 4 mg PO Q8H:PRN muscle spasms
7. Buprenorphine 20 mg SL DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
RX *ascorbic acid (vitamin C) 500 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Buprenorphine 20 mg SL DAILY
RX *buprenorphine HCl 8 mg 2.5 tablet(s) sublingually Daily Disp
#*18 Tablet Refills:*0
3. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice a day Disp #*30 Tablet Refills:*0
4. FoLIC Acid 1 mg IV Q24H
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
6. Cetirizine 10 mg PO QAM:PRN allergies
7. LORazepam 1 mg PO Q8H:PRN anxiety
8. Mirtazapine 30 mg PO QHS
9. Ondansetron 4 mg PO Q4H nausea
10. Tizanidine 4 mg PO Q8H:PRN muscle spasms
11. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Primary diagnoses
- Malnutrition
- Peripheral edema
- Anemia
#Secondary diagnoses
- Short gut syndrome
- History of opiate use
- Anxiety
- Depression
- Costochondritis
- Chronic nausea
- Insomnia
- OSA
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 chest pain and concern for PE// please
evaluate for parenchymal congestion/ischemia is possible for PE
COMPARISON: None
IMPRESSION:
Heart size is upper limits of normal. There are no focal consolidations,
pleural effusion, or pulmonary edema. There are no pneumothoraces.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT BILATERAL
INDICATION: ___ year old woman with history of obesity s/p RNYGB now with
short gut syndrome requiring TPN. For tunneled line placement// Evaluate
bilateral IJ
TECHNIQUE: Grayscale and Doppler assessment of the right and left internal
jugular veins.
COMPARISON: None
FINDINGS:
Grayscale and Doppler evaluation of the right and left internal jugular veins
was performed demonstrating normal blood flow, appropriate and symmetric
waveforms and normal compressibility.
IMPRESSION:
Patent bilateral internal jugular veins.
Radiology Report
INDICATION: ___ year old woman with history of OUD, obesity s/p NYGB now with
short gut syndrome, admitted for ___ edema and malnutrition, now requiring
tunneled line for TPN and blood draws.// Place tunneled line for TPN and blood
draws
COMPARISON: Chest radiograph on ___
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: Lidocaine
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.8 minutes min, 1 mGy
PROCEDURE:
1. Single lumen midline placement through the right brachial vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the right
brachial vein was punctured under direct ultrasound guidance using a
micropuncture set. Ultrasound images were not saved. A peel-away sheath was
then placed over a guidewire. The guidewire was then advanced into the distal
axillary vein using fluoroscopic guidance. A single lumen midline measuring
20 cm in length was then placed through the peel-away sheath with its tip
positioned in the axillary vein 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.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach single lumen right midline with tip in the axillary
vein.
IMPRESSION:
Successful placement of a right 20 cm brachial approach single lumen midline
with tip in the axillary vein. The line is ready to use.
Radiology Report
INDICATION: ___ year old woman with malnutrition from roux en y gastric
surgery and now short gut syndrome// please place double lumen tunneled power
line for TPN and no access ___ is aware
COMPARISON: Ultrasound of the bilat upper extremity from ___
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure.
Dr. ___ supervised during the key components of the procedure and
has reviewed and agrees with the findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service
time of 23 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: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2 min, 3 mGy
PROCEDURE:
1. Tunneled non-dialysis line placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The access site 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 018 stainless steel
measuring wire was advanced to make appropriate measurements for catheter
length. The 018 stainless steel measuring 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 20 cm double-lumen catheter was selected. The catheter
was tunneled from the entry site towards the venotomy site from where it was
brought out using a tunneling device. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the 018 stainless steel 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. 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 each lumen was capped. The
catheter was sutured in place with 0 silk sutures. Steri-strips were used to
close the venotomy incision site. Steri-Strips were applied. Sterile dressings
were applied. The patient tolerated the procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing right
internal jugular approach double-lumen tunneled catheter with tip terminating
in the right atrium.
IMPRESSION:
Successful placement of a 20 cm double-lumen power tunneled line via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: B Leg swelling, Dyspnea on exertion
Diagnosed with Localized edema
temperature: 100.0
heartrate: 106.0
resprate: 15.0
o2sat: 100.0
sbp: 141.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old female with a history of obesity (s/p
RNYGB c/b afferent limb obstruction and multiple re-operations
now with short gut syndrome s/p TPN ___ years) who presented
with ___ edema x 1 day, dyspnea on exertion, and fatigue
concerning for hypoalbuminemia and malnutrition.
# Bilateral Lower Extremity Edema
# Malnutrition - 2+ pitting edema of ___ lower extremities was
likely secondary to hypoalbuminemia due to poor nutrition
(albumin 2.3 pre-albumin 9). Given normal EKG and recent stress
and Echo, unlikely cardiac cause for patient's ___ edema. Patient
initially received lasix and ___ edema improved with compression
stockings. Nutrition was consulted and given that she consumes
approximately ___ calories per day and has had recent
weight loss, was not meeting nutritional needs with PO intake. A
R chest tunneled line was placed on ___ and TPN was started on
___ as a temporizing measure to improve her overall
nutritional status. She was continued on TPN, and also started
on ascorbic acid, B12, vitamin D, clacium carbonate, and folic
acid. To be discharged on TPN with TPN home services.
#Dyspnea - Initial dyspnea on presentation likely related to her
poor nutritional status and fluid overload. Resolved on hospital
day 1.
#Anemia - Hb on admission was 9.6, down from 13 in ___. Hb
remained between ___ during hospital admission, demonstrating a
macrocytic anemia. Iron studies showed Fe 49, ferritin 31, TIBC
251 however there was no hypochromia/microcytosis on peripheral
smear making Fe deficiency anemia unlikely. B12 and folate
levels were normal. Retic 2.1, hemolysis labs showed a low
detectable haptoglobin (thought due to low synthetic function)
with normal LDH, ruling out hemolysis. She received IV ferric
gluconate, B12, and micronutrient lab testing was also ordered
to evaluate for other causes of anemia.
CHRONIC ISSUES
==========================
#Fibromyalgia - continued home tizanidine
#h/o opiate use - continued home buprenorphine 20mg SL
#OSA - patient used CPAP at night while an inpatient
#Anxiety/depression - continued home mirtazapine and lorazepam
PRN
#Nausea - continued home Zofran PRN
#Insomnia - held home zolpidem. Can continue as outpatient
TRANSITIONAL ISSUES
==========================================
[ ] Pending micronutrient lab data to follow-up workup of anemia
and replete as necessary:
ZINC
COPPER (SERUM)
NIACIN
VITAMIN B2 (RIBOFLAVIN)
METHYLMALONIC ACID
[ ] Continue B12 1000mcg Q weekly, and later transition to Q
monthly as an outpatient once B12 level has normalized.
[ ] Although abdominal pain and nausea attributed likely to
short gut syndrome, would consider celiac disease work-up as
outpatient and potential endoscopy of no improvement in
patient's symptoms.
[ ] Please draw CBC to trend H/H in one week from discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ranitidine
Attending: ___.
Chief Complaint:
Diffuse pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with history of sickle cell disease,
right intraparenchymal hemorrhage in ___ thought ___ aneurysm,
seizure disorder on lacosamide/zonesimide, and migraines who
presents with 4 days of diffuse pain.
Mr. ___ notes that on ___ or ___ he ran out of his
pain medication. Since that time, he began to develop worsening
diffuse body pain. Yesterday, he had an argument with his
uncle. At that time, he became so upset that he "punched a
wall." He struck the wall with his right hand. Since that time,
he has noted right hand pain that is sharp in nature and
radiates up his arm. The pain primarily affects his right
knuckle. The pain seem to spread to involve his head (temples
bilaterally without vision changes), his arms, his legs and his
abdomen. Due to the progression of his pain he decided to come
to the hospital. Otherwise, he denies any fevers, chills or URI
symptoms. He has had an intermittent cough, but no dyspnea. No
melena or hematochezia. No new diarrhea, other than intermittent
loose stools. No urinary symptoms. No trouble with ambulating.
In the ED, his vitals were notable for Tmax of 97.8, HR: 60-80s
BP: 130-150/94-100 and he was on RA. His labs were notable for
Hct: 20.1 close to his baseline with Retic: 2.6. He has lipase,
LFTs and BMP that were normal. UA was without infection. CXR did
not show evidence of pneumonia. He had hand XR that did not show
fracture.
I did speak to his outpatient provider ___ who noted they
had been in the process of downtitrating his pain medication.
According to her, Mr. ___ has struggled to follow up with
attempts at social support.
Past Medical History:
- Sickle cell anemia
- Complex partial & simple partial seizures with secondary
generalization
- s/p right parietal intraparenchymal hemorrhagic stroke ___
believed due to aneurysm
- Periodic limb movements of sleep
- Depression
- Migraine headaches
- Chronic knee pain
- s/p stab wound to LUQ requiring splenectomy and partial colon
resection at age ___ years
- s/p multiple C. diff infections, last episode ___
Social History:
___
Family History:
- Mother died of brain aneurysm in her early ___
- Father with sickle cell disease with history of stroke
- One brother with sickle cell disease
Physical Exam:
98.2 PO 118 / 72 98 18 96 RA
Lying in bed, very uncomfortable noting significant pain
diffusely
Cardiac: RRR, no murmurs
Pulm: Clear to auscultation bilaterally
Abd: Soft, but diffusely tender, + BS, no guarding, no
peritoneal signs
Ext: TTP at right ___ digit MCP. Warm well perfused without
edema
Neuro: CN II-XII intact. ___ Strength X 4 extremities. Alert,
oriented and appropriate.
Pertinent Results:
___ 01:00PM WBC-5.9 RBC-1.84* HGB-7.4* HCT-21.5* MCV-117*
MCH-40.2* MCHC-34.4 RDW-25.3* RDWSD-111.5*
___ 01:00PM PLT COUNT-159
___ 01:20AM ALT(SGPT)-12 AST(SGOT)-29 ALK PHOS-47 TOT
BILI-1.1
___ 01:20AM LIPASE-19
___ 01:20AM ALBUMIN-4.5
___ 01:20AM WBC-5.5 RBC-1.79* HGB-7.3* HCT-20.5* MCV-115*
MCH-40.8* MCHC-35.6 RDW-25.5* RDWSD-108.8*
___ 01:20AM RET AUT-2.6* ABS RET-0.05
Right hand XR:
Normal right hand and wrist radiographs.
Chest CXR:
No acute cardiopulmonary process. Stable mild cardiomegaly.
DC LABS:
___ 08:25AM BLOOD WBC-7.0 RBC-1.84* Hgb-7.6* Hct-21.2*
MCV-115* MCH-41.3* MCHC-35.8 RDW-25.4* RDWSD-109.2* Plt ___
___ 08:05AM BLOOD Glucose-84 UreaN-10 Creat-0.7 Na-138
K-4.6 Cl-103 HCO3-26 AnGap-14
___ 01:20AM BLOOD ALT-12 AST-29 AlkPhos-47 TotBili-1.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. LACOSamide 200 mg PO BID
3. Zonisamide 200 mg PO QHS
4. LOPERamide 2 mg PO QID:PRN Diarrhea
5. Hydroxyurea 500 mg PO DAILY
6. Hydroxyurea 1000 mg PO QHS
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Citalopram 40 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (MO)
11. OxyCODONE (Immediate Release) 20 mg PO BID
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Hydroxyurea 500 mg PO DAILY
6. Hydroxyurea 1000 mg PO QHS
7. LACOSamide 200 mg PO BID
8. LOPERamide 2 mg PO QID:PRN Diarrhea
9. OxyCODONE (Immediate Release) 20 mg PO BID
RX *oxycodone 10 mg 2 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
10. Vitamin D ___ UNIT PO 1X/WEEK (MO)
11. Zonisamide 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic pain
Sickle cell disease
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 sickle cell, chest/belly pain // ?pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. Mild cardiomegaly is unchanged. The cardiac and
mediastinal silhouettes are otherwise unremarkable.
IMPRESSION:
No acute cardiopulmonary process. Stable mild cardiomegaly.
Radiology Report
EXAMINATION: DX HAND AND WRIST
INDICATION: ___ with sickle cell dz, s/p trauma to R hand. Evaluate for
fracture.
TECHNIQUE: Three views right hand, three views right wrist
COMPARISON: None.
FINDINGS:
No acute fracture, dislocation, or degenerative change is detected. No bone
erosion or periostitis identified. No suspicious lytic or sclerotic lesion is
identified. No soft tissue calcification or radio-opaque foreign body is
detected.
IMPRESSION:
Normal right hand and wrist radiographs.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Headache, Body pain
Diagnosed with Hb-SS disease with crisis, unspecified
temperature: 97.8
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 154.0
dbp: 100.0
level of pain: 10
level of acuity: 2.0 | #Sickle Cell Pain Crisis
Mr. ___ had a sickle cell pain crisis triggered by his
running out of his medications and potentially the change in
weather, as cold exposure can trigger crises. We did not
uncovere alternative reasons including: anemia (just below
baseline), infection (CXR clear, UA negative, no fever or
leukocytosis, no diarrhea),
electrolyte abnormality (normal BMP), abdominal syndrome (normal
LFT, lipase and nonfocal abd pain). His counts remained stable
and he has been continued on his home regimen of Hydroxyurea
500mg QAM, Hydroxyurea 1000mg QPM, gabapentin, in addition to
IVF. He was given his home oxycodone with dilaudid for
breakthrough. After discussion with his outpatient provider
___, NP from heme-onc, we will continue his current
regimen with no escalation. He understands need for continued
follow up. He expressed understand of the risks of opioids, and
to avoid driving and alcohol. PMP reviewed.
#Seizures
- Continued Vimpat
- Continued Lacosamide
- Continued Gabapentin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Darvocet-N 100 / Percocet / Ceclor / Flagyl / Erythromycin Base
/ Iodine-Iodine Containing / Demerol / Provigil / Latex /
Carafate / Codeine
Attending: ___.
Chief Complaint:
Thigh numbness, urinary incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old -handed female who presents with
1
day of photopsia, urinary incontinence, and bilateral lower
extremity sensory changes.
Her symptoms started ___ evening around 10pm. While watching
television she began to experience flashing, lights
predominantly
in her right vision with obscuration of vision. She woke up the
next morning feeling normal and went to a GI clinic appointment.
She straight cath'd herself as she normally would; however, 10
minutes later she was incontinent of a moderate amount of urine.
This happened several more times throughout the day.
Additionally, she noted numbness in her medial thighs
bilaterally.
Currently, she has no visual complaints, but continues to
experience urinary incontinence and medial thigh numbness.
Of note, the patient finished a 14 day course of doxycycline for
a lyme disease. She says she was bitten by a tick that may have
appeared engorged. She developed a targetoid rash around the
area
and left wrist arthragias.
MS ___ chart review):
Initially developed symptoms in ___ but not diagnosed until
___. Initially, she had numbness in her legs and arms. In
___, she began dropping things and had a few falls. In
___ she developed acute onset blindness while driving
followed by diplopia. An MRI was obtained that showed
demyelination.
Her symptoms have included left-sided optic neuropathy,
Lhermitte's, bilateral trigeminal neuralgia, neurogenic bladder
(straight caths herself at baseline), and chronic pain syndrome
with severe burning dysesthesiae throughout her body. She also
has esophageal dysmotility that is probably related to her
multiple sclerosis.
She was initially treated with IFN-beta, then capaxone, then
glatimer acetate for many years, which she remains on currently
at 240 mg BID. She has a baclofen pump for chronic
pain/spasticity.
Past Medical History:
Multiple sclerosis
Spastic bladder
Diabetes type II
Glaucoma
HTN
HLD
Social History:
___
Family History:
Sister with SLE and ___ lymphoma
Multiple family members with heart disease
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals: Afebrile, 140s-199/60s-80s, RR 18, SpO2 94%
General: Awake, cooperative, NAD.
HEENT: No scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Non-labored breathing on ambient air
Cardiac: RRR, no MRG.
Abdomen: Soft, NT/ND, no masses or organomegaly noted.
Extremities: Warm, well-perfused, no cyanosis, clubbing or edema
bilaterally
Skin: no rashes or lesions noted.
NEUROLOGIC:
-----------
-Mental Status:
Awake, alert, oriented to self, place, time and situation. Able
to relate history without difficulty. Attentive, able to name
___
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Left red
desaturation
III, IV, VI: Full range, conjugate gaze, no nystagmus. Normal
saccades.
V: Decreased temperature on left side of face
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___ 5 ___ 5 5 4 4 4
R 5 ___ 5 ___ 5 5 4 4 4
-Sensory:
Complex, diffuse pattern of decreased pinprick sensation
throughout most of body with relative sparing of the hands.
Dense
loss of pinprick sensation on medial thighs (more so than
surrounding areas). Decreased JPS in feet to ankles and at
fingers bilaterally.
-Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on
FNF or HKS bilaterally.
-Gait:
Able to walk without support from AFOs or walker/cane. Bilateral
foot drop. Cannot heel or toe walk.
DISCHARGE EXAMINATION
=====================
-Mental Status: Awake, alert, cooperative, fluent speech with
intact comprehension, follows midline and appendicular commands.
-Cranial Nerves:
II: PERRL 4 to 2mm ___, no rAPD
III, IV, VI: EOMI without nystagmus aside from questionable
conjugate limitation of left gaze
V: Patchy decrease in sensation to PP along left face
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation
IX, X: Palate elevates symmetrically
XI: ___ strength in trapezii bilaterally
XII: Tongue protrudes in midline
-Motor: Pain-limited weakness (4+/5) in left deltoid and right
iliopsoas, otherwise full power throughout (including, on
initial though unsustained effort, in bilateral TAs).
-Sensory: Diffuse, patchy decrease in sensation to LT and PP
bilaterally, though also including medial thighs not extending
past the knees.
-Reflexes: Deferred.
-Coordination: No intention tremor or dysmetria on FNF
bilaterally.
-Gait: Steady gait with walker without support from AFOs.
Pertinent Results:
___ 06:03AM BLOOD WBC-4.8 RBC-4.49 Hgb-12.8 Hct-40.9 MCV-91
MCH-28.5 MCHC-31.3* RDW-14.5 RDWSD-48.0* Plt ___
___ 06:03AM BLOOD Neuts-67.3 Lymphs-17.6* Monos-11.0
Eos-1.9 Baso-1.0 Im ___ AbsNeut-3.26 AbsLymp-0.85*
AbsMono-0.53 AbsEos-0.09 AbsBaso-0.05
___ 06:03AM BLOOD Glucose-211* UreaN-19 Creat-0.5 Na-138
K-4.5 Cl-101 HCO3-25 AnGap-12
___ 06:03AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
___ 07:22PM BLOOD ALT-23 AST-21 AlkPhos-152* TotBili-<0.2
___ 07:22PM BLOOD Lipase-23
___ 07:22PM BLOOD cTropnT-<0.01
___ 07:22PM BLOOD CRP-3.8
___ 07:22PM BLOOD Lyme Ab-PND Trep Ab-PND
___ 11:21AM URINE Color-Straw Appear-Clear Sp ___
___ 11:21AM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-NEG
___ 11:21AM URINE RBC-5* WBC-6* Bacteri-FEW* Yeast-NONE
Epi-0
___ 09:05PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 11:21 am URINE Source: Catheter.
URINE CULTURE (Pending):
___ 3:21 AM MR ___ SCAN WITH CONTRAST; MR ___ SPINE SCAN
WITH CONTRAST
1. Study is moderately degraded by motion. Additionally, study
is limited due to lack of axial images of thoracic spine.
2. Multilevel cervical spondylosis as described without definite
moderate or severe vertebral canal or neural foraminal
narrowing.
3. Thoracic multilevel spondylosis and epidural lipomatosis with
multilevel moderate vertebral canal narrowing, as described.
4. Within limits of study, no evidence of cervical or thoracic
spinal cord
lesion or enhancement.
5. Please see preceding contrast brain MRI examination for
description of
cranial findings.
6. Limited imaging of the kidneys demonstrate left at least
partially cystic structures, incompletely characterized. If
clinically indicated, consider renal ultrasound for further
evaluation.
___ 3:20 AM MR HEAD W & W/O CONTRAST
1. Study is moderately degraded by motion.
2. Grossly stable nonenhancing white matter lesions as
described, compatible with patient's provided history of
multiple sclerosis.
3. Within limits of study, no definite evidence of new or
enhancing white
matter lesions compared to ___ prior contrast brain
MRI.
4. No definite evidence of acute infarct.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amantadine 100 mg PO BID
2. dimethyl fumarate 240 mg oral BID
3. Esomeprazole 40 mg Other DAILY
4. FLUoxetine 40 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Gabapentin 1800 mg PO TID
7. GlipiZIDE 5 mg PO BID
8. dalfampridine 10 mg oral BID
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Promethazine 25 mg PO Q6H:PRN Nausea
11. Simvastatin 40 mg PO QPM
12. felodipine 10 mg oral daily
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Ursodiol 300 mg PO TID
15. Jardiance (empagliflozin) 10 mg oral Daily
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 (One)
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
2. Amantadine 100 mg PO BID
3. dalfampridine 10 mg oral BID
4. dimethyl fumarate 240 mg oral BID
5. Esomeprazole 40 mg Other DAILY
6. felodipine 10 mg oral daily
7. FLUoxetine 40 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
9. Gabapentin 1800 mg PO TID
10. GlipiZIDE 5 mg PO BID
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Jardiance (empagliflozin) 10 mg oral Daily
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Promethazine 25 mg PO Q6H:PRN Nausea
15. Simvastatin 40 mg PO QPM
16. Ursodiol 300 mg PO TID
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
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: History: ___ with MS and new urinary incontinence and bilateral
sensation changes in legs, also with vision changes yesterday.// Evidence of
MS flare?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: MRI of the head dated ___.
FINDINGS:
Study is moderately degraded by motion, especially on postcontrast imaging.
Within these confines:
Numerous T2 and FLAIR hyperintensities in the white matter, pons and in the
cerebellum are grossly unchanged compared to the prior study. There is mild
to moderate brain atrophy seen, unchanged. There is no abnormal intracranial
enhancement. There is no midline shift. There are no microhemorrhages.
There is no evidence of restricted diffusion. Suprasellar the visualized
portion of the major vascular flow voids are grossly preserved.
Both orbits and globes are preserved. Limited imaging of parotid gland
suggest bilateral subcentimeter nonspecific probable lymph nodes. Right
maxillary sinus probable mucous retention cyst is noted. Bilateral maxillary
sinus and ethmoid air cell mucosal thickening is present.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Grossly stable nonenhancing white matter lesions as described, compatible
with patient's provided history of multiple sclerosis.
3. Within limits of study, no definite evidence of new or enhancing white
matter lesions compared to ___ prior contrast brain MRI.
4. No definite evidence of acute infarct.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: History: ___ with MS and new urinary incontinence and bilateral
sensation changes in legs, also with vision changes yesterday. IV // Evidence
of MS flare?
TECHNIQUE: Sagittal T2, STIR, and T1, and axial T2 and T1 postcontrast
imaging was performed of the cervical and thoracic spine after within ___
contrast brain MRI (clip ___ was performed.
COMPARISON: MRI cervical and thoracic spine dated ___.
FINDINGS:
Study is moderately degraded by motion. Additionally, study is limited due to
lack of axial images of thoracic spine. Within these confines:
CERVICAL AND THORACIC:
Cervical vertebral body alignment is preserved. There is levoscoliosis of the
thoracic spine. Vertebral body heights are preserved. C7, T1 and T8 superior
endplate type ___ ___ changes are seen. Schmorl's nodes seen at multiple
levels throughout the cervical and thoracic spine. There is no prevertebral
soft tissue swelling.
The visualized portion of the spinal cord is grossly preserved in signal and
caliber, without definite abnormal enhancement.
There is loss of intervertebral disc signal throughout the cervicothoracic
spine. Intervertebral discheights are grossly preserved. Nonspecific facet
joint fluid is noted at multiple levels of the cervical spine.
At C2-3 there is facet joint hypertrophy, ligamentum flavum thickening, with
no vertebral canaland no neural foraminal narrowing.
At C3-4 there is facet joint hypertrophy, ligamentum flavum thickening, with
no vertebral canaland no neural foraminal narrowing.
At C4-5 there is disc bulge, facet hypertrophy, ligamentum flavum thickening,
deformation of the ventral thecal sac and spinal cord without definite
associated cord signal abnormality, with mild vertebral canaland mild
bilateral neural foraminal narrowing.
At C5-6 there is disc bulge, facet joint hypertrophy, ligamentum flavum
thickening, left-sided probable perineural cyst, deformation of the ventral
thecal sac and spinal cord without definite associated cord signal
abnormality, with mild vertebral canaland at least mild bilateral neural
foraminal narrowing.
At C6-7 there is disc bulge, facet hypertrophy, ligamentum flavum thickening,
with mild vertebral canaland no neural foraminal narrowing.
At C7-T1 there is disc bulge, right-sided probable perineural cysts, facet
hypertrophy, with no vertebral canaland no neural foraminal narrowing.
At T1-2 there is disc bulge, facet hypertrophy, ligamentum flavum thickening,
with no vertebral canaland no neural foraminal narrowing.
At T2-3 there is facet hypertrophy, ligamentum flavum thickening, epidural
fat, with mild vertebral canaland no neural foraminal narrowing.
At T3-4 there is disc bulge, facet hypertrophy, ligamentum flavum thickening,
pleural fat, with mild vertebral canaland no neural foraminal narrowing.
At T4-5 there is disc bulge, facet joint hypertrophy, ligamentum flavum
thickening, neural fat, with moderate vertebral canaland no neural foraminal
narrowing.
At T5-6 there is disc bulge, facet joint hypertrophy, ligamentum flavum
thickening, epidural fat, with moderate vertebral canaland no neural
foraminal narrowing.
At T___ there is facet joint hypertrophy, ligamentum flavum thickening,
epidural fat, with moderate vertebral canaland no neural foraminal narrowing.
At T7-___ there is disc bulge, facet joint hypertrophy, epidural fat, with
moderate vertebral canaland no neural foraminal narrowing.
At T8-9 there is disc bulge, facet hypertrophy, epidural fat, with moderate
vertebral canaland no neural foraminal narrowing.
At T___-10 there is disc bulge, facet hypertrophy, epidural fat, with mild
vertebral canal and no neural foraminal narrowing.
At T___ there is facet hypertrophy, epidural fat, with mild vertebral canal
and no neural foraminal narrowing.
At T11-___ there is facet joint hypertrophy, ligamentum flavum thickening,
epidural fat, with mild vertebral canal and no neural foraminal narrowing.
At T12-L1 there is facet joint hypertrophy, epidural fat, with mild vertebral
canaland no neural foraminal narrowing.
OTHER:
There is no paravertebral or paraspinal mass identified. Limited imaging of
the kidneys demonstrate left at least partially T2 hyperintense structures,
incompletely characterized.
IMPRESSION:
1. Study is moderately degraded by motion. Additionally, study is limited due
to lack of axial images of thoracic spine.
2. Multilevel cervical spondylosis as described without definite moderate or
severe vertebral canal or neural foraminal narrowing.
3. Thoracic multilevel spondylosis and epidural lipomatosis with multilevel
moderate vertebral canal narrowing, as described.
4. Within limits of study, no evidence of cervical or thoracic spinal cord
lesion or enhancement.
5. Please see preceding contrast brain MRI examination for description of
cranial findings.
6. Limited imaging of the kidneys demonstrate left at least partially cystic
structures, incompletely characterized. If clinically indicated, consider
renal ultrasound for further evaluation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Urinary incontinence
Diagnosed with Unspecified urinary incontinence
temperature: 97.8
heartrate: 102.0
resprate: 16.0
o2sat: 94.0
sbp: 199.0
dbp: 70.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ woman with history notable for
secondary progressive RRMS c/b spastic bladder, trigeminal
neuralgia, DMII, glaucoma, depression, HTN, and HLD presenting
with one day of bilateral medial thigh numbness and urinary
incontinence following usual straight catheterization. Despite
concerns for new MS flare, MRI of the brain and spine did not
reveal evidence of a new inflammatory lesion. Laboratory testing
suggestive of mild urinary tract infection, but otherwise
without evidence of new toxic/metabolic or infectious processes,
though history was notable for recent suspected early localized
Lyme disease s/p appropriate treatment. Symptoms
stable-to-partially-improved at time of discharge.
Precipitant of symptoms unclear though suspect contribution from
urinary tract infection, reassuringly without new inflammatory
or compressive CNS lesions.
TRANSITIONAL ISSUES
1. If symptoms persist, consider repeat urine testing or
broadening of urinary coverage (admission cultures pending at
time of discharge).
2. Consider outpatient Urology follow-up for continued urinary
symptoms despite above.
3. Follow up pending treponemal, Lyme serologies.
4. Outpatient follow-up with PCP, ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization/Coronary angiography ___
History of Present Illness:
The patient is a ___ year old man with no significant PMH who
presents with two days of intermittent mid scapular pain that
radiates through to the mid-chest. The first episode occured two
nights ago while the patient was laying down and lasted about 4
hours and resolved on its own. The second episode occured last
night again while laying down in bed. The pain is sharp, coming
and going and worse when laying flat and with deep inpiration,
relieved by sitting up and associated with shortness of breath
and palpitations. The pain again lasted about four hours and
relieved once he got ASA in the ED. He denies associated
dizziness, dipahoresis, nausea, vomiting. He denies recent URI,
cough, fevers, orthopnea, PND, leg swelling.
.
In the ED, initial vitals were 97.7 64 125/70 16 100%
Labs and imaging significant for troponin of 0.24 and EKG with
RBBB and STE in lead 3, anterior preordial and lateral leads.
D-dimer was negative and CXR showed no acute cardio-pulmonary
process. Cardiology was consulted and recommned plavix load,
heparin drip and the patient was taken to the cath lab. Cardiac
catheterization revealed clean coronaries.
.
On arrival to the floor, patient is feeling well and is chest
pain free at this time.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
syncope or presyncope.
Past Medical History:
None
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMSSION
VS: T=.98.9.BP=.119/66.HR=.64.RR=.18.O2 sat= 100RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, wide splitting of S2 noted at LUSB. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
.
DISCHARGE
VS:97.6 120/79 58 18 100 RA 73.4KG
GENERAL: Oriented x3.
HEENT: pink conjunctiva, moist mucous membranes, oropharynx
clear
NECK: Supple with no JVD.
CARDIAC: RRR, normal S1, widely split S2, No m/r/g. No S3 or S4.
LUNGS: CTABL
EXTREMITIES: No c/c/e. 2+ distal pulses bilaterally
Pertinent Results:
ADMISSION
___ 02:15AM BLOOD WBC-11.7* RBC-5.04 Hgb-15.8 Hct-44.5
MCV-88 MCH-31.2 MCHC-35.4* RDW-12.4 Plt ___
___ 02:15AM BLOOD Neuts-83.2* Lymphs-11.1* Monos-4.0
Eos-1.2 Baso-0.6
___ 02:15AM BLOOD Glucose-117* UreaN-15 Creat-0.8 Na-139
K-3.5 Cl-102 HCO3-30 AnGap-11
___ 10:52AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.4
.
DISCHARGE
___ 07:19AM BLOOD WBC-11.7* RBC-5.12 Hgb-16.4 Hct-45.8
MCV-89 MCH-32.0 MCHC-35.8* RDW-12.2 Plt ___
___ 02:15AM BLOOD Neuts-83.2* Lymphs-11.1* Monos-4.0
Eos-1.2 Baso-0.6
___ 07:19AM BLOOD Glucose-100 UreaN-11 Creat-0.8 Na-141
K-3.7 Cl-104 HCO3-27 AnGap-14
___ 07:19AM BLOOD Calcium-9.2 Phos-2.2 Mg-2.1
.
PERTINENT
___ 02:15AM BLOOD CK(CPK)-225
___ 10:52AM BLOOD ALT-45* AST-49* CK(CPK)-295 AlkPhos-98
TotBili-0.9
___ 05:00PM BLOOD CK(CPK)-573*
___ 07:19AM BLOOD CK(CPK)-470*
___ 02:15AM BLOOD CK-MB-13* MB Indx-5.8
___ 02:15AM BLOOD cTropnT-0.24*
___ 10:52AM BLOOD CK-MB-19* MB Indx-6.4* cTropnT-0.45*
___ 05:00PM BLOOD CK-MB-44* MB Indx-7.7* cTropnT-0.83*
___ 07:19AM BLOOD CK-MB-36* MB Indx-7.7* cTropnT-0.92*
___ 02:15AM BLOOD D-Dimer-<150
.
CXR ___
No focal consolidation, pleural effusion, or pneumothorax is
seen.
Heart and mediastinal contours are within normal limits.
.
EKG
___ 2:27:12 AM
Sinus rhythm. Right bundle-branch block. J point elevation in
leads V4-V6 which may be non-specific but cannot rule out acute
myocardial injury. Repeat tracing and clinical correlation are
suggested. No previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
63 ___ 34 132 29
.
___ 5:25:14 AM
Sinus rhythm. Right bundle-branch block. Small Q waves in leads
V4-V6. Compared to the previous tracing of ___ small Q waves
are now noted in leads V4-v6 along with normalization of the J
point elevation previously noted. This raises the possibility of
myopericarditis. Clinical correlation is suggested.
.
Coronary angiography ___ (Preliminary)
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically apparent coronary artery
disease. The
LMCA, LAD, LCx, and RCA were without agiographically apparent
flow-limiting stensosis.
2. Limited resting hemodynamics revealed systemic arterial
normotension.
FINAL DIAGNOSIS:
1. No angiographically aparent coronary arteries disease.
2. Recommend further work-up for chest pain, EKG changes, and
elevated
troponin, consider myocarditis.
.
ECHOCARDIOGRAPHY
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Medications on Admission:
NONE
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 7 days.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with chest pain and shortness of breath.
COMPARISON: None available.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
FINDINGS: No focal consolidation, pleural effusion, or pneumothorax is seen.
Heart and mediastinal contours are within normal limits.
IMPRESSION: No radiographic evidence for acute cardiopulmonary process.
Gender: M
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: DIFFICULTY BREATHING
Diagnosed with CHEST PAIN NOS, ABN CARDIOVASC STUDY NEC
temperature: 97.7
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 125.0
dbp: 70.0
level of pain: 8
level of acuity: 3.0 | Mr ___ is a ___ with no significant PMH who presented with
chest pain.
.
# CHEST PAIN
The patient's chest pain was pleuritic in nature with relief
when laying forward, suggestive of pericaditis. However, EKG did
not show classic diffuse STE wit PR depression but was
significant for RBBB with some STE in lateral limb leads and j
point elevation in ___ lateral precordial leads. With these
EKG findings, elevated troponins, were most concerning for
STEMI. However, the patient underwent coronary angiography with
no evidence of coronary atherosclerosis or thrombus.
Furthermore, echocardiography revealed normal ventricular wall
motion and EF. In the setting of symptoms suggestive of
pericarditis with elevated cardiac enzymes and abnormal EKG, it
is most likely that the patient has a myocarditis. Patient's
symptoms were mild and myocardial function intact. He remained
hemodynamically stable throughout his course. He was treated
symptomatically and discharged on a course of NSAIDS and
colchicine. Arrangements will be made for outpatient MRI for
further evaluation. He was instructed to follow up with
cardiology upon discharge and avoid strenuous exercise for 6
months.
.
TRANSION OF CARE
The patient had no health insurance, but did apply for Health
Safety Net (HSN). He met with a social worker who provided
assistance. Unfortunately prescription medication not covered on
Target or ___. The Financial ___ Office
was unavailable to approve free care for prescriptions, however,
patient stated that he would be able to pay out-of-pocket.
Follow up was made for patient to be seen at ___ for primary
care through free care. He will also follow up with cardiology
upon discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Optiray 300
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with recent diagnosis of extra-axial right
cerebellopontine angle and anterior parafalcine masses in
___ after a fall, s/p steroids, complicated by gastric ulcer
perforation, s/p gastrectomy in ___, s/p recent EGD given
hemetemesis ___ gastritis and gastric ulcer around the
anastomosis, presents from the rehab with nausea, vomiting, and
abdominal pain.
Per report, patient has AMS over the last ___ of days prior to
presentation. Of note, she was tapered off of steroid for her
meningioma given recent gastric ulcer perforation and
gastrectomy last ___ (about 5 days PTA). She was noted to
be more somnolent. No fever was reported. Nausea and abdominal
discomfort started about 2 days PTA and non-bilious, non-bloody
vomiting started on the day of presentation. Daughters also
reports diarrhea last week.
In the ED, initial VS: 98.5 86 135/58 16 99%. Exam was notable
for abdominal pain and guaiac positive brown stool and bloody
mucous. A&Ox2-3 but with delayed response. Labs are significant
for Crt 1.2 (baseline 1.2 this year), Hct 33.7 (baseline low
___, + UA. Neurosurgery and ACS evalauted patient given her
recently diagnosed intracranial masses, abdominal pain, N/V,
initially thought to be from increased intracranial pressure. CT
head showed no acute change other than the previously noted
masses. Abd CT did not show any acute process. CXR without
consolidations but has mild left sided pleural effusion. She
received 1 L NS, 400 mg cipro IV, morphine, zofran, and
Dilaudid. Foley was placed in the ED showing purulent urine. VS
upon transfer: 97.8 po. HR; 78. BP: 115/45. o2: 98% ra. rr:
___.
Currently, denies pain, sleepy, answers questions appropriately
but delayed response.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, constipation, BRBPR, melena, hematochezia, hematuria
Past Medical History:
- extra-axial masses in the right cerebellopontine angle and
also in the anterior parafalcine regions, likely meningioma,
base on MRI ___
- recent gastric ulcer and perforation, hemorrhagic shock, ARF
___ steroid use, requiring ex-lap Bilroth II gastric resection
and esophago-gastroduodenoscopy
- UGIB s/p EGD ___ found gastritis and ulcer around the
anastomosis
- h/o uterine CA treated with chemo in ___
- HTN
- vertigo
- lumbar stenosis
Social History:
___
Family History:
N/C
Physical Exam:
VS - Temp 97.7 F, BP 130/61, HR 81, R 16, O2-sat 99% RA
GENERAL - elderly female, appropriate, lethargic
HEENT - sclerae anicteric, mucous membrane dry
NECK - supple
LUNGS - bibasilar crackles, no wheeze or rhonchi
HEART - RRR, ___ SEM in RUSB
ABDOMEN - distended, NT, BS+, passing gas, + J tube in place,
minimal erythema around the tube, TTP in epigastrium, no
guarding
EXTREMITIES - WWP, 1+ edema up to the thighs, 2+ DP pulses
bilaterally
SKIN - no rashes or lesions
NEURO - lethargic, oriented to self/location/time, noncompliant
with examination but follows simple commands
On discharge:
vs tm 98.8 tc97.2 BP 144/67 (138-173/81-98) HR 80 (68-87) 22 93%
RA
Gen: well appearing elderly female, NAD, sitting upright in bed
HEENT: PEERL, no icterus, OP clear, MM dry
Neck: no lymphadenopathy
CV: RRR, ___ midsystolic murmur best at RUSB. no rubs/gallops
Lungs: clear bilaterally
Abd: soft, ND, NT. Gtube site appears clean dry, dressing
intact.
Ext: warm and well perfused, ___ pulses. 2+ pitting edema
bilaterally to thighs. also in upper extremities extending past
elbow.
Neuro: CN2-11 intact. Unable to shrug shoulders for me. Finger
to nose intact, though not able to reach far. Alert and oriented
X3, responding to questions appropriately.
Pertinent Results:
Labs on Admission:
___ 07:50PM WBC-9.5# RBC-3.88* HGB-11.3* HCT-33.2*
MCV-86# MCH-29.1# MCHC-33.9 RDW-16.5*
___ 07:50PM NEUTS-88.7* LYMPHS-8.4* MONOS-2.1 EOS-0.7
BASOS-0.1
___ 07:50PM PLT COUNT-280
___ 07:50PM ___ PTT-31.7 ___
___ 07:50PM GLUCOSE-102* UREA N-52* CREAT-1.2* SODIUM-141
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-22 ANION GAP-13
___ 07:50PM ALT(SGPT)-25 AST(SGOT)-26 ALK PHOS-105 TOT
BILI-0.2
___ 07:50PM LIPASE-157*
___ 09:50PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 09:50PM URINE RBC-15* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-2
___ 09:50PM URINE WBCCLUMP-MANY MUCOUS-RARE
Labs on Discharge:
___ 04:15AM BLOOD WBC-8.8 RBC-3.15* Hgb-9.0* Hct-27.8*
MCV-88 MCH-28.5 MCHC-32.3 RDW-16.1* Plt ___
___ 04:15AM BLOOD Glucose-53* UreaN-46* Creat-1.3* Na-142
K-3.7 Cl-108 HCO3-22 AnGap-16
___ 04:20AM BLOOD Calcium-7.6* Phos-4.3 Mg-1.7
Relevant labs:
___ 08:45AM BLOOD Cortsol-18.7
Imaging:
CT head: ___. Large mass in the right posterior fossa seen on MRI causing
mass effect on the right cerebellar hemisphere and fourth
ventricle. No significant change in adjacent edema and no
evidence of obstructive hydrocephalus.
2. Stable appearance of left parafalcine frontal extra-axial
mass. Both lesions described in impression #1 and 2 are thought
to represent meningiomas and were more thoroughly characterized
on the previous MRI.
3. Interval development of right maxillary sinus opacification
which likely represents acute sinus disease.
CXR: ___
Low lung volumes, with a small bilateral pleural effusions
CT abdomen/pelvis: ___. No acute intra-abdominal process. Specifically, no bowel
obstruction or
free air. Patent gastrojejunostomy anastomosis.
2. Trace contrast material lining the anterior surface of the
left hepatic
lobe and posterior to the spleen is likely old spillage, as
there is lack of
free intraperitoneal air or simple fluid on the current
examination.
3. Cholelithiasis.
4. Small bilateral pleural effusions with adjacent compressive
atelectasis.
Microbiology:
___ 7:50 pm URINE Site: NOT SPECIFIED
GRAY TOP HOLD ___.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
- ferrous ulfate 300 mg
- folic acid 1 mg
- hydroxyzine 50 mg IM q4hprn
- lactobacillus 4 tab TID
- metoprolol 25 mg q8h prn
- nystatin powder TID
- zofran 4 mg IV q6h prn
- quetiapine 25 mg qHS prn
- sucralfate 1000 mg QID
- omeprazole 40 mg BID
- atorvastatin 10 mg
- amlodipine 2.5 mg daily
- tylenol ___ mg q6h prn for pain
- aspirin 81 mg daily
.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydroxyzine HCl 25 mg Tablet Sig: ___ Tablets PO every four
(4) hours as needed for itching.
5. lactobacillus acidophilus Capsule Sig: Four (4) Capsule
PO three times a day.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. nystatin (bulk) 1 billion unit Powder Sig: One (1)
application Miscellaneous three times a day: to affected area.
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Tablet(s)
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. senna 8.6 mg Capsule Sig: One (1) Tablet PO twice a day as
needed for constipation.
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
18. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 10 days. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
nausea/vomiting
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Recent J-tube placement and Billroth II for gastric ulcer
perforation. Concern for small-bowel obstruction or perforation.
COMPARISON: CT available from ___.
TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were
obtained with the use of oral contrast only. Coronal and sagittal
reformations were performed at 5-mm slice thickness.
ABDOMEN:
Small bilateral pleural effusions are present, with adjacent compressive
atelectasis (2:2). The heart is mildly enlarged. There is no pericardial
effusion. Severe atherosclerotic calcifications are seen at the aortic valve
and coronary vessels (2:7). The proximal ascending thoracic aorta is
prominent, measuring 35 mm (2:1).
There is a small hiatal hernia (2:15).
A 3.3 x 2.8 cm well-circumscribed hypodense lesion within the left hepatic
lobe (2:26) has enlarged since the ___ examination, most likely
a cyst. A tiny calcification within the right lobe (2:21) is unchanged. An
ill-defined subcentimeter hypodensity at the inferior aspect of the right
hepatic lobe (2:10) and two adjacent subcentimeter lesions are slightly
increased in size since ___, but remain too small for further
characterization. There is no intra- or extra-hepatic bile duct dilation.
Gallstones are present within an otherwise normal-appearing gallbladder (2:32,
27). The pancreas, adrenal glands, kidneys, and spleen are within normal
limits.
The patient is status post partial gastrectomy and Billroth II. Oral
contrast, introduced from a J-tube terminating within the mid jejunum,
refluxes into the stomach via the gastrojejunostomy, and into the duodenal
limb (301B:25). There is no evidence of obstruction.
A trace amount of hyperdense material lining the anterior surface of the left
hepatic lobe (2:20) and posterior to the spleen (2:16) is likely contrast
material. This finding more likely related to contrast spillage prior to the
current examination, as there is lack of free intraperitoneal air or free
simple fluid.
PELVIS: Numerous iliac surgical clips denote prior lymph node dissection.
The uterus is surgically absent. No adnexal masses are detected. A Foley
catheter terminates within a collapsed bladder. There is no intrapelvic free
fluid or lymphadenopathy. Sigmoid diverticulosis is present.
OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or
lytic lesions are identified. Severe multilevel degenerative changes are seen
throughout the thoracolumbar spine, including a mild wedge compression
deformity at T12, with neighboring endplate sclerosis, loss of disc height
superiorly and inferiorly, and extensive anterior and posterior osteophytosis.
There is grade 1 anterolisthesis of L4 over L5, with loss of intervertebral
disc height, vacuum phenomenon (___), and moderate thecal sac narrowing.
The patient is status post total right hip arthroplasty, with no evidence of
hardware failure or loosening. (301B:35).
IMPRESSION:
1. No acute intra-abdominal process. Specifically, no bowel obstruction or
free air. Patent gastrojejunostomy anastomosis.
2. Trace contrast material lining the anterior surface of the left hepatic
lobe and posterior to the spleen is likely old spillage, as there is lack of
free intraperitoneal air or simple fluid on the current examination.
3. Cholelithiasis.
4. Small bilateral pleural effusions with adjacent compressive atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with SWELLING IN HEAD & NECK, NAUSEA WITH VOMITING
temperature: 98.5
heartrate: 86.0
resprate: 16.0
o2sat: 99.0
sbp: 135.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | ___ yo F with recent diagnosis of extra-axial right
cerebellopontine angle and anterior parafalcine masses in
___, s/p steroids taper because of gastric ulcer
perforation, s/p gastrectomy in ___, s/p recent EGD given
hemetemesis ___ gastritis and gastric ulcer around the
anastomosis ___, who presented with nausea anda bdominal pain.
.
# Nausea/abdominal pain: Etiology unclear but likely ___ known
gastritis and PUD as visualized on EGD ___. She was evaluated
by neurosurgery, who confirmed elevated ICP likely not a
contributing factor. Adrenal insufficiency ___ steriod taper
unlikely given normal cortisol. Her symptoms improved by the
following morning. S hew as continued on PPI, sucralfate, and
zofran. It is anticipated that her symptoms will continue to
wax and wane as her gastric ulcer heals. Tube feedings can be
held if symptoms recur.
.
# complicated UTI. UA grossly positive with > 100,000 CFU ecoli
from chronic indwelling foley catheter. Abd/pelvis CT did not
show signs of hydronephrosis/ pyelonephrosis. Foley was
discontinued. No reported fever or leukocytosis although has a
left shift. She was treated with ___efpodoxime for
complicated UTI.
.
# Acute metabolic encephalopathy. Based on history, most likely
delirium/ toxic metabolic encephalopathy ___ UTI, recent
illness. CT head without significant change, unlikely to
represent subclinical seizures. No other obvious infectious
etiology at this time. Symptoms improved by following morning
.
# Intracranial masses: likely meningioma given extra-axial
nature of the masses. Masses causing significant midline shift
with risk of uncal herniation but per neurosurgery, no acute
inpatient treatment is indicated. Steroids were held given
recent GI bleeding and complications.
- f/u with neurosurgery as outpatient for operative management
- neurology follow up with Dr. ___ as outpatient
.
# HTN. Normotensive at this time
- continue metoprolol and amlodipine as before
.
# HLD
- continue atorvastatin 10 mg qHS |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Transfer for ECG changes from ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ with history of CAD s/p remote LAD stenting
___, ___, PVD s/p angioplasty to the R leg, ESRD on HD
(___ Dialysis), CML (dx ___, on hydroxyurea), HTN,
and T2DM who is transferred from ___ after he was found
to have ECG changes concerning for ACS.
Patient was initially evaluated at ___ earlier on
___ after he experienced bleeding from his fistula during
HD that morning. A figure-eight stitch was placed with good
hemostasis and patient was subsequently discharged home. While
eating at ___ with his wife ~1h later, patient became
acutely nauseous and lightheaded, nearly fainting as per his
wife (concern for vasovagal syncope - patient had eaten a full
meal since the night before). An ambulance was called and
patient was brought back to ___. ECG on arrival showed
lateral ST depressions and ST elevations in V1 and aVR,
concerning for L main disease (though not meeting STEMI
criteria). Request was
made for transfer to ___ so that patient could possibly
undergo coronary angiography over the weekend. Other than the
episode of syncope/emesis, patient denies any recent chest pain,
SOB, or palpitations. Of note, patient did not have any anginal
symptoms at the time of his LAD stent.
In the ED, initial VS were: 98 73 102/52 18 94% RA
Exam notable for:
Fistula in the right upper extremity with good thrill and bruit
with a figure-of-eight stitch neurovascular intact distally
EKG: NSR (71bpm), normal axis, normal intervals, RSR' V1-V2,
diffuse TWIs, 1mm STE aVR, ~1mm inferolateral STDs.
Labs showed:
CBC 12.1>11.___.7<333 (75% PMNs, MCV 123)
BMP ___
___ 32331
ALT 13
AST 18
ALP 56
Tbili .5
Albumin 3.7
Lipase 16
Trop .06
INR 1.3
___ 13.8
PTT 31.9
UA : 1.014 SG, pH 8.5, urobilinogen NEG, bilirubin NEG, leuk
NEG, nitrite NEG, >600 prot, 150 glucose, ketone NEG, 1 RBC, 6
WBCs, non bacteria
Imaging showed:
CXR ___
FINDINGS:
There is elevation of the right hemidiaphragm with overlying
atelectasis. Streaky right middle lobe opacity may relate to
atelectasis, but underlying infection is not excluded in the
appropriate clinical setting. The left lung is grossly clear. No
pleural effusion or pneumothorax is seen. The cardiac silhouette
size is top-normal. Mediastinal contours are unremarkable. No
pulmonary edema is seen.
IMPRESSION:
Elevated right hemidiaphragm with overlying atelectasis. Streaky
right middle lobe opacity may relate to atelectasis, but
underlying infection is not excluded in the appropriate clinical
setting.
Consults: Cardiology
Patient received: NOTHING
Transfer VS were: 97.9 73 112/44 14 98% RA
On arrival to the floor, patient recounts the history as above.
He denies any chest pain, SOB, palpitations, or recurrent
lightheadedness/dizziness. Of note, patient did undergo likely
LAD stenting in ___ ___, and at that time he had
experienced no anginal equivalents. Otherwise, no ongoing
issues with RUE fistula. No fevers/chills.
10-point ROS is otherwise NEGATIVE.
Past Medical History:
CAD s/p remote LAD stenting ___, ___
PVD b/ claudication s/p angioplasty to the R leg
ESRD on HD (MWF Fresenius Dialysis)
CML (dx ___, on hydroxyurea)
HTN
T2DM
Hypothyroidism
Restless legs syndrome
Gout
Vertigo
Social History:
___
Family History:
Reviewed and non-contributory to this admission.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: 98.8 123/51 69 16 97 RA
GENERAL: NAD, pleasant in conversation
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: JVP elevated 2cm above the clavicle with HOB at 45degrees.
HEART: RRR, S1/S2, ___ systolic murmur best heard at the LUSB,
no gallops or rubs
LUNGS: Decreased breath sounds, especially in the lower R lung
field. Otherwise CTABL, no wheezes.
ABDOMEN: Normoactive BS throughout, nondistended, nontender in
all quadrants, no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema. RUE fistula s/p
superficial repair, no bleeding, +palpable thrill.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
=======================
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 1009)
Temp: 97.6 (Tm 98.8),
BP: 145/63 (123-172/51-73),
HR: 59 (53-74),
RR: 16 (___),
O2 sat: 96% (95-99), O2 delivery: Ra,
Wt: 167.55 lb/76.0 kg
GENERAL: Well appearing man sitting up in bed speaking to me
comfortably
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
Small persistent bleed on face from shaving cut.
NECK: JVP visible at the base of the neck at 90 degrees
HEART: S1/S2 regular, ___ systolic murmur auscultated throughout
the procordium
LUNGS: Moderately decrease lung sounds throughout. Otherwise
clear to auscultation, no wheezes.
ABDOMEN: Normoactive BS throughout, nondistended, nontender in
all quadrants, no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema. RUE fistula s/p
superficial repair, no bleeding, +palpable thrill.
PULSES: 2+ radial pulses bilaterally. Warm lower extremities
with very faint DP pulses.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 07:51PM WBC-12.1* RBC-2.83* HGB-11.2* HCT-34.7*
MCV-123* MCH-39.6* MCHC-32.3 RDW-14.4 RDWSD-65.5*
___ 07:51PM NEUTS-75* BANDS-1 LYMPHS-3* MONOS-11 EOS-0
BASOS-8* ___ METAS-1* MYELOS-1* AbsNeut-9.20* AbsLymp-0.36*
AbsMono-1.33* AbsEos-0.00* AbsBaso-0.97*
___ 07:51PM ___
___ 07:51PM cTropnT-0.06*
___ 07:51PM LIPASE-16
___ 07:51PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-56 TOT
BILI-0.5
___ 07:51PM GLUCOSE-149* UREA N-15 CREAT-2.9* SODIUM-140
POTASSIUM-5.1 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15
___ 09:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN->600*
GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-NEG
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 07:55AM BLOOD WBC-9.8 RBC-2.76* Hgb-11.1* Hct-34.3*
MCV-124* MCH-40.2* MCHC-32.4 RDW-14.2 RDWSD-64.3* Plt ___
___ 07:55AM BLOOD Glucose-137* UreaN-21* Creat-3.7* Na-141
K-4.9 Cl-96 HCO3-30 AnGap-15
___ 07:51PM BLOOD cTropnT-0.06*
___ 01:55AM BLOOD CK-MB-3 cTropnT-0.07*
___ 07:55AM BLOOD CK-MB-3 cTropnT-0.07*
===========================
REPORTS AND IMAGING STUDIES
===========================
___ CARDIAC PERFUSION STUDY
HISTORY: ___ year old man with history of PCI to LAD, ESRD, now
presenting with
syncope.
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was
infused
intravenously over 20 seconds followed by a saline flush.
TECHNIQUE:
ISOTOPE DATA: (___) 10.1 mCi Tc-99m Sestamibi Rest;
(___) 27.0 mCi Tc-99m Sestamibi Stress; DRUG DATA: (Non-NM
admin) Regadenoson;
IMAGING METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was injected approximately 45 minutes prior to obtaining
the resting images.
Following intravenous infusion of the pharmacologic agent, the
stress dose of sestamibi was administered intravenously. Stress
images were obtained
approximately 30 minutes following tracer injection.
Following resting images and following intravenous infusion,
approximately
three times the resting dose of Tc-99m sestamibi was
administered intravenously. Stress images were obtained
approximately 30 minutes following tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
FINDINGS:
The image quality is adequate.
Left ventricular cavity size is enlarged with EDV of 158ml.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is decreased
at 43%.
IMPRESSION:
LV enlargement and low EF. No perfusional defect or wall motion
abnormality.
============
MICROBIOLOGY
============
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Labetalol 100 mg PO BID
4. Allopurinol ___ mg PO DAILY
5. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Hydroxyurea 1000 mg PO 5X/WEEK (___)
8. Hydroxyurea 500 mg PO 2X/WEEK (___)
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Meclizine 12.5 mg PO Q8H:PRN dizziness
11. rOPINIRole 0.5 mg PO QPM
12. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Cinacalcet 30 mg PO DAILY
14. bromfenac 0.09 % ophthalmic (eye) DAILY
Discharge Medications:
1. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. bromfenac 0.09 % ophthalmic (eye) DAILY
5. Cinacalcet 30 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Hydroxyurea 1000 mg PO 5X/WEEK (___)
8. Hydroxyurea 500 mg PO 2X/WEEK (___)
9. Labetalol 100 mg PO BID
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Meclizine 12.5 mg PO Q8H:PRN dizziness
12. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
13. rOPINIRole 0.5 mg PO QPM
14. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
1) Coronary artery disease
# End stage renal disease on hemodialysis
# Diabetes mellitus II
# Hypertension
# Chronic myeloid leukemia
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 chest pain// eval for chest pain
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
There is elevation of the right hemidiaphragm with overlying atelectasis.
Streaky right middle lobe opacity may relate to atelectasis, but underlying
infection is not excluded in the appropriate clinical setting. The left lung
is grossly clear. No pleural effusion or pneumothorax is seen. The cardiac
silhouette size is top-normal. Mediastinal contours are unremarkable. No
pulmonary edema is seen.
IMPRESSION:
Elevated right hemidiaphragm with overlying atelectasis. Streaky right middle
lobe opacity may relate to atelectasis, but underlying infection is not
excluded in the appropriate clinical setting.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Abnormal EKG, Syncope, Transfer
Diagnosed with Syncope and collapse
temperature: 98.0
heartrate: 73.0
resprate: 18.0
o2sat: 94.0
sbp: 102.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | ___ with history of CAD s/p remote LAD stenting ___, ___,
PVD s/p angioplasty to the R leg, ESRD on HD (MWF Fresenius
Dialysis), CML (dx ___, on hydroxyurea), HTN, and T2DM who
presented to ___ on ___ after an episode of
dizziness. He was found to have ECG changes including TWI and
STD and transferred to ___ for further management. Initial
TropT was 0.06 -> 0.07 with CK-MB 3. His ECG changes were felt
to be non-specific most likely ___ LVH. He had a stress nuclear
study which showed no perfusion defects per the attending
radiologist. The final report, however, was not uploaded by the
time of discharge. Pt was discharged with instructions to follow
up with his PCP and cardiologist.
# Leukocytosis -
WBC count only mildly elevated at 12.1, 75% neutrophils on
admission. No sign of pneumonia on CXR. UA is not consistent
with cystitis. Of note, patient has a history of CML, currently
on hydroxyurea. His WBC was 13.5 on ___ and 15 on ___.
He was last seen by his oncologist on ___ and thought to be
doing well on his regimen of hydroxyurea. Patient WAS afebrile
and HD stable, no indication for empiric antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Left brachial access,angiogram with celiac stent L
brachial access
History of Present Illness:
___ w/ PMHx of HTN, anterior MI in ___ w/ unclear history of
cardiac stenting and depression, who presented to osh with
approx 3 weeks of abdominal pain improved w/ food, and melena.
Pt underwent outpt CT abdomen/pelvis for workup of this pain and
was found to have aortic dissection of lower thoracic arota and
abdominal aortia w/ marked narrowing of celiac at takeoff, and
complete occlusion of the SMA. ___ is also occluded, as are both
iliac arteries appear occluded. Renal arteries appear to be fed
off of true lumen.
Past Medical History:
Patient is an extremely poor historian
CAD, anterior MI in ___ s/p ? stenting, HTN, HL,
depression, dvt (refractory to coumadin)
PAST SURGICAL HISTORY: cornoary stenting
Social History:
___
Family History:
Dm, vascular disease
Physical Exam:
Gen: Thin male in nad
CV: RRR
Lungs: CTA bilat
Abd: Soft, non tender, no masses
Extremities: Warm, no edema, no wounds. Non palpable distal
pulses-dopplerable dp/pt bilat
Groin: puncture site c/d/i
Pertinent Results:
___ 03:30AM BLOOD WBC-6.9 RBC-3.95* Hgb-12.9* Hct-38.2*
MCV-97 MCH-32.6* MCHC-33.7 RDW-13.4 Plt ___
___ 04:15AM BLOOD ___ PTT-149.3* ___
___ 03:30AM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-140
K-3.7 Cl-107 HCO3-24 AnGap-13
___ 03:30AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.3
Radiology Report CTA ABD & PELVIS Study Date of ___ 6:13 ___
IMPRESSION:
1. Type B aortic dissection, originating from the distal
descending
intrathoracic aorta. Celiac axis originates from the true lumen
and appears narrowed. The branches of the celiac axis appear
patent. The ostium of the SMA is thrombosed, which
reconstitutes distally. Infrarenal aorta is completely
thrombosed. The ___ is not opacified. Common iliac vessels
bilaterally are thrombosed. Internal and external iliac vessels
reconstitute just distal to the bifurcation of common iliac
arteries.
2. Wedge-shaped renal hypodensities, left greater than right,
most likely
represent renal infarcts.
3. Colonic diverticula without associated inflammatory changes.
4. Punctate 2mm nodule in the right lower lobe. Recommed
follow-up CT in 12 months in the setting of smoking history or
high risk for malignancy,
otherwise no follow-up is needed.
Medications on Admission:
ASA 81', pravastatin 20', lisinopril 20'
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Enoxaparin Sodium 100 mg SC QD
take until inr 2.0
RX *enoxaparin 100 mg/mL 100 mg daily Disp #*30 Syringe
Refills:*0
3. Lisinopril 20 mg PO DAILY
4. Pravastatin 20 mg PO DAILY
5. Aspirin 81mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Celiac Artery Stenosis
Chronic Aorto-iliac occlusion
Type B Aortic Dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with new diagnosis of aortic dissection Assess for
extent of the dissection.
COMPARISONS: Reference CT abdomen of the same date from ___.
TECHNIQUE: MDCT-acquired contiguous images from thoracic inlet to pubic
symphysis were obtained with intravenous contrast. Coronally and sagittally
reformatted images were provided.
FINDINGS:
CT OF THE CHEST: Pulmonary artery is well opacified without perfusion defect.
There are scattered mediastinal and hilar lymph nodes, which do not meet CT
criteria for pathologic enlargement. Heart is normal in size without
pericardial effusion. LAD stent is in place. There is mild centrilobular
emphysema, most pronounced in lung apices. No suspicious pulmonary mass or
nodule is identified. There is no focal consolidation. Bibasilar dependent
atelectasis is noted, no pleural effusion. Linear opacities in the lung
bases, most likely represent atelectasis. There is a punctate 2mm nodular
opacity in the right lower lobe (2:45). Tracheobronchial tree is patent to
subsegmental levels.
CT OF THE ABDOMEN: The liver enhances homogeneously without suspicious focal
lesions. There is no intrahepatic biliary ductal dilatation. The portal vein
appears patent. The gallbladder is incompletely distended. There is no
gallbladder wall edema or pericholecystic fluid collection to suggest acute
inflammation. Small amount of contrast is seen within the gallbladder lumen,
which likely reflects vicarious excretion of contrast. The spleen is
unremarkable. The pancreas enhances homogeneously without ductal dilatation
or peripancreatic fluid collection. The adrenal glands are normal. The
kidneys enhance and excrete contrast symmetrically without evidence of
hydronephrosis. Wedge-shaped hypodensity involving the lower pole of the left
kidney is noted. Perfusion of the superficial cortex is preserved (300b:31).
Similar but smaller hypodensity in the lower pole of the right kidney is also
seen (300b:34).
Small and large bowel loops are normal in caliber without evidence of bowel
wall thickening or obstruction. There is no free air or free fluid within the
abdomen. There are scattered mesenteric and retroperitoneal lymph nodes,
which do not meet CT criteria for pathologic enlargement.
CT OF THE PELVIS: The bladder, distal ureters, rectum and sigmoid colon are
unremarkable. There are scattered diverticula within sigmoid colon without
associated inflammatory changes. There is no free air or free fluid within
the pelvis. There is no pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions seen.
CTA: The ascending aorta is intact. The great vessels are unremarkable.
There is a type B dissection, which originates from the distal descending
intrathoracic aorta just above the hiatus. The celiac axis originates from
the true lumen, however, it appears narrowed. The distal branches of the
celiac axis appear patent. The ostium of the SMA appears thrombosed. The SMA
reconstitutes distally. Two renal arteries are seen on the right and a single
renal artery is noted on the left, which appear patent. The infrarenal
portion of the aorta is completely thrombosed. The ___ appears thrombosed.
No fluid detected within common iliac arteries bilaterally. Internal and
external iliac arteries reconstitute at the level of the common iliac artery
bifurcation bilaterally. Common femoral arteries appear patent.
IMPRESSION:
1. Type B aortic dissection, originating from the distal descending
intrathoracic aorta. Celiac axis originates from the true lumen and appears
narrowed. The branches of the celiac axis appear patent. The ostium of the
SMA is thrombosed, which reconstitutes distally. Infrarenal aorta is
completely thrombosed. The ___ is not opacified. Common iliac vessels
bilaterally are thrombosed. Internal and external iliac vessels reconstitute
just distal to the bifurcation of common iliac arteries.
2. Wedge-shaped renal hypodensities, left greater than right, most likely
represent renal infarcts.
3. Colonic diverticula without associated inflammatory changes.
4. Punctate 2mm nodule in the right lower lobe. Recommed follow-up CT in 12
months in the setting of smoking history or high risk for malignancy,
otherwise no follow-up is needed.
Radiology Report
INDICATION: Aortic dissection and leg ischemia, vein mapping for bypass
surgery.
No comparison.
TECHNIQUE: Realtime grayscale and Doppler ultrasound imaging of bilateral
great saphenous veins for mapping purposes.
FINDINGS: The right great saphenous vein is patent with caliber ranging from
2.0 mm to 6.3 mm. The left great saphenous vein is patent with calibers
ranging from 2.5 mm to 4.5 mm. The small saphenous veins were very small in
caliber and therefore not measured.
CONCLUSION: Bilateral patent great saphenous veins with diameters as above,
please see technologist's worksheet for more detailed measurements. Small
saphenous veins were very small in caliber.
Radiology Report
INDICATION: Aortic dissection with leg ischemia.
COMPARISON: Abdominal CTA ___.
TECHNIQUE: Bilateral lower extremity blood pressure, pulse volume recording,
and arterial Doppler tracing.
FINDINGS: The ABI cannot be accurately measured as there are no dopplerable
arterial waveforms in the posterior tibial or dorsalis pedis arteries in
either leg. Pulse volume recordings are severely dampened throughout both
lower extremities. There are monophasic arterial Doppler tracings in
bilateral common femoral and popliteal arteries. Absent waveforms in
bilateral posterior tibial and dorsalis pedis arteries.
CONCLUSION: Severe arterial insufficiency, bilateral lower extremities,
likely on the basis of known aortic occlusion. Difficult in this setting to
assess for superimposed femoral, popliteal or tibial level disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DISSECTION
Diagnosed with DISS AORT ANEURYSM UNSPEC SITE, THORACIC AORTIC EMBOLISM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Mr. ___ was transfered to the CVICU, on an esmolol gtt for
htn control, and a heparin gtt for anticoagulation given his
aorto-iliac occlusion and celiac stenosis. Given his heavy
drinking history, he was also started on a ciwa scale. His type
B dissection was managed medically with blood pressure control.
The decision was made to take him to the OR for celiac artery
stenting on ___. He tolerated the procedure well, and was
transfered to the VICU postoperatively. He remained
hemodynamicaly stable and was transitioned to oral
antihypertensives. His aorto-iliac occlusion is chronic, and
there is no intervention other than long term anticoagulation.
He was transitioned off a heparin gtt and onto lovenox. We
initially planned to put him on a lovenox/coumadin bridge, but
in talking with his PCP, ___ learned that he has
previously failed coumadin therapy - taking up to 60mg daily
without a therapeutic INR. He had recommended sending Mr. ___
on 10mg of coumadin dialy but given that the patient will not be
getting an INR draw for 5 days, we decided to send him on only
lovenox ___ daily, and no coumadin. We will ask Dr. ___ to
initiate coumadin next week and follow very closely. We also
asked Dr. ___ to refer Mr. ___ to a hematologist for
further workup given his severe occlusive disease, and failed
coumdain therapy in the past. Mr. ___ was discharged on ___
with instructions to follow up with his PCP on ___. He will
see Dr. ___ in a month with a duplex of his celiac
artery, abi's and pvrs, as well as a carotid duplex. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ceftazidime / omeprazole / rufinamide / tiagabine / vancomycin
Attending: ___.
Chief Complaint:
s/p motor vehicle collision
Major Surgical or Invasive Procedure:
___: renal angiography
History of Present Illness:
This patient is a ___ year old male who transferred from OSH for
MVC. history is all per transfer paperwork and Medflight as
patient is nonverbal, which is baseline per med flight. He was
restrained in chair car versus tree MVC this morning. CT imaging
at outside hospital showed grade 4 renal laceration with
extravasation and fluid around the liver concerning for
hemoperitoneum. He dropped his blood pressure to 80 systolic at
one point. Hematocrit was 42. he received 2 L normal saline, one
unit of packed red blood cells infusing.
Past Medical History:
PMH: developmental delay, spastic quadriplegia, GERD, horseshoe
kidney, seizure d/
PSH: vagal stimulator, Gtube, C2-C5 laminectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION
Temp: 99.2 HR: 130 BP: 106/88 Resp: 18 O(2)Sat: 92% RA
Constitutional: nonverbal at baseline occasionally moaning
HEENT: Normocephalic, atraumatic
Chest: course breath sounds
Cardiovascular: tachycardic, regular
Abdominal: soft, tender epigastrium
GU/Flank: frank blood in Foley
Extr/Back: No cyanosis, clubbing or edema
Skin: ecchymosis lower abdomen
Neuro: awake
Psych: nonverbal
___: left femoral TLC in place
Pertinent Results:
___ 06:10AM BLOOD WBC-9.2 RBC-4.30* Hgb-13.2* Hct-37.9*
MCV-88 MCH-30.8 MCHC-34.9 RDW-13.7 Plt ___
___ 12:45PM BLOOD WBC-8.4 RBC-4.18* Hgb-13.2* Hct-36.7*
MCV-88 MCH-31.7 MCHC-36.1* RDW-13.9 Plt ___
___ 02:03AM BLOOD WBC-8.9 RBC-3.72* Hgb-11.8* Hct-31.9*
MCV-86 MCH-31.6 MCHC-36.8* RDW-14.1 Plt ___
___ 12:24AM BLOOD WBC-11.7* RBC-4.13* Hgb-12.9* Hct-36.1*
MCV-87 MCH-31.2 MCHC-35.8* RDW-13.8 Plt ___
___ 02:25PM BLOOD Hct-34.4*
___ 04:10AM BLOOD WBC-12.4* RBC-4.28* Hgb-13.4* Hct-36.4*
MCV-85 MCH-31.4 MCHC-36.9* RDW-14.2 Plt ___
___ 08:30PM BLOOD WBC-15.9* RBC-4.61 Hgb-14.4 Hct-40.5
MCV-88 MCH-31.3 MCHC-35.6* RDW-14.3 Plt ___
___ 05:26PM BLOOD WBC-13.5* RBC-4.43* Hgb-13.8* Hct-39.4*
MCV-89 MCH-31.1 MCHC-35.0 RDW-14.0 Plt ___
___ 05:00PM BLOOD WBC-11.1* RBC-3.92* Hgb-12.4* Hct-34.9*
MCV-89 MCH-31.5 MCHC-35.4* RDW-14.0 Plt ___
___ 02:50PM BLOOD WBC-14.0* RBC-4.01* Hgb-12.4* Hct-35.3*
MCV-88 MCH-31.0 MCHC-35.2* RDW-13.2 Plt ___
___ 05:15AM BLOOD Glucose-96 UreaN-8 Creat-0.4* Na-135
K-4.0 Cl-101 HCO3-25 AnGap-13
___ 01:34PM BLOOD Glucose-98 UreaN-4* Creat-0.4* Na-135
K-3.2* Cl-98 HCO3-27 AnGap-13
___ 02:03AM BLOOD Glucose-90 UreaN-6 Creat-0.4* Na-136
K-3.2* Cl-100 HCO3-27 AnGap-12
___ 12:24AM BLOOD Glucose-109* UreaN-7 Creat-0.5 Na-133
K-3.5 Cl-103 HCO3-20* AnGap-14
___ 04:10AM BLOOD Glucose-111* UreaN-9 Creat-0.4* Na-137
K-3.6 Cl-111* HCO3-19* AnGap-11
___ 01:34PM BLOOD Calcium-7.7* Phos-2.0* Mg-1.8
___ 02:03AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.5*
___ 12:24AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.6
Imaging Findings:
CT A/P: Horseshoe kidney with grade IV renal laceration in the
midline. There is a small volume of hyperdense fluid around the
laceration. There is no active extravasation of contrast.
renal stones are visualized bilaterally. Hyperdense material
layering in the bladder. Small amount of perihepatic fluid with
intermediate density
RENAL ARTERIOGRAM
Horseshoe kidney. No active renal extravasation. No
embolization was
performed.
CT CHEST
New right pleural effusion of moderate extent, with subsequent
right lower lobe collapse. The collapse is likely the result of
the effusion, pneumonia is less likely. A new effusion on the
left and its subsequent atelectasis is minimal. Moderate
cardiomegaly. No pericardial effusion. Massive respiratory
motion artifacts limits the assessment of the lung parenchyma.
CXR:
Unchanged technically limited examination. Severe elevation of
the right hemidiaphragm with subsequent atelectasis of right
basal lung parenchyma. Moderate cardiomegaly persists.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pantoprazole 40 mg PO Q24H
2. LaMOTrigine 350 mg PO BID
3. LACOSamide 200 mg PO BID
4. LeVETiracetam 500 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Baclofen 10 mg PO TID
7. Diastat (diazepam) 15 Other Prn Seizure
Discharge Medications:
1. Baclofen 10 mg PO TID
2. LACOSamide 200 mg PO BID
3. LaMOTrigine 350 mg PO BID
4. LeVETiracetam 500 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Acetaminophen 325-650 mg PO Q6H:PRN pain
7. Diastat (diazepam) 15 Other Prn Seizure
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
grade IV renal laceration
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Trauma.
TECHNIQUE: Single portable view of the chest.
COMPARISON: Correlation made to same date chest CT performed infarct in
hospital.
FINDINGS:
There is relative elevation of the right hemidiaphragm. Low lung volumes are
noted. The lungs are grossly clear besides streaky right basilar opacity which
is likely atelectasis. The cardiomediastinal silhouette is within normal
limits. No displaced fractures identified. Left chest wall pacing device is
noted.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with awake fiberoptic intubation ? ett placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: Exam from earlier the same day at 14:59
FINDINGS:
ET tube is seen, the tip is estimated 4.5 cm from the carina which is not
clearly delineated on this exam. Extremely low lung volumes are noted with
probable bibasilar atelectasis. Enteric tube seen in the region of the gastric
body. Left chest wall dual lead pacing device is again identified.
IMPRESSION:
Limited exam with endotracheal tube tip approximately 4.5 cm from the carina
which is not particularly well seen.
Radiology Report
INDICATION: ___ year old man with horseshoe kidney and traumatic renal
laceration.
COMPARISON: Same day CT abdomen and pelvis.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure.
The attending, Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings
ANESTHESIA: General anesthesia.
MEDICATIONS: Please review anesthesia sheet.
CONTRAST: 60 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 8.4 min, 51 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Inferior pole left renal arteriogram.
3. Inferior pole right renal arteriogram.
4. Superior pole right renal arteriogram.
5. Superior pole left renal arteriogram.
6. Common femoral arteriogram with deployment of a 6 ___ Angio-Seal closure
device.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. Both groins were
prepped and draped in the usual sterile fashion.
Using palpatory, ultrasound and fluoroscopic guidance, the right common
femoral artery was punctured using a micropuncture set at the level of the
mid-femoral head. No ultrasound images were stored. A 0.018 wire was passed
easily into the vessel lumen. A small skin incision was made over the needle.
Then the inner dilator and wire were removed and ___ wire was advanced
under fluoroscopy into the aorta. The micropuncture sheath was exchanged for a
5 ___ sheath which was attached to a continuous heparinized saline side arm
flush.
A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire
was removed and the left inferior pole renal artery was selectively cannulated
and a small contrast injection was made to confirm position. An arteriogram
was performed.
The catheter was withdrawn and selectively cannulated the right inferior pole
renal artery. An arteriogram was performed.
The catheter was withdrawn and selectively cannulated the right superior pole
renal artery. An arteriogram was performed.
The catheter was withdrawn and selectively cannulated the left superior pole
renal artery. An arteriogram was performed.
The catheter was then removed over the wire and the sheath was removed. A
right common femoral arteriogram was performed and a 6 ___ Angio-Seal
closure device was deployed. In addition, Manual pressure was held until
hemostasis was achieved. Sterile dressings were applied. Unchanged triphasic
Doppler right posterior tibial and dorsalis pedis arteries. The patient
tolerated the procedure well.
FINDINGS:
1. No active extravasation. Horseshoe kidney. Focal, segmental lack of
enhancement at the right inferior pole consistent with known laceration.
2. 3 renal arteries: Right superior, left superior, and inferior pole renal
arteries.
3. Patent right common femoral artery with anatomy suitable for Angio-Seal
closure device deployment.
IMPRESSION:
Horseshoe kidney.No active renal extravasation. No embolization was
performed.
Radiology Report
INDICATION: ___ year old man with trauma, possible aspiration before intubated
// Please eval interval change
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiograph. ___. Chest CT ___.
FINDINGS:
Poor positioning of the head obscures the right upper lung field. Heart size
is top-normal. The mediastinal contours are unremarkable. A right pleural
effusion is significantly increased in size compared to the prior exam. Lung
volumes are improved with bibasilar atelectasis. The right hemidiaphragm is
markedly elevated. ETT appears low, terminating near the level of the carina,
but the head is also down, which causes caudal migration of ETT. An enteric
tube is noted with tip terminating in the stomach. A left axillary pacemaker
is noted, but the pacemaker lead tip is not definitely visualized.
IMPRESSION:
Limited exam given poor head position. No definite evidence of aspiration.
Increased right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with trauma, possible aspiration before intubated
// Please eval interval change
IMPRESSION:
Exam is severely limited by difficulties with patient positioning. With this
limitation in mind, there has not been a substantial change in the appearance
of the chest since the recent study of 1 day earlier except for removal of a
nasogastric tube. .
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ?aspir pna , s/p ett. ___ year old man with
?aspir pna , s/p ett. now on RA pls perform ___ am // ___ year old man
with ?aspir pna , s/p ett. now on RA pls eval pna perform ___ am ___
year old man with ?aspir pna , s/p ett. now on RA pls ev
COMPARISON: Comparison to ___ at 06:11
FINDINGS:
Portable semi-erect chest film ___ at 05:29 is submitted.
IMPRESSION:
Somewhat limited examination due to patient positioning. Patient's mandible
obscures the apices. Lung volumes remain dramatically diminished and the right
hemidiaphragm remains elevated. Visualized lungs demonstrate streaky
opacities, predominantly at the right base suggestive of atelectasis. Left
axillary pacemaker is again seen but no definite lead is identified. No
evidence of pulmonary edema. Overall cardiac and mediastinal contours cannot
be assessed due to patient positioning.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new O2 requirement // eval for
aspiration/pna
TECHNIQUE: AP views of the chest
COMPARISON: Multiple prior radiographs the most recent on ___
FINDINGS:
Similar to multiple prior examinations, the exam is limited due to patient
positioning. Given that, lung volumes are persistently low. Bilateral
opacities are again demonstrated and may be increased from the prior
examination raising the possibility of infection or aspiration.
Cardiomediastinal contours cannot be evaluated due to patient positioning. .
IMPRESSION:
Low lung volumes. Bilateral pulmonary opacities appear increased from the
prior examination could represent atelectasis, aspiration or infection.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with desats and O2 req // Eval for pna
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 350 mGy-cm
COMPARISON: ___
FINDINGS:
The examination is compared to ___.
Again, the interpretation of the examination is severely limited by massive
respiratory motion artifact 's. In the interval, has been development of a
moderate right-sided pleural effusion. The lung parenchyma shows signs of
predominantly interstitial fluid overload. A right lower lobe partial
collapse is likely the result of the right effusion, pneumonia is less likely.
An effusion on the left and the subsequent atelectasis is minimal. Unchanged
moderate cardiomegaly without substantial coronary calcifications. Unchanged
mild dilatation of the main pulmonary artery. A reasonable assessment for
small pulmonary nodules as well as 4 the smaller airways is not possible,
given the presence of massive respiratory motion artifacts. Unchanged
position of a left pectoral ICD.
IMPRESSION:
New right pleural effusion of moderate extent, with subsequent right lower
lobe collapse. The collapse is likely the result of the effusion, pneumonia
is less likely. A new effusion on the left and its subsequent atelectasis is
minimal. Moderate cardiomegaly. No pericardial effusion. Massive respiratory
motion artifacts limits the assessment of the lung parenchyma.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with tachypnea // eval for interval change
COMPARISON: ___
IMPRESSION:
No relevant change as compared to the previous image, very limited technical
quality of the examination. Low lung volumes. Elevation of the right
hemidiaphragm. Moderate cardiomegaly. Mild fluid overload. Compression
atelectasis at the right lung bases. The left lung bases appears minimally in
better ventilated than at the previous examination.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion // eval for interval
change, to be done AM on ___
COMPARISON: ___.
IMPRESSION:
Unchanged technically limited examination. . Severe elevation of the right
hemidiaphragm with subsequent atelectasis of right basal lung parenchyma.
Moderate cardiomegaly persists.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with KIDNEY LACERATION-CLOSED, PERITONEUM INJURY-CLOSED, MV COLL W OTH OBJ-PASNGR
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ with h/o developmental delay, spastic quadriplegia,
horseshoe kidney, seizure disorder with vagal stimulator,
transfer from ___ s/p MVC as restrained passenger with
grade IV renal lac. Patient was secured in wheelchair in back of
van when the van struck a tree. At OSH, he was noted to have R
flank bruising and was hypotensive to ___. CT showed horseshoe
kidney with grade IV laceration as well in hemoperitoneum of
unclear source. He was given 3L of NS and hypotensive resolved,
but 1 unit of blood was initiated on transfer due to new
tachycardia. Patient is nonverbal at baseline and cannot give
history. MedFlight reports he is at his baseline mental status.
Interventional radiology was consulted, but no large
hematoma/collection seen on CT, so plan to monitor for
downtrending HCT. The patient was admitted to the TICU
intubated, sedated on fent/midaz. Placed right radial a-line.
Taken to ___ for embolization by anesthesia at 1800. Renal
arteriogram showed no active extravasation, no embolization was
performed.
___: HCT stable 37.6-->36.4. SBP slowly downtrending overnight
while on propofol, 1L bolus of LR at 0500. ABG in AM was stable.
AM CXR showed no significant changes (still low-volumes due to
fusion & body habitus). The patient was successfully extubated.
Temperature spike to 101 @ 2PM, sent sputum culture which was
growing 2+ GPCs. The patient was started on linezolid / zosyn
per ID and received tylenol via GT and PO pain meds. Kept NPO &
GT to gravity. 2 ___ Hct = stable at 34 - spaced out to BID.
___: Increased work of breathing -> midnight ABG = borderline;
maintaining O2 sats into AM. Patient remained afebrile since
___. AM hct = 36.1, stable. The patient developed
seizure-activity @ 6:30 AM, 1mg ativan, EKG, prolactin sent
stat. Lytes repleted. AM CXR worse. Responded well to 20 mg
lasix and net negative 1.8L. Patient continued on 10 mg lasix x
2 days. Pt has vagal nerve stimulator in place
___: Restarted SQH. Nutrition consult for tube feeds, which
were started. Patient hemodynamically stable and transferred to
the floor.
___: Patient refused speech and swallow evaluation. Diet was
advanced to regular ground solids and thin liquids, which the
patient was tolerating well.
___ O2 requirement, tachycardic, CBC nl, R pleural
effusion; gross hematuria
___ off O2, Hct stable.
The patient remained hemodynamically stable while on the floor.
A repeat chest x-ray was ordered for ___ which showed no
worsening of the pleural effusions and the patient remained
stable on room air.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a Ground
(dysphagia); Nectar prethickened liquids diet, voiding with a
condom cath with no hematuria noted, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions. He is scheduled for a follow-up
appointment in the ___ clinic where he will have a repeat UA. He
was discharged to his original group home with ___ services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hip pain after mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ PMHx of schizophrenia and DM presents after fall from
his wheelchair ___ in the morning at ___.
Denies HS, LOC. Remembers the event. After the fall, he
complained of severe pain in his left hip, especially with
attempted left hip flexion. CT scan showed a left femur
fracture. Orthopedics was consulted and decided to manage the
fracture non-operatively given his baseline of being wheelchair
bound. Labs notable for sodium of 120 and urinalysis was
positive. The patient was admitted to the Trauma service for 24
hour monitoring and then transferred to the Medicine service for
management of hyponatremia and urinary tract infection.
Past Medical History:
hyperlipidemia
schizophrenia
urinary retention s/p 'microwave prostate procedure'
h/o gait abnormalitiy with spinal fracture
DM
constipation
tobacco use
hernia surgery
h/o patellar fracture, ambulates with assistive device
Cellulitis
Left Thigh Abscess
Urinary Tract Infection
Hyponatremia
Syndrome of Inappropriate Antidiuretic Hormone
Social History:
___
Family History:
CAD
Colitis
Diabetes
Physical Exam:
ADMISSION EXAM:
===============
Vitals: ___ 2347 Temp: 98.4 PO BP: 156/93 HR: 99 RR: 20 O2
sat: 93%
General: Well-appearing, alert and somewhat confused, handling
foley, breathing comfortably
MSK: LLE: moves foot/toes spontaneously; well-perfused
DISCHARGE EXAM:
===============
VITALS: ___ 0817 Temp: 98.2 PO BP: 170/97 HR: 79 RR: 18 O2
sat: 94% O2 delivery: Ra FSBG: 151
GENERAL: Elderly gentleman, speaks with somewhat
slurred/noncoherent speech, somnolent but easily arousable to
voice
HEENT: AT/NC, EOMI, anisocoria with pinpoint R pupil and
rectangular L pupil, anicteric sclera, pink conjunctiva, MMM,
good dentition
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended, soft, active bowel sounds, nontender in all
quadrants, no rebound/guarding
EXTREMITIES: No cyanosis or edema, talipes valgus
NEURO: Somnolent but arousable, unable to assess orientation, no
facial asymmetry
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 07:15PM PLT COUNT-237
___ 07:15PM NEUTS-81.9* LYMPHS-9.0* MONOS-7.5 EOS-0.0*
BASOS-0.6 IM ___ AbsNeut-6.36* AbsLymp-0.70* AbsMono-0.58
AbsEos-0.00* AbsBaso-0.05
___ 07:15PM WBC-7.8 RBC-4.69 HGB-14.0 HCT-40.0 MCV-85
MCH-29.9 MCHC-35.0 RDW-12.8 RDWSD-39.3
___ 07:15PM estGFR-Using this
___ 07:15PM GLUCOSE-218* UREA N-14 CREAT-0.9 SODIUM-120*
POTASSIUM-6.4* CHLORIDE-86* TOTAL CO2-24 ANION GAP-10
___ 08:50PM URINE MUCOUS-RARE*
___ 08:50PM URINE AMORPH-RARE*
___ 08:50PM URINE RBC-1 WBC-33* BACTERIA-MOD* YEAST-NONE
EPI-0
___ 08:50PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR*
GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 08:50PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 08:50PM URINE UHOLD-HOLD
___ 08:50PM URINE HOURS-RANDOM
___ 09:59PM K+-4.7
___ 11:47PM LACTATE-1.6
___ 11:47PM ___ TEMP-37.0 COMMENTS-GREEN TOP
MICROBIOLOGY:
=============
___ 8:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ BLOOD CULTURE: Pending
___ BLOOD CULTURE: Pending
IMAGING/DIAGNOSTICS:
====================
___ PELVIS AND FEMUR:
Left femoral neck fracture, basicervical.
___ CXR:
Supine portable AP chest radiograph provided. The lungs are
clear. No large effusion or pneumothorax. Heart is within
normal limits of size. There is prominence of the mediastinum
which likely reflect AP supine technique. Bony structures
appear intact.
___ CT LOWER EXT:
Mildly displaced basicervical left femur fracture.
Large amount fecal material in the rectum.
Foley catheter in-situ with probable chronic outflow
obstruction.
DISCHARGE LABS:
===============
___ 07:11AM BLOOD WBC-7.6 RBC-4.50* Hgb-13.5* Hct-39.8*
MCV-88 MCH-30.0 MCHC-33.9 RDW-12.8 RDWSD-41.6 Plt ___
___ 07:11AM BLOOD Plt ___
___ 07:11AM BLOOD Glucose-169* UreaN-18 Creat-0.9 Na-134*
K-4.5 Cl-94* ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OLANZapine 40 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. TraZODone 50 mg PO QHS:PRN insomnia
4. Metoprolol Tartrate 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth three times a day Disp #*84 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*6 Tablet Refills:*0
3. Lisinopril 5 mg PO DAILY
4. OLANZapine 40 mg PO DAILY
5. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Left femur fracture with mild displacement
Secondary diagnosis:
- Schizophrenia
- Type II diabetes mellitus
- Neurogenic bladder
- Syndrome of inappropriate ADH secretion complicated by
hyponatremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with left hip fracture// eval left hip fracture
TECHNIQUE: ___ MD CT imaging was performed through the left hip without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.3 s, 50.6 cm; CTDIvol = 25.3 mGy (Body) DLP =
1,278.3 mGy-cm.
Total DLP (Body) = 1,278 mGy-cm.
COMPARISON: Pelvis and left hip radiographs ___
FINDINGS:
A sella prior radiographs there is a mildly displaced basicervical fracture of
the left femur. The distal femur fragment is externally rotated and
proximally displaced. The femoroacetabular joint is congruent. Probable
small femoroacetabular joint effusion. No additional fractures are seen.
Surgical hardware in the lumbar spine is incompletely imaged.
Evaluation of the pelvic parenchymal structures is somewhat limited. There is
large amount fecal material in the rectum. A Foley catheter is in-situ. The
bladder appears decompressed and evaluation is limited, nonetheless the wall
appears thickened, possibly due to chronic outflow obstruction. No pelvic
lymphadenopathy or pelvic free fluid seen. Mild atherosclerotic calcification
seen.
IMPRESSION:
Mildly displaced basicervical left femur fracture.
Large amount fecal material in the rectum.
Foley catheter in-situ with probable chronic outflow obstruction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hip injury, s/p Fall
Diagnosed with Pain in right hip
temperature: 98.8
heartrate: 75.0
resprate: 18.0
o2sat: 99.0
sbp: 178.0
dbp: 100.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ with a past medical history of SIADH,
schizophrenia, neurogenic bladder, and type II diabetes mellitus
who presented after fall from his wheelchair, found to have L
femur fracture, with plan for non-operative management,
transferred to medicine for management of hyponatremia and
concerning urinalysis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sulfa or amoxicillin
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an ___ year old male with PMH of ischemic cardiomyopathy
with an EF of 45% s/p PPM/AICD placement in ___ ___lock,
HTN, recently diagnosed sarcoidosis after a sinus biopsy, and
recent brief admission for bronchiectasis/UTI with discharge on
___ now returning with shortness of breath. He was discharged
on a course of ciprofloxacin for UTI/bronchiectasis. He was
doing well at home until a few day ago when he developed
gradually worsening shortness of breath and cough productive of
clear sputum. His symptoms were exacerbated by activity. He
reports no fevers or chills, no headache, change in vision or
neck pain. He continues to have burning with urination since his
recent diagnosis of UTI, difficulty starting urinary stream.
Denies any abdominal pain, no focal numbness tingling or
weakness, no rash. This episode of shortness ofbreath was more
severe than his previous.
On admission from ___ to ___, patient presented with acute
onset shortness of breath with cough productive of whitish
sputum without fever or leukocytosis, felt to be consistent with
bronchiectasis flare. Sxs resolved overnight so pt was
discharged on ciprofloxacin to be completed on ___.
In the ED, initial VS were: 98.0, 86, 107/50, 22, 100% 4L Nasal
Cannula. He then became hypoxic to the ___ and tachypneic to the
___, but was never hypotensive. Exam was notable for diffuse
rhonchi, no JVD, trace ___ edema, and patient was placed on
non-rebreather to maintain sats in the low ___. He was then
placed on BiPap and unable to be weaned. EKG was at baseline.
Labs notable for a lactate of 2. CXR was unremarkable. He
received Combivent, albuterol nebs x 2, 125mg of IV solumedrol,
40mg IV lasix, and 750mg IV levofloxacin.
On arrival to the MICU, patient was breathing comfortably on
bipap which was placed in the ED in the late afternoon. He
reports improvement since arrival on bipap. He soon became
tachypneic to ___ and uncomfortable. ABG was obtained at 1AM and
showed 7.46/45/57/bicarb=33 with no previous comparison. He was
transitioned to high flow oxygen shortly after arriving. He
continues to have burning with urination despite treatment for
his UTI with cipro.
Past Medical History:
bradycardia - with primary AV block s/p AICD and pacer placement
Recurrent urethral strictures ___ childhood infection
Mild systolic dysfunction - EF of 40-45% on Echo in ___
Chronic cough, congestion and hoarseness with referral for
possible sarcoidosis.
Chronic sinusitis.
Osteoarthritis.
Right knee surgery.
Defibrillator/pacemaker.
Social History:
___
Family History:
Father died of CVA; sister has ___.
Physical Exam:
ON ADMISSION:
Vitals: T: 98.5, BP: 110s-130s/60s-70s, P: 90s-100s, R: 35, O2:
96% on bipap
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, difficult to auscultate heart
sounds over bipap
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, trace ___ edema
bilaterally
Neuro: motor strength and sensory grossly equal and intact
bilaterally, gait deferred
AT DISCHARGE:
VS: Tmax/Tc 97.7/97.7; 110/80; 90; 18; 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, EOMI, PERRL
Neck: supple, JVP not elevated
CV: RRR, nl S1, S2, no MRG
Lungs: CTAB, respirations unlabored
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, no edema
Neuro: motor strength and sensory grossly equal and intact
bilaterally, gait deferred
Pertinent Results:
Admission Labs:
___ 03:55PM BLOOD WBC-7.4 RBC-3.82* Hgb-12.0* Hct-35.8*
MCV-94 MCH-31.5 MCHC-33.6 RDW-14.3 Plt ___
___ 03:55PM BLOOD Neuts-70.4* ___ Monos-6.5 Eos-2.8
Baso-1.7
___ 03:55PM BLOOD Glucose-115* UreaN-11 Creat-1.1 Na-139
K-4.1 Cl-98 HCO3-32 AnGap-13
___ 06:59PM BLOOD Lactate-2.0
___
___ 05:36PM BLOOD ___ PTT-150* ___
___ 02:22AM BLOOD ___ PTT-150* ___
___ 07:00AM BLOOD ___ PTT-56.3* ___
___ 07:15PM BLOOD ___ PTT-71.9* ___
___ 06:33AM BLOOD ___ PTT-69.8* ___
Discharge labs:
___ 06:33AM BLOOD WBC-9.0 RBC-3.67* Hgb-11.6* Hct-33.8*
MCV-92 MCH-31.5 MCHC-34.2 RDW-14.8 Plt ___
___ 06:33AM BLOOD Glucose-99 UreaN-11 Creat-0.9 Na-140
K-3.9 Cl-103 HCO3-31 AnGap-10
___ 02:22AM BLOOD ALT-22 AST-47* LD(LDH)-246 AlkPhos-53
TotBili-0.4
___ 03:55PM BLOOD proBNP-379
___ 06:33AM BLOOD Calcium-9.3 Phos-2.1* Mg-2.3
___ 06:33AM BLOOD Vanco-36.7*
IMAGING:
ECHO ___:
The left atrium is elongated. No right-to-left shunt is seen on
intravenous saline injection at rest. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
hypokinesis of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 35-40 %), but the
apical half of the ventricle is not well seen. The estimated
cardiac index is normal (>=2.5L/min/m2). No masses or thrombi
are seen in the left ventricle. 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. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD. Mild
mitral regurgitation. No right-to-left intracardiac shunt
identified. Dilated ascending aorta.
Compared with the prior report (images unavailable for review)
of ___, the severeity of mitral regurgitation may be
somewhat reduced and global systolic function is slightly worse.
CXR ___ MPRESSION: Increased retrocardiac density consistent
with left lower lobe collapse and/or consolidation, worse
compared with ___.
Bilateral LENIS ___:
IMPRESSION: Nonocclusive thrombus within the distal left common
femoral vein extending to the proximal superficial femoral vein.
CT Chest ___: Bilateral bronchiectasis with bronchial wall
thickening consistent with a bronchial inflammatory process.
Again noted is right middle lobe loss of volume with a
peripheral consolidation which may represent atelectasis, but
malignancy cannot be excluded. Dedicated chest CT is again
recommended in 3 months. Stable lung nodules
Microbiology:
Blood cultures ___: pending
URINE CULTURE (___): <10,000 organisms/ml.
Urine culture ___: no growth
Speech and Swallow Eval ___:
This swallowing pattern correlates to a Functional Oral Intake
Scale (FOIS) rating of 5.
RECOMMENDATIONS:
1. Ground consistency solids with thin liquids.
2. Meds whole with water.
3. TID oral care.
4. Recommended video swallow and barium swallow as outpatient
for
further evaluation of symptoms. To schedule, please call ___.
Medications on Admission:
Medications (confirmed w/ wife):
-Finasteride 5 mg PO once a day.
-Furosemide 40 mg PO daily.
-Metoprolol tartrate 12.5 mg PO BID.
-Rosuvastatin 40 mg once a day.
-Potassium chloride 20 mEq Tablet PO every other day.
-Sertraline 12.5 mg PO daily.
-Tamsulosin 0.4 mg PO HS.
-Aspirin 81 mg PO daily.
-Multivitamin PO daily.
-Calcium carbonate-vitamin D3 600 mg-400 unit PO twice a day.
-Aleve 220 mg PO twice a day as needed for pain.
-Sinus rinse with steroid.
-Terazosin 5 mg PO daily
-Ofloxacin 0.3% One drop four times a day into both eyes.
-Ciprofloxacin 500 mg PO Q12H until ___
-fluticasone nasal spray
Discharge Medications:
1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO every other day.
6. sertraline 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
11. Aleve 220 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for pain.
12. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. sodium chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
Disp:*1 unit* Refills:*0*
14. ofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic QID (4
times a day).
15. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
16. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days: last day ___.
Disp:*6 Tablet(s)* Refills:*0*
17. warfarin 4 mg Tablet Sig: One (1) Tablet PO q4pm: as
instructed by Dr. ___.
Disp:*30 tablets* Refills:*0*
18. Lovenox ___ mg/0.8 mL Syringe Sig: One ___ (110) mg
Subcutaneous once a day: unless otherwise instructed by Dr.
___.
Disp:*7 units* Refills:*0*
19. Outpatient Lab Work
Please have ___ check INR on ___. Please fax results to
patient's PCP ___ MD at ___
20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
Disp:*qs qs* Refills:*0*
21. guaifenesin 50 mg/5 mL Liquid Sig: Five (5) mL PO every six
(6) hours as needed for cough.
Disp:*1 bottle* Refills:*1*
22. nebulizer & compressor Device Sig: One (1) unit
Miscellaneous every ___ hours as needed for shortness of breath
or wheezing: dx: pneumonia.
Disp:*1 unit* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Deep vein thrombosis
-Suspected pulmonary embolism
-Community acquired pneumonia
Secondary:
-Ischemic cardiomyopathy
-Bronchiectasis
PE
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 RADIOGRAPHS
HISTORY: Shortness of breath and pedal edema. Question acute process.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: A dual-lead pacemaker/ICD device appears unchanged. The heart is
mildly enlarged with left ventricular configuration. The mediastinal and
hilar contours appear unchanged. There is similar elevation of the right
hemidiaphragm compared to the left. Patchy right basilar atelectasis has
resolved. A linear opacity in the left costophrenic angle suggests scarring
that appears unchanged. Degenerative changes are similar along the thoracic
spine.
IMPRESSION: No evidence of acute disease.
Radiology Report
INDICATION: Shortness of breath.
TECHNIQUE: Bilateral lower extremity ultrasound.
COMPARISON: None available.
FINDINGS: Grayscale and Doppler sonograms of the bilateral common femoral,
superficial femoral, popliteal, posterior tibial and left peroneal veins were
performed. The right peroneal veins were not visualized. On the left, there
is non-occlusive thrombus seen within the distal common femoral vein just
distal to the origin of the greater saphenous vein with clot extending to the
proximal superficial femoral vein. The mid and distal portions of the
superficial femoral vein, popliteal, posterior tibial and peroneal veins
appear patent with normal flow.
On the right, there is normal compressibility, flow and augmentation.
IMPRESSION: Nonocclusive thrombus within the distal left common femoral vein
extending to the proximal superficial femoral vein.
Findings discussed with Dr. ___ at 12:00 p.m., ___.
Radiology Report
HISTORY: New PE, elevated white count, question new pneumonia.
CHEST, SINGLE AP PORTABLE VIEW.
Lordotic positioning and low inspiratory volumes. A left-sided pacemaker is
present, with lead tips over right atrium and right ventricle. There is
increased retrocardiac density, consistent with left lower lobe collapse
and/or consolidation, worse compared with one day earlier. Upper zone
redistribution is likely accentuated by low inspiratory volumes. Otherwise,
no evidence for CHF. The right lung is grossly clear, without focal
infiltrate or gross effusion.Cardiomediastinal silhouette unchanged.
IMPRESSION: Increased retrocardiac density consistent with left lower lobe
collapse and/or consolidation, worse compared with ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HEART DISEASE NOS
temperature: 98.0
heartrate: 86.0
resprate: 22.0
o2sat: 100.0
sbp: 107.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with PMH of ischemic cardiomyopathy s/p
PPM/AICD placement, HTN, recently diagnosed sarcoidosis after a
sinus biopsy, and recent brief admission for bronchiectasis/UTI
with discharge on ___, who presented with shortness of breath.
# DVT/presumed PE: Pt presented with SOB, with LENIS positive
for DVT of LLE. Pt is highly immobile at home, although no
recent surgery or known history of malignancy. Last colonoscopy
in ___ with polypectomy, plan repeat in ___ years. Given
sob/respiratory distress (see below), presumed to have PE. No
evidence of RH strain. Started on hep gtt on ___.
Respiratory status improved: initially required BiPAP in MICU
but quickly transferred to the floor, where he remained stable,
satting mid-high ___ on 3L NC, O2 sat high ___ on room air and
mid ___ on ambulation at the time of discharge. Pt was started
on warfarin 2.5 on ___, 2.5 on ___, and 4mg on ___, ___ on
4mg daily. Heparin drip DCed on ___, and started Lovenox
1.5mg/kg daily (110mg daily) to bridge. Likely will need 6
months anticoagulation for provoked DVT/PE. Contacted Dr.
___ office to follow Lovenox/Coumadin bridging and future
INR.
# Respiratory distress/hypoxia - Rapidly resolved after BIPAP in
MICU. Suspicion for PE given DVT and new O2 requirement/hypoxia
and pt was started on anticoagulation (see DVT/PE above). On
admission, BNP was <400 pointing away from a cardiac etiology.
ECHO on ___ showed slightly worse global dysfunction compared
to ___, now EF 35%. Out of concern for possible pneumonia (HCAP
as pt was recently hospitalized)and pt was started on levoquin
in the ED, transitioned to vanc/cefepime in the MICU. Pt was
also given steroids in the ED on arrival. CXR initially did not
suggest acute infection. CT scan from prior admission showed
bronchiectasis, and it was felt some of his SOB/hypoxia could be
related to superinfection or bronchiectasis flare. On ___
WBC was elevated but pt afebrile and with improving respiratory
status. Leukocytosis thought to be from steroids received in ED.
However on ___ showed retrocardiac opacity which could
represent consolidation, and pt was continued on antibiotics. Pt
was administered respiratory therapy - chest ___ treatments,
acapella, pulmonary toilet. Patient switched back to Levaquin on
___ and planned for total 7-day course for CAP. Blood culture
pending at time of discharge.
# UTI/BPH- pt sent home on cipro from last admission, had not
yet finished his course. Cipro was DCd, pt placed on
vanc/cefepime c/f CAP. Pt has history of recurrent UTIs likely
___ BPH. Continued home regimen of finasteride, terazosin, and
tamsulosin. Urine culture on ___ grew <10,000 organisms. DC
home on 7-day course of levaquin to cover CAP which also covers
UTI.
# Possible Sarcoid. Patient has chronic sinusitis, Chronic
cough, congestion and hoarseness with a sinus bx in ___
c/w sarcoidosis, however definitive diagnosis remains unclear.
Continued home nasal saline. Steroids, after the 1 time dose in
the ED, were not continued.
# Ischemic cardiomyopathy. ECHO on ___ showed slightly worse
global dysfunction compared to ___, now EF 35%. BNP on
admission <400. Pt did not appear fluid overloaded on exam.
Furosemide initially held in the setting of presumed PE.
Restarted on discharge. Continued home metoprolol, ASA,
rosuvasatin. Patient has previously been on lisinopril, but was
discontinued for unclear reason. Please address this on follow
up.
# Conjunctivitis. Continued outpatient ofloxacin.
# Depression/anxiety - Patient was recently started on
sertraline which was continued.
# Aspiration risk- Patient's wife expressed concern about
patient choking on his food. Speech and swallow eval reveals a
swallowing pattern correlates to a Functional Oral Intake Scale
(FOIS) rating of 5. Recommended Ground consistency solids with
thin liquids (which patient is already doing at home), meds
whole with water. Also recommended video swallow and barium
swallow as outpatient for
further evaluation of symptoms.
___ WAS MAINTAINED AS FULL CODE THROUGHOUT THE COURSE OF THIS
HOSPITALIZATION.
# Transitional issues:
1. Anticoagulation: Dr. ___ was contacted
regarding management of anticoagulation with Lovenox to coumadin
bridge. ___ to help administer daily lovenox. ___ to draw
___ on ___ and fax results to Dr. ___.
2. Follow up final blood culture results
3. Address restarting ___ given repeat ECHO findings.
4. Outpatient video swallow |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Caffeine / Percocet
Attending: ___.
Chief Complaint:
Chills
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o F with PMHx significant for HTN, HLD, GERD,
hypothyroidism s/p thyroidectomy for papillary thyroid cancern,
who presented to the ED with shaking chills. Per report, the
patient developed shaking chills while eating dinner tonight.
Presented to the ED for evaluation. Denies headache, sore
throat, dysuria, belly pain, or pain in legs or cough. She did
bump her right shin into furnature several days ago.
In the ED, initial VS were 101.2 88 149/74 20 100%. Labs were
significant for WBC of 14.6, lactate of 2.6. Hct 32.8 (around
baseline). CXR without acute process, UA unremarkable. Exam did
reportedly show a small cut on the right lower extremity with
surrounding warm erythema, concerning for cellulitis. Given lab
findings, ED did not feel comfortable sending patient home and
requested admission to medicine. They gave her 2 liter of NS
and vancomycin x1.
REVIEW OF SYSTEMS:
+ per HPI
Past Medical History:
1)Papillary thyroid cancer, s/p total thyroidectomy
2)Hypertension
3)Hyperlipidemia
4)Osteoporosis
5)GERD
6)Asthma
7)s/p hysterectomy for fibroids
8)Hemorroids
9)s/p cataract sx
10)Sciatica
Social History:
___
Family History:
She has 2 brothers; one died of pancreatic cancer, as did her
father. Mother had late-onset breast cancer and died of heart
disease. She has a son with NIDDM (deceased), and a daughter who
lives in ___.
Physical Exam:
101.2 (tmax on admission) 99.0 (t current) 120/60 80 18
98 RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP non-elevated, no carotid
bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi
ABDOMEN - soft/NT/ND, no masses or HSM
EXTREMITIES - right shin with excoriation, surrounding erythema
and increased warmth compared to opposite leg, no prominent
edema, no fluctuance or exudate.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
___ 03:15AM BLOOD WBC-14.6*# RBC-4.06* Hgb-10.0* Hct-32.8*
MCV-81* MCH-24.7* MCHC-30.5* RDW-14.2 Plt ___
___ 03:15AM BLOOD Neuts-86.8* Lymphs-9.4* Monos-3.3 Eos-0.3
Baso-0.1
___ 03:15AM BLOOD Glucose-124* UreaN-17 Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-22 AnGap-18
___ 03:15AM BLOOD ALT-15 AST-29 AlkPhos-82 TotBili-0.4
___ 03:15AM BLOOD Albumin-4.2
___ 03:21AM BLOOD Lactate-2.6*
CHEST (PA & LAT) Study Date of ___ 3:39 AM
COMPARISON: PA and lateral chest radiograph ___.
PA AND LATERAL CHEST RADIOGRAPH: The cardiac silhouette
demonstrates
borderline cardiomegaly. Both lungs are clear with no focal
consolidation, pleural effusion or pneumothorax. Mild pulmonary
vascular congestion.
___ 04:45AM URINE Color-Straw Appear-Clear Sp ___
___ 04:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:45AM URINE
___ 04:45AM URINE Hours-RANDOM
___ 04:45AM URINE Gr Hold-HOLD
Medications on Admission:
prilosec 20mg qd
norvasc/valsartan ___ daily
aricept 10mg qd
simvastatin 20mg qd
synthroid ___ mg qd
asa 81mg qd
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Exforge ___ mg Tablet Sig: One (1) Tablet PO once a day.
3. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. amoxicillin 500 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
8. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
cellulitis
Secondary:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with fevers and cough. Evaluate for
infection.
COMPARISON: PA and lateral chest radiograph ___.
PA AND LATERAL CHEST RADIOGRAPH: The cardiac silhouette demonstrates
borderline cardiomegaly. Both lungs are clear with no focal consolidation,
pleural effusion or pneumothorax. Mild pulmonary vascular congestion.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, CELLULITIS OF LEG, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 101.2
heartrate: 88.0
resprate: 20.0
o2sat: 100.0
sbp: 149.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | ___ y/o Female w/ PMH of HTN, HLD, GERD, hypothyroidism s/p
thyroidectomy for papillary thyroid cancer who presented with
fever, leukocytosis, and right lower extremity redness and
warmth.
# Non-purulent Cellulitis/Sepsis: right lower extremity w/
eryethma, warmth and port of entry given trauma. Meets 2 SIRS
criteria w/ Temp >100.4 and elevated WBC with suspected source
for infection of right lower extremity which technically meets
criteria for sepsis. However, patient is hemodynamically stable
otherwise with signs of good end organ perfusion, mentating well
with baseline BUN/Cre. Given 2 Liters of IVF in ED for elevated
lactate along with Vancomycin. Given nursing home environment,
will be important to cover for MRSA/MSSA as well as Group A
strep which is the most likely pathogen given lack of purulence.
She was started on oral antibiotics and continued to feel well.
It was decided she was doing well enough to be discharged with
close PCP followup and on oral Amoxicillin 500 mg PO/NG Q8H and
Sulfameth/Trimethoprim DS 1 TAB PO/NG BID for 6 more days.
# Lactate: 2L NS given in ED. Likely secondary to volume
depletion but also possibly related to SIRS hypoperfusion state
secondary to infection. Hemodynamically stable and only mildly
elevated. Source of infection identified as leg cellulits and
antibiotics were given.
# Dementia: continued aricept
# GERD: continued PPI
# Hyperlipidemia: continued simvastatin
# Hypothyroid: continued levothyroxine.
# CODE: Full (confirmed)
# CONTACT: husband ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sore throat
Major Surgical or Invasive Procedure:
blood transfusion ___
History of Present Illness:
___ presented to ED with sore throat, nausea and occasional
vomiting for the last four days; found incidentally to have a
Hct of 14. Pain is worst on the left side of her throat. Has
odynophagia with solids and liquids, but is able to take PO.
Several members of her household have had similar symptoms. Some
subjective fevers and chills, no rigors, no cough, no rhinorrhea
or nasal congestion. Last vomited at noon today; non-bloody. No
diarrhea or abdominal pain.
Patient is currently on her period which she states occurs about
every 4 weeks (sometimes a few days early). Her period usually
lasts 7 days and is heavy for the first 2 days, requiring ___
pads/day. Currently changing her pad ___ times per day. Has been
told she had fibroids in the past. Has had mild fatigue for the
last few days that she attributes to sore throat, but otherwise
denies fatigue. Has SOB only with climbuing several flights of
stairs. No chest pain, dizziness, vision changes, melena,
hematochezia,numbness or tingling. No h/o nosebleeds or
bleeding with procedures (had Cesarean in ___. No known family
h/o blood disorders. Diet consists mostly of chicken, vegetables
and wheat products; rarely eats red meat. From ___ without
extensive previous medical care. Patient is a Jehovah's Witness.
She declines blood transfusion at the presents time, but "wants
to sleep on it". States she would consider it if she becomes
more tachycardic or hypotensive ("if I needed it to save my
life").
.
In the ED, initial vital signs were: 3 99.6 110 122/66 20 100%
Rectal exam showed Guaiac negative brown stool.
Pelvic exam showed scant blood, no active bleeding.
Labs were notable for wbc 21.8, Hct 14.1, plt 140, nl LFTs, nl
direct and total bili, nl LDH, nl lactate, negative U/A,
negative uCG.
CXR showed top-normal to mildly enlarged cardiac
silhouette. No pulmonary edema or focal consolidation
seen.
.
Patient was given zofran
On Transfer Vitals were: 102 120/74 20 100% RA
Past Medical History:
uterine fibroids
Cesarian and ovarian cyst removal in ___
Social History:
___
Family History:
Mother died of ovarian cancer at ___. Father's history unknown.
Two sons are alive and healthy. One sister had dysmenorrhea
requiring uterine surgery. Other sister and one brother are
healthy.
Physical Exam:
ADMISSION:
Vitals- T 101.5 109/53 105 16 100% RA
General: Well appearing woman, resting comfortably in bed
HEENT:Sclera anicteric. Conjunctiva and oral mucosa pale. OP
clear
Neck: Tender anterior cervical lymphadenopathy (L>R). Shoddy
posterior cervical lymphadenopathy. No occipital or posterior
auricular LNs palpated.
CV:Tachycardic, regular rhythm. Nl S1, S2. No m/r/g
Lungs:CTAB with good air movement. Breathing comfortably.
Speaking in full sentences.
Abdomen:Soft, nt, nd. Nl BS.
GU:No foley
Ext:wwp with no c/c/e.
Neuro:Cn ___ intact. Motor function grossly normal.
Skin:No rash or jaundice.
.
DISCHARGE:
Vitals- Tm 98.6 ___ ___ 16 100% RA
General: Sitting in bed. Conjunctiva and oral mucosa pale. OP
clear
Neck: Tender anterior cervical lymphadenopathy (L>R). Shoddy
posterior cervical lymphadenopathy. No occipital or posterior
auricular LNs palpated.
CV:Normal rate, regular rhythm. Nl S1, S2. No murmurs, no rubs
or gallops
Lungs:CTAB with good air movement. Breathing comfortably.
Speaking in full sentences.
Abdomen:Soft, nt, nd. Nl BS.
GU:No foley
Ext:wwp with no c/c/e.
Neuro:Cn ___ intact. Motor function grossly normal.
Skin:No rash or jaundice.
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-21.8* RBC-2.45* Hgb-3.4* Hct-14.1*
MCV-58* MCH-14.0* MCHC-24.3* RDW-21.9* Plt ___
___ 01:00PM BLOOD Neuts-87.2* Lymphs-8.3* Monos-3.8 Eos-0.2
Baso-0.5
___ 10:15PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Tear
Dr-OCCASIONAL
___ 06:59PM BLOOD ___
___ 10:15PM BLOOD ESR-45*
___ 01:00PM BLOOD Ret Man-2.0*
___ 01:00PM BLOOD Glucose-122* UreaN-8 Creat-0.9 Na-140
K-3.7 Cl-104 HCO3-26 AnGap-14
___ 01:00PM BLOOD ALT-10 AST-13 LD(LDH)-219 AlkPhos-75
TotBili-0.2 DirBili-0.1 IndBili-0.1
___ 01:00PM BLOOD Albumin-4.0 Iron-10*
___ 01:00PM BLOOD calTIBC-384 Hapto-284* Ferritn-21 TRF-295
___ 01:00PM BLOOD D-Dimer-1554*
___ 01:00PM BLOOD HBsAb-POSITIVE HBcAb-POSITIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE
___ 04:50PM BLOOD HBsAg-NEGATIVE
___ 07:02PM BLOOD ___
___ 01:00PM BLOOD RheuFac-12 CRP-134.2*
___ 04:50PM BLOOD HIV Ab-NEGATIVE
___ 01:10PM BLOOD Lactate-1.7
___ 01:00PM BLOOD HCV Ab-NEGATIVE
___ 10:15PM BLOOD Hb A-PENDING Hb S-PND Hb C-PND Hb A2-PND
Hb F-PND
.
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-23.7* RBC-3.94* Hgb-8.5* Hct-29.0*
MCV-74* MCH-21.6* MCHC-29.4* RDW-25.8* Plt ___
___ 07:45AM BLOOD Neuts-75* Bands-1 Lymphs-14* Monos-6
Eos-1 Baso-0 ___ Metas-2* Myelos-1* NRBC-3*
___ 07:45AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+
Macrocy-NORMAL Microcy-3+ Polychr-1+ Schisto-OCCASIONAL Tear
Dr-1+ Ellipto-1+
.
IMAGING:
CXR ___: Top-normal to mildly enlarged cardiac silhouette.
No pulmonary edema or focal consolidation seen.
Radiology Report
HISTORY: Fevers, anemia.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac silhouette is top-normal to mildly
enlarged. There is no overt pulmonary edema.
IMPRESSION:
Top-normal to mildly enlarged cardiac silhouette. No pulmonary edema or focal
consolidation seen.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Anemia
Diagnosed with ANEMIA NOS
temperature: 99.6
heartrate: 110.0
resprate: 20.0
o2sat: 100.0
sbp: 122.0
dbp: 66.0
level of pain: 3
level of acuity: 3.0 | ___ previously healthy female presented to ED for sore throat,
found to have profound microcytic anemia with Hct 14.1 on
admission.
.
# microcytic anemia: Severe anemia with relative absence of
symptoms and severe degree of microcytosis suggests chronic
process. Stool guiaic negative. No evidence of hemolysis or DIC
given nl LDH, nl bili, elevated haptoglobin. Peripheral smear
c/w severe iron deficiency; no blasts or atypical cells, no
schistocytes. Presentation most c/w chronic blood loss due to
uterine fibroids with iron deficiency anemia. Retic count
inappropriately low; this is likely ___ iron deficiency. There
may also be virally mediated bone marrow suppression, although
testing for viral hepatitis, HIV, acute EBV, acute parvo, HTLV-1
and CMV was negative. Hb electrophoreses for thalassemia, sickle
cell trait is pending at time of discharge. Patient received 4
units pRBC on ___ with an appropriate increase in her
hematocrit. She remained hemodynamically stable throughout
admission. She was also treated with IV iron, PO iron, B12 and
folic acid. She will follow up with hematology for continued IV
iron and management of her anemia.
.
# sore throat: She met ___ Centor criteria (fever, no cough,
tender lymphadenopathy) on admission and had a throat culture
that was positive for strep pharyngitis. She was started on
pencillin V 500mg PO q12 with plan for a 10 day course (day 1 =
___, day 10 = ___. She was given viscous lidocaine, lozenges,
tylenol/naproxen for pain relief.
.
# nausea, vomiting: Vomiting seems to have subsided. Persistent
nausea likely ___ poor PO intake in setting of pharyngitis.
Nausea resolved by time of discharge.
.
## Transitional issues:
- most likely cause of anemia is dysfunctional uterine bleeding
___ fibroids. Consider OB referral for possible hysterectomy.
- patient has hematology f/u for IV iron repletion
- Dr. ___ assess for resolution of strep pharyngitis.
She was started on pencillin V 500mg PO q12 X 10 days (day 1 =
___, day 10 = ___.
# Code: Full (confirmed)
# Communication: Patient
# Emergency Contact: ___ (sister and HCP):
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / cefaclor / clindamycin / Levaquin / sulfamethoxazole /
Biaxin / Augmentin / Cephalosporins
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo female with a history of Hodgkin's lymphoma who is
admitted
with proctocolitis. The patient states she started having
diarrhea 5 days ago. She had some nausea the first day but that
mainly resolved except for one episode this morning. She has
been
having diarrhea numerous times a day, up to once an hour at
times. She has not been eating or drinking much at all. She
denies any fevers, cough, dysuria, or rashes. She has no known
sick contacts.
In the ED a CT was done which showed proctocolitis. Stool
studies
and blood cultures were sent. She was noted to have a potassium
of 2.5. She was given IV fluids, meropenum, morphine, calcium,
potassium, and oxycodone.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
--___, the patient had trouble obtaining her thyroid
medication due to unclear reasons and ended up missing many
doses. She then had a lot of anger issues, cutting up pictures
of her family and basically could not take care of herself at
that time. She was hospitalized and sectioned to ___
___;
details are of that hospitalization is unclear. Per report from
her 2 daughters and the patient, her thyroid medication was
restarted and she stabilized.
--___: and she started to have very high fevers to
105.9,,
106, almost on a nightly basis and was rigoring. This actually
continued through ___ and ___ and ___ it does not appear
they
sought medical care during this time.
--___: her family tells me her next presentation to
healthcare was at an ER when they were down in ___
___.
She ended up getting discharged from the ER for fevers of
unclear
etiology at this point.
--___: she was admitted to ___ and diagnosed
with Lyme disease. She says she was treated with vancomycin and
doxycycline at this time and she was scanned and found to have
diffuse lymphadenopathy. A lymph node was biopsied at this time
it was inconclusive. She has followup with outpatient
hematologist at ___, Dr. ___ had a bone marrow
biopsy done that was also inconclusive.
--Late ___ or early ___: she continued to have
fevers and had worsening symptoms including gagging, nausea,
constipation and had severe night sweats as well where she was
waking up soaked with sweat. Shewent to ___ and
was admitted. At ___, she had the following
workup
done: She had a PET scan done, on ___, which showed
findings consistent with malignant lymphoma with extensive
cervical right hilar, mediastinal, bilateral lower lobe
peribronchial, right internal mammary, porta hepatis, periaortic
and bilateral iliac lymphadenopathy. She had two lung nodules
that showed significant increased glucose at the right lung base
and left lower lobe superior segment. She also had a possible
lymphoma deposit in the right hepatic lobe, segment VIII and
multiple tumors are present in the spleen. She had a right
anterior T5 metastatic bone tumor present as well. She had an
echocardiogram done that showed a normal EF. Additionally, she
had a supraclavicular lymph node excisional biopsy. She had
actually three biopsy. She had cervical lymph node 2 and 4R
lymph node. The pathology revealed classical Hodgkin's lymphoma
with mixed cellularity. She was seen by an oncologist locally,
who referred her here for further care.
--Initial heme/onc evaluation: Patient offered clinical trial
___, Cohort D: Phase 2 Study of Nivolumab (___) in
newly diagnosed, previously untreated classical Hodgkin Lymphoma
(cHL) subjects
--___: C1D1 Nivolumab on trial ___: C2D1 Nivolumab
--___: C3D1 Nivolumab
--___: Seen in ___ area for diarrhea, received IVF. Stool
studies could not be obtained as symptoms resolved.
--___: C4D1 Nivolumab
--___: C1D1 Nivo + AD
--___: C1D15 Nivo + AD
--___: C2D1 Nivo + AD
--___: C2D15 Nivo + AD
--___ to ___: Admitted for influenza, discharged with 28 day
course of influenza.
--___: Cycle 3 day 1 Nivo + AD. Scans with continued
response overall. There is low level FDG uptake in the
bilateral
axillary and inguinal inguinal nodes are unchanged. There is
also new focal FDG avidity within the T7 vertebral body that did
not have a CT correlate.
--___: C3D15 Nivo + AD
--___: C4D1 Nivo + AD
--___: C4D15 Nivo + AD
--___: C5D1 Nivo + AD
--___: C5D13 Nivo + AD
--___: C6D1 Nivo + AD
PAST MEDICAL HISTORY:
-Muscular dystrophy, ___ since age ___ that was
diagnosed. Unclear as to which genotype she has.
-thyroidectomy for unclear reasons with subsequent
hypothyroidism
that was in ___.
-Anxiety, depression
Social History:
___
Family History:
Her mother had lung and cervical cancer, father had lung cancer.
Her daughter has ___ syndrome, tubulointerstitial nephritis
and uveitis.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
==================================
General: NAD
VITAL SIGNS: T 97.9 BP 120/78 HR 73 RR 20 O2 96%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, ND, Tenderness to palpation, greatest in lower
quadrants.
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
PHYSICAL EXAM ON DISCHARGE
=======================================
General: NAD
VITAL SIGNS: 98.1 PO 138 / 78 L Lying 86 16 95 RA
HEENT: MMM, no OP lesions
CV: RRR, NL S1S2, no murmurs
PULM: CTAB
ABD: Soft, NDNT
LIMBS: No edema, patient with claw like deformities of hands
and feet
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, moving all extremities w/ purpose
Pertinent Results:
LABS ON ADMISSION:
========================
___ 12:40PM BLOOD WBC-2.1* RBC-2.90* Hgb-9.1* Hct-26.8*
MCV-92 MCH-31.4 MCHC-34.0 RDW-14.2 RDWSD-48.2* Plt ___
___ 12:40PM BLOOD Neuts-46 Bands-0 ___ Monos-24*
Eos-0 Baso-2* ___ Myelos-0 AbsNeut-0.97*
AbsLymp-0.59* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.04
___ 12:40PM BLOOD Plt Smr-LOW Plt ___
___ 12:40PM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-139
K-2.5* Cl-106 HCO3-20* AnGap-16
___ 12:40PM BLOOD ALT-13 AST-15 AlkPhos-49 TotBili-0.2
___ 06:09AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.5*
MICRO:
=========================
___ 3:00 pm STOOL CONSISTENCY: FORMED Source:
Stool.
CRYPTOSPORIDIUM, GIARDIA, CYCLOSPORA, MICROSPORIDIUM,
ECOLI 0157,
YERSINIA, VIBRIO, OVA & PARASITE, MACROSCOPIC WORM, ALL
ADDED PER ADD
ON REQ @ 1526 ON ___.
CYCLOSPORA STAIN (Pending):
MICROSPORIDIA STAIN (Pending):
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
Cryptosporidium/Giardia (DFA) (Pending):
O&P MACROSCOPIC EXAM - WORM (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 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------------ <=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
___ 3:00 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
IMAGING/OTHER STUDIES:
==============================
___BD & PELVIS WITH CO
1. Proctocolitis without evidence drainable fluid collection or
perforation.
2. Mild intrahepatic and extrahepatic biliary dilation,
increased
from prior. Correlation with liver function tests is recommended
to assess for biliary obstruction, and MRCP is suggested further
characterization.
3. Distended bladder. If the patient is unable to although void
spontaneously, consider placing a Foley catheter.
4. Stable hepatic hypodensities and retroperitoneal
lymphadenopathy without new lesions identified.
5. Partly exophytic right upper pole renal cyst has decreased in
size when compared to ___ but increased in internal
complexity suggestive of interval rupture with internal
hemorrhage. Attention to this lesion on follow-up imaging is
recommended.
LABS ON DISCHARGE:
=======================
___ 05:45AM BLOOD WBC-2.5* RBC-2.88* Hgb-8.7* Hct-27.2*
MCV-94 MCH-30.2 MCHC-32.0 RDW-15.3 RDWSD-51.9* Plt ___
___ 05:45AM BLOOD Neuts-38 Bands-1 ___ Monos-19*
Eos-2 Baso-2* ___ Myelos-2* AbsNeut-0.98*
AbsLymp-0.90* AbsMono-0.48 AbsEos-0.05 AbsBaso-0.05
___ 05:45AM BLOOD Hypochr-1+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Stipple-OCCASIONAL
___ 05:45AM BLOOD ___ PTT-30.7 ___
___ 05:45AM BLOOD Glucose-91 UreaN-<3* Creat-0.4 Na-141
K-3.8 Cl-107 HCO3-26 AnGap-12
___ 05:45AM BLOOD ALT-13 AST-19 LD(LDH)-186 AlkPhos-51
TotBili-<0.2
___ 05:45AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.5 Mg-1.6
___ 11:00PM BLOOD TotProt-5.0* Albumin-3.1* Globuln-1.9*
Calcium-7.9* Phos-3.1 Mg-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 800 mg PO BID:PRN Pain - Mild
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 4 mg PO BID:PRN nausea
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
7. Prochlorperazine 10 mg PO Q6H:PRN nuasea
8. Senna 8.6 mg PO BID:PRN constipation
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Morphine SR (MS ___ 15 mg PO Q12H
11. LORazepam 0.5 mg PO BID:PRN Anxiety, Nausea
Discharge Medications:
1. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*16 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 150 mcg PO DAILY
5. LORazepam 0.5 mg PO BID:PRN Anxiety, Nausea
6. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*4 Tablet Refills:*0
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 4 mg PO BID:PRN nausea
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H: PRN Disp #*8
Capsule Refills:*0
10. Prochlorperazine 10 mg PO Q6H:PRN nuasea
11. Senna 8.6 mg PO BID:PRN constipation
12. HELD- Ibuprofen 800 mg PO BID:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until f/u w/ PCP
given GI issues to prevent GI bleed
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=========================
-GASTROENTERITIS NOS
SECONDARY DIAGNOSIS:
==========================
-HODGKIN'S LYMPHOMA
-___
-ANXIETY/DEPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: NO_PO contrast; History: ___ with abdominal pain, diarrhea //
evaluate 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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
2) Spiral Acquisition 5.1 s, 56.4 cm; CTDIvol = 6.3 mGy (Body) DLP = 353.4
mGy-cm.
Total DLP (Body) = 359 mGy-cm.
COMPARISON: CT of the abdomen and pelvis from ___.
PET-CT from ___
FINDINGS:
LOWER CHEST: A small pericardial effusion is slightly diminished from ___. Bilateral dependent atelectasis is mild. Coronary artery calcifications
are re-demonstrated.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Numerous hepatic calcifications are re-demonstrated and compatible with prior
granulomatous disease. Subcentimeter hypodensities within the hepatic dome
and in left hepatic lobe appear unchanged from ___. A 2.3 x 1.2 cm
hypodensity in hepatic segment 4 is likely stable from ___ and CT in
___ and could represent focal fat/transient hepatic attenuation
difference (02:44). No new lesions are identified. There is mild
intrahepatic and extrahepatic biliary dilation, increased from prior, with the
common bile duct measuring up to 7-8 mm. The gallbladder is dilated but
otherwise 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 measures 14.4 cm shows normal attenuation throughout,
without evidence of focal lesions. Numerous calcifications are present
compatible with prior granulomas disease.
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.
Within the upper pole of the right kidney is an exophytic 11 mm hypodensity
which is minimally decreased in size compared to the previous CT, but
substantially decreased in size from ___ and demonstrates minimal
internal complexity, likely a complex cyst that has undergone previous
rupture. Subcentimeter hypodensity in the upper pole left kidney is too small
to fully characterize. There is no evidence of new 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
not visualized. Slight wall thickening, mucosal hyperenhancement and trace
surrounding fat stranding involving the rectum and sigmoid colon is present
(2:79, 601b:30).
PELVIS: The urinary bladder is distended. The distal ureters are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: Left periaortic lymph node measures 10 mm in short axis stable
from ___. No new lymphadenopathy is seen. There is no mesenteric,
pelvic, or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Proctocolitis without evidence drainable fluid collection or perforation.
2. Mild intrahepatic and extrahepatic biliary dilation, increased from prior.
Correlation with liver function tests is recommended to assess for biliary
obstruction, and MRCP is suggested further characterization.
3. Distended bladder. If the patient is unable to although void
spontaneously, consider placing a Foley catheter.
4. Stable hepatic hypodensities and retroperitoneal lymphadenopathy without
new lesions identified.
5. Partly exophytic right upper pole renal cyst has decreased in size when
compared to ___ but increased in internal complexity suggestive of
interval rupture with internal hemorrhage. Attention to this lesion on
follow-up imaging is recommended.
RECOMMENDATION(S): MRCP.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, Weakness
Diagnosed with Ulcerative (chronic) rectosigmoiditis without complications
temperature: 98.1
heartrate: 82.0
resprate: 18.0
o2sat: 99.0
sbp: 106.0
dbp: 73.0
level of pain: 9
level of acuity: 2.0 | Information for Outpatient Providers: ___ yo female with a
history of Hodgkin's lymphoma who is admitted with
emesis/diarrhea found to have proctocolitis on CT A/P likely ___
viral gastroenteritis. Given patient w/ immunosuppression and
between chemotherapy cycles (s/p Clinical Trial ___ cycle 6
Nivolumab + Adriamycin and Dacarbazine) for Hodgkin's Lymphoma,
she was started empirically on 10 day course of IV flagyl,
transitioned to PO flagyl (day 1: ___, anticipated end date:
___ with symptomatic improvement. Apart from 1 episodes of
diarrhea in the ED, the patient had no nausea/vomiting/diarrhea
in house.
#Proctocolitis: Presented w/ 5 days copious diarrhea and emesis
found to have proctocolitis on CT A/P likely ___ viral
gastroenteritis. Given patient w/ immunosuppression and between
chemotherapy cycles (s/p Clinical Trial ___ cycle 6
Nivolumab + Adriamycin and Dacarbazine) for Hodgkin's Lymphoma,
she was started empirically on 10 day course of IV flagyl,
transitioned to PO flagyl (day 1: ___, anticipated end date:
___ with symptomatic improvement. Apart from 1 episodes of
diarrhea in the ED, the patient had no nausea/vomiting/diarrhea
in house. Unlikely autoimmune effect of nivolumab given rapid
resolution. C. diff neg. Stool Cx w/ NG.
#Biliary Dilation: Incidental seen on CT. Without current LFT
abnormalities, or RUQ pain thus no further workup/management
pursued inpatient.
#Hodgkin's Lymphoma: On Clinical trial with the following
protocol: "Protocol Treatment: Monotherapy phase with Nivolumab
240mg IV every 2 weeks x 4 doses, then Combination phase with
Nivolumab flat dose 240mg IV + AVD [Doxorubicin (Adriamycin) 25
mg/m2,Vinblastine 6 mg/m2, Dacarbazine 375 mg/m2] every 2 weeks
x 12
doses. A combocycle is 28 days with treatment on days 1 and 15."
Patient was due for C6D15 Nivolumab + Adriamycin and Dacarbazine
while in house, though held iso acute illness
#Hypothyroidism s/p thyroidectomy
- Continued home synthroid.
#Pyuria (E. coli positive urine culture): Patient with urine cx
positive for E. Coli, though Asx. Treatment deferred. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a history of hypertension and
treated breast cancer who collapsed while at the kitchen sink
earlier today. She was in her usual state of health this
weekend
and enjoyed the ___ weather and was walking regularly and
having no recent illness in the preceding days. This morning
while making breakfast she felt weaker than usual and felt her
legs give out under her as she was dizzy after standing at the
kitchen sink for several minutes. She did not lose
consciousness
or strike her head and per the ED signout she lowered herself to
the ground slowly but was unable to pick herself up from the
floor and was on the ground for 10 minutes and was able to get
to
the door to call for help at her assisted living. She was
transported to the ___ emergency department where there
was no signs of ischemia or arrhythmia on her EKG she had a
pulse
of 86-96 a blood pressure of 126/40 satting 98% on room air and
underwent further diagnostic testing she had a positive
urinalysis with greater than 182. White cells and white cell
clumps and a serum WBC of 22 her chest x-ray was abnormal
consistent with. Underlying pulmonary fibrosis which is known
but when compared to prior chest x-rays this is progressed
somewhat and could obscure signs of acute infection in the
chest.
As well as the addition of azithromycin as the emergency
department also considered possible pneumonia causing her
current
illness.
On arrival to the medical ward she feels well and did not report
any pre-existing urinary symptoms in the days prior to admission
but does note that her bladder feels somewhat uncomfortable now
with a sensation of fullness she denies dysuria hematuria. Or
change in urine color. The ED documentation describes frankly
purulent urine.
One of her sons whose name is ___ is dying of prostate cancer
in the local area and is on hospice. Her daughter ___
expresses concern about how her mother is handling ___
illness
and requests that we involved social work to set up bereavement
counseling.
In the emergency room she got ceftriaxone for her UTI
Past Medical History:
BREAST CANCER ___
s/p L sided lumpectomy, XRT, Tamoxifen x ___ followed by
___
CATARACTS
COLONIC ADENOMA ___
GASTROESOPHAGEAL REFLUX
with chronic cough
HYPERLIPIDEMIA
followed by ___ in ___
HYPERTENSION ___
INTERIM LAB VALUES
OSTEOARTHRITIS
OSTEOPENIA ___
repeat in ___ noted slight decrease in hip density (-1.7 from
-1.3) -- pt prefers watchful waiting for the time being.
PALPITATIONS ___
normal Holter eval
RECURRENT URINARY TRACT INFECTION ___
INGUINAL HERNIA
bilateral, asymptomatic
HEARING LOSS
bilateral hearing aides
SHOULDER PAIN
PULMONARY FIBROSIS
LEFT ROTATOR CUFF TEAR
ENDOMETRIAL CANCER ___
Social History:
___
Family History:
She reports that her mother had uterine cancer. Denies other
gynecologic malignancies.
Physical Exam:
Discharge Exam:
Gen: Lying in bed in no apparent distress
Vitals: Afebrile and vital signs stable (bedside chart reviewed
-
please see bedside record). Specific comments to same:
FSBG:
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
> 30 minutes spent on discharge planning, coordination, and care
Pertinent Results:
___ 08:05AM BLOOD WBC-9.3 RBC-3.88* Hgb-10.9* Hct-33.2*
MCV-86 MCH-28.1 MCHC-32.8 RDW-13.2 RDWSD-41.1 Plt ___
___ 08:05AM BLOOD Glucose-105* UreaN-16 Creat-0.7 Na-135
K-4.4 Cl-98 HCO3-21* AnGap-16
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------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Lovastatin 20 mg Oral QHS
4. Zolpidem Tartrate 5 mg PO HS anxiety
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
6. Psyllium Powder 1 PKT PO BID
7. amLODIPine 2.5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
10. Omeprazole 20 mg PO DAILY
11. Calcium Carbonate 1000 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1000 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
6. Losartan Potassium 100 mg PO DAILY
7. Lovastatin 20 mg Oral QHS
8. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Psyllium Powder 1 PKT PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. Zolpidem Tartrate 5 mg PO HS anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-UTI
-sepsis
-Weakness
Discharge Condition:
Good
Alert and Oriented x 2 (self, hospital, does not know year)
Ambulatory without assistance
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dizziness and fall// Acute cardiopulmonary process
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest CT from ___. Chest x-ray from ___.
FINDINGS:
There is increased interstitial markings throughout the lungs, with the
peripheral predominance, more conspicuous on the right than on the left.
There is no effusion or pneumothorax. Cardiomediastinal silhouette is
unchanged. Hiatal hernia is again noted. No acute osseous abnormalities.
IMPRESSION:
Increased interstitial markings throughout the lungs which with seen on remote
prior chest CT and suggestive of underlying fibrosis. When compared to prior
chest x-ray, this has progressed since ___ which could represent progression
of disease or potentially component of superimposed edema or infection.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall at home// eval for SDH or other ICH
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 14.0 s, 14.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. Mild white
matter hypodensities are nonspecific, likely related to small vessel ischemic
disease in a patient of this age. There is prominence of the ventricles and
sulci suggestive of involutional changes. Dense calcifications are seen along
bilateral carotid siphons.
There is no evidence of fracture. Degenerative changes are seen along the
right temporomandibular joint. There is mild mucosal thickening of the
ethmoid air cells. The visualized portion of the remaining paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits show bilateral lens replacement and bilateral optic nerve head
drusen are noted.
IMPRESSION:
No acute intracranial abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, s/p Fall
Diagnosed with Urinary tract infection, site not specified, Dizziness and giddiness, Fall on same level, unspecified, initial encounter
temperature: 98.4
heartrate: 96.0
resprate: 16.0
o2sat: 97.0
sbp: 101.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | ___ woman who felt weak and lowered herself to
the ground today and is found to have a peripheral leukocytosis
of 22 and suspected urinary tract infection, she globally weak
on admission and improved significantly with IV ceftriaxone. Her
Urine culture grew out pan-sensitive E. Coli . She was
transitioned to PO Ciprofloxacin 500mg BID to complete a 7 day
course on ___. Her daughter ___ expressed concern about how
the patient will
handle ___ death and how she is handling his current illness.
___ was consulted and cleared her for return to her ALF. She was
discharged on hospital day two. No other changes were made in
her medications. She was mobilizing and ambulating without
difficulty. Her hypertension regimen was continued throughout
her hospitalization. Her white count normalized on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / amoxicillin / coconut
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI by Dr. ___ in H&P dated ___:
"Ms. ___ is a ___ year old woman with asthma and PCOS who
presented to the ED with 3 days of dyspnea and wheezing. She
reports a long standing history of asthma that has required
numerous admissions to the hospital in the past, often at
___. She was once admitted to the ICU there,
although did not require intubation. At baseline she takes
flovent and PRN albuterol. She reports approximately three
exacerbations of her symptoms per year. She is unaware of
particular triggers although does reports worsening symptoms
around the time of season, such as ___. She states
that
her cough, dyspnea and wheezing has been progressively worsening
for about 3 days and not responding to her home albuterol
nebulizer treatments, which she has been using every 2 hours or
so. In associated with her dyspnea and wheezing she also
reports
chest tightness, similar to prior episodes although more severe.
Overall she states that her current presentation is one of the
more severe she has had and comparable with the episode that led
to her ICU admission and Children's. In addition to her
pulmonary
symptoms she also endorses headache and increased urination
without dysuria. She also notes intermittent low volume urinary
incontinence with coughing, which has also occurred previously.
In the Ed she was afebrile with HRs ___
120s-150s/60s-70s, RR ___, satting 94-00% on RA
While in the Ed she received prednisone 60 mgx2 (___),
frequent nebulizers, magnesium, macrobidx2 (___)
When seen on the floor she endorses minimal improvement in her
symtpoms since presenting to the ED.
ROS: As per HPI, and 10 point ROS completed and otherwise
negative."
Past Medical History:
Asthma
PCOS
Obesity
UTI x1
Social History:
___
Family History:
No history of pulmonary disease
Physical Exam:
ADMISSION EXAM:
Vital signs: afebrile with HRs ___ ,BPs 120s-150s/60s-70s,
RR ___, satting 94-100% on RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: Heart regular borderline tachy, no murmur
Chest wall: reproducible pain upon palpation of bilateral
anterior rib cage and sternum
RESP: bilateral expiratory rhonchi and wheezes
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic tenderness
MSK: No swollen or erythematous joints
SKIN: No rashes or ulcerations noted
EXTR: wwp, minimal edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
T 97.7, HR 79, BP 127/80, RR 18, SpO2 99% on RA
Ambulatory sat 97-100% on RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, PERRL
ENT: MMM, OP clear
CV: NR/RR, no m/r/g.
RESP: Good air movement, bilateral expiratory wheezes
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; no ___ edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-8.7 RBC-5.57* Hgb-12.3 Hct-38.9
MCV-70* MCH-22.1* MCHC-31.6* RDW-15.9* RDWSD-39.4 Plt ___
___ 06:50PM BLOOD Glucose-83 UreaN-11 Creat-0.8 Na-138
K-3.8 Cl-101 HCO3-25 AnGap-12
IMAGING:
CXR ___
Subtle left basal opacity likely atelectasis, though difficult
to
exclude a very early pneumonia in the correct clinical setting.
MICRO:
___ 6:30 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------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
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
___ 8:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
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
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-15.1* RBC-5.51* Hgb-12.2 Hct-38.7
MCV-70* MCH-22.1* MCHC-31.5* RDW-15.9* RDWSD-39.1 Plt ___
___ 07:10AM BLOOD Glucose-83 UreaN-12 Creat-0.6 Na-143
K-4.3 Cl-106 HCO3-21* AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea, wheezing
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, dyspnea
Discharge Medications:
1. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL ___ mL by mouth every
six (6) hours Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
neb every four (4) hours Disp #*60 Ampule Refills:*0
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
every twelve (12) hours Disp #*8 Capsule Refills:*0
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
5. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea, wheezing
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, dyspnea
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
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 cough// please eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph ___
FINDINGS:
Evaluation is slightly limited on the lateral view due to underpenetration in
the setting of large body habitus. There is no focal consolidation, pleural
effusion, or pneumothorax. Subtle opacity at the left lung base likely
represent atelectasis, difficult to exclude a very early pneumonia in the
correct clinical setting. Otherwise lungs are clear. No large effusion or
pneumothorax. Cardiomediastinal silhouette appears normal. Numerous external
linear densities projecting over the upper chest on the frontal view represent
external artifact. Bony structures are intact.
IMPRESSION:
Subtle left basal opacity likely atelectasis, though difficult to exclude a
very early pneumonia in the correct clinical setting.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Asthma exacerbation
Diagnosed with Unspecified asthma with (acute) exacerbation
temperature: 97.6
heartrate: 108.0
resprate: 20.0
o2sat: 100.0
sbp: 142.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | SUMMARY/ASSESSMENT:
___ year old woman with asthma admitted with asthma exacerbation.
Denies improvement in symptoms, and lung exam still with wheezes
and rhonchi, although she appears comfortable and vital signs
are reassuring. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Left quadriceps tendon rupture
Major Surgical or Invasive Procedure:
Left quadriceps tendon repair
History of Present Illness:
___ otherwise healthy, was skiing in ___ yesterday through deep
powder felt immediate pressure in left knee and fell to ground.
Presents with left thigh soreness and inability to extend knee.
Was seen by doc on mountain who did x-rays that were reportedly
normal, and gave him cruteches and a knee immobilizer. Flew back
last night. Denies actual trauma to the knee. Denies any other
injuries. Denies any numbness, paresthesias, or other weakness.
Past Medical History:
GERD
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
A&O x 3
Calm and comfortable
VS: 97.8, 72, 155/90, 20, 98RA
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
LLE skin clean and intact
Mild bulge proximal to patella, with mild knee effusion
Patella freely moves
Extensor mechanism absent
No tenderness over patella
Tenderness to palpation over anterior medial thigh
Knee stable to varus/valgus stress
Negative anterior drawer and Lachman
No erythema, edema, induration or ecchymosis
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
RLE skin clean and intact
Mild bulge proximal to patella
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Pertinent Results:
___ 03:00PM BLOOD WBC-6.9 RBC-4.55* Hgb-13.9* Hct-42.3
MCV-93 MCH-30.6 MCHC-32.9 RDW-12.7 Plt ___
___ 03:00PM BLOOD ___ PTT-27.3 ___
___ 03:00PM BLOOD Glucose-89 UreaN-21* Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-23 AnGap-14
Medications on Admission:
Prilosec
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): Do not exceed 4000 mg of acetaminophen (Tylenol) per
24 hours.
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QHS (once a day (at bedtime)) for 2 weeks.
Disp:*14 syringe* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use to prevent constipation while taking
oxycodone.
Disp:*60 Capsule(s)* Refills:*2*
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left quadriceps tendon rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with remote history of unrepaired ACL tear,
presents with skiing injury with fall.
COMPARISON: None available.
FINDINGS: Three views of the left knee demonstrate a BB marker over the
anterior aspect of distal femur, indicating site of symptomology. There is no
definite fracture or dislocation. Mild to moderate tricompartmental
osteoarthritis is present with minimal bony spurring. There is a small
effusion. There is no evidence for radiopaque foreign body. Prepatellar soft
tissues are markedly swollen.
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Mild to moderate tricompartmental osteoarthritis.
3. Small effusion.
4. Marked prepatellar soft tissue swelling.
Radiology Report
INDICATION: Evaluation of patient status post knee injury with decreased
ambulation.
COMPARISON: Knee radiographs from the same day.
FINDINGS: Grayscale, color, and spectral Doppler examinations of bilateral
common femoral, superficial femoral, and popliteal veins were performed.
There is normal compressibility, flow, and augmentation. Bilateral posterior
tibial and peroneal veins demonstrate normal flow. CFVs show symmetric flow.
IMPRESSION: No evidence of right or left lower extremity DVT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LEFT THIGH PAIN
Diagnosed with SPRAIN OF KNEE & LEG NEC, FALL FROM SKIS, ACTIVITIES INVOLVING SNOW (ALPINE) (DOWNHILL) SKIING, SNOW BOARDING, SLEDDING,TOBOGGANING AND SNOW TUBING
temperature: 97.8
heartrate: 72.0
resprate: 20.0
o2sat: 100.0
sbp: 155.0
dbp: 90.0
level of pain: 1
level of acuity: 3.0 | Mr. ___ was admitted to the Orthopedic service on ___
for left quadriceps tendon rupture after being evaluated in the
emergency room. He underwent left quadriceps tendon repair
without complication on ___. Please see operative report
for full details. He was extubated without difficulty and
transferred to the recovery room in stable condition. In the
early post-operative course Mr. ___ did well and was
transferred to the floor. He was given ___ brace by
NOPCO, which he will keep locked at all times. He had adequate
pain control while in the hospital. He was evaluated by physical
therapy, who recommended that he is safe for discharge to home.
The remainder of his hospital course was uneventful and Mr.
___ is being discharged to home in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vaginal bleeding
Major Surgical or Invasive Procedure:
___ uterine artery embolization
History of Present Illness:
Ms. ___ is a ___ yo G1P1 ___ s/p SVD on ___, and ___ s/p
ultrasound-guided D&C on ___ for retained POCs c/b hemorrhage
of
450cc, who presents to the ED with vaginal bleeding.
Her D&C on ___ was notable for a 1x1cm protruding tissue on the
posterior aspect of the uterus w/ abnormal Doppler, which was
left in situ due to concern for focal accreta and possibility of
hemorrhage. Plan was made for hysteroscopic evaluation with
possible resection at 12 weeks postpartum.
Postoperatively, she had vaginal bleeding in the PACU, and
received TXA, cytotec, and hemabate (methergine was held due to
recent preeclampsia). Following her procedure, she was admitted
to the GYN service for observation. On POD#1, her Hct had
dropped
from 30.0 (preop) to 18.5, and she received 2 units of pRBCs,
with an follow up Hct of 23.1. She recovered well and was
discharged home on a 10 day course of doxycycline.
Pt states that she felt a gush of blood this evening and went to
the toilet and noted a large amount of bright red blood in the
toilet. She called ___ and was BIBA to ___,
where she was noted to be hemodynamically stable for transfer to
___. Pt denies any HA, vision changes, epigastric pain, CP or
SOB but is reporting some lightheadedness or dizziness. Pad in
place since ~1400 that was only 30% stained with old blood.
ROS: As per HPI, otherwise negative
Past Medical History:
OB HISTORY:
- G1: SVD c/b pre-eclampsia (severe by BP) and PPH (EBL 2100cc)
as above
GynHx:
- denies abnormal Pap or cervical procedures
- denies fibroids/endometriosis/cysts
- denies STIs, including HSV
PAST MEDICAL HISTORY: Preeclampsia
PAST SURGICAL HISTORY:
- D&C for rPOCs under US guidance
Allergies: NKDA
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
Yest 18:02 0 98.3 118 131/93 16 98% RA
Yest 20:06 98.4 106 133/92 18 99% RA
Today 00:06 0 99 121/83 12 98% RA
Today 02:16 0 98.1 98 115/80 12 98% RA
Today 02:16 0 98.1 98 115/80 12 98% RA
General: NAD
Neuro: alert, appropriate, oriented x 3
Pulm: No increased work of breathing
Abdomen: soft, NT, no masses
Pelvic: Normal external anatomy, pink vaginal mucosa, small amt
of bleeding from the os, not pooling in the vault, normal
appearing cervical os
Bimanual: no fundal/uterine tenderness, no adnexal tenderness
Ext: nontender, no edema
Pertinent Results:
___ 08:00PM BLOOD WBC-11.7* RBC-2.59* Hgb-7.7* Hct-24.5*
MCV-95 MCH-29.7 MCHC-31.4* RDW-15.0 RDWSD-51.0* Plt ___
___ 08:00PM BLOOD Neuts-76.8* Lymphs-18.5* Monos-3.4*
Eos-0.3* Baso-0.4 Im ___ AbsNeut-8.98* AbsLymp-2.17
AbsMono-0.40 AbsEos-0.03* AbsBaso-0.05
___ 10:30AM BLOOD WBC-7.0 RBC-2.52* Hgb-7.5* Hct-24.2*
MCV-96 MCH-29.8 MCHC-31.0* RDW-14.4 RDWSD-50.4* Plt ___
___ 10:30AM BLOOD ___ PTT-29.6 ___
___ 08:00PM BLOOD Glucose-89 UreaN-9 Creat-0.5 Na-144 K-4.2
Cl-107 HCO3-23 AnGap-14
___ 12:21AM URINE Color-Straw Appear-Clear Sp ___
___ 12:21AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 12:21AM URINE RBC-35* WBC-41* Bacteri-FEW* Yeast-NONE
Epi-1
___ 12:21AM URINE Mucous-OCC*
___ 12:21 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Medications on Admission:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 6 Days
2. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 1 dose
2. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Subinvolution of placental implantation site
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ s/p SVD (___) s/p US-guided D C for rPOCs (___) c/b
hemorrhage, readmitted ___ with additional vaginal bleeding. Pathology showed
involution of implantation site.// Requesting UAE prior to hysteroscopic
resection.
COMPARISON: MR pelvis ___
TECHNIQUE: OPERATORS: Dr. ___ radiology resident)
and Dr. ___ performed the procedure.
The attending, Dr. ___ was present and supervising throughout the procedure.
Dr. ___ radiologist, personally supervised the trainee during the
key components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
200mcg of fentanyl and 4 mg of midazolam throughout the total intra-service
time of 90 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, Versed
CONTRAST: 100 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 26.9 min, 185 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Left uterine arteriogram.
3. Gel-Foam embolization of the left uterine artery to near stasis.
4. Right uterine arteriogram.
5. Gel-Foam embolization of the right uterine artery to near stasis.
PROCEDURE DETAILS:
Following a discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. Right groin was
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid femoral head. A
___ wire was advanced easily under fluoroscopy into the aorta. A small
skin incision was made over the needle and the needle was exchanged for a 5
___ sheath which was attached to a continuous heparinized saline side arm
flush.
An Omni flush catheter was advanced over the wire. The wire was used to
select the left external iliac artery and the Omniflush catheter was exchanged
for a pudendal catheter. The pudendal catheter was used to cannulate the left
uterine artery. A left uterine arteriogram was performed. Using the
arteriogram as a road map a pre-loaded high-flow Renegade catheter and
Transcend wire was advanced distally into the uterine artery. The pudendal
catheter was withdrawn slightly to improve flow. Gel-Foam was injected to
near stasis.
The micro catheter was then removed and the pudendal catheter was used to
engage the right uterine artery. A right uterine arteriogram was performed.
The pre-loaded Renegade High-Flow catheter and Transcend wire were advanced
distally into the right uterine artery. The pudendal catheter was withdrawn
slightly to improve flow. Gel-Foam was injected to near stasis. The micro
catheter was then removed. A ___ wire was introduced and the pudendal
catheter and wire were removed.
The sheath was then removed. An Angio-Seal device was deployed. Manual
pressure was held until hemostasis was achieved. Sterile dressings were
applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Left uterine artery supplying much of the postpartum uterus without
evidence of uterine AVM.
2. Relatively diminutive right uterine artery without evidence of uterine
AVM.
IMPRESSION:
Right common femoral artery access bilateral uterine artery Gel-Foam
embolization to near stasis.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman s/p SVD on ___ w/ rPOCs, s/p D C on ___
re-admitted with VB// please evaluate for ?AVM
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: None.
FINDINGS:
UTERUS AND ADNEXA:
The uterus is anteverted, overall size measures 10.7 x 6.8 x 8.5 cm.
The endometrial cavity is distended to 8.1 x 4.7 x 6.1 cm with material which
demonstrates heterogeneous hypointense signal on T2 weighted imaging with
patchy mild hyperintensity on the T1 weighted imaging, consistent with
hematoma given the recent dilation and curettage on ___, with
postprocedural empty appearance of the endometrial canal. No convinced
postcontrast enhancement within the hematoma or along the walls of the
endometrial cavity. There is no early draining vein identified.
The right ovary is visualized and appears within normal limits.
The left ovary is visualized and appears within normal limits.
No pelvic free-fluid.
LYMPH NODES: No pelvic lymphadenopathy.
BLADDER AND DISTAL URETERS: Normal
RECTUM AND INTRAPELVIC BOWEL: Normal
VASCULATURE: Patent and normal
OSSEOUS STRUCTURES AND SOFT TISSUES: Normal
IMPRESSION:
1. Endometrial cavity is distended with heterogeneous material, some of which
is T1 hyperintense and is consistent with hematoma.
2. No evidence of uterine arteriovascular malformation or vascularized
products of conception.
Gender: F
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Vaginal bleeding
Diagnosed with Abnormal uterine and vaginal bleeding, unspecified
temperature: 98.3
heartrate: 118.0
resprate: 16.0
o2sat: 98.0
sbp: 131.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ presented to the ED on the evening of ___ with
concern for a repeat episode of vaginal bleeding after admission
from ___ for ultrasound-guided D&C for presumed retained
products of conception. Pathology from the procedure
demonstrated sub-involution of the placental implantation site.
Pelvic ultrasound on ___ demonstrated complex heterogenic
echogenic material distending the uterine cavity consistent with
hematoma, without evidence of arterio-venous malformation or
vascularized retained products of conception.
Maternal-Fetal Medicine was consulted and recommended ___
uterine artery embolization to decrease acute bleeding with
interval hysteroscopy in ___ weeks. ___ was consulted and
proceeded with uterine artery embolization on ___.
Throughout her admission, Ms. ___ bleeding was monitored and
was mild-moderate. Her hematocrit was stable at ___. She
otherwise did well without dizziness, lightheadedness, chest
pain, or shortness of breath. She maintained a normal diet,
ambulated, and after her procedural Foley was discontinued,
voided independently. After her meeting all of her
post-operative milestones, she was discharged home with close
outpatient follow-up. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids
Attending: ___
Chief Complaint:
left hip and buttock ___
Major Surgical or Invasive Procedure:
___ Epidural steroid injection
History of Present Illness:
Ms. ___ is a ___ yo woman with a history of T2DM,
hyperlipidemia, idiopathic urticaria, and previous episode of
lumbar radiculopathy who presents with left-sided hip and
buttock ___ radiating to her left back, abdomen, and foot. Six
days PTA she began experiencing left hip ___ and mild nausea
that worsened until 4 days PTA when she awoke at 4:30 am with
severe left hip and buttock ___ and had an episode of nonbloody
emesis. She describes the ___ as intermitent, ___ at its
worst, ___ at its best, "stabbing and excruciatingly sharp."
The ___ is severe enough to prevent her from walking. Moving,
talking, sitting up, and breathing deeply worsen the ___, while
laying on her stomach relieves her ___ slightly. At home she
tried taking Tylenol and aspirin, both of which did not help her
___, as well as Atarax every 4 hrs, which helped her relax. She
has had tingling ("pins and needles") in her left foot but
denies numbness, weakness, saddle anesthesia, and urinary/fecal
incontinence. The ___ became so unbearable that she presented
to the ED.
Of note, because of her nausea, Ms. ___ stopped taking all
her medications 4 days PTA. She last took metformin and
sitagliptin 5 dayts PTA. She denies polyuria but has felt
dehydrated due to decreased PO solid and liquid intake.
Also of note, Ms. ___ had a previous episode of similar ___
in ___ that was evaluated by MRI, which showed disk
herniation and nerve impingement. She was ultimately treated
with a steroid injection, which made her ___ manageable, and 6
weeks of ___.
In the ED, VS were T 99.0, HR 87, BP 191/93, RR 18, 99% on RA.
Initial labs were notable for HCO3 18, glucose 191, AG 23, H&H
52.3/17.3, lactate 1.2. VBG showed pH 7.25 and pO2 34. Repeat
labs showed HCO3 18, AG 20, and glucose 158. Repeat VBG showed
pH 7.25 and pO2 64. UA showed glucosuria, ketonuria, and
proteinuria. She was given IV fluids, insulin, zofran, home
medications (including metformin) as well as dilaudid, toradol,
percocet, and morphine, which did not help her ___. CT was done
and revealed no renal stones or acute abdominal process, but
showed degenerative changes in the lumbar spine and foraminal
narrowing at L5-S1. She was transferred to the inpatient floor
for further management of her ___ and hyperglycemia. VS on
transfer were T 97.9, HR 66, BP 160/67, RR 18, 97% on RA.
Past Medical History:
# T2DM:
- on metformin and sitagliptin
- Onset in ___
- No previous episodes of HHNS or DKA
- Highest measured blood sugars at home in 200s; lowest in ___
(feels "foggy")
# Hyperlipidemia: stable
- Takes pravastatin
# Hypertension: stable
# Palpitations
# Idiopathic urticaria: stable
- Takes Atarax PRN
# Asthma: hasn't had an exacerbation in years
# Tonsillectomy: ___
# Cardiac catheterization: ___ yrs ago for atypical chest ___ no
abnormal findings
# High grade vulvar squamous intraepithelial lesion: resected in
___
Social History:
___
Family History:
- ___: sudden cardiac death at age ___
- Mother: MI at age ___ yo
- Older brother: bile duct cancer at ___ yo
Physical Exam:
ADMISSION PHYSICAL EXAM:
- VS: 98.3, BP 142/62, HR 71, RR 18, 97% on RA
- General: laying on her stomach in ___
- Neuro: alert; cooperative; CN II-XII intact except decreased
bilateral hearing (due to previous otitis media); ___ left ankle
extension/flexion; ___ right ankle extension/flexion; ___ wrist,
finger, and elbow flexion/extension; normal sensation on UE and
___
- HEENT: PERRL; dry mucus membranes; no oral lesions
- CV: unable to perform due to limited mobility from ___
- Lungs: CTAB; no adventitious breath sounds
- Abdomen: unable to perform due to limited mobility from ___
- Extremities: WWP; no cyanosis or edema
- Skin: ecchymosis over left triceps and left forearm
DISCHARGE PHYSICAL EXAM:
- VS: Tcurrent 98.6, 148/68, 78, 20, 100% on RA, BG 128
- I/O: none recorded/bathroom privileges
- General: sitting up in bed reading
- Neuro: alert; cooperative; normal sensation on ___ b/l; ___
ankle flexion/extension b/l
- HEENT: moist mucus membranes
- CV: RRR; normal S1/S2; ___ systolic murmur; 2+ radial, DP, and
___ pulses b/l
- Lungs: CTAB; no adventitious breath sounds
- Abdomen: +BS; soft; palpable bowel loops; nontender; no HSM
- Extremities: WWP; no cyanosis or edema; cap refill <2 sec
- Skin: red annular patch underneath left breast; ecchymoses
over left triceps and left forearm
Pertinent Results:
ADMISSION LABS:
___ 08:26AM BLOOD WBC-7.8 RBC-5.69* Hgb-17.3* Hct-52.3*
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.1 Plt ___
___ 08:26AM BLOOD Neuts-73.0* ___ Monos-4.5 Eos-0.6
Baso-1.0
___ 08:26AM BLOOD Plt ___
___ 08:26AM BLOOD Glucose-191* UreaN-10 Creat-0.6 Na-137
K-3.9 Cl-100 HCO3-18* AnGap-23*
___ 02:55PM BLOOD Glucose-158* UreaN-7 Creat-0.5 Na-138
K-3.5 Cl-104 HCO3-18* AnGap-20
___ 02:55PM BLOOD ALT-17 AST-15 TotBili-0.4
___ 02:55PM BLOOD Lipase-42
___ 02:55PM BLOOD cTropnT-<0.01
___ 02:55PM BLOOD Calcium-8.2* Phos-2.9 Mg-1.6
___ 02:55PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 08:30AM BLOOD ___ pO2-34* pCO2-42 pH-7.27*
calTCO2-20* Base XS--8
___ 03:04PM BLOOD ___ Rates-/16 FiO2-96 pO2-64*
pCO2-39 pH-7.25* calTCO2-18* Base XS--9 AADO2-584 REQ O2-96
Intubat-NOT INTUBA Vent-SPONTANEOU
___ 08:30AM BLOOD Glucose-178* Na-140 K-4.0 Cl-103
calHCO3-19*
___ 10:56AM BLOOD Lactate-1.2
___ 07:56PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:56PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 07:56PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-3
TransE-<1
___ 07:56PM URINE CastHy-14*
___ 07:56PM URINE Mucous-RARE
___ 03:34AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 10:___BD & PELVIS W/O CONTRAST
IMPRESSION:
1. No acute intra-abdominal process. No evidence of renal
stones.
2. Degenerative changes in the lumbar spine resulting in
moderate to severe
neural foraminal narrowing at L5-S1. MR could be pursued for
further
evaluation, if clinically indicated.
3. Multifibroid uterus.
DISCHARGE LABS:
___ 06:10AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9 Cholest-204*
___ 06:10AM BLOOD %HbA1c-11.1* eAG-272*
___ 06:10AM BLOOD Triglyc-89 HDL-55 CHOL/HD-3.7
LDLcalc-131*
___ 06:20AM BLOOD WBC-6.9 RBC-5.44* Hgb-16.7* Hct-48.7*
MCV-90 MCH-30.7 MCHC-34.3 RDW-12.9 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-140* UreaN-10 Creat-0.4 Na-139
K-3.6 Cl-97 HCO3-31 AnGap-15
___ 06:10AM BLOOD ALT-16 CK(CPK)-157
___ 06:20AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO ONCE:PRN flight
2. Amiloride HCl 10 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Hydrochlorothiazide 150 mg PO DAILY
5. HydrOXYzine ___ mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Potassium Chloride 40 mEq PO DAILY
8. Pravastatin 80 mg PO DAILY
9. Januvia (sitaGLIPtin) 100 mg Oral daily
10. Verapamil SR 240 mg PO Q24H
11. Aspirin 325 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea/cough
Discharge Medications:
1. Amiloride HCl 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*30 Tablet Refills:*0
3. Citalopram 40 mg PO DAILY
4. Potassium Chloride 40 mEq PO DAILY
Hold for K >
5. Pravastatin 80 mg PO DAILY
6. Verapamil SR 240 mg PO Q24H
7. ALPRAZolam 0.25 mg PO ONCE:PRN flight
8. HydrOXYzine ___ mg PO BID:PRN urticaria
Take only as needed for urticaria.
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea/cough
10. Ibuprofen 600 mg PO Q8H:PRN ___ Duration: 5 Days
Take with food.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
11. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours Disp #*60 Tablet Refills:*0
12. Gabapentin 600 mg PO Q8H
RX *gabapentin 300 mg 2 capsule(s) by mouth every 8 hours Disp
#*90 Capsule Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
14. Senna 1 TAB PO BID Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
15. Miconazole Powder 2% 1 Appl TP BID:PRN rash
RX *miconazole nitrate [Anti-Fungal] 2 % Apply to affected area
twice daily Disp #*1 Bottle Refills:*0
16. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
17. Lantus Solostar (insulin glargine) 26 Units Subcutaneous Qhs
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 20
units SC at bedtime Disp #*6 Container Refills:*0
18. Diabetes Home Supplies
ICD-9 250.00
Insulin pen needles - 32
gauge x ___ (4 mm Nano)
Quantity: 200
strips (100/box x2)
Refills: 0
19. Outpatient Physical Therapy
ICD-9 724.3 Sciatica
___ The ___
Tel: ___ Fax: ___
Date of Injury: ___
20. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN severe ___
RX *oxycodone 5 mg 1 tablet(s) by mouth q 4hr Disp #*8 Tablet
Refills:*0
21. Glargine 26 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 26
units subcutaneous 26 Units before BED; Disp #*1 Box Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL as directed
units SC Up to 20 units per day Disp #*1 Box Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: lumbar radiculopathy, diabetic ketoacidosis
Secondary diagnoses: chronic hypertension, hyperlipidemia, type
2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain.
TECHNIQUE: MDCT imaging of the abdomen and pelvis without intravenous
contrast was performed. Multiplanar reformats were prepared and reviewed.
COMPARISON: Comparison is made with CT pelvis from ___.
FINDINGS:
ABDOMEN: Evaluation of the intra-abdominal organs is somewhat limited on this
noncontrast exam. The liver is homogeneous in texture with no focal lesions.
There is no biliary ductal dilatation. The gallbladder is normal. The
spleen, pancreas, and adrenal glands are normal. The kidneys are unremarkable
with no contour irregularities, hydronephrosis, or nephrolithiasis. The
stomach, duodenum, and intra-abdominal loops of bowel are normal in caliber
and unremarkable. There is no retroperitoneal or mesenteric lymphadenopathy.
The intra-abdominal aorta demonstrates atherosclerotic disease but is normal
in caliber.
PELVIS: Scattered diverticula are seen in the colon. The sigmoid colon and
rectum are otherwise normal in appearance. The distal ureters and bladder are
normal. A multifibroid uterus is seen, which has increased in size since
___, including an anterior fundal fibroid which now measures 8.0 x 6.5 cm,
previously 5.1 x 3.9 cm. The fibroids are predominantly subserosal. The
uterus, including the fibroids, currently measures CC 12.0 x AP 6.8 x TRV 10.5
cm. The right ovary is normal in appearance. The left ovary is not well
visualized, and may be obscured by adjacent fibroids. There is no pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen. Degenerative changes are seen in the lumbar
spine, with extensive facet joint hypertrophic changes at L4-5 and L5-S1
resulting in moderate to severe left and moderate right neural foraminal
narrowing at L5-S1.
IMPRESSION:
1. No acute intra-abdominal process. No evidence of renal stones.
2. Degenerative changes in the lumbar spine resulting in moderate to severe
neural foraminal narrowing at L5-S1. MR could be pursued for further
evaluation, if clinically indicated.
3. Multifibroid uterus.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LEFT BUTTOCK PAIN
Diagnosed with LUMBAGO
temperature: 99.0
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 191.0
dbp: 93.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with a history of type 2
diabetes, hyperlipidemia, and previous episode of lumbar
radiculopathy who presents with left-sided hip and buttock ___
radiating to her left back and foot secondary to lumbar
radiculopathy from nerve impingement. |
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 + L cerebellar finding
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
alcohol abuse (no history of alcohol withdrawal seizures),
herniated disc, out of medical care x ___ years due to loss of
health insurance who presents today with seizure, transferred
here from ___ due to hyperdensity in left
cerebellar hemisphere on ___.
He states that he drank two beers tonight. The last thing he
remembers is eating some steak tips at a barbeque with his son.
He was then seen tripping and falling into a ___. He had no
symptoms before falling into the ___. His friend who was with
him (who is not currently present) states that he saw him have a
generalized seizure, with no incontinence. Unknown how long this
lasted. EMS was called. Fingerstick blood glucose was 81.
Mr. ___ remembers waking up in the ambulance on the way to
___. He got 1g Keppra at ___, and was
transferred here after a small hyperdenisty in the left
cerebellar hemisphere was found on ___.
He states that he has been trying to taper off of drinking. He
states that he usually has ___ beers every day. For the past two
days, he had no drinks. Then today, before his seizure, he had 2
beers. Alcohol level today is 187.
For the past week, he does endorse cough and chest pain with
cough, no other infectious symptoms.
He also says he has had a left temporal headache for the past 6
months or so, which is throbbing, and lasts half an hour if he
takes an ibuprofen and ___ hours if he doesn't. No associated
symptoms, does not wake him up from sleep or get worse when
lying
down, with valsalva.
He denies any ___ trauma, clumsiness, or difficulty walking. No
vertigo. While examining him, he does not notice any difference
from his baseline.
On neuro ROS, he denies loss of vision, blurred vision,
diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Alcohol abuse
- Herniated disc in back
Social History:
___
Family History:
No family history of strokes, ___ tumors, or any other
neurologic disease.
Physical Exam:
Admission Exam:
Vitals: 97.6 89 86/69 --> SBP 100s 14 94% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, nontender
Extremities: No edema, well perfused.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Naming intact, calculation intact. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. No apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with slow nystagmus on left gaze. Normal
saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Dysmetria L>>R upper
extremity, and just on the left lower extremity. RAM intact, no
dysdiadokokinesia.
-Gait: Stands on his own, somewhat lightheaded upon standing.
Sways with Romberg, to both sides. Wide-based gait, normal
stride
length.
Discharge Exam:
Awake, alert, language fluent. Follows commands.
PERRL, 3 mm. EOMI, no nystagmus. Normal saccades. VFF. Face
movement/sensation symmetric. Hearing intact.
Strength ___, no drift.
Reflexes ___ 1. Babinski unable to
be tested due to brisk withdrawal.
Intact proprioception.
Intact FNF, fast finger tap, no rebound.
Pertinent Results:
___
CXR
No pneumonia. Left pleural scarring.
___
CTA ___ w/wo contrast
1. Faint 4 mm hyperdensity without surrounding edema in the left
cerebellar hemisphere, most suggestive of an underlying
mineralized lesion, such is a cavernous malformation. Recommend
MRI with and without contrast for further evaluation.
2. Otherwise, there is no evidence for acute intracranial
hemorrhage.
3. Unremarkable CTA of the ___ and neck.
___
MR ___ w/wo contrast
1. Given the appearance on CT, along with the signal intensity
characteristics on MRI, the left cerebellar lesion represents
chronic blood products; a small cavernoma or remote focus of
microhemorrhage. Attention on follow up.
2. Non-specific, non-enhancing FLAIR signal abnormality in the
pons may be due to metabolic or electrolyte abnormalities, a
demyelinating/inflammatory process, or a low grade glioma.
Correlation with clinical details is recommended and close
followup to assess for interval change as no priors. If workup
for a low grade glioma is desired, the area would be amenable to
MR spectroscopy for better assessment.
CSF Cytology/flow cytometry ___: results pending.
___ 07:00AM BLOOD WBC-6.2 RBC-4.92 Hgb-16.8 Hct-48.6
MCV-99* MCH-34.1* MCHC-34.5 RDW-13.1 Plt ___
___ 12:35AM BLOOD Neuts-63.0 ___ Monos-5.7 Eos-1.2
Baso-0.5
___ 07:00AM BLOOD Glucose-64* UreaN-9 Creat-0.7 Na-140
K-4.1 Cl-105 HCO3-23 AnGap-16
___ 07:00AM BLOOD ALT-34 AST-40 LD(LDH)-189 AlkPhos-69
TotBili-0.6
___ 07:00AM BLOOD Albumin-4.1 Calcium-8.7 Phos-3.1 Mg-2.1
___ 07:00AM BLOOD VitB12-471
___ 07:00AM BLOOD TSH-1.3
___ 12:35AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 12:08PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-17* Polys-1
___ ___ 12:08PM CEREBROSPINAL FLUID (CSF) TotProt-35 Glucose-68
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. Ibuprofen 400 mg PO Q8H:PRN pain
2. Chlordiazepoxide HCl 5 mg PO TID Duration: 1 Day
RX *chlordiazepoxide HCl 5 mg *as directed capsule(s) by mouth
*as directed Disp #*4 Capsule Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Men's Multi-Vitamin] 1 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*3
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
5. Thiamine 100 mg PO DAILY Duration: 5 Days
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol-related seizure, likely alcohol induced, though may be
related to alcohol withdrawal.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with new seizure and cough.
TECHNIQUE: Chest PA and lateral
COMPARISON: None available
FINDINGS:
PA and lateral chest radiograph demonstrates clear lungs. Heart size is
top-normal. Mediastinal and hilar contours are otherwise unremarkable.
Elevation and flattening of the left diaphragmatic pleural surface, is due to
pleural scarring, reflected in blunting of the pleural sulcus and
calcification.
IMPRESSION:
No pneumonia. Left pleural scarring.
Radiology Report
INDICATION: ___ with left cerebellar parenchymal hemorrhage.
TECHNIQUE: Following an noncontrast head CT, axial multidetector CT images of
the head and neck were obtained during intravenous contrast administration.
Maximal intensity projection reformatted images, curved reformatted images,
and 3D volume rendered angiographic reformatted images were obtained.
DOSE: DLP 2517.13 mGy cm
COMPARISON: Noncontrast head CT from ___ dated ___.
FINDINGS:
NONCONTRAST HEAD CT Again seen is a stable 4 mm focus of faint hyperdensity
without surrounding edema in the left cerebellar hemisphere on image 2:10.
Its appearance is most suggestive of mineralization related to an underlying
lesion, such is a cavernous malformation, rather than acute hemorrhage. No
other evidence for intracranial hemorrhage is seen. There is no edema or loss
of gray/ white matter differentiation in the brain parenchyma. Evaluation of
the pons is limited by beam hardening artifact from the adjacent calvarium.
Ventricles, cerebral sulci, and basal cisterns are normal in size.
There is trace fluid in the dependent left mastoid air cells and mild partial
opacification of nondependent left mastoid air cells. There is mild mucosal
thickening in the left anterior ethmoid air cells. There is mild mucosal
thickening along a septation in the right maxillary sinus and mild polypoid
mucosal thickening along a septation in the left maxillary sinus. There are
multiple bilateral periapical lucencies in the maxilla.
NECK CTA There is a 3 vessel aortic arch. Common carotid and cervical
internal carotid arteries, as well as V1 through V3 segments of the vertebral
arteries, are widely patent without evidence for stenosis or dissection.
Distal cervical internal carotid arteries measure 4.2 mm in diameter on the
right and 4.2 mm in diameter on the left.
HEAD CTA The intracranial internal carotid and vertebral arteries, and their
major branches, are widely patent without evidence for flow-limiting stenosis,
aneurysm, or arteriovenous malformation.
OTHER FINDINGS Evaluation of the visualized upper lungs is limited by
respiratory motion. There is a bulla at the right apex with mild adjacent
pleural/ parenchymal scarring. There is linear atelectasis or scarring in the
anterior left upper lobe adjacent to the mediastinal margin. It is not clear
whether mild centrilobular emphysema is present. Main pulmonary artery is
normal in caliber. There is no lymphadenopathy in the visualized upper
mediastinum or in the soft tissues of the neck.
IMPRESSION:
1. Faint 4 mm hyperdensity without surrounding edema in the left cerebellar
hemisphere, most suggestive of an underlying mineralized lesion, such is a
cavernous malformation. Recommend MRI with and without contrast for further
evaluation.
2. Otherwise, there is no evidence for acute intracranial hemorrhage.
3. Unremarkable CTA of the head and neck.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with cerebellar bleed. Assess for cause of bleed
and underlying lesions.
TECHNIQUE: MRI of the brain was performed using sagittal T1, axial T1,
gradient echo, FLAIR, T2, diffusion with ADC map, and postcontrast axial T1.
Postcontrast sagittal MPRAGE with coronal and axial reformats were reviewed.
COMPARISON: CTA head and neck dated ___ at 01:53
FINDINGS:
In the left cerebellar hemisphere, there is a tiny non-enhancing focus which
demonstrates low signal on T1 and T2-weighted images, and homogenous negative
susceptibility artifact. These findings, combined with the mildly hyperdense
appearance on CT indicate that this is likely a small cavernoma or focus of
chronic microhemorrhage.
Nonspecific, non-enhancing FLAIR abnormality is seen in the upper pons.
Nonspecific periventricular and subcortical white matter FLAIR
hyperintensities are likely a sequela of chronic small vessel ischemic
disease.
Principal intracranial flow voids are preserved and dural venous sinuses
enhance normally without filling defects.
No pathologic leptomeningeal or pachymeningeal enhancement.
The bone marrow signal is normal.
No pathologic upper cervical lymph nodes are appreciated.
Small mucous retention cyst is seen in the base of left maxillary sinus,
otherwise the paranasal sinuses are clear.
IMPRESSION:
1. Given the appearance on CT, along with the signal intensity
characteristics on MRI, the left cerebellar lesion represents chronic blood
products; a small cavernoma or remote focus of microhemorrhage. Attention on
follow up.
2. Non-specific, non-enhancing FLAIR signal abnormality in the pons may be
due to metabolic or electrolyte abnormalities, a demyelinating/inflammatory
process, or a low grade glioma. Correlation with clinical details is
recommended and close followup to assess for interval change as no priors. If
workup for a low grade glioma is desired, the area would be amenable to MR
spectroscopy for better assessment.
NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ telephone
at ___ ___ on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with SWELLING IN HEAD & NECK, AC ALCOHOL INTOX-UNSPEC, UNSPECIFIED FALL
temperature: 97.6
heartrate: 89.0
resprate: 14.0
o2sat: 94.0
sbp: 86.0
dbp: 69.0
level of pain: 8
level of acuity: 1.0 | Mr. ___ is a ___ year old man with a history of alcohol abuse
but never with withdrawal symptoms who presented with possible
GTC seizure and was transferred from OSH for concern for L
cerebellar lesion on ___ CT. The patient's seizure is most
likely related to alcohol, but unclear if related to alcohol use
or alcohol withdrawal - the patient has been trying to quit
drinking and hadn't drunk EtOH for 2 days and then had several
beers the night of presentation. Initial EtOH level 187 down to
131 during first day of admission, and it is possible that if
EtOH level was below patient's baseline that he could have
withdrawal symptoms. He was started on a librium taper and will
complete this as an outpatient. He is also on
thiamine/folate/multivitamin. During admission he did not score
on CIWA protocol. MR ___ was obtained to further evaluate
lesion on ___ CT, favored to be a left cerebellar hemisphere
cavernoma but possibly an old chronic punctate hemorrhage. MRI
also noted non-specific Flair signal in the pons, possibly
related to electrolyte abnormalities, low grade glioma or a
demyelinating process. LP was performed and bland, with CSF
cytology negative for malignant cells. As the patient had a
normal neurological exam, this lesion will be followed on repeat
MRI and possibly outpatient MR ___ in Neurology ___.
Diagnosis: alcohol-related seizure, non-specific flair
hyperintensity in pons, to be followed on imaging |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
loratadine
Attending: ___.
Chief Complaint:
Generalized malaise, fever
Major Surgical or Invasive Procedure:
___ ___ hepatic abscess drainage
History of Present Illness:
Mr. ___ is a ___ ___ gentleman with an
extensive medical history but most notable for pancreatic
neuroendocrine tumor metastatic to the liver, s/p resection
(___), octreotide systemic therapy (___) and TACE
(___) who presents with generalized malaise of one
week duration. The patient initially presented to ___
___ where he was found to be febrile to ___ F. Initial labs
were notable for a leukocytosis to 19, lactate 4.7, and
transaminitis ALT 73 AST 81 AP 641 Tbili 0.8. An abdominal CT
was notable for a contracted gallbladder with mild
pericholecystic fluid, multiple cystic lesions ___ the liver, and
a filling defect ___ the left portal vein concerning for a
thrombus. The patient was received 2 L NS and empirically
covered with IV Vancomycin, Zosyn, and Levaquin. Given a concern
for hepatic abscesses possibly requiring ___ intervention, the
patient was transferred to the ___ for further care.
At the ___ ED, initial VS T 97.6 HR 77 BP 113/67 RR 22 99% RA.
Repeat labs were notable for WBC 22.4, lactate 4.4 (trended down
to 3.8). The patient was given 1 L NS and 40 mEq of K. UA was
notable for few bacteria, but otherwise no pyuria or hematuria.
On arrival to the FICU, initial VS were T 102.2 HR 107 BP
164/101 SpO2 96% RA. The patient was noted to be rigoring en
route to the FICU. The patient was non-toxic appearing without
any abdominal pain. He was mentating well and denied any chest
pain, dyspnea, cough, or dysuria. He did endorse some diarrhea
with more loose stools. The patient also endorses nausea and
poor appetitie. He was bolused with 1 L LR and continued on IV
Vancomycin and Zosyn.
Past Medical History:
___ has a prior history of prostate
cancer and underwent prostatectomy ___ ___. He presented ___
___ with weight loss, and MRI and CT identified a 6.5 x 5.2 x
5.2 cm mass ___ the pancreatic body/tail. Also notable were 2 cm
and 1 cm masses ___ the right liver concerning for metastases.
Endoscopic ultrasound and biopsy by ___ ___ showed
neuroendocrine tumor. Mr. ___ underwent exploratory
laparoscopy and intraoperative ultrasound and biopsy on
___. Pathology showed metastatic neuroendocrine tumor ___
one of three liver lesions with a mib fraction ___,
intermediate grade. Neuroendocrine tumor was also present ___
the lymph nodes. On ___ he underwent exploratory
laparotomy, extended radical distal pancreatectomy and
splenectomy, and wedge resection of the segment V liver
metastasis. Pathology showed a 7.5 cm well-differentiated
pancreatic endocrine carcinoma, 0 of 21 lymph nodes were
involved, a 2.5 cm liver metastasis was resected with negative
margins. Liver recurrence was identified on MRI ___, and
Mr. ___ began octreotide 30mg IM monthly ___. ___ ___, he underwent Y90 embolization right liver. Right liver
embolization could not be performed due to abarrent vasculature,
and he was referred for DEB-TACE to the left liver ___.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. History of iron deficiency anemia.
3. Hypercholesterolemia.
4. Hypertension.
5. Chronic sinusitis.
6. Depression.
7. GERD.
8. History of prostate cancer status post prostatectomy ___ ___.
The patient reports cancer noted ___ ___ biopsy cores.
9. Pancreatic neuroendocrine tumor with liver metastasis
resected ___.
Social History:
___
Family History:
The patient's mother died of colon cancer ___ her ___. His
father died ___ his ___ of unknown causes. He has one brother
and three children without health concerns.
Physical Exam:
On Admission:
VS T 102.2 HR 107 BP 164/101 SpO2 96% RA
General: Alert, oriented x3, tired-appearing but ___ NAD
HEENT: Sclera anicteric, dyr mucous membranes with no
oropharyngeal lesions
Neck: Supple, no cervical lymphadenopathy, no JVD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, normoactive bowel
sounds, no rebound tenderness or guarding, no organomegaly.
Negative ___ Sign (no pain on palpation with deep
inspiration)
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes, petechiae, or ecchymoses
Neuro: Moving all extremities with purpose, no facial assymetry
On Discharge:
VS 98 140/80 80 18 97%RA
Gen: alert, NAD, eating full liquids this am
HEENT: MMM, thrush resolved, OP clear
CV: RRR, no murmur, peripheral pulses 2+
Resp: CTAB
Ab: soft, NT, ND, BS active, RUQ drain with sm amt yellow-green
liquids, drain #1 slight blood tinged
Ext: no edema, warm and well perfused
Neuro: ___, EOMI, face symmetric, moves all ext against
resistance, sensation intact to light touch, no asterixis
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-35.6*# RBC-3.20* Hgb-9.4* Hct-29.3*
MCV-92 MCH-29.5 MCHC-32.2 RDW-14.2 Plt ___
___ 08:30PM BLOOD Neuts-92.9* Lymphs-1.9* Monos-4.2 Eos-0.2
Baso-0.8
___ 08:30PM BLOOD ___ PTT-27.4 ___
___ 08:30PM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-137
K-3.1* Cl-95* HCO3-24 AnGap-21*
___ 08:30PM BLOOD ALT-96* AST-117* AlkPhos-542* TotBili-0.8
___ 08:30PM BLOOD Albumin-2.9*
___ 08:36PM BLOOD Lactate-3.8*
MICRO:
___ 11:05 am ABSCESS Site: LIVER
LIVER ABSCESS, LEFT LATERAL.
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT ___.
Reported to and read back by ___ @ ___, ___.
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
PREVIOUSLY REPORTED AS (___).
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
FLUID CULTURE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. HEAVY GROWTH.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN <= 0.12 MCG/ML.
LEVOFLOXACIN REQUESTED BY ___ ___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- 0.5 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
DAY OF DISCHARGE:
P: 2.3
ALT: 54 AP: 606 Tbili: 0.5 Alb:
AST: 38
wbc 13.0 hgb 10.8 plt 576
IMAGING:
___ CT A/P:
IMPRESSION:
1. Multiple enlarging hypodense foci ___ the left lobe of the
liver may
reflect necrotic post treatment liver, however given growth of
some of these since MRI of ___ superinfection cannot
be excluded. Consultation with body interventional service is
recommended for feasibility and appropriateness of percutaneous
drainage.
2. Heterogenous appearance of the right lobe of the liver is
likely
representative of change post yttrium 90 treatment.
___ RUQ U/S:
FINDINGS:
Limited ultrasound of the liver demonstrates multiple hypoechoic
left hepatic collections. The largest is ___ the lateral left
lobe measuring 3.7 x 3.9 cm. The second largest was ___ the
medial left lobe measuring 2.5 x 2.2 cm. Both collections were
targeted for drainage. Additional smaller collections are seen
scattered ___ the left hepatic lobe. ___ the anterior left
hepatic lobe, a 4.5 x 6.2 cm heterogeneous, echogenic area was
identified. This may represent necrotic tissue from prior TACE
but did not appear liquefied.
Abdominal U/S ___:
IMPRESSION:
Small nonocclusive thrombus seen ___ the left portal vein on the
recent CT is unchanged.
CXR ___:
IMPRESSION:
The patient has received a new right-sided PICC line. The course
of the line is unremarkable, the tip of the line projects over
the mid to low SVC. There is no complication, notably no
pneumothorax.
___ the interval, the patient has developed new bilateral pleural
effusions with subsequent areas of atelectasis and shows signs
of mild pulmonary edema. Unchanged moderate cardiomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 8 mg PO Q6H:PRN nausea
6. Pravastatin 40 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN fever, pain
8. glimepiride 4 mg ORAL BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO QAM
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g IV daily Disp #*14 Vial Refills:*1
2. glimepiride 4 mg ORAL BID
3. Hydrochlorothiazide 25 mg PO DAILY
this is similar to chlorthalidone, do not take both
4. Glargine 14 Units Bedtime
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO QAM
8. Metoprolol Succinate XL 25 mg PO DAILY
this is similar to labetalol do not take both
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO Q6H:PRN nausea
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
12. Pravastatin 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis
Low blood pressure
Hepatic abscess
Neuroendocrine pancreatic tumor
Liver metastases
Discharge Condition:
Condition - stable
Mental status - alert, coherent
Ambulatory status - independent
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with pancreatic cancer, liver mets, s/p TACE, now
with fever, c/f liver abscess on OSH CT abd/pelvis // Any evidence of liver
abscess, mass, infection?
TECHNIQUE: Outside hospital second read CT of the abdomen and pelvis with
axial, coronal sagittal reconstructions obtained after administration of
contrast.
DOSE: Total body DLP: 525 mGy-cm.
COMPARISON: CT abdomen without contrast ___. CTA abdomen ___. MR abdomen ___.
FINDINGS:
LOWER CHEST: There is mild atelectasis at the lung bases. Heart size is normal
without pericardial effusion.
CT ABDOMEN WITH CONTRAST: Patient has known pancreatic neuroendocrine tumor
status post distal pancreatectomy and splenectomy. Left hepatic metastases
were previously treated with chemoembolization and right hepatic metastases
were treated with the yttrium 90.
Heterogenous appearance of the right lobe of the liver with numerous irregular
hypodensities becoming confluent may be expected appearance post the yttrium
90 treatment. Larger and more well circumscribed hypodense areas in the left
lobe were seen on the recent MRI but have grown in the interim, some with a
peripheral hyper than rim. For example 5.3 x 3.2 cm area in segment 3
previously measured 4.1 x 3 cm.
The gallbladder is not distended. Minimal wall thickening likely relates to
underlying liver disease. Slight nodularity of the left adrenal gland ; the
right adrenal gland appears normal. The kidneys excrete contrast symmetrically
without hydronephrosis. 2.7 cm hypodense focus in the lower pole of the left
kidney is compatible with a simple cyst.
The stomach, small large bowel are normal in caliber without obstruction.
There is no mesenteric or retroperitoneal lymphadenopathy. There is no free
air or free fluid.
CT PELVIS WITH CONTRAST: The urinary bladder and rectum are normal. Patient
appears to be post prostatectomy. There is no pelvic wall or inguinal
lymphadenopathy and no free fluid.
BONES: There are no worrisome blastic or lytic lesions.
IMPRESSION:
1. Multiple enlarging hypodense foci in the left lobe of the liver may
reflect necrotic post treatment liver, however given growth of some of these
since MRI of ___ superinfection cannot be excluded. Consultation
with body interventional service is recommended for feasibility and
appropriateness of percutaneous drainage.
2. Heterogenous appearance of the right lobe of the liver is likely
representative of change post yttrium 90 treatment.
Radiology Report
INDICATION: ___ male with pancreatic cancer and liver metastases
status post trans arterial chemo embolization (TACE). Recent CT demonstrates
collections in the left hepatic lobe. Concern for abscess.
COMPARISON: CT performed on ___.
PROCEDURE: Ultrasound-guided drainage of hepatic collections.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist, who was present and supervising throughout the total procedure
time. The attending radiologist was present during the critical portions of
the procedure and agrees with the 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 scan table. Limited
preprocedure ultrasound of the liver was performed. Ultrasound demonstrated a
3.7 x 3.9 collection in the lateral left hepatic lobe. Smaller collections
were seen in the left lobe, the largest of which measured 2.5 x 2.2 cm.
Based on the ultrasound findings, the largest collection was targeted for
initial drainage catheter placement.
The site was prepped and draped in the usual sterile fashion. 10 cc of 1%
lidocaine were administered to the subcutaneous and deep tissues for local
anesthetic effect. Under continuous ultrasound guidance, a 22 gauge spinal
needle was advanced to the liver capsule and 1% lidocaine was administered for
anesthesia. Subsequently, using trocar technique, an attempt was made to
advance a an 8 ___ catheter into the hepatic collection. However,
perhaps due to scar tissue from prior surgeries, the catheter could not be
advanced even to the peritoneal lining. Therefore, an 18 gauge Chiba needle
was utilized and advanced into the hepatic collection. A 0.038 ___ wire
was advanced through the needle. The needle was removed and serial dilation
with 6 ___ and 8 ___ dilators was performed. An 8 ___ ___
catheter was subsequently advanced over the wire and coiled within the
collection. A total of 8 cc of hemorrhagic fluid and debris was aspirated.
Attention was then turned to the second collection in the medial left hepatic
lobe. The site was again prepped in usual sterile fashion. Under continuous
ultrasound guidance, an 18 gauge ___ needle advanced into the collection. A
0.038" ___ wire was placed in the collection and after serial 6- and
___ dilation, an 8 ___ ___ catheter was advanced to the
collection. A total of 12cc of hemorrhagic fluid and debris was aspirated.
Both catheters were secured with a Stat Lock and placed to bulb suction.
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
65 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited ultrasound of the liver demonstrates multiple hypoechoic left hepatic
collections. The largest is in the lateral left lobe measuring 3.7 x 3.9 cm.
The second largest was in the medial left lobe measuring 2.5 x 2.2 cm. Both
collections were targeted for drainage. Additional smaller collections are
seen scattered in the left hepatic lobe. In the anterior left hepatic lobe, a
4.5 x 6.2 cm heterogeneous, echogenic area was identified. This may represent
necrotic tissue from prior TACE but did not appear liquefied.
IMPRESSION:
1. Ultrasound guided placement of two 8 ___ pigtail catheter is within the
dominant left hepatic collections.
2. Multiple collections in the left hepatic lobe as seen on prior CT were
identified on ultrasound, as described above.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with hx pancreatic neuroendocrine cancer with
mets to liver, s/p ___ drainage of hepatic abscess. CT noted possible
thrombosis. // with dopplers. to look for portal vein thrombosis.
TECHNIQUE: Grey scale and Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT from ___.
FINDINGS:
LIVER: The liver is heterogeneous consistent with known multiple metastases
which have been treated with chemoembolization and Y-90. Catheters are
identified in the left hepatic collections. There is no ascites.
The main portal vein is patent with normal waveforms. The right posterior
portal vein is patent with normal waveform. The right anterior portal vein is
patent with normal waveform. The small nonocclusive thrombus seen in the left
portal vein on the recent CT is unchanged. The middle, left and right hepatic
veins are patent with normal waveforms. The main hepatic artery is patent with
normal waveform.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well evaluated.
KIDNEYS: Limited views of the kidneys are unremarkable.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Small nonocclusive thrombus seen in the left portal vein on the recent CT is
unchanged.
Liver is heterogeneous consistent with known multiple metastases which have
been treated with chemoembolization and Y-90. Catheters are identified in
the left hepatic collections.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new R PICC // 44cm R basilic SL PICC -
___ ___ Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
The patient has received a new right-sided PICC line. The course of the line
is unremarkable, the tip of the line projects over the mid to low SVC. There
is no complication, notably no pneumothorax.
In the interval, the patient has developed new bilateral pleural effusions
with subsequent areas of atelectasis and shows signs of mild pulmonary edema.
Unchanged moderate cardiomegaly.
Gender: M
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS
temperature: 97.6
heartrate: 76.0
resprate: 18.0
o2sat: 97.0
sbp: 107.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ M with an extensive medical history but most
notable for pancreatic neuroendocrine tumor metastatic to the
liver, s/p resection (___), octreotide systemic therapy
(___) and TACE (___) presenting with fever and
hypotension.
# Severe sepsis: On admission, patient was hypotensive to
90/50s and met ___ SIRS criteria. His lactate was elevated to
3.8. Most likely infectious source is hepatic abscesses seen on
imaging. Urine culture was negative and blood cultures remained
negative. His CXR showed no evidence of infiltrate. Patient's
blood pressure responded to IV fluids and he did not require
pressors.
#Hepatic abscesses s/p recent TACE- Found to have hypoechoic
collections ___ liver, with the largest ___ the left lobe
measuring 7 x 6 x 5 cm ___ size. largest two drained ___,
rapidly clinically improved, no fevers since, WBC dramatically
improved. Fluid collection now + strep anginosus. Pt originally
treated with vancomycin and zosyn, upon culture results narrowed
to ceftriaxone. ID consulted and patient will follow up ___ ___
clinic. Repeat CT abdomen ordered for that time. Plan to cont
IV ceftriaxone until ID f/u, improving and drains able to be
removed could consider switching to oral levaquin as was
susceptible. He was given # to contact ___ once drains <10cc per
24 hr x 2 days. Daughter will monitor this and also assist with
daily drain cares.
# Transaminitis/Cholestasis: On admission, ALT 96, AST 117, AP
542, TBili 0.8 (previously ALT 60, AST 47, AP 581, TBili 0.4).
Most likely etiology of elevated liver enzymes is liver
abscesses vs. known liver metastases vs. cholestasis of sepsis.
Enzymes have downtrended with treatment of infection although
alk P persistently elevated.
#Possible portal thrombus: OSH CT mentioned a possible left
portal vein thrombus, though the age of this thrombus was
unknown. RUQ ultrasound here confirmed a small nonocclusive
left portal vein thrombus. Per hepatology, he was not started
on anticoagulation for this.
#Metastatic panc neuroendocrine tumor - currently on active
surveillance following ___ TACE, no recurrence on CT this
admission. Has f/u with Dr ___ ___ ___
# Bowel regimen - added stool softener as patient requiring some
narcotic pain medication although at time of discharge no longer
needing
# Hx HTN - Per daughter patient on chlorthalidone, lisinopril
and labetalol at home although after a recent hospital discharge
here was on lisinopril, HCTZ, metoprolol. Apparently after
discharge he cont'd to have elevated BP so meds were changed by
PCP. Upon arrival all BP meds held and lisinopril, HCTZ,
metoprolol were gradually resumed as the recent switch was not
known until day of discharge. BP were controlled with this
regimen.
DM II - BG elevated on SSI ___ ICU, resumed home glargine,
glimepiride and metformin once far enough out from contrast and
able to eat. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Clindamycin / doxycycline / Minocycline / Remicade
Attending: ___.
Chief Complaint:
SAPHO flare, wound eval
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y.o. female with SAPHO syndrome (on Humira),
hidradenitis suppuritiva, and multiple I/D for abscesses ___ the
past presenting with 1 week of drainage from her b/l axillary
regions, R posteromedial thigh, and beneath both breasts. She
reports increased yellow drainage from these sites ___ the past
week. Her pain has significantly worsened ___ the past week. On
___, she felt feverish, dizzy, and had nausea and one episode
of non-bilious non-bloody vomiting overnight.
She last saw Dermatology ___ ___ for hidradenitis, and was
prescribed Flagyl 500mg tid, rifampin 300mg bid, clindamycin
soln, Hibiclens. She has been using all of the above, except the
rifampin which has caused her GI upset. Of note, she is allergic
to amoxicillin, clinda, doxy, minocycline. She is currently on a
fentanyl 50mcg patch + oxycodone 20mg q3-4h prn for pain,
Tylenol
___ qd prn + gabapentin 500mg tid. Pain is ___, "unbearable"
pain, with the L inframammary area causing most discomfort.
Per Surgery, no recs from surgical standpoint. Rec possible to
US, but nothing drainable from area beneath L breast or L groin.
Per Rheumatology, inpatient team can start prednisone 60mg qd as
per Rheum/Derm ___ joint consultation. Prednisone will have to be
tapered off. Think that this is a flare rather than an
infection.
Could get US to examine for drainage.
___ the ED:
-Initial vital signs were notable for: 96, 110, BP 116/80, 17,
99%RA.
-Exam notable for:
-- Cribriform scaring with pink sinus tracts and ulcers draining
malodorous yellow and serosanguinous fluid from the bilateral
axillae, inguinal folds, and R medial upper thigh.
-- Red hot fluctuant nodule ___ L inframammary fold that is
extremely tender limiting exam. There is no drainage or
ulceration
-- BLE wounds have re-epithelialized almost completely
-Labs were notable for:
CBC: Leukocytosis (WBC = 18) with elevated absolute neutrophils
(12.68), monocytes (1.74), and basophils (0.11).
Elevated platelet count at 442.
-Studies performed include:
Could not perform US due to pain.
Blood culture - pending.
-Patient was given:
2x IV Morphine Sulfate 2 mg
PO OxyCODONE (Immediate Release) 20 mg
-Consults:
Surgery: No recs from surgical standpoint. Rec possible to U/S,
but nothing drainable from area beneath L. breast or L. groin.
Rheumatology: inpatient team can "start prednisone 60mg qd as
per
Rheum/Derm ___ joint consultation."
Dermatology: As above.
Vitals on transfer: 100.6, 103 / 69, 103, 16, 96% Ra
Upon arrival to the floor, patient is febrile, tachycardic, and
laying on her side uncomfortably.
REVIEW OF SYSTEMS:
Per HPI.
Past Medical History:
1. SAPHO syndrome (synovitis, acne, palmoplantar pustulosis,
hyperostosis & osteitis)- failed Remicade, MTX, secukinumab
(Cosentyx, an anti-IL-17), diagnosis ___ ___
2. Possible Sarcoidosis
3. Hidradenitis Suppurutiva
4. Chronic Narcotic Use for chronic neck, back pain
5. History of Pre-eclampsia
6. Elevated transaminases(following methotrexate therapy)
b/l axillary excisions ___ multiple I+D's of buttock, breast
Social History:
___
Family History:
Mother is alive and well. Father with diabetes ___. Two
brothers and one sister (twin) who are well. Sister has SAPHO
syndrome and hidradenitis s/p axillary excision of boils.
Maternal grandmother with history of breast cancer ___ her ___.
Paternal grandmother with CVA. No family hx of rheumatologic
disorders
Physical Exam:
======================
ADMISSION PHYSICAL EXAM:
======================
VITALS: 100.6, 103 / 69, 103, 16, 96% Ra
GENERAL: Lying on left side ___ bed, ___ visible distress.
HEENT: Sclera anicteric and without injection.
CARDIAC: Regular rhythm, tachycardic. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB
ABDOMEN: Soft, NT/ND
NEUROLOGIC: AOx3.
SKIN (per Dermatology note):
-- Cribriform scaring with pink sinus tracts and ulcers draining
malodorous yellow and serosanguinous fluid from the bilateral
axillae, inguinal folds, and R medial upper thigh.
-- Red hot fluctuant nodule ___ L inframammary fold that is
extremely tender limiting exam. There is no drainage or
ulceration
-- BLE wounds have re-epithelialized almost completely
======================
DISCHARGE PHYSICAL EXAM
======================
VS: 24 HR Data (last updated ___ @ 221)
Temp: 97.7 (Tm 98.7), BP: 152/93 (114-152/73-93), HR: 52
(52-65), RR: 18, O2 sat: 95% (95-98), O2 delivery: RA
GENERAL: sitting ___ bed, NAD
HEENT: NC/AT, Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB
ABDOMEN: Soft, NT/ND
EXTREMITIES: wwp, 2+ pitting edema to the shin bilaterally
NEUROLOGIC: AOx3.
SKIN: bilateral axillary and inframammary wounds without
purulence or surrounding erythema. Would on posterior R thigh
without purulence or surrounding erythema.
Pertinent Results:
=============
ADMISSION LABS
=============
___ 11:30AM BLOOD WBC-18.2* RBC-4.68 Hgb-12.1 Hct-38.1
MCV-81* MCH-25.9* MCHC-31.8* RDW-15.9* RDWSD-46.5* Plt ___
___ 11:30AM BLOOD Neuts-69.9 Lymphs-17.6* Monos-9.6 Eos-1.8
Baso-0.6 Im ___ AbsNeut-12.68* AbsLymp-3.20 AbsMono-1.74*
AbsEos-0.33 AbsBaso-0.11*
___ 11:30AM BLOOD Plt ___
___ 02:55PM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-135 K-4.4
Cl-99 HCO3-21* AnGap-15
___ 07:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
___ 03:01PM BLOOD Lactate-1.2
PERTINENT STUDIES
Radiology ReportGROIN, SOFT TISSUE LEFTStudy Date of
___ 6:50 ___
FINDINGS:
Left upper neck: (Image 6) Just lateral to the left
submandibular gland ___ the left upper neck, there is a tiny
subcutaneous anechoic collection measuring 6x 3 x 5 mm.
Left axilla: (Image 23) There is an irregular subcutaneous fluid
collection, slightly complex ___ overall appearance, with
stellate margins. This collection is difficult to measure given
the extent of superficial involvement though its central portion
measures approximately 22 x 10 x 10 mm.
Right axilla: (Image 39-40) A superficial collection ___ the
right axilla
extends over a broad region as on the left though does not
extend to the depth as the collection seen on the left. The
central portion of this collection measures approximately 25 x 7
x 42 mm.
Right breast: (Image ___) At the inferior right breast along
the
inframammary fold, there is a subcutaneous collection with
hypoechoic and
echogenic contents measuring approximately 23 x 5 x 18 mm.
Left breast: (Image 58) A large heterogeneous collection with
irregular
margins is seen within the medial lower left breast at the site
of palpable
abnormality. This collection is actively oozing (pus) at the
time of
ultrasound and measures approximately 26 x 31 x 45 mm.
Right upper posterior thigh: (Image 74) A tiny subcutaneous
sliver of
hypoechoic fluid is noted measuring approximately 27 x 3 x 3 mm.
Right lower quadrant anterior abdominal wall pannus: (Image 82)
There is a
small subcutaneous sliver of a collection measuring 35 x 4 x 36
mm.
Right groin: (Image 101) Multiple reactive lymph nodes are seen
___ the right groin as well as a superficial collection which
appears hypoechoic measuring approximately 27 x 8 x 33 mm.
Left groin: (Image 109) A subcutaneous collection ___ the left
groin measures approximately 43 x 12 x 50 mm.
IMPRESSION:
Superficial collections at multiple body parts detailed above
concerning for superficial abscesses.
MICROBIOLOGY
___ 11:17 am SWAB Source: Drainage from L breast.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND 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, THEY ARE NOT PRESENT
___ this
culture.
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
__________________________________________________________
___ 9:03 am URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 10:35 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:20 am BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
==============
DISCHARGE LABS
==============
___ 05:43AM BLOOD WBC-19.6* RBC-4.30 Hgb-11.4 Hct-35.1
MCV-82 MCH-26.5 MCHC-32.5 RDW-17.2* RDWSD-48.3* Plt ___
___ 05:43AM BLOOD Plt ___
___ 05:43AM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-135
K-5.2 Cl-102 HCO3-19* AnGap-14
___ 05:43AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.1 UricAcd-5.8*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Clindamycin 1% Solution 1 Appl TP DAILY
4. Docusate Sodium 100 mg PO BID
5. Fentanyl Patch 50 mcg/h TD Q72H
6. Multivitamins 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 20 mg PO Q3-4H:PRN Pain -
Moderate
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
10. Senna 8.6 mg PO BID
11. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
12. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
13. Humira (adalimumab) 40 mg/0.8 mL subcutaneous 1X/WEEK
Discharge Medications:
1. CycloSPORINE (Neoral) MODIFIED 150 mg PO Q12H Duration: 2
Weeks
RX *cyclosporine modified 50 mg 3 capsule(s) by mouth twice a
day Disp #*180 Capsule Refills:*0
2. PredniSONE 7.5 mg PO ONCE Duration: 1 Dose
Please take 7.5mg on ___
This is dose # 4 of 6 tapered doses
Tapered dose - DOWN
3. PredniSONE 10 mg PO ONCE Duration: 1 Dose
Please take 10mg on ___
This is dose # 3 of 6 tapered doses
Tapered dose - DOWN
RX *prednisone 2.5 mg 4 tablet(s) by mouth once a day Disp #*49
Tablet Refills:*0
4. PredniSONE 5 mg PO DAILY Duration: 14 Doses
Please continue 5mg prednisone from ___
This is dose # 5 of 6 tapered doses
Tapered dose - DOWN
5. PredniSONE 2.5 mg PO DAILY Duration: 14 Doses
Please take 2.5mg daily from ___
This is dose # 6 of 6 tapered doses
Tapered dose - DOWN
6. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
RX *betamethasone dipropionate 0.05 % One application twice a
day Refills:*2
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
9. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
10. Clindamycin 1% Solution 1 Appl TP DAILY
11. Docusate Sodium 100 mg PO BID
12. Fentanyl Patch 50 mcg/h TD Q72H
13. Humira (adalimumab) 40 mg/0.8 mL subcutaneous 1X/WEEK
14. Multivitamins 1 TAB PO DAILY
15. OxyCODONE (Immediate Release) 20 mg PO Q3-4H:PRN Pain -
Moderate
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
19. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
SAPHO syndrome
hidradenitis suppurativa
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
EXAMINATION: Soft tissue ultrasound
INDICATION: Patient with SAPHOS syndrome with hydradenitis, with acute flare
of multiple body parts with multiple palpable tender lumps concerning for
abscess.
TECHNIQUE: Focused ultrasound was performed at sites of palpable tender lump
concerning for abscess.
COMPARISON: None
FINDINGS:
Left upper neck: (Image 6) Just lateral to the left submandibular gland in the
left upper neck, there is a tiny subcutaneous anechoic collection measuring 6
x 3 x 5 mm.
Left axilla: (Image 23) There is an irregular subcutaneous fluid collection,
slightly complex in overall appearance, with stellate margins. This
collection is difficult to measure given the extent of superficial involvement
though its central portion measures approximately 22 x 10 x 10 mm.
Right axilla: (Image 39-40) A superficial collection in the right axilla
extends over a broad region as on the left though does not extend to the depth
as the collection seen on the left. The central portion of this collection
measures approximately 25 x 7 x 42 mm.
Right breast: (Image 49-51) At the inferior right breast along the
inframammary fold, there is a subcutaneous collection with hypoechoic and
echogenic contents measuring approximately 23 x 5 x 18 mm.
Left breast: (Image 58) A large heterogeneous collection with irregular
margins is seen within the medial lower left breast at the site of palpable
abnormality. This collection is actively oozing (pus) at the time of
ultrasound and measures approximately 26 x 31 x 45 cm.
Right upper posterior thigh: (Image 74) A tiny subcutaneous sliver of
hypoechoic fluid is noted measuring approximately 27 x 3 x 3 mm.
Right lower quadrant anterior abdominal wall pannus: (Image 82) There is a
small subcutaneous sliver of a collection measuring 35 x 4 x 36 mm.
Right groin: (Image 101) Multiple reactive lymph nodes are seen in the right
groin as well as a superficial collection which appears hypoechoic measuring
approximately 27 x 8 x 33 mm.
Left groin: (Image 109) A subcutaneous collection in the left groin measures
approximately 43 x 12 x 50 mm.
IMPRESSION:
Superficial collections at multiple body parts detailed above concerning for
superficial abscesses.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Hidradenitis suppurativa
temperature: 96.0
heartrate: 110.0
resprate: 17.0
o2sat: 99.0
sbp: 116.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | Patient is a ___ with a PMH of SAPHO syndrome (synovitis, acne,
palmoplantar pustulosis, hyperostosis & osteitis) complicated by
hydradentitis suppurative-like disease on Humira, possible
sarcoidosis, and chronic pain presenting w/ drainage from
bilateral axillae, inguinal folds, and R medial upper thigh, and
a nodule ___ the L inframammary fold most likely caused by SAPHO
syndrome flare-up.
#SAPHO
#Hydrandentitis suppurativa-like disease
Presentation most concerning for SAPHO flare ___ the form of
HS-like disease. Patient had previously been on a long steroid
taper that she had recently finished. She had not been taking
her prescribed
antibiotics. Dermatology, breast surgery, general surgery, and
plastic surgery were consulted. She had an ultrasound showing
multiple fluid collections associated with each area of
involvement. Per plastic surgery, no immediate intervention
available while the patient is on steroids that inhibit wound
healing. Per discussions with general and breast surgery, no
drainage of the fluid collections was performed as they were
already self-draining and surgical I&D could have introduced
superinfection. They recommended continuing conservative
management with emphasis on wound care. A wound culture from the
patient's L breast nodule grew GBS but as the patient was
clinically improving rather than worsening while on
immunosuppressives, the decision was made to defer antibiotics.
During this hospitalization, the patient adamantly expressed her
desire to stop using steroids to manage her disease. After
extensive discussion with dermatology and her primary
rheumatologist, Dr. ___, the patient was started on
cyclosporine with a plan to taper off steroids. She will
continue on Humira.
#acute on chronic pain
Patient initially required Toradol and IV Dilaudid but was
eventually stabilized on her home pain regimen: fentanyl patch
50mcg, oxycodone 20mg q3-4h prn, standing Tylenol ___ q8h.
===================
TRANSITIONAL ISSUES
===================
[] please continue cyclosporine 150 BID (dosed for ideal body
weight)
[] please taper prednisone as follows as per Dr. ___: 10mg
___, 7.5mg ___, 5mg 2weeks, 2.5mg two weeks.
[] patient expressed concern about the length of taper, please
discuss this and adjust taper if deemed safe to do so
[] please check renal function, uric acid ___ ___ days from
discharge
[] continue to monitor for evidence of cyclosporine toxicity
[] please make sure wound care recommendations followed:
-Gauze or ABD pads placed ___ the breast and intertriginous areas
to catch drainage.
-Betamethasone dipropionate ointment BID to the wounds,
particularly posterior thigh ulcer.
-Surgibra to assist with maintaining dressings ___ place
-Softsorb to wounds ___ her skin folds, without tape
-Net pants to hold her dressings ___ place
-Betadine wash ___ the shower
-No hibiclens to her open wounds, as this can be caustic
[] Continue encouraging ambulation and smoking cessation.
[] Please make sure patient has outpatient rheumatology,
dermatology, breast surgery, and plastic surgery follow up. All
appointments were scheduled or are ___ the process of being
scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Novocain
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with L olecranon bursitis presenting with fever to 101 at
home. She was seen on ___ by her PCP for left elbow pain and
swelling starting on ___ with temperature up to 37.3C at home.
Of note, she had been treated with laser therapy for painful
skin lesions on the left elbow in ___ and has overlying
scabbing which daughter reports she sometimes scratches. She was
started on cephalexin by her PCP ___ ___. Since then, erythema,
swelling, and pain in elbow improving, but had fever today. She
has no other localizing symptoms including cough, N/V/D,
abdominal pain, dysuria.
In the ED, initial vs were: (unable) 97.2 66 112/61 16 94%. Labs
were remarkable for H/H 10.___ at baseline, INR 2.7 within
goal, UA neg. She was given a dose of ceftriaxone and a dose of
vancomycin. After administration of antibiotics, the patient
became hypoxic transiently to the ___. She did not have CP. She
was given SL nitro x1, Lasix 20mg IV x1 with improvement in
symptoms, and now is satting well on RA. Vitals on Transfer:
98.9 70 105/56 18 98% RA.
On the floor patient reports breathing is much improved. She has
no difficulty moving the elbow and states that this is also much
improved from prior.
This morning she reports that she feels okay and that she has no
difficulty breathing.
Review of sytems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Ten point review of systems is otherwise negative.
Past Medical History:
-Hypertension
-Diabetes, diet-controlled
-Dyslipidemia
-Mild aortic valve stenosis and moderate mitral regurgitation on
previous echocardiogram
-Angina
-CKD stage III
-Atrial fibrillation
-Right carotid stenosis: 60-69% in ___
-GERD
-Gallstones, admission for abdominal pain in ___
-Congestive heart failure with preserved EF
Social History:
___
Family History:
Both parents w/ hypertension. Her mother died at ___ from lung
cancer. No family history of colon cancer.
Physical Exam:
ADMISSION EXAM:
Vitals-98.2 123/69 79 18 97% 5L NC
General- Alert, orientedx3, in no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP to mid-neck
Lungs- Faint rales bases b/l, no wheezes, rhonchi
CV- Normal rate, irregular rhythm, +systolic murmur best heard
at RUSB
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Reducible
umbilical hernia
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis.
trace edema to mid-shins in ___ b/l. Left elbow with very minimal
redness and slight warmth at lateral aspect near head of radius.
No significant palpable fluid collection/fluctuance. Relatively
symmetric to right. Moving elbow with full ROM without pain or
difficulty.
Skin- excoriated lesions from zoster in T7 distribution on side
and front on right. Chronic-appearing hyperpigmented and
thickened skin lesions on extensor surface of left elbow/ulna,
with evidence of excoriation without infected appearance or
purulence
Neuro- motor function grossly normal
DISCHARGE EXAM:
Vitals- 98.3, 112/56, 90, 18, 97% RA
General- Alert, oriented x3, no acute distress sitting up in bed
HEENT- Sclera anicteric, EOMI, MMM
Neck- supple, JVP not seen above clavicle at 90 degrees
Lungs- CTAB, no wheeze or rhonci
CV- Tachycardic, ___ rhythm, ___ systolic murmur heard best
at the RUSB. No rubs or gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present.
Reducible umbilical hernia
Ext: Left elbow has scabbing with excoriations, no warmth or
erythema noted. No pain with ROM (but able to range), no
swelling or point tenderness overlying olecranon.
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD WBC-9.3 RBC-3.59* Hgb-10.9* Hct-34.0*
MCV-95 MCH-30.3 MCHC-32.0 RDW-16.9* Plt ___
___ 09:00PM BLOOD Neuts-65.8 ___ Monos-5.7 Eos-1.7
Baso-0.7
___ 09:00PM BLOOD ___ PTT-41.5* ___
___ 09:00PM BLOOD Glucose-120* UreaN-25* Creat-1.1 Na-137
K-4.2 Cl-103 HCO3-24 AnGap-14
___ 09:08PM BLOOD Lactate-1.3
PERTINENT LABS:
___ 07:34AM BLOOD WBC-7.6 RBC-3.22* Hgb-9.7* Hct-29.4*
MCV-91 MCH-30.3 MCHC-33.1 RDW-16.4* Plt ___
___ 08:40AM BLOOD Neuts-65 Bands-0 ___ Monos-7 Eos-1
Baso-2 ___ Myelos-0
___ 08:40AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 03:00PM BLOOD ___ PTT-37.4* ___ 07:34AM BLOOD ___ PTT-35.5 ___
___ 08:15AM BLOOD ___ PTT-36.7* ___
___ 09:20AM BLOOD ___ PTT-39.0* ___
___ 07:55AM BLOOD ___ PTT-40.2* ___
___ 08:40AM BLOOD Glucose-118* UreaN-27* Creat-1.4* Na-139
K-3.9 Cl-100 HCO3-23 AnGap-20
___ 09:20AM BLOOD Glucose-264* UreaN-31* Creat-1.3* Na-139
K-3.6 Cl-98 HCO3-24 AnGap-21*
___ 03:00PM BLOOD CK(CPK)-29
___ 03:00PM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:10PM BLOOD CK-MB-1 cTropnT-<0.01
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-7.3 RBC-3.21* Hgb-9.7* Hct-29.2*
MCV-91 MCH-30.1 MCHC-33.2 RDW-16.4* Plt ___
___ 07:55AM BLOOD ___ PTT-40.2* ___
___ 07:55AM BLOOD Glucose-158* UreaN-36* Creat-1.4* Na-139
K-4.0 Cl-102 HCO3-25 AnGap-16
___ 07:55AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.6
URINE:
___ 09:00AM URINE Color-Straw Appear-Clear Sp ___
___ 09:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MICRO:
___ BLOOD CULTURE - NO GROWTH
IMAGING:
___ CHEST (PA & LAT)
IMPRESSION: Moderate cardiomegaly with mild interstitial edema.
Asymmetrically increased density at the right lung base is
likely related
edema, however, concurrent pneumonia is not excluded. Consider
repeat imaging after diuresis to assess for improvement
___ ELBOW (AP, LAT & OBLIQUE) LEFT
IMPRESSION: Nonspecific findings consistent with olecrannom
bursitis. No
radiographic evidence of osteomyelitis.
___ ECG
Atrial fibrillation with a controlled ventricular response.
Early R wave
progression in the precordial leads. Compared to the previous
tracing
of ___ the findings are similar.
___ CHEST (PORTABLE AP)
FINDINGS: There has been mild increase in severity of
interstitial edema
compared to examination from three hours prior. No other
significant change.
___ ECG
Atrial fibrillation with a controlled ventricular response.
Early R wave
progression. ST-T wave abnormalities. Since the previous tracing
of ___ the rate is now slightly faster. ST-T wave
abnormalities may be more
prominent. Clinical correlation is suggested.
___ CHEST (PA & LAT)
FINDINGS: As compared to the previous radiograph, the signs
evocative of
pulmonary edema have almost completely disappeared. The size of
the cardiac silhouette has also decreased. There are areas of
mild atelectasis at the right and left lung bases, but no
evidence of pneumonia, pneumothorax or other pathological
change. Mild tortuosity of the thoracic aorta.
___ Stress Test
INTERPRETATION: This ___ year old ___ woman with a history of
D-CHF,
AF, CP, SOB and moderate AS was referred to the lab for
evaluation. The
patient was infused with 0.142 mg/kg/min of dipyridamole over 4
minutes.
No arm, neck, back or chest discomfort was reported by the
patient
throughout the study. There were no significant ST segment
changes
during the infusion or in recovery. The rhythm was atrial
fibrillation
with rare isolated vpbs and several ventricular couplets.
Appropriate
hemodynamic response to the infusion and recovery. The
dipyridamole was
reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
___ CARDIAC PERFUSION PHARM
IMPRESSION: Normal myocardial perfusion and wall motion. No
change compared to prior study of ___.
Medications on Admission:
1. Acyclovir Ointment 5% 1 Appl TP Q4H
2. Allopurinol ___ mg PO DAILY
3. Cephalexin 500 mg PO Q12H
4. Diltiazem Extended-Release 240 mg PO DAILY
5. glimepiride 1 mg Oral daily
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Propranolol 20 mg PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Torsemide 10 mg PO DAILY
12. ValACYclovir 1000 mg PO Q8H
13. Warfarin 2.5 mg PO DAILY
14. Cyanocobalamin 500 mcg PO DAILY
15. Docusate Sodium 100 mg PO TID:PRN constipation
16. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acyclovir Ointment 5% 1 Appl TP Q4H
2. Allopurinol ___ mg PO DAILY
3. Cephalexin 500 mg PO Q8H Duration: 3 Days
(for total 7 day course)
RX *cephalexin 500 mg 1 tablet(s) by mouth three times a day
Disp #*10 Capsule Refills:*0
4. Cyanocobalamin 500 mcg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Docusate Sodium 100 mg PO TID:PRN constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Torsemide 10 mg PO DAILY
12. Warfarin 2.5 mg PO DAILY
13. glimepiride 1 mg Oral daily
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
15. Propranolol 10 mg PO BID
RX *propranolol 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Capsule Refills:*0
16. ValACYclovir 1000 mg PO Q8H
17. Outpatient Lab Work
Please draw INR on ___ and fax results to PCP ___ at
___ ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Cellulitis of left elbow
Atrial Fibrillation with rapid ventricular rate (symptomatic)
SECONDARY DIAGNOSES:
Chronic Congestive Heart Failure (diastolic with preserved EF)
Hypertension
Diabetes mellitus
Mild Aortic Stenosis
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: CHF, now with worsening hypoxia and dyspnea.
COMPARISON: Chest radiograph ___ at 10:22 p.m.
TECHNIQUE: Portable frontal chest radiograph, single view.
FINDINGS: There has been mild increase in severity of interstitial edema
compared to examination from three hours prior. No other significant change.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Chest pain.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the signs evocative of
pulmonary edema have almost completely disappeared. The size of the cardiac
silhouette has also decreased. There are areas of mild atelectasis at the
right and left lung bases, but no evidence of pneumonia, pneumothorax or other
pathological change. Mild tortuosity of the thoracic aorta.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with CELLULITIS OF ARM
temperature: 97.2
heartrate: 66.0
resprate: 16.0
o2sat: 94.0
sbp: 112.0
dbp: 61.0
level of pain: 13
level of acuity: 3.0 | ___ with DM, CHF with preserved EF, HTN, AFib on warfarin and
recent L olecranon cellulitis s/p treatment with 5 days of
Keflex presenting with fever to 101 at home and elbow pain.
ACTIVE ISSUES:
# L elbow cellulitis: Diagnosed by PCP as an outpatient. Patient
had already received 4 of 5 days of Keflex. On presentation to
hospital, L elbow had minimal erythema and warmth with
scarring/scabbing/hyperpigmentation overlying the olecranon
aspect of the joint. She was afebrile She received one dose IV
Vanc and CTX in the ED. Prior to discharge, we noted some
recurrence of minimal blanching erythema, and so restarted
Keflex on ___ with plans for 7 day course. No further fevers
during hospitaliztion. No fluctuance or effusion to suggest role
for I+D or joint tap. Blood cultures were negative.
# Afib: Rate controlled on arrival with diltiazem ER 240mg and
anticoagulated with warfarin. Pt had episode of symtomatic afib
with RVR. Had addtional episodes of SOB and palpitations with
minimal exertion. SOB was most likely secondary to rate as
patient did not develop flash pulmonary edema. She did have
additional rate control as an outpatient with metoprolol BID but
was recently changd to propranolol 20mg BID to treat her
esential tremor. She did not received any beta blockade prior to
her first episode of afib with RVR. She was monitored on
telemetry and an EP consult was placed. EP recommended
restarting her propranolol at 10mg BID and to continue her
diltiazem at her home dose. They commented that she may be a
candidate for amiodarone as an outpatient for rhythm control if
she continues to have afib with RVR. A pacemaker was not
indicated per them. She was placed on ___ of Hearts monitor
to determine how often she is in afib with RVR. She will follow
up with her cardiologist Dr. ___ as an outpatient.
# Acute Diastolic Heart Failure: Resolved at the time of
discharge. First episode associated with fluid overload
secondary to receiving IV antibiotics in the ED. Improved with
diuresis with lasix. Other episodes most likely secondary to RVR
as above. These episodes improved with rate control. She will
continue home torsemide and ACE-inhibitor. Last TTE was ___
and showed EF of >55% with preserved ventricular size and
biatrial enlargement. Noted boarderline pulmonary artery
hypertension.
# Chest pain, NOS: Resolved. EKG ___ showed ~1mm ST depressions
in V2-4. Enzymes negative, nuclear stress imaing with pMIBI
showed EF 70%, without filling defects. She was monitored on
telemetry with the only significant event being the episodes of
afib with RVR. Continued on ASA 325mg.
CHRONIC STABLE ISSUES:
# Hypertension: Continue home meds lisinopril, diltiazem.
# DM: Stable, last A1c was 6.1 in ___. Glymepiride and
metformin while here.
# Dyslipidemia: Stable on Simvastatin, last lipid panel ___
was normal.
# Gout: Stable, continue home dose allopurinol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
worsening RUE weakness and neuropathy
Major Surgical or Invasive Procedure:
posterior C3-T5/T6 decompression and instrumented fusion (___)
History of Present Illness:
___ is a ___ yo woman with Stage IV (spine, pleural
effusion) lung adenocarcinoma s/p radiation, 2 cycles of
cis/pemetrexed, 2 cycles of ___, now on
maintenance pemetrexed/pembro c/b pembro-associated pneumonitis,
who presented with worsening RUE weakness/neuropathy x 2 weeks.
Ms ___ was diagnosed with RUL adenoca ___ and noted on
initial imaging to have tumor eroding into the C7-T2 vertebral
bodies and pathologic C7 fracture. She had weakness of her R
hand
attributed to nerve root compression from her Pancoast tumor.
She
completed 3000 cGy over 12 fractions ___ with some
improvement in her neuropathy symptoms. She also was seen by
ortho spine during her initial admission ___ and recommended
for follow up and possible surgical fixation once tissue
diagnosis was obtained.
In the interim, Ms ___ had a complicated course notable for
radiation esophagitis requiring TPN, DVT/PE, R>L pleural
effusion
requiring chest tube drainage, and most recently, hypoxic
respiratory failure attributed to pembro pneumonitis.
Yesterday, Ms ___ was seen in follow up with Dr ___
Dr ___. She reported that she was having 2 weeks of worsening
RUE neuropathic pain (burning pain) and pins and needles
sensation over the distal forearm. She also noted worsening
weakness to the point where she cannot hold a toothbrush or pen
with that side. She was referred to ED for urgent evaluation.
She denied any numbness or tingling or weakness any where else
in
the body. No saddle anesthesia. No bowel/bladder incontinence.
No
recent falls, trips, trauma. No neck pain or back pain. She has
ongoing night sweats since cancer diagnosis but no new
fevers/chills. She reports improving dyspnea on her ROS and a
rare intermittent cough.
In the ED, MRI spine obtained showed:
Slight interval increase in size of right apex Pancoast tumor
which was previously shown to invade the C7, T1, and T2
vertebral
bodies. Disease within the T1 and T2 vertebral bodies appears
grossly similar, although there has been now complete
destruction/collapse of the C7 vertebral body with increased
anterior subluxation of the superior vertebral body. Because the
C7 vertebral body is destroyed, C6 will be used for measurement
of subluxation, of which there is now grade 2 anterolisthesis of
C6 on T1, previously grade 1 anterolisthesis of C7 on T1.
Grade 1 anterolisthesis of L3 on L4 and L4 on L5 is stable, with
moderate spinal canal narrowing but no compression of the cord.
A CT C and T spine was obtained which showed:
1. Essentially complete collapse of the C7 vertebra with
interval
increase in anterior subluxation of the overriding cervical
vertebrae. There is approximately 7 mm of anterolisthesis of the
C6 on T1 vertebrae which causes
at least moderate spinal canal narrowing.
2. Previously seen lucent lesions seen in ___ involving
the T1 and T2 vertebral bodies posteriorly in the right pedicle
at T2 are now seen as slightly sclerotic regions.
3. Known lung mass and other lung findings are better assessed
on
the dedicated chest CT ___
Spine surgery was consulted. They recommended surgical
intervention for her unstable C7 compression fracture if in line
with goals of care and admission to oncology for coordination of
her care. Thoracic surgery was also consulted to assess whether
her RUE symptoms might be more attributable to her Pancoast
tumor. They felt that this is difficult to tell which her sx are
attributable to brachial plexus involvement from tumor vs spine
involvement, but that in the former case she still remains
unresectable.
Prior to transfer to the oncology service, she received 10 mg IV
dexamethasone.
Past Medical History:
Stage IV lung adenocarcinoma, diagnosed ___
Pembrolizumab pneumonitis
DVT/PE ___
GERD
Social History:
___
Family History:
Mother with ___ CA, father with colon CA.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 98.1 F | 112 / 78 | 113 | 93 RA
General: Well appearing older Caucasian woman, resting in bed
Neuro:
Cranial nerves: PERRL, EOMI, Facial sensation equal bilaterally,
resists eye opening ___, hearing intact to finger rub b/l,
palate
elevates symmetrically, tongue midline, shoulder shrug ___
Motor: ___ handgrip on the right, ___ bicep, tricep. ___
throughout LUE.
___ plantar and dorsiflexion
Alert and oriented, provides clear history
HEENT: Oropharynx clear, MMM, sclera anicteric.
Cardiovascular: tachycardic, regular, no murmurs
Chest/Pulmonary: Clear to anterior and lateral auscultation
Abdomen: Soft, nontender, nondistended
Extr/MSK: No peripheral edema. Prominent wasting over the thenar
eminence on the right hand. Wasting over the right forearm
Skin: No obvious rashes
Access: PIV
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 2254)
Temp: 98.0 (Tm 98.4), BP: 100/68 (100-104/68-71), HR: 112
(97-112), RR: 18, O2 sat: 78% (78-92%), O2 delivery: RA
General: NAD
HEENT: MMM, sclera anicteric. PERRLA.
Cardiovascular: Regular rate & rhythm, regular, no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally.
Abdomen: Soft, non-tender, non-distended
Extr/MSK: No peripheral edema. Alert and oriented. ___ handgrip
on the right, ___ bicep, tricep. ___ throughout LUE.
Access: PIV
Pertinent Results:
ADMISSION LABS
___ 11:00AM BLOOD WBC-10.5* RBC-3.78* Hgb-11.8 Hct-37.0
MCV-98 MCH-31.2 MCHC-31.9* RDW-15.0 RDWSD-53.5* Plt ___
___ 03:50PM BLOOD Neuts-88.9* Lymphs-4.1* Monos-5.2
Eos-0.2* Baso-0.4 Im ___ AbsNeut-7.38* AbsLymp-0.34*
AbsMono-0.43 AbsEos-0.02* AbsBaso-0.03
___ 03:50PM BLOOD ___ PTT-25.7 ___
___ 03:50PM BLOOD Glucose-102* UreaN-22* Creat-0.8 Na-139
K-5.5* Cl-102 HCO3-23 AnGap-14
___ 11:00AM BLOOD ALT-12 AST-13 AlkPhos-39 TotBili-0.3
DirBili-<0.2 IndBili-0.3
___ 07:15AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
___ 03:55PM BLOOD Glucose-131* Lactate-3.4* Na-135 K-4.5
___ 03:55PM BLOOD Hgb-9.9* calcHCT-30
DISCHARGE LABS
___ 06:35AM BLOOD WBC-6.0 RBC-2.78* Hgb-8.7* Hct-27.1*
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.1 RDWSD-51.0* Plt ___
___ 06:35AM BLOOD Glucose-112* UreaN-27* Creat-0.7 Na-139
K-5.4 Cl-97 HCO3-30 AnGap-12
___ 06:35AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.2
IMAGING
MR CERVICAL THORACIC ___. Complete collapse of the C7 vertebral body, resulting in 1 cm
anterior
subluxation of C6-T1.
2. Severe spinal canal narrowing at C7-T1 with cord impingement
and subtle
cord signal abnormality.
3. Unchanged heterogeneously enhancing lesions involving the
posterior
elements of T1, T2 and T4, consistent with metastatic disease.
4. Unchanged right-sided Pancoast tumor. Moderate right pleural
effusion.
5. Grade 1 anterolisthesis of L3-4 and L4-5. Moderate spinal
canal narrowing
at L4-5 and mild spinal canal narrowing at L3-4.
CT SPINE ___. Essentially complete collapse of the C7 vertebra with
interval increase in
anterior subluxation of the overriding cervical vertebrae.
There is
approximately 7 mm of anterolisthesis of the C6 on T1 vertebrae
which causes
at least moderate spinal canal narrowing.
2. Previously seen lucent lesions seen in ___ involving
the T1 and T2
vertebral bodies posteriorly in the right pedicle at T2 are now
seen as
slightly sclerotic regions.
3. Known lung mass and other lung findings are better assessed
on the
dedicated chest CT of ___.
C-SPINE ___
Post C4-T2 posterior fixation without evidence of hardware
complication.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 400 mg PO QHS
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. dalteparin (porcine) 10,000 anti-Xa unit/mL subcutaneous
Other Dvt
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
8. Vitamin D ___ UNIT PO DAILY
9. Atovaquone Suspension 1500 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN Dyspepsia
4. Ibuprofen 800 mg PO 3X/WEEK (___)
can take up to 3x/week starting ___ prior to activity for pain
5. INV dalteparin Study Med 7500 IU sq Q24
Takes at 8PM nightly (___)
6. Lidocaine 5% Ointment 1 Appl TP Q12H:PRN back/RUE pain
7. Methadone 5 mg PO QHS
for cancer related pain management
RX *methadone 5 mg 1 tab by mouth at bedtime Disp #*7 Tablet
Refills:*0
8. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 10 mg ___ tablet(s) by mouth every 3 hours Disp
#*112 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO BID
11. Gabapentin 800 mg PO QHS
12. Atovaquone Suspension 1500 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
C7 fracture and total destruction
SECONDARY DIAGNOSIS
Lung adenocarcinoma
Pembro-pneumonitis
DVT/PE
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: CERVICAL SINGLE VIEW IN OR
INDICATION: Status post C3-T5 fusion.
TECHNIQUE: 4 intraoperative radiographs of the cervical spine.
COMPARISON: CT of the cervical spine from ___.
FINDINGS:
4 intraoperative radiographs of the cervical spine were obtained. The first
image shows a probe over the posterior elements of C3. The second and third
images demonstrate posterior fusion from C3 to the upper thoracic spine with
paired rods and pedicle screws. Collapse of the C7 vertebra and anterior
subluxation of C7 on T1 seen on CT of the cervical spine from ___
are obscured by the patient's shoulders on these images.
IMPRESSION:
1. Intraoperative images of the cervical spine obtained during posterior
fusion from C3 to the upper thoracic spine.
Radiology Report
INDICATION: ___ year old female with stage IV lung cancer, RUL pancoast's
tumor w/ known cervico-thoracic metastatic lesions now w/ new worsening of RUE
weakness and bilateral radicular pain x 2 weeks found to have collapse of the
C7 vertebral body w/ severe spinal canal narrowing with cord impingement, now
s/p PCLF C4-T2.// please assess for interval change
COMPARISON: Radiographs from ___ and CT scan from ___
IMPRESSION:
Heart size is within normal limits. There are bilateral pleural effusions,
right greater than left. There is fluid marginating the right minor fissure.
Emphysematous changes with scarring at the apices, right greater than left,
are again seen. No definite pneumothoraces are present. There is spinal
hardware within the cervical spine. Degenerative changes of the thoracic
spine are present.
Radiology Report
INDICATION: Post C4-T2 fusion.
TECHNIQUE: Frontal and lateral cervical spine radiographs.
COMPARISON: MRI from ___. CT from ___.
FINDINGS:
C4-T2 posterior spinal hardware is demonstrated, without evidence of hardware
failure. There is no traumatic malalignment of the cervical spine. No
concerning sclerotic or lytic lesions are detected. Extensive degenerative
changes throughout the cervical spine are better visualized on the dedicated
cervical MRI examination from ___. The lung apices are clear.
There are no osseous erosions.
IMPRESSION:
Post C4-T2 posterior fixation without evidence of hardware complication.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Arm weakness
Diagnosed with Weakness
temperature: 98.0
heartrate: 113.0
resprate: 18.0
o2sat: 99.0
sbp: 149.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | ___ with Stage IV (spine, pleural effusion) lung adenocarcinoma
s/p radiation, 2 cycles of cis/pemetrexed, 2 cycles of
___, now on maintenance pemetrexed/pembro
c/b pembro-associated pneumonitis, who presented with worsening
RUE weakness/neuropathy x 2 weeks. Imaging on admission showed
complete destruction of C7 with anterior subluxation concerning
for cervical instability. s/p C3-T5/T6 decompression and
instrumented fusion on ___.
# RUE weakness, neuropathy- from peripheral nerve/brachial
plexus
involvement from Pancoast tumor vs C7 subluxation as below
# Complete destruction of C7; anterior subluxation concern for
possible cord compromise. Tumor involvement extends to T1 and T2
as well. Due to worsening neurologic symptoms and imaging with
complete destruction of C7, patient was started on high dose
steroids and ortho spine decided to move forward with surgical
intervention. Now s/p C3-T5/T6 decompression and instrumented
fusion on ___. Following surgery, she regained much function in
her RUE. She was restarted on home dose of prednisone.
Atovaquone and omeprazole were continued. Ortho spine
recommended using CTO brace for any activity. Drain was pulled.
Tissue was sent for further pathology testing. Dalteparin was
restarted for anticoagulation 2 days following surgery. The plan
was to follow up in spine clinic 2 weeks following surgery.
Palliative care followed to help with pain control. ___ and OT
were consulted for rehabilitation. Plan was made for discharge
to rehab. Pain regimen was: methadone 5mg QHS, oxycodone ___
Q3h(20 for activity), dilaudid 0.25-0.5 Q3hr:PRN, lidocaine
ointment, ibuprofen 800 mg prior to activity up to 3x/week
(cannot take more frequently than this while on the clinical
trial).
#Stage IV Lung Adenocarcinoma:
#RUL tumor with brachial plexus involvement
Patient last received maintenance pemetrexed/pembro ___.
Received zometa on ___. She was seen by thoracic surgery who
believed the tumor was unresectable. She was continued on
gabapentin 400 QHS.
#Pembro pneumonitis:
Patient had weaned down to 10 mg prednisone daily. She was
started on high dose dex prior to surgery but restarted on home
prednisone following surgery. She requirement intermittent O2
post-op.
#DVT/PE:
Dx ___ on dalteparin as part of ___ ___ trial.
Dalteparin was held for surgery and restarted on ___.
#Subclinical hypothyroidism:
Continued 50mcg levothyroxine daily.
TRANSITIONAL ISSUES
[]Follow up: ortho spine (2 weeks from ___, oncologist
[]Pain control regimen: continue methadone 5mg QHS(for
cancer-related pain), oxycodone ___ Q3h(20 for activity, 10
mg at other times), 800 mg ibuprofen with food prior to activity
up to 3 times per week, lidocaine ointment, gabapentin 800 QHS.
To be adjusted as needed and slowly weaned off of opioids.
[]Will need to remain on bowel regimen while taking opioid
medications
[]Precautions: patient should be sure to wear brace at all times
until follow up with orthospine. She can wear the neck brace
while in bed but should wear CTO brace with any activity
#HCP/CONTACT: ___ ___
#CODE STATUS: DNR, ok to intubate.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ ___ w/ COPD (2L home O2), bronchiectasis,
remote pulm TB (treated ___ years ago in ___, ruled out for TB
on prior admission), a right loculated pleural effusion s/p IP
drainage (___), HBV cirrhosis c/b esophageal varices s/p
multiple banding procedures, pAF, recent admission
___ for hypercarbic hypoxic respiratory failure
who
presents with a complaint of dyspnea. Daughter translates and
patient has had more difficulty breathing and difficulty
urinating over the past several days. He states his symptoms are
similar to prior episodes of his COPD but more severe. Denies
fevers/chills, nausea/vomiting.
Patient has been hospitalized multiple times in the past year
with pseudomonas respiratory tract infections, treated with IV
cefepime and PO ciprofloxacin. Most recently admitted
___ at ___, initially required MICU stay for
hypercarbic respiratory failure. He was diagnosed with
pseudomonas PNA, improved with BiPAP and was treated with
steroids, and 2wk course of IV abx (vanc/cefepime-->cefepime +
azithro). He was discharged with tobramycin inhaler and steroid
taper.
After discharge, patient had pulmonology follow-up appointment
with Dr. ___ on ___, where despite using tobramycin
inhaler, duonebs, flutter valve and chest percussion vest as
instructed, patient's family noted he was more tired, sleeping
more, more short of breath, and had worsening leg edema. At that
time, patient's steroid regimen had been tapered to prednisone
10
daily. CXR from ___ showed slight interval improvement of his
R-sided pleural effusion (small to moderate), improved left lung
edema, and stable severe R lower lung chronic atelectasis
associated with bronchiectasis.
In the ED:
-Initial vital signs were notable for: BP 155/95, HR 102, RR 36,
O2 97% on RA
-Exam notable for: Comfortable, no scleral icterus, Normal S1,
S2, RRR, no m/r/g, 2+ peripheral pulses bilaterally, diffuse
wheezes bilaterally with restricted air movement, crackles in
right lung
Abdomen soft, nontender, nondistended, no masses, extremities
without lower leg edema, no rashes noted
-Labs: WBC 5.0, Hgb 10.3, Hct 33, plt 97, INR 1.4, pro BNP 771,
AST 87, Tbili 1.7
-VBG: pH 7.31, pCO2 67, pO2 34, HCO3 35
-Studies performed: CXR showing volume loss in the right
hemithorax, chronic changes underlying lung parenchyma without
new consolidation. Right-sided pleural effusion is at least
moderate in size. Irregular interstitial markings on left
likely
related to scarring and underlying bronchiectasis. Cardiac
silhouette enlarged but unchanged. Chronic L posterior rib
fractures.
-Patient given: Vanc 1g, cefepime 2g, Methylprednisolone 40mg,
duoneb, albuterol neb, Lasix 40mg
***foley was placed
-Vitals on transfer: 98.6, HR 82, BP 143/82, RR 18, 100% 2L NC
Upon arrival to the floor, patient said that after discharge
from
___, has had worsening SOB and worsening DOE for last 3 days,
especially in the last day. No fevers/chills, no
nausea/vomiting,
no diarrhea/constipation. No cold symptoms. Prior to 3 days ago,
could walk down hallway without DOE but now can barely move
without SOB. No chest pain. No lightheadedness/dizziness. Has
been on home O2 around the clock for 20 days but required PRN
nasal cannula O2 for many months. Feels like he had trouble
catching his breath when speaking. Denies worsening cough,
although per daughter he was coughing more, unclear if more
purulent sputum. Per daughter, patient was ___ in high ___
on
2L NC but feeling dyspneic, wheezing more, and requesting to
increase to 3L NC. Has already finished prednisone taper.
REVIEW OF SYSTEMS:
Self-catheterizes daily at home and does not spontaneously
urinate.
Past Medical History:
1. COPD
2. Bronchiectasis
3. Cirrhosis ___ hepatitis B
4. H/o variceal bleeds s/p multiple banding procedures; last EGD
___ showed grade I varices
5. Hepatitis B - on lamivudine x ___ years
6. Remote TB - reports was treated ___ years ago in ___
7. Right loculated pleural effusion s/p IP drainage, ___ - pleural studies consistent with exudate
8. Paroxysmal a-fib
9. Iron-deficiency anemia
10. Hypertension
11. Hyperlipidemia
12. BPH and elevated PSA with urinary retention
Social History:
___
Family History:
No family history of lung disease. His parents lived into his
___, says none of his other family members have any illnesses.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___
Temp: 97.9 (Tm 97.9), BP: 163/95, HR: 111, RR: 28, O2 sat:
98%, O2 delivery: 2L
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Sclera anicteric and without injection
NECK: Supple, No JVD.
CARDIAC: Tachycardia, regular rhythm, Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diffuse loud expiratory wheezes, no rhonchi or rales.
Tachypneic with increased work of breathing but without use of
accessory muscles
ABDOMEN: BS+, Soft, NTND
EXTREMITIES: 2+ pulses, 2+ pitting ___ edema to knees bilaterally
SKIN: Warm. No rash.
NEUROLOGIC: Alert, answering questions appropriately, moving all
extremities
24 HR Data (last updated ___ @ 329)
Temp: 98,1 (Tm 98.8), BP: 132/83 (114-132/63-83), HR: 74
(61-88), RR: 18 (___), O2 sat: 98% (97-100), O2 delivery:
Bipap
GENERAL: Alert and interactive. In no acute distress.
NECK: Supple, no appreciable JVD.
CARDIAC: Tachycardia, regular rhythm, Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: L. lower lung base wheezing/crackles, no rhonchi or
rales.
No use of accessory muscles.
ABDOMEN: BS+, Soft, NTND
EXTREMITIES: 2+ pulses, 2+ pitting ___ edema to mid-knees
bilaterally
SKIN: Warm. No rash.
NEUROLOGIC: Alert, answering questions appropriately, moving all
extremities
Pertinent Results:
___ 06:13AM BLOOD WBC-4.5 RBC-2.97* Hgb-9.0* Hct-28.6*
MCV-96 MCH-30.3 MCHC-31.5* RDW-15.9* RDWSD-56.4* Plt Ct-50*
___ 05:43AM BLOOD WBC-4.1 RBC-2.96* Hgb-8.9* Hct-28.8*
MCV-97 MCH-30.1 MCHC-30.9* RDW-16.5* RDWSD-58.9* Plt Ct-57*
___ 06:17AM BLOOD WBC-5.1 RBC-3.26* Hgb-9.9* Hct-31.8*
MCV-98 MCH-30.4 MCHC-31.1* RDW-16.4* RDWSD-59.6* Plt Ct-59*
___ 06:20AM BLOOD WBC-4.7 RBC-2.90* Hgb-8.7* Hct-28.1*
MCV-97 MCH-30.0 MCHC-31.0* RDW-16.7* RDWSD-59.7* Plt Ct-77*
___ 12:47PM BLOOD WBC-5.0 RBC-3.35* Hgb-10.3* Hct-33.0*
MCV-99* MCH-30.7 MCHC-31.2* RDW-17.0* RDWSD-61.4* Plt Ct-97*
___ 12:47PM BLOOD Neuts-74.2* Lymphs-11.2* Monos-12.0
Eos-2.2 Baso-0.2 Im ___ AbsNeut-3.72 AbsLymp-0.56*
AbsMono-0.60 AbsEos-0.11 AbsBaso-0.01
___ 06:13AM BLOOD Glucose-95 UreaN-7 Creat-0.6 Na-145 K-3.5
Cl-100 HCO3-39* AnGap-6*
___ 06:17AM BLOOD ALT-22 AST-23 LD(LDH)-282* AlkPhos-101
TotBili-1.3
___ 06:13AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.1
___ 09:30PM BLOOD ___ pO2-212* pCO2-46* pH-7.42
calTCO2-31* Base XS-5
___ 01:35PM BLOOD ___ O2 Flow-2 pO2-34* pCO2-67*
pH-7.31* calTCO2-35* Base XS-4 Intubat-NOT INTUBA
Comment-BREATHS/MI
___ 1:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
YEAST. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 10:15 am SPUTUM Source: Expectorated.
FUNGAL CULTURE ADDED ON PER ___
___ 16:08 #
___.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
Radiology Report
INDICATION: ___ with dyspnea// eval for PNA
TECHNIQUE: AP view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Volume loss in the right hemithorax is again noted. Chronic changes
underlying lung parenchyma are again noted without new consolidation.
Right-sided pleural effusion is at least moderate in size. Irregular
interstitial markings noted on the left likely related to scarring and
underlying bronchiectasis. No definite new consolidation. Cardiac silhouette
is enlarged but unchanged. Chronic left posterior rib fractures are again
noted.
IMPRESSION:
No significant interval change since prior. Persistent right hemithorax
volume loss, underlying parenchymal changes and moderate right pleural
effusion.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: nan
heartrate: 102.0
resprate: 36.0
o2sat: 97.0
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | SUMMARY:
Mr. ___ is a ___ w/ COPD (2L home O2), bronchiectasis,
remote pulm TB (treated ___ years ago in ___, ruled out for TB
on prior admission), HBV cirrhosis c/b esophageal varices s/p
multiple banding procedures, pAF, recent admission
___ for hypercarbic hypoxic respiratory failure
who was admitted for worsening dyspnea, thought to be ___
chronic, progressive lung disease and acute on chronic diastolic
heart failure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin
Attending: ___.
Chief Complaint:
left lower quadrant pain
Major Surgical or Invasive Procedure:
___ ___ drainage pelvic abscess
History of Present Illness:
___ year old female with diverticulitis ___ episode ___ p/w
LLQ
abdominal pain for last 3 days. Initially had nausea and
vomiting but none since ___. Pain was initially ___
located in LLQ but has subsided to ___ with pain medication.
She reports subjective fevers and chills (Temp 101.7 in ED
today). Last BM was ___, and is currently passing flatus.
Last
colonoscopy was ___ which showed polyps (removed) and
diverticulae in sigmoid colon. No dysuria.
Past Medical History:
Metastatic Melanoma, Hypertension, Diverticulitis
Past Surgical History: Left inguinal node dissection (melanoma
excision), Pulmonary metastectomy x2
Social History:
___
Family History:
Non contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.0 HR: 86 BP: 119/59 Resp: 16 O(2)Sat: 98 RA
Constitutional: uncomfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits
Abdominal: Soft, Nondistended, + LLQ tenderness
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, + pulses
Skin: No rash, Warm and dry
Neuro: Speech fluent, GCS 15, full strength
Psych: Normal mood, Normal mentation
___: No petechiae
Upon discharge: ___
98.7, 73, 129/57, 16, 94%RA
NAD, A&O, comfortable
RRR
CTAB, no resp distress
Abd soft, tender to deep LLQ palpation, nondistended, no rebound
or guarding
Transvaginal ___ drain in place, drainage thin slightly purulent
Ext wwp x4, palp DPs b/l
Pertinent Results:
___ 04:50AM BLOOD WBC-10.1 RBC-4.06* Hgb-11.0* Hct-34.7*
MCV-86 MCH-27.0 MCHC-31.5 RDW-12.2 Plt ___
___ 06:45AM BLOOD WBC-15.6* RBC-3.92* Hgb-10.5* Hct-33.3*
MCV-85 MCH-26.8* MCHC-31.5 RDW-12.2 Plt ___
___ 07:40AM BLOOD WBC-12.9*# RBC-5.50* Hgb-14.8 Hct-46.3
MCV-84 MCH-26.8* MCHC-31.9 RDW-12.0 Plt ___
___ 07:40AM BLOOD Neuts-80.8* Lymphs-13.5* Monos-5.0
Eos-0.1 Baso-0.6
___ 04:50AM BLOOD Plt ___
___ 04:50PM BLOOD ___ PTT-28.2 ___
___ 07:40AM BLOOD ___ PTT-29.7 ___
___ 04:50AM BLOOD Glucose-105* UreaN-9 Creat-0.6 Na-138
K-3.6 Cl-102 HCO3-30 AnGap-10
___ 07:40AM BLOOD Glucose-139* UreaN-12 Creat-0.8 Na-139
K-3.5 Cl-97 HCO3-25 AnGap-21*
___ 07:40AM BLOOD ALT-23 AST-24 AlkPhos-79 TotBili-1.6*
___ 04:50AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
___ 08:13AM BLOOD Lactate-2.8*
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Sigmoid diverticulitis with a 3 x 5.3 x 5.6 cm with a
contained
perforation. Without IV contrast,it is difficult to tell how
much of the
collection is abscess vs phlegmon. Additionally the left ovary
is not well visualized and part of the collection may represent
inflammed ovary. This could be further evaluated with pelvis MRI
if clinically indicated.
2. Hepatic steatosis.
3. Stable left adrenal nodularity.
___: cat scan of abdomen and pelvis:
1. New free intraperitoneal air indicates interval development
of gross
perforation of complicated sigmoid diverticulitis with 3
adjacent fluid and gas containg collections, of which only one
was seen previously. There is enteric contrast within the
collections confirming communication with the bowel lumen. A
left adnexal collection with tubular gas containing component
likely represents involvement of the Fallopian tube, which is
supported by gas in the endometrial cavity.
2. Hepatic steatosis and nodularity in the left adrenal gland
are unchanged.
___: interventional US:
Technically successful ultrasound-guided transvaginal drainage
of
a pelvic collection with ___ pigtail catheter in place.
Medications on Admission:
Vitamin D
Augmentinx1 dose 2 days ago
Atenolol 25 qam, 50qpm
Lorazepam .5mg prn
Methimazole 7.5 qd
Simvastatin 20qd
Discharge Medications:
1. Atenolol 25 mg PO QAM
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Capsule Refills:*0
3. Methimazole 7.5 mg PO DAILY
4. Senna 1 TAB PO BID
5. Simvastatin 20 mg PO DAILY
6. Atenolol 25 mg PO QPM
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Atenolol 25 mg PO QAM
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4-6hr Disp #*50
Tablet Refills:*0
10. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
11. CeftriaXONE 1 gm IV Q24H
12. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
13. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
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
HISTORY: Patient with history of diverticulitis with left lower quadrant
abdominal pain. Question diverticulitis versus appendicitis.
TECHNIQUE: Axial helical MDCT images were obtained through the abdomen and
pelvis without administration of IV contrast and with oral contrast.
Multiplanar reformatted images in coronal and sagittal axes were generated.
DLP: 834 mGy-cm
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
There is unchanged scarring in the right middle lobe and scarring and suture
material in the right lower lobe. The visualized heart and pericardium are
unremarkable.
CT abdomen: Evaluation of the solid organs and soft tissues is limited by
lack of intravenous contrast. Oral contrast is seen refluxing back into the
distal esophagus. The liver is diffusely hypoattenuating consistent with
hepatic steatosis. No focal lesions or intrahepatic biliary dilatation. The
gallbladder, pancreas, spleen and right adrenal gland are unremarkable.
Nodularity of the left adrenal gland is unchanged dating back to at least
___. The kidneys have a normal non contrast appearance without stones or
hydronephrosis. A small hypodensity is noted in the left kidney which is too
small to characterize, but likely represents a cyst.
The small and large bowel are normal in caliber without evidence of
obstruction. There is inflammation around the sigmoid colon with an inflamed
diverticula consistent with diverticulitis. There is a 3 x 5.3 x 5.6 cm
collection in the left pelvis adjacent to the sigmoid which contains locules
of air consistent with a contained perforation. The appendix is visualized
and there is no evidence of appendicitis. The intraabdominal vasculature is
unremarkable. Multiple prominent mesenteric and retroperitoneal lymph nodes
are likely reactive. No ascites, free air or abdominal wall hernia is noted.
CT pelvis: The urinary bladder is unremarkable. There is air in the vaginal,
but no air within the uterus. The right adnexa is unremarkable. The left
adnexa is not well visualized and may be involved in the inflammation adjacent
to the diverticulitis. There is a small amount pelvic free fluid in the
peritoneal space. There is no inguinal or pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious for malignancy
is present.
IMPRESSION:
1. Sigmoid diverticulitis with a 3 x 5.3 x 5.6 cm with a contained
perforation. Without IV contrast,it is difficult to tell how much of the
collection is abscess vs phlegmon. Additionally the left ovary is not well
visualized and part of the collection may represent inflammed ovary. This
could be further evaluated with pelvis MRI if clinically indicated.
2. Hepatic steatosis.
3. Stable left adrenal nodularity.
Change in wet read discussed with Dr ___ the ___ and Dr ___ Surgery
by Dr ___ at 12:00 on ___.
Radiology Report
CLINICAL INDICATION: Second episode of acute sigmoid diverticulitis with a 3
x 5 x 5 left pelvic abscess. The patient has a persistent fever and elevated
white count. Evaluate for interval changes in the abscess.
TECHNIQUE: Multidetector CT scan through the abdomen and pelvis was performed
after the administration of oral contrast only. Coronal and sagittal
reformatted images were obtained.
DLP: 812 mGy-cm.
COMPARISON: CT abdomen and pelvis, ___ and ___.
FINDINGS: Linear opacities within the lung bases again seen consistent with
scarring and atelectasis, and with suture material in the right lower lobe.
There is no pleural or pericardial effusion.
Evaluation of the solid organs and soft tissues is limited by the lack of
intravenous contrast. The liver is hypodense, consistent with diffuse hepatic
steatosis. There are no focal liver lesions or intrahepatic biliary duct
dilation evident on this noncontrast scan. The gallbladder, pancreas, spleen,
and right adrenal gland are unremarkable. Nodularity in the left adrenal
gland measuring 1.2 x 1.7 cm appears relatively unchanged. The kidneys have a
normal non-contrast appearance without stones or hydronephrosis.
Multiple new foci of intrabdominal free air extend from the diaphragm down
into the pelvis adjacent to the fluid collection consistent with gross
perforation. The small bowel normal in caliber without evidence of
obstruction. Wall thickening and fat stranding around the sigmoid colon has
increased, consistent with worsening sigmoid diverticulitis. The previously
seen phlegmon/fluid collection within the left lower quadrant has increased in
extent, now composed of three interconnecting collections. The largest
collection is new, located in the central deep pelvis, measuring 5.3 x 5.7 x
4.2 cm (TRV x AP x CC) (series 3, image 72 and series 5B:33) with an air fluid
level. The previously seen fluid collection is relatively unchanged, now
measuring 3.4 x 5.8 cm (3:69). This appears to be associated with the left
adnexa and there is new gas in the endometrial cavity as well. A third
collection also appears connected and measures 2.1 x 3.3 cm (3:69). High
density within the fluid collection (3:69) indicates a fistulous connection
between the fluid collections and the bowel. Prominent mesenteric lymph nodes
within the abdomen and pelvis are likely reactive and meaure up to 1 cm in the
short axis (4b:23). The bladder is collapsed. The aorta is calcified and
normal in caliber.
OSSEOUS STRUCTURES: There are mild degenerative changes within the lower
lumbar spine.
IMPRESSION:
1. New free intraperitoneal air indicates interval development of gross
perforation of complicated sigmoid diverticulitis with 3 adjacent fluid and
gas containg collections, of which only one was seen previously. There is
enteric contrast within the collections confirming communication with the
bowel lumen. A left adnexal collection with tubular gas containing component
likely represents involvement of the Fallopian tube, which is supported by gas
in the endometrial cavity.
2. Hepatic steatosis and nodularity in the left adrenal gland are unchanged.
COMMENT: ___ and ___ discussed with ___ at 10:55PM, on ___, the time of discovery.
Radiology Report
INDICATION: ___ year old woman with w/ ___ episode of acute sigmoid
diverticulitis, now w/ interval increase in size of pelvic abscess.
COMPARISON: CT dated ___.
PROCEDURE: Transvaginal ultrasound-guided drainage of a pelvic collection.
The risks and benefits of the procedure were explained to the patient, and
written informed consent was obtained. A pre-procedure timeout was performed
verifying three patient identifiers and the nature of the procedure to be
performed. Initial sonographic imaging was performed transvaginally
demonstrating a pelvic fluid collection. The decision was made to proceed with
transvaginal ultrasound-guided drainage.
The skin of the perineum was prepped with Betadine and the vagina was cleansed
with Betadine mixed with topical lidocaine for local anesthesia. Under direct
ultrasonographic guidance, a 18-gauge spinal needle was advanced to the
vaginal wall and the vagina and adjacent tissues were anesthetized via
percutaneous transvaginal injection of 5 cc of 1% lidocaine. Under real-time
ultrasound guidance, an ___ drainage catheter was advanced into
the collection using trochar technique. Once the tip of the catheter was
confirmed within the collection, the inner sharp stylet was removed. A small
sample of fluid was aspirated to confirm the location of the catheter within
the collection. After this was performed, the catheter was advanced over the
metal stiffener into the collection, the stiffener was withdrawn, and the
pigtail was formed. The catheter was then attached to a three-way stopcock
and a drainage bag. The collection was aspirated to completion, yielding 80
ml of brown turbid fluid. A sample was sent to microbiology for analysis. The
catheter was then fixed to the skin using a flexible lock device and a dry
sterile dressing was applied. The patient tolerated the procedure well and
there were no immediate complications.
The attending radiologist, Dr. ___ the procedure.
MODERATE SEDATION: Moderate sedation was provided by administering divided
doses of Versed and Fentanyl intravenously, during which time the patient's
hemodynamic parameters were continuously monitored by the independent trained
radiology department nursing staff.
IMPRESSION: Technically successful ultrasound-guided transvaginal drainage of
a pelvic collection with ___ pigtail catheter in place.
Radiology Report
HISTORY: ___ female with new PICC.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Portable chest radiograph demonstrates new right PICC terminating in the low
superior vena cava. There are low lung volumes with bibasilar atelectasis
right greater than left. No new focal consolidation. No overt pulmonary
edema or pleural effusions. Cardiomegaly is unchanged and chronic,
exaggerated in the setting of low lung volumes. There is no pneumothorax.
IMPRESSION:
New right PICC terminating in the low superior vena cava. These findings were
communicated to the IV nurse upon review of this radiograph.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LLQ ABDOMINAL PAIN
Diagnosed with DIVERTICULITIS OF COLON
temperature: 98.0
heartrate: 86.0
resprate: 16.0
o2sat: 98.0
sbp: 119.0
dbp: 59.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the hospital with left lower
quadrant pain. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging of the abdomen. On
cat scan, she was reported to have a left sigmoid diverticulitis
with a contained perforation. Interventional radiology was
consulted and reported that the collection was too small to
drain. On HD #2, the patient was noted to have temperature
spikes along with a rising white blood cell count. She underwent
a repeat cat scan of the abdomen on HD #4 which showed an
interval increase of the perforation with 3 adjacent fluid and
gas containg collections. Based on these findings, the patient
returned to ___ for ultrasound-guided transvaginal drainage of
the pelvic collection with a ___ pigtail catheter. 80cc of
brown turbid fluid was aspirated and sent for culture. The gram
stain showed gram positve and gram negative rods. The patient
continued on zosyn and her white blood cell count was monitored.
The patient's abdominal pain began to decrease in intensity and
she was started on sips and advanced to clear liquids on HD #7.
The patient's pain was controlled with oral analgesia.
On HD #8 the patient was advanced to a regular diet. Her white
blood cell count was stable at 10. Her abscess culture returned
as E.coli resistant to augmentin but sensitive to ceftriaxone
and her antibiotics were changed to ceftriaxone and flagyl. A
PICC was placed for home antibiotics. The patient was discharged
home with ___ for drain care and intravenous antibiotics. She
will return to clinic in about 10 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / pantoprazole /
smoked fish
Attending: ___.
Chief Complaint:
toxic-metabolic encephalopathy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of ___ disease, dementia, DM II, HTN, and a
long-standing history of urinary retention/incontinence
complicated by recurrent UTIs who presented with altered mental
status and a one-week history of vomiting, lethargy, and not
tolerating her medications. The patient was recently discharged
to rehab after admission for hip fracture. She has been vomiting
over the last week and may not have been tolerating her
medications, and she has been noted to be increasingly lethargic
over the last few days, especially throughout the morning. In
the ED she was unresponsive.
Note from ___ clinic visit (___): Per daughter
patient has been vomiting x3 days, most recently today. Daughter
is extremely concerned. Per daughter patient was altered in the
ambulance on the way to office. Patient has Parkinsons and
dementia but has changed from baseline per daughter. Daughter
visits mother daily in current rehab/living facility. In office
patient does not respond readily to sternal rub.
In the ED, initial vital signs were: 97.2 180/70 68 16 98%/RA
- Exam notable for: arrives with eyes closed, responsive to
painful stimuli.
- Labs were notable for AP 170, WBC 12.2, H/H ___, Plt 663,
negative UA, normal lactate.
- Studies performed include:
-> CXR: Interval placement of a nasogastric tube which appears
to terminate, coiling in the proximal stomach; distal tip may be
pointed at the GE junction
-> CT head: no acute intracranial process
- Patient was given: Atenolol 25 mg, Carbidopa-Levodopa
(___), Citalopram 10 mg, Lisinopril 20 mg, IVF 1000 mL NS 500
mL
Upon arrival to the floor, the patient had sBP in 200s. She was
given captopril. Rechecked and was still in 200s, gave
hydralazine. Called ___ who said yesterday she was
interactive. She said she was concerned that the nursing home
had been giving her medications since the patient had been
having pain when working with ___ and also difficulty sleeping at
night. However, she does not know the medications given. I
called nursing home and they said they would fax them to me.
Ordered narcan x1, but patient awoke and pulled out NG tube and
asked to go home.
Past Medical History:
- HTN
- HLD
- DM type II
- CKD stage III (baseline Cr ~1.5)
- Parkinsons
- Hypothyroidism
- GERD
- Osteoporosis
- H/o colonic adenoma
- Depression
- Lumbar spondylosis
- H/o urinary retention
Social History:
___
Family History:
Asked and unknown
Physical Exam:
admission:
-----------
Vitals- 98.2 200/83 18 78 98%RA
General: somnolent, open eyes to sternal rub
HEENT: PERRLA
Neck: No JVD
CV: RRR no murmurs
Lungs: CTAB/L no w/r/r
Abdomen: s/nt/nd +BS, normoactive BS
GU: no foley
Ext: left hip incision bandaged, no pus, erythema, evidence of
pain with motion
Neuro: unable
Skin: +rash on back, patch on back
discharge:
----------
VS 98.6 151/59 69 18 97 r/a
General: lying in bed with mouth open, masked facies, alert to
person and place, not time
HEENT: PERRLA
Neck: No JVD, no nuchal rigidity, negative Brudzinski's test
CV: RRR, ___ systolic murmur heard best at LUSB
Lungs: CTABL, breath sounds symmetric, no w/r/r
Abdomen: s/nt/nd +BS in all four quadrant, normoactive BS
GU: no foley
Ext: left hip incision bandaged, no pus, erythema, evidence of
pain with motion, able to flex hips minimally bilaterally R>L
Neuro: unable
Skin: +erytheatmous papules
Pertinent Results:
***Admission Labs***
___ 12:23PM BLOOD WBC-12.2* RBC-3.90 Hgb-11.0* Hct-33.9*
MCV-87 MCH-28.2 MCHC-32.4 RDW-14.1 RDWSD-44.0 Plt ___
___ 12:23PM BLOOD Glucose-165* UreaN-27* Creat-0.8 Na-138
K-4.7 Cl-98 HCO3-28 AnGap-17
___ 12:23PM BLOOD ALT-6 AST-7 AlkPhos-170* TotBili-0.2
___ 12:23PM BLOOD Albumin-3.7
___ 12:23PM BLOOD TSH-1.9
___ 01:08AM BLOOD ___ pO2-191* pCO2-41 pH-7.46*
calTCO2-30 Base XS-5
___ 12:52PM BLOOD Lactate-2.0
___ 12:45PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
***Discharge Labs***
___ 04:38AM BLOOD WBC-10.4* RBC-3.47* Hgb-9.6* Hct-29.7*
MCV-86 MCH-27.7 MCHC-32.3 RDW-14.1 RDWSD-43.4 Plt ___
___ 04:38AM BLOOD Glucose-142* UreaN-29* Creat-0.8 Na-139
K-3.8 Cl-101 HCO3-28 AnGap-14
___ 04:38AM BLOOD Calcium-10.4* Phos-3.2 Mg-1.7
***Micro***
___ Blood culture x2
Pending
___ Urine culture
URINE CULTURE (Final ___: NO GROWTH.
***Imaging***
___, Hip XRAY
IMPRESSION:
In comparison with the study of ___, there has been
substantial new bone formation about the fracture of the
proximal left femur, secured by fixation device. Fracture line
is still evident. Otherwise little change.
___, CXR
FINDINGS:
Right-sided PICC terminates in the mid to low SVC without
evidence of
pneumothorax. There are low lung volumes. No focal
consolidation or pleural effusion is seen. Cardiac silhouette
is top-normal. Mediastinal contours are unremarkable.
IMPRESSION:
No focal consolidation to suggest pneumonia.
___, CT head w/o contrast
IMPRESSION:
No acute intracranial process.
___, CXR
IMPRESSION:
Interval placement of a nasogastric tube which appears to
terminate, coiling in the proximal stomach ; distal tip may be
pointed at the GE junction
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 25 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Entacapone 200 mg PO QID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD DAILY
6. Lisinopril 20 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. Nystatin 500,000 UNIT PO Q8H oral candidiasis
9. Nystatin Cream 1 Appl TP BID
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
12. Fleet Enema ___AILY:PRN constipation
13. melatonin 3 mg oral QHS
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
15. urea 40 % topical BID
16. Carbidopa-Levodopa (___) 1.5 TAB PO 6PM
17. Carbidopa-Levodopa (___) 2 TAB PO TID
18. Senna 17.2 mg PO HS
19. Acetaminophen 1000 mg PO TID
20. Ondansetron 4 mg PO Q8H:PRN nausea
21. Polyethylene Glycol 17 g PO DAILY
22. TraMADOL (Ultram) 50 mg PO Q4H pain
23. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
24. Citalopram 10 mg PO DAILY
25. Exelon (rivastigmine;<br>rivastigmine tartrate) 9.5 mg/24 hr
transdermal DAILY
26. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
27. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
breakthrough pain
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Atenolol 25 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Carbidopa-Levodopa (___) 1.5 TAB PO 6PM
5. Carbidopa-Levodopa (___) 2 TAB PO TID
6. Citalopram 10 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Entacapone 200 mg PO QID
9. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD DAILY
12. Lisinopril 20 mg PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN
breakthrough pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q 6 hours
Disp #*24 Tablet Refills:*0
15. Simvastatin 40 mg PO QPM
16. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
18. Fleet Enema ___AILY:PRN constipation
19. melatonin 3 mg oral QHS
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
21. Nystatin 500,000 UNIT PO Q8H oral candidiasis
22. Nystatin Cream 1 Appl TP BID
23. Polyethylene Glycol 17 g PO DAILY
24. Senna 17.2 mg PO HS
25. urea 40 % topical BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
altered mental status
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
INDICATION: ___ year old woman with left hip fx // assess fx assess fx
IMPRESSION:
In comparison with the study of ___, there has been substantial new bone
formation about the fracture of the proximal left femur, secured by fixation
device. Fracture line is still evident.
Otherwise little change.
Radiology Report
INDICATION: History: ___ with ams , recent sutrgery pls eval for pna //
History: ___ with ams , recent sutrgery pls eval for pna
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Right-sided PICC terminates in the mid to low SVC without evidence of
pneumothorax. There are low lung volumes. No focal consolidation or pleural
effusion is seen. Cardiac silhouette is top-normal. Mediastinal contours are
unremarkable.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with ams unresponsive pls efva lfor acute stroke or
hemorrhage // History: ___ with ams unresponsive pls efva lfor acute stroke
or hemorrhage
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 702 mGy-cm.
COMPARISON: Multiple nonenhanced CT head dating back to ___, most
recent ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Prominent ventricles and sulci are consistent with age-related
involutional changes. Periventricular and and subcortical white matter
hypodensities are seen, likely sequelae of chronic small vessel ischemic
disease. Vascular calcifications are seen the distal vertebral arteries and
cavernous carotids.
No acute fracture is seen. The imaged paranasal sinuses are clear. Mastoid
air cells and middle ear cavities are well aerated.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with AMS and s/p NGT placement // eval NGT
placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: Earlier today, ___ at 12:44
FINDINGS:
There has been interval placement of a nasogastric tube which appears to
terminate, coiling in the proximal stomach ; distal tip may be pointed at the
GE junction.
The remainder of the findings are unchanged.
IMPRESSION:
Interval placement of a nasogastric tube which appears to terminate, coiling
in the proximal stomach ; distal tip may be pointed at the GE junction
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Lethargy, Vomiting
Diagnosed with Altered mental status, unspecified
temperature: 97.2
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 180.0
dbp: 70.0
level of pain: Unresponsive
level of acuity: 1.0 | ___ with PMH of ___ disease, dementia, DM II, HTN,
recent MDR E.Coli bacteremia and septic joint (___) and a
long-standing history of urinary retention/incontinence
complicated by recurrent UTIs who presented with altered mental
status and a one-week history of vomiting, and lethargy.
#ALTERED MENTAL STATUS:
Patient presented with altered mental status although quickly
returned to baseline while in the hospital. Rivastigmine patch
was removed and hypertension was treated upon admission. There
was no evidence of infection given normal u/a, no consolidation
on CXR. Leukocytosis is chronic. Pt does have hx of septic hip
although no evidence currently. No hx of diarrhea although she
has had ~1 mo of vomiting, so gastroenteritis is also a
possibility. Per rehab, patient was not given any extra opiates,
or delirium-causing agents prior to presentation at the
hospital. No evidence of metabolic derangement without
hypoglycemia, hypercarbia, or electrolyte abnormality. TSH wnl.
Unclear etiology. Unlikely that removal of rivastigmine would
cause quick return to baseline mental status if rivastigmine is
the cause. Pt was started on hydralazine as well given his
increased blood pressure upon arrival. Was normotensive
throughout hospitalization. Likely multifactorial in setting of
hypertension, possibility of dehydration with vomiting as well
as medication effects.
#VOMITING
Patient w/o vomiting during hospitalization. Unclear if this is
just regurgitation vs. vomitus of digested food. Patient did
"pocket" food during hospitalization. Patient should have speech
and swallow evaluation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Vicodin / tramadol / Flagyl
Attending: ___.
Chief Complaint:
Chest pain and malaise
Major Surgical or Invasive Procedure:
- Echocardiogram
History of Present Illness:
Ms. ___ is a ___ year old woman with history of lupus,
raynauds, anorexia who presents with chest pain.
Over past 2 weeks patient has been feeling unwell with
generalized malaise. She has felt fatigued, low energy, and
lethargic. She noted urinary frequency and was treated for UTI
with macrobid. This week she had to stay home from work 1 day
for feeling unwell, today tried to go to work, called her doctor
as she was feeling unwell with chest pain, worse with deep
inspiration, was instructed to report to ___.
She was referred in for IV fluids and solumedrol for chronic
urethritis and pleuritis however had temp to 102 in ___. Labs
were unremarkable including urine. CXR showed enlarged heart, ?
infiltrate. Bedside u/s showed small pericardial effusion.
Patient was subsequently transferred to ___ for further
evaluation.
In the ___, initial vitals were:
96.7 84 98/64 23 97% RA
Labs notable for: normocytic anemia, INR 1.3, neg UA, trop
<0.01
Imaging notable for: bedside TTE without evidence of tamponade
Patient was given: 500mg IV levofloxacin
Atrius cards consulted and recommended: admit to ___
___ prior to transfer:
96.6 67 124/69 16 100% RA
On the floor patient reports dry mouth. She denies cough.
Intermittent chest pain with deep inspiration. Currently chest
pain free. Also reports had herpes zoster 1 month ago.
Past Medical History:
- Lupus- Diagnosed ___. On Methotrexate and
Hydroxychloroquine.
- Glaucoma
- HX of Lyme disease
- Barretts esophagus.
- Chronic joint pain
- Raynaud's.
Social History:
___
Family History:
- Father with heart attack in mid-___ and blood clots starting
in ___ (etiology unclear)
- No family history of stroke, seizure or other neurologic
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 96.6 67 124/69 16 100% RA
General: Alert, oriented, anxious appearin, very thin, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley , no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: WNL
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric
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
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pulsus: ___
Pertinent Results:
ADMISSION LABS:
===============
___ 10:50PM BLOOD WBC-5.8# RBC-3.59* Hgb-9.5* Hct-30.8*
MCV-86 MCH-26.5# MCHC-30.8*# RDW-14.9 RDWSD-46.6* Plt ___
___ 10:50PM BLOOD Neuts-93.0* Lymphs-3.1* Monos-3.6*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-5.39 AbsLymp-0.18*
AbsMono-0.21 AbsEos-0.00* AbsBaso-0.00*
___ 10:50PM BLOOD ___ PTT-28.8 ___
___ 10:50PM BLOOD Glucose-151* UreaN-10 Creat-0.5 Na-138
K-3.8 Cl-103 HCO3-24 AnGap-15
DISCHARGE LABS:
===============
___ 06:10AM BLOOD WBC-5.4 RBC-3.81* Hgb-10.1* Hct-32.5*
MCV-85 MCH-26.5 MCHC-31.1* RDW-15.0 RDWSD-47.0* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-129* UreaN-11 Creat-0.5 Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
___ 06:10AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:10AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.9 Iron-12*
___ 06:10AM BLOOD calTIBC-238* Ferritn-254* TRF-183*
___ 06:10AM BLOOD CRP-135.8*
MICROBIOLOGY:
=============
N/A
PERTINENT STUDIES:
==================
___ CXR:
- Substantial increase in size of the cardiac silhouette between
___ and ___, with non physiologic bulging of the right and
posterior contours,
accompanied by small pleural effusions and no pulmonary vascular
congestion or edema suggest pericardial effusion. There is no
mediastinal venous engorgement to indicate that the tamponade
physiology. Lungs are generally clear aside from probable left
lower lobe atelectasis.
___ Echocardiogram:
- Compared with the report of the prior study (images
unavailable for review) of ___, a small-moderate
pericardial effusion is seen without echocardiographic signs of
hemodynamic compromise.
- The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%)
___ EKG:
- Sinus 75 NA, prolonged QTc 569, low voltages in III and aVF,
no ischemic changes
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with lupus with chest pain and ?pericarditis.
also with fever // evidence of PNA? evidence of PNA?
IMPRESSION:
Compared to ___ and ___.
Substantial increase in size of the cardiac silhouette between ___ and ___, with non physiologic bulging of the right and posterior contours,
accompanied by small pleural effusions and no pulmonary vascular congestion or
edema suggest pericardial effusion. There is no mediastinal venous
engorgement to indicate that the tamponade physiology. Lungs are generally
clear aside from probable left lower lobe atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with Chest pain, unspecified, Human immunodeficiency virus [HIV] disease
temperature: 96.7
heartrate: 84.0
resprate: 23.0
o2sat: 97.0
sbp: 98.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY:
==============
Ms. ___ is a ___ year old woman with history of lupus
presenting with malaise and chest pain, found to have
pericardial effusion concerning for pericarditis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with history of prior CVA with residual
right-sided weakness and aphasia, diabetes, CKD (baseline 1.1),
CHF who presents from her long-term care facility via EMS with
respiratory distress. She was nonverbal and history is limited
--she is able to nod head yes and no to questions, however her
level of comprehension is unclear. According to EMS report,
patient was found this afternoon to have increasing shortness of
breath, increasing work of breathing. This happened sometime
after eating breakfast. She was noted to have difficulty
swallowing with copious secretions.
On arrival to the emergency department, she was noted to be
somnolent but arousable to voice. Secretions from airway
suction.
She was significantly tachypneic up to the ___, with increased
work of breathing. She had coarse rhonchi throughout all lung
fields, worse on the right. She was hypoxic to about 80% on
nonrebreather.
Patient's paperwork notes that she is DNR/DNI. Family was
immediately contacted and confirmed that she would not want to
be
intubated.
Respiratory therapy was called and she was started on BiPAP. She
had some improvement in her work of breathing. Chest x-ray was
obtained and showed diffuse pulmonary edema. Bedside ultrasound
also showed diffuse B-lines consistent with pulmonary edema as
well as likely consolidation, particularly in the right lower
lobe.
EKG shows a left bundle branch block, with no priors to compare.
She received empiric vancomycin, cefepime, and Flagyl for
concern
for aspiration pneumonia. Due to signs of volume overload, she
received 30 mg of IV Lasix (she takes 30 mg p.o. daily) and she
was started on a nitro drip. She also received PR aspirin.
Around
___, patient noted to have decreasing blood pressure to the ___
systolic. Nitro drip was stopped.
Family was here and after extensive conversation with them, they
continue to corroborate that patient is DNR/DNI, would not want
to have chest compressions, central IV access for pressors, or
intubation. They are okay with noninvasive interventions.
Labs are notable for elevated lactate, significant leukocytosis
with high percentage of lymphocytes. No bands and no blasts. She
also has significant acidosis with CO2 retention, and elevated
blood sugar. Started on insulin drip.
Past Medical History:
CVA with residual right-sided weakness and aphasia
DMII
CKD
CHF
Lives in an ALF, dependent for most ADLs.
Social History:
___
Family History:
Irrelevant.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Reviewed in Metavision
GEN: frail elderly woman, difficulty speaking in full sentences
secondary to aphasia and increased work of breathing
HENNT: MMM, EOMI, PERRLA
CV: RRR, no M/R/G
RESP: coarse rhonchi throughout
GI: soft, NTND
Ext: 1+ edema to mid-shins
SKIN: No rashes
NEURO: AxOx2 with prompting, aphasic
Pertinent Results:
ADMISSION LABS:
===============
___ 12:50PM BLOOD WBC-35.8* RBC-4.42 Hgb-13.5 Hct-43.6
MCV-99* MCH-30.5 MCHC-31.0* RDW-13.2 RDWSD-47.9* Plt ___
___ 12:50PM BLOOD Neuts-38 Bands-1 Lymphs-56* Monos-4*
Eos-0* Baso-1 NRBC-0.1* AbsNeut-13.96* AbsLymp-20.05*
AbsMono-1.43* AbsEos-0.00* AbsBaso-0.36*
___ 12:50PM BLOOD ___ PTT-27.0 ___
___ 12:50PM BLOOD Glucose-539* UreaN-27* Creat-1.6* Na-136
K-6.3* Cl-100 HCO3-17* AnGap-19*
___ 12:50PM BLOOD ALT-30 AST-58* AlkPhos-139* TotBili-0.3
___ 12:50PM BLOOD cTropnT-<0.01 proBNP-614
___ 12:50PM BLOOD Albumin-3.7
IMPORTANT LABS:
===============
___ 12:50PM BLOOD cTropnT-<0.01 proBNP-614
___ 09:53PM BLOOD CK-MB-108* cTropnT-2.09*
___ 03:55AM BLOOD CK-MB-152* cTropnT-4.94*
___ 10:31AM BLOOD CK-MB-137* cTropnT-6.73*
___ 03:36PM BLOOD CK-MB-120* cTropnT-5.69*
DISCHARGE LABS:
===============
___ 03:55AM BLOOD WBC-22.7* RBC-4.08 Hgb-12.3 Hct-38.5
MCV-94 MCH-30.1 MCHC-31.9* RDW-13.2 RDWSD-45.6 Plt ___
___ 03:36PM BLOOD Glucose-265* UreaN-42* Creat-2.1* Na-133*
K-9.1* Cl-100 HCO3-16* AnGap-17
STUDIES:
=======
CXR
Diffuse bilateral opacities which could reflect severe pulmonary
edema, ARDS, or multifocal pneumonia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID
2. Mirtazapine 7.5 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Gabapentin 100 mg PO QHS
6. Senna 17.2 mg PO QHS
7. Ibuprofen 200 mg PO Q8H
8. Atorvastatin 40 mg PO QPM
9. Furosemide 30 mg PO DAILY
Discharge Medications:
1. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q3H:PRN
pain, shortness of breath
RX *hydromorphone 1 mg/mL ___ mg by mouth Q3H Refills:*0
2. Hyoscyamine 0.125-0.25 mg SL Q4H:PRN excess secretions
RX *hyoscyamine sulfate 0.125 mg ___ tablet(s) sublingually
every four (4) hours Disp #*30 Tablet Refills:*0
3. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN SOB
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
IH every six (6) hours Disp #*1 Ampule Refills:*0
4. LORazepam 0.5 mg IV Q4H:PRN anxiety
RX *lorazepam 2 mg/mL 0.5 (One half) mg IV every four (4) hours
Disp #*2 Vial Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute hypoxic respiratory failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with SOB *** WARNING *** Multiple patients with same
last name!// SOB
TECHNIQUE: AP chest
COMPARISON: None.
FINDINGS:
Lung volumes are slightly low. Vascular congestion and diffuse bilateral
airspace opacities, most prominent in the right upper lobe, which could
reflect severe pulmonary edema although ARDS and multifocal pneumonia could
have a similar appearance. Cardiomediastinal silhouette is within normal
limits. No large pleural effusion or pneumothorax.
IMPRESSION:
Diffuse bilateral opacities which could reflect severe pulmonary edema, ARDS,
or multifocal pneumonia
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Dyspnea
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: u/a
level of acuity: 1.0 | ___ with CVA ___, R weakness and expressive aphasia), DM2,
CKD, HF presents from ___ with dyspnea progressing to
respiratory failure. She had been receiving increasing doses of
furosemide for increased ___ edema. On ___ she became suddenly
more dyspneic after breakfast and was BIBEMS to the ED. She was
altered, tachypneic, and after confirming DNR/DNI, placed on NRB
with SpO2 persistently 80%s. Treated with furosemide,
vanc/cefe/flagyl. TnT elevated and cardiology consulted;
recommend medical management/no revascularization. She was
trialed on BiPAP and vomited; NRB was replaced.
# Acute hypoxic respiratory failure
With data and history to suggest aspiration perhaps progressing
to PNA, also with evidence of cardiogenic pulmonary edema. She
was diuresed aggresively and treated with antibiotics, but
ultiamtely failed to improve. The decision was made to
transition to comfort based care.
# NSTEMI
Newly recognized LBBB, TnT elevation, evidence of acute
decompensated heart failure; given patient frailty cardiology
has recommended no PCI. Managed. medically with ASA/Plavix,
heparin x48hr, diuresis. The decision was made to transition to
comfort based care.
# ___ with anion gap metabolic acidosis and hyperkalemia
Presumed cardiorenal but ATN I/s/o sepsis also possible.
Diuresing to remove volume and K. HD not within goals.
# Goals of care
Based on discussions with HCP/ patient/ patient family, goal is
to focus on patient comfort given ongoing tachypnea and work of
breathing despite attempt to treat pulmonary edema/infection
with diuretics and antibiotics.
CODE: DNR/DNI
CONTACT: ___ ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
DOE, lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a history of
hyperlipidemia who presented to the ED with DOE and dizziness
found to have symptomatic sinus tachycardia now admitted to ___
for further management.
The patient states that she was in her usual state of health
until the morning of ___. Specifically, she states that she was
walking to work this morning from her car when she felt very
short of breath. She is usually active at baseline and able to
use a stationary bike at the gym for ___ minutes prior to
feeling short of breath so this was abnormal for her. She sat
down and rested and her symptoms improved. She denied any
associated chest pain, palpitations, nausea, neck or jaw pain.
She then went to the gym to meet her husband where she again
felt
extremely SOB after walking to the exercise machine. She checked
her pulse and it was 130. She then asked the people at the
facility to check her blood pressure and she was notably
hypertensive with SBP 180. She and her husband decided to leave
and while en route to the car, she felt lightheaded, sweaty and
like she was going to syncopize. Therefore, she decided to ___
to the ED for further management.
Past Medical History:
-Hyperlipidemia
-Morbid obesity
-Spinal stenosis
-Depression
Social History:
___
Family History:
Brother: GBM
Mother: CAD, PVD, HTN, ___
Maternal Grandmother: ___
___ Grandmother: ___
Physical ___:
Admission Physical Exam
VS: 98.3PO 134/88 117 18 96 RA
GENERAL: Comfortable, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: Tachycardic, regular, +S1/S2, no murmurs, gallops, or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam
___ 98.2 PO 137/86 L Lying 59 18 95 RA
GENERAL: Comfortable, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: Bradycardic, regular, +S1/S2, no murmurs, gallops, or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs
___ 05:45PM BLOOD WBC-10.3* RBC-4.93 Hgb-14.6 Hct-44.3
MCV-90 MCH-29.6 MCHC-33.0 RDW-15.3 RDWSD-50.2* Plt ___
___ 05:45PM BLOOD Neuts-66.5 ___ Monos-9.7 Eos-0.7*
Baso-0.9 Im ___ AbsNeut-6.85* AbsLymp-2.26 AbsMono-1.00*
AbsEos-0.07 AbsBaso-0.09*
___ 05:45PM BLOOD ___ PTT-33.7 ___
___ 05:45PM BLOOD Glucose-127* UreaN-12 Creat-0.9 Na-137
K-4.5 Cl-97 HCO3-24 AnGap-16
___ 05:45PM BLOOD proBNP-1103*
___ 05:45PM BLOOD cTropnT-<0.01
___ 06:09AM BLOOD Calcium-10.2 Phos-2.9 Mg-2.1
___ 08:56PM BLOOD D-Dimer-471
___ 06:09AM BLOOD %HbA1c-6.7* eAG-146*
___ 05:45PM BLOOD TSH-1.8
___ 05:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:45PM URINE Color-Straw Appear-Clear Sp ___
Pertinent Findings
___ 06:09AM BLOOD CK-MB-2 cTropnT-<0.01
___ Cardiovascular ECHO
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF=55-60%). There is no ventricular septal defect.
Right ventricular chamber size is normal with borderline normal
free wall function. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. An
eccentric jet of Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion along with prominent anterior fat pad.
There are no echocardiographic signs of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global systolic function (image quality somewhat limited,
but no regional dysfunction seen). Low normal right ventricular
systolic function. Mild eccentric mitral regurgitation. Atrial
flutter.
___ Imaging CHEST (PA & LAT)
No acute cardiopulmonary abnormality.
Discharge Labs
___ 06:30AM BLOOD WBC-6.5 RBC-3.91 Hgb-11.6 Hct-36.0 MCV-92
MCH-29.7 MCHC-32.2 RDW-15.3 RDWSD-51.7* Plt ___
___ 06:30AM BLOOD ___ PTT-26.7 ___
___ 06:30AM BLOOD Glucose-110* UreaN-22* Creat-0.9 Na-136
K-4.7 Cl-98 HCO3-28 AnGap-10
___ 06:30AM BLOOD Calcium-10.3 Phos-3.6 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QAM
2. ClonazePAM 0.5 mg PO BID:PRN anxiety
3. Citalopram 20 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Fish Oil (Omega 3) ___ mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Aspirin 81 mg PO QHS
9. BuPROPion XL (Once Daily) 300 mg PO DAILY
10. Pyridoxine 2 mg PO DAILY
11. FoLIC Acid ___ mcg PO DAILY
12. melatonin 2.5 mg oral QHS
13. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral QHS
14. acai berry extract ___ mg oral QAM
Discharge Medications:
1. Apixaban 5 mg PO BID
This was called into your pharmacy and your mail-ordered
pharmacy.
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*15 Tablet Refills:*0
3. acai berry extract ___ mg oral QAM
4. Atorvastatin 10 mg PO QAM
5. BuPROPion XL (Once Daily) 300 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. ClonazePAM 0.5 mg PO BID:PRN anxiety
8. Cyanocobalamin 1000 mcg PO DAILY
9. Fish Oil (Omega 3) ___ mg PO DAILY
10. FoLIC Acid ___ mcg PO DAILY
11. melatonin 2.5 mg oral QHS
12. Multivitamins 1 TAB PO DAILY
13. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral QHS
14. Pyridoxine 2 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
================
Atrial flutter
SECONDARY DIAGNOSES
================
Dyslipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with dyspnea on exertion// dyspnea on
exertion
TECHNIQUE: PA and lateral views
COMPARISON: None
FINDINGS:
The cardiomediastinal silhouette is within normal limits. There is no
pneumothorax or pleural effusion. The lungs are clear.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Lightheaded
Diagnosed with Paroxysmal atrial fibrillation
temperature: 98.1
heartrate: 124.0
resprate: 20.0
o2sat: 99.0
sbp: 172.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY
=================
Ms. ___ is a ___ year old female with PMH of
dyslipidemia, obesity, and depression who presented shortness of
breath and lightheadedness found to have atrial flutter. She was
started on anticoagulation and beta blocker for rate control.
Patient self-converted to sinus prior to TEE with cardioversion.
ACUTE ISSUES:
==============
#New onset atrial flutter: Patient presented with acute onset
dyspnea on exertion and lightheadedness with serial EKGs in the
ED revealing sinus tachycardia and afib with RVR which she
received metop IV x2 and PO metop. Floor tele confirmed atrial
flutter with hemodynamic stability. Trigger of A. flutter is
unclear: trop neg x2, TSH 1.8, ECHO no wall motion
abnormalities, A1C 6.7%, no infectious symptoms, no new
medications, wnl CXR, wnl D-dimer, and no hx of OSA. Recent
stress in ___ without evidence of ischemia. Patient was
started on metoprolol and apixiban with plans for TEE and
cardioversion, but she self-converted to sinus prior to
procedure.
CHRONIC ISSUES:
================
#Dyslipidemia: She was continued on home statin. Aspirin 81 mg
was discontinued to decrease bleeding risk as patient was
started on apixiban. Her ASCVD risk was low.
#Depression: Patient was continued on home wellbutrin and
citalopram. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Syncopal episode with fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with dementia, aortic stenosis status
post AVR, AV node dysfunction status post pacemaker placement,
systolic heart failure (LVEF 35-40% in ___, atrial
fibrillation on warfarin, and gait disorder requiring a walker
at baseline who presents following a syncopal episode with
unwitnessed fall at ___, where she is a permanent
resident. She reportedly was in her usual state of health until
the morning of admission, when she got up from the toilet and
felt lightheaded, losing consciousness, and falling with
headstrike. She regained consciousness rapidly, ambulating to a
nearby nursing station to report her fall. She was seen most
recently by her primary care physician ___ on
___ for follow-up of right foot hematoma found in the ED on
___ after she developed pain, swelling, and erythema at that
site. She also recently completed an approximately 12-day course
of doxycycline for possible right lower extremity cellulitis
(day 1 = ___, though on ___ it was felt that residual
erythema reflected underlying hematoma, and antibiotics were
discontinued.
In the ED, initial vital signs were as follows: 98.2 70 151/98
16 97% RA. Admission labs were notable for BUN/Cr of ___, INR
of 3, and negative urinalysis. EKG was interpreted as paced
rhythm without acute ischemic EKG changes. Chest XR was negative
for acute cardiopulmonary process. Right knee XR was negative
for fracture or dislocation, as was pelvic XR. While noncontrast
head CT was negative for acute intracranial abnormality, small
right frontal scalp hematoma was noted without underlying
fracture. Noncontrast cervical spine CT was negative for
fracture or malalignment. She received acetaminophen 650mg.
Vital signs prior to transfer: 97.4 76 134/76 24 96% RA.
On the floor, she is comfortable, endorsing only mild right
pleuritic pain.
Past Medical History:
Hypothyroidism
Hypertension
Depression/anxiety
Aortic valvular disease status post AVR on warfarin
AV node dysfunction status post dual chamber pacemaker placement
Atrial fibrillation
Myelodysplastic syndrome
Chronic kidney injury
History of hyponatremia
Gait disorder
Memory loss
History of bronchitis
Social History:
___
Family History:
Parents are both deceased (mother at a young age, father had
"heart problems"). Her siblings did not have medical problems
at an early age. She has 2 children, ages ___ and ___, one of whom
had breast cancer.
Physical Exam:
On admission:
Vitals: 97.8 138/80 72 18 94%RA
Gen: Comfortable, calm, and interactive. AOx3.
Cardiac: RRR, II/VI systolic murmur.
Chest: Mild bibasilar crackles. No wheezes.
Abd: Soft, non-distended, non-tender.
Ext: ___ edema with no erythema. L calf/ankle diameter > R
calf/ankle diamter. ___ hematoma stable, no increased erythema
(well demarcated). R knee moderately painful with passive and
active flexion/extension, non-tender on palpation and no
effusion.
Pulses: Pedal pulses intact bilaterally.
Skin: No ulcerations noted.
Neuro: CNs grossly intact. Motor function grossly normal, moving
all four extremities without difficulty. Sensation grossly
intact.
At discharge:
Vitals: 97.8 138/80 (only one value o/n) 72 18 94%RA
Gen: Awoke from sleeping. Comfortable, calm, and interactive.
AOx3.
Cardiac: RRR, II/VI systolic murmur.
Chest: Mild bibasilar crackles. No wheezes.
Abd: Soft, non-distended, non-tender.
Ext: ___ edema with no erythema. L calf/ankle diameter > R
calf/ankle diamter. ___ hematoma stable, no increased erythema
(well demarcated). R knee moderately painful with passive and
active flexion/extension, non-tender on palpation and no
effusion.
Pulses: Pedal pulses intact bilaterally.
Neuro: CNs grossly intact. Motor function grossly normal, moving
all four extremities without difficulty. Sensation grossly
intact.
Pertinent Results:
On admission:
___ 06:00AM BLOOD WBC-10.5 RBC-5.32 Hgb-14.8 Hct-47.5
MCV-89 MCH-27.8 MCHC-31.2 RDW-15.8* Plt ___
___ 06:00AM BLOOD Neuts-37* Bands-1 ___ Monos-23*
Eos-0 Baso-0 Atyps-2* ___ Myelos-0
___ 06:00AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:00AM BLOOD ___ PTT-43.5* ___
___ 06:00AM BLOOD Glucose-83 UreaN-27* Creat-1.3* Na-138
K-4.4 Cl-101 HCO3-28 AnGap-13
___ 06:00AM BLOOD ALT-13 AST-36 CK(CPK)-61 AlkPhos-95
TotBili-0.6
___ 06:00AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:00AM BLOOD Calcium-10.2 Phos-3.9 Mg-2.1
At discharge:
___ 06:30AM BLOOD WBC-13.5* RBC-5.03 Hgb-14.1 Hct-44.3
MCV-88 MCH-28.0 MCHC-31.7 RDW-16.2* Plt ___
___ 06:30AM BLOOD ___ PTT-39.5* ___
___ 06:30AM BLOOD Glucose-82 UreaN-19 Creat-1.1 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
___ 06:30AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.2
In the interim:
___ 06:35AM BLOOD Vanco-11.4
___ 06:40AM BLOOD ___ PTT-46.8* ___
___ 06:40AM BLOOD ___ PTT-46.5* ___
___ 06:35AM BLOOD ___ PTT-42.8* ___
Microbiology:
Urine culture (___): <10,000 organisms/ml.
Imaging:
EKG (___):
Ventricular paced rhythm. Atrial mechanism likely atrial
fibrillation. No
previous tracing available for comparison.
___
___
Cervical spine CT (___):
No acute cervical spine fracture or dislocation.
Head CT (___):
There is a lucency in the right frontal bone that may represent
a linear fracture or vascular channel. Although this is near the
frontal scalp swelling, but it is not directly associated with
the scalp finding.
Right knee XR (___):
No fracture or dislocation.
Pelvic XR (___):
No fracture or dislocation. If there is continued concern for a
fracture, consider an MRI.
Portable CXR (___):
No acute cardiopulmonary abnormality. Elevation of the right
hemidiaphragm of unclear chronicity.
Left lower extremity venous ultrasound (___):
No evidence of DVT.
Right foot/ankle XR (___):
No fracture identified. If there is high concern for a
nondisplaced fracture or soft tissue injury, MRI could be
performed.
Right foot ultrasound (___):
Stable complex collection in the anterior right foot suggesting
the presence of a liquified hematoma.
Left foot/ankle XR (___):
No signs for acute fractures.
Right knee XR (___):
No fracture or significant degenerative change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN severe pain
7. RISperidone 0.25 mg PO HS
8. Warfarin 3 mg PO DAILY16
9. Acetaminophen 650 mg PO Q4H
10. Carbamide Peroxide 6.5% 2 DROP AD BID
11. Docusate Sodium 100 mg PO BID
12. lactobacillus acidophilus 1 capsule oral BID
13. Multivitamins 1 TAB PO DAILY
14. Senna 8.6 mg PO DAILY
Discharge Medications:
Acetaminophen 1000 mg PO/NG TID R knee pain
Multivitamins 1 TAB PO/NG DAILY
Calcitriol 0.25 mcg PO DAILY
Polyethylene Glycol 17 g PO/NG DAILY:PRN Constipation
Carbamide Peroxide 6.5% 2 DROP AD BID
RISperidone 0.25 mg PO HS
Docusate Sodium 100 mg PO/NG BID ___ hold for loose stools
Escitalopram Oxalate 10 mg PO/NG DAILY
Senna 8.6 mg PO/NG BID ___ hold for loose stools
Gabapentin 300 mg PO/NG TID
Vancomycin 1000 mg IV Q 24H
Levothyroxine Sodium 125 mcg PO/NG DAILY
Warfarin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Syncope
Right lower extremity cellulitis
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
HISTORY: Status post fall, evaluate for injury.
COMPARISON: None available.
TECHNIQUE: Frontal pelvis radiograph, two views.
FINDINGS: There is no fracture, dislocation or periarticular erosion. There
are mild degenerative changes of bilateral hip joints as well as of the lower
visualized lumbar spine. There is no soft tissue calcification or radiopaque
foreign body.
IMPRESSION: No fracture or dislocation. If there is continued concern for a
fracture, consider an MRI.
Radiology Report
HISTORY: Dizziness.
COMPARISON: None available.
TECHNIQUE: Frontal chest radiograph, single view.
FINDINGS: Evaluation is somewhat limited by moderate-to-severe S-shaped
scoliosis with dextroscoliosis of the thoracic spine and levoscoliosis of the
lower thoracolumbar spine. Heart size is at least moderately enlarged with
tortuosity of the thoracic aorta. There is a left anterior chest wall
dual-chamber pacer in place as well as aortic valve replacement. Elevation of
the right hemidiaphragm is of unclear chronicity given lack of comparison.
Lungs are grossly clear without confluent consolidation. Pleural surfaces are
clear without large effusion or pneumothorax. There is moderate colonic fecal
load.
IMPRESSION: No acute cardiopulmonary abnormality. Elevation of the right
hemidiaphragm of unclear chronicity.
Radiology Report
HISTORY: Fall, head strike, with confusion.
COMPARISON: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone reformats.
DLP: 891.93 mGy-cm.
CTDIvol: 54.53 mGy.
FINDINGS:
CT HEAD WITHOUT CONTRAST: There is no evidence hemorrhage, edema, mass effect
or infarct. Mild prominence of the ventricles and sulci are suggestive of
age-related involutional change. The basal cisterns are patent and there is
preservation of gray-white matter differentiation. Atherosclerotic
calcifications are noted in bilateral carotid siphons. The orbits are
unremarkable. There is a small right frontal scalp hematoma without
underlying fracture. There is minimal mucosal wall thickening in the left
frontoethmoidal recess. The remainder of the visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality. Small right frontal scalp
hematoma without underlying fracture.
NOTE ADDED AT ATTENDING REVIEW: There is a lucency in the right frontal bone
that may represent a linear fracture or vascular channel. Although this is
near the frontal scalp swelling, but it is not directly associated with the
scalp finding.
Radiology Report
HISTORY: Status post fall and head strike with some confusion.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained of the cervical spine
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 779.92 mGy-cm.
CTDIvol: 36.74 mGy.
FINDINGS:
CT CERVICAL SPINE WITHOUT CONTRAST: There is no cervical spine fracture or
malalignment. The prevertebral soft tissues are unremarkable. There are
overall mild degenerative changes of the cervical spine with multilevel disc
space narrowing, most prominent at C3-4. Mild multilevel uncovertebral and
facet joint hypertrophy minimally narrows the neural foramina. Though CT
resolution of the thecal sac is limited, the contours appear relatively well
preserved. The imaged lung apices are clear.
IMPRESSION: No acute cervical spine fracture or dislocation.
Radiology Report
HISTORY: Status post fall with right knee pain.
COMPARISON: None available.
TECHNIQUE: Right knee radiograph, three views.
FINDINGS: There is no fracture, dislocation or periarticular erosion. There
is no significant degenerative change. There is no joint effusion. There is
no soft tissue calcification or radiopaque foreign body.
IMPRESSION: No fracture or dislocation.
Radiology Report
HISTORY: Left leg swelling. Rule out DVT.
COMPARISON: None.
FINDINGS:
Sonographic assessment of the deep veins of the left lower extremity was
performed. A normal anechoic compressible vessel lumen was seen throughout
with normal phasicity and flow augmentation. Normal flow was seen throughout
on color Doppler imaging.
The right common femoral vein was also unremarkable.
IMPRESSION:
No evidence of DVT.
Radiology Report
STUDY: Right ankle, ___.
CLINICAL HISTORY: ___ woman with persistent right ankle pain.
Evaluate for occult fracture.
FINDINGS:
Right ankle, three views and right foot, three views demonstrate no signs for
acute fractures or dislocations. The ankle mortise is relatively preserved.
There is some minimal spurring involving the medial malleolus. There is no
significant ankle joint effusion. Mineralization is slightly decreased.
Focused imaging of the foot demonstrates some slight demineralization.
Subchondral cyst is seen at the base of the fifth proximal phalanx. There are
no definite erosions identified. The Lisfranc interval appears relatively
preserved. The base of the fifth metatarsal appears normal.
IMPRESSION:
No fracture identified. If there is high concern for a nondisplaced fracture
or soft tissue injury, MRI could be performed.
Radiology Report
HISTORY: ___ female with persistent right soft tissue infection.
COMPARISON: Right foot ultrasound ___.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right foot. There is an oval avascular complex fluid collection which
measures 1.9 x 0.9 x 3.0 cm and. (Previously this collection measured 0.8 x
1.8 x 2.8 cm.) The appearance of this collection is similar to the ultrasound
of ___ however on today's ultrasound the contents has a more
liquified appearance. No new soft tissue mass is visualized and no additional
fluid collection is seen.
IMPRESSION:
Stable complex collection in the anterior right foot suggesting the presence
of a liquified hematoma.
Radiology Report
STUDY: Left foot, ___.
CLINICAL HISTORY: ___ woman with persistent left foot pain. Evaluate
for occult fracture.
FINDINGS: No prior studies of the left ankle available for direct comparison.
There is medial and lateral malleolar soft tissue swelling. No displaced
fractures are identified. There is some generalized demineralization
throughout the foot and ankle. The ankle mortise is preserved. No bony
erosions are seen. There are some degenerative changes of several DIP and PIP
joints.
IMPRESSION:
No signs for acute fractures.
Radiology Report
INDICATION: Knee pain and right foot cellulitis.
COMPARISON: ___.
THREE VIEWS, RIGHT KNEE: There is no acute fracture or dislocation. The
joint spaces are preserved. There is no effusion. No suspicious lytic or
sclerotic lesion. The bones are demineralized.
IMPRESSION: No fracture or significant degenerative change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Syncope
Diagnosed with SYNCOPE AND COLLAPSE, CONTUSION OF KNEE, UNSPECIFIED FALL, SENILE DEMENTIA UNCOMP
temperature: 98.2
heartrate: 70.0
resprate: 16.0
o2sat: 97.0
sbp: 151.0
dbp: 98.0
level of pain: 4
level of acuity: 2.0 | Ms. ___ is an ___ with dementia, aortic stenosis status
post AVR, AV node dysfunction status post pacemaker placement,
systolic heart failure (LVEF 35-40% in ___, atrial
fibrillation on warfarin, and gait disorder requiring a walker
at baseline who presents following a syncopal episode with
unwitnessed fall at ___, where she is a permanent
resident. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Latex / Norvasc / Sulfasalazine / doxazosin
Attending: ___.
Chief Complaint:
left leg redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Dr. ___ is a ___ year old male with a PMH of hypertension, BPH,
and carotid stenosis, who presents with left leg redness.
Patient reports that on the evening of ___ he hit his shin.
By the next day he noted surrounding redness, and later that
night he had a fever. After two days the redness had rapidly
spread up his leg and into his scrotum. He reports no fever
other
than ___ night and no pain in the leg, as well as no
numbness. Notes he was on vacation at ___ when this
occurred, but that they were mostly visiting the mountains and
he
did not swim after he bumped his leg.
He notes that he has had ___ bouts of cellulitis over past few
years, one of them around the same area. He was hospitalized in
___ for cellulitis from Shewanella algea.
On review of records, patient has no recent hospitalizations at
___. He is followed in ___ clinic for MGUS, which has
remained low-level. He has also been noted to have borderline
thrombocytopenia
In the ED:
Initial vital signs were notable for: T 97.1, HR 81, BP 157/76,
RR 16, 95% RA
Exam notable for: Lesion on L lateral leg with profuse erythema
extending from the medial ankle to the groin. Mild edema
unilaterally in L leg.
Labs were notable for:
- CBC: WBC 13.7 (87%n), hgb 16.2, plt 157
- Lytes:
139 / 104 / 37 AGap=16
-------------- 126
3.6 \ 19 \ 1.7
- LFTs: AST: 29 ALT: 31 AP: 47 Tbili: 0.6 Alb: 3.7 LDH: 187
- CK: 157
- lactate 0.8
- A1c 5.6%
Studies performed include: CT left lower extremity: No evidence
of necrotizing fasciitis. Extensive soft tissue stranding is
consistent with clinical history of cellulitis.
Patient was given: clindamycin, ceftriaxone, vancomycin,
CefePIME, doxycycline. Also received IVF, gabapentin, losartan,
finasteride, atorvastatin
Consults: Surgery was consulted, who felt that there was no
evidence of nec fasc and no surgically drainable abscess.
Recommended admission to medicine for IV antibiotics. ID was
contacted, and recommended vancomycin, clindamycin, CefePIME,
and
doxycycline
Vitals on transfer: T 97.9, HR 68, BP 166/84, RR 16, 94% RA
Upon arrival to the floor, he notes that he has been up all
night
because he was given an antibiotic at 2 in the morning. He has
also developed new diarrhea. He does feel much stronger
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- arthritis
- carotid stenosis
- GI bleed
- hypercholesterolemia
- hypertension
- left ventricular hypertrophy
- polycythemia
- BPH
- actinic keratosis
- IgA-lambda MGUS
- spindle cell tumor
- Osteoporosis with partial T5 and T6 and complete T7
compression fractures.
- Gastrointestinal bleeding in ___ of uncertain source.
- Benign retroperitoneal neoplasm without change in size in
___, previously evaluated by Dr. ___.
- Left lower pole thyroid nodule, benign by FNA and ultrasound
exams.
- ___: s/p open reduction internal fixation, right distal
humerus
Social History:
___
Family History:
father - required ___
mother - presumed lung cancer
brother - colon cancer (___)
Physical Exam:
Admission exam:
VITALS: T 98.0, HR 64, BP 138/69, RR 18, 96% Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, 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
MSK: LLE with dark erythema over most of shin, and spreading up
inner thigh to groin. Warm to palpation, no pain with palpation.
Pulse intact. Redness is decreased from previously marked line
SKIN: LLE erythema as above
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:
GENERAL: NAD laying in chair
EYES: EOMI, anicteric sclera
ENT: MMM
CV: RR, no m/r/g
RESP: CTAB w/ nl WOB
ABD: +moderate gaseous distention, not tender to percussion or
firm palpation throughout, BS+
SKIN:
-LLE with bright erythema over most of shin. Warm to palpation.
Not tender. Overall extent of erythema is significantly
decreased from previously
marked line and compared with yesterday.
-Photos placed in OMR for today
-2+ pitting edema of Left ankle
-Has 2 small ulcers of the skin on the anterior lower leg that
appear to be traumatic in etiology (he reports this is where he
bumped his leg) which are healing
-Left foot DP pulse is 2+.
MSK: aROM of left ankle and left knee are not painful
NEURO: awake, alert, conversant with clear speech; has normal
proprioception of toes of left foot and light touch sensation is
intact
PSYCH: calm, cooperative
Pertinent Results:
Admission labs:
===============
___ 09:00PM BLOOD WBC-13.7* RBC-4.96 Hgb-16.2 Hct-47.4
MCV-96 MCH-32.7* MCHC-34.2 RDW-13.4 RDWSD-47.1* Plt ___
___ 09:00PM BLOOD Neuts-87.0* Lymphs-5.4* Monos-6.9
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.88* AbsLymp-0.74*
AbsMono-0.95* AbsEos-0.02* AbsBaso-0.03
___ 09:00PM BLOOD Glucose-126* UreaN-37* Creat-1.7* Na-139
K-3.6 Cl-104 HCO3-19* AnGap-16
___ 06:01AM BLOOD CRP-206.6*
___ 09:09PM BLOOD Lactate-0.8
.
.
Notable Labs since admission:
===============
___ CRP: 206.6
___ ESR: "Test not performed. Quantity not sufficient."
___ CRP: 87.7
.
.
MICRO:
=======
- ___ BCx: NGTD
- ___ BCx: NGTD
- ___ BCx: NGTD
- ___ BCx: NGTD
.
.
IMAGING:
==========
___ CT left lower ext CT scan:
No evidence of necrotizing fasciitis. Extensive soft tissue
stranding is consistent with clinical history of cellulitis.
___ LLE venous duplex u/s: No evidence of deep venous
thrombosis in the left lower extremity veins.
.
.
Discharge labs:
=================
___ 07:08AM BLOOD WBC-8.3 RBC-4.94 Hgb-15.8 Hct-46.9 MCV-95
MCH-32.0 MCHC-33.7 RDW-13.5 RDWSD-47.4* Plt ___
___ 07:08AM BLOOD Glucose-96 UreaN-20 Creat-1.0 Na-142
K-3.7 Cl-104 HCO3-24 AnGap-14
___ 07:08AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.8
___ 06:16AM BLOOD %HbA1c-5.6 eAG-114
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. tadalafil 2.5 mg oral DAILY
3. LORazepam 0.5 mg PO BID:PRN anxiety, insomnia
4. Gabapentin 300 mg PO QHS pain
5. Atorvastatin 40 mg PO QPM
6. Chlorthalidone 25 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Denosumab (Prolia) 60 mg SC TWICE PER YEAR
___. Ranitidine 150 mg PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Hydrocerin 1 Appl TP TID
3. Levofloxacin 500 mg PO Q24H
Last day will be ___
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
4. Linezolid ___ mg PO Q12H
Last day will be ___
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
5. Ranitidine 150 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Chlorthalidone 25 mg PO DAILY
8. Denosumab (Prolia) 60 mg SC TWICE PER YEAR
9. Finasteride 5 mg PO DAILY
10. Gabapentin 300 mg PO QHS pain
11. LORazepam 0.5 mg PO BID:PRN anxiety, insomnia
12. Losartan Potassium 100 mg PO DAILY
13. Spironolactone 25 mg PO DAILY
14. tadalafil 2.5 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis (resolved)
LLE cellulitis/erysipelas with lymphangitic spread
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT left lower extremity without contrastQ61L
INDICATION: ___ year old man with ___, rapidly expanding cellulitis to thigh//
L leg necrotizing fasciitis?
TECHNIQUE: Axial CT of the left lower extremity without contrast. Scout
films and coronal/sagittal reformats were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 12.5 s, 98.1 cm; CTDIvol = 22.8 mGy (Body) DLP =
2,237.9 mGy-cm.
Total DLP (Body) = 2,238 mGy-cm.
COMPARISON: None.
FINDINGS:
Soft tissue: There is no gas tracking along the fascial planes to suggest
necrotizing fasciitis. There is extensive soft tissue stranding, most notably
along the anterior and lateral thigh, posterior knee, and circumferentially
along the calf, consistent with clinical history of cellulitis.
Vascular: There are extensive vascular calcifications.
Bones: There is no evidence of fracture or concerning lesions in the
visualized portions of left femur, tibia, and fibula. There are moderate
degenerative changes to the knee. There is minimal to no knee joint effusion.
Pelvis: There is colonic diverticulosis. There may be a hydrocele. There is
prominence of the left inguinal nodes, likely reactive.
IMPRESSION:
No soft tissue gas. Extensive soft tissue stranding may be consistent with
clinical history of cellulitis.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with recent complicated cellulitis of distal LLE
with lymphangitic spread to proximal LLE. Improving with abx but still with
pronounced pitting edema of LLE. Want to assess for underlying/provoked DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler 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.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, L Leg Redness
Diagnosed with Cellulitis of left lower limb
temperature: 97.1
heartrate: 81.0
resprate: 16.0
o2sat: 95.0
sbp: 157.0
dbp: 76.0
level of pain: 2
level of acuity: 3.0 | Had sepsis from LLE erysipelas/cellulitis w/ lymphangitic
spread. ACS was consulted in ED and after CT revealed no fluid
collections nor evidence of necrotizing skin infection, they
signed off. ID team was consulted because of the onset while he
was in a tropical location (___) and because of rapid
spread and hx of prior cellulitis of leg. Was treated with
vancomycin, cefepime, and PO doxycycline while inpatient and he
improved. BCx all remain NGTD. Discharged on linezolid ___ BID
plus levofloxacin 500 daily to complete total of 10 days of abx
per ID team recs. Last dose of abx will be ___. We
counseled him repeatedly to keep his leg elevated above the
level of his heart when not ambulating. We have asked him to be
seen by PCP ___ ___ days to evaluate for interval resolution of
the skin infection.
He had some ___ in setting of sepsis which resolved with fluid
resuscitation. His home antihypertensives were held initially in
setting of sepsis and ___ and were gradually resumed. He had
some mild confusion, consistent with toxic encephalopathy from
sepsis, early in his hospital course that resolved with
treatment of the underlying infection. He also had some mild
antibiotic-induced diarrhea early in his hospital course, which
resolved without issue.
.
.
.
.
.
Time in care: > 45 minutes in discharge-related activities
today. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg wounds
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of venous stasis, seizure d/o presents w/ bilateral
lower extremity wounds. Patient states that he has had these
wound for approximately ___ years but over the last several weeks
the wounds on the left leg has been expanding and he has had
increased pain. The patient is followed at the ___ but does not
seem to have regular wound care. He denies any fevers, chills,
chest pain, shortness of breath, abdominal pain, nausea. Denies
any weakness or numbness. Patient is homeless and lives in a
shelter.
In the ED, initial vs were: 99 80 148/76 18 100% ra. Pt
initially presented with poor hygiene, malodorousness, and BLE
ulcers with maggots present. He was taken to decon, showered,
wounds washed with sterile saline and adaptic dressing applied
and legs wrapped in kerlex. Labs were remarkable for normal CBC
and lactate, mild anemia with Hct of 37.2. Blood cultures were
drawn. Patient was given morphine for pain, vanc and cefepime.
On the floor, vs were 99.5, 149/73, 71, 18, 98% on RA. He
reported ___ leg pain worse in the L leg. He also endorses ___
edema. No other complaints. He says the wounds have been open
for ___ weeks. He has not taken any antibiotics, only oxycodone
which he received from the ___. He has been using
paper towels to wrap the wounds.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
Seizure disorder x ___ yrs
Venous stasis
Homelessness
HLD
Social History:
___
Family History:
No known family history of medical problems.
Physical Exam:
Admission Physical Exam:
Vitals: 99.5, 149/73, 71, 18, 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not visualized due to neck fat, 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: b/l lower extremities are diffusely edematous, nonpitting,
and erythematous. Left leg with well demarcated areas of
erythema, induration, and warmth along with shallow large
(largest 5 cm) necrotic areas of purulent ulceration. Right leg
has well demarcated area of erythema and induration but no
ulcers. 2+ distal pulses. Full sensation of feet b/l.
Neuro: CNs intact. Normal strength and tone.
Discharge Physical Exam:
Vitals: 99.1, 134/69, 57, 20, 97% on RA
General: Alert, oriented, no acute distress
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
Ext: b/l lower extremities with bandages in place. R leg has no
areas of ulceration, but diffuse erythema and some areas of
flaking dry skin. L leg looks slightly better today, erythema
less intense, ulcers draining less. 2+ distal pulses.
Pertinent Results:
Admission Labs:
___ 07:43PM BLOOD WBC-10.1 RBC-4.24* Hgb-12.4* Hct-37.2*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.4 Plt ___
___ 07:43PM BLOOD Neuts-71.9* Lymphs-17.5* Monos-6.0
Eos-3.8 Baso-0.8
___ 07:43PM BLOOD Glucose-87 UreaN-12 Creat-0.7 Na-138
K-4.4 Cl-100 HCO3-25 AnGap-17
Pertinent Interval Labs:
___ 08:54AM BLOOD HIV Ab-NEGATIVE
Discharge Labs:
Studies:
___ Bilateral Lower Extremity Ultrasound w/ Doppler: Small
segment partially occlusive thrombus in the right popliteal
vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
Discharge Medications:
1. LeVETiracetam 500 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Aquaphor Ointment 1 Appl TP BID LLE ulcers
4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
5. Enoxaparin Sodium 130 mg SC Q12H Duration: 2 Weeks
RX *enoxaparin 120 mg/0.8 mL 120 mg sc twice a day Disp #*28
Syringe Refills:*0
6. Sarna Lotion 1 Appl TP QID:PRN itchiness
7. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 1 Weeks
Final day of antibiotic is ___.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*30 Tablet Refills:*0
8. Acetaminophen 1000 mg PO Q6H:PRN pain or fever
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Duration:
5 Days
Don't take while driving or drinking alcohol.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours as
needed for pain Disp #*20 Tablet Refills:*0
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Cellulitis, Right leg Deep Venous Thrombosis
Secondary Diagnosis: Chronic venous stasis, seizure d/o
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Lower extremity edema, left greater than right.
COMPARISON: None.
FINDINGS: Grayscale and color Doppler ultrasonography of the bilateral common
femoral veins as well as the bilateral femoral, popliteal, posterior tibial,
and peroneal veins were performed. There is non-occlusive thrombus in the
right popliteal vein. All other imaged vessels demonstrated normal
compressibility, flow, and augmentation.
IMPRESSION: Small segment partially occlusive thrombus in the right popliteal
vein.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with CELLULITIS OF LEG
temperature: 99.0
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 148.0
dbp: 76.0
level of pain: 9
level of acuity: 3.0 | ___ yr old homeless male with chronic venous stasis of the lower
extremities presents with 2 wks of open skin wounds on left leg.
Active issues:
# Cellulitis: Mr. ___ was admitted for venous stasis
ulcers on his left leg, complicated by cellulitis. He was
treated at ___ for cellulitis of these ulcers ___. Here, his
wounds initially contained maggots. His wounds were thoroughly
washed, debrided, and dressed. He was started on iv vancomycin
and transitioned to po Bactrim DS a few days later (2 tablets
BID. End date = ___. He was discharged to ___
___ for further care.
# New R popliteal DVT: A new DVT was found by ultrasound in his
right leg. This is his second unprovoked DVT (previously in left
leg in ___, however given that there was some evidence of DVT
on prior studies, it is unclear if it was acute or chronic. He
was started on lovenox. Social situation makes warfarin
unfeasible (meds getting stolen, non-compliance with keppra due
to belief that it is causing his ulcers, etc).
Chronic issues:
# Anemia: Normocytic, normochromic. No s/s blood loss. Likely
due to poor diet and/or chronic inflammation. Will defer workup
to outpatient providers.
# Seizure disorder: continue keppra 500mg BID. Patient continues
to refuse nighttime dose due to belief that it is causing his
ulcers.
# HLD: continue home simvastatin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / cephalexin
Attending: ___.
Chief Complaint:
left leg fracture
Major Surgical or Invasive Procedure:
Left tib-fib ORIF ___
History of Present Illness:
___ y/o female with history of CAD s/p stent (___), recent
NSTEMI ___ s/p DES to LAD, CHF, presented on ___ to ___
___ after a mechanical fall at home. She was found to have
distal tib-fib fx and transfered to ___, now s/p open
reduction and internal fixation of left tib-fix fx on ___.
Patient experiencing ___ pain in L anterior patella, but
otherwise no complaints.
Intra op patient had 150cc blood loss. Admission Hgb 9.6, with
drop to 7.9 post op. Received 1U rbc transfusion, with
appropriate bump to 9.7. No episodes of hypotension. Hospital
course has been further complicated by a new O2 requirement of
2L which developed after surgery. She denies any dyspnea or
cough. She does not use oxygen at baseline, but did require 2L
O2 during past hospitalizations as well. She has also been
tachycardic to low 100s since the operation. She is
insulin-dependent at baseline, A1C 9.2%, and has had ___ 300s
during this hospitalization. She has new ___ with creatinine 2.2
post surgery, from baseline 0.9. Also noted to be hyperkalemia
at 5.5, and hypertension to 172/56.
On transfer to Medical team, patient is hemodynamically stable.
eview of Systems, she endorses frequent urinary incontinence for
many years (>60% of the time), worsening abdominal distension
for past 2 months. She denies fevers, chills, nausea, vomiting,
chest pain, dyspnea, cough, abdominal pain, diarrhea,
constipation, dysuria, rash, vision changes.
Past Medical History:
- CAD (s/p 1 stent in ___ at ___
- Hyperlipidemia
- Diabetes
- Hypothyroidism
- Depression
Social History:
___
Family History:
- Father died of MI at ___.
- Brother with history of CABG.
- Mother with lung cancer.
Physical Exam:
ON ADMISSION:
ox3, nad
ncat, no c/s tenderness
lungs ctab
rrr, no mrg
abd obese, soft nt nd
LLE exam:
palpable ___ pulses
SILT over LLE but diffusely diminished which is her baseline ___
DM-incuced neuropathy
distal swelling, erythema and ecchymosis
ankle everted and somewhat shortened
no skin breakdown or laceration
ON DISCHARGE:
97.4 122/52 - 153/55 ___ 18 97%ra
GENERAL: alert and oriented, no acute distress
HEENT: Sclera anicteric, MMM,
NECK: supple, JVP not elevated, no LAD, no thyromegaly
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 S2, II/VI systolic
ejection murmur at aortic area
ABD: obese, soft, non-tender, focal region of distension over
epigastrium and RUQ that is tympanic to percussion, no rebound
tenderness or guarding, no organomegaly, +BS
EXT: Warm, well perfused. Left leg wrapped in bandage and
covered with protective boot. Wrap is clean with no overt
bleeding or blood stain. Underneath wrap, the guaze overlying
the patella is dry with blood stains.
SKIN: no rash
NEURO:AOx3
Pertinent Results:
==========================
ADMISSION LABS:
==========================
___ 03:30PM WBC-9.6 RBC-3.05* HGB-9.6* HCT-28.5* MCV-93
MCH-31.5 MCHC-33.7 RDW-13.2 RDWSD-45.0
___ 03:30PM NEUTS-53.1 ___ MONOS-17.5* EOS-2.1
BASOS-0.6 IM ___ AbsNeut-5.11 AbsLymp-2.51 AbsMono-1.68*
AbsEos-0.20 AbsBaso-0.06
___ 03:30PM PLT COUNT-261
___ 03:30PM ___ PTT-23.8* ___
___ 03:30PM GLUCOSE-70 UREA N-25* CREAT-2.2*# SODIUM-134
POTASSIUM-5.2* CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
___ 09:20PM GLUCOSE-157* UREA N-27* CREAT-2.3* SODIUM-133
POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-24 ANION GAP-19
=======================
PERTINENT LABS:
=======================
___ 03:30PM BLOOD Glucose-70 UreaN-25* Creat-2.2*# Na-134
K-5.2* Cl-96 HCO3-28 AnGap-15
___ 09:20PM BLOOD Glucose-157* UreaN-27* Creat-2.3* Na-133
K-5.7* Cl-96 HCO3-24 AnGap-19
___ 06:50PM BLOOD Glucose-226* UreaN-26* Creat-1.6* Na-135
K-4.9 Cl-99 HCO3-24 AnGap-17
___ 06:34AM BLOOD Glucose-316* UreaN-25* Creat-1.4* Na-133
K-5.5* Cl-95* HCO3-21* AnGap-23*
___ 08:13PM BLOOD Glucose-362* UreaN-22* Creat-1.2* Na-133
K-5.8* Cl-97 HCO3-26 AnGap-16
___ 05:05AM BLOOD Glucose-263* UreaN-22* Creat-1.0 Na-135
K-4.6 Cl-97 HCO3-29 AnGap-14
___ 05:00AM BLOOD Glucose-149* UreaN-28* Creat-1.2* Na-133
K-4.0 Cl-95* HCO3-24 AnGap-18
___ 07:05AM BLOOD Glucose-63* UreaN-29* Creat-0.9 Na-134
K-4.5 Cl-95* HCO3-30 AnGap-14
___ 03:30PM BLOOD WBC-9.6 RBC-3.05* Hgb-9.6* Hct-28.5*
MCV-93 MCH-31.5 MCHC-33.7 RDW-13.2 RDWSD-45.0 Plt ___
___ 06:50PM BLOOD WBC-11.0* RBC-2.57* Hgb-7.9* Hct-24.7*
MCV-96 MCH-30.7 MCHC-32.0 RDW-13.0 RDWSD-45.1 Plt ___
___ 06:34AM BLOOD WBC-11.9* RBC-3.12* Hgb-9.7* Hct-29.7*
MCV-95 MCH-31.1 MCHC-32.7 RDW-13.2 RDWSD-45.2 Plt ___
___ 08:13PM BLOOD WBC-13.5* RBC-2.96* Hgb-9.2* Hct-27.8*
MCV-94 MCH-31.1 MCHC-33.1 RDW-13.1 RDWSD-44.5 Plt ___
___ 05:05AM BLOOD WBC-13.5* RBC-2.83* Hgb-8.8* Hct-26.7*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.3 RDWSD-45.7 Plt ___
___ 01:00PM BLOOD WBC-13.8* RBC-2.95* Hgb-9.1* Hct-28.0*
MCV-95 MCH-30.8 MCHC-32.5 RDW-13.1 RDWSD-45.1 Plt ___
___ 05:00AM BLOOD WBC-9.6 RBC-2.47* Hgb-7.7* Hct-23.3*
MCV-94 MCH-31.2 MCHC-33.0 RDW-13.2 RDWSD-45.4 Plt ___
___ 01:00PM BLOOD WBC-8.7 RBC-2.60* Hgb-8.5* Hct-25.1*
MCV-97 MCH-32.7* MCHC-33.9 RDW-13.4 RDWSD-47.4* Plt ___
___ 07:05AM BLOOD WBC-8.0 RBC-2.55* Hgb-7.9* Hct-23.9*
MCV-94 MCH-31.0 MCHC-33.1 RDW-13.2 RDWSD-45.6 Plt ___
___ 05:05AM BLOOD %HbA1c-8.7* eAG-203*
============================
DISCHARGE LABS:
============================
___ 07:05AM BLOOD WBC-8.0 RBC-2.55* Hgb-7.9* Hct-23.9*
MCV-94 MCH-31.0 MCHC-33.1 RDW-13.2 RDWSD-45.6 Plt ___
___ 07:05AM BLOOD Glucose-63* UreaN-29* Creat-0.9 Na-134
K-4.5 Cl-95* HCO3-30 AnGap-14
___ 07:05AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.1
___ 06:12AM BLOOD WBC-7.2 RBC-2.83* Hgb-8.8* Hct-27.0*
MCV-95 MCH-31.1 MCHC-32.6 RDW-13.3 RDWSD-45.7 Plt ___
___ 06:12AM BLOOD Plt ___
___ 06:12AM BLOOD Glucose-37* UreaN-27* Creat-0.8 Na-138
K-4.3 Cl-96 HCO3-31 AnGap-15
___ 06:12AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.3
========================
STUDIES:
========================
CT HEAD ___: IMPRESSION: No acute intracranial process.
CT LOWER EXTREMITY ___: IMPRESSION:
1. Angulated and displaced distal tibia and distal fibula
fractures as
described above with preservation of the ankle mortise. Soft
tissue
edema/hematoma is noted surrounding the fracture sites.
2. Fracture through the talar dorsal osteophytes.
3. Mild displacement of the anterior tibial tendon into the
fracture site of the tibia, which may represent borderline
entrapment. The tendon is not torn.
XRAY LOWER EXTREMITY ___: IMPRESSION: Acute fracture
involving the distal tibia and fibula without appreciable change
in alignment from prior exam.
CXR ___: IMPRESSION: No acute findings in the chest.
EKG ___: Sinus rhythm with increase in rate as compared to
the previous tracing of ___. The inferolateral ST segment
changes persist without diagnostic interim change. Clinical
correlation is suggested.
___: IMPRESSION: As compared to the previous radiograph,
the patient now shows signs of mild pulmonary edema. Areas of
atelectasis at both the left and the right lung bases are
increasing in extent. No pleural effusions. Moderate
cardiomegaly persists. No evidence of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Paroxetine 40 mg PO DAILY
4. QUEtiapine Fumarate 600 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Ranitidine Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Paroxetine 40 mg PO DAILY
6. QUEtiapine Fumarate 600 mg PO QHS
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN Asthma
RX *albuterol sulfate 90 mcg 1 puff every six (6) hours Disp #*2
Inhaler Refills:*3
8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
9. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*2
10. Atorvastatin 80 mg PO DAILY
11. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC q24h Disp #*20 Syringe
Refills:*1
12. Metoprolol Succinate XL 100 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
14. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 1 tablet(s) by mouth four times a day
Disp #*60 Tablet Refills:*2
15. levemir 34 Units Breakfast
levemir 38 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] qachs Disp
#*200 Strip Refills:*4
RX *blood-glucose meter [FreeStyle Lite Meter] daily Disp #*1
Kit Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 10
Units QID per sliding scale Disp #*5 Syringe Refills:*2
RX *lancets [FreeStyle Lancets] 28 gauge qachs Disp #*2 Package
Refills:*2
RX *insulin detemir [Levemir FlexTouch] 100 unit/mL (3 mL) AS
DIR 34 Units before BKFT; 38 Units before BED; Disp #*5 Syringe
Refills:*2
16. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Left tibia-fibula fracture
2. Anemia
3. Insulin depended diabetes mellitus
4. Acute Kidney Injury
SECONDARY DIAGNOSIS
1. Coronary Artery Disease
2. Hyperkalemia
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 (AP AND LAT)
INDICATION: ___ with fall, preop CXR
COMPARISON: ___
FINDINGS:
AP semi upright and lateral views of the chest provided. Lungs are grossly
clear. No large effusion or pneumothorax. Cardiomediastinal silhouette
appears normal. No acute bony injury.
IMPRESSION:
No acute findings in the chest.
Radiology Report
INDICATION: ___ with l ankle fx s/p reduction // alignment s/p reduction?
COMPARISON: Outside hospital radiographs performed earlier today.
FINDINGS:
5 images provided of the left tibia fibula and left ankle. An overlying
plaster cast is noted. Acute fracture involving the distal tibia is oblique
in orientation and does not involve the articular surface. There is unchanged
alignment with approximately 1 cm medial displacement of the distal fracture
fragment. Also noted, is an oblique fracture of the distal fibula with
approximately 1 cm medial displacement of the distal fracture fragment. The
mortise appears well aligned and symmetric. There is no definite fracture of
the posterior malleolus. No fractures involving the proximal tibia and
fibula.
IMPRESSION:
Acute fracture involving the distal tibia and fibula without appreciable
change in alignment from prior exam.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall // bleed s/p fall
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Sagittal and coronal reformats were also obtained.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of age-related involutional
changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT left lower extremity without contrast
INDICATION: ___ year old woman with L ___ fracture // further definition
___ fracture for preoperative planning. OK to CT from knee to foot.
TECHNIQUE: 2.5 mm axial images were obtained of the left lower extremity from
the distal femur through the foot in soft tissue and bone algorithms. Coronal
sagittal reformats.
DOSE: Total DLP 601.52 mGy cm
COMPARISON: Tibia fibula and ankle radiograph ___
FINDINGS:
There is an obliquely oriented fracture through the distal tibial diaphysis
with dorsal angulation at the fracture site. There is lateral displacement of
the distal aspect of the proximal fracture fragment. The distal tibial
fracture has lateral tilt and dorsal angulation. The tibial plafond remains
in articulation with the talar dome. There is a obliquely oriented fracture
through the distal fibula with approximately 1.3 cm of overriding fracture
fragments. There is dorsal angulation of the proximal aspect of the distal
fibular fracture. There is lateral displacement of the distal aspects of the
proximal fibular fracture the lateral ankle joint space is preserved.
Soft tissue edema seen is seen overlying the medial and anterior aspect of the
lower leg as well as along the anterior lateral aspect of the ankle and foot.
There is a more focal hematoma in the medial plantar aspect of the hindfoot.
Dorsal osteophytes are noted at the talus with suggestion of a fracture
through the dorsal osteophyte (series 401b, image 106 and 107).
The anterior tibial tendon crosses the site of the tibial fracture and is
minimally displaced within the fracture site (series 3, image 174), which may
suggest entrapment. The remaining anterior extensor tendons, medial long
flexor tendons, and peroneal tendons are intact. The Achilles tendon is
intact.
Mild degenerative changes at the first MTP joint.
There are tiny tricompartmental osteophytes in the knee joint. Enthesopathic
changes are seen at the insertion of the quadriceps tendon origin of the
patellar tendon. There is a small suprapatellar joint effusion.
Mild enthesopathic changes at the insertion of the Achilles tendon.
There is diffuse fatty infiltration of the visualized musculature.
Vascular calcifications are noted.
IMPRESSION:
1. Angulated and displaced distal tibia and distal fibula fractures as
described above with preservation of the ankle mortise. Soft tissue
edema/hematoma is noted surrounding the fracture sites.
2. Fracture through the talar dorsal osteophytes.
3. Mild displacement of the anterior tibial tendon into the fracture site of
the tibia, which may represent borderline entrapment. The tendon is not torn.
s
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: ORIF LEFT TIB/FIB
TECHNIQUE: ___ FLUOROSCOPIC VIEWS OF THE LEFT TIBIA AND FIBULA
COMPARISON: LEFT TIBIA AND FIBULA RADIOGRAPHS ___
FINDINGS:
There is interval placement of an intramedullary tibial rod with proximal
distal interlocking screws traversing the previously seen distal tibial
fracture, now with improved alignment. The obliquely oriented mildly
displaced fracture of the distal fibula is again seen. The ankle mortise is
preserved.
IMPRESSION:
Intraoperative images were obtained during open reduction internal fixation of
the distal tibial fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p ORIF, now with new hypoxia post op. //
Effusion, infiltrate?
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient now shows signs of mild
pulmonary edema. Areas of atelectasis at both the left and the right lung
bases are increasing in extent. No pleural effusions. Moderate cardiomegaly
persists. No evidence of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, L Leg injury
Diagnosed with FX ANKLE NOS-CLOSED, UNSPECIFIED FALL
temperature: 97.0
heartrate: 72.0
resprate: 18.0
o2sat: 94.0
sbp: 131.0
dbp: 64.0
level of pain: 5
level of acuity: 3.0 | ___ with hx of NSTEMI s/p DES to LAD (___), IDDM, morbid
obesity, presents after mechanical fall and left tib-fib
fracture.
# LEFT TIB-FIB FRACTURE: She underwent ORIF on ___. EBL
150cc. Post op course was complicated by hyperkalemia, ___, new
O2 requirement, tachycardia, and worsening hyperglycemia.
Transferred to medicine service. She will continue lovenox for 4
weeks post op (end date ___. She will follow up with Dr.
___ in 10 days. Please call to make an appointment.
# Anemia: Secondary to acute blood loss on chronic anemia. Hgb
was 12 in ___, but on this admission was 9.6. EBL 150cc and
acutely dropped to 7.9 post-op. Was transfused 1u pRBCs with
bump in Hgb to 9.7. H/H remained stable throughout admission.
Discharge Hgb 8.8. Restarted on aspirin and plavix for DES.
# ___: Baseline Cr 0.9. On admission, Cr 2.2.
Hyperkalemia peaked at 5.5 (5.8 in hemolyzed sample) requiring
kayexalate. EKG and telemetry did not show any arrhythmias or
findings consistent with hyperkalemia. Her ___ was felt to be
multifactorial including hypoperfusion and immobilization.
Lisinopril held while inpatient, then restarted on ___. Cr
on discharge 0.8. Should have CHEM 10 checked on ___ and
___. Lisinopril should be discontinued if evidence of
rising Cr.
# Hypoxia: She developed a 2L O2 requirement after operation.
CXR showed pulmonary edema and atelectasis. This improved with a
one-time dose of furosemide 20mg IV. Concern for missed cardiac
event in setting of ASA/Plavix for surgery. EKG at baseline.
Patient should be seen by cardiolgoist and ASA/Plavix should not
be stopped at any point without talkint to cardiologist.
# Post-op tachycarida: She had post-operative sinus tachycardia
to low 100s, which improved after re-starting her beta blocker.
# Insulin dependent DM 2: Her blood glucose initially ranged
from 200s-360. A1c 8.9. Patient did not know her home sliding
scale. Glargine increased to 38 units BID from 34 units, with
improving Glucose control. As clinical status improved, insulin
requirement decreased and switched back to 34U BID. Will need
further follow up for diabetes management.
# CAD: hx of NSTEMI in ___ with DES to LAD. ASA and Plavix
initially held for surgery. Restarted on ___ when H/H
stabilized. Continued Metoprolol 50mg BID and then transitioned
to succinate. Lisinopril held for ___. Restarted at time of
discharge.
# Constipation: Post-op constipation likely secondary to opioid
use. No nausea, vomiting. Aggressive bowel reg started.
CHRONIC:
# Depression: She was continued on her home paroxetine 40mg
daily and home quetiapine 600mg qHS.
# Hypothyroidism: She was continued on her home levothyroxine
150mcg daily.
=========================
TRANSITIONAL ISSUES
=========================
# Please check CBC, CHEM 10 on ___ and ___ and inform
MD of any changes to values. If Cr increasing, please stop
lisinopril. If H/H downtrending, please call Dr. ___ PCP
in regards to anticoagulation.
#Please do not stop aspirin or plavix without discussion with
cardiologist. Patient had DES placed 3 months ago and high risk
for recurrent cardiac events.
# Please call to make appointment with Dr. ___ Dr.
___.
# Pending labs: Blood cultures ___
# Lovenox to be continued for 4 weeks post op (end date ___
# Hgb on discharge 8.8.
# Cr on discharge 0.8.
# ___ and Hyperkalemia, resolved. Lisinopril held in-patient but
restart prior to discharge for cardioprotective effects. Cr
remained stable.
# Please continue to assess FSBG daily and adjust insulin
regimen as needed.
# New medications: Acetaminophen, albuterol, bisacodyl,
docusate, enoxaparin, oxycodone
# CONTACT: ___, Husband ___
# CODE: FULL CODE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / latex /
Amoxicillin / aspirin / Erythromycin Base / Betadine / iodine /
Novocain / red dye / sulfite / preservatives / egg / bee venom
(honey bee) / fish derived / Iodinated Contrast Media - Oral and
IV Dye / kiwi / passion fruit / Gadolinium-Containing Contrast
Media
Attending: ___
Chief Complaint:
SOB, hypoxa
Major Surgical or Invasive Procedure:
___: liver biopsy
History of Present Illness:
Ms. ___ is a ___ female with a h/o of TBI, endometriosis,
childhood asthma who comes for work up for her dyspnea as well
as her newly found liver and lung lesions.
Cough: began in ___ with what she thought was a cold
with associated congestion. Other cold like symptoms went away
but cough persisted, non productive. Underwent evaluation at
that time for the cough and new right upper quadrant pain and
lump that was diagnosed as a muscle strain secondary to her
cough. Her cough progressively worsened which would trigger
abdominal pain not only in the RUQ but at other locations in her
abdomen and chest. Cough symptoms peaked in early ___ and
has since improved.
Abdominal lump: noticed in ___, persisted until
eventually seeing Dr. ___ PCP, in ___ who
subsequently ordered a U/S which revealed numerous liver
lesions, which led to the MRI liver which confirmed multiple
liver lesions.
SOB: began around the time of her cough. She says that her
abdominal pain which prevent her from taking deep breaths
leading to her perception of being short of breath. SOB peaked
in early ___ and has since improved. SOB is best when laying
flat, worse with exertion to the point where she could not speak
in complete sentences in early ___. Denied hemoptysis.
Denies: headache, vision changes, neck stiffness, hemoptysis,
diarrhea, constipation, focal muscle weakness, sensation
changes, h/o blood clots, h/o prolonged immobilization, h/o
recent estrogen use, leg swelling or pain
Confirms: weight loss (unintentional) of 25 lbs since ___.
Abdominal fullness since ___.
Never had a colonoscopy. Had mammogram in past ___ years
(unremarkable per patient), pap smear in ___ (negative for
malignancy).
Past Medical History:
Asthma
Concussion/traumatic brain injury from trip and fall
Paroxysmal atrial fibrillation
Thyroid nodule
Endometriosis
Concern for lupus
Social History:
___
Family History:
- Mother: lymphoma, Factor V ___
- Father: prostate cancer, h/o CVA
- Sister: esophageal cancer
- Has 4 other sisters: some have factor V leiden (3 of them)
Physical Exam:
Admission Exam:
===============
Vitals: 98.3 100 20 99 RA
GENERAL: nontoxic appearance, no apparent respiratory distress
HEENT: PERRL, EOMI, anicteric sclera
NECK: supple neck, no cervical/supraclavicular LAD
LUNGS: clear to auscultation bilaterally on posterior
auscultation
CV: tachycardic but regular rhythm, normal s1 and s2, no g/r/m
ABD: b/s present, tender to deep palpation in RUQ, liver edge
note 1-2cm below rib cage
EXT: warm, no edema noted
SKIN: no obvious skin lesions noted
NEURO: CN2-12 intact, ___ muscle strength in U and L extremities
bilaterally
ACCESS: PIV
Discharge Exam:
===============
Vitals: 97.7 135 / 85 91 18 98 RA
GENERAL: nontoxic appearance, no apparent respiratory distress
HEENT: EOMI, anicteric sclera
NECK: supple neck
LUNGS: clear to auscultation bilaterally on posterior
auscultation
CV: tachycardic but regular rhythm, normal s1 and s2, no g/r/m
ABD: b/s present, no tenderness in all quadrants on deep
palpation
EXT: warm, no edema noted
SKIN: no obvious skin lesions noted
NEURO: moving all extremities with purpose against gravity
ACCESS: PIV
Pertinent Results:
Admission Labs:
===============
___ 09:10AM BLOOD WBC-7.1 RBC-4.84 Hgb-13.1 Hct-42.2 MCV-87
MCH-27.1 MCHC-31.0* RDW-15.4 RDWSD-48.9* Plt ___
___ 09:10AM BLOOD Neuts-72.3* Lymphs-16.4* Monos-7.8
Eos-1.7 Baso-1.0 Im ___ AbsNeut-5.12 AbsLymp-1.16*
AbsMono-0.55 AbsEos-0.12 AbsBaso-0.07
___ 06:15AM BLOOD ___ PTT-30.5 ___
___ 06:15AM BLOOD Glucose-78 UreaN-5* Creat-0.6 Na-139
K-4.4 Cl-101 HCO3-28 AnGap-14
___ 06:15AM BLOOD ALT-20 AST-49* LD(LDH)-264* AlkPhos-349*
TotBili-1.4
___ 06:15AM BLOOD Albumin-3.5 Calcium-9.4 Phos-3.8 Mg-2.1
UricAcd-4.2
Interim Labs:
=============
___ 06:35AM BLOOD calTIBC-190* Ferritn-1153* TRF-146*
___ 06:15AM BLOOD HBsAg-Negative HBsAb-Negative
___ 06:35AM BLOOD Smooth-POSITIVE *
___ 06:35AM BLOOD ___ * Titer-1:40
___ 06:15AM BLOOD CA125-183*
___ 06:15AM BLOOD HCV Ab-Negative
___ 06:35AM BLOOD ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY-PND
Discharge Labs:
===============
___ 06:50AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.3
___ 06:50AM BLOOD ALT-21 AST-52* LD(LDH)-288* AlkPhos-384*
TotBili-1.4
___ 06:50AM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-139 K-3.9
Cl-100 HCO3-25 AnGap-18
___ 06:50AM BLOOD ___ PTT-29.8 ___
___ 06:50AM BLOOD WBC-7.0 RBC-4.99 Hgb-13.9 Hct-43.2 MCV-87
MCH-27.9 MCHC-32.2 RDW-15.4 RDWSD-48.4* Plt ___
Micro:
======
URINE CULTURE (Final ___: negative
Studies:
========
___ Liver biopsy pathology pending
___ CT abdomen/pelvis without contrast
1. Innumerable hepatic metastases are better characterized on
MR dated ___. Retroperitoneal adenopathy, omental deposits,
and trace
ascites are findings compatible with carcinomatosis. Primary
malignancy is not elucidated on current examination.
2. Splenomegaly.
3. Partially imaged pericardial effusion appears stable.
4. Moderate amount of ascites
___ V/Q: IMPRESSION: Normal perfusion and ventilation. No
evidence of pulmonary embolus.
___ TTE: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). 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) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is a moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
___ CXR: Multiple nodular opacities bilaterally correlate with
nodule seen on recent CT, not significantly changed. No new
focal consolidation.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
==================
- Pericardial effusion
- Malnutrition
- Cirrhosis
- Hypoxia
- Multiple liver and lung lesions, pending biopsy
Secondary Diagnoses:
====================
- Multiple allergies
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 shortness of breath// eval for pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: CT chest on ___
FINDINGS:
Multiple nodular opacities bilaterally correlate with nodules seen on recent
CT. No new focal consolidation. No pleural effusion or pneumothorax is seen.
The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
Multiple nodular opacities bilaterally correlate with nodule seen on recent
CT, not significantly changed. No new focal consolidation.
Radiology Report
INDICATION: ___ year old woman with hx of TBI, endometriosis coming in for
work up for her multiple liver and lung mets.// No contrast please (multiple
allergies). ?primary malignancy
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 7.7 s, 50.0 cm; CTDIvol = 4.8 mGy (Body) DLP = 239.0
mGy-cm.
Total DLP (Body) = 239 mGy-cm.
COMPARISON: MR liver dated ___.
FINDINGS:
LOWER CHEST: There is a small pericardial effusion which is unchanged in
volume since examination dated ___. A cluster of nodules within
the right middle lobe, recently described on dedicated chest CT dated ___. There is no pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver is heterogeneous in attenuation with innumerable
hepatic hypodensities better characterized on MR dated ___.
There is trace perihepatic fluid anteriorly and ill-definedgallbladder with
pericholecystic fluid. There is no appreciable intra or extrahepatic duct
dilation.
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 is enlarged measuring 15.0 cm in the coronal dimension.
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. Scattered diverticula involve
the sigmoid:. The appendix is not definitely visualized. Trace interloop
fluid is associated with nodularity of the omentum, most conspicuous in the
lower and left hemipelvis (03:59, 57, 62, 68), worrisome for omental deposits.
PELVIS: The urinary bladder and distal ureters are unremarkable. Moderate
volume pelvic free fluid is noted.Nodularity within the right hemipelvis
suggests peritoneal implants.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no inguinal adenopathy. Scattered left pelvic sidewall
nodes are present (3:69). Numerous retroperitoneal nodes are noted and
include a aortocaval node which measures 1.2 cm (03:29) left periaortic
measuring 0.7 cm (03:42) and scattered periaortic nodes just below level of
the renal veins.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Innumerable hepatic metastases are better characterized on MR dated ___. Retroperitoneal adenopathy, omental deposits, and trace
ascites are findings compatible with carcinomatosis. Primary malignancy is
not elucidated on current examination.
2. Splenomegaly.
3. Partially imaged pericardial effusion appears stable.
4. Moderate amount of ascites
This preliminary report was reviewed with Dr. ___ radiologist.
Radiology Report
EXAMINATION: Ultrasound-guided targeted and nontargeted biopsy.
INDICATION: ___ year old woman with no significant pmh but significant allergy
who is here for malignancy work up.// ? liver lesion and ? cirrhosis
COMPARISON: CT ___
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___ trainee, Drs. ___
attending radiologist. Dr. ___ personally 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 liver was
performed. The lesion for biopsy was identified in the right hepatic lobe. A
suitable approach for targeted liver biopsy was determined. A second site for
non targeted liver biopsy was identified in the Left lobe.
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 sites were 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 at both sites.
Under real-time ultrasound guidance, Two 18-gauge core biopsy sample was
obtained from the targeted site. A single 18-gauge core biopsy sample was
obtained from the targeted site. The samples were provided to the on-site
cytologist who indicated an adequate sample.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
35 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 2, and non targeted liver
biopsy x 1 with specimens provided to the cytologist.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Shortness of breath, Pericardial effusion (noninflammatory)
temperature: 96.0
heartrate: 109.0
resprate: 20.0
o2sat: 100.0
sbp: 148.0
dbp: 89.0
level of pain: 5
level of acuity: 3.0 | Brief Summary:
===========
Ms. ___ is a ___ with a h/o TBI, asthma, endometriosis,
but with no prior malignancy history who was admitted for
hypoxia work up and for an expedited malignancy work up for her
new lung and liver lesions. Given her significant anaphylactic
history for both gadolinium and iodine contrast, a V/Q scan was
ordered and revealed a low likelihood of acute pulmonary edema;
anticoagulation was therefore not started. Her shortness of
breath was likely multifactorial: splinting ___ abdominal pain
and disease burden in lungs. An echocardiogram revealed moderate
sized pericardial effusion with no evidence of tamponade; her VS
remained stable during entirety of hospitalization. Given her
significant allergy list, we consulted allergy who gave
recommendations about testing her for reactions to anesthetics
prior to her liver biopsy. She was sent to the ICU for close
observation after chloroprocaine SC injection which she
tolerated well and subsequently moved forward with a liver
biopsy. No subsequent complications after the procedure were
noted. Given evidence of cirrhosis on a prior MRI liver, an
autoimmune work up was pursued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
1) Left intertrochanteric femur fracture
2) Left distal radius fracture
Major Surgical or Invasive Procedure:
1) Left radius open reduction internal fixation
2) Left short trochanteric femoral nail placement
History of Present Illness:
___ female past medical history significant for EtOH,
COPD (not on home O2), and ?lupus who presents to the emergency
department as a transfer from ___ for a left
distal radius fracture, left intertrochanteric fracture after a
fall. Patient was attempting to reach a light fixture on
___ night while intoxicated and fell directly onto her left
side, noted immediate pain and deformity in the left wrist and
left hip. According to patient she was at ground level, but
according to OSH reports, she was on a chair trying to fix light
bulb. No heads strike or loss of consciousness. She received
conscious sedation at OSH and became lethargic and needed to be
bagged and then found to be in rapid rate with hypotension. She
received 3 rounds of
Lopressor and recovered quickly. Complained of left wrist pain,
left hip pain, and low back pain. She had low back pain at
baseline. Patient denied any numbness, weakness, tingling.
Past Medical History:
Reported h/o EtOH use
COPD, used to be on home O2 but not on O2 currently
Social History:
___
Family History:
Reviewed. none pertinent to this hospitalization
Physical Exam:
DC EXAM:
___ ___ Temp: 98.3 PO BP: 128/76 R Lying HR: 77 RR: 16
O2 sat: 93% O2 delivery: 1.5L NC
GEN: sitting up in bed in chair in NAD
CV: RRR no m/r/g, no carotid bruits appreciated
PULM: Poor air movement stable, no clear wheeze or crackles.
diffusely diminished breath sounds. Symmetric expansion
GI: soft NT/ND +BS no rebound or guarding
BACK: mild paraspinal muscle TTP
EXT: warm well perfused, no pitting edema. L wrist/distal arm
wrapped in splint
Pertinent Results:
ADMISSION LABS:
___ 08:15AM BLOOD WBC-16.2* RBC-4.05 Hgb-12.6 Hct-38.6
MCV-95 MCH-31.1 MCHC-32.6 RDW-13.6 RDWSD-47.8* Plt ___
___ 08:15AM BLOOD Neuts-84.3* Lymphs-9.1* Monos-5.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-13.66* AbsLymp-1.47
AbsMono-0.89* AbsEos-0.02* AbsBaso-0.05
___ 08:15AM BLOOD ___ PTT-33.3 ___
___ 08:15AM BLOOD Glucose-117* UreaN-19 Creat-1.0 Na-141
K-5.1 Cl-105 HCO3-27 AnGap-9*
___ 08:15AM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.8
PERTINENT INTERVAL LABS:
___ 03:05AM BLOOD Lipase-69*
___ 12:28PM BLOOD ALT-8 AST-21 LD(LDH)-222 CK(CPK)-118
AlkPhos-85 TotBili-0.5
___ 03:05AM BLOOD ALT-8 AST-19 LD(___)-219 AlkPhos-86
TotBili-0.5
___ 12:28PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3441*
___ 10:47PM BLOOD CK-MB-6 cTropnT-0.06*
___ 04:40AM BLOOD CK-MB-4 cTropnT-0.06*
___ 10:56PM BLOOD Type-MIX pO2-31* pCO2-53* pH-7.41
calTCO2-35* Base XS-6
___ 12:51PM BLOOD Lactate-5.0*
___ 11:24PM BLOOD Lactate-0.7
IMAGING AND STUDIES:
___ L WRIST
Comparison to ___. Distal radial fracture is now
reduced ending caused. Reduction has improved the alignment of
the fractured components.
___ CXR
IMPRESSION:
1. Findings consistent with chronic obstructive pulmonary
disease including areas of atelectasis and mucous plugging at
each lung base. Developing broncho pneumonia is not excluded,
however, in one or both lower lobes. Short-term follow-up repeat
radiographs may be helpful
2. Right-sided aortic arch.
3. Rim calcified structure at the medial left lung apex of
unclear etiology although probably not an aneurysm since it does
not appear to pass very close to any of the large vessels on the
CT.
___ CXR
Overall, no significant interval change in the appearance of the
chest, with findings consistent with COPD. Persistent bibasilar
atelectasis.
___ TTE
Biatrial enlargement. Mildly dilated right ventricle with
preserved biventricular systolic function. Moderate to severe
tricuspid regurgitation in the setting of severe pulmonary
hypertension. Mild to moderate mitral regurgitation.
DC LABS:
___ 06:40AM BLOOD WBC-8.4 RBC-3.01* Hgb-9.6* Hct-29.8*
MCV-99* MCH-31.9 MCHC-32.2 RDW-14.9 RDWSD-51.8* Plt ___
___ 06:40AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-142
K-4.5 Cl-100 HCO3-33* AnGap-9*
___ 03:05AM BLOOD ALT-8 AST-19 LD(LDH)-219 AlkPhos-86
TotBili-0.5
___ 06:40AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7 Iron-60
___ 06:40AM BLOOD calTIBC-212* Hapto-227* Ferritn-290*
TRF-163*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl ___AILY:PRN Constipation - Third Line
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QHS
take through ___
5. FoLIC Acid 1 mg PO DAILY
6. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN coughing
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % apply 1 patch to back and right
chest once a day Disp #*6 Patch Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD QAM
to right chest wall
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. OxyCODONE (Immediate Release) 2.5-7.5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5-1.5 tablet(s) by mouth every four (4)
hours Disp #*15 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID
15. Thiamine 100 mg PO DAILY
16. Hydroxychloroquine Sulfate 200 mg PO DAILY
17. Sertraline 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Left intertrochanteric femur fracture
2) Left distal radius fracture
3) Alcohol withdrawal
4) atrial fibrillation
5) COPD
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: History: ___ with distal radius fx// post reduction eval
post reduction eval
IMPRESSION:
Comparison to ___. Distal radial fracture is now reduced ending
caused. Reduction has improved the alignment of the fractured components.
Radiology Report
EXAMINATION: Intraoperative fluoroscopic images of the left hip.
INDICATION: Left intertrochanteric fracture.
TECHNIQUE: Fluoroscopic time 62.4 seconds.
COMPARISON: ___.
FINDINGS:
3 intraoperative images were acquired without a radiologist present.
Images show placement of a antegrade intramedullary nail with helical screw.
IMPRESSION:
Intraoperative images were obtained during intramedullary fixation for
intertrochanteric fracture. Please refer to the operative note for details of
the procedure.
Radiology Report
EXAMINATION: Intraoperative images
INDICATION: ___ woman with ORIF of the left distal radial fracture
TECHNIQUE: Total fluoro time: 29.2 seconds
COMPARISON: Radiographs, most recently dated ___
FINDINGS:
9 intraoperative images were acquired without a radiologist present.
Images show ORIF of the distal radial fracture with volar plate and
transfixing screws.
IMPRESSION:
Intraoperative images were obtained during ORIF of the distal radial fracture.
Please refer to the operative note for details of the procedure.
Radiology Report
EXAMINATION: .
INDICATION: Hypoxia. Query pulmonary edema.
COMPARISON: CT from the prior day.
FINDINGS:
Again noted is a right-sided aortic arch. Cardiac, mediastinal and hilar
contours appear stable including rim calcified structure along the medial left
lung apex. There is possibly a trace right-sided pleural effusion, none on
the left. No indication of pneumothorax. Coarse lung markings are consistent
with the background chronic obstructive pulmonary disease including emphysema.
Streaky opacities in each lower lobe correspond to atelectasis and areas of
mucous plugging, very similar to the prior CT although differential may
include developing pneumonia.
IMPRESSION:
1. Findings consistent with chronic obstructive pulmonary disease including
areas of atelectasis and mucous plugging at each lung base. Developing
broncho pneumonia is not excluded, however, in one or both lower lobes.
Short-term follow-up repeat radiographs may be helpful
2. Right-sided aortic arch.
3. Rim calcified structure at the medial left lung apex of unclear etiology
although probably not an aneurysm since it does not appear to pass very close
to any of the large vessels on the CT.
Radiology Report
INDICATION: ___ year old woman with afib rvr, hypotension// volume overload "?
TECHNIQUE: AP portable radiograph of the chest.
COMPARISON: Radiograph the chest performed 1 day prior.
FINDINGS:
Re-demonstrated is a right-sided aortic arch. The cardiac, mediastinal, and
hilar contours appear unchanged including a calcified structure along the
medial left lung apex. Small left pleural effusion is unchanged. There is no
evidence of pneumothorax. Coarse lung markings are consistent with background
of COPD including emphysema. Bibasilar atelectasis is unchanged.
IMPRESSION:
Overall, no significant interval change in the appearance of the chest, with
findings consistent with COPD. Persistent bibasilar atelectasis.
Radiology Report
INDICATION: ___ year old woman with COPD, hypoxia, s/p RIJ CVL placement//
Post-CVL placement Contact name: ___: ___
TECHNIQUE: Portable AP radiograph of the chest
COMPARISON: Chest x-ray from 1 hour prior
FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. A right-sided IJ
terminates within the right atrium. There is no evidence of pneumothorax.
Mild pulmonary vascular congestion and mild pulmonary edema seen. Left
basilar atelectasis is persistent. Possible small bilateral pleural effusions.
IMPRESSION:
Right-sided IJ terminates within the right atrium. No pneumothorax.
NOTIFICATION: The findings were discussed with Dr ___, M.D. by
___, M.D. on the telephone on ___ at 3:11 pm, 5 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Low back pain
temperature: 98.1
heartrate: 80.0
resprate: 18.0
o2sat: 94.0
sbp: 118.0
dbp: 72.0
level of pain: 9
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left intertrochanteric femur fracture and left distal
radius fracture and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for open reduction internal fixation of left radius and left
short trochanteric femoral nail, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. Postoperatively however,
she developed hypoxia requiring 10L, and tachycardia to 130s,
improved with esmolol push. She was stabilized on ___ NC in the
PACU and transferred to the surgical floor. Her post-operative
course was notable for persistent O2 requirement of ___ NC and
sinus tachycardia, for which medicine was consulted on ___. Of
note, she was given IVF at 80cc/hr for while on the floor under
ortho team. She had been requiring frequent doses of diazepam
for high CIWA scores.
Ms. ___ is a ___ yo F with COPD, alcohol use disorder, GERD,
HTN, possible SLE, who presented s/p s/p fall w
intertrochanteric femur fx and L distal radius fx now s/p ORIF L
distal radius fx and L short TFN, course complicated by AF with
RVR and respiratory failure requiring itubation, as well as
agitation. She subsequently improved and was transferred from
the ICU to the floor for ongoing care.
L intertrochanteric femur fx and L distal radius fx:L
Suffered as a result of her fall. s/p ORIF on ___. Started
on Lovenox to take through ___.
- ___ consults
- WBAT LLE, NWB LUE
- PER ORTHO:
- Activity: WBAT LLE, NWB LUE in splint, may use platform walker
- Anticoagulation: per medicine - recommend enoxaparin 40 mg sc
qhs x 30 days
- Analgesia: per medicine
- Dressings:
- splint to LUE to remain on until f/u
- okay to change LLE dressings PRN
- Physical therapy & occupational therapy evaluations
- Follow Up: ~ 2 weeks post operatively with ___,
NP. Please have the ___ rehab facility contact the
orthopaedic trauma clinic at ___ to schedule this
appointment. SHOULD FOLLOW UP AROUND ___
- cont Tylenol, Oxycodone, Lidocaine patch. Adjust as needed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Morphine / Aspirin /
Benadryl
Attending: ___
Chief Complaint:
Slurring, falls, right hand poor coordination.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Ms. ___ is a ___ year-old
right-handed woman with a history of a TIA (admitted here), as
well as COPD, HTN and Obstructive sleep apnea who was called to
___ office because of history of slurred speech, drooling, and
right hand poor coordinationover the last 2 weeks.
The moved into a new apartment about a year ago and describes
that since that time she has been having some health trouble.
She
reports that she was previously taking care of her kids and
grandkids and didn't may much attention to her own health. She
reports some nonspecific lapses of memory and word finding
problems, but says these only last seconds and have been going
on
for quite some time.
What is more concerning is that the patient has had about 3
episodes of slurring of her words, ___ episodes of trouble with
her hand writing and 2 episodes or so of drooling - all during
the last two weeks. These episodes do not occur together, and
happen randomly. They only last a few seconds or so each (this
is
not confirmed with a third party). She does not report any
facial
droop (as had been mentioned in other notes) and states that she
lives alone and there is no one to witness most of these things.
She also reports that in the last month she has fallen about 3
times, and she has barely fallen since ___ when she fractured
her right hip. She describes that she does not trip, and that
she just falls randomly. She does not lose consciousness and is
able to get right up. She reports that a week or two ago she was
sitting in her rocking chair at home starting to doze off, when
she was "thrown to the floor across the room." She felt like a
"ghost" lives in her apartment and pushes her over.
The patient does not endorse any HAs, vision changes and only
mentions a ringing in her right ear when there is a loud siren
or
bell outside. No problems with PO intake or fevers/chills.
Denies new medication changes.
Review of Systems: On neuro ROS, No lightheadedness, dizziness,
ataxia, HA, loss of vision, diplopia, dysarthria, dysphagia,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel incontinence. Walks with a cane at
baseline.
On general review of systems, She denies any URI sxs,
rhinorrhea.
She denies recent fever or chills. No night sweats or recent
weight loss or gain. Denies shortness of breath, palpitations,
chest pain. Denies nausea, vomiting, constipation or abdominal
pain. Diarrhea and change in bowel habits as above. No recent
change bladder habits. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
HTN
OSA (noncompliant with CPAP)
COPD
h/o TIA
osteopenia
stress urinary incontinence
Angioedema to ASA ___ in setting of ___
___ History:
___
Family History:
She has two healthy daughters - one daughter with
seizures in infancy related to hypoglycemia. No strokes. Mother:
Lung CA died from sepsis after surgical procedure. Father: died
from complications after an accident
Physical Exam:
Physical Exam on admission:
Vitals: T: 97.8 HR 66, BP 152/134, RR 18, O2 100% RA
General: Awake, cooperative, in NAD.
HEENT: NC/AT, no sclera 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: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to place, person, and date.
Attentive, ___ backwards. Language is fluent with intact
repetition and naming. Aware of current events. There were no
paraphasic errors. Speech is normal. Normal calcs, normal
naming. Following commands appropriately. No evidence of apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3 mm and brisk. VFF to confrontation.
Fundoscopic
exam reveals sharp disc margins b/l.
III, IV, VI: EOMI with ___ beats of nystagmus in both directions
on horizontal gaze. No diplopia.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift. Mild
resting tremor, no other adventitious movements. No asterixis
noted. Nml finger tapping.
Delt Bic Tri FFl FE IO IP Quad Ham TA ___
L 5 5 ___ 5 5 5 5 5 5 5
R 5 5 ___ 5 * 5 5 5 5 5
* Right hip fracture, unable to assess.
-Sensory: Intact and symmetric light touch, sharp and temp in
upper extremities and lower extremities.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 t
R 2 2 2 0 t
Plantar response was flexor b/l.
-Coordination: No dysmetria on FNF.
-Gait: Gets up with assistance and takes a couple steps. Narrow
based, no obvious ataxia. No Rhomberg.
Physical exam on discharge:
Afebrile, VSS. Exam unchanged from admission.
Pertinent Results:
CT Head ___:
COMPARISON: Head CT from ___.
FINDINGS: There is no acute intra-axial or extra-axial
hemorrhage, mass,
midline shift, or territorial infarct. There is prominence of
the ventricles
more so than the sulci, but stable in configuration from prior.
The
gray-white matter differentiation is preserved. There is subtle
hypodensity
in periventricular white matter (series 2, image 20) which could
be due to
small vessel ischemic change. Subcortical white matter
hypodensity also seen
in the left parietal lobe not clearly seen on most recent exam
from ___.
Included orbits which are unremarkable. Visualized mastoid air
cells and
paranasal sinuses are clear. Skull and extracranial soft
tissues are
unremarkable.
IMPRESSION: No definite evidence of acute intracranial process.
There is,
however, new white matter hypodensity in the left parietal
region. MRI would
be more sensitive in detecting acute ischemia and if this is of
concern should
be performed.
MR HEAD ___
FINDINGS: There is ventriculomegaly including mild-to-moderate
prominence of
temporal horns. The ventriculomegaly has slightly increased
since the
previous MRI of ___. There is also slightly more
periventricular
hyperintensities seen since the previous study. There are
multiple foci of T2
hyperintensity in the white matter indicate mild-to-moderate
changes of small
vessel disease within the brain as well as within the brainstem.
There is no
evidence of chronic blood products.
Although there is prominence of temporal horn, the choroidal
fissure only
minimally widened and the appearances are not typical for
significant
hippocampal atrophy. In addition, the frontal sulci are not
proportionately enlarged.
The sagittal T2-weighted image demonstrate a prominent flow
void, best
visualized on series 10, image 12 within the aqueduct extending
to the fourth ventricle. The phase contrast imaging study,
although does not provide diagnostic information on the sagittal
scans demonstrates markedly increased flow through the aqueduct
on the axial images seen as aliasing . Both the T2 and the
axial phase contrast findings are suggestive of increased
pulsatile flow through the aqueduct.
IMPRESSION:
1. The ventricular size has increased since the previous MRI of
___
along with some prominence of temporal horns suggestive more of
hydrocephalus
as compared to central atrophy.
2. Increased flow through pulsatile flow through the aqueduct
is a finding
which is suggestive of normal pressure hydrocephalus in proper
clinical
settings.
3. Small vessel disease without mass effect or hydrocephalus.
4. Although mild-to-moderate brain atrophy seen it is not
focussed to the frontal lobes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Nicotine Polacrilex 2 mg PO Q4H:PRN craving
4. Alendronate Sodium 70 mg PO DAILY
5. Cyclobenzaprine 2.5 mg PO HS:PRN muscle spasm
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Oxybutynin 5 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Naproxen 250 mg PO Q8H:PRN pain
10. Loratadine *NF* 10 mg Oral daily
11. Vitamin D 400 UNIT PO DAILY
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Cyclobenzaprine 2.5 mg PO HS:PRN muscle spasm
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Lisinopril 20 mg PO DAILY
6. Naproxen 250 mg PO Q8H:PRN pain
7. Nicotine Polacrilex 2 mg PO Q4H:PRN craving
8. Oxybutynin 5 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Alendronate Sodium 70 mg PO DAILY
12. Loratadine *NF* 10 mg ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Gait abnormalities and speech slurring
Adjustment disorder
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
HEAD CT WITHOUT CONTRAST ___
HISTORY: ___ female with slurred speech, drooling and memory lapse.
Question TIA.
TECHNIQUE: Contiguous axial images were obtained from skull base to vertex
without intravenous contrast. Coronal and sagittal reformats.
COMPARISON: Head CT from ___.
FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass,
midline shift, or territorial infarct. There is prominence of the ventricles
more so than the sulci, but stable in configuration from prior. The
gray-white matter differentiation is preserved. There is subtle hypodensity
in periventricular white matter (series 2, image 20) which could be due to
small vessel ischemic change. Subcortical white matter hypodensity also seen
in the left parietal lobe not clearly seen on most recent exam from ___.
Included orbits which are unremarkable. Visualized mastoid air cells and
paranasal sinuses are clear. Skull and extracranial soft tissues are
unremarkable.
IMPRESSION: No definite evidence of acute intracranial process. There is,
however, new white matter hypodensity in the left parietal region. MRI would
be more sensitive in detecting acute ischemia and if this is of concern should
be performed.
Radiology Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with inability to perform IADL with occasional
urinary incontinence concern for frontotemporal dementia versus normal
pressure hydrocephalus.
TECHNIQUE: T1 and T2 sagittal and FLAIR T2 susceptibility and diffusion axial
images of the brain were acquired. MP-RAGE coronal images were obtained.
Using a cine phase contrast imaging, sagittal and axial CSF flow imaging was
performed.
FINDINGS: There is ventriculomegaly including mild-to-moderate prominence of
temporal horns. The ventriculomegaly has slightly increased since the
previous MRI of ___. There is also slightly more periventricular
hyperintensities seen since the previous study. There are multiple foci of T2
hyperintensity in the white matter indicate mild-to-moderate changes of small
vessel disease within the brain as well as within the brainstem. There is no
evidence of chronic blood products.
Although there is prominence of temporal horn, the choroidal fissure only
minimally widened and the appearances are not typical for significant
hippocampal atrophy. In addition, the frontal sulci are not proportionately
enlarged.
The sagittal T2-weighted image demonstrate a prominent flow void, best
visualized on series 10, image 12 within the aqueduct extending to the fourth
ventricle. The phase contrast imaging study, although does not provide
diagnostic information on the sagittal scans demonstrates markedly increased
flow through the aqueduct on the axial images seen as aliasing . Both the T2
and the axial phase contrast findings are suggestive of increased pulsatile
flow through the aqueduct.
IMPRESSION:
1. The ventricular size has increased since the previous MRI of ___
along with some prominence of temporal horns suggestive more of hydrocephalus
as compared to central atrophy.
2. Increased flow through pulsatile flow through the aqueduct is a finding
which is suggestive of normal pressure hydrocephalus in proper clinical
settings.
3. Small vessel disease without mass effect or hydrocephalus.
4. Although mild-to-moderate brain atrophy seen it is not focussed to the
frontal lobes.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R/O CVA
Diagnosed with OTHER SPEECH DISTURBANCE
temperature: 97.8
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 152.0
dbp: 134.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year-old right-handed woman with a history
of a TIA, as well as COPD, HTN and Obstructive sleep apnea who
presents with increased falls and episodes of slurred speech,
drooling, and right hand poor coordination over the last 2
weeks. The patient's exam is notable for mood lability,
sadness, suicidal ideation without current plan, and a prominent
dysexecutive syndrome (MOCA ___, poor clock draw/Luria/go-no
go/FAS/animals) consistent with mild cognitive impairment. Also
some evidence that pt is mismanaging her finances and otherwise
struggling with IADLs. Her current living situation is
suboptimal (e.g., due to bedbug infestation) and is making the
pt upset. Although it is possible that pt has been having
seizures verusus transient ischemic attacks, the story is not
very convincing for either. Ventricles are enlarged on CT head,
and in light of the cognitive impairment, falls, and occasional
urinary incontinence, NPH is also on the differential. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone
Attending: ___.
Chief Complaint:
Incision drainage
Major Surgical or Invasive Procedure:
Left complex primary total knee arthroplasty ___
History of Present Illness:
Pt is ___ year old female s/p L complex primary TKA on ___ ___, admitted with 24 hours of serosanguinous wound
drainage. Her knee was aspirated on ___, and joint fluid
aspirate showed 144 WBC, 78%PMN, afb pending.
Past Medical History:
HPI: PMH: DEPRESSION
ARTHRITIS
CERVICAL RADICULITIS
CHRONIC PAIN
KNEE PAIN
RHEUMATOID ARTHRITIS
MONOCLONAL IGM KAPPA
Hematologic History: see note of ___.
___ DISEASE
Social History:
___
Family History:
noncontributory
Physical Exam:
Discharge PE:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 06:22AM BLOOD WBC-8.1 RBC-3.61* Hgb-10.6* Hct-34.3
MCV-95 MCH-29.4 MCHC-30.9* RDW-15.2 RDWSD-52.0* Plt ___
___ 01:00PM BLOOD WBC-10.8* RBC-3.71* Hgb-11.1* Hct-35.4
MCV-95 MCH-29.9 MCHC-31.4* RDW-15.3 RDWSD-53.2* Plt ___
___ 01:00PM BLOOD Neuts-65.4 ___ Monos-7.1 Eos-1.0
Baso-1.1* Im ___ AbsNeut-7.03* AbsLymp-2.67 AbsMono-0.76
AbsEos-0.11 AbsBaso-0.12*
___ 06:30AM BLOOD Plt ___
___ 06:22AM BLOOD Plt ___
___ 01:00PM BLOOD Plt ___
___ 06:22AM BLOOD Glucose-85 UreaN-11 Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-27 AnGap-12
___ 01:00PM BLOOD UreaN-11 Creat-0.8 Na-137 K-4.7 Cl-100
HCO3-26 AnGap-16
___ 01:00PM BLOOD CK(CPK)-88
___ 06:22AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0
___ 01:00PM BLOOD Calcium-9.8
___ 01:00PM BLOOD CRP-9.0*
___ 06:22AM BLOOD
___ 01:00PM BLOOD
___ 01:00PM BLOOD SED RATE-Test
___ 01:27PM JOINT FLUID WBC-144 HCT,Fl-6.5* Polys-78*
___ Monos-3 Other-4*
___ 01:27PM JOINT FLUID Crystal-NONE
___ 1:27 pm JOINT FLUID Source: Knee.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1.5 TAB PO QID
2. Lovenox (enoxaparin) 40 mg/0.4 mL subcutaneous Q24H
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 100 mg PO DAILY
5. LORazepam 0.5 mg PO BID:PRN anxiety
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. QUEtiapine Fumarate 25 mg PO QHS
8. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Calcium Carbonate 1500 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Multivitamins 1 TAB PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*28 Capsule Refills:*0
2. Enoxaparin Sodium 40 mg subcutaneous EVERY DAY
Start: ___, First Dose: Next Routine Administration Time
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Calcium Carbonate 1500 mg PO DAILY
6. Carbidopa-Levodopa (___) 1.5 TAB PO QID
7. Docusate Sodium 100 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 100 mg PO DAILY
10. LORazepam 0.5 mg PO BID:PRN anxiety
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. QUEtiapine Fumarate 25 mg PO QHS
14. Senna 8.6 mg PO BID:PRN constipation
15. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
16. Vitamin B Complex 1 CAP PO DAILY
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left knee seroma s/p left total knee on ___
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: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with left TKR with concern for septic joint. //
hardware change? effusion? hardware change? effusion?
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of left knee
COMPARISON: Left knee radiograph ___.
FINDINGS:
Patient is status post total knee arthroplasty.
There is an obliquely oriented lucent line along the medial epicondyle of the
distal left femur above the implant, only appreciated on AP view. There is a
moderate suprapatellar joint effusion and a moderate infrapatellar joint
effusion with opacification in ___ fat pad. There is no evidence of
lucencies around the implants.
IMPRESSION:
1. Moderate suprapatellar and infrapatellar joint effusions.
2. Oblique lucent line in the distal femoral metaphysis does not have the
typical appearance of an acute fracture and most likely represents
postoperative change although a tiny nondisplaced periprosthetic fracture
cannot be excluded. If there is clinical concern for periprosthetic fracture,
CT of the knee may be helpful to clarify.
3. No evidence of loosening.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: L Knee pain
Diagnosed with Pain in left knee
temperature: 97.8
heartrate: 85.0
resprate: 16.0
o2sat: 100.0
sbp: 107.0
dbp: 59.0
level of pain: 0-2
level of acuity: 3.0 | The patient was admitted to the orthopedic surgery service and a
wound vac was placed on her wound with minimal drainage noted.
She was also started on IV antibiotics to treat any potential
colonization of the wound. The results of her joint aspiration
were unremarkable and did not suggest infection. Joint fluid
cultures showed no growth.
On HD #1, the patient was found to be orthostatic and she was
given a one-liter bolus of normal saline. On HD #2, her
woundvac was putting out a scant amount of fluid. It was removed
and a compressive dressing was applied. On HD #3, her dressing
had a moderate amount of serosanginous drainage after ambulating
with physical therapy. A new compressive dressing was applied
and was checked later in the day. The dressing was clean, dry,
and intact.
Her pain was controlled with oral pain medications. The patient
received Lovenox for DVT prophylaxis to continue her 28 day
postoperative course. The patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient
remained afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Ms ___ is discharged to home with services in stable
condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Wellbutrin / Ibrance
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Anaesthesia assisted MRI of head/neck
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of breast cancer w/ metastasis to bone and lung on
chemotherapy, chronic hypoxemic respiratory failure on 2L home
O2, depression, anxiety, claustrophobia, ocular migraines, GERD,
osteopenia who presents as a transfer from ___ with
pain.
The pain is located on the left side of her chest/breast and
began about 3 days prior to admission but has been progressive.
It is ___, worse with inspiration and with any movement but
improved when she is holding her chest, and feels "crackly" but
not burning. She took Percocet which only brought it down to a
6
or 7. She had a fall approximately 10 days prior to admission,
but she and her husband report that she received work-up for
this
which was unrevealing for any acute fracture of change.
There is some increased dyspnea on exertion, though she does not
report needing additional O2. She reports that she has chronic
headache which was in remission, but that she has had vision
changes for the past 2 days without nausea or vomiting. She
also
notes that her right upper back tingling and numbness which is
new. She denies having any focal weakness or new numbness aside
from her chronic parasthesias and low back pain.
She went to ___ where CT showed left-sided metastases
and
incidental right-sided subsegmental PE. CT head showed 4mm
lesion concerning for metastasis, so she was refered here for
MRI. Per her husband and her, they were told that ___ could not
do MRI overnight, but that ___ could, which is why she was
transferred. Per ER notes, it seems like this was to facilitate
discussion about the need for anticoagulation with these new
findings.
Vitals in the ___ ER: 97.8 88 ___ 95% 2L NC
There, the patient received:
___ 18:35 IV Ketorolac 15 mg
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
PAST MEDICAL HISTORY:
- Depression, anxiety, claustrophobia, GERD, Hemorrhoids,
osteopenia, ocular migraines
- Admission to ___ in ___ for acute hypoxic respiratory
failure thought to be secondary to Palbociclib hypersensitivity
pneumonitis
PAST ONCOLOGIC HISTORY (per OMR):
Stage IV Breast Cancer
- High risk stage IIIC left breast cancer in ___
(multifocal pT2 pN3a pMx, 18 out of 22 positive axillary nodes,
ER positive, PR focally positive, HER2/neu FISH negative).
Status post left mastectomy and left axillary lymph node
dissection (Dr. ___.
Status post adjuvant chemotherapy with dose dense Adriamycin and
cyclophosphamide followed by Taxol every 14 days, completed ___.
Status post adjuvant radiation to chest wall and axilla.
Adjuvant aromatase inhibitor endocrine therapy, started
___ (initially anastrozole held due to arthralgias, then
Aromasin since ___.
Osteopenia, status post bone density ___, initiated
Prolia
60 mg subcu every 6 months in ___, borderline
hypercalcemia.
- Clinically recurred in ___ with findings of elevated
tumor
markers. CA153 and CA2729 were elevated.
She had also new bone pain and CT scan revealed bony metastasis
and metastatic pulmonary nodules (___)
Staging PET/CT done on ___ confirmed metastatic
disease
in lung and bone, clinical stage IV.
Initial CT guided lung biopsy nondiagnostic ___ , bone biopsy
___ positive for metastatic mammary Carcinoma
She had a course of palliative radiation therapy for pain
control
under care by Dr. ___ and then ___ spine)
She was on first line Femara as endocrine disease for metastatic
hormone receptor positive breast cancer.
Then switched to Ibrance and Femara and then Faslodex/ Ibrance
since ___.
INTERVAL HISTORY FROM then to ADMISSION PER PATIENT:
Received a line of chemo that was unsuccessful and is now on a
new one week on, week on, week off, unsure of the name.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Stage IV Breast Cancer
- High risk stage IIIC left breast cancer in ___
(multifocal pT2 pN3a pMx, 18 out of 22 positive axillary nodes,
ER positive, PR focally positive, HER2/neu FISH negative).
Status post left mastectomy and left axillary lymph node
dissection (Dr. ___.
Status post adjuvant chemotherapy with dose dense Adriamycin and
cyclophosphamide followed by Taxol every 14 days, completed ___.
Status post adjuvant radiation to chest wall and axilla.
Adjuvant aromatase inhibitor endocrine therapy, started
___ (initially anastrozole held due to arthralgias, then
Aromasin since ___.
Osteopenia, status post bone density ___, initiated
Prolia
60 mg subcu every 6 months in ___, borderline
hypercalcemia.
- Clinically recurred in ___ with findings of elevated
tumor
markers. CA153 and CA2729 were elevated.
She had also new bone pain and CT scan revealed bony metastasis
and metastatic pulmonary nodules (___)
Staging PET/CT done on ___ confirmed metastatic
disease
in lung and bone, clinical stage IV.
Initial CT guided lung biopsy nondiagnostic ___ , bone biopsy
___ positive for metastatic mammary Carcinoma
She had a course of palliative radiation therapy for pain
control
under care by Dr. ___ and then ___ spine)
She was on first line Femara as endocrine disease for metastatic
hormone receptor positive breast cancer.
Then switched to Ibrance and Femara and then Faslodex/ Ibrance
since ___.
PAST MEDICAL HISTORY:
- Depression, GERD, Hemorrhoids.
Social History:
___
Family History:
- HTN, TIA, Pancreatic Cancer.
Physical Exam:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored, left chest wall/breast tenderness
GI: Abdomen soft, non-distended, no hepatosplenomegaly
appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: anterior left chest pain on palpation
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, parasthesias in her
bilateral ___ and ___ which are chronic, but abnormal sensation in
her right upper back near scapula. No focal motor deficits.
PSYCH: normal thought content, logical thought process,
appropriate affect
Pertinent Results:
___ 06:08PM BLOOD WBC-23.7* RBC-4.33 Hgb-12.9 Hct-38.9
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.1* RDWSD-52.2* Plt ___
___ 05:05AM BLOOD WBC-9.1 RBC-3.92 Hgb-11.6 Hct-36.3 MCV-93
MCH-29.6 MCHC-32.0 RDW-16.6* RDWSD-54.9* Plt ___
___ 05:05AM BLOOD Neuts-85* Bands-5 Lymphs-8* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.19*
AbsLymp-0.73* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.00*
___ 05:05AM BLOOD UreaN-7 Creat-0.6 Na-142 K-4.2 HCO3-26
AnGap-18
___ 06:08PM BLOOD ALT-22 AST-26 AlkPhos-92 TotBili-0.4
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old woman with metastatic breast cancer//
eval for
metastatic cancer
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR
technique.
Axial T2 imaging was performed. Axial GRE images of the cervical
spine were
performed. After the uneventful administration of 9 mL of
Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: None.
FINDINGS:
CERVICAL:
The visualized elements of the posterior fossa and
craniocervical junction are
unremarkable. The cervical cord is normal in volume, signal
intensity and
morphology. No abnormal enhancement. No epidural collection.
There is extensive replacement of the normal fatty marrow which
in some areas
demonstrate mild associated enhancement most obvious in C2 and
C4 vertebral
bodies in keeping with diffuse osseous metastatic disease.
Degenerative changes of the cervical spine in the form of disc
desiccation,
mild broad-based disc bulge, facet joint osteophytosis and
ligamentum flavum
hypertrophy as described below:
C2-3: Both neural foramina are patent, there is no evidence of
spinal canal
stenosis
C3-4: There is mild bilateral uncovertebral hypertrophy
resulting in
mild-to-moderate bilateral neural foraminal narrowing, there is
no evidence of
central spinal canal stenosis.
C4-5: There is mild bilateral uncovertebral hypertrophy cause
and mild
left-sided neural foraminal narrowing, the right neural foramina
appears
normal, there is no evidence of spinal canal stenosis no cord or
nerve root
compromise.
C5-6: There is mild disc bulge causing mild anterior thecal sac
deformity,
mild uncovertebral hypertrophy is producing mild bilateral
neural foraminal
narrowing with no evidence of neural compression, there is a
perineural cyst
on the left (20:21). No cord or nerve root compromise.
C6-7: No cord compromise. Right uncovertebral hypertrophy is
causing moderate
to severe right neural foraminal narrowing. There is no
evidence of central
spinal canal stenosis, the left neural foramina appears patent.
C7-T1: No cord or nerve root compromise.
THORACIC:
Diffuse osseous metastatic disease involving the vertebral
bodies as well as
thoracic ribs. Very minimal preserved normal marrow.
Multilevel endplate
insufficiency fractures, but no insufficiency wedge-type
compression
fractures. No marked body height loss.
The thoracic cord is normal in volume, signal intensity and
morphology. No
cord lesions. No epidural collections. No paraspinal
collections.
There is multilevel shallow disc bulges involving levels T3-4
through T7-8
which partially effaces the CSF space anterior to the cord but
there is no
cord compromise. No abnormal cord signal intensity.
There is no high-grade neural foraminal stenosis
OTHER: Minimal retained secretions/aspiration present in the
trachea. Retained
secretions also present in the right ___ and oropharynx. Note
is made of a
right-sided pleural effusion and nonspecific airspace
opacification.
Incompletely image right lobe of liver lesion (series 31, image
32).
IMPRESSION:
1. Diffuse cervical, thoracic and upper lumbar spine as well as
rib sclerotic
osseous metastatic disease. No pathological vertebral body
fractures.
2. No compromise of the cervical cord in the cervical spinal
canal. Neural
foraminal stenosis most prominent at the C6-7 level as described
above.
3. No compromise of the thoracic cord in the spinal canal. No
high-grade
neural foraminal stenosis.
4. Retained secretions/aspirate present in the trachea.
5. Right-sided pleural effusion with associated airspace
opacification for
which dedicated chest imaging is advised.
6. Incompletely imaged right lobe of liver lesion for which
dedicated imaging
is advised if clinically indicated.
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old woman with metastatic breast cancer//
eval for
metastatic breast cancer.
TECHNIQUE: Sagittal and axial T1 weighted imaging were
performed. After
administration of intravenous contrast, axial imaging was
performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: None.
FINDINGS:
There is a 7 mm focus of enhancement at the gray-white matter
junction of the
right cerebellar lobe (14:54, 70:80). In addition, there are at
least 3
additional foci of enhancement in the bilateral cerebellar
lobes, some of
which are near the gray-white matter junction (7:97, 76, 72).
There are
additional 4 mm enhancing foci in the bilateral anterior frontal
lobes near
the vertex, at the gray-white matter junction (17:53, 51).
These lesions do
not have corresponding findings on remaining sequences.
Moreover, there is no
evidence of surrounding edema on FLAIR sequences. No evidence
of diffusion
abnormalities within these lesions. Additionally there is right
frontal
pachymeningeal enhancement which is also suggestive of
metastatic disease.
There is no evidence of hemorrhage, edema, mass effect, midline
shift or
infarction.
The ventricles and sulci are normal in caliber and
configuration. The basal
cisterns are patent. The major intracranial flow voids are
preserved. The
dural venous sinuses are patent on post-contrast MPRAGE
sequences. The
paranasal sinuses are clear. The orbits are unremarkable.
IMPRESSION:
1. Several supratentorial and infratentorial subcentimeter foci
of
enhancement, without surrounding edema or correlate associated
findings, are
too small to fully characterize however are suspicious for
metastatic lesions
in the setting of primary malignancy.
2. Right frontal pachymeningeal enhancement is also suggestive
of metastatic
disease.
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with PE// eval for dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation
was performed
on the bilateral lower extremity veins.
COMPARISON: No prior similar.
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the tibial and peroneal
veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Sertraline 250 mg PO QPM
3. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
4. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO TID:PRN Pain
- Moderate
5. Fentanyl Patch 25 mcg/h TD Q48H
6. Pantoprazole 40 mg PO DAILY
7. Zolpidem Tartrate 10 mg PO QHS
8. Aspirin 81 mg PO QPM
9. Cyanocobalamin 50 mcg PO DAILY
10. Vitamin D 5000 UNIT PO DAILY
11. Cyclobenzaprine 10 mg PO TID:PRN spasm
12. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s)
by mouth every 6 hours Disp #*120 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once on
___ Disp #*1 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 10 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH
PAIN
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily Refills:*0
7. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Start: After 30 mg DAILY tapered dose
This is dose # 3 of 4 tapered doses
8. PredniSONE 10 mg PO DAILY Duration: 2 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 4 of 4 tapered doses
9. PredniSONE 40 mg PO DAILY Duration: 2 Doses
This is dose # 1 of 4 tapered doses
RX *prednisone 10 mg taper tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
10. PredniSONE 30 mg PO DAILY Duration: 2 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 2 of 4 tapered doses
11. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tab by mouth twice a day Disp #*60
Tablet Refills:*0
12. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
13. Aspirin 81 mg PO QPM
14. Cyanocobalamin 50 mcg PO DAILY
15. Cyclobenzaprine 10 mg PO TID:PRN spasm
16. Fentanyl Patch 25 mcg/h TD Q48H
17. Gabapentin 800 mg PO TID
18. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
19. Pantoprazole 40 mg PO DAILY
20. Sertraline 250 mg PO QPM
21. Vitamin D 5000 UNIT PO DAILY
22. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Possible right sided pulmonary embolism that per oncology does
not require anticoagulation.
Bony spine metastatic breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with PE// eval for dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: No prior similar.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
INDICATION: ___ year old woman with tunneled cath// tunneled catheter line
placement
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. Right-sided central line is seen terminating within the
mid SVC. There is mild pulmonary vascular congestion. Moderate right-sided
pleural effusion is seen. Opacity at the right lung base is seen. Mild left
basilar atelectasis seen. Visualized osseous structures are unremarkable. No
evidence of pneumothorax.
IMPRESSION:
1. No evidence of pneumothorax.
2. Moderate right-sided pleural effusion with adjacent opacities likely
secondary to atelectasis however a superimposed infectious process cannot be
excluded.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old woman with metastatic breast cancer// eval for
metastatic breast cancer.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: None.
FINDINGS:
There is a 7 mm focus of enhancement at the gray-white matter junction of the
right cerebellar lobe (14:54, 70:80). In addition, there are at least 3
additional foci of enhancement in the bilateral cerebellar lobes, some of
which are near the gray-white matter junction (7:97, 76, 72). There are
additional 4 mm enhancing foci in the bilateral anterior frontal lobes near
the vertex, at the gray-white matter junction (17:53, 51). These lesions do
not have corresponding findings on remaining sequences. Moreover, there is no
evidence of surrounding edema on FLAIR sequences. No evidence of diffusion
abnormalities within these lesions. Additionally there is right frontal
pachymeningeal enhancement which is also suggestive of metastatic disease.
There is no evidence of hemorrhage, edema, mass effect, midline shift or
infarction.
The ventricles and sulci are normal in caliber and configuration. The basal
cisterns are patent. The major intracranial flow voids are preserved. The
dural venous sinuses are patent on post-contrast MPRAGE sequences. The
paranasal sinuses are clear. The orbits are unremarkable.
IMPRESSION:
1. Several supratentorial and infratentorial subcentimeter foci of
enhancement, without surrounding edema or correlate associated findings, are
too small to fully characterize however are suspicious for metastatic lesions
in the setting of primary malignancy.
2. Right frontal pachymeningeal enhancement is also suggestive of metastatic
disease.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:20 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old woman with metastatic breast cancer// eval for
metastatic cancer
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of 9 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: None.
FINDINGS:
CERVICAL:
The visualized elements of the posterior fossa and craniocervical junction are
unremarkable. The cervical cord is normal in volume, signal intensity and
morphology. No abnormal enhancement. No epidural collection.
There is extensive replacement of the normal fatty marrow which in some areas
demonstrate mild associated enhancement most obvious in C2 and C4 vertebral
bodies in keeping with diffuse osseous metastatic disease.
Degenerative changes of the cervical spine in the form of disc desiccation,
mild broad-based disc bulge, facet joint osteophytosis and ligamentum flavum
hypertrophy as described below:
C2-3: Both neural foramina are patent, there is no evidence of spinal canal
stenosis
C3-4: There is mild bilateral uncovertebral hypertrophy resulting in
mild-to-moderate bilateral neural foraminal narrowing, there is no evidence of
central spinal canal stenosis.
C4-5: There is mild bilateral uncovertebral hypertrophy cause and mild
left-sided neural foraminal narrowing, the right neural foramina appears
normal, there is no evidence of spinal canal stenosis no cord or nerve root
compromise.
C5-6: There is mild disc bulge causing mild anterior thecal sac deformity,
mild uncovertebral hypertrophy is producing mild bilateral neural foraminal
narrowing with no evidence of neural compression, there is a perineural cyst
on the left (20:21). No cord or nerve root compromise.
C6-7: No cord compromise. Right uncovertebral hypertrophy is causing moderate
to severe right neural foraminal narrowing. There is no evidence of central
spinal canal stenosis, the left neural foramina appears patent.
C7-T1: No cord or nerve root compromise.
THORACIC:
Diffuse osseous metastatic disease involving the vertebral bodies as well as
thoracic ribs. Very minimal preserved normal marrow. Multilevel endplate
insufficiency fractures, but no insufficiency wedge-type compression
fractures. No marked body height loss.
The thoracic cord is normal in volume, signal intensity and morphology. No
cord lesions. No epidural collections. No paraspinal collections.
There is multilevel shallow disc bulges involving levels T3-4 through T7-8
which partially effaces the CSF space anterior to the cord but there is no
cord compromise. No abnormal cord signal intensity.
There is no high-grade neural foraminal stenosis
OTHER: Minimal retained secretions/aspiration present in the trachea. Retained
secretions also present in the right ___ and oropharynx. Note is made of a
right-sided pleural effusion and nonspecific airspace opacification.
Incompletely image right lobe of liver lesion (series 31, image 32).
IMPRESSION:
1. Diffuse cervical, thoracic and upper lumbar spine as well as rib sclerotic
osseous metastatic disease. No pathological vertebral body fractures.
2. No compromise of the cervical cord in the cervical spinal canal. Neural
foraminal stenosis most prominent at the C6-7 level as described above.
3. No compromise of the thoracic cord in the spinal canal. No high-grade
neural foraminal stenosis.
4. Retained secretions/aspirate present in the trachea.
5. Right-sided pleural effusion with associated airspace opacification for
which dedicated chest imaging is advised.
6. Incompletely imaged right lobe of liver lesion for which dedicated imaging
is advised if clinically indicated.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PE, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale, Secondary malignant neoplasm of unspecified lung, Secondary malignant neoplasm of bone marrow
temperature: 96.4
heartrate: 96.0
resprate: 20.0
o2sat: 94.0
sbp: 116.0
dbp: 70.0
level of pain: 7
level of acuity: 2.0 | ___ female with the past medical history of breast
cancer w/ metastasis to bone and lung on chemotherapy, chronic
hypoxemic respiratory failure on 2L home O2, depression,
anxiety, claustrophobia, ocular migraines, GERD, osteopenia who
presents as a transfer from ___ with left chest pain and
new brain lesion, right back parasthesias, vision changes, and
incidental finding of right-sided PE.
#Metastatic breast cancer to lungs, bone, now concerning for
progression with metastasis to brain and possibly C/T spine
-Oncology consulted who recommended MRI brain/spine, neuro-onc
consult.
The patient was set up with anaesthesia assisted MRI at ___
___, the patient went for MRI on ___ and returned. Small
lesions were noted in brain, and metastatic bony spine disease
was noted. The patient should follow up with her PCP and
oncologist.
-As outpt she is on palliative chemo with home eribulen cycle 7
pending restaging prior to next cycle on ___
#Left-sided chest pain - with positional changes and improvement
with her physically holding her left side, this does not seem to
be related to her PE but likely from metastatic disease and
possibly MSK as she fell and hit her chest a few days prior to
___ onto her left chest
- No report of fracture from CT chest
- Increase Oxycodone from Percocet ___ to Oxycodone ___ PO
q4 PRN
-Use additional oxycodone for breatkthrough pain
- Cont home flexaril
- Continue 2 long-acting narcotics, home Oxycontin and Fentanyl
-Patient removed home lidocaine patch because it hurt her left
chest, will dc now
- Added bowel regimen
-Recommend PCP follow up for pain control
#Pulmonary embolism of unknown chronicity of right lung, it was
not recorded in CTA from ___, but it was noted on discussion
with reading radiologist
-No AC was recommended by consulting services
#Increased SOB and wheezing without overt increase in secretions
or O2 requirements with bilateral wheezing likely d/t COPD
exacerbation, she has a home inhaler that as of ___ was
recorded as not using often
-Levaquin switched to PO, c/u solumedrol, and q6h duoneb
-Monitor for improvement
-Patient uses home ventolin - hold now, may need change to home
medications on discharge
#Leukocytosis - different report from OSH that reportedly showed
WBC of 2.1 and here it is 23. Looks like the patient received
dexamethasone 22 milligrams at OSH. Generally she is neutropenic
due to chemo on neupogen at times. She has wbc count 9.1 now.
- Likely related to steroid therapy, monitor
#Anxiety/Depression - home Zoloft
#Chronic neuropathy - gabapentin
#Osteopenia - Vitamin D
Transitional
Follow up with PCP and oncology as outpatient in ___ weeks,
please call to schedule appointments, I have emailed your PCP
___ manage your pain, and do not operate heavy machinery
while on pain control |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
___: ERCP
___ laparoscopic cholecystectomy with liver biopsy x 3
History of Present Illness:
___ now admitted for evaluation and treatment of jaundice
suspected to be caused by choledocolithiasis with biliary
obstruction. He was hospitalized at ___
this past week and discharged home yesterday. During that stay
he had elevated bili, jaundice and underwent ercp that showed
filling defects c/w cbd stones removed w sphinceterotomy and
balloon extraction w PD stent placement. Following ERCP
Performed on ___ he had eelevation of lipase to 2200 consistent
w post ercp pancreatitis and his bile never normalized so he
underwent MRCP that did not show residual biliary tree filling
defects and he was discharged home on ___.
When he returned home he felt that his jaundice worsened and
that he had fluid rise from his lungs to his throat that
improved w sitting up. He has experienced moderate RUQ
discomfort.
ROS he has not had fevers, chills or emesis, difficulty
breathing, peripheral edema. He has had 1 week of constipation.
13pt ROS is otherwise negative
Past Medical History:
gallstones known to exist since ___
HTN
HBV positive status
Social History:
___
Family History:
not pertinent to current management
Physical Exam:
98.3 147/78 58
jaundice present w scleral icterus
not confused
interviewed w ___
clear lungs
regular s1 and s2
soft abdomen, slight grimace w palpation in ruq, no rebound
abd not distended
no peripheral edema or rash
moves all extremities, no focal neuro defects
calm
Pertinent Results:
___ 05:40AM BLOOD WBC-9.3 RBC-3.33* Hgb-9.4* Hct-28.2*
MCV-85 MCH-28.2 MCHC-33.3 RDW-12.1 RDWSD-37.1 Plt ___
___ 05:50AM BLOOD WBC-9.4 RBC-3.15* Hgb-8.9* Hct-27.1*
MCV-86 MCH-28.3 MCHC-32.8 RDW-12.1 RDWSD-37.9 Plt ___
___ 04:00PM BLOOD WBC-10.8* RBC-4.18* Hgb-12.1* Hct-36.3*
MCV-87 MCH-28.9 MCHC-33.3 RDW-12.4 RDWSD-39.3 Plt ___
___ 06:15AM BLOOD WBC-11.9*# RBC-4.23* Hgb-12.3* Hct-36.8*
MCV-87 MCH-29.1 MCHC-33.4 RDW-12.6 RDWSD-39.8 Plt ___
___ 05:40AM BLOOD Plt ___
___ 09:40AM BLOOD ___ PTT-30.5 ___
___ 05:40AM BLOOD Glucose-93 UreaN-8 Creat-0.8 Na-132*
K-3.8 Cl-97 HCO3-25 AnGap-14
___ 05:50AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-135
K-3.6 Cl-99 HCO3-24 AnGap-16
___ 05:40AM BLOOD ALT-72* AST-68* AlkPhos-115 TotBili-3.3*
___ 05:50AM BLOOD ALT-74* AST-67* AlkPhos-106 TotBili-3.7*
___ 04:10AM BLOOD ALT-67* AST-54* AlkPhos-97 TotBili-3.9*
DirBili-2.6* IndBili-1.3
___ 09:40AM BLOOD ALT-71* AST-46* AlkPhos-94 TotBili-4.6*
___ 04:00PM BLOOD ALT-131* AST-78* AlkPhos-137*
TotBili-9.2* DirBili-6.4* IndBili-2.8
___ 05:55AM BLOOD TotBili-8.3* DirBili-5.9* IndBili-2.4
___ 10:54AM BLOOD ALT-166* AST-114* AlkPhos-124
TotBili-8.3* DirBili-5.4* IndBili-2.9
___ 05:05AM BLOOD TotBili-8.0* DirBili-5.4* IndBili-2.6
___ 03:15PM BLOOD CK(CPK)-112
___ 09:55AM BLOOD CK(CPK)-121
___ 06:15AM BLOOD TotBili-6.5* DirBili-3.7* IndBili-2.8
___ 03:35PM BLOOD TotBili-5.8* DirBili-3.6* IndBili-2.2
___ 11:00AM BLOOD ALT-71* AST-71* AlkPhos-175* TotBili-9.8*
DirBili-4.7* IndBili-5.1
___ 04:00PM BLOOD Lipase-67*
___ 05:25AM BLOOD Lipase-173*
___ 06:30AM BLOOD Lipase-352*
___ 05:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
___ DUPLEX DOP ABD/PEL LIMI
IMPRESSION:
1. Cholelithiasis with minimal gallbladder wall edema. The
gallbladder is
minimally distended. These findings are concerning for possible
cholecystitis.
2. No choledocholithiasis seen ultrasound however the common
bile duct
measures 10 mm and a distal common bile duct stone cannot be
excluded.
___ CXR
IMPRESSION:
1. Low lung volumes. No acute cardiopulmonary process.
2. Right upper quadrant calcified gallstone.
___ CT ABDOMEN
IMPRESSION:
1. Pneumobilia and CBD stent in place without significant intra
or
extrahepatic biliary ductal dilatation.
2. Multiple large stones within the gallbladder, including a 1.9
cm stone at the gallbladder neck. No CT signs of acute
cholecystitis.
Liver biopsy ___ see report
EKG ___
Sinus rhythm. Borderline left atrial abnormality. Q waves in the
inferior
leads potentially consistent with an old anterior myocardial
infarction of
indeterminate age. Compared to the previous tracing of ___
the findings are similar.
___ CT abdomen
Multiple dilated loops of small bowel with air-fluid levels,
concerning for small bowel obstruction. While the presence of
air in the colon likely favors a partial obstruction, a complete
obstruction cannot be definitively ruled out.
___ MRCP
IMPRESSION:
1. Heterogeneous material in the gallbladder fossa, as
described above,
likely represents Surgicel and a small amount of surrounding
hematoma.
2. Limited evaluation for bile leak given the patient's
bilirubin, though no obvious bile leak is visualized. A small
one cannot be completely excluded.
3. No biliary duct dilation or choledocholithiasis. The common
bile duct
stent is in satisfactory position and pneumobilia suggests it is
patent.
4. Small bowel ileus.
5. Trace ascites and free air, which is likely post-surgical.
6. Dropped gallstones along the right lobe of liver.
7. Small right and trace left pleural effusions.
___ CT ABDOMEN AND PELVIS
IMPRESSION:
1. Diffusely dilated loops of small bowel, compatible with an
ileus. No focal transition point is identified.
2. Common bile duct stent with pneumobilia, suggesting patency
of the stent. No biliary duct dilation.
3. Surgicel and a small amount of hematoma in the gallbladder
fossa, unchanged from the prior MRCP. While no well-organized
fluid collection is identified,
a small biliary leak is difficult to completely exclude. If
definitive
evaluation for leak is needed, consider direct injection of the
duct by ERCP, as the Eovist MRCP was inadequate and there would
also likely be inadequate excretion of tracer on a hepatobiliary
nuclear scan due to the patient's liver function.
Alternatively, close imaging follow-up would be appropriate to
see
if a discrete fluid collection develops.
4. Small amount of free air, which is presumably post-surgical.
5. Small amount of layering evolving hemoperitoneum in the
pelvis, which is also likely post-operative.
6. Several dropped gallstones.
7. Small hematoma at the upper anterior abdominal wall port
site.
8. Small right and trace left pleural effusion with associated
basilar
atelectasis.
___ GALLBLADDER SCAN
IMPRESSION: Patent biliary collecting system. No evidence of
biliary leak.
___ 5:25 am IMMUNOLOGY
**FINAL REPORT ___
HBV Viral Load (Final ___:
3,840 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
Medications on Admission:
oxycodone 5mg PRN q8hr
dulcolax 100mg PO BID
protonix 40mg daily
unknown anti-hypertensive
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
hold for loose stool
3. Pantoprazole 40 mg PO Q24H
4. Bisacodyl 10 mg PO DAILY:PRN Constipation
5. Lactulose 30 ml PO Q8H:PRN Constipation
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Sarna Lotion 1 Appl TP QID:PRN pruritus
8. Senna 8.6 mg PO BID:PRN Constipation
hold for loose stool
9. Simethicone 40-80 mg PO QID:PRN gas pain
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocolithiasis with biliary obstruction and
hyperbilirubinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with cp, abd pain, recent admission. Evaluate for
pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
Lung volumes are slightly low. No focal consolidation, edema, effusion, or
pneumothorax. The cardiomediastinal silhouette is unremarkable. No acute
osseous abnormality. A large, round opacity projecting in the right upper
quadrant over the expected region of the gallbladder may represent a known
large gallstone on recent ultrasound from ___.
IMPRESSION:
1. Low lung volumes. No acute cardiopulmonary process.
2. Right upper quadrant calcified gallstone.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with jaundice, RUQ abd pain, known cholelithiasis,
recent ERCP*** WARNING *** Multiple patients with same last name! // r/o
cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound on ___.
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 10 mm.
GALLBLADDER: There is a large gallstones seen adjacent to the neck of the
gallbladder. There is mild gallbladder wall edema and the gallbladder is
minimally distended.
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 10.7 cm.
KIDNEYS: The right kidney measures 10.1 cm. The left kidney measures 11.0 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis with minimal gallbladder wall edema. The gallbladder is
minimally distended. These findings are concerning for possible
cholecystitis.
2. No choledocholithiasis seen ultrasound however the common bile duct
measures 10 mm and a distal common bile duct stone cannot be excluded.
RECOMMENDATION(S): Consider MRCP for further evaluation of
choledocholithiasis and cholecystitis if clinically indicated.
Radiology Report
INDICATION: ___ year old man with choledocolithiasis, assess degree of biliary
ductal dilatation.
TECHNIQUE: Multidetector CT images of the abdomen were acquired following
administration of intravenous contrast. No oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
4) Spiral Acquisition 2.6 s, 28.9 cm; CTDIvol = 6.8 mGy (Body) DLP = 196.9
mGy-cm.
Total DLP (Body) = 210 mGy-cm.
COMPARISON: Abdominal ultrasound from ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is slight heterogeneity to the background liver
parenchyma, particularly in segment 4A, likely a perfusion anomaly. There is
pneumobilia as well as air within the common bile duct. A CBD stent is
identified in satisfactory position. There is no significant intra or
extrahepatic biliary ductal dilatation. Large gallstones are seen within the
gallbladder, one of which is seen at the neck measuring 1.9 cm. The largest
is within the gallbladder body measuring 3.1 cm. An air-fluid level is seen
within the gallbladder at the fundus, likely related to recent ERCP. There is
no gallbladder wall thickening or pericholecystic fluid. The portal vein is
patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions. 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 suspicious focal renal lesions. There is no hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Visualized small bowel loops
demonstrate normal caliber and wall thickness. The visualized colon is
unremarkable.
LYMPH NODES: There is no evidence of retroperitoneal or mesenteric
lymphadenopathy.
VASCULAR: There is no upper 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. Pneumobilia and CBD stent in place without significant intra or
extrahepatic biliary ductal dilatation.
2. Multiple large stones within the gallbladder, including a 1.9 cm stone at
the gallbladder neck. No CT signs of acute cholecystitis.
Radiology Report
INDICATION: ___ year old man with PMH of Hep B s/p CCY for cholecystitis with
uptrending bilirubin, fever, abdominal distention and pain // Please assess
for ileus, obstruction and free air
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen dated ___
FINDINGS:
There are multiple dilated loops of small bowel, the largest measuring 4.5 cm,
with multiple air-fluid levels. Some air is seen in the colon. There are no
abnormally dilated loops of large bowel. Pneumoperitoneum is seen,
consistent with expected postoperative changes.
Osseous structures are unremarkable. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies. Note is made of a CBD stent.
IMPRESSION:
Multiple dilated loops of small bowel with air-fluid levels, concerning for
small bowel obstruction. While the presence of air in the colon likely favors
a partial obstruction, a complete obstruction cannot be definitively ruled
out.
Radiology Report
EXAMINATION: MRCP
INDICATION: History of hepatitis-B, status post cholecystectomy for
cholecystitis with rising bilirubin, abdominal pain, and distention. Evaluate
for bile leak, retained stone, or other biliary obstruction.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 3.5 mL Gadavist and 7 mm Eovist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
Lower Thorax: There is a small right and trace left pleural effusion. There
is associated basilar atelectasis. The base of the heart is normal in size.
There is no pericardial effusion.
Liver: The liver is normal in size. There is no hepatic steatosis.
Evaluation of the liver is limited by motion. Within the limitations, in
segment 4A/B, there is a wedge-shaped area of arterial hyperenhancement (12,
27), which normalizes on the delayed phases. This is similar to the prior CT
from ___. Given the stability, it is likely a perfusional
abnormality. Similar smaller foci of arterial hyperenhancement are noted
around the gallbladder fossa, and are also likely perfusional. No focal
worrisome liver lesions are identified. The hepatic arterial anatomy cannot
be determined due to motion. The portal and hepatic veins are patent.
Biliary: The patient is status post a cholecystectomy. In the gallbladder
fossa, there is ill-defined heterogeneous T2 hyperintense and mixed T1
hyperintense and hypointense material, as well as a few locules of air. This
likely represents Surgicel surrounded by a small amount of blood. This
collection is not significantly enhancing to suggest that is superinfected.
Evaluation for a bile leak is limited, as the patient's bilirubin is elevated
which inhibits hepatobiliary excretion of Eovist. On the 4 hour delayed
images, there still is not significant Eovist within the biliary system to
completely exclude a leak. However, the material in the gallbladder fossa
appears to represent primarily hematoma and Surgicel, and no sizeable simple
fluid collection is identified to suggest an ongoing leak, although small leak
cannot be excluded.
There is no intrahepatic biliary duct dilation. A stent stent is in place in
the common bile duct. It appears patent, as there is pneumobilia upstream to
the stent. A linear defect in the common bile duct is compatible with the
known stent. There is no large stone.
Susceptibility artifact posterior to the right lobe of the liver likely
represents small dropped gallstones. There is pneumoperitoneum.
Pancreas: The pancreatic parenchyma is normal in signal and enhances
homogeneously. There is no duct dilation or mass.
Spleen: The spleen is normal in size, measuring 11.5 cm. No focal lesion is
identified.
Adrenal Glands: The bilateral adrenal glands are normal.
Kidneys: The kidneys are normal in size. A few tiny cysts are noted in the
right kidney. There are no worrisome renal lesions, hydronephrosis, or
perinephric abnormalities.
Gastrointestinal Tract: The stomach is distended and fluid-filled.
Additionally, all the visualized small bowel loops are distended and
fluid-filled with air-fluid levels. No focal obstruction is identified. This
suggests an ileus. Note, the entire small bowel is not included in the field
of view. The imaged portions of the large bowel are normal. There is very
trace perihepatic ascites. A small amount of free air is identified. It is
mostly anterior to the liver. This is in keeping with a recent surgery.
Lymph Nodes: There is no periportal, retroperitoneal, or mesenteric
lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber without evidence of an
aneurysm or significant atherosclerotic plaque.
Osseous and Soft Tissue Structures: There are no concerning osseous lesions.
Mild multilevel degenerative changes are noted in the spine. Postsurgical
changes are noted in the anterior abdominal wall. There is a small hematoma
along the port site (16, 29). There is no evidence of a hernia. The soft
tissues are otherwise unremarkable.
IMPRESSION:
1. Heterogeneous material in the gallbladder fossa, as described above,
likely represents Surgicel and a small amount of surrounding hematoma.
2. Limited evaluation for bile leak given the patient's bilirubin, though no
obvious bile leak is visualized. A small one cannot be completely excluded.
3. No biliary duct dilation or choledocholithiasis. The common bile duct
stent is in satisfactory position and pneumobilia suggests it is patent.
4. Small bowel ileus.
5. Trace ascites and free air, which is likely post-surgical.
6. Dropped gallstones along the right lobe of liver.
7. Small right and trace left pleural effusions.
NOTIFICATION: Initial findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 7:49 ___, 20 minutes after discovery of the
findings.
Radiology Report
INDICATION: History of hepatitis-B, gallstones, and recent ERCPs and
laparoscopic cholecystectomy. Evaluate for leak or free air.
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 via an NG tube.
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 8.5 s, 1.0 cm; CTDIvol = 19.7 mGy (Body) DLP =
19.7 mGy-cm.
3) Spiral Acquisition 15.0 s, 51.6 cm; CTDIvol = 8.6 mGy (Body) DLP = 429.9
mGy-cm.
Total DLP (Body) = 464 mGy-cm.
COMPARISON: MRCP from ___. CT of the abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST: There is a small right and trace left pleural effusion. There is
associated bibasilar atelectasis. No discrete nodules are identified. The
base of the heart is normal in size. There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. The portal veins are patent. There is
no intrahepatic biliary duct dilation. Pneumobilia is noted. This suggests
patency of the bile duct stent. The common bile duct stent appears to be in
satisfactory position. The gallbladder is surgically absent. Within the
gallbladder fossa, there is heterogeneous material, compatible with Surgicel.
A small rim of slightly hyperdense fluid around the Surgicel likely represents
a resolving hematoma. Overall, this is not significantly changed from the
prior MRCP from 1 day prior. There is no organized fluid collection. A small
biliary leak cannot be completely excluded. Several calcifications are noted
along the posterior inferior aspect of the liver that were not present on the
pre-operative CT. These are compatible with dropped gallstones.
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 worrisome focal renal lesions or hydronephrosis. A
tiny cyst is noted in the upper pole the right kidney. There is no
perinephric abnormality.
GASTROINTESTINAL: There is small amount of free air layering anterior to the
liver. It is unchanged from the prior MRCP. An NG tube is in satisfactory
position with the tip in the stomach. The stomach and duodenum are not
distended. In the jejunum, the small bowel loops become dilated, measuring up
to 3.2 cm. There is no discrete transition point. A few segments of distal
ileum are noted to be nondilated, though likely due to peristalsis. This is
most compatible with an ileus.
There is mild wall thickening of the colon at the hepatic flexure, likely due
to secondary inflammatory changes from the recent surgery. The remainder of
the large bowel is normal. There is no dilation. The appendix is normal.
There is a small amount of partially hemorrhagic fluid layering in the pelvis
as well as trace fluid around the liver. This is nonspecific, though likely
post-operative.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged, measuring 4.5 cm in the
transverse dimension. There are multiple small calcifications. The
reproductive organs are otherwise normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild multilevel degenerative changes are noted in the lumbar spine.
SOFT TISSUES: There is subcutaneous air along the anterior upper abdomen, near
the site of the port placement. Also at the site of the poor placement, there
is a 32 x 16 mm hematoma which extends both superficially and deep to the port
site (5, 28). There is a small amount of stranding around the umbilicus,
which is presumably another port site. This is expected post-operatively. No
focal hematoma is identified in this location. There is no evidence of a
hernia.
IMPRESSION:
1. Diffusely dilated loops of small bowel, compatible with an ileus. No focal
transition point is identified.
2. Common bile duct stent with pneumobilia, suggesting patency of the stent.
No biliary duct dilation.
3. Surgicel and a small amount of hematoma in the gallbladder fossa, unchanged
from the prior MRCP. While no well-organized fluid collection is identified,
a small biliary leak is difficult to completely exclude. If definitive
evaluation for leak is needed, consider direct injection of the duct by ERCP,
as the Eovist MRCP was inadequate and there would also likely be inadequate
excretion of tracer on a hepatobiliary nuclear scan due to the patient's liver
function. Alternatively, close imaging follow-up would be appropriate to see
if a discrete fluid collection develops.
4. Small amount of free air, which is presumably post-surgical.
5. Small amount of layering evolving hemoperitoneum in the pelvis, which is
also likely post-operative.
6. Several dropped gallstones.
7. Small hematoma at the upper anterior abdominal wall port site.
8. Small right and trace left pleural effusion with associated basilar
atelectasis.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: Dizziness, Jaundice, Abd pain
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst
temperature: 97.7
heartrate: 71.0
resprate: 22.0
o2sat: 100.0
sbp: 124.0
dbp: 82.0
level of pain: 9
level of acuity: 2.0 | ___ year old gentleman who was admitted to an outside hospital
with nausea, vomiting, jaundice and abdominal pain. Imaging
showed choledocholithiasis. He underwent an ERCP with
sphincterotomy, extraction of stones, and placement of a
pancreatic duct stent. He developed post-ERCP pancreatitis with
an elevated lipase and was noted to have persistently elevated
LFTs. An MRCP was obtained after the ERCP which showed no
choledocholithiasis. He was discharged from ___ on
___ and presented here on ___ with chills, nausea, dark urine,
jaundice and RUQ pain. He was afebrile upon admission with
normal WBC, but a total bilirubin of 9.8. An ultrasound was
done which showed a CBD 10 mm, cholelithiasis with a large stone
in gallbladder neck. The patient's liver function tests were
elevated and Hepatology was consulted. The patient underwent a
cat scan of the abdomen which showed pneumobilia as well as air
within the common bile duct. There were gallstones in the
gallbladder neck.
He was taken to the operating room on ___ where he underwent a
laparoscopic cholecystectomy and a liver biopsy. His operative
course was notable for a 200 cc blood loss. He was extubated
after the procedure and monitored in the recovery room. On POD
#1, the patient reported chest pressure. He was given aspirin
and cardiac enzymes were cycled. The cardiac enzymes were
normal. He became febrile on POD #2, spiking to 102.5. Imaging
studies were done which showed dilated loops of small bowel
concerning for small bowel obstruction. The patient had a
___ tube placed for bowel decompression and was made
NPO and started on a course of cefepime and flagyl. He was
continued NPO with NG decompression until he passed gas and had
a bowel movement, at which time he was advanced to a regular
diet. He was able to tolerate the diet well and transitioned to
oral pain medications, and was discharged home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Intra-articular fracture of the right distal humerus
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of right distal humerus
fracture
History of Present Illness:
___ female presents with the above fracture s/p
dancing. Patient was at a nightclub dancing, and felt a sudden
sharp pain in her right elbow. She holds it in comfort in
flexion. No pain radiating down the arm. No numbness/tingling.
Otherwise feeling well.
Past Medical History:
Healthy
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals: AVSS, Afebrile
General: Well-appearing female in no acute distress.
Right upper extremity:
- Splint C/D/I without significant strikethrough
- No pain with passive stretch of the fingers/wrist
- Full, painless ROM at wrist and digits
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Pertinent Results:
___ 12:47PM BLOOD WBC-14.1* RBC-4.33 Hgb-12.8 Hct-38.1
MCV-88 MCH-29.6 MCHC-33.6 RDW-12.6 RDWSD-40.7 Plt ___
___ 08:20AM BLOOD WBC-16.0* RBC-4.23 Hgb-12.3 Hct-36.3
MCV-86 MCH-29.1 MCHC-33.9 RDW-12.7 RDWSD-39.8 Plt ___
___ 08:20AM BLOOD Neuts-81.7* Lymphs-11.6* Monos-5.9
Eos-0.0* Baso-0.4 Im ___ AbsNeut-13.08* AbsLymp-1.86
AbsMono-0.94* AbsEos-0.00* AbsBaso-0.06
___ 12:47PM BLOOD Plt ___
___ 12:47PM BLOOD ___ PTT-29.0 ___
___ 08:20AM BLOOD Plt ___
___ 08:20AM BLOOD ___ PTT-27.3 ___
___ 12:47PM BLOOD Glucose-75 UreaN-15 Creat-0.8 Na-140
K-4.5 Cl-103 HCO3-22 AnGap-15
___ 08:20AM BLOOD Glucose-84 UreaN-13 Creat-0.7 Na-138
K-4.8 Cl-102 HCO3-19* AnGap-17
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY Duration: 28 Days
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Intra-articular distal humerus fracture - RIGHT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT upper extremity without contrast
INDICATION: ___ year old woman with RUE fracture// eval fracture
TECHNIQUE: ___ MD CT imaging was performed through the right elbow without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed
DOSE: 197 mGy-cm
COMPARISON: Right elbow radiographs ___ and ___
FINDINGS:
As seen on the prior radiographic studies there is a displaced, angulated
supracondylar fracture of the distal humerus with intercondylar extension.
There is posterior displacement of the distal fracture fragments by
approximately 1 cm and dorsal angulation by approximately 65 degrees. There
is mild distraction of the articular surface by approximately 2-3 mm (7:86).
Small bony fragments are seen anteriorly in the joint space. A larger
intra-articular fragment is seen posteriorly (7:87) measuring 1.2 x 0.7 cm.
No additional fractures are seen. The articular surfaces remain congruent.
There is a moderate joint effusion.
IMPRESSION:
Comminuted supracondylar fracture of the right humerus with intra-articular
extension. Moderate joint effusion, presumed hemarthrosis.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS RIGHT
INDICATION: ORIF RIGHT DISTAL HUMERUS FX IN O.R.
IMPRESSION:
Fluoroscopic documentation of elbow fixation. No radiologist was present.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS RIGHT
INDICATION: History: ___ with R elbow injury// fx/dislocation
fx/dislocation
fx/dislocation
TECHNIQUE: Single view of the right elbow
COMPARISON: None
FINDINGS:
There is a comminuted and anteriorly displaced fracture of the distal humerus.
A lucency anterior to the fracture may represent a displaced fracture
fragment. Single view of the proximal radius and ulna do not not reveal any
fractures. There is a small joint effusion.
IMPRESSION:
Single-view of a comminuted and anteriorly displaced fracture of the distal
humerus.
Radiology Report
INDICATION: ___ with distal humerus fx// please obtain AP/Lat/Oblique views
COMPARISON: Prior from 5 hours earlier as well as a CT of the right elbow
FINDINGS:
Single lateral view of the right elbow provided. Better assessed on same-day
CT is an acute fracture involving the distal humerus with an oblique
supracondylar component. There is mild posterior displacement of the distal
fracture fragment. A joint effusion is noted given elevation of anterior and
posterior fat pads.
IMPRESSION:
Posteriorly displaced fracture of the right distal humerus with joint
effusion. Please refer to same-day CT for further details.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with right knee pain// R/o fx/dislocation
TECHNIQUE: Three views of the right knee
COMPARISON: None
FINDINGS:
No fracture or dislocation is seen. There are no significant degenerative
changes. There is no knee joint effusion. There is normal osseous
mineralization. No suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
No acute fracture or dislocation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Arm injury
Diagnosed with Oth disp fx of lower end of right humerus, init for clos fx, Exposure to other specified factors, initial encounter
temperature: 97.8
heartrate: 85.0
resprate: 16.0
o2sat: 100.0
sbp: 158.0
dbp: 138.0
level of pain: 10
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have intra-articular fracture of the distal right humerus and
was admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for open reduction and
internal fixation of right distal humerus fracture, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing to the right upper extremity in a splint to
remain in place until follow-up. The patient will be discharged
on aspirin 325 mg to be taken daily for 4 weeks for DVT
prophylaxis. The patient will follow up with Dr. ___ in 2
weeks. A thorough discussion was had with the patient regarding
the diagnosis and expected post-discharge course including
reasons to call the office or return to the hospital, and all
questions were answered. The patient was also given written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient expressed readiness for
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cardizem / Motrin
Attending: ___.
Chief Complaint:
L periprosthetic hip fracture around hemiarthroplasty
Major Surgical or Invasive Procedure:
L periprosthetic hip fracture around hemiarthroplasty, now s/p
ORIF ___, ___
History of Present Illness:
HPI: ___ F with AF on Coumadin, s/p L hip hemiarthroplasty in
___, presents with L periprosthetic hip fracture s/p mechanical
fall. She was ambulating with her walker today when she tripped
and fell on her left hip, with immediate pain and inability to
ambulate. She felt that she had broken her hip. She was taken
to ___ and then to ___, and subsequently
transferred to ___ for further management due to complexity of
her fracture. Prior to this episode, she had no antecedent hip
pain and was ambulating with her walker without difficulty.
Past Medical History:
PMH:
AF
HTN
PSH:
L hip hemiarthroplasty ___, ___
R hip cephalomedullary nail
Social History:
Lives with her children. Ambulates with a walker at baseline.
Very hard of hearing. Denies tobacco, alcohol, illicit drug use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 3 mg PO 2X/WEEK (___)
2. Warfarin 2 mg PO 5X/WEEK (___)
3. Losartan Potassium 50 mg PO DAILY
4. nebivolol 10 mg oral DAILY
Discharge Medications:
1. Losartan Potassium 50 mg PO DAILY
___ MD to order daily dose PO DAILY16
3 mg daily until INR > 2, then back to dosing of 3 mg on ___
and 2 mg all other days.
3. Acetaminophen 1000 mg PO Q8H
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Calcium Carbonate 500 mg PO TID
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Tartrate 50 mg PO BID
8. Milk of Magnesia 30 ml PO BID:PRN Constipation
9. OLANZapine (Disintegrating Tablet) 2.5 mg PO ONCE:PRN
agitation
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN severe
pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q6H: PRN Disp #*50
Tablet Refills:*0
11. Senna 8.6 mg PO BID
12. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L periprosthetic hip fracture around hemiarthroplasty, now s/p
ORIF ___, ___
Discharge Condition:
AOX3 - calmer with patient, ambulatory with ___, overall stable
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hip fx, preop // preop clearance
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___
FINDINGS:
Interval development of mild prominence of the pulmonary vasculature and
increased interstitial prominence, suggests mild pulmonary edema. There is
mild left basilar atelectasis. The heart remains enlarged. No pneumothorax
or pleural effusion.
IMPRESSION:
Mild pulmonary edema.
Radiology Report
EXAMINATION: CT left hip/ femur without contrast
INDICATION: Periprosthetic left hip/ femur fracture. Preoperative planning
TECHNIQUE: Axial helical multi detector CT images were acquired of the left
lower extremity from the mid iliac wing through to the proximal tibia.
Multiplanar reformats were generated in the coronal and sagittal planes.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 7.6 s, 59.6 cm; CTDIvol = 22.7 mGy (Body) DLP =
1,352.4 mGy-cm.
Total DLP (Body) = 1,352 mGy-cm.
COMPARISON: Outside hospital left hip, left knee, left tibia/ fibula and left
femur radiographs ___.
FINDINGS:
The patient is status post left hip hemiarthroplasty. No evidence of hardware
fracture. Bones are diffusely severely demineralized. There is a comminuted,
oblique periprosthetic fracture of the left proximal femur. The fracture
extends through the proximal subtrochanteric femoral diaphysis around the stem
of the prosthesis. There is apparent avulsion and angulation of the lesser
trochanter with maximum distraction from adjacent hardware of 2.3 cm (03:59).
There is possible subtle nondisplaced fragmentation of the greater trochanter.
Visualized portion of the pelvic ring is intact without additional fracture.
Well-circumscribed sclerotic lesion in the right sacrum is seen. This is not
fully characterized --? Atypical bone island.
Distal femur is intact without additional fracture component. Surrounding
intramuscular hematoma is noted.
Contralateral gamma nail and IM rod fixation of a healed femoral neck fracture
is partially imaged. Moderate degenerative changes of the pubic symphysis and
the bilateral SI joints. Chondrocalcinosis of the pubic symphysis is noted.
Limited evaluation of the left knee show a linear cleft subtending the
anterior aspect of the proximal tibia (401b:68). This is not confirmed on the
axial images in this therefore likely not a fracture. However, clinical
correlation to assess for any focal symptoms in this area is recommended. If
so, then dedicated knee radiographs would be recommended. Otherwise, there is
evidence of moderate medial and lateral compartment narrowing with mild
patellofemoral spurring. Small bilateral suprapatellar knee joint effusions.
Limited evaluation of the intrapelvic structures demonstrates diverticulosis
without evidence of diverticulitis and vascular calcifications. No free fluid
detected.
IMPRESSION:
1. Comminuted periprosthetic fracture of the left proximal femur with
surrounding intramuscular hematoma, as above. Indwelling hardware otherwise
remains in good alignment.
2. Severe background osteopenia noted.
3. Linear cleft subtending anterior proximal left tibia. Please see comment
above.
4. Small bilateral knee joint effusions.
RECOMMENDATION(S): Limited evaluation of the left knee show a linear cleft
subtending the anterior aspect of the proximal tibia (401b:68). This is not
confirmed on the axial images in this therefore likely not a fracture.
However, clinical correlation to assess for any focal symptoms in this area is
recommended. If so, then dedicated knee radiographs would be recommended.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 14:23 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AMS // AMS ? PNA
IMPRESSION:
Compared to prior radiograph from several hr earlier, pulmonary vascular
congestion has improved and previously reported pulmonary edema has resolved.
Linear opacities in the lingula and left lower lobe are attributed to
atelectasis and appear slightly improved.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS IN O.R. LEFT
INDICATION: Left hip ORIF.
TECHNIQUE: 10 spot fluoroscopic images obtained in the OR without radiologist
present
COMPARISON: Left femur radiographs ___
FINDINGS:
The available images show steps related to open reduction internal fixation of
a periprosthetic femur fracture. A cerclage wires seen along the proximal
femur with subsequent placement of a lateral fracture plate with proximal and
distal transfixing screws. A left hip hemiarthroplasty is in-situ. Please
see the operative report for further details.
IMPRESSION:
Intraoperative images from open reduction internal fixation of a left hip
periprosthetic fracture
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Hip fracture, Transfer
Diagnosed with Oth fracture of left femur, init encntr for closed fracture, Periprosth fracture around internal prosth l hip jt, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 98.5
heartrate: 66.0
resprate: 18.0
o2sat: 99.0
sbp: 152.0
dbp: 51.0
level of pain: UTA
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left periprosthetic hip fracture and was admitted to the
orthopedic surgery service. She also had a UTI with AMS/agiation
that was treated with ceftriaxone x3 days, lowered doses of
opiates, and seroquel prn. The patient was taken to the
operating room on ___ for ORIF left periprosthetic hip
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI distally in the left lower extremity, and will be discharged
on coumadin for DVT prophylaxis. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Fevers, rash, headache
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Patient is a ___ male with PMH of resting arrhythmia of unknown
significance and s/p ORIF and vascular repair of right ___ digit
following traumatic injury who presents with fatigue, fevers up
to 102.6, chills, rash, then severe headaches since night prior
to admission. He denies vision changes, numbness, or weakness.
24 days prior to admission, patient experienced a traumatic
injury to his right ___ digit requiring ORIF, vascular repair,
and nerve grafting. Following the procedure he was healing well
and undergoing OT exercises but represented to his surgeon 10
days prior to admission with a small amount of purulence
expressed from the hand wound after sutures were removed. He was
placed on Bactrim DS 1 tab BID for a planned 14-day course. F/U
x-ray at the time revealed no hardware complication. Three days
prior to admission, patient had increased pain and swelling in
his affected digit and took oxycodone for the pain. He had not
required it for several days before then. Then two days prior to
admission, he took it again. That night, he developed fever and
malaise by the evening. By the morning of the day prior to
admission, fever and malaise had resolved and patient attributed
the symptoms to a small cold. By the evening however, patient
again had fever and malaise, this time accompanied by a rash and
severe headache. The rash was first noticed on his face, which
patient described as being so red that he had the appearance of
a sunburn. the rash gradually spread to involve a large area of
his body, extending as low as the thighs. Patient eventually
fell asleep but awoke the next morning with the symptoms even
more severe. He went to see his hand surgeon who referred him to
the ED. During the entire time, patient was taking Bactrim as
prescribed and the day of current presentation is ___ of
Bactrim.
In the ED at 1139AM on DOA initial vitals ___, T:101.8,
HR:87 BP:129/82, RR:16, O2sat:100%. LP was done revealing 2WBC
and 2g of CTX was given along with ceftriaxone. He received
morphine 5mg IV for pain. Blood culturesx3 were drawn.
.
On arrival to the floor, patient VS T98.7, BP130/88, HR94, RR16,
O2sat 98%RA. His headache is improved to ___ intensity and his
rash is persistant. It is not itchy or painful
Past Medical History:
Resting arrhythmia of unknown significance
___ - ORIF of the right ___ digit and microvascular repair of
the digital artery with vein grafting and nerve graft repair
Social History:
___
Family History:
diabetes, heart disease
Physical Exam:
Physical Exam on Admission:
VS - T98.7, BP130/88, HR94, RR16, O2sat 98%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear without
oral ulcers, ruddy face
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding, fullness and
tenderness in the LUQ with the fullness extending into the lower
left abdomen as well, the LUQ is tympanic to percussion
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - erythemetous rash confluent over patient's face and neck
and gradually tapering down to a macular rash distributed over
patient's trunk, arms, torso, and upper thighs
LYMPH - no cervical or axillary, LAD. Small 1cm freely mobile LN
in patient's left groin
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Physical Exam on Discharge:
VS: Tmax: 99.1, Tcurr: 98.4 HR:82, BP:106/80, RR:18, O2sat:
100%RA
Exam otherwise unchanged from admission
Pertinent Results:
Lab Results on Admission:
___ 12:50PM BLOOD WBC-6.0 RBC-5.07 Hgb-14.8 Hct-46.3 MCV-91
MCH-29.2 MCHC-32.0 RDW-12.1 Plt ___
___ 12:50PM BLOOD Neuts-71.9* ___ Monos-4.7 Eos-3.6
Baso-1.5
___ 12:50PM BLOOD ___ PTT-33.0 ___
___ 12:50PM BLOOD Glucose-98 UreaN-13 Creat-1.2 Na-135
K-4.3 Cl-98 HCO3-27 AnGap-14
___ 12:50PM BLOOD ALT-35 AST-35 AlkPhos-68 TotBili-0.5
___ 12:50PM BLOOD Albumin-4.5
___ 12:57PM BLOOD Lactate-1.4
Studies:
Radiology Report CHEST (PA & LAT) Study Date of ___ 6:54 ___
IMPRESSION: No evidence of pneumonia or other acute abnormality.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of ___
6:55 ___
FINDINGS: There is a moderate amount of fecal material
throughout a
non-dilated colon with a relative paucity of small bowel gas. No
evidence of obstruction. Specifically, no evidence of
splenomegaly.
Lab Results on Discharge:
___ 06:05AM BLOOD WBC-4.3 RBC-4.80 Hgb-14.4 Hct-43.7 MCV-91
MCH-30.0 MCHC-32.9 RDW-12.3 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD UreaN-13 Creat-0.9
Medications on Admission:
Bactrim DS 1 tab Po BID
ASA 325mg PO daily
Oxycodone prn pain
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for pain: do not drive or operate machinery
while taking this medication. please only take for postoperative
surgical pain.
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain: do not drive or operate machinery
while taking this medication. Do not take more than 8 tablets
per day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Drug Rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Acute fever with diffuse rash.
FINDINGS: No previous images. The heart is normal in size and lungs are
clear without vascular congestion or pleural effusion.
IMPRESSION: No evidence of pneumonia or other acute abnormality.
Radiology Report
HISTORY: Acute fever with left upper quadrant and left lower quadrant
tenderness.
FINDINGS: There is a moderate amount of fecal material throughout a
non-dilated colon with a relative paucity of small bowel gas. No evidence of
obstruction. Specifically, no evidence of splenomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, NONSPECIF SKIN ERUPT NEC
temperature: 101.8
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 129.0
dbp: 82.0
level of pain: 8
level of acuity: 3.0 | Primary Reason for Hospitalization: Patient is a ___ man with
PMH of resting arrhythmia and traumatic injury to R ___ digit
requiring vascular repair and nerve grafting followed by a
post-surgical infection who presents with one day of fevers,
malaise, and general body aches attributed to drug eruption from
bactim. The drug was stopped as his antibiotic course was on the
___ of ___ day and clinically infection had resolved. He was
discharged home to follow-up.
.
ACUTE CARE
1.Drug Rash: Patient was febrile to 102.6 on presentation with
general body aches and malaise along with ___ headache,
nausea, and dizziness for 24 hours. He was on day ___ of
bactrim therapy for a surgical site infection from previous hand
surgery. He was seen by hand surgery in the ED who feels that
the surgical site appears benign. LP showed no leukocytosis or
signs of infection, there was no elevated WBC count, and UA was
unremarkable for infection. BC, CSFC and UC were drawn and
results pending on discharge but no growth to date. Patient had
a rash of rapid onset which began as a ruddy hue to the face and
spread to be a diffuse morbilliform rash covering the neck,
torso, and upper extremities, extending midway down the legs. He
was given one day of Vanc/ceftriaxone in house and discharged
home off bactrim to follow-up.
.
2. S/P hand surgery: Patient experienced traumatic crush injury
to right fifth digit 3 weeks prior to presentation. He underwent
ORIF with vascular repair and nerve grafting and remains largely
insensate beyond the point of injury. He was evaluated in the ED
by hand surgery who feel that his hand shows no signs of
infection. He was given one further day of antibiotic coverage
in house with vancomycin and ceftriaxone and discharged home off
antibiotics.
.
3. Abdominal fullness: On exam patient had abdominal fullness
and tenderness in the LUQ extending to the LLQ. Abdominal plain
film revealed massive fecal loading and patient was given bowel
medication to produce bowel movement.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Zantac / Tagamet / Megace / Zyban / Iodine-Iodine Containing /
Zoloft / Ceftriaxone / Cefepime / Abacavir / Atazanavir /
Amitriptyline / Iodinated Contrast Media - Oral and IV Dye
Attending: ___
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with history of HIV on HAART,
HTN, HLD who presents with three days of acute headache, for
which Neurology is consulted after MRI showed R cerebellar
infarct.
Mr. ___ woke at 0230 on ___ with approx 1
min
of severe pain in a vertical line over his R occiput. This then
resolved and he has had dull R occipital and R>L
frontal/retroorbital headache. He did not note any deficits at
the time. He went back to sleep, and the next morning awoke
with
continued dull headache. He also felt slightly unsteady on his
feet, "as if I were tipsy". Denies room spinning,
lightheadedness. He then presented to ___ ED, where NCHCT was
unremarkable. LP was perfomed with 1 WBC, 0 RBC, protein 46,
glucose 65. He was then discharged to home.
He states the headache continued since that time. He attempted
to
go to work ___, but was unable to work due to headache and
went
back home and slept for much of the rest of the day and
overnight. He then re-presented to the ED ___ am.
He was evaluated and ED ordered MRI brain w/wo contrast, which
showed R inferior cerebellar infarct, prompting neurology
consultation.
Mr. ___ notes onset of neck stiffness and R neck pain
on
the day prior to presentation, which has been mild. He states
the
headache continues. He has tried Tylenol at home, and has
received headache cocktail and morphine in the ED. He states
medicines help but only for a few hours before the pain
intensifies.
No positionality, but the headache is worse when he is
physically
active. He has photophobia, which he states is worse in his R
eye. He has had nausea throughout the past few days, but no
emesis.
He does have history of headaches in the remote past. He states
they happened when he was young when he was hungry or hungover.
He only remembers that they were intense and resolved with
Tylenol. He has not had a headache in many years.
Past Medical History:
HIV on HAART
HTN
HLD
depression
Social History:
___
Family History:
Father with DM, CAD, CKD
Mother with depression, migraine
2 sisters with migraine
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 98.2 HR: 73 BP: 137/103 RR: 18 SaO2: 99% RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with normal grammar and
syntax. No paraphasic errors. Naming intact to low frequency
words. Repetition intact. Comprehension intact to cross-body
commands. Normal prosody.
-Cranial Nerves: PERRL 3->2. Funduscopic exam with crisp disc
OD,
not visualized OS. VFF to confrontation. EOMI without nystagmus.
Facial sensation intact to light touch. Face symmetric at rest
and with activation. Hearing intact to conversation. Palate
elevates symmetrically. ___ strength in trapezii bilaterally.
Tongue protrudes in midline and moves briskly to each side. No
dysarthria.
- Motor: Normal bulk and tone. No drift. No tremor nor
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 3 2 3 3 2 +
R 3 2 3 3 2 +
Plantar response was flexor bilaterally.
-Sensory: Proprioception intact BLE. Intact to LT, temp
throughout.
- Coordination: Overshoot with mirroring RUE. Cerebellar check
without rebound. No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
___ 10:55AM CEREBROSPINAL FLUID (CSF) TNC: 1 RBC: 0 Polys:
0
Lymphs: ___ Monos: ___ 10:55AM CEREBROSPINAL FLUID (CSF) TotProt: 46* Glucose:
65
- Gait: deferred
DISCHARGE PHYSICAL EXAM
T97.9 BP 134/81 HR 86 RR 18 SpO2 94
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with normal grammar and
syntax. No paraphasic errors. Naming intact to low frequency
words. Repetition intact. Comprehension intact to cross-body
commands. Normal prosody.
-Cranial Nerves: PERRL 4->2. VFF to confrontation. EOMI without
nystagmus.
Facial sensation intact to light touch. Face symmetric at rest
and with activation. Hearing intact to conversation. Palate
elevates symmetrically. ___ strength in trapezii bilaterally.
Tongue protrudes in midline and moves briskly to each side. No
dysarthria.
- Motor: Normal bulk and tone. No drift. No tremor nor
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 3 2 3 3 2 +
R 3 2 3 3 2 +
Plantar response was flexor bilaterally.
-Sensory: Proprioception intact BLE. Intact to LT, temp
throughout.
- Coordination: Overshoot with mirroring RUE. No rebound. No
dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements.
Pertinent Results:
___ 05:30AM BLOOD WBC-6.6 RBC-4.46* Hgb-13.5* Hct-40.5
MCV-91 MCH-30.3 MCHC-33.3 RDW-12.4 RDWSD-41.1 Plt ___
___ 09:45AM BLOOD Neuts-65.9 ___ Monos-8.2 Eos-1.4
Baso-0.8 Im ___ AbsNeut-4.36 AbsLymp-1.53 AbsMono-0.54
AbsEos-0.09 AbsBaso-0.05
___ 05:30AM BLOOD Glucose-156* UreaN-19 Creat-1.0 Na-134*
K-4.7 Cl-99 HCO3-21* AnGap-14
___ 05:54AM BLOOD ___ PTT-27.2 ___
___ 05:54AM BLOOD ALT-44* AST-29 AlkPhos-75 TotBili-0.7
___ 05:54AM BLOOD Albumin-4.3 Calcium-9.1 Phos-2.8 Mg-2.3
Cholest-203*
___ 05:54AM BLOOD Triglyc-114 HDL-36* CHOL/HD-5.6
LDLcalc-144*
___ 05:54AM BLOOD %HbA1c-5.3 eAG-105
___ 05:54AM BLOOD TSH-5.1*
___ 05:54AM BLOOD CRP-7.2*
___ 09:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-16
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: CT head w/o: No acute intracranial process.
___ CT neck: Within the limitations of no intravenous
contrast,
there is no evidence of infectious source in the neck. Right
sternocleidomastoid muscle appears atrophic compared to the
left.
___
MRI brain: 1. Areas of slow diffusion in the right
cerebellum and vermis (series 600:6 and series 602:6) with
associated T2 and FLAIR hyperintense signal likely represent
subacute infarction.
2. No evidence of infectious abnormality. No abnormality on post
contrast enhanced images.
___
MRA BRAIN W/O CONTRAST
Loss of flow related signal within the distal right V3 and
proximal right V4 segments, with distal reconstitution within
the mid and distal portions of the right V4 segment. Findings
may
be due to MRA time-of-flight technique and artifactual in
nature,
but stenosis/occlusion cannot be excluded. If there is
ongoing clinical concern, CTA could be considered.
2. The anterior and posterior intracranial circulation is
otherwise widely patent.
3. 1-2 mm posteriorly directed outpouching from the mid left M1
segment, likely tiny infundibulum versus small aneurysm.
___
MRA NECK W&W/O CONTRAST
1. Multiple areas of peripheral, crescentic hyperintensity on
axial T1 fat saturation sequences, worrisome for intramural
hematoma in the setting of arterial dissection.
2. Multiple areas of luminal narrowing in caliber change within
the right vertebral artery, with severe narrowing and near
complete loss of signal within the mid and distal right V4
segments.
3. Left-sided dominant vertebral basilar system.
4. Patency of the bilateral common carotid, internal carotid,
and
left vertebral arteries.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Chlorthalidone 25 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Clindamycin 1% Solution 1 Appl TP BID
6. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL Frequency is
Unknown
7. diclofenac sodium 1 % topical TID:PRN
8. Dolutegravir 50 mg PO DAILY
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. etodolac 400 mg oral BID:PRN
11. fluconazole 200 mg oral DAILY
12. Fluticasone Propionate 110mcg Dose is Unknown IH Frequency
is Unknown
13. Sildenafil 20 mg PO Frequency is Unknown
14. sulfamethoxazole-trimethoprim 400-80 mg oral DAILY
15. Tretinoin 0.025% Cream 1 Appl TP QHS
16. ValACYclovir 500 mg PO Q12H
17. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
18. glucosamine sulfate unknown oral unknown
19. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyclobenzaprine 5 mg PO BID:PRN headache
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth BID PRN Disp #*14
Tablet Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*1
4. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL UN KNOWN
Swish and Spit
5. Fluticasone Propionate 110mcg 1 PUFF IH UN KNOWN
6. glucosamine sulfate 1 tab oral UN KNOWN
7. Sildenafil 20 mg PO UN KNOWN
8. BuPROPion (Sustained Release) 150 mg PO QAM
9. Chlorthalidone 25 mg PO DAILY
10. Citalopram 20 mg PO DAILY
11. Clindamycin 1% Solution 1 Appl TP BID
12. diclofenac sodium 1 liberally topical TID:PRN skin rash
13. Dolutegravir 50 mg PO DAILY
14. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
15. etodolac 400 mg oral BID:PRN as directed
16. Fluconazole 200 mg oral DAILY
17. Loratadine 10 mg PO DAILY
18. sulfamethoxazole-trimethoprim 400-80 mg oral DAILY
19. Tretinoin 0.025% Cream 1 Appl TP QHS
20. ValACYclovir 500 mg PO Q12H
21. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
RT cerebellar ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological exam: some overshoot on mirror testing.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRA NECK WANDW/O CONTRAST ___ MR NECK
INDICATION: ___ year old man with HIV, right ___ infarct, headache and right
neck pain. Evaluate for vessel stenosis, dissection.
TECHNIQUE: Dynamic MRA of the neck was performed during administration of 18
cc ProHance intravenous contrast.
Maximum intensity projection and segmented images were generated. This report
is based on interpretation of all of these images.
COMPARISON: CT head ___, CT neck ___, MR brain ___, MR ___ brain ___.
FINDINGS:
There is a 3 vessel aortic arch.
Axial T1 weighted fat saturation images demonstrate peripheral high signal
involving V1 and proximal V2 segments of the right vertebral artery to the
level of C5, with an additional small focus of high signal in the transverse
foramen of C2 on image 6:10, concerning for intramural hematoma/dissection.
Dynamic gadolinium enhanced MRA demonstrates corresponding irregular narrowing
of the V1 and proximal V2 segments of the right vertebral artery. The right
V3 segment is slightly smaller than the left, but this could be secondary to
the slight left vertebral dominance within the vertebrobasilar system. The
dominant left vertebral artery appears widely patent.
Questionable filling defects in the proximal right and left internal carotid
arteries are morphologically suggestive of turbulent flow in the setting of
arterial tortuosity, versus mild, less than 40% stenosis by NASCET criteria.
Mid left internal carotid artery forms a loop.
IMPRESSION:
1. Findings concerning for dissection/intramural hematoma of the V1 and
proximal V 2 segments of the right vertebral artery to the level of C5, with
associated irregular mild narrowing. Questionable of additional small focus
of intramural hematoma in the V3 segment. The right V3 segment is smaller
than the left, which may be secondary to chronic intramural hematoma versus
slight left vertebral dominance of the vertebrobasilar system.
2. Questionable filling defects in the proximal right and left internal
carotid arteries are morphologically suggestive turbulent flow in the setting
of arterial tortuosity, versus mild, less than 40% stenosis by NASCET
criteria.
NOTIFICATION: Findings regarding the right vertebral dissection/intramural
hematoma were conveyed by Dr. ___ to Dr. ___ text ___ at 08:41 on ___, 2 minutes after discovery. These findings were omitted from the
preliminary report which was provided electronically at 07:24 on ___ by Dr. ___.
Radiology Report
EXAMINATION: MRA BRAIN W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with HIV, right ___ infarct, headache. Evaluate
for vessel stenosis, vascular malformation, aneurysm, vessel cutoff.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
No contrast was administered. Three dimensional maximum intensity projection
and segmented images were generated. This report is based on interpretation of
all of these images.
COMPARISON: CT head ___, MR head ___, MRA neck ___.
FINDINGS:
There is diminished signal in the visualized distal V3 and in the proximal V4
segments of bilateral vertebral arteries, likely due to technical factors as
these are patent on the concurrent neck MRA. The diminished signal appears
asymmetrically worse on the right than the left, which could be due to the
left vertebral dominance. Concurrent neck MRA demonstrates intramural
hematoma/dissection of V1 and proximal V2 segments of the right vertebral
artery to the level of C5, and a possible punctate focus of intramural
hematoma/dissection in the right V3 segment without distal extension.
Right ___ and ___ complex (better seen on the concurrent neck MRA)
are patent. Bilateral superior cerebellar arteries and proximal courses of
bilateral posterior cerebral arteries are patent.
No occlusion or flow-limiting stenosis is seen in the anterior circulation. A
small, 1-2 mm posteriorly directed outpouching from the left mid M1 segment
(2:92).
IMPRESSION:
1. Diminished signal in the visualized distal V3 and in the proximal V4
segments of bilateral vertebral arteries is likely due to technical factors,
as these are patent on the concurrent neck MRA. Concurrent neck MRA
demonstrates intramural hematoma/dissection of V1 and proximal V2 segments of
the right vertebral artery to the level of C5, and a possible punctate focus
of intramural hematoma/dissection in the right V3 segment without distal
extension.
2. The right ___ is patent.
3. 1-2 mm posteriorly directed outpouching from the mid M1 segment of the left
middle cerebral artery, compatible with an infundibulum versus aneurysm.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with right cerebellar stroke// Please assess for
right vertebral dissection vs occlusion. He will need premedication due to
contrast allergy
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 4.9 s, 38.9 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,205.5 mGy-cm.
Total DLP (Head) = 2,041 mGy-cm.
COMPARISON: MRA neck ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Redemonstrated is an evolving acute right ___ territory infarct involving the
medial right cerebellar hemisphere and cerebellar vermis. There is no
evidence of no evidence of a new infarction, hemorrhage, edema, 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:
Redemonstrated 1 mm outpouching of the left MCA M1 segment likely representing
an infundibulum (series 3, image 252) that gives rise to a branching M2
vessel. The vessels of the circle of ___ and their principal intracranial
branches appear otherwise normal without stenosis, occlusion, or aneurysm
formation. There is a left dominant vertebrobasilar system. The distal right
vertebral artery V4 segment is relatively small in caliber, which may be
congenital variation. The left vertebral artery V4 segment is normal. The
dural venous sinuses are patent.
CTA NECK:
There is narrowing of the distal V1 segment of the right vertebral artery
before entering the right C6 transverse foramen compatible with dissection
that was previously described on the MRA neck dated ___. The
cervical carotid and vertebral arteries and their major branches appear
otherwise normal with no evidence of stenosis or occlusion. There is no
evidence of internal carotid stenosis by NASCET criteria.
OTHER:
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. Redemonstrated evolving acute right ___ territory infarct involving the
medial right cerebellar hemisphere and cerebellar vermis. No new sites of
infarction.
2. Short-segment narrowing and luminal irregularity of the right vertebral
artery distal right V1 segment (at the junction of V1 and V 2 segments)
compatible with dissection as previously described on the MRA neck dated ___.
3. Relatively small caliber distal V4 segment of the right vertebral artery is
possibly congenital given the left dominant vertebrobasilar system.
Gender: M
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with Headache, Human immunodeficiency virus [HIV] disease
temperature: 98.3
heartrate: 120.0
resprate: 16.0
o2sat: 99.0
sbp: 159.0
dbp: 112.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ yo man with history of HIV (CD4 121) on
ART, HTN, HLD who presented with three days of acute headache.
He was seen in the ED on ___, LP was performed then and was
bland. He presented again on ___ and was admitted to neurology
after MRI showed R cerebellar infarct in ___ territory.
Etiology of infarct likely small vessel vs embolic
(atheroembolic vs cardioembolic). Infectious/inflammatory
vasculitis or meningitis (i.e. Cryptococcus) were considered
given HIV with CD4 121,but less likely given bland CSF,
concomitant vascular risk factors, and afebrile. TTE was
unremarkable. MRA was poor quality, so CTA needed to be
performed. He has a contrast allergy, so he was pretreated and a
CTA h/n was performed, which was unremarkable. A ___ of hearts
was ordered for him as an outpatient to complete work up. He had
persistent headache during the hospitalization. Did not improve
despite getting prednisone for contrast allergy pre-treatment.
He had been taking OTC medicines frequently before presentation
so possibly a component of medication overuse headache. It did
seem to respond to flexeril, which may indicate MSK origin, so
he was discharged with a short supply of flexeril. He was given
fluid bolus as well. For stroke, his atorvastatin was increased
to 40 mg qhs and aspirin 81 mg daily was started. TTE was
unremarkable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Temazepam
Attending: ___.
Chief Complaint:
Cough, shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ y/o ___ woman with PMHx
notable for diastolic heart failure, chronic AF (s/p AVJ
ablation and ___ pacemaker), HTN, HLD, seizure
disorder, recent worsening dizziness/gait instability. She
presents with fever and cough, confusion, and right forearm
discoloration in the setting of recent humeral fracture.
The patient is hard of hearing, and difficult to communicate,
even with her husband and the ___ present. The
details of her symptoms are vague, despite numerous attempts to
clarify.
She developed a cough about 3 days ago, nonproductive. She also
notes shortness of breath, particularly with movement. She does
not confirm that she has had fevers (as below, she became
febrile in the ED). She has pain in her right arm with movement,
but otherwise denies other symptoms. She denies headache,
dizziness, chest pain, abdominal pain, nausea, vomiting,
diarrhea, dysuria.
Of important note, the patient's husband tested positive for
influenza A today (___). He had onset of non-productive
cough, fevers 4 days ago. He visited her in her SNF (see below)
on the day his symptoms began, but has not visited her since.
Patient is a resident at ___. She has been
there since a fall at home, resulting in an ___ ED visit on
___. During that fall, she sustained a comminuted fracture
of the surgical neck of the humerus with mild, medial
displacement of the dominant distal fracture fragment. She was
discharged with oxycodone and instructions to be NWB of the
right extremity. Ortho did not evaluate her at that ED visit.
Most recently, at her SNF, the patient was noted to have
worsening discoloration of right forearm and some confusion.
- In the ED, initial vitals: 98.6 70 147/82 22 100% 4L Nasal
Cannula. Later her temp was 101.8F.
- Labs/Studies notable for: WBC 9.4, H/H 10.5/32.1, plt 149, BUN
29, creatinine 0.8, trop <0.01, lactate 1.2, INR 1.1, ABG
7.43/___, negative UA, blood culture/urine culture were
obtained.
- Imaging: CXR (___): In comparison with the study of
___, there is again enlargement of the cardiac
silhouette without definite vascular congestion or pleural
effusion. Right humerus films with comminuted fracture through
the surgical neck of the right humerus, with mild medial
displacement. This is unchanged from prior film.
- Patient was given: Duonebs, methylpred 125mg IV x1,
ceftriaxone 1g, IV azithromycin 500mg.
- Vitals prior to transfer: 69 151/76 16 100% RA.
ROS: Please refer to HPI for pertinent positives and negatives.
10 point ROS is otherwise negative
Past Medical History:
-afib on coumadin
-pacer
-HTN
-HLD
-depression
-insomnia
-osteoporosis
-meneire's disease with L>R deafness, uses hearing aids
-hypothyroidism
-osteoarthritis
-sciatica
-___ edema
-GERD
-allergic rhinitis
-left acoustic neuroma
-cataract
-___ neuroma
-pulm HTN, diastolic dysfunction, MR, TR
-chronic hyponatremia
Social History:
___
Family History:
-unable to be obtained
Physical Exam:
Admission Exam
Vitals: 98.8 170/80 68 18 96% on 1L via NC.
General: AAOx3. Coughing occasionally. Not in distress.
HEENT: EOMI, PERRL. Sclera anicteric, conjunctiva pink. Mucous
membranes are moist. OP clear.
Neck: Supple, no LAD, no JVP elevation.
Lungs: Rhonchi bilaterally, and occasional expiratory wheezing.
Breathing is mildly labored.
CV: RRR, soft SEM.
Abdomen: NABS, soft, nondistended, nontender. No HSM.
GU: Foley in place, clear yellow urine.
Ext: Trace ___ edema. Extremities are cool. Right hand with
ecchymosis of dorsum and swelling; ecchymosis extends up the
right forearm. Radial pulse intact.
Neuro: CNs II-XII grossly intact. Grossly normal strength and
sensation. She has difficulty moving right UE due to pain, good
hand squeeze bilaterally.
Discharge Exam
Vitals: 98.1 170/60 70 20 92% on RA
General: AAOx3. Not in distress.
HEENT: EOMI, PERRL. Sclera anicteric, conjunctiva pink. Mucous
membranes are moist. OP clear.
Neck: Supple, no LAD, no JVP elevation.
Lungs: occasional rhonchi/expiratory wheezing, otherwise clear
CV: RRR, soft SEM.
Abdomen: NABS, soft, nondistended, nontender. No HSM.
Ext: WWP. Right hand with ecchymosis of dorsum and swelling;
ecchymosis extends up the right forearm. Radial pulse intact.
Neuro: CNs II-XII grossly intact. Grossly normal strength and
sensation. She has difficulty moving right UE due to pain, good
hand squeeze bilaterally.
Pertinent Results:
Admission Labs
___ 10:05AM WBC-9.4 RBC-3.38* HGB-10.5* HCT-32.1* MCV-95
MCH-31.2 MCHC-32.8 RDW-15.1
___ 10:05AM NEUTS-85.6* LYMPHS-8.8* MONOS-5.3 EOS-0.1
BASOS-0
___ 10:05AM PLT COUNT-149*
___ 10:05AM ALBUMIN-4.0 CALCIUM-9.9 PHOSPHATE-4.1
MAGNESIUM-2.1
___ 10:05AM ALT(SGPT)-26 AST(SGOT)-75* LD(LDH)-682* ALK
PHOS-70 TOT BILI-0.7
___ 10:05AM GLUCOSE-101* UREA N-29* CREAT-0.8 SODIUM-133
POTASSIUM-4.7 CHLORIDE-90* TOTAL CO2-31 ANION GAP-17
___ 10:20AM LACTATE-1.2
___ 10:40AM ___ PTT-25.2 ___
___ 10:05AM cTropnT-<0.01
Discharge Labs
___ 07:15AM BLOOD WBC-7.6 RBC-3.30* Hgb-10.4* Hct-31.5*
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.9 Plt ___
___ 07:15AM BLOOD Glucose-88 UreaN-23* Creat-0.7 Na-136
K-3.3 Cl-91* HCO3-35* AnGap-13
Micro
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Urine Culture
___ 11:15 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ON
___, 10:43AM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS AND.
GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS.
Reported to and read back by ___ (___)
2:20AM ___.
___ 10:05 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 4:00 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
___ 4:00 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
___ 11:15 am URINE Unpreserved urine for UA.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Reports
Humerus XRay
IMPRESSION:
Possibly minimally increased displacement and angulation of the
right humeral neck fracture. No new fracture.
CXR ___
IMPRESSION:
In comparison with the study of ___, there is again
enlargement of the cardiac silhouette without definite vascular
congestion or pleural effusion. There may be minimal atelectatic
changes at the left base. Pacer device is unchanged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine 1 TAB PO ONCE:PRN severe pain
2. Carvedilol 25 mg PO BID
3. CloniDINE 0.1 mg PO BID
4. Duloxetine 60 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Furosemide 40 mg PO BID
7. Lactulose 30 mL PO BID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. lidocaine HCl 3 % topical daily burning feet
10. Lisinopril 10 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Omeprazole 20 mg PO BID
13. Promethazine 25 mg PO DAILY
14. rOPINIRole 0.25 mg oral qHS
15. Simvastatin 10 mg PO DAILY
16. Tolterodine 2 mg PO DAILY
17. TraZODone 75 mg PO QHS:PRN insomnia
18. Acetaminophen 1000 mg PO Q8H:PRN pain
19. Aspirin 81 mg PO DAILY
20. Calcium Carbonate 500 mg PO DAILY
21. Vitamin D ___ UNIT PO DAILY
22. Docusate Sodium 100 mg PO TID
23. melatonin 3 mg oral daily
24. Fish Oil (Omega 3) 1000 mg PO DAILY
25. Senna 34.4 mg PO QHS
26. Senna 17.2 mg PO QAM
27. valerian root 1000 mg oral daily
28. OxycoDONE (Immediate Release) 5 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. CloniDINE 0.1 mg PO BID
6. Docusate Sodium 100 mg PO TID
7. Duloxetine 60 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Furosemide 40 mg PO BID
10. Lactulose 30 mL PO BID
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lisinopril 10 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth q 8 hrs Disp
#*21 Tablet Refills:*0
14. rOPINIRole 0.25 mg oral qHS
15. Senna 34.4 mg PO QHS
16. Senna 17.2 mg PO QAM
17. Simvastatin 10 mg PO DAILY
18. TraZODone 75 mg PO QHS:PRN insomnia
19. Vitamin D ___ UNIT PO DAILY
20. OSELTAMivir 75 mg PO Q12H
Last day is ___
21. Fish Oil (Omega 3) 1000 mg PO DAILY
22. lidocaine HCl 3 % topical daily burning feet
23. melatonin 3 mg oral daily
24. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
25. Omeprazole 20 mg PO BID
26. Promethazine 25 mg PO DAILY PRN nausea
27. Tolterodine 2 mg PO DAILY
28. valerian root 1000 mg oral daily
29. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
-Influenza
-Shoulder Fracture
Secondary
-Heart Failure
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: GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT
INDICATION: ___ year old woman with humeral fracture // assess for
dislocation with Y view assess for dislocation with Y view
IMPRESSION:
In comparison with the study of ___, there is little change in the
appearance of the comminuted fracture through the surgical neck of the
humerus. No evidence of dislocation.
Radiology Report
EXAMINATION: HUMERUS (AP AND LAT) RIGHT
INDICATION: ___ woman with known right humerus fracture or presents
with pain and swelling of the right arm. Evaluate for progression of known
right humerus fracture.
COMPARISON: Radiographs of the right shoulder from ___.
FINDINGS:
Again seen is a comminuted fracture through the surgical neck of the right
humerus, with possibly minimally increased displacement and angulation. Again,
mild degenerative changes of the glenohumeral joint are noted. There are no
focal lesions or osseous erosions. The soft tissues are unremarkable.
IMPRESSION:
Possibly minimally increased displacement and angulation of the right humeral
neck fracture. No new fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: EVAL FOR CHF
IMPRESSION:
In comparison with the study of ___, there is again enlargement of the
cardiac silhouette without definite vascular congestion or pleural effusion.
There may be minimal atelectatic changes at the left base. Pacer device is
unchanged.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with SHORTNESS OF BREATH
temperature: 98.6
heartrate: 70.0
resprate: 22.0
o2sat: 100.0
sbp: 147.0
dbp: 82.0
level of pain: 13
level of acuity: 2.0 | Impression: Mrs. ___ is an ___ y/o ___ woman
with PMHx notable for chronic diastolic heart failure, chronic
AF (s/p AVJ ablation and ___ pacemaker), HTN, HLD,
seizure disorder, recent worsening dizziness/gait instability
who presented with fever and cough, and right forearm
discoloration in the setting of recent humeral fracture.
#) Influenza A: Fever, cough, and hypoxia, concerning for
pulmonary infection. Patient's influenza A PCR returned
positive, and husband also with influenza. CXR without focal PNA
or significant edema. Ceftriaxone and Azithromycin were
initially given, but then stopped with substitution of
oseltamavir at 75mg BID (day ___. She will finish a 5 day
course of oseltamavir.
#) Right humerous comminuted fracture: Sustained during fall at
home ___. Was seen in ___ ED, but not evaluated by ortho.
Neurovascularly intact. Ortho consulted in house as she was
supposed to see them as an outpatient. They recommended
pendulum exercises, continued sling, and f/u in 2 weeks. ___ was
consulted who recommended she return to ___ rehab.
#) Gram positive cocci bacteremia: ___ be contaminant as only
one culture has grown out. Other possibility is seeding from a
pneumonia. Patient was started on vancomycin to empirically
cover MRSA. The culture came back positive for coag negative
staph and also probable strep viridans (not definitively
speciated). Strep viridans was thought to be a contaminant as
only found in 1 set of blood cultures and has been documented in
the literature as commonly a contaminant. ___
___. Clinical significance of viridans streptococci isolated from
blood cultures. J Clin Microbiol ___ 15:___)
#) Atrial fibrillation: s/p AV Node Junction ablation, s/p St.
___ pacemaker placement ___. Continued carvedilol, ASA 81
mg daily.
#) Anemia: Hgb slowly since admission 10.5 to 9.9, and below
baseline of around 11. Normocytic. Likely anemia of chronic
disease.
#) Chronic diastolic CHF: Patient's last ECHO shows evidence of
preserved EF and diastolic dysfunction. She denies any current
dyspnea, and chest xray with no obvious pulmonary edema.
Initially held furosemide in setting of pneumonia but restarted
it once appeared ___ hospital day 2. Continued lisinopril
and carvedilol.
# Hypertension:
- continued home regimen of clonidine, lisinopril and
carvedilol.
# Hypothryoidism:
- continued levothyroxine 50mcg daily
# Anxiety/depression:
- continued duloxetine 60mg daily
- continued trazadone 75mg qHS prn insomnia
- continued clonidine 0.1mg BID
TRANSITIONAL ISSUES
-Needs to follow up with orthopedics in two weeks (see above).
She should get XRays of right shoulder on same day as
appointment. SNF needs to make the arrangements
-Needs follow up of culture data
-Needs to follow up with cardiology NP in 2 weeks time
-Pt needs repeat blood culture on ___ to rule out
contamination with 1 set of blood cultures drawn on admission
with coag negative staph and strep viridans. (Strep viridans
still likely contaminant)
-Likely needs tailoring of anti-hypertensive regimen given
frequently hypertensive in the hospital (SBP 150s-170s). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Workup of possible colon cancer
Major Surgical or Invasive Procedure:
Liver lesion biopsy
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of COPD on home O2 (3L), non-insulin dependent DM type
II, h/o prostate cancer s/p XRT ___ years ago, h/o pulmonary
nodule s/p resection, and HTN who presented to ___
with abdominal pain and was transferred to the ___ ED after a
CT abdomen showed evidence of colon cancer with metastases and
thrombus in SMV and portal vein.
He first developed right sided abdominal pain around one week
ago
which progressively became more severe, up to ___. He had some
nausea but no vomiting. He was otherwise feeling well.
He presented to ___, where CT was notable for
colonic mass and likely metastatic disease as well as portal/SMV
thrombus. He received a dose of lovenox there and was
transferred
to ___ for further evaluation.
In the ED, he was started on a heparin drip and GI was
consulted.
Past Medical History:
COPD on home O2 (3L)
Non-insulin dependent DM type II
Prostate cancer s/p XRT ___ years ago
Pulmonary nodule s/p resection
HTN
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
GENERAL: Alert and in no apparent distress. Laying in bed. 02 by
nasal cannula.
EYES: Anicteric, pupils equally round
ENT: Noticeably heard of hearing. Ears and nose without visible
erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, systolic murmur.
RESP: Diminished air entry bilaterally
GI: Abdomen soft obese. Non-distended, non-tender to palpation.
Bowel
sounds present.
MSK: Neck supple, moves all extremities, strength gross
symmetric
bilaterally in all limbs
SKIN: No rashes or ulcerations noted. Mild bruising of R hand
noted.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect.
Pertinent Results:
___ 07:20AM BLOOD UreaN-4* Creat-0.6 Na-143 K-4.5 HCO3-31
AnGap-12
___ 07:20AM BLOOD ALT-12 AST-22 AlkPhos-133*
___ 07:20AM BLOOD Albumin-2.8*
___ 07:20AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.3
___ 07:40AM BLOOD WBC-7.1 RBC-3.98* Hgb-9.7* Hct-31.8*
MCV-80* MCH-24.4* MCHC-30.5* RDW-16.7* RDWSD-48.1* Plt ___
___ 07:40AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-138
K-4.1 Cl-98 HCO3-30 AnGap-10
___ 07:40AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.9
___ 07:20AM BLOOD TSH-2.6
___ 01:20AM BLOOD CEA-14.5*
___ 01:36AM BLOOD Lactate-1.3
___ 07:40AM BLOOD ___
CT Chest: ___
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ likely colon adenoCa (prelim path) with liver
mets. Abd
imaging done at OSH. Chest imaging to complete staging.//
Evaluate for staging
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in
inspiration,
administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 428 mGy-cm
COMPARISON: No comparison.
FINDINGS:
No incidental thyroid findings. No supraclavicular,
infraclavicular or
axillary lymphadenopathy. No enlarged lymph nodes in the
mediastinum.
Moderate aortic wall calcifications. Moderate coronary
calcifications, no
pericardial effusion. The posterior mediastinum is
unremarkable, with the
exception of a small hiatal hernia. Upper abdominal evaluation,
including the
large hypodense liver lesions, was performed previously. No
osteolytic
lesions at the level of the ribs, the sternum, or the vertebral
bodies. Mild
degenerative vertebral disease. No vertebral compression
fractures. Severe
pulmonary emphysema with multiple punctate interstitial
calcifications.
Extensive calcifications along the major fissure on the right.
Multiple
calcified micro nodules are also seen at the bases of the right
lower lobe.
No pleural thickening, no pleural effusions. No fibrotic lung
disease.
IMPRESSION:
Extensive pulmonary emphysema with multiple calcified micro
nodules, notably
in perifissural and right lower lobe location. No suspicious
pulmonary
nodules or masses. No adenopathy. No pleural abnormalities.
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with colon CA w/ mets to abdomen// ?
mass.
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.3 cm; CTDIvol = 46.7 mGy
(Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction,
intracranial
hemorrhage, edema, or mass effect. There is prominence of the
ventricles and
sulci suggestive of age-related involutional changes. There are
periventricular and subcortical hypodensities, which are
nonspecific and may
represent changes due to chronic small vessel ischemic disease.
Vascular
arteriosclerotic calcifications are seen in the carotid siphons
bilaterally.
There is no evidence of fracture. There is a small amount of
fluid and mild
mucosal thickening in the right sphenoid sinus. The visualized
portion of the
remaining paranasal sinuses, mastoid air cells, and middle ear
cavitiesare
essentially clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No acute intracranial process or hemorrhage. Please note that
MR is more
sensitive in the detection of intracranial masses or metastatic
disease.
Liver Biopsy:
Diagnosed by: ___, MD
___ Out: ___ 15:04
PATHOLOGIC DIAGNOSIS:
Liver, right hepatic lobe mass, biopsy:
- Metastatic adenocarcinoma with necrosis, well to moderately
differentiated. See note.
Note: By immunohistochemistry, tumor cells are strong positive
for CDX-2 and are negative for CK7,
CK20. While not specific, this immunophenotype is supportive of
a gastrointestinal origin, including
metastatic colonic adenocarcinoma in the reported clinical and
radiographic context of colonic mass.
Preliminary results communicated with Dr. ___ on
___ by Dr. ___.
Immunohistochemistry stains for mismatch repair protein are in
progress and will be reported as
revised report.
SURGICAL PATHOLOGY REPORT -REVISED A:
This report is revised to report the results of DNA mismatch
repair testing, requested by ___.
This Immunohistochemistry for DNA mismatch repair proteins shows
loss of nuclear staining for MLH1 and PMS2 in the tumor cells,
with intact staining of MSH2 and MSH6. Internal controls are
adequate.
Dr. ___ was notified of the results by email at 2:30 ___ on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PARoxetine 37.5 mg PO DAILY
2. Zolpidem Tartrate 10 mg PO QHS
3. ClonazePAM 1 mg PO TID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. RisperiDONE 0.5 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Diazepam 2 mg PO BID
Discharge Medications:
1. Apixaban 5 mg PO BID
2. ClonazePAM 1 mg PO TID
3. Levothyroxine Sodium 88 mcg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. PARoxetine 37.5 mg PO DAILY
6. RisperiDONE 0.5 mg PO BID
7. Tiotropium Bromide 1 CAP IH DAILY
8. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Colon cancer with metastasis to the liver
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: History: ___ with colon CA w/ mets to abdomen// ? mass.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.3 cm; CTDIvol = 46.7 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction, intracranial
hemorrhage,edema,or mass effect. There is prominence of the ventricles and
sulci suggestive of age-related involutional changes. There are
periventricular and subcortical hypodensities, which are nonspecific and may
represent changes due to chronic small vessel ischemic disease. Vascular
arteriosclerotic calcifications are seen in the carotid siphons bilaterally.
There is no evidence of fracture. There is a small amount of fluid and mild
mucosal thickening in the right sphenoid sinus. The visualized portion of the
remaining paranasal sinuses, mastoid air cells, and middle ear cavitiesare
essentially clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process or hemorrhage. Please note that MR is more
sensitive in the detection of intracranial masses or metastatic disease.
Radiology Report
INDICATION: ___ year old man with COPD on 3 L of O2, T2DM and depressive
disorder. Referred to ___ for evaluation of colon mass on CT scan with possible
liver metastasis. Patient was being considered for colonoscopy but
reassessment liver biopsy might be less invasive and better approach. Thanks
for considering.// Possible liver metastasis to be biopsied
COMPARISON: Outside CT ___.
PROCEDURE: Ultrasound-guided 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 liver was
performed. The lesion for biopsy was identified in the inferior aspect of the
right hepatic lobe. A suitable approach for targeted liver biopsy was
determined.
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 17 gauge trocar was introduced at the
margin of the right hepatic lesion followed by 18-gauge core biopsies of the
lesion. A total of four samples were obtained given the possible marked
necrosis of the metastases on prior CT.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION:
Moderate sedation was provided by administering divided doses of 0.5 mg Versed
and 50 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.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 4. No immediate complications.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ likely colon adenoCa (prelim path) with liver mets. Abd
imaging done at OSH. Chest imaging to complete staging.// Evaluate for staging
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: 428 mGy-cm
COMPARISON: No comparison.
FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. No enlarged lymph nodes in the mediastinum.
Moderate aortic wall calcifications. Moderate coronary calcifications, no
pericardial effusion. The posterior mediastinum is unremarkable, with the
exception of a small hiatal hernia. Upper abdominal evaluation, including the
large hypodense liver lesions, was performed previously. No osteolytic
lesions at the level of the ribs, the sternum, or the vertebral bodies. Mild
degenerative vertebral disease. No vertebral compression fractures. Severe
pulmonary emphysema with multiple punctate interstitial calcifications.
Extensive calcifications along the major fissure on the right. Multiple
calcified micro nodules are also seen at the bases of the right lower lobe.
No pleural thickening, no pleural effusions. No fibrotic lung disease.
IMPRESSION:
Extensive pulmonary emphysema with multiple calcified micro nodules, notably
in perifissural and right lower lobe location. No suspicious pulmonary
nodules or masses. No adenopathy. No pleural abnormalities.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal CT
Diagnosed with Portal vein thrombosis
temperature: 97.6
heartrate: 92.0
resprate: 18.0
o2sat: 98.0
sbp: 125.0
dbp: 71.0
level of pain: 7
level of acuity: 3.0 | # Colonic mass with possible metastatic lesions: CT with likely
metastatic colon cancer complicated by portal/SMV thrombus. CEA
was elevated at 14.5.
GI consulted, but pt ultimately underwent ___ guided liver biopsy
of concerning lesions which revealed metastatic adenocarcinoma
with necrosis, well to moderately differentiated. By IHC, tumor
cells are strongly positive for CDX-2 and negative for CK7,
CK20, supportive of GI origin. Immunohistochemistry stains for
mismatch repair protein shows loss of nuclear staining for MLH1
and PMS2 in the tumor cells, with intact staining of MSH2 and
MSH6.
Pt was seen by oncology - given his relatively poor performance
status (ECOG ___, pt was not felt to be a candidate for typical
colon cancer regimens like FOLFOX or FOLFIRI, but if his
condition improved after d/c they could consider treatment
with single-agent fluropyrimidine. They also recommend MSI
testing (as above), as patient may be a candidate for
immunotherapy as a possible second-line treatment
# SMV/portal vein thrombus: may be related to compression from
mass, however could also consider tumor thrombus. Pt was
initially placed on a heparin drip and transitioned to warfarin.
Given his poor and unreliable po intake and difficulty
coordinating INR monitoring at home, it was felt a transition to
apixaban 5mg BID was the safest option. Of note, INR on the day
of d/c was 3.7 (warfarin held the day prior as well) and pt was
given 5mg PO Vitamin K with plan to transition to apixaban the
following day.
# Microcytic anemia: likely secondary to bleeding from colonic
mass. Pt was placed on iron supplementation. There was no
evidence of overt GI bleeding and his hgb remained stable
despite anticoagulation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydromorphone
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
___ CTC Virtual Colonography
___ Colonoscopy/EGD
History of Present Illness:
___ with ESRD on dialysis (last session ___, s/p L
nephrectomy and hematoma at the surgical site presenting with
anemia.
Patient reports that she went to dialysis and was found to be
anemic. She was sent here for further evaluation. Denies recent
bleed, chest pain, shortness of breath, lightheadedness. Per
record, lost approximately 2 units since beginning of ___.
In the ED, initial VS were 97.6 94 158/56 18 100% RA.
Exam notable for bright red blood on rectal exam.
Labs showed Cr 2.9 and Hgb 6.8, 17 WBC on UA.
Received 1u pRBCs.
Transfer VS were 100.1 88 162/65 16 98% RA.
GI and urology were consulted.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports (with phone
interpreter) that she feels a little lethargic but is in no
pain. She denies feeling any differently at dialysis today but
was told her blood counts were low and was sent in. She denies
any prior episodes of GI bleeding.
Past Medical History:
- History of either cervical (per GYN notes) or uterine cancer
s/p debulking surg, b/l nephrostomy tubes, XRT and chemotherapy
___ and ___
- Obstructive uropathy ___ radiation
- ESRD ___ obstructive uropathy from radiation therapy on HD MWF
- "Multiple UTIs E coli confirmed for ESBL, K Pnemonia,
coagulase negative staph, stenotrophomonas maltophilia and
finally
Klebsiella oxytoca sensitive to everything except ampicillin".
- DM poorly controlled
- HTN
- HLD
Social History:
___
Family History:
Mother died after a fall. Father is still alive. She does not
know about the health of her siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T99 BP 144/67 HR 83 RR 20 Sats 96 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Has one open site in
left upper quadrant and one open surgical site in right lower
quadrant draining serosanguinous discharge. R.nephrostomy site
looks clean and draining clear urine.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VITALS: T98.7 BP:157/62 HR:82 RR:18 SAT: 98%
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2. Crescendo decrescendo systolic murmur heard
best at RUSB. No gallops or rubs
LUNG: Decreased breath sounds bilaterally at lower lobes. No
wheezes, rales, rhonchi. Breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Has one open site in
left upper quadrant and one open surgical site in right lower
quadrant draining serosanguinous discharge. R.nephrostomy site
looks clean and draining clear urine.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. No CVA tenderness.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 10:30AM BLOOD Hgb-6.8*# Hct-22.1*#
___ 05:50PM BLOOD WBC-9.7 RBC-2.49*# Hgb-7.1* Hct-23.4*
MCV-94 MCH-28.5 MCHC-30.3* RDW-18.4* RDWSD-62.6* Plt ___
___ 05:50PM BLOOD Neuts-83.6* Lymphs-8.4* Monos-6.0 Eos-1.0
Baso-0.3 Im ___ AbsNeut-8.13* AbsLymp-0.82* AbsMono-0.58
AbsEos-0.10 AbsBaso-0.03
___ 05:50PM BLOOD ___ PTT-27.2 ___
___ 05:50PM BLOOD Plt ___
___ 05:50PM BLOOD Glucose-116* UreaN-11 Creat-2.9*# Na-137
K-4.9 Cl-98 HCO3-28 AnGap-16
___ 05:50PM BLOOD VitB12-854 Folate->20
___ 05:50PM BLOOD GreenHd-HOLD
DISCHARGE LABS:
================
___ 09:10AM BLOOD WBC-8.5 RBC-3.40* Hgb-9.7* Hct-32.1*
MCV-94 MCH-28.5 MCHC-30.2* RDW-17.9* RDWSD-60.6* Plt ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-74 UreaN-15 Creat-5.6*# Na-142
K-4.7 Cl-101 HCO3-22 AnGap-24*
___ 09:49AM BLOOD ALT-16 AST-17 AlkPhos-209* TotBili-0.3
___ 09:10AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0
___ 09:49AM BLOOD calTIBC-130* Ferritn-595* TRF-100*
___ 05:50PM BLOOD VitB12-854 Folate->20
___ 06:17AM BLOOD Vanco-18.2
PERTINENT LABS AND STUDIES:
============================
___ 09:49AM BLOOD calTIBC-130* Ferritn-595* TRF-100*
___ 05:50PM BLOOD VitB12-854 Folate->20
MICROBIOLOGY:
============================
___ 4:05 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
SERRATIA MARCESCENS. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
___: URINE CULTURE
**FINAL REPORT ___
URINE CULTURE (Final ___:
SERRATIA MARCESCENS. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:36 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
===========================
___ CTC Virtual Colonography: WET READ
Prep was incomplete and there was still a lot of stool that was
mostly able to be displaced. Nothing in colon, no straining, and
no evidence of colonic AVM. There was a segment of small bowel
that was thickened with mucosal hyperintensity consistent with
small bowel enteritis but of unclear origin. Fluid collection in
the left flank stable in size from previous CT with rim
enhancing fluid collections around the post-surgical site. Fluid
collections were not drainable. Mild right hydroureter
hydronephrosis. Main Finding: Abnormal small bowel segment.
___ CXR (PA & LAT): There has been clearing of previously
noted bilateral densities with only a small amount of residual
density in the left and right bases. There is a left effusion
present. There is no pneumothorax or CHF. I would recommend a
repeat chest x-ray when the patient's symptoms have cleared to
re-evaluate the bases.
___ US EXTREMITY LIMITED SOFT TISSUE RIGHT ULTRASOUND: No
fluid collection.
___ CXR (PORTABLE AP): There is patchy consolidation in the
left lower lobe. There may be a small area patchy density in
the right lung base. There is no pneumothorax or CHF.
___ CT ABD & PELVIS WITH CONTRAST:
1. Post left nephrectomy. An intermediate density fluid
collection at the
postsurgical bed of the left retroperitoneum, measuring 6.9 x
5.4 x 12.8 cm, likely represents a retroperitoneal hematoma.
2. The right kidney has a percutaneous nephrostomy tube and mild
right
hydronephrosis.
3. Small nonhemorrhagic, layering, dependent left pleural
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. sevelamer carbonate 2400 mg oral DAILY
4. Docusate Sodium 100 mg PO BID constipation
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Discharge Medications:
1. Losartan Potassium 100 mg PO DAILY
2. sevelamer carbonate 2400 mg oral DAILY
3. Amlodipine 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID constipation
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
6. Ciprofloxacin HCl 500 mg PO Q24H Duration: 8 Days
start ___ end ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*8
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Retroperitoneal hematoma
HCAP
UTI
SECONDARY DIAGNOSES:
ESRD on HD
DMII
Hypertension
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 without contrast
INDICATION: ___ with ESRD on dialysis (last session today), s/p L nephrectomy
and hematoma at the surgical site presenting with anemia. // ?RP bleed
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 4.7 s, 51.4 cm; CTDIvol = 9.0 mGy (Body) DLP = 464.8
mGy-cm.
Total DLP (Body) = 465 mGy-cm.
COMPARISON: CT abdomen and pelvis without contrast from ___.
FINDINGS:
LOWER CHEST: There is a small nonhemorrhagic, layering, dependent left
pleural effusion with associated atelectasis.
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. An accessory splenule is incidentally noted.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Status post left nephrectomy with overlying surgical clips. There
is a intermediate density fluid collection in the left retroperitoneum, likely
hematoma, measuring 6.9 x 5.4 x 12.8 cm TV x AP x CC (2:32, 601b:30) at the
postsurgical bed. The right kidney has a percutaneous nephrostomy tube with
mild hydronephrosis. There is no evidence of focal renal lesions of the right
kidney within the limitations of an unenhanced scan. There is no
nephrolithiasis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace non-hemorrhagic 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: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes are seen in the lumbar spine, particularly at the L5-S1
vertebral level. There is grade 1 retrolisthesis of L5-S1 level.
SOFT TISSUES: There are calcified granulomas and foci of edema in the left
gluteal region, likely injection sites. The abdominal and pelvic wall is
within normal limits.
IMPRESSION:
1. Post left nephrectomy. An intermediate density fluid collection at the
postsurgical bed of the left retroperitoneum, measuring 6.9 x 5.4 x 12.8 cm,
likely represents a retroperitoneal hematoma.
2. The right kidney has a percutaneous nephrostomy tube and mild right
hydronephrosis.
3. Small nonhemorrhagic, layering, dependent left pleural effusion.
Radiology Report
INDICATION: ___ year old woman with fever, perinephric hematoma, bloody stools
// ?PNA ?acute process
COMPARISON: The comparison is made with prior studies including ___.
IMPRESSION:
There is patchy consolidation in the left lower lobe. There may be a small
area patchy density in the right lung base. There is no pneumothorax or CHF.
Radiology Report
EXAMINATION: CT Colonography with contrast
INDICATION: ___ with ESRD on dialysis (last session today), s/p L nephrectomy
and hematoma at the surgical site, gynecologic cancer status post radiation
therapy, with BRBPR, presenting with anemia, on limited colonoscopy (aborted
due to inability to tolerate) sigmoid with AVM consistent with radiation
proctitis. // Unable to tolerate full colonoscopy; evaluation of colon for
AVM, polyps per GI
TECHNIQUE: Axial contiguous slices were obtained from the lung bases to the
pubis symphysis after insufflation of intrarectal air in the prone and supine
positions. Exam is limited due to incomplete prep and patient discomfort with
colonic insufflation.
Intravenous contrast was was administered and axial slices were obtained in
the arterial and portal venous phase in the supine position. Coronal and
sagittal reformats were obtained.
DOSE: Total DLP (Body) = 1,394 mGy-cm.
COMPARISON: CT abdomen pelvis with contrast on ___
FINDINGS:
CT COLONOGRAPHY: There is small amount of fluid with retained fecal matter in
the sigmoid, ascending and descending colon matter. The fluid mostly
displaces with repositioning.
No suspicious lesions are seen. There is no evidence of polyps or mass.
There is no evidence of stricture or inflammatory disease. There is no large
draining vein to suggest a colonic AVM.
CT abdomen and pelvis with contrast:
LOWER CHEST: Again seen is a small nonhemorrhagic left pleural effusion with
adjacent atelectasis, similar to prior. There is 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 shows normal size and attenuation throughout, without
evidence of focal lesions. There is a small accessory spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The left kidney is surgically absent, with surgical clips in the
nephrectomy bed. There is a 5.3 x 4.4 x 11.8 cm fluid collection in the left
retroperitoneum, stable to slightly decreased in size from prior, and
consistent with postsurgical change (9b:225). There are several small rim
enhancing collections adjacent to the is fluid collection (9b:245).
A right percutaneous nephrostomy tube is present. There is mild right
hydroureter. There is no evidence of suspicious right focal renal lesions or
hydronephrosis. There is no right perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is a segment of small
bowel wall thickening and mucosal hyper enhancement, consistent with small
bowel enteritis (9b:307, 9:306). The colon and rectum are described above.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small amount of nonhemorrhagic free fluid in the pelvis, similar to prior.
REPRODUCTIVE ORGANS: The uterus is not visualized.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Again seen are degenerative changes in the lumbar spine, worst at
L5-S1. There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There are postsurgical changes in the left flank at prior
surgical site (9:222). The abdominal and pelvic wall are otherwise within
normal limits.
IMPRESSION:
1. Exam is slightly limited due to incomplete prep and to patient discomfort
during the exam with colonic insufflation. Within this limitation, there is
no significant polyp or mass identified (greater than 1 cm). The sensitivity
of CT colonography for polyps greater than 1 cm is 85-90%. The sensitivity
for polyps 6-9mm is about 60-70%. Flat lesions may be missed with CT
Colonography. No colonic AVM identified.
2. Abnormal segment of small bowel wall thickening and mucosal
hyperenhancement, consistent with small bowel enteritis.
3. Postsurgical fluid collection in the left nephrectomy bed, with several
adjacent small rim enhancing fluid collections.
4. Right percutaneous nephrostomy and mild right hydroureter. No right
hydronephrosis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 5:20 ___, 10 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old woman with RUE fistula for HD access and fever //
?abnormality ?infection
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
superficial tissues of the right upper arm.
COMPARISON: None relevant
FINDINGS:
Limited evaluation of the area of the fistula demonstrates patent vessels and
no fluid collection.
IMPRESSION:
No fluid collection.
Radiology Report
INDICATION: ___ year old woman with fever, perinephric hematoma after
nephrectomy, now with pleural effusion, fevers. // evaluate pleural effusion,
infiltrates
COMPARISON: The comparison is made with prior studies including ___.
IMPRESSION:
There has been clearing of previously noted bilateral densities with only a
small amount of residual density in the left and right bases. There is a left
effusion present.
There is no pneumothorax or CHF. I would recommend a repeat chest x-ray when
the patient's symptoms have cleared to re-evaluate the bases.
RECOMMENDATION(S): I would recommend a repeat chest x-ray when the patient's
symptoms have cleared to re-evaluate the bases.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.6
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 158.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | ___ ___ Speaking F with ESRD on hemodialysis MWF (last
session ___ due to obstructive uropathy, with hx of
cervical cancer s/p radiation therapy c/b retroperitoneal
fibrosis, bilateral obstructive uropathy treated with long
standing bilateral PCNs s/p L nephrectomy on ___ and
hematoma at the surgical site presenting with anemia.
#Anemia: Thought to be secondary to post surgical
Retroperitoneal Bleed. On admission, patient found to have
normocytic with elevated RDW and a Hgb of 6.8 from baseline ~10,
with appropriate bumped s/p 1 unit pRBC. CT ab/pelvis showed
impressive 6.9 x 5.4 x 12.8 cm hematoma at the nephrectomy bed;
there is no prior imaging to compare stability of hematoma
reported at surgical site from ___ L nephrectomy. Given the
size of hematoma, the acute hgb drop is likely due to bleeding
into hematoma; patient was hemodynamically stable during
admission with Hb on discharge of 9.7. Urology recommended
conservative approach for RP hematoma. Patient also had evidence
of GI Bleeding with sigmoid AVMs seen on colonoscopy. Patient
takes IV iron 125mg IV Ferric gluconate and ___ ___ QHD as
per outpatient for iron deficiency anemia and anemia ___ to CKD
respectively.
#Fevers: ___ to HCAP, serratia UTI, and possibly infected RP
hematoma:
On admission, patient was started on IV ceftriaxone Q24 given
history of multiple UTIs and was found to have UTI with serratia
marcescens. Over hospital course, patient was found to
uptrending leukocytosis with fever to ___ on ___ and to
101.1 on ___. Imaging showed patchy consolidation in the
left lower lobe, small area patchy density in the right lung
base, and small non loculated, non septated pleural effusion
concerning for HCAP. Antibiotics were broadened with
improvements in leukocytosis and symptoms.
Discharged on Ciprofloxacin (___ for
Serratia UTI (w/likely plasmid resistance). Will require follow
up urine culture for clearance as grew threw prior antibiosis.
#Urinary Infection with SERRATIA MARCESCENS: Patient has a ___
history of multiple UTI positive for Serratia marcescens,
klebsiella oxytoca, Staph Aureus Coag +, morganella ___. As
per OMR, multiple UTIs E coli ESBL, K Pnemonia, coagulase
negative staph, stenotrophomonas maltophilia and finally
Klebsiella oxytoca sensitive to everything except ampicillin. On
admission, patient was found on admission to have UTI with
pan-sensitive serratia marcescens. Initial growth through
ceftriaxone. Discharged as above.
#Hemorrhoidal Bleeding and Radiation Proctitis: Patient has
history of BRBPR. Patient did not sedate well for EGD and did
not tolerate ___ on ___. Patient has evidence of GI
Bleeding most consistent with hemorrhoidal bleeding by way of
history and physical however her GI losses do not explain the
rapidity at which her Hb dropped. Sigmoidoscopy showed AVM
consistent with Radiation Proctitis. On ___, patient underwent
___ Virtual colonograph for further work-up.
# Obstructive uropathy ___ radiation: Patient is s/p L.
nephrectomy on ___ baseline Cr approximately ___, ESRD on
HD ___.
# ESRD ___ obstructive uropathy from radiation therapy on
hemodialysis MWF. Continued on home sevalamer, calcium, and
vitamin D.
#Wound infection: On admission, patient found to have purulent +
serosanguinous drainage from L abdominal trochar site indicative
of possible wound infection. Urology felt wound was not infected
and blood cultures remained negative throughout admission.
CHRONIC ISSUES
# DM: Last HbA1c 6.8% in ___, not on any home medications for
DM2, treated with ISS while in house.
# HTN- Was continued on home losartan while in house. Home
amlodipine was held and re-started on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
CRT-P placed ___
History of Present Illness:
___ year old male with h/o HLD, HTN and PVC-induced
cardiomyopathy(EF 39%, PVC burden 27%) s/p PVC ablation
___. During the procedure he developed LBBB during LV
mapping and complete heart block with junctional escape during
the last ablation lesion. He was evaluated on ___ and found
to have 3rd degree heart block with a rate of 30 bpm after which
his amiodarone, metoprolol, and lisinopril were D/C. He presents
to the ED for severe episodes of lightheadedness.
Mr. ___ was initially evaluated by cardiology on ___.
Prior to this date he had no significant prior cardiac history
apart from risk factors of hypertension and hyperlipidemia. At
the begginig of ___ he had a routine health evaluation and was
noted to have frequent PVCs. Subsequently, he underwent an
echocardiogram on ___, which showed biatrial dilation,
mild
LVH with moderate global LV dysfunction (LVEF 39%) with beat to
beat variability in the setting of frequent PVCs. Initially,
underwent stress echocardiogram that was negative for ischemia,
and then had a Holter that showed a significant burden of
PVCs(27%).
It was considered that this high burden of PVCs could cause
cardiomyopathy that explained the newly found reduced ejection
fraction. Thus, he underwent a cardiac MRI followed by EP with
ablations in the RV septum, LV septum and RCC. During the
procedure he developed LBBB during LV mapping and complete heart
block with junctional escape during the last ablation lesion.
However before discharge conduction recovered and had 1:1
conduction and was discharged on Metorpolol, Amiodarone, and
Lisinopril.
On ___ he was evaluated as an outpatient with a complain of
lightheadedness. On that occasion he was found to be in complete
heart block with a ventricular rate around 30 bpm and a
junctional rhythm with an incomplete right bundle branch block.
He had normal BP without orthostatc changes. At that time he was
reluctant to stay in the hospital and therefore his amiodarone
and metoprolol were discontinued.
Today, after waking from a nap he was talking with his daughter
when he began shaking like a seizure with snorting and drooling
and was unresponsive for about ___ seconds before recovering.
He relates the episodes to heart rates less than 50 bpm. He has
not had any chest pain, shortness of breath, or syncope during
these episodes. He has not noticed any increased swelling in his
legs and states he has been taking his weight daily at home
since the procedure and it has been stable.
ED course:
Initial VS: HR 50-70s, BP 120-140s/70-80s, RR ___, O2Sat high
___ on RA
Exam: Bradycardic heart sounds but otherwise unremarkable
EKG: 56 bpm, normal axis, 3rd degree heart block, QTC 488,
prolonged QRS with a right bundle branch block, no T wave
inversions or ST segment changes
Labs notable for: CBC with mild leukocytosis (10.1) but
otherwise
wnl, Glucose: 102, UreaN: 20, Creat: 1.4, Na: 141, K:4.9,
Cl:109, HCO3: 18, AnGap: 14, Troponin T: <0.011, BNP: 443.
Studies notable for: CXR with no pulmonary edema and possible
small pleural effusion.
Consults: EP
Patient was given: 1L bolus of IV fluids
On the floor he endorses the above HPI. He denies having any new
episodes of lightheadedness.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, or palpitations.
On further review of systems, denies fevers or chills. Denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
PVC induced cardiomyopathy (EF 39%, PVC burden 27%) s/p PVC
ablation ___
Complete Heart Block
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Mother BREAST CANCER
Father DIABETES TYPE ___
Brother HEALTHY
___ COLON CANCER
DIABETES TYPE ___
EMPHYSEMA
MGM GLAUCOMA
Physical Exam:
General: Alert, oriented, no acute distress
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; patient with pacer pads on chest and defibrillator at
bedside
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 03:40PM ___ PTT-28.2 ___
___ 03:40PM PLT COUNT-273
___ 03:40PM NEUTS-75.5* LYMPHS-14.5* MONOS-7.9 EOS-0.9*
BASOS-0.4 IM ___ AbsNeut-7.61* AbsLymp-1.46 AbsMono-0.80
AbsEos-0.09 AbsBaso-0.04
___ 03:40PM WBC-10.1* RBC-4.98 HGB-15.1 HCT-44.3 MCV-89
MCH-30.3 MCHC-34.1 RDW-12.9 RDWSD-41.9
___ 03:40PM CALCIUM-9.8 PHOSPHATE-1.4* MAGNESIUM-2.0
___ 03:40PM proBNP-443*
___ 03:40PM cTropnT-<0.01
___ 03:40PM estGFR-Using this
___ 03:40PM GLUCOSE-102* UREA N-20 CREAT-1.4* SODIUM-141
POTASSIUM-4.9 CHLORIDE-109* TOTAL CO2-18* ANION GAP-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 5 mg PO DAILY
3. Amiodarone 200 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute heart block
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 bradycardia lightheadedness s/p cardiac
ablation// fluid overload?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
There are 2 drains projected over the mediastinum, and a battery assisted
device projected over the left hemithorax.
There are diminished lung volumes. Mild blunting of the costophrenic angles
could represent small pleural effusions.
No pulmonary edema.
Irregularity of the fifth and sixth posterior ribs on the right, may represent
prior thoracotomy or healed rib fractures.
IMPRESSION:
No pulmonary edema. Possible small pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with post ppm// Post PPM, ? Pneumothorax
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There is a left chest wall cardiac pacing device with three leads terminating
in the regions of the right atrium, right ventricle and left ventricle. There
is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are identified. There are healed right rib fractures.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with post ppm// Eval lead position Eval lead
position
IMPRESSION:
Heart size and mediastinum are stable. Pacemaker leads terminate in right
atrium right ventricle and left epicardial vein. Lungs are overall clear.
There is no appreciable pleural effusion. There is no pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with Atrioventricular block, complete, Bradycardia, unspecified, Syncope and collapse
temperature: 96.9
heartrate: 57.0
resprate: 18.0
o2sat: 97.0
sbp: 139.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | SUMMARY: ___ year old male with h/o HLD, HTN and PVC-induced
cardiomyopathy
(EF 39%, PVC burden 27%) s/p PVC ablation ___, who
presented with syncope, found to be in complete heart block. He
received a biventricular pacemaker (CRT-O) on ___: the lead was
placed in the RV in slightly atypical location pointing towards
PA (by design).
====================
Acute Medical Issues
====================
# PVC-induced cardiomyopathy (EF 39%, PVC burden 27%) s/p PVC
# 3rd degree heart block
Patient with a non-ischemic cardiomyopathy (EF 39%, likely
PVC-induced)who presented to the ED with increasing frequency of
dizzy spells and suspicion for syncope. On ___ he underwent
a PVC ablation with the procedure complicated by LBBB and
transient complete heart block. He now is having ongoing
symptomatic heart block with frequent PVCs and short
intermittent periods of sinus rhythm with LBBB. His conduction
system disease did not improve after stopping nodal-blocking
agents. He received a biventricular pacemaker (CRT-O) on ___:
the lead was placed in the RV in slightly atypical location
pointing towards PA (by design).
================
CHRONIC ISSUES:
================
# Hypertension: Held home lisinopril during admission, to resume
at home 5mg daily outpatient.
# Dyslipidemia: Continue home atorvastatin
===================
Transitional Issues
===================
[] Patient will have follow up in device clinic in one week
[] Patient will follow up with Dr. ___ on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old F w/ hx of DM c/b retinopathy with
blindness in R eye, HTN, and CHF who presents with vertigo. Hx
obtained from pt and husband at bedside.
Pt was at work today (___ Cafeteria) when at 1200 she had an
episode of emesis followed by gradual onset (within a few min)
of
dizziness. Pt threw up two more times, sat down and put her head
down on table. Her boss told her to stay still and called her
husband. When trying to get her up from table, husband and her
boss noticed that she couldn't stand up well, eventually falling
onto her knees. Pt reports that her legs felt so weak that she
couldn't tell whether she was falling towards a single side. She
then developed a headache, bifrontal in region, sharp in quality
and severe in quantity. EMS was called who brought pt to ED for
evaluation. En route, pt described a tightness in her chest. At
time of interview, after administration of IVFs and Meclizine,
pt's nausea is resolved but pt continues to experience vertigo.
Headache is mostly resolved.
Of note, pt had a URI recently which improved spontaneously this
past ___. No hearing changes, tinnitus, or aural fullness. No
UE weakness, sensory deficits, dysarthria, or dysphagia. No ear
pain or popping sensation. No recent head trauma.
Pt had an episode of vertigo ___ yrs ago with associated
nausea/emesis. Reportedly attributed to an ear infection and pt
was given some medication for her vertigo which was unrelieving.
She returned to ___ ED where she was given another medication
providing some mild relief. However, pt continued to experience
sustained vertigo for 1 month with resultant reduced hearing in
L
ear, found on associated studies.
Neuro ROS negative except as noted above
General ROS + for b/l hip pain
Past Medical History:
DMII c/b b/l retinopathy, OD>OS (can see barely)
CHF
?cervical spondylosis
HTN
Social History:
___
Family History:
FAMILY HISTORY:
Significant hx of cardiovascular dz in family
Physical Exam:
Admission Exam:
Temp: 98.5 HR: 90 BP: 166/89 Resp: 18 O(2)Sat: 97 room air
Normal
Constitutional: She looks mildly uncomfortable
HEENT: Her vision is quite poor in both eyes. This makes
even nystagmus testing difficult. In primary gaze, I do not
see any nystagmus but when she looks to the left, she has
some pathological horizontal left beating nystagmus. On
rightward gaze, I do not see any nystagmus.
Pupils are symmetric and ___ mm.
Mucous membranes are moist
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds
Abdominal: Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No edema
Skin: Warm and dry
Neuro: Awake and alert. Speech is normal. Her ocular motor
exam as above.
I did not do a head impulse test on her because given the
rest of her exam as below, I would not trust a positive head
impulse test to exclude a central cause.
No facial asymmetry. Hearing is intact.
Finger to nose testing is worse on the left than the right
but abnormal bilaterally although this may well be due to
her visual issues. Heel to shin is somewhat better but even
there, she is somewhat limited by leg pain.
I did not get her up to a walker since she fell before
she came in.
Psych: Normal mentation
===============
Discharge Exam
___ 1126 Temp: 97.7 PO BP: 143/81 HR: 74 RR: 18 O2 sat: 96%
O2 delivery: Ra FSBG: 261
General: Awake, cooperative, NAD, obese Hispanic female.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: pupils 2.5mm, minimally reactive. EOMI,
difficult to appreciate end gaze nystagmus due to repeated
sacchadic intrusions. Similarly unable to adequately perceive
corrective sacchades on head impulse testing. No skew deviation.
VFF in L eye. Blind in R eye, ___ in L eye.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: HOH L>R.
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. Full strength throughout.
No adventitious movements, such as tremor, noted. No asterixis
noted.
-Sensory: Decreased sensation to PP over distal LEs up to mid
foot in stocking-glove distribution. No deficits to light touch
or proprioception throughout. Vibratory sense intact at level of
great toe (6 second on R, 12 second on L) No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1 trace
R 2 1 1 1 trace
Plantar response was flexor bilaterally.
-Coordination: Subtle dysmetria on FNF and dysdiadochokinesia on
R. Unable to adequately test HKS.
-Gait: Narrow based, intact stride and arm swing. Romberg
absent.
Pertinent Results:
___:40AM BLOOD WBC-9.8 RBC-4.15 Hgb-11.4 Hct-36.2 MCV-87
MCH-27.5 MCHC-31.5* RDW-16.3* RDWSD-51.0* Plt ___
___ 03:40AM BLOOD Glucose-177* UreaN-40* Creat-1.1 Na-138
K-4.1 Cl-98 HCO3-27 AnGap-13
___ 03:52PM BLOOD ALT-22 AST-19 AlkPhos-144* TotBili-0.3
___ 03:40AM BLOOD %HbA1c-11.3* eAG-278*
___ 03:40AM BLOOD Triglyc-1021* HDL-39* CHOL/HD-8.8
LDLmeas-129
___ 03:40AM BLOOD TSH-2.1
Medications on Admission:
MEDICATIONS:
Insulin Novolog 20 units TIDAC
Metformin 1g BIDAC
Trulicity 0.75mg qwk
Januvia 40mg qhs
Torsemide 40mg daily
Losartan 50mg daily
Carvedilol 12.5mg BID
ASA 81mg daily
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*2
2. Glargine 65 Units Bedtime
Humalog 22 Units Breakfast
Humalog 22 Units Lunch
Humalog 22 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 65 Units before BED; Disp #*10 Syringe Refills:*2
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
Up to 16 Units QID per sliding scale 22 Units before LNCH; Units
QID per sliding scale 22 Units before DINR Disp #*30 Syringe
Refills:*2
3. Aspirin 81 mg PO DAILY
4. CARVedilol 6.25 mg PO BID
5. Torsemide 20 mg PO DAILY
6.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Acute vertigo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with chest pain, presyncope// chest pain, presyncope
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is mild to moderately enlarged, as seen previously. The
mediastinal and hilar contours are normal. The pulmonary vasculature is
normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There
are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: History: ___ with r/o dissection, also left hip pain// r/o
dissection, also left hip pain
TECHNIQUE: AP view of the pelvis, two views of the left hip
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
No acute fracture or dislocation. Minimal degenerative spurring in both hips.
Hips and sacroiliac joints are otherwise preserved. No concerning lytic or
sclerotic osseous abnormality. Clip projects over the midline sacrum. No
concerning soft tissue calcifications.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with history of hypertension, diabetes, CHF,
presenting with vertigo. Evaluate for 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 intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 13.3 mGy (Body) DLP = 522.6
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 23.7 mGy (Body) DLP =
11.9 mGy-cm.
Total DLP (Body) = 536 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Noncontrast head CT from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
No evidence for acute intracranial hemorrhage, edema, mass effect, or acute
major vascular territorial infarction. Minimal mucosal thickening in the
ethmoid and maxillary sinuses. Ethmoid air cells appear grossly well-aerated.
Status post bilateral cataract surgery.
CTA NECK:
Common origin of the right innominate and left common carotid arteries, normal
variant. Widely patent cervical carotid and vertebral arteries without
evidence for dissection. Specifically, no carotid stenosis by NASCET
criteria.
CTA HEAD:
There is irregularity and up to moderate narrowing of the distal M1 segment of
the right MCA. The right A1 segment is hypoplastic, likely a congenital
variant. No evidence for an aneurysm. Incidental note is made of a short
segment fenestration of the proximal basilar artery.
The dural venous sinuses are patent.
OTHER:
The adenoids are enlarged, similar to the CT from ___. However, the patient
was ___ years old in ___. The thyroid is unremarkable. Multiple bilateral
nonenlarged cervical lymph nodes are present, including the suboccipital
regions. The lymph nodes are top normal in size at level 2 bilaterally. Main
pulmonary artery is borderline enlarged, 3.1 cm. The heart is enlarged, as
seen on same-day chest radiograph. Evaluation of the included upper lungs is
limited by respiratory motion artifact and dependent atelectasis.
IMPRESSION:
1. No evidence of acute intracranial abnormalities. MRI would be more
sensitive for posterior fossa pathology in the setting of vertigo, if
clinically warranted.
2. Normal neck CTA.
3. Irregularity and up to moderate stenosis of the distal M1 segment of the
right MCA.
4. Fenestration of the proximal basilar artery.
5. Enlarged adenoids, similar to a head CT from ___, though the patient was
___ years old at that time, and adenoidal prominence was less concerning. If
clinically warranted, this may be further evaluated by direct visualization.
6. Multiple top-normal and prominent nonenlarged bilateral cervical lymph
nodes.
7. Cardiomegaly. Borderline enlargement of the main pulmonary artery, which
may reflect mild pulmonary arterial hypertension; please correlate clinically.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST PORT ___ MR HEAD
INDICATION: ___ year old woman with history of hypertension, diabetes, CHF,
presents with vertigo.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA of the head and neck from ___
CT head from ___.
FINDINGS:
There is no evidence of acute infarction, edema, mass effect, or intracranial
blood products. Few scattered T2/FLAIR hyperintense foci in the
periventricular and subcortical white matter of the frontal lobes are
nonspecific, though likely sequela of mild chronic small vessel ischemic
disease given the patient's cardiovascular risk factors. Ventricles and sulci
are age-appropriate.
There is mild mucosal thickening in the ethmoid and maxillary sinus. The
adenoids are enlarged, and they also appeared enlarged on the CT from ___,
though this may have been related to the patient's young age of ___ in ___.
Status post bilateral cataract surgery. Sagittal images demonstrate
incompletely evaluated degenerative changes in the included upper cervical
spine.
IMPRESSION:
1. No acute infarction. No evidence for posterior fossa abnormalities on
noncontrast MRI.
2. Few scattered T2/FLAIR signal abnormalities in the bifrontal white matter
are nonspecific but likely sequela of mild chronic small vessel ischemic
disease given the patient's cardiovascular long factors.
3. Mildly enlarged adenoids, with adenoidal enlargement also seen on the head
CT from ___ when the patient was ___ years old. If clinically warranted, the
adenoids may be more accurately assessed by direct visualization.
Gender: F
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Presyncope
Diagnosed with Unspecified disorder of vestibular function, unspecified ear
temperature: 98.5
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 166.0
dbp: 89.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ presented to BI ED for acute onset of vertigo,
nausea, and leg weakness. She was evaluated by Neurology service
in ED and deemed at risk for a posterior circulation stroke. CTA
H&N was performed which did not show any significant disease. Pt
was admitted to Neurology Stroke Service and received
symptomatic treatment with IVFs and Meclizine. She underwent MRI
Head which showed no stroke. Due to alleviation of her sx,
patient was discharged from the hospital. Of note, during
admission her blood sugar and HgbA1c were high requiring
Diabetes consult and uptitration of her insulin regimen.
Atorvastatin was also started for high cholesterol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
___ guided bone biopsy
History of Present Illness:
___ w h/o pituitary macroadenoma, thyroid cancer, wegner's
granulomatsosis presents w mid torso and back pain for several
days that is severe. She has imaging done at ___
with
CTA chest that showed findings in T6-T7 concerning for
osteomyeleitis and she was transferred to ___ for spine
consult
evaluation. Spine evaluated patient and she had spine MRI.
Pain
is now ___, severe, she says it wrapped around ribs from front
to back and now is mostly in the back. She has modified
activity
as bending and sitting makes it worse, used ice without relief.
Tylenol and NSAIDs don't relieve pain. She says her illness
began earlier in ___ when she went to ___, diagnosed
w
pyelonephritis, Rx w cipro, then called 9d later that antibiotic
choice not appropriate and then Rx for 5d of macrobid. Pain
developed in torso and back, laying flat also difficult. No
urinary or stool retention or incontinence. No saddle
anesthesia
no numbness in legs or torso. She describes fatigue from poor
sleep and generalized weakness/malaise.
Past Medical History:
pituitary macroadenoma w multiple surgeries
thyroid cancer
wegner's granulomatosis, managed by Dr. ___ at ___
gastritis
ED visit to ___ in ___ w endoscopy w gastritis seen
Social History:
___
Family History:
not pertinent to management of current diagnosis
Physical Exam:
Temp: 97.8 PO BP: 100/67 HR: 72 RR: 18 O2 sat: 93%
O2 delivery: ra
she appears uncomfortable when sitting forward, and wants me to
avoid percussion of mid back
when I palpate and percusss thoracic vertebrae it produces
significant pain
she has full grip strength bilaterally and can flex and extend
at
ankles fully
no numbness in arms or feet
no peripheral edema
soft abd
clear breath sounds
no wheezes
regular s1 and s2
Patient examined on day of discharge. AVSS. Pain over lower
thoracic spine on light palpation. Patient ambulates with normal
gait.
Pertinent Results:
___ 09:51PM BLOOD WBC-9.4 RBC-4.16 Hgb-10.8* Hct-35.2
MCV-85 MCH-26.0 MCHC-30.7* RDW-14.4 RDWSD-44.3 Plt ___
___ 09:51PM BLOOD Neuts-72.8* Lymphs-13.7* Monos-8.5
Eos-3.8 Baso-0.9 Im ___ AbsNeut-6.83* AbsLymp-1.29
AbsMono-0.80 AbsEos-0.36 AbsBaso-0.08
___ 01:05PM BLOOD ___ PTT-32.4 ___
___ 09:51PM BLOOD Glucose-90 UreaN-11 Creat-0.7 Na-138
K-6.4* Cl-99 HCO3-25 AnGap-14
___ 09:51PM BLOOD ALT-10 AST-31 AlkPhos-103 TotBili-<0.2
___ 09:51PM BLOOD Calcium-9.9 Phos-4.5 Mg-2.2
___ 09:51PM BLOOD CRP-230.9*
___ 09:51PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 09:54PM BLOOD Lactate-1.7 K-5.0
MRI ___:
IMPRESSION:
Spondylodiscitis with paravertebral abscess formation at the
T6-7 level as
described above.
No epidural abscess or cord compromise.
No high-grade spinal canal or neural foraminal stenosis.
Trace pleural effusions bilateral.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___. ___ @ 1538,
___.
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-11.9* RBC-4.15 Hgb-10.8* Hct-34.4
MCV-83 MCH-26.0 MCHC-31.4* RDW-13.8 RDWSD-41.3 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:51AM BLOOD Glucose-97 UreaN-14 Creat-0.6 Na-140
K-5.1 Cl-96 HCO3-27 AnGap-17
___ 06:24AM BLOOD ALT-6 AST-10 AlkPhos-88 TotBili-<0.2
___ 04:57AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.2
___ 05:45AM BLOOD CRP-202.8*
___ 09:51PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 06:35AM BLOOD HCV Ab-NEG
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Norethindrone-Estradiol 1 TAB PO DAILY
2. Levothyroxine Sodium 250 mcg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Sucralfate 1 gm PO QID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV Daily
Disp #*35 Intravenous Bag Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth Three times a day
Disp #*90 Capsule Refills:*0
5. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone 4 mg 1 tablet(s) by mouth Every three hours as
needed Disp #*40 Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % Place patch over thoracic spine One
daily Disp #*30 Patch Refills:*0
7. Methocarbamol 1500 mg PO QID
RX *methocarbamol 750 mg 2 tablet(s) by mouth Four times daily
as needed Disp #*28 Tablet Refills:*0
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Every eight hours as
needed Disp #*10 Tablet Refills:*0
9. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
10. Levothyroxine Sodium 250 mcg PO DAILY
11. Norethindrone-Estradiol 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Sucralfate 1 gm PO QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Osteomyelitis d/t e. coli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ ANDW/O CONTRAST ___ MR SPINE
INDICATION: History: ___ with back pain, concern for osteomyelitis/discitisIV
contrast to be given at radiologist discretion as clinically needed//
Osteomyelitis, Discitis, Cord Compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of Gadavist
contrast agent.
COMPARISON: Prior CT chest done ___
FINDINGS:
Spondylodiscitis at the level C6-7 as evidenced by vertebral body edema,
destruction of the intervertebral disc and adjacent endplates and wedge-shaped
deformities of the T6 and T7 vertebral bodies with a resultant mild kyphotic
deformity. There is paravertebral phlegmon formation measuring 10 mm in the
left paraspinal area and 11 mm in the right paraspinal area. Multiple small
nonenhancing areas within the phlegmon likely reflect abscess formation. No
epidural abscess. No compromise of the cord in the spinal canal.
Edema in the interspinous soft tissues at the level C6-7 and T7-8, but no
focal collection.
No high-grade spinal canal or neural foraminal stenosis.
Trace bilateral pleural effusions.
IMPRESSION:
Spondylodiscitis with paravertebral abscess formation at the T6-7 level as
described above.
No epidural abscess or cord compromise.
No high-grade spinal canal or neural foraminal stenosis.
Trace pleural effusions bilateral.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:25 am, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Thoracic spine bone biopsy
INDICATION: ___ year old woman with acute back pain in setting of
sub-optimally treated UTI, now w findings on MRI spine of
osteomyelitis,discitis,phlegmon, abscess.// please biopsy affected spine and
send for stat rush culture, gram stain, and save for fungal and additional
studies as well if possible
COMPARISON: MRI of the spine dated ___
PROCEDURE: CT-guided thoracic spine biopsy.
OPERATORS: Dr. ___, attending radiologist, performed the
procedure.
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 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 11 gauge coaxial bone biopsy needle was
introduced into the lesion. A 13 gauge core biopsy was used to obtain 1 core
biopsy specimen, which was sent for microbiology examination. Additional
passes were taken for pathology but they yielded a paucity of material.
The biopsy trocar/needle was removed and limited CT scan was performed in the
area which demonstrated no hematoma.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 22.7 cm; CTDIvol = 6.8 mGy (Body) DLP = 156.5
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
13) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
14) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
15) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
16) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
17) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
18) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
19) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
20) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
21) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
22) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
23) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
24) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
25) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
26) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
27) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
28) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
29) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
30) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
31) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
32) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
33) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
34) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
35) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
36) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
37) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
38) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
39) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
40) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
41) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
42) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
43) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
44) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
45) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
46) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
47) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
48) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
49) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
50) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
51) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
52) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
53) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
54) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
55) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
56) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
57) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
58) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
59) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
60) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
61) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
62) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
63) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
64) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
65) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
66) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
67) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
68) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
69) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
70) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
71) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
72) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
73) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
74) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
75) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
76) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
77) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
78) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
79) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
80) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
81) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
82) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
83) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
Total DLP (Body) = 501 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
4.5 mg Versed and 200 mcg fentanyl throughout the total intra-service time of
53 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Irregularity and destruction at the T6-T7 level which corresponds to the
prior imaging.
2. Bone biopsy needle within the irregular bone on CT fluoro imaging.
3. No significant hematoma noted post procedure.
IMPRESSION:
Technically successful thoracic spine cone biopsy for microbiology. A paucity
material was obtained for pathology.
RECOMMENDATION(S): Additional sampling may be necessary if a more complete
pathologic exam is required.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with right PICC// Right 38cm PICC ___ ___
Contact name: ___: ___
IMPRESSION:
In comparison with the study of ___, there is an placement of right
subclavian PICC line that extends to the midportion of the SVC. Slightly
improved lung volumes with blunting of the costophrenic angle on the right
that could reflect some combination of pleural fluid and atelectatic change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Transfer
Diagnosed with Osteomyelitis of vertebra, thoracic region
temperature: 98.5
heartrate: 88.0
resprate: 16.0
o2sat: 100.0
sbp: 114.0
dbp: 79.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ was initially admitted with acute mid back pain. An
MRI was performed, which showed spondylodiscitis with a
paravertebral abscess at T6-T7. She then received a CT-guided
bone biopsy, which returned E. coli, sensitive to
cephalosporins. Likely source was her recent pyelonephritis.
Spine team recommended medical management. The ID team was
consulted, a PICC was placed, and she was started on ceftriaxone
2gm daily, with a plan for at least 6 weeks of therapy. She will
be contacted by OPAT for follow up.
Her course was complicated by severe pain. She was started on PO
hydromorphone, but continued to have a considerable amount of
pain limiting her movement. She was then started on gabapentin
300 mg TID and methocarbamol 1500 mg TID with considerable
improvement in her symptoms. She will be discharged on one week
of this therapy, and can be continued by her PCP as necessary.
Finally, on admission, she had a urine tox screen that was
positive for cocaine. There was initially some concern for IV
drug use; however, the patient had no track marks on exam, and
admitted to cocaine use previously. This will be followed up
with her primary care doctor as ___ transitional issue. |
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:
LLQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo s/p IVF with egg retrieval ___ and embryo (2) transfer ___
presenting to the ED for evaluation of acute-onset LLQ pain that
began this morning. She has had ___ episodes today, each lasting
___ minutes and characterized as sharp, "stabbing" pain.
Denies associated nausea or vomiting. On review of systems no
other associated symptoms including bleeding, fevers, chills,
dysuria.
In the ED she has received Zofran and morphine and currently
feels better. HCG was found to be positive at 333.
Past Medical History:
OBHx: G1P0
GynHx: denies h/o STIs or abnormal Paps
MedHx: denies
SurgHx: laparoscopic appendectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
Vitals - BP:128/83 HR:77 RR:20 O2sat:100% r/a
General: NAD, appears fatigued but comfortable
CV: RRR
Lungs: CTAB
Abdomen: soft, non-distended, moderate LLQ TTP, no
rebound/guarding
Pelvic: on bimanual exam, small mobile uterus, no CMT, mild left
adnexal TTP without rebound/guarding, bilateral enlarged ovaries
to around 8cm
On discharge:
afebrile, stable vital signs
Gen: NAD, AxO
CV: RRR
Resp: CTAB
Abd: normoactive BS, soft, nontender without rebound or
guarding, nondistended
Ext: calves nontender
Pertinent Results:
Blood:
___ 03:45PM BLOOD WBC-9.0 RBC-3.80* Hgb-11.9* Hct-35.8*
MCV-94 MCH-31.3 MCHC-33.2 RDW-12.1 Plt ___
___ 03:45PM BLOOD Neuts-75.8* ___ Monos-3.4 Eos-0.3
Baso-0.4
___ 03:45PM BLOOD Glucose-94 UreaN-8 Creat-0.8 Na-138 K-3.7
Cl-105 HCO3-23 AnGap-14
___ 03:45PM BLOOD HCG-333
Urine:
___ 03:45PM URINE Color-Straw Appear-Clear Sp ___
___ 03:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ urine culture pending at time of discharge summary
___ 03:45PM URINE UCG-POSITIVE
___ Gonorrhea/Chlamydia pending at time of discharge summary
Pelvic US (prelim):
IMPRESSION:
1. Enlarged bilateral ovaries with normal flow, however,
intermittent torsion cannot be excluded.
2. Multiple large functional cysts within the ovaries. Small
amount of free fluid.
3. No evidence of intrauterine pregnancy, likely due to early
gestation however ectopic is not excluded. Serial quantitative
hcgs recommended and repeat ultrasound can be performed in ___
weeks to document IUP or earlier if clinically indicated.
Medications on Admission:
vaginal progesterone, PNV
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain, r/o ovarian torsion
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left pelvic pain, status post IVF, rule out
torsion.
TECHNIQUE: Grayscale and color Doppler ultrasound images of the pelvis were
obtained.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
The ovaries are enlarged bilaterally with the left ovary measuring 9 x 6.2 x
6.2 cm and the right ovary measuring 8.1 x 5.8 x 5.5 cm. Normal venous and
arterial flow in both ovaries. Multiple large follicles, some of which with
retracting clot are seen. There is small amount of free fluid in the pelvis
tracking superiorly around the liver. The endometrium is difficult to image
but there is no evidence of gestational sac or intrauterine pregnancy at this
point.
IMPRESSION:
1. Enlarged bilateral ovaries with normal flow, however, intermittent torsion
cannot be excluded.
2. Multiple large functional cysts within the ovaries. Small amount of free
fluid.
3. No evidence of intrauterine pregnancy, likely due to early gestation
however ectopic is not excluded. Serial quantitative hcgs recommended and
repeat ultrasound can be performed in ___ weeks to document IUP or earlier if
clinically indicated.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with FEM GENITAL SYMPTOMS NOS, POLYCYSTIC OVARIES
temperature: nan
heartrate: 77.0
resprate: 20.0
o2sat: 100.0
sbp: 128.0
dbp: 83.0
level of pain: 9
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology
service for serial abdominal exams given the concern for
intermittent torsion based on pelvic ultrasound with enlarged
ovaries bilaterally (consistent with recent hyperstimulation for
IVF) and LLQ pain. She was kept NPO with IVF in the event that
she would require urgent diagnostic lapaorscopy. Her pain
spontaneously resolved, and she had no dizziness, nausea, or
other concerning symptoms. Her vital signs were stable within
normal limits and serial abdominal exams were benign, without
evidence of torsion or peritoneal signs. On hospital day 2, she
was advanced to a regular diet without problems and she required
no further pain medication. At this point, as she was tolerating
a regular diet, ambulating independently, voiding spontaneously,
and had no abdominal pain, she was discharged in stable
condition with plan for outpatient follow-up HCG. Ectopic
pregnancy and ovarian torsion precautions were reviewed prior to
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Extended-Release / clonidine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac Catheterization (no intervention)
Right IJ Central Catheter Placement
Intra aortic balloon pump placement
Arterial Line placement
History of Present Illness:
Mr. ___ is a ___ yo male with a history of CLL,
thalassemia, and DM who presents with ___ weeks of worsening
fatigue and dyspnea on exertion and cough occasionally
productive of streaky blood. The patient reports that for the
past ___ weeks, he has also had worsening orthopnea relieved by
leaning over the side of the bed. He says he typically sleeps
with one pillow. He denies fevers, chest pain, nausea, vomiting,
or diaphoresis. Mr. ___ has not been on chemotherapy for
over ___ years, but says that his oncologist was considering
restarting chemo in the upcoming weeks, given a rising white
count and worsening anemia.
Of note, Mr. ___ had pneumonia three weeks ago, which
presented primarily with a fever. He was treated with
levofloxacin for 10 days of treatment (5 days of medication,
then every other day for five more doses of medication). Mr.
___ was also transfused approximately one month ago without
complications.
In the ED, initial vitals were: 97.4 85 148/50 20 95%. His PE
in the ED was significant for cough, rales at the LLL base.
Notable lab values included a WBC count of 135.7 up from 93.2
(___), a Hgb 8.1/Hct 23.5 down from 10.0/29.7 on ___,
and a troponin of 0.40. CXR in the ED showed an infiltrate in
the LLL. EKG was significant for ST depressions in I, II, V4-V6.
Given a clinical picture concerning for demand ischemia and
pneumonia, the patient was given 1g IV ceftriaxone and 3 X 81mg
apirin. He was transfused with 1 unit PRBC.
While in ED, patient's O2 sats noted to drop to 88% on 4L NC
while sleeping. When he aroused, they return to 94-95%. Patient
reports he feels better, cough is resolving, denies CP or
increased SOB. On transfer to the floor, he was still feeling
well with cough, but decreased SOB and no chest pain.
Past Medical History:
CLL - was last on chemo ___ years ago in ___, chemo treatment
with FCR and Rituximab
Thalassemia
DM
HTN
CKD
Left inguinal herniorrhaphy in 1990s
Basal cancer removed from nose in ___
GI bleed - Capsule endoscopy performed in ___ as part of
evaluation of iron deficiency revealed multiple erosions and
ulcerations in his small bowel
Social History:
___
Family History:
Mom has history of DM, Dad had an MI.
His daughter has thalassemia.
Physical Exam:
Admission Physical:
VS: T= 99 BP= 123/56 HR= 74 RR= 22 O2 sat= 96% on RA
weight: 78.0 kgs (171.96 lbs)
GENERAL: Older Caucasian male, in no apparent distress wearing
4L NC.
HEENT: NCAT. Sclera anicteric. Wearing glasses. PERRL, EOMI.
MMM.
NECK: Supple with JVP to lower neck.
CARDIAC: RRR, normal S1, S2. ___ systolic murmur. No S3 or S4.
No carotid bruits.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at LLB.
ABDOMEN: Soft, nondistended, nontender to palpation. No
hepatosplenomegaly or tenderness.
EXTREMITIES: 1+ pitting edema to knees. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ ___ 1+
Left: Carotid 2+ Radial 2+ ___ 1+
Discharge Physical:
T 98.1, BP 125/65, HR 68, RR 18, POx 97%RA
weight: 72.3 kg
GENERAL: NAD, comfortable lying flat on room air
HEENT: NCAT. Sclera anicteric. Wearing glasses. PERRL, EOMI.
MMM.
NECK: Supple with no JVD when lying at 30 degrees
CARDIAC: RRR, normal S1, S2. ___ systolic murmur. No S3 or S4.
No carotid bruits.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diminished at LLB.
ABDOMEN: Soft, nondistended, nontender to palpation. No
hepatosplenomegaly or tenderness.
EXTREMITIES: Minimal edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ ___ 1+
Left: Carotid 2+ Radial 2+ ___ 1+
Pertinent Results:
ADMISSION LABS
___ 10:15AM BLOOD WBC-135.7* RBC-2.43* Hgb-8.2* Hct-23.5*
MCV-97 MCH-33.7* MCHC-34.9 RDW-17.5* Plt ___
___ 10:15AM BLOOD Neuts-3* Bands-0 Lymphs-97* Monos-0 Eos-0
Baso-0 ___ Myelos-0 Other-0
___ 10:15AM BLOOD ___ PTT-31.1 ___
___ 10:15AM BLOOD Glucose-261* UreaN-41* Creat-1.8* Na-129*
K-4.5 Cl-96 HCO3-21* AnGap-17
___ 10:15AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1
CARDIAC ENZYME TREND:
___ 10:15AM BLOOD CK-MB-8 ___
___ 10:15AM BLOOD cTropnT-0.40*
___ 09:20PM BLOOD CK-MB-12* MB Indx-2.8 cTropnT-0.97*
___ 03:30AM BLOOD CK-MB-13* cTropnT-0.97*
___ 07:35AM BLOOD CK-MB-11* MB Indx-3.1
___ 02:30AM BLOOD CK-MB-8 cTropnT-1.68*
___ 05:14AM BLOOD CK-MB-12* MB Indx-3.4 cTropnT-1.65*
___ 04:27PM BLOOD CK-MB-17* MB Indx-5.6 cTropnT-1.92*
___ 03:32AM BLOOD CK-MB-12* MB Indx-5.1 cTropnT-2.21*
___ 09:52AM BLOOD CK-MB-10 MB Indx-4.9 cTropnT-1.77*
___ 05:24PM BLOOD CK-MB-8 cTropnT-1.39*
DISCHARGE LABS:
___ 07:03AM BLOOD WBC-86.9* RBC-2.37* Hgb-7.5* Hct-21.6*
MCV-91 MCH-31.5 MCHC-34.6 RDW-19.1* Plt ___
___ 07:03AM BLOOD ___ PTT-79.8* ___
___ 07:03AM BLOOD Glucose-144* UreaN-50* Creat-2.2* Na-139
K-3.8 Cl-105 HCO3-20* AnGap-18
___ 07:03AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.9
===============================================================
EKG ___ 10:40:16 AM
Sinus rhythm. ST segment depression in leads I, aVL and V4-V6
consistent with lateral myocardial ischemia. Compared to the
previous tracing the ST segment changes are new.
CXR ___:
PA and lateral views of the chest show an irregular, patchy
retrocardiac opacity in the mid and lower left lung zones. In
comparison to the prior exam, this consolidation predominantly
involves the left lower lobe as opposed to the lingula. No
consolidation is identified in the right lung. There is mild
increased prominence of the interstitial markings and ___ B
lines at the right base, suggestive of mild pulmonary edema.
There is no pleural effusion. There is no pneumothorax. The
cardiomediastinal silhouette is normal.
IMPRESSION:
1. Left lingular and lower lobe pneumonia.
2. Probable mild pulmonary edema.
TRANSTHORACIC ECHOCARDIOGRAM (___):
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. 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 moderate to severe regional left ventricular systolic
dysfunction with basal to mid septal/anterior hypokinesis and
distal LV/apical akinesis suggested. 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 aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
CXR (___):
Large area of consolidation and small-to-moderate left pleural
effusion at the base of the left hemithorax is stable. There is
greater consolidation developing at the base of the right lung,
accompanied by a smaller pleural effusion. Previous vascular
congestion has improved slightly. Cardiac silhouette is
obscured and given the presence of infection in the left
hemithorax, possibility of pericardial effusion should be
entertained. There is no mediastinal vascular engorgement,
however, to suggest tamponade physiology.
TRANSTHORACIC ECHOCARDIOGRAM ___:
No atrial septal defect is seen by 2D or color Doppler. There is
moderate regional left ventricular systolic dysfunction with
hypokinesis of the basal to mid anterior and septal walls and
distal akinesis including the true apex. No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Physiologic mitral regurgitation is seen (within
normal limits). The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is mild stenosis of the RV outflow tract and
pulmonic valve suggested with color turbulence seen in the RVOT
and mildly elevated peak velocities (2.0 m/s in RVOT, 2.2 m/s
maximum through pulmonic valve). There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Moderately depressed left ventricular systolic
function with regional wall motion abnormalities as above. Mild
stenosis of the RVOT and pulmonic valve.
Compared with the prior study (imaes reviewed) of ___,
the findings are similar. The RVOT and pulmonic valve were not
well seen in the prior study.
CARDIAC CATHETERIZATION ___:
1. Selective coronary angiography of this right dominant system
demonstrated three vessel disease. The LMCA had a 30% stenosis
at its
origin. The LAD had moderate to severe diffuse disease, with 60%
proximal stenosis and 70% mid-vessel stenosis. The LCx also had
diffuse
diasease with a 50% stenosis in OM1 and 70% in LPL branch. The
RCA had
severe diffuse disease, with a 95% mid occlusion and left to
right
collateral flow.
2. Resting hemodynamics revealed slightly increased LVEDP at 14
mmHg.
The central aortic systolic and diastolic blood pressures were
normal.
3. Left ventriculogram was deferred.
4. The site of access (left femoral artery) had adequate
hemostasis
after manual compression.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal systemic arterial pressure.
CXR ___:
Multiple skin folds are present bilaterally, but there are no
visible pneumothoraces. Swan-___ catheter has been removed.
Intra-aortic balloon pump remains in place with tip terminating
about 4 cm below the superior aspect of the aortic knob.
Bilateral asymmetrically distributed perihilar and basilar
opacities affecting the left lung to a greater degree than the
right, have slightly worsened in the interval.
Moderate-to-large left pleural effusion tracking to the left
apex has also increased.
CXR ___:
Improving multifocal pneumonia, but residual lingular
consolidation has a mass-like configuration. Considering the
presence of a lingular abnormality since ___, the
possibility of a malignant mass in this region should be
considered, and CT may be helpful for further assessment when
the patient's condition allows.
CT CHEST WITH CONTRAST ___:
1. Multifocal consolidations, predominantly involving left
lower lobe with specifically no mass-like lesions present.
Multifocal peripheral opacities most likely reflect the areas of
multifocal infection as well.
2. Small bilateral pleural effusion.
3. Extensive coronary calcifications.
4. Axillary and mediastinal lymph nodes. The mediastinal lymph
nodes might be potential reactive to the pulmonary process.
Axillary lymph nodes might potentially reflect known CLL,
although of note is their relatively small size.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
Please hold if SBP < 100 or DBP < 50
3. Atenolol 50 mg PO DAILY
Please hold if SBP < 100 or DBP < 50
4. FoLIC Acid 1 mg PO DAILY
5. GlyBURIDE 10 mg PO BID
6. Simvastatin 10 mg PO DAILY
7. Januvia *NF* (sitaGLIPtin) 50 mg Oral DAILY
8. Multivitamins 1 TAB PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Omeprazole 20 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
7. Guaifenesin-CODEINE Phosphate ___ mL PO QHS cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth hs
Disp #*1 Bottle Refills:*0
8. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
RX *isosorbide mononitrate 60 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*2
9. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg one tablet(s) by mouth daily
Disp #*30 Tablet Refills:*2
10. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg one tablet(s) by mouth daily Disp #*20
Tablet Refills:*2
11. Januvia *NF* (sitaGLIPtin) 25 mg Oral DAILY
12. Warfarin 6 mg PO DAILY16 Duration: 1 Doses
RX *warfarin 2 mg three tablet(s) by mouth daily Disp #*90
Tablet Refills:*2
13. HydrALAzine 100 mg PO TID
RX *hydralazine 100 mg one tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*2
14. GlipiZIDE XL 2.5 mg PO DAILY
RX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic systolic CHF
Legionella pneumonia
Non ST elevation myocardial infarction
Chronic Lymphocytic Leukemia
Hypertension
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: Shortness of breath. History of CLL.
COMPARISON: Chest radiograph, ___. Chest radiograph,
___.
FINDINGS: PA and lateral views of the chest show an irregular, patchy
retrocardiac opacity in the mid and lower left lung zones. In comparison to
the prior exam, this consolidation predominantly involves the left lower lobe
as opposed to the lingula. No consolidation is identified in the right lung.
There is mild increased prominence of the interstitial markings and ___ B
lines at the right base, suggestive of mild pulmonary edema. There is no
pleural effusion. There is no pneumothorax. The cardiomediastinal silhouette
is normal.
IMPRESSION:
1. Left lingular and lower lobe pneumonia.
2. Probable mild pulmonary edema.
Radiology Report
AP CHEST, 7:27 P.M., ___
HISTORY: Shortness of breath, question edema or TRALI. ___ man with
CLL, thalassemia and diabetes. Two to three weeks of worsening fatigue.
IMPRESSION: AP chest compared to ___ through ___:
Consolidation limited to the lingula on ___, accompanied by mild
interstitial edema on ___ at 10:42 a.m. is now joined by new
consolidation in the right lower lung. This could be asymmetric edema, but
raises real concern for spreading pneumonia. Small left pleural effusion has
accumulated since earlier in the day. No pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pneumonia, chronic heart failure, worsening hypoxia, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is a newly appeared
right pleural effusion, leading to obliteration of the right costophrenic
sinus. There is unchanged evidence of moderate pulmonary edema but on the
left another pleural effusion has newly occurred and causes relatively massive
atelectasis in the retrocardiac lung areas. In the well-ventilated lungs
there is no evidence of pneumonia. No pneumothorax.
Radiology Report
AP CHEST, 2:19 A.M., ___
HISTORY: ___ man with increasing oxygen requirement.
IMPRESSION: AP chest compared to ___:
Large area of consolidation and small-to-moderate left pleural effusion at the
base of the left hemithorax is stable. There is greater consolidation
developing at the base of the right lung, accompanied by a smaller pleural
effusion. Previous vascular congestion has improved slightly. Cardiac
silhouette is obscured and given the presence of infection in the left
hemithorax, possibility of pericardial effusion should be entertained. There
is no mediastinal vascular engorgement, however, to suggest tamponade
physiology.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient with CHF, CLL, cardiogenic shock, acute worsening of
dyspnea, interval change.
COMPARISON: Multiple chest x-rays from ___ to ___.
FINDINGS:
Left lower lung pneumonia is better seen due to decrease in size of moderate
left pleural effusion. Right basilar pneumonia is unchanged. Mild pulmonary
edema has slightly decreased. New right jugular sheath ends in the upper SVC.
There is no pneumothorax. Mediastinal and cardiac contours are top normal.
CONCLUSION:
1. Bilateral pneumonia are unchanged in extent; the one on the left side is
better seen because of decrease in size of left moderate pleural effusion.
2. Mild pulmonary edema has slightly improved.
Radiology Report
PORTABLE CHEST FROM ___ AT 13:09
CLINICAL INDICATION: ___ with Legionella pneumonia and CHF, has IBPM
placed for heart failure, check placement.
Comparison is made to the patient's previous studies dated ___ at
17:38.
AP semi-supine portable chest film ___ at 13:09 is submitted.
IMPRESSION:
1. An intra-aortic balloon pump is in place with its tip approximately 4.5 cm
below the top of the aortic arch. A femoral Swan-Ganz catheter is in place
with the tip in the pulmonary outflow tract. There are persistent areas of
consolidation in the right lower lobe and in the left lower lobe which appear
to be slightly less consolidative when compared to the prior study of
___. These findings, however, likely represent pneumonia. There is
also retrocardiac consolidation that could reflect an area of pneumonia or
partial lower lobe atelectasis. The stomach is distended with a prominent
amount of gas. No pulmonary edema. Right internal jugular introducer
catheter with the tip in the proximal SVC. There is an apparent curvilinear
line traversing the right fourth interspace. This is felt to most likely
represent a skin fold rather than a pleural line related to a pneumothorax.
This area can be better assessed on followup imaging. A triangular opacity
along the medial right upper lobe is also felt to likely represent an artifact
from something external to the patient. Overall cardiac and mediastinal
contours are unchanged.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Multiple skin folds are present bilaterally, but there are no
visible pneumothoraces. Swan-Ganz catheter has been removed. Intra-aortic
balloon pump remains in place with tip terminating about 4 cm below the
superior aspect of the aortic knob. Bilateral asymmetrically distributed
perihilar and basilar opacities affecting the left lung to a greater degree
than the right, have slightly worsened in the interval. Moderate-to-large
left pleural effusion tracking to the left apex has also increased.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Intra-aortic balloon pump has been withdrawn slightly, now
terminating about 4.8 cm below the superior aspect of the aortic knob.
Multifocal areas of consolidation in the lingula and both lower lobes has
slightly improved, but the lingular consolidation has a rounded mass-like
configuration. Of note, the lingular consolidation has not cleared since the
radiograph of ___. Exam is otherwise remarkable for pulmonary
vascular congestion and minimal interstitial edema as well as a persistent
small left pleural effusion.
IMPRESSION: Improving multifocal pneumonia, but residual lingular
consolidation has a mass-like configuration. Considering the presence of a
lingular abnormality since ___, the possibility of a malignant
mass in this region should be considered, and CT may be helpful for further
assessment when the patient's condition allows.
Dr. ___ has been telephoned with this result at 9:40 a.m. on ___ at the time of discovery.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with Legionella pneumonia
and concern for lingular mass on chest radiograph.
COMPARISON: Multiple chest radiographs dating back to ___.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen after administration of IV contrast. Axial images were reviewed in
conjunction with coronal and sagittal reformats.
FINDINGS:
Multiple mediastinal lymph nodes ranging up to 5 mm in the right paratracheal
area, 7 mm in the anterior mediastinal area, 7.3 mm in the right lower
paratracheal area, 13 mm in the subcarinal, and 8 mm in the paraesophageal
area. Right hilus reveals no substantial lymphadenopathy. Subcentimeter
lymph nodes are noted in the left hilus. Aorta and pulmonary arteries are
normal in diameter. Heart size is mildly enlarged. Coronary calcifications
are present. No pericardial effusion is seen. The imaged portion of the
upper abdomen reveals atherosclerosis of the aorta, but no appreciable other
abnormality.
The trachea, right bronchus, left bronchus as well as lobar bronchi on the
right and left upper lobe and lingular bronchi are patent. Left lower lobe
bronchus appears to be obstructed partially due to large consolidation
occupying the vast majority of the left lower lobe, relatively homogeneous
with appearance most likely concerning for pneumonia. In addition, there are
bilateral consolidations peripherally located in the upper lobes, 2:27, as
well as in right middle lobe, right lower lobe. Bilateral pleural effusion is
demonstrated, small on both.
There are no bone lesions worrisome for infection or neoplasm.
Several bilateral axial lymph nodes are noted, none of them exceeding 1.5 cm,
but multiple.
Hemangiomas in the spine are demonstrated at two levels.
IMPRESSION:
1. Multifocal consolidations, predominantly involving left lower lobe with
specifically no mass-like lesions present. Multifocal peripheral opacities
most likely reflect the areas of multifocal infection as well.
2. Small bilateral pleural effusion.
3. Extensive coronary calcifications.
4. Axillary and mediastinal lymph nodes. The mediastinal lymph nodes might
be potential reactive to the pulmonary process. Axillary lymph nodes might
potentially reflect known CLL, although of note is their relatively small
size.
Radiology Report
INDICATION: Patient with CHF and hypertension, shortness of breath after
removal of balloon pump, suspect flash pulmonary edema.
COMPARISON: Multiple chest x-rays from ___ to ___.
FINDINGS:
Multifocal consolidations in both lungs are unchanged since this morning, but
worst since ___. Considering the fact that the opacity in the
lingular region is present since ___ and is slightly lobular,
malignancy has to be considered. Left pleural effusion is small and
unchanged. There is no pneumothorax. The aortic balloon pump has been
removed.
CONCLUSION:
The exam is unchanged since this morning with multifocal consolidations.
There is no significant pulmonary edema. Considering that the lingular
opacity is mass like and present since ___, malignancy is not
excluded, a chest CT has already been suggested.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SHORTNESS OF BREATH
Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, ANEMIA NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.4
heartrate: 85.0
resprate: 20.0
o2sat: 95.0
sbp: 148.0
dbp: 50.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with CLL, thalassemia, and DM2
who presented with new-onset heart failure, NSTEMI, and
Legionella pneumonia. His hospital course was significant for
treatment of his heart failure including CCU transfer, NTG drip,
brief IABP placement, as well as investigation of his coronary
arteries with cardiac catheterization. He was stabilized on a
CHF medication regimen and discharged home with plans to follow
up with Cardiology regarding his diffuse coronary artery artery
disease.
#. CHF: EF ___, now compensated.
Echo showed moderate to severe regional left ventricular
systolic dysfunction with basal to mid septal/anterior
hypokinesis and distal LV/apical akinesis. Despite attempts at
diuresis, patient had worsening hypoxia which led to cardiac ICU
transfer. Right heart catheterization showed markedly elevated
filling pressures and suggested cardiogenic shock: PCWP 40,
mixed venous O2 sat 27% (CI ~1.8). He was treated with
diuresis, Nitroglycerin drip, BiPAP, and preload/afterload
reduction. At one point he had flash pulmonary edema and
worsening ischemia requiring balloon pump placement for ~4 days.
The etiology of his CHF is likely ischemia, as cardiac
catheterization revealed 3 vessel disease (LMCA 30%, LAD 60%
proximal/70% mid-vessel, OM1 50%, LPL branch 70%, RCA 95%) - he
would likely benefit from CABG in the future (not pursued this
admission). He will follow up with Cardiology (Dr. ___
after discharge.
-weight: 78kg on admission --> 72.3kg on discharge
-diuresis: Torsemide 20mg daily
-preload/afterload reduction: Imdur, Hydralazine (renal function
prohibits ACEi), also on Amlodipine
-on a beta blocker (Metoprolol)
#. Coronary artery disease: s/p NSTEMI.
EKG was significant for ST depressions in I, II, V4-V6 and he
did have a cardiac enzyme leak. Diagnostic cath on ___ showed
3VD and pt will likely benefit from CABG intervention at later
time. His CLL does not preclude him from being a surgical
candidate. He continues on Aspirin (dropped to 81mg given that
he will be on Warfarin), Atorvastatin, and Metoprolol. He will
have outpatient Cardiology f/u with Dr. ___ to address his
3VD.
#. Apical akinesis on TTE: now on anticoagulation.
LV with basal to mid septal/anterior hypokinesis and distal
LV/apical akinesis. he was started on Warfarin this admission
(goal INR ___.
#. Legionella pneumonia: now s/p treatment.
He had been treated a few weeks prior to admission with
Levofloxacin but did not complete an appropriate course for
Legionella, which was diagnosed this admission. He had a LLL
infiltrate. Here, he did complete a 14 day course of
Levofloxacin (ended ___. he did have fever which was
presumed to be related to his underlying PNA but given that he
had been in the hospital, he was treated with
Vancomycin/Cefepime as well, for 1 week after his last fever
(ended ___. He will follow up with his PCP.
#. ___ on CKD: recent baseline Cr 1.8, and is 2.2 on discharge.
Admitted at Cr 1.8, peaked at Cr 3.5 on ___ due to CIN/CHF,
then resolved. But then trended back up and was 2.2 on
discharge. Nephrology was following this admission; it was
determined that he did not need dialysis this admission but this
is still an ongoing outpatient discussion. He will f/u with Dr.
___ discharge.
#. Hyponatremia: resolved.
Na was intermittently down to low 130's in the setting of
decompensated heart failure, but then resolved. Na on discharge
was 139.
#. DM2: stable.
He was covered with bedtime Lantus and SSI Humalog while he was
admitted, but upon discharge will change to Glyburide to
Glipizide, and will take ___ dose Sitagliptin due to his renal
function. His PCP should follow up his DM2 as he might need to
be on insulin in the future.
INACTIVE ISSUES
#. Anemia: chronic issue.
Likely due to leukemia and CKD. Has h/o thalassemia. Received
3u pRBC total this admission. hct remained in the low 20's this
admission.
#. CLL: s/p chemotherapy regimen in ___. WBC> 100 on admit.
WBC 87 on discharge. He will have outpatient Heme/onc follow-up
with Dr. ___.
#. HTN: difficult to control, but reasonable on current regimen.
He continues on Amlodipine, Imdur, Hydralazine, and Metoprolol.
TRANSITIONAL ISSUES
#. Code status: Full Code
#. Emergency contact: ___ (wife): ___, ___
(Daughter): ___
#. Labs/studies pending at discharge: None
#. Issues requiring follow-up:
--outpatient discussin re: plans for CVD (?CABG in the future)
--f/u imaging to ensure resolution of pleural effusion
--f/u imaging to ensure resolution of pneumonia
--Heme-Onc f/u to determine future chemo |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / Risperdal
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with hx of CAD s/p CABG ___, HTN, PVD, Prostate cancer
s/p brachytherapy ___ and AAA s/p open repair ___ and s/p
endovascular repair ___ presents with altered mental
status.
The patient was recently hospitalized from ___ to ___
after he presented with abdominal pain and was found to have a
ruptured AAA on CT scan. The scan did not show active
extravastion, but evidence of recent leakage into the left
retroperitoneal space. He underwent an emergent endovascular AAA
repair with bilateral hypogastric coiling. Given the placement
of the EVAR device, they placed a right chimmey renal stent, for
which he was started on ___ (need to continue x1 month). His
hospital course was c/b volume overload that resolved with
diuresis. He was also delirious during his stay. He was given
zyprexa without effect. Geriatrics was consulted, and they
recommended trazadone at night. He has a history of becoming
more confused/altered with administration of antipsychotics
(Haldol/Risperdal). Per discharge summary, "we hope that his
delirium will improve once he is outside the hospital setting."
The patient returns to the ED with ongoing delirium, which, per
family, has been present since ___. In the ED, initial vitals
were: 98.8 95 122/63 16 98% RA, FSG 131. Labs were significant
for white count of 13.6 with 80% PMNs, stable H/H, elevated BUN
at 23 (creatinine stable at 1.1), lactate 1.6, neg UA. CXR
negative for acute process, KUB negative for obstruction or
significant stool burden, and CT head very poor quality but no
obvious acute processes. He was given 12.5 of trazodone and 1L
IVF.
On the floor, patient has no complaints, denies pain. Is AAOx1.
Past Medical History:
PMH:
HTN, CAD s/p CABG, PVD, Prostate cancer s/p brachytherapy
(___),
HLD, Demand ischemia EF:60%, Glaucoma, Corneal abnormality,
Cataract
PSH:
- open AAA (___)
- CABG x4 (___)
- bilateral CEA (___)
- cataract surgery, corneal transplant
Social History:
___
Family History:
Brother - ___
No known family history of aneurysms
Physical Exam:
ADMISSION EXAM
==================
Vital Signs: 99.2 154/60 98 22 98%RA
General: Alert, conversant, AAOx1 (to person and ___, not to
___ or hospital, not to date/year, cannot do days of the week
forward)
HEENT: PERRL, MMM, edentulous
CV: RRR, ___ SEM at ___
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, no edema. Has mild bruising at b/l
groin sites, no hematoma/bruits
Neuro: Grossly intact, does not follow commands
DISCHARGE EXAM
===================
Vital Signs: 98 127/58 88 16 100RA
General: Alert and pleasant, AAOx3
HEENT: PERRL, edentulous
CV: RRR, ___ SEM at ___
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, no edema.
Neuro: Grossly intact
Pertinent Results:
ADMISSION LABS
====================
___ 12:45PM PLT COUNT-177
___ 12:45PM WBC-13.8* RBC-3.26*# HGB-10.3*# HCT-31.2*#
MCV-96 MCH-31.6 MCHC-33.0 RDW-14.8 RDWSD-51.7*
___ 02:00AM ___ PTT-24.6* ___
___ 02:00AM PLT COUNT-186
___ 02:00AM WBC-13.6* RBC-2.99* HGB-9.4* HCT-28.8* MCV-96
MCH-31.4 MCHC-32.6 RDW-14.8 RDWSD-52.5*
___ 02:00AM GLUCOSE-106* UREA N-23* CREAT-1.1 SODIUM-142
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16
___ 02:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR
___ 03:52AM LACTATE-1.6
DISCHARGE LABS
========================
___ 07:07AM BLOOD WBC-10.0 RBC-2.90* Hgb-9.0* Hct-27.7*
MCV-96 MCH-31.0 MCHC-32.5 RDW-14.8 RDWSD-52.1* Plt ___
___ 05:49AM BLOOD ___ PTT-65.6* ___
___ 05:49AM BLOOD Glucose-92 UreaN-20 Creat-0.9 Na-143
K-4.3 Cl-107 HCO3-29 AnGap-11
___ 05:49AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.2
MICROBIOLOGY
=========================
URINE CULTURE: NO GROWTH.
BLOOD CULTURES: NO GROWTH.
IMAGES/STUDIES
=========================
CXR ___:
IMPRESSION:
No evidence of acute cardiopulmonary process.
CT Head NON Contrast ___:
IMPRESSION:
Extremely limited study due to patient motion. Structures above
the third
ventricle are not assessed. No evidence for acute abnormalities
below the
level of the third ventricle.
Abdomen Xray ___:
IMPRESSION:
Nonspecific nonobstructive bowel gas pattern. No significant
stool burden.
Radiology Report
INDICATION: ___ with altered mental status, please evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiographs dated ___.
FINDINGS:
The small left pleural effusion is new from the prior study. There is no
focal consolidation, pulmonary edema, or pneumothorax. The right IJ central
venous catheter has been withdrawn compared with the prior study. Mediastinal
clips and median sternotomy wires are unchanged.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with altered mental status, evaluate for intracranial
hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Multiple images were repeated due to motion on the initial scan.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 12.0 s, 12.8 cm; CTDIvol = 47.1 mGy (Head) DLP =
602.1 mGy-cm.
2) Sequenced Acquisition 10.0 s, 10.6 cm; CTDIvol = 47.1 mGy (Head) DLP =
501.7 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: None.
FINDINGS:
Study is markedly limited due to patient motion despite 2 imaging attempts.
Images above the level of the third ventricle are not diagnostic. Below the
level of the third ventricle, no acute hemorrhage, edema, or loss of
gray/white matter differentiation is seen. Mild age-related parenchymal
volume loss is noted. No lower calvarial or skullbase fracture is identified.
Mastoid air cells, middle ear cavities, and visualized portions of the
paranasal sinuses are well aerated. There is evidence of bilateral cataract
surgery.
IMPRESSION:
Extremely limited study due to patient motion. Structures above the third
ventricle are not assessed. No evidence for acute abnormalities below the
level of the third ventricle.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:49 AM, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ with constipation during ICU stay, unknown if BM since,
evaluate for stool burden.
TECHNIQUE: Single supine frontal view radiograph of the abdomen.
COMPARISON: Outside hospital CT of the abdomen and pelvis dated ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. Retained oral contrast is noted within
the hepatic flexure. Surgical changes related to abdominal aortic aneurysm
repair are noted. There is minimal stool burden.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific nonobstructive bowel gas pattern. No significant stool burden.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.8
heartrate: 95.0
resprate: 16.0
o2sat: 98.0
sbp: 122.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of CAD s/p CABG ___, HTN, PVD, prostate cancer
s/p brachytherapy ___ and AAA s/p open repair ___ and s/p
endovascular repair ___ who presented with altered mental
status.
# Toxic metabolic encephalopathy: Patient presented from rehab
with delirium since his last hospitalization. Risk factors for
delirium include age, possible underlying cognitive impairment
(history of memory loss as per wife, who feels it is apart of
normal aging), inflammatory burden due to AAA rupture, recent
SICU stay, hearing impairment. Patient with leukocytosis
initially but no e/o acute infection. No significant electrolyte
abnormalities. Avoided anti-psychotics due to possible bad
reaction in the past. Instead, used trazodone as needed for his
agitation. Delirium resolved by discharge and he was at his
baseline mental status.
# NSTEMI: Patient with asymptomatic, unsustained episode of
tachycardia 140s while agitated which resolved without
intervention. EKG was obtained, which showed lateral ST
depressions more pronounced than a prior EKG. Troponins trended
upward. Echo with WMA on ___: There is mild regional left
ventricular systolic dysfunction with hypokinesis of the
inferior wall. Patient was started on IV heparin, given full
dose ___, and was continued on ___, Metoprolol, and statin.
His atorvastatin was increased to 80mg. Also started Lisinopril.
Cardiology was consulted and agreed that NSTEMI likely related
to Type II demand-ischemia due to recent stress (Endovascular
surgery and sinus tachycardia). Cardiology recommended medical
management of NSTEMI with the aforementioned medications.
Patient remained chest pain free during hospital stay.
# AAA s/p endovascular repair: ___, Atorvastatin
continued. Goal SBP 110-160. He will continue ___ until
___.
# HTN: Discontinued amlodipine. Began metoprolol tartrate and
lisinopril inpatient. Will send home with metoprolol succinate
and lisinopril at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
painless hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male presents with painless hematuria since early this
morning. The patient has voided 5 times this morning, all with
bright red blood, most recent two voids have included small
clots. Patient last saw his PCP for ___ URI possible PNA with
fevers and shortness of breath for which he was given a 5 day
course of azithromycin - symptoms have subsequently resolved.
Patient denies lightheadedness, fevers, chills, nausea,
vomiting, chest pain, shortness of breath. No recent traumatic
instrumentation applied to urinary tract including foley
catheter.
Exam is benign. No costovertebral angle tenderness. There is
dried blood overlying the patients underwear. There is no
bleeding from the urethra or trauma do the penis on exam.
In the ED, initial vital signs were 98.2 80 148/58 18 98% RA.
Patient was given cipro for UTI, Renal US done showing a large
clot in bladder, no nephrolithiasis or pathology involving upper
GU tract
unsuccessfully attempted ___ foley in ED, as were unable to pass
prostate. Admitted for bladder irrigation.
Most recent vitals: 97.2 79 132/71 18 99% on RA.
On the floor, patient in no acute distress and without
complaints.
Review of Systems:
(+) as 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:
# CAD s/p CABG
- Inferior MI ___, MI ___
- 3 vessel CABG in ___ (LIMA to LAD, SVG to RCA, and SVG to D1,
jump to OM2)
- ___: angioplasty of native small OM distal to SVG insertion
site.
# s/p ICD placement
- ___ - ICD placed for nonsustained VT / syncope
- ___ - Generator change
- ___ - Generator change, ventricular lead revision,
atrial lead upgrade
- ___ - ICD lead replacement ___ inappropriate sensing of ICD
# Chronic systolic CHF (EF ___ by echo ___
# Hypertension
# Diabetes mellitus
# Duodenal ulcer
# Status post appendectomy
# Status post implantable cardioverter-defibrillator
placement for nonsustained ventricular tachycardia
# Hyperlipidemia
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals- 97.9 147/74 80 16 99%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Dsicharge Physical Exam:
Vitals- 98.2 98-130/50-60 ___ 18 97%RA fs 161
insulin 24hours: 4H
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- foley draining clear urine, no clots
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 01:35PM BLOOD WBC-6.1 RBC-3.54* Hgb-10.7* Hct-32.1*
MCV-91 MCH-30.2 MCHC-33.4 RDW-12.7 Plt ___
___ 09:16PM BLOOD Hct-31.6*
___ 06:35AM BLOOD WBC-6.7 RBC-2.87* Hgb-8.7* Hct-25.7*
MCV-90 MCH-30.5 MCHC-34.0 RDW-13.1 Plt ___
___ 01:35PM BLOOD ___ PTT-31.4 ___
___ 01:35PM BLOOD Glucose-153* UreaN-28* Creat-1.3* Na-139
K-4.4 Cl-104 HCO3-27 AnGap-12
___ 06:35AM BLOOD Glucose-134* UreaN-55* Creat-1.7* Na-136
K-4.4 Cl-102 HCO3-29 AnGap-9
___ 04:03PM BLOOD Calcium-8.5 Phos-1.8* Mg-1.6
___ 06:35AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.0
___ 01:34PM URINE Color-Red Appear-Cloudy Sp ___
___ 01:34PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 01:34PM URINE RBC->182* WBC-34* Bacteri-FEW Yeast-NONE
Epi-0
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
___ Renal US: COMPARISON: Renal ultrasound ___.
FINDINGS:
The right kidney measures 12.1 cm. A small simple appearing
cyst is seen in
the upper pole which measures 1.6 cm. There is no
nephrolithiasis, mass or
hydronephrosis seen within the right kidney.
The left kidney measures 13.6 cm. A large simple appearing cyst
is again seen
in the lower pole left kidney which measures 7.9 cm. It appears
unchanged
from prior. There is no nephrolithiasis, mass or hydronephrosis
seen on the
left.
A large homogeneous echogenicity is seen within the bladder
which measures 5.5
x 3.8 cm. This mass demonstrates no flow and is thought to
represent a blood
clot, although an underlying lesion is not excluded. This mass
was noted to
be mobile on real time imaging.
The prostate is enlarged, measuring 4.8 cm in the transverse
dimension. A
simple appearing prostatic cyst is present.
IMPRESSION:
1. Enlarged heterogeneous echogenicity within the bladder is
thought to
represent a blood clot, however, an underlying lesion could be
obscured.
2. No hydronephrosis or nephrolithiasis seen within either
kidney.
___ Urine cytology: ATYPICAL, see note.
Numerous neutrophils and red blood cells.
Note: There is granular and homogenous material in the
background. The origin and significance cannot be
determined. Necrotic debris cannot be excluded. Additional
re-submission for urine cytology is recommended after
treating infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Carvedilol 25 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
6. Lisinopril 20 mg PO DAILY
please hold for SBP<100, HR<60
7. Hydrochlorothiazide 25 mg PO DAILY
please hold for SBP<100, HR<60
8. Lorazepam 0.5 mg PO BID:PRN anxiety
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
please notify MD if patient requests this medication
11. Pantoprazole 40 mg PO Q24H
12. Simvastatin 80 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Cyanocobalamin ___ mcg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Cyanocobalamin ___ mcg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lorazepam 0.5 mg PO BID:PRN anxiety
6. Pantoprazole 40 mg PO Q24H
7. Amiodarone 200 mg PO BID
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
8. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
10. Ferrous Sulfate 325 mg PO DAILY
11. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN
pain
12. Nitroglycerin SL 0.4 mg SL PRN chest pain
please notify MD if patient requests this medication
13. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*8 Tablet Refills:*0
14. Outpatient Lab Work
Please obtain BUN, Cr, glucose, UA, CBC on ___ and fax
results to Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Hematuria
Urinary tract infection
Secondary diagnosis:
Diabetes mellitus type II
Chronic congestive heart failure
CAD s/p CABG
PUD
Anemia
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: Painless hematuria, right hydronephrosis or nephrolithiasis.
TECHNIQUE: Grayscale Doppler examinations of 1 of the kidneys and bladder.
COMPARISON: Renal ultrasound ___.
FINDINGS:
The right kidney measures 12.1 cm. A small simple appearing cyst is seen in
the upper pole which measures 1.6 cm. There is no nephrolithiasis, mass or
hydronephrosis seen within the right kidney.
The left kidney measures 13.6 cm. A large simple appearing cyst is again seen
in the lower pole left kidney which measures 7.9 cm. It appears unchanged
from prior. There is no nephrolithiasis, mass or hydronephrosis seen on the
left.
A large homogeneous echogenicity is seen within the bladder which measures 5.5
x 3.8 cm. This mass demonstrates no flow and is thought to represent a blood
clot, although an underlying lesion is not excluded. This mass was noted to
be mobile on real time imaging.
The prostate is enlarged, measuring 4.8 cm in the transverse dimension. A
simple appearing prostatic cyst is present.
IMPRESSION:
1. Enlarged heterogeneous echogenicity within the bladder is thought to
represent a blood clot, however, an underlying lesion could be obscured.
2. No hydronephrosis or nephrolithiasis seen within either kidney.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: UTI COMPLAINTS
Diagnosed with HEMATURIA, UNSPECIFIED
temperature: 98.2
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 148.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Assessment and Plan: ___ yo male presents with painless hematuria
since early this morning, found to have positive UA and
continuous painless hematuria.
#Painless hematuria: Acute in onset. Given age, most likely
hemorrhagic cystitis given positive UA vs malignancy. Cytology
results require repeat given concurrent infection to evaluate
for malignancy. Autoimmune process unlikely given age and stone
unlikely given lack of pain or discomfort. Foley placed for
comfort as patient was passing large clots. Urology was
consulted and will follow patient in clinic. He will need repeat
cytology and CT urogram. Foley eventually draining clear urine,
patient passed trial void and discharged with urology
appointments.
#Afib/ICD interrogation: Episodes of afib with RVR noted on
telemetry that activated ICD. Cardiology/EP called to
interrogate ICD, amiodarone started, simvastatin 80mg changed to
atorvastatin 40mg. Follow up with cardiology confirmed.
___: likely due to dehydration, will bolus lightly and monitor
for improvement. hematuria likely also a contributing factor.
Unresolved upon discharge given length of hematuria and
infection, outpatient follow up and repeat Cr strongly
recommended. Patient made aware and verbalized understanding.
Held Lisinopril, HCTZ, metformin for now.
#anemia: has dropped 32.1->26.7 since admission. Stopped Plavix
given no recent stents and continued bleeding/hematuria during
admission. Patient was transfused
1u PRBCs, hcts stabilized. Continued ferrous sulfate.
# positive UA: Ecoli, pansensitive. Given ceftriaxone IV while
in house, transitioned to cepodoxime to complete ___M: in setting of ___, held metformin, ISS while in house.
Sugars well controlled, discharged with close follow up to
evaluate renal function and restart metformin vs other diabetes
medication.
#HTN: in setting of ___, d/c lisinopril/hydrochlorathiazide,
continued carvedilol.
#CAD: continued ASA, carvedilol. Discontinued plavix as no
indication for current use, out of window of stent placement and
patient had continued bleeding. Cardiologist made aware.
Simvastatin change to atorvastatin as above after initiation of
amiodarone.
#Anxiety: continued home lorazepam
#GERD/PUD: continued home pantoprazole
Transitional Issues:
-repeat lytes, Cr
-repeat urine cytology
-CT urogram
-f/u cardiology for amiodarone |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending: ___
Chief Complaint:
Chest and arm pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with H/O HFpEF, hypertension, hyperlipidemia,
atrial fibrillation on warfarin presenting with chest pain. He
was transferred from ___ due to elevated troponin for
stress testing.
Patient initially presented to ___ with chief complaint
of left finger numbness and intermittent gastric / chest
discomfort. He has a history of rotator cuff injury and carpal
tunnel, but over the last 2 weeks has noticed worsening numbness
in his first 3 digits which has occasionally been associated
with epigastric discomfort that radiates into his chest and left
arm. He stated that burping improves the pain and taking
antacids have helped with his pain as well. He denied any
associated shortness of breath. He reported no fever or chills,
no nausea, vomiting or diarrhea.
Labs at ___-N were significant for a troponin-T of 0.083. EKG
showed atrial fibrillation with no ST elevations. He has never
undergone coronary angiography before but has presumed CAD given
history of anginal symptoms in the past and inferolateral defect
on ETT-MIBIs ___ & ___. He was given full dose ASA. Cardiology
was consulted and recommended transfer to ___ for a stress
test.
In the ED initial vitals were: T 97.5 HR 45 BP 136/63 RR 16 SaO2
99% on RA. EKG: atrial fibrillation, no ST elevations or
depressions, no T wave inversions. Labs/studies notable for:
Trop-T 0.06, Cr 1.4 (baseline 1.3-1.6), NT-proBNP ___, INR 3.2.
Vitals on transfer: T 97.9 HR 56 BP 118/48 RR 16 SaO2 97% on RA.
After arrival to the cardiology ward, the patient reported no
chest pain, but continued to have tingling in his left hand. The
tingling involves his thumb and first three fingers and feels
similar to previous carpal tunnel pain. It occasionally radiates
farther up his arm and is worse at night. The hand symptoms are
not made any worse with activity. He had no shortness of breath
or difficulty breathing.
Past Medical History:
-Atrial fibrillation on warfarin
-CAD (angina, inferolateral nuclear perfusion defect on
ETT-MIBIs
___ and ___
-Hyperlipidemia
-Elevated CK
-Polymyalgia rheumatic - per chart, patient states he has
rheumatoid arthritis, not PMR
-___ esophagus
-Lumbar spinal stenosis
-Gout
-Hearing loss
-Diverticulosis
-BPH
Past Surgical History
-Laminectomy L2-L5, facetectomy and foraminotomy with
arthrodesis -Screw instrumentation and allograft ___
-I+D of wound from spine surgery ___
-Right inguinal hernia repair ___
-Appendectomy ___
-Right inguinal hernia repair ___
-Bilateral laparoscopic spigelian hernia repairs
-Bilateral cataract surgery
-Bilateral carpal tunnel surgery
Social History:
___
Family History:
Father with "arteriosclerosis," both parents died ___ years.
Physical Exam:
On admission
GENERAL: Elderly white man in NAD
VS: T 98.1 BP 153/61 HR 57 RR 18 SaO2 99% on RA
HEENT: NCAT. PERRL.
CARDIAC: RRR; without murmurs, rubs or gallops; normal S1 and
S2.
LUNGS: CTAB without increased work of breathing.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema.
At discharge
GENERAL: Elderly man in NAD
Vitals: T 98.1 BP 117/54-127/56 HR 53-60 RR 20 SaO2 97% on RA
DISCHARGE Weight: 73.8 kg
Telemetry: atrial fibrillation with bradycardia to ___
HEENT: NCAT.
CARDIAC: irregular irregular rhythm, normal rate; without
murmurs, rubs or gallops; normal S1 and S2.
LUNGS: CTAB without increased work of breathing.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema.
Pertinent Results:
___ 01:40AM BLOOD WBC-5.9 RBC-3.02* Hgb-9.0* Hct-28.0*
MCV-93 MCH-29.8 MCHC-32.1 RDW-15.3 RDWSD-50.4* Plt ___
___ 01:40AM BLOOD Neuts-61.5 ___ Monos-11.6 Eos-4.4
Baso-0.7 Im ___ AbsNeut-3.65 AbsLymp-1.28 AbsMono-0.69
AbsEos-0.26 AbsBaso-0.04
___ 01:40AM BLOOD ___ PTT-37.2* ___
___ 01:40AM BLOOD Glucose-102* UreaN-38* Creat-1.4* Na-142
K-3.4 Cl-104 HCO3-25 AnGap-16
___ 01:40AM BLOOD ALT-20 AST-29 CK(CPK)-597* AlkPhos-100
TotBili-0.4
___ 08:45AM BLOOD Albumin-3.9 Calcium-8.6 Phos-3.1 Mg-2.3
___ 01:40AM BLOOD CK-MB-9 MB Indx-1.5 proBNP-2144*
___ 01:40AM BLOOD cTropnT-0.06*
___ 08:45AM BLOOD CK-MB-8 cTropnT-0.08*
___ 07:33AM BLOOD calTIBC-346 VitB12-750 Ferritn-35 TRF-266
Discharge labs
___ 07:15AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.5* Hct-27.3*
MCV-94 MCH-32.6* MCHC-34.8 RDW-15.6* RDWSD-51.4* Plt ___
___ 07:15AM BLOOD ___ PTT-28.6 ___
___ 07:15AM BLOOD Glucose-100 UreaN-35* Creat-1.6* Na-140
K-3.3 Cl-100 HCO3-27 AnGap-16
___ 07:15AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3
___ CXR
Mild cardiomegaly is chronic. There may be minimal interstitial
pulmonary edema, but there is no particularly engorgement of
either pulmonary or mediastinal vasculature and no pleural
effusion.
___ Dipyridamole-nuclear stress test
This ___ yo man with h/o HFpEF, atrial fibrillation, minimal AS,
HTN, and HLD was referred to the lab from the inpatient floor
for evaluation of chest discomfort. The patient was administered
0.142 mg/kg/min of Persantine over 4 minutes. There were no
reports of chest, back, neck, or arm discomforts during the
study. There were no significant ST changes noted during
infusion or recovery. Rhythm was atrial fibrillation with no
ectopy. Mild resting systolic hypertension with an appropriate
blood pressure and heart rate response to the infusion.
Post-MIBI, the Persantine was reversed with 125 mg Aminophylline
IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes to
vasodilator stress. Normal hemodynamic response to Persantine.
IMAGING:
Left ventricular cavity size is normal. Rest and stress
perfusion images reveal mild attenuation of the inferior wall
with no reversible myocardial perfusion abnormalities. Gated
images reveal normal wall motion. The calculated left
ventricular ejection fraction is 70%.
IMPRESSION:
1. Normal myocardial perfusion with no wall motion
abnormalities.
2. Normal LV cavity size and systolic function, EF of 70%.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest discomfort// eval for fracture,
pneumonia eval for fracture, pneumonia
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Mild cardiomegaly is chronic. There may be minimal interstitial pulmonary
edema, but there is no particularly engorgement of either pulmonary or
mediastinal vasculature and no pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Epigastric pain, L Hand numbness
Diagnosed with Epigastric pain
temperature: 97.5
heartrate: 45.0
resprate: 16.0
o2sat: 99.0
sbp: 136.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | ___ year old man with a history of HFpEF, hypertension,
hyperlipidemia, atrial fibrillation on warfarin presenting with
chest pain. He was transferred from ___ due to elevated
troponin (which has been chronically abnormal since ___ with eGFR 48) for vasodilator MIBI stress test. Stress test
was normal and he was discharged home with services in good
condition.
# Chest and arm pain: Patient complained of intermittent chest
discomfort and was found to have mildly elevated troponin-T
without acute EKG changes. Troponin-T has been similarly
elevated in the past, likely due to stage 3 CKD. There was no
acute rise and fall in troponin-T this admission to suggest an
acute myonecrotic event. His description of symptoms is
compatible with carpel tunnel syndrome in respect to arm pain.
He has previously had carpal tunnel release surgeries. However
his left sided chest pressure was still concerning. He underwent
dipyridamole-MIBI which, unlikely prior tests, showed uniform
perfusion. He reported having been straining at home to lift his
wife who is wheelchair bound. His discomfort is likely
musculoskeletal and related to this. Social Work and Case
Management discussed increased home services. We also increased
his home gabapentin for likely neuropathy in his left wrist
related to CTS. He was discharged home in good condition with
services and on continued aspirin, warfarin, statin and
carvedilol in case his nuclear imaging represents global
ischemia.
# HFpEF: TTE LVEF>55% in ___. Patient appeared euvolemic on
admission. NT-pro-BNP similar to previous admissions. Continued
home metolazone and furosemide.
# Atrial fibrillation: On warfarin with INR slightly
supratherapeutic at 3.2 on presentation. INR 1.6 on discharge
with holding for several days. Due to relative bradycardia, home
carvedilol was decreased to 3.125 mg BID.
# Anemia: Consistent with iron deficiency as has been the case
in the past. Started po iron and bowel regimen and should be
followed as outpatient and consider repeat colonoscopy as
outpatient if within goals of care.
# Hypertension: BP slightly elevated on admission to 150s
systolic, but home carvedilol adjusted as above due to
bradycardia. Continued on diuretics.
# Hyperlipidemia: Stable. Continued home rosuvastatin.
# Gout: Chronic, continued home allopurinol.
Transitional Issues
- Due to relative bradycardia, home carvedilol was decreased to
3.125 mg BID.
- Started po iron and bowel regimen and should be followed as
outpatient and consider repeat colonoscopy as outpatient if
within goals of care.
- Gabapentin was increased to BID to help with carpal tunnel
pain in left wrist.
# CODE: Presumed full
# CONTACT:
Name of health care proxy: ___
___: Daughter
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p Fall
Rib fractures ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female who complains of R RIB
PAIN. s/p mechanical fall going up stairs and fell back landing
on R side - c/o " fierce pain " to R side of back when she
moves.
Past Medical History:
Past Medical and Surgical History: OA, Breast cancer, HTN,
hypercholesterolemia, R wrist fx, diverticulitis, Alzheimers,
Dementia
Family History:
N/C
Physical Exam:
On admission:
Temp: 97.9 HR: 61 BP: 181/99 Resp: 18 O(2)Sat: 100 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, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, back NT
Skin: No rash, Warm and dry
Neuro: Speech fluent, CN intact, strength/sensation
symmetric.
Psych: Normal mood, Normal mentation
___: No petechiae
Pertinent Results:
LABS:
___ 07:25AM BLOOD WBC-9.1 RBC-4.37 Hgb-12.4 Hct-39.7 MCV-91
MCH-28.5 MCHC-31.3 RDW-14.1 Plt ___ Glucose-106* UreaN-25*
Creat-1.0 Na-145 K-3.6 Cl-108 HCO3-25 AnGap-16 Calcium-9.2
Phos-3.5 Mg-2.3
___ 02:00AM BLOOD WBC-10.3 RBC-4.43 Hgb-13.2 Hct-41.4
MCV-93 MCH-29.7 MCHC-31.8# RDW-14.4 Plt ___ Neuts-75.6*
Lymphs-16.5* Monos-4.5 Eos-3.0 Baso-0.3 Glucose-112* UreaN-28*
Creat-1.1 Na-139 K-5.9* Cl-106 HCO3-23 AnGap-16 cTropnT-<0.01
___ 03:18AM BLOOD Na-144 K-3.9 Cl-109*
IMAGING:
___ ECG:
Normal sinus rhythm. Right bundle-branch block. Intra-atrial
conduction
defect. T wave abnormalities. Cannot exclude old inferior
myocardial
infarction. No previous tracing available for comparison.
___ CHEST (PA & LAT)
IMPRESSION:
1. No acute cardiothoracic process.
2. Superior endplate depression fracture of a mid thoracic
vertebral body, of unknown chronicity.
___ CT HEAD W/O CONTRAST:
IMPRESSION:
No acute intracranial process. Moderate-to-severe small vessel
disease
___ CT C-SPINE W/O CONTRAST:
IMPRESSION:
No evidence of fracture or subluxation
___: CT ABD & PELVIS W/O CONTRAST/ CT CHEST W/O CONTRAST:
IMPRESSION:
1. Minimally displaced fractures of the eighth, ninth, and
possibly tenth
right posterior ribs; no evidence of pneumothorax.
2. Right simple renal cystic lesions.
3. Diverticulosis of the entire colon without evidence of
diverticulitis.
___: ANKLE (AP, MORTISE & LAT) LEFT
IMPRESSION: Diffuse osseous demineralization. No acute fracture
of left
ankle or foot detected, but followup radiographs may be helpful
if symptoms persist as a subtle fracture may be difficult to
detect in the setting of diffuse osseous demineralization.
___ FOOT AP,LAT & OBL LEFT:
IMPRESSION: Diffuse osseous demineralization. No acute fracture
of left
ankle or foot detected, but followup radiographs may be helpful
if symptoms persist as a subtle fracture may be difficult to
detect in the setting of diffuse osseous demineralization.
Medications on Admission:
Simvastatin 40 mg daily
Atenolol 25 mg daily
Cymbalta 20 mg daily
Alendronate 70 mg daily
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
Disp:*0 0* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*0 0* Refills:*0*
3. tramadol 50 mg Tablet Sig: 0.5 to 1.0 Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
4. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*0 0* Refills:*0*
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
___.
9. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
10. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right ___ posterior rib fractures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fall, please assess for rib fractures.
FINDINGS: The lungs are clear, the cardiomediastinal silhouette and hila are
normal. There is no pleural effusion and no pneumothorax. There is a healed
right rib fracture. There is superior endplate depression fracture of a mid
thoracic vertebral body, likely chronic.
IMPRESSION:
1. No acute cardiothoracic process.
2. Superior endplate depression fracture of a mid thoracic vertebral body, of
unknown chronicity.
Radiology Report
INDICATION: ___ with fall and right rib pain. Please assess for
other traumatic injury.
TECHNIQUE: CT of the head was obtained without intravenous contrast. Axial
and coronal reformats were acquired.
COMPARISON: There are no prior studies for comparison available. There is no
evidence of hemorrhage, edema, masses or infarction. The ventricles and sulci
are enlarged in an atrophic pattern. There are moderate-to-severe confluent
centrum semiovale and periventricular hypodensities consistent with sequela of
chronic small vessel disease. Moderate atherosclerotic calcifications of the
cavernous segments of the carotid arteries and the vertebral arteries are
seen.
The paranasal sinuses and mastoid air cells are clear. There are no
suspicious lytic or sclerotic bony lesions and no fractures. No subgaleal
hematoma.
IMPRESSION:
No acute intracranial process. Moderate-to-severe small vessel disease.
Radiology Report
INDICATION: ___ with fall and right rib pain. Please assess for
fracture or other traumatic injury.
TECHNIQUE:
Contiguous MDCT images through the C-spine were obtained. Axial, coronal, and
sagittal reformats were acquired.
COMPARISON: There are no prior studies for comparison available.
FINDINGS:
The height of the vertebral bodies of the C-spine is preserved. There is no
evidence of fracture or subluxation. There is scoliosis of the cervical spine
convex to the left. There is fusion of the C6/C7 vertebral bodies. There is
moderate intervertebral disc degenerative disease and posterior osteophyte
formation at C4/C5 and C5/C6 and uncal hypertrophy, but no significant spinal
canal or neural foraminal narrowing.
There is no large neck hematoma. The lung apices are clear.
IMPRESSION:
No evidence of fracture or subluxation.
Radiology Report
INDICATION: ___ with fall, right rib pain. Please assess for
fracture, traumatic injury.
TECHNIQUE:
Contiguous MDCT images through the chest, abdomen and pelvis were performed
without intravenous or oral contrast. Axial, coronal, and sagittal reformats
were acquired.
COMPARISON: Chest radiograph from ___.
FINDINGS:
CT OF THE CHEST:
There is no pneumomediastinum or mediastinal hemorrhage. There is no
pericardial or pleural effusion. There are mild bibasilar atelectatic
changes. There are moderate atherosclerotic calcifications of the thoracic
aorta and the coronary arteries. There is no pneumothorax. There is no focal
lung consolidation.
CT OF THE ABDOMEN:
The liver, gallbladder, pancreas, spleen, both adrenal glands and kidneys show
no acute injury. There is a 5 x 3.5 cm simple right upper pole exophytic
renal cyst as well as a 1.9 cm right mid pole exophytic renal cyst and a 2 x
1.5 cm right lower pole cystic renal lesion with Hounsfield unit measurement
of 9, consistent with a simple cyst as well.
There are only mild atherosclerotic calcifications of the aorta, but moderate
calcifications of the distal aorta and the iliac arteries.
There are calcified retroperitoneal lymph nodes.
There is no free air and no free fluid. Small hiatal hernia is present. The
esophagus, stomach and small bowel are normal. There is moderate
diverticulosis of the entire colon without evidence of diverticulitis. Mild
nonspecific wall thickening of the transverse colon is seen, perhaps from
nondistention.
CT OF THE PELVIS:
The urinary bladder is normal. The uterus and ovaries are not visualized, and
likely surgically removed. No pelvic lymphadenopathy, no pelvic hernias.
BONES: There are moderate degenerative changes in the lower lumbar spine with
facet arthropathy. Mild anterolisthesis of L4 on L5 and mild superior
endplate depression of T8 thoracic vertebral body.
There are very minimally displaced transverse fractures of the right posterior
eighth, ninth, and possibly tenth ribs. There are no left-sided rib
fractures. The scapula and clavicles are normal. There is a chronic healed
fracture of the body of the sternum.
IMPRESSION:
1. Minimally displaced fractures of the eighth, ninth, and possibly tenth
right posterior ribs; no evidence of pneumothorax.
2. Right simple renal cystic lesions.
3. Diverticulosis of the entire colon without evidence of diverticulitis.
Radiology Report
LEFT FOOT STUDY OF ___
No prior studies for comparison.
FINDINGS: Bones are diffusely demineralized, consistent with the patient's
advanced age. Although no acute fracture is identified, a subtle fracture may
be difficult to detect in this setting.
Three views of the left ankle demonstrate no evidence of acute fracture,
dislocation, or significant soft tissue abnormality except for mild apparent
soft tissue swelling.
IMPRESSION: Diffuse osseous demineralization. No acute fracture of left
ankle or foot detected, but followup radiographs may be helpful if symptoms
persist as a subtle fracture may be difficult to detect in the setting of
diffuse osseous demineralization.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R RIB PAIN
Diagnosed with SYNCOPE AND COLLAPSE, FRACTURE THREE RIBS-CLOS, FALL ON STAIR/STEP NEC, HYPERTENSION NOS
temperature: 97.9
heartrate: 61.0
resprate: 18.0
o2sat: 100.0
sbp: 181.0
dbp: 99.0
level of pain: 13
level of acuity: 3.0 | Ms. ___ presented to the ___ Emergency Department on ___ after sustaining a fall down stairs. Multiple
radiographic images were obtained including Chest x-ray, CT-
head, spine, abd/ pelvis, chest, x-rays ankle/foot without
evidence of acute cardiothoracic, intracranial or
abdominal/pelvic process. However, minimally displaced fractures
of the eighth, ninth, and possibly tenth right posterior ribs
were noted without evidence of pneumothorax. Additionally, an
ECG was performed due to unknown mechanism of fall; no ischemic
changes were noted. The patient was subsequently evaluated by
the Acute Care Surgical Service and admitted for further
management of rib fractures and observation.
While hospitalized, the patient was reported to be alert and
oriented x ___ with poor safety awareness at times; safety
precautions were implemented per nursing staff. Additionally, a
Geriatrics was consulted to evaluate for any component of
delerium, who felt there was no current delerium, however, a
risk for its development due to ongoing pain and hx of dementia
remained. Recommendations included adjusting the pain regimen to
standing acetaminophen and prn tramadol and to evaluate further
for dispo to home with services. The patient had also been
evaluated by Physical and Occupational Therapy with
recommendation for discharge to home with services and continued
encouragement with self-care prn; please see evaluation and
follow-up notes for details.
Additionally, the patient remained stable from both a
cardiovascular and respiratory stanpoint; incentive spirometer
and deep breathing were encouraged throughout the hospitalized.
The patient tolerated a regular diet without difficulty;
urinalysis was positive for a urinary tract infection and the
patient was initiated on ciprofloxacin, which she will continue
for a total ___t the time of discharge on ___, the patient was
afebrile with stable vital signs. She was alert and oriented,
confused intermittently, without signs of delerium. She
continued to tolerate a regular diet and was voiding adequate
amounts. She was discharged to ___ and will follow-up
in the Acute Care Clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Atropine
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
___ ___ coil embolization of superior pole arteries
History of Present Illness:
___, is a ___ female with history of
atrial fibrillation on Eliquis presents as a transfer from
outside hospital after a fall in her hot tub. CT from the
outside hospital demonstrates a left renal laceration
with active extravasation and adjacent left-sided rib fractures.
The patient received blood transfusions at the outside hospital.
Foley catheter was placed and has dark red bloody output. The
patient was given an andexanet for apixaban reversal in the ED.
Past Medical History:
Iron deficiency Anemia
Atrial Fibrillation
Mitral Valve Prolapse
R Renal Mass
HTN
Glaucoma
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Examination: upon admission: ___
Vitals: Systolic blood pressure in the ___. Heart rate in the
___.
General Appearance: NAD, emaciated.
Neck: No cervical lymphadenopathy
Chest: CTA
Cardiovascular: RRR, no murmurs
Abdomen: Soft and nontender
Extremities: no lower extremity edema
Neurological: A&O x3
Pulses: Palpable bilateral femoral, ___ and DP pulses. Palpable
bilateral brachial/radial pulses
Airway: Mallampati Class 2
ASA: 2
Physical examination upon discharge: ___:
vital signs at discharge: t=99.2, hr=72, bp=130/65, rr=18, 99%
room air
GENERAL: Frail female, NAD
CV: irreg rate
LUNGS: diminished BS right side
ABDOMEN: distended, hypoactive BS, soft, non-tender, no
rebound, no guarding, right groin DSD, no hematoma
EXT: no calf tenderness bil, no pedal edema bil, + DP bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 03:22PM BLOOD WBC-10.3* RBC-2.87* Hgb-8.7* Hct-27.3*
MCV-95 MCH-30.3 MCHC-31.9* RDW-19.0* RDWSD-65.1* Plt ___
___ 05:53AM BLOOD WBC-9.0 RBC-2.59* Hgb-8.0* Hct-24.8*
MCV-96 MCH-30.9 MCHC-32.3 RDW-19.2* RDWSD-65.9* Plt ___
___ 10:56AM BLOOD WBC-11.1* RBC-2.45* Hgb-7.4* Hct-23.2*
MCV-95 MCH-30.2 MCHC-31.9* RDW-19.4* RDWSD-65.3* Plt ___
___ 11:05PM BLOOD WBC-18.1* RBC-2.96* Hgb-8.8* Hct-28.3*
MCV-96 MCH-29.7 MCHC-31.1* RDW-19.9* RDWSD-67.7* Plt ___
___ 05:34AM BLOOD Neuts-87.1* Lymphs-2.7* Monos-8.6
Eos-0.0* Baso-0.1 NRBC-0.1* Im ___ AbsNeut-15.34*
AbsLymp-0.47* AbsMono-1.51* AbsEos-0.00* AbsBaso-0.02
___ 02:03AM BLOOD ___ PTT-22.7* ___
___ 03:22PM BLOOD Glucose-134* UreaN-16 Creat-0.6 Na-139
K-4.5 Cl-103 HCO3-26 AnGap-10
___ 05:53AM BLOOD Glucose-103* UreaN-16 Creat-0.6 Na-139
K-4.6 Cl-104 HCO3-25 AnGap-10
___ 03:22PM BLOOD Calcium-8.2* Phos-1.8* Mg-2.2
___ 05:53AM BLOOD Calcium-8.1* Phos-1.8* Mg-2.2
___ 05:34AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.8
___ 01:27PM BLOOD ___ Temp-36.7 pO2-69* pCO2-47*
pH-7.36 calTCO2-28 Base XS-0
___ 07:24AM BLOOD Lactate-1.1
___ 07:24AM BLOOD freeCa-1.20
___: CXR:
1. No evidence of pneumothorax.
2. New fracture through the ninth left rib.
3. Increased opacity in the left base could be positional or
represent
subsegmental atelectasis. Correlate clinically.
___: renal arteriogram:
Successful embolization of 2 vessel supplying the superior pole
of the Left kidney
___: CXR:
In comparison with the study of ___, there are areas of
hazy
opacification at both bases with obscuration of the
hemi-diaphragms, consistent with pleural fluid and compressive
atelectatic changes. Otherwise, little overall change.
Medications on Admission:
apixaban 5mg''
atenolol 12.5mg'
denosumab 60mg twice per year
hydroxyurea 500mg'
losartan 12.5mg'
omeprazole 20mg'
travoprost 2ggt in each eye
ASA 81mg'
calcium carbonate-vitamin D3
Colace
thiamine
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
after pain controlled, may decrease to PRN regimen
2. Bismuth Subsalicylate ___ mL PO TID:PRN indigestion
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
continue until follow-up with PCP, and then address the need
for eliquis
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Phosphorus 500 mg PO BID
please check phosphorous weekly
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*6 Tablet Refills:*0
11. Atenolol 12.5 mg PO DAILY
12. Hydroxyurea 500 mg PO DAILY
13. Losartan Potassium 12.5 mg PO DAILY
14. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
retroperitoneal hematoma
left ___ rib fractures
left foot ___ 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
INDICATION: ___ year old woman with left renal laceration and active
extravasation.
COMPARISON: None.
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: MAC sedation was provided by anesthesia.
MEDICATIONS: Please see anesthesia note for medication details.
CONTRAST: 63 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 22.1 minutes, 83 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Left renal arteriogram.
3. Superior branch left renal arteriograms.
4. Super selective coil embolization of superior Left renal arteries.
5. Post-embolization Left renal arteriogram.
6. Suprarenal aortogram.
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 right groin was prepped and draped in the usual sterile fashion.
Under palpatory guidance, the right common femoral artery was accessed using a
micropuncture set at the mid femoral head. A ___ wire was advanced easily
through the micropuncture sheathinto the aorta. A small skin ___ was made at
the skin entry site. The needle was then exchanged for a 35 cm 6 ___ sheath
which was attached to a continuous side arm heparinized flush.
A ___ catheter was advanced over the wire and used to cannulate the
Left renal artery. Contrast was injected to confirm position. A digitally
subtracted Left renal arteriogram was performed. A ___ microcatheter and
Transcend microwire were used to select and abnormal artery feeding the
superior pole of the Left kidney. The wire was removed and contrast was
injected to confirm position. A digitally subtracted a superior branch Left
renal arteriogram was performed, which demonstrated a focal arterial
pseudoaneurysm. The vessel was subsequently embolized with several pushable
platinum fibered Concerto coils. A repeat arteriogram was performed
demonstrating stasis of the blood vessel.
The microcatheter was then retracted. The Transcend microwire were was
readvanced and used to select an additional artery feeding the superior pole
of the Left kidney. The wire was then removed and contrast was injected to
confirm position. A digitally subtracted superior branch Left renal
arteriogram was performed, which identified several truncated vessels. The
vessel was subsequently embolized with several pushable platinum fibered
Concerto coils. A repeat arteriogram was performed demonstrating stasis of
the blood vessel.
The microcatheter was removed. The ___ was advanced into the aorta. A
___ wire was extent advanced through the ___ catheter which was
subsequently exchanged for an Omni flush catheter. Contrast was injected to
confirm position. A digitally subtracted suprarenal aortogram was performed,
showing no other arterial bleed.
Sterile dressings were applied. The patient tolerated the procedure well and
there were no immediate post-procedure complications.
FINDINGS:
1. 2 vessels feeding the superior pole of the Left kidney corresponding to
area of injury on recent CT of the abdomen/pelvis. The first superior pole
renal arterial branch demonstrated focal pseudoaneurysm. The second superior
pole renal arterial branch demonstrated truncated vessels.
2. Super selective coil embolization of superior pole left renal arteries.
3. Post embolization Left renal arteriogram demonstrates stasis to the
superior pole.
4. Aortogram without evidence of additional sites of bleeding.
For reporting clarification, diagnostic arteriograms were medically necessary
to evaluate for anatomy, abnormal vasculature, and the presence or absence of
active bleeding, pseudoaneurysms, and or arteriovenous fistula.
IMPRESSION:
Successful embolization of 2 vessel supplying the superior pole of the Left
kidney.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall w/ retroperitoneal hematoma and kidney laceration
s/p ___ procedure as well as L 9th rib fracture, L ___ metatarsal zone 2 ___
___// interval change
IMPRESSION:
In comparison with the study of ___, there are areas of hazy
opacification at both bases with obscuration of the hemidiaphragms, consistent
with pleural fluid and compressive atelectatic changes. Otherwise, little
overall change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.4
heartrate: 85.0
resprate: 16.0
o2sat: 97.0
sbp: 91.0
dbp: 64.0
level of pain: 1
level of acuity: 1.0 | ___ female with history of atrial fibrillation on
Eliquis who presented as a
transfer from an outside hospital after a fall in her hot tub.
A cat scan
from the outside hospital demonstrated a left renal laceration
with active extravasation and adjacent left-sided rib fractures,
___.
The patient received blood transfusions at the outside hospital.
Foley catheter was placed and drained dark red bloody urine. .
At time of arrival here, the patient was hypotensive and noted
to have a large RP bleed on imaging. She received two doses of
NOAC reversal, 1u of PRBC and was taken urgently to ___. She
underwent coil embolization of superior pole of L renal artery.
She was transferred to the ICU for continued monitoring. She
remained hemodynamically stable. She received blood products as
needed for resuscitation.
She was transferred to the surgical floor on HD #3. Her vital
signs remained stable and she was afebrile. In addition to her
RP bleed, the patient reportedly sustained a left ___ fracture
to the ___ metartarsal. The Orthopedic service was consulted
and recommended an air cast boot with WBAT. Follow-up in the
___ clinic was recommended in 4 weeks. The patient's rib
pain was controlled with oral analgesia. She was encouraged to
use the incentive spirometer. She maintained an oxygen
saturation of 93 % on room air.
In preparation for discharge, the patient was evaluated by
physical therapy and recommendations were made for discharge to
a rehabilitation facility where the patient could further her
strength and mobility.
The patient was discharged to a rehabilitation facility on HD
#6. Her hematocrit stabilized at 27 with a white blood cell
count of 10. Her eliquis was on hold and recommendations made
for her to address resuming it with her primary care provider.
During her hospitalization, she was maintained on heparin sc.
She continued to have ___ colored urine. Discharge
instructions were reviewed and questions answered. A follow-up
appointment was made in the Acute care and the ___
clinic.
Rehabilitation stay <30 days
++++++++++++++++++++++++++++++++++
Of note: Patient to see PCP about resuming ASA and eliquis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose
Attending: ___.
Chief Complaint:
Pain and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with breast cancer (Left stage IIA invasive ductal
carcinoma, triple negative, recurrent and metastatic) on
palliative chemotherapy presents to the ED with increasing pain
and weakness.
Patient's complicated oncologic history is outlined below,
however she was recently admitted ___ to ___ for chest pain.
Cardiac causes were ruled out and etiology of pain was felt to
be tumor progression and patient was discharged on palliative
chemotherapy and pain regimen. Per clinic notes she had being
doing well recently, meeting with her oncologist and palliative
care team. However, after receiving IVF at clinic yesterday
afternoon her chronic left thorax and arm pain became too much
to bear and she presented to the ED.
In the ED intial vitals were pain 8, T 97.8, HR 91, BP 158/81,
RR 18, O2 96%RA. HCT was stable at recent baseline at 25.0 and
PTT was elevated at 41.1. Remainder of Chem7, CBC, INR, and UA
were unremarkable. Patient was given IV dilaudid x3 and zofran
IV x1. A bed request for OMED was planned, but due to lack of
available oncology beds, a medicine bed was obtained with plan
to transfer patient to oncology as soon as possible.
Past Medical History:
ONCOLOGIC HISTORY:
Left breast cancer stage IIA (pT1c pN1 M0), grade 3 IDC,
triple-negative on palliative chemo (eribulin C1D8 as of
___
-please see OMR for full onc history details
PMH:
- T1DM (hemoglobin A1c ___ was 10.2%) complicated by
gastroparesis
- LUE DVT on lovenox
- Left lymphedema
- HTN
- Asthma
- Anemia
- Depression and anxiety
- Insomnia
- Chlamydia, syphilis
Social History:
___
Family History:
Diabetes and hypertension, both run in the family, but there is
no known family history of breast cancer.
Physical Exam:
Admission Exam:
Vitals- 177/101 pain 10
General- chronically ill appearing woman lying on her right
side. Does not cooperate with exam due to pain.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Unable to examine
Lungs- Poor inspiratory effort with minimal air movement. Non
labored appearing
CV- Soft S1, S2
Abdomen- soft, non-tender, non-distended,
GU- no foley
Ext- Left arm with diffuse 1+ pitting edema. Otherwise warm,
well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro- symetric face, PERLL, moves all extremities spontaneously
but does not attempt antigravity in any limbs.
Discharge Exam:
Vitals- 99.0 120-144/87 96 18 95/RA
General- AO x 3
HEENT- Sclera anicteric, MMM, oropharynx clear
Lungs- Clear to auscultation bilaterally
CV- Soft S1, S2
Abdomen- soft, non-tender, non-distended,
GU- no foley
Ext- Left arm with diffuse 1+ pitting edema. Otherwise warm,
well perfused, 2+ pulses, no clubbing, cyanosis or edema. ___
strength
Neuro- CN II-XII intact
Pertinent Results:
Admission labs:
___ 01:20AM BLOOD WBC-7.0 RBC-2.71* Hgb-7.9* Hct-25.0*
MCV-92 MCH-29.1 MCHC-31.6 RDW-13.9 Plt ___
___ 01:20AM BLOOD Glucose-102* UreaN-7 Creat-0.6 Na-137
K-4.5 Cl-101 HCO3-29 AnGap-12
___ 08:55AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.7
___ 01:24AM BLOOD Lactate-0.5
___ 08:55AM BLOOD ALT-12 AST-18 LD(LDH)-981* AlkPhos-71
TotBili-0.2
Discharge labs:
___ 07:00AM BLOOD WBC-5.9 RBC-2.84* Hgb-8.1* Hct-26.0*
MCV-91 MCH-28.4 MCHC-31.1 RDW-13.7 Plt ___
___ 07:00AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-140 K-4.6
Cl-102 HCO3-31 AnGap-12
___ 07:00AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
CXR ___
IMPRESSION:
1. No consolidation or pulmonary edema. Unchanged appearance
of multiple
lung nodules.
2. Probable new trace bilateral pleural effusions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 50 mg SC Q12H
5. Gabapentin 300 mg PO TID
6. Hydrocortisone Cream 2.5% 1 Appl TP BID
7. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Polyethylene Glycol 17 g PO Q12H
11. Senna 2 TAB PO BID
12. TraMADOL (Ultram) 50 mg PO HS:PRN pain
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
14. Ibuprofen 600 mg PO Q6H:PRN pain
15. Prochlorperazine 5 mg PO Q6H:PRN nausea
16. Morphine SR (MS ___ 30 mg PO Q12H
17. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
18. Lidocaine 5% Patch 1 PTCH TD DAILY
19. Lorazepam 0.25-5 mg PO Q6H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 50 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Gabapentin 300 mg PO TID
6. Ibuprofen 600 mg PO Q6H:PRN pain
7. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Morphine SR (MS ___ 30 mg PO Q12H
10. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO Q12H
13. Prochlorperazine 5 mg PO Q6H:PRN nausea
14. Senna 2 TAB PO BID
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
16. TraMADOL (Ultram) 50 mg PO HS:PRN pain
17. Hydrocortisone Cream 2.5% 1 Appl TP BID
18. Lorazepam 0.25-5 mg PO Q6H:PRN nausea
19. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with history of metastatic breast cancer, on
chemotherapy, presenting with fatigue and weakness.
COMPARISON: CT of the chest from ___ and chest radiograph from
___
AP FRONTAL AND LATERAL CHEST RADIOGRAPHS:
A right Port-A-Cath terminates in the low SVC, unchanged from prior. There is
no confluent consolidation or pulmonary edema. Known lung nodules appear
similar to prior. There is mild blunting of the bilateral costophrenic
angles, which suggests new trace pleural effusions. There is no pneumothorax.
Cardiomediastinal and hilar contours are within normal limits.
IMPRESSION:
1. No consolidation or pulmonary edema. Unchanged appearance of multiple
lung nodules.
2. Probable new trace bilateral pleural effusions
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: GENERAL WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE, CHEST PAIN NOS, VOMITING, MALIGN NEOPL BREAST NOS, MAL NEO LYMPH NODE NOS, DIABETES UNCOMPL JUVEN, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 97.8
heartrate: 91.0
resprate: 18.0
o2sat: 96.0
sbp: 158.0
dbp: 81.0
level of pain: 8
level of acuity: 2.0 | ___ with breast cancer (Left stage IIA invasive ductal
carcinoma, triple negative, recurrent and metastatic) on
palliative chemotherapy who presented with increasing pain and
weakness.
#Left arm pain: likely due to progression of tumor as witnessed
on the CT scan from the previous admission. No signs of cardiac
ischemia or compartment syndrome. Her pain improved with her
home oral medications.
# Metastatic breast cancer to bone: The patient is currently
receiving palliative platinum based chemotherapy. She is in the
process of discussing goals of care, HCP, and code status with
palliative care and oncology. While in house, palliative care as
well as oncology visited the patient. She will follow up with
further palliative chemotherapy on ___
#HTN: Patient markedly hypertensive on arrival. Her blood
pressure improved with pain control.
# DM1 controlled: Patient's sugars were maintained on a reduced
dose of Lantus in house because of poor oral intake.
# Hx of DVT: Continued therapeutic Lovenox
# Depression: continued on Celexa
Transitional Issues
- Code care discussion with oncology/palliative care
- HCP discussion with oncology/palliative care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
right quad tendon rupture
Major Surgical or Invasive Procedure:
___ quadricep tendon repair with Dr. ___
___ of Present Illness:
Patient is a ___ woman with past medical history of
fibromyalgia, type 2 diabetes, bipolar disorder, who presents
status post mechanical fall down 4 stairs at home with a right
quad tendon rupture.
Patient reports that she had no prodromal symptoms, and tripped
and fell down the stairs. After this, she felt immediate pain
in
her right leg and inability to raise her knee. She subsequently
presented to the emergency department, where ultrasound
demonstrated possible quad tendon rupture. Surgery was
consulted
for further evaluation management.
Upon interview, the patient denies numbness or tingling
distally.
Review of systems is negative for fevers, chest pain, shortness
of breath or other symptoms prior to her fall. She has no other
associated injuries, and she did not have head strike or loss of
consciousness with her fall.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- undergoing work-up for question of fibromyalgia vs lupus
- Mild asthma
- osteoarthritis
- chronic back pain
- disc degeneration
- GERD,
- Depression
- Insomnia
Social History:
___
Family History:
Sister had brain aneurysm in middle-age. Mother died of colon
cancer in her ___. Patient is adopted and does not know other
biological family history.
Physical Exam:
Vitals: ___ ___ Temp: 98.1 PO BP: 103/70 HR: 94 RR: 18 O2
sat: 95% O2 delivery: Ra
General-alert and oriented x3, resting comfortably
Right Lower Extremity Exam:
cylinder cast in place
SILT sp/dp/s/s/t
Firing ___
WWP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
2. Qvar RediHaler (beclomethasone dipropionate) 80 mcg/actuation
inhalation 2 puffs PRN asthma flair
3. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection PRN asthma
attack
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
6. Ibuprofen 800 mg PO Q6H:PRN Pain - Mild
7. Ipratropium Bromide MDI 2 PUFF IH Q6H PRN wheezing, SOB
8. Montelukast 10 mg PO DAILY
9. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
10. Xolair (omalizumab) 375 mg subcutaneous EVERY 2 WEEKS
11. Omeprazole 20 mg PO DAILY
12. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
13. Deltasone (predniSONE) 40 mg oral DAILY
14. Pregabalin 100 mg PO BID
15. Topiramate (Topamax) 75 mg PO DAILY
16. Venlafaxine XR 75 mg PO DAILY
17. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
18. Cetirizine 10 mg PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
20. Docusate Sodium 100 mg PO BID
21. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous at bedtime Disp
#*28 Syringe Refills:*0
3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
7. Cetirizine 10 mg PO DAILY
8. Deltasone (predniSONE) 40 mg oral DAILY
9. Docusate Sodium 100 mg PO BID
10. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection PRN asthma
attack
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
13. Ibuprofen 800 mg PO Q6H:PRN Pain - Mild
14. Ipratropium Bromide MDI 2 PUFF IH Q6H PRN wheezing, SOB
15. Montelukast 10 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
18. Pregabalin 100 mg PO BID
19. Qvar RediHaler (beclomethasone dipropionate) 80
mcg/actuation inhalation 2 puffs PRN asthma flair
20. Tiotropium Bromide 1 CAP IH DAILY
21. Topiramate (Topamax) 75 mg PO DAILY
22. Venlafaxine XR 75 mg PO DAILY
23. Vitamin D 1000 UNIT PO DAILY
24. Xolair (omalizumab) 375 mg subcutaneous EVERY 2 WEEKS
25. HELD- Naproxen 500 mg PO Q12H:PRN Pain - Moderate This
medication was held. Do not restart Naproxen until no longer
taking lovenox and ibuprofen at the same time.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right quadricep tendon rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pain s/p fall// fx?
TECHNIQUE: AP, lateral, oblique views of the right knee.
COMPARISON: None.
FINDINGS:
There is no fracture. No focal osseous abnormality. Enthesophyte formation
seen at the quadriceps tendon insertion on the patella. No suprapatellar
effusion. Soft tissues are unremarkable.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CT LOW EXT W/O C RIGHT
INDICATION: ___ year old woman with fall, knee pain, Neg x-rays but
significant pain with any movement. Question tibial plateau fracture.
TECHNIQUE: Multiplanar axial CT images of the right knee were obtained.
Sagittal and coronal obtained and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.8 s, 20.9 cm; CTDIvol = 20.4 mGy (Body) DLP = 425.5
mGy-cm.
Total DLP (Body) = 426 mGy-cm.
COMPARISON: Right knee radiograph performed the same day.
FINDINGS:
There is abnormal appearance of the quadriceps tendon which appears irregular
and without visualized contiguous fibers worrisome for rupture.. There is
relatively mild surrounding stranding in the overlying soft tissues. No
evidence of fracture or dislocation. Minimal degenerative changes are noted
at the patellofemoral joint with spurring at the patella. There is soft
tissue swelling and edema seen anterior to the patella, superficially. No
evidence of knee joint effusion.
IMPRESSION:
Abnormal quadriceps tendon with surrounding soft tissue edema concerning for
quadriceps tendon rupture. No acute fracture.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:06 pm, 15
minutes after discovery of the findings.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ with RLE pain swelling// dvt?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Knee pain, s/p Fall
Diagnosed with Other specified injuries of right lower leg, init encntr, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 96.3
heartrate: 86.0
resprate: 18.0
o2sat: 95.0
sbp: 112.0
dbp: 71.0
level of pain: 10
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right quadricep tendon repair and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right quad tendon repair, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with services was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue, nausea, vomiting, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with metastatic breast cancer now
on
taxol (___), who presents with nausea, vomiting, fatigue,
and was found to have hypotension to ___.
Ms. ___ reports that she has had months of nausea, vomiting, and
abdominal discomfort that were ultimately worked up and found to
be from metastatic recurrence of breast cancer with liver
lesions
in ___. More recently, she began taxol ___ and last received
this ___. A few days after C1D7 of taxol she had fatigue and
nausea with multiple episodes of emesis (nonbloody, occasionally
bilious) whenever she attempted to eat. Over these last 2 weeks
with chemotherapy, she feels she also has been greatly
deconditioned with dyspnea and intermittent cough productive of
white phlegm. She endorses lightheadedness whenever she got up
to
walk around at home during this time period.
She denies any fevers/chills, sick contacts, cold symptoms,
diarrhea, suspicious food intake.
In the ED, she was found to be hypotensive to 74/50 w/ HR 108, T
96.1, 100% on RA. Per ED report she was notably tachypneic to 32
and unable to complete sentences. Ms. ___ herself is not able to
give a clear report that this occurred. She received stress dose
hydrocort and 2 L NS with stabilization of BPs to
100s-130s/70s-90s.
A CTA was obtained:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mediastinal and hilar lymphadenopathy of indeterminate
chronicity and etiology. Comparison to prior studies is
recommended.
3. Numerous reticulonodular pulmonary opacities are typical of
bronchiolitis in the setting of small airways disease. No large
focal consolidations.
4. Osseous lucencies within the T6 vertebra and anterolateral
right fourth rib are worrisome for metastasis.
5. Likely subacute healing fracture of the posterolateral right
sixth rib. Pathologic fracture is difficult to exclude.
6. Likely pulmonary arterial hypertension.
EKG was normal sinus without ischemic changes. Lactate 3.2-> 1.7
after fluids. Troponin negative.
Past Medical History:
HTN
HLP
IDDM
Obesity
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; sister with breast cancer, father with
prostate cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: ___ 0044 BP: 124/83 L Lying HR: 98 O2 sat: 96% O2
delivery: RA
___ 0044 BP: 128/84 L Standing HR: 95 O2 sat: 96% O2
delivery: RA
General: Well appearing obese ___ woman, resting in
bed comfortably. Breathing comfortably on RA
Neuro:
Cranial nerves: PERRL, EOMI, Facial sensation equal bilaterally,
resists eye opening ___, hearing intact to finger rub b/l,
palate
elevates symmetrically, tongue midline, shoulder shrug ___
Moves all extremities to command without difficulty
Sensation intact to light touch over UE and ___
Alert and oriented to person, place (___) and time (___)
HEENT: Oropharynx clear, MMM, no cervical/supraclavicular LAD
Cardiovascular: RRR no murmurs heard
Chest/Pulmonary: Lungs clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended. No suprapubic tenderness
to palpation
Extr/MSK: No peripheral edema, no calf tenderness
Skin: No rashes. +Tattoos
Access: R POC not accessed (reportedly had ?serous return when
attempted to access in ED). Overlying scab from recent
placement,
surgical incision site looks clean, no surround erythema,
fluctuance, tenderness to palaption
DISCHARGE EXAM:
Patient examined on day of discharge. AVSS. Able to walk ~ 500
feet with a normal gait and no shortness of breath. Lungs CTAB.
Port accessed successfully with. No erythema surrounding her
port.
Pertinent Results:
LABORATORY RESULTS:
___ 10:10AM BLOOD WBC-4.8 RBC-5.08 Hgb-13.7 Hct-40.8
MCV-80* MCH-27.0 MCHC-33.6 RDW-15.1 RDWSD-42.7 Plt ___
___ 12:00AM BLOOD WBC-5.7 RBC-4.00 Hgb-10.8* Hct-33.1*
MCV-83 MCH-27.0 MCHC-32.6 RDW-15.3 RDWSD-44.7 Plt ___
___ 06:40AM BLOOD Neuts-61.6 ___ Monos-5.7 Eos-0.0*
Baso-0.3 Im ___ AbsNeut-4.20 AbsLymp-2.17 AbsMono-0.39
AbsEos-0.00* AbsBaso-0.02
___ 10:10AM BLOOD Neuts-47.3 ___ Monos-5.9 Eos-0.2*
Baso-0.8 Im ___ AbsNeut-2.26 AbsLymp-2.17 AbsMono-0.28
AbsEos-0.01* AbsBaso-0.04
___ 10:10AM BLOOD Glucose-381* UreaN-17 Creat-1.3* Na-132*
K-4.5 Cl-95* HCO3-19* AnGap-18
___ 12:00AM BLOOD Glucose-231* UreaN-17 Creat-0.9 Na-138
K-4.6 Cl-100 HCO3-24 AnGap-14
___ 10:10AM BLOOD ALT-36 AST-34 AlkPhos-177* TotBili-0.5
___ 10:10AM BLOOD Lipase-29
___ 10:10AM BLOOD cTropnT-<0.01
___ 10:10AM BLOOD proBNP-6
___ 06:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.8
___ 10:15AM BLOOD ___ pO2-131* pCO2-19* pH-7.64*
calTCO2-21 Base XS-2
___ 10:15AM BLOOD Lactate-3.2*
___ 03:35PM BLOOD Lactate-1.7
___ 10:15AM BLOOD O2 Sat-98
TTE:
Suboptimal image quality. Normal biventricular cavity sizes,
regional/global systolic function.
No valvular pathology or pathologic flow identified. Normal
estimated pulmonary artery systolic pressure. No
echocardiographic evidence for left ventricular diastolic
dysfunction. Mild ascending aorta dilation.
CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mediastinal and hilar lymphadenopathy of indeterminate
chronicity and
etiology. Comparison to prior studies is recommended.
3. Numerous reticulonodular pulmonary opacities are typical of
bronchiolitis
in the setting of small airways disease. No large focal
consolidations.
4. Osseous lucencies within the T6 vertebra and anterolateral
right fourth rib
are worrisome for metastasis.
5. Likely subacute healing fracture of the posterolateral right
sixth rib.
Pathologic fracture is difficult to exclude.
6. Likely pulmonary arterial hypertension.
MICROBIOLIOGY:
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) @14:13
(___).
___ BCx x2 NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. GlipiZIDE 5 mg PO BID
3. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. Pravastatin 20 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. GlipiZIDE 5 mg PO BID
3. lisinopril-hydrochlorothiazide ___ mg oral DAILY
4. Pravastatin 20 mg PO QPM
5. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension due to nausea and vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with vomiting, tachypnea, cough// ?pna, plueral effusion,
cardiomegaly
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Evaluation is limited due to poor penetration. The lungs are mildly
underinflated, similar to prior, possibly due to poor inspiratory effort, but
are otherwise clear. No pneumothorax. There are no large bilateral pleural
effusions. Prominence of the SVC as well as apparent rightward shift of the
trachea are due to patient rotation. Borderline enlarged heart size may be
accentuated by low lung volumes. Tip of right chest Port-A-Cath terminates in
the lower SVC.
IMPRESSION:
Limited/negative chest radiograph.
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ with metastatic breast cancer, dysnea and hypotension// ?PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 693 mGy-cm.
COMPARISON: None
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main pulmonary artery is dilated,
measuring 3.7 cm, which may suggest pulmonary arterial hypertension. No
evidence of right heart strain.
There is considerable mediastinal and hilar lymphadenopathy measuring up to
1.3 cm at the lower right paratracheal station and 1.0 cm at the right hilum.
There is mild prominence of subcentimeter lymph nodes in the left axilla. No
supraclavicular lymphadenopathy. The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is biapical pleuroparenchymal scarring, right greater than left.
Small focus of subpleural fat is seen in the left lung base (3:144). There is
mild dependent atelectasis. Subtle peripheral reticulonodular opacities are
seen throughout the lungs with ground-glass like appearance. There is no
large focal parenchymal consolidation. The airways are patent to the
subsegmental level.
Upper abdomen: There is a small hiatal hernia. Otherwise, limited images of
the upper abdomen are unremarkable.
Bones: A lytic lesion within the T6 vertebra is associated with a soft tissue
lesion causing encroachment of the anterior thecal sac, right greater than
left which may be associated with nerve root impingement. There is no
associated pathologic fracture. A lytic destructive lesion is also seen
involving the anterolateral arch of the right fourth rib. A healing fracture
of the right sixth rib may represent a pathological fracture and is
incompletely healed. There is diffuse bridging osteophytosis of the thoracic
spine with gross maintenance of the intervertebral disc disc spaces, likely
diffuse idiopathic skeletal hyperostosis.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mediastinal and hilar lymphadenopathy. Comparison to prior studies is
recommended.
3. Numerous reticulonodular pulmonary opacities are typical of bronchiolitis
in the setting of small airways disease. No evidence of pneumonia.
4. Lytic bone lesions concerning for metastatic disease with T6 lesion with
associated encroachment upon the anterior thecal sac and right neural
foramina.
5. Likely subacute healing fracture of the posterolateral right sixth rib.
Pathologic fracture is difficult to exclude.
6. Enlarged main PA suggests pulmonary arterial hypertension.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hypotension, Nausea, Weakness
Diagnosed with Orthostatic hypotension, Dehydration, Acidosis, Dyspnea, unspecified
temperature: 96.1
heartrate: 108.0
resprate: 24.0
o2sat: 100.0
sbp: 74.0
dbp: 50.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ was IV fluid resuscitated in the emergency room, with
another liter on the floor, with complete resolution of her
hypotension, nausea, and vomiting. She was able to tolerate a
regular diet and ambulate at her baseline. The cause of her
hypotension was likely due to her chemotherapy. I discussed this
with Dr. ___ will see her in follow up.
HOSPITAL COURSE BY PROBLEM
1. Hypotension, due to severe nausea and vomiting. Resolved.
Will follow up with Dr. ___.
2. Coagulase negative staph bacteremia. One of four bottles.
Patient was afebrile with no signs of infection; this was almost
certainly contamination. Repeat blood cultures were negative.
She did not receive antibiotics, but has been counseled to look
out for fevers.
3. Large pulmonary artery seen on CT scan. Patient gave history
of progressive shortness of breath, with a large PA seen on CT
c/w PAH. However, a TTE was performed which showed no PAH.
Patient also expressed that her breathlessness had resolved with
IV fluid hydration.
4. Metastatic breast CA. Dr. ___ continue taxol as an
outpatient.
5. DM2. Home glipizide and Trulicity
6. HTN. Her lisinopril-HCTZ was held on admission, restarted on
discharge.
7. ___. Her creatinine was mildly elevated on admission,
returned to normal with IV fluid hydration.
> 35 minutes spent on discharge activities. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
R EVD placement ___
Suboccipital Craniotomy and resection of tumor on ___
Left VP shunt ___
History of Present Illness:
___ y/o F presented to ___ today with headaches
and nausea. She was given 600mg ibuprofen for migraine headaches
and then a head CT was performed which revealed a R cerebellar
lesion with edema and compression of ___ ventricle. She was
intubated, given 10mg decadron, 1g of fosphenytoin, 1mg of
ativan, and transferred to ___ for further management.
Past Medical History:
anxiety
Social History:
___
Family History:
unknown
Physical Exam:
Physical Exam on Admission:
Intubated and sedated. EO to voice. Face symmetrical.
MAE, follows commands in BLE. Spontaneous in BUE, but does not
follow command.
Physical Exam on Discharge:
a&ox3, PERRL, EOMI, face symmetric, tongue midline, no pronator
drift. MAE ___ strength. incision is c/d/i
Pertinent Results:
___ CT/CTA
1. Interval placement of EVD catheter from a right frontal
approach, with tip terminating at the left aspect of the ___
ventricle, in close proximity with the left thalamic nucleus.
There is interval mild improvement of the noncommunicating
hydrocephalus.
2. Large partially calcified mass at the right posterior fossa
jump, as
described above, without significant mass effect on the adjacent
cerebellum, surrounding edema and compression of the fourth
ventricle which is nearly completely effaced. Findings are most
suggestive of an extra-axial mass, such as a meningioma. There
is resultant noncomplicating hydrocephalus as described above.
3. CTA head demonstrates no evidence of hypervascularity or
large vessels
supplying the described right posterior fossa mass. There is no
evidence of aneurysm greater than 3 mm, significant stenosis or
dissection. Arterial supply to the mass can be better assessed
by conventional angiography.
___ CXR
1. ET tube tip terminates at the carina with the tip oriented
towards the
right main bronchus. Recommend withdrawing by 2-3 cm.
2. Patchy opacity in right lung base, likely due to atelectasis
or aspiration. Pneumonia cannot be excluded in the appropriate
clinical setting.
___ MRI Brain with and without
1. Right tentorial extra-axial mass, most likely a meningioma,
exerting mass effect on the fourth ventricle which is nearly
compressed as well as edema within the right cerebellar
hemisphere.
2. Downward herniation of the cerebellar tonsils into the
foramen magnum with an incompletely imaged syrinx in the upper
cervical cord. This is most likely due to a preexisting Chiari I
malformation however the degree of cerebellar tonsillar
herniation is likely exacerbated by mass effect from the tumor.
3. Improved hydrocephalus after shunt placement. Small amount of
intraventricular hemorrhage new since the previous exam.
___
No acute cardiopulmonary process.
___ MRI Brain with and without
Unchanged appearance of the posterior fossa meningioma since the
previous MRI. The examination performed for surgical planning.
___ NCHCT
Postoperative changes from posterior fossa tumor resection
including small
amount of blood products in the postoperative bed and along the
right
tentorium. Lateral ventricles are slightly larger compared to
preoperative MRI but smaller from initial presentation/post
catheter placement imaging.
Tissue: BRAIN/MENINGES FOR TUMORProcedure Date of ___
___*********
MRI of the Head: ___
IMPRESSION:
Status post resection of posterior fossa meningioma. No nodular
area of residual enhancement seen. Blood products and fluid are
seen at the surgical site. There remains downward herniation of
tonsils and syrinx in the upper cervical spinal canal.
Restricted diffusion is seen at the margin of the surgical
cavity which appears postoperative likely venous ischemia, but
no territorial infarcts are seen.
CT HEAD W/O CONTRAST ___
1. Postoperative changes from posterior fossa tumor resection
with a small amount of blood in the postoperative bed and along
the right tentorium likely redistributed but not significantly
changed in amount.
2. Stable ventricular size when compared to prior MR
examination, decreased ventricular size since prior CT dated ___.
Head CT ___
1. Continued postoperative appearance of the posterior fossa
with increasing edema and effacement of the fourth ventricle and
quadrigeminal cistern. Persistent hemorrhage within this
postoperative area appears to be stable in quantity.
2. Right temporal subdural fluid collection is slightly larger,
although
still small.
3. EVD unchanged in position.
Lower Extremity Bilateral ultrasound: ___
No evidence of deep vein thrombosis in the right or left lower
extremity.
CT Head ___
1. Interval removal of the right ventriculostomy catheter and
placement of a left frontal approach ventriculoperitoneal shunt
catheter with tip terminating in the frontal horn of the right
lateral ventricle with minimal increase in size of ventricles as
compared to ___.
2. No change in size of encephlomalacia in the right cerebellar
hemispheric resection bed with similar degree of surrounding
edema along with effacement of the quadrigeminal cistern and
fourth ventricle.
Medications on Admission:
No known medications.
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6 hours PRN pain
Disp #*45 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Cerebellar Lesion
Hydrocephalus
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: Status post intubation, evaluate for tube placement.
COMPARISON: None available.
FINDINGS:
Single AP portable chest radiograph was obtained.
The tip of the ET tube is situated at the carina with tip oriented towards the
right main bronchus. A nasogastric tube has its tip terminating in the body
of the stomach with the side port below the GE junction. There is patchy
opacity projecting over the right lung base. The left lung is clear. The
cardiomediastinal silhouette and hilar contours are normal. There is no
pleural effusion or pneumothorax.
IMPRESSION:
1. ET tube tip terminates at the carina with the tip oriented towards the
right main bronchus. Recommend withdrawing by 2-3 cm.
2. Patchy opacity in right lung base, likely due to atelectasis or aspiration.
Pneumonia cannot be excluded in the appropriate clinical setting.
Finding #1 discussed with ___ by Dr. ___ telephone at 5pm on
___.
Radiology Report
HISTORY: ___ woman with large cerebellar mass status post EVD
placement. Please evaluate EVD placement and vasculature of mass.
TECHNIQUE: Using a multidetector CT scanner, noncontrast volumetric data was
acquired through the head and collimated at 5mm slice thickness. Sagittal and
coronal reformmated images were obtained. Volumetric data was also acquired
through the head following the uncomplicated administration of intravenous
contrast and collimated at 1.25 mm slice thickness. 3D maximum intensity
projections of the head were provided. Additional multiplanar reformats were
generated on a separate workstation.
COMPARISON: CT head without contrast ___ at 9:11.
FINDINGS:
CT Head: There has been interval placement of an EVD catheter from a right
frontal approach. The tip appears to terminate within the third ventricle, in
close proximity with the left thalamus. Again seen is a large partially
calcified mass extraaxial, dural-based mass in the right posterior fossa. The
mass measures approximately 4.4 cm TR x 3.7 cm AP x 3.5 cm CC. There is
significant mass effect on the adjacent cerebellum, with parenchymal edema and
severe compression of the fourth ventricle. The third ventricle and temporal
horns of the lateral ventricles are mildly decreased in size since the pre-EVD
exam, but the third and lateral ventricles remain dilated. There is no
evidence of acute hemorrhage. Cerebral sulci are effaced. There are
secretions in the sphenoid sinus and small amount of fluid in the mastoid air
cells.
CTA Head: There is a right dominant vertebral artery. The right posterior
communicating artery is robust, with a corresponding small right P1 segment.
The left posterior communicating artery is diminutive but visualized. There is
a branch of the right posterior cerebral artery which extends to the anterior
margin of the right posterior fossa mass (image ___. This is only minimally
asymmetric from the course of a comparable branch of the left posterior
cerebral artery, and the right posterior cerebral artery is not enlarged.
Otherwise, there is no evidence of hypervascularity or large vessels supplying
the described right posterior fossa mass. The mass abuts the right transverse
sinus, which appears patent.
Note is made of variant anterior cerebral artery branching pattern, with a
diminutive right A2 giving rise to right callosal branches, and a large A2 on
the left giving right to right pericallosal branches, in addition to giving
rise to left callosal and pericallosal branches. Otherwise, the internal
carotid and middle cerebral arteries demonstrated normal opacification and
branching pattern. The anterior communicating artery complex is visualized.
There is no evidence of significant stenosis, dissection or aneurysm greater
than 3 mm.
IMPRESSION:
1. Right frontal approach EVD catheter terminates at the left aspect of the
___ ventricle, in close proximity with the left thalamus. Mild improvement in
obstructing hydrocephalus.
2. Large partially calcified extraaxial mass in the right posterior fossa,
likely a meningioma, with adjacent right cerebellar edema and compression of
the fourth ventricle
3. A branch of the right posterior cerebral artery extends to the anterior
margin of the right posterior fossa mass. This is only minimally asymmetric
from the course of a comparable branch of the left posterior cerebral artery,
and the right posterior cerebral artery is not enlarged. Arterial supply to
the mass may be better assessed by conventional angiography, if clinically
warranted.
Radiology Report
INDICATION: History of right cerebellar mass. Evaluate mass.
COMPARISON: CTA head from ___.
TECHNIQUE: Multiplanar, multisequence MRI was obtained of the brain prior to
and following contrast. The following sequences including sagittal T1, axial
T1, axial susceptibility, axial FLAIR, axial T2 and diffusion-weighted imaging
were obtained prior to contrast. Axial T1 and axial and coronal and sagittal
MP-RAGE sequences were obtained.
FINDINGS: There is a 4.7 x 4.6 x 4.4 cm (AP x TRV x CC) well-circumscribed
mass with a broad-based dural origin from the right leaflet of the tentorium
and a surrounding "CSF cleft," thus making it most likely extra-axial in
location. This mass is hypointense on T1-weighted imaging, only mildly
hyperintense on T2-weighted imaging, demonstrates internal susceptibility
likely due to calcifications seen on the prior CT and demonstrates homogenous
enhancement. These findings are most consistent with a meningioma. The mass
causes adjacent vasogenic edema and compresses the fourth ventricle which is
nearly slit-like. There is upward transtentorial herniation and effacement of
the quadrigeminal plate cistern.
On the sagittal T1-weighted images, there is marked inferior herniation of the
cerebellar tonsils below the plane of the foramen magnum ,with a peg-like
configuration. Additionally, there is a syrinx within the imaged portion of
the upper cervical cord measuring approximately 7 mm in the AP dimension,
causing expansion of the cord, incompletely imaged. Given the configuration
of the cerebellar tonsils, this most likely represents pre-existent Chiari I
malformation with the downward herniation likely exacerbated by mass effect
from the tentorial meningioma. Incidental note is made of a "partially empty"
sella turcica.
There is a right frontal approach extraventricular catheter terminating in the
left lateral ventricle. The degree of hydrocephalus has improved since the
prior CT. Small amount of layering blood products are present in the lateral
ventricles. There is no evidence of acute infarction. The principal
intracranial flow voids, including those of the dural venous sinuses, are
preserved, and these structures enhance normally.
The visualized paranasal sinuses and mastoid air cells are clear. The globes
are unremarkable.
IMPRESSION:
1. Right posterior fossa extra-axial mass, likely a meningioma of tentorial
origin, with vasogenic edema within the right cerebellar hemisphere, exerting
mass effect with effacement of the fourth ventricle.
2. Marked descent of the cerebellar tonsils with peg-like configuration, and
prominent hydromyelic cavity in the upper cervical cord, incompletely imaged.
This most likely represents pre-existent Chiari I malformation, with the
degree of cerebellar tonsillar herniation likely exacerbated by mass effect
from the posterior fossa tumor.
3. Improved hydrocephalus after ventriculostomy placement, with small amount
of intraventricular hemorrhage, new since the previous exam and likely
post-procedural.
COMMENT: Recommend comparison with any prior (outside) cross-sectional
imaging studies, as well as MR imaging of the entire spinal cord, if this has
not been done elsewhere.
Radiology Report
HISTORY: ___ female with right calcified cerebellar lesion and
obstructive hydrocephalus, for preoperative evaluation.
COMPARISON: None.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates low lung volumes
with resulting bronchovascular crowding. The cardiomediastinal and hilar
contours are unremarkable. There is no pneumothorax, pleural effusion, or
consolidation.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with posterior fossa meningioma, for
preoperative assessment.
TECHNIQUE: Axial T1 and MP-RAGE post-contrast images were obtained with
surface markers for surgical planning. Comparison was made with the MRI of
___.
FINDINGS: Again a large homogeneously enhancing mass seen in the posterior
fossa, consistent with a meningioma. The meningioma appears to be attached to
the lateral aspect of the posterior fossa along the transverse sinus, but
there appears to be enhancement of the transverse sinus seen which appears to
show flow both anteriorly and posteriorly. There is mass effect on the
fourth ventricle as seen before. A right frontal ventricular drain is
identified.
IMPRESSION: Unchanged appearance of the posterior fossa meningioma since the
previous MRI. The examination performed for surgical planning.
Radiology Report
HISTORY: ___ female status post cerebellar lesion resection.
TECHNIQUE: Contiguous axial images obtained from skullbase to vertex without
intravenous contrast. Coronal and sagittal reformats were reviewed.
COMPARISON: Head CT from ___, brain MRI is from ___.
FINDINGS:
Interval postoperative changes of suboccipital craniectomy are seen with
overlying cranioplasty changes. There is low density fluid and air within the
postoperative site within the posterior fossa on the right. Small amount of
peripheral high density in the postoperative cavity is compatible with a small
amount of hemorrhage. There is persistent mass effect in the posterior
fossa, although the ___ ventricle is now more clearly identified.
Small subdural hemorrhage seen layering along the tentorium on the right. Low
density subdural fluid tracking along the falx and left side of the tentorium.
Blood seen layering dependently within the left lateral ventricle. The
ventricular catheter via a right frontal region is seen with tip in close
proximity to the left thalamus as on prior. The ventricles are slightly
larger when compared to preoperative MR but smaller than ___ ventricular
shunt imaging on ___.
Included paranasal sinuses and mastoids are clear.
IMPRESSION:
Postoperative changes from posterior fossa tumor resection including small
amount of blood products in the postoperative bed and along the right
tentorium. Lateral ventricles are slightly larger compared to preoperative
MRI but smaller from initial presentation/post catheter placement imaging.
Radiology Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient is status post resection of posterior fossa
meningioma for residual mass.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion
axial images obtained before gadolinium. T1 sagittal and axial images and T1
axial and MP-RAGE sagittal images acquired following gadolinium.
FINDINGS: Since the previous MRI study, the patient has undergone resection
of a large posterior fossa meningioma. Fluid and blood seen in the region of
surgical cavity. No definite nodular area of residual enhancement is seen.
There remains mass effect on the fourth ventricle, but it has decreased from
the previous study. There is restricted diffusion seen at the margin of the
surgical cavity which appears postoperative in nature and is not in an
arterial territorial distribution. Small amount of fluid or blood is seen in
the occipital horn of both lateral ventricles.
A right frontal approach shunt projects over the left thalamus.
IMPRESSION: Status post resection of posterior fossa meningioma. No nodular
area of residual enhancement seen. Blood products and fluid are seen at the
surgical site. There remains downward herniation of tonsils and syrinx in the
upper cervical spinal canal. Restricted diffusion is seen at the margin of
the surgical cavity which appears postoperative likely venous ischemia, but no
territorial infarcts are seen.
Radiology Report
HISTORY: Headaches and nausea transferred from ___ with a right calcified
cerebellar lesion. Assess for interval change.
COMPARISON: Prior brain MR from ___ and head CT from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without IV contrast. Sagittal, coronal and bone thin algorithm
reconstructions were generated.
Total exam DLP: 892 mGy-cm.
CTDI: 53 mGy.
FINDINGS:
Patient is status post right-sided suboccipital craniotomy with postoperative
changes and overlying cranioplasty changes identified. There is
redemonstration of high density material within the postoperative cavity this
and along the right tentorium, consistent with a small amount of hemorrhage
which is likely redistributed. Low-density fluid within the postoperative
site is again seen. There is interval resolution of air within the
postoperative site. There is persistent mass effect within the posterior
fossa with tonsillar herniation. The ___ ventricle is not as clearly
identified as on prior CT examination. A right-sided ventricular drain is
again seen with its tip in close proximity to the left thalamus as on prior.
There has been interval decrease in ventricular size as compared to prior CT
examination, stable in size when compared to prior MRI. There is the tiny
residual amount of blood layering within the left lateral ventricle. There is
no evidence of acute major territorial infarction.
There is mild opacification of the mastoid air cells bilaterally. Small
amount of fluid is seen layering within the left sphenoid sinus. Otherwise,
the remaining visualized paranasal sinuses and middle ear cavities are clear.
IMPRESSION:
1. Postoperative changes from posterior fossa tumor resection with a small
amount of blood in the postoperative bed and along the right tentorium likely
redistributed but not significantly changed in amount.
2. Stable ventricular size when compared to prior MR examination, decreased
ventricular size since prior CT dated ___.
Radiology Report
HISTORY: Right cerebellar lesion status post resection with EVD placement.
Evaluate for interval change post-clamping.
COMPARISON: ___.
TECHNIQUE: Contiguous axial MDCT images through the brain were obtained
without intravenous contrast. Coronal and sagittal as well as bone
reformatted images were acquired.
DLP: 1003.42 mGy-cm.
CTDIvol: 52 mGy.
FINDINGS: Compared to the prior study, the right temporal subdural fluid
appears slightly larger, although still small overall. External ventricular
drain with a frontal approach terminates with the tip in close proximity to
the left thalamus. Post-surgical changes in the posterior fossa include
hemorrhage and hypodense regions of edema, which have increased slightly,
resulting in effacement of the fourth ventricle and quadrigeminal cistern. No
new hemorrhage is identified. Craniotomy changes overlying the right occiput.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. Continued postoperative appearance of the posterior fossa with increasing
edema and effacement of the fourth ventricle and quadrigeminal cistern.
Persistent hemorrhage within this postoperative area appears to be stable in
quantity.
2. Right temporal subdural fluid collection is slightly larger, although
still small.
3. EVD unchanged in position.
Radiology Report
HISTORY: Prolonged bed rest, assess for DVT.
COMPARISON: None available.
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed of
the bilateral lower extremities.
FINDINGS: There is normal compressibility, flow, and augmentation of the
bilateral common femoral, proximal femoral, mid femoral, distal femoral, and
popliteal veins. Normal color flow is demonstrated in the posterior tibial
and peroneal veins bilaterally. There is normal respiratory variation in the
common femoral veins bilaterally.
IMPRESSION: No evidence of deep vein thrombosis in the right or left lower
extremity.
Radiology Report
HISTORY: VP shunt catheter placement.
COMPARISON: Non-contrast head CT ___.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 891.93 mGy-cm.
CTDIvol: 50.31 mGy.
FINDINGS:
CT HEAD WITHOUT CONTRAST: There has been interval removal of the right
frontal approach ventriculostomy catheter. There has been interval placement
of a left frontal approach ventriculoperitoneal shunt catheter with tip
terminating in the frontal horn of the right lateral ventricle indenting upon
the caudate nucleus. There are associated post-surgical changes including
trace pneumocephalus as well as a locule of air within the frontal horn of the
right lateral ventricle. Compared to ___, there has been minimal
increase in size of the ventricles. There are redemonstration of
post-surgical changes from right suboccipital craniectomy and mesh repair with
no change in size and appearance of mainly hypodense fluid collection within
the right cerebellar hemispheric resection bed with trace amount of hyperdense
blood product somewhat evolved in appearance compared to prior examination.
There remains surrounding edema with persistent effacement of the fourth
ventricle and quadrigeminal cistern. There is no new focus of hemorrhage.
There is no infarct. The visualized paranasal sinuses, mastoid air cells and
middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Interval removal of the right ventriculostomy catheter and placement of a
left frontal approach ventriculoperitoneal shunt catheter with tip terminating
in the frontal horn of the right lateral ventricle with minimal increase in
size of ventricles as compared to ___.
2. No change in size of encephlomalacia in the right cerebellar hemispheric
resection bed with similar degree of surrounding edema along with effacement
of the quadrigeminal cistern and fourth ventricle.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: INTUBATED
Diagnosed with BRAIN CONDITION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Eu Critical ___ was taken to the operating room after being
transferred from ___ and underwent a right frontal
EVD. The EVD was set at 10. She tolerated the procedure well was
transferred to the Neuro ICU post-operatively. She underwent a
post-operative non-contrast head CT/ CTA which showed a large
right cerebellar mass; the scan was negative for aneurysm. She
was extubated.
On ___, she underwent a brain MRI for further evauation of the
right cerebellar lesion to assist with operative planning. The
patient was made NPO at midnight, the subcutaneous Heparin was
stopped at midnight and the patient was started on IV fluids in
anticipation to undergo a suboccipital craniotomy and resection
of lesion the following day.
___, Ms. ___ was taken to the operating room for a
suboccipital craniotomy for resection of her cerebellar tumor.
She tolerated the procedure well and was transferred to the
Neuro ICU post-operatively. She remained NPO and intubated. She
underwent a post-operative non-contrast head CT which showed
post-operative changes. The EVD was raised to 15 above the
tragus.
___, Ms. ___ had an MRI of the brain with and without
contrast which showed expected post opererative changes. She
remained stable on exam and following commands. She was
exatubated and placed on a face tent for humidification, her
oxygenation level are above 94%.
On ___, the patient was neurologically and hemodynamically
stable. She was out of bed to chair with physical therapy and
tolerated it well. Her EVD was increased to 20cm. She was
transferred to the floor in stable conditions. Neuro-oncology
and radiation-oncology were consulted.
On ___, patient had a head CT performed which was stable from
previous scan. Exam remained unchanged.
On ___, her EVD was clamped at 11am. Around 1pm, patient's ICP
were elevated and the drain was unclamped.
On ___, she remained stable on exam. Head CT was performed and
showed slight increase in edema in posterior fossa, but patent
___ ventricle. A clamping trial was attempted once again which
failed after intracranial pressures in the twenties. There was
a possibility that the higher pressures were secondary the
patient having a bowel movement.
___, another clamping trial was attempted and failed after
sustained intracranial pressures in the twenties. The drain was
opened. A csf sample was taken for analysis of protein which
came back low and within range.
___, Ms. ___ had LENIS which were negative for a deep vein
thrombosis. Her drain remained opened and draining.
___ She was consented for a ventricular peritoneal shunt. Pre
operative workup was completed.
On ___, a physical therapy consult was ordered.
On ___, the patient complained of left ear pain. Nystatin cream
was ordered for red, irritated skin underneath her breasts.
On ___ and ___, she remained stable waiting for discharge to
rehab.
On ___ Patient was re-evaulated by ___. They have recommended
patient be discharged home with ___ services, OT services and ___
services. She was discharged home in stable conditions with
services and information for follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
Mesenteric Angiogram
History of Present Illness:
Dr. ___ is a ___ yo male with history of diverticulosis
(whole colon on ___ Colonoscopy, no history of GI bleed) who
presents with BRBPR. He awoke with bowel urgency at 3am, has
had 5 episodes of frankly bloody diarrhea before presentation to
ED. On ASA 325 and Clopidogrel for TIA, no cardiac history. No
abdominal surgeries. He has also been taking Ibuprofen 800mg BID
for back pain over the past 3 days.
In the ED, initial vs were: 97.8 64 124/60 18 100% RA. Labs were
remarkable for hct 43.3 (baseline 48), cr 1.1. He had 2 episodes
of bloody BMs in ED, ~300 cc. Patient was given 1L NS prior to
transfer. Vitals on Transfer: 97.8 64 124/60 18 100% RA.
On the floor, vs were: T 97.8 P 58 BP 140/64 R 18 O2 sat 97% RA.
He reports that BMs have subsided, last movement 1.5 hours ago.
Some lower abdominal cramping subsequent to BMs, but no pain,
N/V, GERD sx or chest pain. Some lightheadedness since onset of
bleeding. Denies SOB, weakness or fevers/chills.
Past Medical History:
PAST MEDICAL HISTORY:
# HLD
# hx DVT s/p ortho surgery
# BPH
# TBI (concussion)
# TIA on clopidogrela and ASA for this. Head imaging w/o e/o
stroke
Surgical Hx:
1. Left knee arthroscopy.
2. Left knee lateral meniscectomy, subtotal: ___. Left knee medial meniscectomy, subtotal: ___. left total hip replacement on ___.
Social History:
___
Family History:
No history of GI disease or cancers.
Physical Exam:
INITIAL PHYSICAL EXAM:
Vitals- T 97.8 P 58 BP 140/64 R 18 O2 sat 97% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Few bibasilar crackles, cleared with few breaths.
Otherwise clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, tender to lower quadrant/suprapubis.
Non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 100.6, Tc 97.7, BP 157/62, HR 72, RR 18, SaO2 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
___ 04:40AM ___ PTT-27.2 ___
___ 04:40AM PLT COUNT-219
___ 04:40AM NEUTS-70.5* ___ MONOS-6.0 EOS-1.1
BASOS-0.5
___ 04:40AM WBC-10.3 RBC-4.62 HGB-14.6 HCT-43.3 MCV-94
MCH-31.5 MCHC-33.7 RDW-13.9
___ 04:40AM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-2.9
MAGNESIUM-2.0
___ 04:40AM LIPASE-29
___ 04:40AM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-43 TOT
BILI-0.5
___ 04:40AM GLUCOSE-120* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
___ 04:56AM LACTATE-1.3
Interim labs:
___ 09:00AM HCT-38.2*
___ 05:42PM HCT-34.5*
___ 09:21PM HCT-31.4*
___ 03:40PM BLOOD WBC-7.7 RBC-3.91* Hgb-12.2* Hct-36.2*
MCV-93 MCH-31.2 MCHC-33.7 RDW-14.3 Plt ___
___ 02:20AM BLOOD WBC-9.6 RBC-3.41* Hgb-10.4* Hct-32.4*
MCV-95 MCH-30.5 MCHC-32.2 RDW-14.2 Plt ___
Discharge labs:
___ 06:00AM BLOOD WBC-10.2 RBC-3.37* Hgb-10.7* Hct-31.2*
MCV-93 MCH-31.7 MCHC-34.3 RDW-14.3 Plt ___
___ 05:00PM BLOOD Hct-34.3*
___ 06:00AM BLOOD Glucose-99 UreaN-9 Creat-1.0 Na-141
K-3.2* Cl-106 HCO3-29 AnGap-9
Imaging:
CTA Abdomen/Pelvis w/wo contrast ___
IMPRESSION:
1. Extensive diverticulosis of the entire colon without evidence
of diverticulitis. The findings were discussed on the phone by
Dr. ___ with referring physician ___ ___ at 9.15
am.
2. No evidence of active extravasation to explain GI bleed.
3. Small-to-moderate hiatal hernia.
4. Small umbilical hernia containing fat.
5. Left inguinal hernia containing fat.
Nuclear medicine GI bleeding study ___
IMPRESSION: Active GI bleeding from the proximal ascending
colon. Tracer activity in the region of the cecum may represent
blood pooling from the more distal ascending colon source or the
primary source of hemorrhage.
Mesenteric angiogram ___
IMPRESSION: Uncomplicated superior mesenteric angiogram without
evidence of active
extravasation. No intervention performed.
Colonoscopy ___
Impression:
Diverticulosis of the whole colon
Polyp in the ascending colon (injection)
Otherwise normal colonoscopy to terminal ileum
Recommendations:
No active bleeding or evidence of prior bleeding during the
procedure.
A single sessile polyp noted in the ascending colon requires
removal upon follow up colonoscopy. This was not removed given
his recent bleeding and recent aspirin/plavix use.
Continue to trend hematocrit, maintain IV access, and maintain
active type and cross. Rest of plan per inpatient team.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 10 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Rosuvastatin Calcium 10 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth up
to twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal Bleed
Whole colon diverticuli
Anemia of acute blood loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Bright red blood per rectum and hematocrit drop of 10 points.
Evaluation for source of GI bleeding.
COMPARISON: CT from ___.
TECHNIQUE: Axial CT images were acquired in axial mode with non contrast,
arterial and portal venous phase of imaging. Multiplanar reconstructions were
also performed.
Total exam DLP is 2,283 mGy x cm.
FINDINGS:
LUNG BASES: Linear atelectasis in the left lower lobe and lingula.
ABDOMEN: The liver demonstrates atrophy of the left lobe, unchanged compared
to the prior study. A single hypodense lesion measuring 8 mm is seen in
segment 7 of the liver (series 4B image 241), also unchanged compared to the
prior study, most probably represents a cyst. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The portal vein is patent.
The gallbladder is unremarkable. The pancreas is within normal limits, apart
from prominence of the ventral pancreatic duct, also unchanged compared to the
prior study. There is no focal masses in the pancreas. The spleen is
unremarkable. The adrenals are within normal limits. Small sub 5mm cortical
hypodense lesions within both kidneys most probably represent small cysts.
There is no evidence of hydronephrosis bilaterally. There is no evidence of
retroperitoneal or mesenteric lymphadenopathy. Extensive atherosclerotic
disease of abdominal aorta is noted. Small to moderate hiatal hernia is seen.
Small umbilical hernia containing fat. Small bowel loops are unremarkable.
PELVIS: Extensive diverticulosis of the entire colon is noted without
evidence of diverticulitis. There is no evidence of active extravasation.
The prostate is enlarged. There is no evidence of pelvic or inguinal
lymphadenopathy. Left inguinal hernia, containing fat, is noted.
BONE: Status post left hip replacement. Degenerative changes of the lumbar
spine.
IMPRESSION:
1. Extensive diverticulosis of the entire colon without evidence of
diverticulitis. The findings were discussed on the phone by Dr. ___ with
referring physician ___ ___ at 9.15 am.
2. No evidence of active extravasation to explain GI bleed.
3. Small-to-moderate hiatal hernia.
4. Small umbilical hernia containing fat.
5. Left inguinal hernia containing fat.
Radiology Report
HISTORY: Intermittent lower GI bleed.
COMPARISON: CTA abdomen pelvis ___, nuclear medicine GI bleeding study
___.
PHYSICIANS: Dr. ___ radiology fellow), Dr. ___
___ resident) and Dr. ___ radiology attending)
performed the procedure. The attending, Dr. ___ was present and
supervising throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
75 mcg of fentanyl and 1.5 mg of Versed throughout the total intraservice time
of min during which the patients hemodynamic parameters were continuously
monitored. Local anesthesia with 1% lidocaine was given in the subcutaneous
tissues of the right groin.
FLUOROSCOPY TIME AND DOSE: 10.8 minutes, 429 mGy.
CONTRAST: 50 mL of Optiray 320.
PROCEDURE:
1. Right common femoral artery access.
2. Superior mesenteric arteriogram.
3. Selective angiography of the right colic and ileocolic arteries.
PROCEDURE IN DETAIL:
Written informed consent was obtained from the patient after explaining the
procedure, benefits, alternatives and risks involved. The patient was brought
to the angiography suite and placed supine on the imaging table. Both groins
were prepped and draped in the usual sterile fashion. A preprocedural time
out was performed per ___ protocol.
Using palpatory and fluoroscopic guidance, access to the right common femoral
artery was achieved using a 19 gauge needle. A ___ guidewire was then
advanced into the aorta and the needle was exchanged for a 5 ___ by 10 cm
___ sheath. A Cobra C2 catheter was then inserted and used to cannulate
the superior mesenteric artery. Position was confirmed with a small contrast
injection. An angiogram was performed. An ___ catheter preloaded with a
Transcend wire was used to access the right colic and ileocolic arteries,
separately. An arteriogram was performed, again demonstrating no active
extravasation within the ascending colon.
The right femoral artery sheath was removed, manual pressure was held for 15
min and hemostasis was achieved. The patient tolerated the procedure well and
was transported back to the floor after the procedure.
FINDINGS:
No active extravasation or vascular anomalies from the SMA or its right colic,
or ileocolic branches.
IMPRESSION:
Uncomplicated superior mesenteric angiogram without evidence of active
extravasation. No intervention performed.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.1
heartrate: 98.0
resprate: 18.0
o2sat: 97.0
sbp: 131.0
dbp: 101.0
level of pain: 0
level of acuity: 2.0 | # GI Bleed with anemia of acute blood loss: The patient was
admitted for BRBPR onset on the morning of admission. His
hematocrit at admission was 43, down from his baseline of 48. He
had a colonoscopy done on ___ showing whole colon
diverticulosis, so this was felt to be most likely due to a
diverticular bleed. He continued to have ongoing bloody stools
with resultant hematocrit drop to a nadir of 30.8. He became
symptomatic with dyspnea on exertion and orthostatic
hypotension, and received a total of 3 units of pRBCs . We
obtained a CTA of the abdomen that did not reveal active
bleeding at the time of imaging. A tagged RBC scan was
performed, and identified the site of bleed in the ascending
colon. He was sent to Interventional Radiology for embolization,
but this was not successful as there was no active extravasation
during the procedure. Finally, a colonoscopy was obtained, but
by this time the bleeding had subsided and did not reveal any
areas amenable to intervention. Aspirin and Clopidogrel were
held in the setting of bleed. At discharge, the patient was able
to ambulate the halls without symptoms and was no longer
orthostatic. Last hematocrit was 34.2, and he was discharged
with an iron supplement.
#Fever with dysuria: The patient developed chills with dysuria
and urinary frequency, which self resolved overnight. A UA and
urine culture were obtained, and returned negative. He had a
temperature to 100.6 that spiked at the time of his ___ blood
transfusion, although the chills had occurred prior to
initiation. Due to the timing of the fever, it was considered a
transfusion reaction, although this likely preceded the
transfusion. Chills/fever resolved and the patient did not
appear to be infected. No interventions were performed.
Transitional Issues:
# A sessile poyp was found on colonoscopy and inked, but no
intervention was performed given recent bleed and antiplatelet
use. He will a follow up colonoscopy for removal
# Aspirin and Clopidogrel were discontinued in setting of active
bleed. They were prescribed for indication of TIA symptoms. He
does not have any cardiac disease history. Need for ongoing
antiplatelet medications will need to be assessed in the
outpatient setting |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lomotil / Erythromycin Base / Cephalosporins /
vancomycin
Attending: ___.
Chief Complaint:
severe constipation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with history of PE, recent TKR on right complicated by
post-op stidor requiring intubation, ? DVT on left now on
xarelto presenting from ___ rehab with abdominal
distention and urinary retention. He describes the abdominal
pain as cramping and a sensation that his abdomen is ___ times
the normal size.
Patient underwent R TKR on ___ at ___. Patient was started on
rivaroxaban for DVT prophylaxis (? left leg DVT). He was
discharged to ___ and reports that he has not had any
bowel movement since prior to surgery (going on 14 days) with
report per patient of no passage of gas since that time either.
He was treated aggressively with several days of MOM, mag oxide,
senna, colace and lactulose at ___ without effect.
Received enemas yesterday with nursing note of bowel movement
that was large and loose yesterday with some relief of symptoms
though patient reports this was not very large and has not
helped symptoms. He has been taking pain meds sparingly with
last dilaudid 2mg PO on ___.
He also reports that for the past 2 days he has had urinary
retention. He has an urge to pee but couldn't get it to come
out. This has never happened to him before.
In the ED initial vitals were: 98.2 101 147/93 20 100%
- Labs were significant for WBC 13.5 (80% polys), Hct 31 (from
28 two days ago) and mild ___ with Creatinine 1.3 up from 1.0.
- Patient was given tap water enema without significant relief
of constipation. Manual disimpaction attempted unsuccessfully.
He was also seen by ortho/spine consult due to concern for cauda
equina causing his urinary retention but they felt that this was
due to constipation and his neurologic exam was normal for them
so a foley was placed.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
# Sinus bradycardia s/p pacemaker placement ___
# CAD s/p stent to RCA ___
# hypertension
# pulmonary emboli ___ year in ___, ___ stopped
warfarin due to coagulopathy supratherapeutic INR (and prior h/o
epistaxis on warfarin; no known cerebral or GI hge)
# trigeminal neuralgia s/p two neurosurgical at ___ in the
mid ___, now with left hemifacial anesthesia, but continued
pain which has been refractory to many different medications
including alprazolam, nortriptyline, amitriptyline, gabapentin,
methadone, fentanyl, and trazodone.
# prolonged hospitalization ___ at ___ in ___) after he was found down at home
in the setting of multiple narcotics use and observed
hallucinations in the weeks prior; reported seizure activity on
EEG monitoring at this OSH, and subsequent increase in AED
regimen.
# Hyperlipidemia
# Multiple spinal, knee, and foot surgeries (including excision
of coccyx in childhood) last in ___. Recently walked with
walker in ___, stooped, on increased pain medication (methadone
and fentanyl pops) leading up to ___ hospitalization.
# Multiple septoplasties/rhinoplasties in the 1990s for
chronic/recurrent sinusitis
# GERD; h/o GIB vs. gastritis (?minor) ___ in ___
# possible seizure disorder, where patient describes going into
a black hole. (previous treatments include lamotragine,
gabapentin, Dilantin, Keppra, Depakote)
# chronic insomnia, refractory in the past to nortriptyline,
amitriptyline, trazadone, methadone, Ativan, Xanax, Ambien,
Lunesta (pt says none of these help and he cannot sleep at all).
Currently taking clonazepam QHS (amitriptyline recently stopped
as above)
# Restless legs syndrome, previously on ropinerole (stopped in
___ due to inefficacy)
# Previously on Aggrenox (denies h/o stroke)
# Mood disorder, treated previously with various
TCA/SSRI/SNRI/pain medications.
# Unclear h/o weight loss / muscle wasting, given testosterone
injections as recently as ___
Social History:
___
Family History:
grandfather with DM, but his parents died in a car crash when he
was a teenager
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=====================
Vitals - 97.2, 157/84, 90, 20, 100 RA
GENERAL: NAD, odd affect with slow speech production
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, 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: very distended, firm, dull to percussion, slow but
present BS, mildly tender in all quadrants, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. right knee with surgical incision healing no
dehiscence or drainage, surrounding bruise and erythema without
tenderness
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength in bilateral hip flexors
and knee extensors and plantar and dorsiflexion
SKIN: warm and well perfused, surgical wound as above, no rashes
PHYSICAL EXAM ON DISCHARGE:
======================
Vitals: 97.9 142/74 75 20 98% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, 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: soft, ND, NT, hyperactive BS, no rebound or gaurding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. right knee with surgical incision healing no
dehiscence or drainage, surrounding bruise and erythema without
tenderness
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, surgical wound as above, no rashes
Pertinent Results:
LABS ON ADMISSION:
====================
___ 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-NEG
___ 10:15PM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-FEW
EPI-0
___ 10:07PM LACTATE-1.3
___ 04:50PM GLUCOSE-126* UREA N-38* CREAT-1.3* SODIUM-140
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
___ 04:50PM cTropnT-<0.01
___ 04:50PM WBC-13.9*# RBC-3.33*# HGB-10.5*# HCT-31.7*#
MCV-95 MCH-31.6 MCHC-33.2 RDW-13.7
___ 04:50PM NEUTS-81.5* LYMPHS-11.5* MONOS-4.3 EOS-2.4
BASOS-0.3
___ 04:50PM PLT COUNT-401#
___ 04:50PM ___ PTT-36.1 ___
PERTINENT LABS:
===============
___ 05:51AM BLOOD Neuts-49.3* ___ Monos-5.5
Eos-10.8* Baso-0.5
___ 04:33AM BLOOD LD(LDH)-410*
___ 04:05PM BLOOD LD(LDH)-434*
___ 07:48AM BLOOD ALT-26 AST-27 LD(LDH)-427* AlkPhos-56
TotBili-0.7
___ 04:50PM BLOOD cTropnT-<0.01
___ 04:33AM BLOOD calTIBC-319 Hapto-77 TRF-245
LABS ON DISCHARGE:
===================
___ 05:51AM BLOOD WBC-2.9* RBC-2.74* Hgb-8.2* Hct-26.9*
MCV-98 MCH-30.0 MCHC-30.5* RDW-14.6 Plt ___
___ 05:51AM BLOOD Plt ___
___ 05:51AM BLOOD Glucose-84 UreaN-14 Creat-1.1 Na-143
K-3.7 Cl-110* HCO3-23 AnGap-14
___ 05:51AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9
MICROBIOLOGY:
=============
__________________________________________________________
___ 12:27 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:30 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 10:02 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
==========
___ CT CHEST/ABD/PELVIS:
1. Diffusely dilated loops of colon and rectum, containing a
large amount of stool and fluid without definite evidence of an
obstructing lesion.
2. No evidence of pulmonary embolism.
CT A/P ___:
Mildly improved diffuse dilatation of the colon and rectum
without focal
transition point. No evidence of perforation. Of note, the
patient does not appear severely constipated as noted in the
clinical history. The colon is diffusely fluid-filled without
any significant formed stool. In the presence of peritoneal
signs and a diffusely dilated colon toxic megacolon would be in
the differential diagnosis.
CT A/P ___:
1. The right side of the colon and the transverse colon is
minimally distended
without evidence of a zone of transition. The degree of
distention has
decreased since the previous study.
2. Lobulated cystic lesion within the tail of the pancreas
measuring up to 1.1 cm that may represent either focal
dilatation of the main duct or a separate lesion. The main
pancreatic duct is diffusely dilated. These findings have
progressed slightly since ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 150 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Clonazepam 1 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY constipation
6. Zonisamide 200 mg PO QAM
7. Zonisamide 300 mg PO QPM
8. Acetaminophen 1000 mg PO TID
9. CloniDINE 0.2 mg PO HS
10. Docusate Sodium 200 mg PO BID
11. meloxicam 15 mg oral HS
12. Pravastatin 20 mg PO DAILY
13. Pregabalin 150 mg PO TID
14. Senna 17.2 mg PO BID
15. desvenlafaxine succinate 50 mg oral daily
16. Rivaroxaban 10 mg PO DAILY
17. AndroGel (testosterone) 1 %(50 mg/5 gram) transdermal daily
18. Bisacodyl ___AILY
19. Bisacodyl 10 mg PO BID:PRN constipation
20. ClonazePAM 0.5 mg PO Q8H:PRN agitation
21. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
22. Lactulose 30 mL PO Q2H: PRN constipation
23. Magnesium Citrate 300 mL PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Amitriptyline 100 mg PO HS
RX *amitriptyline 100 mg 1 tablet(s) by mouth every night Disp
#*30 Tablet Refills:*0
3. AndroGel (testosterone) 1 %(50 mg/5 gram) transdermal daily
4. Aspirin 81 mg PO DAILY
5. Bisacodyl ___ID:PRN constipation
Take up to twice a day if not having bowel movements every other
day
RX *bisacodyl 10 mg 1 suppository(s) rectally twice a day Disp
#*30 Suppository Refills:*0
6. ClonazePAM 0.5 mg PO Q8H:PRN agitation
7. CloniDINE 0.2 mg PO HS
8. Lisinopril 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO BID:PRN constipation
Take up to twice a day if not having bowel movements every other
day
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*30 Packet Refills:*0
10. Pravastatin 20 mg PO DAILY
11. Pregabalin 150 mg PO TID
12. Rivaroxaban 10 mg PO DAILY
13. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tabs by mouth twice a day Disp
#*60 Capsule Refills:*0
14. Zonisamide 200 mg PO QAM
15. Zonisamide 300 mg PO QPM
16. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
17. ClonazePAM 1 mg PO BID
18. desvenlafaxine succinate 50 mg oral daily
19. meloxicam 15 mg ORAL HS
20. Outpatient Lab Work
please check CBC and diff on ___ and call in results to Dr.
___: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE DIAGNOSES:
1. severe constipation
2. acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam dated ___.
CLINICAL HISTORY: Chest pain and shortness of breath.
FINDINGS: AP upright and lateral views of the chest were provided. Dual-lead
pacemaker is noted with leads extending to the right atrium and right
ventricle. Elevated right hemidiaphragm is noted with underlying gas-filled
bowel. There is bibasilar atelectasis. No large effusions. Heart size and
mediastinal contour are normal. Bony structures are intact.
IMPRESSION: Bibasilar atelectasis. Gas-filled bowel in the upper abdomen can
be further assessed on the subsequent CT of the abdomen and pelvis.
Radiology Report
INDICATION: ___ man with a history of CAD, recent DVT status post
total right knee replacement, on Xarelto, presenting with shortness of breath
and tachycardia and constipation, evaluate for bowel obstruction and possible
pulmonary embolism.
COMPARISON: CTA chest from ___ and CTA abdomen from ___.
TECHNIQUE: Axial multidetector CT images were obtained through the chest,
abdomen and pelvis during rapid administration of intravenous contrast with
coronal and sagittal reformats.
DLP: 4578 mGy-cm.
FINDINGS:
CTA CHEST: Thoracic aorta is of normal caliber without evidence of aneurysm
or dissection. Pulmonary arteries are well opacified to the subsegmental
level without a filling defect to suggest pulmonary embolism.
CT CHEST: Thyroid enhances homogeneously. There is no axillary, mediastinal
or hilar lymphadenopathy by CT criteria. Heart is normal in size. Pacemaker
leads are noted. There is no pericardial effusion.
Airways are patent to the subsegmental level. Increased basilar opacities
likely relate to atelectasis and expiratory phase of imaging. There is no
focal consolidation or pleural effusion. No pneumothorax.
CT ABDOMEN: The right hemidiaphragm is elevated. Dilated loops of colon are
present anterior to the liver and extending superiorly to below the right
diaphragm. Liver enhances homogeneously without concerning lesions or biliary
dilatation. The portal vein is patent. Gallbladder, spleen, pancreas and
adrenal glands are unremarkable. Kidneys enhance and excrete symmetrically
without concerning lesions or hydronephrosis.
Stomach is mildly distended with ingested material. Duodenum is distended
with fluid. Loops of small bowel are normal in course and caliber and
decompressed proximally. The distal loops of small bowel are distended with
fluid, but not dilated. The entire length of the colon is dilated up to 7 cm
and filled with a large amount of stool and fluid. The rectum is also
distended with stool. There is no transition point or obstructing lesion to
suggest mechanical obstruction. There is no bowel wall thickening or adjacent
stranding. There is no intra-abdominal free air or fluid. There is no
mesenteric or retroperitoneal lymphadenopathy. Abdominal aorta contains
moderate amount of atherosclerotic calcifications but no aneurysmal
dilatation.
CT PELVIS: The bladder, seminal vesicles and prostate gland are unremarkable.
There is no pelvic free fluid or lymphadenopathy. Edema is noted in the
subcutaneous tissue along the right lateral gluteal region.
BONE WINDOW: Posterior fusion and laminectomies are again noted in the lower
lumbar spine as well as degenerative changes. No concerning osteolytic or
osteosclerotic lesion, however, is identified. Old rib deformities are noted.
IMPRESSION:
1. Diffusely dilated loops of colon and rectum, containing a large amount of
stool and fluid without definite evidence of distal obstructing lesion.
2. No evidence of pulmonary embolism.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with severe constipation // obstruction
COMPARISON: No comparison
IMPRESSION:
Severe scoliosis, status post spine surgery. No pathological calcifications.
Moderately distended stomach. The entire length of the colon is dilated, with
loops up to 7 cm in diameter, an appeared to be filled with gas and small
amount of stool. The rectum is distended. There is no evidence for a
transition point. No evidence of bowel wall thickening. The diameter of the
small bowel loops are at the upper range of normal. The visible parts of the
lung bases are unremarkable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with severe constipation and acute abd // right
diaphragm cannot be seen on recent KUB, need to repeat to r/o free air
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, there is on going elevation of the
left and the right hemidiaphragm, caused by massively distended bowel loops.
These distensions have slightly increased as compared to the previous image.
The lung bases show mild bilateral areas of atelectasis. The overall lung
volumes are low. Unchanged normal appearance of the cardiac silhouette. No
pneumonia, no pleural effusions. No free subdiaphragmatic air.
Radiology Report
EXAMINATION: ABD SUPINE AND LAT DECUB
INDICATION: ___ year old man with severe abd pain in setting of constipation
// perforation?
COMPARISON: ___.
IMPRESSION:
Severe scoliosis, status post spine surgery. Foley catheter in situ. Known
massive colonic dilatation, without substantial progression as compared to the
previous examination. Contrast material is now seen in the descending colon.
The left lateral decubitus view shows no safe evidence of free intra-abdominal
air. However, given the difficult technically a conditions, CT of the abdomen
should be considered if the clinical suspicion for perforation persists.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with severe constipation and peritoneal signs //
IV contrast to assess for bleed, no po contrast d/t severe constipation, ACS
requested gastrografin enema. assess for bleed, perforation, obstruction
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous administration of 130cc of Omnipaque. Coronal and
sagittal reformations were performed. Oral contrast was administered.
DOSE: DLP: 870 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
ABDOMEN:
LUNG BASES: There is bibasilar atelectasis.
HEPATOBILIARY: The liver demonstrates homoenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is noted to have layering
hyperdense material which was not present on the previous exam. This likely
represents vicarious contrast excretion related to the recent
contrast-enhanced CT..
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The adrenals glands are unremarkable bilaterally.
KIDNEYS: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions or hydronephrosis.
BOWEL: An NG tube is noted in the stomach. The stomach and small bowel are
otherwise normal in appearance. There is a stable to mildly improved diffuse
dilatation of the colon and rectum without focal transition point. The colon
is diffusely fluid filled. There are no findings to suggest colonic
perforation as questioned.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: The abdominal aorta demonstrates atherosclerotic changes of the
abdominal aorta and branch vessels. The abdominal vasculature appears patent..
PELVIS:
The visualized pelvic organs are normal. There is no significant pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES:
The patient is status post prior lower lumbar spinal fusion and interbody
spacer placement. No acute osseous abnormalities are identified. The soft
tissues are unremarkable.
IMPRESSION:
Mildly improved diffuse dilatation of the colon and rectum without focal
transition point. No evidence of perforation. Of note, the patient does not
appear severely constipated as noted in the clinical history. The colon is
diffusely fluid-filled without any significant formed stool. In the presence
of peritoneal signs and a diffusely dilated colon toxic megacolon would be in
the differential diagnosis.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with severe constipation. Interval changes.
TECHNIQUE: Portable abdominal radiograph.
COMPARISON: CT of the abdomen pelvis and abdominal radiograph from ___.
FINDINGS:
Compared to prior study, there has been interval decrease in the gaseous
colonic dilatation. Air-filled loops of small and large bowel are again seen
with no evidence of obstruction. Residual contrast is noted in the rectum
where a rectal tube is seen. Severe scoliosis and lumbar spinal hardware is
again noted. Nasogastric tube tip terminates in the stomach.
IMPRESSION:
Interval improvement in colonic dilatation with continued gaseous containing
loops of colon.
Radiology Report
STUDY: Left upper extremity venous duplex.
REASON: Left arm swelling.
FINDINGS: Duplex was performed of the left upper extremity veins and limited
views of the right subclavian vein were obtained for comparison. Phasic flow
is seen in the subclavian veins bilaterally.
On the left, the jugular, subclavian, axillary, brachial, basilic and cephalic
veins were interrogated. There is thrombus seen in the cephalic vein at the
antecubital fossa. Otherwise, there is normal compression and augmentation
throughout.
IMPRESSION: No evidence of left upper extremity deep vein thrombosis. There
is superficial thrombosis in the cephalic vein at the antecubital fossa.
Radiology Report
INDICATION: History of new right-sided PICC line. Please evaluate location.
COMPARISONS: Chest radiographs dated back to ___.
TECHNIQUE: Single AP portable radiograph of the chest.
FINDINGS: There is a right-sided PICC line which terminates in the low SVC.
There is an enteric tube which terminates in the lower, distal esophagus. The
heart size is normal. The hilar and mediastinal contours are normal. There
is mild bibasilar atelectasis. Lungs are clear without evidence of focal
consolidations concerning for pneumonia. There is no pleural effusion or
pneumothorax. The visualized osseous structures are unremarkable. Left-sided
pacer device is in appropriate position with leads in the right atrium and
right ventricle.
IMPRESSION: Right-sided PIC line terminates in the mid to low SVC.
Findings were discussed with ___ by Dr. ___ by phone at 9:50 a.m. on
the day of the exam.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with severe constipation. Evaluate for interval
change.
TECHNIQUE: Portable abdominal radiograph
COMPARISON: ___
FINDINGS:
The nasogastric tube is in the air-filled stomach. The bowel gas pattern is
essentially unchanged from 1 day prior. A rectal tube is again seen in the
rectum where residual contrast is still present.
IMPRESSION:
No interval change from 1 day prior. Nasogastric and rectal tubes in standard
position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with severe constipation // ?NGT placement
COMPARISON: CHEST RADIOGRAPHS SINCE ___ MOST RECENTLY ___
THROUGH ___.
IMPRESSION:
3 IMAGES OF THE CHEST SHOW AN UPPER ENTERIC DRAINAGE TUBE ENDING IN THE UPPER
STOMACH THAT WOULD NEED TO BE ADVANCED 8 CM TO MOVE ALL THE SIDE PORTS BEYOND
THE GE JUNCTION. RIGHT PIC LINE ENDS IN THE LOW SVC, TRANSVENOUS
ATRIOVENTRICULAR PACER LEADS ARE CONTINUOUS FROM THE LEFT PECTORAL GENERATOR.
LUNGS ARE FULLY EXPANDED AND CLEAR. NO PNEUMOTHORAX OR PLEURAL EFFUSION.
NORMAL CARDIOMEDIASTINAL SILHOUETTE.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with severe constipation. Interval changes?
TECHNIQUE: Portable abdominal radiograph
COMPARISON: ___, 4, 6, and 7 ___.
FINDINGS:
Compared to the prior radiographs, the nasogastric tube is not confidently
visualized. This can be advanced if still present. The rectal tube is in an
unchanged position. The contrast that was in the rectum is now not visualized.
The air-filled loops of large bowel are essentially the same caliber. Compared
to the radiograph from ___, the caliber of the large bowel has decreased.
Stable appearance of lumbar hardware and scoliotic changes.
IMPRESSION:
Minimal interval change from ___ with continued air-filled loops of large
bowel. Compared to ___, the caliber of the large bowel has decreased. The
nasogastric tube is not clearly seen and should be advanced if still present.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with severe constipation s/p neostigmine // gas
vs. stool in bowel
TECHNIQUE: Portable abdomen
COMPARISON: ___.
FINDINGS:
Scoliosis and lumbar hardware again visualized. Bowel continues to be
gas-filled and dilated with transverse colon measuring up to 8.4 cm. This is
a supine film only and therefore assessment for free air is limited gas is
seen in the descending colon and rectum. The rectal tube is no longer
visualized.
IMPRESSION:
Ileus.
Radiology Report
INDICATION: Severe constipation. Evaluate for obstruction.
COMPARISON: Multiple abdominal radiographs dating back to ___, the
most recent on ___.
FINDINGS:
AP and left lateral decubitus views of the abdomen again demonstrate multiple
distended loops of small, grossly unchanged in caliber. Multiple air-fluid
levels are seen on left lateral decubitus views. There is no free air.
Scoliosis and lumbar hardware is unchanged.
IMPRESSION:
Air-fluid levels and unchanged distended bowel loops, consistent with ileus.
Radiology Report
INDICATION: Severe constipation. Evaluate for obstruction, ileus, interval
change.
COMPARISON: Multiple abdominal radiographs dating back to ___, the
most recent on ___.
FINDINGS:
2 abdominal radiographs again demonstrate multiple dilated loops of bowel,
which overall appear slightly decreased in caliber compared to abdominal
radiograph from 10 hours prior, but still measuring up to 5.5 cm. The
remainder the exam is unchanged, including scoliosis and lumbar spinal
hardware.
IMPRESSION:
Multiple dilated loops of bowel consistent with ileus, possibly minimally
decreased in caliber.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with severe constipation despite neostigmine and
aggressive bowel regimen // please evaluate fecal load, obstruction
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with intravenous and oral contrast . Sagittal and coronal reformats were
prepared.
DLP: 488.7 mGy-cm
COMPARISON: CT dated ___.
FINDINGS:
ABDOMEN:
The cecum, ascending colon and transverse colon are mildly distended and
contain fluid within them. The degree of distension is less than on the
previous CT. Similar to the previous CT, there is no fully-formed stool within
the colon. Multiple diverticula are noted within the sigmoid colon, without
evidence of diverticulitis. The distal descending colon, sigmoid colon are
decompressed. There is air within the rectum. No free air or fluid within the
abdomen or pelvis.
The small bowel is unremarkable. The liver is within normal limits. No focal
liver lesions. The portal and hepatic veins are patent. No intra or
extrahepatic duct dilatation. The gallbladder is unremarkable.
The main pancreatic duct is dilated measuring up to 6 mm in the body of the
pancreas (2:22). A lobulated cystic lesion is noted within the tail of the
pancreas that may represent a focal dilatation of the main duct or a separate
lesion. The pancreas is otherwise unremarkable. The spleen and adrenals are
within normal limits. The kidneys are unremarkable. No hydronephrosis.
No retroperitoneal or mesenteric adenopathy. The abdominal aorta is of normal
caliber. There is moderate calcified atheromatous plaque within the abdominal
aorta.
The lung bases are clear. Pacemaker wires are noted within the right side of
the heart. The visualized portion of the heart and pericardium is otherwise
unremarkable.
PELVIS:
There is a Foley catheter within the bladder. The bladder is otherwise
unremarkable. The prostate gland and seminal vesicles are unremarkable. No
pelvic adenopathy.
OSSEOUS STRUCTURES:
There is severe lumbar scoliosis convex to the left. Previous L2-L5 fusion
noted with intervertebral disc spacers identified at L2-3 L3-4 and L4-5. There
is an anterior wedge compression fracture at L1 with approximately 25% loss of
vertebral body height, unchanged since previous. There is a large bridging
osteophyte at the left sacroiliac joint. No concerning sclerotic or lytic
osseous lesions are identified within the abdomen or pelvis.
IMPRESSION:
1. The right side of the colon and the transverse colon is minimally distended
without evidence of a zone of transition. The degree of distention has
decreased since the previous study.
2. Lobulated cystic lesion within the tail of the pancreas measuring up to 1.1
cm that may represent either focal dilatation of the main duct or a separate
lesion. The main pancreatic duct is diffusely dilated. These findings have
progressed slightly since ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Constipation
Diagnosed with RETENTION URINE UNSPECIFIED, UNSPECIFIED CONSTIPATION
temperature: 98.2
heartrate: 101.0
resprate: 20.0
o2sat: 100.0
sbp: 147.0
dbp: 93.0
level of pain: 8
level of acuity: 2.0 | ___ yo M with h/o TKA and constipation for 14 days presents with
abdominal pain and distension.
# severe constipation: This is likely multifactorial including
pain meds after surgery and decreased ambulation after surgery.
Pt was initially managed conservatively with po laxatives
including senna, docusate, bisacodyl, miralax in addition to
enemas (lactulose, fleet, mineral oil, tap water) with minimal
response. He also received methylnaltrexone injections every
other day with minimal response. Ambulation was encouraged. Pt's
abd exam became concerning for peritneal signs but KUB
reassuring. Surgery as well as GI were consulted. Rectal tube
and NG tube were placed that helped with decompression but not
with stool output. As pt did not respond to this regimen, he was
transferred to ICU for neostigmine administration, which was
uneventful and resulted in one large bowel movement. Pt was
transferred back to the floor for further management. He further
developed ileus and KUB was concerning for dilated loops of
bowel with significant gas. Thus, CT A/P was repeated to assess
for amount of stool in bowel vs. gas. CT showed overall
improvement in bowel distention. Pt was started on moviprep in
addition to methylnaltrexone injection at this time, and this
resulted in significant stool output and resolution of symptoms
and pt was able to be discharged. For outpatient management, we
strongly recommend avoiding narcotics, encouraging ambulation,
fiber-rich diet, adequate hydration, and po and PR laxatives to
aim for at least every other day BM.
# left UE DVT (___) and left ___ DVT (at OSH s/p TKA): both
superficial. We continued prophylaxis dose of rivaroxiban.
# urinary retention: most likely secondary to constipation. Pt
was evaluated by ortho spine and thought cauda equina unlikely.
Foley was placed for symptom relief. Symptoms resolved by
discharge.
# Anemia: Hct on admission 31.7. It trended down to 21.___ut improved to 26.9 by discharge with no intervention. No
source of bleeding identified on CT A/P x3 during
hospitalization. Stool output from rectal tube was guaiac
positive and thus, pt was most likely bleeding from GI tract due
to severe constipation resulting in inflammation.
# recent TKA: pain controlled with tylenol. no e/o infection.
- cont. rivaroxaban as above at prophylaxis dose 10mg daily
# h/o HTN:
- continue aspirin 81 mg daily, statin, clonidine, and
lisinopril
# chronic pain:
- continue pregabalin
- continue desvenlafaxine
- amitriptyline was held for its contipation effects but to
prevent withdrawal symptoms, it was resumed at lower dose of
100mg daily (from 150mg daily) with plan for a slow taper over
___ weeks.
# h/o seizures:
- continue zonisamide and pregabalin
# h/o insomnia:
- continue clonazepam
TRANSITIONAL ISSUES
[] patient to be discharged with daily senna and colace and
instructed to increase to BID and add bisocodyl if constipated.
Aim for BM every other day
[ ] consider moviprep if continues to be constipated despite
bowel regimen
[ ] consider further downtitration of TCA
[ ] patient had leukopenia (2.9) and thrombocytosis thought to
be result of acute illness. Gave script for repeat CBC and diff
on ___ (results to be faxed to Dr. ___.
[ ] repeat CT abdomen showed lobulated cystic lesion within the
tail of the pancreas measuring up to 1.1 cm that may represent
either focal dilatation of the main duct or a separate lesion.
The main pancreatic duct is diffusely dilated, progressed
slightly since ___. Please consider MRCP if patient
reports abdominal pain.
[ ] discharged with outpatient ___ and ___ services
[ ] will follow up with ortho for R knee on ___. Length of
rivaroxaban ppx will be determined during the appointment
(usually 4 weeks post procedure, procedure done on ___
[ ] please taper amitriptyline slowly x2-3 weeks with goal to
discontinue this medication due to its constipation effects |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patinet is a ___ with h/o cocaine induced cardiomyopathy with
LVEF 10% (has been using recently), on warfarin for h/o CVA x3
from LV
apical thrombus (transient right hemiparesis, right facial droop
with vocal impairment, no residual deficits), frequent
admissions to ___ for CHF, presents with dypsnea and abdominal
pain, consistent with his prior episodes of CHF exacerbation.
He states that his current symptoms are similar to prior
episodes of CHF exacerbation (his CHF apparently always causes
abdominal pain). Regarding his dyspnea, he notes that he is able
to go ___ block before becoming dyspneic; this represents a
decline from his previously being able to walk ___ blocks
without DOE. He denies any SOB at rest, CP, or worseninig BLE
edema. He denies fever, diarrhea, black or bloody stools.
Of note, he was recently discharged from ___ in ___ for
cardiogenic shock with BNP in the 4500s and significant
abdominal pain concerning for abdominal ischemia, requiring
transfer to the CCU for dobutamine and IABP placement. RHC was
performed and he required Swan in place for tailored therapy. He
required diuresis with lasix gtt. At time of discharge, he
refused inotropic medication as outpatient. He was eventually
transitioned to torsemide 20 mg daily. Discharge weight was 82.3
kg. He was not started on a b-blocker due to concern that
previous treatment with carvedilol caused decompensated heart
failure complicated by cardiogenic shock. His course was
complicated by multiple runs of NSVT. EP recommended ICD
placement, but the patient and his family deferred and he was
discharged with a Life Vest instead.
Regarding his non-ischemic cardiomyopathy and LV apical thrombus
complicated by TIA, he has an LVEF of ___ per recent ECHO.
His cardiac cath in ___ showed no significant CAD and cardiac
MR during his last admission was also consistent with a
non-ischemic dilated cardiomyopathy, likely ___ cocaine-use. A
LV apical thrombus was detected on echo in ___ though it was
not seen on repeat ECHO in ___. He has had TIAs x 3 with
resultant R hemiparesis and speech impairment. He is followed by
___.
He was recently seen in ___ clinic with Dr. ___. He was
actually started on metoprolol succinate 12.5 mg and lisinopril
10 mg daily for which he appeared to be stable.
In the ED, initial vitals were 97.3 62 130/87 18 96% on RA.
Initial labs showed Cr 1.9 (baseline Cr _____), K 4.9, lactate
3.6 (at this time his BPs were in the ___. ALT 153, AST
136, AP 81, Tbili 1.0. WBC 10.9, H/H stable, INR 1.7. ___
12058, trop-t 0.04, dig 0.7. Serum tox was negative. Utox was
positive for cocaine. He was diuresed with 80 IV Lasix x 1 at
~11am to which he put out at least 1L UOP. He was placed on
dobutamine 2.5 mg briefly but his lactate shortly normalized
with improvement of his systolic BPs to the 100s. However,
repeat lactate increased to 2.1 and he was placed back on
dobutamine in the ED prior to transfer.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Hyperlipidemia
Cocaine use (quit ___
GERD
Social History:
___
Family History:
Brother with schizophrenia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 102 101/70 20 99% RA
Gen: Tired appearing, lethargic male resting in bed, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, JVP to mandible, brisk carotid upstroke
CV: tachycardic, regular, ___ systolic ejection murmur
LUNGS: Clear to auscultation, No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP, no pitting edema. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Preserved sensation throughout. MAE Normal
coordination. Gait assessment deferred
DISCHARGE PHYSICAL EXAM:
Gen: Resting in bed, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, JVP t12-15cm
CV: tachycardic, regular, ___ systolic ejection murmur
LUNGS: Clear to auscultation, No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP, no pitting edema. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
ADMISSION LABS:
___ 05:15AM BLOOD WBC-10.9*# RBC-4.91 Hgb-14.2 Hct-43.6
MCV-89 MCH-28.9 MCHC-32.6 RDW-18.1* RDWSD-57.0* Plt ___
___ 05:15AM BLOOD Neuts-76.5* Lymphs-15.2* Monos-7.4
Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.34* AbsLymp-1.66
AbsMono-0.81* AbsEos-0.01* AbsBaso-0.04
___ 05:15AM BLOOD ___ PTT-27.3 ___
___ 05:15AM BLOOD Plt ___
___ 04:10PM BLOOD ___ PTT-126.1* ___
___ 10:10AM BLOOD Plt ___
___ 05:15AM BLOOD Glucose-77 UreaN-36* Creat-1.9* Na-135
K-5.3* Cl-99 HCO3-18* AnGap-23*
___ 10:10AM BLOOD Glucose-72 UreaN-33* Creat-1.7* Na-135
K-4.6 Cl-99 HCO3-22 AnGap-19
___ 06:10PM BLOOD Glucose-97 UreaN-29* Creat-1.4* Na-134
K-3.8 Cl-98 HCO3-23 AnGap-17
___ 10:10AM BLOOD ALT-153* AST-136* AlkPhos-81 TotBili-1.0
___ 10:10AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.1
___ 06:10PM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9
___ 05:29AM BLOOD Lactate-3.6* K-4.9
___ 05:15AM BLOOD cTropnT-0.04* ___
DISCHARGE LABS:
___ 09:02AM BLOOD WBC-6.6 RBC-4.75 Hgb-13.5* Hct-42.3
MCV-89 MCH-28.4 MCHC-31.9* RDW-17.9* RDWSD-57.6* Plt ___
___ 06:16AM BLOOD Neuts-65.2 ___ Monos-7.5 Eos-1.8
Baso-0.7 Im ___ AbsNeut-5.48 AbsLymp-2.03 AbsMono-0.63
AbsEos-0.15 AbsBaso-0.06
___ 09:02AM BLOOD Plt ___
___ 09:02AM BLOOD ___ PTT-82.7* ___
___ 09:02AM BLOOD Glucose-110* UreaN-36* Creat-1.4* Na-134
K-4.8 Cl-98 HCO3-28 AnGap-13
___ 06:32AM BLOOD ALT-120* AST-61* AlkPhos-94 TotBili-0.4
PERTINENT IMAGING:
___ CXR PA/LAT:
INDICATION: Evaluate for cardiomegaly in a patient with CHF and
dyspnea on
exertion.
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs again demonstrate a
severely enlarged
heart, similar in appearance compared to ___. The lungs
are well
aerated, without focal consolidation, pleural effusion, or
pneumothorax.
There is no vascular congestion or pulmonary edema. The
visualized upper
abdomen is unremarkable.
IMPRESSION:
Unchanged severe cardiomegaly. No acute cardiopulmonary
process.
MICRO:
Blood cultures pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 20 mg PO DAILY
2. Warfarin 7 mg PO DAILY16
3. Digoxin 0.25 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
6. HydrALAzine 50 mg PO Q8H
7. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Ranitidine 150 mg PO DAILY
11. Simvastatin 10 mg PO QPM
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Digoxin 0.25 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 90 mg subcutaneous every twelve (12)
hours Disp #*14 Syringe Refills:*0
5. HydrALAzine 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*120 Tablet Refills:*0
6. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Ranitidine 150 mg PO DAILY
10. Torsemide 20 mg PO DAILY
11. Warfarin 7 mg PO DAILY16
12. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Cardiogenic shock
- Acute decompensated systolic heart failure
- Acute kidney injury
SECONDARY DIAGNOSES:
- Left ventricular apical thrombus
- Substance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluate for cardiomegaly in a patient with CHF and dyspnea on
exertion.
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs again demonstrate a severely enlarged
heart, similar in appearance compared to ___. The lungs are well
aerated, without focal consolidation, pleural effusion, or pneumothorax.
There is no vascular congestion or pulmonary edema. The visualized upper
abdomen is unremarkable.
IMPRESSION:
Unchanged severe cardiomegaly. No acute cardiopulmonary process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, ABDOMINAL PAIN GENERALIZED, PRIM CARDIOMYOPATHY NEC
temperature: 97.3
heartrate: 62.0
resprate: 18.0
o2sat: 96.0
sbp: 130.0
dbp: 87.0
level of pain: 8
level of acuity: 3.0 | ___ with h/o cocaine induced cardiomyopathy w/ LVEF 10% (has
been using recently), LV apical thrombus with h/o CVA x3 (on
warfarin), and frequent admissions for CHF, presented with
dyspnea and abdominal pain consistent with his prior CHF
exacerbations. The patient reported he has not been compliant
with his medications and has been drinking alcohol/using cocaine
recently. He presented with signs c/w cardiogenic shock,
including elevated lactate, ___, and transaminitis. He was
started on dobutamine and was aggressively diuresed. His course
was complicated by asymptomatic VT, likely ___ dobutamine, which
resolved on its own and the dobutamine was stopped. He was
restarted on all of his home medications except the metoprolol.
In addition, his INR was low. He was re-started on lovenox BID
and continued on his home dose coumadin with plans to follow-up
with the ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin / Statins-Hmg-Coa Reductase Inhibitors /
Glimepiride / Zetia / Flagyl / Colestipol / Penicillins / Ace
Inhibitors / Benzonatate / Plavix / Bactrim
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Cardiac catheterization with drug eluting ___ to
the left anterior descending coronary artery, very late in ___
thrombosis.
___- repeat cardiac cath performed due to recurrent chest
pain; showed clean coronaries
History of Present Illness:
Ms. ___ is a ___ with a history of DMII, HLD, HTN, recurrent
rhabdomyolysis and CAD with previous ___ placement (DES to
mid-LAD in ___, then DES to mid-LAD and mid-Lcx in ___
for NSTEMI s/p DES x2 to the RCA and POBA to the LCx) who
presented to the ED with complaints of burning, central chest
pain radiating to the neck. The pain was not tearing/ripping and
did not radiate to the back. Ms. ___ reports that she first
experienced the pain after eating a sandwich at 1:30 pm on
___. The pain started gradually but began to worsen and she
took a sublingual nitroglycerin 10 minutes after the onset of
her pain without effect. She called her son, who arrived within
20 minutes to take her to the ED. She took a second
nitroglycerin during this time period also without effect. By
the time she reached the ED, pain was an ___.
Of note, Ms. ___ takes an aspirin 325 daily and took one on
the morning of presentation. She was on ticagrelor for
anticoagulation (1 tablet bid) but in ___ began to experience
nosebleeds. She was in ___ at the time and saw a
cardiologist there who recommended that she downtitrate her
ticagrelor to 1 tablet daily three times weekly. She continued
this regimen until 5 days prior to presentation, when she
stopped the medication completely.
Upon arrival in the ED, VS: T 98.0 HR 64 BP 135/60 RR 18 98% ra.
EKG was concerning for STEMI. A code STEMI was called and
triggered to room 6, attending/resident in room. Cardiology
consulted. Pt placed on 4L via NC, pt took nitro x2 at home
without effect/3rd dose given sublingual per MD, 5000u heparin
bolus given, 50mcg fentanyl given ___ no effect w/ nitro. Labs
sent, per cardiology, pt to be brought directly to cath lab.
Consented en-route. Arrived to cath lab/report given. Pt
stable/VSS. No acute distress. SBP 150s, HR ___. Reports ___
from ___ pain s/p medications. Pain left center radiating to
left neck. MDs/RNs in cath lab notified of Plavix
allergy/morphine intolerance. Pt on table in cath lab by ___
and received an export thrombectomy followed by drug-eluting
___ of LAD. R radial initially used and then converted to a R
groin approach (TR band and angioseal placed respectively). She
was transferred to the CCU in stable condition.
Upon interview on the floor, VS: T 98, HR 57, BP 119/53, HR 68,
RR 17, SpO2 95% on ra. The patient was in no acute distress and
only complained of a waxing and waning headache and mild throat
pain. No chest pain or shortness of breath.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: NONE
- PERCUTANEOUS CORONARY INTERVENTIONS: per below.
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- CAD s/p DES to mid-LAD in ___, then DES to mid-LAD and
mid-Lcx in ___ for NSTEMI s/p DES x2 to the RCA and
POBA to the LCx
- HLD (not on a statin ___ rhabdo) - LDL 188, HDL 49, ___ ___
- DMII (A1c ___
- HTN
- Recurrent Rhabdomyolysis ___ statins, glimepiride
- Non-alcoholic fatty liver disease
Social History:
___
Family History:
Mother, son, and siblings all have DM, brother has HLD. No h/o
CAD, rhabdomyolysis or cancer. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION EXAM
VS: T 98, HR 57, BP 119/53, HR 68, RR 17, SpO2 95% on ra
General: An ___ woman lying flat in bed in no
acute distress.
HEENT: Normalocephalic, atraumatic, MMM
Neck: Supple, no JVD
CV: RRR, no M/G/R, normal S1/S2
Lungs: CTAB, no wheezes/crackles/rhonchi
Abdomen: Somewhat distended but soft and nontender. Organomegaly
difficult to assess given body habitus.
GU: No foley
Ext: 1+ radial pulses, DP pulses difficult to palpate. R radial
and R groin access sites clean and dry.
Neuro: A&O x 3, ___ strength in the upper and lower extremities,
PERRLA, CN II-XII intact.
Skin: No rashes or lesions
Discharge physical:
VS: T 98.8, BP 123/61, HR 58, RR 18, SpO2 100 ra
General: sitting comfortably in chair, no acute distress.
HEENT: supple, no JVD
CV: RRR, no M/R/G noted,
Resp: CTAB, mildly dec at bases
ABD: soft, obese
Extr: Left and right groin with no ecchymosis or hematoma.
Neuro: A&O x 3, affect somewhat flat.
Pertinent Results:
ADMISSION LABS
___ 02:10PM BLOOD WBC-7.3 RBC-4.09* Hgb-11.5* Hct-36.1
MCV-88 MCH-28.0 MCHC-31.7 RDW-13.5 Plt ___
___ 02:10PM BLOOD Neuts-54.5 ___ Monos-8.1 Eos-4.5*
Baso-0.5
___ 02:10PM BLOOD ___ PTT-32.0 ___
___ 02:10PM BLOOD Glucose-217* UreaN-19 Creat-1.0 Na-138
K-4.6 Cl-102 HCO3-24 AnGap-17
___ 02:10PM BLOOD ALT-43* AST-35 AlkPhos-72 TotBili-0.2
___ 09:54PM BLOOD CK-MB-120* MB Indx-3.2
___ 04:39PM BLOOD CK-MB-108* MB Indx-2.8 cTropnT-6.13*
___ 02:10PM BLOOD cTropnT-<0.01
___ 02:10PM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.6* Mg-1.3*
___ 02:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:21PM BLOOD Lactate-2.9*
DISCHARGE LABS
___ 05:45AM BLOOD WBC-5.4 RBC-3.12* Hgb-8.8* Hct-26.4*
MCV-85 MCH-28.2 MCHC-33.3 RDW-13.3 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-181* UreaN-17 Creat-1.1 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
___ 05:45AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9
MICROBIOLOGY:
___ 2:38 am URINE Source: ___.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=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
___ CXR
FINDINGS: In comparison with the study of ___, there is
little change.
With better inspiration, the areas of suspected opacification in
the left
perihilar and lower lung are less pronounced and could merely
reflect some
atelectatic change.
___
Sinus rhythm. Right bundle-branch block. Left axis deviation
with left
anterior fascicular block. Borderline low voltage. Possible old
anterior wall
myocardial infarction. Compared to the previous tracing of
___ there are
no significant changes noted.
CXR (___):
AP radiograph of the chest was reviewed with comparison to
___.
Heart size is normal. Lungs are essentially clear. Prominence
of the
pulmonary artery is noted and concerning for pulmonary
hypertension. No
appreciable pleural effusion is seen.
In the left lower lung, there is questionable opacity that might
reflect
interval development of infectious process. In addition, there
is also left
perihilar opacity that is also new and might reflect infectious
process as
well. Followup of the patient four weeks after completion of
antibiotic
therapy is recommended for documentation of resolution.
CARDIAC CATHETERIZATIONS
___ Echo
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypo to akinesis of
the mid-distal anterior septum, distal anterior wall and apex.
The remaining segments contract normally (LVEF = 45%). A left
ventricular mass/thrombus cannot be excluded. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
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 a very
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Compared with the prior study (images reviewed) of ___,
left ventricular regional systolic dysfunction is new and
suggestive of CAD (LAD territory). There is now a very small
pericardial effusion. Other findings are similar.
___: Cardiac cath
FINAL DIAGNOSIS:
1. Single vessel CAD with widely patent ___ placed in
Proximal LAD.
2. Mild to modertae LV systolic dysfunction, LV EF 40% with
regional
wall motion abnormalities.
3. Moderately elevated LVEDP.
4. Continue with dual antiplatelet therapy.
___:
Coronary angiography: right dominant
LAD: 100% mid thrombotic occlusion at proximal ___ border
inserted on ___
LCX: patent POBA site distally
RCA: 30% proximal, patent stents
Interventional details
Change for ___ XB3.5 guide via right femoral artery after unable
to seat guide from right radial artery.Export thrombectomy
followed by drug-eluting ___ of LAD with 2.5 by 12 Promus and
postdilated new ___ and first ___ of old stented area with
2.75
mm balloon with good result.Initial TIMI flow 0 and final TIMI
flow 3 with 0% residual. Angiomax used. Angioseal right
femoral
artery.
Assessment & Recommendations
1. Ticagrelor and ASA 81 mg daily indefinitely.
2. CCU for continued care of anterior STEMI secondary to very
late LAD ___ thrombosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Glargine 60 Units Breakfast
4. irbesartan 300 mg oral Daily
5. MetFORMIN (Glucophage) 1000 mg PO QPM
6. TiCAGRELOR 90 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. omega 3-dha-epa-fish oil 350-235-90-640 mg oral daily
9. Aspirin 325 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Outpatient Lab Work
Please check chem-7 and INR on ___ at ___
___ in the morning.
ICD-9:
___ at ___, RN and ___
anticoagulation clinc, please call with any questions or
concerns. She will contact you on ___ to follow up with the
blood test results.
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*2
4. Glargine 60 Units Breakfast
5. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. Vitamin D 1000 UNIT PO DAILY
7. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
8. irbesartan 300 mg oral Daily
9. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
10. MetFORMIN (Glucophage) 1000 mg PO QPM
11. omega 3-dha-epa-fish oil 350-235-90-640 mg oral daily
12. Ciprofloxacin HCl 500 mg PO Q12H Catheter-associated Urinary
Tract Infection Duration: 14 Days
Day 1 = ___ please continue until ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*22 Tablet Refills:*0
13. Atenolol 37.5 mg PO DAILY
RX *atenolol 25 mg 1.5 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
14. MetFORMIN (Glucophage) 500 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
#STEMI ___ thrombosis)
Chronic issues: DMII, HTN, HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Cough and low-grade fever.
AP radiograph of the chest was reviewed with comparison to ___.
Heart size is normal. Lungs are essentially clear. Prominence of the
pulmonary artery is noted and concerning for pulmonary hypertension. No
appreciable pleural effusion is seen.
In the left lower lung, there is questionable opacity that might reflect
interval development of infectious process. In addition, there is also left
perihilar opacity that is also new and might reflect infectious process as
well. Followup of the patient four weeks after completion of antibiotic
therapy is recommended for documentation of resolution.
Radiology Report
HISTORY: MI with possible consolidation on previous chest x-ray without the
clinical signs.
FINDINGS: In comparison with the study of ___, there is little change.
With better inspiration, the areas of suspected opacification in the left
perihilar and lower lung are less pronounced and could merely reflect some
atelectatic change.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: Chest pain
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 98.0
heartrate: 64.0
resprate: 18.0
o2sat: 98.0
sbp: 135.0
dbp: 60.0
level of pain: 9
level of acuity: 2.0 | Ms. ___ is a ___ y/o female w/ PMH CAD s/p DES to LAD ___
and ___ and LCx (___), rhabdomyolysis ___ statins,
glimepiride, and plavix, s/p NSTEMI s/p DES x2 to the RCA and
POBA to the LCx (___) p/w chest pain radiating to jaw found
to have STEMI ___ to instent restenosis of LAD, now s/p DES to
LAD.
ACTIVE ISSUES
# Chest pain: Chest pain after catheterization on ___ was
consistent with prior MI pain and accompanied by tachypnea. VS
all remained stable (HR ___ BP 130s-150/50s-60s; SPO2 96+ on
RA). Repeated EKG showed some increase in STE in V2-V4, t wave
inversions in V1-V4, and new Q in V2. Largest concern would be
for acute ___ rethrombosis, however, pain improved with
nitro, EKG changes not dramatic, and pt. remained
hemodynamically stable. Given persistent EKG changes and
persistent low grade pain, the pt returned to ___ lab for
reimaging; her coronaries were clean. She completed her
integrelin course. She subsequently had some episodes of "gas
pains", describing some intermittent RUQ pain and R lateral
chest pain; EKG during one such episode was unchanged.
# Acute Coronary Syndrome (STEMI): Patient with significant
history of CAD, diabetes, hypertension and hyperlipidemia with
chest pain radiating to the jaw. On ___ pt. found to have ST
elevations in anterolateral leads consistent with LAD territory.
Cathetrization revealed 100% mid thrombotic occlusion at
proximal ___ border and received an export thrombectomy
followed by drug-eluting ___ of LAD. Patient received
ticagrelor 180 @ 233pm prior to hitting floor. Given large
infarct there is concern for apical dykinesia or akinesis and
risk for LV thrombus. Continued ticagrelor and added Coumadin
for triple anticoagulation therapy. Will need to continue
coumadin for 3 months and will also need a f/u echo in 1 month.
Continued home medications including aspirin and
atenolol/amlodipine/losartan (ibesartan not on formulary).
# Anemia - Hct trend was noted to slowly trend down over the
course of hospitalization. Some oozing was noted at groin sites
immediately post-cath, but resolved spontaneously without
evidence of ongoing bleeding or hematoma. Stool guaiac was
negative on ___. Likely releated to daily phlebotomy, but
given she is on ASA, ticagrelor, and Coumadin, will need close
monitoring. To have CBC repeated within 1 week of discharge.
CHRONIC ISSUES
# DM2: Held metformin and maintained on Lantus QAM and ISS.
# HTN: Continue beta blocker, CCB, and ___.
# HLD: LDL 180, HDL 41. Cannot start Statin and has not
tolerated other agents. Continued home omega 3 fatty acids. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Atrial fibrillation/flutter with rapid ventricular response
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of atrial fibrillation, IVDU, and
recent prolonged admission for multiple CVA (see below) who
presents with Afib with RVR. Patient discharged from Neurology
on ___. Upon arrival to rehab, found to be in Afib with RVR
with HR. Given diltiazem 90mg PO without improvement.
The patient was admitted at ___ from ___ for multiple
embolic CVA. Briefly, the patient presented to OSH with
hypertensive emergency resulting in pulmonary edema requiring
intubation. CT head and MRI revealed multiple acute infarcts.
The patient was transferred to ___ Neurology. Infarcts were
felt to be cardioembolic as patient has been noncompliant with
anticoagulation. Patient did not receive tPA due to risk of
hemorrhagic cardioversion. Blood cultures returned positive with
Strep anginosus, therefore endocarditis was considered. TTE was
negative for vegetation. Patient was started on ceftriaxone for
6 week course which should be completed on ___. Hospital
course was also complicated by inferior STEMI, Afib with RVR,
dysphagia requiring PEG placement, and PICC line infection.
Patient did not undergo cardiac catheterization for STEMI given
contraindication for heparinization. In terms of Afib/flutter he
had difficult to control rates requiring high dose diltiazem and
metoprolol with intermittent IV pushes. Cardiology felt TEE and
cardioversion was too risky and planned for cardioversion ___
weeks after anticoagulation. They also felt as long as he was
not having chest pain or shortness of breath, they would
tolerate HR 150-160s. Prior to discharge, the patient converted
to sinus rhythm. Therefore, amiodarone was started. PICC line
blood culture grew staph epidermis and enterococcus faecalis.
PICC line changed and patient started on vancomycin (end date
___.
In the ED initial vitals were: 97.9 107 130/95 14 98% RA.
- Labs were notable for H/H 12.2/37.7, INR 1.5, Na 132, Cr 0.5,
troponin 0.31, digoxin 0.2.
- EKG: Afib with ST depression in I, aVL, V4-V5.
- CXR: Moderate cardiomegaly.
- CTA CHEST: No evidence of pulmonary embolism.
- Patient was given diltiazem 15mg IV x 1 and 30mg POx 1,
amiodarone 400mg, metoprolol 50mg, apixaban, and
vanc/ceftriaxone.
- Patient continued to be tachycardic to 120s so was started on
a diltiazem gtt.
- Cardiology: hyper-excitable AV node.
On the floor, patient unable to communicate though coughing.
Past Medical History:
Diabetes
Hypertension
Hyperlipidemia
Atrial fibrillation
Diastolic heart failure
Non-ischemic cardiomyopathy
Substance abuse (heroin, cocaine)
___ syndrome
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Physical Exam:
========================
VS: 98.6 133/94 137 20 96RA
GENERAL: Unable to communicate. Follows some commands (ex
squeeze fingers).
HEENT: NCAT. Sclera anicteric. Oropharynx clear.
NECK: Supple, JVP not elevated.
CARDIAC: Clear to auscultation anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm and well perfused. Pulses 2+. No edema.
Discharge Physical Exam:
========================
VS:Tm 97.9, BP 128/76%, HR 56(56-67) R20 100%2L
I/O: 8h - 310/none recorded; 24h - 1260/1000
Wt: NR
tele- normal sinus rhythm; alarmed for PVCs
GENERAL: NAD. Opens eyes when spoken to, looking around room.
HEENT: NCAT. PERRL.
NECK: No JVP elevation appreciated.
CARDIAC: Regular heart rate. No murmurs.
LUNGS: Clear to auscultation on anterior exam.
ABDOMEN: Soft, +BS, nontender to palpation. Feeding tube in
place. EXTREMITIES: No pedal edema. DP pulses present. R arm
with picc line in place c/d/i
SKIN: No stasis dermatitis, ulcers, scars. R axilla with
hyperpigmented plaque in armpit with peripheral scale.
NEURO: Squeezes hand on command. ___ strength
in LUE and bilateral ___.
GU: foley catheter draining dark yellow fluid
Pertinent Results:
Admission Labs:
===============
___ 07:00AM BLOOD WBC-7.0 RBC-4.14* Hgb-12.3* Hct-37.8*
MCV-91 MCH-29.7 MCHC-32.5 RDW-13.1 RDWSD-42.9 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-202* UreaN-11 Creat-0.5 Na-133
K-4.5 Cl-93* HCO3-26 AnGap-19
___ 03:00AM BLOOD cTropnT-0.31*
___ 07:00AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.7
Microbiology:
=============
___ 2:33 pm URINE Source: Catheter.
**FINAL REPORT ___ URINE CULTURE (Final ___: NO
GROWTH.
___ 3:00 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___ Blood Culture, Routine (Final
___: NO GROWTH.
___ 3:52 pm BLOOD CULTURE
**FINAL REPORT ___ Blood Culture, Routine (Final
___: NO GROWTH.
___ 6:49 pm URINE Source: Catheter.
**FINAL REPORT ___ URINE CULTURE (Final ___: NO
GROWTH.
___ 6:49 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___ Blood Culture, Routine (Final
___: NO GROWTH
___ 6:13 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
Imaging:
========
___ CTA Chest
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
___ CXR
IMPRESSION:
1. Moderate cardiomegaly, unchanged.
2. No focal opacity to suggest a site of aspiration pneumonitis
identified.
No frank consolidation or gross effusion.
3. Doubt but cannot entirely exclude a tiny right apical
pneumothorax.
Clinical correlation and attention to this area on followup
films is
requested.
4. PICC line traverses the right atrium and the PICC line tip
overlies the
lower portion of the right atrium. If clinically indicated,
retraction by
approximately 5-6 cm could help to position this near the
cavoatrial junction.
___ TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction with near
akinesis of the inferior septum, inferior, and inferolateral
walls. The apex is mildly dyskinetic. The remaining walls are
mildly hypokinetic. Quantitative (3D) LVEF = 12%. No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Left ventricular cavity dilation with extensive
regional systolic dysfunction most c/w CAD (large PDA
distribution). Increased PCWP. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
estimated PA systolic pressure is now lower and global left
ventricular systolic function is now lower (previously
overestimated and likely ~30%). The rhythm is now atrial
fibrillation.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor ___
___ CXR
IMPRESSION:
In comparison with the study of ___, the right subclavian
PICC line is not well seen past the upper to mid SVC. Continued
low lung volumes without evidence of acute pneumonia or vascular
congestion.
___ CXR
Mild to moderate cardiomegaly is chronic, improved since
___, stable since ___. Lungs lung volume but
clear. There is no pulmonary edema or vascular engorgement or
obvious pleural effusion. Right PIC line ends in the low SVC.
No pneumothorax.
___ CXR
Lung volumes are unchanged compared to the prior study. A
right-sided PICC terminates in the mid to distal SVC. Mild to
moderate cardiomegaly is stable compared to the prior study. No
pulmonary vascular congestion pulmonary edema. No
consolidation, pneumothorax or pleural effusion seen.
IMPRESSION: No acute cardiopulmonary process seen. Moderate
cardiomegaly is unchanged.
___ CXR
IMPRESSION: In comparison with the study of ___, there
is again enlargement of the cardiac silhouette, but no evidence
of vascular congestion, pleural effusion, or acute focal
pneumonia. The tip of the right subclavian PICC line is
somewhat difficult to see, though it appears to be in the distal
SVC.
EKGs:
====
ECG Study Date of ___ 11:27:54 AM
Atrial flutter with 2:1 block. Compared to tracing #3 consistent
2:1 block is seen throughout the tracing with a faster
ventricular response.
TRACING #4
R137 QRS102 QT308 QTc442
ECG Study Date of ___ 3:13:41 AM
Again likely atrial flutter with variable block, mostly 2:1.
Compared to
tracing #2 ventricular response is faster. Other findings are
similar.
TRACING #3
R124 PR134 QRS102 QT367 QTc___
ECG Study Date of ___ 5:36:58 ___
Atrial flutter with variable block. Marked lateral ST-T wave
changes most
likely due to underlying left ventricular hypertrophy. Inferior
myocardial
infarction, age undetermined. Compared to the previous tracing
of ___
no diagnostic change.
___ QRS106 QT370 QTc457
ECG Study Date of ___ 6:18:32 AM
Baseline artifact. Consider atrial flutter with variable block.
Left axis
deviation. RSR' pattern in leads V1-V2. Q waves in leads II, III
and aVF.
Consider inferior wall myocardial infarction, age undetermined
in the presence of ST segment elevation in particularly leads
III and aVF as well as ST segment depression in leads I and aVL.
Other ST-T wave abnormalities. Compared to the previous tracing
of ___ the ventricular rate is now slower.
P92 QRS106 QT396 QTc452
Discharge Labs:
===============
___ 08:44AM BLOOD WBC-6.6 RBC-3.79* Hgb-11.6* Hct-35.6*
MCV-94 MCH-30.6 MCHC-32.6 RDW-14.1 RDWSD-47.0* Plt ___
___ 08:44AM BLOOD Glucose-125* UreaN-20 Creat-0.6 Na-132*
K-4.9 Cl-97 HCO3-25 AnGap-15
___ 08:44AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 20 mg PO DAILY
2. Apixaban 5 mg PO BID
3. CeftriaXONE 2 gm IV Q24H
4. Vancomycin 1000 mg IV Q 8H
5. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
6. Atorvastatin 80 mg PO QPM
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. Famotidine 20 mg PO BID
9. Metoprolol Tartrate 50 mg PO Q6H
10. Diltiazem 90 mg PO Q6H
11. Amiodarone 400 mg PO BID
12. Lisinopril 2.5 mg PO DAILY
13. Glargine 28 Units Bedtime
Discharge Medications:
1. Amiodarone 200 mg PO BID Duration: 3 Weeks
2. Atorvastatin 80 mg PO QPM
3. CeftriaXONE 2 gm IV Q24H
4. Famotidine 20 mg PO BID
5. Fluoxetine 20 mg PO DAILY
6. Glargine 28 Units Bedtime
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. Metoprolol Tartrate 50 mg PO Q6H
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
10. Spironolactone 25 mg PO DAILY
11. Valsartan 40 mg PO DAILY
12. Apixaban 5 mg PO BID
13. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation
Diabetes
Hypertension
Hyperlipidemia
Congestive heart failure
Cerebrovascular infarcts
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Intermittently interactive in ___ and
___.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ male with prior cerebellar infarcts, now presenting
for evaluation of tachycardia
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:
Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
5) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3
mGy-cm.
6) Spiral Acquisition 3.2 s, 25.1 cm; CTDIvol = 13.7 mGy (Body) DLP = 344.6
mGy-cm.
Total DLP (Body) = 348 mGy-cm.
COMPARISON: Chest CTA ___
FINDINGS:
The visualized portion of the thyroid gland enhances homogeneously.
There are a few sub-cm mediastinal lymph nodes, measuring up to 8 mm in short
axis in the pretracheal station (02:29). No axillary, supraclavicular,
mediastinal or hilar lymphadenopathy by CT size criteria.
The heart size is top normal, without pericardial effusion. Thoracic aorta is
normal in course and caliber, without aneurysmal dilation. Main pulmonary
artery is normal in caliber. The pulmonary arterial branches are well
opacified, without evidence of pulmonary embolism to the proximal subsegmental
levels. Distal subsegmental levels are difficult to evaluate due to
respiratory motion.
Airways are patent to the subsegmental levels. There is minimal bibasilar
dependent atelectasis. No pleural effusions. No concerning nodular opacities
are identified.
Evaluation of the osseous structures demonstrates no suspicious lytic or
sclerotic lesions that are concerning for malignancy. No acute fracture.
Chest wall is unremarkable.
Limited images of the upper abdomen demonstrate no gross abnormalities.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ year old male with history of atrial
fibrillation, IVDU, and recent prolonged admission for multiple CVA (see
below) who presents with Afib with RVR. Patient discharged from Neurology on
___. Upon arrival to rehab, found to be in Afib with RVR with HR. // ?
aspiration pna
COMPARISON: Chest x-ray from ___. Targeted review of chest CT
from ___.
FINDINGS:
Inspiratory volumes are slightly low, but not substantially changed compared
with the prior chest x-ray.
Again seen is moderate cardiomegaly, similar to the prior study. Also again
seen is upper zone redistribution without overt CHF. No focal opacity to
suggest a site of aspiration is identified. Minimal atelectasis in the right
cardiophrenic region is similar to the prior study. Trace blunting of the
right cardiophrenic angle is unchanged. No gross effusion detected on either
side.
A right PICC line is again noted. On the current study, the PICC line tip
overlies the right atrium No in keeping with findings on the ___
chest CT.
A tiny curvilinear density at the right lung apex raises the unlikely
possibility of a tiny right apical pneumothorax. Alternatively, this could be
artifact due to overlying densities.
IMPRESSION:
1. Moderate cardiomegaly, unchanged.
2. No focal opacity to suggest a site of aspiration pneumonitis identified.
No frank consolidation or gross effusion.
3. Doubt but cannot entirely exclude a tiny right apical pneumothorax.
Clinical correlation and attention to this area on followup films is
requested.
4. PICC line traverses the right atrium and the PICC line tip overlies the
lower portion of the right atrium. If clinically indicated, retraction by
approximately 5-6 cm could help to position this near the cavoatrial junction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male with history of Afib on apixaban, IVDU, and
recent prolonged admission for multiple CVA infarcts s/p PEG, complicated by
inferior STEMI s/p medical management, presumed endocarditis d/t Strep
anginosus, and difficult to control Afib/flutter who presents with Afib with
RVR, HR improving now with echo showing newly depressed EF. // please eval
for infection please eval for infection
IMPRESSION:
In comparison with the study of ___, the right subclavian PICC line is
not well seen past the upper to mid SVC. Continued low lung volumes without
evidence of acute pneumonia or vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with history of atrial fibrillation, IVDU, and
recent prolonged admission for multiple CVA who presents with Afib with RVR.
Getting tube feeds and started coughing, c/f aspiration pna. // please assess
for aspiration pna versus pneumonitis please assess for aspiration pna
versus pneumonitis
COMPARISON: Prior chest radiographs ___ through ___.
IMPRESSION:
Mild to moderate cardiomegaly is chronic, improved since ___, stable
since ___. Lungs lung volume but clear. There is no pulmonary edema
or vascular engorgement or obvious pleural effusion. Right PIC line ends in
the low SVC. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male with history of Afib on apixaban, IVDU, and
recent prolonged admission for multiple CVA infarcts s/p PEG, complicated by
inferior STEMI s/p medical management, presumed endocarditis d/t Strep
anginosus, and difficult to control Afib/flutter who presents with Afib with
RVR, HR improving and now in sinus rhythm with echo showing newly depressed
EF. Coughing, desatted to high ___, c/f aspiration // please assess for
aspiration
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are unchanged compared to the prior study. A right-sided PICC
terminates in the mid to distal SVC. Mild to moderate cardiomegaly is stable
compared to the prior study. No pulmonary vascular congestion pulmonary
edema. No consolidation, pneumothorax or pleural effusion seen.
IMPRESSION:
No acute cardiopulmonary process seen. Moderate cardiomegaly is unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male with history of Afib on apixaban, IVDU, and
recent prolonged admission for multiple CVA infarcts s/p PEG, complicated by
inferior STEMI s/p medical management, presumed endocarditis d/t Strep
anginosus, and difficult to control Afib/flutter who presents with Afib with
RVR, with cough and new O2 requirement // new O2 requirement new O2
requirement
IMPRESSION:
In comparison with the study of ___, there is again enlargement of the
cardiac silhouette, but no evidence of vascular congestion, pleural effusion,
or acute focal pneumonia. The tip of the right subclavian PICC line is
somewhat difficult to see, though it appears to be in the distal SVC.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Unspecified atrial fibrillation, Palpitations
temperature: 97.9
heartrate: 107.0
resprate: 14.0
o2sat: 98.0
sbp: 130.0
dbp: 95.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
========
___ year old male with history of atrial fibrillation on
apixaban, IVDU, and recent prolonged admission for multiple CVA
infarcts s/p PEG, complicated by inferior STEMI s/p medical
management, presumed endocarditis d/t Strep anginosus, and
difficult to control atrial fibrillation/flutter who presented
with atrial fibrillation with rapid ventricular response.
ACUTE ISSUES:
=============
# AFIB W/RVR: Patient with difficult to control Afib/flutter
during recent hospitalization with average HR 120-130bpm. Given
heart failure noted on echo, diltiazem discontinued, and
uptitrated metoprolol and optimize heart failure. Digoxin was
discontinued. He was initiated on amiodarone, with conversion to
normal sinus rhythm. He was continued on apixaban for
anticoagulation. He is s/p amiodarone 400mg BID x 1 week (D1=
___, change ___ now ___ BID x 3 week (D1= ___, 200mg
daily.
# CAD S/P STEMI: Diagnosed during prior admission, and treated
medically due to contraindication to heparinization. At time of
admission, troponin trending down from STEMI. Continued
atorvastatin 80mg and metoprolol, and started valsartan given
depressed EF.
# CHF: Quantitative (3D) LVEF = 12% following STEMI. He was
started on valsartan. He was continued on metoprolol.
Spironolactone was added. He did not require any maintenance
diuresis.
# Hematuria: Previously noted on UA and grossly evident in foley
bag ___. Likely traumatic due foley in the setting of apixiban.
He did not require any bladder irrigation, and had no issues
with foley drainage. He will need outpatient cystoscopy to
further evaluate for underlying cause.
#?Aspiration: None noted on CXR. Since then, afebrile and no
leukocytosis, though with more upper respiratory sounds on exam
today. TF were held due to high residuals; potentially due to
change in body weight. TF were restarted at lower rate of 55
with no further events.
# FEVER: Tm 100.8 axillary during hospital stay. 100.4 rectal.
CXR x2 with no evidence of pneumonia. C diff negative. No
leukocytosis. UA bland or few bacteria with no nitrites/ketones.
Blood or urine cultures negative or ngtd. Per neurology, may be
due to issues with thermoregulation post stroke.
# PRESUMED ENDOCARDITIS: TTE negative though blood cultures
during previous admission grew Strep anginosus. Recultured UA
and BCX x2, which were negative. he was continued on ceftriaxone
(end date ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Pen-Vee K
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 12:48PM BLOOD WBC-23.6* RBC-3.95 Hgb-12.3 Hct-37.0
MCV-94 MCH-31.1 MCHC-33.2 RDW-12.3 RDWSD-42.4 Plt ___
___ 12:48PM BLOOD Neuts-84.1* Lymphs-4.2* Monos-10.2
Eos-0.0* Baso-0.3 Im ___ AbsNeut-19.84* AbsLymp-0.99*
AbsMono-2.40* AbsEos-0.00* AbsBaso-0.07
___ 12:48PM BLOOD ___ PTT-29.1 ___
___ 12:48PM BLOOD Glucose-124* UreaN-55* Creat-2.5* Na-139
K-3.8 Cl-97 HCO3-15* AnGap-27*
___ 12:48PM BLOOD Albumin-4.1
___ 12:48PM BLOOD ALT-45* AST-85* CK(CPK)-195 AlkPhos-118*
TotBili-2.0*
___ 12:48PM BLOOD cTropnT-0.02*
___ 02:35PM BLOOD Lactate-0.9
MICRO:
BCx (___): pending
UCx (___): >100K CFUs/mL E.coli (prelim)
IMAGING/STUDIES:
XR right knee (___):
IMPRESSION: Mild tricompartmental degenerative changes. No
acute osseous injury.
XR right ankle (___):
IMPRESSION: No acute osseous injury or significant degenerative
change of the right ankle.
RUQ US (___):
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
2. Prominent common bile duct to 12 mm may reflect the patient's
age and post cholecystectomy appearance. No ductal stones or
intrahepatic biliary dilatation.
CXR (___):
IMPRESSION:
In comparison with the study of ___, there are lower lung
volumes. The cardiac silhouette remains within normal limits
with no evidence of vascular congestion, pleural effusion, or
acute focal
CT abd/pelvis with contrast (___):
IMPRESSION:
No acute intra-abdominal or intrapelvic process explaining
patient's symptom.
CT head with contrast (___):
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild soft tissue stranding along the left side of the frontal
bone, recommend clinical correlation. No evidence of underlying
fracture.
CXR PA/Lat (___):
IMPRESSION:
No acute cardiopulmonary abnormality.
Renal ultrasound ___:
IMPRESSION:
No evidence of nephrolithiasis or hydronephrosis.
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-16.4* RBC-3.05* Hgb-9.5* Hct-29.8*
MCV-98 MCH-31.1 MCHC-31.9* RDW-13.2 RDWSD-46.6* Plt ___
___ 06:10AM BLOOD Glucose-82 UreaN-20 Creat-1.1 Na-144
K-4.2 Cl-109* HCO3-20* AnGap-15
___ 06:10AM BLOOD ALT-39 AST-28 AlkPhos-130* TotBili-0.4
___ 06:10AM BLOOD Albumin-2.9* Phos-2.6* Mg-2.2 Iron-19*
DISCHARGE EXAM:
GENERAL: Alert, NAD, lying in bed. calm on evaluation this AM
EYES: Anicteric, PERRL
ENT: MMM, OP clear
CV: NR/RR, no m/r/g. No JVD.
RESP: CTAB, no wheezes, crackles, or rhonchi
ABD/GI: Soft, ND, No TTP, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities. LEs with bilateral
pitting edema, symmetric in appearance without any erythema
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: No rashes or lesions noted on visible skin
NEURO: CN II-XII intact, tremors in bilateral UEs. Moves all
limbs, ___ strength in UE bilaterally, ___ strength in lower
extremities bilaterally
PSYCH: pleasant, calm
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Verapamil SR 240 mg PO BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Albuterol Inhaler 2 PUFF IH BID:PRN shortness of breath
6. Potassium Chloride 10 mEq PO DAILY
7. ALPRAZolam 0.25 mg PO BID:PRN anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days
3. FoLIC Acid 1 mg PO DAILY
4. Heparin 5000 UNIT SC BID
5. Ramelteon 8 mg PO QPM
6. Thiamine 100 mg PO DAILY
7. ALPRAZolam 0.25 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH BID:PRN shortness of breath
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Hydrochlorothiazide 25 mg PO DAILY
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Potassium Chloride 10 mEq PO DAILY
13. Verapamil SR 240 mg PO BID
14. Ferrous sulfate 325 daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Toxic metabolic encephalopathy
Sepsis
Urinary tract infection
Alcohol use disorder
Acute kidney injury
Alcoholic hepatitis
Discharge Condition:
Stable, two person assist to chair
Mental status: Awake, alert. Oriented to self. On day of
discharge was oriented to place and date as well
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with weakness and elevated WBC// Pneumonia?
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Biapical scarring is unchanged. Lungs are
otherwise clear. No pleural effusion or pneumothorax is seen. There are no
acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with weakness and failure to thrive// Hemorrhage? Bleed?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.1 cm; CTDIvol = 48.6 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
Evaluation is limited by motion artifact.
There is no evidence of acute territorial infarction,hemorrhage,edema, or
mass. Subcortical and periventricular white matter hypodensities are
nonspecific, likely the sequelae of chronic small vessel ischemic disease.
Again seen is cerebral atrophy, most prominently involving bilateral frontal
lobes. There is prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of fracture. There is mild soft tissue stranding along
the left side of the frontal bone. There is mild mucosal thickening of the
right maxillary sinus. There is chronic appearing opacification of several
left mastoid air cells. The visualized portion of the remaining paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild soft tissue stranding along the left side of the frontal bone,
recommend clinical correlation. No evidence of underlying fracture.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITHOUT CONTRAST
INDICATION: ___ with elevated white blood cell count and RLQ tenderness.NO_PO
contrast// Appendicitis? 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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.8 s, 47.6 cm; CTDIvol = 11.6 mGy (Body) DLP =
533.9 mGy-cm.
Total DLP (Body) = 547 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 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 either small or has been resected with a
prominent cystic ductal..
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no suspicious
renal lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. Mild perinephric stranding may
be related to chronic kidney disease.
GASTROINTESTINAL: Small hiatal hernia. Small bowel loops demonstrate normal
caliber and wall thickness throughout. The colon and rectum are within normal
limits. Appendix is not visualized, but there are no secondary signs of
appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate degenerative changes to the imaged spine with grade 1 anterolisthesis
of L4 on L5.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No acute intra-abdominal or intrapelvic process explaining patient's symptom.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with elevated wbc. eval for pneumonia//
pneumonia?
IMPRESSION:
In comparison with the study of ___, there are lower lung volumes. The
cardiac silhouette remains within normal limits with no evidence of vascular
congestion, pleural effusion, or acute focal
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with failure to thrive and leukocytosis,
concerning for infection with abnormal LFTs// ? evidence of biliary
obstruction/ cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
LIVER: The liver is echogenic. The contour of the liver is smooth. There is
no focal liver mass. The main portal vein is patent with hepatopetal flow.
There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CBD: 12 mm
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 10.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 8.0 cm
Left kidney: 9.1 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. Prominent common bile duct to 12 mm may reflect the patient's age and post
cholecystectomy appearance. No ductal stones or intrahepatic biliary
dilatation.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman with knee pain// ? evidence of fracture or
dislocation
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the right knee
COMPARISON: None
FINDINGS:
No fracture or dislocation is seen. There is mild tricompartmental
degenerative changes evidenced by joint space narrowing and osteophyte
formation. A small knee joint effusion is present. There is normal osseous
mineralization. No suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
Mild tricompartmental degenerative changes. No acute osseous injury..
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old woman with ankle pain// ? evidence of fracture or
dislocation ? evidence of fracture or dislocation
TECHNIQUE: Three views of the right ankle were obtained
COMPARISON: None
FINDINGS:
No fracture or dislocations are seen. There are no significant degenerative
changes. The mortise is congruent on these nonweightbearing views. The
tibial talar joint space is preserved and no talar dome osteochondral lesion
is identified. A small plantar calcaneal enthesophyte is present. No
suspicious lytic or sclerotic lesion is identified. No soft tissue
calcification or radiopaque foreign body is identified.
IMPRESSION:
No acute osseous injury or significant degenerative change of the right ankle.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with delirium, persistent leukocytosis//
persistent leukocytosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen and pelvis ___. Liver ultrasound ___.
FINDINGS:
An echogenic focus within the lower pole of the right kidney measures 0.7 cm,
and may reflect milk of calcium within a caliceal diverticulum. No definite
renal stones identified. There is no hydronephrosis or worrisome masses
bilaterally. The renal parenchyma is thinned bilaterally, likely reflecting
medical renal atrophy.
Right kidney: 9.4 cm
Left kidney: 10.2 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
No evidence of nephrolithiasis or hydronephrosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Acute kidney failure, unspecified
temperature: 98.5
heartrate: 115.0
resprate: 16.0
o2sat: 94.0
sbp: 114.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
Ms. ___ is a ___ female with alcohol use
disorder, htn, hypothyroidism, asthma, gout, chronic kidney
disease (baseline 1.5-2.0) who presented for evaluation of acute
encephalopathy, global weakness, and acute renal failure, found
to have a UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with Hep C cirrhosis/HCC s/p tranplant ___ presents
with N/VD. Patient was recently hospitalized ___ for
hyperkalemia and portal vein stenosis, s/p stenting on ___.
.
She was recently hospitalized ___ for hyperkalemia and portal
vein stenosis, s/p stenting on ___. She presented to an OSH
with yellow-green emesis, diarrhea (yellow loose stool), and RUQ
pain, improved with Dilaudid. She has subjective fever and
chills. She was also hypokalemic at OSH, so she was given IV
K+.
.
She says that starting ___ night, around 6 ___, she had
sudden onset of nausea, associated with several episodes of
vomiting, without BRB, but was initially with her food, then
yellow-green emesis. When she was having diarrhea (she reports
25 BM in 18 hours), she says that there was no blood in her
stools, but that they did appear "maroon." She denies any sick
contacts with anybody who had similar symptoms. She also says
that as soon as she was discharged last week, she had some
shaking chills, which she attributes to the flu, although she
does believe she received her flu shot. She endorses night
sweats and chills at home, rhinorrhea, a sore throat, a dry
cough, and her last episode of vomiting and diarrhea was around
9:30 on the morning of ___.
.
Since admission overnight, patient reports only 1x bowel
movements, not loose anymore, but soft. She reports no more
nausea and vomiting. She was able to tolerate dinner and
breakfast wtihout issue. She was wondering what can be done for
her abdominal pain, even thought this proceeded the acute N/V/D.
She thinks the abdominal pain over all is improving.
.
Review of systems:
(+) Per HPI. She had mild subjective fever, chill, slight dry
cough, rhinorrhea, and sore throat.
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, or congestion. Denied shortness of
breath. Denied chest pain or tightness, palpitations. Denied
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
- HCV: Dx ___ she is infected with G3A genotype. She has no
history of UGIB or varicies. She has no history of IDU or
transfusions. now s/p liver transplant ___
- portal vein thrombosis, s/p stenting ___
- DM-2
- Asthma: never required hospitalization or intubation
- Migraine headaches
- history of Gallstones
- ? peripheral vascular disease
- Cirrhosis
- Diuretic refractory ascites s/p TIPS ___
- ___ s/p RFA ablation
Social History:
___
Family History:
There is no known family history of liver disease or liver
cancer. She has 6 brothers and 5 sisters; her father died when
she was ___ (ETOH abuse) and her mother is alive and living in
___ now.
Physical Exam:
Physical Exam on Day of admission/discharge:
Vitals: T:99.8, Tm 100.3, BP 153/85, HR 66, RR 20, O2Sat 98% RA,
BS 163.
Gen: well appearing, slightly uncomfortable, but not in acute
distress
HEENT: PERRLA, EOMi, sclera anicteric, MMM
Neck: supple, obese, no JVD
Lungs: CTAB, no w/c/r, good air movements
CV: PMI non-displaced, RRR, ___ systolic murmur best at left
lower SB
Abd: distended, old well-healed ___ scar, soft, no rebound
or guarding, mostly in the RUQ
EXTREMITIES - WWP, no c/c/e
NEURO - awake, A&Ox3, no asterixis
Pertinent Results:
___ 04:10PM BLOOD WBC-1.7*# RBC-3.00* Hgb-9.1* Hct-28.1*
MCV-94 MCH-30.2 MCHC-32.3 RDW-14.8 Plt ___
___ 04:10PM BLOOD Neuts-63.4 Lymphs-17.6* Monos-16.9*
Eos-1.0 Baso-1.2
___ 04:10PM BLOOD ___ PTT-26.5 ___
___ 04:10PM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-140
K-4.3 Cl-110* HCO3-25 AnGap-9
___ 04:10PM BLOOD ALT-19 AST-40 LD(LDH)-341* AlkPhos-83
TotBili-0.3
___ 04:10PM BLOOD Lipase-5
___ 11:26PM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:26PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 11:26PM URINE RBC-2 WBC-11* Bacteri-MOD Yeast-NONE
Epi-6 TransE-<1
___ 11:26PM URINE Mucous-RARE
___ 06:38AM BLOOD WBC-1.8* RBC-2.88* Hgb-8.8* Hct-27.0*
MCV-94 MCH-30.5 MCHC-32.5 RDW-14.3 Plt ___
___ 06:38AM BLOOD Neuts-64.0 Lymphs-14.2* Monos-15.9*
Eos-4.1* Baso-1.8
___ 06:38AM BLOOD ___ PTT-27.1 ___
___ 06:38AM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-139
K-3.7 Cl-108 HCO3-25 AnGap-10
___ 06:38AM BLOOD ALT-25 AST-57* LD(LDH)-297* AlkPhos-79
TotBili-0.3
___ 06:38AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.1
Mg-1.5*
___ 06:38AM BLOOD Cortsol-5.2
___ 06:38AM BLOOD tacroFK-2.8*
Microbiology:
___ 4:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 11:26 pm URINE Source: ___.
URINE CULTURE (Pending):
___ 6:38 am Immunology (CMV)
CMV Viral Load (Pending):
___ 11:08 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Pending):
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Liver U/S ___
The liver shows no focal or textural abnormality. There is no
intra- or extra-hepatic bile duct dilation. The common duct
measures 3 mm. The visualized portions of the pancreatic head
and body are normal, although
the tail and inferior head are not well seen due to overlying
bowel gas. A
single view of the right kidney is normal. The visualized
portion of the IVC is normal. The spleen is enlarged to 13.2 cm.
There is no ascites.
DOPPLER: Color Doppler assessment and spectral analysis of the
hepatic
vasculature was performed. In the porta hepatitis, the main
portal vein stent is seen. Flow through the stent is excellent
with normal hepatopetal flow and normal waveform. The right
anterior portal vein, right posterior portal vein and left
portal veins are patent with normal flow and waveforms. The
right, middle and left hepatic veins are patent. A 1-cm
isoechoic area just anterior to the portal vein stent is
unchanged from ___ and may represent a small lymph node.
IMPRESSION:
1. Status post main portal vein stenting. Doppler assessment
shows normal
flow and waveforms in the main portal vein, left portal vein and
right portal veins.
2. Porta hepatic lymph node adjacent to the portal vein is
unchanged from
___.
CXR ___
In comparison with the earlier study of this date, there is
little overall change. Cardiac silhouette is at the upper limits
of normal in size. No acute focal pneumonia, vascular
congestion, or pleural effusion.
Medications on Admission:
pantoprazole 40 mg Daily
mycophenolate mofetil 500 mg BID
Tacrolimus 3 mg BID
pentamidine 300 mg inh monthly
albuterol sulfate 2 puffs Qmonth prior to pentamidine
ergocalciferol (vitamin D2) 50,000 unit weekly
sodium polystyrene sulfonate as needed PRN transplant team
docusate sodium 100 mg BID
insulin lispro protam & lispro 100 unit/mL (75 ___ Insulin
Pen Sig: Ten (10) Units Subcutaneous twice a day: As directed 10
units at breakfast and 10 units at dinner.
clopidogrel 75 mg Daily
aspirin 325 mg Daily
senna 8.6 mg BID
Dilaudid ___ mg Q4-6H PRN pain
Cipro 500 mg BID for 6 days
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
4. pentamidine 300 mg Recon Soln Sig: Three Hundred (300) mg
Inhalation once a month.
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation once a month: Use prior to pentamidine.
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. insulin lispro protam & lispro 100 unit/mL (75-25) Insulin
Pen Sig: Ten (10) units Subcutaneous twice a day.
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Probable viral gastroenteritis
- Chronic abdominal pain
Secondary diagnosis:
- history of hepatitis C with hepatocellular carcinoma status
post transplant on immunosuppressive therapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman status post transplant for hepatitis C
and HCC with recent portal vein stent placement. Now with right upper
quadrant pain. Evaluate portal vein stent.
COMPARISON: Abdominal ultrasound ___ and CT ___.
FINDINGS: The liver shows no focal or textural abnormality. There is no
intra- or extra-hepatic bile duct dilation. The common duct measures 3 mm.
The visualized portions of the pancreatic head and body are normal, although
the tail and inferior head are not well seen due to overlying bowel gas. A
single view of the right kidney is normal. The visualized portion of the IVC
is normal. The spleen is enlarged to 13.2 cm. There is no ascites.
DOPPLER: Color Doppler assessment and spectral analysis of the hepatic
vasculature was performed. In the porta hepatitis, the main portal vein stent
is seen. Flow through the stent is excellent with normal hepatopetal flow and
normal waveform. The right anterior portal vein, right posterior portal vein
and left portal veins are patent with normal flow and waveforms. The right,
middle and left hepatic veins are patent. A 1-cm isoechoic area just anterior
to the portal vein stent is unchanged from ___ and may represent a small
lymph node.
IMPRESSION:
1. Status post main portal vein stenting. Doppler assessment shows normal
flow and waveforms in the main portal vein, left portal vein and right portal
veins.
2. Porta hepatic lymph node adjacent to the portal vein is unchanged from
___.
Radiology Report
HISTORY: Low-grade temperature and immunosuppression.
FINDINGS: In comparison with the earlier study of this date, there is little
overall change. Cardiac silhouette is at the upper limits of normal in size.
No acute focal pneumonia, vascular congestion, or pleural effusion.
Gender: F
Race: HISPANIC OR LATINO
Arrive by AMBULANCE
Chief complaint: RUQ PAIN/HYPOKALEMIA
Diagnosed with ABDOMINAL PAIN RUQ, NAUSEA WITH VOMITING
temperature: 99.0
heartrate: 68.0
resprate: 18.0
o2sat: 96.0
sbp: 165.0
dbp: 90.0
level of pain: 4
level of acuity: 2.0 | ___ yo F with h/o Hep C cirrhosis/___ s/p transplant ___
presented with N/V/D
# Nausea, vomiting, diarrhea. Probable viral gastroenteritis
given the acuity and the rapid onset and rapid resolution of her
symptoms. She also had leukopenia and borderline fever.
However, because of her immunocompromised state due to recent
transplant and recent hospitalization on antibiotics for UTI,
stool cultures and CMV VL were sent. C. diff was noted to be
negative. CMV and other stool cultures were pending at the time
of discharge. It is also possible that the Dilaudid was
contributing to part of the nausea and vomiting. Ultram was
offerred to the patient. Patient's nausea, vomiting, and
diarrhea resolved at the time of discharge and understood to
return if her symptoms were to return.
# Chronic abdominal pain: She has a history of chronic abdominal
pain after her liver transplant. A CT on ___ did not show
any acute cause. She was continued on her home doses of dilaudid
with a trial of Ultram. It is possible that she could be
experiencing nausea and vomiting from the Dilaudid. Chronic
pain syndrome was discussed with the patient. It is recommended
that she avoid the use of narcotics as much as possible. She
was encouraged to use Ultram.
# Pancytopenia. This has been a chronic issue. There was
thought that it could be ___ tacro toxicity, MMF, and
valgancyclovir in combination. MMF was previously decreased to
500 mg BID, and Valgan and fluconazole were discontinued. Tacro
level was low, and she was kept on 3 mg BID, as in outpatient
setting. Patient's outpatient hepatologist was contacted with
regard to decreasing MMF, but given patient is still in the
early phase of her transplant, no change was done.
# Portal vein stenosis, s/p stent. Patient's repeat ultrasound
during this admission showed patent portal vein. She was kept
on aspirin and Plavix.
# T2DM. She was continued on ___ insulin, but dose was
reduced to 5 units BID given nausea and vomiting. Her blood
sugar was < 200 during hospital stay. She was discharged on
home dose insulin since her oral intake improved throughout the
day. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w HIV non-compliant on HAART here with abdominal pain, N/V.
He reports the pain started 2 days ago and has been
progressively worse. It is localized around the umbilicus and it
is non-radiating. This was followed by nausea/vomiting (brown
colored per his report) He has had some subjective chills but no
fevers or night sweats. He also developed loose watery diarrhea
around the same time as the onset of his abdominal pain. He
denies any dysuria, perianal pain, chest pain, shortness of
breath, or weight loss. He does report that he has not taken his
HIV medication in the last week and is usually non-compliant. He
denies any sick contacts.
Past Medical History:
HIV non-compliant on HAART (dx ___, CD4 344)
Gonorrhea
Syphilis
Social History:
___
Family History:
Non-contributory
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals:
98.4 97 128/89 16 97% RA
GEN: A&Ox3, NAD
HEENT: NCAT, anicteric
CV: RRR but with intermittent tachycardia
PULM: no respiratory distress, unlabored respirations
BACK: no vertebral tenderness
ABD: soft, non-distended, mildly tender in the ___
area and the suprapubic region, no rebound or guarding
Ingurinal: no evidence of hernia, well healed prior scars, there
is a small dime-sized area of non-indurated erythema on the b/l
groins
EXT: WWP, no edema
NEURO: A&Ox3, no focal neurologic deficits
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 1147)
Temp: 98.2 (Tm 98.2), BP: 133/90 (129-141/81-91), HR: 77
(75-91), RR: 18 (___), O2 sat: 98% (94-98), O2 delivery: Ra
GENERAL: lying in bed, tired but interactive, in no apparent
distress
HEENT: No mucosal lesions, no rash on face
HEART: regular rhythm, no murmur appreciated
LUNGS: no increased work of breathing
ABDOMEN: nondistended, +BS, nontender
EXTREMITIES: warm and well perfused, no edema
NEURO: CN II-XII intact, AOx3
SKIN: patches of erythema on trunk and groin, coalescing, none
on back or legs or upper/lower extremities, 3x ~2cm deeply
erythematous circular lesions on groin, all nontender but
pruritic
Pertinent Results:
ADMISSION LABS:
==============
___ 12:05AM BLOOD WBC-5.9 RBC-5.66 Hgb-15.1 Hct-48.5 MCV-86
MCH-26.7 MCHC-31.1* RDW-14.5 RDWSD-44.9 Plt ___
___ 12:05AM BLOOD Neuts-36.0 ___ Monos-14.3*
Eos-2.4 Baso-0.8 Im ___ AbsNeut-2.12 AbsLymp-2.73
AbsMono-0.84* AbsEos-0.14 AbsBaso-0.05
___ 12:05AM BLOOD WBC-5.9 Lymph-46 Abs ___ CD3%-84
Abs CD3-2271* CD4%-13 Abs CD4-344* CD8%-65 Abs CD8-1776*
CD4/CD8-0.19*
___ 12:05AM BLOOD Glucose-91 UreaN-12 Creat-1.2 Na-136
K-6.5* Cl-97 HCO3-25 AnGap-14
___ 12:05AM BLOOD ALT-34 AST-65* AlkPhos-57 TotBili-0.4
___ 12:05AM BLOOD Lipase-16
___ 06:37AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.7
___ 12:05AM BLOOD Albumin-3.8
___ 11:00AM BLOOD Trep Ab-POS*
___ 12:00PM BLOOD CMV IgG-POS* CMV IgM-POS* CMVI-In the app
___ 05:30PM BLOOD HIV1 VL-4.8*
___ 06:37AM BLOOD HIV1 VL-4.0*
___ 12:27AM BLOOD Lactate-0.8 K-3.8
DISCHARGE LABS:
==============
___ 07:28AM BLOOD WBC-4.9 RBC-4.80 Hgb-12.8* Hct-40.4
MCV-84 MCH-26.7 MCHC-31.7* RDW-13.8 RDWSD-42.7 Plt ___
___ 07:28AM BLOOD Glucose-93 UreaN-4* Creat-0.8 Na-143
K-3.9 Cl-105 HCO3-28 AnGap-10
___ 07:28AM BLOOD ALT-23 AST-28 AlkPhos-51 TotBili-<0.2
___ 07:28AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9
RADIOLOGY RESULTS:
================
___ CT A/P:
IMPRESSION:
1. Findings compatible with partial small-bowel obstruction with
a transition
point in the right lower quadrant distal ileum, with no cause of
obstruction
identified. The nondilated terminal ileum has a small amount of
fluid in it,
without wall thickening to suggest ileitis as the cause of
obstruction. No
free air or fluid.
2. Fluid in the colon, compatible with provided history of
diarrhea.
3. Prominent number of non pathologically enlarged mesenteric
lymph nodes may
be reactive or due to history of HIV.
4. Fluid in the right inguinal canal with small amount of
surrounding fat
stranding, of uncertain clinical significance. Correlate with
symptoms and
physical exam.
MICRO RESULTS:
=============
___ 6:37 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final ___:
REACTIVE AT A TITER OF 1:2.
Reference Range: Non-Reactive.
___ 10:42 am STOOL CONSISTENCY: WATERY Source:
Stool.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Pending):
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 8:15 am STOOL CONSISTENCY: NOT APPLICABLE
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.
___ 8:15 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
BLASTOCYSTIS HOMINIS. MODERATE. CLINICAL SIGNIFICANCE
UNCERTAIN.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
___ 12:05 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:05 am URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with HIV non compliant on meds, abd
painNO_PO contrast// Collitis, diverticulitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 6.0 s, 47.6 cm; CTDIvol = 9.0 mGy (Body) DLP = 429.8
mGy-cm.
Total DLP (Body) = 437 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___
FINDINGS:
LOWER CHEST: There is minimal right basilar atelectasis. There is no evidence
of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: 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. The proximal small bowel loops
are decompressed in the left upper quadrant. The more distal small bowel
loops are fluid-filled and dilated up to 4 cm, with a transition point in the
distal ileum (601:23; 02:49; 201:23). The terminal ileum partially
decompressed however containing a small amount of fluid, without wall
thickening (02:45). There is no bowel wall thickening or pneumatosis. There
is fluid in the colon. The colon and rectum are otherwise within normal
limits. The appendix is normal (02:49). No extraluminal air or fluid
collection.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There are prominent number of non pathologically enlarged
mesenteric 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: Patient is status post repair of a right inguinal hernia in
___. There is fluid in the right inguinal canal which is new compared with
prior CT ___, with mild stranding of the surrounding fat (2:79; 601:23).
There is a tiny fat containing umbilical hernia.
IMPRESSION:
1. Findings compatible with partial small-bowel obstruction with a transition
point in the right lower quadrant distal ileum, with no cause of obstruction
identified. The nondilated terminal ileum has a small amount of fluid in it,
without wall thickening to suggest ileitis as the cause of obstruction. No
free air or fluid.
2. Fluid in the colon, compatible with provided history of diarrhea.
3. Prominent number of non pathologically enlarged mesenteric lymph nodes may
be reactive or due to history of HIV.
4. Fluid in the right inguinal canal with small amount of surrounding fat
stranding, of uncertain clinical significance. Correlate with symptoms and
physical exam.
Radiology Report
INDICATION: ___ with ?SBO, abdominal pain// eval contrast passing
COMPARISON: CT of the abdomen pelvis from 9 hours prior.
FINDINGS:
Supine and upright views of the abdomen pelvis were provided. Bowel supine and
upright views the abdomen pelvis provided. Contrast is seen within small
bowel loops with numerous air-fluid levels and dilated small bowel measuring
up to 4.1 cm, consistent with bowel obstruction. No definite contrast is seen
within the colon. No free air below the right hemidiaphragm. Contrast is seen
within the stomach. Bony structures are intact. Contrast within the urinary
bladder reflects recent CT.
IMPRESSION:
No contrast passage into the colon. Persistent dilated small bowel loops with
numerous air-fluid levels concerning for bowel obstruction.
Radiology Report
INDICATION: ___ w ? pSBO now s/p water-soluble contrast challenge// ?
interval change
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Same day abdominal radiograph performed at 10:00
FINDINGS:
There are air-filled mildly prominent small bowel loops with scattered
air-fluid levels. Ingested contrast is now seen throughout the entire colon
and passing into the rectum.
IMPRESSION:
Mildly prominent loops of small bowel with passage of contrast into the colon
and rectum suggestive of mild persistent ileus without obstruction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, n/v/d
Diagnosed with Other intestnl obst unsp as to partial versus complete obst
temperature: 97.5
heartrate: 102.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 95.0
level of pain: 6
level of acuity: 3.0 | SUMMARY:
================
___ is a ___ MSM male with HIV non-adherence on HAART
(last CD4 342, negative VL), and current daily IV methadone use,
and hx of RPR who presented with abdominal pain, N/V found to
have a partial SBO, found positive stool norovirus, and
development of rash. Rash was determined to be "pruritic papular
eruption in HIV" and does not require further evaluation.
ACTIVE ISSUES:
=================
#Abdominal Pain
#Norovirus
#Blastocystis hominis
Patient presented with abdominal pain, nausea, and vomiting,
found to have partial SBO on CT with transition point in the
right lower quadrant distal ileum, with no cause of obstruction
or ileitis identified. Patient did not require NG tube for
decompression, and was treated with bowel rest. His diet was
slowly advanced, which he tolerated well. Norovirus stool PCR
found to be positive. Stool culture notable for moderate
blastocystis hominis, per ID thought colonization, but could
consider treatment outpatient if symptoms recur. Further
infectious workup, including urine and rectal STD, were
negative. Diarrhea improved throughout hospital stay, and he was
able to tolerate PO well.
#Pruritic papular eruption in HIV
Developed rash on ___, consisting of coalescing patches of
erythema on trunk and groin, none on back or legs or upper/lower
extremities. Also with unrelated 3x ~2cm deeply erythematous
circular lesions on groin, all nontender but significantly
pruritic. Derm was consulted, biopsy obtained. Initiated
Benadryl standing with topical betamethasone treatment that
provided some relief. Preliminary pathology reading showed
eosinophils and hypersensivity reaction most c/w a pruritic
papular eruption in HIV per dermatology. This does not require
continued hospitalization for the rash, treatment will consist
of ongoing anthistamines, topical steroids, and followup with
derm for further options as outpatient.
#HIV non-adherent on HAART:
Last CD4 342 in ___ with non detectable viral load at the
time, now CD4 344, HIV viral load elevated at (log)4.6.
Hospitalization complicated by pruritic papular eruption in HIV.
States that he has access to medications via ___ but
"some days forgets to take and days turn into a week". On
further discussion, he waxes and wanes in regards to motivation
for adherence but upon final conversation prior to discharge was
motivated to restart home regimen in order to "prevent future
infections and stays in the hospital". He hopes that his partner
will keep him motivated and will followup with outpatient
provider for monitoring. He is also aware of the importance of
close follow up ___ with his PCP at ___. Of note, he says he
has upcoming prison sentence of ___ year scheduled to begin in
the "coming months". During admission he took
truvada/dolutegravir with plan to transition to home genvoya at
___. Will require continued motivational interviewing with
regards to adherence. Also, given hx of anal dysplasia and
elevated risk given HIV, requires renewed screening for anal
cancer as outpatient.
# Positive UA:
UA showed elevated WBC, but patient denies symptoms. UCx on
admission grew skin flora. Urine STD screen negative. Given
patient is asymptomatic this does not require treatment at this
time. Continue to monitor as outpatient and treat if symptoms
develop.
============================================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
___ Endoscopic US FNA
___ EGD with glue injection of gastric varices
___ ___ Splenic Vein Stent and femoral line placement
___ EGD
___ RIJ central line placement
___ splenic artery gelfoam embolization
History of Present Illness:
Mr ___ is a ___ male with history of GERD, PUD, depression,
and recently discovered pancreatic mass with likely liver mets
s/p EUS today with biopsy of a pancreatic mass, p/w hematemesis
and melena 2 hours after procedure.
He was ___ ___ following ERCP, went to restroom, vomited BRB,
brought to ED by ambulance.
___ the ED, initial vitals: 98.1 90 110/68 18 98% RA.
Labs notable for H/H 9.9/30.1, WBC 21.0, INR 1.3, AST/ALT of 47,
lactate 3.7, normal lytes. While ___ ED had repeat episode of
hematemasis and melena, intubated, pressures dropped to 69/58
transiently, improved with fluid.
Given 3 L NS, octreotide and pantoprazole gtt. Given 2 U PRBCs.
GI c/s'd who recommended above, 1g CTX, plus urgent CTA to eval
for bleed. ___ also FYI'd.
CTA A/P did not show active source of bleed. Went directly to
___, where they also did not visualize a bleed, however given h/o
biopsy/tumor invasion of GDA they embolized this area as likely
source of bleed.
A little back story: without insurance, and thus medical care,
for some time. Started presenting to ___ ED ___
___ for abadominal pain, on ___/P which
demonstrated a solid 3.8 cm x 4.2 cm mass within the body of the
pancreas, encasing the superior mesenteric vein and extends to
the hepatic artery and splenic arteries. ALso at least 2 lesions
___ liver concerning for mets. Established care with ___
Oncology ___ 127.
Past Medical History:
- GERD
- PUD
- depression
- Pancreatic mass w/ liver mets, elevated ___
- HTN
- pre-diabetes
- h/o alcohol abuse (sober ___ yrs)
Social History:
___
Family History:
- Father died of MI
- Mother died of lung cancer age ___
- One of 7 sibs
- No children
- 2 mat aunts with breast cancer
Physical Exam:
ADMISSION EXAM
Vitals: 98 132/77 92
GENERAL: intubated, but alert, opening eyes, able to follow
simple commands
HEENT: Sclera anicteric, blood around oropharynx and ___ OG-tube
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM
VS: Afebrile, HR 100-110s, BP 120/90s, 96% RA
GEN: AxOx3, NAD, lying comfortably ___ bed
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: tachycardic, S1/S2 normal. no murmur/gallops/rubs.
Pulm: BS decreased at bases, otherwise clear
Abd: BS+, soft, NT, ttp epigastrium and L abdomen w/o rebound or
guarding, moderately distended
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: A&Ox3, knows we are at BI ___ floor, knows date. CNs
II-XII grossly intact. moving all extr
Pertinent Results:
ADMISSION LABS:
___ 03:30PM ___ PTT-24.6* ___
___ 03:30PM PLT COUNT-312
___ 03:30PM NEUTS-85.2* LYMPHS-6.4* MONOS-7.3 EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-17.86* AbsLymp-1.35 AbsMono-1.53*
AbsEos-0.04 AbsBaso-0.08
___ 03:30PM WBC-21.0* RBC-3.77* HGB-9.9* HCT-30.1*
MCV-80* MCH-26.3 MCHC-32.9 RDW-14.4 RDWSD-41.7
___ 03:30PM ALBUMIN-3.3* CALCIUM-8.1* PHOSPHATE-3.1
MAGNESIUM-1.7
___ 03:30PM LIPASE-19
___ 03:30PM ALT(SGPT)-47* AST(SGOT)-47* ALK PHOS-74 TOT
BILI-0.8
___ 03:30PM GLUCOSE-147* UREA N-17 CREAT-0.9 SODIUM-140
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17
___ 03:53PM LACTATE-3.7* K+-3.4
___ 11:16PM PLT COUNT-226
___ 11:16PM WBC-21.0* RBC-3.43* HGB-9.4* HCT-28.2* MCV-82
MCH-27.4 MCHC-33.3 RDW-14.8 RDWSD-43.9
___ 11:37PM freeCa-1.00*
___ 11:37PM LACTATE-1.2
DISCHARGE LABS
===============
___ 07:05AM BLOOD WBC-18.1* RBC-3.29* Hgb-9.2* Hct-28.4*
MCV-86 MCH-28.0 MCHC-32.4 RDW-15.9* RDWSD-50.1* Plt ___
___ 07:05AM BLOOD Neuts-90* Bands-0 Lymphs-2* Monos-7 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-16.29* AbsLymp-0.36*
AbsMono-1.27* AbsEos-0.18 AbsBaso-0.00*
___ 07:05AM BLOOD ___ PTT-25.6 ___
___ 07:05AM BLOOD Glucose-117* UreaN-13 Creat-0.4* Na-135
K-3.3 Cl-97 HCO3-28 AnGap-13
___ 07:05AM BLOOD ALT-36 AST-41* LD(LDH)-575* AlkPhos-97
TotBili-1.5
___ 07:05AM BLOOD Calcium-7.8* Phos-2.2* Mg-2.1
IMAGING:
==========
CXR ___: Subtle right midlung opacity, nonspecific. No
evidence of intra-abdominal free air.
CTA C/A/P ___:
1. No evidence of active gastrointestinal bleed or enteric
fistula.
2. Poorly evaluated pancreatic mass encasing the celiac artery
and its branches with multiple hepatic lesions concerning for
metastatic malignancy.
3. High density material ___ the cecum, ascending colon and
transverse colon likely reflective of recent gastrointestinal
bleed.
4. Nodular opacities ___ the right upper lobe suggestive of
aspiration.
Mesenteric Angiogram ___:
FINDINGS:
1. Pre embolization arteriogram of the common trunk of the
celiac artery and SMA demonstrating a narrow common hepatic
artery and an irregular gastroduodenal artery, likely tumor
related. No active extravasation of contrast identified.
2. Coil embolization of the GDA with six 3 mm x 3 cm Hilal
coils, 6 mm x 2 cm Concerto coil, and 5 mm x 6 cm Hilal coil.
3. Post embolization arteriogram of the common trunk of the
celiac artery and SMA demonstrating no significant flow into the
GDA. No active extravasation
of contrast identified.
4. Intravenous right femoral catheter.
5. Left common femoral arteriogram showing normal anatomy with
low common femoral artery bifurcation.
IMPRESSION:
Successful left common femoral artery approach coil embolization
of the
gastroduodenal artery.
CT A/P ___:
IMPRESSION:
1. Interval coiling of the GDA, with as well as variceal
treatment ___ the
gastric fundus. Interval significant decrease ___ the
intraluminal hemorrhage within the gastrointestinal tract. No
evidence of active extravasation.
2. Small to moderate hemoperitoneum,
3. Large ill-defined mass ___ the pancreatic neck and body,
likely representing primary adenocarcinoma. Complete encasement
of the celiac axis branches as well as contact of the SMA ___ the
context of a common trunk supplying celiac and SMA. Obliterated
portal confluence, proximal SMV, and splenic vein. Multiple
small peripancreatic satellite nodules.
4. Mildly enlarged peripancreatic lymph nodes.
5. Multiple hepatic metastases.
6. Interval worsening consolidation within the left lower lobe
superimposed over atelectasis, likely related to aspiration.
GI Embolization ___: IMPRESSION:
1. Successful recannulization of occluded splenic vein with
stent placement from the splenic vein to the main portal vein
with reduction ___ gastric varices on splenic venogram.
2. Successful placement of a left common femoral vein triple
lumen central venous catheter.
CT A/P ___:
1. Large hemoperitoneum is increased compared to prior, with new
perisplenic hematoma and sentinel clot tracking within the left
upper quadrant to the mid abdomen. These findings suggest the
spleen as a source of bleeding, although no active extravasation
is appreciated. The Amplatzer device is ___ place at the site of
splenic access with some adjacent hypoperfusion of the splenic
parenchyma compatible with infarct or post procedure changes.
2. The portal and splenic veins stent placed on the preceding
day is occluded, with new small focus of partially occlusive
thrombus ___ the main portal vein adjacent to the stent. Stable
occlusion of superior mesenteric vein.
3. Stable pancreatic mass, enlarged surrounding lymph nodes and
hepatic
metastases.
4. New bibasilar foci of hypoperfusion of atelectatic lung could
reflect
pulmonary infarcts, infection, or new metastases. No filling
defects are
identified ___ the pulmonary arteries at the lung bases.
Probable mild
pulmonary edema, with increased bilateral pleural effusions.
5. A small curvilinear hyperdensity ___ the right posterior
portal vein,
presumably embolized intravascular glue, has moved slightly
proximally and abuts the new thrombus ___ the main portal vein.
Splenic Embolization ___:
1. Common celiac/SMA arteries trunk.
2. Significantly attenuated proximal splenic artery compatible
with tumor compression from known pancreatic mass.
3. No evidence of active extravasation about the spleen
although there is increased patchy parenchymal blush ___ the
lower spleen likely related to recent procedure.
4. Gelfoam embolization to slow flow of the distal splenic
artery.
5. Post-embolization splenic artery angiogram demonstrating
significantly slower filling of the distal splenic arterial tree
with heterogeneous parenchymal enhancement.
IMPRESSION: Successful right common femoral artery approach mid
to distal splenic artery gelfoam embolization to slow flow.
___ CTA Abd/Pelvis
IMPRESSION:
1. Large pneumoperitoneum and perisplenic hematoma are not
significantly changed ___ size relative to prior study obtained
___. There is however decreased density of the fluid
consistent with evolution of blood products. There is no
evidence of active extravasation. Progressed relative to prior
study, there is involving splenic infarction. The splenic artery
appears attenuated by pancreatic mass.
2. Patient is status post PDA coil embolization and Amplatzer
device placement within the spleen, stable ___ position.
3. Thrombosed splenic and portal vein stent with a portion of
thrombus extending outside of the stent and into the distal
portal vein. Thrombosis of the superior mesenteric vein is not
significantly changed.
4. Bowel wall thickening and edema involving the splenic
flexure and descending colon is nonspecific for which attention
on follow-up is advised, likely ischemic ___ origin.
5. Large pancreatic head mass with soft tissue which appears to
infiltrate the tissue along the greater curvature of the stomach
___ transverse mesocolon.
6. Small curvilinear hyperdensity within the right posterior
portal vein is presumably embolize intravascular glue, unchanged
___ appearance and position.
___ CXR IMPRESSION:
No significant interval change when compared to the prior study.
___ MRCP
IMPRESSION:
1. No intra or extrahepatic biliary ductal dilatation.
Specifically, no MR evidence for active cholangitis or biliary
obstruction.
2. Known large pancreatic body mass, characterized ___ detail on
the recent CT examination from ___, with encasement of
the proximal celiac axis and SMA.
3. Numerous liver metastases appear similar to prior.
4. Moderate hemoperitoneum appears similar to prior.
5. Evolving splenic infarcts, also seen on the prior CT
examination.
6. Unchanged occluded splenic and portal venous stent. Chronic
obliteration of the upper SMV by the pancreatic mass.
MICROBIOLOGY:
==============
___ 11:16 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 7:55 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
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.
ESCHERICHIA COLI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ESCHERICHIA COLI
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S =>16 R
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S
OXACILLIN-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
___ 3:27 am BLOOD CULTURE R ARM.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:54 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:02 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 12:22 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
4. Lactulose 30 mL PO Q6H:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 10 mg Use 1 suppository rectally daily Disp #*14
Suppository Refills:*0
2. Fentanyl Patch 50 mcg/h TD Q72H
RX *fentanyl 50 mcg/hour Apply 1 patch every 72 hours Disp #*5
Patch Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN breakthrough pain
RX *hydromorphone [Dilaudid] 2 mg Take ___ tablets by mouth
every 3 hours Disp #*80 Tablet Refills:*0
4. MethylPHENIDATE (Ritalin) 2.5-5 mg PO BID:PRN fatigue
Take at 8AM and noon.
RX *methylphenidate 5 mg Take ___ to 1 tablet by mouth twice
daily Disp #*30 Tablet Refills:*0
5. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg Take 1 tablet by mouth four times
per day Disp #*56 Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg Take 1 tablet by mouth every 8 hours Disp
#*14 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose Take 17g powder by
mouth daily Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg Take 1 capsule by mouth twice daily
Disp #*30 Capsule Refills:*0
9. Lactulose 30 mL PO DAILY
RX *lactulose 20 gram/30 mL Take 1 30 mL by mouth daily
Refills:*0
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg Take 1 tablet by mouth twice daily
Disp #*30 Tablet Refills:*0
11. Sertraline 100 mg PO DAILY
RX *sertraline 100 mg Take 1 tablet by mouth daily Disp #*14
Tablet Refills:*0
12. TraZODone ___ mg PO QHS:PRN insomnia
RX *trazodone 50 mg Take ___ to 1 tablet by mouth every night
Disp #*14 Tablet Refills:*0
13. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg Take 1 tablet by mouth twice daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Pancreatic Adenocarcinoma
- Upper GI bleed
- Ventilator Associated Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hematemesis status post ERCP
TECHNIQUE: Supine AP view of the chest
COMPARISON: ___ at 15:49
FINDINGS:
There has been interval placement of an endotracheal tube with tip terminating
approximately 2.2 cm from the carina. Enteric tube is noted with tip coursing
below the left hemidiaphragm, into the stomach with tip off the inferior
borders of the film. Cardiac and mediastinal contours are unchanged. There is
mild upper zone vascular redistribution with crowding of bronchovascular
structures, likely related to supine AP positioning and low lung volumes.
Patchy opacities in the right mid lung field and right lung base may reflect
areas of aspiration and/or atelectasis. No pleural effusion or large
pneumothorax is detected on this supine exam. There are no acute osseous
abnormalities.
IMPRESSION:
1. Endotracheal tube is low lying, turning approximately 2.2 cm from the
carina, and can be withdrawn by 1 cm for optimal positioning.
2. Enteric tube in standard position.
3. Low lung volumes with patchy right mid and lower lung field opacities,
possibly due to aspiration and/or atelectasis.
Radiology Report
INDICATION: ___ year old man with UGI bleed // mesenteric angiography
COMPARISON: CT torso ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___,
___ radiologist performed the procedure. Dr. ___ supervised
the trainee during the key components of the procedure and has reviewed and
agrees with the trainee's findings.
ANESTHESIA: General anesthesia. 1% lidocaine was injected in the skin and
subcutaneous tissues overlying the access site.
CONTRAST: 120 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 17.7 min, 222 mGy
PROCEDURE:
1. Left common femoral artery access.
2. Arteriogram of the common trunk of the celiac and superior mesenteric
arteries.
3. Coil embolization of the gastroduodenal artery.
4. Right common femoral arteriogram.
5. Left common femoral arteriogram.
6. Targeted ultrasound of the right superficial femoral artery.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the health care proxy.
The patient was then brought to the angiography suite and placed supine on the
exam table. A pre-procedure time-out was performed per ___ protocol. Both
groins were prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the left common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ 25 cm sheath which was attached to a
continuous heparinized saline side arm flush.
A C2 glide catheter was advanced over ___ wire into the aorta. The wire
was removed and the common trunk of the celiac artery and SMA was selectively
cannulated and a small contrast injection was made to confirm position. An
arteriogram of the common trunk was attempted but the C2 catheter buckled out
of the common trunk ostium during power injection. The C2 glide catheter was
exchanged for ___ catheter for greater stability in the common trunk.
An arteriogram of the common trunk was successfully performed.
Given the recent transduodenal EUS-guided biopsy, the GDA was the most likely
source of recent active bleeding. Therefore, a decision to embolize the GDA
was made. An ___ microcatheter preloaded with a headliner wire was advanced
through the ___ catheter into the GDA. The GDA was then embolized with
six 3 mm x 3 cm Hilal coils (via saline push), followed by a 6 mm x 20 mm
Concerto coil and a 5 mm x 6 cm Hilal coil (both manually deployed). A
post-embolization arteriogram was then performed of the common trunk.
The ___ catheter was then withdrawn to the iliac bifurcation and a right
common femoral arteriogram was performed, demonstrating a low bifurcation and
confirming the right femoral central line to be intravenous.
A left common femoral arteriogram was then performed, confirming low femoral
bifurcation. All catheters and wires were removed. A left common femoral
arteriogram was performed through the 5 ___ femoral sheath. The sheath was
then removed and an Angio-Seal closure device was deployed. Additional manual
pressure was held until hemostasis was achieved. Sterile dressings were
applied.
A targeted ultrasound was then performed of the right superficial femoral
artery, confirming the right femoral catheter to be intravenous and not cross
arterial structures.
The patient tolerated the procedure well and remained hemodynamically stable
throughout.
FINDINGS:
1. Pre embolization arteriogram of the common trunk of the celiac artery and
SMA demonstrating a narrow common hepatic artery and an irregular
gastroduodenal artery, likely tumor related. No active extravasation of
contrast identified.
2. Coil embolization of the GDA with six 3 mm x 3 cm Hilal coils, 6 mm x 2 cm
Concerto coil, and 5 mm x 6 cm Hilal coil.
3. Post embolization arteriogram of the common trunk of the celiac artery and
SMA demonstrating no significant flow into the GDA. No active extravasation
of contrast identified.
4. Intravenous right femoral catheter.
5. Left common femoral arteriogram showing normal anatomy with low common
femoral artery bifurcation.
IMPRESSION:
Successful left common femoral artery approach coil embolization of the
gastroduodenal artery.
Radiology Report
EXAMINATION: CTA ABD WANDW/O C AND RECONS
INDICATION: ___ year old man with Mr ___ is a ___ male with history of
GERD, PUD, depression, and recently discovered pancreatic mass with likely
liver mets s/p EUS today with biopsy of a pancreatic mass, p/w GIB //
Triphasic Mesenteric Arteriogram to eval mesenteric vasculature (both arterial
and venous) for ___ planning for embolization
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous, and
delayed phase images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 2,791 mGy-cm.
IV Contrast: 150 mL of Omnipaque
COMPARISON: Comparison is made to previous from ___.
FINDINGS:
VASCULAR: Interval coiling of the GDA, in addition to tissue adhesive
injection of varices within the gastric fundus. 1 small coil also appreciated
within hepatic segment 6. No evidence of active extravasation is appreciated
in the current study. There is interval significant decrease in the
hemorrhagic content within the stomach compared to previous. There is
persistent hemo peritoneum, with hemosiderin layering dependently. Mild
interval increase in the stranding and fluid are along the pericolic gutters
bilaterally, representing extension of hemoperitoneum.
Moderate atherosclerosis within the abdominal aorta and visceral arteries. A
right-sided femoral line is in situ.
LOWER CHEST: Small left pleural effusion. Bilateral basal atelectasis, left
greater than right. There is some superimposed consolidation within the left
lower lobe, likely aspiration related.
LIVER: At least 8 hypodense hepatic metastases once again appreciated, with
the largest located in segment 8 measuring 2.3 x 2.6 cm. There is relative
sparing of segment 2 and 3. There is no intrahepatic or extrahepatic biliary
ductal dilatation. Normal appearance of the gallbladder, containing contrast.
SPLEEN:
Mild splenomegaly measuring up to 14 cm, with no evidence of infarct.
PANCREAS:
The pancreatic neck and body is replaced with a predominantly hypodense mass
measuring approximately 4.7 x 7.5 x 3.6 cm. The mass is fairly ill-defined
and hypoenhancing. There is sparing of the head and uncinate process of the
pancreas, with no dilatation of the main pancreatic duct at this level. There
is a common channel of the celiac axis and SMA. There is encasement of the
celiac axis at the trifurcation, with complete encasement of the splenic
artery, proximal common hepatic, and left gastric artery. There is also
contact of the anterior aspect of the proximal SMA by a slightly greater than
180 degrees, but only over a few mm. There is soft tissue infiltration along
the peripancreatic fat and along the transverse mesocolon and lesser curvature
of the stomach. Multiple tiny peripancreatic satellite nodules are
appreciated.
There is obliteration of the SMV at the level of the mass, as well as that of
the portal confluence. The splenic vein is occluded. The main portal vein is
still patent.
There is an enlarged peripancreatic lymph node measuring approximately 1.6 cm
in short axis. An elongated portacaval lymph node measures up to 0.9 cm in
short axis.
No additional sites of mesenteric or retroperitoneal lymphadenopathy.
ADRENALS:
Bilateral adrenals unremarkable.
GENITOURINARY:
Bilateral kidneys unremarkable. No evidence of hydronephrosis. The bladder
is decompressed with a Foley catheter in situ. Mild prostatic enlargement.
GASTROINTESTINAL TRACT: The stomach is largely decompressed compared to
previous.
Small hiatal hernia, with associated herniation of fluid. Small duodenal
diverticulum.
BONES AND SOFT TISSUES: No worrisome osseous findings. Small right fat
containing inguinal hernias as well as small fat containing umbilical hernia
unchanged.
IMPRESSION:
1. Interval coiling of the GDA, with as well as variceal treatment in the
gastric fundus. Interval significant decrease in the intraluminal hemorrhage
within the gastrointestinal tract. No evidence of active extravasation.
2. Small to moderate hemoperitoneum,
3. Large ill-defined mass in the pancreatic neck and body, likely representing
primary adenocarcinoma. Complete encasement of the celiac axis branches as
well as contact of the SMA in the context of a common trunk supplying celiac
and SMA. Obliterated portal confluence, proximal SMV, and splenic vein.
Multiple small peripancreatic satellite nodules.
4. Mildly enlarged peripancreatic lymph nodes.
5. Multiple hepatic metastases.
6. Interval worsening consolidation within the left lower lobe superimposed
over atelectasis, likely related to aspiration.
Radiology Report
INDICATION: ___ year old man with newly placed advanced venous access device
in R IJ. // AVAD placement, r/o PTX Contact name: ___, Phone:
___
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiographs ___.
FINDINGS:
The cardiomediastinal and hilar contours are stable. There is no
pneumothorax. A new left pleural effusion with adjacent compressive
atelectasis is small. There is no focal consolidation concerning for
pneumonia. ETT is present in standard position. Right internal jugular
catheter is new, with tip very proximal, projecting above the thoracic inlet.
IMPRESSION:
New right internal jugular catheter, with tip projecting above the thoracic
inlet. No pneumothorax. New small left pleural effusion.
Radiology Report
INDICATION: ___ year old man with variceal bleeding due to left sided HTN //
Please address bleeding from splenogastric varices
COMPARISON: CT abdomen of ___.
TECHNIQUE: OPERATORS: Dr. ___, Dr. ___
___ attending) and Dr. ___ radiologist performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
ANESTHESIA: General anesthesia.
CONTRAST: 180 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 53.1 min, 952 mGy
PROCEDURE: 1. Ultrasound-guided percutaneous splenic vein access
2. Splenic venogram.
3. Splenic vein rotational angiogram with cone beam CT.
4. Placement of left common femoral vein triple lumen central venous
catheter.
5. Recanalization of occluded splenic vein
6. Main portal venogram.
7. Angioplasty of the splenic vein and portal confluence with 4 mm x 4 cm
balloon.
8. Transsplenic stent placement with 8 mm x 8 cm Luminex stent from splenic
vein to main portal vein.
9. Stent angioplasty to 8 mm followed by splenic venogram.
10. Proximal (splenic side) stent extension 8 mm x 4 cm Luminex stent.
11. Stent angioplasty to 8 mm followed by splenic venogram.
12. Distal (hepatic side) stent extension with 8 mm x 4 cm Luminex stent.
13. Stent angioplasty to 8 mm followed by splenic venogram.
14. Balloon maceration along the length of the stent followed by splenic
venogram.
15. Mechanical Angiojet thrombolysis along the length of the stent followed by
splenic venogram.
16. Administration of 10 mg tPA into the main portal vein followed by splenic
venogram.
17. Splenic vein access tract embolization with 8 mm Amplatzer plug.
18. Targeted splenic ultrasound.
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.
Under continuous ultrasound guidance, a 21 gauge x 15 cm Cook needle was
advanced through the splenic parenchyma into a patent splenic vein until blood
return was noted. A Headliner wire was then advanced into the splenic vein
through the needle. The Cook needle was removed and an Accustick set sheath
was placed, followed by placement of an 0.035in ___ wire into the splenic
vein. Next, a 6 ___ by 25 cm sheath was advanced. Contrast was injected to
confirm position and a venogram was performed.
Rotational cone-beam CT angiography was then performed to help delineate the
anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered
images of the arterial anatomy required post-processing on an independent
workstation under direct physician ___. These images were used in the
interpretation, decision making for intervention and reporting of this
procedure.
A Kumpe catheter was advanced over the ___ wire and the ___ wire was
exchanged for a Glidewire. Access into the gastric varices was attempted
using a combination of the Kumpe catheter and a Glidewire.
At this point the patient was noted to be bradycardic with a heart rate in the
___ and a code was called. Attention was immediately turned to the placement
of a left common femoral vein triple-lumen central venous catheter. The left
groin was prepped. Under continuous ultrasound guidance, the patent left
common femoral 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 IVC using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced into the IVC. A triple-lumen central venous catheter was advanced
over the wire into the inferior vena cava. All 3 access ports were aspirated,
flushed and capped. The catheter was secured to the skin with a 0 silk suture
and sterile dressings were applied. Spot fluoroscopic image demonstrating good
alignment of the catheter and no kinking. The wire was removed.
The patient's bradycardia resolved after administration of atropine and all
vital signs were stable.
Attention was then turned back to accessing the gastric varices. During
attempted navigation through the splenic varices into the gastric varices with
the Kumpe catheter and Glidewire, the level of splenic vein occlusion was
encountered. The occluded splenic vein was cannulized using a combination of
a Quick Cross catheter, stiff straight Glidewire, and angled Glidewire. Hand
injection contrast through the catheter confirmed tip position in the main
portal vein. Main portal venogram was then performed, demonstrating patency
of the main portal vein and intrahepatic portal branches. The Quick Cross
catheter was exchanged for a Kumpe catheter, through which the glidewire was
exchanged for an Amplatz wire. The Kumpe catheter was removed and angioplasty
of the splenic vein and portal confluence was performed with a 4 mm x 4 cm
mustang balloon.
A 8 mm x 8 cm Luminex stent was placed across the splenic vein and portal
confluence. Following stent deployment, the stent was dilated using an 8 mm
balloon. Post-stent venogram demonstrated persistent poor flow.
Stent extension was performed using a 8 mm x 4 cm Luminex stent deployed
proximally along the splenic vein. Following stent deployment, the stent was
dilated using an 8 mm balloon. Post-stent venogram demonstrated persistent
poor flow.
Stent extension was performed using a 8 mm x 4 cm Luminex stent deployed
distally at the main portal vein. Following stent deployment, the stent was
dilated using an 8 mm balloon. Post-stent venogram demonstrated persistent
poor flow with in-stent thrombosis.
Balloon maceration with a 8 mm balloon was performed along the length of the
stent followed by splenic venogram demonstrating persistent poor flow with
in-stent thrombosis.
The 6 ___ 25 cm sheath exchanged for a 6 ___ 45 cm sheath. A pull back
sheath portal venogram demonstrating poor flow with thrombosis. Mechanical
thrombectomy was then performed along the length of the stent using an
AngioJet device. Sheath angiogram was then performed of the splenic vein
demonstrating excellent flow through the portosplenic stent with resolution of
previously seen gastric varices, but with an eccentric filling defect within
the main portal vein and poor filling of the left portal vein. The glidewire
and Kumpe catheter were unable to be advanced into the left portal vein. 10
mg of tPA was administered via the Kumpe catheter into the main portal vein.
Repeat sheath angiogram was then performed of the splenic vein, demonstrating
excellent flow through the stent from the splenic vein to the main portal vein
with decreased size of previously seen main portal vein filling defect and
increased filling of left portal vein branches.
Next, the transsplenic 6 ___ sheath was pulled back over the wire with
contrast injection to the vein entry site. Contrast injection through the
sheath demonstrated parenchymal location. An 8 mm Amplatzer vascular plug was
deployed in the parenchymal tract, and the sheath and wire were removed. A
sterile bandage was applied. Targeted splenic ultrasound demonstrated adequate
position of the plug and small ___ hematoma.
The patient was transferred to the ICU in stable condition.
FINDINGS:
1. Splenic venogram and cone-beam CT demonstrating complete occlusion of the
splenic vein from the pancreatic mass. Extensive perigastric collaterals were
noted, including filling into recently endoscopically glued gastric varices.
The main portal vein was noted to be patent, filling via extensive
collaterals.
2. Recannulization of the occluded splenic vein with stent placement to the
main portal vein.
3. Splenic venogram after mechanical thrombectomy and tPA administration
demonstrating excellent flow from the splenic vein to the main portal vein
with no evidence of in-stent thrombosis and no filling of splenic and gastric
varices. Thrombus noted within the main portal vein that continued to decrease
in size towards the end of the case.
4. Targeted splenic ultrasound demonstrated adequate position of the Amplatzer
plug and small ___ hematoma.
5. Successful placement of a left common femoral vein triple lumen central
venous catheter.
IMPRESSION:
1. Successful recannulization of occluded splenic vein with stent placement
from the splenic vein to the main portal vein with reduction in gastric
varices on splenic venogram.
2. Successful placement of a left common femoral vein triple lumen central
venous catheter.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with advanced venous access device incompletely
visualized on CXR // please incorporate neck in CXR Contact name: ___
___, Phone: ___ please incorporate neck in CXR
IMPRESSION:
In comparison with the earlier study of this date, the right IJ sheath tip is
projected above the upper portion of the hemithorax. There appears to be
extensive kinking of the visualized portion of the sheath.
Otherwise little change.
Radiology Report
INDICATION: ___ year old man with intubated, GIB s/p colloid resuscitation,
consolidation on CT, on vanc and cef, still spiking fevers // eval worsening
PNA, pulm edema
TECHNIQUE: Portable semi upright chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects towards the right mainstem bronchus
and should be retracted. Kinking of the right internal jugular sheath is again
noted. Left pleural effusion and left lower lobe atelectasis have increased
since the prior study. Small right pleural effusion is likely. Heart size
and mediastinal contours are within normal limits.
Right lower lobe pneumonia has worsened since the prior radiograph.
IMPRESSION:
1. Low position of the endotracheal tube warrants retraction.
2. Persistent kinking of the right internal jugular sheath.
3. Bilateral pleural effusions, left greater than right, with moderate left
lower lobe atelectasis.
4. Right lower lobe pneumonia worsened since the prior radiograph.
NOTIFICATION: Findings discussed with the ICU resident by Dr. ___
telephone at 09:46, upon discovery.
Radiology Report
EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS
INDICATION: ___ year old man with pancreatic mass, gastric varicies, with on
going blood loss, unclear etiology // Triphasic Mesenteric Arteriogram to
eval mesenteric vasculat
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous, and
delayed phase images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE:
DLP: 2951 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL of Omnipaque
COMPARISON: CTA abdomen and pelvis ___
FINDINGS:
VASCULAR:
The patient is status post coil embolization of the GDA as well as glue
injection of gastric varices at the gastric fundus, and is more recently
status post recanalization and stenting of the splenic vein and portal vein,
which was done via splenic access with Amplatz plug placed at the splenic
access site.
Endovascular coils within the GDA in unchanged position. Tissue glue
injection of varices within the gastric fundus is noted, also unchanged.
Linear radiopaque focus presumably representing embolized glue within the
right posterior portal vein has moved slightly proximally in the interval (4B:
249, compared to IIIb: 239 on prior study). There has been interval placement
of splenic vein stent with extensions along the splenic vein and portal vein
margins. The stent is thrombosed and occluded. Some thrombus is seen within
the main portal vein just distal to the portal venous terminus of the occluded
stent (4B: 250), and the aforementioned focus of hyperdensity that might
represent embolized glue is adjacent to this thrombus. The SMV is occluded
with thrombus as has been the case previously, unchanged.
Hemo peritoneum is increased compared to the prior CT. There is a new
perisplenic hematoma. An Amplatzer device is in place within the splenic
parenchymal access site. There is no evidence of active extravasation of
contrast from this site or elsewhere about the spleen. An ill-defined focus
of hyperdensity within the perisplenic hematoma that does not change during
this examination is consistent with contrast extravasated from the previous
procedure. Heterogeneously dense clot within the abdominal portions of the
hemo peritoneum are compatible with recent or ongoing bleeding, but no sites
of active extravasation are identified.
The splenic parenchyma surrounding this devise is hypoperfused, which may
represent small splenic infarct or post access changes.
There is no abdominal aortic aneurysm. There is moderate calcium burden in
the abdominal aorta and great abdominal arteries. A left -sided femoral vein
line is noted.
LOWER CHEST: Small left and trace right pleural effusion are increased
compared to prior. Bibasilar atelectases are similar as before. New
bilateral areas of hypoperfusion are seen within the atelectatic segments (4A:
23; right lower lobe, 4A: 22; left lower lobe). These could represent small
areas of pulmonary hypoperfusion due to infarct, pulmonary embolus, infection,
or neoplasm; no gross filling defects are appreciated in the pulmonary
arteries seen at the lung bases. In addition, there is ground-glass density
and interlobular septal thickening in the lower lobes suggestive of mild
pulmonary edema.
ABDOMEN:
HEPATOBILIARY: Multiple hepatic metastases are again demonstrated with the
largest located in the segment 8 measuring 2.3 x 2.6 cm. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits and contains contrast.
PANCREAS: Hypodense pancreatic mass measuring 4.7 x 7.5 x 3.6 cm is again
demonstrated. This mass encases the celiac axis and comes in contact with
SMA. Of note, there is a common origin of the celiac and SMA. Soft tissue
infiltration is noted along the transverse mesocolon and lesser curvature of
the stomach. Multiple tiny peripancreatic satellite nodules. The 1.6 cm
peripancreatic lymph node and 0.9 cm portacaval lymph nodes are stable. No
other lymphadenopathy is identified.
SPLEEN: As above under vascular.
ADRENALS: The right and left adrenal glands are not significantly changed,
with minimal focal thickening of the common limb of the right adrenal gland
but no discrete nodule.
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.
PELVIS: Bladder is decompressed around the Foley catheter. There is no
evidence of pelvic or inguinal lymphadenopathy. Hemo peritoneum in the pelvis
is increased compared to ___.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are within normal limits.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Small fat containing bilateral
inguinal hernia and small fat containing umbilical hernia are unchanged.
IMPRESSION:
1. Large hemoperitoneum is increased compared to prior, with new perisplenic
hematoma and sentinel clot tracking within the left upper quadrant to the mid
abdomen. These findings suggest the spleen as a source of bleeding, although
no active extravasation is appreciated. The Amplatzer device is in place at
the site of splenic access with some adjacent hypoperfusion of the splenic
parenchyma compatible with infarct or post procedure changes.
2. The portal and splenic veins stent placed on the preceding day is occluded,
with new small focus of partially occlusive thrombus in the main portal vein
adjacent to the stent. Stable occlusion of superior mesenteric vein.
3. Stable pancreatic mass, enlarged surrounding lymph nodes and hepatic
metastases.
4. New bibasilar foci of hypoperfusion of atelectatic lung could reflect
pulmonary infarcts, infection, or new metastases. No filling defects are
identified in the pulmonary arteries at the lung bases. Probable mild
pulmonary edema, with increased bilateral pleural effusions.
5. A small curvilinear hyperdensity in the right posterior portal vein,
presumably embolized intravascular glue, has moved slightly proximally and
abuts the new thrombus in the main portal vein.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 10:00 ___, 15 minutes after discovery of the
findings, and with Dr. ___ at 3:15 am.
Radiology Report
EXAM: SPLENIC ARTERY EMBOLIZATION
INDICATION: ___ year old man with hematoperitoneum, s/p transsplenic access.
Please stop bleeding.
COMPARISON: CTA abdomen and pelvis from ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: The patient was intubated and sedated when he was brought into
the ___ suite. 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None.
CONTRAST: 55 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 10.8 min, 283 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Celiac arteriogram with cone beam CT.
3. Splenic artery gelfoam embolization.
4. Post-embolization splenic artery angiogram.
5. Right common femoral arteriogram.
6. Arterial closure with Angioseal device.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
health care proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. The right groin was prepped and draped in the usual sterile
fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A MIK catheter was advanced over ___ wire into the aorta. The wire was
removed and the common trunk of the celiac and SMA arteries was selectively
cannulated and a small contrast injection was made to confirm position. A
celiacarteriogram was performed. A ___ microcatheter pre-loaded
with a Transcend wire was used to access the splenic artery. The
microcatheter was parked in the mid to distal splenic artery and gelfoam
embolization to slow flow was performed at this level. A post-embolization
splenic artery angiogram was performed with findings detailed below.
The catheter was then removed over the wire and the sheath was removed. A
common femoral arteriogram was performed prior to use of a closure device. An
Angioseal closure device was deployed and manual pressure was held until
hemostasis was achieved. The patient tolerated the procedure well.
FINDINGS:
1. Common celiac/SMA arteries trunk.
2. Significantly attenuated proximal splenic artery compatible with tumor
compression from known pancreatic mass.
3. No evidence of active extravasation about the spleen although there is
increased patchy parenchymal blush in the lower spleen likely related to
recent procedure.
4. Gelfoam embolization to slow flow of the distal splenic artery.
5. Post-embolization splenic artery angiogram demonstrating significantly
slower filling of the distal splenic arterial tree with heterogeneous
parenchymal enhancement.
IMPRESSION:
Successful right common femoral artery approach mid to distal splenic artery
gelfoam embolization to slow flow.
Radiology Report
INDICATION: ___ year old man with pancreatic mass now with gastric varices and
bleeding. Please place central IJ line.
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: The patient was intubated and sedated when brought into the ___
suite. 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 0.3 min, 1 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the healthcare proxy. The patient was then brought to the
angiography suite and placed supine on the exam table. A pre-procedure
time-out was performed per ___ protocol. The neck was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath.
The Nitinol wire was removed and a short ___ wire was advanced into the IVC.
After dilation of the soft tissue tract using a ___ F dilator, a triple lumen 7
F central venous line was advanced over the wire into the superior vena cava
with the tip in the cavoatrial junction. All three access ports were
aspirated, flushed and capped. The catheter was secured to the skin with a 0
silk suture and sterile dressings were applied. Final spot fluoroscopic image
demonstrating good alignment of the catheter and no kinking.
The patient tolerated the procedure well without immediate complications.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing double
lumen temporary pheresis catheter with catheter tip terminating in the distal
superior vena cava.
Catheter tip at the cavoatrial junction.
IMPRESSION:
Successful placement of a right internal jugular approach ___ triple lumen 16
cm central venous line. The line is ready to use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pancreatic mass c/b by GI bleeding now s/p
NGT placement // Eval for NGT placement
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has received a nasogastric
tube. The course of the tube is unremarkable, the tip of the tube projects in
pre-pyloric position. No evidence of complications.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with new dx pancreatic ca, massive GI bleed,
being treated for ventilator assoc PNA // Eval for interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
In comparison to the prior chest radiograph, all lines and tubes have been
removed.
The bilateral lung aeration has improved dramatically. There is a small left
pleural effusion. There is a subtle right basilar opacity. Heart size is
normal. The mediastinal and hilar contours are normal. The pulmonary
vasculature is normal. No pneumothorax is seen.
IMPRESSION:
1. Small left pleural effusion.
2. Subtle right basilar opacity, which could represent residual pneumonia.
Radiology Report
INDICATION: ___ man with worsening abdominal pain and absence of
bowel sounds. Evaluate for obstruction or ileus.
TECHNIQUE: Supine and upright abdominal radiographs.
COMPARISON: CTA abdomen and pelvis from ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Splenic and portal venous stents are intact. Irregular density overlying the
left upper quadrant likely reflects gastric variceal glue injection.
IMPRESSION:
No evidence of mechanical obstruction or ileus.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ male with recently diagnosed pancreatic
adenocarcinoma and liver metastasis who presents with massive GI bleed and
melena lb have hemo peritoneum, perisplenic hematoma currently status post GDA
and splenic embolization. Evaluate for interval change.
TECHNIQUE: Multidetector and multi phasic CT images through the abdomen and
pelvis were obtained after the administration of intravenous contrast.
Coronal and sagittal reformations were generated and reviewed. Coronal
maximal intensity projection images were acquired on a separate workstation.
Oral contrast was not administered.
DOSE: Total DLP (Body) = 1,424 mGy-cm.
COMPARISON: CTA abdomen and pelvis dated ___.
FINDINGS:
The splenic artery appears attenuated. This is associated with progressed and
evolving splenic infarction as demonstrated by peripheral geographic
hypoenhancing parenchyma. Patient is status post GDA coil embolization as
well as glue injection of the gastric varices at the gastric fundus. The
endovascular coils within the GDA appear in similar position. Linear
radiopaque focus within the posterior right portal vein (06:46) is similar in
position. This is presumably embolized glue. There is a stent within the
splenic and portal veins which appears thrombosed and occluded, unchanged in
appearance relative to study dated ___. Best appreciated on the
coronal sequence 12 image 50, some thrombus extends into the distal main
portal vein. Similar to prior examination, there is thrombus identified
within the superior mesenteric vein (10:59).
Relative to prior examination, the degree of hemoperitoneum is not
significantly changed. A perisplenic hematoma is persistently present though
decreased in density suggestive of evolution (10:52). An Amplatzer device is
again noted within the splenic parenchymal access site (10:36). There is no
evidence of active extravasation. Previously heterogeneously dense clot
within the abdominal portions of the hemo peritoneum is no longer present.
A hypodense pancreatic mass a 7.6 x 4.4 x 4.6 cm pancreatic head mass is not
significantly changed in size or appearance. The mass appears to encase the
celiac axis (06:50) as well as a put the superior mesenteric artery (06:54). A
common origin of the celiac and superior mesenteric artery is noted. Again
noted, there is soft tissue infiltration along the greater curvature of the
stomach (06:50) as well as extending along the transverse mesocolon. A 1.1 cm
peripancreatic node (06:57) and 0.6 cm portacaval node are stable in
appearance.
Chest: Bibasilar atelectasis is mild. Visualized heart and pericardium are
unremarkable.
Abdomen: Multiple hepatic metastases are again demonstrated throughout the
liver, the largest lesion within the right hepatic lobe within segment VI
measures approximately 2.1 x 2.6 cm (10:44) relative to prior study performed
recently dated ___, these appear not significantly changed. There is
no intrahepatic biliary ductal dilatation. The gallbladder is without
radiopaque cholelithiasis. A small accessory spleen is noted posteriorly.
Bilateral adrenal glands are unremarkable. Bilateral kidneys present
symmetric nephrograms excretion of contrast. No focal lesions identified.
There is no hydronephrosis.
The abdominal aorta is normal in caliber without aneurysmal dilatation.
Atherosclerotic calcifications are mild. There is no retroperitoneal or
mesenteric adenopathy.
Loops of small bowel are without evidence of bowel wall thickening or
obstruction. Bowel wall thickening and edema involving the splenic flexure
and descending colon appears new relative to prior examination. An umbilical
fat containing hernia is small, the fascial defect measuring 1 cm (6:96).
Pelvis: The bladder is normal distended and grossly unremarkable. Prostate
gland and seminal vesicles are normal in appearance. Pelvic free fluid is
moderate in amount, extension of abdominal hemo peritoneum. Bilateral fat
containing inguinal hernias are small. A trace amount of fluid tracks within
the right inguinal hernia. Inguinal and pelvic sidewall nodes are not
pathologically enlarged.
Osseous structures: No suspicious lytic or blastic lesions are identified.
IMPRESSION:
1. Large pneumoperitoneum and perisplenic hematoma are not significantly
changed in size relative to prior study obtained ___. There is
however decreased density of the fluid consistent with evolution of blood
products. There is no evidence of active extravasation.
Progressed relative to prior study, there is involving splenic infarction.
The splenic artery appears attenuated by pancreatic mass.
2. Patient is status post PDA coil embolization and Amplatzer device
placement within the spleen, stable in position.
3. Thrombosed splenic and portal vein stent with a portion of thrombus
extending outside of the stent and into the distal portal vein. Thrombosis of
the superior mesenteric vein is not significantly changed.
4. Bowel wall thickening and edema involving the splenic flexure and
descending colon is nonspecific for which attention on follow-up is advised,
likely ischemic in origin.
5. Large pancreatic head mass with soft tissue which appears to infiltrate
the tissue along the greater curvature of the stomach in transverse mesocolon.
6. Small curvilinear hyperdensity within the right posterior portal vein is
presumably embolize intravascular glue, unchanged in appearance and position.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pancreatic adenca, PNA // Interval change
of PNA
TECHNIQUE: PA and lateral chest radiographs.
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low resulting crowding of the pulmonary bronchovascular
structures. The heart is not enlarged. The cardiomediastinal contour is
unchanged compared to prior studies. There is persistent subtle airspace
opacity in the right mid to lower lung, this may reflect the residua of the
patient's known pneumonia. The left lung is clear. No pleural effusion seen.
Radiopaque material in the left upper quadrant consistent with prior splenic
embolization.
IMPRESSION:
No significant interval change when compared to the prior study.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with pancreatic cancer here s/p GI bleed, now s/p
fall w head strike, neurologically stable
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformatted images were acquired.
DOSE: This study involved 7 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 1.0 s, 4.0 cm; CTDIvol = 47.0 mGy (Head) DLP =
188.0 mGy-cm.
4) CT Localizer Radiograph
5) CT Localizer Radiograph
6) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
7) Stationary Acquisition 2.0 s, 7.7 cm; CTDIvol = 44.4 mGy (Head) DLP =
342.2 mGy-cm.
Total DLP (Head) = 1,386 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration. 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, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with new dx pancreatic adenocarcinoma w/ liver
mets now rising TBili, LFTs // Evaluate for cholangitis/obstruction
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 9 mL Gadavist
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT angiogram abdomen and pelvis, ___.
FINDINGS:
Lower Thorax: There are small bilateral pleural effusions, left greater than
right.
Liver: Numerous metastatic lesions are seen throughout the liver similar to
prior examination, largest in the right lobe measuring up to 2.7 cm. Occluded
stent within the splenic and portal veins is again visualized. The main
portal vein is occluded. Right and left portal veins and branches are
opacified from collaterals. Thrombus is again seen within the superior
mesenteric vein. A GDA coils is noted, better seen on the prior CT. The
proximal common hepatic artery is encased by the pancreatic mass. There is a
moderate amount of hemoperitoneum similar in appearance to prior.
Biliary: There is no intra or extrahepatic biliary ductal dilatation. The
gallbladder appears normal. There are no areas of abnormal enhancement or
signal changes to suggest cholangitis.
Pancreas: There is a large hypointense mass in the pancreatic body measuring
approximately 6.9 x 3.7 cm unchanged from priors given differences in
technique. The mass encases the common origin of the celiac and SMA. Celiac
trunk and branches are severely narrowed by the mass.
Spleen: Spleen is heterogeneous in signal intensity on both precontrast
sequences and the post-contrast dynamic series, related to prior
injury/infarcts, similar in appearance to prior examination. An Amplatz
device is again noted within the spleen.
Adrenal Glands: The adrenal glands appear normal.
Kidneys: Kidneys are normal in size. No hydronephrosis is appreciated. There
is no concerning renal mass.
Gastrointestinal Tract: No evidence of intestinal obstruction.
Lymph Nodes: No lymphadenopathy is appreciated.
Vasculature: There is an occluded stent in the splenic and portal veins. GDA
coils are noted. There is superior mesenteric vein thrombus. Pancreatic mass
encases the celiac axis and branches.
Osseous and Soft Tissue Structures: No suspicious osseous or soft tissue
lesions.
IMPRESSION:
1. No intra or extrahepatic biliary ductal dilatation. Specifically, no MR
evidence for active cholangitis or biliary obstruction.
2. Known large pancreatic body mass, characterized in detail on the recent CT
examination from ___, with encasement of the proximal celiac axis
and SMA.
3. Numerous liver metastases appear similar to prior.
4. Moderate hemoperitoneum appears similar to prior.
5. Evolving splenic infarcts, also seen on the prior CT examination.
6. Unchanged occluded splenic and portal venous stent. Chronic obliteration
of the upper SMV by the pancreatic mass.
Radiology Report
INDICATION: ___ male with hematemesis status post gastrointestinal
biopsy. Evaluate for free air.
TECHNIQUE: Frontal radiographs of the chest was obtained.
COMPARISON: None available.
FINDINGS:
There is possible subtle opacity in the right midlung. The lungs are
otherwise clear without focal consolidation, pleural effusion, pneumothorax.
No pulmonary edema is seen. The heart size is normal. The mediastinal and
hilar contours are normal. No signs of intra-abdominal free air are seen.
IMPRESSION:
Subtle right midlung opacity, nonspecific. No evidence of intra-abdominal
free air.
RECOMMENDATION(S): Repeat with PA and lateral suggested.
Radiology Report
INDICATION: ___ male with massive hematemesis. Please evaluate
aortoenteric fistula.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast in the arterial phase. Then, imaging was obtained through the
abdomen and pelvis in the arterial phase phase. Reformatted coronal and
sagittal images through the chest, abdomen and pelvis, and oblique maximal
intensity projection images of the chest were submitted to PACS and reviewed.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 6.1 mGy (Body) DLP = 3.0
mGy-cm.
4) Spiral Acquisition 8.7 s, 68.4 cm; CTDIvol = 15.0 mGy (Body) DLP =
1,022.9 mGy-cm.
Total DLP (Body) = 1,026 mGy-cm.
COMPARISON: Chest radiograph from ___.
FINDINGS:
VASCULAR:
The thoracic aorta is unremarkable without dissection or aneurysm. The
thoracic great vessels are unremarkable. The pulmonary arteries are well
opacified to the subsegmental level without filling defect to suggest
pulmonary embolism. Pulmonary arteries are normal in caliber.
There is no aortic aneurysm or dissection. There is moderate calcium burden in
the abdominal aorta and great abdominal arteries. The abdominal aorta and its
major branches are patent. The celiac artery and superior mesenteric artery
arise from a common trunk (series 602b:image 46). There is no evidence for
aortoenteric fistula.
CHEST:
The esophagus contains an enteric tube and appears unremarkable without
evidence of perforation, wall thickening, or presence of esophageal varices.
No esophageal fistula is present. There is no supraclavicular or axillary
lymphadenopathy. There is no mediastinal or hilar lymphadenopathy. An
endotracheal tube terminates in the distal trachea, and the airways are patent
to the segmental level. The esophagus is normal with an enteric tube
terminating in the stomach. The heart is normal in size without pericardial
effusion. Left ventricular hypertrophy is noted (series 2:image 58).
There are centrilobular nodular opacities in the right upper lobe likely
reflective of aspiration (series 2: Image 46, 43). Dependent atelectasis is
noted in the bilateral lower lobes. No pleural effusion or pneumothorax is
seen.
ABDOMEN:
HEPATOBILIARY: There are multiple peripherally enhancing lesions scattered
throughout the liver with the largest measuring 2.4 x 2.2 cm in the right
hepatic lobe (series 2:80, 83, 100,105,117). These are concerning for
metastatic disease. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits.
PANCREAS: There is an ill-defined mass arising from the pancreatic body which
encases the celiac artery, splenic artery, common hepatic artery and left
gastric artery (series 2: Image 104, 100). There is no pancreatic ductal
dilation. There is a mildly enlarged periportal lymph node measuring 1.1 x
1.8 cm (series 2:image 112).
SPLEEN: The spleen shows normal size. Heterogeneous enhancement of the spleen
is due to timing of imaging.
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 lesion or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: An enteric tube terminates in the stomach. A small hiatal
hernia is noted. There is no evidence of active contrast extravasation within
the stomach, small bowel or large bowel. Small bowel loops demonstrate normal
caliber, wall thickness and enhancement throughout. High-density material
within the lumen of the distal ileum, cecum, ascending colon and transverse
colon likely reflect blood given clinical history. There is no definite
colonic wall thickening or signs of obstruction.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
There is no free intraperitoneal fluid. There is a mild amount of mesenteric
free fluid (series 2:image 130).
PELVIS: The urinary bladder is decompressed by a Foley catheter. There is no
evidence of pelvic or inguinal lymphadenopathy. There is a small amount of
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are unremarkable.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions.
There is no fracture. Bilateral fat-containing inguinal hernias are seen as
well as a small fat containing umbilical hernia. .
IMPRESSION:
1. High density material in the lumen of the distal ileum, cecum, ascending
colon and transverse colon compatible with blood. Source of bleeding is
unclear with no evidence of active contrast extravasation within the
gastrointestinal tract or aortoenteric fistula. The esophagus appears
unremarkable without evidence of varices or perforation.
2. Poorly evaluated malignant pancreatic mass encasing the celiac artery and
its branches with multiple hepatic lesions compatible with metastases.
3. Nodular opacities in the right upper lobe compatible with aspiration.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematemesis
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 98.1
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 110.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Mr ___ is a ___ male with history of GERD, PUD, depression,
and recently discovered pancreatic mass with likely liver mets
s/p EUS ___ with biopsy of a pancreatic mass confirmed
pancreatic adenocarcinoma p/w massive hematemsis.
# Pancreatic Cancer: came ___ for diagnostic biopsy which showed
poorly differentiated pancreatic cancer. Patient had a lot of
pain, both from pancreatic mass and intraperitoneal bleed.
Patient's case reviewed by liver tumor board and deemed not a
candidate for surgery. Patient's functional status also too poor
to begin chemotherapy. After multiple family meetings and goals
of care discussions patiently ultimately made DNR/DNI and
discharged home with hospice.
# UGIB: Hbg 15 at baseline, 9.9 on presentation. Intubated on
admission ___ setting of hematemesis. On admission (___)
underwent ___ without clear bleed, but embolization of artery
(GDA) invaded by tumor. Continued to bleed however, with EGD
showing gastric varicies, which were glued on ___. However,
continued bleeding, with CTA on ___ showing re-bleed of
varicies. Went to ___ on ___ with stenting of thrombosed splenic
vein, ___ attempt to relieve the splenic HTN which was leading to
the gastric varicies. However, continued to bleed on ___, with
EGD showing no bleed from varicies. CT A/P showed bleed into
splenic capsule/peritoneum from site where splenic stent had
been placed through the day prior; splenic stent had thrombosed
___ this interval. Underwent embolization of spleen with
cessation of bleeding. Pancreatobiliay surgery had been
consulted ___ the setting of these recurrent bleeds; did not feel
patient was surgical candidate. On pantoprazole gtt and
octreotide gtt (total 5 days), and then transitioned to PPI BID.
___ total recieved 12 U PBRBCs, 2 U FFP, 1 U platelets.
# Direct Hyperbiliruminemia: Unclear etiology from turmor burden
versus possible medication effect as patient was on ceftriaxone
for treatment of PNA. Elevated direct bilirubinemia along with
rising LFTs and WBC raised concern for possible obstructive
process and/or cholangitis. Patient switched from ceftriaxone to
zosyn after which LFTs downtrended. CT Abdomen showed no
evidence of biliary dilitation and MRCP also w/o evidence of
biliary obstruction or cholangitis. Bilirubin normalized at time
of discharge.
# Pneumonia: VAP vs aspiration pneumonia ___ setting of
hematemesis. Intubated ___ setting of hematemesis/need for
intevention, but remained intubated for several days due to
heavy sputum production. Sputum eventually speciated out as MSSA
and E.coli. Initially covered broadly with vanc/cefepime/flagly
on ___, eventually narrowed to ceftriaxone on ___, with plan
for ___ut patient switched to zosyn (___) after
concern for possible gastrointestinal infection.
# Pain control: Has ongoing abdominal pain likely component of
tumor pain but primarily due to hemoperitoneum. ___ ICU pain
controlled with MS ___ and dilaudid PCA. After transfer to
oncology med floor patient, PCS discontinued, written for IV
dilaudid prn, and eventually transitioned to Fetanyl patch with
PO dilaudid for breakthrough pain.
# Fall: Occurred overnight on medicine floor while attempting to
ambulate to the bathroom and positive head strike. Unclear
etiology which patient describes mechanical but also may have
some presyncopal symptoms. CT head w/o bleed or mass. Patient
found to be orthostatic and given IVF.
==================== |
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:
Ms. ___ is a ___ with CHF, afib, COPD, Hep C, transferred
from ___ for one week of worsening DOE and
hypotension. Over the past week, she has experienced worsening
DOE, now short of breath even with a few steps. She was recently
taken off of her spironolactone due to "too much fluid in my
belly." Her weight has been variable day to day but is overall
unchanged. She is unclear if she has been gaining weight over
that period but denies any worsening orthopnea.
Per ___, pt saw PCP 4 days prior, stopped Spironolactone.
She was advised to present to ED for hypotension at that time
but refused. ___ reported persistent hypotension, in addition to
weakness, faituge, SOB and increased leg swelling. Seen in
___. Initial SBP in the ___ -> 100s s/p 1L NS. Trop
<0.02 but D-dimer 1036. Cre 2.1 -> CTA deferred. Referred to
___ for V/Q scan. BNP 89.4
She presented to the ___ ED at 22:17. Initial vitals were 97.5
88 110/70 22 98%. She was noted to have L>R ___ edema (stable per
patient). D-dimer was sent and elevated to 1030. INR was 1.2.
BNP was 297; troponin <0.01. The patient underwent a chest x-ray
which was unremarkable. On ultrasound her IVC was 100%
collapsable with inspiration; no abdominal fluid pockets were
identified for paracentesis. The patient's O2 saturation was
maintained on nasal cannula. However, she was transiently
hypotensive to the ___ (systolic). She received a total of 2L NS
from presentation and was started on ___ for suspected PE in the
setting of dyspnea and unilateral leg swelling. No chest pain or
orthopnea.
Lactate 2.2. Trop <0.01.
On arrival to the MICU, patient was alert, interactive, and in
no acute distress. Unilateral leg swelling has been stable over
the past ___ years.
Review of systems:
(+) Per HPI
(-) Denies fever, headache, chest pain, chest pressure or
weakness. Denies nausea, vomiting, diarrhea, or abdominal pain.
Acholic stools a few days ago. Denies dysuria, frequency, or
urgency. Denies rashes or skin changes.
Past Medical History:
NIDDM2 (recent dx)
COPD (prescribed O2 but not using; baseline unable to walk
___ w/o SOB)
Paroxysmal A Fib (not on anticoagulation given thrombocytopenia;
on metop and dilt; hx afib w/ RVR on dilt gtt)
CHF (triggered by afib w/ RVR; normal EF)
HTN
Lung nodule (s/p right lower lobectomy)
Cirrhosis (due to HCV; c/b chronic thrombytopenia; on HCTZ,
spironolactone; prior EGD with grade I varices)
Hep C (IVDU; currently not treated; tried IFN in past but did
not erradicate the Hep C)
Social History:
___
Family History:
Father- MI in ___. Mother- colon and gastric cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.5 88 110/70 22 98%
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals - Tm 98.6, Tc 98.6, HR ___ per tele, BP 91-99/56-69,
___ on RA
FSG: 184, 198, 193, 161
I/O: 1500/740, BM x3
General - awake, supine in bed in NAD; mild tachypnea
HEENT - MMM and pink; no cyanosis.
Lungs - mild tachypnea, but no accessorry muscle use; improved
air movement throughout all lung fields; mild expiratory
wheezwes throughout; no crackles
CV - Irregular irregular; not tachy; no murmurs
Abdomen - obese, soft, non-tender, mild distension, bowel sounds
present, no rebound tenderness or guarding, liver percussed
below right costal margin. + flank dullness
GU - no foley
Ext - warm, well perfused, 2+ pulses, large but no pitting edema
Pertinent Results:
===================================
LABS ON ADMISSION:
===================================
___ 11:15PM BLOOD WBC-5.5 RBC-4.10* Hgb-14.0 Hct-42.5
MCV-104* MCH-34.3* MCHC-33.1 RDW-13.1 Plt Ct-65*
___ 11:15PM BLOOD Neuts-67.8 ___ Monos-9.4 Eos-0.1
Baso-1.2
___ 11:15PM BLOOD ___ PTT-33.2 ___
___ 11:15PM BLOOD Glucose-179* UreaN-48* Creat-1.9* Na-136
K-4.1 Cl-103 HCO3-26 AnGap-11
___ 11:15PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.3
___ 08:20AM BLOOD ALT-106* AST-120* AlkPhos-173*
TotBili-0.6
___ 11:23PM BLOOD Lactate-2.2*
___ 08:39AM BLOOD Lactate-1.9
===================================
LABS ON DISCHARGE:
===================================
___ 05:22AM BLOOD WBC-3.2* RBC-3.37* Hgb-11.5* Hct-35.2*
MCV-104* MCH-34.2* MCHC-32.8 RDW-13.5 Plt Ct-45*
___ 05:22AM BLOOD ___ PTT-38.0* ___
___ 05:22AM BLOOD Glucose-152* UreaN-41* Creat-1.4* Na-137
K-4.2 Cl-100 HCO3-29 AnGap-12
___ 05:22AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.2
===================================
OTHER RESULTS:
===================================
___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG
___ UCX - No growth.
___ BCX x2 - No growth.
===================================
IMAGING:
===================================
___ CXR: No acute intrathoracic process.
___ RUQ US: Minimal ascites.
___ B/L ___ DOPPLERS: No evidence DVT.
___ VQ SCAN: low probability of PE
___ CXR:PA and lateral views of the chest demonstrate
interval decreased degree of pulmonary venous congestion since
the prior study from ___. Otherwise, there is no
significant change. No focal consolidation or pneumothorax is
present. Post-surgical appearance involving the right
hemithorax is stable. There is no evidence of overt pulmonary
edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 1 mg PO TID PRN anxiety, sob
3. Pantoprazole 40 mg PO Q24H
4. QUEtiapine Fumarate 25 mg PO QHS
5. glimepiride 1 mg ORAL WITH DINNER
6. Diltiazem Extended-Release 360 mg PO DAILY
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN wheeze
8. ClonazePAM 1 mg PO DAILY:PRN anxiety
9. Torsemide 20 mg PO DAILY
10. Metoprolol Succinate XL 150 mg PO DAILY
11. Spironolactone 50 mg PO DAILY
12. QUEtiapine Fumarate 25 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN wheeze
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 1 mg PO TID PRN anxiety, sob
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Metoprolol Succinate XL 150 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. QUEtiapine Fumarate 25 mg PO QHS
8. ClonazePAM 1 mg PO DAILY:PRN anxiety
9. glimepiride 1 mg ORAL WITH DINNER
10. QUEtiapine Fumarate 25 mg PO DAILY:PRN anxiety
11. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
diskus INH twice daily Disp #*1 Unit Refills:*3
13. Lactulose 30 mL PO TID
Please titrate to ___ per day.
RX *lactulose 10 gram/15 mL (15 mL) 15 mL by mouth three times
per day Disp #*30 Unit Refills:*3
14. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
15. Ursodiol 250 mg PO TID
RX *ursodiol 250 mg 1 tablet(s) by mouth three times per day
Disp #*90 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hypovolemia, Acute Kidney Injury
Secondary: Atrial fibrillation, Chronic Obstructive Pulmonary
Disease, Hepatitis C Cirrhosis
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: ___ female with unilateral leg swelling right greater than
left, evaluate legs bilaterally for DVT.
COMPARISON: No previous exam for comparison.
FINDINGS:
Grayscale, color and Doppler images were obtained of bilateral common femoral,
femoral, popliteal and tibial veins. Normal flow, compression and
augmentation is seen in all of the vessels.
IMPRESSION:
No evidence of deep vein thrombosis in either leg.
Radiology Report
HISTORY: ___ female with hepatitis C cirrhosis, dyspnea.
COMPARISON: Abdomen ultrasound ___.
FINDINGS:
The hepatic architecture is nodular in appearance. No concerning liver lesion
is identified. No biliary dilatation is seen. The spleen is enlarged
measuring 17.8 cm. A small right pleural effusion is noted. A scant trace of
ascites is seen in the perihepatic space.
Doppler images were obtained of the portal veins. The main, right and left
portal veins are patent with hepatopetal flow.
IMPRESSION:
1. Scant trace of ascites in the right upper quadrant. No tappable pocket is
visualized in the lower quadrants. Small right pleural effusion also noted.
2. Patent portal veins.
Radiology Report
HISTORY: Cirrhosis and COPD with increased work of breathing.
FINDINGS: In comparison with the study of ___, there is little change in the
postoperative appearance involving the right hemithorax. No acute focal
consolidation. There is some increased prominence of the pulmonary vessels in
the left mid and lower zones, which most likely reflects either the patient in
an AP supine versus PA projection, or possibly some asymmetric elevation of
pulmonary venous pressure.
Radiology Report
HISTORY: ___ female with COPD and right lower lobe resection with
AFib, now with tachypnea and elevated D-dimer. Evaluation for pulmonary
edema.
FINDINGS: PA and lateral views of the chest demonstrate interval decreased
degree of pulmonary venous congestion since the prior study from ___. Otherwise, there is no significant change. No focal consolidation or
pneumothorax is present. Post-surgical appearance involving the right
hemithorax is stable. There is no evidence of overt pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypotension
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.5
heartrate: 88.0
resprate: 22.0
o2sat: 98.0
sbp: 110.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with CHF, afib, COPD, Hep C, presenting with
worsening DOE and hypotension.
# Hypotension. On admission, pt. was hypotensive. This was
likely due to hypovolemia given decreased PO intake, FENA 0.28,
and decreased urine production. Sepsis was unlikely given no
clear source and no fevers, leukocytosis, or other infectiuos
symptoms. Given her concomitant ___ and cirrhosis, the patient
was started on albumin and IVF and her home diuretics were held.
Her blood pressure responded approriately.
# ___. Cr on admission was 1.9, up from a baseline of 1.1.
Given eleavted BUN:Cr ratio and FENA 0.28 both suggested
prerenal azotemia. Her Cr appropriately dropped with IVF.
Unfortunately once her diuretics were restarted, it again began
to rise. Once these were held, her kidney function improved and
she was discharged on a decreased dose of her home diuretic.
# Paroxysmal Afib. Rate controlled at home with metoprolol and
diltiazem. Pt. is not chronically anticoagulated on anything
other than baby aspirin given thrombocytopenia related to
cirrhosis. On admission, her metoprolol and dilt had been held
due to hypovolemia. The patient went into afib with RVR, which
likely triggered flash pulmonary edema (see below). Her rate
was brought back under good control by restarting her home
metoprolol and diltiazem.
# Dyspnea. On admission, patient reported a subjective one-week
history of dyspnea on exertion. She was only mildly dyspnic on
admission and saturating well on room air. TTE was of poor
quality but showed EF >45%. Given asymetric swelling of her LEs
and afib without anticoagulation, there was concern for
pulmonary embolism. Lower extremity dopplers showed no evidence
of DVTs. A CTA was not feasible given elevated Cr. After
administration of fluids, the patient began experiencing
increasing dyspnea with accesory muscle use. She continued to
saturate well on room air. She was empirically started on a
heparin drip, though this was soon stopped after a VQ scan
returned negative. Her CXR showed pulmonary edema and her
respiratory status improved significantly with diuresis,
suggesting that while she was initially hypovolemic, her afib
with RVR prevented her from appropriately compensating for
increased intravascular volume and caused pulmonary edema.
# COPD. On albuterol at home. Pulmonary exam revealed poor air
movement and significant wheezes, likely further exacerbating
her dyspnea. She was started on albuterol nebs, ipratropium,
and fluticasone-salmeterol with good effect.
# Cirrhosis. History of Hepatitis C refractory to IF/ribavirin.
Last HCV load in ___ was 70,300. Ceftriaxone was started on
admission for empiric SBP coverage, but was discontinued after
abdominal ultrasound was negative for ascites.
# New DM, tan skin: Given the pt's new diagnosis of diabetes and
report of unusually tan skin, hemochromatosis was considered. A
ferritin was checked while in the MICU, which was elevated at
304.
# DM2: Home glimeperide was held. Patient received insulin
sliding scale while inpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Latex / Erythromycin Base / shellfish derived
Attending: ___.
Chief Complaint:
altered mental status
right upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
open cholecystectomy
History of Present Illness:
___ breast cancer, hypertension, traumatic brain injury and
possible dementia per Atrius notes, presents with worsening
consusion. Patient is a nursing ___ resident. Has been noted to
have progressive confusion over the past approximately 3 days.
She had some URI symptoms for which she was started on p.o.
levofloxacin 2 days ago. Today her confusion continued to worsen
and therefore she was brought to the emergency department.
In the ED intial vitals were: 98.5 137 141/94 18 91% ra
Labs were significant for Lactate:3.1 -> 1.5 after IVF. In ED pt
had fever to 102.6 improved with APAP. EKG: sinus tach. Given
Vanc/cefepime. CXR: unremarkable, UA: unremarkable. When she
arrived in the ED, she reportedly endorsed upper abdominal pain
so surgery saw pt; Ultrasound demonstrated cholelithiasis, but
no clear signs of cholecystitis; rec'd HIDA scan in AM.
Vitals prior to transfer were: 99.8 103 177/80 22 96% Nasal
Cannula
Upon arrival to the floor she is minimally able to provide
history but does awaken easily. Does not respond whether she's
having pain anywhere. Had recent admission ___ for Titanium
femoral nailing of the femur s/p R hip fall. Is following
comands to open eyes, open mouth, etc.
Review of Systems:
(+) per HPI
Past Medical History:
Breast cancer, intraductal
Hiatal hernia
Traumatic brain injury
Asthma
Chronic kidney disease
Duodenal ulcer
GERD
Hyperlipidemia
Colonic adenoma
Osteoporosis
Depression
Colonic adenoma
Onchomycosis
s/p Sacral fracture
s/p Lumbar fracture
s/p Ulnar fracture
multiple falls
?dementia per Atrius records
Social History:
___
Family History: Maternal grandmother w/ breast ca.
Family History:
(from ___) MGM with breast cancer
Physical Exam:
=====================
ADMISSION ___
=====================
Vitals - T: 97.9 BP:147/73 HR:116 RR: 18 02 sat: 96%2L
GENERAL: sleeping, arouses, follows commands, not conversant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, no LAD, no JVD
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: difficult exam as pt cannot cooperate with exam and
supine. breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, 3+ soft edema to mid
shins b/l
NEURO: CN II-XII intact
=====================
DISCHARGE ___
=====================
Vitals - T: 98.2 BP:141/61 HR:116 RR: 18 02 sat: 94%2L
GENERAL: NAD
HEENT: EOMI, PERRL
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: Clear to auscultation bilaterally; breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mildly tender in all quadrants, no
rebound/guarding; incisions intact with staples, no erythema or
swelling and no discharge
EXTREMITIES: moving upper extremities and left leg well,
minimal movement right leg, 3+ soft edema to mid shins b/l
NEURO: mildly confused but cooperative; follows commands; no
numbness or tingling; no decreased sensation
Pertinent Results:
___ 03:30PM WBC-11.3*# RBC-5.36# HGB-16.8*# HCT-52.4*#
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.6
___ 03:30PM NEUTS-87.6* LYMPHS-6.5* MONOS-5.6 EOS-0.1
BASOS-0.1
___ 03:30PM ALBUMIN-3.6 CALCIUM-9.9 PHOSPHATE-4.2#
MAGNESIUM-1.8
___ 03:30PM LIPASE-38
___ 03:30PM ALT(SGPT)-22 AST(SGOT)-64* ALK PHOS-156* TOT
BILI-0.4
___ 03:30PM GLUCOSE-199* UREA N-24* CREAT-1.5* SODIUM-138
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
___ 03:46PM LACTATE-3.1*
___ 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR
___ 06:35AM CK-MB-3 cTropnT-0.02*
___ 04:44PM CK-MB-3 cTropnT-0.02*
___ 04:44PM GLUCOSE-124* UREA N-17 CREAT-0.8 SODIUM-143
POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15
___ 04:44PM CK(CPK)-44
ECG Study Date of ___
Impression: Sinus tachycardia. Inferior myocardial infarction,
age undetermined. Late R wave progression with borderline Q
waves in leads V4-V5. Cannot exclude anterior myocardial
infarction, age undetermined. Lateral ST segment depression in
leads I and aVL, likely due to rate. Cannot exclude active
ischemia. Single ventricular premature beat. Compared to the
previous tracing of ___ the sinus rate is faster. A
ventricular premature beat is now seen. The ST segment changes
in leads I and aVL are slightly more pronounced. Other findings
are similar.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
IMPRESSION: Distended gallbladder with gallstones but without
specific signs for acute cholecystitis.
PORTABLE HEAD CT W/O CONTRAST Study Date of ___
IMPRESSION:
1. No evidence of acute intracranial process.
2. Apparent interval enlargement of the bilateral anterior
temporal horns as
compared to the prior examination. These findings likely
represent
differences in technique, but attention on follow up is
recommended.
3. Cerebral atrophy and evidence of chronic small vessel
ischemic disease.
GALLBLADDER SCAN Study Date of ___
IMPRESSION: Abnormal hepatobiliary scan consistent with acute
cholecystitis.
Reflux of biliary tracer into the stomach is also noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q6H pain
4. Pantoprazole 40 mg PO Q12H
5. Paroxetine 20 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. Calcium Carbonate 500 mg PO BID
9. Vitamin D 400 UNIT PO BID
10. Vitamin D ___ UNIT PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. melatonin 3 mg oral qHS
13. Ondansetron 4 mg PO Q8H
14. Benzonatate 200 mg PO TID:PRN cough
15. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation TID
16. Levofloxacin 250 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Pantoprazole 40 mg PO Q12H
4. Paroxetine 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Simvastatin 20 mg PO QPM
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, SOB
9. Ipratropium Bromide Neb 1 NEB IH Q6H
10. Miconazole Powder 2% 1 Appl TP BID
11. Senna 8.6 mg PO BID:PRN constipation
hold for loose stools
12. Benzonatate 200 mg PO TID:PRN cough
13. Calcium Carbonate 500 mg PO BID
14. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation TID
15. melatonin 3 mg oral qHS
16. Vitamin D 400 UNIT PO BID
17. Vitamin D ___ UNIT PO DAILY
18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
hold with RR <12 and for increased sedation
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Acute cholecystitis (Gangrenous cholecystitis)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST OF ___
COMPARISON: Study of two days earlier, ___.
FINDINGS: Interval placement of endotracheal tube, nasogastric tube and right
internal jugular vascular sheath, in standard position. No visible
pneumothorax. Cardiomediastinal contours are stable. New small-to-moderate
right pleural effusion as well as multifocal patchy and linear opacities which
may be due to atelectasis, aspiration, or a developing pneumonia. Small left
pleural effusion is also noted.
Radiology Report
HISTORY: Altered mental status.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were acquired.
CTDIvol: ___
DLP: ___
COMPARISON: Comparison is made to CT head dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. The anterior temporal horns appear larger as compared to the prior
examination, and may be secondary to differences in technique. Prominent
ventricles and sulci suggest age-related involutional changes or atrophy.
Periventricular white matter hypodensities are consistent with chronic small
vessel ischemic disease.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation. No fracture is identified. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Apparent interval enlargement of the bilateral anterior temporal horns as
compared to the prior examination. These findings likely represent
differences in technique, but attention on follow up is recommended.
3. Cerebral atrophy and evidence of chronic small vessel ischemic disease.
Radiology Report
HISTORY: Right femoral subtrochanteric fracture followup.
RIGHT FEMUR, TWO VIEWS.
COMPARISON: Pre-operative film dated ___.
Since ___, the patient has undergone ORIF of the right proximal femur
fracture, now transfixed by gamma nail and long intramedullary rod, in overall
anatomic alignment. No hardware loosening or failure is detected. The
distracted and slightly comminuted lesser tuberosity fragment is again noted.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WORSENING CONFUSION, TACHY
Diagnosed with FEVER, UNSPECIFIED
temperature: 98.5
heartrate: 137.0
resprate: 18.0
o2sat: 91.0
sbp: 141.0
dbp: 94.0
level of pain: 13
level of acuity: 1.0 | Patient is an ___ year old woman with a history of dementia,
breast cancer, hypertension, traumatic brain injury and current
upper respiratory infection treated with antibiotics sent in
from ___ with worsening confusion and right upper
quadrant abdominal pain. She was admitted on ___ to the
hospital after a negative ultrasound of the gall bladder then a
positive finding of acute cholecystitis on a subsequent HIDA
exam. Based on the patient's symptoms, she was offered a
laparoscopic, possible open, cholecystectomy. She was taken to
the OR on ___ for the above stated procedure which
resulted as an open surgery.
The patient had some bleeding during the surgery which was
managed in the operating room with 2Units of packed red blood
cells and 1 unit of fresh frozen plasma. Otherwise the patient
tolerated the procedure and was then brought to the SICU post op
while intubated, and off pressors. The patient was extubated
___ and then transferred to the floor to be monitored.
The patients hematocrit decreased on post operative day 1 which
resulted in the need for a unit of packed red blood cells in the
ICU. Her hematocrit continued to be closely monitored and it
normalized. It is now stable.
The patient was transferred to floor on ___ where her foley
was discontinued, she was able to void. She has been
incontinence since removal of the foley catheter. The JP drain
was removed on arrival to the floor. Because the patient has a
prior history of EGD on ___, which revealed medium hiatal
hernia she was followed closely by speech and swallow as well as
nutrition. Speech and swallow team evaluated the patient while
in the hospital and transitioned her diet from NPO to PO with
aspiration precautions on ___. The patient has been
tolerating this diet and needs to have speech and swallow at her
rehabilitaion center evaluate and decide when to advance her
diet.
Her pain was well controlled throughout her hospitalization and
upon discharge. During this hospitalization, the patient
ambulated according to recommendations of physical therapy and
in accordance to her orthopedic recommendations from prior hip
surgery.
The patient received subcutaneous heparin and venodyne boots
were used during this stay. She used incentive spirometry and
her respiratory status was monitored. She required 1L nasal
cannula to maintain an oxygen saturation at 94%.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was discharged to
rehabilitation center. She will continue to use 1L nasal cannula
until able to maintain 94% on room air. Follow up appointment
with ACS has been made. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Wrist pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old male CAD/MI s/p ICD/PPM, sCHF EF35%, CKD, DM2
presents with worsening left wrist pain.
Mr. ___ has been having left wrist pain wrist pain over the
last week, he as noted the pain to become worse over time up as
his wrist joint became more swollen, warm and red. Today the
pain reached ___ and he could barely move his wrist due to pain
and swelling.
He went to an episodic visit at ___ yesterday where he was
evaluated and referred to the ED for urgeny work-up to rule out
septic arthritis. He notes that he has not had any fever, chills
or malaise.
On arrival to the ED his vitals were 98.7 | 88 | 132/64 | 18 |
98%.
-The patient complained of ___ pain in his writst and
decreased ROM at that time
-CBC was significant for WBC 11.4 with 80%NPh
-Chem-7 with HCO3 18 and Cr 1.9 (b/l 1.4-1.6), CRP 60
-Evaluated by hand who recommended arthrocentesis which revealed
joint fluid with 207K WBCs (96%PMNs) and monosodium urate
crystals
-Patient received percocet x1, colchicine 1.8mg , morphine 5mg
iv x1
Vitals prior to transfer were: 98.1 60 117/77 18 99% RA
On the floor, his initial vitals were 98.0 | 130/53 | 62 | 16 |
93%RA
-Patient complains of ___ pain in his L wrist, cannot flex or
extend wrist without ___ pain
-Otherwise feels well and has no complains
Past Medical History:
-CAD s/p IMI in ___ s/p RCA and circumflex stent with 80%
LAD lesion - being managed medically s/p ICD/PPM
-Morbid obesity
-Systolic CHF
-Type II DM
-HLD
-OSA
-CKD
-Nephrolithiasis
-Diverticulosis
-Erectile dysfunction
-Seasonal Allergies
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.0 | 130/53 | 62 | 16 | 93%RA
GENERAL: Morbidly obese gentleman in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pale conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, unable to assess JVD due to
habitus
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing, +1 BLE edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact. Non-focal.
SKIN: warm and well perfused, hyperpigmentation in distal
extremities, no rashes
DISCHARGE PHYSICAL EXAM:
98.1 62 18 113/63 98RA
GENERAL: Morbidly obese gentleman in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pale conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, unable to assess JVD due to
habitus
CARDIAC: Very soft heart sounds. RRR, S1/S2, no murmurs,
gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing, +1 BLE edema, moving all 4
extremities with purpose. no open wounds/ulcers on feet
bilaterally. left write still edematous and warm, improved from
yesterday. patient able to wiggle fingers and flex/extend at
wrist to 45 degrees with minimal pain.
NEURO: CN II-XII intact. Non-focal.
SKIN: warm and well perfused, hyperpigmentation in distal
extremities, no rashes
Pertinent Results:
ADMISSION LABS:
___ 05:49PM BLOOD WBC-11.4* RBC-4.36* Hgb-12.1* Hct-36.5*
MCV-84 MCH-27.7 MCHC-33.0 RDW-15.9* Plt ___
___ 05:49PM BLOOD Neuts-80.0* Lymphs-12.1* Monos-6.5
Eos-1.1 Baso-0.3
___ 07:13AM BLOOD ___ PTT-37.9* ___
___ 07:13AM BLOOD ___
___ 05:49PM BLOOD Glucose-166* UreaN-54* Creat-1.9* Na-138
K-4.6 Cl-99 HCO3-21* AnGap-23*
___ 07:13AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.5
UricAcd-15.7*
___ 05:49PM BLOOD CRP-60.0*
___ 06:50PM JOINT FLUID ___ Polys-96*
___ ___ 06:50PM JOINT FLUID Crystal-MOD Shape-NEEDLE
Locatio-I/E Birefri-NEG Comment-c/w monoso
MICRO:
___ 6:50 pm JOINT FLUID JOINT FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): pending
DISCHARGE LABS:
___ 05:05AM BLOOD WBC-7.9 RBC-3.83* Hgb-10.4* Hct-32.3*
MCV-84 MCH-27.2 MCHC-32.3 RDW-16.0* Plt ___
___ 07:13AM BLOOD Neuts-79.7* Lymphs-11.5* Monos-7.5
Eos-1.1 Baso-0.3
___ 05:05AM BLOOD Glucose-115* UreaN-54* Creat-1.9* Na-139
K-3.8 Cl-100 HCO3-27 AnGap-16
___ 05:05AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.5 UricAcd-15.8*
IMAGING:
___ WRIST 3 VIEWS: IMPRESSION: Soft tissue swelling without
fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 80 mg PO BID
2. Gabapentin 300 mg PO TID
3. Carvedilol 12.5 mg PO BID
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Furosemide 80 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. tadalafil 20 mg oral daily : prn sex
9. Omeprazole 20 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Metolazone 2.5 mg PO QWEEK
12. HumuLIN R U-500 Concentrated (insulin regular hum U-500
conc) ___ U subcutaneous qid:prn sliding scale
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Furosemide 80 mg PO BID
4. Metolazone 2.5 mg PO QWEEK
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Omeprazole 20 mg PO DAILY
8. Rosuvastatin Calcium 20 mg PO DAILY
9. Valsartan 80 mg PO BID
10. Colchicine 0.6 mg PO DAILY Duration: 30 Days
Please take one tablet daily until two days after pain resolves.
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
11. Gabapentin 300 mg PO TID
12. HumuLIN R U-500 Concentrated (insulin regular hum U-500
conc) ___ U subcutaneous qid:prn sliding scale
13. tadalafil 20 mg oral daily : prn sex
___. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
Do not drive or operate heavy machinery while on this
medication.
RX *hydromorphone 2 mg 1 tablet(s) by mouth Q6H PRN pain Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Acute gouty arthritis
2. Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: Left wrist swelling and pain.
TECHNIQUE: Frontal, lateral, oblique and scaphoid views of the left wrist.
COMPARISON: None
FINDINGS:
There is no fracture, dislocation or periarticular erosion. Radiocarpal
alignment is preserved. Dedicated scaphoid view is unremarkable. There is no
soft tissue calcification or radiopaque foreign body. Soft tissue swelling
around the distal forearm.
IMPRESSION:
Soft tissue swelling without fracture or dislocation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Wrist pain
Diagnosed with JOINT EFFUSION-FOREARM
temperature: 98.7
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 132.0
dbp: 64.0
level of pain: 4
level of acuity: 4.0 | BRIEF HOSPITAL COURSE
___ year-old male CAD/MI s/p ICD/PPM, sCHF EF35%, CKD, DM2
presented with worsening left wrist pain, was found to have MSU
crystals in synovial fluid, and treated with colchicine for
acute gouty arthritis.
#ACUTE GOUTY ARTHRITIS: He presented with an acute
monoarthritis, risk factors (obesity, male gender, CKD), and
inflammatory synovial fluid with negatively birefringent MSU
crystals. There was very low concern for septic arthritis given
no fevers and negative gram stain. Fluid culture was negative on
discharge. Pain improved with colchicine and opioids. He was
discharged on 0.6 mg po colchicine daily (not BID dosing due to
CKD and rapid improvement on 0.6 mg) and instructed to continue
daily until two days after resolution of pain. He was also given
some hydromorphone for severe pain on discharge and instructed
to use tylenol for milder pain. He was also give advice about
dietary modifications. Uric acid was found to be elevated at
15.8 on discharge.
#T2DM: On U-500 sliding scale ___ QID) at home and followed
by ___ was consulted for assistance with sliding
scale given U-500 formulation.
#Anemia and thrombocytopenia: Last Hb and plt in ___ were
11.3 and 142, respectively. He had did not report any melena or
obvious blood loss. No actions were taken as this is likely a
chronic process and therefore outpatient issue.
#sCHF: He did not appear decompensated on admission. He had
neither O2 requirement nor evidence of volume overload on exam.
He continued his home meds carvedilol, furosemide, and
valsartan.
Transitional Issues
===================
#Gout - given that serum uric acid elevated, he may benefit from
a xanthine-oxidase inhibitor. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of an undifferentiated autoimmune disease and
secondary adrenal insufficiency ___ steroid use and unspecified
hemolytic anemia requiring transfusions presents with acute
onset
right shoulder pain with non-pruritic rash and fevers.
Patient states that yesterday evening she noted the onset of
right shoulder pain. Had difficulty sleeping due to this, and
took tylenol and tramadol without significant relief. She was
able to go to work this morning where her colleagues noted a
rash
on the skin overlying her right scapula. Her colleagues outlined
the area to monitor for spreading. She continued to feel poorly,
so she went home where she measured a fever to 100.2. She took
tylenol for this. She has not established care with a new
primary
physician, so she went to ___ for evaluation on ___, where she
stated she has had cellulitis in the past, but only on her legs.
At her ___ visit, she was given bactrim and keflex for
cellulitis. Since being seen at ___ on the day prior to
admission, she has been compliant with hydrocortisone (usually
___, and today took stress dose (___).
In the ED, initial vitals were: Pain 5, 99.3 141 131/84 18 100%
Labs were notable for: normal WBC count, hemoglobin 10.9 (MCV
80), normal platelets. K 4.7, AST 127 on hemolyzed specimen.
Bicarbonate was 19, anion gap 14 with lactate 1.8. Urinalysis
showed few bacteria, 30 protein and 150 ketones.
Patient was given: 2L NS, vancomycin, unasyn and IV
methylprednisolone 125mg.
Consults: none.
She was admitted for worsening cellulitis and adrenal
insufficiency. VS upon transfer Pain 2, 98.6 104 116/67 18 100%
RA.
On the floor, she feels well. Her back rash which had been
painful (never itchy) has largely disappeared since being in the
ER. Pt with photos on her phone of rash, denoting ill-defined
pink erythema on L scapular area, growing to encompass about
half of her back over course of a day, prior to ER presentation.
Currently denies feverishness, chills, sore throat, sinus
pressure, ear drainage, headache, sick contacts, recent travel,
bug bites or any additional rashes, nausea, vomiting and
diarrhea; only lightheaded/dizzy if walking around; no CP, SOB.
No new medications. Was not out in sun recently. Was in wooded
rural area in ___ in last few wks, but not near any animals,
recalls no bites. Lives with 1 roommate who has no similar rash.
No new topicals applied in last few days. Denies trauma to area,
although had her back massaged by colleague "all day long" the
day prior to rash appearing. No application of cold/hot packs.
Review of systems:
(+) Per HPI
Past Medical History:
Autoimmune Disorder NOS- beginning in the mid ___, manifested
by urticarial lesions and photosensitivity; s/p treatment with
cyclosporine, azathioprine, MMF, now on hydrocortisone
(previously prednisolone)
- Adrenal Insufficiency ___ longtime steroid use; followed by
___
- H/o adrenal crisis
- Hemolytic anemia NOS on IV iron infusions
- Tachycardia NOS
- Pneumocystis pneumonia ___
- Pyelonephritis ___
- Shingles
Social History:
___
Family History:
___. Her maternal grandfather had ___ disease
first diagnosed in his mid ___ and thyroid disease as well as
other autoimmune disease. Maternal grandmother with breast
cancer diagnosed mid ___. Father deceased in ___ from ALS.
Mother and brother healthy.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
Vitals: Tmx 99.1, BP 118/68, HR 108 (range 88--135), RR 20, 100%
RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, no
cervical/clavicular lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
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, minimal trace ___ edema
Skin: overall skin pallor. Mid-upper back and L mid back with
two ~palm sized areas of fine reticular pink blanching erythema;
areas of confluent erythema from her photos is completely gone.
Remainder of skin unremarkable. Teeth appear wnl, no oral
lesions.
PHYSICAL EXAM ON DISCHARGE:
=============================
Vitals: Tmx 98.8, BP 116/72, HR 100, RR 18, 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, no
cervical/clavicular lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
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
Skin: overall skin pallor. Mid-upper back and L mid back with
two ~palm sized areas of fine reticular pink blanching erythema;
areas of confluent erythema from her photos is completely gone.
Remainder of skin unremarkable. Teeth appear wnl, no oral
lesions.
Pertinent Results:
LABS ON ADMISSION:
=====================
___ 05:20PM BLOOD WBC-5.4 RBC-4.45 Hgb-10.9* Hct-35.4*
MCV-80* MCH-24.6* MCHC-30.8* RDW-18.9* Plt ___
___ 05:20PM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-134
K-6.8* Cl-101 HCO3-19* AnGap-21*
___ 05:20PM BLOOD ALT-26 AST-127* LD(___)-925* AlkPhos-57
TotBili-0.5
___ 06:25AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
___ 05:43PM BLOOD Lactate-1.8 K-4.7
LABS ON DISCHARGE:
=====================
___ 07:48AM BLOOD WBC-4.2 RBC-4.12* Hgb-10.0* Hct-33.2*
MCV-81* MCH-24.3* MCHC-30.2* RDW-18.8* Plt ___
___ 07:48AM BLOOD Glucose-76 UreaN-8 Creat-0.6 Na-137 K-4.2
Cl-107 HCO3-15* AnGap-19
___ 05:05PM BLOOD ALT-12 AST-16 LD(LDH)-145 AlkPhos-59
TotBili-0.2
___ 07:48AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.0
___ 09:00AM BLOOD Cortsol-11.5
___ 10:15AM BLOOD Cortsol-32.0*
___ 10:45AM BLOOD Cortsol-50.6*
___ 09:00AM BLOOD Cortsol-11.5
___ 10:15AM BLOOD Cortsol-32.0*
___ 10:45AM BLOOD Cortsol-50.6*
___ 08:55AM BLOOD ___ pO2-67* pCO2-39 pH-7.28*
calTCO2-19* Base XS--7 Comment-GREEN TOP
___ 01:44PM BLOOD ___ pO2-64* pCO2-39 pH-7.24*
calTCO2-18* Base XS--10
STUDIES ___:
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Fever.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: ___.
FINDINGS:
The heart is normal in size. The mediastinal and hilar contours appear within
normal limits. There is no pleural effusion or pneumothorax. The lungs
appear clear. There has been no significant change.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with CELLULITIS/ABSCESS OF TRUNK
temperature: 99.3
heartrate: 141.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 84.0
level of pain: 5
level of acuity: 2.0 | ___ with a history of an undifferentiated autoimmune disease and
secondary adrenal insufficiency ___ steroid use and unspecified
hemolytic anemia requiring transfusions in the past presents
with acute onset right shoulder pain with non-pruritic rash and
fever; rash initially concerning for cellulitis nearly resolved
within hours while in ER.
# Cellulitis, R back/scapula:
Ms. ___ was admitted to the hospital for a rash on her back
that had rapidly progressed prior to admission. She had gone to
outpatient ___ clinic where she had received bactrim and Keflex
though despite this had progression of her rash that prompted
her to come to the ED. In the ED the patient received IV
antibiotics and IV methylprednisone with rapid improvement of
her apparent cellulitis prior to admission to the floor. The
patient's IV antibiotics were transitioned to PO Keflex and she
remained afebrile prior to discharge. She was discharged with PO
Keflex for total ___actrim use (which decreases
aldosterone sensitivity) was avoided in the setting of secondary
adrenal insufficiency at time of this hospitalization though
ultimately this diagnosis is under question (see below.)
#Non-gap acidosis
Ms. ___ was noted to have a non-gap acidosis with bicarb of
___ this hospitalization. Overall there was concern that this
was related to patient's underlying adrenal insufficiency.
Ultimately patient had ___ stim test with appropriate response
that essentially ruled out primary and secondary adrenal
insufficiency. Her non-gap acidosis could be secondary to
developing renal tubular acidosis. Bicarb remained stable at
time of discharge. Patient was discharged with plan for follow
up laboratory testing within days of discharge to be followed up
by outpatient Endocrinologist Dr. ___.
#Secondary Adrenal insuffiency:
Patient with diagnosis secondary to adrenal insufficiency due to
chronic steroid use. Patient noted to have tachycardia in ED in
setting of acute illness with need for stress dose steroids with
IV solumedrol. Upon transfer to the medical floor patient
remained hemodynamically stable and was provided with stress
dose steroids with hydrortisone dosing of ___ that was
tapered to ___ for two days then back to patient's usual
dose. Endocrine team consulted and ___ stim testing was
completed. The results of this testing were pending at time of
discharge but ultimately showed appropriate response with a
baseline cortisol of 11, 30 minute cortisol 32.6 and 60 minute
cortisol of 50. In discussion with Endocrinology consultants it
was felt that this suggested that patient did not have primary
or secondary adrenal insufficiency and that taper off of
steroids could be possible over time. Endocrinology team
contacted patient with this information after discharge and will
discuss further with patient's Endocrinologist Dr. ___.
# Hemolytic anemia:
Patient has had coombs positive tests and elevated LDH and retic
counts in the past. Eval'd by GI at ___ in ___, where no
further GI w/u was recommended. Porphyria results pending. Used
to be followed by hematologist Dr. ___ at ___. Now
Receives care at ___ by Dr. ___. Per his notes:
"erythropoietic protoporphyria causes microcytic hypochromic
anemia (though typically mild), gallstones (one detected on
U/S), and solar urticaria (her diagnosis in the ___.; thought
typically painful and presenting in childhood) and congenital
erythropoietic porphyria (Gunther disease) can cause hemolytic
anemia (though typically mild) and photodermatitis (though
usually severe and disabling). ___ test for
paroxysmal cold hemoglobinuria is still pending. Meanwhile the
plan is to treat her supportively with RBC transfusions and iron
as needed. I recommend a weekly CBC and iron studies for now. I
will give strong consideration to plasmapheresis (or eculizumab)
if she has another life-threatening episode." She says she has
been on several cycles of dexamethasone (last 8wks ago); no
unifying Dx yet at ___, although has been told she has Fe
deficiency anemia, intravascular hemolysis, and low IgG. H/H
and platelets remained stable during this hospitalization.
Patient transiently became leukopenic though without neutropenia
with recovery of counts without any intervention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
house dust / mold / grass pollen
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Successful ultrasound-guided placement of ___
pigtail catheter into the gallbladder. Samples was sent for
microbiology evaluation.
History of Present Illness:
___ here with RUQ pain since ___, that has persisted
over three days. He had poor PO intake in the setting of pain
but has continued to move his bowels and flatus. He has a
history of
ETOH pancreatitis and developed a benign CBD stricture related
to the pancreatitis. He has undergone plastic stent placement x2
and then progressed to a fully covered metal stent placed on
___.
Past Medical History:
Back pain and L 1 compression fracture 1 month
Tonsillectomy
Broken arm as a child
PNA as a child
No hospitalizations as an adult
Social History:
___
Family History:
Sister has DM.
Father had MI at age ___.
Brother ___ with pancreatitis from ETOH.
Physical Exam:
Admission Physical Exam:
T 97.8 HR 58 BP 107/72 RR 16 98RA
NAD
RRR
no resp distress
abd soft, tender in RUQ without guarding
thin, no peripheral edema
Discharge Physical Exam:
VS: 98.1, 59, 120/74, 18, 96% RA
Gen: Awake, alert, sitting up in bed. Pleasant and interactive.
HEENT: No deformity. PERRL, EOMI. Neck supple, trachea midline.
Mucus membranes pink/moist.
CV: RRR
Pulm: Clear to auscultation bilaterally.
Abd: Soft, tender at drain site as anticipated, non-distended.
Active bowel sounds x 4 quadrants. RUQ drain in place with
bloody/serous output in drain bag.
Ext: Warm and dry. 2+ ___ pulses
Pertinent Results:
___ 05:20AM BLOOD WBC-7.3 RBC-3.33* Hgb-9.5* Hct-29.3*
MCV-88 MCH-28.5 MCHC-32.4 RDW-15.7* RDWSD-50.5* Plt ___
___ 02:24AM BLOOD WBC-12.6*# RBC-3.75* Hgb-10.7* Hct-32.6*
MCV-87 MCH-28.5 MCHC-32.8 RDW-15.5 RDWSD-49.7* Plt ___
___ 02:24AM BLOOD ___ PTT-27.3 ___
___ 05:20AM BLOOD Glucose-87 UreaN-16 Creat-0.9 Na-133
K-3.3 Cl-99 HCO3-24 AnGap-13
___ 02:24AM BLOOD Glucose-119* UreaN-24* Creat-1.5* Na-132*
K-3.9 Cl-95* HCO3-24 AnGap-17
___ 05:20AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.9
___ 02:24AM BLOOD Albumin-3.2*
___ 02:32AM BLOOD Lactate-1.1
URINE CULTURE (Final ___: NO GROWTH.
___ 3:20 pm BILE
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ Liver US:
1. Distended gallbladder with gallbladder wall thickening and
edema is associated with a positive sonographic ___ sign,
findings consistent with acute cholecystitis.
2. Pneumobilia is present within the left hepatic lobe,
expected in a patient with a biliary stent in place.
Medications on Admission:
Creon, Cipro
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
do not exceed 4 grams Tylenol per 24 hours
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation
hold for diarrhea.
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
7. Creon 12 1 CAP PO TID W/MEALS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ pain // Acute Chole?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis dated ___
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 mild intrahepatic biliary dilation and evidence of
pneumobilia within the left hepatic lobe. A stent is identified traversing
the common hepatic duct. .
GALLBLADDER: The gallbladder appears distended with gallbladder wall
thickening and edema. There is no stone or present.
PANCREAS: Imaged portions of the pancreas demonstrate numerous calcifications
additionally characterized on CT dated ___. There is no pancreatic
duct dilation.
SPLEEN: Enlarged measuring 13.6 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Distended gallbladder with gallbladder wall thickening and edema is
associated with a positive sonographic ___ sign, findings consistent with
acute cholecystitis.
2. Pneumobilia is present within the left hepatic lobe, expected in a patient
with a biliary stent in place.
Radiology Report
EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement.
INDICATION: ___ year old man with RUQ pain US shows cholecystitis hx of
pancreatitis with stent // percutaneous cholecystostomy drain placement
COMPARISON: Right upper quadrant ultrasound from earlier the day
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
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 ultrasound table. Limited
preprocedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ drainage catheter
was advanced via trocar technique into the gallbladder. The catheter was
advanced over the stiffener. Approximately 100 cc of bile was aspirated. The
pigtail was deployed. Postprocedural imaging demonstrated a collapsed
gallbladder, and confirmed position of the pigtail. Ultrasound images were
stored on PACS.
Approximately 100 cc of bilious fluid was drained 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.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 15
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Successful ultrasound-guided placement of 8 ___ pigtail catheter in the
gallbladder, with aspiration of 100 cc, cloudy, bilious fluid.
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Acute cholecystitis
temperature: 97.9
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 88.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
Service on ___ with right upper quadrant pain. He has a
past medical history significant for alcoholic pancreatitis with
common bile duct strictures status post metal stent placement on
___. He had an ultrasound of his liver that showed a
distended gallbladder with wall thickening and edema associated
with a positive sonographic ___ sign consistent with acute
cholecystitis. His white blood cell count was elevated at 12.6
with normal liver function tests.
On HD1 he was given IV antibiotics and had an ultrasound-guided
placement of a pigtail catheter into the gallbladder. Samples
were sent for microbiology evaluation. He was admitted to the
surgical floor for monitoring and further management. He was
given a clear liquid diet which he tolerated well.
On HD2 his white blood cell count was trending down, his
abdominal pain was improved, and he was tolerating a regular
diet.
On HD2 he was discharged to home afebrile and hemodynamically
stable. The patient was tolerating a diet, ambulating, voiding
without assistance, and pain was well controlled. Visiting
nursing services were arranged to assist with drain management.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. Follow appointment was schedule for drain
assessment and to discuss future surgical intervention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
___ Intubation / Extubation
History of Present Illness:
___ man with PMH of severe obesity (BMI 50+), hypertension,
G6PD, FSGS/CKD (Cr 1.5-1.8),HTN, severe OSA on Triology at home
presenting with shoulder pain and dyspnea to the ED, found to be
in hypoxemic/hypercapnic respiratory failure s/p intubation.
Patient was admitted in ___ (OSH) and ___ at ___ for
similar presentation with acute hypoxemic/hypercapnic
respiratory failure requiring intubation. He was treated for CAP
and diuresed with improvement of respiratory status. Evaluated
by ENT and sleep medicine with plan for outpatient
tonsillectomy/adenoidectomy and septum correction but patient
has been lost to follow up. He was also found to have
significant proteinuria with renal biopsy consistent with FSGS.
He follows with Dr. ___ intermittently compliant
with medications and frequently lost to follow up.
In the ED patient endorsed "acute on chronic pain to his right
shoulder. He associates this with shrapnel that he notices in
his shoulder from a previous traumatic incident. It is worse
with moving his shoulder. It is not worse with exertion or deep
breath. It does not radiate to his back jaw or arm. He is felt
this pain before, it is simply worse now than usual.Regarding
his shortness of breath, he is not able to provide a robust
history as to the exact timing or cause of his shortness of
breath. He reports he has been using his BiPAP machine. He
denies any fever or chills. He reports bilateral leg swelling,
but he states this is "on and off"."
In the ED, initial vitals: T 98.8 HR 107 BP 131/112 RR 17 Sat
88% RA
Exam notable for: Sleepy but arouses to voice, loud upper airway
noises, trace wheezes and decreased air movement to the bases,
2+ pitting edema of lower extremities.
VBG showed: pH 7.19 pCO2 84 pO2 59 HCO3 34
He was intubated and admitted to the ICU.
Past Medical History:
Severe obesity
OSA with obstructive and mixed apneas
FSGS (renal bx ___
CKD stage III
HTN
G6PD deficiency
History of GSW to R soulder and abdomen ___ (s/p exlap and
prolonged SICU admission at ___)
Social History:
___
Family History:
FAMILY HISTORY: obesity, diabetes mellitus - type II
Physical Exam:
Admission Exam:
================
PHYSICAL EXAM:
VITALS: T 97.7 HR 75 BP 84/37 Sat 97% intubated
GENERAL: Obese, intubated and sedated
HEENT: Pinpoint pupils minimally reactive to light, anicteric
NECK: unable to assess JVP given body habitus
LUNGS: Clear to auscultation bilaterally on anterior fields
CV: Distant heart sounds,Regular rate and rhythm, no murmurs
ABD: soft, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, 2+Edema bilaterally to
knees
ACCESS: PIV x2
DISCHARGE
VS: ___ ___ Temp: 97.6 PO BP: 100/65 L Sitting HR: 95 RR:
18 O2 sat: 97% O2 delivery: RA 151kg
Telemetry - reserved
Gen - ambulating into room, then sitting up in bed, comfortable
Eyes - EOMI
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft obese, nontender, normal bowel sounds
Ext - no edema at ankles
Skin - no rashes
Vasc - 2+ DP/radial pulses; midline c/d/i
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
Admission labs:
====================
___ 10:29PM BLOOD WBC-8.8 RBC-4.83 Hgb-13.7 Hct-45.7 MCV-95
MCH-28.4 MCHC-30.0* RDW-13.7 RDWSD-47.4* Plt ___
___ 10:29PM BLOOD Plt ___
___ 10:29PM BLOOD Glucose-116* UreaN-29* Creat-2.1* Na-141
K-4.9 Cl-103 HCO3-29 AnGap-9*
___ 10:29PM BLOOD cTropnT-<0.01 proBNP-176*
___ 10:29PM BLOOD Calcium-7.8* Phos-3.4 Mg-2.2
___ 04:02AM BLOOD D-Dimer-1175*
___ 03:56AM BLOOD TSH-1.8
___ 10:38PM BLOOD ___ pO2-60* pCO2-67* pH-7.26*
calTCO2-31* Base XS-0 Intubat-NOT INTUBA Comment-GREEN TOP
___ 12:00AM BLOOD pO2-59* pCO2-84* pH-7.19* calTCO2-34*
Base XS-1
___ 03:41AM BLOOD ___ pO2-69* pCO2-49* pH-7.38
calTCO2-30 Base XS-2
___ 03:41AM BLOOD freeCa-1.05*
Imaging:
============
___ CXR
Somewhat underpenetrated examination presumed due to patient
body habitus.
Given this, there may be mild pulmonary vascular congestion.
1.1 x 1 0.0 cm square radiopaque structure projects over the
right hilum,
possibly external to the patient, if not, could have been
aspirated.
___ CXR
Moderate pulmonary edema worsened over 2 hours. ETT almost 2 cm
below optimal position. At least two bullet fragments projecting
over the right chest, precise locations indeterminate. Multiple
right rib fractures, chronicity indeterminate.
___ LENIs
No DVT bilaterally
___ TTE
Extremely limited image quality. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Global left
ventricular systolic function is at least mildly depressed. The
visually estimated left ventricular ejection fraction is 45%.
Dilated right ventricular cavity with SEVERE global free wall
hypokinesis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Cetirizine 10 mg PO DAILY:PRN allergies
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg ` tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*3
2. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
3. Cetirizine 10 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. HELD- Losartan Potassium 100 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you meet with your
primary care doctor
6.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute hypoxic respiratory failure secondary to
# ACUTE ON CHRONIC DIASTOLIC CHF
# HYPERTENSION
# OSA
# ___
# CKD stage 3 secondary to FOCAL SEGMENTAL GLOMERULOSCLEROSIS
# CHRONIC R SHOULDER PAIN
# Seasonal allergies
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with s/p intubation// eval ETT placement
TECHNIQUE: Single AP view chest
COMPARISON: Chest radiograph ___
FINDINGS:
ET tube tip less than 2 cm from the carina could be withdrawn 2 cm for more
standard positioning. Nasogastric drainage tube passes into a nondistended
stomach and out of view. No pneumothorax or pleural effusion. Bullet
fragments project over the right hilus and right scapula, precise location
indeterminate. Multiple fracture deformities, lateral right middle ribs.
Lung volumes are lower, exaggerating new moderate pulmonary edema and
progressive moderate cardiomegaly.
IMPRESSION:
Moderate pulmonary edema worsened over 2 hours. ETT almost 2 cm below optimal
position.
At least to bullet fragments projecting over the right chest, precise
locations indeterminate.
Multiple right rib fractures, chronicity indeterminate.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:43 am, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with acute hypoxemic respiratory failure//
evaluate for right sided radiopaque object ? aspiration evaluate for
right sided radiopaque object ? aspiration
IMPRESSION:
Comparison to ___. No relevant change is noted. The lung volumes
remain low. Moderate to severe pulmonary edema and moderate cardiomegaly
persist. Likely small left pleural effusion. No pneumonia, no pneumothorax.
The right-sided and potentially aspirated radiopaque structure is in stable
position.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with acute hypoxemic respiratory failure w/
concern for PE.// ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. The study was limited and the
posterior tibial and peroneal veins were not visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
INDICATION: ___ year old man with acute hypoxemic respiratory failure and
acute on chronic shoulder pain// evaluate for fracture
COMPARISON: Compared to the chest x-ray from yesterday.
IMPRESSION:
Single AP view of the right shoulder is limited due to the patient's large
body habitus, lordotic projection, and internal rotation of the humerus. No
large displaced fractures are seen. The scapula including the glenoid appears
hypoplastic; however, this may be partially due to rotation. Would recommend
dedicated shoulder radiographs if the patient is able. There is thickening of
the right fifth lateral rib which may be due to old fracture. If there is
high clinical concern, this could be further evaluated with CT. There is an
endotracheal tube whose distal tip is 2.4 cm above the carina, this could be
pulled back 2-3 cm for more optimal placement. There are low lung volumes.
There is again seen a metallic 1.2 cm density projecting over the right hilum
of unclear etiology and anatomic location.
Radiology Report
INDICATION: ___ man with PMH of severe obesity (BMI 50+), hypertension,
G6PD, FSGS/CKD (Cr 1.5-1.8),HTN, severe OSA on Triology at home presenting
with shoulder pain and dyspnea to the ED, found to be in hypoxemic/hypercapnic
respiratory failure s/p intubation// interval changes in pulm edema,
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Support lines and tubes unchanged. Lungs are low volume. Consolidative
opacities in both lower lobes right greater than left most likely represents
edema. Bilateral effusions unchanged. Cardiomediastinal silhouette is
stable. No pneumothorax is seen.
1 cm radiopaque structure projecting of the right hilum is unchanged position
is unclear without is external or internal to the patient, could represent an
aspirated foreign object.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with heart failure, pHTN, intubated in FICU//
eval for effusions, ETT tube placement eval for effusions, ETT tube
placement
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous moderate pulmonary edema has substantially cleared. Small right
pleural effusion remains. No pneumothorax. Heart size normal.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, R Arm pain
Diagnosed with Acute respiratory failure with hypercapnia, Dyspnea, unspecified
temperature: 98.8
heartrate: 107.0
resprate: 17.0
o2sat: 88.0
sbp: 131.0
dbp: 112.0
level of pain: 5
level of acuity: 3.0 | This is a ___ year old male with obesity, OSA, hypertension, G6PD
deficiency, CKD stage III secondary to FSGS, and diastolic CHF
admitted admitted ___ with acute hypoxic and hypercarbic
respiratory failure secondary to acute-on-chronic diastolic CHF,
treated with lasix drip, now transitioned to oral regimen and
able to be discharged home.
# Acute hypoxic respiratory failure secondary to
# ACUTE ON CHRONIC DIASTOLIC CHF
# HYPERTENSION
Patient presented with significant hypoxia requiring intubation
in the ICU. TTE at the time showed an EF of 45% and severe RV
systolic dysfunction suggestive of massive RV overload. Given
significant peripheral edema and history of subacute weight
gain, patient TTE abnormalities and clinical presentation were
felt to have acute on chronic diastolic CHF. He was diuresed
with IV Lasix 120mg BID with subsequent ability to extubate. In
setting ___ his losartan was held. He was started on
cardedilol for blood pressure control during this time. Over
the course of 8 days, he was diuresed to dry weight and changed
to new augmented dose of torsemide. Would consider Cr and K
check at follow-up. Would consider repeat TTE check as
outpatient to reassess R sided pressures.
# OBSTRUCTIVE SLEEP APNEA
# OBESITY HYPOVENTILATION SYNDROME
# ENLARGED TONSILS, DEVIATED SEPTUM
Given concern for possible pulmonary hypertension from OSA
contributing to his symptoms, he was seen by sleep medicine
managed on a Trilogy niPPV. Continued intranasal fluticasone,
cetirizine. Recommended for ENT follow up for Septoplasty,
tonsillectomy, adenoidectomy with Dr ___. Patient should
follow-up at sleep ___ outpatient follow up appointment on
___ at 4:20PM.
# ___
# CKD Stage 3
# FOCAL SEGMENTAL GLOMERULOSCLEROSIS
Patient with biopsy-proved FSGS, baseline Cr 1.8, with Cr 2.1 on
admission, peaking at 2.3. Losartan held as above. Cr
stabilized at 2.2, felt to be new baseline.
# CHRONIC R SHOULDER PAIN
Patient with chronic R shoulder pain, felt to be secondary to
history of gunshot wound. No fracture seen on single view XR.
He was seen by ___ and recommended for outpatient ___
# Seasonal allergies
Continued Cetirizine and intranasal Fluticasone
TRANSITIONAL ISSUES
- Discharged home
- Weight 151.05 kg
- Losartan held in setting ___ as above; would consider blood
pressure check and creatinine check at follow-up to guide
restarting this medication
- Contacts/HCP: ___, ___
- As above would repeat TTE as an outpatient to look at R sided
pressures, look for signs of residual pulmonary hypertension
- Will need ___ clinic follow up for septoplasty, tonsillectomy,
adenoidectomy.
- Follow up at sleep medicine clinic after ENT procedures for
Trilogy titration.
> 30 minutes spent on this discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Erythromycin Base / Motrin / Clindamycin / Aspirin
/ lorazepam / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
na
History of Present Illness:
Ms. ___ is a ___ F w PMHx of stroke ___ years ago
(generalized weakness), fibromyalgia, osteoarthritis, and HTN
who
presents after an episode of garbled speech.
Ms. ___ states that she was alone in her apartment and had
not spoken during the day until her daughter called around
___.
Ms. ___ notes that she had not eaten during the day and
had
a vague headache that she attributed to poor sleep from her
fibromyalgia pain. As she was speaking with her daughter, she
had
several episodes of "garbled" speech. Her daughter described it
has speaking in "rag-time." Ms. ___ also reports that
concurrent with her speech difficulties (which she herself could
easily appreciate), her headache had grown worse and settled in
around her left eye.
She and her daughter both agree she should go to the hospital
for
further evaluation. On my interview, she denies focal weakness,
numbness, or visual disturbances. She does still have a mild
left-sided headache, improved from its peak. She believes that
her speech has returned to baseline.
On neurological review of systems, Ms. ___ endorses the
above noted symptoms: headache and difficulty speaking. She
denies associated confusion, difficulty comprehending speech,
visual changes, focal weakness, sensory changes, gait
difficulties. She reports chronic pain with her fibromyalgia,
unchanges from her recent baseline.
Past Medical History:
- prior stroke ___ years ago
-- symptoms at that time were generalized weakness
-- patient cannot recall any focal findings
- fibromyalgia
- osteoarthritis
- HTN
- environmental allergies
- intention tremor
-- worsening over the past several months
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Examination:
VS T97.8 HR70 BP163/92 -> 137/83 RR18 Sat100%RA
GEN - elderly F, NAD, cooperative and pleasant
CV - RRR, extremities WWP
RESP - normal WOB, CTAB
ABD - soft, NT, ND
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
Neurologic Examination:
Mental Status - Awake, alert, oriented x3. Attention to examiner
easily attained and maintained. Concentration maintained when
recalling months backwards. Recalls a coherent history.
Structure
of speech demonstrates fluency with full sentences, intact
repetition, and intact verbal comprehension. Content of speech
demonstrates intact naming (high and low frequency) and no
paraphasias. Normal prosody. No dysarthria. Some infrequent
stumbling over words when recounting lengthy details of HPI.
Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] No facial movement
asymmetry with forced eyelid closure or volitional smile. [VIII]
Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally.
[XII] Tongue midline.
Motor - Normal bulk and tone. No pronation, no drift. No
orbiting
with arm roll. B/L UE intention tremor (baseline).
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5* 5 5 5 5 5 5 5 5
R 5 5 5* 5* 5 5 5 5 5 5 5
*Mild symmetric weakness - per patient, related to FM/OA
Sensory - No deficits to light touch, pinprick bilaterally. No
extinction to double simultaneous tactile stimulation.
Reflexes
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response flexor bilaterally.
Coordination - No dysmetria with finger to nose or heel-shin
testing. Intention tremor noted. Good speed and intact cadence
with rapid alternating movements.
Gait - Deferred
=============================================
On discharge the patient was afebrile with stable VS
Pt's neurologic exam remained stable and unremarkable.
Pertinent Results:
___ 07:45AM BLOOD WBC-5.1 RBC-4.25 Hgb-13.0 Hct-36.8 MCV-87
MCH-30.6 MCHC-35.4* RDW-13.3 Plt ___
___ 10:15PM BLOOD Neuts-72.4* ___ Monos-5.0 Eos-1.0
Baso-0.3
___ 07:45AM BLOOD Glucose-105* UreaN-12 Creat-0.7 Na-142
K-3.7 Cl-105 HCO3-26 AnGap-15
___ 07:45AM BLOOD ALT-13 AST-21 LD(LDH)-162 AlkPhos-82
TotBili-0.7
___ 07:45AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:45AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.1 Cholest-205*
___ 07:45AM BLOOD %HbA1c-6.1* eAG-128*
___ 07:45AM BLOOD Triglyc-188* HDL-36 CHOL/HD-5.7
LDLcalc-131*
___ 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:45AM BLOOD TSH-2.6
___ CTA head and neck
1. Hypodensity of the right caudate anterior body, which may
represent age indeterminate lacunar infarct. If there is high
clinical suspicion, MRI if there no contraindications may be
more sensitive.
2. Possible left subclavian artery origin dissection as
described. Recommend clinical correlation.
3. No evidence of large vessel occlusion or aneurysm of the
intracranial
circulation. 4. There is 25% stenosis of the right cervical
internal carotid artery. There is no stenosis of the left
cervical internal carotid artery by NASCET criteria.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atenolol 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Ascorbic Acid ___ mg PO BID
6. TraMADOL (Ultram) 50 mg PO QHS:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
4. Ascorbic Acid ___ mg PO BID
5. Atenolol 25 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO QHS:PRN pain
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
transient ischemic attack vs complicated migraine
carotid artery disease
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with TIA // eval eval
COMPARISON: The only prior chest radiograph was performed ___.
IMPRESSION:
Heart size top-normal. Lungs clear. No mediastinal, hilar, or pleural
abnormality.
Radiology Report
FINDINGS:
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: CVA, disease seen on CTA
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is moderate homogeneous plaque in the ICA. On the left there
is moderate heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 196/59, 138/36, 109/21 cm/sec. CCA peak systolic
velocity is 55 cm/sec. ECA peak systolic velocity is 105 cm/sec. The ICA/CCA
ratio is 3.6. These findings are consistent with 60-69% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 116/25, 116/30, 71/21 cm/sec. CCA peak systolic
velocity 92 cm/sec. ECA peak systolic velocity is 191 cm/sec. The ICA/CCA
ratio is 1.3. These findings are consistent with 40-59% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA 60-69% stenosis.
Left ICA 40-59% stenosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with TRANS CEREB ISCHEMIA NOS, MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS
temperature: 97.8
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 163.0
dbp: 92.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ yo woman with PMH of stroke ___
years ago, fibromyalgia, osteoarthritis, and HTN who presented
after an episode of garbled speech. Her symptoms were transient.
She was unable to get an MRI due to claustrophobia and allergies
to sedation. CTA shows considerable atherosclerosis and carotid
echo shows bl disease with 60-69% stenosis on the right. She
reported similar symptoms in the past, and also noted that her
current symptoms were followed by intense throbbing headache
with nausea, making complex migraine a quite likely scenario.
She was started on high dose statin and aspirin. The patient was
not interested in meeting with our vascular surgeons at this
point. She will under go repeat carotid US in 6 mo and surface
echo as an out patient.
================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
131) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Xylocaine
Attending: ___.
Chief Complaint:
R ankle pain, swelling
Major Surgical or Invasive Procedure:
___ - R ankle aspiration: WBC 3444 (Hct 27)
History of Present Illness:
___ history of HTN, asthma s/p Right THA on ___ who was doing
well post-operatively until approximately two days where she
developed atraumatic right lower ankle pain. The pain has gotten
progressively worse over the course of the last two days. She is
currently unable to bear weight at this time. She denies any
trauma. She reports increase swelling in the right ankle,
redness and no fevers at home but she is frebile in the ED. No
Chest pain, no shortness of breath
Past Medical History:
PMH: asthma, HTN, dyslipidemia, hypothyroidism, GERD, anemia
Pshx: appendectomy, C-section, cholecystectomy, tonsillectomy,
adenoidectomy.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Gen: NAD
MSK:
RLE: mild swelling of the ankle but no TTP, able to plantar and
dorsiflex without pain, no pain with PROM, SILT s/s/sp/dp/t,
Fires ___, FHL, G/S, TA
1+ DP
Pertinent Results:
___ 08:31PM JOINT FLUID WBC-3444* HCT-27* POLYS-77*
___ MONOS-5 EOS-2*
___ 08:31PM JOINT FLUID NUMBER-NONE
___ 05:00PM CRP-112.8*
___ 11:55AM WBC-7.9 RBC-3.12* HGB-10.0* HCT-30.1* MCV-97
MCH-32.1* MCHC-33.2 RDW-12.8 RDWSD-45.1
Medications on Admission:
1. Cetirizine 10 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Acetaminophen 1000 mg PO Q8H
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days
Start: ___, First Dose: Next Routine Administration Time
6. Senna 8.6 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. TraMADol 50 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Cetirizine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID:PRN constipation
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
8. TraMADol 50 mg PO Q4H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R ankle pain, swelling
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with R ankle swelling and pain // ?fracture or DVT
COMPARISON: None
IMPRESSION:
There is a tiny bony density adjacent to the lateral malleolus medially. This
may represent a tiny avulsion fragment. There is soft tissue swelling both
medially and laterally and is more pronounced laterally. The mortise alignment
is congruent on these nonstress views. Calcaneal spurs are present. There is
arthropathy in intertarsal joints.
NOTIFICATION: Dr. ___ reported the findings to Dr. ___ by telephone
on ___ at 12:50 ___, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with R ankle swelling and pain // ?fracture or DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
There is a 18 x 9 x 6 mm fluid collection immediately posterior to the medial
malleolus. This is not contiguous with a vein and likely represents a small
hematoma or possibly a synovial cyst.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1 No evidence of deep venous thrombosis in the right lower extremity veins.
2. There is a 18 x 9 x 6 mm fluid collection immediately posterior to the
medial malleolus. This is not contiguous with a vein and likely represents a
small hematoma or possibly a synovial cyst.
Radiology Report
INDICATION: History: ___ with recent right total hip arthroplasty, evaluate
for postoperative changes
TECHNIQUE: AP view of the pelvis, two views of the right femur
COMPARISON: ___
FINDINGS:
Patient is status post right total hip arthroplasty. Hardware appears in
unchanged alignment without evidence of complications. No fracture or
dislocation is seen. There are mild degenerative changes of the left femoral
acetabular joint with mild joint space narrowing. No diastases of the pubic
symphysis or sacroiliac joints is present. No concerning lytic or sclerotic
osseous abnormalities are detected. Mild degenerative changes are noted
within the lumbosacral spine. The imaged aspect of the right knee
demonstrates moderate degenerative changes with a small joint effusion.
IMPRESSION:
Status post right total hip arthroplasty without evidence of hardware
complications or change in alignment.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: R Ankle pain
Diagnosed with Pain in right ankle and joints of right foot, Other specified soft tissue disorders
temperature: 101.2
heartrate: 77.0
resprate: 18.0
o2sat: 95.0
sbp: 112.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient's exam was
concerning for a potential septic ankle and the patient was
admitted to the orthopedic surgery service. The ankle was
aspirated with WBC 3444 (Hct 27). She was started on empiric
Vancomycin and Cefazolin prior to the aspiration results
returned. The antibiotics were d/c prior to discharge. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the RLE , and will be discharged on her home lovenox for
DVT prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Chest pain, tachypnea
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Ms. ___ is an ___ year old woman with history of CAD s/p DES to
LCx (___) and unsuccessful LAD stenting, recent admission for
chest pain with cath deferred, presenting with L-sided chest
pain. She states that the pain started at 4:30AM, describes it
as
left-sided, severe, and radiating down her left arm. She also
endorses associated shortness of breath. Her daughter gave her 3
SL nitro around 6:15AM 50 min apart, which decreased her pain
from ___ to ___. She also is on home O2 at night and was 91%
on
room air when ___ EMS arrived. 12-lead ECG unchanged from
prior. She was then brought to the ___ ED for further
management.
On arrival to the ED, she reported pain significantly improved,
at a ___. Initial vitals notable for T 98.1, HR 88, BP 128/57,
93% on 2L. Exam notable for bilateral rhonchi without wheezing
and with mild tachypnea. Also with diffuse venous stasis changes
of bilateral lower extremities and 1+ pitting edema. Labs in the
ED notable for lactate 1.1, trop 0.01, Cr 1.2 (baseline ~1.5),
proBNP 5930 (4490 on non-CHF last admission). CXR with LLL
pneumonia and R-sided atelectasis. She was given ceftriaxone and
azithromycin for CAP coverage.
On arrival to the floor, she endorses the story as above. She
states that her pain has persisted as a ___, which worsens with
deep breaths. She also notes 100 pounds of unintentional weight
loss over the past year (50 pounds per chart review). She also
endorses mild diffuse abdominal pain without nausea or vomiting.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
HTN
Hypercholestrolemia
Hypothyroidism
MI ___ - acute anterior MI. At CATH, she has a right dominant
system. The left main was free of any lesions. The LAD had
discrete 99% lesion in the proximal segment that was stented to
0% residual. The left circumflex coronary artery had a discrete
80% lesion. The right coronary artery had a mid 35% lesion and a
proximal 40% lesion. LVEF: 50% (___)
Coronary angioplasty w/ ___ reflux
CKD Stage III
CHF w/ normal EF
RLD ___ obesity
Sleep apnea
Asthma
Arthritis
Stress incontinence
Social History:
___
Family History:
Both parents passed away from MI. Family history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 1310 Temp: 97.4 PO BP: 114/61 HR: 92 RR: 20 O2
sat: 93% O2 delivery: 3L Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally in posterior fields
with
crackles in left lower field. No wheezes or rhonchi. No
increased
work of breathing.
ABDOMEN: Bruising present from insulin injections. Normal bowels
sounds, non distended, mildly tender to deep palpation
throughout.
EXTREMITIES: Warm. Venous stasis skin changes to shins
bilaterally. 1+ pitting edema to lower calf bilaterally. No
clubbing or cyanosis.
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 816)
Temp: 98.9 (Tm 98.9), BP: 122/60 (114-124/53-69), HR: 95
(79-95), RR: 18 (___), O2 sat: 87% (87-94), O2 delivery: RA
(2l-3L), Wt: 163.14 lb/74 kg
GENERAL: NAD
HEENT: MMM.
NECK: Supple, no LAD.
CV: slightly tachycardic on exam with irregularly irregular
rhythm with audible S1/S2 and no murmurs, gallops, or rubs. JVP
visible at 16 cm. Lancisi sign positive.
PULM: Breathing comfortably without use of accessory muscles.
Dullness to percussion with fremitus present at the left lung
base. Lung fields generally clear to auscultation bilaterally
with some crackles present on the left lung base.
MSK: Palpable tender nodule located under left breast on chest
wall.
EXTREMITIES: No cyanosis or clubbing. Lower extremities with 1+
pitting edema up to the mid-lower leg.
Pertinent Results:
ADMISSION LABS:
___ 08:00AM BLOOD WBC-8.2 RBC-3.17* Hgb-9.6* Hct-30.6*
MCV-97 MCH-30.3 MCHC-31.4* RDW-14.9 RDWSD-52.5* Plt ___
___ 08:00AM BLOOD Neuts-79.4* Lymphs-11.1* Monos-6.7
Eos-1.7 Baso-0.5 Im ___ AbsNeut-6.48* AbsLymp-0.91*
AbsMono-0.55 AbsEos-0.14 AbsBaso-0.04
___ 08:00AM BLOOD Plt ___
___ 02:58PM BLOOD ___ PTT-38.1* ___
___ 08:00AM BLOOD Glucose-205* UreaN-40* Creat-1.2* Na-144
K-4.9 Cl-105 HCO3-25 AnGap-14
___ 08:00AM BLOOD proBNP-5930*
___ 08:00AM BLOOD cTropnT-0.01
___ 03:45PM BLOOD cTropnT-0.02*
___ 09:15PM BLOOD cTropnT-0.02*
___ 08:38AM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 06:57AM BLOOD WBC-8.6 RBC-3.09* Hgb-9.2* Hct-30.0*
MCV-97 MCH-29.8 MCHC-30.7* RDW-15.4 RDWSD-54.1* Plt ___
___ 06:57AM BLOOD Plt ___
___ 06:57AM BLOOD ___ PTT-37.8* ___
___ 06:57AM BLOOD Glucose-88 UreaN-42* Creat-1.0 Na-148*
K-4.2 Cl-108 HCO3-27 AnGap-13
___ 06:57AM BLOOD ALT-11 AST-15 AlkPhos-77 TotBili-0.4
___ 06:57AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8
CXR ___:
Left lower lobe pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with left-sided chest pain. History of COPD and CAD//
Pneumonia? Pneumothorax ?
COMPARISON: Prior chest radiographs dated ___
FINDINGS:
Portable AP chest radiograph. Airspace consolidation is noted in the left
lower lobe concerning for pneumonia. Mild right basal atelectasis. No
effusion or pneumothorax. There are no signs of congestion or edema. The
cardiomediastinal silhouette is stable with redemonstration of cardiomegaly.
Imaged osseous structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION:
Left lower lobe pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Tachypnea
Diagnosed with Pneumonia, unspecified organism
temperature: 98.1
heartrate: 88.0
resprate: 22.0
o2sat: 93.0
sbp: 128.0
dbp: 57.0
level of pain: 7
level of acuity: 2.0 | TRANSITIONAL ISSUES:
====================
[] She has had 50-100 pounds of weight loss over the past ~year
that was unintentional. This can be further worked up in the
outpatient setting.
[] Her INR should be checked within the next week for warfarin
dosing.
[] She has been on colchicine 0.3mg daily without urate lower
therapy since ___. This should be addressed in the outpatient
setting.
[] She will be discharged on 3 more days of antibiotics for a
total of a 5-day course for community acquired pneumonia. She is
being discharged on cefpodoxime and doxycycline.
[] She was told to use her home O2 full-time while she recovers
from her pneumonia as her ambulatory O2 saturation was low
(mid-80s). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lower leg swelling and redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo ___ with PMHx of RA not currently on
therapy, Spinal stenosis, disc herniation s/p microdiscectomy in
___, chronic back pain, peripheral neuropathy, ADD, PTSD,
foot ulcers, HCV s/p Harvoni now with undetectable VL, ITP,
recent DVT on xarelto, presents with lower extremity swelling
from his PCPs. Patient is all over the place in his story, but
from what I can discern, he has had chronic ulceration of his
lower legs and redness. About 1 week ago the redness and
swelling
increased. He notes no fever/chills. No cough, chest pain, or
diarrhea. He notes no areas of purulent infection. He does note
loose stools with intermittent constipation due to his chronic
narcotic use.
He also brings up when he was recently discharged from rehab, he
was on Morphine 15mg ___ q2h, but PCP did not want to prescribe
this frequency. I concur that 15mg ___ q2h at this point in time
is a LOT of morphine. Offered patient a pain consult inpatient
as
I am no willing to give him 15mg q2h, which he then brought up
an
outpatient pain specialist and did not seem interested in the
CPS
while here.
As per his anemia, patient notes no frank bleeding other than
from his right knee. He denies red/black stools. When bringing
up
nutrition and his low iron patient notes he hasn't been eating
well. HE tried to be vegan but found that to be financially
unavailable. He has no teeth so He cannot eat meat. he notes
sometimes he takes a MVI, but then brings up multiple
supplements
to me including some nutrient in a green pill form that comes
from the ocean off of ___. He also notes his primary
protein intake is in the way of a supplement - but some off
market supplement that a company doesn't make anymore(?).
Past Medical History:
RA,
Spinal stenosis
disc herniation s/p microdiscectomy in ___
chronic back pain
peripheral neuropathy
ADD
PTSD
foot ulcers
HCV s/p Harvoni - now with undetectably VL
ITP
recent DVT on xarelto ___ diagnosed at ___
hernia repair
psoriasis (per patient)
venous stasis
remote MVA in ___ with ___
Social History:
___
Family History:
No family history of depression, substance abuse, chronic pain
Physical Exam:
VS: (ED) Temp: 97.5, HR: 71, BP 109/71, RR:16 100% on RA
Gen: Cooperative. Pleasant. NAD
HEENT: Endentulous. EOMI
CV: RRR
Resp: CTA-B
Abd: Soft, NT, ND
Ext: Both legs symmetrically swollen. 3+ pitting edema to knee.
Redness extends from toes to knee with some sloughing of skin on
right toes. Large ulceration on right heal and right medial
maleous. Skin of his right toes seems to be sloughing as well.
Left foot his top of his toes skin has come off. He notes this
injury happened a few months ago
Skin: Areas of redness not symmetric - more on right leg than
left. Extends to the knee anteriorally. Does have some rubor and
calor. Pain sensation somewhat limited for patient
Neuro: Non focal
Psych: Pleasant, off topic.
----------------
24 HR Data (last updated ___ @ 300)
Temp: 99.3 (Tm 99.3), BP: 138/80 (106-140/60-106), HR: 84
(81-92), RR: 16, O2 sat: 97% (97-100), O2 delivery: ra
Gen: Cooperative. NAD
HEENT: Endentulous. EOMI
CV: RRR
Resp: CTA-B
Abd: Soft, NT, ND
Ext: Both legs symmetrically swollen. In gravity dependent
thighs. Legs wrapped. Skin: Erythema improved. stasis dermatitis
noted on lower extremity
Neuro: Non focal
Psych: Frustrated.
Pertinent Results:
Echocardiogram ___
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global
biventricular systolic function. Mild pulmonary artery systolic
hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Furosemide 80 mg PO DAILY
3. Gabapentin 600 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Morphine SR (MS ___ 30 mg PO Q8H
6. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
7. Narcan (naloxone) 4 mg/actuation nasal ONCE
8. Omeprazole 40 mg PO DAILY
9. Oxazepam 30 mg PO QHS
10. Oxazepam 30 mg PO BID:PRN anxiety
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
12. Potassium Chloride 10 mEq PO DAILY
13. Rivaroxaban 20 mg PO DAILY
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
15. Acetaminophen 1000 mg PO Q8H
16. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
17. Senna 8.6 mg PO BID:PRN Constipation - Third Line
18. Dextroamphetamine 60 mg PO BID
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 4 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*10 Capsule Refills:*0
2. CeraVe (ceramides ___ 1 app topical DAILY
RX *ceramides ___ [CeraVe] 1 application daily Refills:*1
3. econazole 1 % topical BID
RX *econazole 1 % 1 application to toenails twice a day
Refills:*0
4. Hydrocerin 1 Appl TP DAILY legs
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Acetaminophen 1000 mg PO Q8H
7. Atenolol 25 mg PO DAILY
8. Dextroamphetamine 60 mg PO BID
9. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
RX *morphine 30 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*42 Tablet Refills:*0
10. Furosemide 80 mg PO DAILY
11. Gabapentin 600 mg PO BID
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Morphine SR (MS ___ 30 mg PO Q8H
14. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*84 Tablet Refills:*0
15. Narcan (naloxone) 4 mg/actuation nasal ONCE
16. Omeprazole 40 mg PO DAILY
17. Oxazepam 30 mg PO QHS
18. Oxazepam 30 mg PO BID:PRN anxiety
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
20. Potassium Chloride 10 mEq PO DAILY
21. Rivaroxaban 20 mg PO DAILY
22. Senna 8.6 mg PO BID:PRN Constipation - Third Line
23. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Cellulitis
Lymphedema
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 R foot ulcer// R foot ulcer, assess for bony
involvement/infx
TECHNIQUE: Right foot, three views
COMPARISON: Right foot radiographs ___
FINDINGS:
Soft tissue ulcer is seen along the plantar aspect of the foot subjacent to
the calcaneus. No cortical destruction or osteolysis is visualized. No soft
tissue gas. No acute fracture or dislocation. Osseous structures are
diffusely demineralized. Similar smooth periosteal reaction along the lateral
aspect of the proximal fourth metatarsal. Large plantar calcaneal spur.
Minimal joint space narrowing involving the interphalangeal joints and first
MTP joint. Diffuse soft tissue swelling is demonstrated. 1 mm radiopaque
density is seen within the plantar soft tissues at the level of the midfoot,
which could reflect a tiny radiopaque foreign body.
IMPRESSION:
Soft tissue ulcer along the plantar aspect of the foot subjacent to the
calcaneus without radiographic evidence for osteomyelitis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with a history of RA, spinal stenosis, disc
herniation s/p microdiscectomy in ___, chronic back pain, peripheral
neuropathy, ADD, PTSD, foot ulcers, HCV s/p Harvoni, ITP, recent DVT on
xarelto, presents with lower extremity swelling.// LLE swelling (bilateral,
already had RLE ultrasound)
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. Peroneal veins have not been well
visualized..
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Please note that the peroneal veins are not well visualized.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Leg swelling, Wound eval
Diagnosed with Cellulitis of right lower limb, Cellulitis of left lower limb
temperature: 97.8
heartrate: 100.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 60.0
level of pain: 8
level of acuity: 3.0 | A/P: Mr ___ is a ___ year old man with a history of RA,
spinal
stenosis, disc herniation s/p microdiscectomy in ___,
chronic
back pain, peripheral neuropathy, ADD, PTSD, foot ulcers, HCV
s/p
Harvoni, ITP, recent DVT on xarelto, presents with lower
extremity swelling and pain, concerning for cellulitis.
# ___ swelling - Pt with significant 3+ edema to lower
extremities
and takes furosemide outpatient. Had increased to 160mg qD
without improvement of swelling. No hx of heart failure noted in
chart - but with chronic Lasix use may have some. Albumin 3.8.
Most likely due to volume overload. Patient is somewhat
difficult
in terms of following directions while inpatient. Refusing Heart
Healthy diet. Refusing condom cath for accurate I/O output.
Derm was consulted who noted patient would most likely benefit
from ACE wraps of legs or compression stockings. At time of
discharge patient is to wrap legs daily and transitioned back to
his home PO dose of Lasix.
# ___ redness and calor - Bilateral which usually is not
indication for cellulitis but for hemostasis, although at this
time looking at patient's open wounds could entertain multiple
entry for infections on both legs for patient. At this time
without areas of purulence that would make me concerned for
Staph
infection. Patient improved with cefazolin and continued on a PO
course of Keflex for 7 days of total treatment. His foot wounds
are to be wrapped in ACE wraps and cleansed with Iodine. Patient
to be set up with home nursing to help with these wraps. He will
also be prescribed econazole for his toenails.
# Acute on Chronic Anemia - Stable Hgb at 8, although with
increased poikilocytosis + occ schitocytes and elevated INR will
obtain repeat CBC and INR to ensure no active hemolysis. Unsure
of the cause. Does have a low iron, and patient has not been
being treated for RA so most likey both ___ and Anemia of
inflammation. 2G drop in the last month though? seems slightly
excessive.
- Will need outpatient colonoscopy
# Back pain ___ spinal stenosis, disc herniation, and neuropathy
- on 30mg MS ___ q8h and 15 immediate release Q4H.
- Added 15mg ___ BID PRN while inpatient and with acute pain
needs - did not discharge on this extra dose. Needs narcotic
contract outpatient.
- Gabapentin
# Hx DVT - in ___, on xarelto. Without evidence of DVTs
currently on
LENIs
# ADD - Methylphenidate BID
# ITP - Plts slowly downtrending, but without precipitous drop.
Should follow up with PCP to have rechecked.
# RA - currently not on therapy due to waiting for wounds to
heal. Had been on Enbrel before. Has been off for about ___
months
# HCV s/p Harvoni - VL undetectable |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Penicillins / Ketorolac / Tessalon Perles /
Amitriptyline
Attending: ___.
Chief Complaint:
?Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ a history of chronic back pain, triple A (largest 5.8
cm), recurrent cellulitis, presenting with left lower extremity
erythema and fevers to 102 (patient reported). Patient reports
he was in his normal state of health until yesterday. While
sleeping overnight noted increased sweating and chills. He took
his temperature and noted it to be 102. Took 2 Advil, and went
back to bed but noted increased temperature again to 102 this
morning with expanding erythema on the left lower extremity.
Denies any chest pain, cough, shortness of breath. Denies any
new abdominal pain, nausea, vomiting, diarrhea. Reports that his
chronic back pain is unchanged. And that the numbness in his
legs is unchanged.
Pt was recently admitted in hospital ___ to ___ for lower back
pain and ?cellulitis which was treated with po bactrim/cipro.
Lasix and lisinopril were held ___ rising Cr.
Of note, when EMS arrived, patient's apartment was incredibly
dirty with fleas and cockroaches running around. Patient is
supposed to be in an ___ facility where they are
cleaning his apartment however this may not be happening.
In the ED, initial Vitals were pain ___ temp 99 HR 95 BP 115/85
RR 16 98% on RA. In the ED, patient expressed some concerns to
the nurse about people placing powder on his feet he thought was
Narcan and that they were trying to detox him without his
permission. Also reports he thought people were picking at scabs
on his face. Labs were remarkable for Hct to f 30.5, lactate of
0.7, Cr of 2.1 (dc-ed on ___ with 1.3), wbc of 7.4 and normal
LFTs. LENIS showed no dvt. Pt had dopplerable pulses bilaterally
and had guaiac negative brown stool. Pt had blood cultures X 2
drawn and was given ig IV vanc, 1L NS, 1mg of dilaudid and
transferred to Med floor for mx of cellulitis. Patient may
require psychiatric evaluation on the floor
REVIEW OF SYSTEMS:
Denies headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
-- COPD, used to use home O2, but denies current use
-- Cellulitis
-- Venous insufficiency
-- AAA 5cm ___
-- Hepatitis C
-- etoh abuse
-- ivdu with cocaine and heroine
-- depression
-- History of cardiac catheterization showing mild diastolic
dysfunction, left main 20% stenosis, hypokinetic anterior wall,
left ventricular ejection fraction 50%, otherwise normal.
-- Urinary incontinence
-- Chronic Back pain (repeated MRIs @ multiple hospitals ___
acute findings. h/o associated opioid abuse. Has been tapered
off methadone and opioids are supplied on daily basis by PCP, Dr
___
Social History:
___
Family History:
Per records, father has had anxiety, panic and depression, was
hospitalized at ___ and had ECT. Mother died of breast
cancer, father died of tongue cancer
Physical Exam:
ADMISSION:
GEN Alert, AOX3, pt appears agitated, with pressured speech
HEENT NCAT MMM EOMI sclera anicteric, OP clear, multiple
excoriations around eyebrows, forehead
NECK supple, no JVD, no LAD
PULM Good aeration, mild expiratory wheezes, but no rales or
ronchi
CV RRR normal S1/S2, no mrg
ABD soft, tender with scars from previous surgeries, midline
scar appears excoriated, normoactive bowel sounds, no r/g
EXT has erythema of both lower extremities, left greater than
right. Both equally warm, but without any oozing. Partially
healed scars on LLE. Pt complainging of severe pain.
NEURO CNs2-12 intact, motor function grossly normal, gait not
assessed
DISCHARGE:
VS - 98.1-98.9 108-121/60-65 73 ___ 97 RA
GEN Alert, AOX3, pt agitated, with pressured speech
HEENT NCAT MMM EOMI sclera anicteric, OP clear, multiple
excoriations around eyebrows, forehead
NECK supple, no JVD, no LAD
PULM Good aeration, mild expiratory wheezes, but no rales or
ronchi
CV RRR normal S1/S2, no mrg
ABD soft, tender with scars from previous surgeries, midline
scar appears excoriated, normoactive bowel sounds, no r/g
EXT has erythema of both lower extremities. Both equally warm,
without any oozing. Partially healed scars on LLE. pain.
NEURO CNs2-12 intact, motor function grossly normal, gait not
assessed
Pertinent Results:
ADMISSION:
___ 04:30PM BLOOD WBC-7.4 RBC-3.46* Hgb-10.8* Hct-30.5*
MCV-88 MCH-31.1 MCHC-35.3* RDW-15.2 Plt ___
___ 04:30PM BLOOD Neuts-55.0 ___ Monos-5.7 Eos-4.3*
Baso-0.8
___ 04:30PM BLOOD Glucose-86 UreaN-34* Creat-2.1* Na-138
K-4.9 Cl-106 HCO3-21* AnGap-16
___ 04:30PM BLOOD ALT-17 AST-27 AlkPhos-44 TotBili-0.1
___ 06:50AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.4
___ 04:30PM BLOOD Albumin-3.9
___ 04:42PM BLOOD Lactate-0.7
BLOOD CULTURES x 2 ___: NGTD
LENIS ___: No evidence of deep venous thrombosis in the left
lower extremity.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 5 mg PO DAILY
2. Albuterol-Ipratropium 1 PUFF IH BID
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Tiotropium Bromide 1 CAP IH DAILY
5. Docusate Sodium 100 mg PO BID
6. Senna 2 TAB PO HS:PRN constipation
7. Aspirin 81 mg PO DAILY
8. Clonazepam 2 mg PO TID
hold for sedation
9. Duloxetine 40 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. HydrOXYzine 10 mg PO TID
14. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
hold for rr<8, sedation
15. Fentanyl Patch 150 mcg/hr TP Q72H
16. mometasone-formoterol *NF* 100-5 mcg/actuation Inhalation
bid
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Albuterol-Ipratropium 1 PUFF IH BID
3. Aspirin 81 mg PO DAILY
4. Clonazepam 2 mg PO TID
hold for sedation
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 40 mg PO DAILY
7. Fentanyl Patch 150 mcg/hr TP Q72H
8. FoLIC Acid 1 mg PO DAILY
9. HydrOXYzine 10 mg PO TID
10. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
hold for rr<8, sedation
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 2 TAB PO HS:PRN constipation
13. Thiamine 100 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. mometasone-formoterol *NF* 100-5 mcg/actuation Inhalation
bid
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Chronic Venous Stasis
SECONDARY DIAGNOSIS:
1. COPD
2. Abdominal Aortic Aneurysm
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: Patient with swelling and cellulitis of the left lower extremity.
Assess for DVT.
COMPARISONS: None available.
FINDINGS: Grayscale and Doppler images of bilateral common femoral, left
superficial femoral, deep femoral, popliteal and upper calf veins demonstrate
normal flow, compressibility and response to augmentation.
IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CELLULITIS
Diagnosed with CELLULITIS OF LEG, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPERTENSION NOS
temperature: 99.0
heartrate: 95.0
resprate: 16.0
o2sat: 98.0
sbp: 115.0
dbp: 85.0
level of pain: 9
level of acuity: 3.0 | ASSESSMENT AND PLAN: ___ admitted with suspicion of cellultis
found to have chronic venous stasis. Discharged on home meds,
and was not given any antibiotics.
# Chronic Venous Stasis: Pt has been recently treated with
cipro/bactrim for cellulitis in prior admission. Has a long
history of lower extremity changes dating back to the ___. Has
been previously treated with po/iv clinda and more recently po
cipro/bactrim. Pt has no WBC, documented fever, and/or any signs
of systemic infection. Pt has redness and warmth bilaterally on
both lower extremities. Has been confused with cellulitis in the
past. Pt remained afebrile and stable without any abx.
# Narcotic Dependance: Pt has a long standing documented hisotry
of narcotic dependance. Pt currently complaining of ___ pain in
the abdomen and legs that appears to be non specific and out of
proportion to history, physical exam and lab findings. We
maintained patient on home pain meds (fentanyl patch,
oxycodone). We continued polyethyene glycol, docusate, senna
for constipation
# Psych Issues: pt has a long hx of narc dependance and has had
code purpled several times on previous admissions. Pt was
verbally abusive towards primary care team including PCTs, MDs,
and RNs. We continued home clonazepam and duloxetine. Pt also
left the medicine floor against medical advice and had to be
brought back by security. Pt also threatened to leave AMA but
___ changed his mind.
# COPD: pt had some wheezes on exam but stable on RA. We
continued home albuterol inhalers, tiotropium bromide, adviar
(swithced from Mometasone/ formoterol as non formulary)
# GERD: stable although pt complaining of belly pain not likely
to be reflux related. we continued home omeprazole 40mg qd
# CAD: stable. We continued asa 81mg
# HTN: stable. Systolics in 110s. We held home lisinopril due to
Cr of 2.1 on admission which will need to be restarted by PCP
after ___ check.
# Nutrition: pt appears disheveled and may be malnurished given
alcohol hx. We continued thiamine, folic acid |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, sore throat, generalized malaise
Major Surgical or Invasive Procedure:
___ - Diagnostic cerebral angiogram
___ - Left craniotomy for aneurysm clipping and
reconstruction
___ - Diagnostic cerebral angiogram
History of Present Illness:
___ is ___ year old male who presented to the ED on
___ as a transfer from an outside facility with
complaints of fever, sore throat, and generalized malaise over
the last 3 days. He was incidentally found to have a left MCA
aneurysm on imaging at the outside facility and was transferred
to ___ for escalation of care. Neurosurgery was consulted for
evaluation and management recommendations. On evaluation in the
ED, the patient states that he has also been having intermittent
headaches over the last 3 days. He states that they are
generalized and are sometimes sharp in quality. He denies any
aggravating or alleviating factors. He also reports slight
dizziness over the last 3 days. He denies any additional
neurologic symptoms including confusion, visual changes,
difficulty with memory, difficulty with speech, nausea,
vomiting, numbness, and tingling. He denies any recent trauma.
Past Medical History:
- Status post removal of bony abnormality behind left ear at age
___
Social History:
___
Family History:
No known family history of cerebral aneurysm.
Physical Exam:
On Admission:
-------------
Vital Signs: T 98.4F, HR 60, BP 134/59, RR 16, O2Sat 96% on room
air
General: Well nourished adult male. Comfortable appearing. No
acute distress.
Head, Eyes, Ears, Nose, Throat: Normocephalic. Atraumatic.
Extremities: Warm and well perfused.
Neurologic:
Mental Status: Awake and alert. Cooperative with examination.
Normal affect.
Orientation: Oriented to person, place, and time.
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, 4-3mm,
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. No abnormal
movements,tremors. ___ strength throughout. No drift.
Sensation: Intact to light touch.
On Discharge:
-------------
Physical Examination:
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
EOMs: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
BUE/BLE full strength ___ throughout
Sensation: Intact to light touch.
Wrist Site:
- Clean, dry, intact
- Soft, no hematoma
- Palpable pulses
Cranial Site:
- Clean, dry, intact
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN fever or pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Please continue while taking narcotic pain meds.
3. Docusate Sodium 100 mg PO BID
Please continue while taking narcotic pain meds.
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) to six
(6) hours Disp #*80 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
Please continue while taking narcotic pain meds.
Discharge Disposition:
Home
Discharge Diagnosis:
Left MCA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Cerebral angiogram to evaluate the left M3 aneurysm
The following vessels likely catheterized and angiography was performed
Right radial artery
Right vertebral artery
Right common carotid artery
Left external carotid artery
Left internal carotid artery
Three-dimensional rotational angiography was performed requiring post
processing on an independent workstation and concurrent attending physician
interpretation and review
INDICATION: ___ year old man with L MCA aneurysm// diagnostic angio with
possible ___ of L MCA aneurysm
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed and fentanyl throughout the total intra service time of 45minutes
during which the patient's hemodynamic parameters were continuously monitored
by a trained, independent observer. Patient received a total of 100 mcg of
fentanyl and 0.5 mg of Versed and was continuously supervised by the attending
physician.
TECHNIQUE: Cerebral angiogram, complete
COMPARISON: None.
PROCEDURE: The patient was identified and brought to the neuroradiology
suite. He was transferred to the fluoroscopic table supine. Moderate sedation
was administered. Bilateral groins and right wrist were prepped and draped in
the standard sterile fashion. A time-out was performed. The right radial
artery was identified using anatomical landmarks. Infiltration of local
anesthetic was performed. Using a micropuncture set, the radial artery was
accessed and a 5 ___ slender glide radial sheath was advanced over the
microwire. The microwire was removed and radial artery cocktail, consisting
of 2.5 mg of verapamil, 200 mcg of nitroglycerin, and ___ units of heparin,
were diluted and given through the radial sheath. The sheath was then
connected to continuous heparinized saline flush. Next a 5 ___ ___ 2
catheter was brought onto the field, flushed, and connected to continuous
heparinized saline flush the power injector. Catheter was inserted into the
sheath and angiography was performed the right radial artery. Next a 038
glidewire was introduced common under fluoroscopic guidance, the wire catheter
were advanced in selected into the right vertebral artery. The catheter was
advanced over the wire and the wire was withdrawn. Vessel patency was
confirmed via hand injection. Standard AP and lateral views were obtained.
Next catheter was withdrawn and the wire was reintroduced selected into the
descending aorta. The catheter was shaped into the ___ hook in selected
the right common carotid artery. Vessel patency was confirmed via hand
injection. Standard AP and lateral views were obtained as well as high
magnification transorbital and oblique views. Next the catheter was advanced
well maintained ___ hook and selected into the left common carotid artery.
Roadmap angiography was performed. Under roadmap guidance wire was
reintroduced and used to select the left external carotid artery. The
catheter was advanced over the wire and the wire was withdrawn. Vessel patency
was confirmed via hand injection. Standard AP and lateral views were
obtained. Next the catheter was withdrawn roadmap angiography was again
performed. Under roadmap guidance wire was reintroduced and used to select
the left internal carotid artery. The catheter was advanced over the wire and
the wire was withdrawn. Vessel patency was confirmed via hand injection.
Standard AP and lateral views were obtained as well as high magnification
oblique views and 3D rotational angiography. Next the diagnostic catheter
was removed. A TR band selected and placed over the arteriotomy site of the
right radial artery. This was insufflated to 15 cc of air. The radial sheath
was then removed and there is no evidence of bleeding for the arteriotomy
site. A small amount of air was removed from the TR band until there was a
small amount of pulsatile blood. At that 1 cc of air was reinjected into the
TR band. Pulse oximetry was placed on the index finger and the ulnar artery
was compressed to confirm patent hemostasis. The patient was removed from the
fluoroscopy table and remained at his neurologic baseline without any evidence
of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Right radial artery: Vessel caliber smooth regular. There is filling of the
radial artery retrograde filling into the brachial artery. There is filling
into the ulnar artery, anterior, and posterior interosseous arteries. No
evidence of vasospasm or occlusion.
Right vertebral artery: Vessel caliber smooth and regular. There is filling
of right vertebral artery filling the right posterior inferior cerebral
artery. There is retrograde filling into the left vertebral artery filling
was left posterior inferior cerebral artery. There is filling of bilateral
anterior inferior cerebral arteries, bilateral superior cerebellar arteries
and bilateral posterior cerebral arteries and their distal territories. There
is filling of the right posterior communicating artery filling the right
anterior circulation. No aneurysms or AVMs are identified.
Right Common carotid artery: Vessel caliber smooth and regular. There is
filling of the anterior and middle cerebral arteries and the distal
territories. There is filling across the anterior communicating artery
filling contralateral A 2. The ophthalmic artery is patent as is posterior
communicating arteries which fills the posterior cerebral circulation. No
aneurysms or AVMs are identified.
Left external carotid artery: Vessel caliber smooth and regular. There is
filling of the external carotid artery and its distal branches. There is a
robust left superficial temporal artery
Left internal carotid artery: Vessel caliber smooth and regular. There is
filling of the anterior and middle cerebral arteries and the distal
territories. There is filling across the anterior communicating artery into
the contralateral A2. The ophthalmic artery is patent as is the posterior
communicating artery no other aneurysms or AVMs are identified. Fills the
posterior cerebral circulation. There is a 10 mm x 6 mm left M3 fusiform
aneurysm.
IMPRESSION:
Left M3 10 mm x 6 mm fusiform aneurysm
RECOMMENDATION(S):
1. Patient will be scheduled for left-sided craniotomy and aneurysm
reconstruction.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT) ___
INDICATION: ___ year old man pre-op// cardiopulmonary process Surg: ___
(L crani aneurysm bypass) CEREBRAL ANEURYSM
IMPRESSION:
No prior chest radiographs available.
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
and pleural margins are normal.
Radiology Report
EXAMINATION: PRE-SURGICAL WAND OR THERAPY PLANNING T7744 MR HEAD
INDICATION: ___ year old man with L MCA aneurysm. OR at 9:30AM ___, please do
wand anytime prior to OR// WAND FOR LEFT CRANI. OR at 9:30AM ___, please do
wand anytime prior to OR
TECHNIQUE: After administration of mL of Gadavist intravenous contrast,
axial imaging was performed with MPRAGE and T1 technique. Sagittal and coronal
orientation reformatted images of the MPRAGE acquisition was then produced.
COMPARISON: CTA head neck ___
FINDINGS:
The patient's previously noted 11 mm x 6 mm fusiform left M3 aneurysm is again
seen. Consider connective tissue disease, prior inflammatory, infectious or
posttraumatic causes as etiology.
Benign developmental venous anomaly right cerebellum.
IMPRESSION:
1. 11 mm x 6 mm fusiform left M3 MCA aneurysm.
Radiology Report
EXAMINATION: Cerebral angiogram to evaluate left M3 aneurysm clipping
The following vessels were selectively catheterized and angiography was
performed
Left internal carotid artery
Three-dimensional rotational angiography was performed requiring post
processing on an independent workstation and concurrent attending physician
interpretation and review
INDICATION: ___ year old man with Left M3 aneurysm s/p clip reconstruction//
Eval left M3 clipping
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed and fentanyl throughout the total intra service time of 25minutes
during which the patient's hemodynamic parameters were continuously monitored
by a trained, independent observer. Patient received a total of 100 mcg of
fentanyl and 0.5 mg of Versed and was continuously supervised by the attending
physician.
TECHNIQUE: Cerebral angiogram, single-vessel
COMPARISON: Cerebral angiogram ___
PROCEDURE: The patient was identified and brought to the neuroradiology
suite. He was transferred to the fluoroscopic table supine. Moderate sedation
was administered. Bilateral groins and right wrist were prepped and draped in
the standard sterile fashion. A time-out was performed. The right radial
artery was identified using anatomical landmarks. Infiltration of local
anesthetic was performed. Using a micropuncture set, the radial artery was
accessed and a 5 ___ slender glide radial sheath was advanced over the
microwire. The microwire was removed and radial artery cocktail, consisting
of 2.5 mg of verapamil, 200 mcg of nitroglycerin, and ___ units of heparin,
were diluted and given through the radial sheath. The sheath was then
connected to continuous heparinized saline flush. Next a 5 ___ ___ 2
catheter was brought onto the field, flushed, and connected to continuous
heparinized saline flush the power injector. Catheter was inserted into the
sheath with a 038 glidewire. The wire and catheter was advanced over the arm
selected into the descending aorta. The catheter shaped into the ___ hook
in selected into the left common carotid artery. The wire was advanced and
used to select the left internal carotid artery. The catheter was advanced
over the wire and the wire was withdrawn. Vessel patency was confirmed via
hand injection. Standard AP and lateral views were obtained as well as high
magnification transorbital and oblique views and 3 D rotational angiography.
Next the diagnostic catheter was removed. A TR band selected and placed over
the arteriotomy site of the right radial artery. This was insufflated to 15
cc of air. The radial sheath was then removed and there is no evidence of
bleeding for the arteriotomy site. A small amount of air was removed from the
TR band until there was a small amount of pulsatile blood. At that 1 cc of
air was reinfected into the TR band. Pulse oximetry was placed on the index
finger and the ulnar artery was compressed to confirm patent hemostasis. The
patient was removed from the fluoroscopy table and remained at his neurologic
baseline without any evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Left internal carotid artery: Vessel caliber smooth and regular. There is
filling of the anterior and middle cerebral arteries and their distal
territories. There is filling across the anterior communicating artery
filling the contralateral A 2. The ophthalmic artery is patent as is the
posterior communicating arteries fills the posterior cerebral circulation.
The area where the left M3 aneurysm had been clipped as visualized. The
aneurysm is been reconstructed with the vessel now having a more normal
appearance. The branch vessel near the aneurysm continues to fill there is no
evidence of stenosis at the aneurysm reconstruction site.
IMPRESSION:
Successfully treated left M3 middle cerebral artery aneurysm
RECOMMENDATION(S):
1.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p L MCA aneurysm clipping, now febrile// R/o
infectious process
TECHNIQUE: Frontal and lateral view radiographs of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are identified.
IMPRESSION:
No pneumonia or acute cardiopulmonary process.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man s/p crani for aneurysm repair with fevers.
Evaluation for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: No relevant prior imaging for comparison.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. A duplicated left
femoral vein is incidentally noted. Duplication of the distal right femoral
vein is incidentally noted. Normal color flow and compressibility are
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Transfer
Diagnosed with Cerebral aneurysm, nonruptured
temperature: 98.4
heartrate: 60.0
resprate: 16.0
o2sat: 96.0
sbp: 134.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | ___ year old male incidentally found to have a left MCA aneurysm.
#Left MCA Aneurysm
The patient was admitted to Neurosurgery on ___ for
further evaluation management. He was taken to the Angiography
Suite on ___ for a diagnostic cerebral angiogram, which
confirmed the presence of the left MCA aneurysm. He recovered in
the PACU post procedurally and was transferred back to the
floor. He remained intact on ___. MRI WAND was done overnight on
___ in preparation for surgery and patient was taken to the OR
___ for Left Craniotomy for L MCA Aneurysm clipping and arterial
reconstruction. Patient tolerated the procedure well. Please see
formal op report in OMR for intra operative details. Patient was
successfully extubated in the OR and transferred to the PACU for
post op care. He remained hemodynamically and neurologically
stable in the PACU and was transferred to ___ for ongoing
monitoring. Repeat diagnostic angiogram was performed on ___,
which showed no filling of the aneurysm. He remained
neurologically stable on post-angio check. He was transferred to
the floor where he remained stable and neuro intact. He was
medically cleared for discharge on ___.
#Pharyngitis
The patient initially presented with fever, sore throat, and
generalized malaise. A rapid strep test at the outside facility
was negative. CT of the neck at the outside facility was
consistent with pharyngitis. The patient was started on a 7-day
course of amoxicillin. Throat cultures eventually resulted with
Group C beta strep. Patient was continued on amoxicillin course
and completed his course on ___.
#Fevers
Patient intermittently spiked fevers during his hospital course.
Infectious workup including, UA, CXR, blood cultures were sent
multiple times and all were negative. LENIs were done and
negative for DVT. Patient white count was within normal limited
and not indicative of infection. Fevers were though to be due to
anticholinergic response secondary to scopolamine patchy in
combination with antiemetics. Scopolamine patch was
discontinued. Patient's fevers resolved and he remained afebrile
as of ___.
#Disposition
On day of discharge, patient labs and vitals were within normal
limits. He was tolerating a regular diet, and voiding without
difficulty. Patient was mobilizing independently with no ___
needs. His pain was well controlled. Patient was medically
stable for discharge home on ___. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with h/o asthma who presents with dyspnea and dry cough x
3 days. Pt has a history of asthma for which she takes symbicort
and PRN albuterol, has been using the albuterol ___ times daily
for the past several months. Her typical triggers are infections
and exposures to pets. 3 days ago, she developed a dry cough and
shortness of breath. Also c/o mild muscle and joint aches. No
fevers or chills, no sick contacts or recent travel. Does
endorse exposure to pets, as her boyfriend has a dog and a cat.
She presented to the ED on ___ where a CXR showed mild lung
hyperinflation. She was diagnosed with an asthma exacerbation
and was discharged with prescription for cough medicine,
albuterol and symbicort, and a 5 day prednisone taper. She has
not yet started the prednisone.
Today she presented to her PCP office complaining of worsening
dyspnea. She has been using her albuterol inhaler q1h without
relief. Has NOT yet filled her presciption for prednisone. Peak
flow (checked in office) was 210. PCP sent her to the ED for
urgent eval.
Currently, she complains of dyspnea which is mild at rest, worse
on exertion. Also endorses epigastric/substernal chest pain
which worsens with deep inspiration.
In the ED intial vitals were: 98 95 ___ 20 99% ra. Patient was
given: Albuterol nebs x4, ipratropium nebs x2, prednisone 20mg
PO x1, ketorolac x1, lorazepam 1mg x1. CXR again showed
hyperinflated lungs, no e/o infiltrate/effusion/edema. Because
nebs were unable to be spaced out beyond q2 hrs, pt was admitted
for asthma exacerbation.
Vitals on transfer: 98.4 118 135/75 20 99% RA
Review of Systems:
(+) bifrontal headache, chills
(-) fever, night sweats, vision changes, congestion, sore
throat, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
PNC: EDC ___ by ___ TM U/S (was until today noted as
___ by ___ - but ERA shows >7d discrepancy)
Labs O+, Ab neg, RPRNR, RI, HepBsAg neg
U/S scheduled ___
Routine ERA low risk
OBHx: SVD x1, SAB x1
GynHx: h/o abnl Pap ___ "treated" -> neg since
h/o chlamydia s/p tx
PMHx: asthma, anxiety
PSHx: denies
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
Vitals- 98.4 118 135/75 20 99% RA
General- Awake, alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- diffuse expiratory wheezes bilaterally. No rales or
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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
Vitals- 98.5, 131/87, 88, 18, 100% RA
General- Alert, oriented x3, no acute distress, lying in bed,
slightly flattened affect
HEENT- Sclera anicteric, MMM, oropharynx clear with no lesions
and erythema
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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, gait
normal
Pertinent Results:
ADMISSION LABS:
___ 06:00AM BLOOD WBC-8.6 RBC-4.44 Hgb-11.9* Hct-34.6*
MCV-78* MCH-26.8* MCHC-34.5 RDW-13.6 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-121* UreaN-8 Creat-0.5 Na-134
K-4.6 Cl-101 HCO3-22 AnGap-16
___ 06:00AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-6.8 RBC-4.05* Hgb-10.9* Hct-31.5*
MCV-78* MCH-26.9* MCHC-34.5 RDW-13.5 Plt ___
___ 06:00AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-136 K-3.7
Cl-105 HCO3-22 AnGap-13
___ 06:00AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
URINE: None
MICRO: None
IMAGING:
___ CHEST (PA & LAT)
IMPRESSION: Hyperinflated lungs. Otherwise, no acute
cardiopulmonary
process.
___ CTA CHEST W&W/O C&RECONS, NON-CORONARY
FINDINGS: The pulmonary arteries enhance symmetrically without
evidence of filling defect to suggest pulmonary embolism. There
is no evidence of aortic aneurysm or dissection. The heart is
normal in size. There is no pericardial effusion. The
visualized portions of the thyroid are normal. There is no
significant mediastinal, hilar, or axillary lymphadenopathy. The
central airways are patent. The lungs and pleural spaces are
clear. The visualized upper abdominal structures are normal.
The osseous structures are within normal limits.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation 2 puffs BID
3. Ranitidine 150 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Fexofenadine 180 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate 90 mcg ___ puffs inhalation every ___
hours Disp #*1 Inhaler Refills:*2
2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation 2 puffs BID
RX *budesonide-formoterol [Symbicort] 80 mcg-4.5 mcg/actuation 2
puffs inhalation twice a day Disp #*1 Inhaler Refills:*1
3. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*1
4. Citalopram 10 mg PO DAILY
RX *citalopram 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. Senna 1 TAB PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*1
6. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
7. Fexofenadine 180 mg PO DAILY
RX *fexofenadine 180 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*15 Packet Refills:*1
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
10. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN sore throat
RX *phenol [Chloraseptic Throat Spray] 1.4 % 1 spray to the back
of the throat four times a day Disp #*1 Bottle Refills:*0
11. PredniSONE 10 mg PO DAILY
___ take 3 pills/ day
___ take 2 pills/ day
___ take 1 pill/ day
stop after ___
Tapered dose - DOWN
RX *prednisone 10 mg As directed below tablet(s) by mouth as
directed Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute asthma exacerbation
SECONDARY DIAGNOSIS:
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: Cough and dyspnea.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. The lungs
are hyperinflated, as was also the case on the prior study, may relate to the
patient's history of asthma. No focal consolidation is seen. There is no
pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are
stable and unremarkable. Hilar contours are also stable.
IMPRESSION: Hyperinflated lungs. Otherwise, no acute cardiopulmonary
process.
Radiology Report
HISTORY: Asthma exacerbation now with acute onset chest pressure.
TECHNIQUE: Volumetric CT scan was performed through the chest after the
administration of 100 mL Omnipaque nonionic intravenous contrast. Post
processing performed in the coronal and sagittal planes.
COMPARISON: None.
FINDINGS:
The pulmonary arteries enhance symmetrically without evidence of filling
defect to suggest pulmonary embolism. There is no evidence of aortic aneurysm
or dissection. The heart is normal in size. There is no pericardial
effusion. The visualized portions of the thyroid are normal. There is no
significant mediastinal, hilar, or axillary lymphadenopathy.
The central airways are patent. The lungs and pleural spaces are clear. The
visualized upper abdominal structures are normal. The osseous structures are
within normal limits.
IMPRESSION:
No evidence of pulmonary embolism.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Asthma exacerbation, ILI
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION
temperature: 98.0
heartrate: 95.0
resprate: 20.0
o2sat: 99.0
sbp: 95.0
dbp: 79.0
level of pain: 7
level of acuity: 3.0 | ___ F with PMH significant for asthma, anxiety and borderline
intellectual disability who presents with dyspnea and peak flow
in 200's at ___ office in setting of recent URI, found to have
asthma exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
trazodone
Attending: ___.
Chief Complaint:
aphasia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ left-handed woman with a history of
migraines and congenital IVH at birth who presents with a
one-day history of difficulty speaking and left sided
weakness/numbness. On ___ (four days prior to
presentation) she developed a migraine, which she describes as
holocephalic throbbing pain associated with nausea and
dizziness. She says this was typical of her usual migraines.
This continued through ___, when she started vomiting at
work and had to be sent home. She drove herself to a friend's
house who then took her to the ED at ___. There a CT
head was done which showed no acute process and her neurologic
exam was reportedly normal. There was a note made that she had
"some trouble expressing herself" when asked questions directly
but seemed to be speaking normally to her friends. ___ were wnl
and she was treated symptomatically with IVF, toradol, ativan,
and reglan with improvement in her symptoms. She was given
prescriptions for compazine and percocet and advised to follow
up with neurology. She returned home and seemed fine the rest of
the night. On ___ morning she reportedly looked well when
she initially woke up. Her boyfriend went to take a shower and
when he came back he noticed that the left side of her face was
drooping and she was having difficulty speaking. She also
complained of numbness in her L arm and leg and some difficulty
controlling this side of her body. This persisted throughout the
day on ___, and when her symptoms were still present ___
morning she decided to return to ___. There she was
noted to have "expressive aphasia," left sided sensory loss, but
no weakness on exam. No imaging was done and she was transferred
to ___ for further evaluation.
On our initial evaluation she is quite anxious and tearful and
is visibly very
frustrated by her difficulty speaking. She is able to speak in
___ word phrases but has great difficulty finding the correct
words and makes frequent paraphasic errors as well. She seems to
have trouble with comprehension as well and has a lot of
difficulty following commands. She continues to report numbness
and weakness in her L arm and leg. She thinks her symptoms have
remained constant since their onset, with no clear improvement
or worsening over the last day. She denies any headache or
nausea currently.
Her mother reports that she began getting migraines in middle
school. They had initially improved but the over the past ___
they returned again. She was seen in the ___ ED in ___ for
severe headache for 3 days located in the bilateral retroorbital
and occipital regions associated with some type of visual
disturbance (unclear per notes, pt unable to describe
currently). CT head showed dilation of the ventricular system
and subsequent MRI showed enlargement of the R lateral ventricle
consistent with congenital variation. No mass lesion or areas of
abnormal enhancement were seen. She was treated for a migraine
and sent home.
She has otherwise been feeling well with no recent illnesses,
fever/chills. Her boyfriend reports that she smoked "Peak" on
___ night (a synthetic cannabinoid) but she denies any
other recent drug use and has not used that substance before.
She recently stopped smoking about a week ago and says she is on
some type of pill to help her with this but is unsure of the
name. She
has smoked for a few years prior to this and also takes OCP's.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. +nausea, no vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias.
Her mother also noticed some "bug bites" over her R neck. They
are not itchy and currently not bothering her but she says she
has been outdoors recently. No known tick exposures.
Past Medical History:
Migraines with aura
Congenital IVH - thought to be related to complications during C
section. Had a seizure disorder during infancy and was on
phenobarbital and dilantin from ages ___. She has had no
further seizures since then. She went on to develop normally
with no neurologic deficits.
Social History:
___
Family History:
Father with DVT in his ___ s/p vein stripping. Has also had
blood clots after long car rides in recent years.
Mother healthy
Aunt with migraines
Paternal grandfather died of cancer
Maternal grandmother had ___, died in her ___
Physical Exam:
Admission Physical Exam:
Vitals: 98.8 68 119/68 16 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: small erythematous papules over R neck near hairline
Neurologic:
-Mental Status: Awake and alert, quite anxious, becomes
frustrated and tearful frequently due to her difficulty
expressing herself. Says day is ___ but otherwise unable to
answer orientation questions. She has a nonfluent aphasia and is
unable to say more than ___ words at once. She has significant
word finding difficulties and also makes some paraphasic errors.
She repeats somewhat stereotyped phrases frequently such as
"that's all it is" and "can't do it." When asked to name objects
she becomes very distressed and keeps saying "I can take it" but
is unable to name any of the items on the stroke card. Speech is
not dysarthric. Unable to read or write. At times she seems to
understand and attempts to respond appropriately to questions,
but at other times her comprehension seems to be quite impaired,
particularly when trying to follow commands. She is unable to
follow simple commands such as open your mouth or show me two
fingers. She appears to have difficulty coordinating movements
particularly on the left side and even has trouble matching
movements (such as raising arms or spreading fingers) when
demonstrated to her. She is unable to repeat.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation - appears to
have some left-sided visual neglect.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Slight flattening of the left nasolabial fold
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. Has difficulty cooperating
with pronator drift testing but appears to have some pronation
on
the L.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 5 5 5 5 5 5 5
R 5 ___ ___- 5 5 5 5 5 5 5
-Sensory: Reports decreased sensation to light touch, pinprick,
and cold sensation over the L arm and leg. Intact on the face.
Vibration and proprioception intact at b/l great toes.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on R, mute on L.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Mild unsteadiness on tandem gait. Romberg absent.
=================
DISCHARGE EXAM:
Afebrile, VSS. Aphasia improving: now able to say name, days of
week, and count to 12. Some approximately ___ word sentences.
Some persistent difficulty following commands likely due to a
component of sensory language deficit. No weakness, no sensory
deficits.
Pertinent Results:
___ 04:40PM BLOOD WBC-8.7 RBC-4.15* Hgb-13.4 Hct-39.5
MCV-95 MCH-32.2* MCHC-33.9 RDW-12.7 Plt ___
___ 04:40PM BLOOD Neuts-63.2 ___ Monos-5.0 Eos-1.0
Baso-0.5
___ 04:40PM BLOOD Glucose-76 UreaN-9 Creat-0.7 Na-140 K-4.0
Cl-107 HCO3-17* AnGap-20
___ 04:40PM BLOOD ALT-21 AST-24 AlkPhos-54 TotBili-0.3
___ 04:40PM BLOOD Albumin-4.4 Calcium-9.4 Phos-2.8 Mg-2.2
___ 07:05AM BLOOD %HbA1c-5.7 eAG-117
___ 07:05AM BLOOD Triglyc-88 HDL-58 CHOL/HD-2.4 LDLcalc-62
___ 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
NCHCT ___:
1. Hypodense area in the right temporoparietal region most
consistent with subacute infarct in the right MCA territory.
MRI could be considered for further evaluation.
2. Left maxillary sinus disease.
CTA ___:
Near-complete occlusion of the M1 segment of the right middle
cerebral artery with apparently a small trickle of flow passing
beyond the thrombus. Strong collateral flow appears to
contribute to vascularity in the right hemisphere.
MRI ___:
Extensive infarction in the distribution of the inferior
division
of the right middle cerebral artery with scattered involvement
in the superior division territory. A small component in the
occipital lobe may represent the distal inferior division MCA
distribution, rather than posterior cerebral artery involvement.
NCHCT/CTA ___:
1. Grossly unchanged non-contrast CT head, in keeping with the
known large right MCA infarct.
2. Unchanged subtotal occlusion of the distal M1 segment of
right MCA.
Distal M3 branches appear normally opacified, suggesting of
collateral
filling.
TRANSESOPHAGEAL ECHO:
No intracardiac source of embolism found. No ASD/PFO seen by
color doppler or bubble study with provocative manoevers. No
athersclerosis or dissection seen in aorta.
Medications on Admission:
Reclipsen (OCP)
Multivitamin
Compazine as needed
Percocet as needed
Discharge Medications:
1. Fluoxetine 40 mg PO DAILY
RX *fluoxetine 40 mg 1 capsule(s) by mouth daily Disp #*90
Capsule Refills:*3
2. Multivitamins 1 TAB PO DAILY
3. Warfarin 7.5 mg PO DAILY16
RX *warfarin 7.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
4. Outpatient Speech/Swallowing Therapy
5. Outpatient Lab Work
___ and INR, ___. ICD-9: 434.01. CORE Physicians ___.
Fax ___ (phone ___
Discharge Disposition:
Home
Discharge Diagnosis:
primary: Right MCA cerebral embolism with infarction
Discharge Condition:
Mental Status: Clear and coherent. (Aphasic)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with three days left-sided weakness, word
finding difficulties, rule out acute hemorrhage or mass.
COMPARISONS: CT head from ___ and from ___.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
FINDINGS: There is a large area of hypodensity in the right temporoparietal
region concerning for subacute infarct. There is additional loss of
gray-white matter differentiation. There is no evidence of acute hemorrhage
or mass effect. The ventricles and sulci are normal in size and
configuration. There are secretions within the left maxillary sinus. No
acute fracture.
IMPRESSION:
1. Hypodense area in the right temporoparietal region most consistent with
subacute infarct in the right MCA territory. MRI could be considered for
further evaluation.
2. Left maxillary sinus disease.
Radiology Report
CTA HEAD AND NECK, ___
HISTORY: Evaluate for stenosis or occlusion. Difficulty speaking, left-sided
weakness and right temporoparietal hypodensity on CT.
CTA was performed during rapid infusion of 70 mL of Omnipaque intravenous
contrast. Images were processed on a separate workstation. Comparison to
head CTs of ___ and ___.
FINDINGS: No non-contrast CT scan was performed. Therefore, it is difficult
to evaluate the progression of the posterior temporal and parietal infarction
demonstrated on the prior CT scan. The CTA examination demonstrates a large
thrombus in the distal right middle cerebral artery M1 segment with a tiny
trickle of antegrade flow, apparently extending around the obstruction. There
is generous vascularization of the MCA territory, likely due to collateral
flow. There is no evidence of hemorrhage, but the possibility of hemorrhage
is not well evaluated on this CTA examination. Images of the remaining
intracranial arteries appear normal with no other areas of stenosis or
occlusion detected.
The right and left common and internal carotid arteries appear normal, with no
evidence of stenosis or occlusion. The proximal internal carotid arteries are
greater in diameter than the distal cervical ICAs. Thus, there is no stenosis
by NASCET criteria. Images of the vertebral arteries appear normal.
CONCLUSION: Near-complete occlusion of the M1 segment of the right middle
cerebral artery with apparently a small trickle of flow passing beyond the
thrombus. Strong collateral flow appears to contribute to vascularity in the
right hemisphere.
A preliminary report was generated that read "right-sided edema, better
appreciated on non-contrast CT. Right MCA occlusion and distal M1 segment
with good collateral flow. No aneurysms of the arteries of head or neck.
Patent venous sinuses. Incidental note of sinus mucosal thickening with
aerosolized mucus. ___ discussed with Dr. ___ at 12:40
a.m."
Radiology Report
MR HEAD NEURO, ___
HISTORY: Difficulty speaking and left-sided weakness and numbness. Evaluate
right temporal hypodensity on CT.
Sagittal short TR, short TE spin echo imaging was performed along with axial
diffusion, FLAIR, long TR, long TE fast spin echo, and gradient imaging.
Comparison to a head CT and CTA of ___.
FINDINGS: There is no evidence of hemorrhage.
There are extensive areas of slow diffusion involving the right temporal and
parietal lobes with scattered involvement of the frontal and occipital lobes.
These findings suggest acute-subacute infarction in these territories. They
are compatible with an embolus lodging proximally in the middle cerebral
artery with subsequent distal embolization. The occipital lobe involvement
appears to extend into the posterior cerebral artery territory. However, it
is possible that this simply reflects the posterior extent of the inferior
division of the MCA.
CONCLUSION: Extensive infarction in the distribution of the inferior division
of the right middle cerebral artery with scattered involvement in the superior
division territory. A small component in the occipital lobe may represent the
distal inferior division MCA distribution, rather than posterior cerebral
artery involvement.
Radiology Report
HISTORY: ___ woman, with known right MCA stroke. Assess for interval
change.
COMPARISON: Multiple prior studies with the latest CTA head on ___ and MR ___ on ___.
TECHNIQUE: Non-contrast MDCT images were acquired through the head. Followed
by IV administration of iodinated contrast, MDCT images were acquired through
the head per standard CTA head protocol. Dedicated 3D rendering was performed
for better evaluation of the underlying vessels.
FINDINGS:
NON-CONTRAST CT HEAD: Again noted is an extensive hypodensity involving the
right middle cerebral artery territory, grossly similar in size and extent
compared to the study three days ago. There is no evidence of hemorrhagic
conversion. There is persistent adjacent sulcal effacement but no shift of
normally midline structures. The ventricles are similar in configuration
compared to the prior study. There is again a slightly prominent cisterna
magna, unchanged.
No acute skull base fracture is noted. There is moderate opacification in the
left maxillary sinus. The remaining visualized paranasal sinuses and mastoid
air cells are clear.
CTA HEAD: Again noted is a subtotal occlusion of the distal right M1 segment,
compatible with the known intraluminal thrombus. There is near-normal distal
opacification of the M3 branches, suggesting robust collateral leptomeningeal
filling. The overall CTA study is unchanged from three days ago. There is no
evidence of intracranial aneurysm, vascular malformation, or new occlusion.
IMPRESSION:
1. Grossly unchanged non-contrast CT head, in keeping with the known large
right MCA infarct.
2. Unchanged subtotal occlusion of the distal M1 segment of right MCA.
Distal M3 branches appear normally opacified, suggesting of collateral
filling.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L SIDED WEAKNESS
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 98.8
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 119.0
dbp: 68.0
level of pain: 13
level of acuity: 2.0 | AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (x) Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 62) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
___ was admitted to the hospital for workup and management of
a R MCA stroke seen on CT and confirmed on MRI, with an M1
occlusion with good collateral flow on CTA. Most likely
etiologies are a combination of stroke risk factors including
smoking, migraine with aura, and oral contraceptive use, with
possible contribution from the synthetic marijuana compound she
reported using the night before her symptoms started. Workup for
cardioembolic cause with TEE was negative for right-to-left
shunt. She was started on a heparin drip and bridged to Coumadin
after repeat CTA showed no improvement in the occlusion, with
plan to continue anticoagulation (INR goal ___ for three months
and then discontinue and perform hypercoagulability workup. Oral
contraceptive was discontinued. Her aphasia improved slowly over
the course of her admission; weakness had resolved by the time
of admisson to the floor; and numbness resolved over the course
of admission. She did not qualify for ___ rehabilitation
but should receive intensive outpatient speech therapy upon
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
prednisone / Hydromorphone / morphine / Oxycodone / capsaicin
Attending: ___.
Chief Complaint:
elbow pain
Major Surgical or Invasive Procedure:
___ - ORIF left distal humerus
History of Present Illness:
___ w/ hx of rectal prolapse s/p colostomy, HTN who presents
s/p fall with L supracondylar humerus fx. Patient reports that
she was getting up to the restroom this morning, at which point
her right foot got stuck on the sheets and she fell on her left
side. Thinks she blacked out for several minutes. Presents from
___, where she received 2 mg of hydromorphone, as
well as Zofran, despite allergies to hydromorphone.
Patient underwent CT contrast of the head that was negative for
any intracranial abnormality.
Past Medical History:
___/PSH:
L knee replacement ___ at ___ by ___
R knee replacement ___ at ___ by ___ hip total arthroplasty ___ @ ___
rectal prolapse surgery ___, s/p colostomy
Family History:
NC
Physical Exam:
Per OMR, on admission:
PHYSICAL EXAMINATION:
In general, the patient is an awake, alert, pleasant ___
Vitals:
97.6 80 180/64 18 96% RA
Right upper extremity:
Abrasion over right upper arm
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Skin intact
Tender over elbow w/ ecchymosis
Severe pain with flexion/extension of elbow
Full, painless AROM/PROM of shoulder, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Large effusion and ecchymosis over left patella, mildly tender
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 02:35PM GLUCOSE-119* UREA N-24* CREAT-1.1 SODIUM-140
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18
___ 02:35PM estGFR-Using this
___ 02:35PM CALCIUM-8.4 PHOSPHATE-3.7 MAGNESIUM-2.2
___ 02:35PM WBC-10.0 RBC-4.05* HGB-12.4 HCT-39.5 MCV-98
MCH-30.6 MCHC-31.4 RDW-12.6
___ 02:35PM NEUTS-78.1* LYMPHS-13.9* MONOS-7.3 EOS-0.4
BASOS-0.4
___ 12:40PM URINE HOURS-RANDOM
___ 12:40PM URINE HOURS-RANDOM
___ 12:40PM URINE UHOLD-HOLD
___ 12:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:40PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-6
___ 12:40PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-6
___ 12:40PM URINE MUCOUS-RARE
Medications on Admission:
MEDS:
prednisone 10 mg tablet oral
1 tablet(s) Once Daily
lisinopril 2.5 mg tablet oral
1 tablet(s) Twice Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Lisinopril 2.5 mg PO BID
3. PredniSONE 10 mg PO DAILY
4. Cephalexin 500 mg PO Q8H Duration: 6 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*15 Capsule Refills:*0
5. Docusate Sodium 100 mg PO BID
take while taking narcotic pain medication
6. Senna 17.2 mg PO HS
7. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4-6H
Disp #*60 Tablet Refills:*0
8. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right supracondylar humerus 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
INDICATION: Left elbow fracture.
COMPARISON: Outside hospital radiographs, ___.
THREE FLUOROSCOPIC VIEWS OF THE LEFT ELBOW:
There is plate and screw fixation of the left distal humeral fracture. On
these views, there is improved alignment. The total fluoroscopic time was 3.6
seconds. For further details, please see the intraoperative note.
Radiology Report
HISTORY: Mechanical fall. Assess for fracture or malalignment.
TECHNIQUE: Noncontrast axial images obtained through the cervical spine.
Coronal and sagittal reformations provided.
COMPARISON: No prior studies for comparison.
FINDINGS:
No fracture is identified. Multilevel degenerative detected including a 2 mm
anterolisthesis of C4 on C5. In addition, there is a moderate to severe disc
space narrowing at C5-6 with a large posterior disc osteophyte complex causing
mild narrowing of the spinal canal. There is mild uncovertebral hypertrophy
and facet arthropathy causing minimal narrowing of the multilevel neural
foramen. No prevertebral soft tissue swelling identified. No lymphadenopathy
present. A 12 mm nodular hypodensity is noted within the right thyroid lobe.
The lung apices are incompletely captured.
IMPRESSION:
No fracture or acute malalignment. Multilevel degenerative detected including
a 2 mm anterolisthesis of C4 on C5.
12 mm right thyroid lobe nodule.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with SUPRCONDYL FX HUMERUS-CL, HEAD INJURY UNSPECIFIED, CONTUSION OF KNEE, UNSPECIFIED FALL
temperature: 97.6
heartrate: 82.0
resprate: 16.0
o2sat: 96.0
sbp: 157.0
dbp: 96.0
level of pain: 3
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left supracondylar humerus fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
left distal
humerus fracture with lateral column intra-articular
comminution, 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 ___ 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 NWB in the LUE extremity, and will
be discharged on aspirin for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Facial Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with recurrent MRSA cellulitis and hx of
zoster presenting with facial abscess. Pt states that a few
weeks ago she had a MRSA abscess under both arms drained at ___
___ and treated with po bactrim. This resolved and she
went on trip to ___. She had N/V and diarrhea upon
returning with other family members with similar symptoms.
Yesterday, she had intense burning nasal pain radiating toward
eyes and bumps in her nostrils. She also had fever to 102.6.
Bumps are increasing in number and feels that her entire nose is
swollen. Has had clear yellow drainage from bumps in nose. She
presented to ___ where she was given 2 doses of
vancomycin and discharged home on bactrim. She describes a
burning pain across her nose and left cheek that feels like her
prior episode of shingles. Has had pain around left eye and
headache pain mostly on the left. Her ___ daugther seems
to be developing what appears to be a cold sore on her lip.
Patient herself has never had HSV. She called her infectious
disease doctors ___, Dr ___ who recommended that
she be seen by a healthcare provider.
In the ED, initial VS were: 96 89 171/89 18 99% ra. She was
given 1g iv vancomycin, 500mg po cephalexin, and 1 tablet
percocet. Labs were largely unremarkable. Per ED note,
aspiration of the lesion did not yield pus.
REVIEW OF SYSTEMS:
(+) Per HPI; reports headache
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Asthma
Disk surgery x 2
Gestational diabetes / Prediabetes
PCOS
Obesity with current eval for gastric bypass
Depression
Recurrent MRSA cellulitis
Zoster (___)
Social History:
___
Family History:
Father with DM, heart attack before ___. No autoimmune disorders
or known immunodeficiencies.
Physical Exam:
ON ADMISSION
VS: 98.2 156/79 89 18 99%RA
GENERAL: well appearing, no acute distress
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM; left nare
with yellow crusting and surrounding erythema. No lesions on
cheeks, mildly warm to touch, 1cm/.5cm abscess behind L ear
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact
Vitals: T: 98.7 BP: 128/84, P-94, RR-20 97%RA
General: Alert, oriented, no acute distress, morbidly obese
HEENT: Sclera anicteric, erythema around L eye resolved with
minimal swelling and some tenderness to palpation, 1cm abscess
behind L ear tender to palpation, 3 crusted vesicles under L
nostril that are less erythematous than prior exam
Neck: supple, enlarged submandibular and cervical lymph nodes
bilaterally, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, 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:
Neuro: normal range of motion of eye, cranial nerves intact;
normal vision noted
Pertinent Results:
___ 11:20PM GLUCOSE-106* UREA N-14 CREAT-0.5 SODIUM-140
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-26 ANION GAP-18
___ 11:20PM WBC-7.6 RBC-4.64 HGB-14.0 HCT-39.5 MCV-85
MCH-30.1 MCHC-35.4* RDW-12.9
___ 11:20PM NEUTS-55.1 ___ MONOS-4.0 EOS-3.7
BASOS-1.4
CT Orbits/Sinus ___
There is no abscess or subcutaneous edema. The orbits and globes
are normal. Mild-to-moderate sinus disease.
BLOOD CX ___ X2- PENDING
DAT FOR HERPES AND VARICELLA ___- INADEQUATE SPECIMEN
___ 4:38 pm SKIN SCRAPINGS
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Pending):
VARICELLA-ZOSTER CULTURE (Pending):
ON DISCHARGE
___ 08:35AM BLOOD WBC-4.9 RBC-4.23 Hgb-12.8 Hct-36.0 MCV-85
MCH-30.2 MCHC-35.5* RDW-12.7 Plt ___
___ 08:35AM BLOOD Glucose-120* UreaN-9 Creat-0.5 Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
___ 08:35AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.9
___ 08:50AM BLOOD HIV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Ibuprofen 800 mg PO Q8H:PRN pain
4. melatonin *NF* 10 mg Oral qhs
5. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q6h prn SOB
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q6h prn SOB
4. melatonin *NF* 10 mg Oral qhs
5. Ibuprofen 800 mg PO Q8H:PRN pain
6. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily as
needed Disp #*40 Capsule Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*20 Tablet Refills:*0
8. ValACYclovir 1000 mg PO Q8H Duration: 8 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth Three times daily
Disp #*24 Tablet Refills:*0
9. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 8 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth Twice Daily Disp #*32 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Possible Herpes Zoster Infection
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Cellulitis and a rash over left eye and cheek. Pain with eye
movement. Pain over sinuses.
TECHNIQUE: MDCT images were obtained through the facial bones with IV
contrast. Coronal and sagittal reformations were performed. Bone algorithm
was obtained.
COMPARISON: None available.
FINDINGS:
There is no subcutaneous soft tissue swelling. No fracture. The bones are
unremarkable with no evidence of scerosis or erosion. There is mild mucosal
thickening in the maxillary sinuses bilaterally, ethmoid air cells, and
frontal sinuses. The sphenoid sinus is nearly filled with mucus. The mastoid
air cells are well aerated. There are prominent level 1 b lymph nodes on the
left, likely reactive. The parotid and submandibular glands are unremarkable
bilaterally. The facial muscles are unremarkable. The orbits and globes are
normal. There is no evidence of abnormal enhancement
IMPRESSION:
There is no abscess or subcutaneous edema. The orbits and globes are normal.
Mild-to-moderate sinus disease.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L NASAL ABCESS/PAIN
Diagnosed with OTHER DISEASE OF NASAL CAVITY AND SINUSES, METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE, CARRIER OR SUSPECTED CARRIER OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
temperature: 96.0
heartrate: 89.0
resprate: 18.0
o2sat: 99.0
sbp: 171.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | ___ female with recurrent MRSA cellulitis and hx of
zoster presenting with facial rash associated with burning and
swelling.
# Facial rash: Pt with hx of recurrent MRSA abscesses and
cellulitis. Presented with parasthesias over L side of face with
erythema/swelling and 3 crusted vesicles over L nostril. On
presentation, there was certainly an element of cellulitis here
that is improved with vancomycin. Story was also consistent with
zoster opthalmicus. Crusted lesion under L nostril consistent
with impetigo but also looked vesicular. Given concern for
zoster opthalmicus, optho consulted. Optho exam showed no
evidence ov uveitis or keratitis. ID consulted who recommended
CT scan to rule out underlying abscess and viral DFA scraping.
CT showed no orbital/sinus abscess. Initial FA slide was
inadequate for culture. Viral culture pending. Patient improved
rapidly on IV vanco and IV acyclovir. Was transitioned to PO
Bactrim/Valacyclovir to complete 10 day course. Has follow-up
with Dr ___ on ___. Blood cx pending at discharge.
#Depression:
-continued citalopram
#Asthma:
-continued albuterol
-continued flovent
Transitional Issues
-Blood cx Pending X2
-Viral Scarpings for HSV and VZV pending at discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ferrous sulfate
Attending: ___.
Chief Complaint:
Diaphoresis
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ y/o ___ speaking gentleman w/ EtOH cirrhosis diagnosed
___
years ago being evaluated in liver transplant clinic when he
developed diaphoresis on his face and forehead and facial
warmth.
Interview conducted via phone interpreter. The episode lasted 30
min and resolved spontaneously. He denies chest pain,
palpitations, SOB, cough, abdominal pain, nausea/vomiting,
fevers/chills, diarrhea. Denies poor PO intake. Denies dysuria.
BG at ___ today was 98. Recently admitted at ___ ~2 weeks ago for similar complaints accompanied by
lightheaded/faintness lasting 1 hr that improved on his way to
the hospital when he drank some ___. Recalls his blood
pressures and blood glucose were low on presentation at that
time. Regarding his cirrhosis, he said he started drinking
heavily after his son passed away from a train accident but has
not ingested any alcohol for ___ years. Recalls history of 2
paracenteses ___ years ago but denied h/o hematemesis. Had ___
edema in the past, not currently.
Per dc summary from ___, cirrhosis history c/b ascites,
bleeding esophageal varices and portal vein thrombosis.
Progressive lower extremity edema, jaundice, confusion, ascites,
and loss of
appetite over the past ___ years. Underwent planned TIPS procedure
and SRS embolization w/ 15 coils on ___ w/o complications.
Currently undergoing liver transplant work-up. Had another
previous hospitalization at ___ that was reportedly for
asymptomatic anemia for which he was transfused.
-ED initial VS: T 96.6 BP 101/47 HR 72 RR 18 O2 100% on RA
-Labs: Cr 1.2 (baseline ___, Na 127 (baseline 128-134), K 5.8
(hemolyzed; repeat 4.2), Hb 10.1, WBC 4.7, AST 112, ALT 38, ALP
198, -Tbili 4.8, albumin 2.9, INR 1.6, Lactate 2.6
-Patient was given: Albumin 75g IV, Sodium polystyrene sulfonate
30g
-Consults: Hepatology recommended albumin and admission to ET
-Vitals on transfer: T 98 BP 118/69 HR 89 RR 17 O2 100% on RA
Upon arrival to the floor, patient was comfortable and denying
any complaints.
Past Medical History:
Alcoholic cirrhosis
SBP
Gastrointestinal bleeding
Lung Nodule
H. pylori gastritis
Portal vein thrombosis
Hyperglycemia
Anasarca
Social History:
___
Family History:
cardiac disease in his father and "stomach problems" in his
mother. There is no history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.9, BP 97 / 57, HR 96, RR 18, 100 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Sclera mildly icteric without injection.
NECK: Supple
CARDIAC: Slightly fast rate, normal rhythm, no m/r/g
LUNGS: CTAB, no r/r/w, no increased WOB
ABDOMEN: BS+, Soft, NTND, Liver tip palpable with deep
palpation,
spleen tip non-palpable, -fluid wave
EXTREMITIES: WWP, no c/c/e, 2+ distal pulses
SKIN: WWP, no spider telangiectasias
NEUROLOGIC: A&O x 3, moves all extremities, answers questions
appropriately, no asterixis
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 2313)
Temp: 98.1 (Tm 98.4), BP: 105/66 (104-109/55-66), HR: 94
(74-94), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA, Wt: 128.1
lb/58.11 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Sclera mildly icteric without injection.
NECK: Supple, JVP not elevated
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no r/r/w, no increased WOB
ABDOMEN: BS+, Soft, NTND, Liver tip palpable with deep
palpation,
spleen tip non-palpable, -fluid wave
EXTREMITIES: WWP, no c/c/e, 2+ distal pulses
SKIN: WWP, no spider telangiectasias
NEUROLOGIC: A&O x 3, moves all extremities, answers questions
appropriately, no asterixis
Pertinent Results:
ADMISSION LABS
==============
___ 11:45AM BLOOD WBC-4.7 RBC-2.91* Hgb-10.1* Hct-30.5*
MCV-105* MCH-34.7* MCHC-33.1 RDW-17.9* RDWSD-68.4* Plt ___
___ 11:45AM BLOOD Neuts-58.2 ___ Monos-15.7*
Eos-4.5 Baso-0.6 Im ___ AbsNeut-2.70 AbsLymp-0.96*
AbsMono-0.73 AbsEos-0.21 AbsBaso-0.03
___ 11:45AM BLOOD ___ PTT-31.1 ___
___ 11:45AM BLOOD Glucose-104* UreaN-16 Creat-1.2 Na-127*
K-5.8* Cl-94* HCO3-21* AnGap-12
___ 11:45AM BLOOD ALT-38 AST-112* AlkPhos-198* TotBili-4.8*
___ 11:45AM BLOOD Albumin-2.9*
___ 06:12AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9
___ 12:02PM BLOOD Glucose-103 Lactate-2.6* Creat-1.2
Na-126* K-5.5* Cl-96 calHCO3-23
___ 12:02PM BLOOD Hgb-10.8* calcHCT-32
___ 11:53AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:53AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 11:53AM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 11:53AM URINE Hours-RANDOM Creat-163 Na-20 K-82
Phos-45.1
DISCHARGE LABS
==============
___ 06:05AM BLOOD WBC-2.8* RBC-2.37* Hgb-8.2* Hct-24.3*
MCV-103* MCH-34.6* MCHC-33.7 RDW-17.4* RDWSD-66.5* Plt Ct-78*
___ 06:05AM BLOOD ___ PTT-48.3* ___
___ 06:05AM BLOOD Glucose-86 UreaN-12 Creat-1.1 Na-135
K-4.2 Cl-99 HCO3-22 AnGap-14
___ 06:05AM BLOOD ALT-22 AST-49* AlkPhos-127 TotBili-4.4*
___ 06:05AM BLOOD Albumin-3.2* Calcium-8.5 Phos-2.8 Mg-1.8
OTHER LABS
=========
___ 11:45AM BLOOD Lipase-64*
___ 06:12AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 11:45 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 11:53 am URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING
========
___ Imaging DUPLEX DOPP ABD/PEL
IMPRESSION:
1. Cirrhotic liver with no focal lesions. No ascites.
2. Patent TIPS with slightly decreased velocities compared to
prior study from ___.
___ Imaging CHEST (PA & LAT)
FINDINGS:
Lungs are clear. There is no consolidation, effusion, or edema.
The
cardiomediastinal silhouette is within normal limits. Tips
noted in the right upper quadrant and multiple coils seen in the
left upper quadrant.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 40 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Spironolactone 100 mg PO DAILY
4. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
5. Multilex-T and M (multivitamin,tx-iron-minerals) 1 tablet
oral DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Multilex-T and M (multivitamin,tx-iron-minerals) 1 tablet
oral DAILY
3. Omeprazole 40 mg PO DAILY
4. Spironolactone 100 mg PO DAILY
5. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
6.Outpatient Lab Work
BMP, CBC, LFTs, coags on ___
ICD-9 code ___.5
Please fax results to Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
===================
Diaphoresis
Alcoholic cirrhosis
Hyponatremia
Secondary diagnoses:
=====================
-History of variceal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cirrhosis, presenting with diaphoresis// Pneumonia or
pleural effusion present?
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. Tips noted in the right
upper quadrant and multiple coils seen in the left upper quadrant.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ with EtOH cirrhosis and diaphoresis// Ascites, other
intraabdominal abnormality including liver pathology present?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is no ascites.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 68 cm/sec, previously 97 cm/sec
Proximal TIPS: 125 cm/sec, previously 177cm/sec
Mid TIPS: 114 cm/sec, previously 141 cm/sec
Distal TIPS: 83 cm/sec, previously 116 cm/sec
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior portal vein is towards the TIPS. Appropriate flow is seen in
the hepatic veins and IVC.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9.1 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys.
Right kidney: 11.7 cm
Left kidney: 10.4 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with no focal lesions. No ascites.
2. Patent TIPS with slightly decreased velocities compared to prior study from
___.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: DIAPHORESIS
Diagnosed with Hypo-osmolality and hyponatremia
temperature: 96.6
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 101.0
dbp: 47.0
level of pain: 0
level of acuity: 3.0 | ___ y/o ___ speaking gentleman w/ EtOH cirrhosis Child B,
admission MELD 25 (c/b ascites/SBP, bleeding esophageal varices
and portal vein thrombosis), listed for transplant now s/p TIPS
for PV thrombus and has undergone embolization of a
portosystemic
shunt, who presented with diaphoresis. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Versed / fentanyl / Zofran (as hydrochloride) /
Flomax / ACE Inhibitors / prednisone
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture attempted at bedside (___) and by
interventional radiology (___)
History of Present Illness:
___ male with history of meningitis and VP shunt for
normal pressure hydrocephalus who presents with 1 week of
agitation and AMS.
History obtained through combination of discussion with patient,
collateral from daughter, and review of records. Mr. ___ was
recently treated with a steroid taper for a full body rash that
was thought to be a reaction (unclear to what, has hx of rashes
particularly in the hospital, unknown what the exposure is).
___ he was started on prednisone starting with 60mg daily
tapered every 2 days by 10 mg. His last dose was one week ago.
Rash pretty much completely resolved by end of pred course. He
finished his taper but the next day developed worsening manic
behavior. Symptoms mostly odd behaviors, altered, combative,
confused, manic, compulsive, doesn't sleep, talking
nonsensicially, fidgety motions, extreme emotional lability. His
handwriting has become impossible to read. He is also had
increasing urinary incontinence, and difficulty with walking
with
an unsteady gait.
Patient himself reports main issue is confusion and lability.
Endorses some increased phlegm production, no cough. Has diffuse
muscle aches. Increased thirst. Denies chest pain, SOB. Reports
intermittent episodes of "vertigo" during which he loses
consciousness and sometimes continence.
He was seen by his neurosurgeon today who did a head CT which
showed improved ventricle size. They thought that this
presentation was less likely related to recurrence of his NPH
symptoms and thought that this was more likely related to
steroids. The family left to go to the pharmacy to pick up Rx
for
potassium, where he became physically aggressive. Family then
brought pt to ___ for eval.
At ___ he was found to have Na 135, K 2.8. AST elevated.
Creatine Kinase (CK): ___ Trop-T: 0.017. CXR showed "Slight
increased opacity in the region of the lingual and right upper
lobe could reflect developing pneumonia in the proper clinical
setting. 1 cm apparent nodule opacity right lower lobe
laterally, possibly nipple shadow. No nodule seen on chest CT
of
___. Possibly it could be inflammatory. After
treatment, suggest chest x-ray with nipple markers, in ___ weeks
to confirm clearance of the findings bilaterally." Transferred
to
___ for further eval, including neurosurgery.
Past Medical History:
Past Medical History:
NPH, Parkinsonian disease w/ short term memory deficits from
meningitis/encephalitis in ___, non-sustained atrial
fibrillation (never on AC), HTN, HLD, infectious mononucleosis
c/b splenic rupture s/p splenectomy, spinal stenosis, herniated
disc, prostate cancer
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.2 158/67 65 17 95/Ra
GENERAL: tangential, pressured speech with word finding
difficulty and preservations on specific words, fidgety,
restless on exam
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry MM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing; trace edema on R
PULSES: 2+ DP pulses bilaterally
NEURO: A&O, CN ___ intact and strength/sensation intact on
limited exam
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 734)
Temp: 97.8 (Tm 98.3), BP: 165/78 (160-183/78-91), HR: 59
(58-70), RR: 16 (___), O2 sat: 96% (95-97), O2 delivery: RA
GENERAL: Slightly pressured/tangential speech. Otherwise AAOx3.
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry MM.
NECK: Supple, no LAD, no JVD
HEART: NR, RR. S1/S2, no murmurs, gallops, or rubs.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing; trace edema on R
PULSES: 2+ DP pulses bilaterally
NEURO: A&O, CN ___ intact and strength/sensation intact on
limited exam
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. Swelling R > L foot, no redness/erythema.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 07:50PM BLOOD WBC-11.7* RBC-3.93* Hgb-12.3* Hct-36.7*
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.2 RDWSD-45.6 Plt ___
___ 07:50PM BLOOD Neuts-53.0 ___ Monos-15.0*
Eos-3.0 Baso-1.2* Im ___ AbsNeut-6.18* AbsLymp-3.20
AbsMono-1.75* AbsEos-0.35 AbsBaso-0.14*
___ 07:50PM BLOOD Plt ___
___ 06:33AM BLOOD ___ PTT-31.2 ___
___ 07:50PM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-139
K-3.4* Cl-98 HCO3-27 AnGap-14
___ 06:33AM BLOOD ALT-75* AST-103* LD(LDH)-505*
CK(CPK)-1419* AlkPhos-65 TotBili-0.6
___ 07:50PM BLOOD cTropnT-0.02*
___ 06:33AM BLOOD CK-MB-14* MB Indx-1.0 cTropnT-0.02*
___ 05:49PM BLOOD CK-MB-11* cTropnT-<0.01
___ 06:33AM BLOOD Albumin-3.8 Calcium-9.2 Phos-2.6* Mg-2.3
___ 06:33AM BLOOD VitB12-671
___ 06:33AM BLOOD TSH-2.8
___ 05:49PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:38AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:38AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:38AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
===============
DISCHARGE LABS:
===============
___ 05:57AM BLOOD WBC-7.4 RBC-3.62* Hgb-11.5* Hct-34.9*
MCV-96 MCH-31.8 MCHC-33.0 RDW-13.9 RDWSD-49.2* Plt ___
___ 05:57AM BLOOD Glucose-83 UreaN-11 Creat-0.9 Na-141
K-4.2 Cl-104 HCO3-24 AnGap-13
___ 06:00AM BLOOD ALT-31 AST-27 LD(LDH)-362* AlkPhos-57
TotBili-<0.2
___ 05:57AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9
================
IMAGING STUDIES:
================
CT HEAD (___):
1. Status post right frontal ventriculostomy with the tip of the
catheter
terminating in the region the foramen of more.
2. No evidence of acute intracranial process or hemorrhage.
3. Areas of low attenuation in the subcortical and
periventricular white
matter appear unchanged, suggestive of chronic microvascular
ischemic disease.
RUQ U/S (___):
Borderline echogenic liver, cannot exclude mild hepatic
steatosis. No biliary dilation or focal lesion.
CXR (___):
No evidence of focal consolidation concerning for pneumonia.
LOWER EXTREMITY U/S (___):
No evidence of acute deep venous thrombosis in the left lower
extremity veins.
MRI BRAIN (___):
1. No evidence of recent infarct.
2. Status post right frontal ventriculostomy, with the tip of
the catheter
terminating in a similar position as prior.
3. FLAIR hyperintensity within the splenium of the corpus
callosum, new from ___, which may reflect an old infarct from
prior meningitis.
4. Scattered periventricular FLAIR hyperintensities, which are
nonspecific but may reflect chronic ischemic small vessel
disease.
=============
MICROBIOLOGY:
=============
__________________________________________________________
___ 5:26 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
__________________________________________________________
___ 12:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H
2. Senna 8.6 mg PO DAILY
3. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY
4. amLODIPine 5 mg PO DAILY
5. Rivaroxaban 20 mg PO DAILY
6. Carbidopa-Levodopa (___) 2 TAB PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Cetirizine 10 mg PO DAILY
10. Citalopram 30 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO BID
Discharge Medications:
1. Acyclovir 700 mg IV Q8H
2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
3. QUEtiapine Fumarate 25 mg PO QPM insomnia
4. Ramelteon 8 mg PO QHS
5. amLODIPine 10 mg PO DAILY
6. Cetirizine 5 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Acetaminophen 500 mg PO Q8H
9. Carbidopa-Levodopa (___) 2 TAB PO DAILY
10. Citalopram 30 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Rivaroxaban 20 mg PO DAILY
14. Senna 8.6 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Steroid induced psychosis
#Altered mental status
#Contact dermatitis
#Hypertension
#Depression
#GERD
#History of PEs
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: ___ male with history of meningitis and VP shunt for
normal pressure hydrocephalus who presents with 1 week of new agitation and
AMS, transaminitis on ___ labs.// any e/o liver pathology?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound ___
FINDINGS:
LIVER: Liver may be slightly echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: Gallbladder is contracted/nondistended. It is noted the patient
had a percutaneous cholecystostomy in ___.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.Right kidney
measures 10.2 cm. Left kidney measures 10.4 cm.
IMPRESSION:
Borderline echogenic liver, cannot exclude mild hepatic steatosis. No biliary
dilation or focal lesion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ male with history of meningitis and VP shunt for
normal pressure hydrocephalus who presents with 1 week of new agitation and
AMS, c/f possible PNA. Evaluation for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison to radiograph from ___. Comparison to CT chest from ___.
FINDINGS:
The cardiomediastinal silhouette is stable and within normal limits. The
pulmonary vasculature is normal. Lungs are clear without evidence of focal
consolidation. No pleural effusion or pneumothorax is seen. Tubing from the
patient's ventriculoperitoneal shunt is visualized projecting over the right
hemithorax.
IMPRESSION:
No evidence of focal consolidation concerning for pneumonia.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with asymmetric swelling of L ankle.// Concern
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 and compressibility
are demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of acutedeep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with h/o meningitis and hydrocephalus with
worsening cognition, gait. Evaluate for any infarct, infection.
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 ___. Head MRI ___, performed at an
outside facility. Head MRI ___.
FINDINGS:
The right frontal ventriculostomy catheter is redemonstrated, causing
surrounding susceptibility artifact and limiting evaluation of adjacent
structures. The tip of the catheter appears to terminate in an unchanged
position as prior.
Scattered periventricular foci of FLAIR hyperintensity are nonspecific, and
may reflect chronic ischemic small vessel disease. An area of high signal
within the splenium of the corpus callosum appears new from the MRI from ___,
and may reflect a prior infarct from meningitis. There is no evidence of
hemorrhage, edema, masses, mass effect, midline shift, or recent infarction.
The ventricles and sulci appear within normal limits.
The imaged paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of recent infarct.
2. Status post right frontal ventriculostomy, with the tip of the catheter
terminating in a similar position as prior.
3. FLAIR hyperintensity within the splenium of the corpus callosum, new from
___, which may reflect an old infarct from prior meningitis.
4. Scattered periventricular FLAIR hyperintensities, which are nonspecific but
may reflect chronic ischemic small vessel disease.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old man with encephalopathy likely steroid induced vs.
HSV. Improved (but not resolved) after discontinuation of steroids and
initiation of acyclovir.// CSF cytology, HSV PCR
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 were attempted at L4-5 and L5-S1.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 3 cm spinal needle was attempted to
be inserted into the thecal sac at the levels mentioned above. No CSF fluid
was obtained from punctures.
COMPARISON: None.
FINDINGS:
Unsuccessful fluoroscopic guided lumbar puncture as described.
IMPRESSION:
1. Unsuccessful fluoroscopic guided lumbar puncture as described.
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
INDICATION: ___ year old man with new altered mental status and cough//
evaluate for consolidation
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A partially imaged ventriculoperitoneal shunt catheter is seen overlying the
right hemithorax and right upper quadrant. There is no focal consolidation,
pleural effusion or pneumothorax identified. The size of the cardiac
silhouette is within normal limits. A small mineralized density projects
adjacent to the right humeral head and may reflect calcific tendinopathy.
There are degenerative changes around both acromioclavicular joints.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ year old man with left PICC// Left 44cm PICC ___ ___
Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the left PICC line projects over the mid to distal SVC. There is
no focal consolidation, pleural effusion or pneumothorax identified. The size
of the cardiac silhouette is within normal limits.
IMPRESSION:
The tip of the left PICC line projects over the mid to distal SVC.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Other encephalopathy, Altered mental status, unspecified
temperature: 98.2
heartrate: 70.0
resprate: 16.0
o2sat: 100.0
sbp: 152.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | ___ male with history of meningitis and VP shunt for
normal pressure hydrocephalus who presents with 1 week of new
agitation, altered mental status, and bizarre behaviors at home.
#Steroid induced psychosis
#Altered mental status
Most likely corticosteroid induced psychosis. On admission,
patient had severely pressured, tangential speech, irritability,
restlessness. Per family, he was demonstrating bizarre
repetitive behaviors at home, writing ineligible notes,
re-organizing his closet, etc. He also complained of insomnia,
and had not slept in weeks prior to admission. Was recently on
steroids for vesicular rash, which is the most likely culprit
for his altered mental status given otherwise unremarkable
workup and relatively rapid improvement during his hospital
course. Workup including CT head, blood cultures, CXR, RUQ U/S,
R ___ U/S, UA/urine cultures, sputum cultures, TSH, B12, RPR all
negative. Brain MRI showed previous infarcts, but no evidence of
acute infarct, hydrocephalus, or meningitis. Neurosurgery was
consulted who interrogated his VP shunt, which was found to be
working properly. CT head also without evidence of
hydrocephalus. Neurology was consulted who felt this was likely
not consistent with primary neurologic process, but he may have
some underlying dementia/cognitive decline. Neurology will
follow up in clinic. Patient was started on IV acyclovir
empirically on admission given history of rash. Lumbar puncture
was attempted bedside (___) as well as by ___ (___), but
unsuccessful. Confusion resolved prior to discharge, most likely
___ steroid washout but can not rule out that this improvement
may have been related to IV acyclovir treatment. Will plan to
complete empiric HSV encephalitis treatment with 2 week course
of IV acyclovir. Patient was also started on ramelteon and
Seroquel 25mg QHS to restore circadian rhythms. Will continue
both at discharge. Please consider weaning Seroquel as an
outpatient as mental status continues to improve.
#Contact Dermatitis
Had recurrence of rash on bilateral forearms that started ___
during hospital course. He has had similar rash in the past and
was followed by Dr. ___ dermatology. Rash is follicular
with eczematous papules and some vesicles draining clear fluid.
Rash likely ___ contact dermatitis related to exposures
(antiseptic prep/needles, etc.) during hospitalization. He says
this is the same rash which recently recurred in a month ago,
treated with steroids, and complicated by altered mental status
as above. Rash is improving with topical steroids PRN. Will
continue topical steroids at discharge, BUT PLEASE AVOID ANY PO
STEROIDS AS ABOVE.
#Transaminitis, resolved.
Hepatocellular pattern with 2:1 AST:ALT elevation; vs. may
represent muscle enzyme elevation. CK elevated at ___ as
well, now down-trending from prior. RUQ U/S negative, hepatitis
panel also negative. Could consider rhabdomyolysis given
elevated CK vs. steroid induced myopathy. Subsequently resolved
on admission.
CHRONIC ISSUES:
===============
#HTN:
Patient with elevated BP on admission, 160s-170s systolic. On
amlodipine 5mg daily and hydrochlorothiazide 25 mg BID at home.
Both were held initially given altered mental status, but
restarted prior to discharge. Amlodipine increased to 10mg
daily. HCTZ decreased to 25mg daily in the setting of
hypokalemia on admission. Please continue to monitor BP and
titrate anti-hypertensives as an outpatient.
___: Continue home carbidopa-levodopa.
#Depression: Continue home citalopram 30 mg daily.
#GERD: Continue omeprazole 20 mg daily.
#History of PEs: Continue rivaroxaban 20 mg daily.
#Allergies: Decreased cetirizine to 5 mg daily given altered
mental status.
TRANSITIONAL ISSUES:
====================
[] Please AVOID PO steroids given steroid induced psychosis
[] Complete empiric HSV encephalitis treatment with 2 week
course of IV acyclovir (last day ___
[] Patient was started on ramelteon and Seroquel 25mg QHS to
restore circadian rhythms. Will continue both at discharge.
Please consider weaning Seroquel as tolerated as an outpatient
as mental status improves.
[] Patient with elevated BP 160s-170s/70s-80s during hospital
course. Amlodipine increased to 10 mg daily. Please continue to
monitor BP and titrate anti-hypertensives as an outpatient.
[] Amlodipine increased to 10 mg daily. HCTZ decreased to 25 mg
daily in the setting of hypokalemia on admission. Please
continue to monitor BP and titrate anti-hypertensives as an
outpatient. Please repeat chemistry panel in 1 week at ___
follow up to ensure K+ has stabilized.
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa(Sulfonamide Antibiotics) / Penicillins / azithromycin
Attending: ___.
Chief Complaint:
Left proximal humerus fracture
Left intratrochanteric femoral neck fracture
Major Surgical or Invasive Procedure:
___: L femur short TFN
History of Present Illness:
___ PMH notable for hypothyroidism, glaucoma & macular
degeneration who is transferred from ___. She
sustained a ground-level fall today after getting out of her car
with immediate L hip and shoulder pain & inability to ambulate.
She denies HS or LOC. She denies presyncopal symptoms. Workup at
___ revealed L IT hip fx & L proximal humerus fx;
she was subsequently transferred to ___ ED for further care.
She denies paresthesias or sensory deficits in injured
extremities. Endorses pain in her L wrist & elbow.
CT head/C-spine OSH reviewed & negative for acute pathology. She
has a h/o R hip IT fx s/p R short TFN by Dr. ___ ___ years ago
at ___.
Of note, she is the mother-in-law of Dr. ___,
retired ___ ___ from ___ and a close friend of Dr. ___
___.
Past Medical History:
PMH:
GLAUCOMA
HYPOTHYROIDISM
MACULAR DEGENERATION
PSH:
Cataract surgery & posterior chamber intraocular lens placement
in both eyes
Social History:
___
Family History:
N/C
Physical Exam:
PHYSICAL EXAMINATION:
GEN: NAD, A&Ox3
AVSS
LEFT LOWER EXTREMITY: C/D/I dressing. Thigh & leg compartments
soft. Sensation intact to light touch in saphenous, sural, deep
peroneal & superficial peroneal distributions. Motor intact for
___, FHL, GSC, TA. Dorsalis pedis palpable, toes warm & well
perfused
LEFT UPPER EXTREMITY: Sling in place. Arm & forearm compartments
soft. Sensation intact to light touch in axillary, radial,
median & ulnar nerve distributions Motor intact for EPL, FPL,
EIP, EDC, FDP, FDI. Radial pulse palpable, fingers warm & well
perfused.
Pertinent Results:
ADMISSION LABS:
___ 12:31AM BLOOD WBC-9.5 RBC-3.44* Hgb-8.9* Hct-29.7*
MCV-86 MCH-25.9* MCHC-30.0* RDW-15.4 RDWSD-47.8* Plt ___
___ 12:31AM BLOOD Neuts-83.9* Lymphs-9.6* Monos-5.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-7.92* AbsLymp-0.91*
AbsMono-0.52 AbsEos-0.01* AbsBaso-0.03
___ 12:31AM BLOOD ___ PTT-28.7 ___
___ 12:31AM BLOOD Glucose-147* UreaN-22* Creat-0.8 Na-138
K-4.4 Cl-99 HCO3-24 AnGap-19
IMAGING:
Left shoulder x-ray ___:
1. Minimally displaced fracture of the surgical neck of the left
humerus.
2. Partially visualized opacity in the left lower lung could
reflect
pneumonia. Recommend further evaluation with dedicated chest
x-ray.
3. Thoracic spine compression deformities, recommend thoracic
spine
radiographs.
Left hip x-ray ___:
Unchanged appearance of left intratrochanteric femoral neck
fracture.
Slight cortical irregularity of left superior inferior pubic
rami raises
possibility of nondisplaced fractures.
Left elbow/wrist x-ray ___:
No acute fracture or dislocation within limitations above.
Degenerative
changes at the first CMC joint.
T-spine x-ray ___:
3 technically limited cross-table views of the thoracic spine
are provided. There are thoracic vertebral body wedge
deformities of at least 2 vertebral these wedge deformities,
however, were present on a chest radiograph from ___.
Chest x-ray ___:
Comparison to ___. New parenchymal opacities are
visualized in the perihilar lung regions as well as at the lung
bases. In addition, the vascular diameters are increased and
the size of the cardiac silhouette is large. A platelike
opacity is seen at the basis of the right upper lobe and likely
reflect atelectasis. Overall, the findings are suggestive of
mild pulmonary edema, potentially complicated by a atelectatic
changes in the right upper lobe and the retrocardiac lung
region. No pleural effusions.
Medications on Admission:
1. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
2. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY
3. Travatan Z (travoprost) 0.004 % ophthalmic QHS
4. Multivitamins 1 TAB PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID constipation
3. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*28 Syringe
Refills:*0
4. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
5. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY
6. Travatan Z (travoprost) 0.004 % ophthalmic QHS
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*50 Tablet Refills:*0
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Senna 17.2 mg PO QHS constipation
11. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric hip fracture
Left proximal humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: ORIF HIP
IMPRESSION:
Images from the operating suite show placement of fixation device about
previous fracture of the proximal left femur. Further information can be
gathered from the operative report.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with ? opacity seen on left humerus XR // ?
opacity ? opacity
IMPRESSION:
Comparison to ___. New parenchymal opacities are visualized in
the perihilar lung regions as well as at the lung bases. In addition, the
vascular diameters are increased and the size of the cardiac silhouette is
large. A platelike opacity is seen at the basis of the right upper lobe and
likely reflect atelectasis. Overall, the findings are suggestive of mild
pulmonary edema, potentially complicated by a atelectatic changes in the right
upper lobe and the retrocardiac lung region. No pleural effusions.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: ___ year old woman with ? compression fx seen on L humerus XR //
Eval for compression fractures Eval for compression fractures
IMPRESSION:
3 technically limited cross-table views of the thoracic spine are provided.
There are thoracic vertebral body wedge deformities of at least 2 vertebral
these wedge deformities, however, were present on a chest radiograph from ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, s/p Fall, L Hip fracture, L Arm fracture
Diagnosed with Disp fx of greater tuberosity of left humerus, init, Displaced intertrochanteric fracture of left femur, init, Other fall on same level, initial encounter
temperature: 98.2
heartrate: 88.0
resprate: 18.0
o2sat: 91.0
sbp: 121.0
dbp: 58.0
level of pain: 9
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a Left intertrochanteric hip fracture and left proximal
humerus fracture. She was admitted to the orthopedic surgery
service. It was felt that her left proximal humerus fracture
could be treated non-operatively with the patient being
non-weightbearing to her left upper extremity in a sling. The
patient was taken to the operating room on ___ for a left
femur IM nail with short TFN, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weightbearing to the left upper extremity and weightbearing
as tolerated to the left lower extremity. She will be discharged
on lovenox for DVT prophylaxis. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMHx of breast cancer (sp
bilateral mastectomy, followed at ___) and hx of alcohol abuse,
who presents with tremulousness, visual hallucinations, and
difficulty walking for the last week.
Pt met with her oncologist at ___ 1 week prior. She had been
feeling depressed since that time. Additional stressors have
included deaths of her friends' children. Per record, she
reported having re-started drinking during late ___. On
interview today, she reports that her last drink was ___.
Pt's depression was initially treated with Celexa 20mg (per pt,
she has been taking celexa 30mg). Pt reports that, for the past
several days, she has developed inability to control her motor
skills, causing her to experience 2 falls and to have slurred
speech.
Pt is also experiencing visual and auditory hallucinations. She
states that auditory hallucination have been present for several
years but that visual hallucinations are new. She has also been
unable to sleep for 2 - 3 nights, due to visual hallucinations
of men in suits sitting in her room (hallucinations do not talk
to patient). She has also noticed other images "clouds on the
walls, with fingers reaching toward me". Recently, she walked
into a bedroom with her ___ daughter and asked her who
the two other children in the room were (room was empty). Per
PCP record, pt tried melatonin and Tylenol Cold and Sinus and
Benadryl, but this did not relieve her symptoms (per husband,
these meds were taken prior to sx onset). Pt reported taking
Xanex ___ pills per month) to her PCP.
Per my conversation with pt's husband, pt had episode of acute
anxiety "panic attack" on ___, 2d prior to admission. At
that time, she experienced shaking and had an unwitnessed fall.
Pt took Xanax x 2 (from a friend). She also used benadryl, cough
syrup and several vitamins. The following evening (night prior
to day of admission), she was experiencing above symptoms of
hallucination. Per husband, pt also had bottle of ativan but he
is unsure where this was obtained or how much was used.
She presented to her PCP at ___ on day of admission with report
of these symptoms and was referred to the ED. In the ED, she had
difficulty explaining exactly how much she had been using,
however she estimated that she had used ~10 mg of Ativan daily
for several weeks. She reported trying to cut back on the Ativan
and Xanax recently such that she is using the Ativan and Xanax
on and off rather than daily. Patient adamantly denied any
recent alcohol or other drug use.
In the ED intial vitals were: 98.8 116 118/83 18 100% RA. Labs
were significant for Mg 1.9, HCG, Utox and Stox negative.
- Patient was given thiamine and 2mg lorazepam and experienced a
decrease in HR.
Vitals prior to transfer were: 98.5 106 116/81 17 100% RA
On the floor she relates a slightly different sotry re. her BZD
use, more consistent with her report to PCP ___ pills per
month, rather than daily). Shortly after arrival to floor, pt
eloped and was brought back by ___ security from ___
___, given concerns that she would attempt to drive in an
altered state.
Past Medical History:
- Breast cancer
- ER-, PR-, HER2+ (FISH 8.4), grade 3, left breast cancer status
post left mastectomy following neoadjuvant AC-TH chemotherapy
with complete response to pathology, sp chest wall XRT and
bilateral mastectomies.
- Auditory Hallucinations
Social History:
___
Family History:
Father - HTN, prostate ca
Mother - ___ ca
Grandmother x 2 - breast ca, pancreatitis
Uncle x 2 - pancreatic ca
Physical Exam:
ADMISSION EXAM:
=================
Vitals - T: 97.9 BP: 120/81 HR: 104 RR: 18 02 sat: 100%RA
GENERAL: NAD, A+Ox3, pt found fiddling with sheets and talking
into remote as though it was a telephone ("I'll be right back").
HEENT: ATNC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, Strength ___ in all extremities;
Sensation intact to LT; no asterixis. +occasional
gross/exagerated tremmor-like motions in UE; speech pressured
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
=================
Vitals - 98.8 ___ ___ 16 100%RA
Orthostatics: 111/78, HR 108 sitting in bed
125/89, HR 147 standing
GENERAL: NAD, A+Ox3
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: no cyanosis, clubbing or edema
NEURO: alert, oriented x 3, no tremor
Pertinent Results:
ADMISSION LABS:
=================
___ 06:50PM BLOOD WBC-7.3 RBC-4.32 Hgb-13.5 Hct-41.1 MCV-95
MCH-31.2 MCHC-32.9 RDW-12.1 Plt ___
___ 06:50PM BLOOD Neuts-69.4 Lymphs-17.0* Monos-7.7
Eos-4.9* Baso-0.9
___ 06:50PM BLOOD Glucose-105* UreaN-8 Creat-0.7 Na-135
K-3.6 Cl-95* HCO3-26 AnGap-18
___ 06:50PM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
___ 06:50PM BLOOD TSH-2.0
___ 06:50PM BLOOD Free T4-1.3
___ 07:30AM BLOOD VitB12-685 Folate-19.9
___ 07:30AM BLOOD ALT-30 AST-45* LD(LDH)-176 AlkPhos-58
TotBili-0.4
___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
=================
___ 08:35AM BLOOD WBC-4.0 RBC-3.91* Hgb-12.0 Hct-37.1
MCV-95 MCH-30.6 MCHC-32.2 RDW-11.9 Plt ___
___ 08:35AM BLOOD Glucose-82 UreaN-4* Creat-0.5 Na-139
K-3.8 Cl-102 HCO3-26 AnGap-15
___ 08:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
___ 08:35AM BLOOD ALT-27 AST-42* AlkPhos-59 TotBili-0.3
STUDIES:
=================
___ MRI Brain w/ and w/o contrast: No findings to suggest
metastatic disease. There is no evidence of hemorrhage
or infarction. Prominent left putaminal perivascular space.
___ EKG: Sinus tachycardia. Extensive baseline artifact.
Borderline low limb lead voltages. Delayed R wave progression,
likely a normal variant. No previous tracing available for
comparison.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Lorazepam 0.5 mg PO Frequency is Unknown
Discharge Medications:
1. hydrOXYzine pamoate 25 mg oral TID:PRN Anxiety
RX *hydroxyzine pamoate 25 mg 1 capsule(s) by mouth three times
a day Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Delirium
SECONDARY: Alcohol/Benzodiazepine Dependence, Anxiety Disorder,
history of Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Mental status changes.
Sagittal and axial T1 weighted imaging was performed. After administration of
5 cc of Gadavist intravenous contrast, axial imaging was performed with
diffusion, gradient echo, FLAIR, T2, and T1 technique. Sagittal MP rage
imaging was performed in re-formatted in axial and coronal orientations.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, or infarction. There is a
large perivascular space in the left putaminal. Scattered subcortical and
periventricular white matter hyperintensities on FLAIR may be a consequence of
chronic ischemia. There is no abnormal enhancement after contrast
administration.
IMPRESSION:
No findings to suggest metastatic disease. There is no evidence of hemorrhage
or infarction. Prominent left acute abdominal perivascular space.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with HALLUCINATIONS, ABN INVOLUN MOVEMENT NEC, DRUG WITHDRAWAL SYNDROME, BARBITURAT DEPEND-CONTIN
temperature: 98.8
heartrate: 116.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with a PMHx of breast cancer (sp
bilateral mastectomy, followed at ___) and hx of alcohol abuse,
who presents with tremulousness, visual hallucinations, and
difficulty walking for the last week.
# Hallucinations, Altered Mental Status: Patient was admitted
for behavior changes and visual hallucinations consistent with
delirium that occurred in the setting of numerous potentially
psychoactive medications in the days prior, perhaps including
Xanax (obtained from a friend), ___ cold and sinus,
Benadryl, melatonin, numerous OTC supplements, and her usual
antidepressant and home meds (although the exact combination of
medications are unclear). These were taken in the setting of
worsening anxiety and a self-described panic attack. The patient
was monitored and treated with benzodiazepine withdrawal and
over the next ___ hours improved significantly. Inpatient
psychiatry followed, and advised to hold Celexa and
benzodiazepines, and to use hydroxyzine for anxiety. We also
recommend she establishes with an outpatient Psychiatrist.
# Sinus tachycardia: sinus tach in the 100s, up to the 150s when
standing. This corrected w/ 1L NS.
# Breast Cancer: An MRI brain to evaluate for breast CA mets
was unrevealing except for a stable prominent perivascular space
in the left putamen (seen on prior studies several years ago).
Transitional Issues:
- Discontinued citalopram and lorazepam.
- Started hydroxyzine prn for anxiety.
- Recommend pt establish care w/ outpatient psychiatrist.
# Code: Full Code
# Emergency Contact: Husband: ___ patient cell
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
morphine / Codeine / Percocet
Attending: ___
Chief Complaint:
right BG IPH with IVE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx of HTN, HLD, DM who woke up in her usual state
of
health at 7:30am and subsequently developed sudden onset of left
sided weakness at 8:30am while she was caring for her
grandchildren. At that time, she lowered herself to floor, had a
slight hit of the head on a chair leg with no LOC, and her
husband called ___. She was transported to ___. There, she
was
found to have a right BG bleed with IVE and edema. She was
transferred to ___ for advance management.
On neuro ROS, (+) left arm>face>leg weakness (+) decrease
sensation on the left arm>leg (+) double vision on extreme right
gaze (+) chronic hearing loss. The pt denies headache, loss of
vision, dysphagia, lightheadedness, vertigo, tinnitus. Denies
difficulties producing or comprehending speech. No bowel or
bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HTN
- DMII c/b diabetic neuropathy
- HLD
- OSA
- cardiomyopathy
- congenital hearing loss
Social History:
___
Family History:
- no known family history of strokes, seizures, congenital or
developmental neurological issues
Physical Exam:
ADMISSION EXAM:
- Vitals: 97.8 76 167/86 19 98%
- General: drowsy
- HEENT: NC/AT
- Neck: Supple. No nuchal rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, distended secondary to obesity
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: drowsy, oriented month, day, year, hospital.
Able to relate history with some confusion about timing of
events
(some discrepancies on specifics of fall with EMS report).
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Able to name
both high and low frequency objects on the stroke card. Speech
was mildly dysarthric although per her husband it sounded normal
to him. Able to follow both midline and appendicular commands.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. VFF to confrontation.
intermittent roving ocular movements
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to pin prick.
VII: left facial droop
VIII: Hearing intact to room voice, R>L
XII: Tongue protrudes in midline.
- Motor: Normal bulk and tone throughout. No adventitious
movements such as tremor or asterixis noted.
Delt Bic Tri WrE FFl IP Quad Ham TA Gastroc
L 2 0 2 0 ___ 4- 0 5
R 5 ___ ___ 5 5 5
- Sensory: no sensation to deep noxious on LUE proximally and
distally. No sensation to deep noxious on LLE distally but
hypersensitive to light pinch proximally. Unable to test for
extinction to DSS secondary to sensory loss.
- DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was extensor on the left and flexor on the
right
- Coordination: No dysmetria on FNF on the right.
- Gait: deferred
DISCHARGE EXAM:
Left sensory loss to touch and temperature, left facial droop in
UMN pattern.
Left hemiparesis not in a clear upper motor neuron pattern:
Delt Bic Tri WrE FFl IP Quad Ham TA Gastroc
L 2 ___ ___ 4 4- 4+
R 5 ___ ___ 5 5 5
Decreased sensation to light touch and temperature on left.
Otherwise unchanged.
Pertinent Results:
ADMISSION LABS: ___
WBC-7.8 RBC-5.55* Hgb-15.4 Hct-46.8* Plt ___
Neuts-56.6 ___ Monos-7.7 Eos-1.8 Baso-0.9 Im ___
AbsNeut-4.42 AbsLymp-2.54 AbsMono-0.60 AbsEos-0.14 AbsBaso-0.07
___ PTT-27.4 ___
Glucose-291* UreaN-23* Creat-0.9 Na-138 K-4.0 Cl-99 HCO3-28
AnGap-15
ALT-23 AST-22 AlkPhos-94 TotBili-0.8
Albumin-3.9 Calcium-9.6 Phos-2.7 Mg-1.7
Lipase-16
CK-MB-4 cTropnT-<0.01
cTropnT-<0.01
UA: bland
serum/urine tox: negative
STROKE WORKUP
Cholest-191 Triglyc-223* HDL-46 CHOL/HD-4.2 LDLcalc-100
%HbA1c-11.1* eAG-272*
IMAGING:
CTA Head/Neck:
IMPRESSION:
1. No evidence for an arteriovenous malformation.
2. Atherosclerosis of bilateral carotid siphons and of the left
vertebral
artery without evidence for flow-limiting stenosis.
3. Complete opacification of right middle ethmoid air cell. The
right mastoid is underpneumatized and completely opacified, in
the right middle ear cavity is also opacified. Please correlate
with any associated clinical symptoms.
MRI Head w/wo ___
IMPRESSION:
1. Stable right thalamic hematoma with essentially stable
intraventricular extension compared to 1 day earlier.
2. Small foci of nodular and curvilinear enhancement along the
inferior and posterior aspect of the hematoma, which are likely
venous or parenchymal, as there are not seen on the CTA from 1
day earlier.
3. No evidence of an intracranial mass or prior hemorrhage
elsewhere in the brain.
4. Unchanged mild leftward shift of midline structures and
compression of the third ventricle, without dilatation of the
lateral ventricles.
RECOMMENDATION(S): After blood products resolve, follow up MRI
with and
without contrast is recommended to assess for an underlying mass
or a
cavernous malformation in the right thalamus.
Shoulder XR ___
INDICATION:
___ year old woman with left shoulder pain // stroke, fell on
left side
TECHNIQUE: Shoulder three view
COMPARISON: None.
IMPRESSION:
On the internal rotation film the humeral head appears slightly
low and it is unclear if this is due to projection or if there
is some inferior subluxation. However on the Y-views the humeral
head appears well-seated within the glenoid there is no
fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO BID:PRN pain
2. Atorvastatin 80 mg PO QPM
3. NovoLOG (insulin aspart) 100 unit/mL subcutaneous ___ units
with meals
4. Lantus (insulin glargine) 100 unit/mL subcutaneous 48-60
units QHS
5. Lisinopril 40 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Atenolol 50 mg PO BID
Discharge Medications:
1. Atenolol 50 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. TraMADOL (Ultram) 100 mg PO BID
5. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
6. Docusate Sodium 100 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Hydrochlorothiazide 50 mg PO DAILY
9. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Senna 8.6 mg PO BID:PRN constipation
12. Famotidine 20 mg PO BID
13. Atorvastatin 40 mg PO QPM
14. Gemfibrozil 600 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE INTRAPARENCHYMAL HEMORRHAGE
HYPERTENSION
DIABETES
HYPERLIPIDEMIA
HYPERTRIGYLCERIDEMIA
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 WANDW/O C AND RECONS
INDICATION: Right thalamic hemorrhage .
TECHNIQUE: Rapid axial imaging was performed through the brain during
infusion of 70 cc of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered and segmented images were
generated. This report is based on interpretation of all of these images.
DOSE: DLP: 719 mGy-cm
COMPARISON: Noncontrast head CT from ___ at 09:24.
FINDINGS:
There is plaque in bilateral carotid siphons without flow-limiting stenosis.
Middle cerebral arteries are widely patent. The M1 segments are relatively
symmetric, but some of the right MCA branches are slightly larger in caliber
compared to the left. Anterior cerebral arteries are also patent. Left A1
segment is hypoplastic. Left A2 segment is also smaller than the right, as
the left callosal arteries arise from the right A2 segment.
Left vertebral artery is dominant. There is calcified plaque at the junction
of the V3 and V4 segments of the left vertebral artery, and in the more distal
V4 segment of the left vertebral artery, without flow-limiting stenosis. The
remainder of the major posterior circulation arteries appear widely patent.
There is no evidence for abnormal arterial enhancement in the region of the
right thalamic hematoma to suggest an underlying arteriovenous malformation.
Major dural venous sinuses appear patent.
This exam is not technically optimized for evaluation of nonvascular
intracranial structures. Right thalamic hemorrhage extending into the right
lateral ventricle does not appear significantly changed compared to the
earlier head CT.
A right middle ethmoid air cell is opacified. There is soft tissue density in
the right external auditory canal compatible with cerumen. Right mastoid is
underpneumatized and completely opacified. Right middle ear cavity is also
opacified. There is evidence of left otomastoidectomy.
IMPRESSION:
1. No evidence for an arteriovenous malformation.
2. Atherosclerosis of bilateral carotid siphons and of the left vertebral
artery without evidence for flow-limiting stenosis.
3. Complete opacification of right middle ethmoid air cell. The right mastoid
is underpneumatized and completely opacified, in the right middle ear cavity
is also opacified. Please correlate with any associated clinical symptoms.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with spontaneous parenchymal hemorrhage,
evaluate for mass lesions.
TECHNIQUE: Sagittal T1 weighted, and axial T1 weighted, T2 weighted, FLAIR,
gradient echo, and diffusion-weighted images of the brain were obtained.
Following intravenous gadolinium administration, axial T1 weighted images of
the brain and sagittal MPRAGE images of the brain with multiplanar
reformations were obtained.
COMPARISON: Noncontrast head CT and head CTA from ___.
FINDINGS:
Postcontrast MP RAGE images are moderately limited by motion artifacts.
Multiple other sequences are mildly limited by motion artifacts.
Right thalamic hematoma appears stable in size compared to the CT from 1 day
earlier, allowing for differences in modalities. Postcontrast images
demonstrate nodular and curvilinear enhancing foci within the inferior and
posterior aspects of the hematoma, as well as curvilinear enhancement along
its posterior margin. This was not seen on the CTA from 1 day earlier,
suggesting that this enhancement is venous or parenchymal.
Hemorrhage within the body of the right lateral ventricle is unchanged
compared to the CT from 1 day earlier, with slightly increased small amount of
blood in bilateral occipital horns indicating redistribution. There is
subependymal contrast enhancement along the posterior body and atrium of the
right lateral ventricle.
There is mild edema surrounding the right thalamic hematoma and extending
towards the hypothalamus. Mild leftward shift of midline structures is
unchanged. The third ventricle appears compressed, as before. However, the
lateral ventricles are not dilated.
Gradient echo images demonstrate no evidence of prior parenchymal hemorrhages.
Aside from the right thalamic hematoma, no enhancing intracranial mass is
seen.
There is no acute infarction on diffusion-weighted images. T2 weighted and
FLAIR images demonstrate small foci of high high signal in the subcortical,
deep, and periventricular white matter of the cerebral hemispheres,
nonspecific but likely sequela of chronic small vessel ischemic disease in a
patient of this age. Major arterial flow voids are grossly preserved. Major
dural venous sinuses appear patent.
Right middle ear cavity and right mastoid air cells are opacified, as seen
previously. The right mastoid is also again noted to be underpneumatized.
Evidence of left mastoidectomy is again seen. Opacification of a right middle
ethmoid air cell is again noted.
IMPRESSION:
1. Stable right thalamic hematoma with essentially stable intraventricular
extension compared to 1 day earlier.
2. Small foci of nodular and curvilinear enhancement along the inferior and
posterior aspect of the hematoma, which are likely venous or parenchymal, as
there are not seen on the CTA from 1 day earlier.
3. No evidence of an intracranial mass or prior hemorrhage elsewhere in the
brain.
4. Unchanged mild leftward shift of midline structures and compression of the
third ventricle, without dilatation of the lateral ventricles.
RECOMMENDATION(S): After blood products resolve, follow up MRI with and
without contrast is recommended to assess for an underlying mass or a
cavernous malformation in the right thalamus.
Radiology Report
EXAMINATION:
SHOULDER ___ VIEWS NON TRAUMA LEFT
INDICATION:
___ year old woman with left shoulder pain // stroke, fell on left side
TECHNIQUE: Shoulder three view
COMPARISON: None.
IMPRESSION:
On the internal rotation film the humeral head appears slightly low and it is
unclear if this is due to projection or if there is some inferior subluxation.
However on the Y-views the humeral head appears well-seated within the glenoid
there is no fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with ICH, to be admitted to NSICU // eval ? infection
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Reference chest radiograph ___ at 09:24
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax. Accounting
for portable technique, the cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities are identified.
IMPRESSION:
No acute cardiopulmonary radiographic abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH
Diagnosed with MUSCSKEL SYMPT LIMB NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Ms. ___ is a ___ female with PMHx of HTN, HLD, DM who
presented to an OSH after a sudden onset of left weakness
causing her to lower herself to floor. There she was found to
have a right thalamocapsular bleed with IVE and edema on CT
Head. She was transferred to ___ for advance management. On
initial exam, her BP was elevated (167/86) and she was quickly
started on a nicardipine drip. He blood pressure decreased to
SPB 100s. On admission exam, she was drowsy and oriented
although somewhat confused about the sequence of events. PERRL
with roving ocular movements when asked to hold her eyes still.
Left facial droop + ptosis at rest with slowed activation,
plegic left arm, minor left leg weakness, marked loss of
sensation to noxious in the left arm and leg, some dysarthria
secondary to congenital deafness and the facial droop. CT showed
a left bleed with extension into the lateral ventricle and ___
ventricle with no obstruction of the ___ or ___ ventricle.
Subsequent MRI showed stable right thalamic hematoma with
essentially stable intraventricular extension with no evidence
of an intracranial mass or prior hemorrhage elsewhere in the
brain. She was started on subcutaneous heparin for DVT
prophylaxis. During her hospitalization the strength in her left
upper extremity waxed and waned, which was expected given her
hemorrhage. She was evaluated by ___ and rehabilitation was
recommended.
# Neuro
The etiology of the hemorrhage was thought to be most likely
secondary to hypertension although the presence of underlying
lesion will need to be further assess on repeat MRI in three
months. Her stroke workup was notable for CTA which demonstrated
atherosclerosis, LDL of 100 on atorvastatin 80, and elevated
triglycerides. Her A1c was 11.1% and she was persistently
hypertensive during her hospitalization requiring adjustment of
her blood pressure medications. In the setting of an acute
hemorrhage her atorvastatin dose was decreased to 40 mg daily.
Given her elevated triglycerides she was started on gemfibrozil
in addition to her atorvastatin.
# Cardiovascular:
For her blood pressure, her home lisinopril and atenolol were
continued. She was started on hydrochlorothiazide. Although her
blood pressures remained below the strict cutoff of 160/105
mmHg, she was persistently hypertensive to the 150s. We planned
to change her atenolol to carvedilol for improved alpha blockade
with a cross-taper. Her long term goal is normotension.
# Pulm:
Given her history of OSA she was placed on CPAP overnight.
# Endocrine:
For her diabetes, ___ was consulted. Her insulin regimen was
adjusted and she was started on metformin three days after her
CTA with contrast. The dose was advanced to 500 mg BID and
should continue to be adjusted as an outpatient.
============================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Status post fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is an ___ year old male with a history significant for
atrial fibrillation on coumadin, Alzheimer's dementia, chronic
urinary retention, who presents s/p fall at home. He states
that he recalls the fall and denies any preceding
lightheadedness, chest pain, palpitations, or syncope. Per his
wife via telephone, he was sitting on his toilet and tried to
get to wheelchair and slipped to the ground on his knees slowly.
She denies headstrike, loss of consciousness. She reports he had
a similar slow slip 2 wks ago from sofa to wheelchair.
In the ___ he was apparently found to have UTI with elevated
WBC/postive urinalysis although Mr. ___ denies any recent
dysuria or urine changes.
Past Medical History:
1. Chronic Systolic Congestive Heart Failure with EF 17%
2. Atrial Fibrillation
3. Coronary Artery Disease s/p CABG in ___
- ___ Cardiac cath: Native three vessel coronary artery
disease, Severely depressed ventricular systolic function (EF
17%). Anterolateral, apical and inferoapical hypokinesis, no
mitral regurgitation, mild ventricular diastolic dysfunction,
Patent LIMA to LAD, SVG to OM, SVG to Diag, SVG to PDA
5. s/p CVA in ___
6. Thrombophlebitis in Right Leg
7. s/p Cholecystectomy
8. s/p TURP
9. ? Pulmonary Embolism
Social History:
___
Family History:
Sister - died of breast cancer
Mother - heart problems
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
VITALS - T 97.8 HR 83 RR 18 BP 120/66 SaO2 96% on RA
GENERAL - Well-appearing ___ yo M who appears comfortable,
appropriate and in NAD
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - Irregularly irregular, S1-S2 clear and of good quality
without murmurs, rubs or gallops
NEURO - awake, alert, not oriented ("year is ___, unable to
answer location, month day), significant word-finding
difficulties/aphasia. Thought process is tangential. CN II-XII
grossly intact, muscle strength ___ throughout, sensation
grossly intact throughout. Exam per ___ RN records "Found to be
incontinent of stool, skin barrier oitnment on sacral area.
Stage 2 foudn on ___ continue to reposition pt. Pt. has
red marks on left back. NO breakdown. ___ red no open
areas noted"
DISCHARGE PHYSICAL EXAMINATION
VS - T 97.8 HR 76 RR 18 BP 126/58 SaO2 97% on RA
GENERAL - Well-appearing ___ yo M who appears comfortable,
appropriate and in NAD
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - Irregularly irregular, S1-S2 clear and of good quality
without murmurs, rubs or gallops
NEURO - awake, alert, oriented to person only. Continues to
have significant word-finding difficulties/aphasia. Thought
process is more goal-directed today.
Pertinent Results:
___ 09:36PM BLOOD WBC-16.7*# RBC-4.40* Hgb-14.2 Hct-42.4
MCV-96 MCH-32.2* MCHC-33.5 RDW-14.7 Plt ___
___ 07:40AM BLOOD WBC-10.6 RBC-4.53* Hgb-14.1 Hct-44.0
MCV-97 MCH-31.0 MCHC-31.9 RDW-14.5 Plt ___
___ 09:36PM BLOOD Glucose-109* UreaN-33* Creat-1.3* Na-140
K-4.4 Cl-106 HCO3-24 AnGap-14
___ 07:40AM BLOOD Glucose-89 UreaN-24* Creat-1.2 Na-140
K-4.8 Cl-103 HCO3-29 AnGap-13
___ 09:41PM BLOOD Lactate-1.4
___ 09:20PM URINE RBC-5* WBC-178* Bacteri-MANY Yeast-NONE
Epi-0
___ 09:20PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 09:20PM URINE Color-Yellow Appear-Hazy Sp ___
___ 9:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S <=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-------- 32 S <=16 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
CT HEAD W/OUT CONTRAST
INDICATION: Frequent falls, on Coumadin.
COMPARISON: CT available from ___.
TECHNIQUE: MDCT-acquired 5-mm axial images of the head were
obtained without the use of IV contrast. Coronal and sagittal
reformations were performed at 2-mm slice thiness. Additional
2.5-mm bone reconstructions were obtained.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema,
mass, mass
effect, or large vascular territorial infarction. A left
frontal hypodensity (2:21) is unchanged since ___,
suggestive of a small chronic infarct. The ventricles and sulci
are moderately prominent, reflecting age-appropriate cortical
atrophy. There is relative hypoattenuation of the
periventricular white matter, denoting chronic microvascular
ischemic disease. There is no shift of normally midline
structures. The basilar cisterns remain preserved. Moderate
atherosclerotic calcifications are seen in the cavernous
portions of the ICAs bilaterally (2:9). There is no acute
fracture. Minimal mucosal thickening within the ethmoid sinuses
is present. The middle ear cavities and mastoid air cells are
clear.
IMPRESSION: No evidence of acute intracranial process.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: TUE ___ 2:___-SPINE W/O CONTRAST
INDICATION: Fall.
No comparison studies available.
TECHNIQUE: MDCT-acquired 2.5-mm axial images of the cervical
spine were
obtained without the use of IV contrast. Coronal and sagittal
reformations were performed at 2-mm slice thickness.
FINDINGS:
There is no acute fracture or traumatic malalignment of the
cervical spine. Mild uncovertebral hypertrophy and facet
arthropathy is present. Mild to moderate posterior disc bulging
at C5/6 results in minimal thecal sac narrowing but no obvious
indentation of the cord, which is hard to visualized on CT
imaging. There are no prevertebral soft tissue abnormalities.
Included views of the lung apices are clear. Extensive
atherosclerotic calcifications are seen at the carotid bulbs
(2:25).
IMPRESSION: No acute fracture or traumatic malalignment of the
cervical
spine.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ PELVIS (___): No evidence of fracture.
ECG (___)
Atrial fibrillation with a rapid ventricular response.
Intraventricular
conduction delay. Consider prior anteroseptal myocardial
infarction. Compared to the previous tracing of ___ the
ventricular response has increased. There is variation in
precordial lead placement. The increase in rate may have
resulted in pseudonormalization of the ST-T wave changes
previously recorded, as well as variation in lead placement.
Clinical correlation is suggested.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 5 mg PO DAILY
Hold if SBP < 90
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Warfarin Dose is Unknown PO DAILY16
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
Hold if SBP < 90
4. Cefpodoxime Proxetil 100 mg PO Q12H UTI
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
5. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary-
recurrent falls
urinary tract infection, pansensitive E.coli
Secondary-
Atrial fibrillation
Coronary artery disease
chronic systolic congestive heart failure.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Frequent falls, on Coumadin.
COMPARISON: CT available from ___.
TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without
the use of IV contrast. Coronal and sagittal reformations were performed at
2-mm slice thickness. Additional 2.5-mm bone reconstructions were obtained.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass, mass
effect, or large vascular territorial infarction. A left frontal hypodensity
(2:21) is unchanged since ___, suggestive of a small chronic
infarct. The ventricles and sulci are moderately prominent, reflecting
age-appropriate cortical atrophy. There is relative hypoattenuation of the
periventricular white matter, denoting chronic microvascular ischemic disease.
There is no shift of normally midline structures. The basilar cisterns remain
preserved. Moderate atherosclerotic calcifications are seen in the cavernous
portions of the ICAs bilaterally (2:9). There is no acute fracture. Minimal
mucosal thickening within the ethmoid sinuses is present. The middle ear
cavities and mastoid air cells are clear.
IMPRESSION: No evidence of acute intracranial process.
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Status post fall and failure to thrive.
COMPARISONS: ___.
TECHNIQUE: Chest, AP upright and lateral views.
FINDINGS: The patient is status post coronary artery bypass graft surgery.
The heart is again mild to moderately enlarged. There is mild unfolding of
the thoracic aorta. The arch is again calcified. The cardiac, mediastinal
and hilar contours appear unchanged. The lungs appear clear. There are no
pleural effusions or pneumothorax. Mild degenerative changes are noted along
the lower thoracic and upper lumbar spines. There has been no significant
change.
IMPRESSION: No evidence of acute disease.
Radiology Report
INDICATION: Fall.
No comparison studies available.
TECHNIQUE: MDCT-acquired 2.5-mm axial images of the cervical spine were
obtained without the use of IV contrast. Coronal and sagittal reformations
were performed at 2-mm slice thickness.
FINDINGS:
There is no acute fracture or traumatic malalignment of the cervical spine.
Mild uncovertebral hypertrophy and facet arthropathy is present. Mild to
moderate posterior disc bulging at C5/6 results in minimal thecal sac
narrowing but no obvious indentation of the cord, which is hard to visualized
on CT imaging. There are no prevertebral soft tissue abnormalities. Included
views of the lung apices are clear. Extensive atherosclerotic calcifications
are seen at the carotid bulbs (2:25).
IMPRESSION: No acute fracture or traumatic malalignment of the cervical
spine.
Radiology Report
RADIOGRAPHS OF THE PELVIS
HISTORY: Status post fall. Question fracture.
COMPARISONS: CT from ___.
TECHNIQUE: Pelvis, supine AP.
FINDINGS: There is no evidence for fracture, dislocation, or bone
destruction. There is a prominent right lateral osteophyte along the L2-L3
interspace. The hip joint spaces are mildly narrowed. Mild degenerative
changes involve the sacroiliac joints. Patchy vascular calcifications are
present. A clip projects along the medial soft tissues of the left lower
extremity. A calcification projecting over the right groin is unchanged.
IMPRESSION: No evidence of fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FTT FALL
Diagnosed with URIN TRACT INFECTION NOS, HISTORY OF FALL, ALZHEIMER'S DISEASE, DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIROAL DISTURBANCE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 3.0 | #) FALL: Was on coumadin. CT head negative, hemodynamically
stable throughout admission. Was thought to be mechanical fall.
Less likely to be cardiogenic, but possible given A-fib. Pt
denied CP, palpitations, syncope, but was confused. Likely
altered mental status contributed to fall. Workup negative for
any CVA. Possible neurogenic component, in setting of gait
difficulties and urinary difficulties, considered normal
pressure hydrocephalus, but imaging showed no evidence of this.
Concurrent UTI could have been contributing to confusion,
especially since treating the UTI, he began to improve
cognitively. Physical therapy evaluation confirmed he is at
high risk to fall, with increased risk of bleeding secondary to
coumadin use. Recommended 24hr care at home vs discharge to
rehabilitation facility.
#) ALZHEIMER'S DEMENTIA/ALTERED MENTAL STATUS: Significant
word-finding difficulties. Unlcear if baseline. No focal
neurological deficits. Long-term memory may be intact: "I
remember meeting some Tuttles in ___ when I was a
child." Multiple admissions for falls and per wife he is
becoming more unsteady. High risk for morbidity and mortality
while on coumadin. Not safe to live at home without 24h care.
Team met with son/HCP, who flew in from ___, and he agreed
to SNF placement, at least for the short term.
#) URINARY TRACT INFECTION: Mr. ___ never had any urinary
complaints or fevers, but given chronic indwelling catheter and
confusion in an elderly gentleman, got urinalysis and urine
culture showing bacteriuria. Urine culture positive for
pan-sensitive E.coli. Initial leukocytosis to 16k trended down
to 9 after IV ceftriaxone. Condition stabilized. Was
transitioned to PO cefpodoxime. Should complete 14 day course
for complicated UTI.
#) ATRIAL FIBRILLATION: No RVR while in hospital. Discontinued
warfarin on ___, PCP Dr ___ in agreement that risks of
bleeding outweigh the benefits of anticoagulation at his age and
functional status. |
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 cramping, bleeding
Major Surgical or Invasive Procedure:
D&C for retained placenta
History of Present Illness:
Pt is a ___ G1 at 17w2d with ___ ___ by U/S on ___. Pt
presents to ED as a transfer from ___ for
further evaluation of abdominal pain, elev wbc and concern for
appendicitis. Pt presented to OSH multiple times (3 times in 3
days) due to abdominal pain. Ultrasound there was reportedly
unremarkable with a normal amount of amniotic fluid; the
appendix was not visualized due to bowel gas. Surgery has
evaluated the pt and do not feel she has appendicitis.
Pt reports she had not received any prenatal care and thought
shewas about "3 months" pregnant so she presented to ___ ED on
___ to make sure everything looked ok. She had no
symptoms at that time. The following day (___), she developed
lower abdominal cramping. She has baseline discomfort, but
frequent, intermittent severe cramping. The pain has not
worsened since ___ evening, she developed a small
amount of vaginal bleeding which has continued intermittently
since then. No heavy bleeding, no clots. Denies leaking of
fluid. Pain assoc with n/v, however, pt has has intermittent n/v
throughout pregnancy. Pt reports increased urinary frequency,
denies dysuria or back pain. In ED yesterday, c/o chills and
temp at that time was 99.6, has been afebrile otherwise. Denies
diarrhea. Had normal BM last night. Last intercourse on
___. Pt has received IV morphine for pain in the ED, states
it spaces out her cramping, but doesn't improve the intensity.
WBC trend at OSH 15.6 -> 20.1 -> 19.7 -> 22.5 -> 24.8 (89.9%N)
Urine cx: (prelim) negative [per verbal report from micro lab]
Genital cx: nl flora; negative for GC/CT, yeast, BV, GBS
Past Medical History:
PNC: (no PN care yet, saw Dr ___ at ___)
___ ___ by U/S on ___ (LMP ___, 10d discrepancy)
blood type: not available
ObHx: G1
GynHx:
hx LEEP (___), nl paps since
denies hx STDs, ovarian cysts, fibroids
LMP ___
PMH:
- Hx Crohns dz (dx'd by bx/coloscopy in ___, was on meds for 1
month then stopped because she was asymptomatic. Pt denies any
GI
issues in years.
SurgHx:
- ___ gastric band, resulting in 100# wt loss
- bone spur removed from foot
Social History:
___
Family History:
non-contributory
Physical Exam:
(on admission)
GEN appears moderately uncomfortable
VS: 106/62, HR 98, RR 16, T 98.6
Lungs: CTAB
Heart: RRR
Abd: soft, nondistended; +lower abd/uterine tenderness
SSE: small amt creamy red blood mixed with small clots in vault.
slow ooze from os. no frank pus. cervix without lesions, smooth
and without friability, appears closed
SVE: closed, nodular consistency (? due to scarring from LEEP)
Pertinent Results:
___ WBC-16.0 RBC-3.46 Hgb-11.0 Hct-33.3 MCV-96 Plt-199
___ Neuts-89.0 ___ Monos-1.8 Eos-0.4 Baso-0.1
___ WBC-18.1 RBC-3.53 Hgb-11.5 Hct-33.6 MCV-95 Plt-228
___ Glu-78 BUN-2 Creat-0.4 Na-138 K-3.4 Cl-111 HCO3-20
___ ALT-6 AST-12 AlkPhos-76 TotBili-0.2 Albumin-2.8
___ URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-70
Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ URINE RBC-0 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1
___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
URINE CULTURE (Pending):
Medications on Admission:
prenatal vitamins
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for Pain.
Disp:*20 Tablet(s)* Refills:*0*
3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chorioamnionitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: 17 weeks pregnant with right lower quadrant pain and elevated
white blood cell count of 24,000, evaluate for appendicitis.
COMPARISON: None.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired through the
abdomen and pelvis on a 1.5 Tesla magnet without intravenous contrast.
MR OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: A reservoir is present in the
subcutaneous tissues of the right upper abdomen, and a gastric band is noted
about the gastric fundus, consistent with prior laparoscopic gastric banding.
Susceptibility artifact from the reservoir and band limit some sequences,
particularly fat saturated sequences. The gastric pouch superior to the
laparoscopic gastric band shows an air-fluid level and is appropriate in size
and configuration.
Despite multiple attempts to re-image, the appendix is not clearly visualized.
There is no evidence of periappendiceal fluid collection, although a small
amount of free fluid is noted in the right lower quadrant of the abdomen. The
small bowel loops are normal in caliber, and there is no evidence of bowel
wall thickening. The gallbladder is mildly distended and without evidence of
stones. There is no intra- or extra-hepatic biliary ductal dilation.
Pancreas appears normal. In segment VII of the liver, a 9-mm structure is
hyperintense on T2-weighted images compatible with a cyst or hemangioma. The
spleen, adrenal glands, appear unremarkable. Minimal pelviectasis in the left
kidney without evidence of hydronephrosis or hydroureter. The gonadal veins
are prominent with multiple flow voids visualized within them on SSFSE
sequences, but preserved flow noted on time-of-flight imaging. A few lymph
nodes are noted in the retroperitoneum that are not pathologically enlarged.
MR PELVIS: A single intrauterine pregnancy with anterior placenta is noted.
The cervical length is 2.5 cm. Multiple uterine contractions are occurring
during the examination and are transient in their location. There is grade 1
anterolisthesis of L5 on S1 with endplate degenerative change. Cannot exclude
spondylolysis at L5, although the pedicles are not well displayed on this
examination which is not targeted for this purpose. The urinary bladder is
collapsed. Imaged portion of lung bases appear unremarkable.
The ovaries are normal in size and configuration (11:53, 56).
IMPRESSION:
1. Appendix not identified. Trace amount of free fluid in the right lower
quadrant, however, no evidence of periappendiceal fluid collection.
2. No other abnormality identified to account for the patient's abdominal
pain and elevated white blood cell count. Uterine contractions are noted to
be occurring during the examination.
3. 9-mm hepatic cyst or hemangioma in the right hepatic lobe.
4. Prior laparoscopic gastric banding procedure with expected post-operative
appearance.
The results were provided by Dr. ___ to Dr. ___ telephone at
4:50 a.m. on ___.
Radiology Report
INDICATION: ___ pregnant woman with right central pelvic pain. MRI
non-diagnostic for torsion.
TECHNIQUE: Gray scale and color ultrasound images of the fetus and pelvis
were obtained.
COMPARISON: MRI from the same day (MRI of the abdomen and fetus).
FINDINGS:
There is a single live intrauterine pregnancy with the fetus in a vertex
position. The placenta is anterior. There is grossly an appropriate amount
of amniotic fluid. Fetal measurements are technically difficult, however, the
femur measures about 2.6 cm corresponding to 18 weeks 0 days. The AC measures
11.8 cm corresponding to 17 weeks 4 days.
The right ovary measures 2.5 x 1.3 x 2.7 cm. There is normal arterial and
venous flow in the right ovary. The left ovary is not visualized.
The cervix was not evaluated in this study.
IMPRESSION:
1. Single live intrauterine pregnancy.
2. Normal right ovary, left ovary not visualized.
3. The cervix was not evaluated in this study.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with OTH CURR COND-ANTEPARTUM, ABDOMINAL PAIN OTHER SPECIED
temperature: 98.6
heartrate: 98.0
resprate: 16.0
o2sat: 97.0
sbp: 106.0
dbp: 62.0
level of pain: 8
level of acuity: 3.0 | ___ y/o G1 admitted at 17w2d with lower abdominal pain, bleeding,
and elevated wbc.
.
Ms ___ was admitted to the antepartum service for observation
given the concern for chorioamnionitis versus abruption. She
continued to report intermittent severe cramping. She was
followed by MFM and was given IV dilaudid for pain control of
her intermittent cramping and she was observed very closely. She
then experienced leakage of vaginal fluid and was confirmed to
have PPROM. The patient was then transferred to L&D. Her cervix
was closed and she therefore received cytotec.
She was also started on IV antibiotics
(ampicillin/gentamicin/clindamycin) given uterine tenderness and
presumed chorioamnionitis. She had a Tmax of 100.8 during labor
and subsequently was afebrile. She had a vaginal delivery of a
nonviable fetus complicated by manual removal of placenta and a
subsequent D&C for retained placenta. Postpartum, she was
continued on antibiotics for 24 hours. Ms. ___ was seen by
social work and the hospital chaplain. She was discharged home
in stable condition on postpartum day #1. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Removal of tunneled L IJ HD line (___)
History of Present Illness:
___ w/ hx of COPD (baseline CO2 ___, afib on coumadin, ___
recently admitted for respiratory failure presents from rehab w/
BRBPR x2. He presented tachypneic and tachycardic, satting 90%
on 10L, but normotensive initially. He felt dizzy but had no
pain and no other complaints (was awake, alert).
In the ED, initial vitals: 98.4 119 100/71 40 94% RA. He then
had another large bloody BM (total #3), with subsequent
hypotension with systolic pressures in the ___. He was given 4
units pRBCs (O-negative) and 1.5 L IVF. He has a R femoral
cordis, and 2 PIV. He also received 2 units matched blood as
well as 2 units FFP. Labs were significant for HCT 21.2, Trop
0.08, Na 150, Cr 2.0, INR 1.8, UA demonstrating few bact, 129
WBC, lg leuk, mod blood, and VBG: 7.38 68 30. Pt was transfused
3 units pRBCs, 2 units FFP. GI was consulted. PEG tube lavage
was negative for blood. CTA was ordered, but did not show any
active bleeding. On transfer, vitals were:
Pt had a recent admission from ___ for dyspnea which
evolved into acute hypoxemic hypercapnic respiratory failure. He
was found to have severe ARDS thought ___ to influenza with
bacterial superinfection, requiring pressor support for septic
shock. Pt was treated with vanc/zosyn from ___, tamiflu
from ___ and then given zanamavir ___. Vent was
successfully weaned from ___ to PEEP of 10 and FiO2 40%. but
due to persistent barrier to extubation including lung
compliance limitations and weakness from prolonged paralysis, pt
had a trach and PEG placed on ___. Pt was then weaned to trach
mask later on ___. He also developed ___ ___ ATN requiring
CRRT. He eventually did not require further renal replacement as
his urine output began to pick up and it was felt his tunneled
line could be removed shortly with close renal follow-up. His
hospital course was further complicated by serratia tracheitis,
critical care myopathy, and RUE ___-associated DVT, for which
he was started on coumadin.
On arrival to the MICU, pt had another 2 large bright red bloody
BMs. He is awake and alert. He is asking for water, but denies
any pain. He otherwise has no complaints. He states he had a
colonoscopy on ___ at ___ that showed polyps which were
all benign except 1, the details of which he said were not
explained. He has never had an EGD, and he does not suffer from
heartburn.
Past Medical History:
DM II, on insulin
Paroxysmal afib
hypertension
peripheral neuropathy
hyperlipidemia
Tobacco Use
COPD
HFpEF
Social History:
___
Family History:
Per recent dc summary, mother with hx colon cancer. Father with
a stroke and diabetic. Grandmother on father's side with
diabetes.
Physical Exam:
Admission:
General- Ventilator hooked up to trach. Pt is awake, alert,
answering questions appropriately
HEENT- PERRL, MMM
Neck- Trach hooked up to ventilator
CV- Tachycardic, regular rate no murmurs/rubs/gallops
Lungs- CTAB with exception of slightly coarse breath sounds at
the right base
Abdomen- Soft, NT, ND. No dullness to percussion. Sluggish bowel
sounds.
GU- Foley draining clear yellow urine
Ext- No edema
Discharge:
General- Pt on trach collar. Pt is awake, alert, answering
questions appropriately.
HEENT- PERRL, MMM
Neck- Trach collar
CV- RRR, no murmurs/rubs/gallops
Lungs- CTAB with exception of slightly coarse breath sounds at
the right base
Abdomen- Soft, NT, ND. No dullness to percussion. Normoactive
bowel sounds.
GU- Foley draining clear yellow urine
Ext- No edema
Psych- Good mood. Telling jokes
Pertinent Results:
ADMISSION:
___ 10:45PM BLOOD WBC-10.3 RBC-2.33* Hgb-6.3* Hct-21.2*
MCV-91 MCH-26.8* MCHC-29.6* RDW-15.2 Plt ___
___ 10:45PM BLOOD Neuts-75.7* Lymphs-16.6* Monos-5.3
Eos-1.4 Baso-1.0
___ 11:00PM BLOOD ___ PTT-40.2* ___
___ 10:45PM BLOOD Glucose-246* UreaN-46* Creat-2.0* Na-150*
K-4.4 Cl-105 HCO3-32 AnGap-17
___ 10:45PM BLOOD ALT-5 AST-21 AlkPhos-66 TotBili-0.1
___ 10:45PM BLOOD Lipase-17
___ 10:45PM BLOOD cTropnT-0.08*
___ 10:45PM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.8 Mg-2.0
___ 11:52PM BLOOD ___ pO2-30* pCO2-68* pH-7.38
calTCO2-42* Base XS-11
DISCHARGE:
___ 04:15AM BLOOD WBC-9.2 RBC-2.77* Hgb-7.7* Hct-25.1*
MCV-91 MCH-27.9 MCHC-30.8* RDW-14.7 Plt ___
___ 01:54AM BLOOD ___ PTT-29.9 ___
___ 04:15AM BLOOD Glucose-182* UreaN-45* Creat-1.5* Na-147*
K-3.9 Cl-103 HCO3-35* AnGap-13
Imaging:
___ CXR:
FINDINGS: Single portable view of the chest. Tracheostomy tube
is in place. Left-sided tunneled central venous dual-lumen
catheter is seen with distal tip in the right atrium. There is
at least a moderate right-sided pleural effusion which
contributes due to increased opacity projecting over the right
lung with superimposed infection also possible. There is some
degree of pulmonary vascular congestion. Cardiac silhouette is
slightly enlarged butlikely accentuated by technique. No acute
osseous abnormality is identified.
___ CTA Abdomen/Pelvis:
1. Subtle focus of increased density in the sigmoid colon which
progresses
between arterial and venous phase but is not detected on the non
contrast
enhanced phase. This is concerning for active extravasation.
Reviewed with Dr. ___, on call radiology fellow,
per Dr.
___, who agreed with the initial interpretation that
there was no CT evidence for active extravasation. Upon
attending review, there was felt to be a subtle focus of
possible active extravasation. At 08:41 at the time of
attending radiologist discovery of this finding, this was
communicated to Dr. ___ by Dr. ___ by telephone.
2. Bilateral lower lobe pulmonary consolidations, concerning for
pneumonia or aspiration.
EGD ___
Impression: Clean based cratered ulcer in the antrum
PEG in the stomach body with a small erythematous area adjacent
Food in the stomach
Otherwise normal EGD to third part of the duodenum
Recommendations:
PPI gtt for 72 hours given degree of bleeding from antral ulcer.
Clear liquids only, please hold tube feeds.
Continue to trend hemodynamics and hematocrit.
Monitor today in the ICU.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain, light
headache
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Diltiazem 60 mg PO QID
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Guaifenesin ___ mL PO Q6H
8. Ipratropium Bromide Neb 1 NEB IH Q6H
9. Senna 8.6 mg PO BID:PRN Constipation
10. Warfarin 3 mg PO DAILY16
11. Pravastatin 10 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain, light
headache
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
3. Aspirin 81 mg PO DAILY
4. Diltiazem 60 mg PO QID
5. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
8. Pravastatin 10 mg PO DAILY
9. Warfarin 5 mg PO DAILY16
Adjust based on daily INR
10. Heparin 5000 UNIT SC TID
Can stop when INR is >2
11. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
12. Docusate Sodium (Liquid) 100 mg PO BID
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Guaifenesin ___ mL PO Q6H
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 8.6 mg PO BID:PRN Constipation
17. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with rapid gastrointestinal bleed on Coumadin.
COMPARISON: None available.
TECHNIQUE: CT mesenteric angiogram of the abdomen and pelvis was performed
before and after administration of intravenous contrast in the arterial and
venous phases. Multiplanar reformatted images were reviewed.
FINDINGS:
A very subtle focus of increased intraluminal density progresses between
arterial and venous phases in the sigmoid colon (4a:142, 4b:333). There is no
corresponding hyperdensity on the non contrast enhanced phase.
Abdomen: The lung bases demonstrate bibasilar right greater than left
consolidations with adjacent atelectasis. No pericardial effusion is seen.
Dialysis catheter is seen terminating in the right atrium. Dense mitral
anulus calcifications are noted.
No acute abnormalities are detected of the liver, collapsed gallbladder,
spleen, pancreas, adrenal glands, kidneys, stomach with gastrostomy tube, or
small bowel. There is no free intraperitoneal air or ascites. The appendix
is normal. The abdominal aorta is normal in caliber with moderate
atherosclerotic change and patent branch vessels. The portal vein, splenic
vein, and superior mesenteric vein appear patent. Few colonic diverticula do
not demonstrate evidence for acute inflammation.
Pelvis: No acute abnormalities are detected of the decompressed urinary
bladder with a Foley catheter, seminal vesicles, prostate, or rectum. There
is no free fluid in the pelvis. A small amount of air in the right common
femoral vein with a right common femoral vein catheter is likely post
procedural.
No concerning lytic or sclerotic osseous lesions are detected.
IMPRESSION:
1. Subtle focus of increased density in the sigmoid colon which progresses
between arterial and venous phase but is not detected on the non contrast
enhanced phase. This is concerning for active extravasation.
Reviewed with Dr. ___, on call radiology fellow, per Dr.
___, who agreed with the initial interpretation that there was no
CT evidence for active extravasation. Upon attending review, there was felt
to be a subtle focus of possible active extravasation. At 08:41 at the time
of attending radiologist discovery of this finding, this was communicated to
Dr. ___ by Dr. ___ by telephone.
2. Bilateral lower lobe pulmonary consolidations, concerning for pneumonia or
aspiration.
Radiology Report
INDICATION: ___ male with GI bleed and temporary need for
hemodialysis, which has now resolved. HD line removal requested.
PROCEDURE: Tunneled HD line removal.
PROCEDURE IN DETAIL: Using sterile technique, the catheter sutures were
removed and under gentle traction, the hemodialysis catheter was easily
removed from the tunnel. Gentle pressure was applied to the right internal
jugular venotomy site for five minutes until hemostasis was achieved. A small
sterile dressing was placed over the tunnel tract site. The patient tolerated
the procedure well. No complications.
IMPRESSION: Successful tunneled hemodialysis catheter removal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RESP DISTRESS
Diagnosed with MELENA, AC POSTHEMORRHAG ANEMIA, SHOCK W/O TRAUMA NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ M with recent admission for respiratory failure now s/p
trach/peg tube placement who now presents from rehab with BRBPR
and subsequent hypotension.
# HEMATOCHEZIA - Presumed to be due to a diverticular bleed. Pt
presents with BRBPR, now with 5 total episodes, 3 of which were
large enough in volume to cause hypotension. He presented with
HCT 21 from 27 (from ___. He does not have a colonoscopy in
our system, he states he had a recent colonoscopy in ___
that was significant for polyps, though specific pathology of
one of them is unknown. His PEG tube did not flush with anything
resembling blood (no frank blood, nothing blood tinged), making
an upper GI source less likely, though still possible to have a
duodenal ulcer. EGD revealed gastric/antral ulcer but was not
thought to be the culprit source. Lower GI source is most
likely, which includes a differential of diverticula or AVM.
Given lack of abominal pain, much less likely to be secondary to
ischemic colitis. Patient received 5 pRBC, ___ FFP, and 1.5 L IVF.
Pt went for CTA which did not show active bleeding. Received 72
hrs protonix drip. Crits remained stable. Colonoscopy was not
pursued given recent OSH colonoscopy ___ (done for ___
screening/surveillance of polyps) which did not suggest a source
of bleeding. Presumed to be a diverticular bleed given CT
findings of diverticulosis. Given stability, restarted warfarin
___ for atrial fibrillation/upper extremity DVT without any
recurrence of bleeding.
# Chronic respiratory needs: Pt is now s/p trach placement after
a complicated hospital course for ARDS secondary to influenza
with bacterial superinfection and difficulty weaning from the
vent. Pt was able to wean from the vent on ___ and placed on
trach collar, though relapsed with tachypnea and O2 sats 90% on
10L O2. He oscillates between using ventilatory support and
trach collar. His current vent settings demonstrate synchrony
and pt appears comfortable. Sutures from his trach placement
were removed ___. His current respiratory settings include
daytime tach mask at 60% and at nighttime scheduled ventilation
of A/C with tidal volume 450ml and rate of 16/minute at an FiO2
of 40%. Vent requirement can be weaned as tolerated. Will need
trach down-sizing 4 weeks after discharged.
# Acute renal failure: Resolved. Pt noted on his last admission
to have ___ secondary to ATN. He was maintained on CRRT
initially through a tunneled line, but pt did not eventually
need HD just prior to discharge as his UOP was increasing and Cr
improving. He did not receive HD at rehab. Never received HD on
this admission. Creatinine stabilized at 1.5 and patient was
making good urine. HD line was removed ___.
# Hypernatremia: Resolved after free water repletion. Likely
secondary to free water depletion.
# Paroxysmal afib/aflutter: EKG currently demonstrates sinus
rhythm. Diltiazem and coumadin were held due to acute bleed
initially, but was restarted on warfarin ___ and his INR should
be followed with a goal INR ___.
# RUE PICC-associated DVT: Recent U/S on ___ revealed extensive
clot extending up to R IJ. Pt was started on coumadin with a
planned 3 months of anticoagulation.
# T2DM: No HbA1C in our system. Cont Lantus 5 units at bedtime
with HISS.
# COPD: No PFTs in our system. Per previous documentation,
baseline PaCO2 in the ___ mmHg. His baseline COPD is not known
although patient is on Spiriva and advair at home.
# Diastolic CHF: EF 50-60% on ___. Patient volume overloaded
after resuscitation and have been slowly diuresing. Would
continue diuresis at the discretion of rehab MD. ___ well
to 80mg IV furosemide.
# Hyperlipidemia: Cont pravastatin
# HCM - Aspirin was initially held and re-started no ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yrs old female pt with hx of gastric bypass surgery (@ ___
___, then revised with Dr. ___ at ___,
cholecystectomy in ___, hx of esophageal stricture that
required "10 dilatations" and eventual corrective surgery,
vomiting as many as ___, progressively worse, and now not
able to keep fluids down. Positive odynophagia, severe, feels
like food getting stuck in mid chest, not going down. Lab showed
ALT/AST 200's at ___ and pt was referred in for CT scan and
hydration.
In the ED, initial vitals were: 98.5 91 120/84 16 100% RA
- Labs were significant for ALT: 195 AP: 60 Tbili: 1.2 Alb: 4.7
AST: 263 Lip: 127, WNL chem 7, H&H ___, WBC 3.1, paltelets of
269, lactate 1.3, UA negative.
- Imaging with CT Abd showed Marked hepatic steatosis.
Postoperative changes of gastric bypass. Otherwise unremarkable
CT of the abdomen and pelvis.
- The patient was given IV Benedry 50 mg x2, Hydroxyzine 25mg
IV x2, and Dilaudid 0.5 IV x1, 1mg IV x4, 2L of IVF.
Upon arrival to the floor, She reports pain and pruitis. The
rash started 6 weeks ago. She has not been in any hot tubs or
natural pools of water. She did go in a salt water pool 2 times.
The itching became so bad that it became secondarily infected
for which she was prescribed Bactrim. She completed a 10 day
course on ___. On ___ she developed RUQ and Epigastric ABD pain
that was followed by nasuea and vomiting.
Dysphagia - Yes
Odynophagia - Yes
Diarrhea - No, pt has not had a BM in 1 week
Stomach pain - RUQ and epigastric. Sharp pain with movement. Pt
states it feels like she been hit with a baseball bat and
coughing or moving makes the pain worse.
Bowel movements - Last week, passing gas.
Headache/Neck stiffness - None
Vision changes - none
Past Medical History:
HTN, Gastric Bypass Surgery, cholecystectomy in ___, esophageal
stricture that required dilatation, Congenital Nystagmus.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: 98 137/94 110 20 98RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Baseline nystagmus.
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:TTP in RUQ and epigastric region, 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: 98.6 120/74 77 18 100%RA
General: AAOx3, well-appearing, NAD, pleasant
HEENT: Baseline nystagmus. Sclera anicteric, MMM, oropharynx
clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Obese, TTP in RUQ and epigastric region, bowel sounds
present, no organomegaly, no rebound or guarding
GU: Deferred per patient
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.
Pertinent Results:
___ 07:25AM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND
MCH-PND MCHC-PND RDW-PND RDWSD-PND Plt Ct-PND
___ 07:12AM BLOOD WBC-2.5* RBC-3.11* Hgb-8.7* Hct-28.2*
MCV-91 MCH-28.0 MCHC-30.9* RDW-16.3* RDWSD-53.7* Plt ___
___ 05:45AM BLOOD WBC-3.2* RBC-3.31* Hgb-9.4* Hct-30.1*
MCV-91 MCH-28.4 MCHC-31.2* RDW-16.2* RDWSD-54.5* Plt ___
___ 11:40AM BLOOD WBC-3.1* RBC-3.62* Hgb-10.4* Hct-32.0*
MCV-88 MCH-28.7 MCHC-32.5 RDW-16.5* RDWSD-53.1* Plt ___
___ 07:25AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND
Baso-PND AbsNeut-PND AbsLymp-PND AbsMono-PND AbsEos-PND
AbsBaso-PND
___ 11:40AM BLOOD Neuts-57.2 ___ Monos-11.8 Eos-1.9
Baso-1.3* Im ___ AbsNeut-1.79 AbsLymp-0.87* AbsMono-0.37
AbsEos-0.06 AbsBaso-0.04
___ 07:25AM BLOOD Plt Ct-PND
___ 07:25AM BLOOD ___ PTT-PND ___
___ 07:12AM BLOOD Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-27.0 ___
___ 11:40AM BLOOD Plt ___
___ 11:40AM BLOOD Ret Aut-1.2 Abs Ret-0.04
___ 07:25AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
___ 07:12AM BLOOD Glucose-91 UreaN-3* Creat-0.4 Na-141
K-3.2* Cl-100 HCO3-26 AnGap-18
___ 05:45AM BLOOD Glucose-81 UreaN-5* Creat-0.6 Na-139
K-3.6 Cl-99 HCO3-24 AnGap-20
___ 11:40AM BLOOD Glucose-86 UreaN-7 Creat-0.5 Na-140 K-3.6
Cl-96 HCO3-26 AnGap-22*
___ 07:25AM BLOOD ALT-PND AST-PND AlkPhos-PND TotBili-PND
___ 07:12AM BLOOD ALT-135* AST-155* CK(CPK)-55 AlkPhos-46
TotBili-0.5
___ 05:45AM BLOOD ALT-184* AST-280* LD(___)-331* AlkPhos-53
TotBili-0.8 DirBili-0.4* IndBili-0.4
___ 11:40AM BLOOD ALT-195* AST-263* LD(___)-258* AlkPhos-60
TotBili-1.2
___ 07:25AM BLOOD Calcium-PND Phos-PND Mg-PND
___ 07:12AM BLOOD Calcium-9.3 Phos-4.9* Mg-1.8 Cholest-163
___ 05:45AM BLOOD Albumin-4.4 Calcium-9.5 Phos-3.9 Mg-1.4*
___ 11:40AM BLOOD Albumin-4.7 Calcium-9.8 Phos-2.8 Mg-1.6
Iron-71
___ 11:40AM BLOOD calTIBC-335 VitB12-GREATER TH Folate-8.7
___ Ferritn-158* TRF-258
___ 07:12AM BLOOD Triglyc-68 HDL-72 CHOL/HD-2.3 LDLcalc-77
___ 11:40AM BLOOD Triglyc-55
___ 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 11:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HAV-NEGATIVE
___ 05:45AM BLOOD Smooth-NEGATIVE
___ 07:12AM BLOOD CRP-0.4
___ 05:45AM BLOOD ___
___ 05:45AM BLOOD IgG-614*
___ 07:12AM BLOOD HIV Ab-Negative
___ 05:45AM BLOOD tTG-IgA-3
___ 11:40AM BLOOD HoldBLu-HOLD
___ 05:45AM BLOOD HCV Ab-NEGATIVE
___ 11:40AM BLOOD HCV Ab-NEGATIVE
___ 11:50AM BLOOD Lactate-1.3
___ 09:29PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
___ 07:12AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIOSIS AGENT) IGG-PND
___ 07:12AM BLOOD SED RATE-PND
___ 05:45AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG)-PND
___ 05:45AM BLOOD CERULOPLASMIN-PND
___: UGI Barium Swallow Xray Series
FINDINGS:
ESOPHAGUS: Barium passes freely through the esophagus into the
stomach.
There is no evidence of abnormal narrowing or dilation within
the esophagus.
Normal primary peristaltic contractions were seen. No hiatal
hernia was seen.
No gastroesophageal reflux was identified during the
examination. A 13-mm
barium tablet was given without holdup.
Barium passes through the gastric remnant and into the small
bowel without
focal narrowing or obstruction.
Barium passes through the small bowel, reaching the colon within
150-170
minutes which is within normal limits. The duodenum, jejunum,
and ileum
appear within normal limits in caliber. There is normal fold
pattern, with no
masses, stricture, or mucosal abnormality. The terminal ileum
appears within
normal limits.
IMPRESSION:
Normal esophagram and small bowel follow through
___:
CT abd/pelvis
IMPRESSION:
Marked hepatic steatosis. Postoperative changes of gastric
bypass. Otherwise
unremarkable CT of the abdomen and pelvis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Acyclovir 400 mg PO Q12H
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Acyclovir 400 mg PO Q12H
3. Outpatient Lab Work
___: CBC with diff, LFTs.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: transaminitis, dysphagia/nausea/vomiting,
leukopenia, anemia.
Secondary Diagnoses: HSV, gastric bypass surgery, pruritus.
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 epigastric pain, elevated LFTs, RNYGB ___ years ago+PO
contrast
TECHNIQUE: 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 DLP (Body) = 977 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: No significant abnormalities are seen at the lung bases.
ABDOMEN:
HEPATOBILIARY: The liver is markedly hypodense. There is no evidence of focal
lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions 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: Sutures are seen in the left upper quadrant and at the
jejuno jejunal anastomosis status post Roux-en-Y gastric bypass. Small bowel
caliber is normal. Contrast material is seen passing through the distal small
bowel. Small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits.
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.
BONES: A sclerotic lesion is noted in the right femoral neck, which likely
represents a bone island. There is mild height loss of the L1 vertebral body
which appears chronic.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Marked hepatic steatosis. Postoperative changes of gastric bypass. Otherwise
unremarkable CT of the abdomen and pelvis.
Radiology Report
EXAMINATION: Upper GI with mall bowel follow through
INDICATION: ___ year old woman with hx gastric bypass, esophageal strictures,
w/ N/V, odynophagia, concerning for recurrent strictures. // ___ year old
woman with hx gastric bypass, esophageal strictures, w/ N/V, odynophagia,
concerning for recurrent strictures.
TECHNIQUE: Following ingestion of thin barium, multiple radiographs and spot
fluoroscopic images were obtained during the transit of barium through the
small bowel.
DOSE: Acc air kerma: 31 mGy; Accum DAP: 773.5 uGym2; Fluoro time: 01:49
COMPARISON: CT abdomen/pelvis with contrast dated ___.
FINDINGS:
ESOPHAGUS: Barium passes freely through the esophagus into the stomach.
There is no evidence of abnormal narrowing or dilation within the esophagus.
Normal primary peristaltic contractions were seen. No hiatal hernia was seen.
No gastroesophageal reflux was identified during the examination. A 13-mm
barium tablet was given without holdup.
Barium passes through the gastric remnant and into the small bowel without
focal narrowing or obstruction.
Barium passes through the small bowel, reaching the colon within 150-170
minutes which is within normal limits. The duodenum, jejunum, and ileum
appear within normal limits in caliber. There is normal fold pattern, with no
masses, stricture, or mucosal abnormality. The terminal ileum appears within
normal limits.
IMPRESSION:
Normal esophagram and small bowel follow through
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V, Abnormal labs
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.5
heartrate: 91.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 84.0
level of pain: 7
level of acuity: 3.0 | ASSESSMENT & PLAN: ___ with PMH of gastric bypass, esophageal
strictures s/p dialation p/w intractable N&V and unable to
tolerate POs.
#Nausea/Vomiting: Patient presented to the ED with persistent
N/V, mild dysphagia, odynophagia, inability to tolerate POs. She
was treated with hydration, and early re-feeding, to which she
tolerated liquids, and some solid food without dysphagia or
odynophagia. In the setting of her previous gastric bypass
surgery and hx of esophageal strictures (>10 times, ___ years
ago), the leading differential was recurrent esophageal
strictures vs. other anatomical obstruction vs. dysmotility vs.
gastroenteritis vs. pancreatitis (lipase 127). We performed a
barium swallow UGI series which was normal and did not show any
areas of narrowing. We consulted GI and they recommended
outpatient manometry workup for the n/v, and that it was
reassuring that she was tolerating POs at the time of discharge.
#Transaminitis: Patient was found to have a transaminitis to
the 200s that continually downtrended throughout the
hospitalization. An RUQ u/s showed steatosis concerning for
___. Broad differential includes NASH vs. viral hepatitis, drug
induced as pt completed a 10 day course of DS Bactrim last
___ for UTI and superimposed bacterial skin infection with
N&V and ABD pain starting ___. Bactrim is a culprit
medication for drug-induced transaminitis and pancreatitis as
well. Pt denies significant alcohol use ___ drinks/week." . CT
w/ contrast did not note a PVT. Current leading etiology
includes NASH vs. acute autoimmune hepatitis vs. viral
infection. A lipid panel was normal. We also sent for autoimmune
hepatitis labs, CMV/EBV and anaplasma which were all pending.
#Anemia/Leukopenia: Patient has a chronic hypoproliferative
anemia with low retic, high RDW and normal MCV. Now on this
admission she was found to have a new leukopenia to 2.6 with all
lines down. The ___ was 1200 at nadir. This could be secondary
to viral process in the setting of her being a ___
(potential exposure to ParvoB19 vs. other viruses) vs. drug
induced (Bactrim), all of which can cause marrow suppression.
B12 and folate were normal. HIV and Hepc C were also normal.
#Rash -Maculopapular rash with erythematous base that began 6
weeks ago on her chest initially and spread to her upper back.
It is intensely pruritic and pt scratched to the point of it
becoming secondarily infected which prompted 10 day course of
Bactrim. She denies swimming in natural water in ___ making
"duckage" or Cercarial dermatitis unlikely. She denies a change
in cosmetic or detergents. It does not have the appearance of
poison ___. We treated her pruritus with sarna lotion and
recommend outpatient follow-up with PCP or dermatology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ female with history of non ischemic
cardiomyopathy (EF 20% on TTE versus 45% on TEE) presumed tachy
mediated, hypertension, A. Fib on amiodarone/Elequis planned for
PVI, pulmonary hypertension, labile blood pressures who was sent
in from her cardiologist's office at ___ due to
concern for volume overload.
Patient reports that over the past 2 weeks she has had
increasing
lower extremity edema, weight gain and dyspnea on exertion. She
has missed doses of lasix over the last few weeks, mostly in
setting of holding Lasix for lightheadedness. Her weight has
been
up almost 10 pounds over the past month, despite having RHC in
___ revealing elevated filling pressures (PCW 20). She was seen
by Dr. ___ ___ in clinic in ___ and was noted to be
volume overloaded. In addition she complained on new exertional
chest pressure. She was advised to present to ___ for IV
diuresis for suspected volume overload.
For the past 3 or 4 days she has had brief intermittent left
anterior chest pain, both sharp and pressure-like in nature, not
associated with exertion, lasting only a few minutes at a time
and resolving on its own. She has had a mild nonproductive
cough.
Denies fevers. She has been taking 40 mg p.o. Lasix daily for
the
past 2 weeks, which is an increase from her usual 20 mg (though
she notes that for a few days over the past week she took a
lower
dose by accident). Dosing of her diuretics has been difficult
given her labile blood pressures. Denies abdominal pain,
vomiting, diarrhea, blood in the stool, dysuria, hematuria,
headaches, vision changes.
In the ED initial vitals were: 97.5 63 121/71 18 98% RA
EKG: NSR with 1st degree AV delay, low voltage, unchanged from
prior.
Labs/studies notable for: negative troponin x2, Cr 1.6 from
baseline of , NA 133, proBNP 310 (near baseline)
Patient was given: 20 mg IV lasix
Vitals on transfer: 98.1 70 114/47 18 99% RA
On the floor, she notes that she has had progressive weight gain
and DOE over the past month. She has missed some doses of Lasix,
but has been complaint over the past week and has not had relief
from her symptoms. She denied orthopnea or PND. She noted new
onset exertion chest pressure, that is pinpoint in location and
lasts for approximately 1 min prior to resolving. She denied
prior events of this pain. This pain is reproducible with
palpation over the left side of her chest wall. She denied
exacerbation with positional changes and it is not pleuritic.
She
has had a dry cough over the past couple days, but denied
fevers,
chills, or sweats.
Past Medical History:
Obesity
HTN
Depression
Social History:
___
Family History:
Mother with history of CHF and atrial fibrillation. Maternal ___
with h/o early death from MI in her late ___.
Physical Exam:
ADMISSION EXAM
VITALS: 98.1 PO 125 / 77 70 18 96 ra
GENERAL: Well-developed, well-nourished. Obese. NAD. Mood,
affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10-12 cm. Carotid pulse full with
normal upstroke bilaterally. No bruit.
CARDIAC: Comfortable laying flat for > 2 min. RRR, quiet but
normal S1, S2. No audible murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP with good peripheral pulses. ___ + pedal edema
bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM
PHYSICAL EXAMINATION:
=====================
24 HR Data (last updated ___ @ 1515)
Temp: 98.3 (Tm 98.6), BP: 131/83 (96-131/52-83), HR: 64
(51-75), RR: 18 (___), O2 sat: 94% (94-99), O2 delivery: Ra,
Wt: 278.22 lb/126.2 kg
Fluid Balance (last updated ___ @ 839)
Last 8 hours No data found
Last 24 hours Total cumulative 520ml
IN: Total 520ml, PO Amt 520ml
OUT: Total 0ml, Urine Amt 0ml
GENERAL: Well-developed, well-nourished. Obese body habitus, no
apparent distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. No appreciable JVD . No bruit.
CARDIAC: Comfortable laying flat for > 2 min. RRR, quiet but
normal S1, S2. No audible murmurs/rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Clear
to
auscultation bilaterally. No crackles, wheezes or rhonchi. No
increased WOB
ABDOMEN: Soft, NTND. Obese.
EXTREMITIES: WWP with good peripheral pulses. 1+ edema to
ankles.
Pertinent Results:
Labs
Admission
___ 05:50PM BLOOD WBC-9.2 RBC-4.14 Hgb-12.1 Hct-35.9 MCV-87
MCH-29.2 MCHC-33.7 RDW-13.9 RDWSD-43.7 Plt ___
___ 05:50PM BLOOD Neuts-57.5 ___ Monos-8.3 Eos-1.0
Baso-0.3 Im ___ AbsNeut-5.28 AbsLymp-3.00 AbsMono-0.76
AbsEos-0.09 AbsBaso-0.03
___ 05:50PM BLOOD ___ PTT-34.7 ___
___ 05:50PM BLOOD Plt ___
___ 05:50PM BLOOD Glucose-94 UreaN-23* Creat-1.6* Na-133*
K-4.2 Cl-94* HCO3-25 AnGap-14
___ 05:50PM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD proBNP-310*
___ 05:50PM BLOOD Osmolal-278
___ 05:50PM BLOOD TSH-11*
Discharge
___ 06:15AM BLOOD WBC-7.5 RBC-4.33 Hgb-12.9 Hct-38.8 MCV-90
MCH-29.8 MCHC-33.2 RDW-14.0 RDWSD-45.1 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-94 UreaN-25* Creat-1.6* Na-137
K-4.2 Cl-95* HCO3-29 AnGap-13
___ 06:15AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.6
___ 06:15AM BLOOD
Studies
Admission CXR ___ -
IMPRESSION: No acute intrathoracic process.
TTE ___
FINDINGS:
LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Normal RA size.
LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity
size. Normal regional systolic function.
Normal overall systolic function (greater than 55%). No resting
outflow tract gradient. Normal diastolic
function.
RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall
motion.
AORTA: Normal sinus diameter for gender. Normal ascending
diameter for gender. Normal arch diameter.
AORTIC VALVE (AV): Normal/thin (3) leaflets. No stenosis. No
regurgitation.
MITRAL VALVE (MV): Mildly thickened leaflets. No systolic
prolapse. Mild MAC. Trivial regurgitation.
PULMONIC VALVE (PV): PV not well seen Physiologic regurgitation.
TRICUSPID VALVE (TV): Not well seen. Physiologic regurgitation.
Undertermined pulmonary artery systolic
pressure.
PERICARDIUM: No effusion.
ADDITIONAL FINDINGS: Frequent VPBs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Non Ischemic dilated cardiomyopathy with
recovery
SECONDARY DIAGNOSIS: Chronic kidney disease, Paroxysmal Atrial
fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with DOE and normal BNP// Evidence of pulmonary
process, amiodarone toxicity
COMPARISON: Chest radiographs ___ and ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. 6 mm calcified
granuloma is noted in the right upper lobe. Heart size is top normal. Imaged
osseous structures are intact. No free air below the right hemidiaphragm is
seen.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea on exertion, Leg swelling, Transfer
Diagnosed with Heart failure, unspecified
temperature: 97.5
heartrate: 63.0
resprate: 18.0
o2sat: 98.0
sbp: 121.0
dbp: 71.0
level of pain: 4
level of acuity: 3.0 | ___ female with history of non ischemic cardiomyopathy
(EF 20% on TTE versus 45% on TEE) presumed tachymediated,
hypertension, A. Fib on amiodarone/Eliquis planned for PVI,
pulmonary hypertension, labile blood pressures who was sent
in from her cardiologist's office at ___ due to
concern for volume overload with weight gain, DOE as well as
chest pressure.
# Decompensated HFrEF/HFpEF
- previous Echo w/ EF of 40/45%,TTE on admission with recovery
of NI cardiomyopathy and normal EF
- Admission BNP 310, Trop neg, ECG w/o ischemic changes
- Precipitating events - Took ___ dose of Lasix for ___ days
prior to admission because she forgot about the recent change in
dose
- several doses of IV Lasix w/ marked improvement, back on home
dose of 40mg PO Lasix daily
- continued all other home medications
# Possible CKD:
- per ___ records Cr 1.3-1.6 seems to be new baseline,
etiology unknown
- may consider outpatient renal follow-up
# Paroxysmal Atrial fibrillation: In NSR s/p TEE DCCV ___ and
on
amiodarone.
- Well controlled this admission, continued home amiodarone and
apixiban.
TRANSITIONAL ISSUES:
Discharge Weight: 126.2 kg
Discharge Diuretic: Lasix 40mg daily
- needs follow-up apt in ___ clinic within week after discharge,
email sent to set up on day of 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:
dyspnea
Major Surgical or Invasive Procedure:
Thoracoscopy with pleural biopsy
Pleurodesis
Pleurex placement and removal
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with history of
hypertension, hyperlipidemia, DM2, and distant history of left
parapharyngeal and retropharyngeal phlegmon/cellulitis presented
with shortness of breath, cough, and confusion over the last ___
weeks who was found to have a large left plerual effusion and
left upper lobe nodule.
He had been feeling his normal self ___ months ago. Over the
last ___ months he has been felling like he had the flu or a
URI. For the last 2 weeks he had a severe cough that caused him
to cough so much/often that it caused stomach pain. He tried
robitussin with codeine for the last 2 weeks with some
improvement, but not durable improvement. He has had some white
and clear sputum. He has not had headaches, fevers, chills,
changes in vision, chest pain, or lower extremity edema.
Normally he can walk many miles (he reports 10) when he "mall
walks" with his friends, walking many laps most days. However
he has not been able to do this for the last ___ months due to
his "URI's" that were going around, and on the day of
presentation he was walking only blocks before being too dyspnic
to continue.
His ex-wife and Mr. ___ both report that he has had
increased confusion and memory loss over the last ___ weeks.
They are unable to correlate it with his codeine use. He had
been tracking his diet and blood sugars regularly for a month or
so, and then stopped in mid ___. Four days prior to admission
he was unable to be reached and phone was dead, which is
atypical for him.
He does not have a history of jail/prison, homelessness, TB
contacts, or significant international travel ___ many
years ago on vacation).
In the ED his initial vitals were 97.6 ___ 22 99% RA,
and his tachycardia and hypertension downtrended. He remained on
room air.
CXR revealed large effusion and IP placed a chest tube;
subsequently 2.5 L of hemorrhagic/serosanguinous fluid with a pH
of 7.29 was drained from the left chest. Lactate was 3.3.
He was given acetaminophen, 1L NS and 8 units of insulin for a
FSBG in the 330's.
On the floor, he does not have any complaints and is "done with
being asked these questions."
ROS: No nausea, vomiting, diarrhea, dysuria, flank pain,
hematuria. He reported a 10 pound weight loss over the past 6
months, unintentional. Patient denies any known falls, headache,
neck pain, vision changes, weakness, numbness.
Past Medical History:
COLONIC POLYPS
adenoma last ___ adenome ___
DIABETES MELLITUS ___
___ = 7.1%
GASTROESOPHAGEAL REFLUX
HYPERCHOLESTEROLEMIA
HYPERTENSION ___
OSTEOARTHRITIS
B/L TKR ___ ___, L knee arthroscopy ___
DIABETIC NEUROPATHY
podiatry Dr. ___.
H/O POLIO in ___
Social History:
___
Family History:
Father had heart disease, diabetes. Brother just had valve
surgery ("pig valve") and recent ___ disease diagnosis.
Denies a history of lung cancer, breast cancer, colon cancer, or
leukemia/lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9 150/84 113 20 98% RA 298
General: Alert, appears generally oriented however does not wish
to answer those questions, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. Has
redness under left eyelid.
Neck: Supple, no rigidity
CV: Mildly tachycardic rate, nortmal rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Decreased lung sounds on left side with mild expiratory
wheezes. No rales, rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
Chronically smaller right calf.
Neuro: EOMI, PERRL. facial movement symmetric upper and lower.
tongue midline, SCM/Trap ___ proximal and distal strength
upper/lower extremities, grossly normal sensation, gait limited
by carrying his chest tube and tubing around, but appears
normal.
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.8 112/57 93 18 98 RA
General: Alert, NAD. sitting. Remains calm in interview, in
street clothes.
HEENT: Sclera anicteric, MMM.
CV: RRR, no M/G/R. Neck veins flat.
Lungs: Decreased breath sounds at left base ___ of lung field).
Breathing on room air. No accessory muscle use.
Abd: Soft, NT/ND. BS+.
Extremities: No ___ edema. Chronically smaller on right calf.
Neuro: facial movement and sensation symmetric upper and lower.
Normal gait, moving all 4 extremities. A&O to self, ___.
States the year is "13 or 15", does not know the month. Able to
complete a task of attetion (SAVEAHEART)
Pertinent Results:
ADMISSION LABS
==========================
___ 08:00AM BLOOD WBC-14.5* RBC-5.56 Hgb-16.0 Hct-46.3
MCV-83 MCH-28.7 MCHC-34.5 RDW-13.4 Plt ___
___ 08:00AM BLOOD Neuts-79.5* Lymphs-14.1* Monos-4.8
Eos-1.2 Baso-0.4
___ 08:00AM BLOOD ___ PTT-33.1 ___
___ 08:00AM BLOOD Glucose-299* UreaN-20 Creat-1.3* Na-138
K-4.3 Cl-99 HCO3-23 AnGap-20
___ 08:00AM BLOOD ALT-13 AST-18 AlkPhos-75 TotBili-0.8
___ 08:00AM BLOOD cTropnT-0.01
___ 08:00AM BLOOD Albumin-4.0
___ 05:10AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8
___ 06:20AM BLOOD VitB12-462
___ 06:20AM BLOOD TSH-4.4*
___ 06:26AM BLOOD T4-7.2 T3-109
___ 09:31PM BLOOD Type-ART pO2-76* pCO2-31* pH-7.50*
calTCO2-25 Base XS-1
___ 08:18AM BLOOD Lactate-3.3*
___ 09:31PM BLOOD Lactate-1.5
___ 06:29AM BLOOD WBC-9.1 RBC-4.37* Hgb-12.2* Hct-35.4*
MCV-81* MCH-27.8 MCHC-34.3 RDW-13.0 Plt ___
DISCHARGE AND SIGNIFICANT LABS
=======================================
___ 06:48AM BLOOD ___ PTT-47.5* ___
___ 06:48AM BLOOD UreaN-16 Creat-0.9 Na-142 K-4.1 Cl-106
___ 06:29AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
MICRO
======================================
__________________________________________________________
___ 8:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:28 am PLEURAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:28 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
X2.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
__________________________________________________________
___ 3:13 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
___ 12:40 pm TISSUE LEFT PLEURAL BIOPSY.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
__________________________________________________________
___ 11:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:13 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:00 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 6:20 am SEROLOGY/BLOOD CHM S# ___ ADDED ___.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 9:42 am CSF;SPINAL FLUID TUBE 3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
IMAGING
=============================
___ CXR
FINDINGS:
There is a large left-sided pleural effusion causing significant
compressive atelectasis. The upper left lung and right lung are
grossly clear. The cardiac size is difficult to evaluate given
the large pleural effusion.
IMPRESSION:
Large left pleural effusion with adjacent substantial left lung
atelectasis. Potential etiologies of a large pleural effusion
include malignancy, infection, and, in the appropriate clinical
setting, a hemothorax.
___ ___
FINDINGS:
There has been interval placement of a left-sided pigtail
catheter, which appears coiled overlying the left lower lobe. A
left side hydropneumothorax with adjacent atelectasis has
decreased in size, now moderate. The upper left lung and right
lung are grossly clear. There is no evidence of large
pneumothorax. The cardiomediastinal silhouette is incompletely
visualized secondary to the pleural effusion, but appears
grossly unchanged from the prior examination. Asymmetric
opacity overlying the first costochondral joint, may be
degenerative versus overlying lung nodule.
IMPRESSION:
1. Placement of a pigtail catheter in the lower left hemi thorax
with interval decrease in size of a now moderate left
hydropneumothorax.
2. Opacity overlying left first costochondral joint may
represent asymmetric degenerative changes versus pulmonary
nodule. Recommend CT chest for further evaluation.
CT HEAD W/O CONTRAST ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large
territorial infarction. Prominent ventricles and sulci are
compatible with age-related volume loss. Periventricular white
matter hypodensities are consistent with chronic small vessel
ischemic disease. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation. No fracture
is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
No intracranial hemorrhage or calvarial fracture.
___ CT CHEST W/CONTRAST
FINDINGS:
Supraclavicular and axillary lymph nodes are not pathologically
enlarged and there is no soft tissue abnormality in the left
chest cage suspicious for malignancy. There is no fluid
collection or hemorrhage at the insertion site of the left
pleural drainage tube.
Thyroid is unremarkable. Atherosclerotic calcification is
moderately heavy in head and neck and coronary arteries, in the
annulus of the normal caliber ascending aorta, arch, descending
thoracic aorta and upper abdominal aorta, all normal caliber.
Pulmonary arteries are normal size.
Mediastinal and hilar lymph nodes are not pathologically
enlarged, ranging in diameter up to 7 mm in the prevascular and
10 mm in the left lower paratracheal stations. Esophagus is
unremarkable. This study is not designed for subdiaphragmatic
diagnosis but shows no adrenal enlargement or heterogeneity in
the imaged portion of the suboptimally enhanced liver An
irregularly shaped peripheral opacity in the left upper lobe
anteriorly, 18 x 34 mm at the level of its greatest
cross-sectional area, 02:11, has attenuation values of soft
tissue, ___ ___. The pleura adjacent to it and
contiguous along the mediastinum, is thickened.
Large areas of ground-glass opacification scattered in the left
lung are probably due to re-expansion edema, and there are other
higher attenuation areas, with a peribronchial distribution in
the left lower lobe which could be residual atelectasis perhaps
with local hemorrhage.
The pigtail pleural drainage catheter curled in the posterior
pleural sulcus has evacuated nearly all of the left pleural
effusion, with only a small volume nonhemorrhagic fluid
remaining adjacent to the spine. Small bubbles of air in the
left pleural space are clinically insignificant, presumably
introduced at the time of pleural tube insertion.
There is no right pleural abnormality.
Right lung is essentially clear. The tracheobronchial tree
normal to
subsegmental levels.
There are no bone lesions in the chest cage suspicious for
malignancy or infection.
IMPRESSION:
In addition to areas of likely re-expansion edema and persistent
atelectasis in the left lung, there is a lesion in the left
upper lobe suspicious for bronchogenic carcinoma with local
extension to the pleura. However, if cytology of the pleural
fluid is negative for malignancy, I would recommend followup
with conventional chest radiographs to see if the left upper
lobe lesion clears prior to any repeat chest CT or CT-guided
biopsy.
RECOMMENDATION(S): However, if cytology of the pleural fluid is
negative for malignancy, I would recommend followup with
conventional chest radiographs to see if the left upper lobe
lesion clears prior to any repeat chest CT or CT-guided biopsy.
MRI HEAD WITH CONTRAST ___
FINDINGS:
There are nonspecific T2/FLAIR signal hyperintensity scattered
throughout the periventricular, subcortical and deep white
matter which can be seen in the setting of small vessel ischemic
disease. There is no evidence of hemorrhage, edema, masses,
mass effect, or infarction. The ventricles and sulci are normal
in caliber and configuration. There is no abnormal enhancement
after contrast administration. No leptomeningeal disease.
IMPRESSION:
1. Nonspecific T2/FLAIR signal hyperintensities can be seen in
the setting of small vessel ischemic disease.
2. Otherwise normal examination. No leptomeningeal disease,
mass lesions, or evidence of encephalitis.
PATHOLOGY
===============================
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: PLEURAL FLUID
DIAGNOSIS:
PLEURAL FLUID, LEFT:
NEGATIVE FOR MALIGNANT CELLS.
Blood, lymphocytes, and a few mesothelial cells.
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
1. Pleura, biopsy:
- Dense fibroadipose tissue with acute and chronic inflammation;
no carcinoma identified.
2. Pleura, left, biopsy:
- Metastatic carcinoma, see note.
Note: Immunohistochemical stains for CK5/6 and CK7 are positive
in tumor cells. Scattered cells are
positive for TTF-1 and p63. Napsin and mucicarmine are negative.
This is a mixed
immunohistochemical profile, and an adenosquamous carcinoma of
the lung is favored.
CARDIOLOGY
===================================
Cardiovascular ReportECGStudy Date of ___ 8:03:50 AM
Sinus tachycardia. Generalized low voltage. Minor lateral ST-T
wave
abnormalities. No previous tracing available for comparison.
Intervals Axes
RatePRQRSQTQTc (___) ___
___
Cardiovascular ReportECGStudy Date of ___ 8:54:04 AM
Sinus tachycardia and frequent ventricular ectopy. Low limb lead
voltage. Consider prior anterior wall myocardial infarction.
Compared to the previous tracing of ___ the rate has
increased. Followup and clinical correlation are suggested.
Intervals Axes
RatePRQRSQTQTc (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. MetFORMIN (Glucophage) 500 mg PO QID
6. sitaGLIPtin 100 mg oral DAILY
7. valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY
8. Aspirin 81 mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Acetaminophen 1000 mg PO Q6H:PRN pain/fever
7. Atenolol 25 mg PO DAILY
8. Ibuprofen 800 mg PO Q8H:PRN pain
9. MetFORMIN (Glucophage) 500 mg PO QID
10. sitaGLIPtin 100 mg oral DAILY
11. OLANZapine 2.5 mg PO QHS
RX *olanzapine 2.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Metastatic Adenosquamous Lung Carcinoma
- Delirium
- Cognitive Impairment
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with tachycardia, reduced breath sounds // eval
ptx, effusion
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiographs dated ___.
FINDINGS:
There is a large left-sided pleural effusion causing significant compressive
atelectasis. The upper left lung and right lung are grossly clear. The
cardiac size is difficult to evaluate given the large pleural effusion.
IMPRESSION:
Large left pleural effusion with adjacent substantial left lung atelectasis.
Potential etiologies of a large pleural effusion include malignancy,
infection, and, in the appropriate clinical setting, a hemothorax.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with L effusion, s/p pigtail placement // eval for
CT placement
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiograph dated ___ at 08:22.
FINDINGS:
There has been interval placement of a left-sided pigtail catheter, which
appears coiled overlying the left lower lobe. A left side hydropneumothorax
with adjacent atelectasis has decreased in size, now moderate. The upper left
lung and right lung are grossly clear. There is no evidence of large
pneumothorax. The cardiomediastinal silhouette is incompletely visualized
secondary to the pleural effusion, but appears grossly unchanged from the
prior examination. Asymmetric opacity overlying the first costochondral
joint, may be degenerative versus overlying lung nodule.
IMPRESSION:
1. Placement of a pigtail catheter in the lower left hemi thorax with interval
decrease in size of a now moderate left hydropneumothorax.
2. Opacity overlying left first costochondral joint may represent asymmetric
degenerative changes versus pulmonary nodule. Recommend CT chest for further
evaluation.
Radiology Report
INDICATION: History: ___ with confusion, hx of falls. L effusion on CXR with
tachycardia, SOB. // eval for fracture, ICH. Please characterize L effusion
on CXR.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Coronal and sagittal reformations, and
thin slice bone algorithm reconstructions were reviewed.
CTDIvol: 110 mGy.
DLP: 1115 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. Prominent ventricles and sulci are compatible with age-related
volume loss. Periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease. The basal cisterns appear patent and
there is preservation of gray-white matter differentiation. No fracture is
identified. The visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear.
IMPRESSION:
No intracranial hemorrhage or calvarial fracture.
Radiology Report
EXAMINATION: CT - CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with confusion, hx of falls. L effusion on CXR with
tachycardia, SOB. // eval for fracture, ICH. Please characterize L effusion
on CXR.
TECHNIQUE: 2.5 mm helical axial MDCT sections were obtained from the skull
base through the cervical spine. Axial images were interpreted in conjunction
with coronal and sagittal reformats.
DLP: 887 mGy-cm
CTDIvol: 67 mGy
COMPARISON: CT neck of ___
FINDINGS:
No acute cervical spine fracture is identified. Mild height loss of the C7
vertebral body likely represents a combination of degenerative and chronic
changes. Multilevel cervical spine degenerative changes are mild with disc
bulges and mild facet arthrosis. No acute alignment abnormality is
identified.
No prevertebral soft tissue abnormality. No lymphadenopathy is present by CT
size criteria. The thyroid is unremarkable. 13 mm nodular opacity in the left
upper lobe likely represents apical scarring but is incompletely imaged.
IMPRESSION:
1. No acute cervical spine fracture or alignment abnormality. No
prevertebral soft tissue edema.
2. 13 mm left upper lobe nodular opacity likely represents apical scarring
but is incompletely imaged and may be further evaluated with nonemergent
dedicated chest CT.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with new left sided pleural effusion of unknown
etiology s/p chest tube. // Change in size of pleural effusions
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
There has been interval marked decrease in small left pleural effusion and
adjacent atelectasis. There is no evident pneumothorax. No other interval
change from prior study.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with DOE found to have large serosanguinous
pleural effusion and LUL nodule. // Please evaluate for source of
serosanguinous pleural effusion and better characterize LUL nodule.
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSAGE: TOTAL DLP 644.9mGy-cm
COMPARISON: THERE ARE NO PRIOR CHEST CTS AVAILABLE. THIS STUDY IS READ IN
CONJUNCTION WITH CONVENTIONAL CHEST RADIOGRAPHS MOST RECENTLY ___ AND ___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not pathologically enlarged and
there is no soft tissue abnormality in the left chest cage suspicious for
malignancy. There is no fluid collection or hemorrhage at the insertion site
of the left pleural drainage tube.
Thyroid is unremarkable. Atherosclerotic calcification is moderately heavy in
head and neck and coronary arteries, in the annulus of the normal caliber
ascending aorta, arch, descending thoracic aorta and upper abdominal aorta,
all normal caliber. Pulmonary arteries are normal size.
Mediastinal and hilar lymph nodes are not pathologically enlarged, ranging in
diameter up to 7 mm in the prevascular and 10 mm in the left lower
paratracheal stations. Esophagus is unremarkable. This study is not designed
for subdiaphragmatic diagnosis but shows no adrenal enlargement or
heterogeneity in the imaged portion of the suboptimally enhanced liver
An irregularly shaped peripheral opacity in the left upper lobe anteriorly, 18
x 34 mm at the level of its greatest cross-sectional area, 02:11, has
attenuation values of soft tissue, 40 ___ ___. The pleura adjacent to it
and contiguous along the mediastinum, is thickened.
Large areas of ground-glass opacification scattered in the left lung are
probably due to re-expansion edema, and there are other higher attenuation
areas, with a peribronchial distribution in the left lower lobe which could be
residual atelectasis perhaps with local hemorrhage.
The pigtail pleural drainage catheter curled in the posterior pleural sulcus
has evacuated nearly all of the left pleural effusion, with only a small
volume nonhemorrhagic fluid remaining adjacent to the spine. Small bubbles of
air in the left pleural space are clinically insignificant, presumably
introduced at the time of pleural tube insertion.
There is no right pleural abnormality.
Right lung is essentially clear. The tracheobronchial tree normal to
subsegmental levels.
There are no bone lesions in the chest cage suspicious for malignancy or
infection.
IMPRESSION:
In addition to areas of likely re-expansion edema and persistent atelectasis
in the left lung, there is a lesion in the left upper lobe suspicious for
bronchogenic carcinoma with local extension to the pleura.
However, if cytology of the pleural fluid is negative for malignancy, I would
recommend followup with conventional chest radiographs to see if the left
upper lobe lesion clears prior to any repeat chest CT or CT-guided biopsy.
RECOMMENDATION(S): However, if cytology of the pleural fluid is negative for
malignancy, I would recommend followup with conventional chest radiographs to
see if the left upper lobe lesion clears prior to any repeat chest CT or
CT-guided biopsy.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with high concern for pulmonary malignancy and 2
weeks of confusion/memory impairment. Could not exclude fall prior to
admission ___ bruising). // Please evaluate for evidence of
malignancy or subdural.
TECHNIQUE: MRI of the brain was performed using sagittal T1, axial gradient
echo, FLAIR, T2, and diffusion with ADC map.
COMPARISON: Head CT from ___.
FINDINGS:
There is no intracranial mass effect or midline shift. There are scattered
predominant subcortical white matter T2/FLAIR hyperintensities which are
nonspecific but can be seen in setting of chronic small vessel disease.
Please note that contrast was not administered to exclude the possibility of
underlying enhancement. Ventricles and sulci are age-appropriate. There is
no restricted diffusion to suggest acute infarct. No abnormal susceptibility
artifact identified. Major intravascular flow voids are preserved including
within the major dural venous sinuses.
Mild mucosal thickening seen in the ethmoid air cells.
IMPRESSION:
Scattered white matter FLAIR/T2 hyperintensities which are likely secondary to
chronic small vessel disease. Please note that due to lack of intravenous
contrast, detection of underlying enhancing lesions cannot be performed and
therefore cannot be excluded.
No definite intracranial mass based on an unenhanced MRI.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion and chest tube // Please
evalaute pleural effusio nand chest tube*** Please perform before 6 am ***
Please evalaute pleural effusio nand chest tube*** Please pe
IMPRESSION:
In comparison with the study of ___, there is little overall change in the
degree of left pleural effusion with the chest tube in place. No definite
pneumothorax. The right lung remains essentially clear.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L pleural effusion s/p pleurX, chest tube,
pleurodesis // chest tube positioning, r/o pneumothorax chest tube
positioning, r/o pneumothorax
IMPRESSION:
In comparison with the study of earlier in this date, the pigtail catheter has
been removed and replaced with a left PleurX catheter. There has been a small
decrease in the amount of left pleural effusion and no evidence of
pneumothorax. The right lung remains essentially clear.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion and lung nodule s/p
pleurodesis and pleurex // Monitor pleural effusion*** PLEASE PERFORM BEFORE
6 AM *** Monitor pleural effusion*** PLEASE PERFORM BEFORE 6 AM ***
IMPRESSION:
In comparison with the study ___, there is little overall change in the
degree of opacification at the left base. The PleurX catheter remains in
place and there is no evidence of pneumothorax.
The right lung remains essentially clear.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year-old gentleman with history of hypertension,
hyperlipidemia, DM2, and distant history of left parapharyngeal and
retropharyngeal phlegmon/cellulitis presented with shortness of breath, cough,
and confusion over the last ___ weeks who was found to have a large left
plerual effusion. Now s/p chest tube placement and new pleurx placement on
___. Please assess for change from earlier xray. // r/o PTX or other
intrapulmonary etiology of tachypnea/desaturation r/o PTX or other
intrapulmonary etiology of tachypnea/desatu
IMPRESSION:
In comparison with the earlier study of this date, the PleurX catheter remains
in place and there is little change in the amount of pleural fluid and
atelectasis at the left base. The patient has taken a slightly better
inspiration. The right lung is essentially clear. No evidence of
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion, nodules, and chest tubes
s/p pleurodesis // *** PLEASE PERFORM BEFORE 6 AM ***
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Multiple prior exams, most recently ___.
FINDINGS:
A left lateral approach chest tube remains in place within a loculated left
pleural effusion, which is not appreciably changed. The right lung remains
clear. There is no pneumothorax. The cardiomediastinal contours are stable.
A cortical irregularity with step-off in the lateral rib cage at the level of
the chest tube insertion site is due to an acute rib fracture. In addition,
the side port of the chest tube is setting in the rib cage, which is
suboptimal for drainage purposes.
IMPRESSION:
Acute left lateral rib fracture at the chest tube insertion site.
Side port of chest tube projects over the rib cage, which is suboptimal for
drainage purposes.
Unchanged loculated left pleural effusion.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 12:37 ___, 20 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with nodule and pleural effusion now s/p chest
tube and pleurodesis. // s/p Chest tube and pleurodesis *** PLEASE PERFORM
BEFORE 6 AM *** s/p Chest tube and pleurodesis *** PLEASE PERFORM BEFORE 6
A
COMPARISON: Prior chest radiographs ___ through ___
IMPRESSION:
Since ___ the left pleural drainage catheter is been repositioned, with
side port no longer visible. Extent of left pleural abnormality is stable,
including combination of dependent pleural effusions small to moderate in
volume and circumferential pleural thickening. These are responsible for
persistent left lower lobe atelectasis and leftward mediastinal shift. Right
lung is essentially clear. There is no pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with lung cancer and pleural effusion s/p pleurex
placement and pleurodesis. // Monitoring pleural effusion and pleurex tube***
PLEASE PERFORME BEFORE 6 AM ***
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with lung cancer and pleural effusion s/p pleurex
placement and pleurodesis. // Monitoring pleural effusion and pleurex tube***
PLEASE PERFORME BEFORE 6 AM ***
COMPARISON: None.
FINDINGS:
Again seen is the left-sided chest tube, similar in position. Also again seen
is the left pleural effusion , overall similar to the prior study. Mild
vascular plethora previously seen on left lung has improved. The right lung
is grossly clear, allowing for minimal atelectasis at the right lung base. No
pneumothorax detected .
IMPRESSION:
Essentially unchanged compared with 1 day earlier.
Radiology Report
EXAMINATION: Portable AP chest radiograph
INDICATION: ___ year old man with malignant pleural effusion s/p pleurodesis
and pleurex. // Please evaluate pleural effusion and pleurex.*** PLEASE
PERFORM BEFORE 6 AM ***
COMPARISON: Chest radiograph dated ___. CT chest dated ___.
FINDINGS:
No significant interval change. A pluerex drain projects over the left
hemithorax, unchanged in position. Small left pleural effusion with
atelectasis and pleural thickening is overall unchanged. Left upper lung
opacity corresponding to mass on CT is unchanged. The right lung is clear.
No pneumothorax. Degenerative changes in the shoulders, worse on the right
are unchanged. The heart size is normal.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ yo M with new diagnosis of lung adenosquamous carcinoma with
acute on subacute change in personality, behavior, and memory. Assess for
evidence of metastasis or lepto-meningial involvement, encephalitis, or other
etiology for change in behavior.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MR ___, noncontrast head CT ___.
FINDINGS:
There are nonspecific T2/FLAIR signal hyperintensity scattered throughout the
periventricular, subcortical and deep white matter which can be seen in the
setting of small vessel ischemic disease. There is no evidence of hemorrhage,
edema, masses, mass effect, or infarction. The ventricles and sulci are normal
in caliber and configuration. There is no abnormal enhancement after contrast
administration. No leptomeningeal disease.
IMPRESSION:
1. Nonspecific T2/FLAIR signal hyperintensities can be seen in the setting of
small vessel ischemic disease.
2. Otherwise normal examination. No leptomeningeal disease, mass lesions, or
evidence of encephalitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with PLEURAL EFFUSION NOS, ALTERED MENTAL STATUS
temperature: 97.6
heartrate: 142.0
resprate: 22.0
o2sat: 99.0
sbp: 161.0
dbp: 121.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ year-old gentleman with history of
hypertension, hyperlipidemia, and DM2 who presented with DOE,
found to have pulmonary carcinoma with pleural invasion and
associated malignant pleural effusion and severe
encephalopathy/delirium and possible underlying neurologic
process.
For the malignant pleural effusion, he underwent a pleurodesis
and had a pleurex placed, which was able to be removed during
this hospital stay.
As part of his work up for agitation and altered mental status,
an MRI with contrast was performed, which did not reveal an
etiology (no metastatic disease, etc). Neurology was consulted
and followed him during his hospitalization. A lumbar puncture
to look for encephalitis or other causes of his encephalopathy
was done. Preliminary results showed an elevated protein with
normal glucose and cell count, further studies are pending at
the time of discharge.
# Metastatic Adenosquamous Carcinoma: Diagnosed by pleural
biopsy, with invasion into pleura noted at time of diagnosis.
Immunohistochemical stains for CK5/6 and CK7 are positive in
tumor cells. Scattered cells are positive for TTF-1 and p63.
Napsin and mucicarmine are negative. Seen by heme/onc, who will
follow him as an outpatient, at which point he will need an
abdominal scan with contrast and a bone scan for staging.
# Malignant pleural effusion: It was over 3 liters with a
hematocrit of 4 and very symptomatic. His dyspnea resolved with
drainage and pleurodesis/pleurex placement and removal. All
chest tubes removed prior to discharge.
# Aggressive behavior:
# Cognitive deficits/short term memory impairment:
# Delirium:
He experienced general confusion, inattention, short term memory
loss and agitation. He had some confrontations with staff
(nursing, hit a security officer) and required a security sitter
and seclusion for the majority of his stay. No focal neuro
deficits. Last known clear baseline that the family was very
confident in was in ___, when he was the primary caregiver
for ___ after her surgery. Clinically seemed most
consistent with encephalopathy on top of another neurologic
conditions (such as araneoplastic syndrome/limbic encephalitis,
dementia, or other). He was evaluated with an MRI that did not
reveal any metastasis. An LP revealed mild elevated protein,
otherwise unremarkable, with advanced tests (paraneoplastic
panel) pending at discharge.
Prior to discharge, he was able to complete a task of attention
for the first time this hospital stay. He was calm and
nonagressive for 36 hours prior to discharge. Initially his
behaviors were managed with haldol, however his behaviors
improved and he was transitioned to scheduled quetiapine at
bedime without PRNs.
# Tachycardia: He was persistently in the 90-110's, even at
rest. Attributed to inflammation from pleurodesis and agitation.
It was frequently associated hypertension and was not fluid
responsive. He was on atenalol prior to admission, which was
replaced with metoprolol during the admission. Clinical
suspicion for PE was very low.
# Rib fracture: Incidentally noted on chest X ray near where the
surgical chest tube had been, he did not endorse pain at the
site.
# Coagulopathy: Stable at 1.3. Unclear etiology, partially
responded to PO vitamin K.
# ___: On presentation which resolved without significant
intervention. Normal Cr at baseline.
# HCP: His friend and ex-wife ___ was designated
as his health care proxy on admission. This was discussed with
___, and Mr. ___.
Family was well coordinated and supportive, and frequently at
the bedside and in agreement with his care decisions.
Chronic
# DM2: As an outpatient he was on sitagliptin 100mg daily and
metformin 500 QID. These were initially held during his work up
and he was started on a sliding scale. He eventually required
20unit lantus at night for glucose control. Metformin was
restarted towards the end of his hospitalization. On discharge
the insulin was discontinued and he was restarted on
sitagliptin, as starting insulin for the first time as an
extensive oncologic work up, a new medication regimen, and while
he was encephalopathic was felt to be more dangerous. He will
need close blood glucose follow up.
# HTN: Continued Amlodipine 5 mg PO DAILY. Replaced Atenolol
with metoprolol while in house. Valsartan-hydrochlorothiazide
160-12.5 mg oral DAILY was held during admission and on
discharge as it was not needed.
# HLD: Continued atorvastatin, fish oil.
# CONTACT: Brother and ex-wife ___
brother ___ - Phone number: ___, Cell phone:
___
___ to be his HCP. ___ (cell),
___
========================================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose / Vicodin
Attending: ___.
Chief Complaint:
Fevers, hypotension
Major Surgical or Invasive Procedure:
___ Line Placement
History of Present Illness:
___ year old woman with recurrent breast cancer on
Herceptin/Eribulin CD11 with recent history notable for Staph
___ bacteremia (cx + ___ and C. diff colitis
developed fever and rigors the night prior to admission. She
presented to clinic and was observed rigoring with a BP drop
from
150 to 104 and cool extremities. She was bolused with fluids
and
sent to the ED with concern for sepsis.
Past Medical History:
ONCOLOGIC HISTORY:
- Originally diagnosed in ___ with a breast cancer that was
grade III and almost triple negative. There were few weak ER
positive cells.
- In the adjuvant setting, she had had a complete pathological
response to neoadjuvant ACT treatments and then had not
tolerated
tamoxifen and had to stop that.
- Left-sided breast ultrasound revealed no discrete masses. MR
of
the brachial plexus visualized a 4-cm spiculated left axillary
mass consistent with recurrent malignant disease likely
involving
the smaller neural branches of the medial cord of the brachial
plexus and tethering the left axillary vein, which remains
patent. Cytology of an axillary lymph node done and that was
positive for malignant disease consistent with metastatic
adrenal carcinoma. These were negative for cytokeratins,
mammaglobin, GCDFP and estrogen receptor. HER-2 by FISH was
attempted and negative.
- Biopsy of mets done in ___ for circulating tumor cells
determination and that had turned out positive for circulating
tumor cells and these had been positive for HER2 giving her the
opportunity to enroll in the Navelbineand trastuzumab study
- Taxotere ___ x 2 cycles then progressed
- Weekly Adriamycin started ___
- Gemzar/Carboplatin started ___
- Herceptin/Navelbine protocol ___ started ___
CURRENT TREATMENT PLAN: Herceptin D1 every 21 days
navelbine D1,D8,d15 every 21 days
Research Protocol: ___
PAST MEDICAL HISTORY:
- non-insulin dependent diabetes mellitus
- hypertension
- hyperlipidemia
- locally advanced breast cancer (see above)
Social History:
___
Family History:
Cousin with leukemia. Brother with unknown cancer. Grandmother
with pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================
VITAL SIGNS: T 100.0 BP 131/75, HR 89, RR 18, SpO2 97%
RAGeneral: Pleasant, but anxious woman at times tearful seen
lying
in bed. Somewhat somnolent but easily awakened.
HEENT: Alopecia, constricted pupils equally reactive to light,
MMM, no OP lesions, comfortable bending her chin to her chest
CV: RR, NL S1S2, no murmurs appreciated
PULM: CTAB without rales or rhonchi
ABD: obese, BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: + LUE lymphedema with left axillary surgical changes, no
neck pain when flexing knees
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities;
finger-to-nose and rapid alternating hand movements are intact;
no pronator drift
DISCHARGE PHYSICAL EXAM:
==================
VS: T:98.2 BP:113/52 P:79 RR:18 O2:100% on RA BS:182
GEN: AOx3, NAD.
HEENT: PERRLA, MMM
Neck: No JVD, supple. No cervical, supraclavicular, or axillary
LAD
CV: RRR, S1/S2 normal, no murmurs/gallops/rubs
Pulm: No dullness to percussion, CTAB, no crackles or wheezes
Abd: Soft, NT/ND, no rebound/guarding, no HSM, no ___ sign
Extremities: Warm and well-perfused, no edema. DPs, PTs 2+.
Skin: No rashes or bruising
Neuro: CNs II-XII intact. ___ strength in U/L extremities. DTRs
2+ ___. Sensation intact to LT, cerebellar fxn intact (FTN, HTS),
gait WNL.
Pertinent Results:
RELEVANT STUDIES:
============
- MR HEAD W/ AND ___ CONTRAST (___): No evidence of
metastatic disease or intracranial infection.
- MR SPINE ___/ AND ___ CONTRAST (___):
1. No epidural abscess, evidence of discitis/osteomyelitis, or
evidence of metastatic disease.
2. Mild thoracic spine disc bulges but no cord compression.
- CT CHEST W/ CONTRAST (___): No intrathoracic source of
infection identified.
- CT ABD/PELVIS W/ CONTRAST (___):
1. No intraabdominal source of infection
2. Hepatic steatosis
3. Fibroid uterus
MICRO:
=====
- BLOOD CULTURES (___):
Blood Culture, Routine (Preliminary):
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
- CATHETER TIP CULTURE (___): No growth (FINAL).
- URINE CULTURE (___): No growth (FINAL).
ADMISSION LABS:
===========
___ 11:05AM BLOOD WBC-15.6*# RBC-2.71* Hgb-8.2* Hct-25.5*
MCV-94 MCH-30.4 MCHC-32.2 RDW-17.3* Plt ___
___ 01:50PM BLOOD Neuts-89.4* Lymphs-7.8* Monos-1.6*
Eos-1.2 Baso-0.1
___ 11:05AM BLOOD ___
___ 11:05AM BLOOD ___
___ 01:50PM BLOOD Glucose-354* UreaN-15 Creat-1.1 Na-134
K-3.8 Cl-96 HCO3-24 AnGap-18
___ 01:50PM BLOOD ALT-31 AST-31 AlkPhos-86 TotBili-0.4
___ 01:50PM BLOOD Albumin-3.7
___ 11:05AM BLOOD LDLmeas-173*
___ 01:53PM BLOOD Lactate-3.9*
DISCHARGE LABS:
===========
___ 06:18AM BLOOD WBC-19.3* RBC-2.80* Hgb-8.5* Hct-26.6*
MCV-95 MCH-30.4 MCHC-32.0 RDW-18.1* Plt ___
___ 07:50AM BLOOD Neuts-64 Bands-4 ___ Monos-3 Eos-1
Baso-0 ___ Myelos-0
___ 06:18AM BLOOD ___ PTT-36.4 ___
___ 06:18AM BLOOD Glucose-165* UreaN-7 Creat-1.2* Na-137
K-4.1 Cl-101 HCO3-24 AnGap-16
___ 06:18AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 7.5 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
5. Warfarin 5 mg PO DAILY16
6. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
7. Amlodipine 5 mg PO DAILY
8. Sucralfate 1 gm PO Q6H:PRN stomach upset
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
2. Ondansetron 4 mg PO Q8H:PRN nausea
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
4. Warfarin 5 mg PO DAILY16
5. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
6. Sucralfate 1 gm PO Q6H:PRN stomach upset
7. GlipiZIDE XL 7.5 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
9. Sulfameth/Trimethoprim DS 3 TAB PO TID
PLEASE CONTINUE UNTIL ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 3
tablet(s) by mouth three times a day Disp #*27 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Stenotrophomonas Bacteremia
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fever // eval for PNA
COMPARISON: Multiple prior exams, most recently of ___
TECHNIQUE: Frontal and lateral views of the chest.
FINDINGS:
Tip of a right PICC is not well visualized but likely terminates in the lower
SVC. Heart size and cardiomediastinal contours are stable. Lungs are clear
without focal consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
No focal consolidation.
Radiology Report
EXAMINATION: MRI of the cervical, thoracic, and lumbar spine without and with
intravenous contrast
INDICATION: ___ year old woman with Breast cancer now with fever and new
headache, neck and back pain. Known history of Staph bacteremia. Concern for
abscesses. // Please evaluate for abscess.
TECHNIQUE: MRI of the cervical, thoracic, and lumbar spine was performed
without and with intravenous contrast. 10 cc of Gadavist was administered
intravenously.
COMPARISON: None
FINDINGS:
The cervical, thoracic, and lumbar vertebrae are normal in stature and
alignment. There is no suspicious marrow signal abnormality. Intervertebral
discs of the cervical and lumbar spine are normal. There are disc bulges or
protrusions causing minimal encroachment on the thecal sac in the thoracic
spine. There is no cord encroachment. The spinal cord is normal in course,
caliber, and signal. The conus is normal in appearance and position,
terminating at T12-L1. The nerve roots of the cauda equina are normal. There
is no fluid collection or epidural abscess within the spinal canal. There is
degenerative facet joint disease of the lumbar spine at L4-5 with fluid in the
facet joints. The paravertebral soft tissues are normal.
IMPRESSION:
1. No epidural abscess, evidence of discitis/osteomyelitis, or evidence of
metastatic disease.
2. Mild thoracic spine disc bulges but no cord compression.
Radiology Report
EXAMINATION: MRI head without and with intravenous contrast
INDICATION: Breast cancer, fever, somnolence, new headache, evaluate for CNS
infection.
TECHNIQUE: Multi planar multi sequence MR images of the brain were obtained
before and after the administration of intravenous contrast. 10 cc Gadavist
was administered intravenously.
COMPARISON: MRI head ___
FINDINGS:
There is no intracranial hemorrhage or acute infarct. No acute process is
identified on water diffusion or ADC weighted images. There are nonspecific
small scattered T2/FLAIR high signal foci in the subcortical and deep white
matter, unchanged from MRI on ___ and likely the sequela of
chronic microvascular changes. Gray white matter differentiation is
maintained. Ventricles and extra axial spaces are within normal limits. The
major intracranial vessels exhibit the expected signal void related to
vascular flow.
No enhancing mass is identified. There is no abnormal meningeal enhancement.
The paranasal sinuses and mastoid air cells are clear. The sella turcica,
craniocervical junction, and orbits are unremarkable.
IMPRESSION:
No evidence of metastatic disease or intracranial infection.
Radiology Report
INDICATION: ___ year old woman with metastatic breast cancer now w/ GNR
bacteremia/sepsis of unknown etiology // source of GNR bacteremia/sepsis
TECHNIQUE: CT of the abdomen and pelvis with IV contrast.
DOSE: 959 mGy-cm
COMPARISON: ___
FINDINGS:
Lung bases are clear. Please see CT chest report for full lung findings.
The liver is diffusely hypodense compatible with hepatic steatosis. No focal
liver lesions are noted. The portal vein is patent. Spleen is within normal
limits. Both adrenal glands are normal. The pancreas appears normal without
lesions. Abdominal aorta is normal in caliber with very minimal
atherosclerotic calcifications. Both kidneys are normal. The stomach, small
and large bowel loops are normal in their course and caliber without
distension.
Bladder is normal. There is no hydroureter. Rectum is normal. There is no
pelvic free fluid.
Once again there are numerous hypodense uterine masses, compatible with
fibroids. The uterus is retroflexed. Both ovaries appear within normal
limits.
A well-circumscribed lytic area in the pubic symphysis (04:21) measuring 9 x
16 mm appears nonaggressive and is stable since ___.
IMPRESSION:
1. No intraabdominal source of infection
2. Hepatic steatosis
3. Fibroid uterus
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with metastatic breast cancer now with gram
negative rod bacteremia and sepsis. Evaluate for source of infection.
TECHNIQUE: Contrast-enhanced 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. 153 cc of
Omnipaque 350 were administered intravenously without reported complication.
DOSE: As per CT abdomen/pelvis
COMPARISON: ___.
FINDINGS:
An irregular soft tissue mass at the lateral aspect of the left breast
associated with biopsy markers is stable as compared to ___ measuring
1.7 x 2.4 cm (4, 32). Mild localized breast skin thickening is unchanged. Left
axillary lymphadenopathy is also stable, with a representative node showing
central low attenuation measuring 3.8 x 3.0 cm, previously 3.9 x 3.0 cm (4,
15). No new internal mammary, mediastinal, hilar or right axillary
lymphadenopathy is identified. The thyroid gland is unremarkable.
Heart size is normal with no pericardial effusion. The main pulmonary artery
and thoracic aorta are normal caliber. There is no incidental central
pulmonary embolus.
There are several new small pulmonary nodules, the largest of which is in the
left lower lobe measuring 5 mm (5, 188). Additional nodules are identified in
the right lower (5, 187) and right upper lobes (5, 106). There is no
consolidation, bronchial wall thickening, or ground-glass opacities to suggest
an infectious process. Minimal lingular volume loss, subpleural scarring and
peripheral interlobular septal thickening are likely due to radiation
fibrosis. There is no endobronchial lesion or pleural abnormality.
Mild spinal degenerative changes are stable. There are no bony lesions in the
thorax worrisome for infection or malignancy.
IMPRESSION:
No intrathoracic source of infection identified.
Several new pulmonary nodules measuring up to 5 mm in the left lower lobe are
worrisome for metastases.
Stable left breast mass and left axillary lymphadenopathy.
Stable mild radiation changes involving the left breast and anterior left
lung.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old woman with new R PICC // 48cm R basilic DL PICC -
___ ___ Contact name: ___: ___
COMPARISON: Chest x-ray ___
FINDINGS:
The new right-sided PICC line terminates at approximately the cavoatrial
junction/ proximal right atrium. There are no other significant changes. No
pneumonia, pulmonary edema or pneumothorax. No large pleural effusions.
Cardiomediastinal silhouette is stable.
IMPRESSION:
Right PICC line terminates at the cavoatrial junction/ proximal right atrium.
Retracting the catheter by 1 cm would definitely place it above the cavoatrial
junction.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with SEPTICEMIA NOS, FEVER, UNSPECIFIED, SEPSIS , ACCIDENT NOS
temperature: 102.0
heartrate: 112.0
resprate: 18.0
o2sat: 100.0
sbp: 154.0
dbp: 64.0
level of pain: 13
level of acuity: 2.0 | HOSPITAL COURSE: Ms. ___ is a ___ year old woman with a past
medical history of metastatic breast cancer and C. difficile
colitis, who presented with fevers, rigors, somnolence, and
hypotension. Blood cultures grew Gram negative rods, which were
speciated to Stenotrophomonas. She was initially treated with IV
vancomycin and cefepime, and continued on cefepime only until
speciated and then was changed to IV Bactrim. ID recommended
oral bactrim for 2 weeks total. MRI of her head and spine were
taken because of her somnolence and did not show evidence of
infection. Blood sugars were controlled with sliding scale
insulin while admitted, but improved as her infection resolved.
# STENOTROPHOMONAS BACTEREMIA: Patient recently completed
daptomycin course on ___ for Strep ludgenensis bacteremia. She
presented to clinic and had fever/rigors. Cultures were drawn
from her PICC and she was sent to the ED. She had a chest x-ray
and a urinalysis, which were both negative. She was empirically
started on vancomycin and cefepime in the ED. She was bolused
multiple times due to concern of sepsis and a lactate of 3.9. Of
note, she also had a high blood glucose in the 350s in the ED.
Once patient arrived at the floor, her blood cultures returned
positive for gram negative rods, which spectated to
Stenotrophomonas, a nosocomial microbe most likely introduced
via her PICC line. Infectious disease was consulted and felt
that since pt improved after PICC line was pulled, despite being
on cefepime (suboptimal antibiotic therapy), combined with the
fact that bug was a nosocomial organism, made PICC line
infection the most likely source of bacteremia. Pt was put on
Bactrim after blood microorganism was speciated, and will need
to complete a 2 week course of oral Bactrim, completing on
___. Pt had old PICC pulled and a new PICC was placed for
chemotherapy purposes, until she can get a port (see below). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___ Right Femoral Cardiac Catheterization
History of Present Illness:
___ yo female with PMH HTN, HLD, hypothyroidism, aortic stenosis
and sCHF (LVEF 45-50%) transferred from ___ for
further workup of dyspnea and aortic stenosis. Presents with
intermittent shortness of breath over the last month that has
become worse over the past few days. This morning she woke up in
the morning short of breath and had a hard time speaking in full
sentences because of it. States that she used to be able to walk
the length of a whole mall a couple months ago but currently has
trouble walking ___ yards or up a flight of stairs. States that
she can sleep flat at home and usually doesn't wake up dyspenic
but has had a cough that is worse with lying flat. States that
over the last several weeks her feet have gotten swollen more
than usual. Has not been following a low salt diet at home, eats
everything. Has a history of severe aortic stenosis and was
recently seen by PCP ___ few days ago and recommended she follows
up with a cardiologist.
Denies chest pain, abdominal pain.
At ___, labs were: 140 ___ 4.2 22 1.19
BNP 17000, Trop 0.052 CK 77 MB ___ MBI 4.2, Received 20mg IV
Lasix there. EKG: sinus @ 75, NA, QRS 100, ST elevation V2,
depressions laterally and inferiorly, increased from prior in
___
In the ___ initial vitals were:
97.3 84 ___ 97% 2L Nasal Cannula(baseline room air)
Troponin: 0.08
Labs/studies notable for: 105* 22* 1.2* 140 4.1 100 25; troponin
0.08.
No therapy was administered.
Vitals on transfer: 70 164/73 18 99% RA
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
2. CARDIAC HISTORY: severe AS. LVEF 45-50% on ___ TTE
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
Hypertension
Hyperlipidemia
CKD
Social History:
___
Family History:
Brother: MI at ___; Mother: Heart disease and asthma. Otherwise
no other cardiac history. Sister breast cancer in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VS: 98.0 80 190/82 18 97% 2L
GENERAL: WDWN elderly female in NAD. Alert&Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1. Diminished S2. ___ harsh systolic ejection
murmur heard precordially with radiation to carotids. No
thrills, lifts.
LUNGS: Resp were mildly labored, no accessory muscle use. No
wheezes or rhonchi. Bibasilar crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. Trace pedal edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
======================
VS: 98.6 134-163/45-58 56-62 18 99% RA
Wt: 76.8
GENERAL: WDWN elderly female in NAD. Alert&Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1. Diminished S2. ___ harsh systolic ejection
murmur heard precordially with radiation to carotids. No
thrills, lifts.
LUNGS: Resp unlabored, no accessory muscle use. No wheezes or
rhonchi. Mild bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. Trace pedal edema. Small hematoma right
groin, normal distal pulses, warmth, and sensation, no bruits
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
=============
___ 05:12PM BLOOD WBC-9.9 RBC-4.52 Hgb-11.9 Hct-38.0 MCV-84
MCH-26.3 MCHC-31.3* RDW-15.8* RDWSD-47.8* Plt ___
___ 05:12PM BLOOD Neuts-76.7* Lymphs-15.2* Monos-5.2
Eos-1.9 Baso-0.6 Im ___ AbsNeut-7.62* AbsLymp-1.51
AbsMono-0.52 AbsEos-0.19 AbsBaso-0.06
___ 05:12PM BLOOD ___ PTT-27.1 ___
___ 05:12PM BLOOD Glucose-105* UreaN-22* Creat-1.2* Na-140
K-4.1 Cl-100 HCO3-25 AnGap-19
___ 05:12PM BLOOD CK-MB-3
___ 05:12PM BLOOD cTropnT-0.08*
___ 01:00AM BLOOD CK-MB-3 cTropnT-0.08*
___ 06:30AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.1
DISCHARGE AND PERTINENT LABS
==========================
___ 06:30AM BLOOD WBC-7.2 RBC-3.88* Hgb-10.2* Hct-33.7*
MCV-87 MCH-26.3 MCHC-30.3* RDW-15.9* RDWSD-50.1* Plt ___
___ 06:30AM BLOOD ___ PTT-25.7 ___
___ 06:30AM BLOOD Glucose-107* UreaN-29* Creat-1.2* Na-142
K-4.0 Cl-105 HCO3-26 AnGap-15
___ 06:30AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.3
MICROBIOLOGY
===========
None
IMAGING
=======
___ Cardiac Cath
Dominance: Left
The ___ had no angiographically apparent CAD. The OM was a
trifurcating vessel with a small lowestpole and medium sized
middle pole which had proximal 60% stenosis and the upper pole
2.0 mm vessel had a 60% stenosis. The RCA only supplied a
marginal branch and had a 90% stenosis in the ostium which was
calcified in a 2.0 mm vessel.
___ TTE
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is low normal. Quantitative (biplane) LVEF = 53 %.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The number of aortic valve leaflets cannot be
determined, but there is systolic doming of the aortic valve
leaflets raising suspicion for a bicuspid aortic valve. There is
severe aortic valve stenosis (valve area 0.84cm2, indexed
0.44cm2/m2). Mild to moderate (___) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and low normal global systolic function.
Severe calcific aortic stenosis with suspected bicuspid valve
(?functional versus congenital). Mild to moderate aortic
regurgitation.
___ CT Chest
RECOMMENDATION(S):
1. Multiple bilateral pulmonary nodules should be followed up
with dedicated
CT chest in ___ months.
2. A thyroid nodule can be further evaluated with dedicated
ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO BID
2. Atenolol 50 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Aspirin EC 81 mg PO DAILY
5. Calcium Carbonate 600 mg PO TID
6. Fish Oil (Omega 3) 1200 mg PO BID
7. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Valsartan 160 mg PO BID
5. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Calcium Carbonate 600 mg PO TID
8. Fish Oil (Omega 3) 1200 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Symptomatic aortic stenosis
SECONDARY DIAGNOSIS
===================
Congestive heart failure, systolic
Chronic Kidney Disease
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ yo female with PMH HTN, HLD, hypothyroidism, aortic stenosis
and sCHF (LVEF 45-50%) transferred from ___ for further workup of
dyspnea and aortic stenosis. // evaluate for porcelain aorta
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: Total DLP (Body) = 398 mGy-cm.
COMPARISON: None.
FINDINGS:
There is diffuse ground-glass opacity and septal thickening, compatible with
mild pulmonary edema. Mosaic attenuation may reflect air trapping versus
sequela of pulmonary hypertension. Subpleural reticulation, architectural
distortion, and bronchiectasis bilaterally, right greater than left, is
compatible with interstitial lung disease, likely NSIP. There are multiple
pulmonary nodules bilaterally, measuring up to 7 mm on the right (4:130) and 8
mm on the left (4:114). A tubular opacity in the left lower lobe (4:171)
likely reflects small airway mucous impaction. There is no pleural effusion
or pneumothorax.
A hyperdense nodule with central hypodensity and a small calcification in the
left lobe of the thyroid gland measures 1.1 x 1.4 cm (4:10). Axillary and
supraclavicular lymph nodes are visualized, but not pathologically enlarged.
Mediastinal lymph nodes are enlarged, measuring up to 1.0 cm in the
prevascular station, 1.3 cm in the right lower paratracheal station, and 1.6
cm in the paraesophageal station. Hilar lymph nodes are not well evaluated on
this noncontrast exam.
The heart is top-normal in size. Severe atherosclerotic calcification of the
coronary arteries is noted. There is severe calcification of the aortic and
mitral valves. Multiple areas of calcification are noted in the ascending
aorta and aortic arch, particularly near the origins of the vessels. The very
proximal ascending aorta is severely calcified. The first area without heavy
calcification is approximately 4.9 cm from the plane of the aortic valve, at
the approximate level of the roof of the left pulmonary artery. The aorta is
normal in caliber. The pulmonary artery is slightly enlarged, measuring 3.5
cm.
There is heavy atherosclerotic calcification of the visualized abdominal
aorta, with narrowing of the ostium of the celiac artery. Marked splenic
artery calcifications are also noted. Low density nodules in the left adrenal
gland are compatible with adrenal adenomas. The visualized upper abdomen is
otherwise unremarkable.
No focal lytic or sclerotic osseous lesion to suggest neoplasm or infection.
IMPRESSION:
1. Multiple areas of calcification noted in the ascending aorta and aortic
arch, particularly near the origins of the vessels and with severe
calcification of the very proximal ascending aorta. The first area without
heavy calcification is approximately 4.9 cm from the plane of the aortic
valve, approximately at the level of the roof of the left pulmonary artery.
2. Heavy atherosclerotic calcifications of the visualized abdominal aorta,
with narrowing of the celiac artery ostium.
3. Mild enlargement of the pulmonary artery. This is suggestive, but not
diagnostic, of pulmonary hypertension.
4. Severe coronary artery and aortic and mitral valve calcification.
5. Mild pulmonary edema and right greater than left interstitial lung disease,
likely NSIP. Small airway mucous impaction in the left lower lobe.
6. Multiple pulmonary nodules bilaterally, measuring up to 7 mm on the right
and 6 mm on the left.
7. Hyperdense nodule with central hypodensity in a small calcification in the
left lobe of the thyroid gland, measuring 1.1 x 1.4 cm.
8. Mild mediastinal lymphadenopathy.
RECOMMENDATION(S):
1. Multiple bilateral pulmonary nodules should be followed up with dedicated
CT chest in ___ months.
2. A thyroid nodule can be further evaluated with dedicated ultrasound.
NOTIFICATION: The recommendation above was entered by Dr. ___ on
___ at 15:49 into the Department of Radiology critical communications
system for direct communication to the referring provider.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Heart failure, unspecified
temperature: 97.3
heartrate: 84.0
resprate: 28.0
o2sat: 97.0
sbp: 202.0
dbp: 95.0
level of pain: 0
level of acuity: 2.0 | ___ yo female with PMH HTN, HLD, hypothyroidism, aortic stenosis
and sCHF (LVEF 45-50%), ___ transferred from ___ for
further workup of dyspnea and aortic stenosis.
Symptomatic aortic stenosis/Congestive heart failure: Patient
was found to be fluid overloaded and diuresed with IV Lasix with
resolution of her symptoms. pBNP at ___ was ___. She
was found to have an elevated troponin with normal CKMB most
likely in the setting of her chronic kidney disease. She had ECG
changes consistent with left ventricular hypertrophy. She had a
repeat TTE showing an aortic valve area of 0.8cm squared. She
underwent a right femoral cardiac cath that showed branch vessel
CAD with no need for intervention. Post procedure she developed
a small non-expanding hematoma. A chest CT showed a calcified
aorta which . Patient was deemed high risk for a surgical aortic
valve replacement with calcified aorta and was evaluated by the
TAVR team to work her up as an outpatient for a TAVR in the near
future. Patient was discharged on 20mg PO furosemide and
carvedilol 25mg BID
#Hypertension - Continued home vasartan 160mg bid and changed
home atenolol 100mg to carvedilol 25mg BID as she had systolics
in the 150s.
#CKD - baseline creatinine appears to be ~ 1.3 from ___
records spanning several years. No actually history per patient,
possibly from uncontrolled HTN. Appears at baseline w/ Cr 1.2
#Hypothyroidism - continue home levothyroxine. Thyroid nodule
was coincidentally found on Chest CT which should be followed up
with an ultrasound as an outpatient.
TRANSITIONAL ISSUES
====================
Discharge weight: 76.8kg
[] thyroid nodule coincidentally found on Chest CT which should
be followed up with ultrasound as an outpatient
[] started on furosemide 20mg, will need follow up lytes and
weight check
[] atenolol was replaced with carvedilol 25mg BID for better BP
control
[] f/u patient's right groin hematoma for resolution
[] patient will need a follow up appointment with the ___ team.
They are aware and will contact patient with date and time
[] follow patient's kidney function as it appears she has CKD
given prior creatinine values |