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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion, right neglect; left parietal ischemic stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 3 minutes
Time/Date the patient was last known well: ___, 4:30 ___
___ Stroke Scale Score: 5
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: on warfarin
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
HPI: The patient is a ___ right-handed man with a history of
prior CVA ___, R MCA), hypertension, T2DM, dyslipidemia and
schizophrenia presenting after an episode of altered mental
status and speech changes.
This afternoon around 4:30 his daughter called him and he
sounded
fine. They received a call again at 8:30 ___ from his neighbor.
They reported that Mr. ___ walked over to his neighbor's
apartment and knocked on the door, complaining of dizziness and
not feeling well. He was only dressed in his underwear. He asked
for help calling his family and they called ___ first, before
calling the family. They noticed his speech was somewhat
slurred,
but he was still comprehensible. He also complained that he
"couldn't see anything," but was still looking at people when
they spoke to him. His children arrived to find him confused and
disheveled. When EMS arrived, they evaluated him and told the
family he was "all right" and left. While at home with his
family, they noticed he had not taken his medications all day
and
that he was still very off from his baseline. He was able to
ambulated and go to the bathroom, but he was unable to wipe
himself. They called EMS again and they brought him to the ___
ED.
On the way, Mr. ___ was falling asleep in between speaking.
His speech continued to be more slurred than his baseline. They
did not notice any deficits in his ability to move his arms or
legs.
Of note, Mr. ___ has been quite ill as of late. His children
report that over the weekend he started taking laxatives because
he was constipated. On ___, he and his son went up to ___ to
get fresh lobster and sea urchin and he cooked them for dinner.
That night, he was up all night vomiting. Since then, he has not
been eating or drinking at his baseline. Mr. ___ also told
one
of his daughters that he has been getting over a cold.
Regarding his prior stroke, Mr. ___ had sudden onset of
electric shock sensation in his feet and left-sided weakness
before he fell and developed slurred speech in the ___.
He was treated at ___ where he had a workup
revealing
a R MCA stroke and a "clot in his heart." He was known to have
had cardiomyopathy with an LV thrombus and was on Coumadin, but
he stopped it just before his stroke because of guiac-positive
stools. He went to rehab after this stroke, but has had
stiffness
and weakness in his left arm and leg since. He will often have
recurrence of his left facial droop as well from time to time.
Review of systems was difficult to assess given his level of
inattention and agitation during our encounter. He was also
actively vomiting. His children were able to respond to the
following:
On review of systems, they report the following:
- Constitutional: no fever, rigors, night sweats
- Cardiovascular: unclear
- Gastrointestinal: + nausea/emesis nausea, unclear if he had
diarrhea
- Genitourinary: unclear
- Ear, Nose, Throat: +rhinorrhea
- Musculoskeletal: unclear
- Psychiatric: unclear
- Respiratory: no dyspnea, cough, hematemesis.
Past Medical History:
Past Medical History:
- Hypertension
- type 2 diabetes
- hx CVA ___: thought to have been embolic in nature (see
neuro note from ___ in the setting of having stopped the
warfarin he was taking for LV thrombus. Neurology recommended
ASA/warfarin long-term. Pt with residual L sided weakness
- cardiomyopathy: followed by Dr. ___ ___, no
thrombus noted at that time
- BPH
- chronic kidney disease: creatinine stable ~1.5 since ___
Social History:
___
Family History:
.
FAMILY HISTORY: one brother with type 2 diabetes. Mother died of
CVA at ___, father died of CVA at ___.
Physical Exam:
****ADMISSION PHYSICAL EXAMINATION:****
VS T: 97.2 HR: 62 BP: 159/94 (while examining him, his
pressures
were around 100-110s/80-90s) RR: 18 SaO2: 100% on RA
- General/Constitutional: Lying in bed comfortably, but
agitated
with woken up. Over the course of our exam, he started vomiting
and was quite uncomfortable
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Ear, Nose, Throat: No oropharyngeal lesions. Normal
appearance
of the tongue.
- Neck: No meningismus. No bruits appreciated. No
lymphadenopathy.
- Musculoskeletal: Range of motion with neck rotation full
bilaterally.
- Skin: No rashes.
- Cardiovascular: RRR, well-perfused
- Respiratory: Lungs clear to auscultation bilaterally.
Breathing comfortably on RA.
- Gastrointestinal: Soft. Nontender. Nondistended.
___ Stroke Scale - Total [6]
1a. Level of Consciousness - 0
1b. LOC Questions - 1
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 1
4. Facial Palsy - 0
5a. Motor arm, left - 0 (old weakness)
5b. Motor arm, right - 0
6a. Motor leg, left - 0 (old weakness)
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 1
9. Language - 1
10. Dysarthria - 1
11. Extinction and Neglect - 2
Neurologic Examination:
- Mental Status - Awake, alert, oriented only to person and
place (BI), not to time/date. Attention to examiner easily
attained but patient easily distracted. Did not follow commands
to name months backwards, but able to repeat and recall remote
history. Has no recollection of recent history. He
intermittently
loses fluency of speech (ie: gets stuck pronunciating "23" wrong
over and over, but is able to move on and say the year
correctly). Demonstrates good comprehension intermittently.
Unable to name objects or children in the room. Mild dysarthria
with compound consonant sounds. Mr. ___ seems to have some
visual and sensory neglect of his right side.
- Cranial Nerves - [II] PERRL 3->1 brisk. Did not comply with
visual field testing to finger wave, but blinked to threat less
on the right than on the left. Did not tolerate fundascopic
exam.
[III, IV, VI] EOMI, no nystagmus. [V] Responded to light touch
in
V1-V3. [VII] No facial movement asymmetry with forced eyelid
closure or volitional smile. [VIII] Did not respond to finger
rub, but did hear my voice from both sides. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally.
[XII] Tongue midline.
- Motor - Normal bulk. Left leg appears somewhat swollen.
Increased tone in right arm and leg. Did not participate in
confrontational examination of upper extremities, but did lift
both arms in the air and push objects away from him with good
strength. ___ exam with ___ strength in IPs, hamstrings, quads,
TA
and gastrocs on the right. LLE strength 4+/5 proximally, ___
distally. No tremor.
- Sensory - Inconsistent, but did not grimace to noxious stim
on
the right about 75% of the time. +extinction to double
simultaneous tactile stimulation over right arm and leg.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 2 3 3 2
R 2 2 2 2 2
L toe withdrew, R toe down.
- Coordination - No dysmetria when reaching for exam tools with
right arm. Did not comply with FNF or RAM testing.
- Gait - Deferred
****DISCHARGE PHYSICAL EXAMINATION****
General: Awake, alert, NAD
HEENT: bilateral cataracts, MMM
CV: pulse regular and palpable
Resp: no increased WOB
Abd: soft, minimally distended, non-tender
Ext: WWP
Neuro:
MS: awake, interactive. Oriented to name, place. Able to perform
days of week forward with effort, backward with one mistake
(improved from prior) but still with significant effort. Poor
attention but again improved from prior. Speech fluent without
paraphasic errors. No visual neglect or right sided sensory
neglect
CN: pupils reactive bilaterally, EOMI, VFFC bilaterally, trace
nasolabial fold effacement on the right, intact light touch
bilaterally
Motor: cupping of the right hand but no downward drift;
pronation of the left arm but it does not drift downwards;
mildly increased tone of the left arm and leg. Nl tone of the
right arm and leg. ___ strength of all four extremities except
4+ finger extensors bilaterally
Sensory: intact light touch bilaterally; intact DSS light touch
bilaterally
Reflexes: right toe mute, left toe upgoing
Coord: intact FNF bilaterally
Pertinent Results:
NC Head CT ___: Encephalomalacia in the right MCA
distribution is consistent with evolution of the patient's
infarction from ___. No evidence of acute
intracranial hemorrhage, edema, mass effect or infarction.
MRI Head ___:
1. Small focus of acute/early subacute infarction in left
parietal cortex.
2. Chronic right MCA territory infarct with hemosiderin
staining.
3. Prominent, chronic microangiopathic ischemic changes.
Generalized volume loss.
4. Cervical spine degenerative changes have progressed since
___.
Bilateral carotid ultrasound ___:
IMPRESSION:
No evidence of atherosclerotic disease in the bilateral carotid
vasculature.
Transthoracic echocardiogram ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild to moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the distal half of the ventricle. The
apex is mildly aneurysmal. There is mild hypokinesis of the
remaining segments (LVEF = 25 %). No masses or thrombi are seen
in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, laterally directed jet of moderate (2+)
mitral regurgitation is seen (clip 53). Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is borderline pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
and global systolic dysfunction. At least moderate mitral
regurgitation. Increased PCWP. Compared with the prior study
(images reviewed) of ___, the severity of mitral
regurgitation has increased.
___ 09:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:40AM BLOOD CRP-5.4*
___ 05:40AM BLOOD TSH-0.58
___ 05:40AM BLOOD Triglyc-36 HDL-89 CHOL/HD-1.6 LDLcalc-48
___ 05:40AM BLOOD %HbA1c-11.0* eAG-269*
___ 09:48PM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD CK-MB-7 cTropnT-<0.01
___ 05:40AM BLOOD Lipase-24 GGT-8
___ 09:48PM BLOOD ALT-23 AST-41* AlkPhos-59
___ 05:40AM BLOOD ALT-24 AST-28 LD(LDH)-326* CK(CPK)-361*
AlkPhos-60 Amylase-140* TotBili-0.7
___ 05:03PM BLOOD CK(CPK)-317
___ 10:15PM BLOOD Creat-1.5*
___ 05:40AM BLOOD Glucose-100 UreaN-22* Creat-1.3* Na-143
K-3.9 Cl-100 HCO3-34* AnGap-13
___ 05:40AM BLOOD Neuts-83.1* Lymphs-10.9* Monos-5.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.33# AbsLymp-0.57*
AbsMono-0.29 AbsEos-0.00* AbsBaso-0.01
___ 09:48PM BLOOD WBC-4.5 RBC-4.58* Hgb-12.8* Hct-39.4*
MCV-86 MCH-27.9 MCHC-32.5 RDW-14.7 RDWSD-45.8 Plt ___
___ 05:40AM BLOOD WBC-5.2 RBC-4.49* Hgb-12.7* Hct-38.9*
MCV-87 MCH-28.3 MCHC-32.6 RDW-15.0 RDWSD-48.0* Plt ___
___ 05:40AM BLOOD Glucose-100 UreaN-22* Creat-1.3* Na-143
K-3.9 Cl-100 HCO3-34* AnGap-13
___ 10:15PM BLOOD Creat-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 7.5 mg PO 2X/WEEK (WE,SA)
2. Atorvastatin 20 mg PO QPM
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Glargine 20 Units Lunch
7. HydrALAZINE 25 mg PO Q8H
8. Doxazosin 8 mg PO HS
9. Carvedilol 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left parietal ischemic stroke
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: ED CODE STROKE ONLY CT
INDICATION: ___ with confusion, aphasia // eval for 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: Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: MRI/MRA brain ___
FINDINGS:
Encephalomalacia in the right MCA distribution is consistent with evolution of
the patient's infarction from ___. Additional periventricular and
deep white matter hypodensities are nonspecific but likely represents sequela
of chronic small vessel ischemic disease. No evidence mass, mass effect or
intracranial hemorrhage. Extensive vascular calcifications are noted.
There is no evidence of fracture. Moderate mucosal thickening in the ethmoid
air cells is noted. Otherwise, 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:
Encephalomalacia in the right MCA distribution is consistent with evolution of
the patient's infarction from ___. No evidence of acute
intracranial hemorrhage, edema, mass effect or infarction.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old man with right sided neglect // stroke?
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON MRI brain: ___.
CT head: ___ at 22:03.
FINDINGS:
A cortical focus of restricted diffusion in the left parietal lobe
demonstrates mild FLAIR signal hyperintensity (3:17, 4:17, 08:17). Extensive
encephalomalacia and white matter FLAIR signal hyperintensity in the right MCA
distribution corresponds to chronic infarction. There is no evidence of acute
hemorrhage, masses, mass effect, or midline shift. The ventricles and sulci
are stable and size and morphology, and remain prominent in keeping with age
related global involutional changes. Periventricular T2/FLAIR signal
abnormalities are likely related to the sequelae of chronic small vessel
ischemic disease. Cervical spine degenerative changes have progressed since
___.
IMPRESSION:
1. Small focus of acute/early subacute infarction in left parietal cortex.
2. Chronic right MCA territory infarct with hemosiderin staining.
3. Prominent, chronic microangiopathic ischemic changes. Generalized volume
loss.
4. Cervical spine degenerative changes have progressed since ___.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
___ at 3:12 AM, 5 minutes after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with R parietal infarct with abdominal distension
and pain, constipation // Any acute intraabdominal process
TECHNIQUE: Abdomen supine and right lateral decubitus film
COMPARISON: None
FINDINGS:
There is seen in small and large bowel loops There are no abnormally dilated
loops of large or small bowel. The large bowel is normal in caliber measuring
up to 5.2 cm. There are no air-fluid levels.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence for obstruction or ileus.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with DMII, HTN, prior ___ stroke admitted with
new L parietal stroke. Evaluate for carotid stenosis.
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None available
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 36 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 28, 43, and 61 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 19 cm/sec.
The ICA/CCA ratio is 1.7.
The external carotid artery has peak systolic velocity of 66 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 54 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 31, 52, and 56 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 18 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 20 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
No evidence of atherosclerotic disease in the bilateral carotid vasculature.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dizziness, Lightheaded, Confusion
Diagnosed with Cerebral infarction, unspecified, Essential (primary) hypertension, Type 1 diabetes mellitus without complications, Long term (current) use of insulin
temperature: 97.2
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 159.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ year old gentleman with history of prior
R MCA stroke, prior LV thrombus on chronic anticoagulation, IDDM
II, HTN, dyslipidemia who was admitted to the hospital in the
setting of confusion, dizziness, vomiting, disorientation found
to have an acute L parietal ischemic stroke on CT and MRI. On
admission, his labs were notable for a subtherapeutic INR of
1.7.
# Left parietal ischemic stroke: Thought most likely
cardioembolic in the setting of known CAD, known LV hypokinesis
(in patient also with history of prior LV thrombus), and
subtherapeutic INR in the setting of several days of vomiting.
Patient was re-started on his home warfarin with INR therapeutic
at 2.5 on the day of discharge. It was discovered that patient
may has been taking his home warfarin 5 mg daily 5 days per week
and 7.5 two days per week for a prolonged period of time
(whereas ___ clinic notes had on record that patient
was 5mg daily ___ and ___ and 7.5 mg daily the remaining
5 days). He will be discharged on warfarin 7.5 mg daily on
___ and ___ and 5 mg daily the remaining days as he had
been taking at home; this may be titrated further by the
anticoagulation service further as an outpatient.
Upon admission, patient's blood pressure was allowed to
autoregulate (SBP 120-200); home antihypertensives were
re-started before discharge with the exception of his HCTZ. Of
note, patient did have a bump in his creatinine from 1.4-1.6 up
to 1.8 after re-starting lisinopril. As such, his lisinopril was
also held on discharge. He may re-start this after discharge
while monitoring his creatinine. Patient's LDL on admission was
48, so he was continued on his home atorvastatin 20 mg daily.
Echocardiogram showed an LVEF of 25%, regional and global
systolic dysfunction with a mildly aneurysmal apex, at least
moderate mitral regurgitation (increased from prior) and
increased pulmonary capillary wedge pressure. No masses or
thrombi were seen. Given mildly aneurysmal apex as well as the
history of prior intracardiac thrombus, it was felt that
cardioembolic was the most likely etiology.
Carotid ultrasound did not show evidence of atherosclerosis in
either carotid artery.
# Endo: Patient has insulin-dependent type II diabetes at
baseline. His HbA1c on admission was 11. ___ was consulted,
and his Lantus was decreased from 20 units to 16 units at noon
with the addition of a sliding scale. He should take Lantus
(glargine) 16 units with the sliding scale on discharge. Given
hyperglycemia (glucose 314 on admission with UA showing
glucosuria), elevated HbA1c, patient not tolerating medications
at home, DKA was also a consideration. However, patient with
negative ketones on UA, chemistry on admission with HCO3 of 30,
less consistent with DKA.
# ID: Patient was admitted with vomiting and was noted to be
febrile on arrival to the floor the morning of admission. He had
a UA which showed known proteinuria as well as 8 WBC, 12 RBC,
few bacteria, large leukocyte esterase, negative nitrite, 1 epi,
rare mucous. With the history of having started vomiting soon
after eating lobster and sea urchin, foodborne illness (e.g.
vibrio) was also a consideration. Patient without diarrhea but
had been quite constipated prior to emesis. Given concern for
possible bacterial gastroenteritis vs UTI, patient was started
on ciprofloxacin. Urine culture showed GBS, so patient was
switched to cefpodoxime ___- ). He should complete a ___lood culture was no growth to date at the time of
discharge.
# FENGI: Patient vomiting on admission. Labs on admission with
AST, ALT wnl, amylase 140.
# Renal: Patient with known renal impairment. CK of 361 on
admission possibly combination of chronic renal impairment as
well as dehydration.
TRANSITIONAL ISSUES:
1. COUMADIN: Take 7.5mg daily on ___ and ___, 5 mg daily
on ___, Wedns, ___. Check INR daily and may adjust
to goal of ___. INR was 2.5 on day of discharge (up from 2.1 on
day prior).
2. Anti-hypertensives: discharged on home regimen except holding
lisinopril and HCTZ. ___ re-start these or consider additional
anti-hypertensives as needed. Monitor creatinine if re-starting
lisinopril or HCTZ
3. Chronic kidney disease with acute bump in creatinine: holding
lisinopril and HCTZ. Monitor creatinine at least twice weekly
until stabilizes back to baseline (1.3-1.6).
4. Diabetes: continue 16 units of glargine at noon with sliding
scale as on medication list
5. Followup: patient will need followup with his PCP, ___,
___, and the ___ clinic to be scheduled by
patient/family with help of rehab
============================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =48 ) - () 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? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Aggrenox
Attending: ___
Chief Complaint:
Left hand tremor, and generalized weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old female with Afib on coumadin
who presented to the neurology clinic on ___ for follow-up
of seizures. At that visit, she complained of 1 week left sided
tremor, difficulty picking things up with her left hand,
generalized weakness and difficulty walking down stairs. She
was
referred to urgent care for infectious workup and was noted to
be
dehydrated, hyponatremic and positive for UTI. INR was 2.5. She
was transferred to ___ where ___ was obtained in the ED
which
revealed bilateral mixed-density SDH. Neurosurgery was
consulted
for further evaluation.
Past Medical History:
Past Medical History
small bowel lymphoma dx ___, s/p chemotherapy last completed
___
afib on Coumadin
epilepsy
hyperlipidemia
osteoporis
cardiomyopathy, systolic heart failure
moderate to severe MR
posterior fossa embolic strokes
PAST SURGICAL HISTORY
HERNIA REPAIR ___
___'S RIGHT FOREHEAD
RIGHT CATARACT REMOVAL
GASTRIC RESECTINO OF LARGE CELL LYMPHOMAS
LEFT CATARACT REMOVAL
LEFT LACUNAR INFARCT
GASTRIC LARGE CELL LYMPHOMAS
Social History:
___
Family History:
Mother: bone cancer
Father: heart disease, PD
Brother: cancer (unknown type), smoking
Sister: dementia (alive at ___)
Maternal grandfather: cirrhosis
___ grandmother: heart attack
Children:
- daughter with liver transplant (unclear reason)
- daughter with lyme disease
- son with prostate ca s/p resection
- son (deceased) heart disease
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 97.4 BP: 154/74 HR: 70 R: 18 O2Sats: 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial 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. + tremors to LUE.
Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge:
AOx3 (options for year), L pupil 3.5-2, R pupil ___, ___,
___ ___, tremulous left side > right
Pertinent Results:
___ Non contrast Head CT
IMPRESSION:
1. Predominantly hypodense mixed-density bilateral
acute-on-chronic subdural hematomas with more acute component
seen posteriorly bilaterally. No midline shift.
___ Non contrast Head CT
IMPRESSION:
Similar appearance of bilateral acute on chronic subdural
hematomas. No new intracranial hemorrhage.
Medications on Admission:
BRIMONIDINE - brimonidine 0.15 % eye drops. once a day -
(Prescribed by Other Provider)
DIGOXIN [DIGOX] - Digox 125 mcg tablet. 1 tablet(s) by mouth
once
a day - (Prescribed by Other Provider)
LATANOPROST - latanoprost 0.005 % eye drops. once a day -
(Prescribed by Other Provider)
LEVETIRACETAM - levetiracetam 500 mg tablet. 2.5 tablet(s) by
mouth twice a day
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth once
a
day
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth once a day
SIMVASTATIN - simvastatin 10 mg tablet. 1 tablet(s) by mouth
every evening
WARFARIN [___] - ___ 2.5 mg tablet. 1 tablet(s) by
mouth once a day
Medications - OTC
CALCIUM CARBONATE [CALTRATE 600] - Caltrate 600 600 mg (1,500
mg)
tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other
Provider)
CETIRIZINE - cetirizine 10 mg tablet. 1 tablet(s) by mouth once
a
day
STARCH (THICKENING) [THICK-IT] - Thick-It oral powder. ___
powder(s) by mouth with all fluids
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
do not exceed 3gm acetaminophen in 24 hours.
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. Senna 17.2 mg PO HS
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Digoxin 0.125 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. LevETIRAcetam 1250 mg PO BID
12. Lisinopril 20 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Simvastatin 10 mg PO QPM
16. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Bilateral acute on chronic ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with left hand tremor // sdh? ischemia?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
There is predominantly hypodense mixed-density subdural hematoma along the
bilateral cerebral convexities with associated sulcal effacement, consistent
with acute-on-chronic subdural hematoma, with a more acute component seen
posteriorly bilaterally. Subdural blood measures up to 1.5 cm in the right
and 1.6 cm on the left. There is no appreciable shift of normally midline
structures. Basal cisterns are patent. There is no evidence of
hydrocephalus.
There is no acute large territorial infarction. Focal area of
encephalomalacia in the right occipital lobe is unchanged and consistent with
remote infarct. Mildly prominent ventricles and sulci suggest age-related
involutional changes.
No acute calvarial fracture identified. Mild mucosal thickening of the
ethmoidal air cells. Otherwise, the remaining visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear. Visualized portions of
the orbits are unremarkable.
IMPRESSION:
1. Predominantly hypodense mixed-density bilateral acute-on-chronic subdural
hematomas with more acute component seen posteriorly bilaterally. No midline
shift.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with acute on chronic subdural hematomas.
Please obtain at 0500. Please evaluate for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.8 cm; CTDIvol = 47.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
There are bilateral mixed density, predominantly hypodense, subdural hematomas
along the lateral convexities. They are stable in size with the left subdural
hematoma measuring 15 mm in width and the right subdural hematoma measures 14
mm in width. No new hemorrhage, mass or infarct is noted. There is no shift
of midline structures, and the basilar cisterns are patent.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The patient is
status post bilateral lens replacement.
IMPRESSION:
Similar appearance of bilateral acute on chronic subdural hematomas. No new
intracranial hemorrhage.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness, N/V
Diagnosed with Dehydration, Tremor, unspecified
temperature: 97.8
heartrate: 73.0
resprate: 15.0
o2sat: 99.0
sbp: 145.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | Ms ___ is a ___ year old female with history of Afib on
coumadin who presented to the neurology clinic for follow-up of
seizures on ___ where she complained of 1 week left sided
tremor, L hand clumsiness, generalized weakness, and difficulty
walking down stairs. She was referred to Urgent Care where an
infectious work-up was concerning for dehydration, hyponatremia
and UTI. INR was 2.5. She was transferred to ___ where a NCHCT
showed mixed density bilateral SDH and she was admitted to the
neurosurgery service.
#Subdural hematoma
She was admitted on ___ to the neurosurgery service. A repeat
NCHCT on ___ showed stable bleed without new hemorrhage. Her
neurologic exam remained stable and she did not require surgery.
On ___ she was started on SQ Heparin. Her Coumadin should
continue to be held.
#Hyponatremia
Her sodium levels adjusted and were stabilized within normal
range. She did not require additional supplementation at
discharge.
#UTI
She is being treated with Cipro for 5 days. Her WBC are trending
down on discharge and she is afebrile. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers; confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of bilateral acute-on-chronic
subdural hematomas in the setting of a fall in ___ status
post right craniotomy in ___ and left craniotomy on ___
who presents with fevers and confusion. On review of the OMR, he
has had 2 recent admissions to the neurosurgical service,
initially from ___ for headache and gait disturbance
attributed to acute-on-chronic subdural hematoma after a fall
with headstrike on ice in ___, requiring right craniotomy for
evacuation of right subdural hemorrhage and subdural drain
placement and subsequent removal; admission was complicated by
new-onset rapid atrial fibrillation responsive to treatment with
nodal agents. Following a brief rehabilitation stay, he was
discharged home, but soon after developed recurrent gait
disturbance and confusion and was readmitted from ___,
during which time he underwent left craniotomy for left subdural
hematoma evacuation on ___. He was evaluated by the
neurology service for ongoing confusion and gait disturbance,
with brain MRI without secondary cause for subdural hematomas
and normal LFTs and TSH. While there was some concern for
transient seizure activity on the part of the neurosurgery
service, prompting phenytoin load and initiation of maintenance
dosing in addition to preexisting levetiracetam prophylaxis,
there was ultimately low suspicion on the part of the neurology
service, hence phenytoin discontinued and EEG deferred. A
neurology note dated as recently as ___ describes ongoing
mild confusion, persistent right parietal drift, and minimal
improvement in gait disturbance, with slow recovery expected. Of
note, urine culture from ___ grew out vancomycin-sensitive
Enterococcus, with no antibiotic treatment listed on review of
inpatient POE.
He was discharged back to rehabilitation on ___, where he
initially was recovering as anticipated. On ___, the day
prior to admission, he reportedly developed fever to 101, with
urinalysis, CXR, and bilateral lower extremity venous
ultrasounds reassuring at that time. Per rehabilitation
documentation and in discussion between the neurosurgery
resident in the ED and his wife and daughter, who could not be
reached by this provider due to the late hour, he developed
fever to 102.5 and worsening confusion with newly recognized
incontinence on the day of admission, remaining otherwise
hemodynamically stable; in fact, he received hydralazine 10mg PO
for systolic blood pressure of 166/90 per rehabilitation
documentation. He also reportedly experienced a fall without
headstrike. Given concern for recurrent subdural bleeding, he
was sent to the ED for further evaluation.
In the ED, initial vital signs were: 99.5 (Tm 102) 80 169/71 16
96% RA. Admission labs were significant for Wbc of 13.6 (81.8%
PMN), Hct of 36.5, normal chemistries, lactate of 1.3, normal
coagulation panel, negative influenza swabs, and urinalysis with
small leukocyte esterase, trace blood, positive nitrite, 45 Wbc,
and many bacteria. Blood and urine cultures were sent.
Noncontrast head CT revealed no significant change since ___
of bilateral acute-on-subacute-on-
chronic subdural hematomas. CXR PA/lateral was negative for
acute cardiopulmonary process. He was evaluated by the
neurosurgery service and felt to have stable right-sided
weakness and worsened confusion in the setting of stable head CT
and positive urinalysis, hence delirium seemingly attributable
to urinary tract infection, with admission to the medical
service advised. He was given acetaminophen 650mg and
ceftriaxone 1g IV. Vital signs prior to transfer were: 98.8 78
113/59 18 99% RA.
On arrival to the floor, he is aware that he is in the hospital,
but believes that he is admitted for his "second head bleed." He
denies subjective fevers, chills, sweats, headache, neck
stiffness, visual changes, URI symptoms, chest pain, cough,
shortness of breath, nausea, vomiting, abdominal pain, loose
stools, or dysuria, but does recall that he has been newly
incontinent of urine with urinary frequency. He is entirely
comfortable.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
Bilateral acute-on-chronic subdural hematomas in the setting of
a fall in ___ status post right craniotomy in ___ and left
craniotomy on ___
Hypertension
Basal cell carcinoma
Childhood appendectomy - age ___
Social History:
___
Family History:
Unable to elicit
Physical Exam:
ADMISSION EXAM:
================
Vitals: 98.3, 174/65, 78, 20, 99% RA
General: Alert, oriented x3, no acute distress, able to repeat 3
words immediately, but not at 5 minutes, unable to spell WORLD
backwards, knows president
___: Right craniotomy incision healing, left incision with
sutures in place, sclerae anicteric, MMM, EOMI, anisocoric
(right 4->2 and left 3->2, reportedly consistent with baseline)
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, 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, no CVAT
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CN intact with the exception of II as above, resting
tremor in upper extremities bilaterally (reportedly consistent
with baseline), strength ___ in right hand and right lower
extremity (reportedly consistent with baseline), ___ strength
upper/lower extremities, grossly normal sensation, right
parietal drift, gait deferred.
DISCHARGE EXAM:
===============
Vitals- Tc 98.5 Tm 99 HR 64(52-67) BP 132/57(132/54-151/66) RR
16 O2: 98RA I/O: incontinent
Weight: 98.75kg
General: Alert, oriented x3, no acute distress
HEENT: Right craniotomy incision healing, left incision with
sutures in place, sclerae anicteric, MMM, EOMI
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, 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, no CVAT
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CN intact II-XII without evidence of facial droop,
strength ___ in upper/lower extremities, grossly normal
sensation, right parietal drift, gait deferred.
Pertinent Results:
ADMISSION LABS:
==================
___ 06:25PM BLOOD WBC-13.6* RBC-4.12* Hgb-13.3* Hct-36.5*
MCV-89 MCH-32.4* MCHC-36.5* RDW-12.5 Plt ___
___ 06:25PM BLOOD Neuts-81.8* Lymphs-10.9* Monos-5.8
Eos-1.2 Baso-0.3
___ 06:45PM BLOOD ___ PTT-26.9 ___
___ 06:25PM BLOOD Glucose-122* UreaN-11 Creat-0.9 Na-134
K-3.8 Cl-97 HCO3-24 AnGap-17
___ 06:25PM BLOOD CK(CPK)-32*
___ 06:25PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:25PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.6
___ 06:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:34PM BLOOD Lactate-1.3
OTHER PERTINENT LABS:
======================
___ 06:25PM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:00AM BLOOD CK-MB-<1 cTropnT-<0.01
DISCHARGE LABS:
===============
___ 08:15AM BLOOD WBC-8.1 RBC-3.82* Hgb-11.8* Hct-34.6*
MCV-91 MCH-30.8 MCHC-34.0 RDW-12.8 Plt ___
___ 08:15AM BLOOD Glucose-134* UreaN-13 Creat-0.8 Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
___ 08:15AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.0
URINE STUDIES:
==============
___ 08:29PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:29PM URINE Blood-TR Nitrite-POS Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 08:29PM URINE RBC-1 WBC-45* Bacteri-MANY Yeast-NONE
Epi-<1
___ 08:12PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICROBIOLOGY:
=============
___ 6:25 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
___ 8:12 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
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
_________________________________________________________
KLEBSIELLA OXYTOCA
| ENTEROCOCCUS SP.
| |
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 <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
___ 8:34 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
IMAGING/STUDIES:
==================
ECG Study Date of ___ 6:25:28 ___
Sinus rhythm with frequent ventricular premature contractions.
Non-specific anterolateral ST-T wave changes. Prolonged Q-T
interval. Compared to the previous tracing of ___
ventricular ectopy is new. Lateral ST segment changes are new.
Read by: ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
82 140 94 418 456 18 21 8
Noncontrast Head CT (___):
1. No significant change since ___ of bilateral acute
on subacute on chronic subdural hematomas, measuring 13 mm on
the right and 18 mm on the left with mild effacement of left
frontoparietal sulci without significant shift of midline
structures.
2. Status post bilateral craniotomies with postsurgical changes
with hyperdense material and left-sided pneumocephalus within
surgical bed.
Chest XRay PA and Lateral (___): No acute cardiopulmonary
process.
ECG Study Date of ___ 12:49:26 AM
Sinus rhythm. Compared to tracing #1 ventricular ectopy has
resolved. Lateral T wave changes have improved.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
82 164 90 396 434 64 26 34
ECG Study Date of ___ 12:46:12 ___
Sinus rhythm. Compared to tracing #2 the heart rate has slowed
and lateral ST segment changes have normalized.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
72 152 94 428 449 85 29 43
Noncontrast Head CT (___): Stable bilateral subdural
hematomas. No new hemorrhage or infarction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Bisacodyl ___AILY:PRN constipation
3. Acetaminophen 500 mg PO Q6H:PRN pain
4. Acetaminophen 1000 mg PO Q6H:PRN moderate pain
5. Calcium Carbonate ___ mg PO TID:PRN indigestion
6. Docusate Sodium 100 mg PO BID
7. Senna 17.2 mg PO QHS
8. Amlodipine 10 mg PO DAILY
9. BuPROPion 75 mg PO TID
10. FoLIC Acid 1 mg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Metoprolol Tartrate 12.5 mg PO BID
13. LeVETiracetam 1500 mg PO BID
14. Heparin 5000 UNIT SC TID
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Heparin 5000 UNIT SC TID
8. LeVETiracetam 1000 mg PO BID
9. Lisinopril 40 mg PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Senna 17.2 mg PO QHS
14. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last day ___ to complete a 7-day course
15. Calcium Carbonate ___ mg PO TID:PRN indigestion
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Urinary Tract Infection
Secondary Diagnosis: Chronic subdural hematomas; toxic metabolic
encephalopathy; hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with difficulty speaking and history of chronic bilateral
subdurals. Assess for worsening subdural.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
Coronal and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
DOSE: DLP: 1003.42 mGy-cm
CTDI: 52.86 mGy
COMPARISON: Comparison to ___ 281 62 41 head CT from ___
FINDINGS:
Bilateral acute on subacute on chronic subdural hematomas measuring 13 mm in
width on the right and 18 mm in width on the left (02:25) with mild effacement
of sulci along the left frontoparietal convexity is unchanged from ___. A layering hematocrit level within the left subdural (02:25) hematoma is
noted. The subdural hematomas extend along bilateral frontoparietal
convexities with no significant shift of midline structures. There is no
evidence of infarction, or mass. Mild prominence of ventricles and sulci are
consistent age-related cortical volume loss. The basal cisterns are patent.
Patient is status post bilateral craniotomies with associated postsurgical
change and hyperdense material. Small amount of pneumocephalus is seen along
the left craniotomy site. No osseous abnormalities seen. Soft tissue density
within bilateral external auditory canals are most consistent with cerumen.
The left mastoid air cells are underpneumatized. The additional visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
orbits are unremarkable. Calcification of bilateral cavernous portions of
internal carotid arteries are present.
IMPRESSION:
1. No significant change since ___ of bilateral acute on subacute on
chronic subdural hematomas, measuring 13 mm on the right and 18 mm on the
left with mild effacement of left frontoparietal sulci without significant
shift of midline structures.
2. Status post bilateral craniotomies with postsurgical changes with
hyperdense material and left-sided pneumocephalus within surgical bed.
RECOMMENDATION(S): The updated findings were discussed by Dr. ___ with
Dr. ___ on the telephone on ___ at 8:25 ___.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with low grade fever*** WARNING *** Multiple
patients with same last name! // acute process?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac silhouette is top-normal. The aorta is
somewhat tortuous. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with acute on chronic bilateral subdural
hematomas now with acute aphasia and new facial droop /
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 then generated.
DOSE: CTDIvol: ___ MGy
DLP: 1009 mGy-cm
COMPARISON: CT head from ___.
FINDINGS:
Again seen are bilateral acute on chronic subdural hematomas, not
significantly changed since prior study from 2 days ago, measuring up to 20 mm
on the left and 13 mm on the right (images ___. No new focus of
hemorrhage is seen. No large territorial infarction identified. Ventricles
and sulci are unchanged in size and configuration. Basal cisterns are patent.
Patient is status post bilateral craniotomies. Small amount of post-surgical
pneumocephalus on the left has slightly decreased. The paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION:
Stable bilateral subdural hematomas. No new hemorrhage or infarction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: STROKE
Diagnosed with URIN TRACT INFECTION NOS, SEMICOMA/STUPOR
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ with history of bilateral acute-on-chronic
subdural hematomas in the setting of a fall in ___ status
post right craniotomy in ___ and left craniotomy on ___
who presented with fevers and confusion found to have a urinary
tract infection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin-pot clavulanate
Attending: ___.
Chief Complaint:
malaise, chills
Major Surgical or Invasive Procedure:
Intervential Radiology core needle biopsy of anterior
mediastinal mass
History of Present Illness:
Ms. ___ is a ___ woman with a history of
recurrent idiopathic pericarditis (on anikinra) and Castleman's
disease (diagnosed in ___ at ___ with node excision to
the left axilla), who presented to the ___ ED with 3 days of
malaise, chills, headache, nausea, and emesis. She went to an
Urgent Care center and was prescribed Flonase and an unknown
antibiotic which were unhelpful. She reports gradual onset
severe headache with no neurological deficits and acute onset
vomiting beginning at 10pm last night. She reports that she
vomited ___ times after which the vomit was streaked with blood.
Patient denies hemoptysis, nosebleeds, cirrhosis, EtOH use, GERD
or gastric ulcers.
In the ED, initial vitals: 99.4 91 112/62 17 100% RA
Exam notable for: normal neuro exam, nasopharynx and oropharynx
without bleeding, ulceration, or rash, lungs CTAB, no abdominal
or flank pain.
Labs were significant for WBC 6.5 (83.4% neutrophils), CRP 5.4,
flu swab negative.
Imaging showed an anterior mediastinal mass on CXR and CT w/
contrast concerning for malignancy.
Patient was given 1 L NS bolus.
Patient was seen by Heme/Onc
Decision made to admit for biopsy of mediastinal mass and
symptomatic management of flu-like illness.
VSS prior to transfer.
On arrival to the floor, VSS (98.1 78 101/54 18 98% RA) and
patient is resting comfortably in bed. Continues to have a
headache, not drinking fluids due to some nausea.
Past Medical History:
ADHD
DEPRESSION
MIGRAINE HEADACHES
PERICARDITIS (idiopathic, recurrent. Followed by rheumatologist
Dr. ___
H/O CASTLEMAN'S DISEASE ___
Localized Castleman's disease: Diagnosed at ___ with
node excision to the left axilla in ___.
Social History:
___
Family History:
Father with prostate cancer
Brother Living ___ MYELODYSPLASTIC SYNDROME
BONE MARROW TRANSPLANT
Physical Exam:
Admission Physical Exam:
========================
VS: 98.1 78 101/54 18 98% RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Discharge Physical Exam:
========================
Vitals: 98.5 110/69 68 18 98% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no m/r/g
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
Pertinent Results:
Admission Labs:
===============
___ 06:15AM BLOOD WBC-6.5# RBC-3.90 Hgb-12.3 Hct-35.4
MCV-91 MCH-31.5 MCHC-34.7 RDW-11.8 RDWSD-38.9 Plt ___
___ 06:15AM BLOOD Neuts-83.4* Lymphs-7.1* Monos-8.3
Eos-0.6* Baso-0.3 Im ___ AbsNeut-5.44# AbsLymp-0.46*
AbsMono-0.54 AbsEos-0.04 AbsBaso-0.02
___ 06:15AM BLOOD ___ PTT-30.0 ___
___ 06:15AM BLOOD Glucose-106* UreaN-11 Creat-0.6 Na-133
K-3.9 Cl-98 HCO3-23 AnGap-16
___ 06:15AM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.1 Mg-1.8
UricAcd-2.3*
___ 06:15AM BLOOD CRP-5.4*
___ 12:53PM BLOOD PEP-NO SPECIFI
___ 06:26AM BLOOD Lactate-0.9
Imaging:
========
___ CXR:
Opacity obscuring the left heart border localizing to the
anterior mediastinum most likely which is new as compared to
chest radiograph ___ suspicious for mediastinal mass.
Correlation with chest CT is required.
___ CT Chest w/ Contrast:
1. Homogeneous, lobulated anterior mediastinal mass most
suspicious for a
neoplastic process such as lymphoma, and direct sampling is
advised. No
lymphadenopathy in the axilla, hila, or middle mediastinum.
2. Clear lungs without evidence of pneumonia.
___ CT Abd/Pelvis w/ Contrast:
1. No intra-abdominal lymphadenopathy.
2. Indeterminate sclerosis involving right side T9 vertebral
body.
3. Suggestion of cholelithiasis.
4. Uterine fibroid
Discharge Labs:
===============
___ 11:07AM BLOOD WBC-2.3* RBC-3.83* Hgb-12.2 Hct-34.9
MCV-91 MCH-31.9 MCHC-35.0 RDW-11.8 RDWSD-38.9 Plt ___
___ 11:07AM BLOOD Neuts-53.7 ___ Monos-10.7
Eos-7.3* Baso-0.4 AbsNeut-1.25*# AbsLymp-0.65* AbsMono-0.25
AbsEos-0.17 AbsBaso-0.01
___ 11:07AM BLOOD Glucose-105* UreaN-6 Creat-0.6 Na-137
K-3.5 Cl-102 HCO3-25 AnGap-14
___ 11:07AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 30 mg PO DAILY:PRN Pericarditis flare
2. butalbital-acetaminophen-caff 50-325-40 mg oral DAILY:PRN
3. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
4. ARIPiprazole 1 mg PO DAILY
5. anakinra 100 mg/0.67 mL subcutaneous BID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe
8. Citalopram 40 mg PO DAILY
9. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral daily
10. Amphetamine-Dextroamphetamine 30 mg PO DAILY:PRN work days
Discharge Medications:
1. Amphetamine-Dextroamphetamine 30 mg PO DAILY:PRN work days
2. anakinra 100 mg/0.67 mL subcutaneous BID
3. ARIPiprazole 1 mg PO DAILY
4. butalbital-acetaminophen-caff 50-325-40 mg oral DAILY:PRN
Migraine
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s)
by mouth every four (4) hours Disp #*15 Tablet Refills:*0
5. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral daily
6. Citalopram 40 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe
9. Multivitamins W/minerals 1 TAB PO DAILY
10. PredniSONE 30 mg PO DAILY:PRN Pericarditis flare
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Anterior mediastinal mass - ___'s flare vs thymoma vs
lymphoma
Viral sinusitis/flu-like illness
Secondary:
Migraines
Castelman's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with Cough, Malaise, vomiting blood.// Pneumonia,
Esophageal Perforation
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
There is a opacity obscuring in the left heart border which localizes to the
anterior or mid mediastinum which is new as compared to ___,
suspicious for a mediastinal mass, demonstrated to be approximately 5 x 3 cm
on the lateral view. There is no pleural effusion or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
Opacity obscuring the left heart border localizing to the anterior mediastinum
most likely which is new as compared to chest radiograph ___
suspicious for mediastinal mass.
Correlation with chest CT is required.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: History: ___ with ? mediastinal mass// ? mediastinal mass
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated 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: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 41.6 cm; CTDIvol = 4.8 mGy (Body) DLP = 199.2
mGy-cm.
Total DLP (Body) = 199 mGy-cm.
COMPARISON: Chest radiograph ___ at 06:33: ___.
FINDINGS:
SOFT TISSUE: There is a lobulated anterior mediastinal mass measuring
approximately 6.3 cm in the AP plane (602b:86), beginning in the pre-vascular
space anterior to the proximal aortic arch and extending inferiorly anterior
to the superior aspect of the left ventricle (___). The mass is
homogeneous in attenuation, and is confined to the anterior mediastinum
without extension around or obvious invasion into the great vessels or into
the lung parenchyma.
Heart size is normal and there is no pericardial effusion. The great vessels
are normal in caliber. Thoracic inlet lymph nodes are of normal size by CT
size criteria, only mildly prominent. There is no axillary or hilar
lymphadenopathy. The esophagus is normal in course and caliber.
The included portions of the upper abdomen demonstrate hypodense renal lesions
bilaterally (likely simple cysts), a hypodense lesion in the left lobe of the
liver (likely hepatic cyst) (02:55), and otherwise no significant abnormality.
LUNGS: The major airways are patent. The lung parenchyma is partially
obscured by respiratory motion artifact, but there is no focal consolidation,
pleural effusion, or pneumothorax. Mild bibasilar atelectasis is present.
BONES: The bones of the chest cage and imaged spine are normal with no
concerning osseous lesions or evidence of fracture.
IMPRESSION:
1. Homogeneous, lobulated anterior mediastinal mass most suspicious for a
neoplastic process such as lymphoma, and direct sampling is advised. No
lymphadenopathy in the axilla, hila, or middle mediastinum.
2. Clear lungs without evidence of pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:25 am, 3 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with Castelman disease, recurrent idiopathic
pericarditis, presented with new mediastinal mass// please eval for evidence
of lymphadenopathy or other abnormalities
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 54.7 cm; CTDIvol = 8.3 mGy (Body) DLP = 451.1
mGy-cm.
2) Stationary Acquisition 2.8 s, 0.5 cm; CTDIvol = 15.4 mGy (Body) DLP =
7.7 mGy-cm.
Total DLP (Body) = 459 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Reference is made to chest CT done earlier today. Trace
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 3
small hypodense hepatic lesions which may represent simple cysts or biliary
hamartomas (the largest measuring 14 x 7 mm in segment 2 of the liver). There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits. Suggestion of cholelithiasis.
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 hydronephrosis. Bilateral simple appearing renal
cysts the largest in the right kidney measuring 43 x 39 mm. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Moderate colonic
fecal loading most marked in the rectum. The appendix is difficult to
identify.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterine fibroid measuring 4 cm.
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.
Spondylotic changes most marked at the L4-5 level. Indeterminate 2 cm
sclerosis involving right lower side T9 vertebral body series 2, image 7.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No intra-abdominal lymphadenopathy.
2. Indeterminate sclerosis involving right side T9 vertebral body.
3. Suggestion of cholelithiasis.
4. Uterine fibroid
Radiology Report
INDICATION: ___ with hx recurrent idiopathic pericarditis (on anikinra) and
Castleman's disease who p/w 3 days of malaise, chills, headache, nausea, and
emesis, found to have a mediastinal mass on imaging concerning for
malignancy.// please perform ****CORE NEEDLE BIOPSY**** of mediastinal mass,
rule out lymphoma
COMPARISON: CT ___
PROCEDURE: CT-guided mediastinal mass core biopsy.
OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the
lesion. An 18 gauge core biopsy device with a 22 mm throw was used to obtain
five core biopsy specimens, which were sent for pathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 18.8 cm; CTDIvol = 6.7 mGy (Body) DLP = 116.9
mGy-cm.
2) Stationary Acquisition 10.0 s, 1.4 cm; CTDIvol = 76.1 mGy (Body) DLP =
109.6 mGy-cm.
Total DLP (Body) = 234 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 4
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 40
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Multiple anterior mediastinal masses.
IMPRESSION:
Technically successful CT-guided core biopsy of a anterior mediastinal mass.
5 core biopsy specimens were obtained according to a lymphoma protocol.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache, ILI, Vomiting
Diagnosed with Viral infection, unspecified
temperature: 99.4
heartrate: 91.0
resprate: 17.0
o2sat: 100.0
sbp: 112.0
dbp: 62.0
level of pain: 9.5
level of acuity: 3.0 | Ms. ___ is a ___ woman with a history of
recurrent idiopathic pericarditis (on anikinra) and Castleman's
disease (diagnosed in ___ at ___ with node excision to
the left axilla), who presented to the ___ ED with 3 days of
malaise, chills, headache, nausea, and emesis, found to have a
mediastinal mass on imaging concerning for malignancy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / levofloxacin
Attending: ___.
Chief Complaint:
L sided chest pain x 3 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of severe COPD not on home O2, chronic bronchitis,
h/o M. ___ infection without e/o recurrence, NSTEMI s/p DES
to RCA, HLD presenting with chest pain and progressive DOE x3
days. Pt reports that she first noted L sided chest pain on
___ am, cannot recall if it was pleuritic, which then
extended to R sided chest pain. She cannot recall if pain woke
her from sleep. Pain was sharp, constant, ___ at its worst with
associated SOB, without nausea. At baseline she can walk 4 city
blocks at slow pace before she develops significant dyspnea, but
since onset of symptoms she has been unable to ambulate any
distance. She denies fevers, chills, cough, sick contacts. She
traveled to ___ for 2 days last week with her mother, but
denies any other travel. She reports that she feels very similar
to prior presentations of pneumonia, of which she believes she
has had 2.
ROS: All else negative
In the ___ ED:
VS 97.5, 113/74, 122, 24, 90% RA
Labs notable for: WBC 24.1, 7 bands, BUN/Cr 33/0.9, TnT negative
x2, BNP 1133, Ddimer 2164, VBG 7.37/51, LA 2.4->1.4, UA negative
for infection, UCx and BCx pending
CXR and CT-PE with evidence of multifocal pneumonia, without PE
RUQ u/s unremarkable
Received:
Nebs
ASA 162 mg
Home meds
Ceftriaxone/azithromycin
Morphine sulfate 5 mg IV x1
Zofran 4 mg IV x2
Prednisone 60 mg x1
2L IVF for SBP ___
Past Medical History:
- COPD: Gold IV; ___ FEV1 0.47L/min or 31%, severe OVD;
baseline 92+% on RA
- Chronic bronchitis
- H/o M. ___ infection: s/p 18 month cipro/clarithro;
resistant to isoniazid/ethambutol; no e/o recurrence on AFB
smear ___
- S/p right lower lung biopsy: ___ results with organizing
pneumonia and no e/o granulomas or malignancy
- NSTEMI in ___, s/p ___ for RCA stenosis
- Hyperlipidemia
- Arthritis in bilateral hands
- ADHD
Social History:
___
Family History:
sister: lung cancer, smoker. She is alive and well
Physical Exam:
VS: 98.2, 107/63, 88, 20 (my measurement), 95% 5L, 94% on 3L,
88% on RA
Gen: pleasant female, NAD, lying in bed, sleeping comfortably
HEENT: PERRL, EOMI, clear oropharynx, neck supple, no cervical
or supraclavicular adenopathy
Lungs: Poor air movement throughout, no wheeze or crackles
appreciated
CV: RRR, no m/r/g
Abd: soft, nontender, nondistended, no rebound, occasional
voluntary guarding, +bowel sounds, no organomegaly
Ext: WWP, no clubbing, cyanosis or edema
GU: No foley
Neuro: grossly intact
Exam on discharge:
Vitals: 98.8 BP: 117/83 HR: 90 R: 18 O2: 94% RA
Gen: NAD, sitting in chair. Able to speak in full sentences,
occasional pursed lip breathing
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: no accessory muscle use, good air entry with occasional
wheezing
GI: soft, NT, ND, BS+
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
___ 05:10PM LACTATE-1.4
___ 12:18PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 12:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
___ 12:18PM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
___ 12:18PM URINE HYALINE-2*
___ 11:31AM URINE HOURS-RANDOM
___ 11:31AM URINE UHOLD-HOLD
___ 07:47AM cTropnT-<0.01
___ 07:47AM LACTATE-2.0
___ 01:29AM LACTATE-2.4*
___ 12:00AM D-DIMER-2164*
___ 11:51PM ___ PO2-33* PCO2-51* PH-7.37 TOTAL
CO2-31* BASE XS-2
___ 11:44PM GLUCOSE-160* UREA N-33* CREAT-0.9 SODIUM-134
POTASSIUM-5.6* CHLORIDE-91* TOTAL CO2-25 ANION GAP-24*
___ 11:44PM estGFR-Using this
___ 11:44PM ALT(SGPT)-19 AST(SGOT)-30 ALK PHOS-101 TOT
BILI-1.1
___ 11:44PM LIPASE-21
___ 11:44PM cTropnT-<0.01 proBNP-1133*
___ 11:44PM ALBUMIN-4.3 CALCIUM-9.7 PHOSPHATE-3.8
MAGNESIUM-2.3
___ 11:44PM WBC-24.1*# RBC-5.22* HGB-16.1* HCT-48.7*
MCV-93 MCH-30.8 MCHC-33.1 RDW-12.3 RDWSD-42.1
___ 11:44PM NEUTS-82* BANDS-7* LYMPHS-5* MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-21.45* AbsLymp-1.21
AbsMono-1.45* AbsEos-0.00* AbsBaso-0.00*
___ 11:44PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-1+ BURR-1+
___ 11:44PM PLT SMR-NORMAL PLT COUNT-236#
EKG: NSR at 89 bpm, normal axis, QTc 412, no TWI, flattening in
V2, no ST segment changes, no pathologic Q waves, no change
compared to prior
CT chest: ___
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level or
aortic
abnormality.
2. Ground-glass and nodular consolidations in the right lower,
right middle and left lower lobes suspicious for multifocal
pneumonia.
3. More masslike consolidation in the right lower lobe adjacent
to the
esophagus warrants follow-up.
4. Stable severe centrilobular emphysema.
RUQ ultrasound ___
IMPRESSION:
Normal right upper quadrant ultrasound.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
2. Lorazepam 0.5 mg PO BID:PRN anxiety
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Tiotropium Bromide 1 CAP IH DAILY
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
7. Ranitidine 150 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Aspirin 81 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Lorazepam 0.5 mg PO BID:PRN anxiety
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze, shortness
of breath
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 vial inh q4hrs as
needed for SOB Disp #*25 Vial Refills:*0
8. PredniSONE 30 mg PO DAILY Duration: 3 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*18 Tablet
Refills:*0
9. PredniSONE 20 mg PO DAILY Duration: 3 Doses
Start: After 30 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
10. PredniSONE 10 mg PO DAILY Duration: 3 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. Levofloxacin 750 mg PO Q24H Duration: 3 Doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q24 Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia, multifocal
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with tachycardia, hypoxia, elevated D-dimer // r/o
PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique
maximal intensity projection images were submitted to PACS and reviewed.
DOSE:
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 4.4 s, 34.6 cm; CTDIvol = 4.4 mGy (Body) DLP = 153.3
mGy-cm.
Total DLP (Body) = 156 mGy-cm.
COMPARISON: CTA chest dated ___
FINDINGS:
The aorta is unremarkable without dissection or aneurysm. Great vessels are
unremarkable. The pulmonary arteries are well opacified to the segmental
level without filling defect to suggest pulmonary embolism. Evaluation of the
subsegmental pulmonary arteries is limited by respiratory motion. Pulmonary
arteries are normal in caliber.
There is severe centrilobular emphysema. There is ground-glass and more
nodular opacities in the right lower and middle lobes as well as the left
lower lobe suspicious for multifocal pneumonia. One focal area of
consolidation in the right lower lobe adjacent to the esophagus appears
somewhat more mass-like measuring 2.4 x 2.3 cm (2:66). There is no pleural
effusion or pneumothorax. There is mucous plugging of the right lower lobe
segmental bronchi.
Heart is unremarkable. There is no pericardial effusion. There is no
supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. Included
portion of the thyroid is unremarkable.
Included portion of the upper abdomen is unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
There is no fracture.
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level or aortic
abnormality.
2. Ground-glass and nodular consolidations in the right lower, right middle
and left lower lobes suspicious for multifocal pneumonia.
3. More masslike consolidation in the right lower lobe adjacent to the
esophagus warrants follow-up.
4. Stable severe centrilobular emphysema.
RECOMMENDATION(S): Recommend follow-up chest CT without contrast in 3 months
to followup masslike consolidation.
NOTIFICATION: The change in wet read was discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 8:54 AM.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ tenderness // Eval for biliary abnormality
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites. A small morphologically normal 6
mm lymph node is noted the periportal region.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
IMPRESSION:
Normal right upper quadrant ultrasound.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.5
heartrate: 122.0
resprate: 24.0
o2sat: 90.0
sbp: 113.0
dbp: 74.0
level of pain: 10
level of acuity: 1.0 | ___ with hx of severe COPD not on home O2, chronic bronchitis,
h/o M. ___ infection without e/o recurrence, NSTEMI s/p DES
to RCA presenting with chest pain and progressive DOE x3 days,
found to have multifocal pneumonia.
# Multifocal pneumonia
#COPD with acute exacerbation
Presented with shortness of breath and CT findings consistent
with multifocal pneumonia. Pt has remote hx of RLL biopsy with
diagnosis of organizing pneumonia, as well as M. ___
infection treated with 18 months cipro/clarithro, with repeat
AFB in ___ without e/o recurrence. She was treated with
prednisone 40mg and Ceftriaxone/azithromycin in addition to
nebulizers. Sputum culture was consistent with normal flora. She
was seen by the pulmonary consult service who recommended
swallowing evaluation. The patient was seen by s/s who found no
overt signs of aspiration but recommended outpatient follow up
with speech and consideration of video swallow. The patient
improved with steroids and antibiotics. She was able to ambulate
off of oxygen and maintained saturations above 90%. She was
discharged home on oral levaqin to complete a ___nd a
steroid taper per pulmonary (30mg x3 days, 20mg x3 days, 10mg x
3 days then stop). The patient has outpatient pulmonary follow
up arranged.
# NSTEMI: S/p DES to RCA in ___. EKG without ischemic changes
on admission. The patient was continued on her home medications
of ASA 162mg daily, metoprolol and statin.
# Anxiety:
Continued home lorazepam |
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:
Persantine ___
History of Present Illness:
___ with h/o of Afib on coumadin, CVA, DM, HTN, HLD who
presented with chest pain nausea and vomiting.
.
Patient had multiple ED visits since ___ when he was in
___ and was struck from behind by a loaded shopping cart.
He was evaluated with both radiographs of hips and spine and CT
scan of his pelvis with no evidence of a fracture. Was seen in
our ED again a day prior to this admission and had negative
right ___. He was discharged with Ibuprofen.
.
Pt reports that today when he was sitting down getting ready to
eat, soon after he took his Ibuprofen, he had acute onset of
dull, left anterior chest without any other radiation or
exacerbating or worsening factors, associated with shortness of
breath, also had nausea and vomiting. No diarrhea. No
diaphoresis. Pain was ___ and remained unchanged for hours
untill presented to the ED. He had NBNB vomiting X 4. Denies
diarrhea. Denies suspicious meals. Pt reports having similar
pain a couple of months ago, sought no treatment for it then.
.
Pain in his RLE is described as mainly in his calf but feels it
along all the length of the lateral and posterior aspect of his
RLE.
.
ED Course:
- Initial Vitals/Trigger: 20:47 4 98.4 60 133/109 18 100%
- labs: Cr 1.7 (___ records: Cr 1.4 on ___, CBC normal
except micorcytosis, normal LFT's, mild proteinuria, CE neg X1.
- EKG: Vpaced 60 with underlying flutter waves
- CXR: no congestion or infiltrate
- right ankle and knee films: non acute
- got ASA 325
- zofran, morphine, GI cocktails with partial relief of symptoms
- admitted for ___ and ___ on ___
.
transfer VS: 98.7-___-137/79-14-100%RA
Past Medical History:
- atrial fibrillation on warfarin
- CVA ___
- pacemaker
- CKD
- DM
- hyperlipidemia,
- hypertension
- peripheral neuropathy
- gastroesophageal reflux disease
- benign prostatic hypertrophy
- glaucoma status post left surgery
- multilevel degenerative change in the
spine with foraminal narrowing at L3-L4, L4-L5, and L5-S1 per CT
___
Social History:
___
Family History:
N/C
Physical Exam:
Admission Exam:
VS - Temp ___, BP 160/105 , HR 59 , R 20, 100 O2-sat % RA
GENERAL - uncomfortable, wretching, better after IV
metoclopramide 5mg, A+OX3, appropriate and cooperative
HEENT - left corneal sclerosis s/p surgery, sclerae anicteric,
MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - bibasilar end inspiratory crackles, no r/rh/wh, good air
movement
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - increased BS X4 Q, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, left ___ spascticity, no signs of
DVT, positive leg raising test on the right.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CN grossly intact except left pupil as
above, left UE spasctic, LLE mild spacticity with ___ strength,
otherwise ___ throughout, sensation grossly intact throughout,
DTRs 2+ and symmetric, cerebellar exam intact, steady gait
.
discharge exam
VS: T 96.8 BP 136/87 (112/71-151/74) HR 60 (60-83) RR 18 O2 Sat
99%RA
GEN: Elderly man in NAD
CV: RRR, normal s1/s2, no s3/s4, no m/r/g
PULM: Lungs CTAB bilaterally
ABD: NTND, NABS, no rigidity rebound or guarding
EXT: WWP, no c/c/e, pulses 2+ bilaterally
NEURO: A/Ox3
Pertinent Results:
Admission Labs:
___ 09:25PM BLOOD WBC-4.2 RBC-6.27* Hgb-14.8 Hct-46.6
MCV-74* MCH-23.6* MCHC-31.8 RDW-15.5 Plt ___
___ 09:25PM BLOOD Neuts-33.5* Lymphs-54.3* Monos-8.6
Eos-2.5 Baso-1.0
___ 09:25PM BLOOD Glucose-115* UreaN-17 Creat-1.7* Na-139
K-4.6 Cl-105 HCO3-25 AnGap-14
___ 09:25PM BLOOD ALT-20 AST-24 CK(CPK)-166 AlkPhos-57
TotBili-0.3
___ 01:45PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.3
.
cardiac enzymes
___ 09:25PM BLOOD CK-MB-3
___ 09:25PM BLOOD cTropnT-<0.01
___ 05:35AM BLOOD CK-MB-4
___ 05:35AM BLOOD cTropnT-<0.01
___ 01:45PM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:40PM BLOOD cTropnT-<0.01
.
Discharge Labs:
___ 07:00AM BLOOD WBC-4.1 RBC-6.59* Hgb-16.0 Hct-49.5
MCV-75* MCH-24.3* MCHC-32.3 RDW-15.6* Plt ___
___ 07:00AM BLOOD Glucose-94 UreaN-19 Creat-1.8* Na-139
K-4.3 Cl-104 HCO3-27 AnGap-12
___ 07:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0
.
studies:
CXR: No acute intrathoracic process.
.
R Knee/Ankle X ray (___):
THREE VIEWS OF THE RIGHT KNEE: There is no evidence of acute
fractures or dislocations. Normal alignment is maintained.
Vascular calcifications are noted. There is an enthesophyte at
the insertion of the quadriceps tendon. Medial and Patellar
compartment osteophytes are noted.
.
THREE VIEWS OF THE RIGHT ANKLE: Chronic deformity of the right
fibula is
possibly due to an old healed fracture. Otherwise, there is no
evidence of
acute fractures. The ankle mortise is preserved. Vascular
calcifications and a posterior calcaneal spur are noted.
.
TIB/FIB xray
Frontal and lateral views of the right lower extremity from the
knee to the ankle joint. There is no fracture or dislocation.
Degenerative
spurring is present on the posterior surface of the tibia. There
is no knee joint effusion. Degenerative calcifications project
into the superior
insertion of the patellar tendon and the tendinous insertions
along the
posterior calcaneus.
.
STRESS
ECG uninterpretable for ischemia. No anginal type symptoms
to pharmacologic stress. Appropriate blood pressure response to
Persantine. Nuclear report sent separately.
.
PMIBI
1. No myocardial perfusion defect or wall motion abnormality
detected. 2. Mild systolic dysfunction with LVEF of 41% and top
normal left ventricular cavity size.
Medications on Admission:
Tylenol ___ mg Tab Oral 2 Tablet(s) PRN
Norvasc 5 mg Tab Oral 1 Tablet(s) Once Daily
Coumadin 5 mg Tab Oral 1 Tablet(s) Once Daily
Simvastatin 10 mg Tab Oral 1 Tablet(s) Once Daily
Neurontin -- Unknown Strength 1 Capsule(s) Once Daily
Discharge Medications:
1. Maalox Advanced 1,000-60 mg Tablet, Chewable Sig: One (1) ML
PO TID (3 times a day) as needed for nausea/chest pain.
Disp:*120 ML(s)* Refills:*3*
2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Tylenol ___ mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Gastritis
Secondary Diagnosis:
Radiculopathy
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
TIB/FIB ON ___
HISTORY: Ongoing right lower extremity pain after trauma a month ago.
IMPRESSION: Frontal and lateral views of the right lower extremity from the
knee to the ankle joint. There is no fracture or dislocation. Degenerative
spurring is present on the posterior surface of the tibia. There is no knee
joint effusion. Degenerative calcifications project into the superior
insertion of the patellar tendon and the tendinous insertions along the
posterior calcaneus.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: PAIN R LEG
Diagnosed with CHEST PAIN NOS, PAIN IN LIMB, NAUSEA WITH VOMITING
temperature: 98.4
heartrate: 60.0
resprate: 18.0
o2sat: 100.0
sbp: 13.0
dbp: 3109.0
level of pain: 4
level of acuity: 3.0 | ___ with h/o of Afib on coumadin, CVA, DM, HTN, HLD who
presented with acute chest pain as well as ongoing RLE pain s/p
trauma 1 month ago.
.
# Chest Pain/Nausea/Vomiting: Patient presented with complaints
of anterior chest pain associated with nausea and vomiting. He
was ruled out for ACS with negative troponins x3. Given hx of
chest pain with exertion and relief with rest, there was also
concern for stable angina. Patient subsequently underwent a
pMIBI which was negative for wall motion abnormalities or
perfusion defects. He had no signs of DVT on ___ and ___
desaturations or pleuritis to suggest PE. He had a CXR that was
negative for pneumonia. It was felt that chest pain was most
likely ___ to gastritis related to recent NSAID use. He pain
improved with GI cocktail and carafate. Patient remained chest
pain free at time of discharge.
.
# Chronic Kidney Disease: Patient with elevated Cr (range
1.4-1.8 on this admission). Unclear baseline. Urine lytes showed
FeNa 1.53%, FeUrea 53% concerning for intrinsic process.
Creatinine did not improve in response to IVF, however remained
stable throughout admission.
.
# RLE Pain: Patient presents with RLE pain for the last month.
Pain in his RLE is described as mainly in his calf but feels it
along all the length of the lateral and posterior aspect of his
RLE. He had X rays of the knee/ankle/tib/fib negative for acute
process. Also had recent ___ negative for DVT. Patient had no
neurologic deficits. Pain was thought to be most likely
neuropathic in nature. He was started on gabapentin for pain
control. In addition, he was evaluated by ___ and deemed safe to
return home. He is scheduled for outpatient follow up with
___ clinic and outpatient physical therapy.
.
# Afib: INR initially stable and patient continued on home dose
of warfarin 5 mg daily. On day on discharge INR elevated to 3.6.
His coumadin was held on ___ and he was discharged with plans
to continue coumadin at 2.5 mg daily. He has follow up on ___ at
which point he should have his INR checked. Patient should also
be followed in ___ clinic.
# depressed EF: Patient found to have depressed EF of 41% on
pMIBI, however, there was no evidence of volume overload on
exam. Can consider initiating bblocker and ACE inhibitor as
outpatient.
.
transitional issues
- no labs or studies pending at time of discharge
- patient will need to have INR monitored closely in ___
clinic
- patient will need to continue outpatient physical therapy
- can consider formal echo to evaluate heart function given
depressed EF on pMIBI. Patient may benefit from bblocker and
ACEi.
- patient full code on this admission
- contact: ___ (___) Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
penacillin / bee venom (honey bee)
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o M w/ hx of esophageal
adenocarcinoma s/p neoadjuvant chemo/radiation and minimally
invasive ___ esophagectomy performed on ___. His
post
operative course was uncomplicated with the exception of a
moderate left sided pleural effusion noted on CXR. The patient
was asymptomatic and weaned off of oxygen and out of bed to
ambulate without assistance, thus he was discharged on ___
with plan to follow up in 2 weeks. Of note, barium swallow was
performed during his hospitalization which showed no evidence of
anastomotic leak, though was noted to have significant pooling
of
contrast within the stomach, but no evidence of obstruction. The
patient was doing well at home until he began to develop
shortness of breath with exertion and speaking over the past 2
days. He also endorses a non productive cough associated with
his
SOB. he denies fevers, chills, night sweats, wheezing. He denies
any difficulty with soft diet which he eats during the day and
has been able to tolerate his tube feeds at night. His bowel
pattern is unchanged since discharge, with multiple bowel
movements a day.
He presented to ___ where CT PE protocol was
performed. He was found to have a leukocytosis w/ left shift of
13.4. Given his past surgical history, he was transferred to the
___ main campus for admission to Thoracic Surgery.
Past Medical History:
Diabetes, hypertension, hyperlipidemia, prior history of GERD.
S/P L ankle Fx
Social History:
___
Family History:
Mother - breast cancer
___ - brother with esophageal cancer
Physical Exam:
Temp: 98 HR: 100 BP: 145/70 RR: 18 O2
Sat: 96%
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] incisions c/d/i, reduced basilar lung sounds [x]
Excursion
normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [x]
incisions c/d/i
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 10:10 8.2 3.96* 10.3* 33.3* 84 26.0 30.9* 15.1
45.7 560*
___ 04:00 8.0 3.37* 9.0* 28.7* 85 26.7 31.4* 15.3
47.7* 516*
___ 05:23 10.3* 3.53* 9.4* 30.2* 86 26.6 31.1* 15.5
47.8* 504*
___ 14:53 10.1* 3.60* 9.5* 30.5* 85 26.4 31.1* 15.4
47.8* 477*
___ 01:32 13.5* 3.44* 9.4* 29.0* 84 27.3 32.4 15.3
46.7* 479*
___ CXR:
Persistent bilateral pleural effusions. Slight improvement in
adjacent
bibasilar lung opacities.
___ CXR :
Since ___, mildly increasing in size dilated neoesophagus.
Stable
bilateral pleural effusions.
___ CXR :
As compared to ___, the postoperative appearance
of the
neoesophagus is unchanged a pre-existing small right pleural
effusion is
constant. On the left, a pre-existing minimal pleural effusion
has increased but is still confined to the costophrenic sinus.
No evidence of new parenchymal opacities suggesting pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Enoxaparin Sodium 140 mg SC DAILY
4. irbesartan 300 mg oral DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Acetaminophen 1000 mg PO Q6H
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO BID
10. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Medications:
1. Enoxaparin Sodium 140 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal Rates:
Midnight - 0600: 1.6 ___
0600 - 1200: 1.6 ___
1200 - 1800: 1.6 ___
1800 - 2400: 1.6 ___
MD acknowledges patient competent
MD has ordered ___ consult
MD has completed competency
5. Amoxicillin-Clavulanate Susp. 500 mg NG Q8H
give via J tube and flush with 30 cc's water
RX *amoxicillin-pot clavulanate 250 mg-62.5 mg/5 mL 10 mls via J
tube every eight (8) hours Refills:*3
6. Bisacodyl 10 mg PR QHS:PRN constipation
7. Lansoprazole Oral Disintegrating Tab 30 mg J TUBE DAILY
dissolve in a cup of water and give via J tube
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) via J tube
once a day Disp #*14 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Slow gastric emptying
Bilateral pleural effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with pleural effusion. RUE clot // eval for clot.
eval for pleural effusion
TECHNIQUE: Portable semi upright frontal radiograph of the chest
COMPARISON: Reference chest CT dated ___ and chest radiograph
dated ___ at 20:04
FINDINGS:
A right chest wall Port-A-Cath is in unchanged position. The neo esophagus is
seen in the right hemi thorax with adjacent atelectasis. There has been
interval slight decrease in bilateral lower lung opacification, which remains
more severe on the right than the left. There are small bilateral pleural
effusions greater on the right than the left. Normal heart size. No
pneumothorax.
IMPRESSION:
Persistent bilateral pleural effusions. Slight improvement in adjacent
bibasilar lung opacities. .
Radiology Report
INDICATION: ___ year old man s/p MIE with dilated neoesophagus // check size
of neoesophagus, check for R effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Since ___, the moderate right pleural effusion and small left
pleural effusion are stable in size. Dilated right neoesophagus has mildly
increased in size. Bibasilar opacities in the lower lobes most likely
atelectasis are is unchanged.
IMPRESSION:
Since ___, mildly increasing in size dilated neoesophagus. Stable
bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p MIE with dilated esoph, B/L eff // check
esophageal dilitation check esophageal dilitation
COMPARISON: ___
IMPRESSION:
Port-A-Cath catheter tip is at the level of cavoatrial junction. Heart size
and mediastinum are stable. Left basal consolidation appears to be slightly
progressing as well as right basal consolidation. The neo esophagus
appearance is unchanged with substantial dilatation and air-fluid level.
Pleural effusion is bilateral and small.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man POD 14 for ___ esophagectomy // ?
interval change of neo-esophagus, ?PTX
TECHNIQUE: PA and lateral chest radiographs.
COMPARISON: Chest radiograph ___
FINDINGS:
The patient is status post esophagectomy with a large dilated knee esophagus
positioned predominately in the right hemi thorax. There is right basilar
consolidation and a moderately large right pleural effusion, this is unchanged
in appearance when compared to the prior study. The right-sided subclavian
Port-A-Cath terminates in the mid SVC. Left basal consolidation is unchanged.
IMPRESSION:
No significant interval change when compared to the prior study.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with esophageal ca s/p ___ esophagectomy
p/w SOB and dilated conduit // please evaluate interval changes; conduit
dilatation. Please schedule for ___ am.
TECHNIQUE: PA and lateral chest radiograph
COMPARISON: Chest radiographs ___
FINDINGS:
There is a dilated neo esophagus with an air-fluid level again seen in the
right hemi thorax. There is a small right pleural effusion with right basilar
atelectasis. Left lower lobe atelectasis versus consolidation also unchanged.
The left lung is otherwise clear. A right subclavian Port-A-Cath terminates
in the mid SVC.
IMPRESSION:
No significant interval change when compared to the prior study.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with dilated neoesophagus post MIE // check
interval change check interval change
IMPRESSION:
As compared to ___, the postoperative appearance of the
neoesophagus is unchanged a pre-existing small right pleural effusion is
constant. On the left, a pre-existing minimal pleural effusion has increased
but is still confined to the costophrenic sinus. No evidence of new
parenchymal opacities suggesting pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with PLEURAL EFFUSION NOS
temperature: 98.0
heartrate: 95.0
resprate: 18.0
o2sat: 99.0
sbp: 114.0
dbp: 43.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was evaluated by the Thoracic Surgery service upon
admission to the hospital. He was made NPO, his medications
were changed to IV as able or via J tube and he was hydrated
with IV fluids. He was also placed on IV heparin for his RUE
DVT treatment as Coumadin and Lovenox was held pending any
surgery or invasive treatments. He clinically looked well but
did have baseline shortness of breath although his saturations
were 95% on room air.
Antibiotics were started in case there was a sub clinical
anastomotic leak as his WBC was 13K. Initially Vancomycin and
Zosyn the changed to Flagyl and Ceftriaxone based on ID
recommendations. He was followed with daily chest xrays and WBC
and his WBC gradually decreased to 10K then 8K. His chest xray
showed a stable small right and left pleural effusion. He
remained NPO and overe a period of a few days felt much better.
He was not dyspneic, had room air saturations of 95% and his WBC
was 8K. He was tolerating his cyclic J tube feedings and up and
walking independently. As he continued to improve, he was
placed on liquid Augmentin via his j tube so that he could
complete treatment at home.
He will maintain anticoagulation with Lovenox only for now as
all oral meds will be on hold except for Metoprolol. He may
take sips for comfort only in limited amounts. The ___ will
continue to follow him and he will see Dr. ___ in clinic
next week with a chest xray to help assess his progress. he was
discharged to home on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
Left ___ with interventional radiology ___
Port removal ___
History of Present Illness:
Ms. ___ is a ___ woman with breast cancer status
post lumpectomy
followed by chemoradiation treatment at ___, Graves' disease
status post radioactive ablation and subsequent hypothyroidism,
CAD status post stent placement at ___ in ___ and recent
diagnosis of T3 N2 MX gastric adenocarcinoma status post gastric
surgery on ___, at ___, presenting with shortness of
breath.
She reported that she got out of bed the morning of
presentation, and she was acutely
short of breath. EMS was called, patient was noticed to be in
SVT
at 150.
Per E.D. visit, on arrival, patient denied dizziness or
lightheadedness, did report nausea. On monitor and EKG, appeared
to be in SVT. Attempted vagal maneuver x2 without success.
Patient received 1 L fluid and converted to sinus tachycardia
120s. Lactate resulted at 10, persistently hypotensive in the
___. Levophed started via port. Patient got CT torso, which was
notable for free air and L mild hydronephrosis ___ UVJ
obstructing stone.
Of note, patient was recently hospitalized at ___ for
nausea/emesis and right sided abdominal pain w/ CT demonstrating
tiny duodenal stump leak with no significantly drainable fluid
collection. She was medically managed with IV antibiotics (Zosyn
and fluconazole) ___ (discharged off antibiotics on ___.
Past Medical History:
CAD s/p LAD stent
hypothyroidism,
hypertension
hyperlipidemia
locally advanced breast cancer
Past surgical history : Status post total abdominal hysterectomy
via lower midline abdominal incision in ___. The pathology
revealed leiomyomas and adenomyosis. In ___, she had an
endocervical polyp removed, and in ___, a rectal
polypectomy revealed an oil granuloma. She also had a left sided
partial mastectomy performed at ___.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Afebrile, SBP 100s, HR 110s up to 130s with ambulation, ___
well on RA
GEN: NAD
HEENT: Normocephalic, atraumatic, EOMI, PERRLA
CV: Tachycardic, no m/r/g appreciated
RESP: CTAB except for very mild end expiratory wheezing
GI: abd ntnd, well healing midline incisional scars
MSK: ___ strength
SKIN: No rashes noted
NEURO: CNII-XII grossly tested and intact
PSYCH: Normal mentation. Appropriate mood.
Lines: Right PIV, Right sided port without erythema
=======================
DISCHARGE PHYSICAL EXAM
=======================
General: Elderly woman, well nourished, in no acute distress
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes or crackles
CV: Regular rate and rhythm, no murmurs. Right chest wall chemo
port has been removed.
Abdomen: Soft, non-tender, non-distended, several scars from
prior surgeries
GU: left nephrostomy tubing in place, dressing is clean and dry
Ext: Warm, well perfused, no lower extremity edema
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. Not dysarthric.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:00AM BLOOD WBC-10.1* RBC-3.92 Hgb-10.0* Hct-31.0*
MCV-79* MCH-25.5* MCHC-32.3 RDW-18.8* RDWSD-54.2* Plt ___
___ 05:00AM BLOOD Neuts-89* Bands-6* Lymphs-4* Monos-1*
Eos-0* Baso-0 AbsNeut-9.60* AbsLymp-0.40* AbsMono-0.10*
AbsEos-0.00* AbsBaso-0.00*
___ 05:00AM BLOOD Anisocy-1+* Poiklo-1+* Macrocy-1+*
Microcy-1+* Ovalocy-1+*
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-136* UreaN-23* Creat-1.5* Na-137
K-4.0 Cl-100 HCO3-14* AnGap-23*
___ 05:00AM BLOOD ALT-15 AST-32 AlkPhos-124* TotBili-0.7
___ 05:00AM BLOOD cTropnT-<0.01
___ 05:00AM BLOOD Albumin-3.3* Calcium-9.6 Phos-2.8 Mg-1.7
___ 05:00AM BLOOD TSH-71*
___ 01:43PM BLOOD T4-2.1*
___ 01:50AM BLOOD Lactate-5.2*
RELEVANT LABS:
==============
___ 01:43PM BLOOD WBC-20.1* RBC-3.67* Hgb-9.5* Hct-28.7*
MCV-78* MCH-25.9* MCHC-33.1 RDW-18.9* RDWSD-53.8* Plt ___
___ 05:00AM BLOOD Neuts-89* Bands-6* Lymphs-4* Monos-1*
Eos-0* Baso-0 AbsNeut-9.60* AbsLymp-0.40* AbsMono-0.10*
AbsEos-0.00* AbsBaso-0.00*
___ 01:35AM BLOOD Plt Smr-LOW* Plt Ct-94*
___ 05:00AM BLOOD cTropnT-<0.01
___ 01:43PM BLOOD cTropnT-0.05*
___ 01:05AM BLOOD CK-MB-2 cTropnT-0.02*
___ 01:43PM BLOOD TSH-30*
___ 05:00AM BLOOD TSH-71*
___ 01:43PM BLOOD T4-2.1*
___ 01:50AM BLOOD Lactate-5.2*
___ 05:03AM BLOOD Lactate-10.3* Creat-1.4*
___ 10:03AM BLOOD Lactate-6.7*
___ 01:12AM BLOOD Lactate-1.4
DISCHARBE LABS:
===============
___ 06:41AM BLOOD WBC-4.7 RBC-2.98* Hgb-7.5* Hct-23.0*
MCV-77* MCH-25.2* MCHC-32.6 RDW-18.6* RDWSD-52.3* Plt ___
___ 06:41AM BLOOD Plt ___
___ 06:41AM BLOOD Glucose-86 UreaN-5* Creat-0.4 Na-141
K-3.6 Cl-109* HCO3-23 AnGap-9*
___ 06:06AM BLOOD ALT-6 AST-12 LD(LDH)-175 AlkPhos-62
TotBili-0.4
___ 06:41AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.7
IMAGING:
========
CTAP ___: 1. Status post distal gastrectomy with
gastrojejunostomy. Locules of air
adjacent to the line ending duodenal anastomosis is concerning
for dehiscence.
However evaluation is limited without oral contrast.
2. There is mild left hydronephrosis with likely a 2 mm
obstructing left UVJ
stone.
3. No evidence of pneumonia. Stable post treatment changes are
noted in the
left upper lobe.
___ ___: No evidence of deep venous thrombosis in the right or
left lower extremity
veins.
TTE ___: Normal right ventricular cavity size and free wall
motion. Mild pulmonary artery
systolic hypertension. Mild to moderate tricuspid regurgitation.
Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global left
ventricular systolic function. Mild
mitral regurgitation.
CTAP ___:
1. Persistent 3 mm obstructing left UVJ stone with associated
mild left
hydroureteronephrosis. Interval increase in left perinephric
fluid is
nonspecific but may suggest calyceal rupture.
2. Retained contrast from prior study within the right kidney is
nonspecific,
although a component of pyelonephritis is difficult to exclude.
3. Redemonstration of locules of air anterior to the liver are
favored to
represent intraluminal air within jejunal loops in the region of
hepaticojejunostomy rather than sequela of anastomotic
dehiscence.
4. Trace pericardial effusion.
PERCUTANEOUS NEPHROURETEROSTOMY PLACEMENT ___
FINDINGS:
Obstructing UVJ stone. No hydronephrosis, mild hydroureter.
IMPRESSION:
Successful placement of 8.5F x 22 cm nephroureterostomy on the
left.
CHEMO PORT REMOVAL ___
FINDINGS:
Final fluoroscopic image showing complete removal of the port.
IMPRESSION:
Successful removal of a right upper chest port.
MICROBIOLOGY:
=============
___ 7:25 pm URINE,KIDNEY Source: Kidney.
FLUID CULTURE (Pending):
ANAEROBIC CULTURE (Pending):
__________________________________________________________
___ 2:04 pm BLOOD CULTURE Source: Line-R chest port.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:35 pm BLOOD CULTURE Source: Line-Right chest
port.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:39 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER AEROGENES. 10,000-100,000 CFU/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
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 9:45 am BLOOD CULTURE Source: Line-port.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
__________________________________________________________
___ 5:35 am BLOOD CULTURE Site: ARM
Blood Culture, Routine (Preliminary):
ENTEROBACTER AEROGENES.
Identification and susceptibility testing performed on
culture #
___ ___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
__________________________________________________________
___ 5:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROBACTER AEROGENES. FINAL SENSITIVITIES.
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
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___) ON
___ AT
18:30.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
3. Atorvastatin 80 mg PO QPM
4. Levothyroxine Sodium 150 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Enterobacter bacteremia and sepsis
SECONDARY:
-Right ureterovesicular junction stone
-Transient supraventricular tachycardia
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 tachycardia// eval for pneumonia
TECHNIQUE: Portable chest radiograph
COMPARISON: CT chest ___.
FINDINGS:
Right chest port terminates in the lower SVC. Mild left lower lung opacities
likely represent atelectasis. No pleural effusion or pneumothorax.
Cardiomediastinal contours are within normal limits.
IMPRESSION:
Mild left lower lung atelectasis.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: +PO contrast; History: ___ with recent gastric surgery, sepsis+PO
contrast// eval PNA, eval abdominal abscess
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
4) Spiral Acquisition 8.0 s, 62.6 cm; CTDIvol = 14.1 mGy (Body) DLP = 880.1
mGy-cm.
Total DLP (Body) = 890 mGy-cm.
COMPARISON: CT torso without contrast ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. A stent is noted in the LAD, and severe mitral
annulus calcifications are again seen. The heart, pericardium, and great
vessels are within normal limits. No pericardial effusion is seen. Patient is
status post left lumpectomy with postsurgical changes again noted in the left
breast. The study is not tailored for evaluation of breast tissue and
evaluation should be correlated with mammography. Right chest port terminates
in the right atrium.
AXILLA, HILA, AND MEDIASTINUM: Postsurgical changes in the left axillary
region is similar to prior. No supraclavicular, axillary, mediastinal, or
hilar lymphadenopathy is present.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Stable post radiation changes are noted in the left upper lobe
in the lingular region. There is bibasilar atelectasis. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck demonstrates an
atrophic thyroid gland.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
There is trace fluid anterior and along the medial aspect of the liver.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is mild left hydronephrosis with a punctate 2 mm stone in the
left ureteral vesicular junction (2; 106). There is symmetric bilateral
nephrograms. No focal lesions are identified. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Patient is status post
distal gastrectomy with a gastrojejunostomy. There are multiple locules of
extraluminal air with significant adjacent edema and fluid noted adjacent to
the blind ending duodenal anastomosis concerning for dehiscence of the
anastomosis. These locules of extraluminal air appear to abut the proximal
jejunum, (2; 53), though evaluation for fistula is limited without oral
contrast. The colon and rectum are within normal limits. The appendix is
normal.
PELVIS:
The urinary bladder is unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Patient is status post hysterectomy. No adnexal
abnormalities are seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Status post distal gastrectomy with gastrojejunostomy. Locules of air
adjacent to the line ending duodenal anastomosis is concerning for dehiscence.
However evaluation is limited without oral contrast.
2. There is mild left hydronephrosis with likely a 2 mm obstructing left UVJ
stone.
3. No evidence of pneumonia. Stable post treatment changes are noted in the
left upper lobe.
NOTIFICATION: The updated findings were discussed with Dr. ___. by
___, M.D. on the telephone on ___ at 9:18 am.
Radiology Report
EXAMINATION: BLADDER US
INDICATION: ___ year old woman with 2mm obstructing stone with mild
hydronephrosis.// Ureteral jet? Completely obstructing?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and
bladder were obtained.
COMPARISON: The report from the CT chest abdomen and pelvis ___
FINDINGS:
The bladder is normal in appearance. The known left UVJ stone is not
visualized. Bilateral ureteral jets are visualized, however the left ureteral
jet is somewhat diminutive in appearance compared to the right.
Prevoid volume of the bladder is 432 cc.
Postvoid volume of the bladder is 92 cc.
IMPRESSION:
Bilateral ureteral jets were identified, however the left ureteral jet is
somewhat diminutive when compared to the right.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with hx/cancer, lactate 10 and SOB c/f PE.//
Clots?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ with PMH of gastric adenoCa s/p subtotal gastrectomy,Bilroth
II reconstruction ___ on ___ now admitted to MICU for sepsis with GNR
bacteremia. Previous UVJ stone seen.// Eval for presence of previous stone or
if passed, given concern for persistent nidus of infection
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 3.4 s, 53.7 cm; CTDIvol = 6.4 mGy (Body) DLP = 343.6
mGy-cm.
Total DLP (Body) = 344 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. Severe mitral annular
calcifications are again seen. Trace pericardial fluid is unchanged. There is
no evidence of pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is hepatic steatosis. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
contains contrast vicariously excreted from prior examinations, but is
otherwise unremarkable. Fluid previously seen along the anterior and medial
aspect of the liver is not well visualized on this noncontrast study.
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. Scattered hyperdensity
within the cortex of the interpolar region of the right kidney is likely
contrast from the prior study. There is no evidence of focal renal lesions
within the limitations of an unenhanced scan. Mild left hydronephrosis is less
prominent than prior. There is no nephrolithiasis. Interval increase in small
volume left perinephric fluid may suggest forniceal rupture.
GASTROINTESTINAL: There is a small hiatal hernia. Patient is status post
Billroth 2 procedure. Few locules of air anterior to the liver persist and
likely represent air within jejunal loops in the region of
hepaticojejunostomy. Small bowel loops otherwise demonstrate normal caliber
and wall thickness throughout. The colon and rectum are within normal limits.
The appendix is normal.
PELVIS: The urinary bladder contains contrast from prior studies. The distal
left ureter is mildly dilated. A 3 mm stone is again seen in the left UVJ
(2:156). There is trace free fluid in the pelvis.
REPRODUCTIVE ORGANS: Patient is status post hysterectomy. No adnexal
abnormality is seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: A punctate hyperdensity just outside the anterolateral aspect of the
psoas muscle (2:110) is outside the confines of the ureter and likely
represents a phlebolith. There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Postsurgical changes are again seen along the midline anterior
abdominal wall.
IMPRESSION:
1. Persistent 3 mm obstructing left UVJ stone with associated mild left
hydroureteronephrosis. Interval increase in left perinephric fluid is
nonspecific but may suggest forniceal rupture.
2. Retained contrast from prior study within the right kidney is nonspecific,
although a component of pyelonephritis is difficult to exclude.
3. Redemonstration of locules of air anterior to the liver are favored to
represent intraluminal air within jejunal loops in the region of
hepaticojejunostomy rather than sequela of anastomotic dehiscence.
4. Trace pericardial effusion.
NOTIFICATION: Findings discussed with ___, MD by ___, MD
via telephone at 15:02 on ___.
Radiology Report
INDICATION: ___ year old woman with obstructing left ureteral stone and
sepsis// Eval for urgent PCN placement
COMPARISON: CT from the same day
TECHNIQUE: OPERATORS: Dr. ___ and ___, attendings
Interventional Radiologist performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 92 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: 15 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 12 min, 34 mGy
PROCEDURE: 1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. Left 8.5F 22cm PCNU placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The left flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. The access
proved difficult due to non-dilated collecting system, however, eventually it
was successful. Ultrasound images of the access were stored on PACS. Prompt
injection of a small amount of contrast outlined a dilated renal collecting
system. Under fluoroscopic guidance, a Headliner wire was advanced into the
renal collecting system. After a skin ___, the needle was exchanged for an
Accustick sheath. Once the tip of the sheath was in the collecting system; the
sheath was advanced over the wire, inner dilator and metallic stiffener. The
wire and inner dilator were then removed and diluted contrast was injected
into the collecting system to confirm position. A ___ wire was advanced
through the sheath into the ureter and into the bladder. The sheath was then
removed and a 8.5 ___ nephroureterostomy tube was advanced into the
bladder. The wire was then removed and the pigtail was formed in the
collecting system. Contrast injection confirmed appropriate positioning. The
catheter was then flushed, 0 silk stay sutures applied and the catheter was
secured with a Stat Lock device and sterile dressings. The catheter was
attached to a bag.
Patient tolerated procedure well. There were no immediate complications.
FINDINGS:
Obstructing UVJ stone. No hydronephrosis, mild hydroureter.
IMPRESSION:
Successful placement of 8.5F x 22 cm nephroureterostomy on the left.
Radiology Report
INDICATION: ___ year old woman with gastric cancer s/p chemo and resection,
now with bacteremia and obstructed renal stone/urosepsis- discussed with
ID/outpatient oncologist, would like port removed as there are no current
plans for further chemo.// remove port
COMPARISON: CT chest with contrast ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 12 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: 0, 0 mGy
PROCEDURE:
1. Right chest Port-a-Cath removal.
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
After a scout image, the port site was incised along the suture line down to
the subcutaneous fat. Blunt dissection was used to free the port. The port
was then removed. The subcutaneous pocket was closed in layers with ___
interrupted and ___ subcuticular continuous Vicryl sutures. Steri-Strips were
applied over the sutures. Final spot fluoroscopic image was obtained.
FINDINGS:
Final fluoroscopic image showing complete removal of the port.
IMPRESSION:
Successful removal of a right upper chest port.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Severe sepsis with septic shock
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: c
level of acuity: 1.0 | Ms. ___ is a ___ woman with breast cancer status
post lumpectomy followed by chemoradiation treatment at ___,
Graves' disease status post radioactive ablation and subsequent
hypothyroidism, CAD status post stent placement at ___ in ___
and recent diagnosis of T3 N2 MX gastric adenocarcinoma status
post gastric surgery on ___, at ___, presenting with SOB,
found to have obstructing L-UVJ stone. She was found to have
high grade GNR bacteremia, likely urosepsis. She got a
percuataneous nephrostomy on ___. She was stabilized and
transferred to the medical floor, where she underwent removal of
port and transition to PO cipro with assistance from ID team.
ACUTE ISSUES
===============
# Septic Shock
# Urosepsis
# UVJ stone
Patient initially presented with nausea, vomiting and lactic
acidosis. She required pressors in the intensive care unit.
Initial UA was unremarkable. CT imaging suggested duodenal
anastomosis dehiscence and left UVJ stone as possible
etiologies. She was started on broad spectrum antibiotics. Blood
and urine cultures grew Enterobacter. It was felt that urinary
source was most likely cause. She was taken for decompression
with ___ on ___, at which time a left PCNU was placed. A
routine TTE was performed due to bacteremia; it was
unremarkable. ID was consulted for further management
recommendations. Her initial regimen of daily cefepime and chemo
port gentamicin locks were transitioned to PO cipro once her
chemo port was removed (with permission from her ___
obcologist). She is planned for a two week course starting from
first date of negative blood cultures (___). Her nephrostomy
was capped on ___ with subsequent appropriate urine output and
no pain or fever to suggest inadequate drainage through the
remaining portion of the PCNU. She will follow up with radiology
for further management of PCNU, and will then see urology for
further management of UVJ stone.
# Duodenal anastomosis concerning for dehiscence
# History of gastric cancer
Surgery evaluated imaging, appeared largely unchanged. Patient
initially covered broadly with cefepime, vancomycin, and flagyl.
Surgery had very low suspicion for intraabdominal source of
infection. CT scan on ___ overall reassuring against sequelae of
dehiscent anastomosis. Antibiotics narrowed to cover
Enterobacter. Patient should follow up with her GI surgeons at
___, as well as her oncologist for gastric cancer at ___ for
further management. We called her oncologist, Dr. ___,
who agreed to removal of the chemo port in the setting of
bacteremia. It was removed on ___.
# ___ (baseline 0.5, currently Cr 1.5), resolved
# Mild hydronephrosis ___ UVJ obstructing stone.
Patient was found to have an ___ was likely due to her
sepsis. Reassuringly, renal U/S shows b/l ureteral jets, however
right greater than left. Patient had ___ guided percutaneous
nephrostomy. Infection treated as per above. Creatinine improved
to 0.4 at time of discharge.
# Asymptomatic supraventricular tachycardia
Patient was dyspneic on admission and found to be in SVT, which
was the likely cause for her dyspnea. She reports having a
history of SVT, but has always been asymptomatic. Arrhythmia was
likely triggered by acute illness. Troponins were negative.
Cardiology was consulted and patient was started metoprolol. She
developed another episode and metoprolol dose was increased to a
total of 50 mg daily. She continued to have occasional episodes
of self-terminating SVT lasting < 2 minutes that were
asymptomatic. She was sent home with a ZIO patch and plan for
follow up with ___ cardiology for further management.
# Hypothyroidism
TSH was 72, although was 30 on repeat test same day. Suspected
component of medication noncompliance or potentially
malabsorption due to vomiting. Clinically does not seem to be
profoundly hypothyroid. We restarted levothyroxine 150mcg daily.
Patient was counseled on how to take levothyroxine before meal
time to improve absorption.
# Anemia
Admission hemoglobin was 10, and by date of discharge it had
slowly decreased to 7.5. She had no clinical signs of bleeding
and was HD stable. Most likely to be related to her sepsis and
inflammation. Recommend close outpatient follow-up.
========================
TRANSITIONAL ISSUES
========================
[ ] PCP: ___ thyroid function studies (___) and CBC
(at follow-up PCP ___. Patient was hypothyroid due to
misunderstanding on proper use of levothyroxine. She also
developed anemia in setting of sepsis.
[ ] Continue cipro, plan for total of two week course (___).
[ ] Follow up with cardiology for evaluation of ZIO patch and
episodes of asymptomatic SVT
[ ] Exchange of left PCNU for PCN and anterograde nephrostogram
with ___ in ___ weeks. If there is adequate antegrade flow with
no evidence of obstruction/stone, ___ will cap PCN. If there is
inadequate antegrade flow, ___ will leave PCN to gravity.
[ ] Follow up with urology 2 weeks after ___ appointment for
non-contrast CT abd/pelv to evaluate persistence of stone.
Further intervention or PCN plan will be determined based on
that.
#CODE STATUS: Full code
#EMERGENCY CONTACT: ___
Relationship: SON
Phone: ___
>30 minutes spent in patient care and coordination of discharge
on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. ___ is a ___ yo woman with history of ESRD (s/p LURT
___ on cyclosporine, prednisone 5 mg daily), anemia, CAD s/p
___ 4 (most recently ___, HFrEF (EF ~40%), IPMN (___),
HTN,
T1DM complicated by neuropathy, retinopathy, neurogenic bladder
(intermittent straight catheterization), autonomic dysfunction
and h/o multiple UTIs(Klebsiella, E.coli, Enterococcus), OSA,
recent ischemic stroke, and scleroderma/CREST who presents to
the
ICU with altered mental status requiring intubation in the
emergency department.
Per her sisters, the pt has not been at her mental baseline
since
her recent discharge from the hospital. She had previously been
using a rolling walker, but instead was now using Hoyer lifts.
Per the sisters, pt had also recently started on linezolid for
presumed UTI a few days prior to presentation.
The patient was seen by her cardiologist (Dr ___ in
clinic on the day of presentation (___) and was found to by
hypotensive to 78/58 and was thought to be cool on exam. Her
mental status at the office visit was "falling asleep in the
wheel chair with no response to questions and intermittently
opening eyes." The patient was urgently referred to the
emergency
department.
She presented to ___ and ___ pressures had
spontaneously
improved to 169/90. She was promptly transferred to ___.
In the ED, the ED resident reports her initial exam was notable
for disconjugate gaze and LUE rigidity as well as marked
obtundation. She was hypoxemic to 89%. She was intubated for
airway control and code stroke was called. She was briefly
started on nifedipine drip due to concern for ICH. CT showed no
acute changes, but global volume loss and changes consistent
with
known prior strokes. The blood glucose on her chemistry panel
was
34.
It was then recognized that her L hemiparesis is from a recent
stroke.
Labs as below. Her urine from ___ was positive for
nitrites, leuk esterase, and WBC and she was started on
linezolid. She was then transferred to the ICU.
Of note, she had been seen extensively by palliative care during
her last admission and recently as an outpatient. She has been
having some functional decline for several months to years, and
at one point considered enrolling in hospice.
In the ED,
- Initial Vitals:
T 98.2 HR75 BP171/82 RR18 97% RA
- Exam: per ED resident, initial exam with disconjugate gaze,
LUE rigidity.
- Labs:
143 / 104 / 87
--------------<34 AGap=18
4.4 / ___ / 4.0
Wbc 6.4 Hgb 8.6 plt 103
Lactate:1.2
UA here: Large leuks, large blood, positive nitrites, > 50 WBC,
many bacteria
- Imaging:
1. No acute intracranial process.
2. Redemonstration of multiple chronic infarcts, global
parenchymal volume loss and sequela of chronic small vessel
disease.
3. Unchanged moderate paranasal sinus disease.
- Consults: Renal Transplant
- Interventions:
___ 22:20 IV Dextrose 50% 25 gm
___ 02:00 IV Etomidate 20 mg
___ 02:00 IV Succinylcholine 100 mg
___ 02:25 IV Dextrose 50% 25 gm
___ 03:17 IV DRIP NiCARdipine ___ mcg/kg/min ordered)
___ 03:17 IV DRIP Fentanyl Citrate ___ mcg/hr ordered)
___ 03:17 IV DRIP Propofol ___ mcg/kg/min ordered)
___ 03:21 IV Linezolid ___ mg ___
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Dysautonomia
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
-Non convulsive status epilepticus
-stroke
-BPPV
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.8 HR 81 BP 152/59 100% on FiO2 40%, CMV ___
GEN: intubated and sedated
EYES: anicteric
HENNT: poor dentition, ETT in place
CV: RRR with ___ at LUSB
RESP: Anterior lung fields are clear
GI: Soft and non-distended
SKIN: LLQ bruise and vaginal winer
NEURO: non-responsive, not following commands
DISCHARGE PHYSICAL EXAM:
VS: ___ 0729 Temp: 98.2 PO BP: 125/59 L Lying HR: 78 RR: 18
O2 sat: 96% O2 delivery: Ra
GEN: NAD, appears comfortable, sitting up in bed,
LUNGS: CTAB
HEART: RRR, nl S1, S2. III/VI SEM
EXTREMITIES: Trace ___ edema. WWP. tenderness on palpation of the
left forearm. Multiple wounds on ___ with eschar (lateral Rt and
Lt thigh the worst), improving from previously
NEURO: AOx2-3, no spontaneous conversation but answers
appropriate with elaborate answers
Pertinent Results:
ADMISSION LABS
===============
___ 08:54PM BLOOD WBC-6.4 RBC-2.52* Hgb-8.6* Hct-27.5*
MCV-109* MCH-34.1* MCHC-31.3* RDW-13.5 RDWSD-54.4* Plt ___
___ 01:15AM BLOOD ___ PTT-28.2 ___
___ 08:54PM BLOOD Glucose-34* UreaN-87* Creat-4.0* Na-143
K-4.4 Cl-104 HCO3-21* AnGap-18
___ 01:15AM BLOOD ALT-23 AST-21 CK(CPK)-158 AlkPhos-84
TotBili-0.5
___ 07:49AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.1
___ 01:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:30AM BLOOD ___ pO2-64* pCO2-43 pH-7.35
calTCO2-25 Base XS--1
___ 09:09PM BLOOD Lactate-1.2
___ 01:30AM BLOOD Glucose-52* Creat-4.1* Na-139 K-4.3
Cl-108 calHCO3-23
___ 01:30AM BLOOD O2 Sat-86
DISCHARGE LABS
===============
___ 06:20AM BLOOD WBC-8.7 RBC-3.14* Hgb-10.1* Hct-32.7*
MCV-104* MCH-32.2* MCHC-30.9* RDW-19.4* RDWSD-73.3* Plt ___
___ 06:02AM BLOOD ___ PTT-29.8 ___
___ 10:27AM BLOOD Glucose-155* UreaN-55* Creat-2.7* Na-146
K-5.1 Cl-107 HCO3-27 AnGap-12
___ 06:20AM BLOOD ALT-5 AST-10 AlkPhos-104 TotBili-0.2
___ 06:02AM BLOOD Cyclspr-65*
OTHER RELEVANT LABS
===================
___ 7:54 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
RARE GROWTH Commensal Respiratory Flora.
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
Piperacillin/Tazobactam test result performed by ___
___.
Levofloxacin REQUESTED BY ___ (___) ON ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFTAZIDIME----------- =>___ R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 2:30 am URINE
URINE CULTURE (Preliminary):
PSEUDOMONAS AERUGINOSA.
>100,000 CFU/mL OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam test result performed by ___
___.
Levofloxacin Susceptibility testing requested per ___.
___
(___), ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
___ 8:20 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 10:35 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
Piperacillin/Tazobactam test result performed by ___
___.
cefepime test result confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 8 S
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES
================
___ MRI
1. No acute infarct or intracranial hemorrhage.
2. Numerous late subacute to chronic infarcts, as previously
seen.
3. Chronic microvascular angiopathy changes.
4. Moderate paranasal sinus disease, as above.
___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because
of diffuse background slowing indicative of mild to moderate
encephalopathy,
nonspecific as to etiology. Common causes include
toxic/metabolic
disturbances, medication effects and/or infection. Frequent
generalized
epileptiform discharges with a frontal predominance are
indicative of diffuse
cortical irritability. There are no electrographic seizures
___ US
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CXR
Unchanged left pleural effusion with associated atelectasis. No
new focal
consolidations.
___ Lumbar XR
No previous images. The vertebra, intervertebral disc spaces,
and alignment
are essentially within normal limits with minimal hypertrophic
spurring. No evidence of compression fracture.
Extensive vascular calcification.
___ CXR
Interval decrease in extent of pulmonary vascular congestion.
No new
consolidation. Persisting retrocardiac opacities likely
reflecting
atelectasis/consolidation and pleural fluid.
___ RUQUS
No ascites.
Pancreatic cystic lesions as seen previously.
Left pleural effusion.
================
PATHOLOGY
Skin, right thigh ___:
___ Mild dermal sclerosis and fat necrosis (see comment).
Comment. Sections show a small punch biopsy consisting of
epidermis, dermis and minimal
subcutaneous fat. The histologic changes are not well developed
nor are they specifically diagnostic.
There is mild dermal sclerosis, minimal perivascular lymphocytic
inflammation and mild fat necrosis
at the biopsy base. Definitive vascular, perivascular or
perieccrine calcification to support a
diagnosis of calciphylaxis is not identified on ___ stains
(performed x 3). Intravascular thrombi
are not seen on multiple routine stains taken through the entire
tissue block, or on a PAS stain.
Given the possibility that this small and relatively superficial
biopsy is not representative of
immediately adjacent or underlying pathology, if there is
continuing concern for calciphylaxis a
repeat biopsy to include the subcutaneous fat may yield
additional information. Correlation with the
clinical findings is suggested.
Preliminary case findings discussed with Dr. ___
team by Dr. ___ on ___ and
___, respectively.
.
Final case findings sent by ___ internal email to Dr. ___
___ by Dr. ___ on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
6. Divalproex (DELayed Release) 750 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS
8. LevETIRAcetam 250 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Mycophenolate Mofetil 500 mg PO BID
12. Pravastatin 30 mg PO QPM
13. PredniSONE 5 mg PO DAILY
14. Senna 8.6 mg PO BID
15. Sodium Bicarbonate 650 mg PO BID
16. HydrALAZINE 50 mg PO TID
17. Metoprolol Succinate XL 50 mg PO DAILY
18. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTUES
19. Multivitamins 1 TAB PO DAILY
20. melatonin 10 mg oral QHS
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
22. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
23. Aspart 5 Units Breakfast
Aspart 5 Units Dinner
Detemir 16 Units Breakfast
Detemir 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
24. Omeprazole 40 mg PO DAILY
25. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
Pain - Mild
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Doses
Last dose on ___. Fosfomycin Tromethamine 3 g PO 1X/WEEK (WE)
4. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #*6
Capsule Refills:*0
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
6. Isosorbide Dinitrate 20 mg PO TID Duration: 2 Doses
7. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
8. Metoprolol Tartrate 25 mg PO Q6H Duration: 1 Dose
9. Modafinil 200 mg PO DAILY
RX *modafinil 200 mg 1 tablet(s) by mouth QAM Disp #*3 Tablet
Refills:*0
10. Mupirocin Ointment 2% 1 Appl TP TID
11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
Hold for sedation and RR<10
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Torsemide 20 mg PO DAILY
15. TraMADol 50 mg PO TID
RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp
#*9 Tablet Refills:*0
16. Allopurinol ___ mg PO EVERY OTHER DAY
17. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT
18. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
19. Glargine 2 Units Breakfast
Glargine 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
20. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
21. Metoprolol Succinate XL 100 mg PO DAILY
1st dose ___ @ 10PM
22. Aspirin 81 mg PO DAILY
23. Calcitriol 0.25 mcg PO DAILY
24. Divalproex (DELayed Release) 750 mg PO BID
25. HydrALAZINE 50 mg PO TID
26. LevETIRAcetam 250 mg PO BID
27. Levothyroxine Sodium 125 mcg PO DAILY
28. Lidocaine 5% Patch 1 PTCH TD QAM
29. melatonin 10 mg oral QHS
30. Multivitamins 1 TAB PO DAILY
31. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
32. Omeprazole 40 mg PO DAILY
33. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
34. Pravastatin 30 mg PO QPM
35. PredniSONE 5 mg PO DAILY
36. Senna 8.6 mg PO BID
37. Sodium Bicarbonate 650 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
=================
Acute complicated Pseudomonal UTI
Sepsis
Ventilator-associated PNA
SECONDARY DIAGNOSIS:
===================
Acute toxic-metabolic encephalopathy
Subacute-on-chronic renal failure
ESRD
T1DM
Hypertension
Microcytic anemia
Thrombocytopenia
CAD
Gout
Hypothyroidism
GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST ___
INDICATION: Suspected stroke with acute neurological deficit.// Please
exclude ICH, signs of early ischemic stroke, large vessel occlusion, or other
vascular abnormality.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT ___.
___ noncontrast brain MRI/MRA.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
mass effect. The ventricles and sulci are prominent in keeping with
age-related involutional change. Moderate periventricular and subcortical
white matter hypodensities are nonspecific, but likely represent sequela of
chronic ischemic microvascular disease. Re-demonstrated are chronic infarcts
involving the right superior frontal gyrus, right caudate lobe, right
thalamus, right internal capsule, right pons and left cerebellum. Basal
ganglial calcifications are unchanged. Dense atherosclerotic calcifications
in the bilateral intracranial carotid arteries are noted.
No acute fractures are seen. Re-demonstrated is partial opacification of the
bilateral ethmoid air cells, right frontal sinus and left sphenoid sinus.
Mild mucosal thickening is seen in the left maxillary sinus and the right
sphenoid sinus. Otherwise, the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality. Please note MRI of the brain is more
sensitive for the detection of acute infarct.
2. Redemonstration of multiple chronic infarcts, global parenchymal volume
loss and sequela of chronic small vessel disease.
3. Grossly stable moderate paranasal sinus disease.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: History: ___ with intubated// intubated
COMPARISON: Multiple prior chest radiographs dating back to ___, most recently ___.
FINDINGS:
Serial AP portable supine views of the chest provided.
There has been interval placement of an endotracheal tube with tip projecting
approximately 2.4 cm above the level of the carina. A nasogastric tube
courses below the level of diaphragm and continues out of view the current
study. Surgical clips project over the right upper quadrant, likely related
to prior cholecystectomy.
Lung volumes are again slightly low bilaterally. There is no focal
consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette
appears borderline in size, although this is likely exaggerated by low lung
volumes and the AP technique. No acute osseous abnormalities are detected.
IMPRESSION:
1. Interval placement of an endotracheal tube with tip projecting
approximately 2.4 cm above the level of the carina.
2. A nasogastric tube appears to be in appropriate position.
3. No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with previous ischemic stroke, ESRD s/p kidney
transplant, recurrent UTIs here with AMS requiring intubation// eval for
stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head without contrast ___
MRI head without contrast ___.
FINDINGS:
Multiple hyperintensities are seen on diffusion-weighted imaging without
hypointense signal on the ADC map. These were seen on the prior MRI and
likely represent late subacute infarcts. No new infarcts are seen.
Old infarcts are seen in the left cerebellum, left brachium pontis, right
pons, right corona radiata, right frontal lobe and right parasagittal parietal
lobe, at the vertex.
Punctate microhemorrhages are re-demonstrated in the pons, unchanged.
The ventricles and sulci are prominent, consistent with global cerebral volume
loss. Confluent periventricular T2 hyperintensities are most consistent with
chronic microvascular angiopathy. There is moderate mucosal thickening of the
frontal, ethmoid and sphenoid sinuses. The mastoid air cells are clear. The
intraorbital contents are normal. The flow voids are unremarkable.
IMPRESSION:
1. No acute infarct or intracranial hemorrhage.
2. Numerous late subacute to chronic infarcts, as previously seen.
3. Chronic microvascular angiopathy changes.
4. Moderate paranasal sinus disease, as above.
Radiology Report
EXAMINATION: MRA NECK W/O CONTRAST T9714 MR NECK
INDICATION: ___ year old woman with previous ischemic stroke, ESRD s/p kidney
transplant, recurrent UTIs here with AMS requiring intubation// no contrast!-
eval for stroke/athero
TECHNIQUE: Axial T1 weighted fat saturated imaging was performed through the
neck. Two dimensional time-of-flight MRA was performed without contrast
administration.
Three dimensional maximum intensity projection images were generated. This
report is based on interpretation of all of these images.
COMPARISON: MRA neck ___.
FINDINGS:
The common, internal and external carotid arteries appear normal. There is no
evidence of stenosis by NASCET criteria. The origins of the great vessels,
subclavian, and vertebral arteries appear normal bilaterally. The common
carotid bifurcations appear normal.
IMPRESSION:
1. Normal neck MRA.
Radiology Report
INDICATION: ___ year old woman with complicated history now with UTI and
intubation from an encephalopathy standpoint// please eval for sign of
consolidation
COMPARISON: Radiographs from ___
IMPRESSION:
Tip of the endotracheal tube is 3 cm above the carina. There is a nasogastric
tube whose tip and side port are within the body of the stomach. There is a
left retrocardiac opacity and left-sided pleural effusion, stable. No
pneumothoraces are seen. Overall, there has been no appreciable change.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old woman with left LURT now here with UTI and concern
for new source of infection// please eval for signs of stone
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Transplant ultrasound ___.
FINDINGS:
The left iliac fossa transplant renal morphology is normal. Specifically, the
cortex is of normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection. Small volume ascites is
seen.
No definite diastolic flow is seen within the intrarenal arteries, as on
prior. The main renal artery demonstrates prompt systolic upstroke, but
absent diastolic flow, with peak systolic velocity measuring approximately 54
centimeters/second, previously 79 centimeters/second. Vascularity is
symmetric throughout transplant. The transplant renal vein is patent and shows
normal waveform.
IMPRESSION:
1. Redemonstration of absent diastolic flow within the intrarenal and main
renal arteries, concerning for renal transplant dysfunction.
2. Small volume ascites, partially imaged.
Radiology Report
EXAMINATION: Chest radiograph, portable AP semi-upright.
INDICATION: PICC line placement.
COMPARISON: Prior study from earlier on the same day.
FINDINGS:
PICC line extends as far as the right upper axilla but then reverses course
and proceed retrograde, terminating lateral to the field of view. Nasogastric
tube is been retracted somewhat but still terminates in the stomach. It may
be appropriate to advance the tube by 5-10 cm for better seating, if
clinically appropriate. No other definite short-term change.
IMPRESSION:
PICC line extends into the right axillary region with than reverses course,
tip not imaged. Mild retraction of nasogastric tube; it could be advanced by
at least 5 cm for better seating if needed clinically. No other change.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old woman with new LLE edema, swelling pain// R/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. Diffuse subcutaneous
edema of the lower extremity.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dyspnea, rhonchi// evaluate for infiltrate
TECHNIQUE: Single AP radiograph of the chest.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Moderate left pleural effusion is unchanged with associated atelectasis. No
right pleural effusion. Upper lung fields are clear without focal
consolidations. No pulmonary edema. Unchanged appearance of the
cardiomediastinal silhouette. No pneumothorax.
IMPRESSION:
Unchanged left pleural effusion with associated atelectasis. No new focal
consolidations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dyspnea, new O2 requirement// Evaluate for
pulmonary edema or new infiltrates
COMPARISON: Multiple prior chest radiographs dating back to ___,
most recently ___.
FINDINGS:
AP portable upright view of the chest provided.
Lung volumes are slightly decreased bilaterally with increased bronchovascular
crowding. There also appears to be worsening pulmonary vascular congestion
and edema. A moderate left pleural effusion appears unchanged. There is no
focal consolidation or pneumothorax. The cardiomediastinal silhouette is
mildly enlarged, similar to prior. Dense coronary artery calcifications are
noted. No acute osseous abnormalities are identified. Surgical clips project
over the right upper quadrant denoting prior cholecystectomy. A cardiac
device again projects over the left lung base.
IMPRESSION:
1. Low lung volumes with worsening pulmonary vascular congestion and edema.
2. Unchanged moderate left pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pulmonary edema// evaluate interval change
COMPARISON: Multiple prior chest radiographs dating back to ___.
FINDINGS:
AP portable upright view of the chest provided.
There has been interval improvement in pulmonary vascular congestion and
edema. A left pleural effusion has also slightly decreased in size. There is
no focal consolidation or pneumothorax. The cardiomediastinal silhouette is
mildly enlarged, unchanged.
IMPRESSION:
1. Interval improvement in pulmonary vascular congestion and edema.
2. Interval decrease in left pleural effusion.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old woman with complex medical hx with new back pain with
RLE neuropathy// Please assess for bony abnormality
IMPRESSION:
No previous images. The vertebra, intervertebral disc spaces, and alignment
are essentially within normal limits with minimal hypertrophic spurring. No
evidence of compression fracture.
Extensive vascular calcification.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dyspnea// evaluate for pulmonary edema
IMPRESSION:
In comparison with the study of ___, there again are relatively low lung
volumes with prominence of the cardiac silhouette and increasing pulmonary
vascular congestion. Left pleural effusion with volume loss in the lower
lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with worsening cough,// ? pulmonary edema or
infiltrate
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
An implantable loop recorder is again present. The size of the cardiac
silhouette is unchanged as well as left basilar opacities. There is no new
focal consolidation on the right. No pneumothorax. The degree of pulmonary
vascular congestion has decreased.
IMPRESSION:
Interval decrease in extent of pulmonary vascular congestion. No new
consolidation. Persisting retrocardiac opacities likely reflecting
atelectasis/consolidation and pleural fluid.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with encephalopathy// ? Cirrhosis, ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: Patient is status post cholecystectomy.
PANCREAS: There are two cystic lesions within the pancreas, one in the
uncinate process and in the body as seen on prior imaging measuring 2.2 x 1.7
x 2.3 and 2.0 x 1.5 x 1.2 cm respectively. The imaged portion of the pancreas
otherwise appears within normal limits, without masses or pancreatic ductal
dilation, with the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9.9 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney:
Left kidney:
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
Extensive arterial calcifications are noted.
Left pleural effusion is partially visualized.
IMPRESSION:
No ascites.
Pancreatic cystic lesions as seen previously.
Left pleural effusion.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT
INDICATION: ___ with history of poorly-controlled T1DM c/b ESRD s/p LURT on
immunosuppression c/b chronic allograft dysfunction, recurrent MDR UTI's, CAD
s/p DES x4, HFrEF (LVEF 40% in ___, scleroderma/CREST, prior ischemic
strokes c/b L hemiparesis, and HTN who was admitted to the MICU with acute
encephalopathy requiring intubation likely ___ Pseudomonal urosepsis, now
extubated and being transferred to the floor for ongoing management of
encephalopathy, now getting diuresed// LUE DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower 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.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cough// ? new infiltrates
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Continued enlargement of the cardiac silhouette without vascular congestion.
Retrocardiac opacification is again consistent with volume loss in left lower
lobe and pleural effusion. In implantable loop recorder is again seen
overlying the cardiac silhouette.
No evidence of acute focal pneumonia. However, given the size of the heart,
it would be very difficult to unequivocally exclude superimposed
aspiration/pneumonia in the appropriate clinical setting, especially in the
absence of a lateral view.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL
INDICATION: ___ with LUE swelling// Eval for DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The left basilic
vein is patent, compressible and show normal color flow. The left cephalic
vein is noncompressible and demonstrates no venous flow on color Doppler
imaging within the mid upper arm. This compatible with superficial thrombosis
and extends to the antecubital fossa.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Superficial thrombus within the left cephalic vein from the mid upper arm
to the antecubital fossa.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, on the telephone on ___ at 9:52 am.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Chest pain, Transfer
Diagnosed with Altered mental status, unspecified
temperature: 98.2
heartrate: 75.0
resprate: 18.0
o2sat: 97.0
sbp: 171.0
dbp: 82.0
level of pain: 4
level of acuity: 2.0 | SUMMARY:
___ poorly-controlled T1DM c/b ESRD s/p LURT on
immunosuppression c/b chronic allograft dysfunction, recurrent
MDR UTI's, CAD s/p DES x4, HFrEF (LVEF 40% in ___,
scleroderma/CREST, prior ischemic strokes c/b L hemiparesis, and
HTN who was admitted to the MICU with acute encephalopathy
requiring intubation likely ___ pseudomonal urosepsis, now s/p
antibiotic treatment for complicated UTI. She also developed a
ventilator associated pneumonia, which was treated with
antibiotics as below. She was then transferred to the medical
service for ongoing toxic metabolic encephalopathy, which slowly
improved by the time of discharge. She did develop volume
overload (in the setting of known CKD and HFmrEF) requiring IV
diuresis and was transitioned to PO diuresis. She also developed
worsening lower extremity pain, with thorough workup for
calciphyalxis including skin biopsy which was negative. She also
developed recurrent UTI with enterobacter, treated with
ciprofloxacin course to end ___. She will then transition to
fosfomycin qweekly with ID follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
Ms. ___ is a ___ yo woman with history of T2DM, HTN, HLD,
CAD s/p PCI and recent STEMI s/p balloon angioplasty of mLAD,
CKD, h/o CVA, and known lung nodules who was transferred for
chest pain.
Since discharge from ___ after admission
___
to ___ for STEMI s/p coronary angiogram with 100% re-stenosis of
mLAD that underwent ballon angioplasty. At that time she had
chest pain, troponins negative. Her discharge Hgb was 8.7,
creatinine 1.2, discharge weight 56.3kg (124 lbs), she was not
taking oral diuretics. Plan had been to continue both ASA and
Plavix indefinitely (beyond potential DAPT score guidance) given
the length of stented segment with small distal LAD runoff and
possibility of stent rethrombosis.
She has been recovering at home in ___, living with her
daughter. She has been having ___ visits throughout the week
with
no major issues reported until today. She reports taking all of
her medications as prescribed including aspirin and plavix, her
daughter helps with medications. She was scheduled to see Dr.
___ on ___.
In the ED...
- Initial vitals: T: 97.7 HR: 70 BP: 137/65 RR: 18 SO2: 98%
RA
- EKG: EKG: sinus, left axis, 1st degree AV block, LVH, TWI I
and
AVL, similar to prior
- POCUS: no effusion
- Labs/studies notable for: baseline anemia, creat: 1.0 Trop-T:
<0.01 x2
- Patient was given:
___ 19:44 PO Aspirin 243 mg
___ 20:03 SL Nitroglycerin SL .4 mg
___ 23:10 IV Heparin 700 units/hr
___ 23:11 IV Heparin 3500 Units
- Vitals on transfer: HR: 84 BP: 111/37 RR: 14 SO2: 98% RA
Case was discussed with ___ Cardiology attending, given
similarity in patient's symptoms compared to prior MI, as well
as
negative troponins during prior MI, she was thought to be high
risk for recurrent occlusion versus stenosis. Recommended
initiation of heparin drip, NPO for possible cath and admission
to ___ service.
On the floor, she confirms no chest pain from early this
afternoon, cannot recall receiving nitroglycerin in ED.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: 99% OM1, 90% LAD; STEMI
LAD ___
- ___: None
3. OTHER PAST MEDICAL HISTORY
Hernia, hiatal
Cranial nerve palsy
Spondylosis, cervical
DM (diabetes mellitus), type 2, uncontrolled, with renal
complications
Hypertension, essential
___
Macular edema due to secondary diabetes
Left ventricular outflow tract obstruction
Multiple lung nodules
ESR raised
Mitral regurgitation
Lumbar disc disease with radiculopathy
Urinary incontinence due to immobility
At high risk for falls
Chronic diastolic CHF (congestive heart failure)
CRD (chronic renal disease), stage III
Pure hypercholesterolemia
Chronic nonintractable headache
Chronic abdominal pain
Chronic mental illness
Insulin long-term use
Proliferative diabetic retinopathy of left eye with macular
edema associated with type 2 diabetes mellitus
Iron deficiency anemia
Coronary artery disease involving native coronary artery of
native heart with angina pectoris
Dizziness
Coronary stent thrombosis
Social History:
___
Family History:
No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death. Notes history of
asthma in several family members.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
================================
VS: 98.6 PO 133 / 70 R Lying 75 16 96 Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, soft pericardial friction rub, no murmurs,
gallops
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAMINATION
================================
VS: 24 HR Data (last updated ___ @ 1127)
Temp: 98.0 (Tm 98.5), BP: 134/61 (134-166/53-77), HR: 63
(61-67), RR: 16 (___), O2 sat: 95% (95-97), O2 delivery: Ra,
Wt: 120.1 lb/54.48 kg
GENERAL: In NAD
HEENT: Anicteric sclera, MMM
NECK: No JVD, no LAD
CV: RRR, S1/S2, no murmurs/gallops/rubs
PULM: CTAB, no crackles/wheezing/rhonchi
GI: Abdomen soft, nondistended, nontender
EXTREMITIES: Warm, no ___ edema
BACK: Diffuse lumbar spine tenderness, mostly paraspinal
NEURO: A&Ox3, CNII-XII intact, ___ strength in upper and lower
extremities, sensation to light touch intact bilaterally.
DERM: No visible rashes
Pertinent Results:
___ 07:51PM BLOOD WBC-7.8 RBC-3.56* Hgb-9.8* Hct-31.5*
MCV-89 MCH-27.5 MCHC-31.1* RDW-15.6* RDWSD-50.3* Plt ___
___ 07:51PM BLOOD ___ PTT-29.5 ___
___ 07:51PM BLOOD Glucose-69* UreaN-29* Creat-1.0 Na-134*
K-4.5 Cl-101 HCO3-22 AnGap-11
___ 07:51PM BLOOD ___ 07:51PM BLOOD cTropnT-<0.01
___ 11:00PM BLOOD cTropnT-<0.01
___ 04:16AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.2
___ 07:51PM BLOOD Iron-19*
___ 07:51PM BLOOD calTIBC-231* VitB12-698 Ferritn-97
TRF-178*
___ 07:51PM BLOOD CRP-108.8*
___ 04:16AM BLOOD CRP-139.1*
DISCHARGE LABS:
___ 07:24AM BLOOD WBC-4.4 RBC-3.40* Hgb-9.2* Hct-30.1*
MCV-89 MCH-27.1 MCHC-30.6* RDW-15.2 RDWSD-48.9* Plt ___
___ 07:24AM BLOOD Glucose-91 UreaN-42* Creat-1.3* Na-138
K-4.9 Cl-103 HCO3-22 AnGap-13
MRI L-spine ___:
IMPRESSION:
1. Findings stable since ___.
2. Changes at L3-L4, L4-5 level are most likely reactive. If
there is
clinical or laboratory concern for infection, follow-up imaging
in 2 weeks recommended.
3. Moderate to severe central canal narrowing L4-5 level.
4. Multilevel significant foraminal narrowing, as above.
Second read MRI L-spine ___ (from ___:
IMPRESSION:
1. Grade 1 spondylolisthesis at L4 over L5 due to disc and facet
degenerative changes with moderate-to-severe spinal stenosis and
severe bilateral foraminal
narrowing with compression of the thecal sac and bilateral
exiting L4 nerve roots. There is a linear enhancement within
the disc which could be seen with degenerative change and there
are no MRI signs suggestive of spondylodiscitis.
2. Multilevel degenerative changes at other levels including
bilateral severe foraminal narrowing at L5-S1 level and moderate
left-sided foraminal narrowing at L2-3 and L3-4 levels.
3. Scoliosis of lumbar spine.
TTE ___:
The left atrial volume index is normal. There is focal
hypertrophy of the basal anterior septum with a
normal cavity size. There is moderate regional left ventricular
systolic dysfunction with akinesis of the
distal ___ of the left ventricle (distal LAD territory; see
schematic) and preserved/normal contractility of
the remaining segments. No thrombus or mass is seen in the left
ventricle. Quantitative biplane left
ventricular ejection fraction is 36 %. There is is a moderate
(peak 35 mmHg) resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter. The
aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is mild [1+]
aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is valvular systolic anterior motion
(___). There is an eccentric, anteriorly directed jet of mild
[1+] mitral regurgitation. Due to the Coanda
effect, the severity of mitral regurgitation could be
UNDERestimated. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w distal LAD-territory
infarction. Moderate resting LVOT obstruction, secondary to
focal basal LVH with compensatory
hyperkinesis of the basal LV segments. Mild aortic
regurgitation. Mild mitral regurgitation.
Compared with the prior TTE ___, the left ventricular
systolic function is now more depressed.
Cardiac cath ___
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel and is normal. This vessel
bifurcates into the Left Anterior Descending and Left Circumflex
systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is
a 40% stenosis in the mid segment. Previously deployed stents in
mid-distal segment are widely patent
The Diagonal, arising from the proximal segment, is a medium
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel with mild luminal
irregularities.
The Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel. There is a 50%
stenosis in the distal segment.
The Atrioventricular Circumflex, arising from the mid segment,
is a medium caliber vessel.
The Superior lateral of the AVCx, arising from the distal
segment, is a medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a small caliber and non-dominant
vessel and is normal.
Complications: There were no clinically significant
complications.
Findings
Mild coronary coronary artery disease.
Recommendations
Maximize medical therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. ARIPiprazole 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Imipramine 25 mg PO QHS
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. LORazepam 0.5 mg PO BID:PRN anxiety
9. Losartan Potassium 25 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
12. Simethicone 80 mg PO QID:PRN abdominal pain
13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Glargine 15 Units Breakfast
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*3
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
3. ARIPiprazole 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Imipramine 25 mg PO QHS
8. Glargine 15 Units Breakfast
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. LORazepam 0.5 mg PO BID:PRN anxiety
11. Losartan Potassium 25 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
15. Simethicone 80 mg PO QID:PRN abdominal pain
16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Chest pain
Spinal stenosis
SECONDARY DIAGNOSIS
====================
Heart failure with reduced ejection fraction
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI LUMBAR SPINE OUTSIDE STUDY FOR SECOND OPINION.
INDICATION: ___ year old woman with h/o back pain and L4/5 spondylodiscitis
seen on prior ___ MR on ___ (report uploaded on at___ records) with
persistent inflammatory marker elevation// please re-read Spine MR ___
___ ___ (report is available on At___). please eval for infectious
vs non-infectious etiology
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
thoracic spine were acquired. T1 sagittal and axial images obtained following
gadolinium. Examination was performed at an outside institution. .
COMPARISON: No prior similar examinations.Correlation was made with the
lumbar spine CT of the same day ___
FINDINGS:
There is scoliosis of lumbar spine convex to the left side in the lower lumbar
region and to the right side in the upper lumbar region.
From T11-12 through L3-4 levels disc degenerative changes and bulging seen.
Moderate left foraminal narrowing is seen at L2-3 and L3-4 levels.
At L4-5 level, there is grade 1 spondylolisthesis of L4 over L5 with severe
facet degenerative changes and thickening of the ligaments resulting in
moderate-to-severe spinal stenosis and deformity of the thecal sac. There is
severe bilateral foraminal narrowing and compression of exiting L4 nerve roots
within the foramen. An incidental hemangioma is seen in the L4 vertebral
body. Mild endplate signal abnormalities are seen at L4 and L5 level.
Postcontrast images demonstrate linear enhancement in the anterior aspect of
the intervertebral disc. No paraspinal soft tissue abnormalities are seen.
No evidence of epidural or paraspinal abscess seen.
At L5-S1 level disc bulging and facet degenerative changes seen with bilateral
severe foraminal narrowing and compression of exiting L5 nerve roots within
the foramina right more pronounced than the left. There is no central canal
stenosis or compression of the thecal sac.
The distal spinal cord and paraspinal soft tissues are unremarkable.
IMPRESSION:
1. Grade 1 spondylolisthesis at L4 over L5 due to disc and facet degenerative
changes with moderate-to-severe spinal stenosis and severe bilateral foraminal
narrowing with compression of the thecal sac and bilateral exiting L4 nerve
roots. There is a linear enhancement within the disc which could be seen with
degenerative change and there are no MRI signs suggestive of spondylo
discitis.
2. Multilevel degenerative changes at other levels including bilateral severe
foraminal narrowing at L5-S1 level and moderate left-sided foraminal narrowing
at L2-3 and L3-4 levels.
3. Scoliosis of lumbar spine.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old woman with back pain and prior MR concerning for L4/5
spondylodiscitis with elevated CRP c/f possible infectious etiology// evaluate
for infection in lumbar spine evaluate for infection in lumbar spine
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: CT lumbar spine ___, MRI lumbar spine ___.
FINDINGS:
Grade 1 L4-5 anterolisthesis, degenerative in etiology. Edema L2, L3, L4, L5
vertebral bodies, most likely degenerative. Minimal paraspinal edema left
side L2-L3 level, right side L4-5 level, similar since ___.
Schmorl's nodes L3-L4, L4-5 levels. Mild linear edema anterior L4-5 disc
space, similar to prior.
Above findings are likely degenerative/reactive. Changes at L3-L4, L4-5 level
are most likely reactive/degenerative, with Schmorl's nodes, stable since
prior. Mild paraspinal edema, bit more prominent than typically seen with
degenerative change, and may be reactive from Schmorl's nodes. If there is
clinical or laboratory concern for infection, follow-up imaging in 2 weeks
recommended.
Other:
Multilevel degenerative changes lumbar spine multilevel diffuse disc bulges.
Advanced lumbar facet arthritis. Effusion left L4-5 facet joint, likely
reactive. Mild multilevel posterior element, paraspinal edema, likely
reactive. Normal visualized cord. Few benign hemangiomas. Paraspinal muscle
atrophy.
At L1-L 2, patent central canal, patent foramina.
At L2-L3, mild central canal narrowing. Mild right, moderate to severe left
foraminal narrowing, similar.
At L3-L4 level, patent central canal. Mild left foraminal narrowing, patent
right foramina.
At L4-5, moderate to severe central canal narrowing, near complete effacement
of CSF, similar. Prominent facet arthritis, diffuse disc bulge. Severe
bilateral foraminal narrowing, similar.
At L5-S1, mild central canal narrowing. Severe right, moderate to severe left
foraminal narrowing, similar.
IMPRESSION:
1. Findings stable since ___.
2. Changes at L3-L4, L4-5 level are most likely reactive. If there is
clinical or laboratory concern for infection, follow-up imaging in 2 weeks
recommended.
3. Moderate to severe central canal narrowing L4-5 level.
4. Multilevel significant foraminal narrowing, as above.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Back pain, Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.7
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 137.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
======================
Ms. ___ is a ___ yo woman with a history of CAD s/p PCI and
recent STEMI s/p balloon angioplasty of mLAD, HTN, DM2, CKD
stage III, h/o CVA, and known lung nodules who was transferred
for chest pain.
She was initially admitted to the cardiology service where
cardiac catheterization revealed patent LAD and mild diffuse
disease that does not explain her chest pain. TTE was done which
did not reveal any pericardial effusion but was notable for
reduced ejection fraction of 36% as well as moderate left
ventricular systolic dysfunction in the distal LAD territory.
CRP was noted to be markedly elevated at 139.1. She was briefly
on colchicine for concern of pericarditis, but this was
discontinued as her clinical picture was inconsistent with
pericarditis and her sxs did not improve with colchicine. Given
an exertional component to her pain she was also started on
nitrate for possible microvascular disease. Overall, it was felt
her chest discomfort was unrelated to her cardiac disease. She
had repeat imaging of her spine out of concern for infection on
imaging from prior admission, but there was no evidence of
discitis or osteomyelitis on MRI of the spine. Her chest and
back pain were well controlled with Tylenol, tramadol, and
lidocaine patch. Colchicine was discontinued given ultimately
low suspicion for pericarditis. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Briefly, Ms. ___ is a ___ h/o HTN, HLD, colonic adenomatous
polyp (last colonoscopy ___ who presents with abdominal pain
and BRBPR. Patient describes for the last ___ hours she has
had multiple bloody bowel movements. She describes these as
watery stools with large amounts of bright red blood including
blood clots. Last BM this AM which was bloody. No black stools.
No history prior to this of black or bloody stools. Denies
fevers, chills, nausea, vomiting, chest pain, shortness of
breath. Does have recent abx exposure (was treated for UTI). She
recently traveled to ___.
In the ED, initial vitals were: 99.4 99 158/88 17 100% RA
Exam notable for: RLQ tenderness to palpation, ?rebound, no
guarding, no masses. -rovsing's
Labs notable for:WBC 13.7 80% neutrophils, lactate 2.6 to 1.0,
UA + leuks few bacteria
Imaging was notable for: CT abd/pelvis: Extensive bowel wall
thickening and surrounding fat stranding of the ascending colon
without evidence of diverticular disease suggests an infectious
process in the appropriate clinical setting.
Stool studies ordered
Patient was given:
___ 14:39 IVF NS
___ 18:25 PO Acetaminophen 1000 mg ___ 19:52 PO/NG
___ Ciprofloxacin HCl 500 mg
___ 19:52 PO/NG MetroNIDAZOLE 500 mg
___ 21:13 PO/NG Aspirin 81 mg
___ 21:13 PO/NG Atorvastatin 20 mg
___ 21:13 PO Metoprolol Succinate XL 25 mg
Vitals prior to transfer: 99.0 82 142/70 16 98% RA
Upon arrival to the floor, patient reports feeling slightly
better. She returned from ___ on ___, had dysuria prior to
travelling and had been on an antibiotic. Given unresolved
symptoms, she returned to ___, who gave her another antibiotic
(unsure of name), most recent script appears to be
Nitrofurantoin, previously given Bactrim. On ___ she
describes "projectile" diarrhea, pink in color, with some blood,
which then has kept her up all night for the last 3 days. She
has had minimal food, no fevers/chills, feels bloating and
diffuse abdominal pain, mild tenderness on RLQ. She estimates
having ___ Bms/day, describes tenesmus. She has not eaten in 2
-3 days. She has no prior history of GI bleeding, had
colonoscopy in ___.
During my interview this morning, patient reports story as
above, and states still having explosive BM's, liquid, brown, no
longer bloody. No abdominal pain at rest. No upper GI symptoms.
Does report eating oysters on ___.
Past Medical History:
CAD (never had MI, has had stress test yearly, never
catheterization, strong family hx)
HTN
HLD
Social History:
___
Family History:
Sister passed away at age ___, unclear etiology but suspect heart
disease, mother had rheumatic heart disease. Father with CAD.
She describes all her uncles as having passed away before ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.3 133/84 76 18 96 Ra
General: well appearing, alert, oriented, no acute distress
HEENT: sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales
CV: regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: brown stool, guaiac +, multiple external hemorrhoids
Ext: warm, well perfused, 2+ pulses, no edema
DISCHARGE PHYSICAL EXAM
Vitals: 98.3 133/84 76 18 96 Ra
General: well appearing, alert, oriented, no acute distress
HEENT: sclera anicteric, dry mucous membranes, oropharynx clear
Lungs: clear to auscultation bilaterally, no wheezes, rales
CV: regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-distended, slightly tender in right side
without rebound or guarding
Rectal: brown stool, guaiac +, multiple external hemorrhoids
(performed ___
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 01:30PM BLOOD WBC-13.7* RBC-4.02 Hgb-13.2 Hct-39.1
MCV-97 MCH-32.8* MCHC-33.8 RDW-15.1 RDWSD-53.8* Plt ___
___ 01:30PM BLOOD Neuts-81.9* Lymphs-6.7* Monos-10.6
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.17* AbsLymp-0.92*
AbsMono-1.45* AbsEos-0.01* AbsBaso-0.03
___ 01:30PM BLOOD Plt ___
___ 01:30PM BLOOD Glucose-118* UreaN-9 Creat-0.6 Na-133
K-3.8 Cl-95* HCO3-27 AnGap-15
___ 01:30PM BLOOD ALT-66* AST-47* AlkPhos-83 TotBili-0.5
___ 01:30PM BLOOD Calcium-9.7 Phos-3.0 Mg-2.1
___ 03:02PM BLOOD Lactate-2.6*
MICRO
=====
___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-PRELIMINARY; FECAL CULTURE - R/O
VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE
- R/O E.COLI 0157:H7-FINAL EMERGENCY WARD
___ STOOL C. difficile DNA amplification
assay-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
IMAGING
=======
___ CT ABD/PELVIS
IMPRESSION: Acute colitis of the ascending colon, likely
infectious or inflammatory. No extraluminal air nor abscess
formation.
DISCHARGE LABS
==============
___ 07:27AM BLOOD WBC-13.4* RBC-3.76* Hgb-12.3 Hct-37.6
MCV-100* MCH-32.7* MCHC-32.7 RDW-15.1 RDWSD-56.3* Plt ___
___ 07:27AM BLOOD Plt ___
___ 07:27AM BLOOD Glucose-79 UreaN-4* Creat-0.5 Na-131*
K-4.9 Cl-98 HCO3-18* AnGap-20
___ 07:27AM BLOOD ALT-42* AST-41* AlkPhos-78 TotBili-0.5
___ 07:27AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
Radiology Report
INDICATION: ___ with RLQ pain/tenderness and significant amounts of BRBPR+PO
contrast// assess for diverticulitis, colonic ischemia
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 701 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is
extensive bowel wall thickening and fat stranding of the entire ascending
colon. There is no evidence of diverticulosis. The colon and rectum are
within normal limits. There is a very short appendix versus appendiceal stump
(601:22) which is within normal limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Multilevel degenerative changes of the visualized thoracolumbar spine
are noted. There is no evidence of worrisome osseous lesions or acute
fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Acute colitis of the ascending colon, likely infectious or inflammatory. No
extraluminal air nor abscess formation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Hemorrhage of anus and rectum
temperature: 99.4
heartrate: 99.0
resprate: 17.0
o2sat: 100.0
sbp: 158.0
dbp: 88.0
level of pain: 2
level of acuity: 2.0 | HOSPITAL COURSE
===============
___ h/o HTN, HLD, colonic adenomatous polyp (last colonoscopy
___ who presented with abdominal pain, and bloody diarrhea,
consistent with acute colitis. CT abdomen showing ascending
colitis with no diverticuli. Infectious etiology seemed most
likely diagnosis. C. diff negative.
Shigella/Salmonella/Yersinia/Vibrio on ddx, cultures sent and
pending at time of discharge. Patient improved symptomatically,
no longer having bloody stools and able to tolerate PO. Noted to
have increased LFTs and cerebellar signs on exam, on history
reported significant EtOH, counseled on EtOH use and started on
MVI/folate/thiamine.
ACTIVE ISSUES
=============
# Ascending colitis
# BRBPR: DDx included infectious diarrhea given recent travel,
antibiotic associated c.diff colitis vs diverticular bleeding/
AVM would be less likely. Mesenteric ischemia was on ddx given
bright red blood with initial RLQ tenderness, and initial
lactate elevation, although now improved, without any further
bleeding and most recent non bloody stool, minimal pain.
Infectious etiology possible given time set associated with abx
use for UTIs with prolonged course. Shigella/Salmonella/Yersinia
on ddx. Cultures send and patient discharged on 5 day course of
Cipro/Flagyl .
# Alcohol use disorder
# Transaminitis: Unknown baseline. No RUQ tenderness. On further
interview, patient with significant alcohol use likely
contributing to elevated LFTs. Patient counseled on alcohol use,
and should have LFTs checked at next PCP ___.
# +UA: recent UTI, received Bactrim and Nitrofurantoin,
continued antibiotics as above for colitis.
CHRONIC ISSUES
==============
# HTN/HLD: Continued metoprolol succinate 25, held statin in
setting of elevated LFTs but restarted on discharge.
# Primary prevention: Continued ASA 81.
# Hypothyroidism: Continued levothyroxine.
# Insomnia: Trazodone PRN
TRANSITIONAL ISSUES
===================
[] Continue Flagyl and ciprofloxacin for 5 days (last day
___
[] Continue MVI/thiamine/folate indefinitely
[] Follow up with PCP ___ as soon as possible
(___) to be seen within the next week
[] Recheck CBC, LFTs at next appointment to ensure stable or
trending right direction
[] Patient to be counseled on alcohol use disorder
# CONTACT: Husband (___) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
aphasia, left MCA stroke
Major Surgical ___ Invasive Procedure:
none
History of Present Illness:
___ with h/o hyperlipidemia, HTN presenting w/ confusion, R
sided facial weakness, severe dysarthria, mild-mod aphasia,
quadrantanopsia (R lateral inferior visual field cut), NIHSS 7.
Last reported well at 6:30pm when talking on the phone with his
son, 7 hours prior to arrival at ___. At that time he was
reportedly coherent, easy to understands. Earlier that day he
was playing golf with his friends until 2pm, none of whom
expressed any concern. Around midnight, patient showed up at his
daughter's house which is located about 1 mile away. It appeared
that he walked to the daughter's house, she noted him to have a
cut on his forehead and his pants were soiled over his knees as
if he has fallen to the knees. He was noted to have word finding
difficulty, he was pronouncing some words clearly, other words
seemed to be mumbled. He was also having difficulty w/ balance,
but was able to ambulate independently. EMS was called and
patient was taken to OSH where ___/CTA was notable for
occlusion in the M3 segment of L MCA. Patient was transferred
here for further evaluation.
Past Medical History:
HTN - remote history, previously on medications, now only
lifestyle modifications
Hyperlipidemia
Social History:
___
Family History:
FAMILY HISTORY: No known h/o stroke, bleeding ___ clotting
disorders. No h/o seizures.
Physical Exam:
ADMISSION:
PHYSICAL EXAMINATION
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles ___ wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to name and date of
birth, unable to state date, month, year, day of the week.
Displays perseverance. Continues to repeat 80 when asked about
date. Unable to relate history. Able to name months of the year
forwards, but unable to name ___ backwards. + Dysarthria.
Intermittently speech is fluent for some words, but at times
words are difficult to understand. Word finding difficulty. Able
to name all activities on the picture, but unable to name
objects on the following picture. When asked to name ___ glove, he
would continue describing what is happening on the previously
shown picture. Normal prosody. Unable to register/repeat 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. Possible left-right confusion - unable to follow
simple commands. Unable to follow both midline ___ appendicular
commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. Mild facial asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. Slight tremor b/l.
[Delt][Bic][Tri] [IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5
R 4+ 4+ 4+ 4+ 4+ 4+ 4+ 4 5
Patient not following commands, thus unable to assess finger
extension ___ flexion, ___.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, ___ proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
DISCHARGE:
General: Appears younger than stated age, sitting in chair with
daughter at bedside.
Lungs: breathing comfortably on room air
CV: well-perfused
Abd: soft, non-distended
Ext: non-edematous
Neuro exam:
Mental status: Alert, awake, regards examiner, participates with
exam. Expressive aphasia, speaks in ___ word sentences but did
say ___ "I hope so." Sings happy birthday fluently and
today he is able to substitute "Good morning to you" to tune.
Follows commands .
CN: Pupils 4->2 bilaterally. 4 beats of end-gaze nystagmus on
left lateral gaze, extinguishable. No nystagmus on right. Subtle
saccadic pursuit. Tongue protrusion midline. Palate elevation
symmetric. No facial weakness but subtle decrease in right NLF
at rest. Right visual field cut.
Motor: Deltoid, triceps 5 b/l. Biceps difficult to assess ___ BP
cuff. L: Hip flexor 5, Quad 5, hamstring 5. R Hip flex 4+.
hamstring 5
Reflexes: Deferred
Sensation: intact to light touch
Coordination: deferred
Gait: Walks with hesitancy with walker, able to maintain balance
while waving to me in the hall
Pertinent Results:
___ 06:15AM BLOOD WBC-7.7 RBC-4.67 Hgb-14.2 Hct-41.8 MCV-90
MCH-30.4 MCHC-34.0 RDW-12.3 RDWSD-40.2 Plt ___
___ 06:35AM BLOOD WBC-9.2 RBC-4.61 Hgb-14.4 Hct-41.6 MCV-90
MCH-31.2 MCHC-34.6 RDW-12.5 RDWSD-41.1 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-96 UreaN-24* Creat-1.0 Na-143
K-4.0 Cl-103 HCO3-25 AnGap-15
___ 01:55AM BLOOD Lipase-78*
___ 06:35AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1
___ 01:55AM BLOOD Triglyc-131 HDL-46 CHOL/HD-2.9 LDLcalc-62
___ 01:55AM BLOOD TSH-4.6*
___ 06:35AM BLOOD Free T4-1.0
IMAGING:
Imaging:
MRI/MRA Brain:
1. Acute infarcts within the vascular territory of the left
middle cerebral artery, with the most dominant area of
infarction within the left inferior parietal lobule. No
evidence of hemorrhagic transformation.
2. Loss of flow related enhancement within a left MCA M3 branch
as seen on CTA from the same date, and likely other more distal
areas of occlusion given the area of infarct.
3. Mild intracranial internal carotid artery atherosclerosis,
without
high-grade stenosis.
4. Additional findings described above.
RIGHT:
The right carotid vasculature has mild heterogeneous
atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is
58 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
right internal
carotid artery are 33, 50, and 55 cm/sec, respectively. The peak
end
diastolic velocity in the right internal carotid artery is 16
cm/sec.
The ICA/CCA ratio is 0.9.
The external carotid artery has peak systolic velocity of 73
cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has moderate heterogeneous
atherosclerotic
plaque.
The peak systolic velocity in the left common carotid artery is
75 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
left internal
carotid artery are 56, 42, and 39 cm/sec, respectively. The peak
end
diastolic velocity in the left internal carotid artery is 17
cm/sec.
The ICA/CCA ratio is 0.7.
The external carotid artery has peak systolic velocity of 82
cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Atherosclerotic plaque within both carotid arteries with less
than 40%
stenosis bilaterally.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
STOP IN 3 MONTHS (___)
4. Heparin 5000 UNIT SC BID
Re-evaluate per mobility in ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left MCA ischemic stroke
Discharge Condition:
Mental Status: Alert but aphasic, can sing what he means to
tunes sometimes
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with r mca stroke// eval vascular
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None.
FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 58 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 33, 50, and 55 cm/sec, respectively. The peak end diastolic
velocity in the right internal carotid artery is 16 cm/sec.
The ICA/CCA ratio is 0.9.
The external carotid artery has peak systolic velocity of 73 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has moderate heterogeneous atherosclerotic
plaque.
The peak systolic velocity in the left common carotid artery is 75 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 56, 42, and 39 cm/sec, respectively. The peak end diastolic
velocity in the left internal carotid artery is 17 cm/sec.
The ICA/CCA ratio is 0.7.
The external carotid artery has peak systolic velocity of 82 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Atherosclerotic plaque within both carotid arteries with less than 40%
stenosis bilaterally.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with stroke// ? Cardiomegaly
TECHNIQUE: Single frontal view of the chest
COMPARISON: None.
FINDINGS:
Cardiac size is normal. The lungs are clear. There is no pneumothorax or
pleural effusion. There are atherosclerotic calcifications of the aortic
arch.
IMPRESSION:
No acute cardiopulmonary abnormality
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: History: ___ with left MCA occlusion// eval for occlusion,
stenosis
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: ___ ___ head neck
FINDINGS:
MR BRAIN:
There is an acute infarct within the left inferior parietal lobule and other
smaller infarcts within the left superior parietal lobule, left posterior
frontal lobe, left occipital and left temporal lobes. There is mild
associated mass effect, however no midline shift. There is no evidence for
hemorrhagic transformation.
There is mild global parenchymal volume loss. Small areas of hyperintense
signal on T2/FLAIR within the subcortical and periventricular white matter
nonspecific, but likely reflect the sequela of mild chronic small vessel
disease.
There is mild diffuse paranasal sinus mucosal thickening. The orbits are
unremarkable.
MRA BRAIN: There is mild intracranial internal carotid artery atherosclerosis,
without high-grade stenosis.
Loss of flow related signal within a left M3 branch (series 10, image 109) is
consistent with thrombus as identified on CTA from earlier the same date.
There are likely other more distal areas of occlusion, however these are
difficult to assess with MR angiography. No new proximal arterial occlusion is
identified.
No aneurysm or vascular malformation is identified.
IMPRESSION:
1. Acute infarcts within the vascular territory of the left middle cerebral
artery, with the most dominant area of infarction within the left inferior
parietal lobule. No evidence of hemorrhagic transformation.
2. Loss of flow related enhancement within a left MCA M3 branch as seen on CTA
from the same date, and likely other more distal areas of occlusion given the
area of infarct.
3. Mild intracranial internal carotid artery atherosclerosis, without
high-grade stenosis.
4. Additional findings described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 98.0
heartrate: 94.0
resprate: 18.0
o2sat: 94.0
sbp: 192.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ year old man with h/o hyperlipidemia, hypertension who
presented with expressive aphasia, dysarthria, right-sided
facial weakness and right lateral inferior visual field cut,
found to have acute ischemic infarct in left M3 MCA, outside
window for tPA and not candidate for thrombectomy due to distal
location of clot. Imaging notable for an acute left MCA infarct
with mild intracranial ICA atherosclerosis and loss of flow
within left M3 MCA branch. Etiology likely secondary to
artery-to-artery occlusion vs cardio-embolic.
Stroke risk factors: HbA1C 5.4, LDL 62
He had no irregular events on telemetry during his hospital
course.
His exam was notable for expressive aphasia with some conductive
aphasia, specifically with difficulty following complex
commands. He also has a right visual field deficit. Otherwise,
non-focal exam.
We started him on DAPT with clopidogrel and aspirin with plan to
discontinue clopidogrel in 3 months and maintain him on aspirin
alone. He was also started on atorvastatin 40 mg in place of his
home simvastatin 20 mg.
# Left M3 MCA
- Carotid U/S: <45% occlusion bilaterally
- ASA 81, clopidogrel 75 mg for 3 months, then ASA alone
- atorvastatin 40 (new on admission)
- stroke risk factors: HbA1C 5.4%, LDL 62
- TSH 4.6, free T4 1.1
- dispo to acute rehab, will need stroke f/u
# Rule-out cardio-embolic etiology:
- ECHO: suboptimal image, no clot, left atrial size 4.1
- ZIO patch on discharge to eval for arrhythmia |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Hip pain and fever
Major Surgical or Invasive Procedure:
___ Right hip posterior arthrotomy, debridement, irrigation,
placement of deep drains
History of Present Illness:
Mr. ___ is a ___ yo M w/ Hx of L4-L5 microdiscectomy in ___
who
presents w/ R inguinal pain. On ___, he developed chills,
fevers, and myalgias. Tmax 103. He was seen at ___
where he had blood work showing a Cr of 1.3, otherwise
unremarkable. Urinalysis and CXR unremarkable. Lyme,
anaplasmosis
and ehrlichiosis tests were negative.
On ___, he developed severe pain in R inguinal region.It
became so severe that he was unable to ambulate. He also notices
the pain into the R buttock and back. He developed pain in his L
knee around this time. He presented to the ___ ED. He is very
active at baseline, playing soccer and running . No recent
cough,
SOB, rhinorrhea, dysuria. No pain in any other joints.
Past Medical History:
R L4-L5 lumbar radiculopathy s/p microdiscectomy in ___
Social History:
___
Family History:
Negative for SLE, RA, or other autoimmune disorders.
Father has diabetes.
Physical Exam:
ON ADMISSION:
=============
VS: ___ 1809 Temp: 103.1 PO BP: 165/95 HR: 72 RR: 18 O2
sat: 96% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, ___ systolic murmur heard best at ___
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: Abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, normoactive BS
EXTREMITIES: No cyanosis, clubbing, or edema
MSK: Pain worst in R inguinal region, severe pain with any
movement of R hip joint, L knee joint warm w/o erythema, tender
to palpation inferior to patella.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE:
=============
___ 2339 Temp: 98.2 PO BP: 138/84 R Lying HR: 53 RR: 20 O2
sat: 98% O2 delivery: Ra
General: NAD
HEENT: MMM
CV: RRR, S1/S2, ___ systolic murmur
PULM: CTAB
GI: Abdomen soft, nondistended, nontender
EXTREMITIES: No cyanosis, clubbing, or edema
MSK: R hip dressing C/D/I.
NEURO: A&Ox3
DERM: No rash
Pertinent Results:
ADMISSION LABS:
===============
___ 08:36AM WBC-9.6 RBC-4.54* HGB-13.6* HCT-40.3 MCV-89
MCH-30.0 MCHC-33.7 RDW-12.3 RDWSD-39.8
___ 08:36AM GLUCOSE-124* UREA N-10 CREAT-1.1 SODIUM-140
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-28 ANION GAP-14
___ 08:36AM CRP-209.7*
___ 04:00PM JOINT FLUID ___ POLYS-78*
___ MONOS-0 EOS-4* MACROPHAG-18
DISCHARGE LABS:
===============
___ 05:15AM BLOOD WBC-10.7* RBC-3.53* Hgb-10.6* Hct-31.9*
MCV-90 MCH-30.0 MCHC-33.2 RDW-13.2 RDWSD-43.8 Plt ___
___ 05:15AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-139
K-4.3 Cl-99 HCO3-29 AnGap-11
___ 05:15AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1
___ 07:15AM BLOOD calTIBC-187* Hapto-262* Ferritn-754*
TRF-144*
___ 07:26AM BLOOD RheuFac-25* ___
___ 08:36AM BLOOD CRP-209.7*
___ 05:10AM BLOOD HIV Ab-NEG
MICROBIOLOGY:
=============
___ 5:21 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
___ 9:20 am JOINT FLUID RIGHT HIP JOINT FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: History: ___ with right hip pain// eval for fracture/ osteo
TECHNIQUE: AP view of the pelvis and AP and lateral views of the right hip.
COMPARISON: ___
FINDINGS:
No evidence of acute fracture or dislocation is seen. Mild to moderate
degenerative changes at the hip joints bilaterally are re-demonstrated,
similar in appearance compared to the prior study from ___.
Degenerative changes seen at the pubic symphysis without widening of the pubic
symphysis. There may also be narrowing of the left sacroiliac joint, possibly
in part related to patient position. No concerning osteoblastic or lytic
lesion is seen of the right hip. Re-demonstrated is a partially imaged
rectangular 5 cm radiopaque structure projecting over the medial thigh of
unclear etiology or clinical significance.
IMPRESSION:
No acute fracture or dislocation seen.
Re-demonstrated bilateral hip degenerative changes.
Degenerative change at the pubic symphysis.
Radiology Report
INDICATION: History: ___ with L knee pn// ? fx ? effusion
TECHNIQUE: Three views of the left knee
COMPARISON: ___
FINDINGS:
No acute fracture or dislocation is seen. No suprapatellar joint effusion is
seen. Joint spaces are preserved. Patellar enthesopathy is again noted.
Subtle lucency through inferior patellar enthesophyte could relate to
fragmentation or nondisplaced fracture, and was likely present on prior
radiograph from ___.
IMPRESSION:
No acute fracture or dislocation. Joint spaces preserved.
No suprapatellar joint effusion.
Subtle linear lucency through the inferior patellar enthesophyte could relate
to fragmentation or nondisplaced fracture, but was likely present on prior
radiograph from ___.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old man with fevers, R hip pain, c/f ? septic arthritis//
right hip
COMPARISON: Right hip radiograph ___
PROCEDURE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
5 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, a 18-gauge spinal needle was advanced into the right
hip. 5 cc of purulent fluid was aspirated.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
Sample was submitted to microbiology and Hematology.
The patient tolerated the procedure well and left the department in good
condition. There were no immediate complications or complaints.
FINDINGS:
Mild degenerative changes in the right hip. No bony destruction seen.
IMPRESSION:
Technically successful aspiration of the right hip joint.
I Dr. ___ supervised the Resident/Fellow during the
key components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation.
Radiology Report
EXAMINATION: Abdominal pelvis CT
INDICATION: ___ year old man with R hip septic arthritis, GBS growing in his
hip// please evaluate for intra abdominal abscess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.0 s, 52.7 cm; CTDIvol = 15.3 mGy (Body) DLP = 804.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 30.2 mGy (Body) DLP =
15.1 mGy-cm.
Total DLP (Body) = 822 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Bilateral lower lung atelectasis. No significant pleural
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The 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. No atherosclerotic disease
is noted.
BONES and SOFT TISSUES: Again seen are bilateral moderate degenerative changes
in the hips. There is signs of avascular necrosis of the left femoral head
without any cortical depression. On the right side, there is a drain near the
left hip articular capsule with small amounts of air along its tract and
extending to the subcutaneous tissues with fat stranding around it but no
drainable collection.
IMPRESSION:
1. No acute intra-abdominal abnormality.
2. Status post surgical drainage of the right hip joint with drain in place
with no soft tissue drainable collection.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new L PICC// 50 cm L basilic SL PICC-
___ ___ Contact name: ___: ___ cm L basilic SL
PICC- ___ ___
IMPRESSION:
No prior chest radiographs available.
Left PIC line ends in the right atrium, approximately 15 mm below the
estimated location of the superior cavoatrial junction.
Heart is mildly to moderately enlarged. Lungs are clear. No pulmonary edema
pulmonary vascular engorgement. Normal mediastinal vascular caliber. No
pleural abnormality.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Inguinal pain, JOINT PAIN
Diagnosed with Fever, unspecified
temperature: 99.3
heartrate: 56.0
resprate: 16.0
o2sat: 100.0
sbp: 131.0
dbp: 73.0
level of pain: 8
level of acuity: 3.0 | ___ yo M w/ hx of L4-L5 microdiscectomy who presented with fevers
and R hip pain, found to have GBS septic arthritis and GBS
bloodstream infection. Patient underwent right hip arthrtomy,
debridement, and irrigation on ___. He was started on
ceftriaxone on ___, as per culture sensitivities. He had
gradual improvement in symptoms and resolution of fever and
leukocytosis.
ACUTE ISSUES:
===============
# Group B Strep blood stream infection
He presented with fevers to 103. His blood cultures were
positive for GBS, source unclear. CT scan w/o evidence of
abdominal source. Denies any exposure to needles or recent
injuries, and otherwise is without risk factor outside of
osteoarthritis. He later developed right hip pain and swelling,
with joint fluid aspirate positive for GBS. He underwent right
hip posterior arthrotomy, debridement, irrigation, and placement
of deep drains on ___. He was treated with IV ceftriaxone
starting on ___. He received PICC line placement on ___. He
was discharged with plan for 6 total weeks of ceftriaxone 2g q24
hr (last day ___, as per ID recommendations. For pain control,
he is being discharged on alternating 1000 mg Acetaminophen and
800 mg Ibuprofen q6hr as needed, as well as tramadol 50mg q6
hours as needed for breakthrough pain (#28).
#Systolic murmur
Present on prior records from ___, last outpatient TTE ___
showed LVH. Given setting of septic joint and bacteremia, TTE
was obtained, without evidence for endocarditis or any new
changes from prior ECHOs. TTE did show continued LVH, would
benefit from outpatient follow up with PCP, and can consider
further outpatient cardiology consultation.
#Anemia
Presented with Hgb of 13.5, which slowly downtrended to 10.3
during his hospitalization, but began to recover prior to
discharge. Reticulocyte count demonstrated inadequate response.
Iron studies were consistent with an inflammatory state given
recent surgery and infection. No evidence for further bleeding
at hip site. Hemoglobin electrophoresis and serum transferrin
receptor pending at time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L wrist pain
Major Surgical or Invasive Procedure:
L distal radius ORIF
History of Present Illness:
Ms. ___ is a ___, RHD, ___ who p/w L wrist pain after a
fall from her bike. She states she was biking along the
___ earlier today and was going a little too fast and lost
control of her bike. She fell onto her L outstretched hand and
struck both of her knees. Denies HS, LOC. She had immediate
pain,
swelling and deformity of the L wrist and she went to ___. There she was found to have an open distal radius
fracture. She had a bedside I&D, was closed reduced and sent to
___ for further eval and treatment.
She is unsure of when her last tetanus was. She denies any
numbness or tingling of the L wrist and hand.
Past Medical History:
None
Social History:
___
Family History:
___
Physical Exam:
PHYSICAL EXAMINATION:
General: NAD, AxOx3
Left upper extremity:
- splint c/d/i
- Soft, compressible arm and forearm
- EPL/FPL/DIO (index) fire weakly, limited ___ pain
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right upper extremity:
- some abrasions to her posterior elbow
- No deformity, erythema, edema, induration
- 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
- 2+ radial pulse
Bilateral lower extremity:
- some abrasions over b/l ___
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 12:41AM GLUCOSE-90 UREA N-10 CREAT-0.6 SODIUM-136
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-20* ANION GAP-16
___ 12:41AM estGFR-Using this
___ 12:41AM NEUTS-63.7 ___ MONOS-8.4 EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-8.91* AbsLymp-3.77* AbsMono-1.18*
AbsEos-0.03* AbsBaso-0.04
___ 12:41AM PLT COUNT-239
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth three times a day as needed for pain Disp
#*120 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day as needed for constipation Disp #*60 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth once every 4
hours as needed for pain Disp #*40 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet by
mouth twice a day as needed for constipation Disp #*60 Tablet
Refills:*0
5.Outpatient Occupational Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
L open distal radius fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - independent
Followup Instructions:
___
Radiology Report
EXAMINATION: WRIST PA AND LAT VIEWS LEFT
INDICATION: Fracture ORIF.
COMPARISON: Radiographs from ___
FINDINGS:
Several fluoroscopic images from the operating demonstrate ORIF of a complex
intraarticular fracture of the distal radius.. There is good anatomic
alignment and no hardware related complications. The total intraservice
fluoroscopic time was 25.5 seconds. Small ulnar styloid fracture is also
seen. Please refer to the operative note for additional details.
IMPRESSION:
ORIF ofthe distal radius intraarticular fracture without complications.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Bicycle accident
Diagnosed with Displ commnt fx shaft of rad, l arm, 7thB, Fall on same level, unspecified, initial encounter
temperature: 97.6
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 136.0
dbp: 85.0
level of pain: 6
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open L distal radius fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for L distal radius ORIF, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left upper extremity, and will be
discharged with no medications 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:
Fever, dysuria, flank pain
Major Surgical or Invasive Procedure:
None at this time
History of Present Illness:
Ms ___ is a ___ with no significant PMH but for a recent
very difficult delivery requiring conversion to cesarean on ___
that was complicated by posterior uterine wall rupture,
intrapartum hemorrhage of ~3L, and left ureteral injury, now s/p
L nephrostomy tube placement. She presents with fevers and
pyuria, admitted for same.
She was initially at ___, transferred to OB/GYN on ___ with L
nephrostomy tube in place. Seen by Urology here, who felt that
she did not have a ureteral leak or tear, but a ureteral injury.
Recommendation was to keep the nephrostomy tube in place for
about 4 months to allow healing, followup in 5 weeks with Dr
___ nephrostomy tube change. She was discharged to home
on ___.
Since discharge, she has has had intermittent low grade fevers
with some intermittent left flank pain. She says that Dr ___
___ her to take tylenol, but that if the fever reached
101 or if she felt unwell to come to the ___. Her symptoms
worsened over the past ___ days in spite of tylenol and motrin,
and on ___ day she spiked fever to >101, so went to the
___, where she was triaged here. She notes some increased
cloudiness in the urine. She has had good output from the
nephrostomy. She does endorse a lack of sensation that she needs
to pee, and has been doing timed q2h voids where she does have
to strain to pass urine, but no frank dysuria. Denies abdominal
pain, abnormal or foul smelling vaginal discharge, passage of
clots or pus, discharge from C-section incision.
In the ___, she had fever to 100.0 but otherwise normal vital
signs. Urology and OB/GYN were consulted and both recommended
admission to medicine. Admission to medicine was requested.
ROS: Complete 10 point ROS completed and otherwise negative
except as above.
Past Medical History:
- Thalassemia minor
- G2P2, second delivery extremely complicated with ureteral
injury
- h/o ___ tumor s/p resection and reportedly left ureteral
implantation in the past in ___
Past Surgical History:
- Nephrostomy tube placement
- C-section x 2
- Wilms tumor resection with ureteral reimplantation
Social History:
___
Family History:
No family history of difficult deliveries.
Physical Exam:
Exam on Admission:
Vitals - 99.7, 110/67, 80, 18, 100%RA
Gen - NAD, very pleasant
Abd - NT,ND,BS+,incision CDI without any erythema
CV - RRR, no MRG
Resp - CTA ___
Ext - WWP, no edema
MSK - Good bulk and tone
Skin - No rashes
GU - No foley; nephrostomy tube with site CDI, clear appearing
urine output
Eyes - Anicteric sclerae, EOMI
HENT - MMM, OP clear
Psych - Normal affect
Neuro - Nonfocal, moves all extremities without deficit. Steady
gait.
Pertinent Results:
Labs from OSH ___, obtained prior to transfer here:
WBC 7.8, Hgb 9.3
Na 131, K 3.8, Cr 0.79
UA: + Nitrite, ___ (reportedly obtained from both clean catch and
nephrostomy tube)
___ 07:30AM BLOOD WBC-6.0 RBC-4.34 Hgb-9.6* Hct-30.7*
MCV-71* MCH-22.1* MCHC-31.3 RDW-21.0* Plt ___
___ 07:30AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.0
___ 07:30AM BLOOD Glucose-87 UreaN-6 Creat-0.8 Na-141 K-4.5
Cl-105 HCO3-29 AnGap-12
___ from nephrostomy tube.
URINE CULTURE Final
___
>100,000 org/ml ESCHERICHIA COLI
1. ESCHERICHIA COLI
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ --------- ------
AMPICILLIN S
4
AMOX/CLAV S
4
CEFAZOLIN S
<=4
CEFTAZIDIME S
<=1
CEFTRIAXONE S
<=1
CIPROFLOXACIN S
<=0.25
ERTAPENEM S
<=0.5
GENTAMICIN S
<=1
IMIPENEM S
<=0.25
LEVOFLOXACIN S
<=0.12
NITROFURANTOIN S
<=16
PIP/TAZ S
<=4
TOBRAMYCIN S
<=1
TRIM/SULFA S
<=20
Abd CT
INDICATION: ___ year old woman with complicated c section early
___ with
uterine rupture and ureteral injury; now with pcn and persistant
low grade
fevers despite abx. // ? uroma or walled off fluid collection
causing fevers
TECHNIQUE: Multidetector CT of the abdomen and pelvis was done
with and
without intravenous contrast with the patient in supine
position. The
non-contrast scan was done with low radiation dose technique.
The post
contrast scan was done with split contrast bolus technique.
Multiplanar image
displays in the coronal and sagittal planes were submitted to
PACS for review.
DOSE: DLP: 521.8 mGy-cm (abdomen and pelvis.
COMPARISON: Comparison is made to outside CTs of the abdomen
and pelvis from
___ ___), as well as CT of
the pelvis from
___.
FINDINGS:
LOWER CHEST:
There is a small nonhemorrhagic right pleural effusion,
unchanged in size
since the prior outside study from ___, with minimal
adjacent
atelectasis. The left pleural effusion has resolved, with only
trace basilar
atelectasis remaining.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within
normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen is enlarged, measuring 14.6 cm in greatest
craniocaudal
dimension (14:28), unchanged since the prior study. No focal
splenic lesions
are identified.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: A left posterior flank approach nephrostomy tube is in
place, coiled
in the left renal pelvis. There is no hydronephrosis or
perinephric
abnormality on the left. The bilateral kidneys enhance
symmetrically, and
excrete contrast promptly. The right renal collecting system is
unremarkable,
with no evidence of hydroureteronephrosis, or other focal
lesion. The left
ureter is nondilated, and is not filled with excreted contrast,
secondary to
the previously described nephrostomy tube.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall
thickness and enhancement throughout. Colon and rectum are
within normal
limits. Appendix contains air, has normal caliber without
evidence of fat
stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no
calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder is partially decompressed by Foley catheter,
with a small
amount of excreted contrast within the posterior bladder, and
air along the
anti-dependent anterior bladder wall. There is no evidence of
pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
The pelvic
drainage catheter has been removed since the ___ study.
REPRODUCTIVE ORGANS: The uterus is enlarged, and contains a
small amount of
hypodense fluid within the endometrial cavity, compatible with
recent
postpartum state.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Subcutaneous fat
stranding along
the lower anterior abdominal wall is related to were prior
cesarean section.
IMPRESSION
1. No evidence of fluid collection or abscess within the abdomen
and pelvis.
2. Enlarged postpartum uterus, with a small amount of fluid
within the
endometrial cavity.
INCIDENTAL FINDINGS
1. Nonspecific splenomegaly, unchanged from prior outside CT.
Clinical
correlation is recommended.
2. Left nephrostomy in appropriate position, with no evidence of
hydronephrosis or perinephric abnormality bilaterally.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN Pain
2. Docusate Sodium 100 mg PO TID
3. Ibuprofen 600 mg PO Q6H:PRN pain
4. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO TID
2. Ibuprofen 600 mg PO Q6H:PRN pain
3. Prenatal Vitamins 1 TAB PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
Completes on ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*23 Tablet Refills:*0
5. Acetaminophen ___ mg PO Q6H:PRN Pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pyelonephritis, acute
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ woman with a history of a recent left ureteral
injury, status-post nephrostomy tube placement. Evaluate for hydronephrosis.
TECHNIQUE: Grey-scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen dated ___, performed at an outside
hospital.
FINDINGS:
The right kidney measures 12.4 cm. The left kidney measures 12.5 cm. A small
focus of central hypoechogenicity just above the nephrostomy tube in the upper
pole of the left kidney likely corresponds to caliectasis rather than
hydronephrosis, and is consistent with the more prominent calices in the left
upper pole recently demonstrated on CT. No frank hydronephrosis in either
kidney. No renal stones or concerning renal mass is in either kidney. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
No frank hydronephrosis in either kidney.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old woman with recent C section with rupture of posterior
uterine wall, left ureteral injury now with nephrostomy, with constipation and
very hypoactive bowel sounds. Please assess for ileus. // ? ileus
TECHNIQUE: Supine and upright views of the abdomen
COMPARISON: Outside facility CT abdomen from ___
FINDINGS:
The bowel gas pattern is nonspecific and nonobstructive. There are no
abnormally dilated loops of small or large bowel. There is no evidence of
pneumatosis or pneumoperitoneum. The visualized osseous structures are
unremarkable.No soft tissue calcifications are detected. Left percutaneous
nephrostomy tube is again seen. Imaged lung bases are clear.
IMPRESSION:
No ileus.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old woman with complicated c section early ___ with
uterine rupture and ureteral injury; now with pcn and persistant low grade
fevers despite abx. // ? uroma or walled off fluid collection causing fevers
TECHNIQUE: Multidetector CT of the abdomen and pelvis was done with and
without intravenous contrast with the patient in supine position. The
non-contrast scan was done with low radiation dose technique. The post
contrast scan was done with split contrast bolus technique. Multiplanar image
displays in the coronal and sagittal planes were submitted to ___ for review.
DOSE: DLP: 521.8 mGy-cm (abdomen and pelvis.
COMPARISON: Comparison is made to outside CTs of the abdomen and pelvis from
___ ___), as well as CT of the pelvis from
___.
FINDINGS:
LOWER CHEST:
There is a small nonhemorrhagic right pleural effusion, unchanged in size
since the prior outside study from ___, with minimal adjacent
atelectasis. The left pleural effusion has resolved, with only trace basilar
atelectasis remaining.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged, measuring 14.6 cm in greatest craniocaudal
dimension (14:28), unchanged since the prior study. No focal splenic lesions
are identified.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: A left posterior flank approach nephrostomy tube is in place, coiled
in the left renal pelvis. There is no hydronephrosis or perinephric
abnormality on the left. The bilateral kidneys enhance symmetrically, and
excrete contrast promptly. The right renal collecting system is unremarkable,
with no evidence of hydroureteronephrosis, or other focal lesion. The left
ureter is nondilated, and is not filled with excreted contrast, secondary to
the previously described nephrostomy tube.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Colon and rectum are within normal
limits. Appendix contains air, has normal caliber without evidence of fat
stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder is partially decompressed by Foley catheter, with a small
amount of excreted contrast within the posterior bladder, and air along the
anti-dependent anterior bladder wall. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis. The pelvic
drainage catheter has been removed since the ___ study.
REPRODUCTIVE ORGANS: The uterus is enlarged, and contains a small amount of
hypodense fluid within the endometrial cavity, compatible with recent
postpartum state.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Subcutaneous fat stranding along
the lower anterior abdominal wall is related to were prior cesarean section.
IMPRESSION:
1. No evidence of fluid collection or abscess within the abdomen and pelvis.
2. Enlarged postpartum uterus, with a small amount of fluid within the
endometrial cavity.
INCIDENTAL FINDINGS:
1. Nonspecific splenomegaly, unchanged from prior outside CT. Clinical
correlation is recommended.
2. Left nephrostomy in appropriate position, with no evidence of
hydronephrosis or perinephric abnormality bilaterally.
NOTIFICATION: The findings were discussed via telephone by Dr. ___ with Dr.
___ on ___ at 11:21 AM, 5 minutes after discovery of the findings.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Fever, UTI, Transfer
Diagnosed with GU INFECTION-POSTPARTUM, URIN TRACT INFECTION NOS
temperature: 98.9
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 114.0
dbp: 82.0
level of pain: 5
level of acuity: 3.0 | ___ with no significant PMH but for a recent very difficult
delivery requiring conversion to cesarean on ___ that was
complicated by posterior uterine wall rupture, intrapartum
hemorrhage of ~3L, and left ureteral injury, now s/p L
nephrostomy tube placement. She presents with fevers and pyuria,
admitted for same.
# L ureteral injury s/p nephrostomy tube, pyelonephritis: Urine
culture from nephrostomy tube showing 100,000 E coli; pan
sensitive, discharged home with ciprofloxacin. Plan for two
weeks of ciprofloxacin.
# urinary retention versus evolving neurogenic bladder: She
failed voiding trial twice in the hospital. Discharged home
with foley catheter and draining left perc nephrostomy tube. She
will followup with urology.
# Acute kidney injury: creatinine of 1.1 on arrival, improved to
0.8 after IVF and holding NSAIDS. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Trauma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents s/p MVC with right trace PTX and L 4th rib fx
Past Medical History:
GERD
Social History:
___
Family History:
N/C
Physical Exam:
Exam on discharge:
Tm: 98.4 T97.7 HR:88 BP: 112/56 RR: 18 O2: 99RA
Gen: NAD
CV: RRR
Resp: NRD, CTAB
Abd: Soft, NT/ND w/o R/G
Medications on Admission:
Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*30 Tablet
Refills:*0
3. Acetaminophen 650 mg PO Q6H pain
4. Docusate Sodium 100 mg PO BID
While taking narcotic pain medications
Discharge Disposition:
Home
Discharge Diagnosis:
4th rib fracture, right trace pneumothorax (resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with 5% pneumothorax on OSH CT // inspiratory and
expiratory standing for eval of pneumo
TECHNIQUE: Inspiration and expiration upright PA views of the chest
COMPARISON: Chest CT ___ at 04:30
FINDINGS:
A tiny left apical pneumothorax is identified, as seen on the previous chest
CT. Lungs are otherwise clear without focal consolidation. No pleural
effusion is present. The cardiac and mediastinal contours are normal, with
the heart size within normal limits. Pulmonary vasculature is normal.
Previously demonstrated fracture of the left fourth rib is again noted.
IMPRESSION:
Unchanged tiny left apical pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with left rib fx with small associated PTX //
Eval for resolution/evolution of left PTX -- please perform UPRIGHT and on
EXPIRATION (*** ___ - 6am ***)
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal contours are normal. The lungs are clear. There is no
pneumothorax or pleural effusion. Left rib fracture is better seen in prior
CT
IMPRESSION:
Previously described tiny left pneumothorax is not clearly visualized in this
examination
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, MVC
Diagnosed with Traumatic pneumothorax, initial encounter, Fracture of one rib, unsp side, init for clos fx, Driver of car injured in clsn w statnry object in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 6
level of acuity: 1.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have trace pneumothorax and left 4th rib fracture and was
admitted to the Acute Care Surgery Service for pain control and
to monitor respiratory status. The patient's home medications
were continued throughout this hospitalization. The patient had
a chest x-ray ___ which showed resolution of the patient
pneumothorax. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, he had good respiratory effort on
incentive spirometery (>1750) and the patient was voiding/moving
bowels spontaneously. 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:
back pain, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with PMH depression, anxiety, chronic back
pain, renal mass suspicious for possible renal cell carcinoma,
as well as concern for MDS ___ bone marrow bx, recently seen and
admitted for withdrawal seizure from benzodiazepines and
narcotics. During that hospitalization there was concern for
prescription drug abuse so both Ativan and Percocet were
stopped. Since the seizure, which occurred about 1 week ago, pt
notes worsening fatigue, nausea, and weakness. This morning, she
was so weak she could not sit up in bed to smoke her cigarette.
She felt dizzy, but did not have chest pain or palpitations. She
has had insomnia and states that she has not slept in the last 4
days. She has had very poor appetite (eating only green grapes,
drinking green tea) ___ nausea. No vomiting. She does endorse a
new cough over the last week, productive of white phlegm. She
denies fevers/chills, no drenching night sweats, however she
does report weight loss.
When the EMTs came to her house, apparently home was disheveled.
EMT recommended section 51a due to concern for neglect.
In the ED, initial VS: 137 ___ RA. The patient triggered
for tachycardia and severe anxiety. EKGs consistent with likely
atrial fibrillation with rate of 150. She received IV ativan 1
mg x 2, and arrhythmia broke. Labs notable for BNP ___, HCT 24
with 7 bands, 5 metas, 7 myelos, 3 blasts. Lipase 91. Serum
tox screen negative. She was admitted to medicine for failure
to thrive and tachycardia. VS prior to transfer: 98.4 88 97/33
18 97% RA.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, sore throat, shortness of breath,
chest pain, abdominal pain, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Son believes that his sister saw some blood in the patient's
stools recently.
Past Medical History:
MGUS
(JAK-2) positive thrombocytosis, now resolved
AAA ___ repair in ___
anxiety
back pain
depression
Renal Mass, presumed renal ca but refused workup
macular degeneration
___: multiple ERCPs, PD stent (removed), balloon dilation of
CBD
___: unknown kidney operation
Social History:
___
Family History:
Mother died age ___ - AAA
Father died age ___ - ___
Denies family hx of autoimmune diseases and cancer.
Physical Exam:
Admission Exam:
Gen: Pleasant woman sitting up in bed in no acute distress,
carrying on conversation
HEENT: EOMI, PERRL, MMM, oropharynx clear
Neck: No lymphadenopathy, thyromegaly or JVD
Card: Irregularly irregular S1, S2, no MRG
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended
Ext: Non-edematous
Neuro: CN II-XII intact; strength ___ in upper and lower
extremities
Skin: Scab on upper chest "from C-collar"; multiple old
scabs/scars on left arm from "rash 2 months ago"
PHYSICAL EXAM on discharge:
VS: 98.5F, 107/45, 76, 18, 94% RA
Gen: elderly woman in no acute distress
HEENT: EOMI, PERRL, MMM, oropharynx clear
Neck: No lymphadenopathy, thyromegaly or JVD
Card: RRR, normal S1, S2, no MRG
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended
Ext: Non-edematous
Neuro: CN II-XII intact; strength ___ in upper and lower
extremities
Pertinent Results:
Admission Labs:
___ 11:30AM BLOOD WBC-10.1 RBC-2.70* Hgb-8.4* Hct-24.3*
MCV-90 MCH-31.2 MCHC-34.7 RDW-25.1* Plt ___
___ 11:30AM BLOOD Neuts-64 Bands-7* Lymphs-9* Monos-4 Eos-1
Baso-0 ___ Metas-5* Myelos-7* Blasts-3* NRBC-3*
___ 11:30AM BLOOD Hypochr-1+ Anisocy-3+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Tear Dr-1+
___ 11:30AM BLOOD Glucose-82 UreaN-32* Creat-1.0 Na-137
K-5.1 Cl-99 HCO3-25 AnGap-18
___ 11:30AM BLOOD ALT-17 AST-19 AlkPhos-98 TotBili-0.3
___ 11:30AM BLOOD Lipase-91*
___ 11:30AM BLOOD ___ 11:30AM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD Albumin-3.5 Calcium-8.2* Phos-3.8 Mg-2.2
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:40AM BLOOD Lactate-2.8*
___ 05:55AM BLOOD Hapto-293*
ERYTHROPOIETIN 80.5 H 2.6-18.5
mIU/mL
Micro:
___ CULTUREBlood Culture, Routine-FINAL
no growth x 2
Imaging:
___ ImagingCHEST (PA & LAT)
FINDINGS: Frontal and lateral views of the chest. The lungs are
hyperinflated. Focal opacity at the right cardiophrenic angle is
compatible with fat pad identified on prior CT. More vertically
oriented opacities seen laterally in the right lung may be due
to atelectasis. There is no focal consolidation worrisome for
infection. Cardiomediastinal silhouette is within normal limits.
Atherosclerotic calcifications identified at the aortic arch. No
acute osseous abnormality is identified. IMPRESSION:
Hyperinflation without superimposed acute consolidation.
___ ImagingSPLEEN ULTRASOUND
FINDINGS: The spleen is enlarged, measuring 16 cm, previously
measuring 11.8 cm. Overall, the spleen is normal in echotexture.
There is no free fluid seen in the left upper quadrant.
IMPRESSION: Splenomegaly, new from ___.
Discharge labs:
___ 06:05AM BLOOD WBC-7.3 RBC-2.60* Hgb-8.1* Hct-22.9*
MCV-88 MCH-31.1 MCHC-35.4* RDW-18.9* Plt ___
___ 05:55AM BLOOD Glucose-82 UreaN-28* Creat-0.8 Na-137
K-4.8 Cl-103 HCO3-25 AnGap-14
___ 05:55AM BLOOD Calcium-7.7* Phos-3.9 Mg-2.0
___ 07:40AM BLOOD ___ pH-7.43
___ 07:40AM BLOOD freeCa-1.09*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Acetaminophen 500 mg PO Q4H:PRN pain, fever
3. Mirtazapine 15 mg PO HS
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN severe pain
5. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
6. Ondansetron 4 mg PO Q8H:PRN nausea when taking mirtazapine
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H:PRN pain, fever
2. Ondansetron 4 mg PO Q8H:PRN nausea when taking mirtazapine
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 tabs by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Endocet (oxyCODONE-acetaminophen) ___ mg oral tid severe
pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*28 Tablet Refills:*0
6. Lorazepam 1 mg PO TID:PRN severe anxiety
RX *lorazepam 1 mg 1 tab by mouth three times a day Disp #*21
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Myelofibrosis (JAK2 Positive)
- Anemia
- Splenomegaly
- Atrial fibrillation
Secondary:
- Essential thrombocytosis (JAK2+) -> myelofibrosis
- IgM kappa MGUS (___)
- AAA ___ repair in ___
- 1.8 cm right renal mass, presumed RCC; patient declined
work-up
- Choledocholithiasis ___ ERCP and sphincterotomy ___
- ___ Cholecystectomy
- AVNRT ___ slow-pathway ablation ___
- Bifasicular block
- Chronic back pain
- Anxiety
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female with tachycardia and crackles. Question
pneumonia.
COMPARISON: Chest x-ray from ___ as well as chest CT from that day
and chest x-ray from ___.
FINDINGS: Frontal and lateral views of the chest. The lungs are
hyperinflated. Focal opacity at the right cardiophrenic angle is compatible
with fat pad identified on prior CT. More vertically oriented opacities seen
laterally in the right lung may be due to atelectasis. There is no focal
consolidation worrisome for infection. Cardiomediastinal silhouette is within
normal limits. Atherosclerotic calcifications identified at the aortic arch.
No acute osseous abnormality is identified.
IMPRESSION: Hyperinflation without superimposed acute consolidation.
Radiology Report
HISTORY: Myelofibrosis with worsening anemia. Assess spleen size and
evidence of sequestration.
TECHNIQUE: Splenic ultrasound.
COMPARISON: MRI abdomen ___.
FINDINGS: The spleen is enlarged, measuring 16 cm, previously measuring 11.8
cm. Overall, the spleen is normal in echotexture. There is no free fluid
seen in the left upper quadrant.
IMPRESSION: Splenomegaly, new from ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BACK PAIN
Diagnosed with OTHER MALAISE AND FATIGUE, TACHYCARDIA NOS, FAILURE TO THRIVE,ADULT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 10
level of acuity: 1.0 | ___ year old woman with PMH depression, anxiety, chronic back
pain, suspected renal cell carcinoma, with recent admission for
benzodiazepine withdrawal seizure admitted for fatigue, back
pain and SVT, now in sinus rhythm but with continued anemia.
# normocytic anemia, thrombocytopenia: Pt has known JAK2 V617F
mutation, prior thrombocytosis and now anemia and
thrombocytopenia, though anemia has acutely worsened from Hgb ~8
previously to now 6.4. Bone marrow biopsy performed during
previous admission consistent with myelofibrosis and repeat SPEP
showed 6% monoclonal band consistent with previously known MGUS.
No lytic lesions on recent bone scan ___. Pt had clearly guaiac
negative dark brown stool on exam ___, her anemia is
normocytic, and her iron is normal, which makes bleeding as a
cause of her anemia to be less likely. There was a concern for
cold agglutinins previously, but her haptoglobin is normal,
which makes hemolysis unlikely, and direct Coombs was checked
and negative. Pt had spleen ultrasound on ___, which showed
significant splenomegaly, and given continued down trending
anemia, concern for continued splenic sequestration. Pt also had
erythropoietin level checked, which was high at 80.5 (reference
range 2.6-18.5 mIU/mL). Erythropoietin administration will
therefore be unlikely to help. Pt received an additional
transfusion of 1 x pRBCs on ___ and Hct only increased from
22.5 to 22.9 on ___. It is therefore unlikely that any
additional transfusions will meaningfully increase her
hematocrit. After both of her transfusions, Pt denied any
significant improvement in her symptoms and when asked about her
fatigue, she repeated said that she would feel better if she
were simply started on her prior percocets and lorazepam. Given
her poor prognosis, palliative care was consulted (see below)
after discussions with the patient and her daughter ___
(health care proxy) and will transition to comfort care.
# palliation: palliative care was consulted and recommended
transitioning to comfort care and restarting Pt's prior
Percocets and lorazepam as a bridge to hospice, with her
medications to be strictly administered by her daughter ___,
who is a ___, given her recent narcotic and
benzodiazepine addiction and abuse. Palliative care will discuss
these recommendations with Pt's PCP.
# Paroxysmal Atrial Fibrillation: Converted to sinus with
metoprolol, and given comorbidities and goals of care,
anticoagulation was not initiated.
# Back pain: chronic. Pt states pain uncontrolled on tramadol
and tylenol, but Pt has been walking without issue. Pt was also
recently seen in ___ pain clinic just days prior to
admission and agreed with not filling benzos or strong opiates.
When patient was evaluated by physical therapy, there was "no
observed non-verbal signs of pain during mobility assessment"
and she ambulated well with a walker. Pt was previously
recommended by spine pain center to have an MRI of her spine.
# History of benzo abuse/withdrawal: Tox screen negative on
admission, and patient previously detoxed.
# Concern for neglect by EMTs: Per ED, patient's house
disheveled and had recent bed bugs. Social work was consulted
and situation was discussed with family. Pt's son states that a
brother is in the fire department and has a personal grudge
against brothers who live with the patient. Pt's daughter and
health care proxy states that the home has been fine.
# anxiety, insomnia: Pt reports severe anxiety but generally
appears calm. Patient was unwilling to continue mirtazepine due
to nausea, though she was never observed to have any emesis, and
she was previously prescribed ondansetron, which she received
prior to her doses here. Mirtazepine was discontinued. Pt
refused SSRI. Pt was given trazadone for sleep but reported
excessive sedation in the morning.
# Renal mass: On MRI concerning for RCC, however per patient's
daughter she has declined work up. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Sulfa (Sulfonamide Antibiotics) / Cipro /
Swine Flu Vaccine
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ year old female with past medical history of
___ disease on chronic prednisone, chronic shoulder pain
presenting with 2 days of worsening leg pain and erythema.
Patient reports that 2 days prior to presentation, she noticed
some itching in her R lower leg. The next morning, she noticed
increased erythema and pain. Subjective fevers at home. Felt
maybe her chronic bilateral shoulder pain was somewhat worsened
during this time as well. Patient was seen at ___
Urgent Care and referred to ___ ED.
In ___ ED, initial vitals were 100.5 95 130/77 18 99%RA. Exam
noted on dashboard as being "R leg with erythema from ankle to
two thirds of lower leg no crepitus" and "petechial rash in
feet". Labs notable for WBC 34.1 (85%N), Hgb 11.4, Plt 227; INR
1.1; K 3.6, Cr 0.9; ALT 15, AST 16, AP 106, Tbili 0.8, Alb 4.0;
UA neg leuk, neg blood, neg nitr, neg prot. Flu PCR negative.
Had chest xray negative for consolidation, shoulder xray with
chronic changes without fracture, and lower extremity doppler
without evidence of deep venous thrombosis in the right lower
extremity veins. Patient was given IV ceftriaxone, vancomycin,
normal saline, morphine and was admitted to medicine for further
management.
On arrival to floor, patient confirmed above, and also reported
recent upper respiratory symptoms included cough, for which she
received doxycycline course. No other recent changes to health
other than described above. Full 10 point review of systems
positive where noted, otherwise negative.
Past Medical History:
- Hypertension
- Chronic pain
- ___ Disease
- GERD
- Macular degeneration
- Gout
- Osteoarthritis
- Insomnia
- Osteoporosis
- R leg pain
- h/o hip fracture and repair
- h/o R Rotator cuff tear
Social History:
___
Family History:
FAMILY HISTORY
Mother with ___ disease.
Physical Exam:
ADMISSION
VS: 100.0 PO 138 / 73 106 18 92 RA
Gen: supine in bed sleeping, awakening to voice, comfortable
Eyes - EOMI, anicteric
ENT - OP clear, dry MM
Heart - RRR no mrg
Lungs - CTA bilaterally, no crackles, wheezes, ronchi;
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - several venous-appearing ulcers over lower legs
bilaterally, each with; very thin skin; areas of chronic
hemosiderin deposition more pronounced on R leg; area of
induration and erythema surrounding one ulcer on R leg, more
pronounced on posterior portion of leg, all within boundaries
drawn on leg; no palpable fluctuance, no purulence; mild macular
rash on tops of feet; right posterior heel fissure;
Vasc - 2+ DP/radial pulses
Neuro - AOx3 (full name, ___, ___, moving
all
extremities
Psych - appropriate
DISCHARGE
VS: 98.3
PO 186 / 73 75 18 94 RA
Gen: sitting up in bed, eating breakfast, wheezing audibly
Eyes - EOMI, anicteric
ENT - OP clear, dry MM
Heart - RRR no mrg, no JVD
Lungs - clear bilaterally, breathing comfortably
Abd - soft nontender, normoactive bowel sounds
Ext - trace edema to mid-thigh
Skin - several venous-appearing ulcers over lower legs
bilaterally, the prior area of confluent erythema surrounding
one
ulcer on R leg has withdrawn and is entirely gone.
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities, ambulates well to the
bathroom with walker
Psych - appropriate
Pertinent Results:
ADMISSION
___ 08:00PM BLOOD WBC-28.3*# RBC-3.86* Hgb-12.2 Hct-36.1
MCV-94 MCH-31.6 MCHC-33.8 RDW-14.6 RDWSD-50.2* Plt ___
___ 08:00PM BLOOD Glucose-132* UreaN-33* Creat-0.9 Na-133
K-3.6 Cl-100 HCO3-20* AnGap-17
CXR - Mild bibasilar atelectasis without focal consolidation.
Unilateral lower extremity Doppler
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Mild amount of edema is seen in the right calf.
GLENO-HUMERAL SHOULDER
1. Severe left glenohumeral and acromioclavicular joint
degenerative changes, but no fracture or dislocation.
2. Chronic rotator cuff tear as demonstrated by a high riding
humeral head.
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-13.5* RBC-3.30* Hgb-10.3* Hct-30.6*
MCV-93 MCH-31.2 MCHC-33.7 RDW-15.0 RDWSD-51.2* Plt ___
___ 06:30AM BLOOD WBC-11.2* RBC-3.08* Hgb-9.6* Hct-28.7*
MCV-93 MCH-31.2 MCHC-33.4 RDW-14.9 RDWSD-51.0* Plt ___
___ 06:35AM BLOOD Glucose-82 UreaN-22* Creat-0.9 Na-138
K-3.7 Cl-102 HCO3-24 AnGap-16
___ 06:30AM BLOOD Glucose-89 UreaN-22* Creat-0.7 Na-137
K-3.6 Cl-103 HCO3-22 AnGap-16
___ 06:35AM BLOOD Calcium-9.2
___ 09:50AM BLOOD ALT-11 AST-13 CK(CPK)-37 AlkPhos-90
TotBili-0.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 37.5 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Gabapentin 400 mg PO QID
4. PredniSONE 10 mg PO DAILY
5. Spironolactone 12.5 mg PO DAILY
6. diclofenac sodium 1 % TOPICAL DAILY
7. esomeprazole magnesium 40 mg oral DAILY
8. olmesartan 40 mg ORAL DAILY
9. Zolpidem Tartrate 5 mg PO QHS
10. DULoxetine 30 mg PO DAILY
11. Allopurinol ___ mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
14. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO BID
Since your Percocet contains Tylenol, be careful not to take
more than 2g daily acetaminophen.
2. Clindamycin 300 mg PO Q8H
last day of antibiotic ___
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 8 hours
Disp #*6 Capsule Refills:*0
3. Lidocaine 5% Patch 2 PTCH TD QPM
4. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
Your PCP is to continue outpatient prescriptions of this
medication.
5. Allopurinol ___ mg PO DAILY
6. Carvedilol 37.5 mg PO BID
7. diclofenac sodium 1 % TOPICAL DAILY
8. DULoxetine 30 mg PO DAILY
9. esomeprazole magnesium 40 mg oral DAILY
10. Furosemide 20 mg PO DAILY
11. Gabapentin 400 mg PO QID
12. olmesartan 40 mg ORAL DAILY
13. PredniSONE 10 mg PO DAILY
14. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
15. Spironolactone 12.5 mg PO DAILY
16. Vitamin B Complex 1 CAP PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# R lower extremity cellulitis
# Hyponatremia
# Venous ulcers
# Hypertension
# Bilateral Shoulder Pain
# Crohns Disease
# GERD
# Gout
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: GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT
INDICATION: History: ___ with left shoulder pain// eval for acute process
eval for acute process
TECHNIQUE: AP in internal rotation, Grashey in external rotation, and
axillary view radiographs of the left shoulder.
COMPARISON: None
FINDINGS:
There is no fracture or dislocation. There is severe glenohumeral joint space
narrowing. There is moderate to severe acromioclavicular joint space
narrowing and osteophyte formation. The humeral head is high riding,
indicative of chronic rotator cuff tear with undersurface remodeling of the
acromion.. The imaged portion of the left lung is clear. The imaged left
ribs are intact. No periarticular calcification or radiopaque foreign body in
the soft tissues. Severe joint space narrowing at the glenohumeral joint is
noted. Bones are moderately to severely diffusely demineralized limiting
assessment for nondisplaced fractures.
IMPRESSION:
1. Severe left glenohumeral and acromioclavicular joint degenerative changes,
but no fracture or dislocation.
2. Chronic rotator cuff tear as demonstrated by a high riding humeral head.
Radiology Report
EXAMINATION: Portable semi upright chest radiograph.
INDICATION: ___ year old woman with cellulitis, off diuretics, now with
increased wheezing not responsive to nebulizers// signs of pulmonary edema?
TECHNIQUE: Chest AP
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS:
There is pulmonary vascular congestion with mild pulmonary edema. Heart size
is mildly enlarged and unchanged. There are no focal consolidations. No
pneumothorax. There is a chronic deformity of the right humeral head with
loose bodies. Surgical clips at the thoracic inlet are suggestive of prior
thyroid surgery. There is dense calcification of the mitral annulus.
IMPRESSION:
Mild pulmonary edema and vascular congestion are new compared to ___. No focal consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, R Leg cellulitis
Diagnosed with Cellulitis of right lower limb
temperature: 100.5
heartrate: 95.0
resprate: 18.0
o2sat: 99.0
sbp: 130.0
dbp: 77.0
level of pain: 9
level of acuity: 3.0 | Summary: Ms. ___ is an ___ y/o woman with PMhx ___
disease on chronic prednisone, chronic shoulder pain admitted
___ with R leg cellulitis, on IV abx, course complicated
by hyponatremia and ongoing chronic shoulder pain.
Hyponatremia resolved after resuming her home diuretic. Pain
consulted for shoulder pain and recommended restarting low dose
Percocet, which she has been on in the past. IV clinda
(allergies to sulfa, quinolones, penicillin) transitioned to po
as of ___. Overall doing better. Hospital course complicated by
loose stools (cdiff negative), which have also improved.
Today, the patient is feeling much better. She states "today is
the first day where I feel comfortable with my situation going
home." Shoulder pain continues but is "manageable" on current
regimen with restarting percocet. Confirmed with case management
home services will be arranged. I spoke with her hc proxy ___
over the phone and confirmed the follow up plan.
Rest of hospital course and plan are outlined below by issue:
# R lower extremity cellulitis
# Sepsis
Patient presented with circumferential erythema of her R lower
leg, fever, and leukocytosis, with exam concerning for
cellulitis. ___ without signs of venous thromboembolism.
Patient started on broad spectrum antibiotic therapy, which was
narrowed to IV clinamycin given her allergy to pencillins.
Erythema slowly improved over subsequent days, with healing
likely slowed by her chronic prednisone use x ___ years.
Clinically improved, and able to ambulate. WBC has dramatically
improved. her IV clindamycin was converted to oral clindamycin
on ___ which she tolerated well. She will be discharged on PO
clindamycin, last day = ___.
# Bilateral Shoulder Pain
Patient with chronic bilateral shoulder pain, controlled with
gabapentin as an outpatient. Patient reports that percocet
caused hyperalgesia and she had self-discontinued this just
prior to admission, but has not had issues such as lethargy or
delirium in response to Percocet in the past. She also reported
increasing her gabapentin to QID based on the instructions of a
physician--she could not remember which (team called her pain
physician and PCP and neither reported they had recommended
this). While inpatient, per discussion with PCP, we increased
her gabapentin and started standing Tylenol 1g q8h + prn
tramadol however developed delirium in response to tramadol
(hallucinations, etc) so tramadol was stopped. Has seen an
orthopedist previously however states intraarticular injections
have not been helpful in the past. Received 1 dose toradol for
acute pain overnight on ___ however NSAIDs not ideal given her
hx of crohns since she has had flares with in the past. Pain
service was consulted per family request.
-family requested pain service consultation. Per discussion with
acute pain service, recommended resuming her previous Percocet
(was on Percocet ___ with 1.5 pills PRN previously), and
discontinued standing Tylenol. Changed to Tylenol ___ BID PRN
(with caution to maintain <3g Tylenol per day along with
Percocet).
-increased lidocaine patches to 2 patches per patient request as
they seemed to help somewhat
-Continuing duloxetine
-I confirmed with the patient that she does indeed have enough
Percocet pills to last until her next PCP appointment on ___ so
I did not prescribe her more tablets.
# Hyponatremia - appeared hypervolemic following volume
resuscitation at in the emergency department. Although she does
have history of SIADH. Now back to baseline following diuresis.
# Wheezing - Patient developed wheezing around hospital day 3.
CXR showed mild pulmonary edema c/w cardiac wheeze. Suspected
iatrogenic volume overload in setting of holding home diuretics
and recent volume resuscitation; associated hypertension
supported this; also hyponatremia as above.
-resolved after resuming home diuretic. Currently euvolemic on
exam.
# Venous ulcers
Seen by wound care consult (see OMR for their recommendations)
# Hypertension
-continued carvedilol, ___
-initially held Lasix and spironolactone, which were
subsequently restarted
-she was hypertensive while inpatient up to SBP 180s at times.
We had to replace her omesartan with a different ___ since it
was nonformulary and suspect this may have played a role. No
changes were made to her home antihypertensive regimen but
regardless should follow up with her PCP to address hypertension
management.
# Crohns Disease
Continued prednisone
# GERD
Continued PPI
# Gout
Continued allopurinol
#Contacts: met with patient's hc proxy ___ and
daughter in law (Dr. ___ at bedside on ___ and on ___ and
held discussions involving the patient regarding plan of care.
Among the patient's hc proxies, I was only able to contact ___
___ on the day of discharge ___ (one of her alternate hc
proxies) and confirmed the discharge plan with her as well as
the patient. I also sent a secure email to her PCP to ___ of
discharge follow up plans.
#Code status - DNR, ok to intubate - confirmed with the patient.
She was very clear she did not want to "die slowly" like her
father had. Her husband recently passed away suddenly but an
attempt was made to resuscitate him, which ultimately failed.
she stated she would not want such an attempt at resuscitation
made if her heart were to stop.
#Transitional issues:
-PCP ___ scheduled ___ for ongoing Percocet Rx, hypertension
management, and discuss pain management. ongoing Percocet rx
-outpatient ___ for wound management with Dr. ___ be
scheduled by patient's family members)
-last day of clindamycin antibiotic ___
Consults: pain
Dispo: ___ recommended home to ___ services
including home ___.
spent > 30 minutes seeing the patient and organizing her
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right and left foot pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male was at work earlier today when he fell 7
feet onto his feet. Seen at outside hospital and found to have a
comminuted right calcaneus fracture as well as second metatarsal
fracture of the left foot. Imaging of the lumbar spine was
performed as well without any evidence of fracture per report.
Patient currently complaining of right foot pain. Patient denies
any numbness or tingling.
Past Medical History:
HTN
Social History:
___
Family History:
non contributory
Physical Exam:
AVSS
NAD
AAOx3
RIGHT LOWER EXTREMITY:
Splint c/d/i with bulky well-padded dressing in place
Extremity without obvious deformity
No skin tenting, or lesions indicative of open fracture
___ FHL ___ TA Fire
SILT distally and proximal to knee
foot warm, well-perfused, cap refill < 2sec
Compartments soft (thigh, leg, foot)
Minimal pain to passive stretch of toes
No noted knee effusion
LEFT LOWER EXTREMITY:
Hard sole shoe in place
Extremity without obvious deformity
No skin tenting, or lesions indicative of open fracture
___ FHL ___ TA PP Fire
SILT LFCN, PFCN, Obturator, Saphenous, Sural, DP, SP, Plantar
Point tenderness ___ metatarsal
2+ DP, ___ pulses; foot warm, well-perfused
Compartments soft (thigh, leg, foot)
Minimal pain to passive stretch of toes
No noted knee effusion
Pertinent Results:
___ 09:30AM BLOOD WBC-10.6 RBC-4.58* Hgb-14.4 Hct-40.9
MCV-89 MCH-31.5 MCHC-35.3* RDW-12.1 Plt ___
___ 09:30AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.2
___ 09:30AM BLOOD Glucose-107* UreaN-18 Creat-1.1 Na-134
K-4.5 Cl-98 HCO3-25 AnGap-16
Medications on Admission:
viagra
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for Pain for 2 weeks.
Disp:*45 Tablet(s)* Refills:*0*
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QHS (once a day (at bedtime)) for 4 weeks.
Disp:*30 syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right calcaneus comminuted fracture
Left ___ metatarsal 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
RADIOGRAPHS OF THE RIGHT HEEL
HISTORY: Evaluation of right heel fracture.
COMPARISONS: Outside radiographs from earlier on the same day scanned into
the ___ PACS system.
TECHNIQUE: Right heel, three views including axial views.
FINDINGS: There is a comminuted fracture of the calcaneus with flattening of
___ angle, primarily involving the body of the calcaneus, with mild
distraction of fragments, particularly along the medial side. Enthesopathy is
noted at the Achilles insertion site onto the calcaneus.
IMPRESSION: Comminuted fracture of the calcaneus.
Radiology Report
RIGHT LOWER EXTREMITY CT WITHOUT CONTRAST DATED ___
CLINICAL INDICATION: ___ male, fall from seven feet with right
calcaneus fracture.
COMPARISON: Right heel radiographs from ___.
TECHNIQUE: Multiple contiguous axial MDCT images from the level of distal
tibia and fibula through the bases of the metatarsals with bone and soft
tissue standard algorithms and coronal, sagittal, and oblique orientations
provided for interpretation.
FINDINGS:
There is an acute markedly comminuted fracture involving the body of the
calcaneus with extension of fracture lines to the middle and subtalar facets
and to the articulation with the cuboid bone (502B:58, 502B:65, 501B:58) with
also fracture lines seen at the anterior base of the sustentaculum talus
(500B:165). There are small osseous fracture fragments at the posterior
subtalar joint level (502B:54).
The peroneus longus and brevis tendons are seen laterally adjacent to fracture
line through the body of the lateral aspect of the calcaneus (501B:55) but do
not appear entrapped. The medial flexor tendons do not appear entrapped by
fracture fragments.
The partly seen anterior tibialis and extensor tendons are grossly intact.
Mild enthesopathy at the dorsal aspect of the calcaneus at Achilles tendon
attachment, with otherwise normal-appearing Achilles tendon. The plantar
fascia remains attached to the plantar base of the calcaneus (502B:72).
No other acute fractures are identified. The Lisfranc interval is maintained.
There is moderate subcutaneous soft tissue stranding in the lateral aspect of
the foot and ankle extending into the lateral plantar aspect of the foot
posteriorly.
The talar dome is intact.
IMPRESSION:
Markedly comminuted fracture of the calcaneus with loss of ___ angle with
fracture line extension to the posterior and middle subtalar facets and
anterior base of the sustentaculum talus. Multiple small fracture fragments
are seen at the posterior subtalar joint level. Fracture line also extends to
the lateral aspect of calcaneocuboid bone articulation.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Calcaneus fracture, possible surgery.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: Lung volumes are normal. Normal shape of the diaphragms. No
pleural effusions. Normal size of the cardiac silhouette. No hilar or
mediastinal changes.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R CALCANEOUS FX TRANSFER
Diagnosed with FRACTURE CALCANEUS-CLOSE, FX METATARSAL-CLOSED, FALL-1 LEVEL TO OTH NEC
temperature: 95.0
heartrate: 120.0
resprate: 20.0
o2sat: 95.0
sbp: 141.0
dbp: 93.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ was admitted to the Orthopedic service on ___ for
right calcaneus fracture and left metatarsal fracture after
being evaluated and treated with closed reduction in the
emergency room. He underwent further closed reduction and
re-splinting without complication on ___.
He had adequate pain management with PO medication and worked
with physical therapy while in the hospital. He continued with
strict leg elevation and received a hard sole shoe for his left
foot. The remainder of his hospital course was uneventful and
he is being discharged to home in stable condition for follow up
in 1 week for possible operative intervention at that time with
reduced foot swelling. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysarthria, left face/arm/leg weakness, and right gaze deviation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___
right-handed male with past medical history remarkable for stage
IV (reported by the family as stage IIIB) metastatic lung cancer
treated by Dr. ___ as well as history of
hypercoagulability as reported by right leg arterial thrombosis
off anticoagulation, who presented to the Emergency Department
with symptoms concerning for a right MCA syndrome.
Per the patient's daughter, ___, he was in his normal state of
health on ___, when he had lunch with his family
and then went to his room for a nap around 1400 hours. At
approximately 1630 hours his daughter heard a thud from his room
and rushed to his aid. She noted that he was on the ground with
slurred speech, although his speech was appropriate in terms of
content and in terms of his response to comprehended words. She
noted that he had a left nasolabial fold blunting as well as he
was moving his left side significantly less than the right. He
did not endorse any deficit at that time, reporting that he was
doing fine and he was moving all of his extremities fine,
although this was not the case. He noted that he had to urinate
for which his family took him to the bathroom, but unfortunately
due to his inability to disrobe he urinated on his pants,
although did not display any other symptoms concerning for
seizure activity. He was brought to ___ where the
decision was made not to give TPA despite being within the
slightly outside of a 3-hour window and was transferred to ___ for further evaluation given his affiliation
here with Oncology.
The patient's daughter was questioned extensively regarding his
ongoing care. She had noted that he was aware of the diagnosis
and had made aware that he did not want any rogue interventions.
She also admitted known that he dislikes the idea of using
Lovenox for anticoagulation despite the necessity of this as a
stroke prophylaxis.
Past Medical History:
- Stage IV nonsmall cell lung cancer (adenocarcinoma), EGFR
mutated
- R leg claudication ___ acute and chronic occlusion of his
popliteal artery, treated with lovenox which the patient
discontinued in ___ due to discomfort with injection and
___
- HLD
- RENAL DISEASE - creatinine baseline 1.4 recently
- mitral regurgitation
Social History:
___
Family History:
Mother with ___ cancer, brother with lung cancer. No
history of early strokes.
Physical Exam:
Physical Examination:
VS 98.7 82 114/61 18 97%RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Neurologic Examination:
- Mental Status -
Awake, alert, attentive to daughter and examiner. Speaks in
___ with daughter who states that speech is slurred but
otherwise intelligable. Able to state his age in ___,
incorrectly states the month as ___. Follows simple axial
and appendicular commands. Uncertain if there is any L sided
neglect due to motor, sensory, and vision defecits on exam.
- Cranial Nerves -
PERRL 3->2. Forced R gaze deviation, able to barely cross
midline to the L with VORs. Decreased blink to threat on the L.
L sided upper and lower facial weakness.
- Motor -
- L arm drifts down to hit the bed, L leg drifts down but does
not hit the bed. R side grossly full strength (___), with
decreased strength in the L arm worse than leg (___), although
confrontational strength testing is difficulty.
- Increased muscle tone throughout, worse on the L > R arm.
There are some regular tremulous movements which are present
with activation and moving the limbs but occasionally seen at
rest as well. Not clearly supressible, but do not spread or
progress, and seem to improve when the patient has lower muscle
tone.
- Sensation -
Patient denies any sensation of examiners touch on the L arm or
leg.
- DTRs -
Increased L>R arm. Toes down.
- Cerebellar -
FNF intact R hand, difficult with L hand which may be ___
weakness. + postural tremor with reaching.
- Gait -
deferred
DISCHARGE EXAM:
Neurologic: Unchanged.
Pertinent Results:
ADMISSION LABS:
___ 08:45PM CREAT-1.6*
___ 08:30PM ___ PTT-22.1* ___
___ 08:41PM GLUCOSE-107* NA+-140 K+-4.0 CL--100 TCO2-26
___ 08:30PM UREA N-31*
___
139 | 105 | 26
------------------< 107
4.0 | 24 | 1.3
TropT < 0.01 x3
Serum tox negative
STROKE WORKUP:
___ 07:39AM
%HbA1c-5.9 eAG-123
Triglyc-95
Cholest-257*
HDL-72
CHOL/HD-3.6
LDLcalc-166*
TSH-3.7
___ CT HEAD W/O CONTRAST: IMPRESSION:
Evolving acute infarction in the right insula and right frontal
operculum, in the right middle cerebral artery territory,
without significant mass effect. No acute hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Erlotinib 100 mg PO QDAY Chemotherapy
2. Multivitamins 1 TAB PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
2. Senna 8.6 mg PO BID:PRN constipation
3. Enoxaparin Sodium 60 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Calcium Carbonate 500 mg PO DAILY
5. Erlotinib 100 mg PO QDAY Chemotherapy
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Right Middle Cerebral Artery Stroke
Secondary:
- Stage IV Adenocarcinoma of the Lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke, stage 4 lung cancer // eval for pna
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have decreased.
Moderate cardiomegaly. Fibrotic changes along the right chest wall as well as
at the left lung bases are unchanged. No new focal parenchymal opacities.
Known an unchanged right apical pleural thickening. Moderate cardiomegaly and
elongation of the descending aorta persist.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with metastatic lung cancer, atrial fibrillation,
presents with right MCA stroke. Evaluate for evolution of stroke.
TECHNIQUE: Noncontrast head CT with sagittal and coronal reformatted images.
DLP 892 mGy cm.
COMPARISON: Noncontrast head CT from ___ dated ___.
FINDINGS:
Compared to slightly less than 24 hr earlier, there is increased loss of gray/
white matter differentiation in the right insula and right frontal operculum,
consistent with an evolving infarction in the right middle cerebral artery
territory. There is no significant mass effect and no acute hemorrhage.
Bilateral middle cerebral arteries appear slightly dense, which may relate to
atherosclerosis and/or high hematocrit. Sylvian branches of the right middle
cerebral artery appear more prominent on the left, similar to the preceding
CT.
Small foci of low density in bilateral lentiform nuclei and internal capsules
are not significantly changed, likely sequela of chronic small vessel ischemic
disease. Areas of low density in the periventricular white matter of the
cerebral hemispheres, corona radiata, and centrum semiovale are also not
significantly changed and likely sequela of chronic small vessel ischemic
disease. The ventricles and sulci are mildly prominent due to age-related
cerebral atrophy, as before.
The bones are unremarkable. The imaged paranasal sinuses and mastoid air cells
are well aerated. There is a punctate metallic foreign body in the soft
tissues overlying the base of the nasal bridge.
IMPRESSION:
Evolving acute infarction in the right insula and right frontal operculum, in
the right middle cerebral artery territory, without significant mass effect.
No acute hemorrhage. MRI could better assess the full extent of infarction,
if clinically warranted.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: CVA
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, ATRIAL FIBRILLATION
temperature: 98.7
heartrate: 82.0
resprate: 18.0
o2sat: 97.0
sbp: 114.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ y/o ___ male with stage 4
NSCLC, prior DVT and popliteal artery occlusion, and
hyperlipidemia, who presented to an OSH with dysarthria, left
face/arm/leg weakness, left hemisensory loss, and right gaze
deviation found to have a right MCA stroke. He was not a tPA
candidate as he presented outside the window. His stroke was
thought to be secondary to thromboembolus in the setting of
atrial fibrillation, hypercoaguable state associated with Lung
CA with history of arterial thromboembolus. He had recently been
declining his Lovenox therapy and had not been anticoagulated.
MRI could not be performed due to presence of shrapnel; his
infarct was demonstrated on CT. Workup showed elevated LDL of
166 and A1C was 5.9%. We spoke with Dr. ___ to confirm that
Tarceva treatment and lovenox were compatible. After a family
discussion, Mr. ___ was willing to resume lovenox. Statin
therapy was not initiated due to concern for interactions with
his chemotherapeutic agent, erlotinib. He underwent swallow
evaluation which demonstrated dysarthria and he was started on a
modified diet.
After discharge, Dr. ___ that a statin would be
acceptable to give with his erlotinib.
==========================================================
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 =
166) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: interaction with erlotinib
chemotherapy ]
(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? () Yes - (x) No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: interaction with erlotinib chemotherapy]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No [if no, reason not
discharge on anticoagulation: on lovenox ] - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Penicillins / Levaquin / Remicade
Attending: ___.
Chief Complaint:
Fever, myalgia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with sarcoidosis, HTN, obesity and T2DM who prestnes with
fever and body aches after infliximab infusion on ___.
Patient was recently diagnosed with sarcoidosis and was
initiated on Remicade ___ and received her second dose the
day prior to admission. She developed headache and HTN to the
170s systolic with first infusion and subsequently developed
hiveson the extensor surfaces of her arms, as well as on her
chest and back during the second infusion of Remicade, but no
dyspnea, mouth/face/neck swelling. She subsequently went home,
but later in the evening started to feel very unwell, with
escalating fevers to 102 at home. She also felt very weak and
had aches all over her body, including a headache, and found it
very difficult to move even a little.
In the ED, initial VS were: 10 103.4 124 131/92 14 100%. Pt
received Tylenol ___ x2, morphine 4mg x2, Benadryl 50mg IV x1,
toradol 15mg x2, famotidine 20mg x1, doxycycline 100mg for pna
vs uti (she has a history of allergic reactions to penicillin,
cephalosporins, levofloxacin), 2L IV normal saline. Labs notable
for dirty UA with large ___ and positive nitrites (microscopy not
sent). CXR showed some mild pulmonary vascular congestion
concerning for early heart failure, but no focal consolidation.
Vitals prior to transfer were: 99.1 115 23 96%.
On arrival to the floor, the patient is complaining of feeling
very tired. Complains of total body aches, as well as a
persistent headache. She denies any dyspnea, chest pain, cough.
She reports nausea yesterday, but none at present, and denies
any vomiting. Last bowel movement was yesterday, not loose and
without blood. She denies any dysuria, polyuria, frequency,
urgnecy. She also denies any numbness or tingling, although
acknowledges some weakness and a heavy feeling of her
extremities, especially her legs. She reports that her daugther
has been unwell with a flu-like illness recently.
Past Medical History:
HTN
Asthma
Depression
Diabetes Mellitus Type II
necrobiosis lipoidica diabeticorum
Uveitis
Social History:
___
Family History:
Diabetes, HTN
Mother with breast cancer
Aunt had sarcoidosis
Physical Exam:
PHYSICAL EXAM:
VS - Temp 99.4 F, 119/62 BP , 116 HR , 20 R , O2-sat 97% RA
GENERAL - well-appearing obese woman in NAD, anxious,
appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Lesions on shins bilaterally consistent with known
necrobiosis lipoidica, reduced sensation bilaterally on legs,
distal pulses difficult to palpate. ___ power in lower
extremities, ___ power in upper extremities. Extremities
diffusely tender to deep palpation.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
Admission Labs:
___ 01:40AM BLOOD WBC-11.0 RBC-5.19 Hgb-15.4 Hct-45.1
MCV-87 MCH-29.6 MCHC-34.1 RDW-13.3 Plt ___
___ 01:40AM BLOOD Neuts-85.1* Lymphs-11.8* Monos-1.6*
Eos-1.3 Baso-0.2
___ 11:55AM BLOOD Glucose-317* UreaN-13 Creat-0.6 Na-130*
K-4.2 Cl-99 HCO3-21* AnGap-14
___ 11:55AM BLOOD ALT-75* AST-31 LD(LDH)-196 AlkPhos-66
TotBili-0.9
___ 11:55AM BLOOD Calcium-8.2* Phos-2.8# Mg-1.1*
___ 01:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Discharge Labs:
___ 07:25AM BLOOD WBC-12.0* RBC-3.99* Hgb-12.0 Hct-34.7*
MCV-87 MCH-30.1 MCHC-34.5 RDW-13.2 Plt ___
___ 07:25AM BLOOD Neuts-66.9 ___ Monos-4.9 Eos-0.9
Baso-0.3
___ 07:25AM BLOOD Glucose-282* UreaN-10 Creat-0.4 Na-136
K-3.9 Cl-101 HCO3-28 AnGap-11
___ 07:25AM BLOOD Calcium-8.2* Phos-1.9* Mg-2.0
Respiratory viral culture: No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B, Parainfluenza
type 1,2 & 3, and Respiratory Syncytial Virus.
URINE Cx: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
CXR: 1. Limited study due to low lung volumes and patient body
habitus demonstrates
no evidence of acute cardiopulmonary process. However, a repeat
radiograph
would be helpful in further evaluation of the lower lobes.
2. Pulmonary arteries appear slightly prominent and raise
suspicion for early
heart failure.
RENAL ULTRASOUND:
The right kidney measures 13.7 cm and the left kidney measures
13.6 cm. There is no evidence of hydronephrosis,
nephrolithiasis, or renal masses bilaterally. The
corticomedullary differentiation is well preserved. The bladder
is distended and is unremarkable in appearance. Partially
imaged liver is increased in echogenicity, compatible with fatty
deposition.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Hepatic steatosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
2. HydrOXYzine 25 mg PO QHS:PRN itch
Take 1 hour before bedtime. Will make drowsy.
3. Silver Sulfadiazine 1% Cream 1 Appl TP BID
4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN severe
pain
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Naproxen 500 mg PO Q12H
awith meals
8. Promethazine 25 mg PO Q8H:PRN nausea/vomiting
9. Albuterol Inhaler 1 PUFF IH BID
10. NPH 62 Units Breakfast
NPH 65 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. HydrOXYzine 25 mg PO QHS:PRN itch
Take 1 hour before bedtime. Will make drowsy.
4. Naproxen 500 mg PO Q12H
awith meals
5. Promethazine 25 mg PO Q8H:PRN nausea/vomiting
6. Silver Sulfadiazine 1% Cream 1 Appl TP BID
7. Diazepam 5 mg PO Q8H:PRN muscle pain/anxiety
RX *diazepam 5 mg 1 Tablet(s) by mouth Every 8 hours Disp #*6
Tablet Refills:*0
8. Albuterol Inhaler 1 PUFF IH BID
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
10. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN severe pain
please take this medication only if you continue to have severe
pain that is not controlled with tylenol. Please take tylenol
first for pain. Do not take if drowsy or driving.
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 8 hours Disp #*8
Tablet Refills:*0
11. NPH 62 Units Breakfast
NPH 65 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Acetaminophen 325-650 mg PO Q6H:PRN pain, muscle aches
use this medication FIRST if you have pain or muscle aches. Do
not take more than 4g in 24 hours.
13. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Infusion reaction to Remicade
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Dyspnea, tachycardia.
COMPARISON: Chest radiograph from ___.
FINDINGS: Evaluation is limited by low lung volumes and patient body habitus.
The pulmonary vascular markings are exaggerated by low lung volumes but there
is suggestion of pulmonary arterial prominence in comparison to the prior
study. There are mild bibasilar atelectatic changes. Otherwise, the lungs
are without focal consolidation, effusion, or pneumothorax. Cardiomediastinal
silhouette is otherwise within normal limits. No acute fractures are
identified.
IMPRESSION:
1. Limited study due to low lung volumes and patient body habitus demonstrates
no evidence of acute cardiopulmonary process. However, a repeat radiograph
would be helpful in further evaluation of the lower lobes.
2. Pulmonary arteries appear slightly prominent and raise suspicion for early
heart failure.
Point 1 was discussed by Dr. ___ with Dr. ___ telephone at 3:11 am on
___.
Radiology Report
INDICATION: Patient with history of UTI, assess for hydronephrosis.
COMPARISONS: CT abdomen of ___.
FINDINGS:
The right kidney measures 13.7 cm and the left kidney measures 13.6 cm. There
is no evidence of hydronephrosis, nephrolithiasis, or renal masses
bilaterally. The corticomedullary differentiation is well preserved. The
bladder is distended and is unremarkable in appearance. Partially imaged
liver is increased in echogenicity, compatible with fatty deposition.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Hepatic steatosis.
Gender: F
Race: WHITE
Arrive by OTHER
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED
temperature: 103.4
heartrate: 124.0
resprate: 14.0
o2sat: 100.0
sbp: 131.0
dbp: 92.0
level of pain: 10
level of acuity: 3.0 | ___ with sarcoidosis, HTN, obesity and T2DM who presents with
fever to 103.4 and body aches after Remicade infusion on ___
.
#Fever and myalgias: Per rheumatology, low grade fevers,
myalgias and malaise are common after infliximab infusion, and
typically come on shortly after infusion of infliximab,
persisting for ___ days after infusion. Hives and nausea, which
this patient also had, typically can occur during or shortly
after infusion, and then recede. This is what happened to Ms.
___. However, fever to >103, as in this case, is very
atypical. Given that this patient has been on immunomodulators
for sarcoidosis, has had contact with her daughter who has a
flu-like illness at present, had a UA positive for leukocytes,
bacteria and nitrites, concern is certainly raised for
infection, with the signs and symptoms perhaps compounded by the
side effects of infliximab. The differential includes UTI (with
concern for pyelonephritis, since CVA tenderness may be masked
by her diffuse myalgias), influenza or other influenza-like
illness. CXR does not raise concern for pneumonia at present,
and she does not have any GI symptoms currently. No signs of
cellulitis on extremities. She does have a headache, but no
photophobia, neck stiffness or mental status changes to raise
concern for meningitis/encephalitis. Given TNF-alpha infusion,
would also rule out fungal infections. The patient continued to
do well and her fever broke several hours after she was
admitted. She reported pain and weakness of her muscles and was
treated with IV Dilaudid and PO Valium. This was transitioned to
PO oxycodone and Valium and the patient continued to do well.
Her infectious work up was negative (save discussion of possible
UTI, see below) including culture for RSV. She had improved to
the point on day of discharge she was able to walk, eat, and was
comfortable. She was discharged home with follow up with her
outpatient rheumatologist.
#UTI: UA positive for WBCs, bacteria, leukocytes, nitrites.
Patient denies urinary symptoms, but does have fevers, myalgias.
Myalgias may be masking CVA tenderness. Elected to treat as
urine cx was consistent with contaminated flora. Patient was
initially on doxycycline while in the hospital but will complete
3 day treatment with Bactrim as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bact___
Attending: ___.
Chief Complaint:
LLE erythema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man with history of homelessness, DM2 c/b
neuropathy, s/p R BKA, HTN, DVT (presumed PE as well, on
warfarin), who presents with ___ days of LLE erythema and
swelling.
Patient says he went to church today and a nurse there mentioned
that patient had a healing ulcer with surrounding erythema.
Patient had not noticed this before, but did think his leg was
more swollen than usual. He notes that he sat in his wheelchair
for much longer than usual over the past day and that this
frequently causes him to have increased LLE swelling.
He also reports missing a dose of warfarin last week and then
taking a double dose (20mg) on ___ to compensate. He says
his INR is generally in the therapeutic range and he gets it
checked every 2 weeks at ___.
He says he drank a significant amount one day this past week
after a friend died from hanging herself. He says he was quite
upset, but is better now. He does not typically binge drink and
only drinks ___.
He also reports getting into a small fight today when somebody
tried to steal some of his things. He held on to his belongings
and was pulled from his wheelchair. He landed on his left
shoulder. He says he does not have any pain.
In the ED, VS were: T 98.5, BP 177/75, P ___, RR 20, O2 95% on
RA. Labs notable for INR 6.6, cr 1.3 (b/l 1.3-1.5), WBC 11.1,
glucose 231. Exam notable for LLE erythema consistent with
cellulitis. He received ceftriaxone IV 1gm, lantus 50u (home
med), ibuprofen PO 600mg, and was admitted to medicine for
further evaluation.
Past Medical History:
- Homelessness
- DM2 c/b neuropathy
- S/p R BKA
- HTN
- DVT (presumed PE, on warfarin)
Social History:
___
Family History:
Unknown, mother died when patient was a child and he has been
without family contact since
Physical Exam:
VS: T 98.1, BP 150/81, P 97, RR 18, O2 100% on RA
Gen: Well-appearing, sitting upright in bed, no acute distress
HEENT: MMM, anicteric sclera, EOMI, PERRL
CV: RRR, normal s1s2, no m/r/g, no JVD
Pulm: Clear to auscultation bilaterally
Abd: Obese, soft, non-tender, non-distended
Ext: S/p R BKA, stump clean without erythema, LLE with 1cm ulcer
with surrounding ecchymosis, erythema extending anteriorly from
below L knee to L ankle (marked)
Neuro: No focal deficits
avss
non toxic, attentive, cooperative and pleasant
clear breath sounds anteriorly
regular pulse
palpable ___ pulses in L foot, foot is warm
ongoing substantial pitting edema in L foot,
erythema now only concentrated around his scab on the anterior
left shin, a few papules that may be neen drained pustules that
are now dry. diminished tenderness along his L calf
Pertinent Results:
IMAGING:
LLE ultrasound (___):
No evidence of deep venous thrombosis in the left lower
extremity veins.
Please note evaluation of the upper calf veins is limited.
LAB VALUES:
BMP:
142 | 106 | 32 AGap=13
---------------< 231
4.9 | 28 | 1.3
ALT: 19 AST: 22
CBC:
11.1 > 11.2/34 < 328
N:62.2 L:26.2 M:6.2 E:3.8 Bas:0.9 ___: 0.7 Absneut: 6.88
Abslymp: 2.90 Absmono: 0.69 Abseos: 0.42 Absbaso: 0.10
___: 74.4 PTT: 58.4 INR: 6.6
___ 07:39AM BLOOD WBC-9.5 RBC-3.42* Hgb-10.6* Hct-32.0*
MCV-94 MCH-31.0 MCHC-33.1 RDW-13.5 RDWSD-45.4 Plt ___
___ 07:23AM BLOOD ___
___ 07:39AM BLOOD Glucose-79 UreaN-25* Creat-1.2 Na-140
K-4.7 Cl-106 HCO3-28 AnGap-11
___ 06:51AM BLOOD Calcium-9.0 Phos-5.2* Mg-2.2
___ 07:46AM BLOOD %HbA1c-9.6* eAG-229*
___ 07:23AM BLOOD Vanco-23.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Glargine 50 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Warfarin 10 mg PO 6X/WEEK (___)
6. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: Today - ___, First Dose: Next Routine Administration
Time
7. Warfarin 12.5 mg PO 1X/WEEK (TH)
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Glargine 50 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 20 mg PO DAILY
4. Warfarin 10 mg PO 6X/WEEK (___)
12.5mg once a week
5. Clindamycin 300 mg PO Q6H Duration: 5 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*20 Capsule Refills:*0
6. Warfarin 12.5 mg PO 1X/WEEK (TH)
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left leg cellulitis
diabetes type 2
chronic dvt left leg
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: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with known DVT dx in ___ on Coumadin who
presents with increased swelling and pain in LLE, evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Left lower extremity DVT ultrasound ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. The posterior tibial and peroneal
veins of the left upper calf are not clearly 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 evaluation of the upper calf veins is limited.
Gender: M
Race: HISPANIC/LATINO - MEXICAN
Arrive by WALK IN
Chief complaint: L Leg swelling, L Shoulder pain
Diagnosed with Cellulitis of left lower limb, Abnormal coagulation profile, Adverse effect of anticoagulants, initial encounter, Oth places as the place of occurrence of the external cause
temperature: 98.2
heartrate: 100.0
resprate: 20.0
o2sat: 95.0
sbp: 177.0
dbp: 75.0
level of pain: 6
level of acuity: 2.0 | ___ year old man with history of homelessness, DM2 c/b
neuropathy, s/p R BKA, HTN, DVT (presumed PE as well, on
warfarin), who presents with ___ days of LLE erythema and
swelling consistent w cellulitis.
He developed cellulitis likey from using a loofah (skin rough
sponge) that may have opened up a slight skin abrasion causing
skin infection.
# LLE cellulitis: given DM2 and appearance of grouped lesions
that may have been pustules and homelessness he is at risk for
MRSA infection. Given that he resides in shelter and sits in
wheelchair during day and has risk of poor response to
antibiotics given DM2 and obesity and limited ability to keep
leg
elevated out of monitored setting, patient requires ongoing
parenteral antibiotics and leg elevation.
He improved with 72hrs of IV vancomycin therapy. He will
continue 5d course of clindamycin for cellulitis. He will go to
___ ___ to recuperate. He should avoid loofah
treatments and keep skin intact and use compression stalking.
The for negative predictive value of a negative MRSA swab to
rule
out past or current MRSA infection may be somewhat unreliable to
avoid covering him with anti-MRSA antibiotic.
# Coagulopathy Likely in the setting of taking double dose of
warfarin and
recent alcohol intake.
- resumed home dose of 10mg Coumadin , 12.5mg on ___
- Trend INR, INR 1.5 on ___
# History of DVT with suspected PE:
- LLE ultrasound negative
- resumed Coumadin on ___
- INR goal ___
Since this was a distal calf vein DVT of left posterior tibial
veins diagnosed in ___, he has already received >3 months of
initial anticoagulation therapy. Continuing anticoagulation now
is primarily to reduce risk of recurrent DVT. He can speak w
PCP
about his preference to remain on Coumadin or to stop it rather
than to continue indefinetly to reduce risk of recurrence w
trade
off of needing INR monitoring and potential higher risk of
bleeding.
# HLD:
- Continued atorvastatin
# IDDM2:
- Continued lantus 50u qhs, Humalog 12 units w meals
- reduced Humalog to 8u with meals
- Insulin sliding scale
- metformin resumed on discharge
# HTN:
- Continue lisinopril 20mg qd
# CKD:
- Baseline Cr 1.3-1.5, slightly improved on discharge
TRANSITIONAL
[]COMPLETE ANTIBIOTICS
[]COMPRESS EDEMA IN LEFT LEG/FOOT
[]NEEDS ANTICOAGULATION MANAGEMENT, FOLLOW INR
[]NEEDS HELP GETTING HIS R BKA PROSTHESIS TO FIT BETTER
[]A1C ELEVATED , NEEDS HELP W BETTER LONG TERM GLUCOSE CONTROL |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
gait unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Stage IV esophageal ca (liver mets) s/p 2 cycles of
FOLFOX (last on ___, COPD, prostate ca in remission s/p
radiation therapy, who p/w gait unsteadiness. States progressive
weakness over 2 days, with orthostatic dizziness and
unsteadiness on his feet when he tried to get up out of bed,
unable to stand
today and had a fall without head strike. Denies any injury from
the fall. States that his legs feel tired, and that he is
generally weak but no focal weakness or sensory deficits. Denies
numbness/tingling, saddle anesthesia, back pain, urinary/fecal
retention/incontinence, fevers. Denies UE symptoms, CP, dyspnea,
abd pain, or flank pain. No sick contacts, URI symptoms.
He has not been using the rolling walker except in the last day
or two prior to admission. His girlfriend notices that when he
does walk, he tends to speed up and "get ahead of himself" and
potentially trip. He has been getting 1L fluid boluses qd at
home since ___ (increased from 1L IVFs q3d), but it did not
improve his symptoms. These symptoms are similar to his
dizziness and unsteadiness that prompted a recent admission for
dehydration and hypotension.
Last discharged ___: admitted with new afib with RVR and
hypotension ("He was also started on ASA 81mg as systemic
anticoagulation would have been too high a risk given his
adenocarcioma. He was started on PO amiodarone 400mg PO BID x 2
weeks (___), then 200mg PO BID x 2 weeks ___ - ___,
then 200mg PO daily. At discharge he was in NSR in the ___
On discharge he was "Scheduled to receive 1L IV normal saline q3
days w/ home ___. ___ need to increase frequency when he resumes
chemotherapy.") Recent admission ___ for hypotension and
dehydration (he received IVF and discontinued his amlodipine,
lisinopril, and furosemide and decreased his metoprolol.)
ED course:
14:44 0 98.5 81 120/80 18 99% RA
Evaluation: "Admission for failure to thrive - gait instability,
nothing else focal. Generalized weakness. Unclear etiology at
this time."
16:08 IVs: Start IV Fluid (Common) NS 1000 mL bolus
Total:1000 mL
Past Medical History:
Oncologic History:
(Please see OMR/Atrius records for full details.)
Stage IV esophageal cancer T3NXM1 (diagnosed ___ on
palliative FOLFOX therapy (___)
--multiple liver mets
PMH/PSH:
COPD
Stage IV esophageal adenocarcinoma, liver mets
Hypercholesterolemia
Hypertension, essential
___ esophagus
Colonic polyp
Prostate cancer
Goiter, toxic, multinodular
Peptic ulcer
Sprain of ankle, right
Aortic valve stenosis, mild
CAD, native vessel ___ TTE shows preserved EF)
h/o impaired fasting blood glucose
h/o murmur
Social History:
___
Family History:
CAD in his mother; Cancer in his father; ___ in his
brother and mother; and ___ Disorder in his paternal aunt.
Physical Exam:
ADMISSION PHYSICAL
-------------------
afebrile, HR ___, 120/80, 16, 99%RA
GEN: NAD
HEENT: PERRL, EOMI, slightly dry MM with oral candidiasis,
posterior oropharynx clear, no cervical ___: CTAB with decreased breath sounds, no wheezes, rales or
rhonchi.
Chest: port site without TTP, erythema, or swelling
CV: RRR without m/r/g, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, non-tender, not distended, firm and
palpable liver that is non-tender
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, CN ___ intact, motor strength
intact. Able to "get up and go" with crossed arms from seated
position. Negative Romberg. 2+ reflexes. Downgoing babinski b/l.
Able to walk without assistance but takes small steps.
DISCHARGE PHYSICAL
-------------------
VITALS: 98.2/98.2 122/58 80 20 95RA
orthostatics:
laying 123/62 84
sitting 134/76 94
standing 105/65 91
GEN: NAD, comfortable
HEENT: PERRL, EOMI, slightly dry MM with oral candidiasis,
posterior oropharynx clear, no cervical ___: CTAB with decreased breath sounds, no wheezes, rales or
rhonchi.
Chest: port site without TTP, erythema, or swelling
CV: RRR ___ murmur heard best at the apex
ABD: normal bowel sounds, non-tender, not distended, firm and
palpable liver that is non-tender
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, CN ___ intact, motor strength
intact in UE and ___.
Pertinent Results:
ADMISSION LABS
---------------
___ 04:14PM BLOOD WBC-9.1 RBC-4.83 Hgb-12.2* Hct-37.9*
MCV-79* MCH-25.3* MCHC-32.2 RDW-16.8* Plt ___
___ 04:14PM BLOOD Neuts-73.8* Lymphs-17.6* Monos-6.8
Eos-1.2 Baso-0.6
___ 04:14PM BLOOD Glucose-119* UreaN-10 Creat-0.8 Na-134
K-4.4 Cl-100 HCO3-20* AnGap-18
DISCHARGE LABS
---------------
___ 06:26AM BLOOD Glucose-95 UreaN-8 Creat-0.7 Na-134 K-4.0
Cl-101 HCO3-25 AnGap-12
___ 06:26AM BLOOD Albumin-2.8* Phos-1.9* Mg-1.4*
___ 06:26AM BLOOD VitB12-406 Folate-17.4
IMAGING
--------
___ CXR
FINDINGS: AP portable upright chest radiograph provided.
Port-A-Cath is unchanged in position with tip residing in the
region of the mid to low SVC. Lungs appear grossly clear
bilaterally without focal consolidation or definite signs of
effusion or pneumothorax. The heart and mediastinal contour
appear stable. There is retrocardiac opacity again seen which
is compatible with known hiatal hernia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID constipation
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Methimazole 10 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Mirtazapine 15 mg PO HS
6. Omeprazole 20 mg PO BID
7. Pravastatin 80 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Aspirin 81 mg PO DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
2puffs qid prn wheezing, SOB
11. Amiodarone 200 mg PO BID
12. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID constipation
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Methimazole 10 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Mirtazapine 15 mg PO HS
8. Omeprazole 20 mg PO BID
9. Pravastatin 80 mg PO DAILY
10. Senna 17.2 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
2puffs qid prn wheezing, SOB
13. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Dehydration
Secondary diagnosis: Malnutrition, Esophageal Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: CTA chest from ___.
CLINICAL HISTORY: Lower extremity weakness, question pneumonia.
FINDINGS: AP portable upright chest radiograph provided. Port-A-Cath is
unchanged in position with tip residing in the region of the mid to low SVC.
Lungs appear grossly clear bilaterally without focal consolidation or definite
signs of effusion or pneumothorax. The heart and mediastinal contour appear
stable. There is retrocardiac opacity again seen which is compatible with
known hiatal hernia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness, Unable to ambulate
Diagnosed with OTHER MALAISE AND FATIGUE, FAILURE TO THRIVE,ADULT
temperature: 98.5
heartrate: 81.0
resprate: 18.0
o2sat: 99.0
sbp: 120.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ with Stage IV esophageal ca s/p 2 cycles of FOLFOX (last on
___, COPD, prostate ca in remission s/p radiation therapy,
who p/w unsteady gait.
#unsteady gait with orthostatic dizziness: likely secondary to
dehydration due to poor PO intake, which is a recurrent issue
for the patient since starting chemotherapy in spite of
receiving IVFs at home. On admission, these symptoms have
resolved. No s/s of infection, cardiac process, or CNS process
(neurologically intact). Folate, vit B12 wnl. Patient was noted
to be orthostatic the morning of admission and was given an
additional 1L bolus (in addition to 1L in the ED). He was seen
by physical therapy who cleared him for home with home ___ and by
nutrition with recommendations for Ensure Plus tid-qid and a
multivitamin with minerals. B12 and folate wnl.
CHRONIC ISSUES
#Onc-met esophageal cancer:continued on PPI and mirtazapine qhs
#oral candidiasis: resume nystatin S&S
#afib with h/o RVR: continued on rate control agents amio, BB
and on ASA 81
# COPD: no home O2 requirement, continued home tiotropium,
fluticasone-Salmeterol and albuterol PRNS
#CV: h/o CAD, HTN, HL: continued on home metoprolol, pravastatin
and ASA
# Toxic goiter/ h/o hyperthyroidism: Continued on methimazole
#constipation: on bowel regimen
#dysuria: with h/o prostate ca s/p XRT and no known BPH. worked
up during ___ admission without e/o infection. Has urology as
outpatient ___ and encouraged to present to that appointment.
TRANSITIONAL ISSUES
# Will be discharged with ___ for qod 1L fluids
# Poor PO intake and low energy since the initiation of his
chemotherapy, PO intake encouraged, started on Ensure Plus
tid-qid and MV.
# Cleared for discharge home with ___
# f/u with Dr. ___ on ___. Please check lytes (including Phos
and Mg) during f/u. Will likely need further discussion
regarding side effects of chemo and options for treatment
# DNR/DNI, contact: ___ (daughter/HCP) ___, (c___
___ |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / erythromycin / Compazine / Aspirin / Ssri
&Antipsych,Atyp,Dop&Serotonin Antag / Maois Non-Selective &
Irreversible / Codeine
Attending: ___.
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with multiple complicated medical
problems who presented to the ED seeking ethanol detoxification.
His last drink was at 6:30pm on ___. On ___ he began
to have withdrawal symptoms, which he is very familiar with.
These included, diaphoresis, paranoia, racing heart, tremors and
anxiety. He reports an unwitnessed seizure on ___, manifest
by "passing out" and 45 minutes of confusion thereafter. Denies
incontinence, shaking/jerking movements. He has been wretching
all day.
In the ED, initial VS: 96.8, 132/90, hr 86, rr 22, sat 98% ra.
Given 2L NS. Also, valium 10mg iv, thiamine 100mg po,
multivitamin, folic acid 1mg, methadone 20mg once, lyrica 100mg
once, omeprazole 20mg once.
Currently, he has no acute complaints other than nausea. He had
one episode of small volume emesis with streak blood while on
the floor.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) fever, nasal congestion, cough, sputum production,
hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
diarrhea, constipation, hematochezia, melena, dysuria, urinary
frequency, urniary urgency, focal numbness, focal weakness,
myalgias, arthralgias
Past Medical History:
# HCV - untreated
# Rheumatic Fever
# s/p endocarditis ___ (IVDU)
# s/p pericarditis ___
# s/p ear surgery
# s/p foot debridements for MRSA infection
# negative for HIV at ___ ___
# Hepatitis C
# Enterococcal Endocarditis diagnosed at ___ in ___,
patient non compliant with antibiotics, admitted here late ___,
c/b valve destruction and renal septic emboli
# s/p MVR ___ c/b liver injury
# fungemia with PICC line
# tooth abcesses
# CKD stage II
# ADHD
# bipolar disorder
# CT scan in ___ showed emphysematous changes and a right
lower lobe nodule
# h/o injection drug use - methamphetamines
# fibromyalgia
# STDs
Social History:
___
Family History:
Patient is adopted and is unaware of his family history
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.5 BP: 130/78 P: 62 R: 17 O2: 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, extremely poor dentition with
many missing teeth
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: midline laparotomy scar weill healed, soft, non-tender,
non-distended. + bowel sounds. no rebound or guarding. Liver
palpable 4fingerbreaths below costal margin, no splenomegaly
appreciated.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema, mild
tremors
Neuro: CN II-XII intact. Strength ___ throughout. motor
function grossly normal
DISCHARGE EXAM:
VS: 97.5; 115-156/97-109; 60-70; 16; 99%RA
Exam unchanged from admission. No gross tremors, no
diaphoresis,
Pertinent Results:
Significant labs:
___ 07:25AM BLOOD WBC-7.5 RBC-4.21* Hgb-14.8 Hct-42.0
MCV-100* MCH-35.1* MCHC-35.2* RDW-14.7 Plt ___
___ 07:25AM BLOOD Neuts-76.5* Lymphs-17.6* Monos-5.1
Eos-0.4 Baso-0.4
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-138* UreaN-14 Creat-1.0 Na-137
K-4.6 Cl-104 HCO3-22 AnGap-16
___ 07:25AM BLOOD ALT-141* AST-150* CK(CPK)-65 AlkPhos-183*
TotBili-0.7
___ 07:25AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:35AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:25AM BLOOD Albumin-4.4
___ 07:35AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
___ 07:35AM BLOOD VitB12-862 Folate-7.0
___ 07:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CXR ___
FINDINGS: Low lung volumes are seen which limit assessment.
There is a an opacity, which obscures the right heart border,
concerning for an early developing right middle lobe pneumonia.
The remainder of the lungs are clear without pleural effusion or
pneumothorax. The heart is normal in size.
Normal cardiomediastinal silhouette.
IMPRESSION: Possible early developing right middle lobe
pneumonia.
Medications on Admission:
omeprazole 20mg daily
benadryl 50mg daily prn itching
keppra 500mg tid
lyrica 200mg tid
alprazolam 1mg bid prn anxiety
hydromorphone ___ po q6hrs prn
methadone 20mg qAM, 20mg qPM, 10mg QHS prescribed by ___
provider and confirmed to be dispensed at ___
___
Zolpidem 20mg qhs (this is per pt and lunesta 2mg qhs)
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. methadone 10 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
5. methadone 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
6. methadone 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed
for indigestion.
11. alprazolam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
12. hydromorphone 2 mg Tablet Sig: ___ Tablets PO q6hrs prn as
needed for pain.
13. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Withdrawal.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pressure. Assess for infiltrate.
TECHNIQUE: PA and lateral radiographs of the chest.
COMPARISON: Chest radiograph from ___.
FINDINGS: Low lung volumes are seen which limit assessment. There is a an
opacity, which obscures the right heart border, concerning for an early
developing right middle lobe pneumonia. The remainder of the lungs are clear
without pleural effusion or pneumothorax. The heart is normal in size.
Normal cardiomediastinal silhouette.
IMPRESSION: Possible early developing right middle lobe pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ETOH WITHDRAWRAL
Diagnosed with ALCOHOL WITHDRAWAL, AC ALCOHOL INTOX-UNSPEC, CHEST PAIN NOS
temperature: 96.8
heartrate: 86.0
resprate: 22.0
o2sat: 98.0
sbp: 132.0
dbp: 90.0
level of pain: 9
level of acuity: 2.0 | ___ year old male with multiple complicated medical problems who
presented to the ED seeking ethanol detoxification.
# Etoh Withdrawal: Patient initially endorsing tremors, anxiety,
palpitations, visual and tactile hallucinations, with CIWA in
the low ___ and received IV Ativan 2mg q3h due to nausea and
inability to take PO. LFTs stable and AAOx3, no concern for
acute alcoholic hepatitis or hepatic encephalopathy. Continued
home dose Keppra for seizure prophylaxis. No seizure activities
in the hospital. By morning of ___, patient decreasing
symptoms and low CIWA score. On discharge, denied
hallucinations, tremors or anxiety. Plan to follow up at ___
___ with PCP on afternoon of discharge and consider
outpatient detox program.
# Cough: New x ___ days. CXR concerning for developing PNA, has
aspiration risk factors given alcohol abuse. However, no
fevers, no leukocytosis, so did not start antibiotics.
# Chronic Pain: Dilaudid PO and lyrica for pain (as per home
dose)
# HCV- defer for oupatient management |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
STEMI/syncope
Major Surgical or Invasive Procedure:
Intubation ___
Cardiac Catheterization ___
PPM implantation ___
History of Present Illness:
___ with HTN, HLD and CAD, brought in after her son found her on
the floor in the middle of the night. She was breathing,
arousable, but out of it. He doesn't know how long she had been
on the floor. He saw blood on her head and called ___. She was
found hypotensive and bradycardic by EMS. On arrival to the ED,
she was bradycardic in the ___ in complete heart block, with
SBPs in the ______. She was started on dopamine gtt at 20, and her
HR's increased to the 40's and her blood pressures improved to
100/70's. An EKG showed ST elevations in V1-V3. A head CT showed
no intracranial bleed, and FAST exam was negative. She was
intubated with etomidate and roc. She was bolused with 7000
heparin, started on a heparin gtt, given a full dose of PR
aspirin, and loaded with Plavix down her OG tube. She was taken
to the Cath lab, where she was found to have ostiol LAD and mid
LAD lesions which received POBA but no stents. Access was
through the R fem, and a temporary pacer wire was placed.
She was then transferred to the CCU. On arrival, she has cold
extremities and non-reactive pupils.
Past Medical History:
HTN
CATARACT
BASAL CELL CARCINOMA
HYPERLIPIDEMIA
OSTEOPENIA
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
Leg Cramps, Sleep Related
Chronic diastolic congestive heart failure (EF 55-60% ___
Social History:
___
Family History:
no known family hx of cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 33.5 (not cooled) 71 122/46 100% on CMV Fio2 30% PEEP 5
Weight: 70 kg
Tele: paced
GEN: intubated, sedated
HEENT: 3x3 superficial laceration over left scalp
NECK: supple, hard c-collar in place, unable to assess JVP
CV: RRR, no murmurs appreciated
LUNGS: vent sounds
ABD: soft, non-distended, + BS
EXT: no edema
SKIN: cold arms and legs, poor cap refill
NEURO: L pupil irregular and 3mm, R pupil 2mm, non reactive.
no movements, unresponsive
DISCHARGE EXAM
Vitals: 98.1 110-130/40-50 70-80s 18 100RA 47.0kg
Gen: lean, frail,conversant,appropriate, no acute distress;
alert, interactive
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. No appreciable JVD. Normal carotid
upstroke without bruits. No thyromegaly.
CV: RRR, normal S1,S2 III/VI holosystolic murmur at apex
consistent with MR; no rubs, clicks, or gallops
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM.
EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral
bruits.
SKIN: large hematoma to lateral aspect of L chest with mild
extension to axilla, very tender, but no fluctuance or
induration noted; stable to resolving from prior
Pertinent Results:
ADMISSION LABS
___ 07:08AM BLOOD WBC-12.0*# RBC-3.75* Hgb-11.7 Hct-35.4
MCV-94 MCH-31.2 MCHC-33.1 RDW-13.5 RDWSD-46.4* Plt ___
___ 07:08AM BLOOD Neuts-76.9* Lymphs-16.9* Monos-5.1
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.24* AbsLymp-2.04
AbsMono-0.62 AbsEos-0.03* AbsBaso-0.04
___ 07:08AM BLOOD ___ PTT-22.9* ___
___ 07:08AM BLOOD Glucose-300* UreaN-74* Creat-1.7* Na-134
K-3.9 Cl-98 HCO3-21* AnGap-19
___ 07:08AM BLOOD ALT-172* AST-206* AlkPhos-87 TotBili-1.0
___ 07:08AM BLOOD Lipase-72*
___ 07:08AM BLOOD proBNP-6078*
___ 07:08AM BLOOD Albumin-3.8
___ 03:50PM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7
___ 07:17AM BLOOD Lactate-3.5*
CARDIAC ENZYME TREND
___ 11:58AM BLOOD CK-MB-128* cTropnT-2.74*
___ 09:00PM BLOOD CK-MB-216*
___ 04:00PM BLOOD CK-MB-51*
___ 06:25AM BLOOD CK-MB-23* cTropnT-4.83*
STUDIES
___ TTE
IMPRESSION: EF ___ to moderate left ventricular
hypertrophy with small cavity, regional systolic dysfunction c/w
LAD territory CAD. Elevated PCWP. Myocardial appearance, RVH and
diastolic parameters suggestive of amyloid cardiomyopathy.
Normal RV cavity size and systolic function. Moderate mitral
regurgitation. Mild aortic stenosis. At least moderate pulmonary
hypertension.
EKG ___
Sinus rhythm with blocked premature atrial contractions. Right
bundle-branch block with left anterior fascicular block. Left
axis deviation. Evolving anterior wall myocardial infarction.
Q-T interval prolongation
Cardiac Cath ___
Impressions:
Anterior STEMI.
Bradycardia.
Succesful POBA of LAD Stenosis
Placement of a transvenous temporary pacemaker.
CXR ___
In comparison with the study of ___, the endotracheal and
nasogastric
tubes have been removed, as has been a possible pacer lead
extended from
below. There has been interval placement of a dual-channel left
subclavian pacer with leads extending to the right atrium and
apex of the right ventricle. No evidence of pneumothorax.
Cardiac silhouette is stable and there is again some elevation
of pulmonary venous pressure. Small bilateral pleural effusions
are again seen.
MICRO
URINE CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
CITROBACTER FREUNDII COMPLEX
|
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
___ 12:40PM BLOOD WBC-10.5* RBC-2.59* Hgb-8.1* Hct-23.9*
MCV-92 MCH-31.3 MCHC-33.9 RDW-13.3 RDWSD-44.3 Plt ___
___ 12:40PM BLOOD Plt ___
___ 05:20AM BLOOD Glucose-129* UreaN-63* Creat-1.3* Na-136
K-3.6 Cl-101 HCO3-26 AnGap-13
___ 05:20AM BLOOD LD(LDH)-PND TotBili-PND
___ 06:25AM BLOOD CK-MB-23* cTropnT-4.83*
___ 05:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9 Iron-PND
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with head injury, bradycardia, // ? ICH, eval ETT
placement
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, 16.2 cm; CTDIvol = 43.5 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or fracture. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Periventricular and subcortical white matter hypodensities are nonspecific but
likely sequelae of chronic small vessel ischemic disease. There is a small
right frontal dural plaque or densely calcified meningioma (image 20, series
2)
The visualized portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable. There is a small focus of gas in the subcutaneous soft tissues
immediately above the left orbit at the site of reported laceration.
IMPRESSION:
Small left supraorbital skin laceration. No evidence of fracture or
intracranial hemorrhage
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with head injury, bradycardia, syncope // ? ICH,
eval ETT placement
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 22.1 cm; CTDIvol = 37.2 mGy (Body) DLP = 821.3
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
Total DLP (Body) = 881 mGy-cm.
COMPARISON: None.
FINDINGS:
There is severe multilevel degenerative changes. There is minimal
anterolisthesis of C3 on C4. Alignment is otherwise maintained. The bones
are diffusely demineralized suggesting osteoporosis. There is no fracture.
At C2-3, intervertebral osteophytes mildly narrow the spinal canal without
contacting the spinal cord. The neural foramina appear normal.
At C3-4, intervertebral osteophytes mildly narrow the spinal canal.
Uncovertebral and facet osteophytes produce severe left neural foraminal
narrowing.
At C4-5, intervertebral osteophytes mildly narrow the spinal canal and
slightly flatten the anterior surface of the spinal cord. Uncovertebral and
facet osteophytes produce moderate left and mild right neural foraminal
narrowing.
At C5-6, intervertebral osteophytes flatten the spinal cord, particularly on
the left. Uncovertebral and facet osteophytes produce severe left neural
foraminal narrowing.
At C6-7, intervertebral osteophytes narrow the spinal canal and flatten the
anterior surface of the spinal cord. Uncovertebral osteophytes produce
moderate right neural foraminal narrowing.
At C7-T1, intervertebral osteophytes mildly encroach on the spinal canal. The
neural foramina appear normal.
Views of the upper thoracic spine demonstrate mild degenerative changes but no
evidence of canal or foraminal encroachment.
There is no prevertebral soft tissue abnormality. Biapical scarring is noted.
Endotracheal and orogastric tubes are partially imaged. There is a 9 mm right
thyroid hypodense nodule. ___ College of Radiology guidelines for
incidental thyroid nodules do not recommend further evaluation for lesions of
this size in patients of this age.
IMPRESSION:
No fracture. Multilevel degenerative changes.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS.
INDICATION: History: ___ with head injury, bradycardia, syncope*** WARNING
*** Multiple patients with same last name! // ? ICH, eval ETT placement
TECHNIQUE: Single AP portable view of the chest.
COMPARISON: ___.
FINDINGS:
An endotracheal tube terminates 3.5 cm above the level of the carina. A
nasogastric tube terminates within the stomach. An additional catheter tube
overlies the mid right hemithorax, likely external to the patient. The heart
is moderately enlarged and there is mild central pulmonary vascular
congestion. Small bibasilar pleural effusions are noted. The upper lungs are
grossly clear without large consolidation. There is no overt pneumothorax
identified.
IMPRESSION:
1. ETT terminating 3.5 cm above the carina.
2. Moderate cardiomegaly, mild central pulmonary vascular congestion, and
small bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old woman with STEMI, now intubated post cath with pacer
wire in place // placement of pacer wire
COMPARISON: Radiographs from ___ at 06:40.
IMPRESSION:
There has been placement of a pacemaker wire from an inferior approach which
projects over the right atrium. Orogastric and endotracheal tubes are
unchanged in position. There is cardiomegaly, stable. There are small
bilateral effusions. No focal consolidation is seen.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p dual chamber PPM // Assess leads placement
and r/o PTx. Assess leads placement and r/o PTx.
IMPRESSION:
In comparison with the study of ___, the endotracheal and nasogastric
tubes have been removed, as has been a possible pacer lead extended from
below.
There has been interval placement of a dual-channel left subclavian pacer with
leads extending to the right atrium and apex of the right ventricle. No
evidence of pneumothorax.
Cardiac silhouette is stable and there is again some elevation of pulmonary
venous pressure. Small bilateral pleural effusions are again seen.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: 3RD DEGREE HB
Diagnosed with Atrioventricular block, complete, Syncope and collapse, STEMI involving oth coronary artery of inferior wall, Unspecified injury of head, initial encounter, Fall on same level, unspecified, initial encounter
temperature: nan
heartrate: 36.0
resprate: nan
o2sat: 96.0
sbp: 98.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | ___ yo F with CAD and dCHF admitted to the CCU after a fall at
home and found to have STEMI complicated by bradycardia and
complete heart block now s/p PPM
# ACUTE CORONARY SYNDROME/STEMI c/b Complete Heart Block.
Patient with known CAD and prior MI per son. She had previously
presented to ___ ED with chest pain in ___, but declined ETT
as it was not in line with her goals of care at the time. On
presentation for fall at home, she had ST elevations in V1-V3
consistent with LAD disease. She underwent catheterization which
revealed ostial and mid LAD lesions which received POBA, no
stents. The patient was admitted to the CCU intubated, on
pressors, with transvenous pacing wire. With diuresis, she was
able to be extubated. PPM was implanted ___ and pressors
were able to be weaned. She was maintained on ASA 81, Plavix,
Atorvastatin, which were continued on the general cardiology
floor. Her lisinopril was continued to be held given her recent
___ and hypotension in setting of cardiogenic shock.
# Complete heart block s/p PPM: HR ___ on admission. Started on
dopamine in ED and temp wire placed in ER. s/p PPM placement
___, c/b large lateral hematoma. Pain was well controlled with
low-dose oxycodone. Hematoma appeared stable at discharge.
# Shock: Likely cardiogenic in setting of STEMI. She required
dopamine, which was transitioned to levophed. Initially she was
hypothermic with ___, elevated LFTs and a lactate of 3.5.
Resolved Started on dopamine in ER. Hypothermic. Creatinine
elevated and uop low, elevated LFTs. Lactate 3.5 which
eventually downtrended to 1.0. When pressures were stable, she
was started on metop. At discharge, she was transitioned to
25XL as her BPs continued to remain stable. Her ACEI was
continued to be held. Notably, UA/UCx were sent at admission
given c/f sepsis; Ucx grew CITROBACTER FREUNDII COMPLEX for
which she was started on a 7-day course of cipro on ___.
# Acute systolic on chronic diastolic heart failure: Patient
initially presented with elevated BNP, pulmonary edema and
pleural effusions on CXR. She was diuresed with IV medications
before being transitioned back to her home diuretic. She was
discharged on her home Furosemide 30 mg PO/NG BID with a weight
of 47.0kg.
# anemia: 9.7 to 7.9 over 48 hours, unclear etiology. Would
expect melena if GIB resulted in such a large hgb drop. Minor
dilutional component possible. Hematoma appeared stable. Groin
benign. Repeat hgb prior to discharge stable. Hemolytic w/up
and iron studies pending at discharge. Patient did not require
any blood transfusions while hospitalized.
# ___: likely in setting of cardiogenic shock/heart failure.
Appears to be resolving. Unclear cr baseline. Peaked at 1.7,
down to 1.3.
CHRONIC ISSUES:
# Hypertension: Held home meds initially given cardiogenic
shock. Reintroduced as able with stabilization of BPs. Patient
was discharged on metop 25XL; her other antihypertensives were
held.
# Hypothyroidism: continued home levothyroxine
TRANSITIONAL ISSUES
- hgb at discharge 8.1; hemolytic lab eval and anemia w/up still
pending at discharge; should get h/h recheck on ___,
consider Plavix/ASA contributing to recent change in hemoglobin
- large left chest hematoma s/p PPM placement; please continue
to assess for enlargement
- ACEI held on admission in setting of [likely] cardiogenic
shock; consider restarting as able
- will need to reassess her home meds and reintroduce meds (in
addition to her ACEI) PRN
# CODE: Full, confirmed
# CONTACT: HCP is grandson: ___ ___,
then son ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope with fall and headstrike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year-old male with a history of dementia, HTN,
and DMII who presented with syncope and fall with headstrike.
At approximately 1530, pt had episode of syncope. No preceding
symptoms. Witnessed. Pt fell backwards. Hit back of head. No
seizure activity. LOC for few seconds. No postictal stage. After
episode complained of abdominal pain. Experienced another
episode of syncope 10 minutes later. Syncopal episode occurred
while lying flat. LOC for few seconds. After the second episode,
patient developed abdominal pain that was alleviated after one
episode of vomiting. Family members noted otherwise that patient
has been having fevers and chills, chest pain, shortness of
breath.
Notably, 3 months ago had epsidoe of presyncope vs syncope and
fall, admitted to ___ ___. Cardiac w/u was negative,
including normal TTE on ___. Found on CT head to have 7mm
temporal lobe lesion, ASA was discontinued. HCTZ was d/c'd as
thought to have contributed to his fall.
Of note, per ___ notes has had worsening functional status over
the last few months in the setting of his wifes illness. Per
notes, daughter says his wife was the "stabilizing force." Has
been requiring 24hr supervision over the last few months due to
history of falls and wandering. He is now dependent for all
IADLs and most ADLs.
Past Medical History:
HTN
DM
BPH with urinary retention and bladder stones s/p TURP
Dementia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.0PO 135/90 L Lying 90 16 97 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
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, or edema, warm and well
perfused
NEURO: strength and sensation intact in upper and lower
extremities throughout. Normal FTN test, RAM. CN2-12 intact. A+O
to person, being in a hospital, month and year.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
===============
___ 0747 Temp: 98.1 PO BP: 145/86 L Lying HR: 89 RR: 18 O2
sat: 97% O2 delivery: Ra FSBG: 205
GENERAL: NAD, affect is flat
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
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, or edema, warm and well
perfused
NEURO: CN2-12 grossly intact, strength and sensation intact in
upper and lower extremities throughout.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 05:15PM ___ PTT-26.3 ___
___ 05:15PM PLT COUNT-234
___ 05:15PM NEUTS-62.8 ___ MONOS-11.1 EOS-2.5
BASOS-0.6 IM ___ AbsNeut-4.32 AbsLymp-1.53 AbsMono-0.76
AbsEos-0.17 AbsBaso-0.04
___ 05:15PM WBC-6.9 RBC-4.59* HGB-12.3* HCT-38.4* MCV-84
MCH-26.8 MCHC-32.0 RDW-13.2 RDWSD-40.6
___ 05:15PM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.4
MAGNESIUM-1.6
___ 05:15PM cTropnT-<0.01
___ 05:15PM LIPASE-96*
___ 05:15PM ALT(SGPT)-15 AST(SGOT)-14 ALK PHOS-61 TOT
BILI-0.3
___ 05:15PM estGFR-Using this
___ 05:15PM GLUCOSE-242* UREA N-16 CREAT-0.9 SODIUM-136
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-22 ANION GAP-18
___ 11:29PM cTropnT-<0.01
IMAGING:
=========
___ CT HEAD W/O CON:
1. Small focus of intracranial hyperdensity in the left temporal
lobe
measuring up to 10 mm may represent intraparenchymal or
subarachnoid
hemorrhage. Alternatively, the finding may represent a
meningioma, given lack of priors for comparison. No surrounding
edema or significant mass effect. No midline shift. Recommend
short-term interval follow-up to assess for change.
2. No acute fracture.
___ CT C-SPINE W/O CON:
No acute fracture or traumatic malalignment.
___ CTA CHEST AND CT ABDOMEN:
1. No pulmonary embolism or aortic dissection.
2. No other acute process in the chest, abdomen or pelvis.
3. Enlarged heterogeneous prostate gland.
4. 11 mm enhancing focus in the right hepatic lobe may represent
a hemangioma. 5. 4 mm pulmonary nodule does not require
additional follow-up if patient is at low risk for primary lung
neoplasm. If patient is at high risk for primary lung neoplasm,
optional follow-up CT chest could be performed in 12 months.
RECOMMENDATION(S):
For incidentally detected single solid pulmonary nodule smaller
than 6 mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT in 12 months is recommended in a high-risk
patient.
DISCHARGE LABS:
===============
___ 06:30AM BLOOD WBC-6.8 RBC-4.92 Hgb-13.1* Hct-40.5
MCV-82 MCH-26.6 MCHC-32.3 RDW-13.2 RDWSD-39.6 Plt ___
___ 06:30AM BLOOD Glucose-207* UreaN-17 Creat-0.9 Na-138
K-4.1 Cl-97 HCO3-26 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. GlipiZIDE 10 mg PO WITH BREAKFAST
3. GlipiZIDE 5 mg PO WITH EVENING MEAL
4. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
BID with meals
5. Finasteride 5 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Senna 17.2 mg PO DAILY constipation
9. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*7 Tablet Refills:*0
2. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
BID with meals
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. GlipiZIDE 5 mg PO WITH EVENING MEAL
6. GlipiZIDE 10 mg PO WITH BREAKFAST
7. Lisinopril 40 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Senna 17.2 mg PO DAILY constipation
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Syncope
- Traumatic brain injury secondary to intraparenchymal
hemorrhage
Secondary diagnosis
- Orthostatic hypotension
- Dementia
- Hypertension
- Benign prostatic hypertrophy
- Type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent, A+O X2 (Person, place, not
time)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance with walker.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, headstrike, LOC, vomiting// r/o fracture,
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, 16.0 cm; CTDIvol = 50.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a small focus of hyperdensity in the left temporal region, measuring
8 x 7 x 10 mm which may be intraparenchymal or in the adjacent subarachnoid
space (2:12, 601:57). Alternatively, it is possible this could represent a
meningioma, given lack of priors for comparison. There is no surrounding
edema or significant mass effect. No midline shift. There is prominence of
the ventricles and sulci suggestive of involutional changes. Subcortical and
periventricular white matter hypodensities are nonspecific, however likely
represent sequela of chronic small vessel ischemic disease. There are
atherosclerotic calcifications in the bilateral cavernous carotids.
There is no evidence of acute fracture. There is mild mucosal thickening in
the ethmoid air cells. The visualized portion of the remainder of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Small focus of intracranial hyperdensity in the left temporal lobe
measuring up to 10 mm may represent intraparenchymal or subarachnoid
hemorrhage. Alternatively, the finding may represent a meningioma, given lack
of priors for comparison. No surrounding edema or significant mass effect.
No midline shift.
Recommend short-term interval follow-up to assess for change.
2. No acute fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall, headstrike, LOC, vomiting// r/o fracture,
bleed
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 21.5 cm; CTDIvol = 22.7 mGy (Body) DLP = 487.9
mGy-cm.
Total DLP (Body) = 488 mGy-cm.
COMPARISON: None.
FINDINGS:
There is straightening and slight reversal of the normal cervical lordosis.
No acute fractures are identified. There are multilevel degenerative changes
with disc space narrowing and small posterior disc osteophyte complexes,
resulting up to mild central canal narrowing, worst at C5-C6 and C6-C7. Facet
arthropathy and uncovertebral hypertrophy results in up to mild bilateral
neural foraminal narrowing, worst at C5-C6. There is no prevertebral edema.
The thyroid and included lung apices are grossly unremarkable.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
EXAMINATION: CTA chest and CT abdomen and pelvis with contrast
INDICATION: History: ___ with syncope without symptoms. Hypotensive at
scene// r/o PE, dissection
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 4.1 s, 32.1 cm; CTDIvol = 9.7 mGy (Body) DLP = 310.9
mGy-cm.
3) Spiral Acquisition 7.1 s, 55.6 cm; CTDIvol = 11.8 mGy (Body) DLP = 655.8
mGy-cm.
Total DLP (Body) = 970 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart is mildly enlarged with coronary artery
calcifications in the LAD. The great vessels are within normal limits. Trace
pericardial fluid is noted.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild bibasilar atelectasis. There is a 4 mm pulmonary
nodule in the right upper lobe (3:77). The airways are patent to the level of
the segmental bronchi bilaterally.
BASE OF NECK: Subcentimeter hypodense nodules in the bilateral thyroid lobes
do not require additional follow-up per ACR guidelines.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is a 1.1 cm hyperenhancing lesion the right hepatic lobe (2:129). There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a lobulated simple cyst arising from the left kidney measuring up to
10.7 cm. A subcentimeter cortical hypodensity in the right kidney is too
small to characterize, however likely represents a cyst. There is no
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal (2:165). There is no
free intraperitoneal fluid or free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged and heterogeneous.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Degenerative changes are noted L4 and L5. Old fracture
deformity the anterior right sixth rib is noted. An umbilical hernia
containing fat is noted.
IMPRESSION:
1. No pulmonary embolism or aortic dissection.
2. No other acute process in the chest, abdomen or pelvis.
3. Enlarged heterogeneous prostate gland.
4. 11 mm enhancing focus in the right hepatic lobe may represent a hemangioma.
5. 4 mm pulmonary nodule does not require additional follow-up if patient is
at low risk for primary lung neoplasm. If patient is at high risk for primary
lung neoplasm, optional follow-up CT chest could be performed in 12 months.
RECOMMENDATION(S):
For incidentally detected single solid pulmonary nodule smaller than 6 mm, no
CT follow-up is recommended in a low-risk patient, and an optional CT in 12
months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse, Abnormal electrocardiogram [ECG] [EKG], Contus/lac/hem crblm w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 98.0
heartrate: 86.0
resprate: 12.0
o2sat: 100.0
sbp: 116.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ year-old male with a past medical history of
dementia, type II diabetes mellitus, and hypertension, who
presented with syncope. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confused
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman, with history of
breast cancer, s/p partial mastectomy in ___, hypertension and
hypothyroidism, prior convulsive seizure and newly diagnosed
multifocal glioblastoma, who presents with 1 week history of
progressive confusion. History provided by patient's husband as
patient cannot provide history.
Patient was seen by her neuro-oncologist Dr ___ for
progressive confusion. Please see his note detailed ___ for
most detailed history. To summarize briefly, she began acting
off
from her baseline about 1 week ago, when she had poor PO intake.
5 days ago, on ___, she was found walking aimlessly in the
lobby of the hospital, prior to a scheduled appointment for lab
draw. She had a syncopal episode. Per report a bystander caught
her before she fell. She had no head strike. VSS per report. She
declined going to the ED. She received IV fluids and completed
the last fraction of her radiation therapy. Since returning home
she spent the majority of the weekend lying in bled. She
appeared
abulic and disengaged. Her husband noted that she slept in the
bathtub a few times and continued with poor PO intake.
Since seeing Dr. ___, she spent most of the night in
bed. Her husband went to sleep in evening. The last thing he
noticed was that she was sitting on the dining room table,
writing down information about her bills. When he woke up to go
to the bathroom a few hours later, he noted that she was staring
'blankly' at the checks. Her husband asked her to acknowledge
him
and say her name, but she had no verbal output. He tried several
times without success. She was able to make some eye contact
with
him initially but was 'staring blankly through him.' He noticed
that her eyes appeared deviated downward. She did not have any
shaking movements, twitching, automatisms, LOC or bowel/bladder
incontinence. He tried to help her to the bed but had difficulty
as she was not moving voluntarily. He was concerned that she was
having complex partial seizures as she had somewhat similar
behavior on ___ prior to her convulsion. As a result he
called ___ and transferred her here to ___ for further
evaluation.
She continues to receive radiation, last received full regimen 5
days ago, and is maintained on dexamethasone. For full details
of
her neuro-oncologic history, please see summary below per Dr
___ ___ note:
"Treatment History:
(1) convulsive seizure on ___ with post ictal left gaze
preference,
(2) non-contrast head CT on ___ shows two brain masses,
(3) hospitalized at ___ from ___ to ___, and
(4) gadolinium-enhanced head MRI from ___ at ___ showed
two enhancing nodules in right and left frontal brain,
(5) neurosurgical resection of the right frontal tumor by Dr.
___ on ___ and the pathology showed
glioblastoma, IDH-1 wild-type and GOPC-ROS1 rearrangement,
(6) started involved-field cranial irradiation and daily
temozolomide on ___,
(7) stopped dexamethasone on ___,
(8) serum creatinine went up to 1.6 on ___, and
(9) serum creatinine at 1.3 on ___.
Her oncologic problem began in ___ when she was diagnosed with
breast cancer and underwent partial mastectomy in ___. Biopsy
showed infiltrating ductal carcinoma 1.2 cm grade 2 with
lymphatic vessel invasion positive, lymph node-negative, ER/PR
positive. DCIS absent. She was subsequently treated with
Cytoxan and Adriamycin ×4 and then received whole breast
radiation therapy. She then took ___ years of hormonal therapy-
letrozole which ended in ___. In ___, there was a
firm area over her left breast which was biopsied and showed fat
necrosis and inflammation. She has been seen yearly for
surveillance without any evidence of recurrence.
Her neurologic problem began on ___ when she was
vacationing
in ___. She had a remote in her hand and was
watching football at night at about 10:50 p.m., which she
normally would never watch. At 11:00 p.m., the patient and her
husband usually switch to the news and when he asked her if she
wanted to do so she did not respond to him and did not change
her
position. Even when he stood in front of her she would not
focus
on him or respond to his questions. He also noticed that both
of
her hands appear to be trembling/shaking in a nonrhythmic
fashion. He then called ___ and she was taken to ___. According to the patient, she was never
unresponsive, she never remembered the events in the evening,
and
instead she reported that she was watching the news
at 11:00 p.m. Her husband wanted to see the end of the game and
asked her to change channels but she told him she wanted to go
to
bed because she was tired. He thought she "did not look good"
and
therefore called ___.
At the hospital in ___, she was initially confused
with head and eyes deviated to the left when not being asked to
look to the right, not following commands well with waxing and
waning periods of lucidity during which she was able to answer
questions, unable to respond appropriately to sensory exam
with a fine tremor. Later in the evening, she experienced a
generalized convulsive seizure for which 2 mg of Ativan was
given. After this, she was notably somnolent but arousable and
appeared encephalopathic, at times mumbling incoherently. Urine
was reportedly suggestive of UTI with nitrite positive, ___
WBCs,
bacteria 3+ but may have been contaminated. Lyme antibody
IgG/IgM negative, TSH 4.38, WBC 12.9, BMP with only mild
irregularities-NA 133, BUN 24, creatinine 0.95 and K 3.2.
Noncontrast head CT showed possible irregularity/hypodensity in
the right frontal lobe. At 02:00 a.m., CTA with delayed imaging
showed enhancing lesions in the right frontal and left frontal
lobes with no signs of shift or herniation. She received a
loading dose of phenytoin 50 mg/kg and transferred to ___,
where her mental status slowly recovered to baseline and was
discharged home on ___. She then underwent neurosurgical
resection of the right frontal tumor by Dr. ___ on
___ and the pathology showed glioblastoma, IDH-1 wild-type
and GOPC-ROS1 rearrangement."
I would like to highlight that patient's husband felt that this
event was similar to her initial symptoms in ___
on
___ (watching the football game blankly), though she did not
have any shaking movements this time (unlike the previous
___
event).
On presentation to ___ ED she received 1mg Ativan due to
?seizure without significant improvement. She has been quite
somnolent since arrival, arousing to voice and following simple
commands but unable to provide history.
Past Medical History:
BREAST CANCER, diagnosed in ___ positive, HER-2
negative, clean lymph nodes. She received Cytoxan and
Adriamycin. She was on letrozole for ___, which ended in
___ and she resumed in ___.
HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
DIVERTICULITIS
UTI
Social History:
___
Family History:
(Per patient's husband) Mother with colon cancer, dementia
Physical Exam:
EXAM ON ADMISSION:
=================
Physical Exam:
Vitals: T98.1F, HR 68, BP 158/85, RR 16, O2 99% RA
General: lethargic. Lying in bed.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; regular on telemetry
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Lethargic, sleeping in bed. She opens her eyes
to
voice, but returns to eyes closed if not repetitively stimulated
verbally. When aroused she is oriented to self, ___, but not
to
year (says it is ___. When asked why she is in the hospital,
says "Because I hurt my foot." Unable to provide other history.
She can repeat simple phrases. Able to name high frequency
objects. Follows one step midline and appendicular commands.
-Cranial Nerves: Eyes closed with eyelid opening apraxia. Gaze
is
conjugate with no gaze deviation. ___ 3>2, EOMI, BTT
bilaterally, face symmetric, palate elevates symmetrically,
tongue midline.
-Sensorimotor: Normal bulk, tone throughout. Unable to assess
pronator drift and confrontational testing given mental status.
Moves all four extremities antigravity and symmetrically against
resistance, with no focal or asymmetric weakness that I can
appreciate (given limitations of her mental status). Briskly
withdraws to noxious in all four extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor on L, flexor on R.
-Coordination, Gait unable to perform due to mental status
EXAM ON DISCHARGE:
==================
Physical Exam:
General: Looks slightly less pale today
Lungs: breathing comfortably
CV: extremities warm to touch
Abd: soft, nontender
Ext: non-edematous
- Mental status continues to be stable. She is more alert today,
with eyes open in bed. Oriented to hospital but says ___.
Oriented to her name and ___. Not oriented to day, month,
year. Able to follow midline and axial commands. She is
inattentive.
-Cranial Nerves: Gaze is conjugate with no gaze deviation. EOMI,
face symmetric, palate elevates symmetrically, tongue
midline.
-Sensorimotor: Normal bulk, tone throughout. No pronator drift.
Strength is full and symmetric in all extremities.
Plantar response was extensor bilaterally
Pertinent Results:
ADMISSION LABS:
___ 04:37AM BLOOD WBC-5.6 RBC-3.17* Hgb-9.6* Hct-28.4*
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.4 RDWSD-43.8 Plt ___
___ 04:37AM BLOOD Plt ___
___ 04:04AM BLOOD K-3.7
___ 04:37AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-138
K-3.5 Cl-99 HCO3-28 AnGap-11
___ 08:35AM BLOOD ALT-18 AST-19 AlkPhos-98
___ 04:04AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.4 Mg-1.8
___ 12:54PM BLOOD TSH-1.4
___ 12:54PM BLOOD Free T4-1.6
___ 03:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CORRECTED DILANTIN LEVEL ___: 9.9
IMAGING DATA:
___: reviewed, discussed with attending.
1. Interval worsening of the bifrontal mass, possibly becoming
necrotic on the left, with increased edema and effacement of the
frontal horns of the bilateral lateral ventricles.
2. No definite cranial hemorrhage is identified.
MRI w and wo contrast ___:
Increased FLAIR signal abnormality surrounding the bifrontal
lesions crosses the corpus callosum, extending into the left
basal ganglia, insula, and internal capsule, and causes mass
effect with partial effacement of the left greater than right
anterior horns of the lateral ventricles.
EEG ___:
FINDINGS:
CONTINUOUS EEG: From the beginning of the recording, there were
very prominent focal high-voltage spike or sharp and slow wave
discharges in the right anterior quadrant, maximal at F4 and at
an 8. They recurred throughout the record, often in a very
periodic fashion every 1.0 to 1.5 seconds. There are also brief
bursts of the same discharges with a frequency of up to 2 Hz for
a few seconds at a time. There was also some posterior ___ Hz
rhythm bilaterally. The faster rhythmic discharges often
occurred in runs of ___ seconds. There was one longer, definite
electrographic seizure at ___ it started with a
high voltage sharp and slow wave at 1 Hz and subsequently
increased to rhythmic 2 Hz sharp and slow wave activity until it
ended with 1-second focal background attenuation. On video,
there was no clinical correlate.
SLEEP: no normal waking or sleep patterns were recorded.
PUSHBUTTON ACTIVATIONS: There was none.
SPIKE DETECTION PROGRAMS: showed the same spike and sharp wave
discharges
described above.
SEIZURE DETECTION PROGRAMS: showed many of the rhythmic sharp
waves described earlier, along with the one electrographic
seizure, as described above.
CARDIAC MONITOR: Showed a generally regular rhythm with a rate
between 50 and 60 bmp.
IMPRESSION: This telemetry captured no pushbutton activations.
It continued to show persistent very frequent and often periodic
high-voltage spike and sharp wave ___ Hz discharges in the
right anterior quadrant and occasionally faster runs for up to
10 seconds, as described above. The background was slow and
disorganized indicating a widespread encephalopathy. Compared to
the prior's day recording, there was continued LPDs and one
electrographic seizure.
EEG ___:
FINDINGS:
CONTINUOUS EEG: From the beginning of the recording, the
background was
disorganized and slow. It was composed of low voltage ___ Hz
theta rhythm with some admixed polymorphic delta rhythm,
although it did reach up to 8 Hz alpha briefly during
wakefulness. There was continuous right frontocentral and
frontotemporal high voltage sharp, spike and polypsike-and- slow
wave discharges with a broad field extending to the parasaggital
and left frontal regions, with sharp waves generally at about 1
Hz. They became of slightly lower voltage and slower at about
0.8 Hz by midnight to the end of the recording. There were
occasional brief bursts when the sharp waves increased in
frequency to about 2 Hz, but just for a few seconds at a time.
SLEEP: no normal waking or sleep patterns were recorded.
PUSHBUTTON ACTIVATIONS: There was none.
SPIKE DETECTION PROGRAMS: showed the same spike and sharp wave
discharges
described above.
SEIZURE DETECTION PROGRAMS: showed no clear electrographic
seizures.
CARDIAC MONITOR: Showed a generally regular rhythm with a rate
between 60 and 70 bpm.
IMPRESSION: abnormal continuous EEG monitoring session due to
the continuous lateralized periodic epileptiform discharges,
mostly recurring at about ___ Hz, but slower later in the
record. The background was slow and disorganized, usually in the
theta range. Discharges were persistent, but no clear
electrographic seizures were evident. There were no pushbutton
activations.
CXR:
Successful placement of a single lumen chest power Port-a-cath
via the right internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. amLODIPine 10 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Dexamethasone 2 mg PO Q12H
This is the maintenance dose to follow the last tapered dose
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO Q12H
7. Hydrochlorothiazide 25 mg PO DAILY
8. LevETIRAcetam 1000 mg PO Q12H
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
12. Pravastatin 80 mg PO QPM
Discharge Medications:
1. Bevacizumab (Avastin) 400 mg IV Days 1 and 22. ___
and ___
(5 mg/kg (Weight used: Actual Weight = 71.2 kg BSA: 1.74 m2))
*Dose before rounding 356 mg
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO Q12H
4. LACOSamide 150 mg PO BID
5. LevETIRAcetam 1000 mg PO Q12H
6. Magnesium Oxide 940 mg PO BID
TAKE AT LEAST 4 HOURS AFTER THYROID MEDICATION
7. Phenytoin Infatab 150 mg PO QHS
8. Phenytoin Infatab 100 mg PO BID
9. Dexamethasone 4 mg PO Q12H
10. amLODIPine 10 mg PO DAILY
HOLD FOR SBP<100
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Pravastatin 80 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Glioblastoma Multiforme
Non-convulsive seizures
Discharge Condition:
Mental Status: Confused - sometimes. (perseverates, never knows
date)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with metastatic ca, seizure// 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 6.4 s, 16.7 cm; CTDIvol = 48.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head dated ___. MR head dated ___.
FINDINGS:
Patient is status post right frontal craniotomy for resection of a right
frontal lobe mass. There are associated postoperative changes in the surgical
bed. 2.9 x 2.1 cm lesion the median right frontal lobe has increased in size.
The previously seen left median frontal lobe lesion appears more hypodense,
possibly becoming necrotic. When compared to prior head CT and MR, there has
been increase edema in the bilateral frontal lobes and effacement of the
frontal horns of the bilateral lateral ventricles.. No definite intracranial
hemorrhage is identified. There is no evidence of large territorial
infarction or additional mass.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Interval worsening of the bifrontal mass, possibly becoming necrotic on the
left, with increased edema and effacement of the frontal horns of the
bilateral lateral ventricles.
2. No definite cranial hemorrhage is identified.
Radiology Report
INDICATION: History: ___ with AMS// ?PNA ?infection
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph dated ___ and ___.
FINDINGS:
No focal consolidation to suggest pneumonia. No pulmonary edema. No pleural
effusion or pneumothorax. Mild atelectatic changes in the retrocardiac
region. Moderate cardiomegaly and mediastinal silhouette are grossly
unchanged accounting for technique differences. No acute osseous
abnormalities.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with known GBM and bifrontal masses, presenting
with progressive confusion and ?seizure, found to have interval worsening and
necrosis on CT.// eval for worsening mass vs post radiation changes
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: Head CT ___.
MR head ___.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
The patient is status post right frontal craniotomy and tumor resection, with
postsurgical changes again noted. However, irregular and thick enhancement
seen within the resection cavity has significantly increased from prior
examination, with increased surrounding T2/FLAIR signal abnormality,
compatible with tumor recurrence and progression.
Additionally, the previously noted irregularly enhancing masses seen along the
right anterior cingulate gyrus and left anterior gyrus rectus have both
substantially increased. On the right, the enhancing component measures 2.4 x
1.7 cm, previously 1.4 x 1.0. On the left, the enhancing component measures
3.0 x 2.4 cm, previously 1.8 x 1.3 cm.
Central areas of hypoenhancement and T2 hyperintensity within the left frontal
lobe mass may represent areas of necrosis. Subtle areas of low signal on GRE
sequences within the right frontal lobe mass may reflect internal
microhemorrhage. Allowing for this, there is otherwise no evidence for acute
intracranial hemorrhage or infarction.
The extent of perianal lesional T2/FLAIR signal abnormality has increased, now
spanning the genu of the corpus callosum. Increased mass effect is seen
bifrontally, with effacement of the sulci and partial effacement of the left
greater than right anterior horns of the lateral ventricles. The remainder of
the ventricular system appears intact.
There is additional extension of FLAIR signal abnormality into the left
insula, left caudate head, and the anterior limb of the left internal capsule.
The dural venous sinuses remain patent. The remainder of the ventricular
system and sulci are mildly prominent compatible with mild background
parenchymal volume loss. The primary intravascular flow voids are grossly
preserved.
There is mucosal thickening seen in scattered ethmoid air cells. The middle
ear cavities, and mastoid air cells are well aerated and clear. The orbits
are within normal limits bilaterally.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Significant interval progression involving bifrontal lobe heterogeneously
enhancing masses with surrounding T2/FLAIR abnormality that crosses the corpus
callosum. Differential considerations include tumor progression, radiation
necrosis, and treatment related effects.
3. Status post right frontal approach craniotomy and tumor resection, with
increased enhancing soft tissue seen surrounding the resection cavity,
concerning for local disease progression.
4. Increased FLAIR signal abnormality surrounding the bifrontal lesions
crosses the corpus callosum, extending into the left basal ganglia, insula,
and internal capsule, and causes mass effect with partial effacement of the
left greater than right anterior horns of the lateral ventricles.
5. Additional imaging findings, as above, suggest areas of central necrosis
predominantly within the left frontal lobe lesion, and areas of possible
internal microhemorrhage within the right frontal lobe lesion.
6. No definite evidence for additional sites of intracranial hemorrhage or
acute infarction.
Radiology Report
INDICATION: ___ year old woman with GBM, multifocal.// Please place single
lumen chest port and leave accessed. Plan for avastin. Use non-absorbale
sutures. ___! Patient cannot consent, Husband will need to consent.
Number in chart. He will arrive at ___ too.
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ Radiologist performed the
procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
fentanyl and midazolam while the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. Doses were
not recorded. 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS:
CONTRAST:
FLUOROSCOPY TIME AND DOSE: 0.4 min, 2 mGy
PROCEDURE
1. Right internal jugular approach chest single lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous non-absorbable Prolene sutures. Steri-strips were
used to close the venotomy incision site. Steri-Strips were applied over the
sutures. Final spot fluoroscopic image demonstrating good alignment of the
catheter and no kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
RECOMMENDATION(S): Removal of non-absorbable suture at the discretion of
oncology team.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.1
heartrate: 68.0
resprate: 16.0
o2sat: 99.0
sbp: 158.0
dbp: 85.0
level of pain: uta
level of acuity: 2.0 | Mrs. ___ is a ___ year old woman with history of breast
cancer, s/p partial mastectomy in ___, hypertension and
hypothyroidism, and multifocal glioblastoma (IDH-1 w GOPC-ROS1
rearrangement, MGMT not tested) that initially manifested as a
convulsive seizure. She is now s/p resection of right frontal
tumor, chemotherapy with temozolomide, and involved-field
radiation therapy. She was admitted for 1-week of progressive
confusion with suspicion for non-convulsive seizures.
Her clinical exam on admission on admission was notable for
somnulence with minimal ability to follow-commands. Her
laboratory values on admission were initially remarkable for an
acute kidney injury, likely pre-renal secondary to diminished PO
intake, which resolved with gentle hydration. She also continued
to be hypomagnesemic, requiring daily repletions of magnesium.
Her EEG on the first night of admission demonstrated frequent
periodic lateral epileptiform discharges localizing to the right
frontal lobe. These discharges occasionally demonstrate brief
periods of evolution with at least one electrographic
seizure-capture event on the night of admission. Since that
event, she has had no further seizures.
Imaging with noncontrast head CT demonstrates interval worsening
of her bifrontal masses with associated edema and likely
necrosis. Further work-up with MRI brain w and wo contrast
demonstrated local disease progression. It is unclear if her
imaging findings are secondary to disease progression with
worsening edema or radiation effect.
She is continuing to show signs of improvement with maintenance
on keppra, phenytoin, lacosamide, and dexamethasone. The
inciting factor for
her nonconvulsive seizures is likely either related to
progression of her GBM or pseudoprogression as an inflammatory
response in the setting of chemo-radiation therapy, as is seen
with MGMT-positive GBM, although her MGMT status is unknown. She
is now s/p port a cath on ___ and is now s/p Avastin therapy on
___ without complications. She will not need additional avastin
for at least 3 weeks and is stable to be discharged to a
facility that will focus on her physical rehabilitation.
On the day of discharge, her PHT corrected (with albumin) to
9.9. Would consider increasing to ___ if level remains
borderline low on subsequent checks. Goal PHT is ___. |
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
Wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of HTN, mild bronchiectasis who presents with an
acute respiratory illness x3 days.
Pt states states that starting 3 days ago she began feeling
unwell, with body aches, cough productive of sputum, nasal
congestion, subj fever. Starting today she began feeling short
of
breath while walking. Denies recent travel or rashes.
She presented to outpt provider. CXR negative for pneumonia. O2
sats 92% on RA. She was started on flovent, albuterol and
azithromycin, but after the visit her d-dimer came back positive
at 714 and she was called to come into the ED for further
evaluation.
In the ED, initial VS were: T 100.1, HR 86, BP 184/53, RR 18,
SpO2 99% RA
Exam notable for: RRR. NTND abd. Trace edema of the ___
bilaterally. Diffuse coarse crackles bilaterally. AAOx3.
Labs showed:
- Chem10 WNL
- CBC WNL
- TropT neg
- Flu neg
Imaging showed:
- CTA CHEST: 1. No evidence of pulmonary embolism or aortic
abnormality. 2. Mild bronchiectasis and mild bronchial wall
thickening is nonspecific.
Patient received:
___ 18:10 IV Acetaminophen IV 1000 mg ___
___ 18:20 PO/NG amLODIPine 10 mg ___
___ 18:20 PO/NG Lisinopril 10 mg ___
___ 20:07 IVF NS 1000 mL ___ Stopped (1h ___
___ 21:11 IV CefTRIAXone (1 g ordered) ___
Admitted to medicine for "failure to thrive at home in setting
of
illness"
On arrival to the floor, patient endorses history above. She
endorses cough productive of green-yellow sputum, sinus
congestion, dyspnea on exertion, and wheezing. Denies weight
loss, hemoptysis.
Past Medical History:
HTN
CAD s/p MI x3
GERD
OSA
Bronchiectasis- mild, seen incidentally on CT, saw pulm with
NTD.
PFTs normal.
Social History:
___
Family History:
Father ___ CAD/PVD - Early
Mother ___ [OTHER]
Other Cancer - Breast
Sister ___ - Unknown Type
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5, BP 137 / 80, HR 67, RR 18, SpO2 91 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Good air movement, bronchial breath sounds RLL
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.3 F BP: 136/84 P:62 R: 18 O2: 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: CTAB. No accessory muscle use.
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
Ext: Warm, well perfused, 1+ DP pulses, no edema. Nontender.
Neuro: A&Ox3
Pertinent Results:
___ 06:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 05:01PM GLUCOSE-78 UREA N-10 CREAT-1.0 SODIUM-144
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
___ 05:01PM cTropnT-<0.01
___ 05:01PM proBNP-143
___ 05:01PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-2.2
___ 05:01PM WBC-8.7# RBC-4.38 HGB-11.7 HCT-37.4 MCV-85
MCH-26.7 MCHC-31.3* RDW-13.7 RDWSD-43.0
___ 05:01PM NEUTS-77.2* LYMPHS-10.1* MONOS-9.2 EOS-2.3
BASOS-0.5 IM ___ AbsNeut-6.74* AbsLymp-0.88* AbsMono-0.80
AbsEos-0.20 AbsBaso-0.04
___ 05:01PM PLT COUNT-322
___ 05:01PM ___ PTT-28.9 ___
___ Na 144 K 4.3 Cl 104 HCO3 24 Cr 1.1 BUN 17
___ WBC 4.3 H/H 11.3/36.2 Plt 318
___ FluAPCR/FluBPCR NEGATIVE
___ Blood cultures NGTD
IMAGING
CTA ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild bronchiectasis and mild bronchial wall thickening is
nonspecific.
CXR ___:
Lungs are clear. Heart size is normal. There is no pleural
effusion. No pneumothorax is seen. Cardiomediastinal silhouette
is stable
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
7. Aspirin 325 mg PO DAILY
8. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Benzonatate 200 mg PO TID
RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
3. Guaifenesin-Dextromethorphan 5 mL PO QHS:PRN Cough
RX *dextromethorphan-guaifenesin [Adult Robitussin Peak Cold DM]
100 mg-10 mg/5 mL ___ mL by mouth every four (4) hours Disp
___ Milliliter Milliliter Refills:*0
4. Simethicone 40-80 mg PO QID:PRN gas/bloating
RX *simethicone 80 mg 1 tab by mouth daily PRN Disp #*10 Tablet
Refills:*0
5. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inh every four
(4) hours Disp #*1 Inhaler Refills:*0
7. amLODIPine 10 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Lisinopril 40 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Pravastatin 40 mg PO QPM
12. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Upper respiratory infection
Reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with elevated d-dimer and SOB// ?PE, aortic pathology
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 3.3 s, 25.8 cm; CTDIvol = 14.6 mGy (Body) DLP = 375.7
mGy-cm.
Total DLP (Body) = 379 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus.
Subsegmental branches are not particularly well assessed due to the suboptimal
opacification of the vessels at this level. The thoracic aorta is normal in
caliber without evidence of dissection or intramural hematoma. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild bibasilar atelectasis. Right upper lobe
calcified granuloma is noted. Lungs are otherwise clear without masses or
areas of parenchymal opacification. The airways are patent to the level of
the segmental bronchi bilaterally. There is mild bronchial wall thickening
and bronchiectasis.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is notable for a small hiatal
hernia.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild bronchiectasis and mild bronchial wall thickening is nonspecific.
Radiology Report
INDICATION: ___ with dyspnea, low normal O2 sat// ?consolidation volume
overload
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Lungs are clear. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen.Cardiomediastinal silhouette is stable
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Weakness, Dyspnea, unspecified
temperature: nan
heartrate: 86.0
resprate: 18.0
o2sat: 99.0
sbp: 184.0
dbp: 53.0
level of pain: 0
level of acuity: 3.0 | ___ with hx of CAD s/p 3x MI, HTN, mild bronchiectasis who
presents with congestion, productive cough and body aches for 3
days found to have wheezing and no evidence of pulmonary
embolism or pneumonia on CTA.
ACUTE ISSUES
=======================
# Acute respiratory illness: the patient's presentation of
dyspnea, congestion, sore throat, cough and myalgias in the
context of negative imaging for pneumonia suggests she has an
upper respiratory infection likely due to a virus. She is
influenza negative. Possible that a viral infection worsened
reactive airway disease given her remote smoking hx. She has had
normal PFTs. CTA showed possible RUL calcified granuloma and
right hemidiaphragm elevation though this does not appear severe
and was compared to imaging in ___. Patient was given duonebs
and albuterol nebulizer to improve wheezing as well as cough
suppressants. Her oxygen saturation improved. She was not given
antibiotics. After controlling her pain with tylenol, she was
better able to tolerate walking.
CHRONIC ISSUES
=======================
# HTN: well controlled on admission.
- Continue home lisinopril, amlodipine, triamterene-HCTZ
# Stress-induced CMP: Reportedly clean cath
- Continue ASA 81 mg on discharge. This was reduced from aspirin
325 mg which the patietn was taking at home without true
indication.
- Continued home metop succinate 25
# OSA on CPAP at home
- Continued CPAP
TRANSITIONAL ISSUES
=======================
Stopped Meds: none
Changed Meds: Aspirin 81 mg (changed from home dose of 325 mg)
[ ] Consider working up for latent TB given possible RUL
granuloma on CTA.
[ ] Blood cultures are pending at discharge. We will follow
these up but PCP should also keep a look out.
FOLLOW-UP
-PCP ___ days after discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left perilunate dislocation
Major Surgical or Invasive Procedure:
___ LEFT OPEN REDUCTION MIDCARPAL DISLOCATION; REPAIR OF
SCAPHOLUNATE LIGAMENT; OPEN REDUCTION INTERNAL FIXATION
TRIQUETRAL FRACTURE; ORIF RADIAL STYLOID FRACTURE; CLOSED
TREATMENT ULNAR STYLOID FRACTURE; CARPAL TUNNEL RELEASE
History of Present Illness:
___ RHD female who sustained a trip & fall last night
(___)
~10pm when she was trying to carry a heavy box up the stairs.
She
used her L hand to break her fall, resulting in immediate pain.
She presented to the ___ where she was diagnosed with a
left wrist perilunate dislocation. She was splinted and sent
home
with instructions to contact ___ Hand service this morning.
She called them, but they weren't able to schedule her for
surgery, thus she was told to come to ___ for
evaluation. She states she has numbness/tingling in her left
digits ___ since last night and decreased strength.
Past Medical History:
Seasonal allergies
Social History:
___
Family History:
NC
Physical Exam:
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
Left Upper Extremity:
Splint clean, dry & intact
No pain with passive motion of the fingers
SILT: R & U nerves, but decreased in the median nerve
distribution
EPL FPL EIP EDC APB FDS FDP FDI fire
Capillary refill <2 secs in all 5 digits
Medications on Admission:
Flonase
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY PRN () as needed for allergies.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a ___: Take this stool softener with oxycodone to help
with constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left wrist perilunate dislocation with median nerve compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or crutches).
Followup Instructions:
___
Radiology Report
STUDY: Seven intraoperative fluoroscopic images of the left wrist ___.
COMPARISON: None.
INDICATION: Dislocation versus fracture right wrist.
FINDINGS AND IMPRESSION: On the initial images there is a midcarpal
dislocation. Status post reduction and CRPP of the carpal bones. The
alignment is near anatomic. The radial styloid and ulnar styloid fractures
are seen. Please see operative report for further details.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ?ORTHO EVAL
Diagnosed with FX LOW RADIUS W ULNA-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING
temperature: 100.2
heartrate: 106.0
resprate: 14.0
o2sat: 100.0
sbp: 122.0
dbp: 60.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to the orthopaedic surgery service and
was taken urgently to the operating room for above described
procedure. Please see separately dictated operative report for
details. The surgery was uncomplicated and the patient tolerated
the procedure well. She received perioperative IV antibiotics
(Ancef). Post-op, she was admitted overnight for monitoring and
pain control. Pain control was initially achieved with a block,
but then when the block wore off, she required IV pain
medication for breakthrough pain. Eventually she was weaned onto
a PO regimen only.
At the time of discharge the patient was tolerating a regular
diet and feeling well. The patient was afebrile with stable
vital signs. Her pain was adequately controlled on an oral
regimen and the splint was clean, dry, & intact. The patient's
neurovascular exam was stable on discharge, with intact
sensation along the radial & ulnar nerve distributions and
decreased sensation along the median nerve distribution,
consistent with her pre-op exam.
The patient's weight-bearing status is non-weight bearing to the
left upper extremity. She should keep her left hand elevated
above the heart at all times.
The patient is discharged to home in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
nausea/ vomitting
Major Surgical or Invasive Procedure:
___ laporatomy, repair of incarcerated ventral
hernia w/ mesh
History of Present Illness:
___ year old F with complicated PMH including AAA with type B
dissection, CHF, CKD, recent hospitalization earlier this month
(___) for upper GI bleed
s/p EGD without evidence of bleeding presents to the ED from her
rehab with episode of n/v. Patient reports that she been feeling
well earlier today. Had a single episode of emesiswhich appeared
like coffee grinds. Patient denies any abdominal pain. Has not
tried eating since then. Patient denies other bleeding. Denies
chest pain or shortness of breath.
Of note she was consulted by Acute Care Surgery during last
admission for surgical evaluation for repair but given multiple
acute active medical issues, acute surgery was not recommended.
Past Medical History:
-Hypertensive cardiomyopathy with diastolic dysfunction. Left
ventricular hypertrophy
-Chronic lower extremity edema/lymphedema.
-Severe osteoarthritis.
-Kyphosis.
-Asthma.
-Past history of nonhealing ulcers with skin grafting to the
shins.
-Esophageal stricture with dilatation.
-AAA w/ type b dissection s/p repair
Social History:
___
Family History:
No cancer or diabetes in family
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98 79 ___ 100% 2L NC
Gen: AAO3, NAD, frail appearing woman
HEENT: Normocephalic. PERRLA, EOMI. dry lips, anicteric. supple
w/o lymphadenopathy.
HEART: RRR, normal S1/S2, systolic murmur ___ LLSB
LUNGS: CTAB, diminished bibasilar. No crackles/wheezes/rhonchi.
No respiratory distress.
ABDOMEN: Obese, soft, nontender, nondistended, ventral hernia
with bowel irreducible
EXTREMITIES: WWP, 2+ edema, w/o cyanosis, clubbing
NEUROLOGICAL: Gross nonfocal
DISCHARGE PHYSICAL EXAM
Vitals: 98.5 87 145/98 18 94% ra
Gen: AAO3, NAD
HEENT: within normal limits
HEART: RRR, normal S1/S2, systolic murmur ___ LLSB
LUNGS: CTAB, diminished bibasilar. No crackles/wheezes/rhonchi.
No respiratory distress.
ABDOMEN: Obese, soft, nondistended, mildly tender around
incision, staples on incision, incision is non-errythamtous
EXTREMITIES: WWP, 2+ edema, w/o cyanosis, clubbing
NEUROLOGICAL: Gross nonfocal
Pertinent Results:
CT A/P ___. No evidence of hemorrhage or fluid in the abdomen or pelvis.
2. Large ventral hernia with a 3.6 cm neck measuring containing
the distal stomach, small bowel loops, and large bowel loops,
which appear unremarkable. The proximal stomach outside of this
ventral hernia appears moderately distended which could
represent
some degree of gastric obstruction.
3. Moderate nonhemorrhagic pericardial effusion is unchanged
from
CT abdomen and pelvis ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Apixaban 2.5 mg PO BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Atorvastatin 40 mg PO QPM
4. Fluticasone Propionate 110mcg 1 PUFF IH BID
5. Torsemide 60 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
7. Aspirin 81 mg PO DAILY
8. Omeprazole 40 mg PO DAILY GERD
9. Oxybutynin 5 mg PO DAILY
10. raNITIdine HCl 150 mg oral BID
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
13. Carbamide Peroxide 6.5% ___ DROP BOTH EARS 2X/WEEK (MO,TH)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Incarcerated ventral hernia with obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis without intravenous contrast
INDICATION: ___ female with coffee-ground emesis. Evaluate for acute
bleed or intra-abdominal abnormality.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 991 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. Moderate
nonhemorrhagic pleural effusion is unchanged from CT abdomen and pelvis ___. There are moderate calcifications of the aortic valve. There is no
pleural effusion. Ectasia of the thoracic ascending aorta measuring up to 4.3
cm is unchanged.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
evidence of inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There are rounded
hypoattenuated foci in both kidneys measuring up to 3.5 x 3.6 cm in the upper
pole of the left kidney (02:26) compatible with simple cysts. There is no
hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: There is a moderate hiatal hernia. Again noted is a large
ventral hernia containing small bowel loops, large bowel loops, and the distal
portion of the stomach. There is layering high-density fluid within the
stomach compatible with blood products. The neck of this hernia measures 3.6
cm (602:52). The proximal stomach appears distended. The small and large
bowel loops within this ventral hernia appear unremarkable. There is
organized fluid measuring 2.7 cm (2:71) in the inferior aspect of this hernia,
unchanged from ___. There is colonic diverticulosis without evidence
of diverticulitis. There is no evidence of obstruction.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is surgically absent.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of hemorrhage or fluid in the abdomen or pelvis.
2. Large ventral hernia with a 3.6 cm neck measuring containing the distal
stomach, small bowel loops, and large bowel loops, which appear unremarkable.
The proximal stomach outside of this ventral hernia appears moderately
distended which could represent some degree of gastric obstruction. There is
no evidence of an obstructing mass or ulceration.
3. Moderate nonhemorrhagic pericardial effusion is unchanged from CT abdomen
and pelvis ___.
4. There is blood in the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with blood in stomach s/p NGT placement// ?NGT
placement
TECHNIQUE: Portable AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Enteric tube tip appears to be coiled in the distal esophagus with tip
directed cephalad. Severe cardiac silhouette enlargement with a water bottle
configuration is compatible with underlying moderate to large pericardial
effusion, as seen previously. Mediastinal and hilar contours are similar.
The pulmonary vasculature is not engorged. Streaky atelectasis is noted in
the retrocardiac region. No focal consolidation, pleural effusion, or
pneumothorax is seen. No acute osseous abnormality is visualized.
Dextroscoliosis of the thoracic spine along with moderate degenerative changes
are noted.
IMPRESSION:
1. Enteric tube is coiled within the distal esophagus and needs repositioning.
2. Similar severe enlargement of the cardiac silhouette with a water bottle
configuration compatible with known pericardial effusion.
3. Streaky left basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with profound atelectasis follow paraesophageal
hernia repair// interval change? interval change?
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Severe enlargement of the cardiac silhouette is long-standing. Lung volumes
are lower today, possibly due to new small pleural effusions. Upper lungs
clear. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman s/p repair of ventral hernia, now with
tachycardia, some shortness of breath, has hx of CHF// ___ year old woman s/p
repair of ventral hernia, now with tachycardia, some shortness of breath, has
hx of CHF
TECHNIQUE: Chest AP
COMPARISON: 629
IMPRESSION:
Moderate cardiomegaly is again seen. The NG tube has been removed. Small
right and moderate left pleural effusions unchanged. No pneumothorax is seen.
There is no evidence of pneumonia or pulmonary edema. The cardiomediastinal
silhouette is stable
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxia, cardiac disease// ? volume
overload ? volume overload
IMPRESSION:
Heart size is enlarged, unchanged. Mediastinum is stable. Lungs overall
clear. There is no appreciable pleural effusion. There is no pneumothorax.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Coffee ground emesis
Diagnosed with Nausea with vomiting, unspecified
temperature: 98.6
heartrate: 84.0
resprate: 16.0
o2sat: 98.0
sbp: 130.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | Ms ___ presented to ___ ER with nausea and vomiting and a
known history of a ventral hernia, with abdominal and pelvic CT
imaging concerning for distal stomach incarceration, therefore
she was admitted to the General Surgical Service on ___ for
treatment of her incarcerated ventral hernia. The patient
underwent an exploratory laparotomy, ventral hernia repair with
mesh, which was well tolerated and without complications. Please
see operative notes for more details. After a brief, uneventful
stay in the PACU, the patient was transferred initially to the
intensive care unit for closer monitoring due to her extensive
past medical history and events, such as her PEA arrest, that
happened during her recent hospitalization back in ___.
On POD #1, her nasogastric tube was removed, she was started on
a clear liquid diet, which she tolerated. Diet was
progressively advanced to regular which she tolerated. Pain was
well controlled with acetaminophen. The patient voided without
problem.
The patient had runs of atrial fibrillation with RVR.
Cardiology was consulted and made recommendations regarding
torsemide and metoprolol dosing. It was recommended that she
have her creatinine level checked in a week while at rehab and
also follow-up with her outpatient cardiologist in approximately
1 week.
During this hospitalization, the patient worked with physical
therapy, and it was recommended that she be discharged to rehab
to continue her recovery. The patient received her home dose of
Apixaban and venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, out of bed with assist, voiding without assistance, and
pain was well controlled. The patient was discharged to rehab
in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
postprandial emesis, abdominal distension
Major Surgical or Invasive Procedure:
___ guided biopsy of the liver
History of Present Illness:
___ without known PMH, s/p TAH/BSO in her ___ for menorrhagia
(has not seen MD in ___ years) presenting with N/V, weight
loss, abdominal distension. Pt was initially seen at ___, where
she underwent a CT scan that revealed ascites and evidence of
metastatic disease. She underwent paracentesis with removal of
4L of bloody fluid, then elected to leave ___ and present to
___ to establish care.
Pt reports that she has developed intermittent postprandial
emesis. Around the time of ___, she noted abdominal
distension. She has been unable to tolerate any significant POs
since ___. Denies fevers, chills. Last BM was 5 and 6
days prior to presentation; she has continued to pass flatus.
She has noted central weight gain, but with peripheral weight
loss. Denies night sweats, abdominal pain, ___ edema. Weight has
decreased from 128 to 115 lbs over approx 2 weeks. She reports
that she did have a mammogram ___ years ago, although her daughter
expresses some concern that her mammogram was more remote.
In the ___ ED:
VS 97.5, 98, 117/58, 18, 100% RA
Labs notable for BUN/Cr ___, LFTs WNL, Hb 8.2, plt 450, INR
1.1
CT read:
1. Extensive ascites, accounting for patient's abdominal
distension.
2. No bowel obstruction.
3. Omental caking and numerous peritoneal implants
4. Soft tissue fullness thickening of the wall of the cecum
and/or ileocecal region. Possible thickening of the wall of the
gastric antrum.
5. Thickened abnormality of the wall of the gallbladder.
6. Hepatic hypodense lesions. Metastases are a consideration.
Admitted to medicine for expedited malignancy workup.
ROS: all else negative
Past Medical History:
TAH/BSO for menorrhagia - she is certain that her ovaries were
removed, and believes appendix was removed as well - ___
___ in ___ - now closed
Social History:
___
Family History:
Mother with leukemia. Mother had 14 siblings: two maternal aunts
died of breast cancer. Maternal brothers with unknown cancer.
Maternal aunt with lung cancer (Aunt ___, heavy smoker),
another with maternal aunt with ovarian malignancy. Multiple
family members with ovarian cancer, single family member with
leukemia.
Father died at ___ with cirrhosis, heavy EtOH use.
Physical Exam:
VSS
Gen: Pleasant elderly female lying in bed, NAD, interactive,
hard of hearing
HEENT: PERRL, EOMI, anicteric sclera, clear oropharynx
Neck: supple, no cervical, supraclavicular, submandibular, or
occipital LAD
CV: RRR, no m/r/g
Lung: CTAB, no wheeze or rhonchi
Breast: No masses appreciated, no axillary LAD
Abd: soft, nontender, mildy distended, dressing in place over
paracentesis site, C/D/I, hypoactive bowel sounds, no
hepatomegaly appreciated
GU: No foley. Bilateral inguinal LAD, mobile, smooth, all <1 cm
in diameter
Ext: WWP, trace bilateral pitting edema, no clubbing or cyanosis
Neuro: grossly intact
Pertinent Results:
___ 10:35PM GLUCOSE-109* UREA N-21* CREAT-0.7 SODIUM-134
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-26 ANION GAP-14
___ 10:35PM estGFR-Using this
___ 10:35PM ALT(SGPT)-18 AST(SGOT)-24 ALK PHOS-69 TOT
BILI-0.3
___ 10:35PM LIPASE-44
___ 10:35PM ALBUMIN-3.8
___ 10:35PM WBC-8.6 RBC-3.80* HGB-8.2* HCT-27.7* MCV-73*
MCH-21.6* MCHC-29.6* RDW-16.3* RDWSD-42.3
___ 10:35PM NEUTS-80.2* LYMPHS-8.1* MONOS-9.7 EOS-1.2
BASOS-0.5 IM ___ AbsNeut-6.91* AbsLymp-0.70* AbsMono-0.84*
AbsEos-0.10 AbsBaso-0.04
___ 10:35PM PLT COUNT-450*
___ 10:35PM ___ PTT-28.3 ___bd pelvis:
1. Extensive ascites, accounting for patient's abdominal
distension.
2. No bowel obstruction.
3. Omental caking and numerous peritoneal implants
4. Soft tissue fullness thickening of the wall of the cecum
and/or ileocecal region. Possible thickening of the wall of the
gastric antrum.
5. Thickened abnormality of the wall of the gallbladder.
6. Hepatic hypodense lesions. Metastases are a consideration.
CT Chest ___
IMPRESSION:
1. 4 mm pulmonary nodule to which attention on follow-up can be
paid.
2. Moderate-sized hiatal hernia with esophageal wall thickening
proximally which may reflect reflux esophagitis but can be
correlated with endoscopy.
3. 14 mm right thyroid nodule. Thyroid ultrasound should be
performed.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN nausea
take ___ tabs every 8hrs as needed for nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Malignancy, metastatic, unknown primary
Discharge Condition:
Stable, she was alert and oriented x 3, she was ambulatory at
the time of discharge
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with new diagnosis of cancer.
COMPARISON: Reference CT abdomen dated ___
PROCEDURE: Ultrasound-guided omental biopsy.
OPERATORS: Dr. ___ fellow, Dr. ___ resident
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 omentum
was performed. An area of omental caking was identified in right abdomen. A
suitable approach for omental 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 5 mL 1% lidocaine.
Under real-time ultrasound guidance, 3 16-gauge core biopsy passes were made.
The sample was placed in formalin.
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
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 10
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 16-gauge omental biopsy x 3, with specimens sent to pathology.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with new extensive malignancy in abd (omental
caking, liver lesions), unknown primary // evaluate for lung mass, LAD
TECHNIQUE: MDCT AXIAL IMAGES OF THE CHEST WERE OBTAINED FOLLOWING THE
ADMINISTRATION OF INTRAVENOUS CONTRAST AND DISPLAYED WITH MULTIPLANAR
REFORMATTED IMAGES.
DOSE: DLP: 155.30 mGy per cm
COMPARISON: None prior
FINDINGS:
There is a 14 mm nodule in the right lobe of the thyroid gland. Rim
calcification is appreciated. There is a 7 mm high right paratracheal lymph
node. The thoracic aorta and pulmonary arteries are normal in caliber. The
central airways are clear.
There is a 4 mm pulmonary nodule in the superior segment of the right lower
lobe (05:21). There is a 2 mm left upper lobe pulmonary nodule (05:13).
There is a moderate-sized hiatal hernia with adjacent fluid and esophageal
wall thickening which may reflect reflux esophagitis.
Please see the recent CT abdomen dated ___ for further details
regarding findings suggesting diffuse metastatic disease. There is studding
along both hemidiaphragms at the lung bases.
IMPRESSION:
1. 4 mm pulmonary nodule to which attention on follow-up can be paid.
2. Moderate-sized hiatal hernia with esophageal wall thickening proximally
which may reflect reflux esophagitis but can be correlated with endoscopy.
3. 14 mm right thyroid nodule. Thyroid ultrasound should be performed.
Radiology Report
EXAMINATION: THYROID U.S.
INDICATION: ___ year old woman with new metastatic malignancy of unknown
primary // Evaluate thyroid nodule
TECHNIQUE: Grey scale and color Doppler ultrasound images of the neck were
obtained.
COMPARISON: None.
FINDINGS:
The right lobe measures: (transverse) 1.2 x (anterior-posterior) 1.9 x
(craniocaudal) 3.8 cm.
The left lobe measures: (transverse) 1.6 x (anterior-posterior) 1.3 x
(craniocaudal) 3.3 cm.
Isthmus anterior-posterior diameter is 0.2 cm.
Thyroid parenchyma is heterogenous and has normal vascularity. There are
multiple nodules bilaterally. The largest in the right lobe in the lower pole
measuring 1.8 x 1.1 x 1.9 cm appears heterogeneous with some
microcalcifications. Coarse calcification is seen in the right thyroid lobe
measuring 4 mm. A predominantly isoechoic nodule with microcalcification is
seen in the upper pole of the left thyroid gland measuring 1 x 0.7 x 1.2 cm.
IMPRESSION:
Multinodular goiter. The dominant nodule on the right measuring 1.9 cm and
dominant nodule on the left measuring 1.2 cm both contain microcalcification
and warrant further evaluation.
RECOMMENDATION(S): Nonemergent FNA of the dominant nodules in both right and
left thyroid lobe.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 2:10 ___, 90 minutes after discovery of the
findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abdominal distention, Abnormal CT
Diagnosed with Malignant neoplasm of abdomen
temperature: 97.5
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | ___ without known PMH, s/p TAH/BSO in her ___ for menorrhagia
(has not seen MD in ___ years) presenting with N/V, weight
loss, abdominal distension, found to have evidence of
intraabdominal metastatic disease (omental caking, ascites,
liver lesions) of unknown primary.
# New malignancy: Found to have large volume ascites, omental
caking, hepatic lesions concerning for metastatic disease,
likely solid primary. Remote history of BSO. Does have
significant family history for malignancy, although with a range
of primaries. Gastric wall and GB wall thickening may represent
infiltrative metastatic disease or primary site. On ___
patient underwent liver biopsy and paracentesis with
interventional radiology. Oncology was consulted...
- F/u ___ peritoneal fluid results were not available from ___
at the time of patients discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck pain and swelling
Major Surgical or Invasive Procedure:
___ Pseudomeningocele repair and Lumbar drain placement
History of Present Illness:
Mr. ___ is a ___ y/o male s/p cerebellar resection of a
pilocytic astrocytoma on ___, left parietal craniotomy
and evacuation of epidural hematoma on ___ and placement of
trach and PEG on ___. His previous course was complicated
by an epidural hematoma, as well as a brain stem ischemic
stroke. He presents from ___ after staff noticed
yesterday that his neck incision was swollen. An ultrasound of
her neck was obtained which showed a fluid collection. He was
running a low grade temperature at Kindred to 101 and his
brother endorsed sweats that started yesterday. He was admitted
for treatment of pseudomeningocele.
Past Medical History:
pilocytic astrocytoma
___ posterior fossa crani for tumor resection
___ Left Parietal craniotomy evacuaton epidural hematoma
___ trach/peg
Gastritis from H. pylori
Social History:
___
Family History:
Brother with an unknown neck tumor
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T:99.5 BP: 108/72 HR:100 R: 20 100% O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL
Neck: moderately firm area of swelling along the surgical
incision line with some areas of fluctuance.
Lungs: CTA bilaterally.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date mouthing
responses.
Language: ___ is second language. Minimally verbal.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ in left upper and lower
extremities. RUE ___ strenth, RLE ___.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally.
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented to self, place and date; mouths words.
___ is second language.
Face symmetric; tongue midline. Right lateral gaze palsy.
Motor Exam:
Right UE: Deltoid, 4, Trapezius 4, Tricep 4, Grip strength 5-,
Right ___: IP 5-, Quad 5, Hamstring 5, AT 5, ___ 5-, Gastroc 5
Left UE: ___ motor strength
Left ___: ___ motor strength
Incision: Clean, dry and intact. No edema, erythema or
discharge.
Pertinent Results:
___ CXR
IMPRESSION: Subtle left basilar opacity could represent
aspiration.
___ NON CONTRAST HEAD CT
IMPRESSION:
1. At the inferior margin of the suboccipital craniotomy, there
is a
subcutaneous 6.9 x 5.3 cm CSF-density fluid collection which
appears
contiguous with the CSF space worrisome pseudomeningocele.
2. Patient is status post suboccipital craniotomy and
cerebellar lesion
resection with continuing evolving post-surgical changes and
previously
characterized cerebellar infarct.
___ CXR
FINDINGS:
Tracheostomy tube is midline in appropriate position. The lungs
are clear
without consolidation, pleural effusion or pulmonary edema, and
the cardiac, mediastinal and hilar contours are normal.
IMPRESSION:
No evidence of acute cardiopulmonary disease to preclude
procedure.
Cardiovascular Report ECG Study Date of ___ 9:45:00 AM
Sinus tachycardia. Normal ECG. Compared to the previous tracing
of ___ no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 132 78 314/394 66 61 47
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
6:10 ___
IMPRESSION:
1. Status post meningocele repair with hemorrhage in the
resection cavity and extensive pneumocephalus extending into the
basilar cisterns and frontal lobes as described above.
2. Status post suboccipital craniotomy and cerebellar lesion
resection with evolving postsurgical changes and evolving
cerebellar infarct.
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 4:22
___
Final Report
HISTORY: Fever with increased secretions.
FINDINGS: In comparison with the study of ___, there is some
relatively
ill-defined opacification at the left base. In view of the
clinical history, this could well represent a developing region
of consolidation.
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 2:52
___
FINDINGS: Recently described opacity at left lung base has
slightly decreased and may be due to improving pneumonia in the
appropriate clinical setting. No new areas of consolidation
have developed. Cardiomediastinal contours are stable in
appearance, and tracheostomy tube remains in standard position.
CT Head ___:
IMPRESSION:
1. Status post meningocele repair with stable appearing
hemorrhage in the
resection cavity and resolving pneumocephalus.
2. Status post suboccipital craniotomy ___ in cerebellar
lesion resection with stable postsurgical changes and evolving
cerebellar infarct.
___ CXR
FINDINGS: In comparison with study of ___, there is still some
increased
opacification at the left base, consistent with a resolving
pneumonia.
Tracheostomy tube remains in place.
Medications on Admission:
Dexamethasone 2 mg BID
Fentanyl 12 mcg/hr patch q72h
Heparin 5000 units SQH
Keppra 1000mg BID
Lopressor 50mg q6h
Zofran 4mg q8h
Oxycodone 5mg q3h
Protonix 40mg daily
Ferrous Sulfate 300 mg
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever; pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. CloniDINE 0.1 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO BID
6. Fentanyl Patch 12 mcg/h TD Q72H
7. Ferrous Sulfate 325 mg PO DAILY
8. Heparin 5000 UNIT SC TID
9. LeVETiracetam 1000 mg PO BID
10. Methocarbamol 750 mg PO TID:PRN muscle spasm
11. Nafcillin 2 g IV Q4H
Please give 3-doses then discontinue.
12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
15. Senna 1 TAB PO BID
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
17. Sodium Chloride 3% Inhalation Soln 15 mL NEB PRN mucus
buildup
18. Ciprofloxacin HCl 500 mg PO Q12H Duration: 1 Dose
Please dispense 1 dose then discontinue as course of treatment
will be completed on ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pseudomeningiocele
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
HISTORY: Recent neurosurgery with low-grade fever, tachycardia. Rule out
pneumonia.
COMPARISON: Prior chest radiograph from ___ through ___.
TECHNIQUE: Portable AP chest radiograph.
FINDINGS:
As compared to prior chest radiograph from ___, there has been
interval removal of a right-sided subclavian central venous catheter.
Tracheostomy tube remains in standard position. The cardiomediastinal and
hilar contours are within normal limits. The lungs are well-expanded. There
is no pleural effusion or pneumothorax. There is decreased opacity of the
right lung base. Subtle left lung base opacity persists and could relate to
aspiration.
IMPRESSION: Subtle left basilar opacity could represent aspiration.
Radiology Report
HISTORY: Status post cerebellar resection and epidural repair, now with
fever.
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.
DLP: 1153.93 mGy-cm.
FINDINGS: There is no hemorrhage, edema, mass effect or acute vascular
territorial infarct. The patient is status post suboccipital craniectomy and
resection of a posterior fossa lesion with expected evolution of previously
characterized cerebellar infarct with more hypodensity and volume loss with
associated enlargement of the fourth ventricle. Hyperdense material from
prior epidural repair is noted. Extraaxial collection overlying the occipital
lobes and cerebellum is unchanged in size and foci of air within it have
resolved. At the inferior margin of the suboccipital craniectomy, just
posterior to the origin of the spinal cord, there appears to be a focal dural
defect communicating with the CSF space with a subcutaneous 6.9 x 5.3 cm
collection with CSF density that has significantly expanded in size compared
to prior study and dissects through the surgical closure.
The ventricles and sulci are unchanged in size and configuration from prior
study. The basal cisterns remain patent and there is preservation of
gray-white matter differentiation. Patient has had prior left parietal
craniotomy. Mucosal wall thickening is noted in the left maxillary sinus and
left ethmoid air cells. Fluid seen within the mastoids bilaterally. Sphenoid
sinus mucosal thickening is noted. The orbits are unremarkable.
IMPRESSION:
1. At the inferior margin of the suboccipital craniotomy, there is a
subcutaneous 6.9 x 5.3 cm CSF-density fluid collection which appears
contiguous with the CSF space worrisome pseudomeningocele.
2. Patient is status post suboccipital craniotomy and cerebellar lesion
resection with continuing evolving post-surgical changes and previously
characterized cerebellar infarct.
Discussed over the telephone with Dr. ___ by Dr. ___ at
19:00 ___.
Radiology Report
HISTORY: ___ man status post posterior craniotomy now with drainage
from incision. Pre-op chest x-ray for revision procedure.
TECHNIQUE: Portable AP semi-erect chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Tracheostomy tube is midline in appropriate position. The lungs are clear
without consolidation, pleural effusion or pulmonary edema, and the cardiac,
mediastinal and hilar contours are normal.
IMPRESSION:
No evidence of acute cardiopulmonary disease to preclude procedure.
Radiology Report
HISTORY: Status post repair of meningocele. Please evaluate for
postoperative changes.
TECHNIQUE: MD CT axial imaging was obtained through the brain without the
administration of intravenous contrast material.
DLP: 191.9 mGy-cm.
CTDIvol: 54.9 mGy.
COMPARISON: CT head without contrast from ___.
FINDINGS:
The patient is status post suboccipital craniectomy and recent repair of a
meningocele. There is a small amount of hemorrhage within the resection site.
There is extensive postoperative pneumocephalus within the surgical cavity,
the basilar cisterns, extending along the midline, anterior to the frontal
lobes and in the left sylvian fissure. Hyperdense material from previous
epidural repair is noted. There is expected evolution of the previously noted
cerebellar infarction. The ventricles and sulci are unchanged in size and
configuration with enlargement of the ___ ventricle as seen previously. There
has been a left parietal craniotomy. There is no evidence of new infarction.
The visualized paranasal sinuses, mastoid are clear. There is fluid within
the mastoid air cells bilaterally, unchanged from the prior study.
IMPRESSION:
1. Status post meningocele repair with hemorrhage in the resection cavity and
extensive pneumocephalus extending into the basilar cisterns and frontal lobes
as described above.
2. Status post suboccipital craniotomy and cerebellar lesion resection with
evolving postsurgical changes and evolving cerebellar infarct.
These findings were discussed with ___ by Dr. ___ telephone at
7:10pm.
Radiology Report
HISTORY: Fever with increased secretions.
FINDINGS: In comparison with the study of ___, there is some relatively
ill-defined opacification at the left base. In view of the clinical history,
this could well represent a developing region of consolidation.
Tracheostomy tube remains in place.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Recently described opacity at left lung base has slightly decreased
and may be due to improving pneumonia in the appropriate clinical setting. No
new areas of consolidation have developed. Cardiomediastinal contours are
stable in appearance, and tracheostomy tube remains in standard position.
Radiology Report
HISTORY: Elevated temperature, to assess for pneumonia.
FINDINGS: The areas of opacification at the bases have decreased, consistent
with resolving consolidation. Tracheostomy tube remains in place.
Radiology Report
HISTORY: ___ male status post meningocele repair. Evaluate for
interval changes.
TECHNIQUE: Contiguous multi detector CT images were obtained through the
brain without administration of intravenous contrast. DLP 891 mGy-cm CTDIvol
54.32 mGy
COMPARISON: Noncontrast head CT ___.
FINDINGS:
The patient is status post prior suboccipital craniectomy and recent left
parietal craniotomy for meningiocele repair. Redemonstration of a small
amount of hemorrhage within the resection site unchanged. Prior
pneumocephalus has decreased with minimal air seen along the midline and the
anterior frontal lobes.
The basal cisterns appear patent. There is preservation of gray-white matter
differentiation. Hyperdense material from prior epidural repair is noted and
expected evolution of prior cerebellar infarction stable. No evidence of new
infarction. The ventricles and sulci are unchanged since prior examination
with enlargement of the ___ ventricle stable.
The visualized paranasal sinuses are remarkable for mucosal thickening within
the sphenoid. The maxillary sinuses are not visualized. Trace amount of
fluid in the mastoid air cells are redemonstrated. Minimal soft tissue
swelling around surgical site new since prior examination. No acute fractures
are identified.
IMPRESSION:
1. Status post meningocele repair with stable appearing hemorrhage in the
resection cavity and resolving pneumocephalus.
2. Status post suboccipital craniotomy ___ in cerebellar lesion resection
with stable postsurgical changes and evolving cerebellar infarct.
Radiology Report
HISTORY: Possible pneumonia in patient with fever.
FINDINGS: In comparison with study of ___, there is still some increased
opacification at the left base, consistent with a resolving pneumonia.
Tracheostomy tube remains in place.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABNORMAL U/S
Diagnosed with HEMATOMA COMPLIC PROCEDURE, ACCIDENT NOS
temperature: 99.5
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 108.0
dbp: 72.0
level of pain: UTA
level of acuity: 2.0 | The patient was admitted to neurosurgery on ___ for evaluation
of posterior neck swelling. CT 6.9 x 5.3cm CSF density fluid
collection consistent with a pseudomeningocele at the inferior
aspect of suboccipital craniotomy. No new acute intracranial
process. The patient had a low grade fever on admission. Blood
cultures were obtained. Chest x-ray showed subtle left basilar
opacity. Urine was negative for infection. Stool cultures were
obtained.
On ___ the patient was prepped for the OR on ___.
On ___ he underwent a repair of a pseudomeningocele and
placement of a lumbar drain. He was taken to the PACU
psot-operatively and recovered there and then was transferred to
the floor. He remained stable on the floor on ___ into ___. On
___ he was febrile and was pancultured and a cxr was ordered. He
also had a short period of time with low lumbar drain output but
it picked up and returned to expected and desired output.
On ___, he remained afebrile. CSF was obtained from the lumbar
drain and was sent for analysis. CSF showed 1+ polymorphonuclear
leukocytes; no microorganisms seen.
On ___, A chest xray was performed which was consistent with an
opacity at left lung base which has slightly decreased. The
foley catheter was changed to condom catheter. Infectious
disease was consulted for sputum from ___ STAPH AUREUS COAG +,
GRAM NEGATIVE ROD(S)and it was recommended to begin cefipime 2mg
every ___. Infectious Disease also recommended sending a stool
culture for cdiff which was found to be negative. Neurologically
the patient was in stabe condition. The lumbar drain remained
in place and was draining ___ with a plan to keep it in
place until ___ or ___ of this week. He remained
stable and a CT head was done on ___ which was stable. On ___
the lumbar drain was discontinued and placed on bedrest. On ___,
patient's HOB was slowly elevated. ID recommended changing his
antibiotics to naficillin and ciprofloxacin. CSF culture showed
no growth to date. LFTs were ordered and showed elevation in
ALT.
On ___, the patient was mobilized and worked with physical
therapy. C. difficle culture was negative. He continued to work
with physical therapy on ___ and ___. His liver function tests
improved on ___. On ___, the sutures were removed and it was
determined he would be discharged to rehabilitation later in the
day. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
thoracentesis ___
History of Present Illness:
___ with abdominal pain for the past week. Last ___ began
experiencing central chest pain, was seen by PCP and found to
have pneumonia, written for cefuroxime. On ___ she began
having nausea and vomiting, was seen at ___ and given
script for ___ (stopped cefuroxime) and zofran along with
IVF. Since then, she has developed worsening diffuse abdominal
pain that radiates to her low back, but most localized pain is
in epigastric area and RUQ and back. She also went back to
___ on ___ and got Ativan and IVF. She completed her
Zpack over the weekend and her cough and chest pain has
completely resolved.
Her abdominal pain is primarily in the RUQ and epigastric area.
It is sharp and intermittent ranging from ___ in severity.
The pain moves around the top of her stomach to her low back. It
is associated with nonbloody n/v. She has had diarrhea once per
day that is also nonbloody. She has been unable to tolerate po.
She denies any urinary symptoms. Her LMP was last week. She has
no new sexual contacts or vaginal discharge.
In the ___ initial vital signs were 98.2 98 ___ 100%.
Labs significant for normal white count with slight left shift,
alk phos of 108. UA showed few bacteria with few WBC but with 6
epis.
Patient had a CXR which showed no acute process. RUQ ultrasound
showed cholelithiasis without evidence for cholecystitis.
Patient was evaluated by surgery who felt that this was not
cholecystitis but recommended HIDA scan. HIDA scan could not be
done until tomorrow so it was determined to admit to medicine
with surgical consult. Patient was given morphine 5 mg x 3 and
zofran.
Vitals prior to transfer 98.3 105 121/75 16 99%.
On the floor, she continues to have epigastric and RUQ pain
rated ___ in severity.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denied chest pain
or tightness, palpitations. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
None
Social History:
___
Family History:
mother had gallbladder issues, also hx of blood clots provoked
by long flight. father with HTN
Physical Exam:
Physical Exam:
Vitals: T: 98.9 BP: 106/67 P: 101 R: 16 O2: 100% RA
General: Alert, oriented, mildly uncomfortable
HEENT: Sclera anicteric, slightly dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, very tender to palpation over epigastric and RUQ
area. +BS. nondistended. no rebound tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3. moving all extremities. strength ___ in upper and
lower extremities.
Pertinent Results:
Admission Labs:
___ 01:39PM BLOOD ___
___ Plt ___
___ 01:39PM BLOOD ___
___
___ 01:39PM BLOOD ___
___
___ 08:00AM BLOOD ___ ___
___ 01:39PM BLOOD ___
___
___ 01:39PM BLOOD ___
___
___ 01:39PM BLOOD ___
___ 01:39PM BLOOD ___
___ 08:00AM BLOOD ___
.
.
Pertinent Labs:
___ 01:10PM BLOOD ___
___ 06:50PM BLOOD ___
___ 07:20AM BLOOD HIV ___
___ 01:10PM BLOOD ___ THAN ASSAY >300
___ 01:04PM URINE ___
___ 01:04PM URINE ___ Sp ___
___ 01:04PM URINE ___
___
___ 01:04PM URINE ___
.
.
___ PLEURAL FLUID GRAM ___ FLUID
___ ANAEROBIC ___
___ Chlamydia trachomatis, Nucleic Acid Probe, with
___ NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID
PROBE, WITH ___
___ URINE Chlamydia trachomatis, Nucleic Acid Probe,
with ___
___ IMMUNOLOGY ___ Viral ___
___ Blood (Toxo) TOXOPLASMA IgG ___
TOXOPLASMA IgM ___
___ Blood (EBV) ___ VIRUS ___
___ VIRUS EBNA IgG ___
VIRUS ___
___ Blood (CMV AB) CMV IgG ___ CMV IgM
___
___ STOOL C. difficile DNA amplification ___
.
Imaging:
___ RUQ US:
1. Cholelithiasis, with no sonographic evidence for
cholecystitis.
2. Two echogenic well defined lesiosn within the left hepatic
lobe are unlikely related to the patient's symptoms, and likely
represent benign lesions such as focal fat or hemangiomas.
3. Normal liver echotexture, with no intra- or ___
bile duct dilation.
.
___ CXR: IMPRESSION: No acute findings in the chest.
.
___ ECG: Sinus rhythm. ___ inferior and anteroseptal
T wave changes. No previous tracing available for comparison.
.
___ HIDA SCAN: IMPRESSION:
1. Appropriate gallbladder filling without acute cholecystitis.
2. Virtually no gallbladder emptying, even with administration
of sincalide, a CCK analog, consistent with biliary dyskinesia.
.
___ CXR:
1. New NG tube with tip in the stomach.
2. New left pleural effusion and right lower lung opacity
concerning for atelectasis versus aspiration.
.
___ CT ABD/PELVIS:
1. Mild retroperitoneal lymphadenopathy. This could represent
diffuse inflammatory or infectious process, although lymphoma is
in the differential.
2. Asymmetric left basilar airspace opacities could represent
aspiration and/or developing pneumonia.
3. Bilateral small pleural effusions with moderate pelvic
ascites.
.
___ CTA CHEST:
1. No evidence of pulmonary embolism or any other acute
cardiopulmonary process.
2. Bilateral small to moderate pleural effusions with associated
bibasilar atelectasis, worse on the left.
3. Prominent hilar lymphadenopathy.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Caziant (28) *NF* ___ estradiol)
___ Oral daily
Discharge Medications:
1. Caziant (28) *NF* ___ estradiol)
___ Oral daily
2. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight hours
Disp #*42 Tablet Refills:*0
3. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
viral infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right upper quadrant pain.
No comparison studies available.
TECHNIQUE: Ultrasonography of the abdomen.
FINDINGS: The liver parenchyma is normal. There is no intra- or
extra-hepatic bile duct dilation. The CBD measures 2 mm. Gallbladder
contains a small amount of sludge, however, does not appear distended, and no
sonographic ___ sign was elicited. No ductal stones are seen. The main
portal vein is patent, demonstrating proper hepatopetal flow.
Within the left lobe of the liver a 3.3 x 1.4 x 2.2 cm hyperechoic focus along
the GB fossa. A second hyperechoic lesion, more geographic and well
marginated, is seen near the porta hepatis, measuring up to 2.7 x 0.8 x 1.6
cm.
There is no free fluid. The spleen measures 10.4 cm. Included views of the
right kidney are normal. The pancreatic head and body are normal, with the
distal tail obscured by overlying bowel gas.
IMPRESSION:
1. Cholelithiasis, with no sonographic evidence for cholecystitis.
2. Two echogenic well defined lesiosn within the left hepatic lobe are
unlikely related to the patient's symptoms, and likely represent benign
lesions such as focal fat or hemangiomas.
3. Normal liver echotexture, with no intra- or extra-hepatic bile duct
dilation.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___.
COMPARISON: None.
CLINICAL HISTORY: ___ with right upper quadrant pain, question
pneumonia.
FINDINGS: PA and lateral views of the chest were provided demonstrating no
focal consolidation, effusion or pneumothorax. The heart and mediastinal
contours are normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No acute findings in the chest.
Radiology Report
HISTORY: ___ year old woman with n/v/abdominal pain and biliary dyskinesia
REASON FOR THIS EXAMINATION: source of pain
COMPARISON: Gallbladder hepatobiliary scan ___, right upper quadrant
ultrasound ___
TECHNIQUE: Standard departmental protocol CT of the abdomen pelvis was
performed with intravenous contrast administration. Coronal sagittal
reformats were obtained. Total exam DLP 329 mGy-cm.
FINDINGS:
Abdomen: Small bilateral pleural effusions with bibasilar associated
subsegmental atelectasis. Patchy airspace opacity in the left lung base may
represent a component of aspiration and/or developing pneumonia. Probable
focal fatty infiltration medial left hepatic lobe. Normal-appearing
gallbladder, spleen, pancreas, bilateral adrenal glands and kidneys.
Esophageal tube terminating in the gastric body. Focal dilatation of a loop
of proximal jejunum in the left upper quadrant is most likely transient. No
definite evidence of small bowel obstruction. Normal caliber abdominal aorta.
Moderate retroperitoneal lymphadenopathy is noted, the largest node is a left
retroperitoneal node adjacent to the left common iliac artery measuring 13 mm
in short axis. This appearance is concerning for lymphoma, although a diffuse
inflammatory or infectious process is possible. No evidence of
intraperitoneal free air.
Pelvis: Normal-appearing urinary bladder, uterus, and bilateral adnexa.
Moderate pelvic ascites, of unclear clinical significance. No evidence of
significant inguinal lymphadenopathy. Minimally prominent bilateral external
iliac chain lymph nodes, the largest is on the left, measuring up to 9 mm in
short axis. Normal-appearing appendix. Visualized osseous structures
unremarkable.
IMPRESSION:
1. Mild retroperitoneal lymphadenopathy. This could represent diffuse
inflammatory or infectious process, although lymphoma is in the differential.
2. Asymmetric left basilar airspace opacities could represent aspiration
and/or developing pneumonia.
3. Bilateral small pleural effusions with moderate pelvic ascites.
Urgent findings discussed with Dr. ___ at 4:44 pm at the time of
discovery and reporting of these findings.
Radiology Report
INDICATION: New NG tube placement.
COMPARISON: Chest radiograph ___.
FINDINGS: Cardiomediastinal and hilar contours are stable. There is a new
left pleural effusion and a new right basilar opacity which may represent
atelectasis or aspiration. There is no pneumothorax. NG tube is seen with
tip terminating in the stomach.
IMPRESSION:
1. New NG tube with tip in the stomach.
2. New left pleural effusion and right lower lung opacity concerning for
atelectasis versus aspiration.
Radiology Report
HISTORY: ___ women with probable pneumonia seen on prior CT, pelvic
ascites, right upper quadrant, epigastric and left lower quadrant pain. Study
requested for evaluation of lung parenchyma, mediastinal lymphadenopathy and
to rule out PE.
COMPARISON: Prior abdominal/pelvic CT and chest radiograph from ___.
TECHNIQUE: Axial helical MDCT images were obtained through the chest to the
upper abdomen in arterial phase scanning after the administration of 100 cc of
Omnipaque IV contrast. Multiplanar reformatted images in coronal, sagittal
and oblique axes were generated.
Total exam DLP: 208.19 mGy-cm.
FINDINGS:
CT OF THE THORAX: The thyroid is unremarkable. There is no supraclavicular
lymph node enlargement. The airways are patent to the subsegmental level.
Mediastinal lymph nodes are identified, measuring between 7 mm and 5 mm in
short axis (4: 105, 123). There is prominent hilar lymphadenopathy (2:42- 45).
A right hilar lymph node measures 10 x 9 mm (2:45). The heart, pericardium and
great vessels are within normal limits.
There are small to moderate bilateral pleural effusions with associated
bibasilar atelectasis, worse on the left. There is no pneumothorax.
Although this study is not designed for assessment of intra-abdominal
structures, the visualized solid organs and stomach are unremarkable.
CTA THORAX: The aorta and thoracic vessels are well opacified. The aorta
demonstrates normal caliber throughout the thorax without intramural hematoma
or dissection. The pulmonary arteries are opacified to the subsegmental
level. There is no filling defect in the main, right, left, lobar or
subsegmental pulmonary arteries. No arteriovenous malformation is seen.
OSSEOUS STRUCTURES: No focal osseous lesion concerning for malignancy.
IMPRESSION:
1. No evidence of pulmonary embolism or any other acute cardiopulmonary
process.
2. Bilateral small to moderate pleural effusions with associated bibasilar
atelectasis, worse on the left.
3. Prominent hilar lymphadenopathy.
Radiology Report
HISTORY: Thoracentesis, to assess for pneumothorax.
FINDINGS: In comparison with the study of ___, there has apparently been
thoracentesis on the left, though the amount of pleural fluid and compressive
atelectasis at the base does not appear to be any left. Specifically, no
evidence of pneumothorax.
Nasogastric tube has been removed and there is some blunting of the right
costophrenic angle.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT ABD PAIN
Diagnosed with CHOLELITHIASIS NOS
temperature: 98.2
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 73.0
level of pain: 8
level of acuity: 3.0 | ___ with no significant past medical history with 1 week of
nausea/vomiting/abdominal pain/pleuritic cheat pain.
.
.
# nausea/vomiting/abdominal pain/pleuritic chest pain: Patient
presented with about one week of pleuritic chest pain, nausea,
vomiting, and eventually RUQ pain. She was given antibiotics
prior to admission and had completed a course of azithromycin
prior to admission. Because her symptoms persisted, she was sent
to the ___ ___. Her labs were notable for thrombocytopenia,
normal LFTs, elevated INR, low albumin. RUQ notable for
cholelithiasis and HIDA notable for biliary akinesia though no
signs of cholecytitis. The surgical service was consulted and
did not feel that biliary akinesia was responsible for all of
her pain, and recommended CCY as outpatient. She had CT
abdomen/pelvis that showed RP LAD and some pelvic ascites,
pelvic exam was concerning for PID and she was started on
empiric ceftriaxone and doxycycline but was stopped when GC/CT
returned negative. CTA chest was done and showed mild hilar LAD
and moderate b/l pleural effusions. She had thoracentesis done
which drain 250cc transudative fluid, no remarkable culture data
to date.
.
Extensive viral serologies were sent including HIV and HIV viral
load, CMV, Toxo, EBV, stool negative for C. diff. ESR and CRP
were significantly elevated at 115 and >300 respectively.
Rheumatology was consulted given systemic nature of her symptoms
and negative infectious workup. Rhematologic workup was negative
except for borderline lupus anticoagulant, and rheumatology
consult service suggested this was persistent viral process.
___ microglobulin was checked given concern for
myelodysfunction and was elevated.
.
She improved with only supportive care, and was eventually able
to tolerate PO and ambulate well around the floor. Upon
discharge she is stable but unclear etiology of these symptoms.
- recommend very close follow up with heme/onc
- follow up with PCP
- follow up with general surgery for cholecystectomy
.
.
Transitional Issues:
- ___ (father) ___
- full code
.
1. f/u with PCP
.
2. f/u Rheumatology for f/u of her SLE panel
.
3. f/u ___ to f/u lymphadenopathy, elevated
___ microglobulin, as well as thrombocytopenia. Consider
bone marrow bx.
.
4. repeat CBC, albumin, and INR to ___ liver synthetic
function
.
5. repeat iron studies and monitor response to trial of iron
supplementation. may need Hgb electrophoresis to further w/u
microcytosis
.
6. ___ with General Surgery for likely laprascopic
cholecystectomy for cholelithiasis and biliary
akinesia/dyskinesia
.
7. Consider f/u imaging of her liver to evaluate the 2 lesions
seen in left hepatic lobe (see on RUQ on ___
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right leg pain
Major Surgical or Invasive Procedure:
ORIF right tibial plateau fracture
History of Present Illness:
___ ___ worker who suffered a R Tibial plateau fx and a
minimally displaced acetabular medial wall fx while at work when
a trench caved in on him. Patient was pinned to the lateral
wall of the trench from waist down. No HS/LOC. Immediate pain
in RLE. Taken to ___ where ct BLLE taken,
demonstrating the above injuries. He was then brought to ___
for definitive management. NVI distally. Knee unstable to
valgus stress.
Past Medical History:
HTN
Social History:
___
Family History:
Non=contributory
Physical Exam:
On discharge:
Afebrile, vitals stable
Right lower extremity:
- Dressing C/D/I
- Fires ___
- SILT S/S/SP/DP/T distributions
- Foot warm and well-perfused.
Radiology Report
INDICATION: ___ with RLE cursh injury // fx?
TECHNIQUE: AP and lateral views of the proximal and distal right tibia and
fibula. AP, lateral, and oblique views of the right foot.
COMPARISON: None.
FINDINGS:
There is an acute fracture of the proximal right tibia involving the lateral
tibial plateau. There is some displacement of the fracture fragment at the
articular surface. Spiral, nondisplaced component of the fracture seen
extending to the proximal right tibial metaphysis. Distally, the tibia is
unremarkable. No fibular fracture identified.
There is no visualized fracture in the foot. Joint spaces are preserved.
IMPRESSION:
Acute lateral right tibial plateau fracture with extension to the proximal
tibial metaphysis.
Radiology Report
INDICATION: ___ with RLE cursh injury // fx?
TECHNIQUE: AP and bilateral oblique views of the pelvis. AP and cross-table
lateral views of the proximal right femur. AP and lateral views of the distal
right femur.
COMPARISON: Correlation made to tibia fibula films from the same day and CT
pelvis performed at outside hospital earlier the same day.
FINDINGS:
The known nondisplaced fracture through the anterior aspect of the right
acetabulum is not clearly delineated on the current exam. No displaced
fractures identified. Pubic symphysis and SI joints are preserved. Excreted
contrast is noted in the bladder.
The femur demonstrates no fracture. Femoroacetabular joint is anatomically
aligned. Right tibial plateau fracture is better seen on dedicated films and
prior CT. Right knee lipohemarthrosis identified.
IMPRESSION:
Known nondisplaced fracture through the anterior aspect of the acetabulum on
the right is not clearly seen.
Right tibial plateau prior fracture as per earlier plain films.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT IN O.R.
INDICATION: ORIF right tibial plateau fracture
TECHNIQUE: Screening provided in the operating room without a radiologist
present.
COMPARISON: ___
FINDINGS:
Total fluoroscopy time was 69.5 seconds. Images demonstrate fixation of
proximal tibial fracture with lateral plate and screw fixation hardware. For
details of the procedure, please consult the procedure report.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Leg injury
Diagnosed with CRUSHING INJURY HIP, FX UPPER END TIBIA-CLOSE, STRUCK BY FALLING OBJECT, HYPERTENSION NOS
temperature: 98.2
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 186.0
dbp: 96.0
level of pain: 8
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF R tibial plateau 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 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
touchdown weight bearing 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
post-operative precautions and 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:
nafcillin
Attending: ___.
Chief Complaint:
Joint pain and swelling
Major Surgical or Invasive Procedure:
Arthrocentesis x2
History of Present Illness:
___ with Hx CAD s/p DES ___, recent admission ___ for
C6-C7 epidural abscess s/p drainage c/b MSSA septic shock
requiring intubation and pressors, ___, ARDS, discharged to
rehab 3 weeks ago who was referred from ___ clinic with concern
for septic knee joint.
The patient was discharged on ___ to a Rehab facility. He was
continued on IV cefazolin for MSSA bacteremia and epidural
abscess, followed by ID. Since discharge, he reports constant
and worsening pain in his bilateral lower extremities with
movement or with light touch. He had ___ weakness that initially
improved with ___ but is now no longer improving. He also notes
less severe anterior R shoulder pain that he attributes to an
injury a few days ago. He reports increased difficulty working
with ___ due to pain in all his joints, most prominently his
knees. He was treated empirically with 1 week of prednisone at
Rehab for possible gout, but this did not resolve his pain.
Of note, he reported diffuse joint pain, including severe ___
pain, at the time of initial presentation in ___. At the
time of discharge he was noted to have significant weakness
(___) with nearly full ROM and no joint tenderness.
Today he presented to the ___ clinic for regular follow-up and
was noted to have swollen and painful bilateral knees, T 99.5,
leukocytosis to 12.4, increased ESR to ___. He was referred to
the ED for suspicion of septic joints given exquisite tenderness
of knees and ankles.
The patient denies pain or drainage at the C spine site. Denies
fever, chills. He has suffered urinary retention requiring Foley
since his admission. He has been constipated requiring daily
Fleet enemas. While at Rehab he had episodes of word finding
difficulties, attributed to narcotic pain relievers that have
since been discontinued. While at Rehab he was also noted to
have a urine culture positive for pan sensitive pseudomanas,
started on Levaquin 2 days ago.
In the ED, initial VS were: 98.1 96 128/78 16 97% RA with ___
b/l ___ pain. He received cefazolin 1g IV, tramadol 50mg PO,
morphine 5mg IV x1, acetaminophen 1000mg PO. He received Mag
repletion. Orthopedics was consulted and performed L knee joint
tap, culture pending. Neurosurgery was consulted given his
recent spinal abscess, recommended workup of joint findings. He
had an episode of AFib with RVR to the 120s that resolved with
diltiazem.
On the floor the patient continues to note knee and ankle pain
bilaterally, but has no other complaints.
Past Medical History:
-CAD s/p ___ 4 in ___
-DM2
-extensive back problems (never cervical)
-prior lumbar laminectomy
-Paroxysmal AF with last episode reported in ___
-Hypertension
-Hyperlipidemia
-Glaucoma
Social History:
___
Family History:
-Father was diagnosed with heart disease in his ___ and had
diabetes and HTN, Died at the age of ___ from Renal disease
-Mother had heart disease and diabetes and died at the age of
___.
-Older sister (___) has Diabetes
-Younger brother, ___ years younger has no known heart disease or
diabetes.
Physical Exam:
ADMISSION:
VS: 98.4 146/88 100 18 98% RA
GENERAL: well appearing man in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: supple, no LAD, no thyromegaly, no JVD. Posterior neck
notable for surgical incision midline with areas of opening at
superior and inferior ends (C2-3 and C5-6), these areas with
yellowish granulation tissue and scabbing. Non-tender,
non-erythematous.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: irregularly irregular, ___ harsh systolic murmur best
heard at ___, 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. Knees swollen
b/l without erythema or warmth. Effusion palpable
medial>lateral. TTP medial knee below and at joint line, less
tender on lateral side and at patella. Some tenderness with
patellar movement. Active ROM very restricted (partially ___
weakness), passive ROM elicits severe pain. L knee lateral side
shows signs of biopsy, bandage CDI.
NEURO: awake, A&Ox3, CNs II-XII intact, muscle strength ___ LUE,
___ RUE at elbow and wrist, R shoulder limited by pain at AC
joint. Muscle strength at hips ___, knees limited by pain,
ankles and feet 4+/5 bilaterally, sensation grossly intact
throughout, DTRs 2+ and symmetric
DISCHARGE:
VS: 97.8 ___ 18 100%RA
GENERAL: well appearing man in NAD
HEENT: NC/AT, sclerae anicteric, MMM, OP clear.
NECK: supple, no LAD, no thyromegaly, no JVD. Posterior neck
notable for surgical incision midline with areas of opening at
superior and inferior ends (C2-3 and C5-6), these areas with
stable yellowish fibrinous tissue, unable to assess status of
underlying granulation tissue. Non-tender, non-erythematous.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: irregularly irregular, ___ systolic murmur best heard at
___ right intercostal and also ___ systolic murmur at apex
radiating to axilla, 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. Knees swollen
b/l L>R but to lesser degree today, without erythema or warmth.
Effusion palpable medial>lateral. TTP medial knee below and at
joint line, less tender on lateral side and at patella. Some
tenderness with patellar movement. Active ROM improving but
still limited on left knee. L knee medial and lateral side with
iodine stain, CDI.
NEURO: awake, A&Ox3, CNs II-XII intact, muscle strength ___ LUE,
___ RUE at elbow and wrist, R shoulder limited by pain at AC
joint. Muscle strength at hips ___, knees limited by pain,
ankles and feet 4+/5 bilaterally, sensation grossly intact
throughout, DTRs 2+ and symmetric
RECTAL: no external lesions, no masses, prostate some minor
enlargement. stool brown.
Pertinent Results:
ADMISSION:
___ 05:20PM BLOOD WBC-12.4* RBC-3.73* Hgb-10.7* Hct-32.9*
MCV-88 MCH-28.7 MCHC-32.6 RDW-16.6* Plt ___
___ 05:20PM BLOOD Neuts-78.1* Lymphs-13.7* Monos-5.4
Eos-2.4 Baso-0.3
___ 05:20PM BLOOD ___ PTT-31.2 ___
___ 05:20PM BLOOD ESR-78*
___ 05:20PM BLOOD Glucose-108* UreaN-26* Creat-0.7# Na-139
K-5.3* Cl-102 HCO3-21* AnGap-21*
___ 05:20PM BLOOD ALT-11 AST-26 CK(CPK)-139 AlkPhos-74
TotBili-0.3
___ 05:20PM BLOOD Calcium-9.0 Phos-4.0# Mg-1.5*
___ 05:20PM BLOOD CRP-102.5*
___ 05:29PM BLOOD Lactate-1.6
DISCHARGE:
___ 05:46AM BLOOD WBC-9.6 RBC-3.93* Hgb-10.9* Hct-34.2*
MCV-87 MCH-27.7 MCHC-31.9 RDW-16.5* Plt ___
___ 01:11PM BLOOD Calcium-8.9 Phos-4.2 Mg-1.7
OTHER RELEVANT:
___ 05:31AM BLOOD WBC-11.8* RBC-3.69* Hgb-10.4* Hct-32.2*
MCV-87 MCH-28.2 MCHC-32.2 RDW-16.7* Plt ___
___ 06:22AM BLOOD WBC-10.8 RBC-3.69* Hgb-10.3* Hct-31.9*
MCV-86 MCH-28.0 MCHC-32.4 RDW-16.8* Plt ___
___ 05:20PM BLOOD ESR-78*
___ 05:31AM BLOOD ESR-89*
___ 05:20PM BLOOD CRP-102.5*
___ 05:31AM BLOOD CRP-116.4*
___ 04:43PM JOINT FLUID WBC-9375* ___ Polys-97*
___ ___ 04:43PM JOINT FLUID Crystal-FEW Shape-NEEDLE
Locatio-EXTRAC Birefri-NEG Comment-c/w monoso
Log-In Date/Time: ___ 10:23 pm
JOINT FLUID Site: KNEE KNEE JOINT.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Reported to and read back by ___. ___ ___
14:15.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
___ ED BLOOD CULTURES: Negative to date.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Heparin 5000 UNIT SC TID
2. Acetaminophen ___ mg PO Q6H:PRN pain
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. CefazoLIN 2 g IV Q8H
6. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using UNK Insulin
7. Atorvastatin 40 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
9. Ascorbic Acid ___ mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
12. Docusate Sodium 100 mg PO BID
13. traZODONE 25 mg PO HS:PRN sleep
14. Tamsulosin 0.4 mg PO HS
15. Levofloxacin 500 mg PO Q24H
16. Milk of Magnesia 30 mL PO Frequency is Unknown
17. Lactulose Dose is Unknown PO Frequency is Unknown
18. Simethicone 40-80 mg PO QID:PRN gas
19. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
20. Senna 1 TAB PO BID:PRN constipation
21. Fleet Enema ___AILY:PRN constipation
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. CefazoLIN 2 g IV Q8H
8. Docusate Sodium 100 mg PO BID
9. Fleet Enema ___AILY:PRN constipation
10. Heparin 5000 UNIT SC TID
11. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Senna 1 TAB PO BID:PRN constipation
16. Simethicone 40-80 mg PO QID:PRN gas
17. Tamsulosin 0.4 mg PO HS
18. traZODONE 25 mg PO HS:PRN sleep
19. Colchicine 0.6 mg PO DAILY
20. Indomethacin 50 mg PO TID Duration: 7 Days
21. Lactulose 15 mL PO DAILY:PRN constipation
22. Milk of Magnesia 30 mL PO Q12H:PRN constipation
23. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Arthritis, likely gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair but should be ambulating soon given improvement in
joint pain.
Followup Instructions:
___
Radiology Report
INDICATION: History of epidural abscess status post drainage, increasing
white count, refusing MRI, evaluate for epidural abscess.
COMPARISON: MR ___ and Lumbar spine on ___.
TECHNIQUE: MDCT images were obtained through the cervical, thoracic, and
lumbar spine following administration of IV contrast. Coronal and sagittal
reformations were performed.
FINDINGS: The patient is status post laminectomy from C2 to C7. Evaluation
for epidural abscess is very limited by CT but no gross displacement of the
spinal cord is identified. There is a 3.9 x 2.9 cm fluid collection within
the posterior neck, posterior to C7 with mild rim enhancement and surrounding
stranding. More superiorly at the level of C2, there is a posterior fluid
collection measuring about 2.0 x 0.9 cm with mild rim enhancement.
There are moderate multilevel degenerative changes of the cervical, thoracic,
and lumbar spine with anterior and posterior bridging osteophytes. No acute
fractures or malalignment are identified. There are moderate to large disc
osteophyte complexes at L2-3 and L3-4 causing moderate to severe spinal canal
narrowing. Mild disc osteophyte complex at L4-5 indents the thecal sac.
Limited evaluation of the lungs is grossly clear. Left PICC tip is seen at the
junction of the SVC and right atrium. There is moderate cardiomegaly, as well
as aortic valvular and coronary artery calcifications. No pleural effusion.
Assessment of the lungs is limited due to respiratory motion. Mild dependent
atelectasis is noted. The liver is grossly unremarkable. The gallbladder is
normal. The spleen contains a non-displaced 2.6 cm hypodense lesion. The
left adrenal gland is mildly thickened and enlarged, possibly hyperplasia.
The right adrenal gland appears normal. Kidneys are grossly unremarkable.
There is no hydronephrosis. The aorta is normal in caliber. There are
atherosclerotic calcifications. The stomach and visualized small bowel are
unremarkable. There is sigmoid diverticulosis with no evidence of
diverticulitis. Foley catheter is seen in the bladder. No free air is
identified. Presacral stranding is nonspecific.
IMPRESSION:
1. Two fluid collections posterior to cervical spine as described above with
mild rim enhancement and surrounding stranding. These may represent
postoperative seromas; however, infection cannot be ruled out.
2. This study is not ___ for evaluation for epidural abscess but there is
no evidence of gross spinal cord displacement. MRI is suggested for further
assessment.
3. Moderate to severe canal narrowing at L2/3 and L3/4, similar to prior MRI
lumbar spine.
4. Probable left adrenal hyperplasia.
5. Hypodense splenic lesion of uncertain etiology; MRI can be done for
further evaluation.
6. Presacral stranding, which is nonspecific.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with study of ___, the left subclavian PICC line
again extends to the upper portion of the right atrium. No evidence of acute
cardiopulmonary disease.
Radiology Report
STUDY: Left ___.
CLINICAL HISTORY: ___ man with recent cervical epidural abscess and
bacteremia. Now with polyarthralgias.
FINDINGS: No previous studies available for direct comparison.
Joint spaces are relatively preserved. There are no signs for acute fractures
or dislocations. There is some spurring involving the tibial plateau medially
and laterally. There is a moderate knee joint effusion. Spurs about the
patellofemoral compartment is also seen on the lateral view. There are
vascular calcifications.
IMPRESSION:
Tricompartmental osteoarthritis, which is mild-to-moderate with moderate-size
knee joint effusion.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ?SEPTIC ARTHRITIS
Diagnosed with OTHER SPEC COMPL S/P SURGERY, ABN REACT-PROCEDURE NOS, PAIN IN LIMB
temperature: 98.1
heartrate: 96.0
resprate: 16.0
o2sat: 97.0
sbp: 128.0
dbp: 78.0
level of pain: 9
level of acuity: 2.0 | ___ with Hx CAD s/p DES ___, recent admission ___ for
C6-C7 epidural abscess s/p drainage c/b MSSA septic shock
requiring intubation and pressors, ___, ARDS, discharged to
rehab 3 weeks ago who was referred from ___ clinic with concern
for newly arthritic knee joints, now with joint fluid showing
monosodium urate crystals though small GPC growth as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
elevated creatinine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ HTN, HLD, CABG ___ LIMA-LAD, SVG-PDA, SVG-OM? but
occluded, inferior STEMI ___ thrombus in SVG-PDA with DES,
on ASA/Plavix since stent, recent admission for chest pain
presents with renal failure.
Breifly, Pt with recent admission from ___ for chest pain
where he initlaly presnted to ___. He underwent stress
test with intolerance at 3:30 that showed 1 mm depressions in
the lateral leads as well as drop in SBP from 140s-->100s. He
was transfered to ___ for cardica catheterization which showed
patient grafts and prior DES, with diffuse diasease in native
coronirires, which was deemed a high risk PCI so no intervention
pursued. Thus, he was medically maximized and started on ranexa,
imdur increased from 30 to 60 mg daily and continued his other
medications.
Since then he was seen twice in cardiology clinic. His discharge
crreatinine went from 1.5 to 2.2 on ___. At that time his
losartan and hctz were held. Recheck on ___ showed it increased
to 2.7 and he was advised to come to the ED. Additionally, in
this time period his ranolazine was decreased from 1000 mg BID
to ___ mg BID as he was having some lightheadedness. Also states
that he had a bout of vomiting and diarrhea with poor PO intake,
attributed to a virus he picked up from another patient last
admission.
In the ED, initial vital signs were 98.5 68 139/67 18 100% ra.
Labs were significant for BUN/Cr of 39/2.5, HCO 15, K 5.1. CBC
with pancytopenia WBC 3.5, Hgb 9.7, and platelets 69. UA with
trace rotein, otherwise negative. He had one episode of chest
pain for which He was given 1L NS and sent to the floor.
Troponins were pending at time of transfer.
Upon arrival to the floor,
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: 3v CABG ___ years prior at ___
-PERCUTANEOUS CORONARY INTERVENTIONS: ___ with DES to
SVG-PDA graft, on ASA/Plavix
3. OTHER PAST MEDICAL HISTORY:
-PVD with Bilateral femoral popliteal bypass graft,
hypertension,
-hyperlipidemia, COPD, diabetes, GERD, depression
Past Surgical/Procedure History:
-CABG, appendectomy, cholecystectomy, bilateral femoropopliteal
bypasses (x3 on the left, x1 on the right)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Father with heart disease, believes his
father died in older age from heart disease. Mother died of lung
cancer (asbestos exposure and smoker). Two older brothers with
___, two great nieces with DMI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 130/72 76 20 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE EXAM:
Vitals: 98.1 126/50 67 18 100RA
General: Mr. ___ is a well appearing ___ yo gentleman who is
AOx3 and in NAD.
HEENT: NCAT, EOMI, MMM, sclera anicteric.
Neck: JVP < 5 cm.
Lungs: CTAB with no WRR. Breathing comfortably on RA w/ no
accessory muscle use.
CV: normal S1/S2, RRR. No murmurs, gallops, or rubs. 2+ pedial
pulses.
Abdomen: Soft, non-distended, non-tender with no HSM.
Ext: WWP, no C/C/E.
Neuro: AOx3 with no appreciable sensory/motor deficits.
Pertinent Results:
ADMISSION LABS
___ 08:10PM BLOOD WBC-3.5* RBC-3.04* Hgb-9.7* Hct-27.4*
MCV-90 MCH-32.0 MCHC-35.4* RDW-14.9 Plt Ct-69*
___ 08:10PM BLOOD Neuts-58.3 ___ Monos-5.1 Eos-2.5
Baso-0.9
___ 08:10PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 08:10PM BLOOD Plt Smr-VERY LOW Plt Ct-69*
___ 04:03PM BLOOD UreaN-42* Creat-2.7* Na-142 K-5.5*
Cl-109* HCO3-17* AnGap-22*
___ 10:16PM BLOOD cTropnT-0.03*
___ 07:45AM BLOOD cTropnT-0.03*
___ 08:10PM BLOOD Iron-57
.
CREATININE TREND:
___ 04:03PM BLOOD UreaN-42* Creat-2.7* Na-142 K-5.5*
Cl-109* HCO3-17* AnGap-22*
___ 08:10PM BLOOD Glucose-77 UreaN-39* Creat-2.5* Na-139
K-5.1 Cl-112* HCO3-15* AnGap-17
___ 07:45AM BLOOD Glucose-88 UreaN-33* Creat-2.2* Na-147*
K-5.4* Cl-119* HCO3-15* AnGap-18
___ 05:11PM BLOOD Glucose-128* UreaN-30* Creat-1.8* Na-140
K-4.8 Cl-112* HCO3-17* AnGap-16
___ 09:00AM BLOOD Glucose-149* UreaN-26* Creat-1.7* Na-139
K-4.5 Cl-111* HCO3-21* AnGap-12
.
STUDIES/IMAGING:
ABD U/S ___ FINDINGS:
LIVER: The liver is coarsened in echotexture. The contour of the
liver is
nodular, consistent with cirrhosis. There is no focal liver
mass. The main portal vein is patent with hepatopetal flow.
There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD 3
mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: Imaged portion of the pancreas appears within normal
limits, without masses or pancreatic ductal dilation, with
portions of the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.5 cm.
KIDNEYS: The right kidney measures 12.2 cm. The left kidney
measures 12 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. The left
kidney demonstrates prominence of the renal pelvis and proximal
ureter, which may represent extrarenal pelvis, and appear
similar from ___. No evidence of hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
1. As seen on the outside hospital renal ultrasound from ___,
dilatation of the left proximal ureter and renal pelvis,
possibly secondary to extrarenal pelvis/UPJ obstruction, however
no evidence of hydronephrosis.
2. Coarsened hepatic echotexture with a nodular contour
compatible with
cirrhosis, with borderline splenomegaly, however no ascites or
focal liver lesion.
.
DISCHARGE LABS:
___ 09:00AM BLOOD WBC-4.0 RBC-3.49* Hgb-11.2* Hct-31.4*
MCV-90 MCH-32.2* MCHC-35.8* RDW-15.0 Plt Ct-62*
___ 09:00AM BLOOD Glucose-149* UreaN-26* Creat-1.7* Na-139
K-4.5 Cl-111* HCO3-21* AnGap-12
___ 09:00AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Niacin SR 1500 mg PO QHS
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Pantoprazole 40 mg PO Q24H
8. Terazosin 4 mg PO QHS
9. Ranexa (ranolazine) 500 mg oral BID
10. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6-8H:PRN
pain
11. MetFORMIN (Glucophage) 1500 mg PO QAM
12. MetFORMIN (Glucophage) 1000 mg PO QPM
13. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
15. levemir 40 Units Breakfast
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6-8H:PRN pain
6. levemir 40 Units Breakfast
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Niacin SR 1500 mg PO QHS
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Terazosin 4 mg PO QHS
12. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
13. MetFORMIN (Glucophage) 1500 mg PO QAM
14. MetFORMIN (Glucophage) 1000 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
___
Diabetes
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with renal failure and pancytopenia. Evaluate for
BOTH cirrhosis as well as both kidneys for obstructive renal failure
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital renal ultrasound from ___
FINDINGS:
LIVER: The liver is coarsened in echotexture. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.5 cm.
KIDNEYS: The right kidney measures 12.2 cm. The left kidney measures 12 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. The left kidney demonstrates prominence of the renal pelvis and
proximal ureter, which may represent extrarenal pelvis, and appear similar
from ___. No evidence of hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. As seen on the outside hospital renal ultrasound from ___,
dilatation of the left proximal ureter and renal pelvis, possibly secondary to
extrarenal pelvis/UPJ obstruction, however no evidence of hydronephrosis.
2. Coarsened hepatic echotexture with a nodular contour compatible with
cirrhosis, with borderline splenomegaly, however no ascites or focal liver
lesion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.5
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | PATIENT: Mr. ___ is a ___ year old gentleman with h/o of HTN,
HLD, CABG ___, inferior STEMI ___, who was admitted for
elevated creatinine.
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pulseless L leg
Major Surgical or Invasive Procedure:
profundaplasty w bovine patch of her Left leg
History of Present Illness:
Mrs. ___ is an ___ yo F, currently smoking, w PMHx
significant for PAD sp left profundal to BK popliteal bypass
with
PTFE (___), sp open thrombectomy with stenting of distal
anastomosis (___) who recently was admitted ___ for 1 day
of cold purple toes which resolved upon presentation who
represents as a transfer from ___ with worsening
cool LLE, blue toes and loss of pedal signals. ___ was
unable to doppler pedal signals so started her on a heparin gtt
and transferred her here for further care.
Past Medical History:
Rheumatoid Arthritis, Peripheal Vascular Disease, GERD,
Hypothyroidism
SURGICAL HISTORY:
___ - distal SFA stent
___ - LLE angio for claudication, spectranetics 1.4 laser
catheter and subsequent stent placement at SFA and AK-Pop for
occlusion
___ LLE angio - completely occluded L SFA with
reconstitution at below knee popliteal. (___)
___: L Femoral profundal to BK Popliteal bypass using
distaflow 6MM PTFE (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
GENERAL: [x]NAD []A/O x 3 []intubated/sedated []abnormal
CV: [x]RRR [] irregularly irregular []no MRG []Nl S1S2
[]abnormal
PULM: [x]CTA b/l []no respiratory distress []abnormal
ABD: [x]soft []Nontender []appropriately tender
[]nondistended []no rebound/guarding []abnormal
WOUND: []CD&I []no erythema/induration []abnormal
EXTREMITIES: []no CCE [x]abnormal blue discoloration of the
toes,
cap refill intact, able to barely range toes and ankle.
PULSES: L ___ dopplerable, non dop DP
Pertinent Results:
Admission Labs:
___ 05:10AM BLOOD WBC-10.0 RBC-4.92 Hgb-12.5 Hct-40.7
MCV-83 MCH-25.4* MCHC-30.7* RDW-14.2 RDWSD-42.5 Plt ___
___ 05:10AM BLOOD Neuts-73.5* ___ Monos-4.8*
Eos-0.6* Baso-0.4 Im ___ AbsNeut-7.36* AbsLymp-2.02
AbsMono-0.48 AbsEos-0.06 AbsBaso-0.04
___ 05:10AM BLOOD ___ PTT-150* ___
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD Glucose-114* UreaN-19 Creat-0.7 Na-139
K-4.1 Cl-106 HCO3-20* AnGap-13
___ 05:17AM BLOOD Calcium-9.6 Phos-3.5 Mg-1.7
Imaging: CTA ___
1. Occluded left superficial femoral artery stent, and occluded
left common femoral to popliteal bypass graft. The left deep
femoral artery is patent. Calf vessels are reconstituted
through collateral flow, and are patent to the level of the
mid/distal tibia as detailed above.
2. Focal severe stenoses of the right popliteal artery.
Three-vessel runoff to the right ankle/foot.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain
2. Atorvastatin 80 mg PO QPM
3. Gabapentin 300 mg PO TID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Venlafaxine XR 150 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
4. Atorvastatin 80 mg PO QPM
5. Cilostazol 100 mg PO BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Rivaroxaban 20 mg PO DAILY
10. Venlafaxine XR 150 mg PO DAILY
11. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Peripheral vascular disease
Secondary Diagnosis: Rheumatoid Arthritis
Peripheral Vascular
Disease
GERD
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ year old woman with pulseless left foot // please acquire w/
runoff to ___ eval acute occlusion
TECHNIQUE: Run off CTA: Non-contrast images and arterial phase images were
acquired from diaphragm through toes. Delayed images were obtained from the
knees to the toes.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 18.3 s, 144.1 cm; CTDIvol = 4.2 mGy (Body) DLP =
606.8 mGy-cm.
2) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
3) Spiral Acquisition 17.8 s, 140.0 cm; CTDIvol = 9.3 mGy (Body) DLP =
1,295.9 mGy-cm.
4) Spiral Acquisition 9.0 s, 70.9 cm; CTDIvol = 5.4 mGy (Body) DLP = 379.8
mGy-cm.
Total DLP (Body) = 2,289 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
CTA abdomen/pelvis:
1. Abdominal aorta:Mild stenosis (<50%).
2. Celiac axis: Moderate stenosis (50-69%)at its origin, unchanged (604:46).
3. SMA: No stenosis.
4. ___: No stenosis.
5. Renal arteries: Left: Moderate stenosis (50-69%).; Right: Moderate stenosis
(50-69%).
6. Left common iliac: Mild stenosis (<50%).
7. Right common iliac: Mild stenosis (<50%).
8. Left external iliac: No stenosis.
9. Right external iliac: No stenosis.
10. Left internal iliac: Mild stenosis (<50%).
11. Right internal iliac: Mild stenosis (<50%).
CTA run-off RLE:
1. Common femoral artery: Moderate stenosis (50-69%).
2. Superficial femoral artery: Mild stenosis (<50%).
3. Deep femoral artery: No stenosis.
4. Popliteal artery: Severe stenosis (70-99%) (4:283, 289)
5. Anterior tibial artery: Patent to the level of the foot.
6. Posterior tibial artery: Patent to the level of foot.
7. Peroneal artery: Patent to the level of the ankle.
8. Dorsalis pedis: Patent.
CTA run-off LLE:
1. Common femoral artery: Occluded.
2. Superficial femoral artery: There is a stent throughout its course, which
is completely occluded. The left common femoral to popliteal bypass graft is
also occluded.
3. Deep femoral artery: Patent
4. Popliteal artery: Occluded.
5. Anterior tibial artery: Reconstituted through collateral flow, patent to
the level of the mid tibia.
6. Posterior tibial artery: Reconstituted through collateral flow, with faint,
intermittent opacification to the level of the distal tibia.
7. Peroneal artery: Reconstituted through collateral flow, patent to the level
of the distal tibia.
8. Dorsalis pedis: Occluded.
There is no abdominal aortic aneurysm. There is extensive atherosclerotic
disease, most pronounced in the infrarenal abdominal aorta.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion. Mitral annular calcifications are severe.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are symmetric size with mild diffuse cortical thinning
and normal nephrograms. Bilateral subcentimeter cortical hypodensities are
too small to characterize, but likely represent cysts. No focal mass lesions
or hydronephrosis.
GASTROINTESTINAL: There is a small hiatus hernia. Small and large bowel loops
are normal in caliber. Diverticulosis of the sigmoid colon is noted, without
evidence of wall thickening or fat stranding.
LYMPH NODES: No abdominopelvic lymphadenopathy.
PELVIS: The urinary bladder is unremarkable. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Redemonstration of a fibroid uterus. No adnexal
abnormality is seen.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild compression deformity of T12 and grade 1 anterolisthesis of L4 on L5 are
unchanged. Right hip prosthesis in situ.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Occluded left superficial femoral artery stent, and occluded left common
femoral to popliteal bypass graft. The left deep femoral artery is patent.
Calf vessels are reconstituted through collateral flow, and are patent to the
level of the mid/distal tibia as detailed above.
2. Focal severe stenoses of the right popliteal artery. Three-vessel runoff
to the right ankle/foot.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hypoxia. Evaluate for pneumonia.
TECHNIQUE: Portable chest radiograph
COMPARISON: Radiograph dated ___
FINDINGS:
Lung volumes are low. Mild bibasilar atelectasis is redemonstrated. The
cardiopulmonary silhouette is unremarkable. No large pleural effusion or
pneumothorax. No focal consolidation.
IMPRESSION:
No acute intrathoracic abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PULSLESS LIMB, Transfer
Diagnosed with Stricture of artery
temperature: 98.1
heartrate: 104.0
resprate: 16.0
o2sat: 95.0
sbp: 174.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Patient was admitted for a pulseless L distal leg that was cool
to touch with delayed capillary refill. Patient was in severe
ischemic pain. Patient was barely able to range toes and ankle
of L foot. It was decided to undergo immediate surgery to
revascularize her Left leg. Patient had a L profundaplasty which
was the only patent inflow vessel to her Distal ___. Post
operatively patient had a faintly dopplerable L ___ and improved
cap refill and temperature. Patient was able to range toes and
ankle, and was able to walk with ___ and a walker. Patient still
complained of severe Left lower extremity pain that was to
believed from reperfusion neuropathy. No further surgical
intervention for revascularization was possible for the left
lower extremity and patient was discharged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / Zetia / Rosuvastatin
Attending: ___.
Chief Complaint:
Jaw and scapular pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
History of Present Illness:
___ h/o CAD s/p multiple PCIs to RCA and ___, AAA s/p repair
in ___, CVA in ___ on warfarin for secondary prevention, and
RAS s/p stents ___ p/w a few weeks of exertional back pain and
the sudden onset of jaw and scapular pain at rest in bed at
11:30pm last night that persisted x2hrs so pt presented to ED
for eval. States these symptoms are typical of his previous ACS
events. Took ASA 325mg and 2 nitro CSL without relief. Has had
atypical symptoms of pain between scapulae with radiation to
jaws, not consistently exertional, per Dr ___ notes as
well. Denies any CP, SOB, DOE, nausea, diaphoresis, abdominal
pain. No teeth ache or recent dental work. No fevers or ear
pain.
In the ED, initial vitals were 99.2 70 178/109 16 95% RA. Labs
significant for CK: 1195, MB: 23 (has been elevated in past even
in absence of ACS, ?neuromuscular etiology), MBI: 1.9, Trop-T:
0.05, normal electrolytes, Cr 1.1 (baseline 1.1-1.3), WBC 4.1 (N
48.6%, eos 8.7%), hct 46.7, plts 225, MCV 94, INR 3.1. EKG
showed sinus tachycardia (HR 102) with possible ectopic source
given inverted Pwaves in II, III, AVF (however resolved with
normal Pwaves at rates subsequently in the ___ as well as left
axis deviation. No ST elevation or depression. Suggestion of
inferior infarct of undetemined age with small Qwave in AVF.
Otherwise unchanged from ___ EKG. CXR showed no acute
process. Of note, repeat biomarkers in ED showed TnT increased
to 0.25, MB to 26. Patient given ASA 325mg, metoprolol tartrate
25mg, and started on a heparin ggt. Vitals on transfer were
Temp: 97.6 ___. HR: 57. BP: 134/75. O2: 96% ra. RR: 18.
Upon interviewing, patient has remained pain free, without other
complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes (+prediabetes last checked in
___, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: CAD s/p MI
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: stents to mid and ___
RCA with 2 DES in ___ and mid and ___ with endeavor stent
in ___, h/o reportedly 11 stents total
3. OTHER PAST MEDICAL HISTORY:
Prediabetes, HgbA1c 6.3% in ___
infrarenal AAA s/p open repair ___
Left renal artery stent ___
CVA x 2: left frontoparietal region in ___, and left
temporal-occipital infarction causing a mild expressive aphasia
and a right inferior quadrantanopia.
Hypertension
Hyperlipidemia
Sleep apnea: CPAP
Schatzki's ring- dysphagia
Lyme disease
Meralgia parasthetica
h/o prostatitis
h/o iron deficiency anemia
Chronic Inflammatory Myopathy - elevated CK, evaluated by
neurology, unclear if this is due to residual effect of statins
or another inflammatory process
left abdominal hernia status post AAA surgery
Social History:
___
Family History:
Brother had an MI at age ___. Father had strokes and MIs. Son
with MI at ___.
Physical Exam:
Admission Exam:
VS: afebrile, 134/70, 109, 20, 94%RA
GENERAL: WDWN elderly man in NAD sitting on edge of bed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma. no
dental or gingival tenderness. no tmj tenderness or click.
NECK: Supple, JVP not elevated.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Discharge Exam:
VS: 97.4, 128/77, 53, 18, 96%RA Wt 92.4kg
GENERAL: WDWN elderly man walking around the room
NECK: Supple, JVP not elevated.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Pertinent Results:
Admission Labs:
___ 02:10AM BLOOD WBC-4.1 RBC-5.09 Hgb-16.1 Hct-47.6
MCV-94# MCH-31.7# MCHC-33.9 RDW-13.1 Plt ___
___ 02:10AM BLOOD Neuts-48.6* ___ Monos-6.6
Eos-8.7* Baso-1.4
___ 02:10AM BLOOD ___ PTT-45.7* ___
___ 02:10AM BLOOD Glucose-175* UreaN-18 Creat-1.1 Na-140
K-3.8 Cl-102 HCO3-25 AnGap-17
___ 02:10AM BLOOD CK(CPK)-1195*
___ 02:10AM BLOOD CK-MB-23* MB Indx-1.9 cTropnT-0.05*
___ 02:10AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
Biomarker Trend:
___ 02:10AM BLOOD CK-MB-23* MB Indx-1.9 cTropnT-0.05*
___ 09:35AM BLOOD cTropnT-0.25*
___ 09:35AM BLOOD CK-MB-26* MB Indx-2.7
___ 07:30PM BLOOD CK-MB-17* MB Indx-2.3 cTropnT-0.14*
___ 05:18AM BLOOD CK-MB-12* MB Indx-2.1 cTropnT-0.12*
___ 06:09AM BLOOD CK-MB-9 cTropnT-0.25*
___ 07:45PM BLOOD CK-MB-10
___ 02:10AM BLOOD CK(CPK)-1195*
___ 09:35AM BLOOD CK(CPK)-978*
___ 07:30PM BLOOD CK(CPK)-739*
___ 05:18AM BLOOD CK(CPK)-577*
___ 06:09AM BLOOD CK(CPK)-453*
___ HgbA1c: 6.3%
Old labs:
___ TSH 3.4, Free T4 1.0
___ Total Chol 203, ___ 220, HDL 45, LDL 114.
Discharge Labs:
___ 06:30AM BLOOD WBC-6.1# RBC-4.91 Hgb-15.2 Hct-46.8
MCV-95 MCH-30.9 MCHC-32.4 RDW-13.6 Plt ___
___ 06:30AM BLOOD ___
___ 12:40AM BLOOD PTT-74.1*
___ 06:30AM BLOOD Glucose-105* UreaN-15 Creat-1.2 Na-142
K-4.5 Cl-105 HCO3-26 AnGap-16
___ 06:30AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3
Imaging:
EKG ___: sinus tachycardia (HR 102) with possible ectopic
source given inverted Pwaves in II, III, AVF as well as left
axis deviation. No ST elevation or depression. Suggestion of
inferior infarct of undetemined age with small Qwave in AVF.
Otherwise unchanged from ___ EKG.
___ CXR: no evidence of acute process. No evidence of pulm
edema.
___ CARDIAC CATHETERIZATION COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated single vessel coronary artery disease. The LMCA
was free
of angiographically apparant coronary artery disease. The LAD
had a 30%
proximal stenosis with mild diffuse disease which was unchanged
from
prior angiography. The ___ was free of angiographically
apparant
coronary artery disease with a widely patent stent. The RCA had
a
ostial subtotal instent occlusion and a focal mid 70% instent
lesion.
2. Limited resting hemodynamics revealed a normal systemic
arterial
blood pressure with a central aortic blood pressure of 113/60.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease of the RCA
2. Patent ___ stent.
3. Normal central aortic blood pressure.
Medications on Admission:
CHOLESTYRAMINE-ASPARTAME [PREVALITE] - 4 gram Packet 1 packet
BID
CLOPIDOGREL [PLAVIX] - 75 mg Tablet ___
ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr
BID LANSOPRAZOLE - 30 mg Capsule, Delayed Release(E.C.) ___
METOPROLOL TARTRATE - 50 mg Tablet BID
MUPIROCIN - 2 % Ointment TID
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet prn chest
pain
WARFARIN 5mg ___ except ___ 7.5mg
ASPIRIN - 325 mg Tablet ___
CALCIUM CITRATE-VITAMIN D3 315 mg-250 unit Tablet BID
CYANOCOBALAMIN (VITAMIN B-12) 1,000 mcg Tablet ___
FERROUS FUMARATE - 324 mg (106 mg iron) ___
MAGNESIUM - 250 mg Tablet BID
MULTIVITAMIN - 1 Capsule qam
NIACIN - 250 mg Tablet Extended Release - 1 Tablet(s) by mouth
once a day Please take with aspirin after evening meal
OMEGA 3-DHA-EPA-FISH OIL - 1,000 mg (120 mg-180 mg) Capsule
___
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet ___.
2. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
___ BID (2 times a day).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet ___
(___).
4. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr ___ twice a day.
5. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
6. mupirocin 2 % Ointment Sig: One (1) application Topical three
times a day: as previously directed.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*50 Tablet, Sublingual(s)* Refills:*0*
8. warfarin 2.5 mg Tablet Sig: Two (2) Tablet ___ once a day:
Take 5mg (2 tablets) ___ except ___ take 7.5mg (3 tablets).
9. calcium citrate-vitamin D3 315-250 mg-unit Tablet Sig: One
(1) Tablet ___ twice a day.
10. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet ___ once a day.
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet ___.
12. magnesium oxide 250 mg Tablet Sig: One (1) Tablet ___ twice a
day.
13. multivitamin Tablet Sig: One (1) Tablet ___
(___).
14. niacin 250 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release ___ once a day.
15. omega-3 fatty acids Capsule Sig: One (1) Capsule ___
___.
16. lisinopril 5 mg Tablet Sig: One (1) Tablet ___.
Disp:*30 Tablet(s)* Refills:*0*
17. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr ___ once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: NSTEMI
Secondary Diagnosis:
Chronic Inflammatory Myopathy
Prediabetes, HgbA1c 6.3%
infrarenal AAA s/p open repair ___
Left renal artery stent ___
CVA
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with chest pain, evaluate for fluid overload.
___.
CHEST, PA AND LATERAL: The lungs are hyperexpanded, with biapical
hyperlucency, flattening of the diaphragms, and widening of the retrosternal
clear space. Mild middle lobe and lingular atelectasis/scarring are
unchanged. There is no focal consolidation. Heart size is normal. There are
no pleural effusions or pneumothorax.
IMPRESSION: COPD. No evidence of fluid overload.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: JAW PAIN
Diagnosed with INTERMED CORONARY SYND, HYPERTENSION NOS
temperature: 99.2
heartrate: 70.0
resprate: 16.0
o2sat: 95.0
sbp: 178.0
dbp: 109.0
level of pain: 3
level of acuity: 2.0 | ___ h/o CAD s/p multiple PCIs to RCA and ___, AAA s/p repair
in ___, CVA in ___ on warfarin for secondary prevention, and
RAS p/w symptoms consistent with previous ACS symptoms as well
as biomarkers elevated from baseline.
# NSTEMI: Patient has known CAD with a history of multiple PCIs
with ___ to RCA and ___. admitted with his typical jaw and
subscapular anginal pain, which he'd noted over the past few
weeks, but acutely worsened last night for 2hours while at rest.
Since ___ CK has ranged from 700-1200s, CKMB ranges from
___ at baseline, with intermittent normal values, and
troponin-T ranging from 0.03-0.07 at baseline. Second set of
troponins were above baseline biomarkers, but trended down by
the third set (TnT 0.05->0.25->0.12). He remained pain free
during admission (since presentation to the ED). Patient was
continued on ASA 325, plavix, metoprolol tartrate 50mg
(increased from BID to TID for improved HR control), and started
on a heparin ggt and lisinopril 5mg ___. Patient was not
placed on statins ___ chronic myopathy possible caused by
previous statin use. Outpt cardiologist, Dr. ___ was
contacted and patient was catheterized via radial approach after
INR trended down to 1.2 (warfarin held for a day, and 1mg
vitamin K was administered). Results of cath were as follows:
single vessel RCA disease s/p 2 DES to the mid-RCA and proximal
RCA. ___ worked with patient and he was discharged home with
cardiology follow up.
# PUMP: Echo on ___ showed LVEF 45-50% (probable basal-mid
lateral AK/HK), however study was suboptimal. Durin present
admission there was no evidence of fluid overload (pulm edema on
CXR, no peripheral edema, and normal O2 sats). Lisinopril 5mg ___
___ was started for optimal cardiac remodelling.
# RHYTHM: Patient remained in normal sinus rhythm, however was
initially transiently with sinus tachycardia with possible
ectopic source on EKG given inverted Pwaves in II, III, AVF at a
rate of 102. Rates were controlled with metoprolol tartrate at
50mg TID, with rates in the ___. At rates<100bpm, normal P waves
were present.
# Hypertension: Controlled on outpatient medications, including
isosorbide mononitrate 120mg ER BID, metoprolol tartrate 50mg
(increased to TID from BID for improved HR control). Started on
lisinopril 5mg ___. BPs steadily in the 130s/80s.
# Hyperlipidemia: Not currently on statins out of concern for
statin induced chronic myopathy described at ___.
Last lipids: ___ Total Chol 203, ___ 220, HDL 45, LDL 114. He
was continued on home regimen of CHOLESTYRAMINE, NIACIN and
OMEGA3FA.
# Prediabetes: Noted last in HgbA1c 6.3% in ___, on repeat
this admission, HgbA1c stable at 6.3%. Outpatient PCP should
discuss lifestyle modifications to prevent increased DM and
cardiac risk.
# History of CVA: Occurred in left frontoparietal region in
___, and left temporal-occipital infarction causing a mild
expressive aphasia and a right inferior quadrantanopia. Echo in
___ revealed a patent foramen ovale was present with
right-to-left shunt across the interatrial septum at rest. An
interatrial septal aneurysm was present. There were simple
atheroma in the aortic arch. Given the right to left shunt,
atrial septal aneurysm and embolic appearance of his strokes he
was started on coumadin for secondary stroke prevention. INR
goal range of 1.8-2.5, per anticoagulation nurse letter. On
admission, INR was 3.1. He was given 1mg vitamin K prior to
catheterizations and coumadin was started after catheterization.
He was also seen recently by neurology and regularly by ___. He
was discharged on his previous home dose of warfarin 5mg ___
except ___ 7.5mg.
# History of Iron Deficiency Anemia: MCV currently 94 on iron
supplementation. Hct 47.6. Iron supplementation has been
sufficient and was continued this admission.
# Hematuria: Small amount of blood noted on UA. On
anticoagulation with ASA, plavix, warfarin, but hematuria noted
as far back at ___, prior to anticoagulation initiation with
warfarin. Should have outpatient follow up and repeat UA, if not
previously worked up. No evidence of UTI on UA. This was
deferred to PCP for further outpatient management.
# Chronic Inflammatory Myopathy: Etiology unknown. Persistently
elevated CK, evaluated by neurology, unclear if this is due to
residual effect of statins or another inflammatory process.
Given need for anticoagulation, Dr. ___ (neurology)
did not recommend pursuing muscle biopsy or prednisone.
Recommended ___ and considering EMG at next visit. Not acutely
addressed this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Event concerning for seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with history of
Alzheimers with known Amyloid followed by ___, history of
mechanical falls complicated by subarachnoid hemorrhage in ___, as well as multiple UTIs who presents from home today
after a witnessed generalized tonic-convulsive seizure. Per her
husband and daughter who accompany her to the ED today, she was
in her usual state of health this morning when she awoke and was
about to use the restroom. She had been incontinent the prior
evening and at baseline uses adult undergarments. She was
apparently more jovial in the morning when walking to the
restroom with her home health aide around 0730hrs on ___.
While in the restroom, the aide called to the patient's husband
who on arrival witnessed the patient with eyes open and rolled
back with posturing of her arms and legs which were tremoring.
This episode lasted for approximately ___ minutes and then
resolved with extreme fatigue and somnolence. Her positioning
was upright at 45 degrees for the balance of the event. She was
taken to ___ where a NCHCT was performed that
demonstrated
an area in the left parietal cortex concerning for subarachnoid
hemorrhage which given her history prompted transfer and
evaluation at ___.
The patient's husband noted that she has had several episodes of
convulsive syncope in the past few weeks which appeared to be
inconsistent in semiology with this event as the prior were
falling to the ground as well only ___ minutes. He also noted a
recent UTI which was associated with a similar event. He
describes her baseline as non-fluent, unable to consistently
recognize others, with a recent decline in her functioning
around
the time of her ___ presentation to ___ at which time
convulsive syncope was diagnosed in a similar episode. She also
is incontinent of urine at baseline.
ROS was unable to be obtained due to advanced state of
non-fluency.
Past Medical History:
- Alzheimer's disease followed by ___ at ___ on
Namenda/Aricept
- Multiple vasovagal syncopal events in the past couple years
- Two mechanical falls with traumatic SAH -> unknown site in
___, and right parietal SAH (___)
- Sleep apnea
- Thyroidectomy
- Multiple UTIs, incontinent at baseline wearing adult
undergarments
Social History:
___
Family History:
- Father died of cancer
- Mother died of unclear cause in 1980s, was on phone when
suddenly lost consciousness and was thought to have had
neurologic event (stroke?)
Physical Exam:
Admission Physical Exam:
T=97.0, HR=66, BP=129/75, RR=16, SaO2=97% RA
General: Awake, confused.
HEENT: NC/AT
Neck: Supple, no nuchal rigidity
Pulmonary: Snoring at first, then on arousal NWOB
Cardiac: RRR
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, and attends to interviewer, but only can
respond "what", "yes", or "no" to all questions. Does not
follow
any requests. There was no evidence of apraxia or neglect.
Frontal release signs including grasp bilaterally, snout, and
palmomental.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Saccadic intrusions.
V: ___ strength noted bilateral in masseter unable to cooperate
with sensation testing
VII: No facial droop, facial musculature symmetric on passive
viewing
VIII: Attends to voice bilaterally
IX-XII: Unable to cooperate with testing.
-Motor: Normal bulk, paratonia noted throughout with any
attempts
at movement of limb. No adventitious movements, such as tremor,
noted. As patient was unable to participate with any strength
testing, motor strength was at least greater than antigravity in
all extremities with no evidence of lateralizing weakness.
-Reflex:
Bi Tri ___ Pat Ach
L 2 1 1 2 1
R 2 1 1 2 1
- Plantar response was flexor bilaterally with brisk withdrawl
-Sensory: Unable to fully assess, however, the patient did
withdraw from tickle.
-Coordination and gait: Unable to assess due to cooperation.
############################
Discharge Physical Exam:
Gen- Awake, NAD
Pulm- Breathing comfortably on room air
Abd- Soft, non-tender
Neuro- Repeats "what" in response to questions and
spontaneously. Did not follow any commands. Paratonias noted in
bilateral upper extremities, grasp reflex present bilaterally.
Eyes track fully horizontally. Withdraws all limbs to light
touch, tickle and painful stimuli. Moves all limbs anti-gravity.
Pertinent Results:
___ 11:55AM BLOOD WBC-8.9 RBC-4.50 Hgb-14.2 Hct-39.2 MCV-87
MCH-31.6 MCHC-36.2* RDW-14.4 Plt ___
___ 11:55AM BLOOD Neuts-84.3* Lymphs-8.5* Monos-5.7 Eos-0.9
Baso-0.5
___ 11:55AM BLOOD ___ PTT-26.7 ___
___ 11:55AM BLOOD Glucose-95 UreaN-15 Creat-0.8 Na-145
K-4.1 Cl-106 HCO3-30 AnGap-13
___ 12:20PM BLOOD Lactate-2.0
CTA Head and Neck ___: IMPRESSION:
1. No evidence of intracranial aneurysm, stenosis, or
occlusion.
2. Stable small focus of subarachnoid hemorrhage in the left
parietal lobe. No new foci of hemorrhage identified.
3. Of note, there is a 3 cm enhancing left paratracheal mass,
possibly of the thyroid. This was present on a CT C-spine from
___. If clinically indicated, consider ultrasound
for further workup.
EEG ___: FINAL RESULT PENDING. Prelim read with Routine EEG
captured no seizures but was overall slowed with some bifrontal
triphasic waves concerning for either toxic-metabolic
encephalopathy or an epileptic predisposition.
Medications on Admission:
- Namenda 20mg daily
- Aricept 10mg daily
- Lorazepam 0.5mg po QHS (not given in past few days per
husband)
- Caltrate and vit D daily
- Levothyroxine 125mcg daily
- HCTZ discontinued due to concern for hypotension
- Lisinopril 5mg daily
Discharge Medications:
1. Donepezil 10 mg PO QHS
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Memantine 10 mg PO BID
4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral BID
5. Lisinopril 5 mg PO DAILY
6. Lorazepam 0.5 mg PO QHS:PRN Insomnia
7. LeVETiracetam 500 mg PO BID
8. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days
9. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Alzheimer's disease
H/o multiple vasovagal syncopal events
H/o traumatic SAH, right parietal SAH (___)
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ with SAH. Evaluate for evidence of aneurysmal disease.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered, curved
reformatted and segmented images were generated. This report is based on
interpretation of all of these images.
DOSE: DLP: 2297.14 mGy-cm; CTDI: 135.03 MGy
COMPARISON: CT head from earlier on the same date and CT cervical spine from
___.
FINDINGS:
Head CT: There is a stable-appearing small focus of subarachnoid hemorrhage
in the left parietal lobe (3:15). No new foci of hemorrhage identified. There
is no evidence of edema, masses, mass effect, or infarction. The ventricles
and sulci are normal in caliber and configuration. No fractures are
identified.
Incidental note is made of enhancing left paratracheal mass measuring 3 cm
(5:64). This was present on the CT cervical spine from ___.
Consider thyroid/neck soft tissue ultrasound for further evaluation.
Head CTA: There are no intracranial vascular abnormalities. There is no
evidence of aneurysm, stenosis or occlusion.
Neck CTA: The carotid and vertebral arteries and their major branches are
patent with no evidence of stenoses. The left carotid artery measures 7.6 mm
proximally and 3.3 mm distally. The right carotid artery measures 6.1 mm
proximally and 2.8 mm distally. There is no evidence of internal carotid
stenosis by NASCET criteria.
IMPRESSION:
1. No evidence of intracranial aneurysm, stenosis, or occlusion.
2. Stable small focus of subarachnoid hemorrhage in the left parietal lobe.
No new foci of hemorrhage identified.
3. Of note, there is a 3 cm enhancing left paratracheal mass, possibly of the
thyroid. This was present on a CT C-spine from ___. If
clinically indicated, consider ultrasound for further workup.
Radiology Report
INDICATION: ___ year old woman with AD, productive cough // Query aspiration,
PNA, other process
COMPARISON: Radiographs from ___.
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There is mild
prominence of the pulmonary interstitial markings without overt pulmonary
edema. There is no focal consolidation, pleural effusions or pneumothoraces.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with Alzheimer's, amyloid angiopathy, SAH,
evaluate for stability.
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast
DOSE: DLP: 937 mGy-cm
CTDI: 54 mGy
COMPARISON: Comparison is made to head CT from ___ and head and neck
CTA from ___.
FINDINGS:
Small focus of subarachnoid hemorrhage in the left parietal region is again
seen, and stable, or mildly smaller when compared to ___. There are no new
areas of hemorrhage identified. The ventricles and sulci are stable in size
and configuration. The basal cisterns are patent and there is preservation of
gray-white matter differentiation. There is no evidence of infarction, edema,
or mass.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
Small focus of subarachnoid hemorrhage in the left parietal region, stable or
slightly smaller when compared to ___. No new areas of hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure, Unresponsive, Transfer
Diagnosed with SUBARACHNOID HEMORRHAGE, OTHER CONVULSIONS, ALZHEIMER'S DISEASE
temperature: 95.3
heartrate: 64.0
resprate: 16.0
o2sat: 99.0
sbp: 140.0
dbp: 80.0
level of pain: nan
level of acuity: 1.0 | ___ RHW h/o progressive Alzheimers Disease non-fluent at
baseline with known Amyloid, as well as multiple syncopal
episodes of seizure in the past presents today after a prolonged
event concerning for seizure.
# Seizures
There was high clinical suspicion for seizures vs convulsive
syncope. Admission CTA head/neck- no evidence of intracranial
aneurysm/stenosis/occlusion, stable small SAH in the left
parietal lobe. Subsequent EEG was abnormal with bifrontal
triphasic waves (toxic-metabolic vs suggestive of epilpetic
risk). She was started on Keppra 500mg PO BID without evidence
of further events.
# Subarachnoid Hemorrhage
- Small SAH visualized on CT imaging- felt likely to be ___ to
amyloid angiopathy. Repeat NCHCT on ___ was stable. No acute
interventionw as felt to be necessary
# Pneumonia
- High Clinical suspicion for pneumonia. She was started on
Amox-Clav + doxycycline for extended CAP coverage. Amox-Clav
was converted to Cefpodoxime pending urine culture sensitivities
(as below). Doxycycline to end on ___. For treatment of UTI,
cefpodoxime to end on ___.
# UTI
- Patient has History of recurrent UTI's. U/A was floridly
positive. She was initially felt to be covered by the Amox-Clav
+ Doxycycline as above. However, urine sensitivities
demonstrated resistant to amox-clav and she was transition to
cefpodoxime to complete course on ___.
# Para-tracheal Lesion
- Incidental finding of CTA of head and neck- There was also a 3
cm enhancing left paratracheal mass, possibly of the thyroid,
that was present on prior CT C-spine on ___. It is unclear
to me if prior evaluation was done, but please consider further
work-up on outpatient basis.
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=====================================================Transitions
of Care
- Follow-up with outpatient Neurology
- Continue Keppra 500mg PO BID
- Complete abx as detailed above.
- Consider further outpatient evaluation of the paratracheal
lesion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived / latex / bees
Attending: ___.
Chief Complaint:
amnesia, confusion, ankle pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with seizure disorder and diabetes presents with altered
mental status. ___ was found by bystanders outside of ___ who got him into a wheelchair and then proceeded to take
him to the emergency room. ___ states his last recollection was
watching the ___ game on ___. At that time ___ was
feeling fine with no fevers/chills, no infectious symptoms. ___
stated that ___ usually does not remember his seizures. ___ denies
any illicit ingestions. Per records ___ was at a Halloween party
last night and was noted to have odd behavior. ___ was taken to
the ___ ED (unclear what was done there) and discharged late at
night/early in the morning. ___ has no recollection of this. The
patient did not have a ride and wandered off in his confused
state, later being found on ___.
Past Medical History:
DM 2
retinopathy
developmental delay
seizure disorder
WC-bound
Social History:
___
Family History:
Adopted, unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: 98.5 155/87 90 98%RA
General: Alert, oriented x1 (to self), no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
+exotropia
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, R ankle with mild
swelling, erythema, +TTP, +tenderes with ROM
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
=========================
VS 2340 Tc 98.3 HR 80 BP 142/86 RR 18 02 96% sat on RA
General: well appearing, NAD
HEENT: MMM, EOMI
Neck: no JVD, no LAD
CV: rrr, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, nontender, nondistended, no HSM appreciated
GU: deferred
Ext: warm and well perfused, pulses, no edema
Neuro: grossly normal
Pertinent Results:
***Admission Labs***
___ 06:50AM BLOOD WBC-3.7* RBC-4.35* Hgb-13.8 Hct-39.5*
MCV-91 MCH-31.7 MCHC-34.9 RDW-11.9 RDWSD-39.3 Plt ___
___ 06:50AM BLOOD Neuts-41.4 ___ Monos-12.3
Eos-12.6* Baso-0.8 Im ___ AbsNeut-1.51* AbsLymp-1.19*
AbsMono-0.45 AbsEos-0.46 AbsBaso-0.03
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-27.6 ___
___ 06:50AM BLOOD Glucose-363* UreaN-9 Creat-0.8 Na-137
K-4.3 Cl-100 HCO3-26 AnGap-15
___ 06:50AM BLOOD ALT-13 AST-11 CK(CPK)-71 AlkPhos-69
TotBili-0.2
___ 06:50AM BLOOD Lipase-61*
___ 06:50AM BLOOD Albumin-5.0 Calcium-9.4 Phos-3.2 Mg-2.0
UricAcd-3.4
___ 06:50AM BLOOD Valproa-85
___ 06:50AM BLOOD ASA-NEG Ethanol-NEG Carbamz-8.6
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:50AM BLOOD LtGrnHD-HOLD
___ 07:04AM BLOOD ___ Comment-GREEN TOP
___ 09:25PM BLOOD Lactate-1.1
___ 07:04AM BLOOD Lactate-2.6*
***Discharge Labs*** (limited per patient refusal)
___ 08:00AM BLOOD Valproa-51
___ 08:00AM BLOOD Carbamz-5.0
OTHER STUDIES AND IMAGING
==========================
___ EEG
History: ___ year old right-handed man with diabetes, seizure
disorder (with h/o non-epileptic events and postictal psychosis)
and cognitive delay who was brought to the ED after bystanders
found him confused. Assess for evidence of nonconvulsive
seizures.
MEDICATIONS: Carbamazepine, Valproic acid
Continuous 23 electrode EEG ___ electrode placement, T1, T2)
and additional EOG and EKG, are recorded 11:50 on ___ until
07:00 on ___. There was no video recording as the patient
refused this.
CONTINUOUS EEG: The background activity shows a symmetric,
well-regulated 10 Hz posterior dominant rhythm which attenuates
with eye opening. There is occasional admixed theta activity
throughout, likely indicative of excessive drowsiness. There are
2 sharp and slow-wave discharges in the left temporal region
(F7/T3) captured over the course of the recording.
SLEEP: The patient progresses from wakefulness to stage 2, then
slow wave and REM sleep at appropriate times with no additional
findings.
PUSHBUTTON ACTIVATIONS: There are three pushbutton activations
at 23:22:26, 06:39:06, and 06:41:05, for unclear reasons
(patient refused video EEG monitoring). The background at the
time is unchanged, or shows electrode artifact. There are no
epileptiform discharges or electrographic seizures.
SPIKE DETECTION PROGRAMS: There are several automated spike
detections,
predominantly for sharp features of the background as well as
one of the left
temporal discharges described above. There are no epileptiform
discharges.
SEIZURE DETECTION PROGRAMS: There are several automated seizure
detections, predominantly for what appear to be electrode and
muscle artifact (no video available for collateral). There are
no electrographic seizures.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software. Panels include automated seizure detection, rhythmic
run detection and display, color spectral density array,
absolute and relative asymmetry indices, asymmetry spectrogram,
amplitude integrated EEG, burst suppression ratio, envelope
trend, and alpha delta ratios. Segments showing abnormal trends
are reviewed, and show findings congruent with the above.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate of
70-90 bpm. IMPRESSION: This is a mildly abnormal continuous EEG
monitoring study due to the presence of 2 left temporal sharp
and slow-wave discharges, indicative of a potentially
epileptogenic focus in the left temporal region. There are three
pushbutton activations for unclear reasons, as the patient
refuses video monitoring, but a normal background rhythm during
the events. There are no epileptiform discharges or
electrographic seizures.
___ CT Head:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
___ EKG Sinus rhythm. Normal ECG. Compared to the previous
tracing of ___ there is no significant change.
___ EEG: This is a mildly abnormal continuous EEG monitoring
study due to the presence of a single left temporal sharp and
slow-wave discharge,
indicative of a potentially epileptogenic focus in the left
temporal region. There are no electrographic seizures. Compared
to the prior day's recording, there is a single left temporal
sharp wave.
___ Ankle Xray: There is mild swelling about the ankle, but no
underlying fracture is identified. The ankle mortise is intact.
There are no lesions suspicious for malignancy or infection
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamazepine (Extended-Release) 800 mg PO BID
2. Divalproex (EXTended Release) 1250 mg PO BID
3. Lisinopril 10 mg PO DAILY
4. Acetaminophen 500 mg PO Q6H:PRN pain
5. DiphenhydrAMINE 25 mg PO Q6H:PRN unknown
6. GlyBURIDE 5 mg PO BID
7. MetFORMIN (Glucophage) 850 mg PO QAM
8. MetFORMIN (Glucophage) 1000 mg PO QPM
9. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE DAILY
10. Tobramycin-Dexamethasone Ophth Susp 1 DROP RIGHT EYE QID
Discharge Medications:
1. Carbamazepine (Extended-Release) 800 mg PO BID
2. Divalproex (EXTended Release) 1000 mg PO BID
3. Lisinopril 10 mg PO DAILY
4. Acetaminophen 500 mg PO Q6H:PRN pain
5. DiphenhydrAMINE 25 mg PO Q6H:PRN unknown
6. GlyBURIDE 5 mg PO BID
7. MetFORMIN (Glucophage) 850 mg PO QAM
8. MetFORMIN (Glucophage) 1000 mg PO QPM
9. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE DAILY
10. Tobramycin-Dexamethasone Ophth Susp 1 DROP RIGHT EYE QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Neurobehavioral disorder
?Seizure disorder
History of pseudo-seizures
Chronic Pain
Diabetes
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with AMS seizure? // eval for pna
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 8.0 s, 8.2 cm; CTDIvol = 49.3 mGy (Head) DLP =
401.4 mGy-cm.
4) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: CT head on ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old man with R ankle pain and swelling.
TECHNIQUE: Right ankle, 3 views, 4 radiographs
COMPARISON: None available for comparison.
FINDINGS:
There is mild swelling about the ankle, but no underlying fracture is
identified. The ankle mortise is intact. There are no lesions suspicious for
malignancy or infection.
IMPRESSION:
No acute fracture.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: 103.0
resprate: 22.0
o2sat: 100.0
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | ___ with a history of cognitive impairment, TBI, PTSD, seizure
d/o c/b proloned post-ictal states characterized by amnesia and
psychosis and pseudoseizure d/o who was found wandering on
___, brought in the EMS to ___ for further
management.
# Amnesia: Mr. ___ complains of amnesia x 4 days ___
after the ___ to the day of admission). His amnesia
was thought to be secondary to a post-ictal state from seizures.
___ has had numerous similar presentations to various EDs. These
episodes are generally precipitated by stressful events and a
recent, ongoing stressor has been his financial troubles related
to his hospitalizations. Also, Mr. ___ has a history of
becoming confused and amnesic per his advocate ___ from
___ ___, on call after hours ___
___ is part of community outreach team who helps patient with
independent living, doctor's visits) who was contacted during
this admission. His mother and outpatient neurologist confirm
these events as well. At discharge, ___ was persistently amnesic
of these days but oriented to self and that ___ was in a
hospital. ___ would intermittently recall being at ___
___. ___ continued to be distressed at his inability to
recall these days.
# Seizure d/o and pseudoseizure d/o: Mr. ___ is followed
closely by Dr. ___ at ___. While ___ was admitted to ___,
___ underwent cEEG monitoring. His EEG did not reveal any
episodes of epileptiform activity. His medication levels were
therapeutic. After discussion with the ___ neurology team and
his outpatient provider, the decision was made to continue his
current medication regimen with planned follow up with ___
Neurology.
# Right sided weakness: Mr. ___ has a history of weakness
after episodes of seizure-like activity. His neurologic exam was
otherwise intact and ___ had a negative NCHCT. Past episodes of
weakness have responded to intense periods of physical therapy.
It was recommended that ___ go to an acute rehab facility in
order to gain strength. His estimated LOS at a rehab facility is
<30 days and this was communicated to Mr. ___ and his
mother.
# Cognitive impairment, TBI: At baseline Mr. ___ has spotty
memory, frequently and easily loses track of time and place,
which is scary for him. ___ also has episodes of odd-behavior,
increased forgetfulness that have, in the past, resulted in
psychiatric hospitalizations.
# Post-traumatic stress disorder: Historically, Mr. ___
works better with female providers than male providers.
TRANSITIONAL ISSUES:
======================
- Patient scheduled for ___ neurology follow up
- Patient needs f/u with ___, outpatient social worker
- No changes to anti-epileptic medications
-___ from ___ ___, on call after hours
___
___ is part of community outreach team who helps patient with
independent living, doctor's visits. ___ will fax current
medications to him as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Lactose
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o pancreatitis and DMII, followed by GI and ___,
presents from ___ clinic with 2 days of abdominal pain. Pain
started ___ AM, ___ at its worst, dull constant pain
located in upper epigsatrium which is higher up than his usual
pancreatitis pain. Also, pain is not as severe as usual pain nor
worsened by food intake. No n/v, fevers, chills, SOB, back pain,
diarrhea, constipation, dizziness, change in appetite. He ___
been able to work and keep down fluids with this pain. The
patient made himself NPO today and took morphine x 1 with no
improvement so he presented for evaluation. He acknowledges
eating more fast food than usual over the past week. Last
alcohol intake was 2 cocktails on ___, which is about what
he ___ every week. Denies any new medications.
In the ER, his initial vitals were 97.4 72 147/85 16 100% and
vitals prior to transfer were 98.0 65 124/80 18 100%. The
patient had CBC, chemistry and LFTs which were within normal
limits. The patient's lipase was elevated at 393. UA with
glucosuria, troponin <0.01. He received 2L NS. CXR is negative
but CT abd and pelvis with contrast with pancreatitis,
peripancreatic fat stranding but no focal fluid collection or
evidence of necrosis. On exam, the patient had epigastric
tenderness. He did not receive medications but was kept NPO.
REVIEW OF SYSTEMS:
(+) per HPI also with recent URI symptoms (ie congestion, sore
throat), higher than normal sugars at home (250s)
(-) headache, hematochezia, dysuria, cough
Past Medical History:
- Chronic Pancreatitis - last episode in ___, initially felt to
be reaction to Tetracycline, followed by Dr. ___
- DM2 - followed at ___, last A1c 6.7 ___
Social History:
___
Family History:
No history of DM or pancreatitis. Mother with HTN and PUD. MGM
with COPD, GERD, HCC. Siblings are healthy. Does not know
father.
Physical Exam:
ADMISSION EXAM
VS: 98.4 157/90 64 19 100%RA ___ 137
GENERAL: well appearing in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: hyperactive bowel sounds, soft, mild ttp in mid
upper-epigastrium, non-distended, no rebound or guarding, no
masses
EXTREMITIES: no edema, 2+ pulses radial and dp
DISCHARGE EXAM
Vital signs stable without any real epigastric pain.
Pertinent Results:
LAB RESULTS
___ 02:45PM BLOOD WBC-8.2# RBC-4.68 Hgb-14.1 Hct-40.8
MCV-87 MCH-30.1 MCHC-34.6 RDW-12.8 Plt ___
___ 06:35AM BLOOD WBC-4.6 RBC-4.33* Hgb-13.2* Hct-38.1*
MCV-88 MCH-30.5 MCHC-34.7 RDW-12.9 Plt ___
___ 02:45PM BLOOD Glucose-315* UreaN-17 Creat-0.9 Na-135
K-3.8 Cl-96 HCO3-26 AnGap-17
___ 06:35AM BLOOD Glucose-134* UreaN-15 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-28 AnGap-13
___ 02:45PM BLOOD ALT-27 AST-17 AlkPhos-43 TotBili-1.1
___ 02:45PM BLOOD Lipase-393*
___ 02:45PM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD Calcium-8.5 Phos-3.5# Mg-1.6
___ 02:45PM BLOOD Albumin-4.8
MICROBIOLOGY: none
IMAGING:
CT abdomen/pelvis
IMPRESSION: Acute pancreatitis with peripancreatic fat stranding
but no focal fluid collection or evidence of necrosis. Atrophy
to the mid body of the gland is as on previous studies and
consistent with the provided history of acute on chronic
pancreatitis.
CXR: IMPRESSION: No acute cardiopulmonary process. Mild
cardiomegaly, decreased in size compared to the prior study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. aluminum chloride *NF* 20 % Topical daily
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. Repaglinide 2 mg PO TIDAC
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
Discharge Medications:
1. aluminum chloride *NF* 20 % Topical daily
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
4. Repaglinide 2 mg PO TIDAC
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute pancreatitis
SECONDARY:
Diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History pancreatitis, diabetes mellitus, with 2 days of epigastric
pain. Nonspecific EKG changes.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The cardiac silhouette size is decreased compared to the prior study, but
remains mildly enlarged. Mediastinal and hilar contours are within normal
limits. There is no pulmonary vascular congestion. No focal consolidation,
pleural effusion or pneumothorax is identified. There are no acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process. Mild cardiomegaly, decreased in size
compared to the prior study.
Radiology Report
HISTORY: Prior episode of acute necrotizing pancreatitis in ___ with
abdominal pain x2 days and elevated lipase. Assess for pseudocyst or abscess.
TECHNIQUE: CT images were obtained from the lung bases to the pubic symphysis
after the uneventful intravenous administration of 130 cc of Omnipaque
contrast medium. No oral contrast was administered. Multiplanar reformations
were prepared.
COMPARISON: ___.
FINDINGS:
CT ABDOMEN WITH CONTRAST: The imaged lung bases demonstrate minimal basilar
atelectasis without pleural or pericardial effusion.
The liver is normal in attenuation without focal lesion, intra or extrahepatic
biliary ductal dilatation. The portal and hepatic veins appear patent. The
gallbladder is unremarkable. The spleen and bilateral adrenal glands appear
normal. The kidneys enhance and excrete contrast symmetrically without
hydronephrosis.
The mid body of the pancreas is relatively atrophic. Inflammatory stranding
surrounding the pancreas is noted with relatively uniform pancreatic
parenchymal enhancement and no specific evidence of frank necrosis. Stranding
extends into the anterior pararenal spaces bilaterally without evidence of
focal fluid collection. No pancreatic ductal dilatation is seen.
The stomach is decompressed as is most of the small bowel. The appendix is
seen and is normal. The colon contains a mild quantity of stool and is
otherwise unremarkable. There is no free air in the abdomen. Peripancreatic
reactive lymph nodes are noted without pathologic lymph node enlargement.
The aorta and major branches are patent and normal in caliber without
atherosclerotic disease identified.
CT PELVIS WITH CONTRAST: The bladder, prostate, and rectum are unremarkable.
There is no pelvic or inguinal lymphadenopathy or pelvic free fluid.
OSSEOUS STRUCTURES: There is no suspicious lytic or blastic bony lesion to
suggest osseous metastatic disease.
IMPRESSION: Acute pancreatitis with peripancreatic fat stranding but no focal
fluid collection or evidence of necrosis. Atrophy to the mid body of the
gland is as on previous studies and consistent with the provided history of
acute on chronic pancreatitis.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ACUTE PANCREATITIS
temperature: 97.4
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 147.0
dbp: 85.0
level of pain: 2
level of acuity: 3.0 | ___ year old male with history of pancreatitis and DM2 presenting
with nausea/vomiting and abdominal pain refractory to morphine,
found to have acute pancreatitis.
#) Pancreatitis: Pain is much less severe and in a slightly
different location than previous episodes, but lipase is
elevated on presentation and CT scan suggestive of inflammation.
This would be his ___ episode and he again does not have a clear
precipitant other than from possible increase in fatty food
intake recently. GERD and PUD are also possibilities, but this
is not supported by imaging or the elevated lipase. His diet
was advanced and IVF stopped after initially being kept NPO
until his pain completely resolved. Given that this pain was in
a new location than his prior pancreatitis and the
characterization of the pain was somewhat distinct, this could
have been a GERD presentation and his outpatient providers may
consider empiric treatment vs. further work-up. Outpatient
follow-up was scheduled with Dr. ___ (PCP) and
Dr. ___ (GI).
#) Diabetes mellitus, type 2: A1c of 6.7% on ___.
Previously on insulin but was very poorly controlled, so ___ now
been changed to oral medications with better result. In ___
notes, the possibility of diabetes secondary to pancreatitis ___
been raised. His home prandin and metformin were held while in
house. His metformin should be held until tomorrow morning,
given contrast exposure from the CT. He was covered with an
insulin sliding scale in house. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Motrin / Penicillins
Attending: ___.
Chief Complaint:
Syncope with fall
Major Surgical or Invasive Procedure:
Electrophysiology changed pacemaker settings on ___.
History of Present Illness:
___ with h/o multiple GIBs as well as ___
chamber pacemaker (last interrogated ___ seen by pcp recently
for lightheadedness suspected ___ orthostatic hypoTN presents
after fall approx 15 hrs prior in setting of syncope after going
from sitting to standing. He states he was leaving his house so
stood up to walk up some stairs and suddenly felt very
lightheaded, tried to grab hold of something for balance, but
passed out. He thinks he lost consciousness for a short period
of time. No confusion upon awakening, no urine/bowel
incontinence. Denies CP, palpitations. Episode was unwitnessed.
Of note, he endorses pre-syncopal episodes regularly upon
standing from a sitting position. He does, however, walk 3 miles
daily without exertional dyspnea, CP, palpitations, or
lightheadedness. Endorses good appetite, eating meals and
drinking liquids very well.
In the ED, initial VS were 98.4 60 175/65 18 98%RA. Initial labs
were notable for trop <0.01. Chem7, CBC, INR and lactate were
unremarkable. CT sinus showed minimally displaced fx of right
nasal bone with left periorbital swelling and hematoma. CT head
and C-spine were unremarkable. Films of his pelvis, left elbow,
and left hand showed possible fracture at the base of the fifth
metacarpal bone and advanced CPPD. His left hand was splinted,
and he received oxycodone and IV morphine prior to transfer to
medicine for further management.
On arrival to the floor, patient reports no complaints and says
his pain is well-controlled.
Past Medical History:
1)hx of LGIB in ___ and ___ with c-scope showing
diverticulosis & internal hemmorrhoids
2)Sick sinus syndrome s/p pacemaker
3)Hyperlipidemia
4)GERD
5)Asthma
___ disease carrier
Social History:
___
Family History:
4 of 6 sibs with pacemakers, brother died of stroke at ___,
father w/ stroke at ___, brother w/ CAD and colon ca, mother w/
cancer, father w/ ___ disease
Physical Exam:
ADMISSION EXAM:
VS - 98.7 148/59 60 18 93%RA
GEN - well-appearing elderly gentleman lying comfortably in bed
in NAD
HEENT - ecchymoses and swelling over left orbit. MMM, sclera
anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - normal rate, regular rhythm, S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, motor function grossly normal
SKIN - no ulcers or lesions
DISCHARGE EXAM:
VS - 98.7 122/70 59 18 93%RA
ORTHOSTATICS: supine - 130/62 60; standing - 58/44 60
GEN - well-appearing elderly gentleman lying comfortably in bed
in NAD
HEENT - ecchymoses and swelling over left orbit. MMM, sclera
anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - normal rate, regular rhythm. II/VI early SEM at ___
intercostal when sitting forward, no carotid upstroke delay, S1
S2 normal. no rubs or gallops
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally. splint in
place on left hand.
NEURO - CN II-XII intact, motor function grossly normal
SKIN - no ulcers or lesions
Pertinent Results:
ADMISSION:
___ 04:50AM BLOOD WBC-7.2 RBC-4.16* Hgb-11.2* Hct-35.8*
MCV-86 MCH-27.0 MCHC-31.3 RDW-15.0 Plt ___
___ 04:50AM BLOOD Neuts-79.8* Lymphs-13.8* Monos-5.4
Eos-0.6 Baso-0.4
___ 04:50AM BLOOD ___ PTT-31.6 ___
___ 04:50AM BLOOD Glucose-102* UreaN-14 Creat-0.7 Na-139
K-3.8 Cl-102 HCO3-26 AnGap-15
___ 04:50AM BLOOD cTropnT-<0.01
___ 11:05AM BLOOD cTropnT-<0.01
___ 06:56AM BLOOD Lactate-1.3
URINE:
___ 12:53AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:53AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:53AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 12:53AM URINE Mucous-FEW
___ 10:11AM URINE Hours-RANDOM Creat-151 Na-146 K-48 Cl-119
DISCHARGE:
___ 07:40AM BLOOD WBC-5.3 RBC-4.24* Hgb-11.4* Hct-36.1*
MCV-85 MCH-26.8* MCHC-31.5 RDW-15.2 Plt ___
___ 07:40AM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-136
K-4.6 Cl-98 HCO3-26 AnGap-17
___ 07:40AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
___ 07:40AM BLOOD Cortsol-13.4
IMAGING:
___ ELBOW X-RAY, WRIST:
IMPRESSION:
1. Possible fracture at the base of the fifth metacarpal bone.
If clinically indicated, dedicated hand radiographs, including
an oblique view of the hand, could help for further assessment.
Otherwise, no fracture detected about the wrist.
2. Evidence of advanced SLAC (scapholunate advanced collapse)
wrist, together with chondrocalcinosis. This could represent
advanced stages of CPPD arthropathy.
3. Erosion and adjoining soft tissue calcifications along the
scaphoid -- ? due to mechanical changes, gout, or possibly due
to abnormality of the radial artery.
___ PELVIS X-RAY:
No lucent or sclerotic fracture line or displaced fracture
fragment is detected. No SI joint or pubic symphysis diastasis.
The sacrum is partially obscured by bowel gas, but visualized
sacral struts are grossly unremarkable. There are mild right
greater than left hip degenerative changes.
No displaced proximal femur fracture is detected on these views.
If there is clinical concern for a proximal femur fracture,
then dedicated views of the hip joint/proximal femur would be
recommended.
___ CT SINUS/MAXILLA:
IMPRESSION:
Likely minimally displaced fracture of the right nasal bone.
Left periorbital swelling/hematoma.
NOTE ADDED IN ATTENDING REVIEW:
1. There are likely acute comminuted right and non-displaced
left nasal bone fractures, with bony nasal septum intact and no
other facial fracture.
2. There is a fluid-filled socket involving the extracted
maxillary right ___ molar, ___ #3 (2:80), which may relate to
the chronic inflammatory disease along this maxillary antral
floor.
3. There is a 3.5mm sialolith in the right submandibular gland
(2:121), without other evidence of sialadenitis; correlate
clinically.
4. There is mucosal thickening involving the OMCs, left more
than right, though they remain patent.
___ CT HEAD:
There is no evidence of acute hemorrhage, edema, mass, mass
effect, or acute territorial infarction. There is mild
periventricular white matter hypodensity, likely the sequelae
of chronic small vessel ischemic disease. The ventricles and
sulci are prominent consistent with age-related atrophy, with
asymmetric prominence of all components of the left lateral
ventricle, unchanged and likely congenital/developmental.
There is minimal mucosal thickening in the left fronto-ethmoidal
recess and the anterior ethmoidal air cells, bilaterally.
Otherwise the visualized paranasal sinuses and mastoid air cells
are well-aerated. No fracture is seen
IMPRESSION: No acute intracranial abnormality
___ CT C-SPINE:
IMPRESSION:
1. No acute fracture.
2. Severe degenerative disease of the mid-cervical spine with
moderately severe canal narrowing at C5-6 and C6-7 and severe
right neural foraminal encroachment at the C6-7 level.
The several alignment abnormalities appear overall unchanged
since the head and neck CTA of ___, and likely relate to
underlying severe degenerative disc and facet joint disease.
___ ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The 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
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild pulmonary artery hypertension. No
pathologic flow identified.
Compared with the prior study (images reviewed) of ___,
mild pulmonary artery hypertension is now identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Syncope
Orthostatic Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Wrist pain status post fall.
LEFT WRIST, THREE VIEWS. LEFT SCAPHOID, SINGLE VIEW. LEFT ELBOW, TWO VIEWS.
LEFT WRIST AND SCAPHOID VW:
There is irregularity at the radial base of the fifth metacarpal, raising the
question of a fracture at the base of the fifth metacarpal. Otherwise, no
acute fracture is detected about the left wrist. Probable diffuse osteopenia.
However, there is evidence of advanced SLAC wrist deformity, with marked
widening of the radioscaphoid interval; proximal migration of the capitate
with bone-on-bone articulation of the capitate and lunate bone; and focally
severe narrowing of the radioscaphoid joint, with mechanical remodeling of the
distal radius related to the scaphoid. There is chondrocalcinosis.
In addition, there are calcifications adjacent to the radial edge of the
scaphoid, where a focal well-circumscribed erosion is detected. This
appearance could represent mechanical erosion or in the appropriate clinical
setting, could relate to gout or even an erosion due to a radial artery
abnormality.
LEFT ELBOW: No definite fracture. A small spur is seen arising from the
coronoid process and spurring along the sublime tubercle is also present.
Joint spaces otherwise preserved. No gross effusion.
IMPRESSION:
1. Possible fracture at the base of the fifth metacarpal bone. If clinically
indicated, dedicated hand radiographs, including an oblique view of the hand,
could help for further assessment. Otherwise, no fracture detected about the
wrist.
2. Evidence of advanced SLAC (scapholunate advanced collapse) wrist, together
with chondrocalcinosis. This could represent advanced stages of CPPD
arthropathy.
3. Erosion and adjoining soft tissue calcifications along the scaphoid -- ?
due to mechanical changes, gout, or possibly due to abnormality of the radial
artery.
The ordering ER resident was paged at the time of discovery at approximately
8:10 am on the day of the exam.
Radiology Report
HISTORY: Fall, hip pain with lateral compression.
SINGLE AP VIEW OF THE PELVIS: No dedicated view of either hip.
No lucent or sclerotic fracture line or displaced fracture fragment is
detected. No SI joint or pubic symphysis diastasis. The sacrum is partially
obscured by bowel gas, but visualized sacral struts are grossly unremarkable.
There are mild right greater than left hip degenerative changes.
No displaced proximal femur fracture is detected on these views. If there is
clinical concern for a proximal femur fracture, then dedicated views of the
hip joint/proximal femur would be recommended.
Radiology Report
HISTORY: Fall and pain.
TECHNIQUE: Contiguous axial images are obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
Bone algorithm was obtained.
COMPARISON: CT head on ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass, mass effect, or acute
territorial infarction. There is mild periventricular white matter
hypodensity, likely the sequelae of chronic small vessel ischemic disease.
The ventricles and sulci are prominent consistent with age-related atrophy,
with asymmetric prominence of all components of the left lateral ventricle,
unchanged and likely congenital/developmental.
There is minimal mucosal thickening in the left fronto-ethmoidal recess and
the anterior ethmoidal air cells, bilaterally. Otherwise the visualized
paranasal sinuses and mastoid air cells are well-aerated. No fracture is
seen.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
HISTORY: Fall and pain, evaluate for fracture.
TECHNIQUE: MDCT images were obtained through the cervical spine without
contrast. Coronal and sagittal reformations were performed. Bone algorithm
was obtained.
COMPARISON: None available.
FINDINGS:
There is no prevertebral soft tissue abnormality. There is no acute fracture.
There is facet arthropathy involving the entire cervical spine, with loss of
the normal lordosis. There is there is grade 1 anterolisthesis of C3 on C4.
The disc space is severely narrowed at C4-5. There is fusion at C5-6 and
posterior osteophytes cause moderate to severe spinal canal narrowing. There
is near fusion of C6-7 and posterior osteophytes cause moderately severe canal
narrowing. There is grade 1 anterolisthesis of C7 on T1.
There is a 8 x 5 mm soft tissue density within the anterior aspect of the
trachea (401b:24), which may represent adherent mucus. The visualized lung
apices are grossly clear. There are mild calcifications of the carotid bulbs,
bilaterally.
IMPRESSION:
1. No acute fracture.
2. Severe degenerative disease of the mid-cervical spine with moderately
severe canal narrowing at C5-6 and C6-7 and severe right neural foraminal
encroachment at the C6-7 level.
The several alignment abnormalities appear overall unchanged since the head
and neck CTA of ___, and likely relate to underlying severe degenerative
disc and facet joint disease.
Radiology Report
HISTORY: Fall and left maxillary ecchymosis
TECHNIQUE: MDCT images were obtained of the facial bones without contrast.
Coronal and sagittal reformations were performed. Bone algorithm was obtained.
COMPARISON: None available.
FINDINGS:
There is mild soft tissue density anterior to the left maxillary sinus and
left orbit. There is a likely minimally displaced fracture of the right nasal
bone (480, 25). There has been minimal mucosal thickening in the maxillary
sinuses bilaterally and the ethmoid air cells. The remaining visualized
paranasal sinuses and mastoid air cells are well aerated. There are no
air-fluid levels in the paranasal sinuses. The orbits and globes are
unremarkable. The temporomandibular joints are unremarkable. There are mild
calcifications of the cavernous portions of the carotid arteries bilaterally.
IMPRESSION:
Likely minimally displaced fracture of the right nasal bone.
Left periorbital swelling/hematoma.
NOTE ADDED IN ATTENDING REVIEW:
1. There are likely acute comminuted right and non-displaced left nasal bone
fractures, with bony nasal septum intact and no other facial fracture.
2. There is a fluid-filled socket involving the extracted maxillary right ___
molar, ___ #3 (2:80), which may relate to the chronic inflammatory disease
along this maxillary antral floor.
3. There is a 3.5mm sialolith in the right submandibular gland (2:121),
without other evidence of sialadenitis; correlate clinically.
4. There is mucosal thickening involving the OMCs, left more than right,
though they remain patent.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 98.4
heartrate: 60.0
resprate: 18.0
o2sat: 98.0
sbp: 175.0
dbp: 65.0
level of pain: 8
level of acuity: 3.0 | ___ with h/o recurrent falls, GIBs, as well as ___
___ chamber pacemaker presents with an episode of syncope
with fall. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
novacaine
Attending: ___
Chief Complaint:
Left sided weakness and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old right handed man with past medical
history remarkable for embolus to the left opthalmic artery
complicated by blindness, hyperlipidemia, and type 2 diabetes
who
presents from home with sudden onset left-sided sensory loss and
weakness. On ___ at 7PM developed the sensation of "pins and
needles" in left arm and leg, but not face. At this time, he
did not have any motor involvement, noting the sensation "that
his body felt like it was asleep
on the left side". This persisted until 8:30PM when he noted to
have tingling and some heaviness in face which persisted for the
next hour. A friend who was visiting noted he was slurring words
and appeared to have facial drooping on the left. Mr. ___
friend drove him
to the ___ ED by 2200hrs and at 2209hrs a code stroke was
called.
Initial NIHSS evaluted by the ED resident noted 12 for left
weakness, visual change, sensory change, and dysarthria. Within
5 minutes, neurology was present and NCHCT was performed, along
with CTA/P for clinical suspicion of right hemispheric ischemia.
Per the patient's assessment, he noted feeling weaker at the
time
of formal evaluation by neurology which demonstrated a NIHSS
score of 6 (as above). He reports no recent changes to
activity,
no recent illness or deficits, and no changes to medication
(although he had not taken his lipitor for the past 3 days as he
had not refilled his prescription).
On neuro ROS, the pt noted a diffuse tension type, non-pounding
headache. He noted no progression of loss of vision from that
in
___, noting only some blurred vision with extreme gaze to the
left. He denied diplopia, lightheadedness, vertigo, tinnitus or
hearing difficulty. He noted dysarthria, and possibly some
dysphagia but had not eaten any food since the onset of
symptoms.
Denies difficulties comprehending speech. Denies 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:
- Embolic event to the left eye per patient in ___ s/p
treatment with coumadin stopped in ___ complicated by vision
loss in left eye
- Hyperlipidemia on Lipitor
- Non-insulin dependant Type 2 Diabetes
Social History:
___
Family History:
- Stroke and MI in mother
- MI in father
- CAD in brother
Physical ___:
Pain=8, T=98.0F, HR=77, BP=110/58, RR=19, SaO2=99% RA
General: Awake, cooperative, concerned.
HEENT: Left facial droop noted
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language was remarkable for dysarthria as
well as intact repetition and comprehension with delay. Prosody
was smooth but some recall delays were noted. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Able to
follow both midline and appendicular commands. Attentive, with
good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation in right in all directions,
left eye was at baseline was decreased in acuity with no blink
to
threat.
III, IV, VI: EOMI without nystagmus. Saccadic intrusions.
V: Facial sensation decreased to light touch, pinprick on left
(40% of right), and ___ strength noted bilaterally in masseter
VII: Left nasolabial fold was blunted with noted decreased
excursion of left mouth, facial musculature was otherwise
symmetric with ___ strength in upper distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes to the left, with some decreased right
strength noted as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. Drift downward with left
arm on raise. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 5 4+ ___ 4+ ___ 4 5 4+ 4+
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1 1
R 2 1 1 1 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
- Sensory: Deficits to light touch, pinprick, cold sensation in
left hemibody, noted to be 40% of right hemibody. No extinction
to DSS.
-Coordination: No intention tremor, Marked dysmetria on FNF on
the left likely ___ weakness.
-Gait: Did not assess.
DISCHARGE NEUROLOGIC EXAM
-Mental Status: Alert, oriented x 3. No dysarthria. Pt. was
able to name both high and low frequency objects. Able to read
without difficulty. Able to
follow both midline and appendicular commands. Attentive, no
evidence of
apraxia or neglect.
-Cranial Nerves:
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation in right in all directions,
left eye was at baseline was decreased in acuity with no blink
to
threat.
III, IV, VI: EOMI without nystagmus. Saccadic intrusions.
V: Facial sensation decreased to light touch, pinprick on left,
and ___ strength noted bilaterally in masseter
VII: Left nasolabial fold was minimally blunted
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes to the left, with some decreased right
strength noted as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. Drift downward with left
arm on raise. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 5 4+ ___ 4+ 5- 5 4+ 4 5
R ___ ___ ___ 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1 1
R 2 1 1 1 1
- Sensory: LT grossly intact. Pinprick decreased in left
hemibody. No extinction
to DSS.
-Coordination: No intention tremor, Mild dysmetria on FNF.
-Gait: Able to walk without support. Wider base, at times
watching his feet as he steps with short stride.
Pertinent Results:
CXR: ___
Widened mediastinum, possibly due to accentuation by low lung
volumes, but a
discrete mass or acute mediastinal process cannot be excluded.
Repeat chest
radiographs are recommended with improved respiratory effort.
Chest CT may
also be considered.
CT/CTA ___
No hemorrhage or evidence of acute infarct.
No significant vessel stenosis or occlusion on the CTA.
Small 2-3mm broad based ACOM aneurysm.
No evidence of infarct or penumbra on CT perfusion.
NCHCT - No acute hemorrhage, CTA: Narrowing of the M1 segment on
the right, but widely patent distal vessels without evidence of
cut off, CTP: Very subtle, if any, increased MTT to the right
temporal region.
ECHO- left atrium is elongated. No thrombus/mass is seen in the
body of the left atrium. No atrial septal defect or patent
foramen ovale is seen normal (LVEF >55%). No masses or thrombi
are seen in the left ventricle. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers.
Medications on Admission:
- Lipitor 20mg daily
- Metformin 1000mg BID
(was on coumadin in ___ or embolic event)
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*3
3. Insulin SC
Sliding Scale
4. Metformin 1000mg BID
Fingerstick qid
Insulin SC Sliding Scale using REG Insulin
5. Outpatient Occupational Therapy
eval and treat
5. Outpatient Physical Therapy
eval and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. TIA
Secondary Diagnosis
1. Hyperlidipemia
2. history of ophthalmic artery embolism
3. Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with left-sided weakness.
TECHNIQUE: The CT noncontrast head CT, CTA head and neck, and CT perfusion
studies were obtained after the intravenous administration of 110 cc Omnipaque
350 contrast.
COMPARISON: No prior studies available for comparison.
FINDINGS:
Noncontrast head CT:
Gray-white matter differentiation is normal. There are no signs of acute
infarct, hemorrhage, or mass effect.
There is right maxillary, right frontal and ethmoid sinus mucosal thickening.
CTA head:
The is a 2-3mm broadbased ACOM aneurysm best seen on image 263, series 4.
There is a hypoplastic right M1 segment. The middle cerebral arteries are
otherwise unremarkable. The PICAS are not identified bilaterally and may
relate to ___ complex. There is no significant stenosis, occlusion or
aneurysm.
CTA neck:
There is a dominant left vertebral artery. The common and internal carotid
arteries are unremarkable. There is no significant vessel stenosis or
occlusion.
CT perfusion: The cerebral blood volume,cerebral blood flow and mean transit
time are normal and symmetric. There is no evidence of acute infarct or
penumbra.
IMPRESSION:
No hemorrhage or evidence of acute infarct.
No significant vessel stenosis or occlusion on the CTA.
Small 2-3mm broad based ACOM aneurysm.
No evidence of infarct or penumbra on CT perfusion.
Radiology Report
HISTORY: ___ year old man with h/o embolic events p/w left weakness and
sensory loss.
TECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility and diffusion axial
images of the brain were acquired.
COMPARISON: None.
FINDINGS:
The ventricles and extra-axial spaces are normal in size. There is no
evidence of midline shift, mass effect or hydrocephalus. There are no acute
infarct or focal signal abnormality seen. The flow voids are maintained. The
suprasellar and craniocervical regions are unremarkable on the sagittal
images.
Mild soft tissue changes are seen in the paranasal sinuses.
IMPRESSION:
No significant abnormalities are seen on the MRI of the brain without
gadolinium. No acute infarcts are identified or mass effect seen.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: STROKE
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ yo RH M with HLD, DM, prior embolic event p/w L sided
weakness and sensory loss. CTA imaging suggestive of right M1/2
distribution stenosis without definite occlusion. MRI and CT
showed no stroke. Over the course of her hospitalization had
improvement in strength though still with minimal residual
weakness in LUE, as well as residual sensory loss to LT and
pinprick on the left at time of discharge. Etiology is likely
TIA, given the stenosis noted in the right MCA. There may have
been transient occlusion from an embolus resulting temporary
ischemia but workup for embolic phenomenon was negative on this
admission. Echo was reassuring without vegetations or PFO.
Workup for vascular risk factors: LDL is 119 and he is already
on lipitor 20mg daily. Metformin was held acutely, A1c-7.5. He
is now on ASA 325mg daily.
# NEURO:
- MRI w/o Gad showed no significant abnormalities. No acute
infarcts are identified or mass effect seen.
- CTA showed stenotic right MCA M1/2 segments without perfusion
mismatch
- Distribute stroke information packet and note in the chart
- Assess stroke risk factors with fasting lipid panel and HbA1c
- Transitioned off heparin gtt in ICU to ASA 325mg daily
- ___
- passed beside swallow
- Precautions: falls and aspiration
.
# ___:
- ECG
- Telemetry - so far, NSR 60-100's
- BP autoregulates 120-160. Might add lisinopril 5mg daily low
dose.
- Hydralazine 10 mg IV Q6H PRN SBP > 200
- LDL 119 added back home Lipitor 20mg daily
- TTE with bubble- no PFO, no vegetation
- Could consider hypercoag workup including Anti-Phospholipid AB
(given family hx of
stroke/MI)
.
# ENDO:
- HbA1c 7.5
- Hold oral hypoglycemics
- Finger sticks QID and Insulin sliding scale with a goal of
normoglycemia
.
# F/E/N:
- Diabetic / Cardiac Prudent Diet
- Replete lytes PRN
TRANSITIONAL ISSUES
- Pt did not know phone number and we were unable to find the
information online. He will arrange a PCP appointment on his
own and follow up vascular risk factors.
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No
4. LDL documented? (x) Yes (LDL = 119) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, groin pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with history of ___, HTN, recent
sternoclavicular dislocation s/p ORIF, recent Enterobacter UTI
on
cefpodoxime now presenting with left groin pain.
Patient underwent ORIF of the right SC joint by Dr. ___ on
___ with discharge home on ___. With respect to his
shoulder, his pain has abated and he has been taking oxycodone
sparingly. He has been doing range of motion exercises as
prescribed.
He was seen in the ED on ___ for increased work of
breathing,
where he underwent CT of his neck which was negative, and was
subsequently discharged home.
He represented to the ED on ___ with hematuria/dysuria, and
per chart review, was noted to have mild retention and required
the placement of a three way catheter. He was discharged on
cefpodoxime. Of note, the urine culture from that time grew
pan-sensitive Enterobacter.
At 1000 on the day prior to presentation, the patient endorsed
acute onset of left testicular pain after trying to get out of
bed and reports he heard a "pop". He thought that he had pulled
a
muscle. He later noted that his left testicle was swollen. He
took Tylenol and oxycodone 5 mg (prescribed for his shoulder),
which helped his pain somewhat.
On the day of presentation, he reports that he was a witness in
his son's custody hearing so he did not take any pain
medications
so that he could be a clear witness. During the court hearing,
he
developed severe, sharp, throbbing pain in his left testicle
without radiation. This pain worsened throughout the lengthy
court appearance, and when he returned home he decided to call
an
ambulance. He denies any fevers or chills at home. He continues
to have dysuria but he reports his hematuria has resolved. No
abdominal pain, nausea, vomiting, diarrhea. He is in a
monogamous
sexual relationship with his wife. No testicular trauma.
Upon arrival to the ED, initial VS were: 8 100.8 115 140/90 18
99% RA
Exam notable for: Left testicle is more swollen compared to
right. Tender to palpation. Normal color. Penis non-tender to
palpation. negative cremasteric reflex b/l
Labs were notable for WBC of 17.2, H/H of 11.9/35.9, Plt 393.
BMP
unremarkable with a Cr of 1.1. UA showed small blood, with large
leuk esterase.
Imaging notable for: Testicular ultrasound significant for left
epididymitis with small left hydrocele and left testicular
microlithiasis.
Patient received:
___ 21:44 PO Acetaminophen 650 mg
___ 21:45 IVF NS 1000 mL
___ 00:09 IV Levofloxacin 500 mg
___ 00:46 IV Morphine Sulfate 4 mg
On arrival to the floor, the patient reports that he has left
testicular pain, about an ___. He tells me that given his twin
brother's substance abuse history, he is reluctant to take
narcotics and would prefer to avoid them if possible. Otherwise,
his shoulder feels slightly sore but not painful. Otherwise, he
feels well and has no complaints.
Past Medical History:
- Diabetes mellitus, insulin dependent
- Hypertension
- R posterior SC joint dislocation s/p ORIF ___
Social History:
___
Family History:
- Father: Heart failure s/p heart transplant, living
- Mother: ___, CAD, dementia, deceased
- Twin brother with substance use disorder
Physical Exam:
Admission physical exam:
VITALS: 99.8 125/77 94 16 96 RA
GENERAL: Aox3, in no acute distress
EYES: Anicteric, PERRL
ENT: Mucous membranes moist
CV: RRR, no murmur
RESP: CTAB
GU: Swollen left testicle, with tenderness to palpation
GI: BS+, abdomen soft, non-distended, nontender to palpation
MSK: Right shoulder with staple line well-apposed,
clean/dry/intact; mild tenderness to palpation over clavicle
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: Pleasant, appropriate affect
Discharge physical exam:
avss
well appearing
moderate L testicular swelling, some firmness inferiorly w
tenderness
no confused
no skin breakdown in scrotum or perineum
Pertinent Results:
Admission labs:
___ 08:40PM BLOOD WBC-17.2* RBC-3.79* Hgb-11.9* Hct-35.8*
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.3 RDWSD-42.5 Plt ___
___ 08:40PM BLOOD Glucose-149* UreaN-19 Creat-1.1 Na-136
K-4.6 Cl-97 HCO3-25 AnGap-14
___ 08:45PM BLOOD Lactate-1.5
Imaging:
Scrotal ultrasound ___
IMPRESSION:
1. Left epididymitis.
2. Small left hydrocele.
3. Left testicular microlithiasis. In the absence of risk
factors of
testicular malignancy, no additional imaging follow-up is
necessary.
IMPRESSION:
Persistent left epididymitis.
Interval increase in the echogenic debris within the left
hydrocele may
represent superimposed infection.
Discharge labs:
___ 06:12AM BLOOD WBC-9.2 RBC-3.38* Hgb-10.4* Hct-31.8*
MCV-94 MCH-30.8 MCHC-32.7 RDW-12.0 RDWSD-41.3 Plt ___
___ 05:42AM BLOOD Glucose-131* UreaN-17 Creat-1.2 Na-141
K-4.7 Cl-101 HCO3-24 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. MetFORMIN (Glucophage) ___ mg PO DAILY
5. Vitamin D 800 UNIT PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
2. Omeprazole 20 mg PO DAILY Duration: 14 Days
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*14
Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Duration: 3 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Atorvastatin 20 mg PO QPM
8. Lisinopril 2.5 mg PO DAILY
9. MetFORMIN (Glucophage) ___ mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Epididymitis
Diabetes
Sternoclavicular joint dislocation s/p ORIF
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: History: ___ with left testicular pain and swelling// r/o torsion
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 2.7 x 3.1 x 4.5 cm.
The left testicle measures: 2.5 x 3.3 x 4.0 cm.
Multiple (more than 5 per field post) microcalcifications are seen in the left
testicle. Otherwise, the testicular echogenicity is normal bilaterally,
without focal abnormalities or mass.
Increased vascular flow in the left epididymis is compatible with
epididymitis. The right epididymis is normal.
Vascularity is normal and symmetric in the testes.
There is a small left hydrocele with debris.
IMPRESSION:
1. Left epididymitis.
2. Small left hydrocele.
3. Left testicular microlithiasis. In the absence of risk factors of
testicular malignancy, no additional imaging follow-up is necessary.
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ year old man with L testicular epidymitis, still painful and
swollen// r/o development of testicular abscess, or worsening epidymitis
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: Scrotal ultrasound ___.
FINDINGS:
The right testicle measures: 2.5 x 3.3 x 4.6 cm
The left testicle measures: 2.8 x 3.2 x 3.8 cm
The testicular echogenicity is normal, without focal abnormalities.
Vascularity is normal and symmetric in the testes.
The right epididymis is unremarkable. Again demonstrated, is persistent
thickening, heterogeneity, and hyperemia of the left epididymis, particularly
the body and tail, consistent with epididymitis.
Again demonstrated, is a left hydrocele with increased echogenic debris which
may represent superinfection.
Stable left testicular microlithiasis.
IMPRESSION:
Persistent left epididymitis.
Interval increase in the echogenic debris within the left hydrocele may
represent superimposed infection.
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ year old man with epididymitis, with acute worsening of pain
and abdominal pain// eval for torsion
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: Testicular ultrasound from ___
FINDINGS:
The right testicle measures: 4.6 x 0.6 x 3.2 cm.
The left testicle measures: 3.9 x 2.7 x 3.0 cm.
The testicular echogenicity is within normal limits, without focal
abnormalities. There is increased vascularity in the left testicle.
The right epididymis is unremarkable. There is a persistent heterogeneous,
thickened appearance of the left epididymis, with hyperemia, consistent with
known epididymitis. A left hydrocele, with internal debris, is again noted.
IMPRESSION:
1. No significant change from ___.
2. No evidence of torsion.
3. Persistent left epididymitis/orchitis and hydrocele.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Testicular pain
Diagnosed with Fever, unspecified
temperature: 100.8
heartrate: 115.0
resprate: 18.0
o2sat: 99.0
sbp: 140.0
dbp: 90.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ y/o man with history of ___, HTN, recent
sternoclavicular dislocation s/p ORIF, recent Enterobacter UTI
on cefpodoxime who presented with left groin pain, found to have
epididymitis. |
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, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with cholangiocarcinoma on chemotherapy C7D17
of Gemcitabine/Cisplatin (last dose ___ who has a known
contained gallbladder perforation treated conservatively with
antibiotics called in the AM reporting T 102 and presented to
the
clinic where she was found to have BP 80/50, HR 112 regular,
with
mental status changes, complaining of headache. She was sent to
the ED where her T 98.5, HR 93, BP 117/71, RR 24, SpO2 98% RA.
Her labs were notable for platelets of 43 down from 119 on
___, Hb 8.7 (stable), WBC 5.4 with 96%N, Cr 1.3 (from 1.2
___ from baseline 1.1), ___ 77, INR 7.4, PTT 50.3. She was
bolused with 3L of normal saline. Her altered mental status
resolved. She was dosed Ciprofloxacin and Flagyl for abdominal
pain and likely biliary/GB related sepsis. She underwent a CT
abdomen/pelvis which showed new liver lesions (bile lakes versus
worsening disease), known contained GB perforation and mild
increased in fluid around the GB. Transplant surgery was
consulted and reported that there was no indication for surgical
intervention at the present time and recommended admission to
OMED.
Past Medical History:
Unresectable Klatskin-type cholangiocarcinoma. On admission
cycle 7, day 12 gemcitabine/cisplatin. Presented in ___
with painless jaundice. ERCP showed a hilar stricture, and
brushings showed atypical cells. Her post-ERCP course was
complicated by E. coli cholangitis and acute kidney injury. She
underwent percutaneous biliary stenting, which was then
transitioned to a permanent internal metal stent. Bile duct
biopsy ___ showed adenocarcinoma. She was diagnosed with
a
left lower extremity DVT in ___. She initiated systemic
chemotherapy with gemcitabine/cisplatin per ABC-2 regimen
___. She was treated with Cyberknife stereotactic
radiotherapy completed ___.
Past Medical History:
- Fatty liver disease
- Morbid obesity
- HL
- HTN
- DM2
- CKD due to DM
- Osteopenia
- s/p TAH/BSO for Ovarian CA ___
Social History:
___
Family History:
mother - DM, ___ CVA
father - ___ brain tumor
other - Aunt with breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================
VITAL SIGNS: T 98.2, HR 68, BP 124/60, RR 20, SpO2 100% RA
General: Obese, pleasant woman in NAD.
HEENT: NC/AT, MMM, no OP lesions, no cervical, supraclavicular,
or axillary adenopathy
CV: RR, NL S1S2
PULM: CTAB
ABD: BS+, soft, + moderate ttp in the epigastrium, examination
of organs limited by body habitus
LIMBS: No edema, clubbing
SKIN: No rashes or skin breakdown
NEURO: A&OX3, strength ___ proximal and distal upper and lower
extremities (mild decrease in right proximal strength), no
pronator drift, sensation grossly intact
DISCHARGE PHYSICAL EXAM:
=================
VS: T:98.0 BP:149/80 P:75 RR:18 O2:98% on RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, tender to palpation in periumbilical area.
Extremities: Warm and well-perfused, no edema. DPs, PTs 2+.
Skin: No rashes or bruising
Neuro: CNs II-XII intact
Pertinent Results:
ADMISSION LABS:
===============
___ 09:55AM BLOOD WBC-5.4 RBC-2.90* Hgb-8.7* Hct-26.7*
MCV-92 MCH-30.0 MCHC-32.5 RDW-18.7* Plt Ct-43*#
___ 09:55AM BLOOD Neuts-96.3* Lymphs-1.5* Monos-1.1*
Eos-1.0 Baso-0.1
___ 09:55AM BLOOD Plt Smr-VERY LOW Plt Ct-43*#
___ 10:15AM BLOOD ___ PTT-60.6* ___
___ 09:51PM BLOOD ___
___ 09:55AM BLOOD ___ ___
___ 09:55AM BLOOD Glucose-84 UreaN-22* Creat-1.3* Na-131*
K-3.3 Cl-97 HCO3-24 AnGap-13
___ 09:55AM BLOOD ALT-28 AST-37 LD(LDH)-162 AlkPhos-399*
TotBili-1.0
___ 09:55AM BLOOD Albumin-2.8* Calcium-8.3* Phos-2.3*
Mg-1.0*
___ 09:55AM BLOOD Hapto-388*
___ 10:54AM BLOOD Lactate-1.5
DISCHARGE LABS:
===============
___ 05:59AM BLOOD WBC-6.0 RBC-2.50* Hgb-7.3* Hct-23.4*
MCV-94 MCH-29.4 MCHC-31.3 RDW-20.3* Plt Ct-24*
___ 05:59AM BLOOD ___ PTT-30.2 ___
___ 05:59AM BLOOD Glucose-212* UreaN-15 Creat-1.1 Na-135
K-3.7 Cl-99 HCO3-27 AnGap-13
___ 05:59AM BLOOD ALT-16 AST-27 AlkPhos-437* TotBili-0.5
___ 05:59AM BLOOD Calcium-7.9* Phos-4.3 Mg-1.5*
___ 05:45AM BLOOD Vanco-20.5*
RELEVANT STUDIES:
=================
- CT ABDOMEN/PELVIS W/ CONTRAST (___):
1. Multiple new small hypodensities seen in the liver
predominantly in the right lobe, not previously seen on the
prior examination may represent bile lakes or infection, spread
of cholangiocarcinoma felt less likely. Consider MRI for further
characterization.
2. Intrahepatic biliary ductal dilatation is minimally increased
from the
prior exam.
3. Discontinuity of the gallbladder wall and adjacent soft
tissue and fat
stranding consistent with gallbladder perforation again seen
with a small
increase in loculated fluid inferior to the gallbladder compared
to the prior study.
- CT HEAD W/O CONTRAST (___): No evidence of acute
intracranial process.
- MRI ABDOMEN W/ AND W/O CONTRAST (___):
1. Worsening dilatation with intrahepatic ducts in segments 7
and 8 with
disappearance of pneumobilia, suspicious for CBD stent
dysfunction. Evaluation of the stent potency is recommended.
2. Multiple lesions consistent with abscesses in segments 7 and
8, which show worsening from the last CT which was done 2 days
prior to the MRI. The abscesses are only mildly hyperintense on
T2WI, indicating mostly phlegmonous contents. This may be
aspirated for micro-organism culture.
3. Gallbladder wall discontinuity with a tract extending to the
fluid
collection abutting the hepatic flexure of the colon, without
significant
change from ___.
4. Stable left adrenal adenoma.
- TTE ECHO (___): In context of suboptimal image quality,
no pathologic flow or valvular vegetations seen. Mild symmetric
left ventricular hypertrophy with preserved global biventricular
systolic function.
MICRO RESULTS:
==============
- Blood Culture, Routine (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
FROM ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS.
- Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Senna 17.2 mg PO BID:PRN constipation
3. Simvastatin 40 mg PO DAILY
4. Warfarin 5 mg PO DAILY16
5. Pioglitazone 45 mg PO DAILY
6. nystatin 100,000 unit/gram topical bid PRN skin irriation in
folds
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 1 ml IV q24 Disp #*20 Vial Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Senna 17.2 mg PO BID:PRN constipation
5. Simvastatin 40 mg PO DAILY
6. nystatin 100,000 unit/gram topical bid PRN skin irriation in
folds
7. Pioglitazone 45 mg PO DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting
9. Outpatient Lab Work
WEEKLY CBC with differential, BUN, Cr, AST, ALT, TB, ALK
PHOS
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bacteremia from Strep. anginosis (millerei)
Common bile duct stent malfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with headache // acute process?
TECHNIQUE: Contiguous axial CT images were obtained through the brain without
the administration of IV contrast. Reformatted coronal, sagittal and thin
section bone algorithm-reconstructed images were then generated.
DOSE: DLP: 780 mGy-cm
CTDI: 50
COMPARISON: CT head on ___ and MRI MRA brain on ___.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction.
The ventricles and sulci are enlarged consistent with age related atrophy.
Periventricular white matter hypodensities are suggestive of chronic small
vessel ischemic disease.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
Again seen is a 1.5 x 1.0 cm dural-based meningioma at the vertex, previously
characterized on MR, and is unchanged in appearance. There is no evidence of
fracture.
There is very minimal mucosal thickening of the ethmoid air cells. The
remainder of the paranasal sinuses are clear. The mastoid air cells are
well-aerated.
The globes are intact.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with previous gallbladder perforation, stable since ___, now with abdominal pain and altered mental status, h/o
cholangiocarcinoma, Cr 1.3 but will hydrate priorNO_PO contrast // change in
gallbladder pathology?
TECHNIQUE: MDCT images were obtained from the lung bases to the lesser
trochanters . IV Contrast was administered. Coronal and sagittal reformations
were prepared.
DOSE: DLP: 874 mGy-cm
COMPARISON: CT abdomen with contrast on ___.
FINDINGS:
Lungs and Heart: There is very minimal bibasilar atelectasis. There is no
pleural or pericardial effusion.
Liver, Gallbladder: There is intrahepatic biliary ductal dilatation, which is
minimally increased from the prior exam. Pneumobilia is seen and is similar to
the prior exam. New from the prior exam are numerous hypodensities throughout
the liver predominantly in the right lobe at the dome, which may represent
bile lakes or infection (microabscesses not excluded) vs ___ of disease(less
likely). A biliary stent is again seen in unchanged position. Again seen is
increased fat stranding and soft tissue density adjacent to the gallbladder
consistent with a history of a contained gallbladder perforation. A 3.1 x 1.6
cm loculated fluid collection just inferior to the gallbladder appears
increased from the prior exam done on ___.
Spleen: The spleen is normal in size and enhancement.
Pancreas: The pancreas is normal with no masses or pancreatic ductal
dilatation seen.
Kidneys, Adrenals: Multiple hypodensities are seen in the kidneys bilaterally
consistent with renal cysts and are unchanged. Other subcentimeter
hypodensities are too small to characterize but likely also represent cysts.
The kidneys are otherwise unremarkable. There is a 2.3 x 1.9 cm left adrenal
adenoma which is unchanged in size and character from the prior examination .
Bowel: The small bowel is unremarkable. The large bowel is grossly normal.
Vessels: There is moderate atherosclerosis of the abdominal aorta. There is
no aneurysmal dilatation of the aorta and its major branches are patent.
Lymph Nodes: There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria.
Pelvis: The bladder is unremarkable. The sigmoid colon and rectum are normal
appearing. There is no pelvic sidewall lymphadenopathy
Osseous Structures: A small sclerotic focus in L4 is again demonstrated and is
likely a bone island. There is moderate degenerative change at L5-S1. No
suspicious lytic sclerotic lesions are identified
IMPRESSION:
1. Multiple new small hypodensities seen in the liver predominantly in the
right lobe, not previously seen on the prior examination may represent bile
lakes or infection, spread of cholangiocarcinoma felt less likely. Consider
MRI for further characterization.
2. Intrahepatic biliary ductal dilatation is minimally increased from the
prior exam.
3. Discontinuity of the gallbladder wall and adjacent soft tissue and fat
stranding consistent with gallbladder perforation again seen with a small
increase in loculated fluid inferior to the gallbladder compared to the prior
study.
NOTIFICATION: Updated findings including new hypodensities possibly
representing infection/microabscesses discussed by Dr. ___ with Dr.
___ at approximately 4:15 pm on ___ in person.
Radiology Report
EXAMINATION: MRI abdomen with and without contrast.
INDICATION: ___ year old woman with metastatic cholangiocarcinoma, s/p
contained gallbladder perforation now w/ new liver lesions. // Assess
etiology of liver lesions
TECHNIQUE: Multiplanar T1 and T2 weighted sequences were obtained in a 1.5
Tesla magnet including dynamic 3D imaging performed prior to, during, and
after the uneventful administration ___ of ___.
COMPARISON: CT from ___. MRI from ___.
FINDINGS:
Lung bases clear. There is no pleural or pericardial effusion. The heart is
enlarged. A small hiatal hernia is seen.
Susceptibility artifacts from metal stents are seen in the CBD and the central
intrahepatic biliary ducts. The cholangiocarcinoma itself at the central duct
bifurcation is not seen well due to the artifacts.
The dilatation of the bile ducts in segments 7 and 8 is more prominent
compared to the last study and do not contain air on this exam, as they used
to, arising suspicion for obstruction. Evaluation of the stent potency is
recommended.
The gallbladder is distended and contains fluid-fluid level, the dependent
portion of which has restricted diffusion (6:33) with low ADC values
consistent with thick inspissated contents. The lateral gallbladder wall is
discontinuous (07:31) with a tract leading to a partially seen multilobular
fluid collection abutting the hepatic flexure of the colon, measuring 4.8 x
2.8 cm (1003:126). This appearance has not significantly changed compared
___.
In segments 7 and 8 multiple hepatic irregular multicystic well defined
lesions are seen in the right lobe, which are internally mildly hyperintense
on T2WI and have rim enhancement (1002:45). These are new compared to ___ and enlarged compared to ___. The largest in segment 8
measures 3.8 x 2.7 cm. Patchy enhancement of the liver parenchyma is seen
around the lesions in segment 8. These are consistent with abscesses which are
mostly phlegmonous and not containing liquefied contents.
A 3 mm cystic lesion seen in the uncinate process of the pancreas (07:36),
representing a side branch IPMN.
Stable bilateral renal cortical cysts are seen.
A 2.8 cm mass seen in the left adrenal, showing areas of signal drop on the
out of phase images compared to in phase images, and unchanged from previous
studies, consistent with an adrenal adenoma (5:31).
No free fluid seen. No lymphadenopathy is seen.
Degenerative changes the spine with mild scoliosis are seen.
IMPRESSION:
1. Worsening dilatation with intrahepatic ducts in segments 7 and 8 with
disappearance of pneumobilia, suspicious for CBD stent dysfunction. Evaluation
of the stent potency is recommended.
2. Multiple lesions consistent with abscesses in segments 7 and 8, which show
worsening from the last CT which was done 2 days prior to the MRI. The
abscesses are only mildly hyperintense on T2WI, indicating mostly phlegmonous
contents. This may be aspirated for micro-organism culture.
3. Gallbladder wall discontinuity with a tract extending to the fluid
collection abutting the hepatic flexure of the colon, without significant
change from ___.
4. Stable left adrenal adenoma.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with FEVER, UNSPECIFIED, SEMICOMA/STUPOR
temperature: 98.5
heartrate: 93.0
resprate: 24.0
o2sat: 98.0
sbp: 117.0
dbp: 71.0
level of pain: 13
level of acuity: 1.0 | HOSPITAL COURSE: Ms. ___ is a ___ year old woman with a history
of cholangiocarcinoma on cisplatin/gemcitabine, s/p common bile
duct stent, s/p cyberknife, history of E. coli cholangitis, a
known contained gallbladder perforation, and a DVT in ___.
She presented with fever/hypotension/altered mental status
secondary to Gram positive cocci bacteremic sepsis. She was
called into clinic with a fever of 102 and altered mental
status. She was admitted through the ED where she had a CT
abdomen that was concerning for liver metastases vs. abscesses.
A follow-up liver MRI showed several small hepatic abscesses,
possibly drainable; it also revealed hepatic ductal dilation
highly suggestive of common bile duct stent
blockage/dysfunction. She was started on vancomycin and
piperacillin-tazobactam, but was ultimately narrowed to
ceftriaxone once blood cultures showed Strep anginosis
(___), a gut bacterium. Pt's sepsis likely caused by
contained gallbladder rupture. She is followed by Infectious
Disease, and will go home on 4 week regimen of IV ceftriaxone
with follow-up in the ___ clinic. We are holding chemo until
then per her oncologist, Dr. ___. Pt was on coumadin on
admission for her history of DVTs, but coumadin was held during
hospitalization as her platelets were <50 throughout course. She
will need a common bile duct stent replacement by ERCP once her
platelets have stabilized, ideally in the next few weeks while
pt not receiving chemo.
# STREP ___ BACTEREMIA: Presumptively due to gallbladder
infection/rupture with complicated cholangiocarcinoma. Seen in
the ED by surgery who felt there were no surgical interventions
at this time. Patient was admitted and had CT abd/pelvis, which
showed multiple liver lesions, metastatic vs. infectious, and a
follow-up liver MRI showed lesions were hepatic abscesses. Blood
cultures were drawn and grew gram positive cocci, speciated to
Strep anginosis (___) and sensitive to ceftriaxone.
Patient's mental status improved with antibiotics, and remained
afebrile after transfer to the floor, and daily surveillance
blood cultures were all negative. TTE on ___ was of poor
quality but concluded that endocarditis was unlikely, which
makes sense given the speciated bacteria is not known to cause
endocarditis. Infectious disease was consulted and recommended
___ biopsy and/or drainage of infectious collections, but
pt's platelet count currently too low to tolerate a procedure.
Pt discharged on 2g IV ceftriaxone for 4 weeks, and may require
chronic suppressive therapy after that.
# COAGULOPATHY: Patient came in with INR >7 at admission.
Concern for DIC given immunosuppression and sepsis, but pt had
normal fibrinogen. On coumadin at home due to history of DVT.
Patient was given 2mg oral Vitamin K for reversal and coumadin
was held. Patient's INR was 1.6 on ___, but coumadin was held
throughout admission and after discharge given low platelets
<50.
# CHOLANGIOCARCINOMA: On admission ___ gemcitabine/cisplatin.
During hospital course, pt complained of slowly increasing right
upper quadrant pain for several days. Liver MRI showed suspicion
of common bile duct stent malfunction. Per pt's Oncologist Dr.
___ be held temporarily while pt gets
antibiotics, and can be resumed once pt has been afebrile, with
cultures clear for a while, ideally with decrease in liver
lesions. Will need to go to ERCP in the future for replacement
of common bile duct stent, once platelet counts have normalized;
ideally within the next few weeks as pt's chemo is being held
temporarily for antibiotic treatment.
# LEFT LOWER EXTREMITY DVT: Diagnosed in ___. Holding
coumadin as above
# INSULIN DEPENDENT DIABETES: Was managed on fingerstick blood
sugars with insulin sliding scale while an inpatient.
# CONSTIPATION => DIARRHEA: Was constipation at first at time of
admission. Was given her home colace 100 mg orally three times a
day, and senna and miralax were added. However, a few days after
starting miralax, her bowel regimen had to be discontinued due
to copious loose stools. Resolved at time of 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:
abdominal pain
Major Surgical or Invasive Procedure:
none this admission
History of Present Illness:
___ y.o female with h.o FAP s/p colectomy, h.o bowel obstructions
requiring surgery, RA on steroids/MTx, osteoporosis, with hx of
ampullary adenoma seen on routine EGD s/p ERCP with ampullectomy
and pancreatic stent placement on ___, discharged on ___
presents with recurrent abdominal pain after eating. She had
epigastric pain yesterday morning but it resolved and she was
able to advance her diet. About 15 minutes after discharge
(5PM), she developed some epigastric discomfort which worsened
to ___ in severity leading her to return to the ER. She tried
taking a percocet x 1 but vomited food contents. Her abdominal
pain resolved in the ER prior to any intervention but then
recurred and was given morphine 5 mg IV x 1 with resolution.
Now she is pain free; denies any nausea, no abdominal
distention. She does have diarrhea at baseline if she misses
doses of loperamide and has watery diarrhea now. No melena.
ROS: no fevers, chills, HA, CP, palpitations; has some sore
throat after the ERCP; no SOB, cough; GI sx - see hpi; no
dysuria, urinary frequency, urgency. + left wrist and MCP
swelling consistent with an RA flare. She has not taken
methotrexate x 8 days now (takes it q week). She rheumatologist
had instructed her to take it today but she has not yet.
Otherwise, no rashes, weakness. 10 point ROS is otherwise
negative.
Past Medical History:
rheumatoid arthritis dx ___
FAP dx ___
colectomy ___
bowel obstruction ___
bowel obstruction ___ with surgery
bowel obsruction ___
osteoporosis
tested NEGATIVE for the BRCA gene
Social History:
___
Family History:
HL
HTN
osteoporosis
grandfather with CVA
breast cancer with BRCA mutation
Physical Exam:
In ED VS were 98 110 118/79 24 100
VS now: 97.6 HR:106 BP:117/71 RR:16 O2 sat:99% on RA
GEN: NAD
HEENT: EOMI, oropharnyx clear, MMM
CV: RRR, no m/r/g
PULM: CTAB
ABD: hyperactive BS, NTND, thin; audible pulse, no masses; well
healed scars.
MS: mild swelling in left wrist and MCP joints, no erythema;
slight decrease in ROM.
DERM: no rashes
Neuro: A&O x 3, no focal deficits, ambulates normally
Psych: normal affect
Pertinent Results:
___ 05:25AM BLOOD WBC-9.5 RBC-4.22 Hgb-12.3 Hct-39.4 MCV-93
MCH-29.0 MCHC-31.2 RDW-14.2 Plt ___
___ 07:30PM BLOOD WBC-13.0* RBC-4.77 Hgb-13.8 Hct-43.9
MCV-92 MCH-29.0 MCHC-31.5 RDW-13.5 Plt ___
___ 05:25AM BLOOD WBC-10.5 RBC-4.36 Hgb-12.6 Hct-39.9
MCV-92 MCH-28.8 MCHC-31.5 RDW-14.1 Plt ___
___ 08:10AM BLOOD WBC-9.7 RBC-5.18 Hgb-15.3 Hct-46.3 MCV-90
MCH-29.6 MCHC-33.1 RDW-14.4 Plt ___
___ 07:30PM BLOOD Neuts-81.7* Lymphs-12.8* Monos-5.1
Eos-0.2 Baso-0.3
___ 08:10AM BLOOD Neuts-66.4 ___ Monos-5.9 Eos-0.6
Baso-0.4
___ 08:10AM BLOOD ESR-12
___ 05:25AM BLOOD Glucose-100 UreaN-5* Creat-0.6 Na-139
K-4.0 Cl-106 HCO3-24 AnGap-13
___ 07:30PM BLOOD Glucose-124* UreaN-7 Creat-0.7 Na-141
K-3.5 Cl-101 HCO3-28 AnGap-16
___ 05:25AM BLOOD Glucose-58* UreaN-6 Creat-0.6 Na-139
K-4.0 Cl-101 HCO3-27 AnGap-15
___ 08:10AM BLOOD UreaN-10 Creat-0.8 Na-142 K-3.8 Cl-101
HCO3-26 AnGap-19
___ 07:30PM BLOOD ALT-37 AST-30 LD(LDH)-200 AlkPhos-75
TotBili-1.4
___ 05:25AM BLOOD ALT-27 AST-20 AlkPhos-63 TotBili-1.2
___ 08:10AM BLOOD ALT-33 AST-19 AlkPhos-83 Amylase-59
TotBili-0.5 DirBili-0.2 IndBili-0.3
___ 05:25AM BLOOD Lipase-150*
___ 07:30PM BLOOD Lipase-153*
___ 05:25AM BLOOD Lipase-174*
___ 08:10AM BLOOD Lipase-25
___ 05:25AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
___ 08:10AM BLOOD ___
___ 08:10AM BLOOD CRP-16.0*
___ 08:10AM BLOOD RO & ___
___ 08:10AM BLOOD SM ANTIBODY-PND
.
ERCP last admission:
Impression: Polypoid tissue was noted at the ampulla measuring
approximately 8 mm, consistent with known adenoma
An ampullary resection was performed using a snare
Successful cannulation of pancreatic duct (cannulation)
Normal pancreatic duct A 7cm by ___ ___ single pigtail
pancreatic stent was placed successfully. Otherwise normal ercp
to third part of the duodenum
.
Recommendations: Admit overnight for observation and evaluation.
NPO overnight with aggressive IV hydration with LR at 200 cc/hr.
If no abdominal pain in the AM, advance diet to clear liquids
and then advance as tolerated.
No aspirin, plavix, NSAIDS, coumadin for 5 days
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call (___)
Repeat ERCP in 2 weeks for stent removal.
Repeat EGD with side viewing scope in 6 months for surveillance
Radiology Report
EXAM: Abdomen, supine and upright views.
CLINICAL INFORMATION: ___ female with history of SBO and
proctocolectomy status post ERCP and ampullectomy yesterday, status post
pancreatic stent placement.
COMPARISON: None.
FINDINGS: Supine and upright views of the abdomen were obtained. The patient
is status post total colectomy. Bowel gas is seen in the pelvis. There is a
loop of bowel in the left upper quadrant presumably small bowel since the
patient is status post total colectomy. The small bowel appears dilated with
possible thumbprinting sign which could indicate bowel edema. These findings
were discussed with Dr. ___ taking care of the patient in the
emergency department at 10:30 p.m. via telephone on ___. Pancreatic
duct stent is noted. There is no evidence of free air. The lung bases are
clear. Chain sutures are noted in the pelvis and the left abdomen status post
total colectomy.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: POST OP ABD PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC
temperature: 98.0
heartrate: 110.0
resprate: 24.0
o2sat: 100.0
sbp: 118.0
dbp: 79.0
level of pain: 8
level of acuity: 2.0 | Pt is a ___ y.o female with h.o FAP s/p colectomy, h.o bowel
obstructions requiring surgery, RA on steroids/MTx, osteoporosis
who initially presented for observation s/p ampullectomy given
presence of polyp who then was discharged and readmitted with
abdominal pain.
.
#ampullary adenoma-history of FAP,s/p colectomy. She was found
to have an adenoma at the ampulla and presented for ERCP with
ampullectomy and PD stent placement on ___. Pt had some mild
post-ERCP abdominal pain but was able to advance her diet and
was discharged. However, she then re-developed abdominal pain
after discharge and represented to the ED. Labs were similiar to
prior and KUB did not show evidence of obstruction or free air.
She was initially given IV fluids and bowel rest. Her diet was
slowly advanced to regular without complication. No fevers or
transaminitis to suggest infection. Biopsy of the ampulla was
taken during last admission and is still PENDING at the time of
discharge. Pt will need repeat ERCP (already scheduled) for
stent removal in 2 week's time. She will need repeat EGD in 6
month's time for surveillance. Pt was instructed not to take any
NSAIDs for 5 days post ERCP. Dr. ___ ordered labs during
last admission ___, anti RO and ___, Sm antibody).
.
#h.o FAP s/p colectomy with pouch with chronic diarrhea. Pt will
continue to follow up with her gastroenterologist after
discharge. She was continued on her outpatient regimen of
psyllium and loperamide.
.
#rheumatoid arthritis. Pt should continue her outpt regimen of
prednisone, methotrexate, hydroxychloroquine. Outpt rheumatology
f/u.
.
#osteoporosis-continue citrical, vitamin D
.
#ppx-ambulation, pneumoboots
.
Transitional care-to be followed up by GI
1.ampulla biopsy
___, anti SM, anti RO and ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bacitracin / Quinidine / Allopurinol And Derivatives
Attending: ___
___ Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with pmhx of afib on coumadin and HTN p/w syncope. Pt
states that he was in his closet putting away clothes and
slipped. Unknown if head strike but denies LOC. States he was on
the ground for 15 mins and called his son to help him get up,
(told his son he was in bed and could not get up but he was on
the ground in the closet). His friends had come over to bring
him to dinner and found him awake, incontinent on the floor. He
had no complaints by the time he arrived to the ED. Denies
cp/sob/n/v/f/c/hemoptysis. States he has been eating normally
and no change in bowel or bladder habits.
On the floor, the daughter states that her friends were going
to take him out to dinner and discovered him on the ground. He
had fallen into his closet. Patient does not quite remember what
transpired but thought he lost his footing. According to
daughter and patient, he has no new shortness of breath, or
dyspnea on exertion. Denies chest pain or palpitations. Uses one
pillow at night to sleep and denies PND. Feels like he is at his
baseline. Preoccupied with having to urinate.
Reviewing notes on OMR, patient had not been taking diltiazem
prescribed medication reliably.
According to the daughter, the patient has been declining in
being able to be independent, and has more short term memory
problems. He can still wash and feed himself and he still
recognizes his family but short term memory problems are evident
on interview.
He just moved into ___ residence 2 months ago
which is an assisted living facility. Was home alone before
that.
In the ED, initial vitals were:
98.1 70 146/63 20 95% RA
- Exam notable for:
Hematoma over the right frontal lobe.
RRR
CTABL
soft NTND
moving all extremities
- Labs notable for:
10.4>9.5/30.9<359
proBNP 19,992
CK 129
TropT 0.02
___
lactate 1.4
INR 3.6
- Imaging was notable for:
CT Head:
1. No acute intracranial process.
2. Parenchymal atrophy and chronic small vessel ischemic
disease.
3. Layering air-fluid levels and aerosolized secretions within
bilateral maxillary sinuses suggestive of acute on chronic
sinusitis.
CXR: ___
IMPRESSION:
Marked enlargement of the cardiac silhouette and mild to
moderate pulmonary edema.
Possible trace pleural effusion, no large pleural effusion.
Concern for consolidation over the posterior, inferior lung on
the lateral view, could be due to underlying pneumonia.
Follow-up to resolution.
Elbow XR
IMPRESSION:
Punctate 1 mm radiopaque density(ies) projecting over the soft
tissue just lateral to the radial head is of indeterminate age
and clinical significance; correlate for possible retained
foreign body or bone chip, although no donor site seen. No
evidence of acute fracture seen elsewhere.
Extensive vascular calcifications.
- Patient was given:
1L NS
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Right leg MSSA cellulitis and abscess s/p I/D in ___
Recurrent Left leg cellulitis ___ and ___
Atrial fibrillation (CHADS 2)
Hypertension
Hypercholesterolemia
Venous insufficiency
GERD
Tonsilectomy
Hypertension
Slight kyphosis
Social History:
___
Family History:
His mother died of spinal cancer at age ___.
His father died of an MI at age ___.
Physical Exam:
Admission physical exam:
========================
VITAL SIGNS: 98.4 178/73 69 20 94 % RA
GENERAL: Patient drowsy but arousable and appropriate. Short
term memory loss evident. Some increased WOB
HEENT: Hematoma over right frontal lobe, dry mucous membranes,
no cervical or supraclavicular LAD
NECK: JVP elevated to mid neck but difficult to appreciate in
setting of strong prominent carotid pulses
CARDIAC: irregular rhythm, regular rate, normal S1/S2,
holosystolic murmur best appreciated at apex and radiating to
the axilla.
LUNGS: Crackles appreciated bilaterally from bases to midlungs
with decreased air entry. Some increased WOB but patient states
at baseline.
ABDOMEN: Soft, non-tender, non-distended, BS+, no organomegaly,
no rebound or guarding
EXTREMITIES: Left leg with 2+ pitting edema to the knee, right
leg with 1+ pitting edema to the knee
NEUROLOGIC: A&O x2-3. Short term memory loss evident
SKIN: Hematoma over right frontal lobe. Venous stasis changes L
worse than right leg
Discharge physical exam:
========================
VITAL SIGNS: 97.9-98.7, 155/72, 65-74, 18 98% on RA
WT 49.8 <- 56.1 <- 56.4 (57.3) on
50/ ___
GENERAL: Short term memory loss evident. Some increased WOB
HEENT: dry mucous membranes, no cervical or supraclavicular LAD
NECK: JVP flat at 90 degrees
CARDIAC: irregular rhythm, regular rate, normal S1/S2,
holosystolic murmur best appreciated at apex and radiating to
the axilla.
LUNGS: CTAB
ABDOMEN: Soft, non-tender, non-distended, BS+, no organomegaly,
no rebound or guarding
EXTREMITIES: no edema, no cyasnosis, clubbing
NEUROLOGIC: A&O x2-3. Short term memory loss evident
SKIN: Venous stasis changes L worse than right leg
Pertinent Results:
Admission labs:
================
___ 06:26PM BLOOD WBC-10.4* RBC-4.04* Hgb-9.5* Hct-30.9*
MCV-77*# MCH-23.5*# MCHC-30.7* RDW-17.1* RDWSD-47.6* Plt ___
___ 06:26PM BLOOD Neuts-86.6* Lymphs-4.8* Monos-7.2
Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.04* AbsLymp-0.50*
AbsMono-0.75 AbsEos-0.01* AbsBaso-0.03
___ 06:26PM BLOOD ___ PTT-36.8* ___
___ 06:26PM BLOOD Plt ___
___ 06:26PM BLOOD Glucose-114* UreaN-26* Creat-1.4* Na-131*
K-4.1 Cl-93* HCO3-16* AnGap-26*
___ 06:26PM BLOOD CK(CPK)-129
___ 04:50AM BLOOD ALT-13 AST-48* AlkPhos-142* TotBili-0.7
___ 06:26PM BLOOD cTropnT-0.02* ___
___ 04:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
___ 04:50AM BLOOD %HbA1c-5.9 eAG-123
___ 04:50AM BLOOD TSH-2.9
Discharge labs:
===============
___ 08:00AM BLOOD WBC-7.1 RBC-4.74 Hgb-11.1* Hct-35.9*
MCV-76* MCH-23.4* MCHC-30.9* RDW-17.1* RDWSD-46.2 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-36.2 ___
___ 08:00AM BLOOD Glucose-94 UreaN-32* Creat-1.5* Na-131*
K-3.8 Cl-87* HCO3-28 AnGap-20
___ 07:11AM BLOOD ___
___ 08:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
Troponin and BNP:
=================
___ 06:26PM BLOOD cTropnT-0.02* ___
___ 12:55AM BLOOD cTropnT-0.03*
___ 04:50AM BLOOD CK-MB-8 cTropnT-0.03*
___ 07:11AM BLOOD ___
Diagnostics:
============
Elbow x ray ___
Projecting over the soft tissue just lateral to the radial head
is punctate 1 mm radiopaque density(ies), unclear whether
represent retained foreign body or tiny bone chip. No donor
site is appreciated. No acute fracture is seen elsewhere.
There is no dislocation. No posterior joint effusion is seen.
No concerning osteoblastic or lytic lesion is seen. There are
extensive vascular calcifications.
Punctate 1 mm radiopaque density(ies) projecting over the soft
tissue just
lateral to the radial head is of indeterminate age and clinical
significance; correlate for possible retained foreign body or
bone chip, although no donor site seen. No evidence of acute
fracture seen elsewhere. Extensive vascular calcifications.
Chest xray ___
The patient is rotated somewhat to the right. The cardiac
silhouette is
markedly enlarged. The aorta is somewhat tortuous and
calcified. There is prominence of the central pulmonary
vasculature and mild to moderate pulmonary edema. Slight
blunting of the right costophrenic angle is seen which may be
due to a trace pleural effusion. On the lateral view posterior,
inferior opacity could be due to focal consolidation and
underlying pneumonia. No pneumothorax is seen.
IMPRESSION: Marked enlargement of the cardiac silhouette and
mild to moderate pulmonary edema. Possible trace pleural
effusion, no large pleural effusion. Concern for consolidation
over the posterior, inferior lung on the lateral view, could be
due to underlying pneumonia. Follow-up to resolution.
CT Head w/o contrast ___
IMPRESSION:
1. No acute intracranial process.
2. Parenchymal atrophy and chronic small vessel ischemic
disease.
3. Layering air-fluid levels and aerosolized secretions within
bilateral
maxillary sinuses suggestive of acute on chronic sinusitis.
ECHO ___
The left atrial volume index is severely increased. No atrial
septal defect is seen by 2D or color Doppler. Mild symmetric
left ventricular hypertrophy with normal cavity size, and
regional/global systolic function (LVEF >65%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta and
aortic arch are mildly dilated. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild aortic valve stenosis. Moderate aortic regurgitation.
Moderate pulmonary artery systolic hypertension. Moderate mitral
regurgitation. Moderate tricuspid regurgitation. Mildly dilated
thoracic aorta.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. aMILoride 7.5 mg PO DAILY
2. Colchicine 0.6 mg PO EVERY OTHER DAY
3. Diltiazem Extended-Release 360 mg PO DAILY
4. Vitamin D ___ UNIT PO 1X/WEEK (___)
5. esomeprazole magnesium 40 mg oral DAILY
6. Febuxostat 40 mg PO DAILY
7. Rosuvastatin Calcium 10 mg PO QPM
8. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Tamsulosin 0.4 mg PO QHS
3. Torsemide 10 mg PO DAILY
4. Warfarin 1.5 mg PO DAILY16 Duration: 1 Dose
5. Colchicine 0.6 mg PO EVERY OTHER DAY
6. esomeprazole magnesium 40 mg oral DAILY
7. Febuxostat 40 mg PO DAILY
8. Rosuvastatin Calcium 10 mg PO QPM
9. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
=================
Diastolic heart failure, preserved ejection fraction
Hyponatremia
Secondary diagnosis
===================
Atrial fibrillation
Chronic kidney disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with afib on Coumadin p/w syncope// eval for bleed
or fractureeval for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The patient is rotated somewhat to the right. The cardiac silhouette is
markedly enlarged. The aorta is somewhat tortuous and calcified. There is
prominence of the central pulmonary vasculature and mild to moderate pulmonary
edema. Slight blunting of the right costophrenic angle is seen which may be
due to a trace pleural effusion. On the lateral view posterior, inferior
opacity could be due to focal consolidation and underlying pneumonia. No
pneumothorax is seen.
IMPRESSION:
Marked enlargement of the cardiac silhouette and mild to moderate pulmonary
edema.
Possible trace pleural effusion, no large pleural effusion.
Concern for consolidation over the posterior, inferior lung on the lateral
view, could be due to underlying pneumonia. Follow-up to resolution.
Radiology Report
INDICATION: History: ___ with edema// r/o fx
TECHNIQUE: Five views of the right elbow
COMPARISON: None.
FINDINGS:
Projecting over the soft tissue just lateral to the radial head is punctate 1
mm radiopaque density(ies), unclear whether represent retained foreign body or
tiny bone chip. No donor site is appreciated. No acute fracture is seen
elsewhere. There is no dislocation. No posterior joint effusion is seen. No
concerning osteoblastic or lytic lesion is seen. There are extensive vascular
calcifications.
IMPRESSION:
Punctate 1 mm radiopaque density(ies) projecting over the soft tissue just
lateral to the radial head is of indeterminate age and clinical significance;
correlate for possible retained foreign body or bone chip, although no donor
site seen. No evidence of acute fracture seen elsewhere.
Extensive vascular calcifications.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with afib on Coumadin p/w syncope. Evaluate for intracranial
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 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 6.0 s, 6.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
301.0 mGy-cm.
3) Sequenced Acquisition 4.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,405 mGy-cm.
COMPARISON: MR head from ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema,or mass effect. There
is prominence of the ventricles and sulci suggestive of involutional changes.
Periventricular and subcortical white matter hypodensities are nonspecific,
but likely reflect sequelae of chronic small vessel ischemic disease.
There is no evidence of acute fracture. There is layering air-fluid level
within the bilateral maxillary sinuses with aerosolized secretions as well as
sclerosis of the maxillary walls suggestive of acute on chronic sinusitis.
There is also mucosal thickening involving the frontal ethmoidal recess. The
remaining visualized portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable with the exception left lens replacement..
IMPRESSION:
1. No acute intracranial process.
2. Parenchymal atrophy and chronic small vessel ischemic disease.
3. Layering air-fluid levels and aerosolized secretions within bilateral
maxillary sinuses suggestive of acute on chronic sinusitis.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with afib on Coumadin p/w syncope// eval for bleed
or fractureeval for PNA eval for bleed or fractureeval for PNA
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 36.9 mGy (Body) DLP = 769.4
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
Total DLP (Body) = 829 mGy-cm.
COMPARISON: CT cervical spine from ___
FINDINGS:
There is no acute fracture or traumatic malalignment. There is no
prevertebral soft tissue swelling. There has been interval progression of
degenerative changes at the dens with increased erosion as well as small bony
fragments. There are also significant degenerative changes in the remainder
of the cervical spine with disc space narrowing, endplate sclerosis, and
osteophyte formation. Posterior disc osteophyte complexes are present at
C4-C5 through C6-C7 levels without significant spinal canal stenosis. There
is also uncovertebral and facet hypertrophy at multiple levels causing
moderate left neural foraminal narrowing at C3-C4, severe bilateral neural
foraminal narrowing at C4-C5, C5-C6, and moderate right neural foraminal
narrowing at C6-C7.
There is interlobular septal thickening of the lung apices suggestive of
pulmonary edema. The thyroid gland is unremarkable. There is no cervical
lymphadenopathy. There are significant atherosclerotic calcifications of the
bilateral carotid bifurcations.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Interval progression of degenerative changes of the dens with large
erosion.
3. Multilevel degenerative changes as described above.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: s/p Fall
Diagnosed with Heart failure, unspecified
temperature: 98.1
heartrate: 70.0
resprate: 20.0
o2sat: 95.0
sbp: 146.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with a past medical history of
atrial fibrillation on warfarin, hypertension, and
hyperlipidemia who presented after having fell and not being
able to get himself up, and shortness of breath. On
presentation, physical exam notable for significant volume
overload, labs notable for INR 3.6, Cr 1.4, peaking to 1.7, BNP
19992, trop .02 -> .03 attributed to demand, EKG with no
ischemic changes, ECHO: EF >65%, preserved regional and global
biventricular systolic function, moderate aortic regurgitation,
moderate pulmonary artery systolic hypertension, moderate mitral
regurgitation, moderate tricuspid regurgitation. CT head with no
abnormalities. Patient given 40mgIV Lasix PRN until euvolemic
and switched to 5mg PO torsemide. During hospital stay, patient
found to be bradycardic so Diltiazem was held. Warfarin dosage
was adjusted per INR and pharmacy. Based on goals of care
discussions, patient was discharged to hospice. At the time of
discharge, medications requiring significant monitoring or that
will not be consistent with goals of care (warfarin,
anti-hypertensives, etc...) were discontinued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, Nausea, Dizziness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo man with hx of migraines, hemorrhoids, and anal fissure
who presented to the ___ ___ with headaches, fatigue, recent
rectal bleeding. Regarding his HA, he reports a few weeks of
bitemporal, throbbing, non-radiating headache that has occurred
daily for the past 3 weeks and does not have positional
component or worsening with valsalva. He has occasional
scotomata. He has had no phono/photophobia or emesis but
endorses mild nausea. He denies vertigo.
He was seen by Neurology in ___ for HA and was started on
propranolol 2 weeks ago for migraine ppx. He states that he has
been taking acetaminophen, Excedrin (APAP, caffeine, ASA),
tramadol, or ibuprofen for his HA in the past two weeks. Mainly,
he has not been taking ibuprofen/naproxen though. He gets some
relief with these, but has been taking them almost daily. In the
past month he has been evaluated at neurology ___ for
headaches, ___ for dehydration, and primary care office
for fatigue. With ongoing fatigue and headaches he presented to
the ___ ER.
When in the BID ___ he was noted to have Hgb 7.4, down from
14.2 ___. He has had hemorrhoids for about ___ years and has
prolapsing internal hemorrhoids that he has to manipulate to
reduce daily. He has one hard stool daily requiring straining to
defecate. He has noticed several (~6) episodes of large volume
BRBPR in the past 3 weeks when stooling in the evening. Prior to
this he notices frequent blood on the toilet paper but not in
the stool. He denies melena, cramping abdominal pain, diarrhea,
small stool caliber, weight loss, night sweats, early satiety,
jaundice, or lymphadenopathy. His PCP has recommended surgery
for his hemorrhoids, but he has been too busy with work to have
surgery. He has noted extreme fatigue over the past ___ weeks
limiting his stamina at work. About 1 week ago, he reports
feeling so dizzy and weak at work that he presented to the
emergency department at ___. He was found to be dehydrated,
so he was given IV fluids then discharged.
He has a cousin with ___ disease, no family history of early
colorectal cancer, and no personal history of EtOH excess, PUD,
H pylori, or cirrhosis.
In the ___ intial vitals were: 98.8 96 128/63 16 96%
- Labs were significant for H/H 7.8/25.2.
- LP was done, which revealed opening pressure 15, 0 WBCs, Prot
19, Gluc 63.
- Exam was notable for external hemorrhoid but no stool in the
rectal vault.
- Patient was given Fiorocet, pantoprazole, acetaminophen,
metoclopramide, and 1L IV normal saline.
Vitals prior to transfer were: 98.2 60 109/54 18 98% RA
On the floor, he denies headaches currently, but endorses
fatigue.
Past Medical History:
- Migraines x ___ years
- Anal fissure s/p surgery
- Low back pain
- Heart murmur
- neprholithiasis ___
- hemorrhoids since ___ at least, s/p bx ___
- headache: seen by Neuro ___ and Rx nortriptyline and
tramadol
- chronic back pain
- tinea versicolor
- scabies
Social History:
___
Family History:
Father - recently had a "mini stroke"
Mother - h/o CABG, breast cancer
Uncle - recently died of MI
No history of colorectal cancer or any other cancer in his
family.
He has a cousin with ___ disease, but no one else with IBD.
He has no familial bleeding diathesis he knows of.
Physical Exam:
ADMISSION EXAM
--------------
Vitals - T: 98 BP: 109/65 HR: 57 RR: 18 02 sat: 99%RA
GENERAL: NAD, very pleasant
HEENT: +conjunctival pallor, sclera anicteric, nontender supple
neck, no lymphadenopathy
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, +right upper/middle
quadrant fullness
RECTAL: No fissures noted, +external hemorrhoid that is
non-bleeding, no stool in rectal vault
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
DISCHARGE EXAM
--------------
GENERAL: NAD, very pleasant, younger than stated age
HEENT: +conjunctival pallor, sclera anicteric,no lymphadenopathy
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, breathing comfortably
ABDOMEN: nondistended, nontender, no HSM
RECTAL: No fissures noted, +external hemorrhoid that is
non-bleeding, palpable anterior internal hemorrhoid, no stool in
rectal vault, no blood
EXTREMITIES: no edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength throughout, 2+ DTRs
symmetrically throughout, no asterixis, speech fluent, A&Ox3,
good attention
Pertinent Results:
ADMISSION LABS
--------------
___ 03:10PM BLOOD WBC-4.3 RBC-3.27*# Hgb-7.8*# Hct-25.2*#
MCV-77* MCH-24.0*# MCHC-31.1 RDW-12.7 Plt ___
___ 03:10PM BLOOD Neuts-52.5 ___ Monos-4.2 Eos-2.2
Baso-0.6
___ 03:10PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
Ovalocy-1+ Target-OCCASIONAL Tear Dr-OCCASIONAL
___ 03:58PM BLOOD ___ PTT-30.2 ___
___ 03:10PM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-138
K-4.0 Cl-106 HCO3-25 AnGap-11
PERTINENT LABS
--------------
___ 03:10PM BLOOD ALT-16 AST-26 LD(LDH)-170 AlkPhos-50
TotBili-0.3
___ 03:10PM BLOOD Iron-13*
___ 03:10PM BLOOD calTIBC-376 ___ Ferritn-4.3* TRF-289
___ 06:30PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 06:30PM CEREBROSPINAL FLUID (CSF) TotProt-19 Glucose-63
DISCHARGE LABS
--------------
___ 06:40AM BLOOD Hgb-8.9* Hct-29.0*
IMAGING
-------
___ CTA HEAD:
NECT: No ICH, mass-effect, or evidence of major vascular
territorial infarct. Mucous retention cysts in the bilateral
maxillary sinuses.
CTV the head: Major intracranial arteries and veins appear
patent. No
enhancing mass, aneurysm greater than 3 mm, or AVM.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Hydrocortisone (Rectal) 2.5% Cream ___ID
3. Ibuprofen 600 mg PO Q6H:PRN pain
4. Propranolol 20 mg PO BID
5. tadalafil 10 mg oral prn prior to sexual activity
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache
7. Excedrin Migraine (aspirin-acetaminophen-caffeine) unknown
oral prn migraine
8. Docusate Sodium 200 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 200 mg PO DAILY
2. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice daily Disp #*60 Tablet Refills:*6
3. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*6
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Hydrocortisone (Rectal) 2.5% Cream ___ID
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache
7. tadalafil 10 mg oral prn prior to sexual activity
8. Excedrin Migraine (aspirin-acetaminophen-caffeine) 1 tablet
ORAL PRN migraine
Discharge Disposition:
Home
Discharge Diagnosis:
#Iron deficiency anemia
#Lower gastrointestinal bleed
#Headache, NOS
#Migraine
#Hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: .
TECHNIQUE: Noncontrast CT head was performed. CTV of the head performed. 3D
MIP angiographic image post-processing was performed on a separate
workstation.
DLP: 1634.17mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
Noncontrast CT head: Evaluation of the parenchyma demonstrates no evidence of
mass effect, edema, hemorrhage or extra axial fluid collections. The basal
cisterns appear unremarkable. Gray/white matter differentiation is preserved.
The sulci appear unremarkable. The ventricles are midline without dilatation.
The calvarium appears intact. The visualized portions of the included
paranasal sinuses straight scattered areas of mucosal thickening with a polyp
or mucous retention cyst within the right maxillary sinus. The mastoid air
cells show normal aeration. Incidentally noted is hypodensity within the
palatine tonsils bilaterally which may be related to inflammation.
CTV head: Normal enhancement is demonstrated within the superior sagittal
sinus, straight sinus, transverse sinuses and bilateral sigmoid sinuses. The
jugular bulbs and proximal jugular veins are patent. Evaluation of the deep
venous system reveals normal enhancement in the thalamostriate veins and
internal cerebral veins. The vein ___ is also unremarkable. Suboptimal
evaluation of the included pencil intracranial arteries demonstrates nodes
obvious aneurysm or the significant stenosis.
IMPRESSION:
Unremarkable CT head without evidence of acute hemorrhage or mass effect.
Unremarkable CTV of the head without evidence of dural sinus venous
thrombosis.
Incidentally noted low-density within the palatine tonsils bilaterally which
may be related to inflammation; this should be correlated clinically.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Headache, Nausea, Dizziness
Diagnosed with HEADACHE
temperature: 98.8
heartrate: 96.0
resprate: 16.0
o2sat: 96.0
sbp: 128.0
dbp: 63.0
level of pain: 5
level of acuity: 3.0 | ___ year old male with a history of migraines, internal
hemorrhoids, and anal fissures presents with subacute onset of
daily headache, fatigue and found to have iron deficiency anemia
with stable vitals.
# Iron deficiency anemia/LGIB: Hgb 7.4 with MCV 7.7 and low
MCH/MCHC. Fe 13, ferritin 4 and dropping MCV over past ___ yrs.
No evidence of hemolysis. Most likely secondary to loss. Lack of
hemodynamic instability indicates likely a slow, low volume
bleed, with hemorrhoidal bleeding being most consistent with the
history of hemorrhoids, constipation, tenesmus. He has no
findings of cirrhosis, history of melena, or history of
abdominal pain or change in PO intake to indicate UGIB. Other
LGIB sources would be angioectasias of the colon (rare) or
malignancies (rare in his age grp). He was transfused 1 unit of
RBCs which dramatically improved his symptoms of HA and fatigue.
He was counseled that he needed to continue oral Fe
supplementation for several months and to use stool softeners.
He was set up with a GI appointment in ___ for ___ to
rule out other causes of bleeding. An appointment was also made
with colorectal surgery for hemorrhoidectomy.
# HEADACHE: Patient has history of migraines and was seen by
neurology in ___ for what were considered to be migraines. He
was started on nortriptyline and then switched to propranolol a
few weeks ago. His headaches have been ongoing for the past ___
weeks with temporary improvement in symptoms with analgesics.
His current headaches lack photo/phonophobia and are associated
with nausea but no emesis. It is unclear if his visual symptoms
(mainly scotomata) are from migraine. Given his anemia, headache
could be associated with this. Another possibility could be
medication overuse headache. He had reassuring head CTA and LP:
normal opening pressure, CSF studies. His headaches improved
with blood transfusion. Propranolol was discontinued as this was
felt to be contributing to his fatigue.
# HEMORRHOIDS/CONSTIPATION: Longstanding issues with hemorrhoids
and constipation. States that he strains with every bowel
movement and frequently has blood on the toilet paper and
sometimes small amounts in the toilet bowel with defecation. His
internal hemorrhoids prolapse daily and he has to reduce them
frequently. He has never pursued surgical treatment because of
job/time constraints. He was treated with stool softeners and
was discharged with stool softeners and an appointment with
colorectal surgery for possible hemorrhoidectomy.
TRANSITIONAL ISSUES
===================
-f/u EGD/colonoscopy to rule out serious causes of blood loss
anemia
-f/u improvement in microcytic anemia with oral iron
supplementation
-f/u with patient regarding constipation management |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ y/o ___ speaking female with dementia and
chronic pleural effusion of unknown etiology who presented with
failure to thrive and an increasing pleural effusion.
.
Pleural Effusion - The patient underwent CT neck on ___
for eval of a skin lesion and was incidentally found to have a
large left pleural effusion. Admitted from ___ during
which time a thoracentesis was discussed was deferred as the
patient was stable and had advanced dementia. Tx'ed for CAP
empirically and d/c'ed. In the ED on this admission, CXR showed
slight increase in left pleural effusion and left basilar
consolidation.
.
Failure to thrive - Per the patient's daughter, Ms. ___ has had
dementia which has been progressive over the past ___ years but
now developing more rapidly over the past 2 months. More
disinterested and withdrawan. Previously eating well but now not
interested in food. Could previously walk with walker but no
longer walks and requires diapers for urinary incontinence. Has
lived at ___ ___ years.
.
Overnight, the patient did well and was without complaint.
Started on cef/vanc. Resting comfortably on 4L NC. Daughter was
spoken to via telephone. Patient was somewhat conversant this AM
and was able to deny any pain. Oriented x2 (___).
Past Medical History:
-Dementia
-DM2
-HLD
-HTN
-Dysphagia
-Macular degeneration
Social History:
___
Family History:
Per prior note.
Mother died in her ___'s, Father died ___. No apparent family
history of memory difficulties. Ms. ___ was an only child.
Physical Exam:
VS - 96.5 120/70 72 24 93% 4L
GENERAL - Appears comfortable, lying in bed
HEENT - PERRLA, EOMI, anicteric, MMM, OP clear
NECK - supple, no cervical LAD, no JVD appreciated
LUNGS - Patient would not cooperate with posterior lung exam. BS
on left are decreased anteriorily.
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - Awake. Oriented x 2 in ___. Moving all extremeties.
Not entirely cooperative with exam.
Pertinent Results:
Labs Admission:
___ 05:53PM BLOOD WBC-6.1# RBC-4.99 Hgb-14.9 Hct-43.7
MCV-88 MCH-29.9 MCHC-34.1 RDW-13.9 Plt ___
___ 05:53PM BLOOD Glucose-222* UreaN-18 Creat-0.8 Na-133
K-6.7* Cl-100 HCO3-25 AnGap-15
___ 06:35AM BLOOD ALT-10 AST-25 LD(LDH)-252* AlkPhos-249*
TotBili-0.9
___ 08:45AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
___ 06:10PM BLOOD Lactate-2.5*
Studies:
.
CXR ___ - FINDINGS: PA and lateral views of the chest
were obtained. Compared with the prior exam there is slight
increase in left pleural effusion and left basilar consolidation
which likely represents compressive atelectasis. There is mild
right basilar plate-like atelectasis. Upper lungs appear well
aerated. Heart size cannot be assessed. Mediastinal contour
appears grossly stable. Bony structures appear intact.
IMPRESSION: Slight increase in left pleural effusion and left
basilar consolidation. Recommend followup to resolution.
Medications on Admission:
1. insulin lispro 100 sliding scale
2. heparin SQ 5000 units TID
3. bupropion HCl ER 150 PO QAM
4. multivitamin DAILY
5. docusate sodium 100 mg BID
6. white petrolatum-mineral oil 56.8-42.5 % PRN dry eyes.
7. senna 8.6 mg BID
8. bisacodyl ___ mg PRN daily
9. lidocaine 5 %(700 mg/patch) daily
10. Fish Oil Oral
Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous ASDIR (AS DIRECTED).
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
3. Medication
Heparin 5000 UNIT SC TID
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 12 days: Please continue for
an additonal 12 days to be completed on ___ .
Disp:*24 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please check a chem-7 on ___. Concern is for elevated
potassium while on bactrim therapy.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Dehydration, Pleural Effusion
Secondary: Advanced Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior study from ___.
CLINICAL HISTORY: Lethargy, low O2 saturation, question pneumonia or pleural
effusion.
FINDINGS: PA and lateral views of the chest were obtained. Compared with the
prior exam there is slight increase in left pleural effusion and left basilar
consolidation which likely represents compressive atelectasis. There is mild
right basilar plate-like atelectasis. Upper lungs appear well aerated. Heart
size cannot be assessed. Mediastinal contour appears grossly stable. Bony
structures appear intact.
IMPRESSION: Slight increase in left pleural effusion and left basilar
consolidation. Recommend followup to resolution.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS
temperature: 98.2
heartrate: 81.0
resprate: 24.0
o2sat: 88.0
sbp: 112.0
dbp: 60.0
level of pain: 13
level of acuity: 1.0 | Ms. ___ is an ___ ___ speaking female with advanced
dementia who presented with failure to thrive and chronic
pleural effusion with increasing oxygen requirement.
.
#. Goals of care - Met with patient's daughter/HCP to discuss
goals for this admission and for planning regarding long term
care. With regard to the patient's effusion; daughter would be
in favor of drainage if there was a major symptomatic benefit
although would not want to treat any underlying malignancy which
is the most likely etiology of the effusion at this time.
Additionally, patient's daughter accurately believes that the
patient's depressed mental status on admission was related to
dehydration and that she is now somewhat improved. Would not
want PEG tube placed for easier hydration. Is not receptive to
the idea of hospice care at this time as has seen hospice
patient's at her mothers nursing facility and does not believe
they receive optimal care. Would also like to speak with case
management. Patient is DNR/DNI.
.
#. Hypoxia/pleural effusion - The patient underwent CT neck on
___ for eval of a skin lesion and was incidentally found
to have a large left pleural effusion. Admitted from
___ during which time a thoracentesis was discussed
was deferred as the patient was stable and had advanced
dementia. The patient received 14 days of levofloxacin for CAP
at her nursing facility. In the ED on this admission, CXR showed
slight increase in left pleural effusion and left basilar
consolidation. Initially given cefepime/vancomycin although
these were stopped as the patient did not have fever,
leukocytosis or cough. Discussion with HCP regarding
thoracentesis as above. The patient was stable on 4L/min NC
while here and should be kept on 4L/min continuously at her
nursing facility. Pulmonology follow-up appointment made where
the patient's oxygen need will be re-evaluated.
.
#. Failure to thrive - The patient was becoming progressively
more withdrawn and had decreased oral intake at her nursing
facility. On admission here the patient received IV fluids and
was placed on oxygen at which time her mental status improved.
On admission the the floor the patient was eating well with
assistance and appeared alert. Also being treated for underlying
urinary tract infection which may have been contributing to
depressed mental status. TSH, B12, folate are pending on
discharge and will be followed-up.
.
#. Urinary tract infection - Urinalysis suggestive of infection.
Urine culture pending on discharge although per microbiology lab
most likely growing enterococcus and strep viridans. Will treat
for complicated UTI with 14 days of bactrim.
.
#. Dementia - Advanced dementia whose progression seems to be
becomming more precipitous. Work-up for organic causes of
decline as above. Also continued wellbutrin which may help with
depression/pseudo-dementia.
.
#. Diabetes II - Insulin sliding scale in house.
.
#. HTN - well controlled without medications, continue to
monitor.
# Transitional Issues
1) Patient will require continuous supplemental oxygen to
maintain saturations >92% until further evaluation by her
pulmonologist.
2) Continue bactrim therapy for 14 days to treat a urinary tract
infection. Check potassium on ___. Will follow-up on
final culture.
3) Please ensure patient is taking good POs and supplement with
IV fluid as needed.
4) Pulmonology follow-up for further evaluation chronic pleural
effusion and possible thoracentesis if oxygenation worsening. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"orthostasis" and weakness - sent in by PCP
gross hematuria
___ Surgical or Invasive Procedure:
Cystoscopy with TURBT ___
History of Present Illness:
___ with a hx of myeloproliferative disorder, FISH-negative for
BCR-ABL and JAK2 V617F negative, hyperlipidemia, mild-mod
cognitive impairment and internal
hemorrhoids presenting with hematuria. Patient is limited in
ability to provide history ___ cognitive impairment. History
based primarily on chart review. Based on geriatrics note
___, pt was seen in clinic after she missed heme/onc visit,
and was noted to be confused when NP called her at home to f/u
on ___. At that visit, she was noted to have ___
neurocognitive impairment given significant functional
impairment, and there was discussion about transitioning to
assisted living. During the course of that visit, a DRE was
performed, which revealed "no stool in the vault, bright red
blood on the examining finger." She was referred to ___ ED for
orthostasis and weakness, in the setting of concern for GIB. It
is not clear what her orthostatic VS were, or whether she was
symptomatic when standing.
The pt is unable to state the reason for her presentation to the
___ ED or for her current hospitalization. She believes that
she was sent to the ED at a prior PCP visit for depression. She
does endorse gross hematuria, which she reports has transitioned
from light pink to red, with "pieces of membrane" in her urine.
She states that this started 4 days prior to presentation,
although is clearly disoriented with respect to time. She
endorses discomfort with urination, denies diarrhea,
constipation, hematochezia, melena, chest pain, shortness of
breath, night sweats. She does endorse weight loss in the
setting of markedly decreased appetite over the preceding
"couple of weeks."
In the ___ ED:
Triage VS 98.0 78 120/72 18 97% RA
Pt reported that she was sent in for vaginal bleeding.
DRE with no stool in rectal vault, +guaiac thought to be from
perineal area
Pelvic exam without blood or lesions with the vagina
Straight cath with gross blood
CT abd/pelvis with bladder mass
Seen by urology, recommended outpatient evaluation
Admitted given concern for home safety
Received ceftriaxone x1
Past Medical History:
Depressive disorder
anxiety disorder
myeloproliferative disease: thrombocythemia, negative BCR/ABL by
FISH, also negative JAK2 V617F - platelet peak ___ at
1123, prescribed hydroxyurea
hyperlipidemia
internal hemorrhoids
presbyacusis
history of polymyalgia rheumatica
hypertension
thyroid nodule
Social History:
___
Family History:
Per OMR records:
She has six siblings and possible family history of blood
disorders (her sister tells her that there is positive history).
She has one sister who has been on Coumadin for her condition.
Another sister had rheumatic fever as a child and now has very
severe osteoporosis. Her father died of stroke in his ___ and
her mother died of ___ at age ___. Has positive family
h/o colon cancer.
Mother died age ___, diabetes mellitus. Father
died age ___, congestive heart failure, head and neck cancer.
Physical Exam:
On admission:
VSS
General: elderly ___ female, pleasant, NAD,
ambulating independently in the room
HEENT: sclerae anicteric, oropharynx pink, moist, without
erythema, exudate, thrush or petechiae. No supraclavicular or
cervical LAD. Dentures appear to be too large.
Lungs: clear to percussion and auscultation
Cardiac: heart rate regular with ___ systolic murmur at ___, no
rubs or gallops
Abdomen: soft, nontender without palpable masses
Extremities: symmetrical, without edema. 1+ DPs bilaterally
Neuro: alert, oriented to person, place, year, month, not date.
able to name current president, but names ___ as vice
president. Spells WORLD forward and backward with mild delay.
Recall ___ items. good eye contact; moving all extremities well.
Speech intact; gait normal.
Skin: warm, dry, without rash, ecchymosis or ulcerations.
On discharge:
Vitals: Afebrile Tm 100.3 at 4PM, 99.5 this AM, BPs
98-110s/50s-60s, HR ___, RR ___, Sa
93-100% on RA
Gen: NAD, sitting up in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, split S2, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx2. No facial droop.
Psych: Full range of affect. Extremely polite and pleasant,
somewhat anxious.
GU: No foley, PVRs all <200, most recently 95cc
Pertinent Results:
___ 02:52PM URINE HOURS-RANDOM
___ 02:52PM URINE HOURS-RANDOM
___ 02:52PM URINE UHOLD-HOLD
___ 02:52PM URINE GR HOLD-HOLD
___ 02:52PM URINE COLOR-Red APPEAR-Cloudy SP ___
___ 02:52PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-250 KETONE-40 BILIRUBIN-LG UROBILNGN->8 PH-8.5* LEUK-LG
___ 02:52PM URINE RBC->182* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-0
___ 02:02PM ___ PTT-34.6 ___
___ 12:05PM GLUCOSE-88 UREA N-11 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
___ 12:05PM estGFR-Using this
___ 12:05PM WBC-12.1* RBC-3.21* HGB-10.7* HCT-34.6*
MCV-108* MCH-33.4* MCHC-31.0 RDW-19.7*
___ 12:05PM NEUTS-71.8* ___ MONOS-6.1 EOS-1.4
BASOS-0.3
___ 12:05PM PLT COUNT-836*
CT Abd/Pelvis w contrast ___:
1. 4.8 cm enhancing bladder mass involving the left lateral wall
and extending anteriorly with possible extension into the fat
adjacent to the anterior bladder wall, recommend cystoscopy for
further evaluation.
2. No definite ureteral lesions identified however, the distal
left and proximal and distal right ureters are not opacified.
CT Head wo contrast ___:
No acute intracranial process.
CT Chest w contrast ___:
No evidence of intrathoracic metastases.
Moderate centrilobular emphysema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Hydroxyurea 500 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. rivastigmine 4.6 mg/24 hr transdermal daily
NOTE per ___ pharmacy, pt has not filled hydroxyurea since first
week ___, at which time 1 month supply was dispensed.
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Hydroxyurea 500 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. rivastigmine 4.6 mg/24 hr transdermal daily
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice daily Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Hematuria
- Bladder tumor
Secondary diagnosis:
- Essential thrombocythemia
- Dementia
Discharge Condition:
Mental Status: Confused - sometimes. Typically AAOx2 (person and
place)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTU (ABD/PEL) W/ANDW/O CONTRAST
INDICATION: ___ year old woman with gross hematuria,? renal stones or
urothelial lesions
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis before and after the administration of intravenous contrast. Axial
images were interpreted in conjunction with coronal and sagittal reformats.
Oral contrast was not administered.
DLP: 710 mGy-cm
COMPARISON: CT torso ___.
FINDINGS:
CHEST: There is bibasilar atelectasis. There is no pericardial or pleural
effusion.
ABDOMEN:
The liver enhances homogeneously and is without focal lesions. The portal
venous system is patent. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is normal and without radiopaque
gallstones.
The spleen and adrenal glands are unremarkable. The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric nephrograms and excretion of contrast. A 1.2 cm
right midpole renal cyst was present dating back to ___ (4a: 32). No other
focal renal lesions are seen. There are no renal stones identified. There are
no ureteral lesions identified however, the right proximal and distal ureter
and the left distal ureter are not well opacified. There is no
hydronephrosis. The ureters are normal in caliber and course to the bladder.
The stomach is collapsed. The small and large bowel are normal in caliber and
without evidence of wall thickening. Multiple collapsed loops of large bowel
are noted within the pelvis. The appendix is not visualized but there are no
secondary signs of appendicitis in the right lower quadrant. Colonic
diverticulosis is present without evidence of diverticulitis.
The abdominal aorta and its major branches are patent . The aorta and iliac
branches contain calcifications and are normal in course and caliber. There is
no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. There is
no free abdominal fluid or pneumoperitoneum.
PELVIS:
There is a 1.5 x 4.0 x 4.8 cm (transverse by AP by CC) enhancing bladder mass
along the left lateral wall and extending anteriorly. Anteriorly, the mass
appears to extend beyond the bladder wall and involves the adjacent fat (4a:
65). There is no pelvic side-wall or inguinal lymphadenopathy by CT size
criteria. No free pelvic fluid is identified.
OSSEOUS STRUCTURES: A left-sided scoliosis of the lumbar spine is noted.
Multilevel degenerative changes with endplate sclerosis at the T12/L1 level as
well as mild anterolisthesis of L4-5. No focal lytic or sclerotic lesion
concerning for malignancy.
IMPRESSION:
1. 4.8 cm enhancing bladder mass involving the left lateral wall and extending
anteriorly with possible extension into the fat adjacent to the anterior
bladder wall, recommend cystoscopy for further evaluation.
2. No definite ureteral lesions identified however, the distal left and
proximal and distal right ureters are not opacified.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with probable bladder cancer admitted with
confusion. Please evaluate for cause of confusion and possibility of
metastatic disease.
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. 75 cc of
Omnipaque 350 were administered intravenously without reported complication.
DOSE: 192.40 mGy.
COMPARISON: ___.
FINDINGS:
A 5 mm hypodense right thyroid lobe nodule is stable. There is no
supraclavicular, mediastinal, hilar or axillary lymphadenopathy.
The heart size is normal with no pericardial effusion. There is stable
nonspecific mild dilatation of the main pulmonary artery to 3.0 cm. The
thoracic aorta is normal caliber. No incidental central pulmonary emboli are
identified.
Moderate centrilobular emphysema is not significantly changed since ___. In addition, a punctate 1 mm right upper lobe subpleural nodule is
stable since ___, and presumed benign (4, 60). There is no
endobronchial lesion or pleural abnormality.
Images of the upper abdomen and show a small right renal lower pole cyst.
Multilevel spinal degenerative changes and moderate levoscoliosis of the
thoracolumbar spine are unchanged.
IMPRESSION:
No evidence of intrathoracic metastases.
Moderate centrilobular emphysema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with probable bladder cancer admitted with
confusion. // Please evaluate for mets and etiology of confusion.
TECHNIQUE: Multi detector CT images were obtained of the head without the
administration of intravenous contrast material. Multiplanar reformatted
images in coronal and sagittal planes are provided.
DOSE: DLP: ___ MGy-cm
CTDI: ___ MGy
COMPARISON: CT of the head dated ___.
FINDINGS:
There is no acute hemorrhage, edema, mass effect or acute large vascular
territorial infarction. Prominent ventricles and sulci are consistent with
age-related involutional change. Periventricular and deep subcortical 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. Hyperostosis frontalis interna is again noted. The
mastoid air cells, middle ear cavities, and visualized paranasal sinuses are
clear. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
MRI is more sensitive for detection of intracranial mass lesions.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hematuria
Diagnosed with URIN TRACT INFECTION NOS, HEMATURIA, UNSPECIFIED, ALZHEIMER'S DISEASE
temperature: 98.0
heartrate: 78.0
resprate: 18.0
o2sat: 97.0
sbp: 120.0
dbp: 72.0
level of pain: 13
level of acuity: 2.0 | ___ with mild-mod dementia, essential thrombocythemia, HTN,
depressive disorder presenting with some failure to thrive and
gross hematuria.
# Hematuria/acute blood loss anemia: Review of notes from
___ mention GIB, vaginal bleeding, and hematuria. Based on
guaiac negative DRE on arrival to medical floor, pelvic
examination in ED without blood in the vault, and grossly bloody
urine, as well as CT findings of bladder mass, it appeared that
blood loss was exclusively GU in nature. She had a CT scan of
her abdomen/pelvis which showed bladder mass. CT of her head and
CT of the chest was negative for any metastases. She was started
on CBI but hematuria continued. She received 2 units PRBCs
during her stay, to maintain Hct at goal >28 (goal determined by
Dr ___ Oncology). She was seen by Urology, and went to
the OR for cystoscopy and TURBT, which was successful at ceasing
her hematuria. CBI was clamped on ___ at 6AM, and she had her
foley catheter removed on ___ at 6AM. She passed her voiding
trial prior to discharge. She received 3 doses of ciprofloxacin
___, and ___ around time of foley removal per
Urology. Followup with Oncology and Urology was arranged.
# Low grade fevers: She had low grade temperatures to max 100.3
on the day prior to discharge and the day of discharge. She had
no localizing signs or symptoms. Since she had had recent
urologic procedures with foley catheter, I sent a UA, which
showed persistent pyria, few bacteria, few red cells. I decided
to continue her ciprofloxacin for another 5 days after discharge
to treat possible urinary tract infection. Urine culture was
pending at discharge and should be followed up.
# Question of failure to thrive: Per review of OMR, pt's weight
loss and progressive cognitive decline with functional
limitations have been noted for >6 months. ___ and OT
evaluations revealed cognitive deficits without significant
physical limitation. She was discharged to home with ___ and 24
hour home care for assistance with ADLs. Her son and HCP is
ultimately planning to bring her with him to ___ and to
find her an assisted living or nursing home facility, but these
plans are not finalized.
# Thrombocythemia: Has had extensive evaluation, presumed to be
essential thrombocythemia. She was seen by her
hematologist/oncologist, Dr ___. ASA was discontinued on
her recommendation given her risk for bleeding. Hydroxyurea was
continued. Her counts were stable.
STABLE ISSUES
# Depressive disorder: Continued celexa as prescribed.
# Dementia: Held Rivastigmine while here. Continued at
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Vicodin / Codeine / Darvon
Attending: ___.
Chief Complaint:
LUQ abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Nasogastric tube placement
History of Present Illness:
Ms. ___ is a ___ year-old G2P2 with history of recurrent ovarian
carcinosarcoma s/p surgical resection x2, currently on
palliative chemo, who presented for chemotherapy and was found
to have persistent left upper quadrant abdominal pain, developed
nausea and vomiting. She was referred to the ED for evaluation.
Prior to transfer, the patient received zofran, dilaudid,
decadron, and IVG but chemo was deferred. In the ED, a CT of
abdomen/pelvis showed high grade small bowel obstruction (SBO).
She was admitted to gynecology oncology service.
Past Medical History:
Oncological hx:
- ___: back pain + vaginal d/c. Pap smear, endometrial bx,
and D&C negative
- Ultrasound: rapidly enlarging mass
- ___: Ex lap w radical abd hys/BSO/omentectomy debulking
of pelvic tumor/washings/cystoscopy to characterize pelvic mass.
Intra op: hemorrhagic/necrotic tumor involving L posterior
pelvic side wall. PATH: carcinosarcoma, hi grade, tumor
involving both ovaries, tubes, cul-de-sac, rectum, and uterine
serosa as well as the uterosacral tissue. The omentum was
negative and she was staged as pT2NxM0.
- ___ Chest CT: ___
- ___: Started on curative intent adjuvant chemotherapy: 7
total doses of taxol completed ___ and 3 cycles of
carboplatin (d/c ___ vascular migraines)
- ___ CT: no residual dz in abd/pelvis. 1.5 cm enlarged LN's
in L intenral iliac artery region.
- ___: p/w bilateral hip pain to ___; CT
concerning for recurrent dz w/ enhancing pelvic masses, Left
pelvic mass, compressed L uretur, resulting in moderate
hydronephrosis
- ___: resection of recurrent pelvic masses by Dr.
___ hospital course c/b GNR bacteremia. PATH: Metastatic
carcinosarc w heterologous chondrosarcomatous differentiation
c/w Mullerian origin - pelvic masses involved small bowel &
sigmoid colon.
- ___ OSH PET CT (done due to increased lower back pain)
showing re-growth/progression w liver implant, L pelvic mass,
mesenteric and RP nodules, presacral mass.
- ___ initiation ___ doxil for symptom control, s/p
two doses (6 total planned)
Ob/GYN hx: G2P2 (SVD x2), menopause at ___, no abnormal Paps or
STIs
Past Medical hx:
- hypertension
- CLL
- benign thyroid disease
- optic neuritis
Past Surgical hx:
- diagnostic laparoscopy, secondary cytoreductive surgery
including exploratory laparotomy, extensive lysis of adhesions,
radical resection of left-sided pelvic mass including
rectosigmoid resection with primary anastomosis, radical
resection of right-sided pelvic mass including a small bowel
resection with anastomosis, partial cystectomy and cystoscopy
with bilateral ureteral stent placement ___ at ___ by Dr.
___ laparotomy, radical abdominal hysterectomy,
bilateral salpingo-oophorectomy, omentectomy, optimal debulking
of pelvic tumor, washings and cystoscopy ___ ___
by Dr. ___ ___
-partial thyroidectomy ___
-right ankle surgery with plate in place ___
Social History:
___
Family History:
-Mother with multiple myeloma
-Father with cardiac issues
-Sister with hypertension
-Brother with heart disease
-Maternal grandmother had colon cancer in her ___
-Paternal grandmother had colon cancer in her ___
Denies family history of breast, ovarian, and endometrial
cancer.
Physical Exam:
*DRAFT*
On the day of discharge:
Afebrile, vital signs stable
Gen: well-appearing, no acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally, no wheezes, rales,
rhonchi; normal respiratory effort; occasional productive cough
Abd: soft, non-distended, non-tender, no rebound or guarding;
well-healed vertical midline incision; normoactive bowel sounds
Ext: warm and well perfused, no edema, no calf tenderness
GU: no spotting on pad
Pertinent Results:
[[IMPORT ALL LAB RESULTS ONCE DISCHARGED]]
---
CT ABD/PELVIS w CONTRAST ___:
FINDINGS:
The lung bases show bibasilar atelectasis.
Hypodensities at the dome of liver, measuring 1.8 cm, and in the
inferior
right hepatic lobe measuring 8 mm and 9 mm are unchanged from
___ and are likely simple cysts (2:9, 29, 34). There
are no concerning focal liver lesions identified. The
gallbladder is collapsed and there is no intra or extrahepatic
biliary ductal dilation. The spleen, pancreas and adrenal
glands are unremarkable. The right kidney enhances as expected
and excretes contrast without hydronephrosis. Punctate
hypodensities within the right kidney are too small to
characterize but are unchanged. The left kidney shows a delayed
nephrogram with severe hydronephrosis and hydroureter, as
previously noted. There has been further atrophy of the left
kidney since ___.
The stomach and duodenum are dilated. Dilated loops of small
bowel range up to 3.3 cm in diameter, consistent with a small
bowel obstruction. The transition point is in the left lower
quadrant (2:47), a point which is proximal to the small bowel
anastomosis seen in the mid pelvis (2:49). Distal loops of
small bowel are collapsed. There is a moderate amount of stool
seen within the distal colon. There is trace perihepatic
ascites. There is no free air. There is no pneumatosis.
The aorta and major branches are unremarkable. The portal vein,
splenic vein and superior mesenteric veins are patent.
There is a large heterogeneous mass, consistent with known
recurrent ovarian carcinoma, within the left hemipelvis
measuring 5.2 x 4.6 cm which is grossly unchanged in size from
___. Centrally, the lesion is necrotic. The external
iliac artery and vein are encased by this mass, as is the left
internal iliac artery, but are patent. The presence of the mass
results in severe left hydroureteronephrosis as before.
Sutures are seen within the sigmoid colon. A small amount of
perirectal and pre-sacral stranding is unchanged and is likely
postoperative or
post-treatment related. The appendix is normal. The uterus is
surgically absent. The patient is status post a partial
cystectomy.
There are no concerning lytic or blastic osseous lesions. A
Tarlov cyst is seen within the sacrum (602:36).
IMPRESSION:
1. High grade small bowel obstruction with a transition in the
left lower quadrant. The point of obstruction is proximal to
the small bowel
anastomosis. No free air or pneumatosis.
2. 5 cm left hemipelvis necrotic mass, unchanged from ___ and
consistent with known recurrent ovarian carcinoma. The presence
of the mass results in severe left hydroureteronephrosis. There
has been marked
progression of left renal atrophy since ___.
3. Trace perihepatic ascites and free pelvis fluid.
----
CXR ___:
FINDINGS: In comparison with the study of ___, the
nasogastric tube
extends to the lower body of the stomach, with the side hole
below the
esophagogastric junction. Swan-Ganz catheter tip is in the mid
portion of the SVC. The lungs are essentially clear.
---
CXR ___:
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates
well-expanded clear lungs. The cardiomediastinal and hilar
contours are unremarkable. There is no pneumothorax, pleural
effusion, or consolidation. A right-sided pectoral Port-A-Cath
ends at the mid SVC. Nasogastric tube is seen ending at the
stomach with the last side port at the GE junction.
IMPRESSION: Nasogastric tube ends in the stomach with the last
side port at the GE junction.
---
CXR ___:
FINDINGS: In comparison with study of ___, there is no
evidence of acute focal pneumonia. Monitoring and support
devices remain in place.
---
Medications on Admission:
-Hydrochlorothiazide, 25mg tablet, once daily
-Dexamethasone, 8mg daily, as needed for nausea
-Hydromorphone, 4mg tablet, every ___ hours as needed for pain
-Hydromorphone, 2mg tablet, every ___ hours as needed for pain
-Exalgo ER 12 mg tablet, extended release, once a day
-Lorazepam 0.5mg tablet, ___ tabs every ___ hours as needed for
nausea, anxiety, insomnia
-Ondansetron 8mg disintegrating tablet, every 8 hours as needed
for nausea
-Compazine, 10mg tablet, every 6 hours as needed for nausea
-Acetaminophen, 500mg tablet, every 6 hours with hydromorphone
-Docusate sodium, 100mg, twice a day
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
2. Promethazine 25 mg PO Q6H:PRN nausea
RX *promethazine 12.5 mg 1 tablet by mouth every 6 hours Disp
#*120 Tablet Refills:*3
3. Docusate Sodium 100 mg PO BID
4. Exalgo ER (HYDROmorphone) 12 mg oral daily pain
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lorazepam 0.5 mg PO Q4H:PRN anxiety, pain
7. Metoclopramide 10 mg PO QID nausea
RX *metoclopramide HCl 10 mg 1 tab by mouth every 6 hours Disp
#*120 Tablet Refills:*3
8. Senna 17.2 mg PO DAILY:PRN constipation
9. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain and vomiting with history of bowel surgery. Evaluate
for obstruction.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
after the uneventful administration of 130 mL of Omnipaque. The patient could
not tolerate oral contrast. Coronal and sagittal reformations were provided
and reviewed.
DLP: 463.18 mGy/cm.
COMPARISON: CT abdomen and pelvis ___. Outside hospital PET-CT
___.
FINDINGS:
The lung bases show bibasilar atelectasis.
Hypodensities at the dome of liver, measuring 1.8 cm, and in the inferior
right hepatic lobe measuring 8 mm and 9 mm are unchanged from ___ and
are likely simple cysts (2:9, 29, 34). There are no concerning focal liver
lesions identified. The gallbladder is collapsed and there is no intra or
extrahepatic biliary ductal dilation. The spleen, pancreas and adrenal glands
are unremarkable. The right kidney enhances as expected and excretes
contrast without hydronephrosis. Punctate hypodensities within the right
kidney are too small to characterize but are unchanged. The left kidney shows
a delayed nephrogram with severe hydronephrosis and hydroureter, as previously
noted. There has been further atrophy of the left kidney since ___.
The stomach and duodenum are dilated. Dilated loops of small bowel range up to
3.3 cm in diameter, consistent with a small bowel obstruction. The transition
point is in the left lower quadrant (2:47), a point which is proximal to the
small bowel anastomosis seen in the mid pelvis (2:49). Distal loops of small
bowel are collapsed. There is a moderate amount of stool seen within the
distal colon. There is trace perihepatic ascites. There is no free air. There
is no pneumatosis.
The aorta and major branches are unremarkable. The portal vein, splenic vein
and superior mesenteric veins are patent.
There is a large heterogeneous mass, consistent with known recurrent ovarian
carcinoma, within the left hemipelvis measuring 5.2 x 4.6 cm which is grossly
unchanged in size from ___. Centrally, the lesion is necrotic. The
external iliac artery and vein are encased by this mass, as is the left
internal iliac artery, but are patent. The presence of the mass results in
severe left hydroureteronephrosis as before.
Sutures are seen within the sigmoid colon. A small amount of perirectal and
pre-sacral stranding is unchanged and is likely postoperative or
post-treatment related. The appendix is normal. The uterus is surgically
absent. The patient is status post a partial cystectomy.
There are no concerning lytic or blastic osseous lesions. A Tarlov cyst is
seen within the sacrum (602:36).
IMPRESSION:
1. High grade small bowel obstruction with a transition in the left lower
quadrant. The point of obstruction is proximal to the small bowel
anastomosis. No free air or pneumatosis.
2. 5 cm left hemipelvis necrotic mass, unchanged from ___ and
consistent with known recurrent ovarian carcinoma. The presence of the mass
results in severe left hydroureteronephrosis. There has been marked
progression of left renal atrophy since ___.
3. Trace perihepatic ascites and free pelvis fluid.
Radiology Report
HISTORY: NG tube placement.
FINDINGS: In comparison with the study of ___, the nasogastric tube
extends to the lower body of the stomach, with the side hole below the
esophagogastric junction. Swan-Ganz catheter tip is in the mid portion of the
SVC.
The lungs are essentially clear.
Radiology Report
HISTORY: ___ female with new nasogastric tube placement for
persistent emesis secondary to small-bowel obstruction. Evaluate placement of
NG tube.
COMPARISON: Multiple prior radiographs of the chest dated ___
through ___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates well-expanded clear
lungs. The cardiomediastinal and hilar contours are unremarkable. There is
no pneumothorax, pleural effusion, or consolidation. A right-sided pectoral
Port-A-Cath ends at the mid SVC. Nasogastric tube is seen ending at the
stomach with the last side port at the GE junction.
IMPRESSION: Nasogastric tube ends in the stomach with the last side port at
the GE junction.
COMMENTS: These findings were discussed with Dr. ___ by Dr. ___
telephone at 1:30 p.m. on ___, 5 minutes after the findings were
discovered.
Radiology Report
HISTORY: Ovarian cancer and SBO with congestion and cough.
FINDINGS: In comparison with study of ___, there is no evidence of acute
focal pneumonia. Monitoring and support devices remain in place.
Radiology Report
HISTORY: Recurrent ovarian cancer failing conservative management of nausea
and vomiting. Evaluate for small bowel obstruction
COMPARISON: ___ CT abdomen pelvis
TECHNIQUE: Volumetric CT acquisition of the abdomen and pelvis was performed
after administration of oral and 130 mL of Omnipaque 350 IV contrast material.
Post-processing reconstruction was performed in the coronal and sagittal
planes.
DLP: 288 mGy-cm
FINDINGS:
The lung bases are clear. Normal heart size. Trace pericardial effusion. An
enteric tube is present within the stomach, which is not distended. The liver
is normal in appearance and enhancement without evidence of solid intrahepatic
mass. 1.8 cm cyst in segment 2. Smaller additional cysts in the segment 6.
There is no intrahepatic biliary ductal dilatation. The portal vein is
patent. The gallbladder is normal in appearance.
There is severe left hydroureteronephrosis to the level of the pelvic mass.
The left kidney continues to take up contrast however none is excreted during
the examination. An enlarged, heterogeneously enhancing mesenteric lymph node
is present, which measures 1.7 x 1.8 x 2.1 cm, previously measuring 1.3 x 1.4
x 1.9cm. (series 5, image 44 and sagittal image 35). A smaller
heterogeneously enhancing lymph node is present in the mesentery to the left
of midline in the pelvis, adjacent to but separate from the bowel anastomosis
(series 5, image 53). This measures 1.2 x 1 cm, not significantly changed
from prior exam where it measured 1.3 x 1 cm. The adrenal glands, right
kidney, pancreas, and spleen are normal in appearance. A single prominent
loop of small bowel is present in the left upper quadrant, however remaining
loops of bowel are normal in caliber without evidence of obstruction. There
is no free fluid or free air. The abdominal aorta is normal in caliber with
scattered atherosclerosis.
Postsurgical changes are present in the colon with anastomoses intact. The
urinary bladder is unremarkable. There is no free fluid in the pelvis. Again
seen is a necrotic left hemipelvis mass, which is heterogeneously enhancing.
The left common iliac runs along the mass superiorly anteriorly. The mass
measures 6.7 x 4.6 x 5.3 cm, which may be slightly enlarged from prior exam
where it measured 5.5 x 4.5 x 4.7 cm. The mass directly abuts the anastomosis
at the rectum sigmoid junction. It does not appear to invade or obstructs the
rectum or sigmoid, however a discrete fat plane is nonvisualized. Osseous
structures are intact.
IMPRESSION:
1. Interval worsening of metastatic disease with mild interval enlargement of
a mesenteric site of metastatic disease. Additional mesenteric lymph node
near the colon anastomosis is stable, but compatible with metastatic focus.
2. Slight interval enlargement of the left pelvic mass, which may be is
approaching the anastamotic sutures at the rectosigmoid junction. There is
mass effect upon the colon, but no evidence of upstream colon obstruction.
3. Severe left hydronephrosis, stable.
4. No evidence of bowel obstruction.
Updated read from preliminary report (regarding worsening tumor burden) was
discussed with Dr. ___ at 12:30pm.
Radiology Report
INDICATION: Recurrent ovarian cancer now with episode of altered mental
status. Evaluate for stroke, brain metastases.
COMPARISON: None available.
TECHNIQUE: Routine enhanced ___ MR examination including axial ___
and sagittal MP-RAGE as well as post-contrast axial and coronal reformations.
Three-dimensional time-of-flight MR arteriography as well as 2D time-of-flight
MR venography were performed, both with rotational targeted MIP
reconstructions.
FINDINGS:
BRAIN MRI: There is no acute infarct. There is no evidence of intra- or
extraaxial mass, and no pathologic pachy- or leptomeningeal contrast
enhancement, to suggest intracranial metastatic disease. There is no evidence
of intracerebral edema or hemorrhage. There are multiple small foci of high T2
signal in the supratentorial white matter, likely sequela of chronic small
vessel ischemic disease in a patient of this age. Multiple prominent
perivascular spaces are incidentally noted. There is 3mm ectopia of the
cerebellar tonsils without effacement of CSF space around the tonsils,
cervicomedullary junction kinking, or other stigmata of a Chiari malformation.
Ventricles and sulci are normal in size.
BRAIN MRA: Normal flow-related enhancement is seen in the intracranial
internal carotid and vertebral arteryies, and their major branches, without
evidence for flow-limiting stenoses or aneurysms.
BRAIN MRV: There is normal flow-related enhancement in the major dural venous
sinuses without evidence of thrombosis.
IMPRESSION:
1. No evidence of intracranial metastatic disease. No acute infarction.
2. Normal brain MRA
3. Normal brain MRV.
4. 3 mm ectopia of the cerebellar tonisls without stigmata of a Chiari
malformation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.8
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 134.0
dbp: 76.0
level of pain: 2
level of acuity: 3.0 | Ms. ___ was admitted to the gynecology-oncology service from
the ED for management of a high grade small bowel obstruction,
secondary to recurrent ovarian carcinosarcoma versus adhesions.
*) SBO: While on the floor, she was placed on bowel rest, IV
fluids, and a nasogastric tube was placed. Her pain was
controlled with IV dilaudid and acetaminophen, and she also
received IV ativan as needed for anxiety and nausea. Her nausea
and abdominal pain initially improved. On hospital day #3, her
NGT was removed and her diet was advanced to sips by hospital
day #4. However, on hospital day #4 and 5, she experienced two
spontaneous bouts of emesis, so an NGT was replaced and she was
again placed on bowel rest with maintenance IV fluids. She was
started on standing anti-emetics (reglan, phenergan). Her nausea
improved but continued to occur intermittently. Her medical
oncologist Dr. ___ was consulted for recommendations. She was
started on octreotide to reduce her bowel wall secretions and
dexamethasone for bowel wall edema on hospital day #7, which led
to significant improvement in her NGT output. On hospital day 10
her NGT was clamped and residuals were checked and minimal. On
HD#11 she tolerated sips of water around the tube well. On HD#11
the NGT was removed and TPN, ocreotide and dexamethasone were
discontinued. She did well and advanced slowly to a regular diet
with well controlled nausea with her po antiemetics. She had no
further episodes of distension or emesis throughout her hospital
stay.
Throughout her hospitalization, her abdominal exam remained
benign with no significant tenderness or distension. Her labs
were monitored and her electrolytes were repleted as needed. At
the time of admission, she was noted to be slightly anemic with
a hematocrit nadir of 26.1. She was transfused one unit of
packed red blood cells on hospital day #2, with improvement in
her hematocrit. Her hematocrit subsequently remained stable
above 30.
Given her prolonged bowel rest secondary to the obstruction, a
nutrition consult was obtained on hospital day #7. She was
started on TPN for nutrition on hospital day #8 which continued
through HD# 14.
*) Congestion: She complained of throat congestion, mucous, and
productive cough, likely secondary to the nasogastric tube. The
congestion improved with Her vital signs remained stable and
her lungs remained clear. She underwent multiple chest x-rays
that demonstrated no evidence of infiltrate or infection. Her
symptoms somewhat improved after she was started on medications
to decrease her bowel secretions, as above.
*) Pain control: while NPO her pain was controlled with standing
Iv dilaudid and prn dilaudid for breakthrough. Once she was
tolerating some po, on HD#16, she was transitioned back to her
home regimen of exalgo with short acting dilaudid for
breakthrough. She required breakthrough IV medication only once
on HD#16 and otherwise had well controlled pain on her home
regimen.
*) Altered Mental Status: On Hospital day #17 she had an episode
of word finding difficulty. She called her nurse to ask for pain
medication and could not remember how to ask when the nurse
arrived. Neurology was consulted. FSBG and lytes were normal,
lipids were normal, EEG was reported as normal and an MRI was
unremarkable. She had no further episodes and neurology
recommended no further workup unless this recurred.
*) HTN: For her hypertension, her home diuretic was held upon
admission. Her blood pressures were monitored throughout her
hospitalization and on hospital day 10 she was noted to be
hypertensive and her home HCTZ was restarted.
*) ppx: She received famotidine for prophylaxis while NPO. She
received lovenox and wore pneumoboots for DVT prophylaxis as
well.
She was gradually advanced to a regular diet begining on
hospital day #15. She met her discharge milestones by day
19--eating a regular diet, voiding spontaneously, ambulating
independently, and pain was controlled with oral medications.
She was then discharged home in stable condition with outpatient
follow-up scheduled with gyn-onc and heme-onc. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old female with a history significant
for atrial fibrillation on Coumadin, pacemaker, DM2, HTN, CKD,
dementia, and peripheral neuropathy who presents from her
nursing
facility with altered mental status. At her baseline she is
oriented to self only. This morning at her facility she became
agitated and combative as well as having decreased PO intake and
was transported via EMS to ___ for evaluation and management.
Upon arrival she was no responding to commands but was awake and
protecting her airway. All extremities were moving. Workup was
done for underlying causes and ultimately a CT scan of the head
was done which showed left sided subdural hematoma measuring
2.2cm in maximal thickness causing approximately 6mm of midline
shift and the SDH was of mixed density with an acute component.
Of note her INR was 4.7 upon arrival and per the ED protocol she
recieved KCENTRA and vitamin K. Neurosurgery was consulted for
assistance with management given her CT findings.
Past Medical History:
DM2, pacemaker, Alzheimer's, HTN, a-fib, GERD, chronic
renal impairment, osteopenia, peripheral neuropathy,
hyperlipidemia
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
Gen: WD/WN, agitated, slightly combative
HEENT: Pupils: PERRL EOMs unable to assess due to patient
cooperation
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: afib, S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert,not cooperative with exam
Orientation: Oriented to self only
Language: speech mostly nonsensical and random, does not answer
questions other than name.
___:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. unable to assess visual fields given patient
cooperation
III, IV, VI: unable to assess EOMS given patients lack of
cooperation with exam
V, VII: Facial strength and sensation appear intact and
symmetric.
VIII: Unable to assess hearing
IX, X: unable to assess given lack of patient cooperation
XI: Unable to assess given patients lack of cooperation
XII: Tongue midline without fasciculations as patient is able to
mimic this movement
Motor: Normal bulk and tone bilaterally, unable to assess muscle
strengths given lack of cooperation however all 4 extremities
appear to move symmetrically and with good strength.
Sensation: unable to adequately assess
On Discharge:
alert to name only
strength intact
requires assistance for transfers
EO spontaneously
pupils equal and reactive
Pertinent Results:
CT HEAD W/O CONTRAST ___
1. Large left frontal extra-axial hemorrhage, likely subdural,
with findings suggesting active bleeding.
2. Associated 5.5 mm rightward shift of normally midline
structures.
CT HEAD W/O CONTRAST ___
Redemonstration of large left frontal extra-axial hemorrhage,
with findings again suggestive of active bleeding. There is
stable 5.5 mm rightward shift of midline structures.
Radiology Report CHEST (PA & LAT) Study Date of ___
3:31 ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Medications on Admission:
lisinopril, lipitor, asa,calcium, vit B12, toprol xl, metamucil,
omeprazole, januvia, depakote, coumadin, risperidone
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Atorvastatin 20 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY
4. Ciprofloxacin 400 mg IV Q24H Duration: 5 Days
5. Cyanocobalamin 1000 mcg PO DAILY
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Divalproex Sod. Sprinkles 250 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Glucose Gel 15 g PO PRN hypoglycemia protocol
11. HydrALAzine ___ mg IV Q6H:PRN SBP>160
12. LeVETiracetam 500 mg PO BID
13. Pantoprazole 40 mg PO Q24H
14. Senna 8.6 mg PO BID
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Lisinopril 20 mg PO DAILY
17. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left sided ___
Discharge Condition:
oriented to person only
full strength
sensation intact
foley catheter in place
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with altered mental status , dementia, diabetes ,
hypertension
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
FINDINGS:
Left-sided dual-chamber pacemaker device is noted with leads terminating in
the right atrium and right ventricle. Moderate enlargement of cardiac
silhouette with left ventricular predominance is noted. The aorta is diffusely
calcified. The mediastinal and hilar contours are within normal limits. The
pulmonary vasculature is normal. No focal consolidation, pleural effusion or
pneumothorax is identified. There are no acute osseous abnormalities.
Multilevel degenerative changes are present within the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with altered mental status, dementia at baseline //
? acute intracranial process
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, without IV administration of contrast. Reformatted coronal
and sagittal and thin-section bone algorithm-reconstructed images were
acquired, and all images are viewed in brain and bone window on the
workstation.
DOSE: DLP (mGy-cm): 780.4.
CTDIvol (mGy): 55.6.
COMPARISON: None.
FINDINGS:
A large left frontal extra-axial mixed heterogeneous collection measures up to
2.2 cm in greatest depth, and causes significant mass effect upon the adjacent
left frontal sulci (2:17, 601b:41), and is associated with approximately 5.5
mm rightward shift of normally midline structures. Dependent mixing of
hyperdense and hypodense internal contents suggest active bleeding. There is
mild effacement of the left lateral ventricle. The basal cisterns appear
patent and there is preservation of the gray-white matter differentiation.
Scattered periventricular white matter hypodensities are compatible with
chronic small vessel infarction.
No fracture or suspicious osseous lesion is identified.The included paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.The orbits are
unremarkable. Intracranial calcification of the cavernous portions of the
carotid arteries are noted.
IMPRESSION:
1. Large left frontal extra-axial hemorrhage, likely subdural, with findings
suggesting active bleeding.
2. Associated 5.5 mm rightward shift of normally midline structures.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
telephone on ___ at 19:55, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: NON CONTRAST HEAD CT
INDICATION: Left subdural hematoma. Evaluate interval change.
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: 55 mGy.
COMPARISON: Head CT from ___.
FINDINGS:
There is redemonstration of a large left frontal extra-axial mixed
heterogeneous collection which measures approximately 1.8 cm in greatest
dimension. There is continued mass effect upon the adjacent left frontal sulci
and stable 5.5 mm rightward shift of normally midline structures. As on prior
examination, there is persistent dependent mixing of the hyperdense and
hypodense components suggesting active bleeding. There is mild effacement of
the left lateral ventricle. Otherwise, the basal cisterns appear patent. There
is no new area of active bleeding. Scattered periventricular white matter
hypodensities are likely the sequela of chronic small vessel ischemic disease.
There is no fracture. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
IMPRESSION:
Redemonstration of large left frontal extra-axial hemorrhage, with findings
again suggestive of active bleeding. There is stable 5.5 mm rightward shift of
midline structures.
NOTIFICATION: Discussed with Dr. ___ by NSR via telephone on ___ and
08:21.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.4
heartrate: 62.0
resprate: 16.0
o2sat: 99.0
sbp: 184.0
dbp: 62.0
level of pain: UTA
level of acuity: 2.0 | ___ y/o F presents with confusion and agitation found to have L
SDH with midline shift. She had an INR of 4.7 which was reversed
with KCENTRA and vitamin K per ED protocol. She was admitted to
the neurosurgery ICU for close monitoring and continued reversal
of INR. On ___, repeat head CT showed stable midline shift, but
question of active hemorrhage. Family discussion was held and
they chose not to pursue surgery.
On ___, the patient remained stable. She had a repeat NCHCT
which showed an unchanged subdural hematoma with associated
midline shift. Attempts were made to contact her nursing home of
origin to see if a transfer directly back and into their memory
unit could be made.
___, the patient was transferred in stable condition to the
neurosurgical floor.
On ___ Patient had a brief self resolved episode of no
speech/not following commands. Upon assessment patient was back
to baseline neurological status. Vital signs were normal. Labs
were WNL.
On ___, The patient was initiated on cipro for a urinary tract
infection.
On ___, The patient was neurologically stable.
On ___, The patient was mobilized out of bed to the chair. The
patient was neurologically stable and was discharged to her
nursing home to a dementia unit. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o woman with ___ notable for medically
managed CAD, h/o TIA, bradycardia/CHB s/p Medtronix pacemaker at
___, and ___, presenting from cardiology clinic with concern
for
acute on chronic ___ exacerbation.
Per discussion with patient and review of records, she has had
ongoing shortness of breath and dyspnea with wheezing for about
a
week now. Her weight may have increased by ___ pounds over this
time (although her weight trend has been quite stable since
___ when she was 131 lb, which is same weight she is
currently). She also endorses anorexia and some orthopnea.
She was seen in urgent care a few days prior to admission, where
she was started on Lasix 20mg PO daily (daughter reports she had
been on lasix in the past but it was stopped). She subsequently
saw her PCP after receiving no therapeutic improvement and had
her Lasix uptitrated to 40mg PO BID. Her weight did drop about 4
pounds and she had some improvements in her breathing. However,
labwork as an outpatient showed increase in Cr from 1.9
(___)
to 2.5 (___).
On day prior to admission, she presented to her ___
clinic, where she was felt to be fluid overloaded. She was
recommended to present to the ___ ED for further care.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
-Diastolic congestive heart failure (EF 55-60% in ___
-Coronary artery disease s/p cath at ___ in ___ (per report no
intervention)
-History of Complete Heart Block s/p PPM in ?___ (now per
patient 100% paced; followed at ___)
-Hypertension (with labile blood pressures)
-Hypercholesterolemia
-Stage IV CKD (baseline Cr in ___ as low as 1.26 - ranging
since ___ between 1.26 and 1.98)
-Type 2 Diabetes Mellitus, on lantus
-History of TIA
-Urinary incontinence
-Osteoporosis
-History of breast cancer
-Polyuria
-Esophagitis
-Sensorineural hearing loss
-Squamous cell carcinoma of skin
-Mild cognitive impairment
-Fall risk
-Anxiety/Depression
-Compression fractures of T12 and lumbar vertebrae
Social History:
___
Family History:
FAMILY HISTORY:
NC to presenting complaint
Physical Exam:
ADMISSION EXAM
ADMISSION PHYSICAL EXAM:
VS: 97.7, 128 / 72 64 18 92 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, JVP elevated to mid neck with HOB at 15 degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Decreased BS at ___ bases, upper lung fields CTAB. Slight
dyspnea with full sentences
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no CVA tendenress
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 EXAM
VITALS: 98.4 131 / 89 65 20 92 Ra
I/O: incontinent
Wt: 59.6 kg
GENERAL: Well appearing elderly woman in NAD
ENT: MMM
CV: JVD <10 cm, pt at 90 degrees
LUNGS: R basilar fine crackles, improved
ABD: non-tender, non-distended, no suprapubic pain
GU: no foley
Extremities: warm, well perfused, and without edema
Pertinent Results:
ADMISSION
___ 10:49PM BLOOD WBC-5.4 RBC-4.01 Hgb-11.9 Hct-36.0 MCV-90
MCH-29.7 MCHC-33.1 RDW-13.2 RDWSD-43.5 Plt ___
___ 10:49PM BLOOD Plt ___
___ 10:49PM BLOOD Glucose-158* UreaN-45* Creat-2.6* Na-143
K-4.3 Cl-101 HCO3-26 AnGap-16
___ 11:30PM BLOOD ___
___ 11:30PM BLOOD cTropnT-0.04*
___ 11:30PM BLOOD Calcium-9.6 Phos-3.8 Mg-1.4*
PERTINENT IMAGING
___ TTE:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Diastolic function could not be
assessed. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a very small pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Mild aortic regurgitation. Mild
mitral regurgitation. Elevated LVEDP and moderate pulmonary
hypertension. Very small pericardial effusion.
___
CXR:
1. Opacity projecting over the lower spine on lateral view could
represent
pleural fusion, however opacity/pneumonia could have a similar
appearance.
2. Small bilateral pleural effusions.
3. Coarsened interstitial markings may be related age however
mild pulmonary edema could have a similar appearance.
DISCHARGE LABS
___ 05:53AM BLOOD WBC-5.2 RBC-3.75* Hgb-10.9* Hct-33.4*
MCV-89 MCH-29.1 MCHC-32.6 RDW-12.9 RDWSD-41.9 Plt ___
___ 05:53AM BLOOD Glucose-82 UreaN-49* Creat-2.1* Na-140
K-4.2 Cl-101 HCO3-24 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO BID
2. Pantoprazole 20 mg PO Q24H
3. Clopidogrel 75 mg PO DAILY
4. FLUoxetine 10 mg PO EVERY OTHER DAY
5. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
6. Acetaminophen 650 mg PO DAILY
7. Acetaminophen 325 mg PO QHS
8. Glargine 10 Units Bedtime
9. Docusate Sodium 100 mg PO DAILY:PRN constipation
10. Senna 8.6 mg PO DAILY:PRN constipation
11. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Isosorbide Mononitrate 20 mg PO BID
2. Levofloxacin 250 mg PO ONCE Duration: 1 Dose
To be taken on ___
3. Furosemide 40 mg PO EVERY OTHER DAY
4. Glargine 10 Units Bedtime
5. Acetaminophen 650 mg PO DAILY
6. Acetaminophen 325 mg PO QHS
7. Atorvastatin 20 mg PO QPM
8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
9. Clopidogrel 75 mg PO DAILY
10. Docusate Sodium 100 mg PO DAILY:PRN constipation
11. FLUoxetine 10 mg PO EVERY OTHER DAY
12. Pantoprazole 20 mg PO Q24H
13. Senna 8.6 mg PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
Diastolic Heart Failure
Urinary Tract Infection
Acute on Chronic Kidney Injury
SECONDARY DIAGNOSES
Coronary Artery Disease
Depression
Insulin Dependent Diabetes
PRIMARY DIAGNOSES
Diastolic Heart Failure
Urinary Tract Infection
Acute on Chronic Kidney Injury
SECONDARY DIAGNOSES
Coronary Artery Disease
Depression
Insulin Dependent Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with hypoxia, shortness of breath// ?pna, pulm
edema, pleural effusion
COMPARISON: None available
FINDINGS:
There is hazy right basilar opacity and retrocardiac opacity projecting over
the spine on the lateral view. There is no pneumothorax. The
cardiomediastinal silhouette is normal. There is mild pulmonary edema. There
is a right chest cardiac device with lead tips in the right atrium and right
ventricle. There are left axillary surgical clips. The aorta is heavily
calcified. No free air below the right hemidiaphragm is seen. Left axillary
surgical clips.
IMPRESSION:
1. Opacity projecting over the lower spine on lateral view could represent
pleural fusion, however opacity/pneumonia could have a similar appearance.
2. Small bilateral pleural effusions.
3. Coarsened interstitial markings may be related age however mild pulmonary
edema could have a similar appearance.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 98.2
heartrate: 65.0
resprate: 17.0
o2sat: 95.0
sbp: 129.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ y/o woman with PMH notable for medically
managed CAD, h/o TIA, bradycardia/CHB s/p Medtronix pacemaker at
___, and ___, presenting from cardiology clinic with concern
for
acute on chronic dCHF exacerbation, found to have positive U/A
concerning for triggering UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cellulitis/abscess
Major Surgical or Invasive Procedure:
___ Bedside I+D of left thigh done by Surgery team
History of Present Illness:
___ with a PMH of CAD s/p CABG ___ (s/p ___ ___, PAD,
insulin resistance, chronic HepC, p/w 5 days of left inner thigh
pain, redness, and swelling. The patient went to ___ ED on ___
where he had the abscess I+D and he was discharged on a course
of Bactrim DS BID. He obtained this medication on ___ and had
taken 4 doses with worsening of his symptoms prompting him to
report to his PCP. His PCP referred him to the ED for further
management. He has endorsed some myalgias, but otherwise denies
systemic symptoms such as fevers and chills.
Vitals ___ the ED: 96.5 86 139/80 18 98% RA
Labs notable for: WBC elevated at 13, Plt low at 116, BUN25 Cr
1.2.
Patient given: IV Vanc 1500mg x1
On the floor, the patient endorses continued pain ___ the left
inner thigh.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
CARDIAC HISTORY:
-___ patient presented for preop ETT for a planned Left
Fem-Pop, noted to have new T wave inversions ___ V2-5 compared to
___ tracing. He went for a cath which demonstrated 2-v
coronary artery disease and left main coronary artery diasese.
The ___ had a 70% distal stenosis. The LAD had a 70% mid
segment stenosis. The LCx had minimal luminal irregularities.
The RCA had serial 30% stenoses. As a result he was referred for
CABG
- CABG: ___ by Dr. ___. Left internal mammary artery to
left anterior descending artery, and saphenous vein graft to
ramus and, obtuse marginal arteries
Hypercholesterolemia
Peripheral vascular disease, bil calf claudication, plan for a
Left Fem-Pop w/ Dr. ___ deferred by pt d/t financial
issues
CAD s/p CABG ___, also s/p ___ ___ - last echo ___
w/ EF 55-60%
chronic genotype 1B hepatitis C (unable to tolerate
IFN/ribavirin, seen by Dr. ___ to start newer agents
___ by ___, attempted telaprevir but discontinued due to
side effects
?Hepatitis B
Thrombosis of left femoral artery
Obesity
Nephrolithiasis
Glucose intolerance
Tobacco dependence
H/o IVDU ___ remission since ___
History paroxysmal a fib ___ setting of ACS, anticoagulation
stopped ___ by ___ cards
Abscess right forearm requiring I&D ___ years ago
Cellulitis LLE (foot, tracked up to thigh) requiring IV abx ___
years ago
s/p Tonsillectomy
s/p Adenoidectomy
s/p Skin grafts from left calf to left chest
Social History:
___
Family History:
Per OMR, Mother and father with CAD and PVD ___ the ___. Father
died of MI at age ___. Father and sister with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.8 65 107/59 16 95% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Slight bibasilar crackles, breathing comfortably without
use of accessory muscles
ABDOMEN: Mildly distended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly, no shifting dullness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. Left inner thigh with large area of
edema, erythema, warmth, and tenderness. There is a small area
of fluctuance surrounding the abscess incision. There is no
packing ___ place. Foul-smelling pus is able to be expressed. On
the right inner thigh there is a small area of erythema and
fluctuance with an overlying scab. No pain upon hip or knee
range of motion. No invovlement of the testicle or perineum.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no stigmata of chronic liver
disease, scattered AKs
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 - 126/___
GENERAL: no respiratory distress, looks comfortable
HEENT: AT/NC, EOMI, anicteric sclera, MMM
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: lungs clear bilaterally
ABDOMEN: Softly distended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly, no shifting dullness
EXTREMITIES: Left medial thigh with area of MUCH improved
erythema and tenderness(previously >10cmx8cm, now receded to
~2-3 cm around incision). Induration surrounding incision site
is now ~3cm wide and less indurated than prior. no crepitance.
Serosanguinous packing ___ place w/o evidence of purulence. On
the right inner thigh there is a (2cm x 2cm) area of
erythema/tenderness with an overlying small scab. This is
stable. No pain upon hip or knee range of motion. No involvement
of the testicle or perineum- able to elevate testicles w/o pain.
PULSES: 2+ DP pulses bilaterally
NEURO: face symmetric
SKIN: see exam above. no stigmata of chronic liver disease,
scattered AKs
Pertinent Results:
ADMISSION LABS
===============
___ 08:10PM BLOOD WBC-13.3* RBC-4.95 Hgb-17.0 Hct-50.6
MCV-102* MCH-34.4* MCHC-33.6 RDW-14.9 Plt ___
___ 08:10PM BLOOD Neuts-76.8* Lymphs-13.7* Monos-7.2
Eos-2.0 Baso-0.2
___ 08:10PM BLOOD Glucose-106* UreaN-25* Creat-1.2 Na-136
K-4.1 Cl-101 HCO3-25 AnGap-14
OTHER PERTINENT LABS
=====================
___ 03:13AM BLOOD %HbA1c-6.8* eAG-148*
DISCHARGE LABS
===============
___ 06:15AM BLOOD WBC-8.6 RBC-4.78 Hgb-16.9 Hct-49.5
MCV-104* MCH-35.3* MCHC-34.1 RDW-14.3 Plt ___
___ 06:15AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-134
K-4.8 Cl-106 HCO3-21* AnGap-12
MICROBIOLOGY
=============
___ Blood Culture, Routine-PENDING
___ 1:58 am SWAB Source: right thigh.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible ___ become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
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.
SENSITIVITIES: MIC expressed ___
MCG/ML
________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 1:37 pm ABSCESS Source: L thigh.
Fluid should not be sent ___ swab transport media. Submit
fluids ___ a
capped syringe (no needle), red top tube, or sterile cup.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING
========
EXAMINATION: US LOWER EXTREMITY, SOFT TISSUE LEFT - ___,
done after I+D
INDICATION: ___ year old man with significant R medial thigh
cellulitis with recent I+D on ___ with continued drainage and
induration of left medial thigh, as well as erythema down leg.
// Please ultrasound soft tissue of left thigh for fluid
collection / tract - looking for potential abscess (+/-
loculations?) to drain. Also, if able please look at L
hamstrings (eg biceps femoris) for e/o fluid collections too
(?pyomyositis, v firm/tender)
TECHNIQUE: Grayscale ultrasound images were obtained of the
superficial
tissues of the left thigh.
COMPARISON: None
FINDINGS: Transverse and sagittal images were obtained of the
superficial tissues of the anterior, medial, and posterior left
thigh demonstrates skin thickening, with no evidence of
underlying fluid collection or abscess. Partially visualized
superficial veins appear patent.
IMPRESSION: Findings compatible with cellulitis, with no focal
fluid collection or abscess identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Lisinopril 2.5 mg PO DAILY
3. Metoprolol Succinate XL 150 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO DINNER
RX *metformin 500 mg 1 tablet(s) by mouth with dinner Disp #*30
Tablet Refills:*0
6. Metoprolol Succinate XL 150 mg PO DAILY
7. Acetaminophen ___ mg PO Q6H:PRN pain
Do not take more than 3,000 mg ___ a day.
8. Clindamycin 450 mg PO Q6H Duration: 6 Days
Ends ___
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hours
Disp #*22 Capsule Refills:*0
9. Supplies
Please dispense iodoform ___ packing for wound care.
**** Clarified with pharmacy after discharge on ___ patient
needs 72 pills clindamycin, not 22 pills as written ****
Discharge Disposition:
Home
Discharge Diagnosis:
Left thigh cellulitis
Left thigh abscess
Newly diagnoses non-insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US LOWER EXTREMITY, SOFT TISSUE LEFT
INDICATION: ___ year old man with significant R medial thigh cellulitis with
recent I+D on ___ with continued drainage and induration of left medial
thigh, as well as erythema down leg. // Please ultrasound soft tissue of left
thigh for fluid collection / tract - looking for potential abscess (+/-
loculations?) to drain. Also, if able please look at L hamstrings (eg biceps
femoris) for e/o fluid collections too (?pyomyositis, v firm/tender)
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left thigh.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
anterior, medial, and posterior left thigh demonstrates skin thickening, with
no evidence of underlying fluid collection or abscess. Partially visualized
superficial veins appear patent.
IMPRESSION:
Findings compatible with cellulitis, with no focal fluid collection or abscess
identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Leg swelling
Diagnosed with CELLULITIS OF LEG
temperature: 96.5
heartrate: 86.0
resprate: 18.0
o2sat: 98.0
sbp: 139.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a pleasant ___ year old gentleman with CAD s/p CABG
___ and ___ ___, known peripheral vascular disease,
HCV who was admitted to ___ this week with purulent
cellulitis/abscess ___ MRSA and new DM2 diagnosis. For DM2 he
had diabetic teaching, started metformin 500mg once daily, and
was seen by nutrition with plans to change his diet. Regarding
MRSA cellulitis, it improved a great deal with 4 days of
vancomycin, and he was discharged on clindamycin for a planned
total course of at least 10 days (will follow up with PCP ___
8days antibiotics and can be re-assessed then). Regarding
peripheral vascular disease, he had previously deferred surgery
but was interested ___ re-referral at time of discharge.
ACTIVE MEDICAL ISSUES
======================
# MRSA Cellulitis w/ abscess s/p I+D: Purulent cellulitis with
associated abscess, which failed TMP/SMX and shallow I+D
incision at another ED. Surgery was consulted and performed I+D
and recommended twice daily iodoform packing. He was taught how
to do the packing and he and his wife will do it at home. He was
initiated on vancomycin given history of staph infection ___ the
past. Cultures grew MRSA sensitive to clindamycin, however
vancomycin was continued for almost 4 days given severity of
cellulitis. For this reason would also consider longer course
for antibiotics (10 days total). Risk factors for cellulitis
likely include PVD, newly diagnosed DM; patient also had a skin
puncture of left thigh at work a few days prior to presentation.
Should continue clindamycin until ___ (can be re-evaluated at
Dr. ___ appointment on ___ with dressing changes as noted
above. Blood culture is still pending.
# Newly diagnosed type 2 DM: Hba1c was 6.8. We started metformin
500mg once daily with dinner, he underwent diabetic teaching,
and he was seen by nutrition and plans to ___ at ___.
CHRONIC MEDICAL ISSUES
======================
# THROMBOCYTOPENIA: Chronic HCV and elevated fibrosure score; no
recent ultrasounds to confirm cirrhosis. Would encourage
outpatient hepatology evaluation and consideration of treating
his HepC.
# CAD s/p CABG ___, s/p ___ ___: continued ASA,
clopidogrel, statin, lisinopril (started given depressed EF ___
past).
# Chronic HCV: Followed by Dr. ___ at ___ with plan to start
newer HCV agents this year s/p fibroscan. Previously unable to
tolerate IFN/ribavirin or telaprevir.
# Peripheral vascular disease/claudication: Seen by Dr. ___
___, recommend fem-pop bypass on left, but pt deferred given
employment/lack of time off. Patient is now interested ___
potential surgery given new diagnoses; we made appt for early
___ with Dr. ___.
# Hypertension: Continued lisinopril, metoprolol.
# Hyperlipidemia: Continued atorvastatin
# Tobacco abuse: Encouraged cessation especially given PVD. Mr.
___ declined nicotine patch, planned to quit cold ___.
TRANSITIONAL ISSUES
====================
- Code status: DNR/DNI, confirmed
- Emergency contact: ___ (wife) ___
- Studies pending on discharge: abscess fluid culture ___,
blood culture ___
- Please encourage tobacco cessation, patient plans to quit
- New diagnosis of DM2: Initiated 500mg metformin once daily; pt
can likely be managed with diet and exercise ___ future
- Twice daily iodoform packing, teaching done with patient and
wife will assist.
- seen by Nutrition at ___ please ___ at ___
- Follow up with hepatology for consideration of newer anti-HCV
agents for genotype 1B HCV.
- Follow up with Dr. ___ fem-pop bypass especially
given significant PVD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HTN, EtOH abuse, depression and several
prior suidicide attempts, seen at ___ yesterday
after taking 27 tabs of lorazepam, discharged to ___, and
who presents now after he was found to he shaky, diaphoretic,
and hypoxic. Per reports, patient took approximately 27
lorazepam tabs, 12 paxil tabs, along with a beer and ___ quart
of rum. Was treated at OSH, where serum EtOH level 216 per
report, and discharged to ___. Received lorazepam there
earlier today after he was noted to be shaky, disorganized,
confused, and picking at air, given his history of EtOH use. Was
later noted to be more somnolent with RR 14 and O2 sat 90% on
RA. Sent to ED for further evaluation.
.
In the ED, initial VS: 96.3 86 145/84 16 100% NRB. Labs notable
for mild leukocytosis of 11.4 with 73.3% N. Chem7 unremarkable,
and serum tox negative. His ABG showed hypoxemia with pO2 77,
but normal pH and no evidence of CO2 retention. Peak flow was
440. He received levofloxacin empirically for PNA, though prelim
read of CXR does not show any acute process. A CT torso was
obtained, which on prelim read is negative for PE. Toxicology
was consulted for new hypoxia in the setting of a recent
lorazepam overdose. They recommended supportive care and further
work-up to exlcude infection or PE. Did not recommend any
decontamination. Patient admitted to Medicine for further
evaluation, as he would still intermittently desat to low ___.
Of note, is under ___ and will need 1:1 sitter.
.
Currently, patient sleeping but arousable. Denies any chest pain
or dyspnea. Denies any current SI or HI.
Past Medical History:
Depression, history of prior suicide attempts
HTN
EtOH abuse
Social History:
___
Family History:
Depression in father, brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp ___ F, BP 138/89, HR 89, R 20, O2-sat 99% 2L
GENERAL: WDWN male, lying flat in bed, sleeping but arousable,
NAD
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, dry mucous
membranes, OP clear
NECK: supple, no cervical LAD
LUNGS: CTAB, no wheezing, rales, or rhonchi, good air movement,
respirations unlabored, no accessory muscle use
HEART: RRR, nl S1-S2, no r/m/g
ABDOMEN: bowel sounds present, soft, NT, ND, ?
hepatosplenomegaly, no guarding or rebound tenderness
EXTREMITIES: warm, well-perfused, 2+ pulses, no edema
SKIN: diaphoretic, no rashes or lesions
NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength ___
throughout
PSYCH: calm, answering questions appropriately
.
DISCHARGE PHYSICAL EXAM:
VS: 98.3, 131/85, 76, 18, 97RA
GENERAL: Well apearing man in NAD, laying in bed calmly
HEENT: Oropharynx clear, thick neck, reports history of snoring
but no workup for OSA
LUNGS: CTAB, no wheezing, rales, or rhonchi, good air movement,
respirations unlabored, no accessory muscle use
HEART: RRR, nl S1-S2, no r/m/g
ABDOMEN: bowel sounds present, soft, NT, ND, firmness of the LUQ
which appears to be his abdominal muscle wall
EXTREMITIES: warm, well-perfused, 2+ pulses, no edema
PSYCH: calm, answering questions appropriately
Pertinent Results:
ADMISSION LABS:
.
___ 08:14PM BLOOD WBC-11.4* RBC-4.50* Hgb-14.2 Hct-40.5
MCV-90 MCH-31.5 MCHC-35.1* RDW-13.7 Plt ___
___ 08:14PM BLOOD Neuts-73.3* ___ Monos-4.7 Eos-0.6
Baso-0.5
___ 08:14PM BLOOD Glucose-90 UreaN-17 Creat-1.0 Na-141
K-4.3 Cl-103 HCO3-29 AnGap-13
___ 08:14PM BLOOD ALT-22 AST-20 LD(LDH)-183 AlkPhos-70
TotBili-0.5
___ 08:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:14PM BLOOD Calcium-9.6 Phos-4.5 Mg-2.0
___ 09:26PM BLOOD Type-ART pO2-77* pCO2-45 pH-7.42
calTCO2-30 Base XS-3
.
PERTINENT LABS:
.
___ 08:14PM BLOOD ALT-22 AST-20 LD(LDH)-183 AlkPhos-70
TotBili-0.5
___ 08:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:26PM BLOOD Type-ART pO2-77* pCO2-45 pH-7.42
calTCO2-30 Base XS-3
.
DISCHARGE LABS:
.
___ 05:40AM BLOOD WBC-10.0 RBC-4.59* Hgb-14.2 Hct-40.7
MCV-89 MCH-30.9 MCHC-34.9 RDW-13.9 Plt ___
___ 05:35AM BLOOD Glucose-79 UreaN-20 Creat-0.9 Na-140
K-4.0 Cl-100 HCO3-31 AnGap-13
.
MICRO/PATH:
.
Blood Cultures x 2 ___: NGTD but final result pending
.
IMAGING/STUDIES:
.
CXR ___:
There is a relatively poor inspiratory effort. Allowing for
this, the cardiomediastinal silhouette is unremarkable and the
lungs appear grossly clear. Some degenerative change is noted
within the thoracic spine.
CONCLUSION: No definitive acute findings.
.
CT Chest/Abdomen/Pelvis With Contrast ___:
IMPRESSION:
1. No evidence of aortic dissection and no large central
pulmonary embolism. However, due to motion artifact, segmental
and subsegmental emboli cannot be excluded.
2. Diverticulosis, but no diverticulitis.
3. Moderate atherosclerotic calcifications of the abdominal
aorta.
Medications on Admission:
MEDICATIONS:
Lisinopril 10mg daily
Bupropion XL 300mg daily
Seroquel XL 100mg HS
Celexa 40mg daily
Paroxetine 30 mg daily
.
MEDICATIONS ON TRANSFER:
Lisinopril 10mg daily
Bupropion XL 300mg daily
Seroquel XL 100mg HS
Celexa 20mg daily
Trazodone 50mg HS prn insomnia
Acetaminophen 650mg Q4H prn pain
Thiamine 100mg daily
MVI daily
Folate 1mg daily
Lorazepam prn EtOH withdrawal symptoms
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. bupropion HCl 100 mg Tablet Extended Release Sig: Three (3)
Tablet Extended Release PO QAM (once a day (in the morning)).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. quetiapine 50 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet PO at bedtime.
8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: MAX OF 3 GRAMS DAILY.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Transient hypoxia from likely COPD and obstructive sleep apnea
-Depression
-Suicidality and suicide attempt
SECONDARY:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: Chest radiograph.
INDICATION: Query infectious process.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: None.
REPORT:
There is a relatively poor inspiratory effort. Allowing for this, the
cardiomediastinal silhouette is unremarkable and the lungs appear grossly
clear. Some degenerative change is noted within the thoracic spine.
CONCLUSION: No definitive acute findings.
Radiology Report
INDICATION: ___ with shortness of breath. Please assess for PE or
aortic dissection.
TECHNIQUE: Contiguous MDCT images through the chest were obtained initially
without and subsequently with intravenous contrast. Axial, coronal, sagittal
and oblique reformats were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
CTA OF THE CHEST:
There are mild atherosclerotic calcifications of the coronary arteries and the
aortic arch. There is no pneumomediastinum and no mediastinal hemorrhage.
There is no pericardial and no pleural effusion.
There is no axillary, hilar, or mediastinal lymphadenopathy.
The thoracic aorta is normal. There is no evidence of aortic dissection and
no large central pulmonary embolism. However, due to motion artifact,
segmental and subsegmental emboli cannot be excluded. Paraseptal emphysema is
seen predominantly in the upper lobes. There are mild bibasilar atelectasis.
There is no focal consolidation.
There is no pneumothorax.
CTA OF THE ABDOMEN:
There are no focal liver lesions. The gallbladder is normal. The pancreas
and spleen are normal. There is a small accessory spleen in the left upper
quadrant. The kidneys are normal. The adrenal glands are normal and there is
no retroperitoneal or mesenteric lymphadenopathy.
There are moderate atherosclerotic calcifications of the abdominal aorta.
Incidental note is made of kinking of the celiac axis. This can be seen in
median arcuate ligament syndrome, however, is nonspecific without abdominal
symptoms. There are moderate-to-severe atherosclerotic calcifications of the
iliac arteries bilaterally.
There is no retroperitoneal or mesenteric lymphadenopathy. The esophagus,
small and large bowel, are normal.
CT OF THE PELVIS: The urinary bladder is partially visualized and appears
normal. There is no free fluid and no free air.
IMPRESSION:
1. No evidence of aortic dissection and no large central pulmonary embolism.
However, due to motion artifact, segmental and subsegmental emboli cannot be
excluded.
2. Diverticulosis, but no diverticulitis.
3. Moderate atherosclerotic calcifications of the abdominal aorta.
Finding that a small PE cannot be excluded was discussed with Dr. ___ at 11 pm
by Dr. ___ on ___/
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB/HYPOXIA
Diagnosed with HYPOXEMIA, MAJOR DEPRESSION-UNSPEC
temperature: 96.3
heartrate: 86.0
resprate: 16.0
o2sat: 100.0
sbp: 145.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | ___ with HTN, EtOH abuse, depression, and several prior suicide
attempts, recent overdose on lorazepam and admission to
___, who was transferred here for evaluation of hypoxia.
.
# Hypoxia/Likely Obstructive Sleep Apnea: He was admitted for
desaturation to as low as 90% on RA after getting a dose of
ativan at ___. Per nursing notes there, he was noted to
apneic pauses for 6 seconds while sleeping. Had unremarkable
CXR, CTA chest and abdomen, and ABG which showed mild hypoxia
but no acidosis or CO2 retention. When evaluated on the floor,
he was satting in the mid-90's on RA at rest and did not
desaturate on ambulation and was without symptoms. His temporary
desaturation may have been secondary to respiratory depression
given recent benzodiazepine overdose on top of likely background
COPD given his 40+ packyear smoking history as well as what
seems to be obstructive sleep apnea (per wife he snores, and he
has a thick neck on exam but no prior sleep study). We would
recommend outpatient pulmonary function testing and sleep study
for obstructive sleep apnea once his larger, psychiatric issues
resolve. Would recommend against sedating medications such as
ativan or narcotics that may decrease respiratory drive as this
may exacerbate sleep apnea and make him more likely to have
hypoxia.
.
# Suicide attempt/Intentional Overdose: Recent overdose on
lorazepam as well as paxil, and per history patient has history
of prior suicide attempts. Currently denies SI or HI but feels
"down". He was on ___ from ___, had a 1:1 sitter,
and was discharged back there for further management.
.
# Major Depressive Disorder: Feeling down and 1 day out from
suicide attempt. He was continued on bupropion XL, seroquel XL,
and celexa in-house.
.
# EtOH abuse: Last drink was morning of ___. He denied prior
history of withdrawal and demonstrated no symptoms or signs of
withdrawal. His LFT's were wnl's. He was monitored on CIWA and
was continued on thiamine, folate, and multivitamin. He did not
require any ativan or valium.
.
# HTN: Stable. Continued on lisinopril.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / naproxen
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Mechanical Thrombectomy
History of Present Illness:
___ (DOB ___ is an ___ woman with
hypertension, rheumatoid arthritis, and a remote history of lung
cancer in remission who presents as a code stroke transfer from
___ for thrombectomy after witnessed onset of a
left MCA syndrome earlier this evening.
History is limited at the present time given the urgency of the
patient's care. Per discussion with the vascular neurology
fellow, the patient developed sudden onset right-sided weakness
and language symptoms at 6:30 ___.
She was brought to ___ where she
received TPA starting at 7:25 ___. Her initial ___ stroke scale
there was at least 12. It was not complete however due to the
urgency of obtaining the below described images and coordinating
subsequent transfer for thrombectomy.
The patient was brought to ___
via med flight. She landed earlier this evening at
approximately
9 ___. She was brought directly from the helicopter pad to the
thrombectomy suite.
Unable to obtain ROS given acuity.
Past Medical History:
HTN
Lung cancer, ___ years ago, currently in remission
Bilateral calf pain for 1 month (being worked up by PCP)
Rheumatoid arthritis
Multiple retinal detachments OD
Social History:
___
Family History:
No family history of stroke or MI.
Physical Exam:
ADMISSION EXAM
Vitals: Afebrile, BP 130s/80s per med flight personnel
General: Awake, alert, minimally conversant
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: Soft, non-distended
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic Exam:
-Mental Status: Alert, eyes open, able to say a few words such
as
hospital. Does not reliably follow commands - able to open/close
eyes but unable to grab/release examiner's hand. Able to name
"glasses" but unable to name the month or how hold she is in
years. x 3.
-Cranial Nerves:
II, III, IV, VI: EOMI without nystagmus.
VII: Right facial droop.
VIII: Hearing intact to conversation
-Motor: Normal bulk, tone throughout. Unable to assess pronator
drift given acuity of situation. No adventitious movements, such
as tremor, noted. No asterixis noted. Patient was apparently
full
strength in the left leg and left arm. Able to raise right arm
antigravity to touch nose. Able to wiggle right toes.
-Sensory: Unable to assess given acuity.
-DTRs: Unable to assess given acuity.
-Coordination: No dysmetria on FNF bilaterally.
-Gait/Station: Unable to assess.
DISCHARGE EXAM
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Pertinent Results:
ADMISSION
___ 12:40AM BLOOD WBC-11.0* RBC-3.50* Hgb-10.5* Hct-32.8*
MCV-94 MCH-30.0 MCHC-32.0 RDW-14.5 RDWSD-49.9* Plt ___
___ 12:40AM BLOOD ___ PTT-33.4 ___
___ 12:40AM BLOOD Glucose-135* UreaN-7 Creat-0.6 Na-133*
K-3.9 Cl-99 HCO3-25 AnGap-9*
___ 12:40AM BLOOD ALT-<5 AST-8 LD(LDH)-160 CK(CPK)-54
AlkPhos-49 TotBili-0.3
___ 12:40AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.6 Mg-1.5*
Cholest-197
___ 12:40AM BLOOD %HbA1c-5.9 eAG-123
___ 12:40AM BLOOD Triglyc-175* HDL-41 CHOL/HD-4.8
LDLcalc-121
___ 12:40AM BLOOD TSH-8.9*
___ 06:37AM BLOOD Free T4-1.0
___ 12:40AM BLOOD CRP-6.5*
___ 12:52AM BLOOD ___ pH-7.33* Comment-GREEN TOP
___ 12:52AM BLOOD freeCa-1.11*
REPORTS
___ CTA H&N - CTA NECK:
1. Severe mixed atherosclerosis the aortic arch and its major
branches.
2. A severely atherosclerotic retroesophageal right subclavian
artery
demonstrates a focal posteriorly oriented outpouching measuring
approximately
8 x 8 mm (series 3, image 68) concerning for pseudoaneurysm
formation.
Calcifications adjacent to this outpouching may imply
chronicity.
3. Calcified plaque formation at the left common carotid origin
with greater
than 50% stenosis.
4. Severe mixed calcified and noncalcified plaque formation at
the left
carotid bifurcation with complete occlusion of the left internal
carotid
artery from just above the internal carotid artery origin
through the distal
petrous ICA, likely secondary to atherosclerosis.
5. There is severe mixed calcified and noncalcified plaque
formation at the
right carotid bifurcation with focal 80% stenosis of the right
proximal ICA by
NASCET criteria, which is reconstituted distally.
Calcified plaque at the right vertebral artery origin with
severe stenosis,
with distal reconstitution.
CTA HEAD:
1. Reconstitution of the occluded left internal carotid artery
at the level of
the cavernous segment. The left ACA and posterior communicating
artery are
patent. There is patency but asymmetric diffuse narrowing of the
left MCA.
2. The right MCA, ACA, posterior communicating arteries and the
posterior
circulation appears normal.
OTHER:
1. Soft tissue density at the left lung apex surrounding the
branches of the
left upper lobe bronchus with bronchiectasis is incompletely
evaluated on the
current study and unchanged since CT chest dated ___.
This may
reflect chronic scarring and atelectasis and/or postsurgical
changes, however
underlying mass is not excluded. Consider follow-up
high-resolution CT of the
chest as well as comparison to any available outside imaging.
Please refer to
report from dedicated CT chest performed ___ for
discussion of
pulmonary findings.
___ Cardiovascular Transthoracic Echo Report
No structural cardiac source of embolism (e.g.patent foramen
ovale/atrial septal defect, intracardiac thrombus, or
vegetation) seen. Normal left ventricular wall thickness, cavity
size, and regional/global biventricular systolic function.
Increased PCWP. No valvular pathology or pathologic flow
identified. Borderline elevated pulmonary artery systolic
pressure.
___ Imaging CT HEAD W/O CONTRAST
Probably unchanged extent of hemorrhagic transformation of left
middle
cerebral artery infarction since the very recent prior MR.
___ Imaging MRI & MRA BRAIN AND MRA
1. Subacute infarction in the left MCA territory, including the
inferior
frontal gyrus, insular cortex, and left basal ganglia.
Unchanged subarachnoid
hemorrhage adjacent to patient's infarct core without evidence
of
intraparenchymal hemorrhage.
2. Additional areas of infarction are seen in the right frontal
as well as the
left frontal and parietal lobes, likely due to distal emboli.
3. Short patent segment of the left internal carotid artery is
visualized
distal to the carotid bifurcation, with occlusion of the
remaining left
internal carotid artery proximal to the supraclinoid segment,
unchanged
compared to final run from patient's recent angiogram.
4. Reconstitution of the supraclinoid ICA as well as the distal
left MCA/ACA
territories is likely due to collateral filling from the
ophthalmic artery, as
seen on patient's angiogram.
5. Atheromatous, stenoses of the ostia of the bilateral common
carotid and
vertebral arteries result in greater than 50% narrowing.
Additional stenosis
at the ostium of the left subclavian artery results in less than
25%
narrowing. However, approximately 1 cm from the ostium of the
left subclavian
artery, there is an additional short segment narrowing of
greater than 50%.
6. High-grade stenosis of the proximal right internal carotid
artery, spanning
approximately 9 mm in length. Stenosis is so severe as to
produce near
complete loss of signal, preventing reliable measurement of the
residual lumen
diameter, likely greater than 75%.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
6. leflunomide 10 mg oral unknown
7. Multivitamins 1 TAB PO DAILY
8. Timolol Maleate 0.25% 1 DROP RIGHT EYE QID
9. Biotene Dry Mouth Oral Rinse (saliva substitute combo no.9)
mucous membrane DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Biotene Dry Mouth Oral Rinse (saliva substitute combo no.9)
mucous membrane DAILY
6. Calcium Carbonate 500 mg PO QID:PRN heartburn
7. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
8. leflunomide 10 mg oral unknown
9. Multivitamins 1 TAB PO DAILY
10. Timolol Maleate 0.25% 1 DROP RIGHT EYE QID
11. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute Ischemic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with left MCA stroke// Eval for hemorrhage. To
be done 19:00 ___
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
2) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.7 mGy-cm.
Total DLP (Head) = 1,308 mGy-cm.
COMPARISON: MRA head ___, CT head ___
FINDINGS:
Effacement of gray-white matter distinction in the mid left frontal lobe
corresponds to a region of cortical infarction, better delineated on the very
recent prior diffusion-weighted imaging. Decreased opacification along left
frontal sulci suggests clearance of contrast compared to the recent prior CT
and to some extent this may also reflect redistribution of subarachnoid
hemorrhage since that time. Compared to the more recent MR, however, the
extent of hyperdense material on this study corresponds well to areas of
susceptibility on the recent recent susceptibility weighted MR imaging. This
is consistent with short-term stability of the extent of subarachnoid
hemorrhage associated with recent infarction. Hypodensity within the left
basal ganglia consistent with known left MCA infarct. No substantial midline
shift or mass effect.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Both orbits
have been replaced, otherwise the visualized portion of the orbits are
unremarkable.
IMPRESSION:
Probably unchanged extent of hemorrhagic transformation of left middle
cerebral artery infarction since the very recent prior MR.
Radiology Report
EXAMINATION: Chest radiographs, three views.
INDICATION: Dobhoff placement.
COMPARISON: Chest CT is available from ___.
FINDINGS:
Third of three views demonstrates Dobhoff tube terminating in the gastric
antrum. Otherwise, there has been no significant short-term change including
no short-term change in left apical opacification.
IMPRESSION:
Dobhoff tube terminating in the stomach.
Radiology Report
EXAMINATION: Video oropharyngeal swallow exam
INDICATION: ___ year old woman with LMCA stroke w/ dysphagia// ?Aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 3 minutes 31 seconds. Air kerma: 21 mGy. DAP: 355 uGym2.
COMPARISON: No prior video oropharyngeal swallows.
FINDINGS:
There was silent aspiration after consumption of thin and nectar thick
liquids. There was difficulty clearing the ingested bolus resulting in
diffuse oro pharyngeal residue.
There is a nasoenteric tube.
IMPRESSION:
1. Silent aspiration with thin and nectar thick liquids.
2. Difficulty clearing the oropharynx after the bolus with diffuse
oropharyngeal residue.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with left MCA syndrome// Any evidence of fluid
overload vs pneumonia?
TECHNIQUE: Frontal AP chest radiograph.
COMPARISON: Comparisons made to prior chest radiograph from ___, as
well as chest CT from ___.
FINDINGS:
Low lung volumes compared to previous. The cardiomediastinal silhouette, and
hila are normal and stable. Stable appearance of left upper lobe density,
which is better seen on chest CT ___, concerning for postobstructive
atelectasis. The pleural surfaces are normal. Interval placement of Dobhoff
tube which courses down the esophagus past the diaphragm and into the distal
stomach. There is no evidence for pulmonary edema..
IMPRESSION:
Interval placement of Dobhoff tube, which terminates in the distal stomach.
Otherwise, stable appearance of the chest without signs of pulmonary edema.
Radiology Report
INDICATION: ___ year old woman with L MCA stroke and persistent dysphagia//
PEG placement
COMPARISON: Chest CT from ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___ fellow performed the procedure. Dr.
___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
37.5mcg of fentanyl throughout the total intra-service time of 35 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: See above
CONTRAST: 35 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2.6 min, 39 mGy
PROCEDURE: 1. Placement of a MIC gastrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A ___ wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
Tract dilation was performed using a 10 x 4 mm Conquest balloon, preloaded
with the MIC gastrostomy catheter. The gastrostomy catheter was advanced
along with the balloon over the wire into position. The catheter was secured
by instilling 7 ml of dilute contrast into the balloon in the stomach. The
indwelling dilation balloon was deflated and removed along with the wire
through the gastrostomy tube. Intragastric positioning was confirmed with a
contrast injection. The tube with the inflated balloon, surrounded by
intraluminal contrast, was freely mobile within the stomach. The catheter was
then flushed, capped and secured to the skin with the disc hubbed close to the
T fastener hubs.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a MIC gastrostomy tube.
IMPRESSION:
Successful placement of a MIC gastrostomy tube. The catheter should not be
used for 24 hours.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with L MCA syndrome// is there complete vs
partial occlusion of left ICA
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
2) Spiral Acquisition 4.6 s, 35.9 cm; CTDIvol = 13.3 mGy (Body) DLP = 477.4
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 17.8 mGy (Body) DLP =
8.9 mGy-cm.
Total DLP (Body) = 488 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: MRI/MRA brain and MRA neck dated ___
Head CT dated ___
CTA chest dated ___
Cerebral angiogram dated ___
CTA neck dated ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is been interval near complete resolution of the previously noted left
MCA territory intraparenchymal hemorrhage and left convexity subarachnoid
hemorrhage, with trace residual sulcal hyperdensity along the left parietal
lobe which may reflect residual blood products. There is decreased
parenchymal edema in the left MCA territory with increasing hypoattenuation
within the left frontal and parietal lobes, left basal ganglia and right
frontal lobe compatible with evolving infarction. No evidence of new
hemorrhage. No mass-effect or midline shift. The basilar cisterns remain
patent.
Additional scattered bilateral periventricular white matter and subcortical
regions of hypoattenuation are nonspecific but compatible with chronic
microvascular ischemic changes. Prominence of the ventricles and sulci
diffusely is compatible with atrophic changes.
The visualized portion of the paranasal sinuses, mastoid air cells,and middle
ear cavities are clear. A hearing aid device is noted on the left. Status
post bilateral lens replacement and scleral band placement on the right.
Nasoenteric tube partially imaged.
CTA NECK:
There is severe atherosclerosis the aortic arch and its major branches. There
is a retroesophageal course of a severely atherosclerotic right subclavian
artery, which demonstrates a focal posteriorly oriented outpouching measuring
approximately 8 x 8 mm (series 3, image 68), likely a pseudoaneurysm.
Calcifications adjacent to this outpouching may imply chronicity.
There is calcified plaque at the left common carotid origin with greater than
50% stenosis. There is severe mixed calcified and noncalcified plaque
formation at the left carotid bifurcation with complete occlusion of the left
internal carotid artery from just above the internal carotid artery origin
through the distal petrous ICA.
There is calcified plaque formation at the origin of the right common carotid
artery from the aorta with less than 50% stenosis. There is severe mixed
calcified and noncalcified plaque formation at the right carotid bifurcation
with focal 80% stenosis of the right proximal ICA by NASCET criteria.
There is calcified plaque at the right vertebral artery origin with severe
stenosis, however distal reconstitution is noted. There is mild calcification
at the left vertebral artery origin without significant stenosis. Otherwise,
the bilateral vertebral arteries appear normal in course and caliber.
CTA HEAD:
There is reconstitution of the left internal carotid artery at the level of
the cavernous segment. The right internal carotid artery demonstrates mild
calcifications within the cavernous segment without stenosis. The right MCA,
ACA and posterior communicating arteries appear normal. The left ACA A1 and
A2 segments appear normal, as does the left posterior communicating artery.
There is patency but asymmetric diffuse narrowing of the left MCA. There is a
2 mm outpouching off the left M1 segment of the left middle cerebral artery
with exiting vessel near its tip, compatible with small infundibulum. The
posterior circulation appears normal. No evidence of aneurysm formation
greater than 3 mm.
The dural venous sinuses are patent.
OTHER:
Soft tissue density at the left apex surrounding the branches of the left
upper lobe bronchus with bronchiectasis is incompletely evaluated on the
current study and unchanged since CT chest dated ___. This may
reflect postsurgical changes/chronic scarring and atelectasis, however
underlying mass is not excluded. Follow-up high-resolution CT of the chest is
recommended as well as comparison to any available outside imaging. There is
mild scarring at the right lung apex. There is mild mediastinal
lymphadenopathy, with a subcarinal lymph node measuring up to 8 mm short axis.
Please refer to report from dedicated CT chest performed ___ for
discussion of pulmonary findings. The thyroid gland is homogeneous in
attenuation. Scattered subcentimeter cervical lymph nodes are noted
bilaterally without evidence of cervical lymphadenopathy by CT size criteria.
IMPRESSION:
CT HEAD:
1. Interval near complete resolution of previously noted left MCA territory
intraparenchymal hemorrhage and left convexity subarachnoid hemorrhage, with
now trace residual subarachnoid hemorrhage along the left parietal lobe.
2. Decreased parenchymal edema in the left MCA territory with increasing
hypoattenuation within the left frontal and parietal lobes, left basal ganglia
and right frontal lobe compatible with evolving infarcts/developing
encephalomalacia.
3. No definite acute intracranial hemorrhage. No significant mass-effect or
midline shift.
CTA NECK:
1. Severe mixed atherosclerosis the aortic arch and its major branches.
2. A severely atherosclerotic retroesophageal right subclavian artery
demonstrates a focal posteriorly oriented outpouching measuring approximately
8 x 8 mm (series 3, image 68) concerning for pseudoaneurysm formation.
Calcifications adjacent to this outpouching may imply chronicity.
3. Calcified plaque formation at the left common carotid origin with greater
than 50% stenosis.
4. Severe mixed calcified and noncalcified plaque formation at the left
carotid bifurcation with complete occlusion of the left internal carotid
artery from just above the internal carotid artery origin through the distal
petrous ICA, likely secondary to atherosclerosis.
5. There is severe mixed calcified and noncalcified plaque formation at the
right carotid bifurcation with focal 80% stenosis of the right proximal ICA by
NASCET criteria, which is reconstituted distally.
Calcified plaque at the right vertebral artery origin with severe stenosis,
with distal reconstitution.
CTA HEAD:
1. Reconstitution of the occluded left internal carotid artery at the level of
the cavernous segment. The left ACA and posterior communicating artery are
patent. There is patency but asymmetric diffuse narrowing of the left MCA.
2. The right MCA, ACA, posterior communicating arteries and the posterior
circulation appears normal.
OTHER:
1. Soft tissue density at the left lung apex surrounding the branches of the
left upper lobe bronchus with bronchiectasis is incompletely evaluated on the
current study and unchanged since CT chest dated ___. This may
reflect chronic scarring and atelectasis and/or postsurgical changes, however
underlying mass is not excluded. Consider follow-up high-resolution CT of the
chest as well as comparison to any available outside imaging. Please refer to
report from dedicated CT chest performed ___ for discussion of
pulmonary findings.
NOTIFICATION: The findings were discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at 4:36 pm, 10
minutes after discovery of the findings.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old woman with left MCA syndrome// Assess stroke
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Brain imaging was performed with diffusion, T1, FLAIR, T2, and gradient echo
technique.
Dynamic MRA of the neck was performed during administration intravenous
contrast.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: Multiple outside exams from ___ at 19:26; CT head from
___ at 02:25
FINDINGS:
MRI BRAIN:
Decreased diffusivity in the left MCA territory, within the inferior left
frontal gyrus, insula, with extension into the left basal ganglia (Series 4;
image 19, series 3; image 19), consistent with left MCA territory infarction.
Multiple additional infarcts are seen throughout the right frontal lobe
(series 4; image 26) as well as in the left frontal and parietal lobes, likely
due to distal emboli. There is increased FLAIR signal in these regions,
consistent with subacute time line.
Additional, periventricular and subcortical white matter FLAIR
hyperintensities are nonspecific, but likely suggestive of chronic
microvascular ischemic disease.
There is subarachnoid hemorrhage in the sylvian fissure, similar to the head
CT examination. There is no evidence of intraparenchymal hemorrhage.
Mild mucosal thickening of the bilateral anterior ethmoid air cells is noted.
Remaining paranasal sinuses are clear. There are bilateral lens replacements.
Right scleral buckle is noted.
MRA BRAIN/NECK:
Aberrant right subclavian is seen as the last vessel off the aortic arch.
Left common and external carotid arteries appear patent. Short, patent segment
of left internal carotid artery is visualized distal to the carotid
bifurcation, with occlusion of the remaining left internal carotid artery
proximal to the supraclinoid segment. The left supraclinoid internal carotid
artery as well as the A1 and M1 segments of the anterior and middle cerebral
arteries are identified. These likely fill via collaterals..
The posterior circulation appears normal. Right-sided anterior circulation
appears patent without aneurysm or stenosis.
Atheromatous stenoses of greater than 50% are noted at the ostia of the
bilateral common carotid and vertebral arteries. Additionally, there is
stenosis of less than 25% at the origin of the left subclavian artery and a
stenosis of greater than 50% approximately 1 cm from the ostium of the left
subclavian artery. Immediately distal to the right carotid bifurcation, there
is high-grade stenosis of the right internal carotid artery. Stenosis is
approximately 9 mm in length, with patency distal to this finding. The
narrowing is so severe as to produce near complete loss of signal. This
prevents a reliable measurement of the residual lumen diameter. It is likely
to be greater than 75% by NASCET criteria.
Beyond their ostia, bilateral vertebral arteries show no high-grade stenosis
with mild left dominance throughout their course. Basilar artery appears
patent.
IMPRESSION:
1. Subacute infarction in the left MCA territory, including the inferior
frontal gyrus, insular cortex, and left basal ganglia. Unchanged subarachnoid
hemorrhage adjacent to patient's infarct core without evidence of
intraparenchymal hemorrhage.
2. Additional areas of infarction are seen in the right frontal as well as the
left frontal and parietal lobes, likely due to distal emboli.
3. Short patent segment of the left internal carotid artery is visualized
distal to the carotid bifurcation, with occlusion of the remaining left
internal carotid artery proximal to the supraclinoid segment, unchanged
compared to final run from patient's recent angiogram.
4. Reconstitution of the supraclinoid ICA as well as the distal left MCA/ACA
territories is likely due to collateral filling from the ophthalmic artery, as
seen on patient's angiogram.
5. Atheromatous, stenoses of the ostia of the bilateral common carotid and
vertebral arteries result in greater than 50% narrowing. Additional stenosis
at the ostium of the left subclavian artery results in less than 25%
narrowing. However, approximately 1 cm from the ostium of the left subclavian
artery, there is an additional short segment narrowing of greater than 50%.
6. High-grade stenosis of the proximal right internal carotid artery, spanning
approximately 9 mm in length. Stenosis is so severe as to produce near
complete loss of signal, preventing reliable measurement of the residual lumen
diameter, likely greater than 75%.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 1:37 pm, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with L ICA/MCA occlusion now s/p tpa and
thrombectomy, no longer speaking, please eval for ?bleed// ?bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Head CT ___ performed at ___
___..
FINDINGS:
There is high density in the left frontal and temporal lobes as well as the
caudate, globus pallidus and putamen. This examination was performed after 2
CTA examinations and extended catheter arteriography, angioplasty, stenting
and thrombectomy. Therefore, much of this high density may represent contrast
enhancement in ischemic brain. However, a component of the high density is
clearly in the subarachnoid space. This would suggest contrast, blood, or
both in the left sylvian fissure. MR imaging may be helpful to determine the
extent of hemorrhage as opposed to contrast enhancement.
There is a broad area of hypodensity in the left middle cerebral artery
distribution that suggests early subacute infarction.
There is mild mass-effect on the left lateral ventricle without midline shift.
The ventricles and sulci are enlarged in an atrophic pattern.
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:
Hyperdensity in the left frontal and temporal lobes and basal ganglia suggests
contrast enhancement involving infarcted brain.
Broad area of hypodensity in the left middle cerebral artery distribution is
likely there are early subacute infarction.
The subarachnoid hemorrhage in the left sylvian fissure.
MR imaging may be helpful to delineate the extent of infarction and
hemorrhage.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with calf swelling, Dimer >21,000// Eval DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman CVA s/p tPA and thrombectomy with elevated
dimer, leg swelling// 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: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
3) Spiral Acquisition 3.6 s, 28.1 cm; CTDIvol = 9.0 mGy (Body) DLP = 252.8
mGy-cm.
Total DLP (Body) = 260 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: There is no definite evidence of pulmonary embolism.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. There are extensive atherosclerotic calcifications of
the thoracic aorta and its major vessels. Calcified and noncalcified
atherosclerotic plaques are seen in the aortic arch (02:26). The heart,
pericardium are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass. The esophagus is patulous.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is atelectasis of the Left upper lobe without definite
evidence of mass or bronchial obstruction. However, in the region of the Left
upper lobe bronchus, there is ill-defined soft tissue density, incompletely
characterized but likely the source of obstruction (02:38). There is
predominantly centrilobular emphysema, most prominent in the bilateral lung
apices. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: The thyroid gland is heterogeneous without evidence of a
discrete nodule. Otherwise, visualized portions of the base of the neck show
no abnormality.
ABDOMEN: There is a small hiatal hernia. A Right Bochdalek's hernia is
partially visualized. Otherwise, included portion of the upper abdomen is
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No definite evidence of pulmonary embolism.
2. Left upper lobe atelectasis without definite evidence of masses or
bronchial obstruction. Ill-defined soft tissue density in the region of the
Left upper lobe bronchus is incompletely characterized, but possibly the
source of obstruction. High-resolution chest CT when the patient is
clinically stable could be considered for further evaluation.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | TRANSITIONAL ISSUES
- We started plavix, but deferred ASA given her NSAID allergy
- Started Atorvastatin, monitor LDL and consider increase
- Continue to re-evaluate and advance diet as safely recommended
by outpatient SLP
- PEG in place
- Pulmonary findings incidentally found on CT H&N - follow up
with lung cancer Dr. ___
- Follow up with vascular surgery for right ICA stenosis within
1 month
Ms. ___ is a ___ year old lady with hypertension,
rheumatoid arthritis, and a remote history of lung cancer in
remission who is admitted to the Neurology stroke service with
Left MCA syndrome including aphasia and right sided weakness
secondary to an acute ischemic stroke in the Left MCA territory.
Her stroke was most likely secondary to an Atheroembolic event
given her risk factors and imaging findings with significant
collateral vasculature and significant intracranial and
extracranial atherosclerosis. She was not previously on
ASA/Plavix. We started plavix, but deferred ASA given her NSAID
allergy. Her deficits improved greatly prior to discharge with
remaining right sided weakness and improved, although still
present expressive aphasia. She will continue rehab at a rehab
center. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
biopsy of L thigh (___)
History of Present Illness:
Ms. ___ is ___ yo F hx poorly controlled IDDM, HLD, obesity,
and cognitive impairment sent in from clinic with pustular rash
on bilateral inquingal folds extending to the mid anterior
thigh.
Pt reports that she has had an ongoing rash in her inguinal
folds, beneath her breasts and bilateral thighs ongoing for the
past 4 months with no improvement with topical nystatin cream
and
powder for presumed intertrigo. Yesterday she noted that
blisters
overlying her rash burst with purulent drainage and worsening
pain. She presented to her PCP office today for daily insulin
injection and was noted to be crying in pain with worsening rash
and concern for superimposed bacterial infection, with
recommendation to admit for treatment as well as dermatology
consult. She denies any recent fever/chills, chest pain, SOB,
abdominal pain, n/v/d, dysuria. She notes that asides from her
daily insulin injection in clinic she manages her medications
herself and has been applying the nystatin cream herself. She
bathes about once weekly and cleans the areas of her rash about
as frequently.
- In the ED, initial vitals were:
T97.7, HR 82, BP 117/72, 95% RA
- Exam was notable for:
GEN: NAD
CV: RRR no mrg
Lung: CTAB
Abd: NTND. Diffuse confluent maculopapular rash on abdomen
Groin: Barrier Cream, in place diffuse erythema throughout the
inguinal fold bilaterally, also with multiple pustules on the
anterior thigh bilaterally. Scabbing bilaterally
Extremities: No edema warm well perfused
- Labs were notable for:
BMP: Cl 95 otherwise WNL, Cr 0.7
CBC: 12.7>10.7/35.2<396
- The patient was given:
IV CTX 1g
On arrival to the floor, patient reports the above. She notes
ongoing pain associated with her rash.
Past Medical History:
HLD
Cognitive impairment
syndrome X
Depression
Morbid obesity
Hypertension
OSA
T2DM
Vitamin D deficiency
Social History:
___
Family History:
Mother IDDM, Father HTN
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T98, BP 98/66, HR 64, RR 20, 92% RA
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. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Diffuse erythema with scale
around umbilicus as well as involving bilateral lower quadrants
and flanks with overlying scale
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: bright red erythema with satellite lesions and white
discharge underlying breast skin folds, panus and in bilateral
inguinal fold, extending down to anterior mid-bilateral thighs.
With several 1-2cm diameter crusted over lesions with no
purulent discharge - no underlying fluctuance, crepitance. no
vesicles or bullae
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
==========================
T 98.8, BP 104/65, HR 73, RR 18, 93% RA
GENERAL: Alert and in no acute distress.
HEENT: EOMI. Sclera anicteric. OP without erythema or white
patches.
CARDIAC: RRR, no murmurs.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender.
Diffuse erythema, which has become darker and less bright, with
scale around umbilicus and over bilateral lower quadrants and
flanks.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: erythema with satellite lesions has decreased in
intensity/brightness-no more white discharge under breast folds,
panus or groin folds. lesions extending down to anterior
mid-bilateral thighs that are improved compared to days prior.
Previously honey crusted lesions have fallen off and there are
remaining 1 and 2cm round erythematous plaques. No crepitus or
fluctuance. bx site on L thigh c/d/I.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. endorses
localized decreased sensation to light touch over lateral right
thigh. ___ strength throughout.
PSYCH: perseverating on burning of legs, on wanting
blood transfusions & surgery because her "blood was poisoned"
Pertinent Results:
ADMISSION LABS:
====================
___ 07:21PM BLOOD WBC-12.7* RBC-4.36 Hgb-10.7* Hct-35.2
MCV-81* MCH-24.5* MCHC-30.4* RDW-17.7* RDWSD-51.4* Plt ___
___ 07:21PM BLOOD Neuts-76.2* Lymphs-16.2* Monos-6.1
Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.69* AbsLymp-2.06
AbsMono-0.78 AbsEos-0.09 AbsBaso-0.04
___ 07:21PM BLOOD Glucose-203* UreaN-15 Creat-0.7 Na-137
K-4.1 Cl-95* HCO3-30 AnGap-12
LABS ON DISCHARGE:
====================
___ 04:55AM BLOOD WBC-10.4* RBC-4.34 Hgb-10.5* Hct-36.4
MCV-84 MCH-24.2* MCHC-28.8* RDW-18.2* RDWSD-54.8* Plt ___
PERTINENT LABS:
====================
___ 05:04AM BLOOD %HbA1c-10.1* eAG-243*
MICROBIOLOGY:
====================
___ 07:52PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-MOD*
PATHOLOGY:
=============
preliminary bx results (r thigh): (epidermal hyperplasia with
hypergranulosis, hyperkeratosis, and perivascular lymphocytic
inflammation), but does not appear consistent with psoriasis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 300 mg PO BID
2. nystatin 100,000 unit/gram topical DAILY
3. Lisinopril 20 mg PO DAILY
4. Glargine 82 Units BedtimeMax Dose Override Reason: home dose
5. Atorvastatin 80 mg PO QPM
6. empagliflozin 25 mg oral DAILY
7. Pioglitazone 15 mg PO DAILY
8. Vitamin D 3000 UNIT PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Clotrimazole Cream 1 Appl TP BID intertrigo
RX *clotrimazole 1 % apply to rash on legs, groins, belly, and
under breasts twice a day Refills:*0
2. Fluconazole 150 mg PO 1X/WEEK (___) Duration: 3 Doses
Give on ___
3. Gabapentin 300 mg PO TID
4. Glargine 82 Units BedtimeMax Dose Override Reason: home dose
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. empagliflozin 25 mg oral DAILY
8. Lisinopril 20 mg PO DAILY
9. Pioglitazone 15 mg PO DAILY
10. Vitamin D 3000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
intertrigo w/ superimposed bacterial infection
Secondary:
DMII
obesity
Cognitive impairment
Obesity hypoventilation syndrome
meralgia paresthetica
Discharge Condition:
Mental Status: cognitively impaired
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with RW and assist x1. Encourage
independence with ADLs and functional mobility as pt
is at risk for deconditioning. OOB to chair ___ with assist
x1. Please use chair alarm when pt OOB
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo F here with leukocytosis// eval for pneumonia
TECHNIQUE: Portable AP chest
COMPARISON: None
FINDINGS:
Lung volumes are low, exaggerating the cardiomediastinal silhouettes. No
focal consolidations are seen. There is mild-to-moderate pulmonary edema.
There is no pneumothorax or large volume pleural effusion.
IMPRESSION:
1. No pneumonia.
2. Low lung volumes and mild to moderate pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Local infection of the skin and subcutaneous tissue, unsp, Type 2 diabetes mellitus without complications
temperature: 97.7
heartrate: 82.0
resprate: 16.0
o2sat: 95.0
sbp: 117.0
dbp: 72.0
level of pain: 8
level of acuity: 3.0 | BRIEF HOSPITAL COURSE
=================================
Ms. ___ is ___ yo F hx poorly controlled IDDM, HLD, obesity,
and cognitive impairment sent in from clinic with pustular rash
on bilateral inquingal folds and pannus extending to the mid
anterior thigh concerting for yeast infection with superimposed
bacterial skin infection. Consulted Derm for help in evaluation
of this rash, which they felt could also be attributed to
inverse psoriasis. They obtained biopsy on ___, with
preliminary results that showed no evidence of psoriasis but
rather changes of chronic inflammation. Transitioned patient
from nystatin to clotrimazole cream for better ___ and tinea
coverate. Initiated and completed 5 day course oral doxycycline
and cephalexin for presumed bacterial impetigo & folliculitis.
Also initiated oral fluconazole once weekly for 4 weeks. Due to
patient's cognitive impairment, wound care followed this patient
for assistance in managing her wounds. Furthermore, ___, OT,
care management also work diligently to evaluate patient and
ensure safe discharge to a rehab facility.
TRANSITIONAL ISSUES:
=================================
MEDICATIONS:
- New Meds: clotrimazole cream (stop only when told by
physician), fluconazole once weekly for 4 weeks ___,
___, & ___, scheduled acetaminophen
- Changed Meds: increased gabapentin from 300mg BID to ___ TID
- Stopped Meds: nystatin
___
[ ]Dermatology: check skin lesions and ___ on bx results
from ___.
[ ]Dermatology: if recommending extension of fluconazole beyond
4th dose on ___, would recommend baseline LFTs as pt has not had
any since ___.
[ ]PCP: continued management of patients DM, A1c 10.1% on
___
[ ]PCP: can consider discontinuation of ASA for primary
prophylaxis
[ ]PCP: please decrease dose of gabapentin from 300mg TID to
original dose of 300mg BID upon resolution of rash.
[ ]PCP: please ___ on pt's burning sensation on Lateral
right thigh. suspect meralgia paresthetica. recommend weight
loss sleeping on back or left side and ___ eval.
[ ]PCP: pt with frequent delusions, similar to her baseline. may
benefit from psychiatric evaluation.
[ ]Rehab: wound care and hygiene assistance, assistance with
medication management and adherence. please remove sutures from
biopsy site on ___.
[ ]Rehab: Please fill out patient's FMLA paperwork
RASH CARE:
Pressure relief per pressure injury guidelines
Support surface: NP 24
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times
Waffle Boots ( X ) Multipodis Splints ( )
If OOB, limit sit time to one hour at a time and
Sit on a pressure redistribution cushion-
Standard Air ( X )
ROHO ( ) Obtain from ___
OR ___ air full length chair cushion ( ) (Obtain from ___
Elevate ___ while sitting.
Moisturize B/L ___ and feet, intact skin only BID with Sooth
And Cool Ointment.
Topical Therapy: After showering
Daily cleanse affected areas with No Rinse foam cleanser
using
disposable wash cloths, pat dry
Apply Xeroform gauze to inguinal folds
Separate folds with Sofsorb pads
Change dressing daily and PRN
BIOPSY SITE CARE (L Thigh):
Clean biopsy site with soap, water, then pat dry every day for 2
weeks.
Cover with a thin layer of vaseline and perform dressing change
every day for 2 weeks.
# CODE: Full - presumed
# CONTACT: ___ (sister) ___ or ___ also a
contact |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HTN, hyperlipidemia and no prior abdominal
surgery presenting with acute onset of abdominal pain. Patient
states she was in her usual state of health until 3am this
morning when she awoke with acute onset of abdominal pain. She
states her pain is mostly in the epigastrium. She was brought
initially to ___, where she underwent a CT scan
concerning for a possible closed loop obstruction. She states
during her work-up there she had a small 'dark' bowel movement.
Since her transfer she states her pain has nearly completely
resolved. She denies nausea or vomiting, currently denies
abdominal pain. She has not had prior similar episodes; denies
any association with food or fear of food; denies fevers, chills
or unintentional weight loss.
She has a history of colonic polyps with last colonoscopy within
the past few years demonstrated such. She denies hematochezia or
melena otherwise with stable weight, energy and appetite. No
recent travel or sick contacts.
Past Medical History:
PMH: HTN, hyperlipidemia, hx colonic polyps
PSH: D&C
Social History:
___
Family History:
Fam Hx: non-contributory
Physical Exam:
Vitals:
AVSS
Gen: AAOx3 NAD comfortable
CV: NRRR
Chest: Clear
Abd: Soft, minimally ttp, nondistended without focal tenderness,
mass, hernia or oranomegaly. Without guarding
Extrem: Without deformity or edema
Pertinent Results:
___ 06:56AM BLOOD WBC-4.8 RBC-3.31* Hgb-10.1* Hct-31.6*
MCV-96 MCH-30.5 MCHC-32.0 RDW-13.6 RDWSD-48.0* Plt ___
___ 07:20PM BLOOD WBC-7.1# RBC-3.66* Hgb-11.4 Hct-34.7
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.5 RDWSD-46.4* Plt ___
___ 07:20PM BLOOD Neuts-82.3* Lymphs-12.3* Monos-4.8*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.81# AbsLymp-0.87*
AbsMono-0.34 AbsEos-0.00* AbsBaso-0.02
___ 06:56AM BLOOD Plt ___
___ 07:20PM BLOOD Plt ___
___ 07:20PM BLOOD ___ PTT-29.5 ___
___ 06:56AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-139
K-3.2* Cl-101 HCO3-27 AnGap-14
___ 07:20PM BLOOD Glucose-112* UreaN-11 Creat-0.7 Na-141
K-3.7 Cl-102 HCO3-24 AnGap-19
___ 06:56AM BLOOD estGFR-Using this
___ 07:20PM BLOOD estGFR-Using this
___ 07:20PM BLOOD ALT-18 AST-20 AlkPhos-95 TotBili-0.7
___ 06:56AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
___ 07:20PM BLOOD Albumin-4.4
___ 07:35PM BLOOD Lactate-1.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QMON
2. Atorvastatin 20 mg PO QPM
3. Hydrochlorothiazide 25 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ capsule(s) by mouth every 6 hours
Disp #*30 Capsule Refills:*0
2. Alendronate Sodium 70 mg PO QMON
3. Atorvastatin 20 mg PO QPM
4. Hydrochlorothiazide 25 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Outside hospital CT abdomen pelvis second opinion
interpretation.
INDICATION: ___ with constipation, nausea.
TECHNIQUE: Study was performed at OSH. MDCT images were acquired after
administration of oral and intravenous contrast. Sagittal and coronal
reformatted images were generated.
DOSE: Outside hospital dose report with DLP of 569 mGy-cm
COMPARISON: Comparison is made with CT torso from ___.
FINDINGS:
LOWER CHEST: The imaged lung bases notable for minimal atelectasis. The
imaged portion of the heart appears normal.
ABDOMEN: The liver, gallbladder, spleen, adrenals, pancreas and kidneys
appear normal. The stomach contains a large amount of enteric contrast. The
duodenum is normal. The proximal loops of jejunum appear contrast filled and
unremarkable. There is a point of caliber transition identified on series 6
image 78. Distal to this transition point, there is an abnormal segment of
small bowel which is fluid distended with mesenteric edema consistent with
closed loop obstruction. A second transition point is identified on series 6,
image 85. Of note, the affected small bowel appears to enhance normally.
Distal to this point, the small bowel normalizes. Abdominal ascites is
moderate. The colon and appendix appear normal.
PELVIS: The uterus and adnexal structures appear normal. Free fluid in the
pelvis is small in overall volume. No pelvic sidewall or inguinal adenopathy.
The urinary bladder is mostly decompressed.
BONES: No worrisome bony lesion. Degenerative changes are notable at L5-S1.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Findings concerning for closed loop small bowel obstruction with associated
ascites and mesenteric edema.
Radiology Report
EXAMINATION: CT abdomen pelvis from intravenous and oral contrast
INDICATION: ___ with history of intermittent abdominal pain, most recent CT
concerning for ? closed loop obstruction with resolution of symptoms, now with
recurrent abdominal pain. evaluate for obstruction. PO and IV contrast // ___
with history of intermittent abdominal pain, most recent CT concerning for ?
closed loop obstruction with resolution of symptoms, now with recurrent
abdominal pain. evaluate for obstruction. PO and IV contrast
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 4.8 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 0.9 s, 0.2 cm; CTDIvol = 14.3 mGy (Body) DLP =
2.9 mGy-cm.
3) Spiral Acquisition 5.1 s, 48.3 cm; CTDIvol = 8.5 mGy (Body) DLP = 414.1
mGy-cm.
Total DLP (Body) = 419 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with adjacent
atelectasis.
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. There is redemonstration of
inflammatory changes involving small bowel loops in the mid abdomen.
Residual wall edema is noted along with mesenteric stranding and free fluid.
Contrast flows into the colon. No evidence of obstruction on this
examination. No free air is visualized. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The 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. Extensive atherosclerotic
disease is noted. The celiac axis, SMA, ___ and branches are patent.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of small-bowel obstruction. No free air. Edematous small
bowel with adjacent mesenteric stranding and free fluid suggestive of
enteritis, possibly infectious or inflammatory.
2. Patent mesenteric vasculature.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified intestinal obstruction
temperature: 97.2
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 149.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ was admitted to ___ on ___ as a transfer from
___ for concern of closed loop bowel obstruction. On admission
she was somewhat diffusely tender on abdominal exam, but this
was mild and without distension or peritoneal signs. She was HDS
without lab abnormalities on admission. She was made NPO and
given intravenous fluid resuscitation on admission however no
NGT was placed as she was not vomiting and denied nausea. Over
the following 12 hours the patient reported passing gas and
multiple small liquid bowel movements. She reported a
substantial improvement in her abdominal discomfort. In the AM
on ___ she was feeling much better and was requesting to eat.
She was initially advanced to clears which she tolerated before
being advanced to regular diet later in the day. Early AM ___
she reported a recurrence of her abdominal pain and cramping,
which required narcotic pain medication. She was unable to pas
gas or stool during the episode which lasted through the
morning. As a result she underwent CT scan for evaluation which
showed fairly focal enteritis in her small bowel of unclear
etiology, in the absence of any indication of small bowel
obstruction. In the several hours following the study she
reported that her pain resolved and she was requesting regular
diet. She did not require further pain medication and requested
discharge home. Ultimately she was discharged home ___ once
she was eating, reliably passing gas, ambulating, and engaging
in her normal activities with only very minimal pain that was
resolving. She was not scheduled for follow up but she was
instructed to return to our clinic or seek emergent medical
attention if she experienced any symptoms of obstipation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / azithromycin /
Amoxicillin / Flagyl
Attending: ___
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Colonoscopy ___
Capsule study ___.
History of Present Illness:
___ year-old woman with PMH aplastic anemia s/p ATG/cyclosporine
currently on cyclosporine and prednisone, DVTs/PE on life-long
anticoagulation with coumadin, recurrent GI bleeds (at least 1
in past requiring embolization), adrenal insufficiency, super
obesity, HTN, CKD stage IIIa who brought by ambulance ___
___ with BRBPR since 0500. Began with
abdominal cramps followed by red blood and clots. At time of
arrival at ___ had ___T Abd/pelv showed extensive diverticulosis w/o
diverticulitis, mild thickening of transverse colon with ?
colitis. Initial hemoglobin 10.2, INR 1.9, Cr 1.3. Received
unasyn 1.5gm flagyl 500 mg, 10mg IV vitamin K, 2 units FFP
Requested transfer to ___ as hematologist Dr. ___ is at
___.
___ course:
In the ED, initial vitals: 97.2 148/59 84
- Exam notable for Resting comfortably in bed in NAD
NT/ND. Vitals stable.
- Labs were notable for: Hgb 8.8 -> 7.8 did not receive and
pRBCs
138/102/25
----------<106
4.1/___/1.1
Normal LFTs
___ 18.1/1.7 PTT 31.8
- Imaging:
OSH CT abd/pelvis with contrast - OSH read: extensive
diverticulosis w/o diverticulitis, mild thickening of transverse
colon with ? colitis
- GI consulted: has history of diverticular bleeds including
requiring embolization, colonoscopy 7 months ago. if bleeds
again would have a low threshold to ct-a to localize.
Prior to transfer, vitals were: 98.8 120/57 84 17 100%RA
On arrival to the MICU, the patient confirms the above history.
She began passing dark red clots that made the toilet bowl water
bright red. They started around 0500, and she had about 7 more,
the last around 11 AM just before she left ___, and
they were progressively smaller in volume. She has not had any
abdominal pain or trouble with constipation. Typically has 1 to
2 soft stools per day and is on a bowel regimen. Denies fevers,
chills, rigors, nausea, vomiting, headache, CP/SOB, abdominal
pain.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ yo ___ women with history of multiple
VTEs on chronic anti-coagulation was admitted on ___ with
melena. In addition to severe anemia CBC revealed severe
thrombocytopenia with PLT count less than 15.000 and moderate
neutropenia. Her prior CBD from ___ showed only mild
normocytic anemia with Hb 10.0. While undergoing evaluation
patient was treated for presumptive ITP. She was treated with
multiple lines of treatment including prednisone, IVIG,
rituximab
and romiplastin without improvement in her platelets count. She
underwent several BMBx on ___ and ___. The
biopsies
revealed progressively hypo-cellular marrow with decreased
megakaryocytes, the findings most consistent with either
hypo-plastic MDS vs aplastic anemia. Because no overt dysplasia
was noted the latter was favored.
She had no abnormalities on cytogenetics and negative FISH for
MDS panel.
She received cycle# 1 of ATG/cyclosporine on ___, first dose
of Atgam was complicated by SVT, but subsequently she tolerated
remaining doses without significant side effects. She also
completed 2 week of serum sickness prophylaxis with prednisone,
but because of her prolonged exposure to high doses of steroids,
decision was made to slowly ___ prednisone off.
She was difficult to transfuse with blood products, as her Solid
phase HLA, PRA were 75% and SAG I were 100%. She had minimal to
no response to HLA matched PLT, but was able to respond to
cross-matched PLTs.
She was briefly hospitalized from ___ to ___ for
respiratory illness and was diagnosed with Influenza B. Recently
underwent outpatient shoulder MRI that revealed rotator cuff
injury of the right shoulder. Currently undergoing physical
therapy. In last few weeks developed severe muscle cramps, that
resolved after last iron infusion.
PAST MEDICAL HISTORY (per OMR):
- Aplastic anemia (see full details above)
- Multiple episodes of PE (initial while taking oral
contraceptive in her late ___, at the time she also had a IVC
filter placed, most recent in ___, this happened while
temporally her anti-coagulation was held due to GI bleeding)
- Chronic hepatitis B infection.
- Gout
- Recurrent GI bleeding
- Morbid obesity with BMI of 50.
- HTN
- Asthma
- Chronic venous stasis left more than right
- Colonic diverticulosis
- Osteoarthritis
- Mucinous adenocarcinoma s/p excision
- Chronic back pain
- Diabetes mellitus steroid induced
- Chronic left ulnar neuropathy
Social History:
___
Family History:
Mother with HTN, CAD, MI. Sister with ovarian cancer. No h/o
colonic malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.4, HR 78, BP 122/66, RR 20, O2 97% RA
GENERAL: Well appearing, obese AA woman, calm, pleasant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
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: non-distended, obese, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
DISCHARGE EXAM:
VITALS: 98.6 155 / 73 83 20 98 Ra
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
ABD: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing. L>R nonpitting
edema with chronic venous stasis changes in the LLE to mid calf.
Pertinent Results:
====================
ADMISSION LABS:
====================
___ 02:10PM BLOOD WBC-6.1 RBC-2.61* Hgb-8.8* Hct-27.0*
MCV-103* MCH-33.7* MCHC-32.6 RDW-15.6* RDWSD-58.9* Plt ___
___ 02:10PM BLOOD Neuts-70.0 ___ Monos-8.7 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-4.26 AbsLymp-1.22 AbsMono-0.53
AbsEos-0.04 AbsBaso-0.02
___ 02:10PM BLOOD ___ PTT-31.8 ___
___ 02:10PM BLOOD Glucose-106* UreaN-25* Creat-1.1 Na-138
K-4.1 Cl-102 HCO3-23 AnGap-17
___ 02:10PM BLOOD ALT-11 AST-25 AlkPhos-71 TotBili-0.4
___ 02:10PM BLOOD Lipase-31
___ 09:11PM BLOOD Calcium-8.7 Phos-2.9 Mg-1.7
====================
DISCHARGE LABS
====================
___ 06:10AM BLOOD WBC-5.6 RBC-2.47* Hgb-7.9* Hct-25.1*
MCV-102* MCH-32.0 MCHC-31.5* RDW-18.7* RDWSD-68.2* Plt ___
___ 04:36PM BLOOD Neuts-67.9 ___ Monos-10.1 Eos-1.2
Baso-0.2 Im ___ AbsNeut-3.92 AbsLymp-1.17* AbsMono-0.58
AbsEos-0.07 AbsBaso-0.01
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-27.9 ___
___ 06:10AM BLOOD Glucose-106* UreaN-16 Creat-1.1 Na-138
K-4.1 Cl-104 HCO3-21* AnGap-17
___ 06:10AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
___ 08:12AM BLOOD Cyclspr-177
___ 04:13AM BLOOD calTIBC-244* Ferritn-379* TRF-188*
=====================
IMAGING
======================
Colonoscopy ___:
Diverticulosis of the right and left colon
No blood seen
Otherwise normal colonoscopy to cecum and TI
Lower extremity ultrasound ___:
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins.
2. Left ___ cyst measuring up to 6.6 cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO TID
2. Amlodipine 5 mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. cyanocobalamin (vitamin B-12) 1,000 mcg sublingual BID
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Furosemide 40 mg PO DAILY
7. LaMIVudine 100 mg PO DAILY
8. Magnesium Oxide 400 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
11. Oxymetazoline 1 SPRY NU BID:PRN congestan
12. Pantoprazole 40 mg PO Q12H
13. PredniSONE 3 mg PO DAILY
14. Ranitidine 300 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. Moxifloxacin 400 mg OTHER Q24H
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN cough
19. Albuterol 0.5% 1 mL IH DAILY PRN sob
20. Warfarin 7.5 mg PO ___ AND ___
21. Warfarin 6.25 mg PO ___,
___
22. CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Acyclovir 400 mg PO TID
3. Albuterol 0.5% 1 mL IH DAILY PRN sob
4. Amlodipine 5 mg PO DAILY
5. Atovaquone Suspension 1500 mg PO DAILY
6. cyanocobalamin (vitamin B-12) 1,000 mcg sublingual BID
7. CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN cough
10. Furosemide 40 mg PO DAILY
11. LaMIVudine 100 mg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Magnesium Oxide 400 mg PO BID
14. Multivitamins 1 TAB PO DAILY
15. Oxymetazoline 1 SPRY NU BID:PRN congestan
16. Pantoprazole 40 mg PO Q12H
17. PredniSONE 3 mg PO DAILY
18. Ranitidine 300 mg PO DAILY
19. Vitamin D ___ UNIT PO DAILY
20.Outpatient Lab Work
Please check CBC. Please fax to: ___ ___.
Diagnosis: Anemia. ICD-9: D50.0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Lower GI bleed
Aplastic anemia
History of recurrent pulmonary embolism
SECONDARY DIAGNOSIS:
Chronic Kidney disease
Hypertension
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 GI bleed, history of recurrent DVT/PE //
any e/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
There is a ___ cyst on the left measuring 6.6 x 2.1 x 2.9 cm.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Left ___ cyst measuring up to 6.6 cm.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ year old woman with aplastic anemia, GIB , h/o diverticulitis
// ?diverticulititis, colitis
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired at
an outside hospital 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 at an outside hospital and
reviewed on PACS.
DOSE: DLP: 1793.3
COMPARISON: CT abdomen pelvis from ___. Chest CT
from ___. CT virtual colonography dated ___.
FINDINGS:
LOWER CHEST: 4 mm pulmonary nodules may be new since ___ (02:5,
29). 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 within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. 2 simple
cyst in the interpolar region and the lower pole of the left kidney are better
evaluated on the prior contrast exam, though grossly unchanged from prior
exam. There is no hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber and wall thickness
throughout. At the splenic flexure, there is a metallic surgical clip, likely
related to prior embolization. There is amorphous hyperdense material within
the transverse colon (02:36, 45), likely stool. Diverticulosis of the sigmoid
colon is noted, without evidence of wall thickening and fat stranding. The
appearance of the rectum is likely due to stool, and given multiple prior
exams demonstrating no intraluminal or mucosal mass. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
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. IVC clip located proximal to the bifurcation of the common iliac
veins are unchanged from prior exams. Multiple surgical clips are seen around
the clip. Along the left common iliac in the left external iliac, there is a
linear metallic density running adjacent to the vessel to the level of the
imaged left common femoral ___ represent prior postsurgical changes.
The left external iliac in the common femoral vein appear slightly smaller in
caliber, unchanged from prior exam. Numerous varices are again noted in the
anterior abdominal and pubic subcutaneous tissue, unchanged from prior exam.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is grade 1 anterolisthesis of L4 over L5.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits, aside
from numerous varices in the anterior abdomen.
IMPRESSION:
1. Diverticulosis without diverticulitis. No evidence of colitis.
2. Status post IVC clip placement with stable subcutaneous varices.
3. 4 mm pulmonary nodules in the lingula. According to the ___
guidelines for incidentally detected pulmonary nodules, if the patient has a
history of smoking or other known risk factors for malignancy, a follow-up
chest CT in 12 months is recommended. In the absence of such risk factors, no
follow-up is required.
RECOMMENDATION(S): 4 mm pulmonary nodules in the lingula. According to the
___ guidelines for incidentally detected pulmonary nodules, if the
patient has a history of smoking or other known risk factors for malignancy, a
follow-up chest CT in 12 months is recommended. In the absence of such risk
factors, no follow-up is required.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: GI bleed
Diagnosed with Gastrointestinal hemorrhage, unspecified, Unspecified atrial fibrillation, Long term (current) use of anticoagulants
temperature: 97.2
heartrate: 84.0
resprate: 14.0
o2sat: 98.0
sbp: 148.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | ___ with a history of aplastic anemia on cyclosporine and
prednisone, h/o multiple DVT/PE on lifelong warfarin, h/o
diverticular bleeding, adrenal insufficiency, super obesity, CKD
stage IIIa who originally presented with bright red blood per
rectum. She was initially managed with reversal of INR and
transfusion of pRBCs. Her warfarin was held in the setting of GI
bleed, but she continued to have bloody stools. Colonoscopy
showed diverticulosis without clear source of bleed and capsule
endoscopy was performed with read pending. Hematocrit
subsequently stabilized. After discussion with her outpatient
hematologist Dr. ___ warfarin was discontinued and
she was initiated on Apixaban 2.5mg BID for anticoagulation. She
was discharged home with plan to follow up with PCP,
hematology/oncology, and gastroenterology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Flank pain, fevers
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement ___
History of Present Illness:
___ with PMHx of nephrolithiasis, HTN, hypothyroidism presenting
with ___ days of fatigue, fever.
Patient was seen by PCP on ___ for right sided flank pain and
fatigue. UA at the time showed reds and several whites so he was
prescribed Flomax. He got a shot of toradol at the time for
pain. Over the subsequent few days he developed fevers, no
chills, no change in urination. Last night he had a fever to 101
for which he took some Advil. This morning he had a fever to
103. He did not take any additional medications today. He denies
any chest pain, cough, shortness of breath, abdominal pain,
nausea or vomiting. He does not have an appetite. He denies any
urinary symptoms or diarrhea.
In the ED, initial VS were: 99.5, 100, 126/71, 20, 100% RA
Exam notable for: R CVA tenderness, benign abdominal exam
Labs showed: CBC 9.2/14.1/41.2/142, INR 1.3, Lactate 1.2, Cr
1.2, UA 14 WBC, 9 RBC, Moderate Leuks, negative nitrates,
Imaging showed; CT A/P with 1.8cm right UPJ stone with upstream
hydronephrosis and perinpehric stranding and multiple non
obstructing left renal stones measuring up to 5mm.
Received:
___ 15:41 IV CeftriaXONE ___ Started
___ 15:41 IVF NS ___ Started
___ 16:34 IV CeftriaXONE 1 g ___ Stopped
(___)
___ 16:34 IVF NS 1 mL ___ Stopped (___)
Urology and ___ were consulted. Urology recommended urgent PCN
for infected obstructing stone. ___ performed right PCN which
patient tolerated well per ED dash.
On arrival to the floor, patient reports that he is feeling
better. Endorses some right sided flank pain at the site of the
PCN. otherwise denies dysuria. no family history of kidney
stones. his last kidney stone was ___ years ago. he currently
works as a ___ but has plans to retire this ___.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
HTN
HLD
Nephrolithiasis
Hypothyroidism
Social History:
___
Family History:
Father CAD/PVD
Other Other(2)
Sister Cancer - ___
Physical Exam:
ADMISSION EXAM
==============
VS: 100.1, 105/62, ___ RA
GENERAL: NAD, warm to touch, pleasant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: Tachycardic, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
BACK: Right PCN in place with dressing overlying insertion site,
minimally tender to RCVA, draining straw colored urine to bag.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, +BS
EXTREMITIES: warm to touch, 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 EXAM
==============
Vitals: 98.6 137/80 83 18 97 RA
I/O: ___
GENERAL: NAD, warm to touch, pleasant
HEENT: EOMI, PERRL, anicteric sclera, conjunctiva not pale, MMM
NECK: supple, no LAD, no elevated JVP
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
BACK: Right PCN in place with dressing overlying insertion site,
slightly tender to palpation, RCVAT improved, draining straw
colored urine to bag.
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, +BS
EXTREMITIES: Warm to touch, 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
=============
___ 03:22PM BLOOD WBC-9.2 RBC-4.64 Hgb-14.1 Hct-41.2 MCV-89
MCH-30.4 MCHC-34.2 RDW-12.9 RDWSD-42.3 Plt ___
___ 03:22PM BLOOD Neuts-80.9* Lymphs-8.1* Monos-10.4
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.41* AbsLymp-0.74*
AbsMono-0.95* AbsEos-0.00* AbsBaso-0.02
___ 03:22PM BLOOD ___ PTT-28.7 ___
___ 03:22PM BLOOD Plt ___
___ 03:22PM BLOOD Glucose-99 UreaN-16 Creat-1.2 Na-136
K-3.9 Cl-100 HCO3-24 AnGap-16
___ 03:22PM BLOOD Calcium-9.0 Phos-2.4* Mg-1.8
___ 03:42PM BLOOD Lactate-1.2
___ 03:44PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:44PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD
___ 03:44PM URINE RBC-9* WBC-14* Bacteri-FEW Yeast-NONE
Epi-<1
___ 03:44PM URINE Hours-RANDOM Creat-168 Na-63 Phos-36.1
Uric Ac-50.5
DISCHARGE LABS
=============
___ 06:20AM BLOOD WBC-4.8 RBC-4.48* Hgb-13.5* Hct-39.5*
MCV-88 MCH-30.1 MCHC-34.2 RDW-13.1 RDWSD-42.3 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-139
K-3.5 Cl-104 HCO3-23 AnGap-16
___ 06:20AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.9
MICRO
=====
___ 3:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:44 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL.
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 3:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:00 pm URINE,KIDNEY Source: Kidney.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 7:08 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
STUDIES/IMAGING
==============
CT A/P ___
IMPRESSION:
1. 1.8 cm right UPJ stone with associated moderate
hydronephrosis and right
perinephric stranding.
2. Multiple nonobstructing left renal stones measuring up to 5
mm.
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast
INDICATION: ___ with hx renal stones, + r flank pain, fever// ? stone
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered. Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 323 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 within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is a 1.8 x 1.6 x 1.0 cm right UPJ stone with upstream moderate
hydronephrosis and perinephric stranding. There are multiple nonobstructing
renal stones in the left kidney measuring up to 5 mm. Left the left kidney is
of normal and symmetric size. There is no evidence of focal renal lesions,
hydronephrosis or perinephric abnormality of the left kidney.
GASTROINTESTINAL: There is small hiatal hernia. 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 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. 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. 1.8 cm right UPJ stone with associated moderate hydronephrosis and right
perinephric stranding.
2. Multiple nonobstructing left renal stones measuring up to 5 mm.
Radiology Report
INDICATION: ___ year old man with obs right renal UPJ stone, for PCN.// right
pcn
COMPARISON: CT A/P dated ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 9 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: 5 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.5 min, 1 mGy
PROCEDURE: 1. Right ultrasound guided renal collecting system access.
2. Right nephrostogram.
3. 8 ___ nephrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the right renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire
was advanced into the renal collecting system. After a skin ___, the needle
was exchanged for an Accustick sheath. Once the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system to confirm position. A ___
wire was advanced through the sheath and coiled in the collecting system. The
sheath was then removed and a 8 ___ nephrostomy tube was advanced into the
renal collecting system. The wire was then removed and the pigtail was formed
in the collecting system. Contrast injection confirmed appropriate
positioning. The catheter was then flushed, 0 silk stay sutures applied and
the catheter was secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag.
FINDINGS:
1. Scout ultrasound images demonstrate a moderately dilated right renal
collecting system.
2. appropriately positioned 8 ___ right percutaneous nephrostomy tube.
IMPRESSION:
Successful placement of 8 ___ nephrostomy on the right.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Fever, Nausea
Diagnosed with Calculus of kidney
temperature: 99.5
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 126.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Patient is a ___ with history of HTN and nephrolithiasis who
presented with fever and R flank pain in setting of 1.8cm
obstructing UPJ renal calculus visualized on CT A/P in the ED.
# Right obstructing UPJ stone, hydronephrosis
# H/o Nephrolithiasis
# Fever, tachycardia, hypotension - Patient's presentation was
consistent with recurrent nephrolithiasis (last occurrence
___ ago), 1.8cm obstructing UPJ stone/R hydronephrosis seen
on CT A/P. Additionally, patient was found to have multiple
non-obstructing stones seen in the left kidney. Patient was SIRS
positive on admission (report of fever, tachycardia), concerning
for evolving sepsis with known large renal calculus as the
infectious source. Lactate was wnl. Blood pressure medications
were held given SBPs 100s, patient remained normotensive with
administration of 3L IVF. He was continued on tamsulosin given
smaller stones in L kidney. Urology was consulted in the ED, R
percutaneous nephrostomy tube was subsequently placed by ___ for
decompression. He was initially started on ceftriaxone in the
ED, broadened to zosyn and then ceftazidime (as per AST).
Patient did have a fever to 102.6 and chills ___ despite
ongoing antibiotics, though he subsequently remained afebrile
and normotensive. Urine culture speciated alpha hemolytic strep
and group B strep and so patient was transitioned to Augmentin
875mg BID ___ ___. Patient will continue Augmentin through ___.
Patient was having good urine output from R PCN tube, >2L on the
day prior to discharge. Sheer size of the stone will most likely
require advanced therapy with urology, possible percutaneous
nephrolithotomy, he will follow-up as an outpatient. Urine
microscopy revealed possible uric acid crystals, patient by
report has not had prior work-up for stone etiology. Urine pH,
however, was 6.5, thus making urate stones less likely. Other
labs were notable for hypophosphatemia and low uric acid, most
likely related to hypovitaminosis D and plant based diet
respectively. Fractional excretion of uric acid/phosphate were
slightly high, though there were no other abnormalities to
suggest Fanconi Syndrome. Patient will follow-up with nephrology
in 1___ for further evaluation of recurrent nephrolithiasis with
litholink. Patient was continued on tamsulosin. HCTZ should be
restarted as outpatient as blood pressures allow in order to
lower urinary Calcium should patient have calcium based stone.
# Hypophosphatemia - Most likely ___ hypovitaminosis D, patient
with VitD 25 levels <20 in Atrius records. Patient was repleted
with PO phos and IV KPhos. Patient should have PTH and repeat
VitD levels drawn as an outpatient. Patient was continued on
home 1000IU VitD daily.
# Elevated INR - 1.2 -> 1.3 on admission, possibly nutritional.
No known hepatic disease. Patient received 2 doses of PO VitK. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin / Neurontin
Attending: ___.
Chief Complaint:
SOB, CP
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a history of cardiomyopathy(dilated and
ischemic) with EF 20% s/p primary prevention ICD in ___, DM2,
CKD (baseline Cr 1.4-1.7), multiple heart failure admissions
over the last year due to med/diet non-compliance, recent
admission from ___ for ICD shock and decompensated heart
failure presenting with chest heaviness and shortness of breath.
Of note, pt was recently admitted from ___ to ___ with
chief complaint of CP and SOB found to have acute on chronic
sCHF exacerbation (tx with lasix gtt) and multiple episodes of
VT treated with lidocaine and ATP. Device interrogation
revealed approximately 10 episodes a day beginning on ___ typically self-terminating or terminating with ATP. VT was
thought to be monomorphic with RBBB morphology with right
superior axis. Only one episode required electrical
cardioversion. Pt. underwent an attempted VT ablation on
___ which failed to induce arrhythmia. As such, pt. was
discharged on amiodarone at a dry weight of 132kg. Of note,
digoxin dose was decreased at discharge(0.125->0.0625) due to
concomitant amiodarone.
He reports that on discharge, he did not feel "100%" and thought
that he still had some SOB. Since discharge, reports developing
a productive cough with thick white sputum and rhinorrhea. Also
endorses worsening SOB and associated chest heaviness, worse
with exertion. No radiation of chest heaviness, or associated
nausea, diaphoresis. No palpitations. Reports taking all
medications as prescribed and avoiding salty food. Reports he
cooks at home, mostly cooking vegetables. Reports increased
intake of fluids, juice and water. Feels he has gained weight.
In the ED, initial vitals were 98.3 87 117/82 20 95%. Trop of
0.04. BNP of 6707. BNP on recent admission 4126. CXR showed
slight interval increase in pulmonary vascular congestion with
stable cardiomegaly and no pleural effusion. Received lasix 80mg
IV and nitro SL.
On ROS, denies fever, chills, myalgia, abdominal pain, joint
pain
Past Medical History:
1. CARDIAC RISK FACTORS: DM (Hba1c 9.4 in ___,
peripheral neuropathy), Dyslipidemia, HTN, CHF, CAD
2. CARDIAC HISTORY:
- ECHO (___): EF ___, severely dilated left ventricle
with severelY depressed function - inferior and inferlateral
akinesis and severe hypokinesis of the other segments. At least
mild mitral regurgitation. Hypokinetic right ventricle.
- Cath (___): Two-vessel coronary artery disease, LCx
totally occluded and RCA with a distal 60% lesion, Mildly
elevated left-sided filling pressure with a LVEDP of 16 mmHg,
Succesful PCI of LCx with drug eluting stents, Aspirin
indefinetly and plavix for at least one year.
- ICD, dual, ___ Protecta ___ ___. ___ for primary
prevention of sudden cardiac death.
- Recurrent CHF exacerbations due to dietary/medication
noncompliance
3. OTHER PAST MEDICAL HISTORY:
- DISC DISEASE - LUMBAR
- OCULAR HYPERTENSION
- TENDON RUPTURE, TRAUMATIC - PATELLA
- ERECTILE DYSFUNCTION
- Obesity
- h/o Colonic Adenoma
- Pulmonary nodule - pt was not aware of this diagnosis
- CKD (baseline Cr 1.4-1.7)- pt was not aware of this diagnosis
- Tachy-brady syndrome
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; His brother died in the setting of heroin
use, but had heart disease. Mother and father died of lung
cancer.
Physical Exam:
admission
VS: 98.3 114/79 70 16 98RA Adm wt: 137.6kg
General: NAD
HEENT: JVP 10cm, OM dry
CV: nl S1/S2, S3, holosystolic murmur over apex, RRR
Lungs: bibasilar crackles
Abdomen: +BS, soft, NT, ND
Ext: 2+ edema to knee
Neuro: motor and sensory function grossly normal
PULSES: 2+ DP
discharge
VS: 98.1 ___ 18 99% Discharge weight: 132 kg
General: NAD
HEENT: JVP nl, OM dry
CV: nl S1/S2, S3, holosystolic murmur over apex, RRR
Lungs: bibasilar crackles
Abdomen: +BS, soft, NT, ND
Ext: trace lower extremity edema
Neuro: motor and sensory function grossly normal
PULSES: 2+ DP
Pertinent Results:
Admission
___ 02:26PM BLOOD WBC-6.7 RBC-4.46* Hgb-13.6* Hct-40.1
MCV-90 MCH-30.6 MCHC-34.0 RDW-16.3* Plt ___
___ 02:26PM BLOOD Neuts-71.3* Lymphs-16.7* Monos-9.7
Eos-1.7 Baso-0.5
___ 02:26PM BLOOD Glucose-271* UreaN-23* Creat-1.9* Na-132*
K-7.6* Cl-98 HCO3-22 AnGap-20
___ 02:26PM BLOOD proBNP-6707*
___ 02:26PM BLOOD cTropnT-0.04*
___ 12:05AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.8
___ 12:05AM BLOOD Glucose-183* UreaN-23* Creat-1.9* Na-138
K-3.8 Cl-99 HCO3-30 AnGap-13
___ 04:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 04:46PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:20PM BLOOD proBNP-1282*
___ 04:20PM BLOOD Glucose-222* UreaN-37* Creat-2.4* Na-141
K-4.1 Cl-99 HCO3-32 AnGap-14
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with 2 days cough dyspena // r/o
infiltrate,chf
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
In comparison the prior study from ___, there is slight
interval
increase in pulmonary vascular congestion and stable
cardiomegaly. Cardiac pacer wires are in standard position. No
evidence of pneumonia. No pleural effusion.
IMPRESSION:
Slight interval increase in pulmonary vascular congestion with
stable
cardiomegaly and no pleural effusion.
Cardiovascular Report ECG Study Date of ___ 1:57:52 ___
Sinus rhythm with first degree atrio-ventricular conduction
delay. Right
bundle-branch block. Left axis deviation. Cannot exclude
inferior wall
myocardial infarction of indeterminate age. Compared to the
previous tracing of ___ multiple abnormalities as
previously described persist without major change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Digoxin 0.0625 mg PO DAILY
5. HydrALAzine 20 mg PO Q8H
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Amiodarone 400 mg PO TID
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest Pain
11. Lantus (insulin glargine) 100 unit/mL subcutaneous daily
12. Amiodarone 200 mg PO BID
13. Torsemide 80 mg PO QAM
14. Torsemide 40 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Amiodarone 200 mg PO BID
Reassess at appt with Dr. ___
5. Digoxin 0.0625 mg PO DAILY
6. HydrALAzine 20 mg PO Q8H
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest Pain
9. Pantoprazole 40 mg PO Q24H
10. Torsemide 140 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute on chronic systolic heart failure exacerbation
Non-sustained ventricular tachycardia
Secondary:
Hypertension
Diabetes
Chronic kidney disease
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with 2 days cough dyspena // r/o infiltrate,chf
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
In comparison the prior study from ___, there is slight interval
increase in pulmonary vascular congestion and stable cardiomegaly. Cardiac
pacer wires are in standard position. No evidence of pneumonia. No pleural
effusion.
IMPRESSION:
Slight interval increase in pulmonary vascular congestion with stable
cardiomegaly and no pleural effusion.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with INTERMED CORONARY SYND, CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.3
heartrate: 87.0
resprate: 20.0
o2sat: 95.0
sbp: 117.0
dbp: 82.0
level of pain: 8
level of acuity: 2.0 | ___ male with a history of cardiomyopathy with EF 20%,
s/p primary prevention ICD in ___, DM2, CKD (baseline Cr
1.4-1.7, multiple heart failure admissions over the last year
due to med/diet non-compliance, recent admission from
___ for ICD shock and decompensated heart failure
presenting with SOB and chest heaviness.
# Acute on Chronic Systolic CHF: Pt presenting with acute on
chronic systolic heart failure. Wt on admission 137.6 kg up from
discharge weight of 132 kg. BNP of 6707. BNP on recent
admission 4126. CXR showed slight interval increase in pulmonary
vascular congestion. Bibasilar crackles on exam and 2+ edema.
HypoNa of 132 likely reflecting low effective circular volume in
the setting of decompensated heart failure. Trigger possibly URI
given rhinorrhea and cough over the last ___ days. Also concern
that volume overload triggered by ischemia, but unlikely given
EKG unchanged and trop .04->.06->.05. Diurised well on lasix gtt
and transitioned to PO torsemide 140 mg. Discharge wt 132 kg and
patient seemed dry so changed to torsemide 120 mg at discharge.
# Chest heaviness: Pt w/ known 2 vessel CAD on cath on ___ s/p
DES to totally occluded LCx. 60% distal RCA lesion. Chest
heaviness and slightly elevated troponin(.04) on presentation
concerning for ischemia but unlikely given stable
trops(.04->.___->.05). Most likely demand in the setting of
decompensated heart failure.
# VT: Hx of recent episodes of VT. Recent episodes likely
infarct-related VT. Device interrogation at last admission
revealed approximately 10 episodes a day beginning on ___ typically self-terminating or terminating with ATP. S/p
failed ablation ___ given inability to induce arrhythmia.
Initiated on amiodarone 400 TID for a week (last day ___. As
planned previously, transitoned to 200 BID for a month (started
___
Transitional Issues
- Given VT during last hospitalization, started on amiodarone
400 TID for a week (last day ___ which was completed and
should be followed by 200 BID for a month (started ___
Patient is supposed to have follow up with Dr. ___ in a
month at which point it will be decided if patient should
continue on amiodarone.
- Continue outpatient sleep workup for likely sleep apnea
- Pt. must follow up with Financial Counseling with verification
documents for his ___ application as this will
assist with both his medication co-pays (which he is unable to
afford even with his Medicare supplemental plan) and should he
require additional services to remain at home as long as
possible.
- Pt. would benefit from referral to local elder services agency
for assessment of services available but this can only be done
when pt. is anticipated for d/c home, either from hospital or
SNF.
Dr. ___ with Dr. ___ the need for early
follow-up and torsemide dose. He was discharged on torsemide 140
mg daily, but repeat renal function will be checked on ___ and
will be downtitrated to 120 mg daily if Dr. ___
appropriate. Dr. ___ will also assume care of the
amiodarone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Strawberry Concentrate Flavor / Baclofen / Latex
Attending: ___.
Chief Complaint:
right upper extremity DVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoF with h/o TBI and recent admission for olecranon bursitis
who presents with right arm swelling.
She was recently admittted ___ to ___ with septic
olecranon bursitis that grew MRSA. She was treated with
vancomycin with plans to continue through ___. She
initially had a left sided PICC which she pulled out during that
hospitalization and was discharged with a right-sided PICC.
Per the vascular consult team, she was noted to have RUE
swelling this AM at rehab. An ultrasound was performed
demonstrating a non occlusive thrombus in the subclavian. The
PICC line was removed and she was sent to ___ ED.
In the ED, initial VS were 97.7 118 152/85 18 98%. RUE
ultrasound showed DVT (nonocclusive). She was started on a
heparin drip and vascular surgery was consulted who recommended
admission to medicine.
On arrival to the floor, she denies pain but will not answer any
further history questions.
Past Medical History:
h/o of TBI at age ___ with CNS shunt, residual lt hemiparesis
MR
HTN
Osteopenia
Lt kidney hydronephrosis
b/l hearing loss
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.7 136/92 90 20 98%RA
GENERAL - sleeping but arousable and will answer questions with
yes/no answers appropriately
HEENT - PERRLA, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - CTA bilat except for occasional rales
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, RUE with marked swelling and some purple
discoloration with boggy right olecranon bursa but has range of
motion fully of elbow joint, radial pulse palpable and able to
move fingers
NEURO - awake but will not answer orientation questions ("I
don't know). does not move left side on command.
LABS: Please see attached
DISCHARGE PHYSICAL EXAM:
VS 99, tm 99, 140/92, 92, 20, 100RA
GENERAL - Alert and interactive, appropriate responses to
questions
HEENT - PERRLA, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - CTAB, no w/r/r
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, RUE with moderate swelling and erythema.
boggy right olecranon bursa but has range of motion fully of
elbow joint, radial pulse palpable and able to move fingers. no
guarding on palpation of elbow.
NEURO - awake but will not answer orientation questions ("I
don't know). does not move left side on command.
Pertinent Results:
ADMISSION LABS:
___ 11:03PM BLOOD WBC-7.4 RBC-4.08* Hgb-12.3 Hct-36.8
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.7 Plt ___
___ 11:40PM BLOOD ___ PTT-26.0 ___
___ 11:03PM BLOOD Glucose-101* UreaN-18 Creat-0.7 Na-138
K-4.2 Cl-103 HCO3-23 AnGap-16
___ 11:03PM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
___ 07:20PM BLOOD Vanco-15.0
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-3.7* RBC-3.75* Hgb-11.1* Hct-34.3*
MCV-92 MCH-29.8 MCHC-32.5 RDW-13.8 Plt Ct-40*#
___ 07:20AM BLOOD Glucose-81 UreaN-14 Creat-0.6 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
___ 07:20AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
PERTINENT MICRO: none
PERTINENT IMAGING:
RUE U/S ___ (PRELIM): Partially occlusive thrombus in the
right subclavian vein, one of the two branchial veins, and a
portion of the basilic vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamazepine 200 mg PO BID
2. Mirtazapine 15 mg PO HS
3. Vitamin D 800 UNIT PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Vancomycin 1250 mg IV Q 12H
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Carbamazepine 200 mg PO BID
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
4. Mirtazapine 15 mg PO HS
5. Vitamin D 800 UNIT PO DAILY
6. Enoxaparin Sodium 50 mg SC Q12H
to be continued until INR is in therapeutic range of ___. Warfarin 5 mg PO DAILY16
to be dosed based on INR checks, next check ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right upper extremity deep venous thrombosis
Right upper extremity cellulitis
Secondary diagnoses:
olecranon bursitis
traumatic brain injury
left sided weakness
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Right upper extremity swelling and pain. History of recent right
PICC removal. Evaluate for DVT.
COMPARISON: Right upper extremity ultrasound from ___.
FINDINGS: Grayscale and color sonograms were acquired of the right internal
jugular, subclavian, axillary, brachial, basilic, and cephalic veins. There
is non-occlusive thrombus within the distal portion of the right subclavian
vein with additional thrombus seen in the mid-to-lower portion of one of the
two paired brachial veins. The upper portion of the basilic vein also is
partially occluded with thrombus. The remainder of the imaged right upper
extremity veins have normal compressibility and flow. Of note, there is a
tubular structure with parallel echogenic borders within the right subclavian
vein (image 5), concerning for a retained fragment of a previously removed
PICC.
Images of the left subclavian vein were not obtained.
IMPRESSION:
1. Partially occlusive thrombus within the distal right subclavian vein,
mid-to-low portion of one of the two paired right brachial veins, and upper
portion of the right basilic vein.
2. Findings concerning for retained PICC fragment in the right subclavian
vein. Further evaluation with a chest radiograph is recommended.
Findings were discussed with Dr. ___ by Dr. ___ at 11 p.m. via
telephone on the day of the study.
Radiology Report
HISTORY: Tachycardia.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Heart size is normal. The aorta is mildly tortuous. Mediastinal and hilar
contours are stable. Right PICC has been removed. Clip projecting over the
right suprahilar region is re- demonstrated. Minimal streaky opacity in the
left lung base likely reflects atelectasis. No pleural effusion or
pneumothorax is seen, and there is no pulmonary vascular congestion. No acute
osseous abnormalities are present.
IMPRESSION:
Minimal left basilar atelectasis. Otherwise no acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DVT
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED
temperature: 97.7
heartrate: 118.0
resprate: 18.0
o2sat: 98.0
sbp: 152.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | ___ yoF with h/o TBI and recent admission for olecranon bursitis
who presents with right arm swelling and DVT.
ACTIVE ISSUES
# RUE DVT: pt presented with right arm redness and swelling,
found to have PICC-associated DVT in the right arm. The PICC was
pulled. She was started on anticoagulation with heparin
initially and changed to lovenox the following day. She will
need to be bridged to coumadin for a minimum of 5 days until INR
reaches 2.5.
# PICC-associated cellulitis: the pt appeared to have fluctuance
at the site of the PICC insertion with concern for cellulitis.
She was started on a course of bactrim and will need a course of
10 days of 1 double strength tab bactrim BID (to be completed
___.
# Olecranon bursitis: pt was to complete her 3 week vancomycin
course on ___. Her olecranon process appeared well healed with
no bogginess, warmth, or swelling of the bursa. Her last dose of
vancomycin was ___. We feel that this is a satisfactory
course length.
CHRONIC ISSUES
# Traumatic brain injury: mental status unchanged. She was
continued on her home carbamazepine and mirtazapine. She has a
head CT scheduled as an outpatient on ___ (schedule prior
to hospitalization).
TRANSITIONAL ISSUES
# Bridge to coumadin with lovenox as above
# 10 day course of bactrim as above |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / erythromycin / tramadol
Attending: ___.
Chief Complaint:
RLE Ulcer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with complaint of "leg ulcer", referred by PCP with history
of RLE 2.2 cm non-healing diabetic ulcer. On ___, patient was
diagnosed with cellulitis by PCP, started on PO clindamycin. On
___, she was given IV vanco x 1, then missed IV doses scheduled
for ___. Doxycycline + ciprofloxacin was started ___
(current regimen). On ___, the wound was culture, (+) for
Pseudomonas. On ___, she underwent minor debridement in office.
She is referred here today ___ PCP concern for poor response to
PO antibiotics.
.
In the ED, initial vitals were 97.3 85 180/80 18 98% RA. She
complained of vaginal discharge and pruritus, with UTI seen on
UA on ___. CBC showed WBC count of 9.5K, platelet count in
500s. Chem7 was remarkable for bicarbonate of 33, blood glucose
of 524. Lactate was 1.7. She was given 10 units regular insulin
and started on a sliding scale. Ciprofloxacin 400 mg IV was
given. On transfer, vitals were 97.7, 85, 137/87, 18 97%.
.
On arrival to the floor, patient reports ___ pain in her right
leg. She has no other complaints currently.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
DMII
HTN
Anemia
CHF
HLD
OSA noncompliant with CPAP
Chronic LBP
Recent PNA ~ 3 months ago at ___
Right eye surgery
___ cellulitis
Social History:
___
Family History:
Mother with bladder cancer. Father and multiple relatives with
colon cancer.
Physical Exam:
Admissions Physical:
VITALS: T 98.0 BP 148/85 P 88 R 18 Sat 98%RA
GENERAL: obese female in NAD, alert, comfortable
HEENT: MMM with no lesions noted
NECK: JVP not elevated, no cervical LAD
LUNGS: CTAB with no adventitious sounds
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NTND, NABS, no organomegaly
EXTREMITIES: 3+ pitting edema bilaterally ___ up lower leg, 2x2
cm ulcer on anterior RLE with purulent, malodorous drainage on
medial right leg with surrounding erythema, 1-2mm ulcer more
medial and posterior with small area of skin breakdown and
purulent drainage, tracking 1cm into soft tissue but with no
bone involvement. Pulses intact in both extremitiess
NEUROLOGIC: A+OX3
Discharge Physical
VITALS: afebrile, normotensive, non-tachycardic,
non-tachypneic, saturating high ___ on RA
GENERAL: obese female in NAD, alert, comfortable
HEENT: MMM with no lesions noted
NECK: JVP not elevated, no cervical LAD
LUNGS: CTAB with no adventitious sounds
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NTND, NABS, no organomegaly
EXTREMITIES: R medial leg ulcer- clean without active bleeding
and discharge, posterior calf with 1cm deep ulcer, no discharge.
NEUROLOGIC: A+OX3
Pertinent Results:
Admissions Labs:
___ 06:25PM BLOOD WBC-9.5 RBC-4.56 Hgb-12.9 Hct-40.7 MCV-89
MCH-28.3 MCHC-31.7 RDW-13.8 Plt ___
___ 06:25PM BLOOD Neuts-60.3 ___ Monos-3.3 Eos-2.6
Baso-0.4
___ 06:25PM BLOOD Glucose-524* UreaN-14 Creat-1.0 Na-139
K-4.1 Cl-96 HCO3-33* AnGap-14
___ 06:32PM BLOOD Lactate-1.7
Discharge Labs:
___ 06:00AM BLOOD WBC-8.5 RBC-4.13* Hgb-11.9* Hct-36.7
MCV-89 MCH-28.7 MCHC-32.3 RDW-14.4 Plt ___
___ 06:00AM BLOOD Glucose-169* UreaN-17 Creat-1.0 Na-142
K-3.5 Cl-101 HCO3-32 AnGap-13
___ 06:00AM BLOOD ALT-9 AST-13 LD(LDH)-114 AlkPhos-106*
TotBili-0.2
___ 06:00AM BLOOD Calcium-9.9 Phos-4.7* Mg-1.7
Micro:
Blood Cx ___: ___
Reports:
TibFib X-ray ___:
1. No specific radiographic evidence of osteomyelitis involving
the right
tibia or fibula. Overlying soft tissue defect consistent with
an ulcer.
Degenerative changes of the right knee and ankle joints.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Labetalol 200 mg PO BID
2. irbesartan *NF* 300 mg Oral daily
3. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral q6h pain
4. Atorvastatin 40 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ranitidine 150 mg PO BID
7. Vitamin D 400 UNIT PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
9. Furosemide 40 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Atorvastatin 40 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. irbesartan *NF* 300 mg ORAL DAILY
5. Labetalol 200 mg PO BID
6. Ranitidine 150 mg PO BID
7. Vitamin D 400 UNIT PO DAILY
8. NPH 64 Units Breakfast
NPH 62 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral q6h pain
10. Levofloxacin 500 mg PO Q24H Duration: 6 Days
may cause some GI upset
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Ulcer
Secondary: Diabetes type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RIGHT TIB/FIB SERIES, ___ AT 15:34
CLINICAL INDICATION: ___ with diabetes and ulcer, question
osteomyelitis.
AP and lateral views of the right tibia and fibula are submitted. There are
no comparison studies.
The bones appear osteopenic. There is a soft tissue defect in the mid to
distal tibial soft tissues consistent with an ulcer. No underlying bony
destruction is seen to suggest osteomyelitis. There are prominent arterial
calcifications consistent with atherosclerosis. Degenerative changes are seen
involving the knee and ankle joints. There is also a radiopaque loose body
within the joint space of the knee. No suprapatellar joint effusion is seen.
IMPRESSION:
1. No specific radiographic evidence of osteomyelitis involving the right
tibia or fibula. Overlying soft tissue defect consistent with an ulcer.
Degenerative changes of the right knee and ankle joints.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RIGHT LEG ULCER
Diagnosed with IDDM W SPEC MANIFESTATION, ULCER OF LOWER LIMB, UNSPECIFIED, CELLULITIS OF LEG
temperature: 97.3
heartrate: 85.0
resprate: 18.0
o2sat: 98.0
sbp: 180.0
dbp: 80.0
level of pain: 4
level of acuity: 3.0 | Ms. ___ was admitted for treatment of the following active
and inactive issues:
Active Issues:
# Cellulitis, Right leg ulcer x 2:
Patient had been treated for cellulitis and purulent ulcer for
over two weeks with no improvement, most recently on oral
doxycycline and ciprofloxacin. Cx of wound at OSH revealed
pseudomonas and klebsiella. Pt has two ulcers, 2x2cm ulcer on
the medial aspect of the RLE draining purulent and malodorous,
trace. 1-2mm ulcer on posterior RLE, 1cm into tissue, also with
purulent, malodorous discharge. Due to concern for osteo, an
X-ray was obtained and showed no evidence of osteomyelitis. ACS
consulted and recommended wound care and leg elevation. They
suggested considering an MRI but there was little suspicion for
osteomyelitis. Pt was treated with levofloxacin and
metronidazole. Pt was discharged home with oral levofloxacin and
metronidazole to complete a total of 6 days. Surgery recommended
the following in terms of dressing: recommend wet to dry
dressing over the larger medial wound and dry dressings to the
posterior wound. She also needs to have her legs wrapped from
her toes to her knees and have her legs elevated above the level
of her heart. The recommendation for MRI was communicated to her
PCP via email to consider this if symptoms do not improve or
persist after completion of antibiotic course.
# Hyperglycemia:
FSG in 500s on admission, on discharge FSG ~120s. Likely related
to ongoing infection in setting of DM. Pt was put on home
regimen of NPH 64 units in AM, 62 units ___ with ISS. From
___, pt had decreased PO intake and had an episode of
altered mental status on ___ and glucose was 48. Pt's mentation
immediately improved after amp of dextrose and D5 maintenance
fluids. She received adequate education on signs and symptoms of
hypoglycemia. Pt was discharged with unchanged NPH dosage and
insulin sliding scale.
# Vaginal discharge
Consistent with candidiasis and responded well to Nystatin VG
(day 1 = ___ for 7d course). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
directed ED from clinic by PCP after abnormal labs resulted at a
routine follow up appointment
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ year old man with CAD, diastolic CHF, HTN, CKD
(baseline Cr 1.2), DM-II (on metformin, well controlled), and
syncope, with new mild-moderate AI, presenting for AoCKD and
hypotension. Referred in to ED by PCP.
He was evaluated in clinic in ___ for syncope, found to be
bradycardic; metoprolol lowered. Syncope again in early ___,
evaluated in ___ ED, found to have WBC 16 (normal UA, CXR),
slight anemia, TTE with known diastolic failure, but new
mild-moderate AI. Discharged home.
In clinic ___, felt well, but BPs in ___ and HRs in high ___.
Decreased metoprolol & losartan. Labs checked and returned with
improving WBC (though now eosinophilia) but worsening AoCKD (Cr
up to 1.9 from baseline 1.2) with mild hyperkalemia. Discussed
with daughter, BP at home today 90/54. Given no beds available
to direct admit; referring to ___ ED for initial evaluation &
admission for AoCKD, hypotension, leukocytosis.
In the ED, initial VS were: 98.1, 55, 99/52, 18, 96% RA
Labs showed: CBC 13.2/___/30.4/187, Eosinophilia 11.9%, Cr 1.5,
K 4.2, Lacatate 1.2
Imaging showed: CXR no acute findings
Received: 500cc IVF
Transfer VS were: 58, 133/66, 16, 95% RA
On arrival to the floor, translation provided by patients
daughter at bedside. patient reports that he feels well. Denies
fevers, chills, lightheadedness, nausea, vomiting, diarrhea.
Some constipation. No recent weight loss. No decreased PO
intake. He lives at home with his daughter. He takes all his BP
meds at the same time in the morning. No recent travel outside
the county.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
STABLE ANGINA
DEPRESSION
CONGESTIVE HEART FAILURE: Type II diastolic dysfunction on TTE
(from ___ in ___
CORONARY ARTERY DISEASE: Based on evidence fo anterior MI (EKG
from ___
HYPERTENSION
DIABETES TYPE II
CHRONIC KIDNEY DISEASE: Stage III-A, GFR 58 in ___
Social History:
___
Family History:
No known family history
Physical Exam:
===========================
ADMISSION PHYSICAL
===========================
VS: 98.3, 138/77, 63 20 98 ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD
HEART: Bradycardic, 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
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
===========================
DISCHARGE PHYSICAL
===========================
Vitals: 98.0 135/66 54 18 94%RA
GENERAL: NAD
HEENT: anicteric sclera,MMM
NECK: JVP not elevated
HEART: Bradycardic, 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
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
=====================================
ADMISSION/LABS
=====================================
___ 03:35PM BLOOD WBC-13.2* RBC-3.74* Hgb-10.8* Hct-32.7*
MCV-87 MCH-28.9 MCHC-33.0 RDW-13.6 RDWSD-43.4 Plt ___
___ 03:35PM BLOOD Neuts-51.3 ___ Monos-9.5
Eos-11.0* Baso-0.8 Im ___ AbsNeut-6.78* AbsLymp-3.56
AbsMono-1.25* AbsEos-1.45* AbsBaso-0.11*
___ 03:35PM BLOOD Plt ___
___ 03:35PM BLOOD UreaN-36* Creat-1.9* Na-139 K-5.4* Cl-101
HCO3-23 AnGap-20
___ 03:35PM BLOOD ALT-9 AST-18 AlkPhos-92 TotBili-0.6
___ 03:35PM BLOOD TotProt-7.5 Calcium-9.4 Iron-59
___ 03:35PM BLOOD CRP-0.5
___ 03:35PM BLOOD PEP-NO SPECIFI
___ 09:29PM BLOOD Lactate-1.2
___ 10:12PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:12PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:12PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 10:12PM URINE CastHy-17*
___ 10:12PM URINE Hours-RANDOM Creat-178 Na-76
___ 10:12PM URINE Osmolal-715
=====================================
DISCHARGE LABS
=====================================
___ 08:30AM BLOOD WBC-12.2* RBC-3.88* Hgb-11.4* Hct-33.7*
MCV-87 MCH-29.4 MCHC-33.8 RDW-13.4 RDWSD-41.9 Plt ___
___ 08:30AM BLOOD Neuts-54.0 ___ Monos-7.2
Eos-12.2* Baso-0.6 Im ___ AbsNeut-6.58* AbsLymp-3.11
AbsMono-0.87* AbsEos-1.48* AbsBaso-0.07
___ 08:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+
Tear Dr-1+ Fragmen-OCCASIONAL
___ 08:30AM BLOOD Glucose-96 UreaN-28* Creat-1.1 Na-137
K-4.4 Cl-104 HCO3-25 AnGap-12
___ 08:30AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
___ 08:30AM BLOOD VitB12-650
___ 08:30AM BLOOD Cortsol-13.0
=====================================
PROCEDURES/STUDIES/IMAGING
=====================================
___ CXR
No acute findings
=====================================
MICRO
=====================================
___ 08:30AM BLOOD STRONGYLOIDES ANTIBODY,IGG- negative
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with low BP// pna?
TECHNIQUE: Chest two views
COMPARISON: ___
FINDINGS:
Borderline heart size, accentuated by shallow inspiration. Normal pulmonary
vascularity, no edema. No effusion, no infiltrates or pneumothorax.
IMPRESSION:
No acute findings.
Gender: M
Race: SOUTH AMERICAN
Arrive by UNKNOWN
Chief complaint: Constipation, Hypotension
Diagnosed with Constipation, unspecified
temperature: 98.1
heartrate: 55.0
resprate: 18.0
o2sat: 96.0
sbp: 99.0
dbp: 52.0
level of pain: 0
level of acuity: 3.0 | =================================
PATIENT SUMMARY STATEMENT
=================================
Mr. ___ is an ___ year old gentleman with stable angina,
hypertension, diabetes mellitus, diastolic dysfunction and
chronic kidney disease, who presented to the ED with ___ in the
setting of hypotensive episodes.
=================================
ACUTE MEDICAL ISSUES ADDRESSED
=================================
# Bradycardia
# Syncope
Patient was noted to have heart rates in the ___ on admission,
which were felt to contribute to syncopal episodes. Felt to be
likely iatrogenic in the setting of metoprolol succinate use,
being downtitrated in the outpatient setting (now 12.5mg daily).
It was held on admission, and heart rates remained stable in the
___. He was able to ambulate without difficulty with no
further bradycardic or syncopal events in the hospital.
# Leukocytosis
# Eosinophilia
Patient was noted to have leukocytosis to 12.2 with 12% eos.
Some concern for adrenal insufficiency, which could also explain
his syncope. Patient has a pan-negative review of systems for an
infectious or neoplastic etiology. His labs do not suggest
systemic involvement. He did not start any new medications. He
does travel frequently to ___, so parasitic infection is on the
ddx, but not having any diarrhea. An AM cortisol was sent,
pending on discharge. B12, SPEP, and Strongyloides Ag were also
sent and pending at time of discharge.
#Hypotension.
SBP 99/52 on presentation, likely iatrogenic in the setting of 4
drug anti-HTN regimen as outpatient. Aside from leukocytosis
(subacute to chronic), no s/s infectious etiology to suggest
sepsis induced hypotension. Improved with 500cc IVF in the ED.
Metoprolol succinate was held, and losartan dose was halved.
Amlodpine and imdur were continued. SBPs remained in 130s-140s.
#Acute on Chronic Kidney Disease.
Baseline Cr 1.2, presenting with Cr 1.5. FeNa 0.5%, suggestive
of prerenal etiology, likely in the setting of hypotension. s/p
500cc IVF in the ED with creatinine normalization. Blood
pressure medications were downtitrated as above.
=================================
CHRONIC MEDICAL ISSUES ADDRESSED
=================================
# Anemia, normocytic.
Iron studies suggestive of possible chronic inflammatory state
given borderline low TIBC with normal Fe, Ferratin. No s/s
bleeding.
# CAD with stable angina.
Continued home aspirin and imdur, held metoprolol as above.
# dCHF. Appeared dry to euvolemic on examination. Not diuresed
in the hospital.
# Type 2 DM.
Metformin was held in setting ___ in the hospital, patient on
ISS. Metformin resumed on discharge
# Depression.
Continued Citalopram 20mg daily.
=================================
TRANSITIONAL ISSUES
=================================
- metoprolol was held given persistent bradycardia
- dose of losartan was decreased to 12.5mg daily for hypotension
- patient should have repeat lytes checked in one week to
monitor kidney function.
- could consider ___ of Hearts as outpatient
- AM cortisol pending at time of discharge => Normal post
discharge
- further workup for eosinophilia, including B12, SPEP, and
Strongyloides Ag were pending at time of discharge. => Post
discharge B12 normal. SPEP normal. Strongy negative.
-CODE: Presumed full
-CONTACT: Daughter ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Nausea and gait instability
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH Sarcoma, brain lesions, right frontal, right splenium,
left parietal convexity, left cerebellum, SRS, headache,
seizures
p/w nausea.
per ER note, pt was finishing steroid taper s/p gamma knife.
Yesterday had gradual onset of whole head headache. Today
progressed to vomiting without nausea. Headache is positional.
Also notes dizziness which makes it difficult to stand.
Neuro exam per ER note says NF except subtle gaze misalignment
with movement. No skew. FNF WNL. MDM
nchct: new worse findings, Neuro surg was consulted. No
immediate
neurosurgical interventions per Nsurg. recommend admission to
OMED, MRI pending. ER resident dw Nsurg re: urgency of MRI, per
Nsurg, MRI can be ordered for tomorrow AM.
On floor, pt reports that he has been having headaches which are
fairly new to him in past 2 days. Location- Frontal, bilaterally
as well has in nape of his neck. Denies fevers, rash, exposure
to
sick contacts. He feels the headaches started after he decreased
the dexamethasone pills from 1mg to 0.5 mg 2 days ago.
He had an episode of vomiting yesterday. He noticed today aM
that
he could not walk very well. He described it as 'wanting to
move,
but my brain feels stuck'. Family with him denies any tendencies
to lean or sway towards left/right. They saw him sway back and
forth while sitting on ER bed. Currently he feels better
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ Left posterior buttock mass
___ U/S showed vascular solid mass
___ MRI
___ Biopsy:
Pathology: high-grade sarcoma c/w alveolar soft part sarcoma
___ FDG-PET showed many lung nodules
___ Local wide resection of the left buttock mass
___ LUL, LLL wedge and sup segment resection by VATS ___ LN
___ Brain MRI showed four lesions
___ SRS to Right Frontal, Left Frontal Dural, Left
Cerebellar, Left Occiptal lesions, 1x22 Gy by Dr. ___
___ Admission with headaches
___ Admission with headaches
___ Brain MRI stable
___ Admission with headaches
___ Brain MRI shows progression
___ Resection of left frontal mass by Dr. ___: viable tumor, metastatic alveolar soft part sarcoma,
morphologically compatible with the patient's prior metastasis
to
the lung
___ Brain MRI stable
___ FDG-PET stable
___ CT torso showed mass in the pancreas
___ Brain MRI showed progression
___ SRS to Left Frontal Resection Cavity 3x8 Gy by Dr.
___
___ Brain MRI stable
___ Brain MRI stable
___ Partial pancreatectomy
___ Brain MRI stable
___ Brain MRI showed progression
___ SRS to Right Cerebellar 3x8 Gy by Dr. ___
___ Brain MRI shows progression
___ CT torso stable
___ SRS to Left Parietal 22 Gy by Dr. ___
___ Brain MRI stable
PAST MEDICAL HISTORY:
1. Sarcoma, brain lesions
Social History:
___
Family History:
The patient's grandfather had a cancer. He does not know the
details. His mother has diabetes ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS:97.6
PO 117 / 70 62 18 96 Ra
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors,
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, very minimal physiologic
nystagmus on L gaze; strength is
___ of the proximal and distal upper and lower extremities;
gait is normal, Romberg is non pathologic, coordination is
intact.
DISCHARGE PHYSICAL EXAM
98.1 PO 110 / 67 67 18 96%RA
GENERAL: Well-appearing young man sitting in bed comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no
murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact
except for mild inducible left-sided horizontal nystagmus.
Strength full throughout. Sensation to light touch intact. Gait
preserved.
SKIN: No significant rashes.
Pertinent Results:
___ 05:14PM BLOOD WBC-8.6 RBC-5.36 Hgb-15.7 Hct-46.2 MCV-86
MCH-29.3 MCHC-34.0 RDW-13.8 RDWSD-43.7 Plt ___
___ 05:14PM BLOOD Neuts-78.6* Lymphs-13.0* Monos-6.8
Eos-0.1* Baso-0.6 Im ___ AbsNeut-6.72* AbsLymp-1.11*
AbsMono-0.58 AbsEos-0.01* AbsBaso-0.05
___ 05:14PM BLOOD Glucose-97 UreaN-12 Creat-0.9 Na-138
K-3.4 Cl-98 HCO3-24 AnGap-19
___ 05:14PM BLOOD ALT-14 AST-13 AlkPhos-53 TotBili-1.0
___ 05:14PM BLOOD Albumin-4.6 Calcium-9.6 Phos-3.4 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Dexamethasone 4 mg PO Q6H
Tapered dose - DOWN
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Senna 17.2 mg PO QHS
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 4 mg PO BID Brain edema Duration: 10 Days
Do not stop abruptly. Decide taper during neuro-oncology
follow-up.
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*90
Capsule Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Senna 17.2 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral edema
Secondary neoplasm of the brain
Metastatic Alveolar Sarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with MD ___ ___ PMH Sarcoma, brain lesions,
right frontal, right splenium, left parietal convexity, left cerebellum, SRS,
headache, seizures p/w nausea.Was finishing steroid taper s/p gamma knife.
Yesterday had gradual onset of whole head headache. Today progressed to
vomiting without nausea. Headache is positional. Also notes dizziness which
makes it difficult to stand....patient with hx of sarcoma-currently undergoing
radiation with steroid taper. currently with nausea, unable to tolerate PO's,
HA...PExamNeuro NF except subtle gaze misalignment with movementNo skewFNF WNL
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: A CT from ___. Multiple MRIs, most recently dated ___.
FINDINGS:
Again seen is hyperdense focus in the right periventricular region, measuring
up to 7 mm with extensive vasogenic edema, exerting mass effect on the
posterior horn of the lateral ventricle, not significantly changed compared to
prior exam. The multiple hyperdense foci abutting the ependymal surface
likely represent blood products as previously characterized on the multiple
MRIs. Previously described enhancing right frontal nodule is not seen on
today's exam, likely due to differences in technique. The enhancing left
parietal nodule is not seen on today's exam, though there remains vasogenic
edema in the expected location, not significantly changed compared to prior
exam, allowing for differences in technique. In the right middle cerebellar
peduncle, there is heterogeneous hyperdensity measuring up to 1.3 x 1.1 cm,
likely corresponding with the enhancing focus on the prior MRI, surrounded by
extensive vasogenic edema, persistently effacing the fourth ventricle. New
since ___, the focus is hyper dense on CT. There was no evidence of
hemorrhage on ___ at this location. There is effacement of the
ambient cisterns especially on the right. The extent of edema is difficult to
compare due to differences in technique, and there is no improvement. Left
cerebellar enhancing focus is not seen on today's exam, though there is mild
edema in the expected location. The size of the ventricles are stable. There
is no evidence of new territorial infarct.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. Interval development of hyperdense focus in the right cerebellar peduncle
since ___. No new territorial infarct, though evaluation would be more
sensitive on MRI. No definite new intracranial hemorrhage.
2. Extensive vasogenic edema involving the right and left parietal lobe, right
and left cerebellum. Hyperdense nodules, likely corresponding with the
previously described enhancing foci.
3. Persistent effacement of the fourth ventricle and the ambient cisterns,
possibly progressed, though difficult to evaluate the progression since ___ due to differences in modality.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Headache, Nausea
Diagnosed with Headache
temperature: 98.3
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 110.0
dbp: 74.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ year-old man with multiple brain metastases
of alveolar sarcoma s/p SRS and resection who, as he tapered his
dexamethasone,presented with nausea, headaches and ataxia. Now
improved afterresuming dexamethasone at higher doses.
#Cerebral Edema in setting of brain metastases s/p SRS: Nausea
and ataxia have resolved. Headache improved on ___ and resolved
on ___. Discharged on dexamethasone 4mg bid to follow-up with
Dr. ___ bevacizumab infusion and taper.
#Metastatic alveolar sarcoma: No immunotherapy indicated given
stable disease. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime
Attending: ___
___ Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man with poorly controlled HTN, type I diabetes, and
ESRD on HD (last dialyzed yesterday) who presented to the ED
today after developing nausea, vomiting, and abdominal pain that
started at 7am on ___. He called EMS and was brought to the ED
where initial VS were 100.8, 93, 194/130, 18, 98% RA. He denied
any hematemesis, hematochezia, or melena, and stated that the
symptoms were similar to prior episodes of gastroparesis. No
fevers, chills, cough, chest pain, or palpitations. He was given
4mg IV zofran and 5mg IV morphine. Labs significant for K 5.9,
HCO3 20, BUN 30, Cr 8.7 (though hemolyzed specimen). Trop 0.26
-> 0.24, CK-MB 6. Nml lactate, neg tox screen. CXR with
perihilar opacities and left mid-lung opacity (fluid vs.
infectious process). He subsequently became tachycardic to the
150s (ekg appears to be sinus tach) and tachypneic with hypoxia
to the low ___. He was placed on a NRB and then intubated with
rocuronium and etomidate. Was given 20mg IV labetalol x2. NG
tube placed with return of bilious material. CTA with multifocal
ground glass and nodular opacities dependantly in left lung and
to lesser extent in right lung (edema vs. infection). He was
given levofloxacin 750mg IV. Was 81% on PEEP of 5, then 99% with
PEEP of 15. Upon transfer from the ED vent settings were AC with
TV 500, RR12, FiO2 100%. Access is 18g in right EJ, 18g in L
wrist.
.
On arrival to the MICU, patient is intubated and sedated with
fentanyl and midazolam. Vent settings are AC with TV 500, RR 16,
FiO2 100%, PEEP 15. This was quickly weaned to PEEP 5 with FiO2
40%.
Past Medical History:
- DM type I since age ___. Uncontrolled with last A1C 12.1 in
___. Complicated by nephropathy, neuropathy, gastroparesis,
retinopathy. Multiple prior hospitalizations with DKA,
nausea/vomiting ___ gastroparesis.
- ESRD on HD ___ via left subclavian tunneled line at ___
___, dry weight 73kg, temporarily inactive on transplant
list
- ___ Excision of infected right arm AV graft
- Hypertension: poorly controlled due to medication
non-compliance
- Nonischemic cardiomyopathy with LVEF 45-50% on echo ___
- Pulmonary hypertension
- Chronic abdominal pain
- Anemia ___ iron deficiency and advanced CKD
- Depression
- Migraines
Social History:
___
Family History:
Paternal grandfather had DM2. No FH DM1. Hypertension in a few
family members. Both parents and several siblings alive and
healthy, without known medical problems.
Physical Exam:
ADMISSION EXAM:
Vitals: 99.2, 90, 190/124, AC with TV 500, RR 16, PEEP 15, FiO2
100%
General: Intubated, sedated
HEENT: +ET tube, +NGT (with return of bilious fluid)
Neck: Right EJ 18g
CV: Regular with nml S1 and S2, no m/r/g
Lungs: Decreased BS at bases on anterior exam, no wheezes
Abdomen: Soft, non-tender, hypoactive BS
GU: No foley
Extrem: Warm and dry, RUE fistula
Neuro: Sedated, unable to assess
Skin: No rashes
.
DISCHARGE EXAM:
Vitals: Afebrile, 74, 148/95, 16, 98% RA
General: A&Ox3, sitting in bed eating lunch
HEENT: No icterus or pallor, MMM
Neck: Supple, no carotid bruits, JVP not elevated
CV: Regular with nml S1 and S2, no m/r/g
Lungs: Clear bilaterally
Abdomen: Soft, non-tender, NABS
GU: No foley
Extrem: Warm and dry, RUE fistula
Neuro: CN II-XII intact, strength and sensation grossly intact,
gait normal
Skin: Warm, dry, no rashes
Pertinent Results:
ADMISSION LABS:
___ 01:53PM BLOOD WBC-6.8 RBC-4.38* Hgb-13.1* Hct-40.0
MCV-91 MCH-29.9 MCHC-32.7 RDW-13.8 Plt ___
___ 01:53PM BLOOD Neuts-86* Bands-0 Lymphs-8* Monos-0
Eos-6* Baso-0 ___ Myelos-0
___ 08:20PM BLOOD ___ PTT-33.3 ___
___ 01:53PM BLOOD Glucose-128* UreaN-30* Creat-8.7*# Na-142
K-5.9* Cl-104 HCO3-20* AnGap-24*
___ 01:53PM BLOOD ALT-19 AST-57* CK(CPK)-313 AlkPhos-129
TotBili-0.5
___ 01:53PM BLOOD Lipase-35
___ 01:53PM BLOOD Albumin-4.6 Calcium-9.8 Phos-4.1# Mg-2.0
___ 01:53PM BLOOD cTropnT-0.26*
___ 04:15PM BLOOD cTropnT-0.24*
___ 08:20PM BLOOD CK-MB-5 cTropnT-0.25*
___ 01:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:05PM BLOOD Lactate-1.9
.
DISCHARGE LABS:
___ 06:11AM BLOOD WBC-5.7 RBC-3.71* Hgb-10.9* Hct-33.3*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.2 Plt ___
___ 06:11AM BLOOD Glucose-366* UreaN-37* Creat-9.5*#
Na-131* K-4.1 Cl-92* HCO3-24 AnGap-19
___ 06:11AM BLOOD Calcium-9.1 Phos-4.5# Mg-2.4
.
MICRO:
___ Blood cultures: no growth to date
___ Sputum gram stain: 2+ GPCs in clusters; culture:
commensal flora
.
IMAGING:
___ CXR: Left subclavian central venous catheter is again
seen with tip in the region of the proximal right atrium. The
cardiac silhouette is mildly enlarged. There are perihilar
opacities which may be due to fluid overload. Additional left
perihilar mid lung opacity is seen which could relate to fluid
overload, although underlying infectious process is not
excluded, or even aspiration. No large pleural effusion or
pneumothorax.
.
___ CTA Torso: Multifocal ground glass and nodular opacites
dependantly through the left lung and to a lesser extent right
lung may be infectious. Nodular components are likely related to
this acute etiology however reimaging in ___ months after
resolution of acute illness is recommend to check for
resolution. Likely a background of mild pulmonary edema. Abdomen
and pelvis CT is acquired in a relatively arterial phase,
possibly secondary to decreased cardiac output. Perioportal,
pericholecystic and trace free edema and generalized soft tissue
edema. Appendix not visualized but no secondary signs of
appendicitis. Collapsed loops of small and large bowel.
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSAT
4. Labetalol 600 mg PO TID
5. Nephrocaps 1 CAP PO DAILY
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Lisinopril 40 mg PO DAILY
8. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. HYDROmorphone (Dilaudid) 4 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSAT
4. Labetalol 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. HYDROmorphone (Dilaudid) 4 mg PO BID:PRN pain
9. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Levofloxacin 500 mg PO ONCE Duration: 1 Doses
Take on ___ after dialysis.
RX *levofloxacin 500 mg 1 tablet(s) by mouth once on ___
after dialysis. Disp #*1 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- flash pulmonary edema
- aspiration pneumonia
- hypertension
Secondary diagnosis:
- type 1 diabetes
- gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain hypoxia.
COMPARISON: ___.
FINDINGS:
Left subclavian central venous catheter is again seen with tip in the region
of the proximal right atrium. The cardiac silhouette is mildly enlarged.
There are perihilar opacities which may be due to fluid overload. Additional
left perihilar mid lung opacity is seen which could relate to fluid overload,
although underlying infectious process is not excluded, or even aspiration.
No large pleural effusion or pneumothorax.
Radiology Report
EXAM: Chest, single supine AP portable view.
CLINICAL INFORMATION: Intubation NG tube placement.
___ at 14:56.
FINDINGS: Interval placement of an endotracheal tube is seen, terminating
approximately 2.9 cm above the level of the carina. Enteric tube is in place
coursing below the level of the diaphragm, inferior aspect not well seen. The
cardiac silhouette remains enlarged. Left perihilar opacity persists.
Prominence of the central pulmonary vasculature again may be due to mild fluid
overload. No pleural effusion or pneumothorax. The cardiac and mediastinal
silhouettes are stable.
Radiology Report
INDICATION: Presenting with nausea, vomiting and abdominal pain, also hypoxic
to 90% on nonrebreather. Evaluate for pulmonary embolism, pancreatitis,
colitis.
COMPARISON: CT abdomen and pelvis, ___. CTA chest and CT abdomen
and pelvis, ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest,
abdomen, and pelvis after the administration of 130 cc of Omnipaque IV
contrast. Multiplanar axial, coronal, and sagittal images were obtained.
Additionally, oblique maximum intensity projection images through the chest
were generated.
FINDINGS:
CT THORAX: The partially visualized thyroid is unremarkable. There is no
supraclavicular, axillary, hilar or mediastinal lymphadenopathy. The airways
are patent to the subsegmental level. The heart is enlarged. There is no
pericardial effusion. The great vessels are within normal limits. There is
no hiatal hernia. An ET tube terminates 2.6 cm from the carina. An enteric
tube is noted in the esophagus and terminates in the stomach. Lung windows
demonstrate multifocal ground-glass nodular opacities dependently throughout
the left lung and to a lesser extent, the right lung. The pulmonary artery is
prominent, measuring 3.8 cm and there is septal thickening, compatible with
mild pulmonary edema.
CTA THORAX: The aorta and main thoracic vessels are well opacified. The
aorta is of normal caliber throughout the thorax without intramural hematoma
or dissection. The pulmonary arteries are opacified to the subsegmental
level. There is no filling defect in the main, right, left, lobar or
subsegmental pulmonary arteries.
CT ABDOMEN: This study is acquired in a relatively arterial phase, possibly
secondary to decreased cardiac output. There is periportal edema in an
otherwise unremarkable liver without focal lesions. The gallbladder is
unremarkable; however, there is pericholecystic fluid, likely due to volume
status. The spleen, pancreas, and adrenal glands are unremarkable. The
kidneys enhance symmetrically without focal lesions or hydronephrosis. The
ureters are normal throughout their visualized course.
The stomach is unremarkable. There are collapsed loops of small and large
bowel without evidence of wall thickening or obstruction. The appendix is not
visualized; however, there are no secondary signs of appendicitis. There is
mild mesenteric edema, trace free fluid about the abdomen and pelvis, and mild
generalized soft tissue edema likely related to fluid status.
The intra-abdominal vasculature is unremarkable except for atherosclerotic
calcifications, which are most prominent in the pelvis. There is no
retroperitoneal or mesenteric lymphadenopathy. There is no free air.
PELVIC CT: The urinary bladder appears unremarkable. There is no pelvic wall
or inguinal lymphadenopathy. There is a small amount of free fluid.
Phleboliths are scattered throughout the pelvis.
OSSEOUS STRUCTURES: There are no concerning blastic or lytic lesions.
IMPRESSION:
1. Multifocal ground-glass and nodular opacities in the left greater than
right lung possibly infectious. Nodular components are likely related to
acute etiology; however, reimaging in three to six months after resolution of
acute illness is recommended.
2. Cardiomegaly and mild pulmonary edema.
3. Periportal edema, pericholecystic fluid, trace free fluid about the
pelvis, mild mesenteric edema and generalized soft tissue edema likely related
to fluid status.
4. No evidence of colitis or pancreatitis.
5. No evidence of pulmonary embolism.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ male with pneumonia. Intubated.
FINDINGS: Comparison is made to the prior radiographs from ___.
There is an endotracheal tube, left-sided vascular catheter, and feeding tube,
which appear appropriately sited in unchanged position. There is marked
cardiomegaly which is stable. There is again seen some areas of consolidation
within the left perihilar region; however, this has improved. There is a left
retrocardiac opacity which is more apparent on today's study. There are no
pneumothoraces.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ man with respiratory failure, on mechanical
ventilation, evaluate for interval changes.
FINDINGS: Comparison is made to prior study from ___.
There is a vasculr catheter with tip in the proximal right atrium. Heart size
is enlarged but stable. Persistent left retrocardiac opacity is stable. No
pulmonary edema is identified.
Radiology Report
HISTORY: ___ year old man with ESRD, severe HTN needs to be ruled out for
secondary causes, rule out renal artery stenosis.
COMPARISON: CT ___
TECHNIQUE: Gray scale and Doppler ultrasound images of the renal transplant
were obtained.
FINDINGS:
Bilateral kidneys are echogenic, this is more pronounced on the right than the
left. The right kidney measures 8.8 cm. The left kidney measures 8.8 cm.
The resistive index of the right intrarenal arteries ranges from 0.75 to 0.63,
within normal limits. The acceleration times and peak systolic velocities of
the main renal arteries are normal.
Assessment of the left intrarenal arteries is more limited. The resistive
indices range from the 0.8-0.7. The acceleration times and peak systolic
velocities of the main renal arteries are normal. The renal vein is patent
and shows normal waveforms.
Bilaterally the cortical thickness appears normal. The renal sinus fat
appears normal. There is no hydronephrosis. There is no perinephric fluid
collection.
IMPRESSION:
The kidneys are bilaterally echogenic consistent with medical renal disease.
Normal waveforms are seen within the intrarenal arteries with normal resistive
indices. There is no evidence of renal artery stenosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: ABD PAIN
Diagnosed with HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, HYPOXEMIA, END STAGE RENAL DISEASE, DIABETES UNCOMPL JUVEN
temperature: 98.3
heartrate: 93.0
resprate: 18.0
o2sat: 98.0
sbp: 194.0
dbp: 130.0
level of pain: 10
level of acuity: 3.0 | ___ year old man with HTN, type I DM, and ESRD on HD, who
presented with nausea, vomiting, and abdominal pain, with
development of hypertensive urgency and hypoxic respiratory
failure requiring intubation.
.
# Hypoxemic Respiratory Failure: CTA negative for PE or acute
aortic pathology, though did show mild pulmonary edema and
possible left middle lobe pneumonia. Acute hypoxia was likely
secondary to flash pulmonary edema in the setting of volume
overload, HTN to 190s, and tachycardia to 150s. Given his
vomiting, patient was likely not absorbing his
antihypertensives. He was started on labetalol and nitroglycerin
gtts and his home antihypertensives were restarted with
improvement in his hemodynamics. He also underwent two sessions
of HD. He was initially treated with levofloxacin and vancomycin
and then the vancomycin was stopped. He will take one dose of PO
levofloxacin 500mg tomorrow (___) to complete a 5-day
course. He was extubated on hospital day 3 without complication.
.
# Hypertensive urgency: Likely due to poor absorption of his
home medications in the setting of vomiting. He was started on
labetalol and nitro gtts as noted above and then his home
antihypertensives (amlodipine 10mg daily, lisinopril 40mg daily,
labetalol 600mg TID, and clonidine patch 0.3mg QWeekly) were
restarted. Patient was educated on the importance of taking all
of his medications as prescribed and checking his blood pressure
daily at home.
.
# Hyperkalemia/ESRD: Initial potassium was 6.9 which rose to
7.2, without associated ekg changes. He was given one dose of
kayexalate and was then dialyzed. We continued nephrocaps and
sevelamer.
.
# Nausea/vomiting: Symptoms were similar to prior episodes of
gastroparesis which he has every few months. He has tried
medications for this in the past, including reglan, without
improvement. Symptoms resolved by discharging and he was
tolerating a regular diet.
.
# Type I DM: Poorly controlled, last A1c 10.1% on ___. We
continued his home doses of glargine 14u at breakfast with a
humalog sliding scale. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Heparin Agents
Attending: ___
Chief Complaint:
hypotension at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F h/o Juvenile DM I s/p renal tx ___ and pancreatic tx ___
(explanted for necrosis) presented to the ED c/o hypotension,
malaise and fever at home and transferred to MICU for managment
of septic shock. Pt treated for pyelonephritis in ___ and
just finished course of valcyte for herpes zoster of left flank.
Recent UTI treated with ciprofloxacin ending 1 wk prior. Fever
to 102.7 at home yesterday. No dysuria, tenderness of tx kidney,
cough, frequency, suprapubic discomfort. Had a headache this
morning during her fevers. Some neck pain put this was
transient. No photophobia. This morning she collapsed into her
husbands grasp on two occasions but did not lose consciousness
or hit her head; this happened when she got up to go to the
bathroom from her bed. She had three episodes of nonbilious
nonbloody nausea and vomiting. No belly pain. No diarrhea. Last
bm 36 hrs prior and brown/solid. Has been able to take po
fluids, not much solid food.
.
.
In the ED, initial VS were: t 100.4, bp 85/50, hr 112, rr14, sat
100% RA. Triggered for hypotension 78/51. SBP recovered to 100s
after 5L ivf resuscitation. Recieved iv zosyn 4.5g, iv vanc 1g,
hydrocort 50mg iv. Renal transplant u/s showed no abscess/hydro.
Transplant surgery evaluated, no intervention. Transplant
nephrology evaluated ___ evaluated and wrote recs for her
continuous insulin pump.
.
Upon transfer to the micu, vitals 99.8, 103/54, hr 97, 97RA. On
arrival to the MICU, no acute complaints.
Past Medical History:
#. Type 1 diabetes mellitus since age ___
#. End-stage renal disease.
#. Status post renal transplant in ___.
#. Status post failed pancreatic transplant on ___, explanted
on ___ in setting of necrotic and thrombotic graft
#. C section ___
#. Bilateral tubal ligation.
#. ankle fracture s/p repair with plate in ___
Social History:
___
Family History:
No history of CAD or cancer
Physical Exam:
Discharge exam
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs
___ 12:15PM ___ PTT-29.6 ___
___ 12:15PM PLT SMR-NORMAL PLT COUNT-214
___ 12:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
___ 12:15PM WBC-30.8*# RBC-4.44 HGB-12.3 HCT-35.9*
MCV-81* MCH-27.7 MCHC-34.1 RDW-15.4
___ 12:15PM CALCIUM-9.6 PHOSPHATE-4.6*# MAGNESIUM-1.8
___ 12:15PM estGFR-Using this
___ 12:15PM GLUCOSE-226* UREA N-49* CREAT-3.1*#
SODIUM-130* POTASSIUM-4.0 CHLORIDE-91* TOTAL CO2-23 ANION GAP-20
___ 12:35PM GLUCOSE-218* LACTATE-1.9 K+-4.2
___ 12:35PM COMMENTS-GREEN TOP
___ 03:00PM URINE RBC-4* WBC-107* BACTERIA-MOD YEAST-NONE
EPI-<1
___ 03:00PM URINE RBC-4* WBC-107* BACTERIA-MOD YEAST-NONE
EPI-<1
___ 03:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 03:00PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 03:00PM URINE UCG-NEGATIVE
___ 03:00PM URINE HOURS-RANDOM
___ 06:09PM PLT COUNT-170
___ 06:09PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-3.4
MAGNESIUM-1.6
___ 06:09PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-3.4
MAGNESIUM-1.6
___ 06:09PM ALT(SGPT)-26 AST(SGOT)-35 LD(LDH)-141 ALK
PHOS-38 TOT BILI-0.7
.
TACROLIMUS LEVELS:
___ 01:51PM BLOOD tacroFK-11.1
___ 03:29AM BLOOD tacroFK-3.9*
___ 04:03AM BLOOD tacroFK-5.3
___ 05:35AM BLOOD tacroFK-7.7
___ 05:55AM BLOOD tacroFK-9.0
___ 06:15AM BLOOD tacroFK-7.0
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-8.6 RBC-3.68* Hgb-9.8* Hct-29.9*
MCV-81* MCH-26.7* MCHC-32.8 RDW-15.7* Plt ___
___ 06:15AM BLOOD Glucose-135* UreaN-28* Creat-1.4* Na-139
K-3.5 Cl-99 HCO3-30 AnGap-14
.
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
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
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
.
RENAL TRANSPLANT ULTRASOUND: The transplanted kidney is
demonstrated within
the right lower quadrant and measures 14.8 cm. Corticomedullary
differentiation is preserved. No renal calculi, renal masses, or
hydronephrosis is demonstrated. Tiny amount of simple free fluid
is
demonstrated superior to the upper pole of the transplant kidney
as well as inferior and medial to the lower pole.
Normal color flow and vascularity is demonstrated throughout the
transplanted kidney. The main renal artery and main renal vein
are widely patent and demonstrate normal arterial and venous
waveforms. Resistive indices within the upper pole, interpolar,
and lower pole intrarenal arteries are 0.76, 0.80, and 0.77
respectively. Previously, the resistive indices were 0.78, 0.73,
and 0.71, respectively.
The urinary bladder is collapsed.
IMPRESSION:
1. No evidence of hydronephrosis or abscess.
2. Resistive indices range from 0.76 to 0.80 on the current
study, which is minimally elevated within the interpolar region
when compared to the prior study. Otherwise, vascularity appears
unremarkable.
.
MRI:
IMPRESSION:
Unremarkable MR of the renal transplant kidney with a
subcentimeter
hemorrhagic / proteinaceous cyst noted in the lower pole. No
evidence for
hydronephrosis or hydroureter or evidence for ___ abscess
or
collection.
Medications on Admission:
alendronate 70mg qweek
gabapentin 300mg tid (started recently has taken only 1 dose)
humalog via continuous pump
mycophenolate mofetil/cellcept 500mg daily
prednisone 5mg daily
tmp/smx ss mwf
tacrolimus (PROGRAF)-brand name only; 2mg bid
mv
vitamin d/ca
.
Allergies:
heparin
morphine
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
___.
2. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO MWF (___).
5. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO bid ().
Disp:*180 Capsule(s)* Refills:*2*
6. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever and pain.
7. Insulin Pump
Humalog Insulin
Basal Rates:
Midnight - 3am: 1 Units/Hr
3am - 11am: 1.2 Units/Hr
11am - 10PM: 1 Units/Hr
10PM - 12am: 1 Units/Hr
Meal Bolus Rates:
Breakfast = 1:12
Lunch = 1:11
Dinner = 1:9
Snacks = 1:9
High Bolus:
Correction Factor = 1:
Correct To ___ mg/dL
8. pravastatin 20 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
12. cranberry 500 mg Capsule Sig: One (1) Capsule PO once a day.
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 16 days: Last dose ___ at night.
Disp:*32 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please ___ Chemistry 10, CBC and tacrolimus level ___
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Complicated urinary tract infection
Sepsis
.
Secondary Diagnosis:
Renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman with sepsis, evaluate for pneumonia.
COMPARISON: ___.
SINGLE AP PORTABLE VIEW OF THE CHEST: The lungs are clear. Cardiomediastinal
silhouette and hilar contours are unremarkable. There are no pleural
effusions noted. There are no pneumothoraces noted. The bones appear intact.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Fever, history of renal transplantation approximately ___ years
previously.
COMPARISON: Renal transplant ultrasound ___.
RENAL TRANSPLANT ULTRASOUND: The transplanted kidney is demonstrated within
the right lower quadrant and measures 14.8 cm. Corticomedullary
differentiation is preserved. No renal calculi, renal masses, or
hydronephrosis is demonstrated. Tiny amount of simple free fluid is
demonstrated superior to the upper pole of the transplant kidney as well as
inferior and medial to the lower pole.
Normal color flow and vascularity is demonstrated throughout the transplanted
kidney. The main renal artery and main renal vein are widely patent and
demonstrate normal arterial and venous waveforms. Resistive indices within
the upper pole, interpolar, and lower pole intrarenal arteries are 0.76, 0.80,
and 0.77 respectively. Previously, the resistive indices were 0.78, 0.73, and
0.71, respectively.
The urinary bladder is collapsed.
IMPRESSION:
1. No evidence of hydronephrosis or abscess.
2. Resistive indices range from 0.76 to 0.80 on the current study, which is
minimally elevated within the interpolar region when compared to the prior
study. Otherwise, vascularity appears unremarkable.
Radiology Report
MRI RENAL
INDICATION: Status post renal transplant in ___, recurrent UTI and fevers.
COMPARISON: Ultrasound, ___.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging were acquired on a 1.5
Tesla magnet. No IV Gadolinium was administered,
FINDINGS:
The renal transplant kidney measures 15 cm in craniocaudal length, previously
measuring 14 cm in ___. There is preservation of corticomedullary
differentiation. There is no evidence for hydronephrosis or hydroureter.
Within the lower pole of the kidney, a 6-mm hemorrhagic / proteinaceous cyst
is identified that is hyperintense relative to renal parenchyma on T1-weighted
imaging (series 10, image 60) and hyperintense relative to renal parenchyma on
T2-weighted imaging (series 4, image 17). There is no surrounding perirenal
collection or abscess identified.
Visualized portions of the liver, gallbladder, spleen, pancreas, adrenals and
native kidneys are unremarkable. There are no retroperitoneal masses or
adenopathy. No abnormally dilated or thickened small or large bowel loop.
Visualized bladder is unremarkable. Uterus and both adnexa are normal. Trace
of physiological free fluid noted within the pelvis (series 4, image 38). No
pelvic adenopathy.
Bone marrow signal is normal and there are no osseous lesions.
IMPRESSION:
Unremarkable MR of the renal transplant kidney with a subcentimeter
hemorrhagic / proteinaceous cyst noted in the lower pole. No evidence for
hydronephrosis or hydroureter or evidence for ___ abscess or
collection.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with SEPTICEMIA NOS, ANAPHYLACTIC REACTION DUE TO PEANUTS, ACUTE KIDNEY FAILURE, UNSPECIFIED, ACCIDENT NOS, KIDNEY TRANSPLANT STATUS, DIABETES UNCOMPL JUVEN
temperature: 100.4
heartrate: 112.0
resprate: 14.0
o2sat: 100.0
sbp: 85.0
dbp: 50.0
level of pain: 8
level of acuity: 1.0 | ___ h/o Juvenile DM s/p renal and pancreas transplants on
prednisone, cellcept, and tacrolimus presented with septic shock
from UTI.
.
#septic shock/UTI: Presented with hypotension and urinary tract
infection from klebsiella and was admitted to the MICU. She was
treated with IVF and vancomycin and meropenem. She was also
briefly treated with stress dose steroids given her chronic
steriod use. Her MMF was briefly held as well. Her Hypotension
improved and she was transferred to the floor. SHe received an
US of her transplanted to kidney to eval for causes of her
recurrent UTIs which was unrevealing. She then went on to an MRI
which also did not show any abscesses or predisposing
abnormalities. She was evaluated by ID who recommended a
prolonged course of ciprofloxacin per culture sensitivities as
well as ID and urology follow up.
.
#Acute on Chronic Kidney Disease: She is several years from her
kidney transplant on tacro, mmf and prednisone. Her graft had
been doing well until she presented with hypotension and ___
from hypoperfusion leading to ATN. Her MMF was held in the
setting of infection. During her admission she began to
auto-diurese and her creatinine improved everyday until
discharge. Later her tacrolimus level was noted to be high and
her dose was decreased to 1.5mg BID.
.
# Type 1 DM - Well controlled with insulin pump. Diagnosed when
the patient was ___ years old. She is on an insulin pump and
manages her sugars closely. The patient's fingersticks were
mildly elevated on admission, requiring small changes as per
___.
.
# Dyslipidemia - Chronic. The patient was continued on home
pravastatin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue and lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with successfully treated HCV
infection, and chronic back pain with prior neurostimulator
trial who presented to the ED with one week of lightheadedness
and fatigue. He says his symptoms started 7 days ago and
progressively worsened. He felt presyncopal, but never had a
syncopal event. However, he did go over to his friends house > 7
week ago and passed out in front of the computer for 1 hour, and
had to be awoken by his friend at that time. He has felt very
tired, has been sleeping more than usual. He has had a poor
appetite for food since ___, and has lost 20 lbs in that
time. He has felt some chest tightness which is worse with
inspiration, no radiation, not associated with exertion. + some
dry cough x 1 week. He has also lost his taste for cigarrettes
and stopped smoking them as he usually dose. However, says his
sense of taste is intact. Denies nausea, vomiting, diarrhea. +
constipation since he ran out of his senna (no BM x 6 days).
Denies sore throat, runny nose. He has noted some b/l calf pain,
but no swelling or redness. He has back pain at baseline which
has not gotten worse. No black stool, no dysuria, no sick
contacts. Denies feeling down or blue.
He seen for regular followup in Liver Clinic yesterday, where he
noted the above symptoms, and his hepatologist was concerned for
infection. Basic labs were sent, which notably showed a 10
point Hct drop since ___, as well as new hyponatremia with
Na 130 from a normal prior baseline 140-142.
Initial vitals in ED triage were T 99.8, HR 108, BP 106/62, RR
18, and SpO2 98% on RA. Rectal exam was guaic negative. His
urine was noted to be red tinged, but UA negative for blood.
Labs were notable for an additional Hct drop from ___ yesterday
to 30.7 today. Coags showed an elevated INR 1.6 and normal
D-dimer 289. His LFTs were fairly unremarkable.
CXR showed no acute process and EKG showed sinus rhythm at 99
bpm with NA/NI and no acute ST-T changes. He was given normal
saline 1000 ml. His PCP was contacted, who agreed with
admission.
He was admitted to medicine for further management of acute
anemia. Vitals prior to floor transfer were T 98.3, HR 90, BP
112/64, RR 20, and SpO2 98% on RA. On reaching the floor, he
reported
REVIEW OF SYSTEMS:
(+/-) Per HPI
Past Medical History:
# Hypertension
# Hepatitis C -- successfully treated
# Hemochromatosis -- compound heterozygote for ___ and H63D
mutations. never phelbotomized
# Cholecystectomy
# Chronic Back Pain
# ACDF C5-C7 (___)
# Left microdiscectomy L5-S1 (___)
# Hand pain ? arthritis (Rheum w/u negative per patient)
Social History:
___
Family History:
No history of blood disorders or clotting disorders, no h/o
blood cancers
# Mother: ___
# Father: ___
# Grandfather: back issues
# Grandmother: skin cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.8 106/68 90 18 95% RA
Gen: Young male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MM dry, OP benign.
Neck: Supple, full ROM. JVP not elevated. + thyroid firm and
palpable, no nodules appreciated.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. No C/C/E. Distal pulses intact
Skin: + venous changes L calf, No rashes, ulcers, or other
lesions.
Neuro: CN II-XII grossly intact. Reflex b/l symmetric 2+ uppers
3+ lowers, ___ beats of clonus on each ankle. Strength ___
throughout.
DISCHARGE PHYSICAL EXAMINATION:
VS: 99.8 106/68 90 18 95% RA
Gen: Young male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MM dry, OP benign.
Neck: Supple, full ROM. JVP not elevated. + thyroid firm and
palpable, no nodules appreciated.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. No C/C/E. Distal pulses intact
Skin: + venous changes L calf, No rashes, ulcers, or other
lesions.
Neuro: CN II-XII grossly intact. Reflex b/l symmetric 2+ uppers
3+ lowers, ___ beats of clonus on each ankle. Strength ___
throughout.
Pertinent Results:
ADMISSION LABS
___ 03:15PM URINE HOURS-RANDOM UREA N-1083 CREAT-797
SODIUM-LESS THAN POTASSIUM-65 CHLORIDE-26
___ 03:15PM URINE OSMOLAL-757
___ 03:15PM URINE UHOLD-HOLD
___ 03:15PM URINE COLOR-DkAmb APPEAR-Hazy SP ___
___ 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.0
LEUK-NEG
___ 03:15PM URINE RBC-0 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 03:15PM URINE HYALINE-30*
___ 03:15PM URINE MUCOUS-MANY
___ 01:20PM GLUCOSE-117* UREA N-7 CREAT-0.8 SODIUM-130*
POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-30 ANION GAP-12
___ 01:20PM estGFR-Using this
___ 01:20PM ALT(SGPT)-28 AST(SGOT)-44* LD(LDH)-159
CK(CPK)-27* ALK PHOS-64 TOT BILI-0.9
___ 01:20PM CK-MB-1 cTropnT-<0.01
___ 01:20PM ALBUMIN-3.1*
___ 01:20PM D-DIMER-289
___ 01:20PM HAPTOGLOB-267*
___ 01:20PM TSH-1.5
___ 01:20PM CORTISOL-18.7
___ 01:20PM WBC-8.5 RBC-3.19* HGB-10.4* HCT-30.7* MCV-96
MCH-32.7* MCHC-34.0 RDW-11.9
___ 01:20PM NEUTS-83.5* LYMPHS-11.5* MONOS-4.4 EOS-0.4
BASOS-0.2
___ 01:20PM PLT COUNT-371
___ 01:20PM ___ PTT-31.8 ___
___ 01:20PM RET AUT-1.9
___ 04:00PM ALT(SGPT)-28 AST(SGOT)-36 ALK PHOS-74 TOT
BILI-1.0 DIR BILI-0.5* INDIR BIL-0.5
___ 04:00PM ALBUMIN-3.3* IRON-24*
___ 04:00PM calTIBC-170* FERRITIN-662* TRF-131*
___ 04:00PM WBC-9.7 RBC-3.50*# HGB-11.6*# HCT-34.4*#
MCV-98 MCH-33.0* MCHC-33.6 RDW-11.9
___ 04:00PM NEUTS-78.0* LYMPHS-17.5* MONOS-4.0 EOS-0.2
BASOS-0.2
___ 04:00PM PLT COUNT-355
ESR 82, CRP 111
___ 01:20PM BLOOD Ret Aut-1.9
___ 01:20PM BLOOD D-Dimer-289
___ 01:20PM BLOOD Hapto-267*
___ 04:00PM BLOOD calTIBC-170* Ferritn-662* TRF-131*
BCx ___ x 2
___ 7:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
further identification on request.
Sensitivity testing performed by Sensititre.
SENSITIVE TO CLINDAMYCIN MIC <=0.12MCG/ML.
CEFTRIAXONE AND Levofloxacin Susceptibility testing
requested by
___. ___ ___ ___.
CEFTRIAXONE = SENSITIVE (0.19 MCG/ML) , Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CEFTRIAXONE----------- S
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- 2 R
LEVOFLOXACIN---------- 2 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ ___,
___.
GRAM POSITIVE COCCI IN CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
BCx ___ - no growth to date, final
pending
UCx- negative
CMV: IgG +, IgM negative, VL negative
Parvo virus - negative
CXR ___
Heart size and mediastinum are unremarkable. Lungs are
essentially clear with unchanged minimal bibasilar scarring,
right more than left. No definitive new consolidations
demonstrated on the current examination. No pleural effusion or
pneumothorax is seen.
TTE ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. The aortic valve is
bicuspid. The aortic valve leaflets are mildly thickened (?#).
No masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets are elongated. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Bicuspid aortic valve with mild aortic regurgitation. Mildly
dilated aortic root and ascending aorta. Mild mitral
regurgitation. Normal pulmonary artery systolic pressure.
The absence of endocarditis on transthoracic echocardiogram does
not preclude its presence. If clinical suspicion is high, a
transesophageal echocardiogram may be considered.
TEE ___
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. Right atrial appendage ejection velocity is good (>20
cm/s). No atrial septal defect is seen by 2D or color Doppler.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 40 cm
from the incisors. The aortic valve is bicuspid with thickening
of the leaflets at the coaptation point. No masses or
vegetations are seen on the aortic valve. No abscess is seen.
There is an eccentric jet of mild (1+) aortic regurgitation
directed toward the anterior mitral leaflet. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No mass or vegetation is seen on the mitral valve.The pulmonary
artery systolic pressure could not be determined. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Bicuspid aortic valve with mildly thickened leaflets
but no discrete vegetation or abscess. Mild aortic
regurgitation.
MRI Spine ___
No evidence of discitis osteomyelitis or epidural abscess in the
cervical thoracic or lumbar region. Postoperative changes in
the cervical spine. Mild spinal stenosis at C4-5 with mild
indentation on the spinal cord and moderate narrowing of the
foramina. Postoperative changes of left hemilaminectomy at
L5-S1 without evidence of recurrent disc herniation.
DISCHARGE LABS
___ 07:45AM BLOOD WBC-6.8 RBC-3.54* Hgb-11.5* Hct-34.7*
MCV-98 MCH-32.4* MCHC-33.1 RDW-12.3 Plt ___
___ 07:45AM BLOOD Glucose-102* UreaN-12 Creat-0.6 Na-142
K-4.5 Cl-103 HCO3-29 AnGap-15
___ 01:20PM BLOOD ALT-28 AST-44* LD(LDH)-159 CK(CPK)-27*
AlkPhos-64 TotBili-0.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
2. Propranolol 80 mg PO DAILY
Once daily
3. Citalopram 20 mg PO DAILY
4. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
5. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H Duration: 4 Weeks
___
RX *ceftriaxone 2 gram 2 grams IV q24 hours Disp #*24 Unit
Refills:*0
2. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
3. Fish Oil (Omega 3) 1000 mg PO BID
4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
5. Citalopram 20 mg PO DAILY
6. Propranolol 80 mg PO DAILY
Once daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Septicemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Fever and cough.
PA and lateral upright chest radiographs were reviewed in comparison to ___ and ___.
Heart size and mediastinum are unremarkable. Lungs are essentially clear with
unchanged minimal bibasilar scarring, right more than left. No definitive new
consolidations demonstrated on the current examination. No pleural effusion
or pneumothorax is seen.
Radiology Report
HISTORY: ___ male with hepatitis C and fever and cough.
COMPARISON: ___.
FINDINGS: Lung volumes are decreased from ___. The cardiac silhouette,
mediastinal contours, and pulmonary vasculature are top normal even accounting
for differences in lung volumes. There is no effusion or pneumothorax. Note
is again made of cervical spinal fusion hardware.
IMPRESSION: No pneumonia, bordering volume overload.
Radiology Report
HISTORY: Patient with lumbar spine microdiscectomy and cervical spine fusion
for further evaluation to rule out epidural abscess or osteomyelitis. The
patient is presenting with bacteremia.
TECHNIQUE: T1-T2 and inversion recovery sagittal and T2 axial images of the
cervical, thoracic and lumbar spine obtained before gadolinium. T1 sagittal
and axial images obtained following gadolinium administration.
COMPARISON: Comparison was made with the previous study lumbar spine MRI of
___ and outside cervical spine MRI of ___.
FINDINGS:
IIn the cervical, thoracic or lumbar spine no evidence of discitis or
osteomyelitis or epidural abscess seen.
N the cervical spine, fusion is identified from C5-C7 level with the artifacts
from the implants anteriorly. At the craniocervical junction and C2-3 and
C3-4 no abnormality is identified. At C4-5 disc bulging and moderate
bilateral foraminal narrowing and mild spinal stenosis seen with indentation
of the anterior aspect of the spinal cord.
The spinal canal is patent and the foramina appear patent from C5-6 to C7-T1.
In the thoracic region mild degenerative changes identified. There is no
significant bulge or herniation seen. The spinal cord shows a normal
intrinsic signal. And decided.
In the lumbar region, from L1-2 to L3-4 no disc bulge or herniation seen. At
L4-5 mild disc bulging identified and broad-based central protrusion seen
minimally indenting the thecal sac with mild narrowing of both subarticular
recesses.
At L5-S1 left-sided hemilaminectomy is identified. Enhancing epidural
scarring is seen. No recurrent disc herniation is identified.
IMPRESSION:
No evidence of discitis osteomyelitis or epidural abscess in the cervical
thoracic or lumbar region. Postoperative changes in the cervical spine. Mild
spinal stenosis at C4-5 with mild indentation on the spinal cord and moderate
narrowing of the foramina. Postoperative changes of left hemilaminectomy at
L5-S1 without evidence of recurrent disc herniation.
Radiology Report
PORTABLE CHEST, ___.
COMPARISON: Chest x-ray ___.
FINDINGS: Radiodense guidewire of right PICC terminates in the lower superior
vena cava at the junction with the right atrium. Cardiomediastinal contours
are stable in appearance, and lungs are grossly clear except for linear
atelectasis at the right base.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LIGHTHEADED
Diagnosed with ANEMIA NOS
temperature: 99.8
heartrate: 108.0
resprate: 18.0
o2sat: 98.0
sbp: 106.0
dbp: 62.0
level of pain: 8
level of acuity: 3.0 | The patient is a ___ year old male with successfully treated HCV
infection, and chronic back pain who presented to the ED with
one week of lightheadedness, fatigue, and cough in the setting
of acute anemia.
# S. Viridans Sepsis: P/w weakness and lightheadedness, found to
be spiking fevers to 103 the night after admission (which the
patient was unaware of). BCx grew strep viridans. ESR and CRP
very elevated. Initially treated with vancomycin and
ceftriaxone, Vanc discontinued after sensitivities returned.
Endocarditis was high on the differential given history of poor
dentition and bicuspid aortic valve. MRI spine did not show
evidence of osteomyelitis. TTE and TEE negative for vegetation,
but ID consult remained concerned about seeding of bacteria onto
the valve even without vegetation. Site of initial entry of
infection thought to be from the mouth given dental history.
Parorex did not show current dental abscess or infection. PICC
line was placed, and the patient was DCed with a plan for 4
weeks CTX tx.
- F/U with ID outpatient
- The patient expressed concern about 4 weeks of antibiotic
treatment as this would interrupt his trip to see his son in
___, which has been planned for some time. He was counseled
extensively on the need to remain on IV antibiotics for 4 weeks,
and that if he were to stop antibiotics his infection could
recur and could be life-threatening at that time.
# Anemia: Hct low on admission but remained stable throughout,
no signs of bleeding. Patient's dizziness, fatigue, and pallor
most likely due to acute anemia (14 point drop in Hct since mid
___ from ~45 to 31). Patient's low reticulocyte index of
0.87 and normal haptoglobin/bili suggestive of a RBC production
issue, likely ___ sepsis (see above).
# Chronic Back Pain: Patient has been experiencing chronic back
pain for several years and notes that his back pain has been
somewhat worse at presentation. Part of the increasing pain may
be in the setting of sepsis. Surgical history includes ACDF of
C5 through C7 in ___ and left-sided L5-S1 microdiscectomy on
___. Neuro exam wnl, and MRI did not show osteomyelitis
or abscess. The patient was continued on home pain regimin.
# HCV, s/p treatment: Patient diagnosed with HCV genotype 1 in
___ and was subsequently treated with 48 week course of
peg-interferon and ribavarian successfully. Patient's most
recent INR and ___ slowly decreasing with Vitamin K. Patient's
coags level most likely in the setting decreased food intake in
the last couple of months but may have an underlying liver
pathology that may need to be further worked up.
#Calf pain: Patient experiencing calf pressure/pain over ___
days prior to admission. No mass, erythema, or parathesias per
patient's report. His pain seems to be most closely related to
chronic back pain/myalgias.
# Arthritis: Patient has had a history of polyarthralgia, more
so in the hands but including feet and shoulder pain. Joint
pains have not acutely changed in the setting of acute Hct drop.
In the past, he has endorsed some morning stiffness. He was
evaluated by Rheumatology for possible RA, but was found to be
negative for ___ factor/cryoglobulins. Rheum felt his
presentation inconsistent with synovitis. Last year, he was also
treated for right shoulder impingement/rotator cuff tendinitis.
# Hemochromatosis: Diagnosed in ___ in the setting of enlarged
liver of ultrasound and MRI showed showed mild fatty deposition
in teh liver but otherwise wnl. Iron saturation ~50%,
heterozygote for ___ and H63D mutations at this time. Has
never been phelobotomized. No enlarged liver or
hyperpigmentation noted on physical exam. Iron Saturation <10%
on ___. Most recent iron studies show decreased transferrin at
131, ferritin 662 (___), decreased TIBC 170, and decreased
iron 24.
# Anxiety: Patient's mood currently stable. Only takes
citalopram intermittently at home and declined to take it in the
hospital.
# Hypertension: Blood pressure currently stable. Patient refused
home perscription of propranolol during admission.
# Constipation
- continue with bowel regimen
## Code status: Full Code
## Contacts: ___ ___
TRANSITIONAL ISSUES
- F/U with ID for full 4 week course of IV Abx therapy
- F/U with PCP for coordination of care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa(Sulfonamide Antibiotics) / shellfish derived /
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ prior R cerebellar stroke ___ I/s/o postoperative Afib,
pontine ischemic stroke ___ and pontine hemorrhagic stroke
___, episodic syncope vs vertigo who presents as transfer from
___ for seizure, s/p initial code stroke
evaluation at ___.
She was USOH until this AM her son found her sitting at the side
of her bed moving her walker back and forth. He noted that she
had a "twisting" motion of her arm with "fingers sticking out"
like she was having a "spasm". She was partially responsive,
though often staring into space, but able to ambulate with
walker to bathroom though bumped into many things as she did so.
She was able to use the bathroom with help, and then her son
called EMS. It is not clear how long this lasted, but was >30
minutes. Her son says there was a period of 1 hour where he did
not see her between 10am-11am. Per ___ records, she was
conversant with medical team upon arrival with noted weakness of
L arm and L leg. Exam documents that she was oriented to self,
place, and her son. At 11AM nursing notes small twitches of LUE
while patient still conversant that progressed to clonic
movements of the L arm. Her son witnessed the episode and does
not recall other extremities being involved. This seizure lasted
___ minutes, resolved with Ativan. Patient has been somnolent
not following commands since Ativan given.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PAST MEDICAL HISTORY:
CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, -diabetes
CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Severe aortic stenosis with bioprosthetic AVR on ___, with a size 21 ___ tissue valve with a perioperative
CVA.
- AFib at the time of surgery that converted spontaneously.
- Moderate MR, mild MS, Mod TR.
OTHER PAST MEDICAL HISTORY:
- GERD.
- History of back surgery.
- Cholecystectomy.
- Partial hysterectomy.
- Rheumatoid arthritis.
- Shaking episodes
Social History:
___
Family History:
Father: died of MI
Brother: died at age ___ of MI
Son: multiple heart attacks
Physical Exam:
ADMISSION EXAM
==============
Physical Exam:
Vitals: T: 97.2 P:76 R: 16 BP: 207/109--> 168/88 without
intervention SaO2: 95% RA
General: Sleeping, difficult to arouse
HEENT: NC/AT, no scleral icterus, MMM, no dentition
Pulmonary: Breathing comfortably on NC initially
Cardiac: well perfused
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
MS: Sleeping, does not follow commands, does not EO to noxious
stimuli but says ___.
CN: EOMs intact with dolls. PERRL 3->2mm. No blink to threat.
Motor/Sensory: Purposeful movements of L arm pulling at foley.
Pt
w/d b/l UE to noxious with AG mvt at elbows. B/l legs withdraw
AG
at hips, however L leg external rotation suggestive of L leg
weakness.
Reflexes: 3+ symmetric patellar, ankles, biceps, brachiordialis.
Gait: deferred
DISCHARGE EXAM
==============
___ ___ Temp: 98.2 AdultAxillary BP: 169/72 HR: 56 RR: 18
O2 sat: 97% O2 delivery: Ra
General: awakens to voice, no distress
HEENT: NC/AT, no scleral icterus, MMM, no dentition
Pulmonary: Breathing comfortably on NC initially
Cardiac: well perfused
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
MS: wakens to voice, oriented to hospital, states she lives in
___ with son, knows her age (says ___, just turned ___ few days
ago), knows the state but not the city. speaks in full
sentences.
asks to repeat some questions but answers appropriately
CN: EOMs intact. PERRL 3->2mm. Slight R NLFF that improves with
smile.
Motor: RUE drift. arms ___ (right slightly weaker than left),
legs 4+ on right and 4 on left.
Sensory: deferred
Reflexes: clonus on right, no clonus on left
Gait: deferred
Pertinent Results:
ADMISSION LABS
===============
___ 04:13PM BLOOD WBC-7.4 RBC-4.08 Hgb-12.5 Hct-38.6 MCV-95
MCH-30.6 MCHC-32.4 RDW-14.3 RDWSD-49.9* Plt ___
___ 04:13PM BLOOD Neuts-84.5* Lymphs-11.3* Monos-3.2*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-6.25* AbsLymp-0.84*
AbsMono-0.24 AbsEos-0.01* AbsBaso-0.03
___ 04:13PM BLOOD Plt ___
___ 04:14PM BLOOD ___ PTT-25.8 ___
___ 05:46PM BLOOD estGFR-Using this
___ 05:46PM BLOOD Glucose-137* UreaN-17 Creat-0.6 Na-141
K-4.1 Cl-104 HCO3-21* AnGap-16
___ 05:46PM BLOOD ALT-10 AST-17 AlkPhos-74 TotBili-0.6
___ 05:46PM BLOOD Lipase-16
___ 05:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:46PM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.4 Mg-2.5
___ 05:33PM BLOOD VoidSpe-PND
___ 03:33PM BLOOD HoldBLu-HOLD
___ 03:33PM BLOOD EDTA ___
___ 03:57PM BLOOD Lactate-1.3
DISCHARGE LABS
===============
___ 07:05AM BLOOD WBC-5.4 RBC-3.82* Hgb-11.8 Hct-36.5
MCV-96 MCH-30.9 MCHC-32.3 RDW-14.3 RDWSD-50.2* Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-63* UreaN-15 Creat-0.5 Na-142
K-3.4* Cl-108 HCO3-20* AnGap-14
___ 07:05AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8
IMAGING
=======
MR head noncon ___
IMPRESSION:
1. No evidence of acute infarction, hemorrhage or intracranial
mass.
2. Slightly progressed extensive white matter changes in the
cerebral
hemispheres bilaterally, likely sequela of severe chronic small
vessel
ischemic changes.
3. Unchanged diffuse microhemorrhages in the pons and bilateral
cerebral
hemispheres.
CTA HN ___
IMPRESSION:
1. No significant intracranial abnormality. No evidence of
acute infarction, hemorrhage or intracranial mass.
2. Confluent periventricular hypodensities are nonspecific but
suggestive of chronic small vessel ischemic changes.
3. 40% focal narrowing of the proximal right internal carotid
artery byNASCET criteria.
4. Mild stenoses along the left PCA without evidence of vessel
occlusion.
5. Otherwise patent cervical and intracranial vasculature
without evidence of dissection, high-grade stenosis, occlusion
or aneurysm formation greater than 3 mm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO 3X/WEEK (___)
2. Lisinopril 5 mg PO BID
3. Pantoprazole 40 mg PO Q12H
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Magnesium Oxide 400 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Pravastatin 40 mg PO QPM
Discharge Medications:
1. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
2. Nitrofurantoin (Macrodantin) 100 mg PO BID Duration: 5 Days
RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth
twice a day Disp #*10 Capsule Refills:*0
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Furosemide 20 mg PO 3X/WEEK (___)
6. Lisinopril 5 mg PO BID
7. Magnesium Oxide 400 mg PO BID
8. Pantoprazole 40 mg PO Q12H
9. Pravastatin 40 mg PO QPM
10. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Seizure (presumed)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with altered mental status and left side weakness.//
Altered mental status, left side weakness.
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 after the
intravenous administration of 55 mL of Omnipaque 350 nonionic contrast.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
3) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 22.4 mGy (Body) DLP =
11.2 mGy-cm.
4) Spiral Acquisition 4.3 s, 34.2 cm; CTDIvol = 15.1 mGy (Body) DLP = 517.3
mGy-cm.
Total DLP (Body) = 529 mGy-cm.
Total DLP (Head) = 1,806 mGy-cm.
COMPARISON: CTA of the head and neck from ___, 4 hours prior.
Noncontrast CT head from ___.
FINDINGS:
Noncontrast CT head:
No evidence of acute large territory infarction, intracranial hemorrhage, mass
or edema.
There are confluent hypodensities within the subcortical and periventricular
white matter nonspecific but likely sequela of prior small vessel ischemic
changes.
There is prominence of the ventricles and sulci which are likely due to
age-related involutional changes.
Atherosclerotic changes are seen along both carotid siphons.
There is mild mucosal thickening of the ethmoid sinuses. The other paranasal
sinuses, and middle ear are well pneumatized. The bilateral mastoid air cells
are partially opacified. The patient is status post bilateral lens replacement
surgery, otherwise the orbits are unremarkable.
CTA head:
There are atherosclerotic changes along both carotid siphons without
high-grade stenosis.
The anterior circulation is otherwise unremarkable.
There is abrupt cutoff of the P3 segment of the left PCA, which may be due to
atherosclerotic disease (series 603, image 23).
There is mild stenosis of the distal P1 (series 603, image 23) and distal P3
segments (series 601, image 56). There is a right fetal type PCA, normal
anatomic variant. The posterior circulation is otherwise unremarkable.
There is no evidence of intracranial dissection, high-grade stenosis,
occlusion or aneurysm formation greater than 3 mm.
CTA neck:
Normal 3 vessel aortic arch. There is calcified atherosclerosis of the right
internal carotid artery resulting in 40% narrowing by NASCET criteria. The
left carotid bifurcation is unremarkable.
The left vertebral artery is hypoplastic. The right vertebral artery is
dominant, normal anatomic variant. No evidence of narrowing of the bilateral
vertebral arteries along their cervical course.
Other:
There is diffuse interlobular septal thickening which may suggest fluid
overload. There is a well corticated mildly displaced defect of the sternum
which may represent a chronic fracture. The thyroid is unremarkable. No
evidence of supraclavicular or axillary lymphadenopathy.
IMPRESSION:
1. No significant intracranial abnormality. No evidence of acute infarction,
hemorrhage or intracranial mass.
2. Confluent periventricular hypodensities are nonspecific but suggestive of
chronic small vessel ischemic changes.
3. 40% focal narrowing of the proximal right internal carotid artery by NASCET
criteria.
4. Mild stenoses along the left PCA without evidence of vessel occlusion.
5. Otherwise patent cervical and intracranial vasculature without evidence of
dissection, high-grade stenosis, occlusion or aneurysm formation greater than
3 mm.
Radiology Report
INDICATION: ___ with altered mental status. Had possible seizure, concerned
for aspiration.// Altered mental status
TECHNIQUE: Three portable views the chest.
COMPARISON: Chest x-ray from ___ at 11:11.
FINDINGS:
Compared to exam from earlier the same day, there has been no significant
interval change. Retrocardiac region is not as well assessed on the current
exam likely due to atelectasis in the setting of a supine AP portable chest
radiograph. Cardiomediastinal silhouette is stable. Median sternotomy wires
and left chest wall loop cardiac monitor noted. Severe degenerative changes
noted at the right shoulder.
IMPRESSION:
Retrocardiac region not as clearly delineated on the current exam though this
is more likely technical and due to atelectasis on this supine radiograph,
underlying aspiration is difficult to entirely exclude. If patient is
amenable, consider repeat with PA and lateral view.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ with prior strokes p/w episode c/f seizure vs stroke/TIA.//
Stroke eval
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON MRI of the head from ___ and CTA of the head and neck
from ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction.
There are extensive confluent T2/FLAIR hyperintensities in the cerebral
hemispheres bilaterally, a nonspecific finding but slightly worse from ___ and likely related to chronic small vessel ischemic changes.
There is diffuse generalized parenchymal volume loss, most likely age related
and similar to ___. Prominence of the ventricular system and extra-axial CSF
spaces appears similar to prior and is consistent with the previously
mentioned parenchymal volume loss.
There are unchanged small old infarcts in the bilateral cerebellar
hemispheres. Punctate foci of susceptibility artifact are again identified in
the pons, bilateral occipital lobes, in the right thalamus, left putamen,
bilateral frontal lobes and left parietal lobe, consistent with
microhemorrhages.
There is mild mucosal thickening along the ethmoid air cells. There is
partial opacification of the right mastoid air cells. Note is made of
bilateral lens replacement surgery. The orbits appear otherwise unremarkable.
IMPRESSION:
1. No evidence of acute infarction, hemorrhage or intracranial mass.
2. Slightly progressed extensive white matter changes in the cerebral
hemispheres bilaterally, likely sequela of severe chronic small vessel
ischemic changes.
3. Unchanged diffuse microhemorrhages in the pons and bilateral cerebral
hemispheres.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Seizure, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 96.9
heartrate: 120.0
resprate: 20.0
o2sat: 96.0
sbp: 207.0
dbp: 109.0
level of pain: Critical
level of acuity: 2.0 | Ms. ___ is a ___ woman with a history of right
cerebellar stroke ___ i/s/o postoperative a-fib, pontine
ischemic stroke ___ and pontine hemorrhagic stroke ___ who
presented due to possible focal seizure w/ left clonic shaking,
with L weakness likely postictal. She was started on Keppra 1g
BID. She was monitored on EEG for 48 hours with no abnormal
electrographic activity. MRI showed no stroke. She was evaluated
by ___ who recommended rehab.
She was also found to have an E.coli UTI (pan-sensitive) for
which she was started on a short course of nitrofurantoin.
- Continue nitrofurantoin for 5 days.
- Continue Keppra indefinitely.
- Follow-up with your PCP in the next ___ weeks and consider
re-checking for a UTI.
- Follow-up with neurology in the next ___ weeks. We will
contact you with an appointment. If you do not hear from us,
please call ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine / codeine
Attending: ___.
Chief Complaint:
chest and left wrist pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old female who complains of Chest
pain, Abd pain, MVC. Is a ___ female who is
transferred from ___ in the setting of a
sternal fracture resulting from an MVC. The patient was the
restrained driver in a car that slid on ice and smashed into
another car. Airbags deployed and the patient was only T.
boned on the passenger side by another car. Again no airbags
deployed. The patient reports she probably took off her
seatbelt at that point call ___ at which time she was struck
again. Believes that this is when her chest struck the
steering wheel. He was seen at ___ she had a scan
of her head, neck, chest and abdomen showing the sternal
fracture and was transferred here for trauma surgery
evaluation. He complains of pain in her sternal area as well
as in her left wrist.
Past Medical History:
none
Social History:
___
Family History:
none
Physical Exam:
PHYSICAL EXAMINATION: Upon admission ___
Temp: 98.3 HR: 88 BP: 120/60 Resp: 16 O(2)Sat: 100 Normal
Constitutional: No board, collar
HEENT: Normocephalic, atraumatic
Chest: Sternal tenderness to palpation
Cardiovascular: Normal
Abdominal: Soft- palpation in the epigastrium reproduces
sternal discomfort
Extr/Back: TTP palpation in the carpal bone of the left
wrist
Skin: Normal
Neuro: Normal
Psych: Normal mentation
Pertinent Results:
___ 06:50PM GLUCOSE-83 UREA N-10 CREAT-0.7 SODIUM-141
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
___ 06:50PM estGFR-Using this
___ 06:50PM WBC-8.0 RBC-4.69 HGB-13.2 HCT-38.3 MCV-82
MCH-28.1 MCHC-34.4 RDW-13.4
___ 06:50PM NEUTS-74.3* ___ MONOS-5.2 EOS-0.7
BASOS-0.3
___ 06:50PM PLT COUNT-181
___ 06:50PM ___ PTT-25.7 ___
Medications on Admission:
trazadone
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
do not exceed >4g per 24 hour period
2. Docusate Sodium 100 mg PO BID
stop taking if having loose stool
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*28 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
stop taking if having loose stool
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*14 Tablet Refills:*0
5. TraZODone 100 mg PO QHS
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
do not drive or use machinery while taking this medication
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
7. Prochlorperazine ___ mg PO Q6H:PRN nausea
RX *prochlorperazine maleate [Compazine] 5 mg ___ tablet(s) by
mouth every six (6) hours Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Non displaced sternal fracture
Left wrist nondisplaced distal radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with s/p mvc // fx?
TECHNIQUE: Frontal, oblique, and lateral views of the right knee. AP and
lateral views of the proximal distal right femur.
COMPARISON: None
FINDINGS:
There is no acute fracture. Mild degenerative changes are noted at the knee
with peaking of the tibial spines. There is no suprapatellar effusion.
Proximally the femur is unremarkable. Excreted contrast seen within the
bladder.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CT TORSO W/O CONTRAST
INDICATION: Status post trauma.
TECHNIQUE: Second read request on an outside hospital CT torso.
DOSE: 1292.7 mGy-cm.
COMPARISON: None available.
FINDINGS:
CT thorax: The airways are patent to the subsegmental level. There is
dependent atelectasis bilaterally. There is no mediastinal, hilar, or axillary
lymph node enlargement by CT size criteria.The heart, pericardium, and great
vessels are within normal limits.No hiatal hernia or other esophageal
abnormality is seen.No pleural effusion or pneumothorax is identified.
CT ABDOMEN:
LIVER: The liver enhances homogeneously without focal lesion or intrahepatic
biliary duct dilation. The portal vein is patent.Patient is status post
cholecystectomy.
SPLEEN: The spleen is homogeneous and normal in size.
PANCREAS: The pancreas is without focal lesion or peripancreatic stranding or
fluid collection.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys demonstrate symmetric nephrograms without focal
abnormality. There is no focal lesion or hydronephrosis.
GI:The stomach is decompressed, but there is no obvious intraluminal mass or
wall thickening.The small and large bowel are within normal limits, without
wall thickening or evidence of obstruction.A normal, air-filled appendix is
visualized. A soft tissue density is seen in the right lower quadrant (06:49)
just anterior to the quadratus lumborum muscle, of unclear etiology.
RETROPERITONEUM: The aorta is normal in caliber, with mild atherosclerotic
calcifications.There is no retroperitoneal or mesenteric lymph node
enlargement by CT size criteria.
CT PELVIS: The urinary bladder appears normal.No pelvic wall or inguinal lymph
node enlargement by CT size criteria is seen.There is no pelvic free fluid.
The patient is status post hysterectomy.
OSSEOUS STRUCTURES:No focal lesions suspicious for malignancy present. There
is a nondisplaced fracture of the sternum (601a: 72) with adjacent soft tissue
stranding in the overlying subcutaneous tissues and the anterior mediastinum.
No other fracture identified.
IMPRESSION:
1. Nondisplaced fracture of the sternum, with adjacent hematoma in the
anterior mediastinum.
2. Soft tissue density in the right lower quadrant, of unclear etiology.
Although not excluded, and this does not have the typical appearance for
sequela of acute trauma. Otherwise, no evidence of acute intra-abdominal
injury
Radiology Report
INDICATION: Wrist pain post trauma.
TECHNIQUE: 4 views of the right wrist.
FINDINGS:
There is subtle disruption of trabeculae in the distal radius and slight
associated soft tissue swelling consistent with a nondisplaced fracture as
suggested on outside radiographs of 1 day previous (not available to me).
Vague lucencies in the distal hamate and adjacent proximal fifth meta carpal
are not confirmed on all views and felt to be artifactual. Remainder bones
and joints are normal.
IMPRESSION:
Subtle undisplaced fracture distal radius.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ woman s/p low speed MVC p/w anterior nondisplaced
sternal fx c/o persistent nausea // Rule out Bowel obstruction
TECHNIQUE: Supine and upright radiograph views of the abdomen.
COMPARISON: No prior abdominal radiographs are available.
FINDINGS:
The bowel gas pattern is nonspecific and nonobstructive. There is slight
paucity of bowel gas in the small intestine. However, there is air and stool
in the colon. The rectum also contains air. There are no abnormally dilated
loops of small or large bowel. There is no evidence of pneumatosis or
pneumoperitoneum. Surgical clips project over the left hemipelvis.
IMPRESSION:
Non-obstructive bowel gas pattern.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Abd pain, MVC
Diagnosed with FRACTURE OF STERNUM-CLOS, MV COLLISION NOS-DRIVER
temperature: 98.3
heartrate: 88.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 60.0
level of pain: 8
level of acuity: 1.0 | The patient presented the hospital on ___. Pt was found to
have a non displaced sternal fracture and a left wrist distal
radius fracture. She was transferred to the floor where she was
monitored, observed and seen by orthopedics.
Neuro: The patient was alert and oriented throughout
hospitalization;
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient's intake and output were closely monitored.
She had some complaints of nausea which subsided with compazine
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
EXT: She had a splint applied to the left wrist
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough, foreign body aspiration
Major Surgical or Invasive Procedure:
Brochoscopy with foreign body removal
History of Present Illness:
___ male transferred from ___ with foreign body in R
mainstem bronhcus. He was at the dentist earlier today having
dental work when the crown fragment became dislodged and he
aspirated on it. He subsequently presented to ___ where
chest x-ray notes foreign body right mainstem bronchus. He
denies any dyspnea or chest pain. In the ED he did note a
rattling sensation in his right chest with coughing.
In the ED, initial vitals were:
18:35 1 97.7 86 161/90 18 97%
- Labs were significant for K 3.1 and normal creatinine
- Imaging revealed
Patient was seen by IP in the emergency room who recommended
steroids, abx and admission to medicine for IP procedure th next
day
- The patient was given 125mg IV methylprednisolone
Vitals prior to transfer were:
Today 20:44 0 97.6 65 166/82 18 97% RA
Upon arrival to the floor, feels well. Denies CP, SOB, abdominal
pain, nausea, vomiting
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias
Past Medical History:
HTN
CVA early ___ no residual
right knee arthritis
gout
Social History:
___
Family History:
no family history of lung disease
Physical Exam:
ADMISSION EXAM
Vitals: 98.4 163/84 69 18 96%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, sight of recent
dental work at left base with some dried blood, non tender 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, reduced sounds at
bases
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, right leg with 1+ edema (pt
ays this is baseline from R knee osteoarthritis, Left leg with
trace edema
DISCHARGE EXAM
VS - temp 98.4, HR 61-80, BP 129-151/64-81, RR 18, 97% RA
General: No acute distress, A+Ox3, anxious to go home
HEENT: Oopharynx without lesion or exudate, moist MM's
Neck: No adenopathy, no JVD
CV: RRR, no murmur/gallop/rub
Lungs: CTA bilaterally w/o rhonchi or wheeze
Abdomen: Nontender, nondistended, +BS, no organomegaly
Ext: Warm and well perfused, no edema
Pertinent Results:
ADMISSION LABS
___ 08:11PM BLOOD WBC-10.0 RBC-4.65 Hgb-13.9 Hct-40.5
MCV-87 MCH-29.9 MCHC-34.3 RDW-13.2 RDWSD-41.4 Plt ___
___ 08:11PM BLOOD Neuts-64.0 ___ Monos-9.9 Eos-1.3
Baso-0.6 Im ___ AbsNeut-6.38* AbsLymp-2.37 AbsMono-0.99*
AbsEos-0.13 AbsBaso-0.06
___ 08:11PM BLOOD ___ PTT-29.1 ___
___ 08:11PM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-140
K-3.1* Cl-100 HCO3-30 AnGap-13
DISCHARGE LABS
___ 06:45AM BLOOD ___ PTT-29.9 ___
___ 06:45AM BLOOD WBC-9.6 RBC-4.79 Hgb-14.2 Hct-41.9 MCV-88
MCH-29.6 MCHC-33.9 RDW-13.2 RDWSD-41.8 Plt ___
___ 06:45AM BLOOD Glucose-150* UreaN-13 Creat-0.6 Na-137
K-4.1 Cl-100 HCO3-27 AnGap-14
___ 06:45AM BLOOD Calcium-9.2 Phos-1.9* Mg-1.9
IMAGING
CXR (___): 1. Dental crown or filling is still lodged in the
right lower lobe bronchus
2. Developing right basal atelectasis, pneumonia, or aspirated
blood.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. meloxicam 15 mg oral DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Hydrochlorothiazide 50 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Hydrochlorothiazide 50 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. meloxicam 15 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Foreign body aspiration
Secondary diagnoses:
Hypertension
Gout
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with tooth aspiration // evaluate for
surrounding inflammation
TECHNIQUE: Portable semi upright chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The metal dental crown or filling in the right lower lobe bronchus is
unchanged in position in comparison to the prior chest radiograph dated ___. Developing right basilar opacification could be atelectasis, infection,
or aspirated blood. The lungs are otherwise clear. Heart size is stable.
The mediastinal and hilar contours are stable. The pulmonary vasculature is
normal. No pleural effusion or pneumothorax is seen.
IMPRESSION:
1. Dental crown or filling is still lodged in the right lower lobe bronchus
2. Developing right basal atelectasis, pneumonia, or aspirated blood.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FB IN CHEST
Diagnosed with FOREIGN BODY BRONCHUS, FB ENTERING OTH ORIFICE
temperature: 97.7
heartrate: 86.0
resprate: 18.0
o2sat: 97.0
sbp: 161.0
dbp: 90.0
level of pain: 1
level of acuity: 2.0 | ___ yo male with a history of HTN, Gout, and remote CVA with no
residual, who is presenting after a dental crown was aspirated
during a routine dental procedure. Crown removed ___ via
bronchoscopy.
ACTIVE PROBLEMS
# Dental crown aspiration: RLL bronchus on CXR. Removed ___ via
bronchoscopy by Interventional Pulmonology. Cough on
presentation, which resolved after removal, and vitals stable
without respiratory symptoms. Received 1 dose Solumedrol for
anti-inflammatory effects prior to bronch, and recieved
Augmentin prior to bronchoscopy, but no need for antibiotics or
steroids anymore given no evidence of inflammation or infection
seen on bronchoscopy. Radiology read of CXR (prior to removal)
showing some mild consolidation (atelectasis vs. pneumonia)
distal to foreign body, but no clinical evidence of pneumonia.
No activity restrictions after discharge. He has been instructed
to call his PCP if he develops any dyspnea, sputum production,
or fevers.
CHRONIC PROBLEMS
# HTN: home meds of Losartan 100mg, HCTZ 50mg. Losartan was held
___, but both HCTZ and Losartan can be continued on discharge.
# Gout: continued on his home med Allopurinol ___. No evidence
of active gout currently.
# OA: predominantly knee involvement, with crepitance
bilaterally on exam. Takes Meloxican 15mg at home. Meloxicam was
held while in house, but can be resumed on discharge.
TRANSITIONAL ISSUES
- No need for antibiotics post-bronchoscopy given no signs of
pneumonia
- Can f/u with PCP as needed if dyspnea, fever, or sputum
production |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dark Stools
Major Surgical or Invasive Procedure:
EGD (___)
History of Present Illness:
Mr. ___ is a ___ year old male with PMH significant for HTN,
COPD, diverticulosis, newly diagnosed pancreatic insufficiency
with ? of Intraductal papillary mucinous neoplasm who presents
with new onset dark stools and ongoing falls.
Pt. had been in his usual state of health until several months
prior when pt. notes onset of malaise, decreased appetite
(eating ___ meals / day), intentional weight loss, and chronic
diarrhea. Work-up revealed elastase deficiency and elevated
lipase. Pt. has since had imaging which has revealed possible
pancreatic structural abnormality. Pt. underwent an EUS
(___) which revealed 1.7 cm oblong cystic dilation of a
sidebranch in the head of the panceas, subtle 0.39x0.28cm
hypoechoic region seen in body of the pancreas (possibly IPMN),
very mild duodenitis, and Brunner gland hyperplasia. Path was
non-diagnostic.
Pt. notes having several episode of falls over the last ___
weeks. He denies any type of tripping episodes and believes
that he is falling ___ acute onset ___ weakness. He also reports
intermittently associated lightheadedness, but denies dizziness
or changes in vision. He was worked up within the last month
and diagnosed with a new lumbar compression fracture. He was
started on etodolac and alleve for his back pain 1 week prior to
presentation.
In regards to dark stools, pt. reports approximate 1 week
history of pasty dark black stools. In this time period, he
also notes several episodes of coffee-ground emesis but denies
any nausea, diarrhea, or worsening of his intermittent
periumbilical abdominal pain (chronic for years). He does
endorse constipation at this time. Prior to this, pt. reports
___ episodes of yearly BRBPR which had been attributed to
hemorrhoidal bleeding. He denies any prior episodes of melena.
In the ED, vitals were. He was found to have giuaiac + stool
that appeared dark brown/black. Labs were notable for Hgb 8.7
(stable from outpt labs) and WBC 12.4. A CTA abdomen (prelim)
did not show any evidence of bleeding or acute changes. GI was
consulted who recommended making NPO for EGD in morning.
Past Medical History:
Positive PPD
GOUT
Hypertension, essential
Varicose veins
Anemia
LUNG DISEASE - CHRONIC OBSTRUCTIVE, UNSPEC
NEPHROLITHIASIS
PROSTATIC HYPERTROPHY
Colonic adenoma
Hypogonadism male
Anxiety
Pulmonary nodules
AAA (abdominal aortic aneurysm) 441.4
Thyroid nodule
Vertebral compression fracture
Social History:
___
Family History:
Pt. denies any hx. of GI conditions including gastric cancer, GI
bleeding, colon cancer, or IBD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals 97.3 107/64 61 18 95 ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, dry mucous membranes
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 extm, gait deferred
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
Vitals 98.1 110/70 (sitting), 110/65 (standing w/ HR 75), 18,
Sat 98% on RA
GENERAL: NAD
HEENT: NCAT, EOMI, PERRL, anicteric sclera, moistmucous
membranes
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
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
Pertinent Results:
ADMISSION LABS
==============
___ 07:45PM BLOOD WBC-12.4* RBC-2.73* Hgb-8.7* Hct-26.7*
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.9 Plt ___
___ 07:45PM BLOOD Neuts-65.6 ___ Monos-5.2 Eos-2.3
Baso-0.4
___ 07:45PM BLOOD ___ PTT-28.9 ___
___ 07:45PM BLOOD Glucose-138* UreaN-35* Creat-1.1 Na-138
K-3.3 Cl-95* HCO3-37* AnGap-9
___ 07:45PM BLOOD ALT-11 AST-15 LD(LDH)-129 AlkPhos-66
TotBili-0.6
___ 07:45PM BLOOD Albumin-3.5 Calcium-8.5 Phos-2.1* Mg-1.9
___ 07:47PM BLOOD Lactate-2.1*
NOTABLE LABS
============
___ 06:00AM BLOOD WBC-7.8 RBC-2.00*# Hgb-6.6* Hct-19.2*#
MCV-96 MCH-32.8* MCHC-34.2 RDW-12.5 Plt ___
___ 07:30PM BLOOD Hgb-8.5*# Hct-24.4*#
___ 05:45AM BLOOD WBC-9.3 RBC-3.07*# Hgb-10.1* Hct-29.6*
MCV-97 MCH-33.0* MCHC-34.2 RDW-13.5 Plt ___
___ 12:50PM BLOOD Hgb-10.7* Hct-31.8*
___ 05:00PM BLOOD Hgb-10.4* Hct-32.2*
___ 07:45PM BLOOD Lipase-18
___ 07:45PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD VitB12-975*
DISCHARGE LABS
===============
___ 05:25AM BLOOD WBC-9.2 RBC-3.04* Hgb-10.0* Hct-29.8*
MCV-98 MCH-33.0* MCHC-33.6 RDW-14.0 Plt ___
___ 05:25AM BLOOD UreaN-10 Creat-0.8 Na-139 K-3.8 Cl-104
HCO3-28 AnGap-11
EGD (___)
============
Diffuse erythema in the esophagus compatible with severe erosive
esophagitis, mild erythema in the antrum compatible with mild
gastritis, Granularity and erythema in the duodenal bulb
compatible with duodenitis, Ulcer with a visible vessel in the
duodenal bulb, s/p epi, BiCAP and hemoclip. Otherwise normal
EGD to third part of the duodenum
IMAGING
=========
CXR (___): Subtle reticular opacities in the left lower lung
likely
represent scarring/atelectasis, though pneumonia is not
excluded. Probable underlying emphysema.
CTA ___: IMPRESSION: 1. No CT evidence of active GI bleed.
2. Calcified atherosclerotic disease throughout the abdominal
aorta without hemodynamically significant narrowing of the
celiac trunk, SMA, renal arteries and ___. 3. Mild aneurysmal
dilatation of the infrarenal aorta measuring up to 3.6 cm and
bilateral common iliacs, measuring up to 1.6 mm on the right.
4. Age-indeterminate compression deformity of the T12 vertebral
body with mild retropulsion resulting in mild canal narrowing.
ECG (___)
=============
Ectopic atrial rhythm. Leftward axis. Early R wave progression.
T wave abnormalities. Since the previous tracing of ___ the
rate is now slower. The QTc interval is shorter. Clinical
correlation is suggested.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Lorazepam 0.5 mg PO Q4H:PRN anxiety
3. Simvastatin 10 mg PO DAILY
4. Terazosin 10 mg PO HS
5. Citalopram 20 mg PO DAILY
6. Creon 12 4 CAP PO TID W/MEALS
7. NAC (acetylcysteine) 600 mg oral Daily
8. testosterone cypionate 100 mg/mL intramuscular Q2Weeks
9. etodolac 200 mg oral Q6H-Q8H PRN Pain
10. Naproxen 250 mg PO Q8H:PRN Pain
11. LOPERamide 2 mg PO QID:PRN Diarrhea
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Creon 12 4 CAP PO TID W/MEALS
3. Lorazepam 0.5 mg PO Q4H:PRN anxiety
4. Simvastatin 10 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*3
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*90
Tablet Refills:*3
7. Sucralfate 1 gm PO QID
Continue for 10 days
RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day Disp
#*500 Milliliter Refills:*0
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*90 Tablet Refills:*0
9. LOPERamide 2 mg PO QID:PRN Diarrhea
10. NAC (acetylcysteine) 600 mg oral Daily
11. testosterone cypionate 100 mg/mL intramuscular Q2Weeks
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
1. Severe Erosive Esophagitis
2. Mild Gastritis
3. Duodenitis
4. Peptic Ulcer Disease
5. Upper Gastrointestinal Bleeding
6. Acute Blood Loss Anemia
7. Recent Falls
SECONDARY DIAGNOSES
===================
1. Spinal Compression Fractures
2. Pancreatic Insufficiency
3. EtOH Abuse
4. Hypertension
5. BPH
6. Depression
7. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Diverticulosis, now with GI bleed and low blood pressure.
Assess for acute intrathoracic process.
FINDINGS: AP portable supine view of the chest was provided. There is
irregular opacity at the left lung base which could represent a very early
pneumonia versus atelectasis/scarring. The lungs appear lucent in the upper
lobes, likely reflecting emphysema. Cardiomediastinal silhouette appears
normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: Subtle reticular opacities in the left lower lung likely
represent scarring/atelectasis, though pneumonia is not excluded. Probable
underlying emphysema.
Radiology Report
INDICATION: ___ man with history of diverticulosis, now with GI
bleed, low blood pressure, evaluate for active bleed.
COMPARISON: None.
TECHNIQUE: Contiguous axial multidetector CT images were obtained prior to
contrast administration and during arterial and venous phases as per
mesenteric CTA protocol. Coronal and sagittal reformats were obtained.
DLP: 1401 mGy-cm.
FINDINGS:
CT ANGIOGRAM: Abdominal aorta demonstrates moderate atherosclerotic
calcifications and mild aneurysmal dilatation measuring up to 3.5 cm along the
infrarenal portion. The celiac axis is patent. The hepatic arterial anatomy
demonstrates a replaced left hepatic artery from the left gastric. The right
lobe of the liver is supplied by the common hepatic artery off the celiac
trunk which also supplies segment IV of the liver. The superior mesenteric
artery is patent. Calcifications are noted at the ostia of the renal arteries
which remain patent. The inferior mesenteric artery is small but patent.
There is also ectasia of the common iliac artery measuring up to 1.6 cm on the
right and 1.3 cm on the left.
CT ABDOMEN:
Partially imaged lungs demonstrate interlobular septal thickening and
peripheral areas of fibrosis and traction bronchiectasis, consistent with
advanced interstitial lung disease. There are also scattered areas of
bronchial mucoid impaction. The heart is normal size, atherosclerotic
calcifications are noted.
The liver enhances homogeneously, but demonstrates numerous scattered
well-defined hypodensities, the larger ones compatible with simple cysts,
others too small to characterize. The spleen, pancreas, gallbladder and
adrenal glands are unremarkable. Kidneys enhance and excrete symmetrically
and demonstrate multiple scattered hypodensities bilaterally, larger ones
compatible with simple cysts, others too small to characterize.
The stomach and fluid-filled loops of small bowel are normal in course and
caliber. There is no obstruction. Colon is notable for extensive
diverticulosis without diverticulitis. Appendix is visualized and is normal.
There is no active extravasation of intravenous contrast into the small or
large bowel during the arterial phase and no pooling of contrast in the bowel
during the venous phase to suggest an active GI bleed.
There is no mesenteric or retroperitoneal lymphadenopathy. There is no
intra-abdominal free air or fluid.
CT PELVIS:
Distended bladder, seminal vesicles and prostate gland are within normal
limits. There is no pelvic free fluid or adenopathy.
Note is made of an age-indeterminate compression deformity of the T12
vertebral body with greater than 50% loss of height and mild retropulsion
resulting in mild canal narrowing.
IMPRESSION:
1. No CT evidence of active GI bleed.
2. Calcified atherosclerotic disease throughout the abdominal aorta without
hemodynamically significant narrowing of the celiac trunk, SMA, renal arteries
and ___.
3. Mild aneurysmal dilatation of the infrarenal aorta measuring up to 3.6 cm
and bilateral common iliacs, measuring up to 1.6 mm on the right.
4. Age-indeterminate compression deformity of the T12 vertebral body with
mild retropulsion resulting in mild canal narrowing.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Hypotension
Diagnosed with GASTROINTEST HEMORR NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: 65.0
dbp: 35.0
level of pain: nan
level of acuity: 1.0 | BRIEF SUMMARY STATEMENTS: Mr. ___ is a ___ yo male with PMH
significant for HTN, COPD, pancreatic insufficiency with
question of IPMN, and diverticulosis who presented with new fall
events over the last several weeks in addition to 1 week of
melena and hematemesis found to have UGIB ___ duodenal ulcer on
EGD. Likely ___ ongoing EtOH and excess NSAID use.
ACTIVE ISSUES
==============
#Duodenal ulcer with bleeding:
Pt. presented with new melena over 1 week duration without prior
history. His risk factors were identified as active drinking (6
glasses of rum/night) in addition to new NSAID exposure on
etodolac and alleve started recently for back pain associated
with spine compression fractures. Pt. received 3 units pRBCs on
admission. GI was consulted and performed an EGD which revealed
a large non-bleeding duodenal ulcer with a visible vessel
(vessel was BICAP'ed and clipped) in the setting of severe
erosive esophagitis in addition to gastritis and duodenitis.
Post-procedure, he was started on a pantoprazole gtt. Pt's
blood counts and vital signs remained stable following
intervention. He was discharged on pantoprazole PO BID and with
close outpatient GI follow-up.
#Anemia: Pt. has known baseline Hct of 40-43 (___). Pt's
anemia on this admission was attributed to acute blood loss and
possibly malnutrition in the setting of alcoholism supported by
MCV. Pt. was given 3 units pRBC and his Hct remained stable
following transfusions.
# Orthostatic Hypotension: Pt. with evidence of asymptomatic
orthostatic hypotension on day prior to disharge. As such, he
was kept overnight and given IVF. Repeat H/H was stable.
Amlodipine and Terazosin were both held given orthostasis. Pt.
was instructed to contact his PCP if having urinary retention.
# Falls: Pt. reported recent fall history without any type of
tripping or inciting events. This was thought to be ___
worsening anemia in the setting of ongoing GI bleed. His Vit
B12 returned non-deficient. ___'s encephalopathy was
considered, however pt. was without confusion or
ophthalmolplegia at this time. ___ evaluated the pt. and cleared
him without issue.
# Spinal Compression Fractures: Pt. was recently diagnosed with
spinal compression fractures in the setting of recent falls. He
was treated with tylenol and lidocaine patch. He was instructed
not to take NSAIDs on discharge (a list of medications to avoid
was provided).
CHRONIC ISSUES
===============
# Pancreatic insufficiency: Pt. diagnosed with pancreatic
insufficiency after he presented with chronic diarrhea and was
found to have a low elastase level. A recent MRCP and EUS have
also demonstrated a possible IPMN with evidence of PD dilation.
FNA of suspicious hypoechoic region was indeterminant. He was
continued on creon supplemenation at discharge.
# Alcohol Abuse: Pt. was placed on CIWA and given thiamine,
folate, and multivitamin supplementation. He was discharged on
thiamine/folate and encouraged to stop drinking given new peptic
ulcer disease.
# HTN: In the setting of ongoing GIB, amlodipine was held.
Given intermittent orthostatic hypotension near the time of
discharge, pt. was d/c'ed without resuming amlodipine.
# BPH: Given ongoing UGIB, initially held terazosin given its a1
antagonist effect. Pt. became hemodynamically stable and
terazosin was temporarily resumed, however he then developed
orthostatic hypotension. In this setting, terazosin was not
continued at discharge.
# Depression: Stable. Continued on citalopram.
# Hyperlipidemia: Stable. Continued on simvastatin.
TRANSITIONAL ISSUES
===================
# ECG Findings: ECG shows evidence of possible ectopic atrial
focus. Consider further outpatient work-up if warranted.
# NSAIDS: Given extensive peptic ulcer disease in setting of
___ weeks of NSAID use, pt. should avoid NSAIDs indefinitely.
# EtOH: Pt. drinks excess amount of alcohol (6 drinks/night)
which is contributing to his peptic ulcer disease. He was
counseled on alcohol cessation, and this should continue to be
discussed as an outpatient.
# Code Status: Full (confirmed), the pt. indicated that he
would not want long-term life-support if no chance for full
neurologic recovery.
# Emergency Contact: ___ (sister, per pt she is ___ of his
HCP) ___ ___ (wife/? ex-wife) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Levaquin in D5W / Latex
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, dry heaves, obstipation & Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of ulcerative colitis and
heterozygote Factor V Leidin on Coumadin w/p total
proctocolectomy with hand-sewn ileal J-pouch to anal anastomosis
presented to the Emergency room with abdominal pain, nausea,
and no BM or flatus for 1 day (normal ___ BM/day). The pain
started suddenly and was constant with intermittent sharp
cramping waves, 10 out of 10 at the worst. It was mainly right
sided without radiation and was not made better or worse by
anything. She felt bloated. No fevers/chills, chest pain or
SOB. No dysuria, hematuria, or urinary frequency. Colorectal
surgery was consulted and she was admitted to the colorectal
service.
Past Medical History:
PMH: Ulcerative colitis, GERD, Factor V Leiden (DVT),
nephrolithiasis, pyelonephritis, vaginal condylomata,
HSV1, hyposplenism, migraines, chronic sinusitis
PSH: total proctocolectomy/ileoanal J-pouch/diverting ileostomy
(___), ileostomy reversal (___), EUA with dilation
of stricture at ileoanal anastamosis ___ and ___
Social History:
___
Family History:
Paternal aunt with ___, no family history of colorectal
cancer
Physical Exam:
Gen: AAO, No distress
___: RRR, S1S2
Resp: CTABL
Abd: +BS, soft, slight distention (greatly improved), well
healed scars
Ext: Warm, no edema
Pertinent Results:
___:04PM ___ PTT-42.6* ___
___ 08:00PM BLOOD WBC-15.2* RBC-4.63 Hgb-13.3 Hct-38.5
MCV-83# MCH-28.7 MCHC-34.6 RDW-14.5 Plt ___
___ 06:25AM BLOOD WBC-8.9 RBC-3.94* Hgb-11.5* Hct-34.4*
MCV-87 MCH-29.2 MCHC-33.5 RDW-14.9 Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-76 UreaN-6 Creat-0.5 Na-137 K-3.9
Cl-101 HCO3-22 AnGap-18
CT ABD: Small bowel obstruction with a distinct zone of
transition in the right iliac fossa at a distal small bowel
anastomosis (presumably the site of previous reversed
ileostomy). Extensive small bowel feces proximal to the point
of transition. Small amount of free fluid within the abdomen
and pelvis.
Medications on Admission:
.
1. Albuterol Inhaler Dose is Unknown IH Frequency is Unknown
2. lidocaine 2 % Topical TID
3. LOPERamide 6 mg PO HS
4. Omeprazole 20 mg PO BID
5. TraZODone 50 mg PO HS:PRN sleep
6. Warfarin 5 mg PO DAILY16
7. Zolpidem Tartrate 10 mg PO HS
8. Calcium Carbonate 500 mg PO BID
9. Cetirizine 10 mg Oral daily
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, SOB
2. Cetirizine 10 mg Oral daily
3. Calcium Carbonate 500 mg PO BID
4. Lidocaine 2 % TOPICAL TID
5. LOPERamide 6 mg PO HS
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. TraZODone 50 mg PO HS:PRN sleep
9. Warfarin 5 mg PO DAILY16
10. Zolpidem Tartrate 10 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain, h/o ulcerative colitis s/p total proctocolectomy.
COMPARISON: ___.
TECHNIQUE: Abdominal radiograph, two views.
FINDINGS: Supine and upright views og the abdomen were provided. There is a
relative paucity of small bowel gas. Given this, evaluation for SBO is
limited. A small amount of air and stool is seen within the distal bowel
projecting over the pelvis. No pneumatosis or pneumoperitoneum.
IMPRESSION: Paucity of small bowel gas without definite evidence for
obstruction. Given the symptoms of obstipation and leukocytosis, CT may be
performed to further evaluate.
Radiology Report
HISTORY: UC status post total proctocolectomy with IP a in ___.
Status post multiple EUAs. Now presenting with abdominal pain obstipation
nausea and leukocytosis. Please evaluate for ileus or obstruction.
COMPARISON: CT dated ___.
TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed after the
uneventful intravenous administration of 130 cc of Omnipaque. The patient
also raised received enteric contrast material. Coronal sagittal reformats
were provided.
DLP: 871.5 mGy-cm.
FINDINGS:
ABDOMEN:
The proximal and mid small bowel is dilated down to the level of a small bowel
anastomosis within the right iliac fossa (301b:27) - this likely represents
the site of previous reversed ileostomy. There is a distinct zone of
transition at this point between dilated and non-dilated small bowel. There
is mild fat stranding surrounding the anastomosis (2:54). Immediately
proximal to the anastomosis, there is extensive small bowel feces and the
small bowel at this point measures up to 4 cm in diameter (2:59 and 300b:25).
The ileum distal to the small bowel anastomosis is completely decompressed up
to the ileoanal pouch anastomosis in the pelvis. There is residual feces
within the ileoanal pouch. The small bowel mesentery appears slightly hazy
(2:44).
There is a small amount of free fluid within the abdomen and pelvis. No free
air. An NG tube is identified with its tip in the antrum of the stomach.
There is a subcentimeter low attenuation lesion within the left lobe of the
liver which is too small to further characterize but likely represents a small
cyst (2:19). There is hypoenhancement within segment IV of the liver adjacent
to the falciform ligament consistent with a perfusion anomaly. There is also
heterogeneous enhancement of the right lobe of the liver again likely
perfusional. The liver is otherwise unremarkable. The portal and hepatic
veins are patent. No intra or extrahepatic duct dilatation. The gallbladder
is normal.
The kidneys are within normal limits. No hydronephrosis. The adrenals are
unremarkable. The spleen is severely atrophic consistent with the patient's
history of hyposplenism - this is unchanged since ___. The pancreas is
within normal limits. No mesenteric or retroperitoneal adenopathy. The
abdominal aorta is of normal caliber. Diminutive inferior mesenteric artery
noted.
The lung bases are clear. No pleural effusion. The visualized portion of the
heart and pericardium is unremarkable.
PELVIS:
The bladder is within normal limits. The uterus and ovaries are unremarkable.
There is a small amount of free fluid within the pelvis. No pelvic
adenopathy.
OSSEOUS STRUCTURES:
There is a small focus of sclerosis within the left iliac bone that appears
consistent with a bone island. The osseous structures of the abdomen and
pelvis are otherwise unremarkable.
IMPRESSION:
1. Small bowel obstruction with a distinct zone of transition in the right
iliac fossa at a distal small bowel anastomosis (presumably the site of
previous reversed ileostomy). Extensive small bowel feces proximal to the
point of transition. Small amount of free fluid within the abdomen and
pelvis.
2. Severely atrophic spleen, consistent with the history of hyposplenism.
The findings were discussed with Dr ___ (surgery resident, ___ at
15.15, ___.
Radiology Report
HISTORY: ___ female with recent NG tube placement. Assess prior to
contrast administration.
TECHNIQUE: Single portable frontal semi-erect chest radiograph.
COMPARISON: Chest radiograph from ___.
FINDINGS: NG tube enters into proximal stomach and is out of view. Mild
interval decrease in lung volumes with new vascular engorgement, mediastinal
vein dilatation and mild heart enlargement. No pulmonary edema or pleural
effusions. No pneumothorax. Mediastinal contour and hila are normal.
IMPRESSION:
1. NG tube enters into the stomach and is out of view.
2. New vascular congestion without pulmonary edema.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New fevers and congestion, assessment for cardiopulmonary
process.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
increased. There is a minimal atelectasis at the left lung bases, potentially
accompanied by a minimal pleural effusion, reflected by blunting of the left
costophrenic sinus. Otherwise, the radiograph is unchanged. No overt
pulmonary edema. No pneumonia. The nasogastric tube is in constant position.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN PERIUMBILIC
temperature: 97.2
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 119.0
dbp: 76.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ presented to the emergency room with abdominal
pain, nausea, leukocytosis of 15, obstipation and constipation.
She clinically appeared to have a small bowel obstruction and
she was admitted to the colorectal service for treatment.
She was started on IVF and kept NPO. Her pain and nausea were
controlled. A CT abdomen was indicated, but the patient could
not tolerate PO contrast, therefore the morning of the ___ an
NGT was placed both for contrast administration and therapeutic
decompression. Her CT demonstrated a transition point in the
lower right quadrant.
On the ___, she had a bowel movement, and felt better. A clamp
trial was attempted, but the patient had increased nausea. On
the ___, her WBC was normal at 8.9 and she had minimal
residuals on clamp trials. She no longer felt nauseated. On the
morning of the ___, her NGT was pulled. She was passing flatus
and stool. Throughout the course of the day, she was advanced
from sips to clears and then toast. She tolerated these well.
On the ___, the patient was discharged home At discharge,
he/she was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. She will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge. She will also follow up
with Dr. ___ her INR checks.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply: |
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 distention, leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ h/o ETOH, ETOH cirrhosis c/b HE, recurrent variceal bleed
s/p TIPS ___ ___, DM, pancytopenia, HTN, HLD, recent
admission for upper GI bleed p/w confusion in the setting of
lactulose and medication non-adherence.
Patient denied chest pain, shortness of breath, fever, chills,
or
abdominal pain in the ED. He endorses b/l leg swelling mostly at
the socks with sensation of abdominal distention.
Per patient last drink was 3 days ago.
Past Medical History:
EtOH abuse
Chronic abdominal pain
Ascites
s/p bone marrow bipsy
Diabetes
Hypertension
Hypercholesterolemia
Vitamin D deficiency
Social History:
___
Family History:
Diabetes - Mother, Father
Liver disease - Brother (deceased)
No cancer hx
Physical Exam:
Admission exam:
===============
VITALS: 97.9 | 170/100 | HR 75 | RR 18 | 100% on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera icteric. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx2 - oriented to self and ___. +asterixis.
Normal
sensation. CN2-12 grossly intact.
Discharge exam:
===============
___ 0453 Temp: 98.9 PO BP: 136/68 R Lying HR: 81 RR: 16 O2
sat: 98% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera icteric. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Increased normal bowels sounds, non distended,
non-tender to deep palpation in all four quadrants
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3 - oriented to self, ___ and date. No
asterixis. Normal sensation. CN2-12 grossly intact.
Pertinent Results:
Admission labs:
===============
___ 01:25PM BLOOD WBC-3.2* RBC-3.21* Hgb-8.8* Hct-27.6*
MCV-86 MCH-27.4 MCHC-31.9* RDW-15.0 RDWSD-46.9* Plt Ct-92*
___ 01:25PM BLOOD Neuts-61.3 Lymphs-18.2* Monos-14.2*
Eos-5.7 Baso-0.3 Im ___ AbsNeut-1.95 AbsLymp-0.58*
AbsMono-0.45 AbsEos-0.18 AbsBaso-0.01
___ 01:25PM BLOOD ___ PTT-38.6* ___
___ 01:25PM BLOOD Glucose-213* UreaN-17 Creat-0.8 Na-141
K-5.0 Cl-113* HCO3-15* AnGap-13
___ 01:25PM BLOOD ALT-20 AST-76* AlkPhos-228* TotBili-2.3*
___ 01:25PM BLOOD proBNP-160*
___ 01:25PM BLOOD Lipase-42
___ 01:25PM BLOOD Albumin-2.7* Calcium-8.8 Phos-3.7 Mg-2.0
___ 01:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:29PM BLOOD Lactate-1.4
___ 03:29PM BLOOD Na-144
Discharge labs:
===============
___ 08:40AM BLOOD Albumin-2.3* Calcium-7.9* Phos-3.3
Mg-1.5*
___ 08:40AM BLOOD ALT-21 AST-63* AlkPhos-217* TotBili-2.2*
___ 08:40AM BLOOD Glucose-329* UreaN-14 Creat-0.8 Na-133*
K-3.7 Cl-106 HCO3-17* AnGap-10
___ 08:40AM BLOOD ___ PTT-42.4* ___
___ 08:40AM BLOOD WBC-3.5* RBC-3.23* Hgb-9.0* Hct-27.4*
MCV-85 MCH-27.9 MCHC-32.8 RDW-14.5 RDWSD-44.4 Plt Ct-84*
Microbiology:
=============
___ urine culture unremarkable
___ blood culture pending
Studies:
========
___ Abdomen U/S
1. Patent TIPS.
2. No detectable flow is again seen in the left portal vein,
similar to the prior ultrasound exam in ___, but CT
exam from ___ demonstrated that the left portal vein
was patent. The right anterior portal vein flow again
demonstrates unchanged antegrade flow.
3. Cirrhotic liver with splenomegaly measuring up to 18.6.
4. Cholelithiasis without evidence of acute cholecystitis.
___ CXR
Low lung volumes with patchy opacities in lung bases, most
likely atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Omeprazole 40 mg PO DAILY
4. Rifaximin 550 mg PO BID
5. Thiamine 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Spironolactone 100 mg PO DAILY
8. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Baclofen 5 mg PO TID
RX *baclofen 5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
2. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth three times a
day Disp #*1 Bottle Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
8. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
==================
-hepatic encephalopathy
Secondary diagnoses:
====================
-cirrhosis
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 confusion, hepatic encephalopathy// eval PNA;
eval PVT
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low. Heart size is mildly enlarged but unchanged. The
mediastinal and hilar contours are similar with atherosclerotic calcifications
noted at the knob. Crowding of bronchovascular structures is present without
frank pulmonary edema. Patchy opacities are seen in the lung bases. No focal
consolidation. No pleural effusion or pneumothorax is seen. There are no
acute osseous abnormalities.
IMPRESSION:
Low lung volumes with patchy opacities in lung bases, most likely atelectasis.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: History: ___ with confusion, hepatic encephalopathy// eval PNA;
eval PVT
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Duplex Doppler ultrasound from ___.
CT abdomen with contrast from ___
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is no ascites. There
is stable splenomegaly, with the spleen measuring 18.6 cm. There is no
intrahepatic biliary dilation. The CHD measures 3 mm. Cholelithiasis without
gallbladder wall thickening.
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: 41.3 cm/sec, previously 40 cm/sec
Proximal TIPS: 87.3 cm/sec, previously 68.8cm/sec
Mid TIPS: 69.6 cm/sec, previously 110 cm/sec
Distal TIPS: 92.2 cm/sec, previously 118 cm/sec
Flow within the left portal vein is not seen on this exam, similar to study in
___. Flow within the right anterior portal vein is antegrade, but
unchanged. Appropriate flow is seen in the hepatic veins and IVC.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
KIDNEYS: Limited views of the right kidney demonstrates no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Patent TIPS.
2. No detectable flow is again seen in the left portal vein, similar to the
prior ultrasound exam in ___, but CT exam from ___
demonstrated that the left portal vein was patent. The right anterior portal
vein flow again demonstrates unchanged antegrade flow.
3. Cirrhotic liver with splenomegaly measuring up to 18.6.
4. Cholelithiasis without evidence of acute cholecystitis.
Gender: M
Race: HISPANIC/LATINO - MEXICAN
Arrive by WALK IN
Chief complaint: Abdominal distention, Chest pain, R Leg swelling
Diagnosed with Altered mental status, unspecified
temperature: 97.0
heartrate: 86.0
resprate: 16.0
o2sat: 100.0
sbp: 176.0
dbp: 90.0
level of pain: 10
level of acuity: 2.0 | Brief summary:
==============
___ w/ h/o ETOH, ETOH cirrhosis c/b HE, recurrent variceal bleed
s/p TIPS ___ ___, DM, pancytopenia, HTN, HLD, recent
admission for upper GI bleed p/w confusion in the setting of
lactulose and medication non-adherence. Was started on q2H
lactulose with clearance of HE and asterixis. Patient was
transitioned to maintenance dose of lactulose TID upon
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cervical spine fractures
Major Surgical or Invasive Procedure:
___ - C6/7 ACDF
History of Present Illness:
___ y.o. male was driving at approximately ___ MPH when a tree
fell on the top of his car and dented the roof in about 1 foot.
He was hit on the head. He did not lose consciousness. He did
experience neck pain immediately as well as right arm numbness
in
the forearm from the elbow to the tips of his first 3 fingers.
Otherwise he had no other complaints. He has long standing left
L5 dermatome numbness that is unchanged. He denies new
weakness,
radicular pain, or bowel/bladder dysfunction.
Past Medical History:
Colitis
Lumbar HNP - L4/5 Laminectomy and/or discectomy ___ years ago in
___. Pt cannot recall what the specific procedure was
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Gen: WD/WN, comfortable, NAD.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch except right C6 dermatome (new)
and left L5 dermatome (old) numbness. Otherwise, intact
sensation
Reflexes: B T Br Pa Ac
Right 1----> 2--->
Left 1----> 2--->
No ___
On Discharge:
Gen: WD/WN, comfortable, NAD.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch except with parasthesias right
C6 dermatome (new) and left L5 dermatome (old) numbness.
Otherwise, intact sensation
Reflexes: B T Br Pa Ac
Right 1----> 2--->
Left 1----> 2--->
No ___
Incision: C/D/I
Pertinent Results:
___ CXR
No evidence of acute injury.
___ CT c spine w/o contrast
At C6-7 there is a jumped facet on the right and subluxed facet
on the
left. Associated fracture through the inferior articular facet
of C6 on the
right. Secondary 4 mm of anterolisthesis of C6 on C7. Cervical
spine MRI is
recommended for further evaluation.
2. Acute fracture through the superior endplate of C7.
3. Acute C6 spinous process fracture.
4. Subtle irregularity and cortical buckling at T1 and T2, may
represent
additional injury and can be further evaluated on MRI.
5. Triangular osseous fragment at the anterior inferior endplate
of C4 is most
likely degenerative in nature, but can also be evaluated on MRI.
At this
time, the widening of the right C4-C5 facet can be assessed
regarding the
possibility of ligamentous injury.
___ NCHCT
1. No acute intracranial process.
2. Scalp laceration at the posterior vertex without underlying
fracture. .
___ CT torso w/ contrast
1. No evidence of intra thoracic or intra-abdominal injury.
2. Subtle regularity of the T1 and T2 vertebral bodies can be
better assessed
on spine MRI.
3. Spondylolysis of L5/S1 due to bilateral L5 spondylolysis,
chronic.
___ MRI c spine w/&w/o contrast
1. In comparison with the prior CT of the cervical spine, again
jumped right
C6 and subluxed left C6 inferior articular joint facet with 3 mm
anterolisthesis at C6-7 level. Anterolisthesis results in
moderate spinal
canal stenosis with effacement of the thecal sac. No cord
signal abnormality.
2. Fractures of the inferior endplate of C5, superior endplate
of C6, and
superior endplate of C7. No vertebral body height loss.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN fever or pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*75 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
C6/7 cervical fracture with mal-alignment
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: Trauma.
TECHNIQUE: Chest, supine AP portable.
COMPARISON: None.
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. Within the limitations of technique, no fracture is identified.
IMPRESSION:
No evidence of acute injury.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man status post motor vehicle accident, evaluate for
intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
Coronal and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
DOSE: DLP: 1003 mGy-cm
CTDI: 53 mGy
COMPARISON: None.
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.
No osseous abnormalities seen. There is minimal mucosal thickening in the
right maxillary sinus. The paranasal sinuses are otherwise clear. A scalp
laceration is noted at the posterior vertex.
IMPRESSION:
1. No acute intracranial process.
2. Scalp laceration at the posterior vertex without underlying fracture. .
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ man status post motor vehicle accident, evaluate for
cervical spine fracture.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 896 mGy
DLP: 37 mGy-cm
COMPARISON: None available.
FINDINGS:
At the C6-C7 level, there is a jumped facet on the right and a subluxed facet
on the left. There is an associated fracture through the inferior articular
facet of C6 on the right. These findings result in anterolisthesis of C6 on
C7. There is also a horizontally oriented fracture through the C6 spinous
process.
Additionally, there is a fracture through the superior endplate of the C7
vertebral body. Subtle irregularity along the T1 and T2 vertebral bodies with
buckling of the anterior cortex, may represent additional fracture.
A triangular osseous fragment at the anterior inferior endplate of C4 may be
degenerative. There is subtle asymmetric widening of the facet joint of the
right at C4-5.
The lung apices are clear. The thyroid is unremarkable.
IMPRESSION:
1. At C6-7 there is a jumped facet on the right and subluxed facet on the
left. Associated fracture through the inferior articular facet of C6 on the
right. Secondary 4 mm of anterolisthesis of C6 on C7. Cervical spine MRI is
recommended for further evaluation.
2. Acute fracture through the superior endplate of C7.
3. Acute C6 spinous process fracture.
4. Subtle irregularity and cortical buckling at T1 and T2, may represent
additional injury and can be further evaluated on MRI.
5. Triangular osseous fragment at the anterior inferior endplate of C4 is most
likely degenerative in nature, but can also be evaluated on MRI. At this
time, the widening of the right C4-C5 facet can be assessed regarding the
possibility of ligamentous injury.
NOTIFICATION: Findings discussed with the trauma team in person by Dr.
___ on ___ at 16:45, at the time of discovery.
Radiology Report
EXAMINATION: CT TORSO WITH CONTRAST.
INDICATION: ___ man who presents after motor vehicle accident.
TECHNIQUE: MDCT images were obtained from the thoracic inlet through the
pelvis. IV Omnipaque contrast was administered. Axial images were
interpreted in conjunction with sagittal and coronal reformats.
DLP: 769 mGy-cm
COMPARISON: None available.
FINDINGS:
CHEST:
There is no focal lung consolidation. There is no pleural effusion,
pneumothorax, or pneumomediastinum. The airway as are patent to the
subsegmental level.
Heart and great vessels are unremarkable. There is no mediastinal hematoma.
There is no pericardial effusion.
There is no axillary, supraclavicular, or mediastinal lymphadenopathy. The
visualized thyroid is unremarkable.
The thoracic esophagus is unremarkable.
ABDOMEN:
The liver enhances homogeneously and is without focal lesion or laceration.
The portal vein is patent. The gallbladder, spleen, adrenal glands, and
pancreas are unremarkable.
The kidneys enhance and excrete contrast symmetrically. There is no
hydronephrosis. The ureters are normal in caliber along their course the
bladder. There are bilateral cysts within the kidneys with the largest in
lower pole on the left measuring 13 mm.
The distal esophagus is unremarkable without hiatal hernia. The stomach is
relatively decompressed. The small bowel is normal in caliber without focal
wall thickening. The large bowel is also normal in caliber without focal wall
thickening. There is no abdominal free fluid or free air.
The abdominal aorta and its major branches are patent. There is no abdominal
aortic aneurysm. There are no enlarged retroperitoneal or mesenteric lymph
nodes.
PELVIS: The bladder is well distended and normal. The prostate contains a
coarse calcification. There is no pelvic sidewall or inguinal adenopathy.
There is no pelvic free fluid.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. There is bilateral L5 spondylolysis with spondylolisthesis of
L5/S1, chronic in nature. Left L4 laminectomy seen. No definite fracture is
identified. Subtle irregularity at the T1 and T2 vertebral bodies, better
evaluated on C-spine CT.
IMPRESSION:
1. No evidence of intra thoracic or intra-abdominal injury.
2. Subtle regularity of the T1 and T2 vertebral bodies can be better assessed
on spine MRI.
3. Spondylolysis of L5/S1 due to bilateral L5 spondylolysis, chronic.
NOTIFICATION: Findings discussed with the trauma team in person on ___ at 16:45, at the time of discovery.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST
INDICATION: ___ year old man with recent neck injury // recent neck injury
recent neck injury
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were performed. 8 cc Gadavist was
administered intravenously. Sagittal and axial T1 post-contrast sequences
were obtained.
COMPARISON: CT cervical spine ___
FINDINGS:
There is a 3 mm anterolisthesis at C6-7 due to a jumped right C6 inferior
articular facet and subluxed left C6 inferior articular. The fracture of the
right inferior articular C6 facet and C6 spinous process is better appreciated
on CT. There are fractures of the inferior endplate of C5, superior endplate
of C6, and superior endplate of C7. There is no vertebral body height loss.
There is no hemorrhage within the spinal cord. Anterolisthesis at C6-7
results in moderate spinal canal stenosis with effacement of the ventral and
dorsal thecal sac. There is prevertebral fluid throughout the cervical and
upper thoracic spine and soft tissue edema in the posterior vertebral
musculature, extending along the interspinous processes from C1 through T1
levels.
There is a disc protrusion at C4-5 that causes mild spinal canal stenosis and
a disc protrusion at C5-6 that causes moderate spinal canal stenosis.
IMPRESSION:
1. In comparison with the prior CT of the cervical spine, again jumped right
C6 and subluxed left C6 inferior articular joint facet with 3 mm
anterolisthesis at C6-7 level. Anterolisthesis results in moderate spinal
canal stenosis with effacement of the thecal sac. No cord signal abnormality.
2. Fractures of the inferior endplate of C5, superior endplate of C6, and
superior endplate of C7. No vertebral body height loss.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: ANT. C6-7 FUSION
IMPRESSION:
Images from the operating suite show steps in an anterior C6-C7 fusion.
Further information can be gathered from the operative report.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man s/p ACDF // evaluation of hardware
evaluation of hardware
TECHNIQUE: C-Spine 2 views.
COMPARISON: CT ___
FINDINGS:
C1 through T1 are demonstrated on lateral view. No prevertebral swelling is
identified. Cervical lordosis is preserved. Patient is status post anterior
fusion at C6-C7. Otherwise the vertebral body and disc heights are preserved.
No spondylolisthesis is detected. No suspicious lytic or sclerotic lesion is
identified. The lateral masses are symmetric about the dens.
IMPRESSION:
Status post ACDF at C6-C7.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with FX C6 VERTEBRA-CLOSED, OPEN WOUND OF SCALP, MULTIPLE CONTUSIONS NEC, ABRASION NEC, SKIN SENSATION DISTURB, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | On ___, the patient was admitted to ___ for cervical
fractures w/ instability as well as minor thoracic compression
deformities. He was kept in a hard collar and was prepared for
cervical decompression and fusion.
On ___, the patient was taken to the operating room where he
underwnt a C6/7 ACDF. 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 was ambulating independently POD#1. 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
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:
perindopril
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
Ms. ___ is a ___ year old woman with PMHx of severe dementia,
TIA, left hip fracture s/p ORIF on ___ on ___ who
presents from rehab with confusion and concern for wound
infection.
Per rehab notes, pt was increasingly confused at rehab and there
was concern for L hip wound infection. Ambulance was called to
transport pt to ___ for surgery eval. However, pt became
increasingly altered and agitated during the ambulance ride and
was redirected to ___ for evaluation.
Of note, pt had been admitted for 3 days at a dementia unit in
___ when she fell and broke her L hip. She was admitted to
the dementia unit because she was no longer able to care of
herself at home.
Upon arrival to ___, pt was noted to be calm, pleasant, A&Ox1.
Per rehab notes, pt had no f/c, n/v or diarrhea.
In the ED, initial vitals: 97.9 84 148/73 16 100% RA
- Exam notable for: LLE edema and erythema, 2+ DP pulses, L hip
wound c/d/i w/o evidence of infection.
- Labs notable for: d-dimer 3341, PTT 46.9, UA clean, HCT 33
- Imaging notable for: Acute occlusive DVT involving one of the
left posterior tibial veins.
- Pt given: started on hep gtt at 800U/hr
- Vitals prior to transfer: 98.5 88 156/86 16 100% RA
On arrival to the floor, pt denies CP, SOB, abd pain. Endorses
pain with attempted ROM at L hip. Agrees she may have been
confused over the past several days, but thinks this is because
she has been moved around frequently to various unfamiliar
places lately.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea. No dysuria or
hematuria. No hematochezia, no melena. No numbness or weakness,
no focal deficits.
Past Medical History:
dementia
anxiety
tia
lymphoma
spinal stenosis
hypothyroidism
htn
osteoporosis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION
=========
Vitals- 98.5 98.0 96 148/100 18 98RA
General- Calm, pleasant, A&Ox2 (unable to name correct year),
NAD
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- Supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- Warm, well perfused, 2+ DP pulses, 3+ pitting edema in LLE
to groin with ecchymosis along L groin, no palpable masses or
fluctuance, L lateral hip wounds stapled and c/d/i. RLE w/o
edema.
Neuro- CNs2-12 intact, LLE ROM limited by pain, RLE motor
function grossly normal.
DISCHARGE
=========
Vitals- 98.5 98.1 92 166/76 18 99RA
General- Calm, pleasant, A&Ox2 (unable to name correct year),
NAD
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- Supple, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, ___ systolic ejection murmur most
appreciable at RU sternal border
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- Warm, well perfused, 2+ DP pulses, 3+ pitting edema in LLE
to groin with ecchymosis along L groin, no palpable masses or
fluctuance, L lateral hip wounds stapled and c/d/i. RLE w/o
edema.
Neuro- CNs2-12 intact, LLE ROM limited by pain, RLE motor
function grossly normal.
Pertinent Results:
ADMISSION LABS
=========
___ 09:00AM BLOOD WBC-6.9 RBC-3.90* Hgb-10.8* Hct-33.2*
MCV-85 MCH-27.6 MCHC-32.4 RDW-17.0* Plt ___
___ 09:00AM BLOOD Neuts-82.8* Lymphs-8.7* Monos-6.8 Eos-1.4
Baso-0.3
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD ___ PTT-26.6 ___
___ 09:00AM BLOOD Glucose-148* UreaN-25* Creat-0.8 Na-136
K-4.2 Cl-101 HCO3-29 AnGap-10
___ 09:00AM BLOOD Calcium-8.7 Phos-2.3* Mg-2.3
___ 09:55AM BLOOD D-Dimer-3341*
___ 09:24AM BLOOD Lactate-1.3
DISCHARGE LABS
=========
___ 06:58AM BLOOD WBC-6.7 RBC-3.73* Hgb-10.7* Hct-32.5*
MCV-87 MCH-28.8 MCHC-33.0 RDW-17.4* Plt ___
MICRO
=====
___ BCx pending
___ UCx FINAL <10,000 CFU
IMAGING
=======
___ bilateral hip xray:
IMPRESSION:
1. Osteopenia.
2. Status post ORIF left intertrochanteric fracture. The
fracture site and hardware appear unchanged.
3. No new fracture detected about the left hip or femur about
the right hip. No displaced fractures seen about the pelvic
girdle.
4. Given the degree of osteopenia, if symptoms persist, consider
followup
radiographs.
___ HCT:
IMPRESSION:
1. No evidence for acute intracranial abnormalities.
2. 11 mm calcified extra-axial left parietal mass with mild
adjacent
hyperostosis, which displaces the adjacent parenchyma without
parenchymal edema, consistent with a meningioma.
___ L ___:
IMPRESSION:
Acute occlusive DVT involving one of the left posterior tibial
veins. The right lower extremity and left popliteal veins were
not visualized due to lack of ___ cooperation.
___ Hip and L femur plainfilm
IMPRESSION:
1. Status post ORIF left intertrochanteric fracture, in overall
anatomic alignment on the available AP views. No hardware
displacement identified.
2. Scattered subcutaneous emphysema is compatible with recent
surgery, but clinical correlation is requested for full
assessment.
3. No new superimposed fracture is identified.
___ CXR:
IMPRESSION:
1. Cardiomegaly and background COPD.
2. Suspected left lower lobe collapse and/or consolidation. If
clinically indicated, lateral view may help to further evaluate
this.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Docusate Sodium 100 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H
8. QUEtiapine Fumarate 12.5 mg PO Q4H:PRN agitation
9. TraZODone 12.5 mg PO QHS:PRN insomnia
10. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO QHS
3. Enoxaparin Sodium 50 mg SC Q12H Duration: 6 Months
Start: ___, First Dose: Next Routine Administration Time
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 - 1 capsule(s) by mouth Q4H:prn Disp #*10
Capsule Refills:*0
5. TraZODone 12.5 mg PO QHS:PRN insomnia
6. Calcium Carbonate 500 mg PO QID:PRN heartburn
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. QUEtiapine Fumarate 12.5 mg PO Q4H:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
deep venous thrombosis of left lower extremity
Secondary diagnosis:
Left hip fracture s/p open reduction internal fixation
Dementia
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 (SINGLE VIEW)
INDICATION: History: ___ with AMS from rehab on lovenox for recent hip ORIF.
// infection? infiltrate? bleed? Left hip hardware in place?
COMPARISON: None.
FINDINGS:
PROBABLE hyperinflation, consistent with copd. There is mild cardiomegaly,
with a left ventricular configuration. There are increased interstitial
markings, which may reflect background chronic parenchymal changes. There is
patchy retrocardiac opacity, consistent with left lower lobe collapse and/or
consolidation. Additional opacity at the left base could reflect either a
hiatal hernia or increased density related to the descending aorta. There is
minimal blunting of the costophrenic angles without gross effusion. Moderate
right convex scoliosis is present.
IMPRESSION:
1. Cardiomegaly and background COPD.
2. Suspected left lower lobe collapse and/or consolidation. If clinically
indicated, lateral view may help to further evaluate this.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: History: ___ with AMS from rehab on ___ for recent hip ORIF.
// infection? infiltrate? bleed? Left hip hardware in place?
TECHNIQUE: AP view of pelvis an AP view of the left femur. No lateral view of
the hip or femur.
COMPARISON: None.
FINDINGS:
The patient is status post ORIF of an intertrochanteric fracture transfixed by
gamma nail of along the IM rod. Overall alignment is anatomic on the frontal
views. The fracture line remains visible. A slightly distracted and probably
comminuted lesser trochanteric fracture fragment is noted. No new superimposed
fracture is detected. No hardware loosening or failure is detected. The distal
most portion of the IM rod and femur excluded from these films. The
possibility of some punctate subcutaneous emphysema in the region of the
fixation site cannot be excluded. There are overlying skin staples.
The pelvic girdle is grossly congruent, without SI joint or pubic symphysis
diastasis. The sacrum is obscured by overlying bowel gas. Allowing for this,
no acute fracture is detected about the pelvic girdle. Limited assessment of
the right hip and proximal femur shows mild degenerative changes. At the
periphery of these films, advanced degenerative changes in lower lumbar spine.
, with mild left-sided wedging of the presumptive L4 and L5 vertebral bodies
noted, likely chronic.
Scattered vascular calcification noted.
IMPRESSION:
1. Status post ORIF left intertrochanteric fracture, in overall anatomic
alignment on the available AP views. No hardware displacement identified.
2. Scattered subcutaneous emphysema is compatible with recent surgery, but
clinical correlation is requested for full assessment.
3. No new superimposed fracture is identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with altered mental status from rehab, on lovenox for recent
hip ORIF, evaluate for acute intracranial process.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Some of the images were repeated due to motion artifact. Coronal
and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
DOSE: DLP: 1226 mGy-cm
CTDI: 102 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of acute hemorrhage, edema, or loss of gray/ white matter
differentiation. A 11 x 8 mm extra-axial left parietal calcified lesion, with
mild adjacent hyperostosis, which displaces the adjacent parenchyma without
parenchymal edema, is likely a meningioma. A small chronic infarct is noted
in the right cerebellar hemisphere. There is another probable small chronic
infarct in the subcortical white matter of the left insula, image ___ Foci
of low density in the periventricular, deep, and subcortical white matter of
the cerebral hemispheres are likely sequela of chronic small vessel ischemic
disease in a patient of this age. There is age-related cerebral atrophy with
associated prominence of the ventricles and sulci.
The bones are demineralized without evidence for a fracture. Visualized
paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. No evidence for acute intracranial abnormalities.
2. 11 mm calcified extra-axial left parietal mass with mild adjacent
hyperostosis, which displaces the adjacent parenchyma without parenchymal
edema, consistent with a meningioma.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with leg swelling, recent orif L hip, evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None available.
FINDINGS:
Please note that this study was extremely limited secondary to lack of patient
cooperation. Assessment of the right lower extremity was not able to be
performed per protocol.
There is normal compressibility, flow and augmentation of the left common
femoral and superficial femoral veins. The popliteal vein was not visualized
due to technique.
There is an occlusive, noncompressible thrombus expanding one of the posterior
tibial veins. The left peroneal veins show normal blood flow and
compressibility.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Acute occlusive DVT involving one of the left posterior tibial veins. The
right lower extremity and left popliteal veins were not visualized due to lack
of patient cooperation.
Radiology Report
EXAMINATION: BILAT HIPS (AP,LAT AND AP PELVIS)
INDICATION: ___ Hx dementia, TIA, left hip fracture s/p ORIF on ___,
found to have LLE DVT on lovenox, had fall last night, no headstrike. //
Please assess for new hip/pevis fractures
TECHNIQUE: AP pelvis and. Right hip two views. Left hip and femur two views.
COMPARISON: Femur radiographs from ___ at 10:33.
FINDINGS:
There is diffuse osteopenia. The patient is status post ORIF of a left
intertrochanteric fracture transfixed by gamma nail and long IM rod. A
distracted lesser tuberosity fragment is again seen, similar prior. No new
left femur fracture and no evidence of left hip/ femur hardware loosening or
failure is detected. Overlying skin staples noted. The left hip remains
congruent, with mild degenerative changes again noted. Degenerative changes of
the left knee are noted. Probable soft tissue swelling about the hip.
On the right, there are mild degenerative changes of the right hip. No acute
fracture or dislocation is detected involving the right hip. The distal
portion of the right femur is not included on these views.
The pelvic girdle is congruent, without SI joint or pubic symphysis diastasis.
No displaced fracture is identified about the pelvis The sacrum is partially
obscured by overlying bowel gas, but no obvious sacral fracture is suggested.
Limited assessment of the lower lumbar spine shows severe degenerative
changes. Vascular calcification noted.
IMPRESSION:
1. Osteopenia.
2. Status post ORIF left intertrochanteric fracture. The fracture site and
hardware appear unchanged.
3. No new fracture detected about the left hip or femur about the right hip.
No displaced fractures seen about the pelvic girdle.
4. Given the degree of osteopenia, if symptoms persist, consider followup
radiographs .
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval, Confusion
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY, SENILE DEMENTIA UNCOMP
temperature: 97.9
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 148.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | ___ with PMHx of dementia, TIA, left hip fracture s/p ORIF on
___ on prophylactic lovenox who presents from rehab with
confusion and concern for wound infection and found to have LLE
DVT.
# LLE DVT: Provoked DVT in setting of recent orthopedic surgery.
Started on hep gtt in the ED and transitioned to 1mg/kg BID
lovenox. ___ will need continued anticoagulation for 6
months. Hematoma to be expected in left hip given recent ORIF
but should not need intervention. Will need CBC for monitoring
h/h on ___.
# L hip fx s/p ORIF: Wound apears c/d/i, however with
significant ecchymosis along L groin. Hematoma after hip fx
repairs are frequent and interventions are not required.
Worsening of hematoma with anticoagulation to be expected before
improving. Serial CBC during hospitalization showed stable h/h.
Pain controlled with scheduled Tylenol and oxycodone as needed.
# Acute delirium: ___ became increasingly confused and
agitated during hospitalization but was able to be re-directed.
She suffered a fall while attempting to walk to ___ on ___
despite fall precautions. Hip films were negative for frature.
___ will f/u with outpatient geriatric neuropsychiatrist Dr.
___ at discharge. She did not require any
antipsychotics or sedatives.
# Dementia: ___ with known history of severe dementia,
followed by Dr. ___. Had previously lived in a
dementia unit where she sustained her initial fall leading to
hip fracture. Known to be a danger to herself and has refused
medical treatment. Daughter very involved in her care and to
schedule follow up with Dr. ___.
# HTN: Held HCTZ as blood pressure is adequate given ___
age and to decrease the risk of fall. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prozac / aspirin / strawberries
Attending: ___.
Chief Complaint:
hyponatremia; abdominal distension
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
___ female w/ pmhx of cirrhosis, w/baseline chronic abdominal
distension, referred to ___ ED due to hyperkalemia on
outpatient blood draw yesterday, transferred from ___ for
admission for hyperkalemia and for therapeutic paracentesis. Pt
reports mild dyspnea secondary to abdominal distention. She
denies abdominal pain, fevers/chills, confusion. Notably, the
patient reports that she has recently been off of lasix, and has
been consuming copious amounts of orange juice.
In the ED, initial vitals were 96.4 64 106/45 24 100
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-cryptogenic cirrhosis
-asthma
-diabetes on metformin
-rheumatoid arthritis
-s/p thyroidectomy
-fibromyalgia
Social History:
___
Family History:
H/o colon cancer (brother), no h/o liver disease
Physical Exam:
ADMISSION EXAM:
VS: 97.7; 110/62; 56; 20; 100%2LNC
GENERAL: Well appearing F, NAD. Comfortable, appropriate. no
jaundice. AAOx2.5 (did not know the year)
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear, ___ holosystolic murmur in the LLSB,
no rubs or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. + shifting
dullness. + fluid wave. No HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
trace b/l ___ edema in the ankles. 2+ ___
No asterixis
DISCHARGE EXAM:
VS: 97.6/98.1; 100-102/50-53; 59-62; 22; 100RA
GENERAL: Well appearing Female, NAD. Comfortable, appropriate.
no jaundice. AAOx3.
ABDOMEN: nondistended but Soft, no shifting dullness. no fluid
wave. mild RUQ tenderness on deep palpation. +
hepatosplenomegaly
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
trace b/l ___ edema in the ankles. 2+ ___
Exam otherwise unchanged since admission
Pertinent Results:
ADMISSION LABS:
___ 06:40AM BLOOD WBC-4.1 RBC-3.28* Hgb-9.8* Hct-31.0*
MCV-95 MCH-29.9 MCHC-31.6 RDW-16.0* Plt ___
___ 06:40AM BLOOD Neuts-75* Bands-0 Lymphs-12* Monos-12*
Eos-1 Baso-0 ___ Myelos-0
___ 06:40AM BLOOD ___ PTT-27.8 ___
___ 06:40AM BLOOD Glucose-141* UreaN-19 Creat-0.5 Na-126*
K-6.5* Cl-100 HCO3-18* AnGap-15
___ 11:15AM BLOOD Na-129* K-5.2* Cl-102
___ 06:40AM BLOOD ALT-39 AST-85* AlkPhos-148* TotBili-0.7
___ 06:40AM BLOOD Albumin-3.5
___: Ascitic fluid
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-2.9* RBC-3.32* Hgb-10.0* Hct-31.9*
MCV-96 MCH-30.2 MCHC-31.4 RDW-16.2* Plt Ct-82*
___ 06:20AM BLOOD Glucose-113* UreaN-25* Creat-0.6 Na-132*
K-4.9 Cl-103 HCO3-20* AnGap-14
___ 07:35AM BLOOD ALT-36 AST-44* LD(LDH)-142 AlkPhos-100
___ 06:20AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.9
MICRO:
Blood culture ___: no growth at the time of discharge
Urine culture ___: no growth at the time of discharge
___ 4:41 pm PERITONEAL FLUID
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.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
CYTOLOGY:
___ peritoneal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes and lymphocytes.
IMAGING:
CXR ___:
As compared to the previous radiograph, a lateral view is now
available, the lateral view shows a mild-to-moderate left
pleural effusion. Otherwise, the radiograph is unchanged. The
nasogastric tube has been removed. There is a minimal pleural
effusion adjacent to the left heart border. No evidence of new
parenchymal opacities. No acute changes. Normal hilar and
mediastinal structures.
Liver U/S with doppler ___:
The liver is again noted to be diffusely nodular in appearance
however no
concerning liver lesion is identified. No biliary dilatation is
seen and the common duct measures 0.4 cm. There are numerous
small shadowing gallstones again seen within the gallbladder.
The pancreas is unremarkable however the tail is obscured from
view by overlying bowel gas. The spleen is enlarged measuring
16.4 cm. No hydronephrosis is seen on limited views of the
kidneys.
A small amount of ascites is seen within the abdomen. There is
a small left pleural effusion.
Doppler examination: Color Doppler, and spectral waveform
analysis was
performed. Nonocclusive thrombus is again seen in the main
portal vein. Slow flow which is hepatopetal is seen within the
main and right portal veins.
Flow within the left portal vein is hepatofugal. The hepatic
veins, IVC,
splenic vein and SMV are patent. Appropriate arterial waveforms
are seen in the main, right and left hepatic arteries.
IMPRESSION:
-> Nonocclusive thrombus again seen within the main portal
vein. Slow
hepatopetal flow is seen in the main and right portal veins.
Reversed flow is seen in the left portal vein.
-> Nodular hepatic echotexture with no focal liver lesion
identified.
-> Splenomegaly.
-> Small amount of ascites and a small left pleural effusion.
-> Cholelithiasis.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Cryptogenic cirrhosis, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, a lateral view is now
available, the lateral view shows a mild-to-moderate left pleural effusion.
Otherwise, the radiograph is unchanged. The nasogastric tube has been
removed. There is a minimal pleural effusion adjacent to the left heart
border. No evidence of new parenchymal opacities. No acute changes. Normal
hilar and mediastinal structures.
Radiology Report
HISTORY:
___ female with hyperkalemia, history of cirrhosis and abdominal
distention, evaluate for portal vein occlusion and mass.
COMPARISON:
Liver ultrasound ___.
FINDINGS:
The liver is again noted to be diffusely nodular in appearance however no
concerning liver lesion is identified. No biliary dilatation is seen and the
common duct measures 0.4 cm. There are numerous small shadowing gallstones
again seen within the gallbladder. The pancreas is unremarkable however the
tail is obscured from view by overlying bowel gas. The spleen is enlarged
measuring 16.4 cm. No hydronephrosis is seen on limited views of the kidneys.
A small amount of ascites is seen within the abdomen. There is a small left
pleural effusion.
Doppler examination: Color Doppler, and spectral waveform analysis was
performed. Nonocclusive thrombus is again seen in the main portal vein. Slow
flow which is hepatopetal is seen within the main and right portal veins.
Flow within the left portal vein is hepatofugal. The hepatic veins, IVC,
splenic vein and SMV are patent. Appropriate arterial waveforms are seen in
the main, right and left hepatic arteries.
IMPRESSION:
-> Nonocclusive thrombus again seen within the main portal vein. Slow
hepatopetal flow is seen in the main and right portal veins. Reversed flow is
seen in the left portal vein.
-> Nodular hepatic echotexture with no focal liver lesion identified.
-> Splenomegaly.
-> Small amount of ascites and a small left pleural effusion.
-> Cholelithiasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FOR ADMISSION
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, HYPERKALEMIA, OTHER ASCITES, OTH SEQUELA, CHR LIV DIS
temperature: 96.4
heartrate: 64.0
resprate: 24.0
o2sat: 100.0
sbp: 106.0
dbp: 45.0
level of pain: 0
level of acuity: 2.0 | ___ female w/ pmhx of cryptogenic cirrhosis, w/baseline chronic
abdominal distension, referred to ___ ED due to hyperkalemia on
outpatient blood draw yesterday, transferred from ___ for
admission for hyperkalemia and for therapeutic paracentesis.
# Abdominal Distention/Ascites- Ascites refractory to diuretics
in the past. Has not been on lasix or aldactone for a few weeks.
Last therapeutic paracentesis was on ___ with around 5
liters removed. No signs of SBP on peritoneal fluid studies. No
abdominal pain, fevers/chills, mild confusion. 5 Liters removed
on diagnostic and therapeutic para on ___ and given 2 grams of
albumin 25%. Restarted 40mg oral lasix the day prior to
admission and continued Na and fluid restrictions.
# Cryptogenic Cirrhosis- No signs of infection, bleeding,
encephalopathy. Workup negative thus far on etiology of
cirrhosis. MELD=10. In the past has been considered for
transplant on ___ but was thought to be too ill to be
considered a liver transplant candidate because of significant
muscle wasting and fat store loss. At times have been fed with
dobhoff tube in the last few months for nutritional support.
Continued Cipro and Rifaximin SBP prophylaxis, increased
lactulose from BID to TID, (titrated to ___ BM per day). Liver
U/S showed non-occlusive portal vein thrombosis (similar to
prior).
# Hyperkalemia- Initial hemolyzed specimen, repeat potassium
5.4. No EKG changes. Potential causes include metabolic
acidosis, beta blockade, type 1 RTA. Patient has been off all
diuretics ___ hyponatremia. Hyperkalemia improved with lasix,
started on ___. Potassium is 4.9 after restarting lasix.
# Hyponatremia- Clinically hypervolemic. Low Na likely from
underlying ascites and liver disease. Adrenal insufficiency and
hypothyroidism ruled out on ___ with normal TSH and AM
cortisol. Urine lytes with low Na and high osms, supporting
liver failure as a cause of hyponatremia. Continued fluid
restriction to <1500ml/day, Na restriction <2g/day. Restarted on
lasix on ___ and Na on discharge was 132.
# Nonanion Gap acidosis- Hemodynamically stable, no signs of
infection, have loose BM associated with lactulose use and has
not been vomiting. Cr. 0.5. Bicarb stable.
# Esophageal Varices - No signs of bleeding currently. Recently
at a EGD which revealed grade 3 varices (which were banded) with
recent stigmata of bleeding on ___. Therefore will be vigilant
for any signs of bleeding and monitor Hct at least Q daily.
Repeat EGD was recommended on ___ in ___ weeks. Continued
nadolol and omeprazole. Plan to schedule f/u EGD as outpatient.
# DM- HISS in the hospital. Restarted metformin on discharge.
# Asthma- Continued fluticasone-salmeterol and PRN Albuterol
# Hypothyroidism- Continued home synthroid
# Transitional issues:
- code status: full code
- follow up: ___ transplant
- pending studies: final peritoneal fluid culture
- follow up issues:
- need to arrange outpatient f/u EGD
- repeat chem 7 on ___, to be followed by Dr. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cefazolin / Cephalosporins
Attending: ___
Chief Complaint:
chest/abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M hx of CKD, HTN, ESRD, s/p extended
criteria donor kidney transplantation (baseline Creatinine ~1.9,
on tacrolimus/MMF) in ___, presenting with left sided
abdominal and chest pain.
The patient was in a transport vehicle on ___ when he that
vehicle made a sharp turn and he hit his left side against the
handrest. No report of head strike, dizziness, weakness, neck or
back pain, SOB or palpitations. Given acute onset pain the
patient was sent to the ___ ED where he had a CT Head, C Spine
and Torso. Extensive imaging only notable for RLQ transplant
kidney with mild hydronephrosis and trace free fluid adjacent to
the transplant which is non specific, though no evidence of
traumatic injury to chest, abdomen, pelvis, and negative C spine
and CT head.
The patient had been feeling better after discharge, however had
increasing pain yesterday and presented to the urgent care
clinic at ___. They wanted to send the patient to ___ but the
patient elected to come to ___ as he received his transplant
here.
In the ED, initial vitals were:
Temp: 100, pulse 90 , BP 153/100 rr16 97% RA
ED exam was notable for left lower chest wall, LUQ, left flank
tenderness.
Prior to transfer vitals were:
97.5 55 113/70 18 96% RA
Blood and urine cultures were sent.
Labs were notable for H/H 13.3/40.5, Cr of 1.6 (improved from
prior baseline), lactate of 1.4. Negative UA.
Imaging notable for:
CXR: Mild cardiomegaly, plate like lower lung atelectasis.
CT Torso w/o contrast: No evidence of intra thoracic or intra
abdominal injury.
Renal Transplant US: Normal renal transplant US.
The patient was given:
___ 00:11 PO/NG Acetaminophen 1000 mg
___ 00:11 IV Morphine Sulfate 2 mg
On the floor the patient notes that he is still having some
abdominal and chest wall pain, ___ in severity, which is much
improved from when he first came in. No other acute concerns.
ROS: positive per HPI
Past Medical History:
1. ESRD of unclear etiology but had episode of
glomerulonephritis in
___ was on peritoneal and then hemodialysis, but received
extended donor criteria kidney (DDRT on tacro/MMF) in ___.
2. Anemia
3. Gout
4. Prostate CA ___ 3+4) s/p radical prostatectomy
5. Spinal stenosis
6. HTN
7. GERD/gastritis
8. Hyperparathyroidism
9. Gout
10. Osteoporosis
11. s/p appendectomy
Social History:
___
Family History:
Father - possible cardiac event
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
===================================
VS: T 98 BP 138/84 HR 58 RR 20 98 RA
General: No acute distress, lying comfortably, alert
HEENT: NCAT, MMM, anicteric sclera
Neck: No JVD appreciated, supple
CV: RRR S1 and S2 appreciated
Lungs: CTAB, no increased work of breathing
Abdomen: soft, non distended. TTP over epigastrium and lefter
upper quadrant, no point tenderness of ribs. No ecchymoses
appreciated.
GU: No foley
Ext: wwp, no edema
Neuro: alert and oriented, neg aserixis
Skin: No jaundice or rashes appreciated
Pertinent Results:
==============================
LABS DURING BRIEF ADMISSION
==============================
___ 12:00AM BLOOD WBC-6.1 RBC-4.64 Hgb-13.3* Hct-40.5
MCV-87 MCH-28.7 MCHC-32.8 RDW-13.8 RDWSD-42.5 Plt ___
___ 12:00AM BLOOD Neuts-75.5* Lymphs-11.9* Monos-9.6
Eos-2.3 Baso-0.2 Im ___ AbsNeut-4.63 AbsLymp-0.73*
AbsMono-0.59 AbsEos-0.14 AbsBaso-0.01
___ 12:00AM BLOOD Glucose-107* UreaN-19 Creat-1.6* Na-136
K-4.4 Cl-101 HCO3-22 AnGap-17
___ 12:16AM BLOOD Lactate-1.4
___ 12:05AM URINE Color-Straw Appear-Clear Sp ___
___ 12:05AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
==============================
MICROBIOLOGY
==============================
___ - Urine Culture - No Growth
___ - Blood Culture - Pending
==============================
IMAGING/STUDIES
==============================
___ CXR
Mild cardiomegaly. Platelike lower lung atelectasis.
___ CT Torso Without Contrast
1. No evidence of acute intrathoracic or intraabdominal injury
within the
limitation of an unenhanced scan.
2. Severe multilevel degenerative changes including
age-indeterminate
compression fractures of T6 and T12.
___ Renal Transplant US
Normal renal transplant ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Alendronate Sodium 70 mg PO WEEKLY
4. Mycophenolate Mofetil 1000 mg PO BID
5. Tacrolimus 1.5 mg PO Q12H
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral Q24H
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO EVERY OTHER DAY
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO BID
11. TraMADol 50 mg PO Q8H:PRN pain
12. Tamsulosin 0.4 mg PO QHS
13. Travatan Z (travoprost) 0.004 % ophthalmic QHS
14. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Mycophenolate Mofetil 1000 mg PO BID
3. Tacrolimus 1.5 mg PO Q12H
4. Alendronate Sodium 35 mg PO QMON
5. Allopurinol ___ mg PO DAILY
6. Calcitriol 0.25 mcg PO EVERY OTHER DAY
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral Q24H
8. Metoprolol Tartrate 50 mg PO BID
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO BID
11. Tamsulosin 0.4 mg PO QHS
12. TraMADol 50 mg PO Q8H:PRN pain
13. Travatan Z (travoprost) 0.004 % ophthalmic QHS
14. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
15. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
===================
Abdominal/Chest Pain
Secondary Diagnoses
===================
ESRD s/p DDRT ___
HTN
Tertiary hyperparathyroidism
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 man s/p renal transplant, now with left flank and
abdominal pain following mechanical injury against car armrest on ___. OSH CT
on ___ had showed small free fluid in abdomen, evaluate for occult fracture
or organ injury.
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis without intravenous contrast. Coronal and sagittal reformats were
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.2 s, 64.4 cm; CTDIvol = 6.4 mGy (Body) DLP = 408.9
mGy-cm.
Total DLP (Body) = 409 mGy-cm.
COMPARISON: Prior CT torso dated ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. The heart, pericardium,
and great vessels are within normal limits. There is a moderate
nonhemorrhagic pericardial effusion (3:79). Moderate coronary arterial
calcifications are noted.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck a calcified right
thyroid nodule and otherwise no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration within the limitation of an
unenhanced scan.There is no perihepatic free fluid. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration within the limitation of an unenhanced
scan.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Bilateral kidneys are atrophic with a right-sided simple cyst and a
hyperdense left upper pole renal cyst most likely hemorrhagic or proteinaceous
(2:95). The right lower pole transplanted kidney appears to have mild pelvic
fullness was otherwise unremarkable, better assessed by recent renal
transplant ultrasound. There is no perinephric abnormality.
GASTROINTESTINAL: There is a moderate hiatal hernia. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber. The colon and
rectum are within normal limits with a large amount of stool within the cecum.
The appendix is normal. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not well visualized, and surgical clips
are seen low within the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
Age-indeterminate compression fractures of T6 and T12 are noted without prior
studies with which to compare (602b:74). Lumbar spine degenerative changes
are otherwise severe, worst at L3-L4 where there is complete loss of
intervertebral disc space, subchondral sclerosis, subchondral cyst formation,
and grade 1 anterolisthesis of L3 on L4.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of acute intrathoracic or intraabdominal injury within the
limitation of an unenhanced scan.
2. Severe multilevel degenerative changes including age-indeterminate
compression fractures of T6 and T12.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man s/p renal transplant now with low grade fever
after mechanical injury of left side, evaluate for evidence of hydronephrosis
or pyelonephritis in renal transplant.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Prior renal transplant ultrasound dated ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is minimal
collecting system fullness without frank hydronephrosis and no perinephric
fluid collection.
The resistive index of intrarenal arteries ranges from 0.62 to 0.74, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 105. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Chest pain, Abd pain, Fever
Diagnosed with Contusion of left front wall of thorax, initial encounter, Striking against or struck by other objects, init encntr, Kidney transplant status, Atelectasis
temperature: 100.0
heartrate: 90.0
resprate: 16.0
o2sat: 97.0
sbp: 153.0
dbp: 100.0
level of pain: 8
level of acuity: 3.0 | ___ y/o M hx of CKD, HTN, ESRD, s/p extended criteria donor
kidney transplantation (baseline Creatinine ~1.9, on
tacrolimus/MMF) in ___ at ___, presenting with
continued left chest and abdominal pain after sharp turn in
vehicle <1 week prior to admission, with extensive negative
workup.
# Left chest and abdominal pain: Patient now status post blunt
trauma in setting of injury while seated in vehicle 6 days prior
to admission. Was previously evaluated on the same day of injury
at ___ with negative CT Head, C Spine, and CT Torso, only
notable for mild hydronephrosis of transplanted kidney in RLQ.
The patient underwent repeat CXR and CT Torso in the ___ ED
which was negative for acute pathology to explain the patient's
pain. Transplant surgery evaluated the patient in the ED and
there were no acute surgical needs. The patient's pain much
improved after admission to the floor and did not require
further narcotic pain medications. The patient was evaluated by
___ and deemed safe for home with rolling walker.
# Elevated temperature: Patient found to have T of 100.0 in ED,
and given immunosuppression on MMF and tacrolimus for renal
transplant, the patient was admitted for workup. Infectious
workup including UA, urine culture and blood cultures were
negative to date. CT Torso and renal transplant US were negative
for infection. There was no evidence of infection on physical
exam, and the patient;s fever resolve on the floor.
=======================
CHRONIC ISSUES
=======================
# ESRD s/p DDRT ___: As above, renal transplant US was
unremarkable. Creatinine stable and at baseline. UA negative,
without proteinuria. Blood pressure stable. The patient was
continued on tacrolimus 1.5 mg BID and MMF 1000 mg BID. The
patient was started on sodium bicarbonate BID per renal
recommendations (unclear if home medication prior to admission)
# HTN: Well controlled. The patient's home metoprolol was
initially held but restarted on discharge. The patient was
continued on aspirin 81 mg daily.
# Tertiary hyperparathyroidism: The patient was continued on
calcitriol.
# Gout: The patient was continued on allopurinol.
=======================
TRANSITIONAL ISSUES
=======================
[ ] Ensure follow up with PCP, renal transplant team
[ ] Continue immunosuppression dosing as per admission
[ ] Recommend avoiding outpatient narcotic use if possible
[ ] Please have labs drawn within one week of discharge, renal
transplant coordinator contacted to help facilitate this
Radiology Follow-Up |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / opiates / morphine / Percodan
/ Macrobid
Attending: ___.
Chief Complaint:
Bilateral PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ primarily ___ speaking with hypothyroidism, mild
dementia with pancreatic and liver masses concerning for
metastatic pancreatic cancer in setting of recent abdominal pain
and constipation, having a staging CT scan done as an outpatient
prior to ___ clinic visit when she was found to have R pulm
artery PE and multiple subsegmental PEs.
The patient does endorse having multiple weeks of central chest
pain that has been worsening. She endorses mild shortness of
breath. Her abdominal pain has been present for several weeks,
on the left side radiating to the back, improved with tramadol
(which was recently started). She has been constipated in the
past week. She has had some orthostatic dizziness, without
falls. She does not use a cane or walker, but daughter states
that she is mostly bed bound now.
PCP note from ___: "In some pain but relieved w tramadol.
Anxiety and sleep are controlled with xanax. She is repeating
herself often and does not remember certain things she just said
at times. Still constipated- will double miralax and colace, add
high fiber cereal. "
ED course:
17:29 (unable) 97.8 95 128/56 20 99% RA
Today 19:18 0 92 121/103 14 95% RA
Today 21:56 0 97.9 93 148/82 24 96% RA
Today 21:56 0 97.9 93 148/82 24 96% RA
20:30 enoxaparin 60 mg SC
Review of Systems: As per HPI. No recent illness. No dysphagia.
Has had poor appetite. All other systems negative.
Past Medical History:
Pancreatic cancer
h/o pancreatic pseudocyst
HL
varicose veins
osteoporosis
diverticulosis
colonic adenoma
hypothyroidism
HTN
Social History:
___
Family History:
father: deceased, h/o CAD/PVD
mother: deceased
no known family history of cancer
Physical Exam:
EXAM ON ADMISSION:
========================
97.2, 150/74, 96, 18, 98%RA
GEN: NAD
HEENT: PERRL, EOMI, slightly dry MM, oropharynx clear, no
cervical ___. dentures in place
Resp: CTAB, no wheezes, rales or rhonchi.
CV: RRR without m/r/g, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, not distended, no organomegaly or
masses. mid-epigastric tenderness to deep palpation
EXTR: Warm, well perfused. mild TTP calves b/l (due to varicose
veins). no edema. 2+ pulses.
NEURO: pleasant and conversant, motor grossly intact without
focal weakness
DISCHARGE EXAM:
========================
Pertinent Results:
ADMISSION LABS:
===========================
___ 02:40PM ___ PTT-30.9 ___
___ 02:40PM PLT COUNT-179
___ 02:40PM WBC-8.7 RBC-3.74* HGB-11.8* HCT-36.6 MCV-98
MCH-31.6 MCHC-32.3 RDW-13.3
___ 02:40PM CEA-1169*
___ 02:40PM ALBUMIN-4.0 CALCIUM-9.4 MAGNESIUM-2.2
___ 02:40PM cTropnT-<0.01 proBNP-185
___ 02:40PM ALT(SGPT)-73* AST(SGOT)-75* ALK PHOS-1143*
TOT BILI-1.7*
___ 02:40PM UREA N-10 CREAT-0.8 SODIUM-135 POTASSIUM-3.8
CHLORIDE-98 TOTAL CO2-29 ANION GAP-12
___ 02:40PM GLUCOSE-106*
IMAGING:
============================
CT Chest w/Contrast ___:
FINDINGS: No incidental thyroid findings. No supraclavicular,
infraclavicular or axillary lymphadenopathy. Several
normal-sized lymph nodes in the mediastinum.
As an incidental finding, the patient has relatively central
bilateral severe pulmonary embolism, partly involving the right
pulmonary artery and large parts of the lower lobe arterial bed,
with near complete occlusion of several segmental vessels.
The known massive intra-abdominal changes are described in
detail on the abdominal MR examination from ___.
Normal appearance of the heart, no evidence of right heart
strain, no pericardial effusion.
Moderate bilateral symmetrical apical thickening. Several
non-characteristic millimetric subpleural granulomas,
nonsuspicious for metastatic disease. The airways are patent.
Minimal non-characteristic fibrosis at the lung bases.
Calcified granuloma at the right lung base (4, 222). No pleural
thickening, no pleural effusions. Calcified 3-mm granuloma in
the left lower lobe (4,
264).
CT HEAD ___ w/o contrast:
No definite evidence of metastatic disease. CT is not as
sensitive as MRI for detection of small metastatic lesions.
TTE ___:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF=55-60%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. 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. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal global biventricular systolic function.
Moderate pulmonary artery hypertension.
DISCHARGE LABS:
============================
___ 06:50AM BLOOD WBC-7.0 RBC-3.41* Hgb-10.8* Hct-32.5*
MCV-95 MCH-31.6 MCHC-33.1 RDW-13.9 Plt ___
___ 07:30AM BLOOD Glucose-106* UreaN-7 Creat-0.7 Na-136
K-3.3 Cl-102 HCO3-24 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. Levothyroxine Sodium 50 mcg PO DAILY
3. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 60 mg/0.6 mL 60 mg SC twice a day Disp #*120
Syringe Refills:*0
2. ALPRAZolam 0.25 mg PO BID:PRN anxiety
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Pulmonary embolism
Secondary: Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent mostly but occasionally
confused.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
COMPUTED TOMOGRAPHY OF THE THORAX
INDICATION: Large pancreatic mass, liver lesions concerning for metastasis.
Evaluation.
COMPARISON: No comparison available at the time of dictation.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
FINDINGS: No incidental thyroid findings. No supraclavicular,
infraclavicular or axillary lymphadenopathy. Several normal-sized lymph nodes
in the mediastinum.
As an incidental finding, the patient has relatively central bilateral severe
pulmonary embolism, partly involving the right pulmonary artery and large
parts of the lower lobe arterial bed, with near complete occlusion of several
segmental vessels.
The known massive intra-abdominal changes are described in detail on the
abdominal MR examination from ___.
Normal appearance of the heart, no evidence of right heart strain, no
pericardial effusion.
Moderate bilateral symmetrical apical thickening. Several non-characteristic
millimetric subpleural granulomas, nonsuspicious for metastatic disease. The
airways are patent. Minimal non-characteristic fibrosis at the lung bases.
Calcified granuloma at the right lung base (4, 222). No pleural thickening,
no pleural effusions. Calcified 3-mm granuloma in the left lower lobe (4,
264).
At the time of dictation and observation, 4:13 p.m., on ___, referring
physician, ___, was paged for notification and the findings were
discussed over the telephone within the following minute.
Radiology Report
HISTORY: Metastatic pancreatic cancer with pulmonary embolism. Evaluate for
brain mets.
Technique: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal and sagittal
and thin section bone algorithm-reconstructed images were acquired.
DLP: 780 mGy-cm.
CTDI: 55 mGy.
COMPARISON: None
FINDINGS:
There is no hemorrhage, mass effect or midline shift, edema, or infarct. The
ventricles and sulci are normal in size and configuration. The basal cisterns
are patent and there is normal gray-white matter differentiation.
Periventricular and subcortical white matter hypodensities are indicative of
chronic small vessel ischemic disease. No definite evidence of metastases.
No bony abnormality is seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No definite evidence of metastatic disease. CT is not as sensitive as MRI for
detection of small metastatic lesions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Chest pain, PE
Diagnosed with PULM EMBOLISM/INFARCT, MALIG NEO PANCREAS NOS
temperature: 97.8
heartrate: 95.0
resprate: 20.0
o2sat: 99.0
sbp: 128.0
dbp: 56.0
level of pain: 13
level of acuity: 2.0 | Ms. ___ is an ___ with likely metastatic pancreatic
cancer to the liver, presenting with incidental finding of
severe bilateral PE on staging CT chest w/contrast.
# Pulmonary embolism- Involving right PA and large parts of the
lower lobe arterial bed, with near complete occlusion of several
segmental vessels. CT chest and echo without evidence of right
heart strain. She is to continue Lovenox 60mg SC BID
indefinitely
# Fall- With head strike but no loss of consciousness. Secondary
to significant global weakness/deconditioning, and represents
unsafe nature of returning home even with assistance of family.
However, given goals of care as stated below, she will be going
home. A hospital bed will be obtained for use at home. Family
will be around to assist, as well as hospice
# Metastatic pancreatic cancer- Recent meeting with Dr. ___
prior to admission. Poor prognosis.Goals of care discussion with
family on ___. Comfort care decided upon and will be going
home with hospice.
# Transitional issues-
- Lovenox to continue indefinitely
- PRN Follow up with outpatient physicians; will be followed by
Hospice |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye / Ecotrin / Advil
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ Insertion of right internal jugular central line
___ Upper endoscopy with epinephrine injection and clipping
of duodenal ulcer
History of Present Illness:
___ year old female with dementia, multiple myeloma and
lumbar/sacral compression fractures who was brought to the ED
this morning by her daughter with GI bleeding. The daughter
states that she found the pt in bed this morning surrounded by
melanic stool and some red blood on the sheets. Of note, she was
recently admitted to ___ on ___ with a
diagnosis of lumbar compression fracture and multiple myeloma.
She was discharged to rehab after that admission.
In the ED, pt was confirmed to have melena and guaiac positive
stool on exam, however there was no BRBPR and she denied
abdominal pain. Patient's BP was initially low and she was
tachycardic despite receiving 1L IVF. Due to difficulty
obtaining access a right IJ CVL was placed.
Vitals in ED:
Triage 11:44, pain zero, T 97.2, HR 106, BP 108/68, RR 20, O2
sat 95%
Labs in ED:
Hct 31 (33 at last discharge)
Cr 1.1 (up from 0.7 baseline)
Lactate 1.2
She was started on a Protonix gtt and admitted to the MICU. She
did not receive any blood transfusions in the ED.
On arrival to MICU, type and crossed for 3units, Protonix drip
continued, received an additional 1L of LR for SBP in ___ and
persistent tachycardia of 100-120. GI was consulted who
recommended medical management for now.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea constipation, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
#IgG lambda MGUS (likely multiple myeloma): dx ___.
Hypercalcemia. Recent OMED admission ___ for back
pain and found to have acute vs subacute compression fracture of
the L1 superior endplate with mild loss of height.
-on dexamethasone and zoledronic acid
-family declined chemo
-complicated by hypercalcemia (PTH, PTH-rp were normal) and
acute kidney injury
#Hx of ductal carcinoma in situ: dx ___. ER/PR+; s/p
lumpectomy, XRT, tamoxifen
#Hypertension, essential
#Hypercholesterolemia
#DM (diabetes mellitus): A1c 6.5 ___
#Dementia
#Osteopenia
#HISTORY TOBACCO USE
#Asthma
#HYSTERECTOMY, SUPRACERVICAL ABDOMINAL (SUBTOTAL)
#History of total knee replacement
#Diverticulitis of colon with perforation
#S/P colostomy
Social History:
___
Family History:
Brother with eye problems and heart disorder. Father with
cancer. Maternal aunt with cancer. Maternal Grandmother with
arthritis and asthma. Mother with ___ and cancer. Sister
with breast disease, headaches/migraine, varicose
veins/phlebitis and a heart disorder.
Physical Exam:
=====ADMISSION PHYSICAL EXAM =====
Vitals- Afebrile BP: 90/39 P: 130 R: 18 O2: 98%RA
GENERAL: Alert but confused, confabulating. Pleasant demeanor
w/o agitation. 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 m/r/g
ABD: soft, slightly tender to palpation in hypogastrium,
non-distended, bowel sounds present, no rebound tenderness or
guarding
EXT: Warm, well perfused, no edema
.
DISCHARGE PHYSICAL EXAM:
97.7 96 128/64 18 95% RA
Gen: NAD, Alert, pleasantly confused
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRRn l s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Pertinent Results:
==== ADMISSION LABS ====
___ 01:35PM BLOOD WBC-16.2*# RBC-3.54* Hgb-10.5* Hct-31.4*
MCV-89 MCH-29.8 MCHC-33.5 RDW-14.5 Plt ___
___ 01:35PM BLOOD Neuts-81.2* Lymphs-11.1* Monos-7.2
Eos-0.3 Baso-0.2
___ 04:50PM BLOOD WBC-12.9* RBC-3.31* Hgb-9.7* Hct-29.7*
MCV-90 MCH-29.4 MCHC-32.8 RDW-14.5 Plt ___
___ 04:50PM BLOOD Neuts-76.8* Lymphs-17.1* Monos-5.8
Eos-0.1 Baso-0.3
___ 01:35PM BLOOD ___ PTT-16.6* ___
___ 01:35PM BLOOD Glucose-105* UreaN-51* Creat-1.1 Na-137
K-4.2 Cl-107 HCO3-18* AnGap-16
___ 04:50PM BLOOD Glucose-148* UreaN-56* Creat-1.5* Na-135
K-4.2 Cl-104 HCO3-20* AnGap-15
___ 04:50PM BLOOD ALT-24 AST-19 LD(LDH)-191 AlkPhos-52
TotBili-0.2
___ 04:50PM BLOOD Albumin-3.5 Calcium-9.4 Phos-3.4 Mg-1.7
___ 02:04PM BLOOD Lactate-1.2
===== OTHER PERTINENT LABS =====
___ 11:55PM BLOOD WBC-9.7 RBC-2.62* Hgb-7.9* Hct-23.6*
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.6 Plt ___
___ 07:55AM BLOOD Hgb-10.7* Hct-31.0*
___ 05:30PM BLOOD WBC-13.3*# RBC-3.10* Hgb-9.5* Hct-27.8*
MCV-90 MCH-30.7 MCHC-34.2 RDW-14.9 Plt ___
___ 04:40AM BLOOD WBC-5.6# RBC-3.39* Hgb-10.3* Hct-30.2*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.9 Plt Ct-90*
___ 04:50PM BLOOD Glucose-148* UreaN-56* Creat-1.5* Na-135
K-4.2 Cl-104 HCO3-20* AnGap-15
___ 11:55PM BLOOD Glucose-123* UreaN-50* Creat-1.1 Na-135
K-3.9 Cl-105 HCO3-23 AnGap-11
___ 04:40AM BLOOD Glucose-90 UreaN-18 Creat-0.7 Na-136
K-3.6 Cl-102 HCO3-24 AnGap-14
MICROBIOLOGY:
==========================
MRSA SCREEN (Final ___: No MRSA isolated.
URINE CULTURE (Final ___:
GRAM NEGATIVE ROD(S). ___.
HELICOBACTER PYLORI ANTIBODY ___: ***** PENDING *****
HELICOBACTER STOOL ANTIGEN (___): ***** PENDING *****
RADIOLOGY:
==========================
CHEST (PORTABLE AP) ___ 3:05 ___
IMPRESSION:
Appropriately positioned right IJ CV catheter.
PROCEDURE REPORTS:
==========================
EGD (___):
Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach
The distal duodenal bulb and second portion of the duodenum had
scattered diffuse ulcerations. One cratered ulcer with visible
vessel with active oozing of blood was noted just distal to the
duodenal bulb. Another clean based ulcer was noted in D2. After
extensive irrigation, the bleeding appeared to be coming from
the cratered ulcer with visible vessel. (injection, endoclip)
Otherwise normal EGD to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Sertraline 25 mg PO HS
3. Simvastatin 40 mg PO QPM
4. Lidocaine 5% Patch 1 PTCH TD QPM
5. Omeprazole 20 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO ___ AND
___ MORNINGS
8. Dexamethasone 20 mg PO ___ AND ___ MORNINGS
9. Acetaminophen 1000 mg PO Q8H:PRN Pain
10. TraMADOL (Ultram) 25 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM
2. Sertraline 25 mg PO HS
3. Simvastatin 40 mg PO QPM
4. TraMADOL (Ultram) 25 mg PO BID
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
6. Acetaminophen 1000 mg PO Q8H:PRN Pain
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
duodenal ulcer with active bleeding
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with R IV, pls eval for plavement of CVL
___
FINDINGS:
Portable semi-upright CXR. Right IJ CV catheter is in place with its tip in
the low SVC. There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
Appropriately positioned right IJ CV catheter.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRBPR
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.2
heartrate: 106.0
resprate: 20.0
o2sat: 95.0
sbp: 108.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ w/ dementia and recent diagnosis of multiple myeloma
admitted for melanic stool and found to have upper GI bleeding.
# Upper GI Bleed: Patient has been receiving 20mg dexamethasone
twice a week for multiple myeloma. Not on aspirin or NSAIDs. No
history of GI bleed. Received 2 units of blood on ___ for
active bleeding with drop in hemoglobin from 9.7 to 8. Received
an additional 2units on ___ for continued melena. EGD was
performed on ___ and showed active bleeding from a duodenal
ulcer which was treated with endoscopic epinephrine injection
and placement of 2 clips, stopping the bleeding. Patient was
briefly hypotensive during procedure which was treated with IV
fluids and transient vasopressors. She received a total of 5
units PRBC's and 1 unit FFP during this hospitalization.
___: Cr 1.1 on admission from baseline of 0.7. Peak Cr of 1.5
on ___. Pre-renal etiology in setting of volume depletion from
GI bleed and poor PO intake. Resolved with administration of IVF
and blood (see above). Creatinine returned to 0.7 by ___. Her
home lisinopril was held for the duration of her ___ and
hemodynamic instability. Her lisinopril was restarted when her
blood pressure and kidney function normalized.
#MULTIPLE MYELOMA: Recently diagnosed with hypercalcemia,
anemia, and ___ with negative bone scan. Family refused BMBx and
chemo. Had been receiving palliative therapy with dexamethasone
and bisphosphonates. Last had IV Zoledronic acid ___. Given
likely contribution to ulcer formation from dexamethasone, her
___ oncologist was consulted regarding stopping this
medication. They agreed and dexamethasone was discontinued on
___. The plan is to likely start Revlimid as an outpatient in
follow-up with ___ Oncology.
#DELIRIUM: From ___ patient was noted to have delirium.
Increased agitation and impaired cognition and memory but no
need for restraints. This improved somewhat by ___ without the
need for antipsychotic medications.
#DEMENTIA: Has history of dementia per Atrius records. Was just
at ___ ECF after her OMED admission for back pain.
Had discharged home. At baseline she carries a conversation well
and can appear near-normal but is actually confabulating.
Patient gave a detailed history of how/why she presented to the
hospital which the daughter confirmed was nearly entirely false.
Daughter is HCP and must make all medical decisions.
===== TRANSITIONAL ISSUES =====
- Follow up H.pylori result: treat if positive.
- Dexamethasone has been DISCONTINUED (outpatient HemeOnc in
agreement). Bactrim also stopped.
- f/u with outpatient ___ HemeOnc and start Revlimid for MM |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Scalp and neck pain and erythema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ history of strep abscess in leg,
psoriasis, idiopathic CDM (now recovered) and possible IVDU who
presents with head and neck erythema and tenderness. Patient was
in USOH until ___ ___ when he developed discomfort along his
scalp. He denied preceding trauma to the area as well as fevers,
but had felt "off". He noted increasing spreading of the
inflamed/swollen area and increasing pain. Pain was what
ultimately drove him to seek medical care. He was referred to
___ ED from urgent care for imaging. He denied problems with
airway, but reported swallowing is starting to be bothersome.
Hearing was intact.
Of note, patient has recent total knee arthroplasty 6 weeks
prior, also with oxycodone vs IVD abuse.
#In the ED, initial vital signs were: 97.5 72 159/107 16 100%
RA
- Exam notable for: excoriation vs psoriatic plaque on
post/lateral scalp with spreading erythema, induration below
this point, extending beyond hairline and wrapping down below
right ear. No facial plethora. No e/o cellulitis near orbit or
anterior facial structures.
- Labs were notable for WBC 7.0, low platelets at 147, lactate
1.5
Studies performed include CT head and neck with contrast.
- Patient was given:
___ 15:18 IV Ampicillin-Sulbactam 3 g
___ 15:23 IV Acetaminophen IV 1000 mg
___ 16:15 IV Ketorolac 30 mg
___ 16:15 IV Vancomycin 1000 mg
___ 17:38 PO Diazepam 5 mg
___ 17:38 PO Diazepam 5 mg
___ 20:02 PO Diazepam 5 mg
#Upon arrival to the floor, the patient reports ___ neck pain
and generalized body aches. He first noted something on ___.
It began to get better on ___, but then worsened again
yesterday evening. He has had fevers/chills, headache, neck
stiffness ___ pain. He denies nausea/emesis, diplopia,
photophobia. He also denies any difficulty swallowing or
tolerating his oral secretions. PO intake has been OK. He has
been taking advil for pain at home.
Past Medical History:
Hypertension
Non ischemic dilated cardiomyopathy, Closely followed by heart
failure clinic EF improved from 35% to
over 55% between ___ and ___
Anxiety/depression
Total Knee Arthroplasty
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
=========================
Vitals- 98.3 167/100 88 20 100RA
GENERAL: AOx3, NAD
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or injection,
sclera anicteric and without injection. Moist mucous membranes,
good dentition. Oropharynx is clear. Uvula midline.
NECK: R-sided edema/erythema as in skin description.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. Tympanic to percussion. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: excoriation vs psoriatic plaque on post/lateral scalp
with spreading erythema, induration below this point, extending
beyond hairline and wrapping down below right ear. No facial
plethora. No e/o cellulitis near orbit or anterior facial
structures.
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation.
DISCHARGE EXAM
=============================
VS - Tmax 98.3, HR 75-92, BP 112-152/52-89, RR ___, 93-98% RA
General: In discomfort but no acute distress
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear. Pinna
nontender
Neck: Right-sided erythema, edema, induration, and tenderness
is improved vs prior exam, on neck and right-posterior scalp. No
fluctuance.
CV: RRR, without murmur or gallop or rub
Lungs: CTAB, nml resp effort
Abdomen: Soft, NT, ND, +BS
Ext: No edema, warm and well perfused
Neuro: A+Ox3, grossly intact
Skin: Scattered psoriatic plaques present throughout.
Neck/scalp as described above.
Pertinent Results:
ADMISSION LABS
==========================
___ 01:50PM BLOOD WBC-7.0 RBC-4.73 Hgb-13.7 Hct-38.1*
MCV-81* MCH-29.0 MCHC-36.0 RDW-12.0 RDWSD-34.6* Plt ___
___ 01:50PM BLOOD Neuts-69.3 Lymphs-17.0* Monos-11.4
Eos-1.6 Baso-0.1 Im ___ AbsNeut-4.86 AbsLymp-1.19*
AbsMono-0.80 AbsEos-0.11 AbsBaso-0.01
___ 01:50PM BLOOD Glucose-128* UreaN-13 Creat-1.1 Na-138
K-4.6 Cl-102 HCO3-26 AnGap-15
___ 01:57PM BLOOD Lactate-1.5
DISCHARGE LABS
=========================
___ 06:40AM BLOOD WBC-8.2 RBC-4.06* Hgb-11.9* Hct-33.8*
MCV-83 MCH-29.3 MCHC-35.2 RDW-12.2 RDWSD-37.2 Plt ___
___ 06:40AM BLOOD Glucose-156* UreaN-18 Creat-1.1 Na-139
K-3.8 Cl-104 HCO3-27 AnGap-12
___ 06:40AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9
MICROBIOLOGY
==========================
Blood cultures no growth to date at time of discharge
REPORTS
==========================
CT Neck ___. Moderate amount of edema and swelling of the soft tissues
overlying the right occipital bone and extending inferiorly to
the right posterior neck, approximately to the level of C2. No
abscess or fluid collection identified.
2. Otherwise, normal neck CT examination.
CT Head ___. Moderate amount of swelling and edema along the soft tissues
overlying the right occipital bone. No abscess or drainable
fluid collection.
2. No acute intracranial abnormalities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth three times
daily Disp #*30 Tablet Refills:*0
5. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth four times daily
Disp #*34 Capsule Refills:*0
6. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice daily Disp #*34 Tablet Refills:*0
7. Naproxen 500 mg PO Q8H:PRN pain
RX *naproxen 500 mg 1 tablet(s) by mouth three times daily Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cellulitis
Secondary:
Cardiomyopathy
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/ CONTRAST
INDICATION: ___ with scalp cellulitis // ? abscess
TECHNIQUE: Contiguous axial images of the brain were obtained after the
uneventful administration of Omnipaque intravenous contrast. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: Same-day neck CT
FINDINGS:
There is no evidence of fracture, infarction, hemorrhage, edema,or mass. The
ventricles and sulci are normal in size and configuration. There is no
abnormal enhancement on post contrast images.
There is moderate amount of superficial subcutaneous fat stranding overlying
the right occipital bone likely representing cellulitis. There is associated
skin thickening. There is no drainable fluid collection or abscess. There is
mild mucosal thickening of the bilateral maxillary sinuses, right greater than
left. The remaining visualized portions of the paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
1. Subcutaneous fat stranding along the right posterolateral neck extending
superiorly to the level of the mid occiput most compatible with cellulitis.
No deeper extension.
2. No acute intracranial abnormalities.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS)
INDICATION: ___ with scalp cellulitis // ? abscess
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Total DLP (Body) = 528 mGy-cm.
COMPARISON: None.
FINDINGS:
There is superficial subcutaneous fat stranding along the right post for
lateral neck extending from the level of the pinna and tracking inferiorly to
the lower neck. There is no fluid collection or subcutaneous gas. Small
focus of nodularity in the right upper posterior neck on series 2, image 16
could represent a small reactive lymph node. The underlying muscles appear
unremarkable. Overall findings are most suggestive of cellulitis.
The salivary glands appear normal. Tonsillar structures are normal. Air or
digestive tract is patent. Thyroid gland is normal. No retroperitoneal
edema. The upper lungs appear clear. The superior mediastinum appears
normal. No signs of dental infection. Bony structures appeared intact and
unremarkable. Minimal mucosal thickening is noted within the imaged paranasal
sinuses.
IMPRESSION:
Findings consistent with cellulitis in the right posterolateral neck.
No signs of deeper extension or complication.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Cellulitis, Transfer
Diagnosed with Cellulitis of head [any part, except face]
temperature: 97.5
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 159.0
dbp: 107.0
level of pain: 8
level of acuity: 3.0 | ___ y/o M presenting with neck/head erythema and pain due to
cellulitis.
ACTIVE ISSUES
=======================
# Cellulitis: Presented with subjective fever, redness,
swelling, and tenderness of the right posterior neck and
occipital area. Could have been exposed to CA-MRSA at his gym.
Did have relatively recent dental procedure (fillings) on ___,
and also was recently swimming in ___. Initially was started
on Vancomycin and Unasyn with improvement, then transitioned to
PO Antibiotics ___, Bactrim and Keflex, with continued
improvement. CT scan showed evidence of soft tissue swelling,
but no evidence of mastoiditis, and no abscess. Airway was
patent, vision intact. With negative cultures, ___'s is
unlikely. No e/o preseptal or orbital cellulitis on exam.
Cultures negative to date, WBC normal. He will complete a 10 day
course of Keflex ___ QID, Bactrim DS 2 tabs BID, as an
outpatient, with last day ___. He will f/u with his PCP to
assess for improvement. For pain control, was maintained on
Toradol and Tylenol while in house. After discharge, he will
take Tylenol and Naproxen.
CHRONIC ISSUES
=====================
# Non ischemic cardiomyopathy: Unclear etiology, possibly
anabolic steroid use. Last TTE showed normal EF. Currently
euvolemic, without cardiopulmonary symptoms. Continued home
carvedilol 12.5 mg BID, home losartan 100mg daily.
# Anxiety: Continue home citalopram 20mg
TRANSITIONAL ISSUES
=====================
- Will complete a total 10 day course of PO Antibiotics as an
outpatient, with Cephalexin 500mg QID, and Bactrim DS 2 tablets
BID. Last day of antibiotic therapy is ___. Patient will
be seen by PCP ___ ___ who can determine if he needs a longer
abx course.
- Will discharge with Naproxen 500mg Q8 PRN, Acetaminophen 1g Q8
PRN for outpatient pain control. Patient has a h/o prescription
opioid abuse.
- Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Benadryl
Attending: ___.
Chief Complaint:
Pelvic Pain
Major Surgical or Invasive Procedure:
laparoscopic right salpingectomy and left paratubal cyst removed
History of Present Illness:
20 G1P0 LMP ___ presented with lower abdominal pain x3
days. Sharp pain, radiated to back but only yesterday. At worst
was ___ but currently ___. She reports spotting since ___.
Denies fever, chills, nausea, vomiting, dysuria, diarrhea,
constipation (last bowel movement today). Able to tolerate a
regular diet (last ate 11:30 am).
Went to ___ earlier today. Transferred here for evaluation
of possible ectopic pregnancy. This is not a desired pregnancy.
HCG 311 at OSH.
Past Medical History:
OB/GYNH: regular periods, qmonth. Sexually active with one male
partner. Uses condoms sometimes. Denies hx STIs.
PMH: Denies
PSURGH: Denies
Meds: None
All: benadryl -> unknown
Social History:
___
Family History:
___: Maternal grandfather with colon cancer. Denies breast,
ovary,
uterine cancers.
Physical Exam:
PE
VS: T-98 HR-92 BP-119/82 RR-16 O2-100% RA
Gen: NAD
Skin: pink, normal color
CV: RRR
Pulm: CTAB
Abd: obese, soft, nondistended, diffuse lower abd tenderness, no
rebound or guarding
Ext: nontender
Pelvic: normal appearing external genitalia, inner labial folds,
urethral meatus. Speculum exam reveals scant blood in vagina, no
active bleeding, normal appearing cervix without lesions or
discharge. Bimanual exam limited due to habitus but small
uterus,
no CMT, diffuse but min lower abdominal tenderness with
abdominal
hand. No uterine or adnexal tenderness.
Discharge physical exam:
Upon discharge
VSS, AF
Gen: NAD, A&O x 3
CV: RRR, S1 S2
Pulm: CTAB, no r/w/c
Abd: soft, NT ND, no r/g/d
Ext: no c/c/e
Pertinent Results:
___ 07:30PM GLUCOSE-98 UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
___ 07:30PM estGFR-Using this
___ 07:30PM ALT(SGPT)-11 AST(SGOT)-21
___ 07:30PM HCG-277
___ 07:30PM WBC-10.0 RBC-4.38 HGB-12.4 HCT-38.9 MCV-89
MCH-28.4 MCHC-32.0 RDW-12.8
___ 07:30PM NEUTS-78.8* LYMPHS-15.6* MONOS-3.7 EOS-1.6
BASOS-0.3
___ 07:30PM PLT COUNT-341
TVUS Final Report
HISTORY: Positive pregnancy test ; spotting; suspicious for
ectopic.
LMP: ___
COMPARISON: Outside ultrasound from ___ dated ___
TECHNIQUE: Transabdominal and transvaginal scans of the pelvis
were obtained. Transvaginal scan was performed to better assess
the endometrial contents and the adnexae.
FINDINGS:
The uterus measures 6.7x2.9x4.3 cm. The endometrium measures 9
mm.
There is no visualized intrauterine pregnancy. Inferior and
medial within the right ovary, there is a 1.6 x 2.1 x 1.7 cm
hyperechoic rounded lesion. This could represent a dermoid.
The left adnexa appears complex and heterogenous. When compared
to the prior ultrasound, there is new heterogenous echogenic
material within the left adnexa adjacent to the ovary that is
worrisome for a left sided ectopic. The margins of the
structures within the left adnexa are ill-defined and cannot be
measured accurately.
There is a moderate amount of complex free fluid demonstrated
within the
pelvis. There appears increased when compared to prior
ultrasound.
IMPRESSION:
1. Complex, ill-defined left adnexal heterogenous material
worrisome for left ectopic pregnancy.
2. No evidence of intrauterine pregnancy.
3. Right ovarian hyperechoic rounded lesion that may represent
a dermoid.
4. When compared to the prior ultrasound done at outside
hospital, there has been an increasing amount of complex free
fluid within the pelvis.
The results of this exam were communicated by telephone on the
date of the exam to Dr. ___ by ___. There
were also communicated to the critical results dashboard. The
patient was informed of the results at the time of the exam.
Medications on Admission:
none
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN Pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 hours Disp #*30
Tablet Refills:*2
2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
q4 hours Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right tubal ectopic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Positive pregnancy test ; spotting; suspicious for ectopic.
LMP: ___
COMPARISON: Outside ultrasound from ___ dated ___
TECHNIQUE: Transabdominal and transvaginal scans of the pelvis were obtained.
Transvaginal scan was performed to better assess the endometrial contents and
the adnexae.
FINDINGS:
The uterus measures 6.7x2.9x4.3 cm. The endometrium measures 9 mm.
There is no visualized intrauterine pregnancy. Inferior and medial within the
right ovary, there is a 1.6 x 2.1 x 1.7 cm hyperechoic rounded lesion. This
could represent a dermoid.
The left adnexa appears complex and heterogenous. When compared to the prior
ultrasound, there is new heterogenous echogenic material within the left
adnexa adjacent to the ovary that is worrisome for a left sided ectopic. The
margins of the structures within the left adnexa are ill-defined and cannot be
measured accurately.
There is a moderate amount of complex free fluid demonstrated within the
pelvis. There appears increased when compared to prior ultrasound.
IMPRESSION:
1. Complex, ill-defined left adnexal heterogenous material worrisome for left
ectopic pregnancy.
2. No evidence of intrauterine pregnancy.
3. Right ovarian hyperechoic rounded lesion that may represent a dermoid.
4. When compared to the prior ultrasound done at outside hospital, there has
been an increasing amount of complex free fluid within the pelvis.
The results of this exam were communicated by telephone on the date of the
exam to Dr. ___ by ___. There were also communicated to
the critical results dashboard. The patient was informed of the results at
the time of the exam.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with UNSPECIFIED ECTOPIC PREGNANCY WITHOUT INTRAUTERINE PREGNANCY
temperature: 98.0
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 119.0
dbp: 82.0
level of pain: 7
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology service
for suspected ectopic pregnancy. She was observed overnight. She
had persistent pelvic pain, and a transvaginal ultrasound
strongly supported an ectopic pregnancy.
She then underwent a diagnostic laparoscopy then laparoscopic
salpingectomy for the removal of the ectopic tissue. Please
refer to the operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with toradol.
By post-operative day 0, she was tolerating a regular diet,
ambulating independently, and pain was controlled with oral
medications. She was then discharged home in stable condition
with outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim / Hydrocodone / Iodine / macrolides / Magnesium Oxide /
Plavix / Sulfur-8 / Tetracycline / Warfarin / Erythromycin Base
Attending: ___.
Chief Complaint:
R leg pain
Major Surgical or Invasive Procedure:
R Femur ORIF
History of Present Illness:
The patient is a ___ yo female who is s/p R THA in ___ who
presents with R femur fracture tranferred from OSH. The injury
occured on ___ when she was getting up from the toilet. She
felt a sharp pain and fell to the ground. She denies head
strike or LOC from fall. Denies numbness/paresthesias distally.
She is in traction splint.
Past Medical History:
HTN
Autoimmune Hepatitis
Mitral valve prolapse
Stroke ___
GERD
diaphragmatic hernia
hyperlipidemia
osteoperosis
DVT
UTI
Diverticulitis ___
Social History:
___
Family History:
nc
Physical Exam:
AVSS
NAD
AxOx4
Breathing comfortably
symmetric chest rise
R L incision c/d/i
SITLT s/s/cp/dp
Fires ___
Pertinent Results:
___ 11:55AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-TR
___ 11:55AM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0
___ 11:55AM URINE MUCOUS-RARE
___ 10:50AM estGFR-Using this
Medications on Admission:
Aspirin 81 mg PO DAILY
Metoprolol Tartrate 50 mg PO BID
Multivitamins 1 TAB PO DAILY
Omeprazole 20 mg PO DAILY
PredniSONE 5 mg PO DAILY
Senna 2 TAB PO HS Patient may refuse. Hold if patient has loose
stools.
Valsartan 320 mg PO DAILY hold SBP<110
Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Calcium Carbonate 500 mg PO TID
5. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
6. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL inject into abdomen at bedtime Disp
#*12 Syringe Refills:*0
7. Metoprolol Tartrate 50 mg PO BID
hold SBP<110,HR<60
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
hold for somnolence, rr<12; please give 10mg prior to ___
RX *oxycodone 5 mg ___ Tablet(s) by mouth q3hr Disp #*90 Tablet
Refills:*0
11. Polyethylene Glycol 17 g PO BID
continue until stool; ok for patient to refuse
12. PredniSONE 5 mg PO DAILY
13. Senna 2 TAB PO HS
Patient may refuse. Hold if patient has loose stools.
14. Valsartan 320 mg PO DAILY
hold SBP<110
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R femur 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
CHEST, TWO VIEWS: ___.
HISTORY: ___ female with femur fracture. Preop.
FINDINGS: AP and lateral views of the chest are compared to previous exam
from earlier the same day performed at an outside institution. Lungs are
clear of focal consolidation. Calcifications project over the medial,
anterior aspect of the right fourth and fifth ribs which are likely due to
costochondral cartilage calcification. There is no effusion.
Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
STUDY: Right femur intraoperative study, ___.
CLINICAL HISTORY: ORIF of right femur. Periprosthetic fracture.
FINDINGS: Comparison is made to previous study from ___.
Multiple fluoroscopic images of the right femur from the operating room
demonstrates interval placement of a large fracture plate fixating a fracture
involving the distal tip of the femoral prosthesis. Cerclage bands have been
placed. There are no signs for hardware-related complications. There is
improved anatomic alignment. Please refer to the operative note for
additional details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R FEMUR FX
Diagnosed with FX FEMUR SHAFT-CLOSED, JOINT REPLACEMENT-HIP, OTHER FALL, HYPERCHOLESTEROLEMIA
temperature: 96.6
heartrate: 84.0
resprate: 16.0
o2sat: 97.0
sbp: 181.0
dbp: 92.0
level of pain: 8
level of acuity: 2.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of a R periprosthetic fracture. The patient was taken to
the OR and underwent an uncomplicated R Femur ORIF. The patient
tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: TDWB RLE.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right buttock pain
Major Surgical or Invasive Procedure:
EUA, sigmoidoscopy, trans anal vac placement (___)
trans-anal vac change (___)
History of Present Illness:
___ with T3N1 rectal CA who underwent radiation and ___
chemotherapy followed by robotic proctosigmoidectomy,
partial left colectomy with completion transanal
proctectomy, hand sewn ___ anastomosis and diverting loop
ileostomy (___), complicated by pre-sacral fluid collection
s/p ___ drainage with placement of ___ pigtail (___),
now presents with right buttock pain ___ association with
worsening malodorous rectal drainage and abdominal bloating.
Reportedly, the pain is localized to the right medial buttock,
exacerbated by lying (especially right-side down) and sitting
and
improved when standing upright. The pain began 2d ago and
progressively worsened. He had been taking oxycodone 5mg daily,
yesterday afternoon/evening reportedly took 10mg q2hr due to the
severity of his symptoms. He reports eating although had had
abdominal "bloating" over the past few days. Ostomy output is
approximately 600-700mL/day, took immodium a few days ago,
output
has since been "normal" ___ consistency per patient. Drain output
is purulent, measured at 50mL 2d ago and 75mL yesterday. He
additionally reports worsening malodorous rectal drainage -
similar ___ quality to drain output. He has had chills, although
denies fevers. No weakness, numbness, or tingling of lower
extremities. No difficulty with urination. No headache or
dizziness. No abdominal pain, nausea, or emesis. No blood per
rectum.
Past Medical History:
PMH: DM, Rectal Ca, HLD
PSH: Vasectomy, Open appendectomy, left portacath placement,
robotic proctosigmoidectomy, partial left colectomy with
completion transanal proctectomy, hand sewn ___
anastomosis and diverting loop ileostomy (___)
Social History:
___
Family History:
No family history of GI cancer.
Father-prostate cancer
Mother- lung cancer
Sister ___ ___ and niece ___ ___ - breast cancer
Physical Exam:
Admission Physical Exam:
T 979.9 HR 72 BP 129/66 RR 16 O2sat 100%RA
Gen: uncomfortable, anxious
CV: RRR
Pulm: clear to auscultation, bilaterally
Abd: obese, soft, distended, non-tender, ostomy with air/stool;
RLQ port site open, no purulence or fluctuance although small
amount bloody drainage
Rectal: anoderm with circumferential erythema; foul smelling
tan
rectal drainage, soft yet tender R medial buttock (medial to
drain entry) with palpation, drain entry site clean / dry /
intact without erythema or drainage surrounding the catheter
Upon discharge:
Afebrile, VSS
General: ___ NAD
HEENT: mucus membranes moist
CV: regular rate, rhythm
P: CTAB
Abd: soft, non-tender, ostomy with + gas/stool
GU: vac dressing ___ place with scant sero-sanguinous drainage
Pertinent Results:
CT A&P (___):
Slight interval decrease ___ 4.4 x 1.9 cm (from pre-drainage
evaluation) presacral fluid collection with pigtail catheter ___
situ, which abuts the right lateral wall of the collection. The
communication between the neorectum and the collection and
anastomotic hypoenhancement are not as well depicted on this
examination. No new collection or other acute process is
identified.
___ 11:25AM BLOOD WBC-7.8 RBC-4.34* Hgb-12.5* Hct-38.2*
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.6 Plt ___
___ 11:25AM BLOOD Glucose-134* UreaN-11 Creat-0.8 Na-139
K-4.5 Cl-100 HCO3-33* AnGap-11
Microbiology:
___ 3:15 pm ABSCESS Source: presacral drain.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS AND ___
SHORT
CHAINS.
FLUID CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
ANAEROBIC CULTURE (Final ___:
Mixed bacterial flora [are] present. Bacterial growth was
screened
for the presence of B.fragilis, C.perfringens, and
C.septicum..
BACTEROIDES FRAGILIS GROUP.
HEAVY GROWTH OF TWO COLONIAL MORPHOLOGIES.
BETA LACTAMASE POSITIVE.
___: blood culture: no growth
___: urine culture: no growth
Medications on Admission:
GlipiZIDE XL 10'', Simvastatin 20', MetFORMIN 1500', LOPERamide
prn, OxycoDONE prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
do not give more than 3000mg of tylenol ___ 24 hours or drink
alcohol while taking
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*45 Tablet Refills:*0
2. GlipiZIDE XL 10 mg PO BID
3. LOPERamide 2 mg PO TID
4. MetFORMIN XR (Glucophage XR) 1500 mg PO QPM
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive a car or drink alcohol while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 14 Days
please monitor yourself for hypoglycemia while taking this
antibiotic and your home meds
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth every twelve (12) hours Disp #*27 Tablet
Refills:*0
7. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pre-sacral fluid collection near coloanal anastomosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Rectal pain with presacral fluid collection status post drainage
with history proctosigmoidectomy. Assess fluid collection.
TECHNIQUE: CT images were obtained from the lung bases to the pubic symphysis
following the uneventful intravenous administration of Omnipaque contrast
medium. Multiplanar reformations were prepared.
COMPARISON: ___.
FINDINGS:
CT ABDOMEN WITH CONTRAST: The imaged lung bases reveal bibasilar atelectasis
without pleural or pericardial effusion. The liver is normal attenuation
without focal lesion, intra or extrahepatic biliary ductal dilatation. The
portal and hepatic veins are patent. The gallbladder, pancreas, spleen and
bilateral adrenal glands are unremarkable. The kidneys enhance and excrete
contrast symmetrically without hydronephrosis.
The patient is status post proctosigmoidectomy with postsurgical changes
noted. Stranding in the omentum anteriorly is consistent with evolving
postsurgical omental infarct/fat necrosis. The small and proximal large bowel
are unremarkable with a diverting ileostomy with unchanged parastomal fat
herniation. Small bowel is largely decompressed. No free air is seen in the
abdomen. The aorta and major branches are patent and normal in caliber with
mild atherosclerotic vascular calcifications. No mesenteric or
retroperitoneal pathologic lymph node enlargement is identified with scattered
nonenlarged lymph nodes noted.
CT PELVIS WITH CONTRAST: The pigtail catheter is seen within a 4.4 x 1.9 x
4.3 cm presacral fluid collection slightly decreased in size from the previous
(pre-drainage) examination where it measured 4.8 x 2.4 x 5.2 cm. The proposed
communication with the neorectum is not as well depicted on the current
examination nor is the hypo enhancement of the anastomosis. The pigtail
catheter is somewhat asymmetrically located in the right side of the
collection, abutting the right lateral wall. The bladder and prostate are
unremarkable aside from central prostatic calcifications. Vas deferens
calcifications suggest diabetes. There is no pelvic or inguinal adenopathy.
OSSEOUS AND SOFT TISSUE STRUCTURES: Bilateral sacroiliac degenerative changes
are seen. Otherwise, there is no suspicious bony lesion with mild L5-S1
degenerative changes.
IMPRESSION: Slight interval decrease in 4.4 x 1.9 cm (from pre-drainage
evaluation) presacral fluid collection with pigtail catheter in situ, which
abuts the right lateral wall of the collection. The communication between the
neorectum and the collection and anastomotic hypoenhancement are not as well
depicted on this examination. No new collection or other acute process is
identified.
Radiology Report
INDICATION: Preoperative chest evaluation prior to pelvic washout.
COMPARISON: Chest radiographs dated ___ and ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: A left subclavian approach Port-A-Cath is unchanged in position
with the tip terminating over the low SVC. The cardiomediastinal and hilar
contours are within normal limits. The trachea is midline. The lungs are
symmetrically well expanded and clear without focal consolidation, pleural
effusion or pneumothorax. The pulmonary vasculature is not engorged and there
is no overt pulmonary edema.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RECTAL PAIN
Diagnosed with ANAL OR RECTAL PAIN
temperature: 97.9
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 129.0
dbp: 66.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ was admitted to the Inpatient Colorectal Surgery
Service after increased ___ pain and CT scan which
revealed a ___ fluid collection. He underwent said
CT with drainage as an out-patient, but developed increased
___ pain and was subsequently admitted for further
management. Drain cultures taken were taken and showed mixed
organisms, and the patient started on vancomycin and zosyn.
The patient was taken to the OR for exam under anesthesia on
HD#2, and underwent vac placement and sigmoidoscopy. He
tolerated this procedure, with diet advanced appropriately.
On HD#4 he underwent repeat EUA, with removal of his previously
placed ___ drain and exchange of his vac dressing. He also
tolerated this procedure well.
He remained afebrile, hemodynamically stable at least 48 hrs
prior to discharge. His pain was well controlled with oral
agents, and he was ambulating well.
Prior to discharge, his ileostomy had a mild increase ___ output
for which he received an increased amount of immodium. His home
medications were resumed without ill effect.
Upon discharge, he was afebrile, ambulating without assistance
with pain controlled with oral agents. He was discharged home
on bactrim with ___ services for his wound vac care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetanus / Penicillins
Attending: ___
Chief Complaint:
Syncope, Fall
Major Surgical or Invasive Procedure:
Left knee arthrocentesis on ___
History of Present Illness:
___ presents found down. Per patient was in kitchen and fell. No
precipitating symptoms, such as chest pain, dyspnea, headache,
lightheadedness. Patient states he is unsure of why he fells,
does not think he tripped. +head strike. Does not think he lost
consciousness. Found on floor by wife who last saw him several
hours prior. Pt states was only on floor for some minutes. Pt
currently denies pain. Was found by EMS to have head laceration
and left arm skin tear. Patient denies recent fevers or chills.
Denies chest pain, dyspnea, abdominal pain, nausea, vomiting,
changes in bowel or bladder habits.
In the ED, initial vs were: 96.8 44 131/56 18 96% RA. Labs were
remarkable for . CXR showed stable cardiomegaly and mild
pulmonary vascular congestion/edema. Head CT showed no acute
intracranial abnormality. Stable left frontal encephalomalacia
from prior infarct. CT spine showed 1. No cervical spine
fracture or malalignment. 2. A 5 mm left apical nodule should be
followed up by CT in 12 months or 6 months if there are high
risk factors. Patient was given the tetanus vaccine. Vitals on
Transfer: 90 110/45 19 96%RA.
On the floor, vs were: T97.6 P48 BP112/62 R18 O2 sat 95%RA
Past Medical History:
-Coronary artery disease status post CABG: LIMA to LAD, SVG to
RCA and SVG to D1. (___)
- Postoperative atrial fibrillation and sick sinus syndrome,
s/p ___ permanent pacemaker implantation. (___)
- Peripheral arterial disease with nonhealing ulcers after RLE
vein graft harvesting. He has previous stenting in his right SFA
and is followed by Dr. ___.
- Infarct-related cardiomyopathy (inferior akinesis) with an
ejection fraction of 35% (___).
- Mild aortic stenosis with a valve area of 1.2-1.9 cm2, peak
gradient 20 mmHg, velocity 2.2 m/sec (___) with 1+ AR.
- Hypertension.
- Bilateral carotid artery stenosis with left CEA in ___
(right occluded, left 60% in-stent stenosis ___.
Procedure was complicated with ACA, CVA in the postoperative
setting.
- ? Type 2 diabetes mellitus.
- Atrial tachycardia complicated by CHF, status post DC
cardioversion ___.
- CKD stage III
- Mixed dyslipidemia.
Social History:
___
Family History:
+ CAD, - DM, - stroke
Physical Exam:
ON ADMISSION:
Vitals: T:97.6 BP:112/62 Pulse:46 Heart Rate: 93 R:20 O2:95%RA
General: Well-appearing, elderly Caucasian gentleman in no
acute distress.
HEENT: Laceration in R frontal/supraorbital area covered by dry
sterile dressings, Ecchymoses in nasal and nasolabial area.
Sclera anicteric, no conjunctival pallor, throat clear
Neck:Supple, no thyromegaly, no LAD
Lungs: Breath sounds present in both lungs. Dry crackles
audible in both lung bases. No wheezes, no ronchi.
CV: Arrhythmic heart sounds, normal S1 and S2, no murmurs, rubs
or gallops.
Abdomen: Mild distension, BS(+), soft, non-tender
Ext: Laceration on L arm covered by dry sterile dressings. Some
bilateral knee edema, crepitus on mobilization
Skin: moist, elastic
Neuro: Intermittently disoriented to time and place.
Uninhibited. Craneal nerves preserved. Strength is normal in 4
extremities.
ON DISCHARGE:
General: Well-appearing, elderly Caucasian gentleman in no acute
distress.
HEENT: Laceration in R frontal/supraorbital area w/sutures in
place, no erythema or induration, resolving ecchymoses in nasal
and nasolabial area. Sclera anicteric, no conjunctival pallor,
throat clear
Neck:Supple, no thyromegaly, no LAD
Lungs: Breath sounds present in both lungs. Dry crackles
audible in both lung bases. No wheezes, no ronchi.
CV: Arrhythmic heart sounds, normal S1 and S2, no murmurs, rubs
or gallops.
Abdomen: Mild distension, BS(+), soft, non-tender
Ext: Laceration on L arm covered by dry sterile dressings, not
indurated, no purulent secretion. L knee with markedly increased
active and passive ROM, it is no longer warm. Tenderness to
palpation is minimal. Skin: moist, elastic, no lesions
Neuro: Intermittently disoriented to time and place.
Uninhibited but not agitated. Craneal nerves preserved. Strength
is normal in 4 extremities.
Pertinent Results:
ON ADMISSION:
___ 03:50AM BLOOD WBC-5.6 RBC-4.18* Hgb-12.5* Hct-37.4*
MCV-90 MCH-29.9 MCHC-33.4 RDW-14.8 Plt ___
___ 03:50AM BLOOD Neuts-61.7 ___ Monos-7.8 Eos-1.7
Baso-0.8
___ 03:50AM BLOOD ___ PTT-24.0* ___
___ 03:50AM BLOOD Glucose-125* UreaN-64* Creat-1.9* Na-142
K-5.1 Cl-100 HCO3-30 AnGap-17
___ 03:50AM BLOOD CK-MB-5 proBNP-8856*
___ 03:50AM BLOOD cTropnT-0.08*
___ 03:15PM BLOOD cTropnT-0.06*
___ 03:50AM BLOOD %HbA1c-5.8 eAG-120
___ 03:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
EKG: ___ 3:38:14 AM
Baseline artifact. Underlying rhythm is therefore difficult to
determine.
Probably there appears to be sinus rhythm with ventricular
pacing. An atrial premature beat occurs on the top of the T wave
as it can be seen clearly in lead V3 and V4 with the next QRS
complex occurring after a longer P-R interval and is also being
paced. The previous tracing showed A-V sequential pacing.
Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 0 ___ 0 -78 97
CT HEAD: ___ 3:37 AM IMPRESSION:
1. No acute intracranial abnormality.
2. Stable encephalomalacia in the left frontal lobe from prior
infarct.
CXR: ___ 3:57 AM
IMPRESSION: Stable cardiomegaly with mild pulmonary vascular
congestion and mild edema. Please note that chest radiography
is limited for evaluation of chest wall trauma.
SIGNIFICANT INTERIM DATA:
L KNEE X-RAY : ___ 5:30 ___
IMPRESSION: No fracture. Tricompartmental osteoarthritis with
severe medial joint space narrowing.
SYNOVIAL FLUID:
___ 01:49PM JOINT FLUID WBC-9000* ___ Polys-99*
___ Macro-1
___ 01:49PM JOINT FLUID Crystal-FEW Shape-ROD
Locatio-INTRAC Birefri-POS Comment-c/w calcium pyrophosphate
___ 1:49 pm JOINT FLUID Source: Knee.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Reported to and read back by ___ ___ @1434,
___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 3 COLONIES ON 1
PLATE.
SPECIMEN IS BEING REPLANTED ___. **REPLANT NO
GROWTH TO DATE.**
COAG NEG STAPH does NOT require contact precautions,
regardless of resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
ON DISCHARGE:
___ 06:50AM BLOOD WBC-6.1 RBC-3.98* Hgb-11.4* Hct-34.9*
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.9 Plt ___
___ 06:50AM BLOOD ESR-31*
___ 06:50AM BLOOD Glucose-150* UreaN-47* Creat-1.6* Na-140
K-4.7 Cl-100 HCO3-31 AnGap-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Sertraline 75 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 1 TAB PO BID:PRN constipation
10. Spironolactone 12.5 mg PO DAILY
11. Torsemide 40 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Torsemide 40 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 1 TAB PO BID:PRN constipation
10. Sertraline 75 mg PO DAILY
11. Spironolactone 12.5 mg PO DAILY
12. Acetaminophen 1000 mg PO Q8H PAIN
13. PredniSONE 40 mg PO DAILY pseudogout Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
# Orthostatic syncope
# Acute Calcium Pyrophosphate Deposition Arthritis of the left
knee
# Acute on Chronic Kidney Injury
# Left frontal laceration
# Left arm laceration
SECONDARY DIAGNOSIS:
# s/p Fall
# Left apical lung nodule
# Dementia
# Coronary Heart Disease
# Atrial fibrilation
# Systolic 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
HISTORY: Unwitnessed fall from standing, on Pradaxa and aspirin.
COMPARISON: Non-contrast head ___.
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: 1153.93 mGy-cm.
CTDIvol: 61.92 mGy.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or acute
infarction. Left frontal encephalomalacia in the left anterior cerebral
artery distribution from prior infarct is unchanged. Prominent ventricles and
sulci are suggestive of age-related involutional change. Mild periventricular
white matter hypodensity is compatible with chronic small vessel ischemic
disease. The basal cisterns are patent, and there is preservation of
gray-white matter differentiation. The globes are unremarkable. Dense
atherosclerotic calcifications are noted within the carotid siphons. No
fracture is identified. Mild mucosal wall thickening is noted in bilateral
maxillary sinuses and anterior ethmoid air cells. The middle ear cavities and
mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Stable encephalomalacia in the left frontal lobe from prior infarct.
Radiology Report
HISTORY: Unwitnessed fall from standing on Pradaxa and aspirin.
COMPARISON: CTA neck ___.
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: 778.28 mGy-cm.
CTDIvol: 32.64 mGy.
FINDINGS: The cervical vertebral body heights and alignment are well
maintained without evidence of fracture or spondylolisthesis. The
prevertebral soft tissue is unremarkable. There are moderate multilevel
degenerative changes of the cervical spine with disc space narrowing, most
prominent at C5/C6 and C6/C7. There are multiple prominent anterior and
posterior osteophytes.
CT resolution of the thecal sac is limited.
At C2-3 there is a disk bulge that flattens the surface of the spinal cord.
At C3-4 there is a disk bulge that flattens the surface of the spinal cord.
Uncovertebral osteophytes severely narrow the neural foramina bilaterally.
At C4-5 there is are intervertebral osteophytes that flattens the surface of
the spinal cord. The left neural foramen is severly narrowed by uncovertebral
osteophytes.
At C5-6 there is a disk bulge that flattens the surface of the spinal cord.
The right neural foramen is severly narrowed by uncovertebral osteophytes.
Dense atherosclerotic calcifications are noted within bilateral carotid
arteries. The left thyroid gland is unremarkable in appearance. A 5-mm
nodule is noted within the left lung apex.
IMPRESSION:
1. No cervical spine fracture or malalignment.
2. 5-mm left apical nodule. Followup CT examination is recommended in 12
months or at six months if there are high risk factors per ___
criteria.
Radiology Report
HISTORY: Unwitnessed fall from standing, on Pradaxa and aspirin.
COMPARISON: Multiple chest radiographs dating from ___ through
___.
TECHNIQUE: Portable frontal chest radiograph, single view.
FINDINGS: Mild cardiomegaly is unchanged since at least ___. A
left-sided pacer remains in place. Mediastinal silhouette is unremarkable.
Prominence of the central pulmonary vasculature with indistinct borders
compatible with fluid overload with mild interstitial edema. Lung volumes are
low with mild bibasilar atelectasis. There is no large pleural effusion,
though the costophrenic angles are not imaged. There is no pneumothorax.
IMPRESSION: Stable cardiomegaly with mild pulmonary vascular congestion and
mild edema. Please note that chest radiography is limited for evaluation of
chest wall trauma.
Radiology Report
HISTORY: Knee pain and swelling.
AP and lateral non-standing views of the left knee show no fracture. There is
prominent medial joint space narrowing, slight patellofemoral joint space
narrowing and tricompartmental osteophytes. Extensive vascular
calcifications. Medial soft tissue clips may reflect previous vein harvest.
An effusion is present.
IMPRESSION: No fracture. Tricompartmental osteoarthritis with severe medial
joint space narrowing.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE, UNSPECIFIED FALL
temperature: 96.8
heartrate: 44.0
resprate: 18.0
o2sat: 96.0
sbp: 131.0
dbp: 56.0
level of pain: 13
level of acuity: 1.0 | Mr. ___ is an ___ year old gentleman with an extensive
cardiovascular past medical history (including CAD, CABG, sick
sinus syndrome, s/p BiV pacemaker, Mild Aortic Stenosis)
additional to CKD, ?T2DM, HTN, HLD who was admitted after an
episode of unwitnessed syncope without any prodromic or
concurrent symptoms.
#) SYNCOPE: His pacemaker was interrogated and it is functioning
well, no arrythmias were reported at the time of syncope. There
was some concern that he was bradycardic since the vitals
machine was calculating his HR in the ___. However, upon
palpation of his pulse and examining his telemetry, he had no
suggestion of bradyarrhthmia. The vitals machine was likely
miscalculating his pulse given his irregular rhythm with AF and
variable ventricular filling times. His CXR, stable NTproBNP,
and physical exam suggest stable systolic CHF and no worsening
valvulopathy. His initially elevated troponin at 0.08 could be
explained by his low eGFR, it trended down and stabilized at
0.06.
He suffered a L scalp laceration during his fall requiring
suturing. These sutures should be removed ___ days after
placement, or on ___.
He was tested for toxic and metabolic causes and he was negative
for hypo/hyperglycemia, hypo/hypernatremia, calcium
derangements. His neurological exam was non-focal, his head CT
was unremarkable and he has no PMH significant for seizures.
He was found to have >10mmHg orthostatic changes in DBP on
admission, PO intake was encouraged and tamsulosin was
discontinued. On discharge his BPs are in the 120-130/60-70
ranges with no significant orthostatic variation.
#) LEFT KNEE PAIN: During his second day of admission Mr.
___ was noted to have a L Knee arthritis. Of note, no fever
spikes were recorded and his WBC remained normal, L knee X-ray
only revealed an effusion and chronic OA related changes. Left
knee arthrocentesis revealed a bloody fluid with WBC count of
9000 (>90%PMN) positive for calcium pyrophosphate crystals. The
fluid gram stain was negative but the culture later grew several
colonies of GPC, and he was empirically started on IV
Vancomycin. Rheumatology was consulted. The culture revealed
coagulase negative Staphylococci sensitive to vancomycin which
were believed to be a a contaminant organism. Empiric
antibiotics were discontinued and prednisone was started. The
next day the joint was markedly improved and stable for
discharge. He was planned for a 5 day course of prednisone
without taper. **If his left knee pain worsens or he otherwise
decompensates clinically, septic joint should be highly
suspected. A knee aspiration should be obtained prior to
starting vancomycin if possible.**
Due to significant impairment in mobility and balance, as
assessed per ___, he is being discharged to a short term
rehabilitation facility. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o MVC s/p ORIF of L posterior wall fx on ___
complicated by L hip MSSA septic arthritis s/p multiple I&D most
recently in ___ admitted for L hip pain 10 days after his
left knee was struck by a car in the process of parking. He
initially fell down on his back and had no joint pain at the
time; he was having ongoing right knee pain from a prior injury
he thinks is an ACL tear. Therefore he had been favoring his L
leg. Noted gradual onset of L hip pain --> couldn't walk
yesterday. No fever chills, no erythema or drainage at either
hip or knee.
.
In the ED, initial VS: 9 99.9 91 152/94 16 100%, no evidence of
infection or fracture on exam or on hip films. L knee film
obtained this morning similarly negative for acute process, no
fracture. Ortho consulted in ED and felt to surgical
intervention/drainage was necessary at this time, no sign of
fracture or infection. He was given dilaudid 1mg IV x5 in the ED
plus 20 PO oxycodone on the floor overnight.
.
He continues to complain of ___ left hip pain 3 hours after
last dose of oxycodone. Wants either 2 mg IV dilaudid or 30 mg
PO oxycodone TID, which worked for him before. Concerned that he
cannot manage his chronic hip pain at home since he is no longer
getting oxycodone regularly from Dr. ___ his PCP only
prescribes ___, no narcotics.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anxiety
Substance Abuse
MVC s/p ORIF of L posterior wall fx on ___
complicated by L hip MSSA septic arthritis s/p I&D on ___,
s/p repeat I&Ds for superficial thigh abscesses ___,
___,
and ___.
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION EXAM (discharge exam unchanged)
AM VS 98.0 97.8 116/63 73 18 98/RA 89.8 kg
GENERAL - Alert, interactive, well-appearing in NAD, moves
around easily in bed for exam
HEENT - NCAT PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD,
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, well healed
vertical incision of posterior left thigh/buttock - no
erythema/fluctuance. TTP along distal end of scar into posterior
gluteal. Left knee TTP lateral aspect and with internal/external
rotation. FROM active flexion/extension L hip and knee, limited
active/passive ROM internal/external rotation ___ pain. no
spinal point tenderness.
SKIN - no rashes or lesions. no ecchymoses on L leg/hip/back
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred (walked with ___
without difficulty)
Pertinent Results:
ADMISSION LABS
___ 10:50PM WBC-8.8 RBC-4.90 HGB-14.5 HCT-43.0 MCV-88
MCH-29.6 MCHC-33.7 RDW-12.6
___ 10:50PM NEUTS-67.8 ___ MONOS-3.4 EOS-5.3*
BASOS-0.8
___ 10:50PM PLT COUNT-263
___ 10:50PM SED RATE-4
___ 10:50PM CRP-19.3*
___ 10:50PM GLUCOSE-112* UREA N-15 CREAT-0.9 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
.
DISCHARGE LABS
___ 07:20AM WBC-6.2 RBC-4.72 HGB-14.0 HCT-41.5 MCV-88
MCH-29.6 MCHC-33.7 RDW-12.6
___ 07:20AM PLT COUNT-246
___ 07:20AM GLUCOSE-102* UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-30 ANION GAP-10
.
MICRO:
___ BLOOD CULTURES X2 PENDING
.
IMAGING
.
___ LEFT HIP FILMS
FINDINGS: No acute fracture or dislocation is seen. The patient
is status
post open reduction and internal fixation of a previous
acetabular fracture
with plate and screw fixation. Hardware appears intact and
unchanged.
Extensive heterotopic ossification about the left hip appears
unchanged. The right hip appears grossly unremarkable.
IMPRESSION: No acute fracture or dislocation.
.
___ LEFT KNEE FILMS
Three views of the left knee are normal. No fracture, bone
destruction, joint space narrowing, or osteophytes. I cannot
assess the presence of an effusion.
Medications on Admission:
(Prescribed by Dr. ___ at ___
___)
Klonopin 1mg TID prn anxiety
Neurontin 800mg TID
Clonidine 0.2mg TID
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
2. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
3. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO every eight
(8) hours as needed for pain for 3 days.
Disp:*24 Tablet(s)* Refills:*0*
6. 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:
Left knee sprain
Referred pain in left hip
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left knee pain post acetabular fracture.
Three views of the left knee are normal. No fracture, bone destruction, joint
space narrowing, or osteophytes. I cannot assess the presence of an effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT HIP PAIN
Diagnosed with JOINT PAIN-PELVIS, JOINT PAIN-L/LEG, FEVER, UNSPECIFIED
temperature: 99.9
heartrate: 91.0
resprate: 16.0
o2sat: 100.0
sbp: 152.0
dbp: 94.0
level of pain: 9
level of acuity: 3.0 | ___ w/ MVC s/p ORIF of L posterior wall fx on ___
complicated by L hip MSSA septic arthritis s/p I&D on ___,
s/p repeat I&Ds for superficial thigh abscesses ___,
___, and ___ and deep debridement ___ who p/w left hip
pain.
.
# Left hip pain
Initially concerning for infection as patient stated this is how
his prior hip infections have begun, but no sign of infection on
exam or labs. Imaging showed no acute injury. ___ be related to
change in gait ___ knee pain after low-speed car-on-pedestrian
MVC, especially since pain now extends into his back. No fever,
no leukocytosis. He was evaluated by an ortho consult resident
in the ED and ortho attending physician on the floor, both of
whom felt there was no indication for further workup and no need
for more than short-term pain relief. With the physical
therapist, he was able to walk. Was also witnessed walking
as-needed in his room. His PCP's office confirmed that he was
seen there 1d prior to admission and was prescribed baclofen.
.
# Anxiety
On exam, pt has anxiety regarding current disease and
interference with life/work. His reported home anti-anxiolytic
medications were continued.
.
# Drug-seeking behavior
Patient asked for IV dilaudid and 30-mg oxycodone tablet
specifically and repeatedly. Was upset at time of discharge to
receive only a 3-day prescription for 15-mg worth of 5-mg
oxycodone tablets despite equivalent medication to 15 mg tablets
previously prescribed in post-op setting by his orthopedic
surgeons.
.
TRANSITIONAL ISSUES
1. FOLLOW-UP PAIN MEDICATION NEEDS, CONCERN FOR NARCOTIC-SEEKING
BEHAVIOR
2. FOLLOW-UP BLOOD CULTURES
3. IF FURTHER PRESENTATIONS TO THE ED FOR PAIN RELATED TO LEFT
HIP/KNEE PAIN, ORTHOPEDICS ATTENDING RECOMMENDS ADMISSION TO
ORTHOPEDICS SERVICE FOR WORKUP RATHER THAN ADMISSION TO MEDICINE
FOR PAIN MEDICATION. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Oxycodone / morphine / vancomycin / vitamin B12 /
ceftriaxone
Attending: ___
Major Surgical or Invasive Procedure:
AVF chemical/mechanical thrombectomy
attach
Pertinent Results:
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 1512)
Temp: 97.7 (Tm 98.7), BP: 98/60 (97-150/60-85), HR: 73 (53-73),
RR: 17 (___), O2 sat: 96% (95-99), O2 delivery: RA
Gen: lying comfortably in bed in NAD
HEENT: PERRL, OP clear
CV: RRR, nl S1, S2, no m/r/g, no JVD, LUE AVF with
thrill/bruit
Chest: CTAB
Abd: + BS, soft, NT, ND
MSK: Lower ext warm without edema
Skin: no rashes
Neuro: AOx1 (person only), face symmetric, follows one-step
commands, ___ strength all ext, sensation testing not performed,
gait not tested
Psych: pleasantly confused
LABS:
===============
___ 03:37PM BLOOD WBC-7.8 RBC-5.53* Hgb-12.6 Hct-44.2
MCV-80* MCH-22.8* MCHC-28.5* RDW-22.3* RDWSD-61.1* Plt ___
___ 07:29AM BLOOD WBC-6.3 RBC-4.00 Hgb-9.3* Hct-31.4*
MCV-79* MCH-23.3* MCHC-29.6* RDW-21.1* RDWSD-58.5* Plt ___
___ 06:50AM BLOOD WBC-5.4 RBC-3.97 Hgb-9.1* Hct-30.8*
MCV-78* MCH-22.9* MCHC-29.5* RDW-21.0* RDWSD-57.2* Plt ___
___ 05:34AM BLOOD WBC-4.4 RBC-4.23 Hgb-9.6* Hct-33.6*
MCV-79* MCH-22.7* MCHC-28.6* RDW-20.9* RDWSD-58.4* Plt ___
___ 03:37PM BLOOD Neuts-66.5 ___ Monos-9.6 Eos-2.2
Baso-0.5 Im ___ AbsNeut-5.18 AbsLymp-1.61 AbsMono-0.75
AbsEos-0.17 AbsBaso-0.04
___ 03:37PM BLOOD ___ PTT-21.9* ___
___ 05:34AM BLOOD ___ PTT-28.3 ___
___ 03:37PM BLOOD Glucose-118* UreaN-65* Creat-7.3*# Na-137
K-6.8* Cl-96 HCO3-22 AnGap-19*
___ 06:05AM BLOOD Glucose-92 UreaN-73* Creat-8.5*# Na-139
K-5.9* Cl-96 HCO3-21* AnGap-22*
___ 07:07PM BLOOD Glucose-87 UreaN-80* Creat-9.2* Na-139
K-7.0* Cl-102 HCO3-17* AnGap-20*
___ 06:37AM BLOOD Glucose-88 UreaN-23* Creat-4.2*# Na-138
K-4.0 Cl-96 HCO3-27 AnGap-15
___ 07:29AM BLOOD Glucose-106* UreaN-32* Creat-5.6*# Na-138
K-4.9 Cl-98 HCO3-25 AnGap-15
___ 06:50AM BLOOD Glucose-86 UreaN-47* Creat-6.9*# Na-140
K-5.5* Cl-100 HCO3-24 AnGap-16
___ 05:34AM BLOOD Glucose-92 UreaN-26* Creat-4.5*# Na-138
K-4.5 Cl-94* HCO3-31 AnGap-13
___ 07:29AM BLOOD ALT-11 AST-16 LD(LDH)-184 AlkPhos-121*
TotBili-0.4
___ 03:37PM BLOOD Calcium-8.6 Phos-4.2 Mg-2.6
___ 05:34AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.1
___ 08:30AM BLOOD %HbA1c-4.9 eAG-94
IMAGING:
==========
EKG (___):
Regular SVT at 128 bpm, LAD, incomplete RBBB, ? retrograde P
waves
EKG (___):
NSR at 64 bpm, PR 168, QRS 101, QTC 458, LAFB, incomplete RBBB
Fistulogram (___):
1. Complete thrombosis of the left upper extremity AV graft to
the level of the outflow vein.
2. Venous anastomosis and venous outflow end stent stenosis with
improvement following angioplasty to 9 mm. Arterial limb graft
stenosis with improvement following angioplasty to 8 mm.
3. Satisfactory appearance of the arterial anastomosis. No
central venous stenosis.
EKG (___):
NSR at 63 bpm, LAFB, PR 170, QRS 100, QTC 461, LVH (no change
from ___
CXR (___):
Stable cardiac enlargement. No signs of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. PARoxetine 20 mg PO DAILY
4. Pravastatin 10 mg PO QPM
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Aspirin 81 mg PO DAILY
7. Calcium Acetate 1334 mg PO TID W/MEALS
8. Cholestyramine 4 gm PO DAILY:PRN diarrhea
9. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
10. Bisacodyl ___VERY OTHER DAY
11. Fleet Enema (Saline) ___AILY:PRN constipation
12. Metoprolol Tartrate 50 mg PO BID
13. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO TID
Hold for SBP <100, HR<50
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___VERY OTHER DAY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. Cholestyramine 4 gm PO DAILY:PRN diarrhea
8. Fleet Enema (Saline) ___AILY:PRN constipation
9. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. PARoxetine 20 mg PO DAILY
12. Pravastatin 10 mg PO QPM
13. Triphrocaps (B complex with C#20-folic acid) 1 mg oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=========
# ESRD on HD (___)
# Clotted Fistula
SECONDARY:
===========
Supraventricular tachycardia
Sinus bradycardia
Dementia
Discharge Condition:
Level of Consciousness: Alert and interactive
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with confusion // ? pna
COMPARISON: Prior exam from ___
FINDINGS:
AP upright and lateral views of the chest provided. Right anterior
hemidiaphragmatic eventration is again seen. Mild cardiomegaly is unchanged.
There is a tortuous and somewhat calcified thoracic aorta. There is no
consolidation, effusion or pneumothorax. No signs of edema. Imaged bony
structures are intact. Mediastinal contour is stable.
IMPRESSION:
Stable cardiac enlargement. No signs of pneumonia.
Radiology Report
INDICATION: ___ year old woman with clotted fistula // fistulogram +/-
intervention
COMPARISON: None
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: Monitored anesthesia care. 1% lidocaine was injected in the skin
and subcutaneous tissues overlying the access site.
MEDICATIONS: Please refer to the anesthesia record.
CONTRAST: 30 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 20:41 min, 6 mGy
PROCEDURE:
1. Left upper extremity AV graft fistulogram.
2. Axillary and subclavian venography.
3. Chemical and mechanical thrombolysis of the thrombosed graft and outflow
vein using injected tPA and the Penumbra device.
4. Balloon angioplasty of the intragraft and outflow vein stenoses.
5. ___ balloon pull through of the arterial inflow.
PROCEDURE DETAILS:
Written informed consent was obtained from the patient outlining the risks,
benefits and alternatives to the procedure. The patient was then brought to
the angiography suite and placed supine on the image table with the left upper
extremity abducted and stabilized.
Clinical examination demonstrated a palpable, but completely thrombosed graft
in the left upper extremity. Further evaluation by targeted ultrasound
demonstrated a completely thrombosed graft extending into the outflow vein.
The left upper extremity was prepped and draped in the usual sterile fashion.
A preprocedure timeout and huddle was performed as per ___ protocol.
Using ultrasound and fluoroscopy, the arterial inflow and outflow stent levels
were identified and the skin was marked with a skin marker. Antegrade
(directed towards the venous outflow) access into the thrombosed graft was
obtained under continuous ultrasound guidance using a 21G micropuncture
needle. An 0.018 wire was then advanced easily into the outflow vein under
fluoroscopic guidance. A 4.5F micropuncture sheath was advanced and used to
exchange for an 0.035 Glidewire. The glide wire was advance to the level of
the subclavian vein. An 8 ___ sheath was placed over the wire. A ___ Kumpe
catheter was then advanced over the wire and slowly withdrawn while injecting
dilute contrast to establish the distal extent of thrombus into the outflow
vein. Tissue plasminogen activator was administered along the entire length of
the thrombosed graft and outflow vein through the Kumpe catheter. A total of 5
mg was infused. The tPA was allowed to dwell for approximately 10 minutes.
During dwell time, retrograde access directed towards the arterial inflow was
then obtained in a similar fashion using continuous ultrasound and
intermittent fluoroscopic guidance. Micropuncture set was exchanged over an
0.035 Glidewire that was directed into the inflow brachial artery for a short
___ vascular sheath. At this point 3000 IU of heparin was administered
systemically.
The Penumbra device was then turned on and mechanical thrombectomy was
performed from the antegrade approach however was unable to successfully
aspirate within the venous outflow stent due to stent collapse during
suctioning. Therefore gentle balloon maceration was performed with a 9mm
Conquest throughout the graft. In areas of tight stenosis at the venous
anastomosis and end-stent of the venous outflow, angioplasty was performed for
a prolonged period. A 5.5 ___ ___ balloon was then advanced through
the antegrade access and along the entire length of the graft and outflow
vein. The ___ balloon was also advanced beyond the arterial anastomosis,
partially inflated and pullback was performed through the arterial anastomosis
into the graft. This resulted in restoration of flow and a faint thrill in the
graft. Fistulogram was performed which demonstrated return of brisk flow
through the graft with evidence of stenosis in the arterial limb of the graft
with small residual clot in the venous outflow. ___ sweep was then
performed over the wire of the venous outflow. Subsequently, angioplasty was
performed of the arterial limb using an 8-mm Conquest balloon. A completion
fistulogram was performed from the proximal brachial artery demonstrating
brisk flow throughout the entire graft with no residual stenosis. Clinical
examination revealed a satisfactory thrill along the length of the graft.
The sheaths were removed and hemostasis was achieved with two ___ Ethilon
pursestring sutures. There were no immediate complications.
FINDINGS:
1. Complete thrombosis of the left upper extremity AV graft to the level of
the outflow vein.
2. Venous anastomosis and venous outflow end stent stenosis with improvement
following angioplasty to 9 mm. Arterial limb graft stenosis with improvement
following angioplasty to 8 mm.
3. Satisfactory appearance of the arterial anastomosis. No central venous
stenosis.
IMPRESSION:
Satisfactory restoration of flow following chemical and mechanical
thrombolysis with a good angiographic and clinical result.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Clotted fistula
Diagnosed with Hyperkalemia
temperature: 97.8
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | ___ ___ woman with dementia, ESRD on HD (___), pAF
(not anticoagulated), HTN, hx GI bleeding (___) who presented
from ___ with thrombosed LUE fistula, s/p chemical/mechanical
thrombolysis/thombectomy with ___ and successful HD on ___,
with
ED course c/b hypoglycemia, hyperkalemia, and SVT, subsequently
with sinus bradycardia after resumption of home metoprolol.
# Thrombosed AVF s/p thrombolysis/thrombectomy:
# Hyperkalemia:
# ESRD on HD:
P/w thrombosed AVF, s/p successful thrombolysis/thrombectomy
with
___. Fistula subsequently functioning well. Successful HD on
___ and again ___. Presenting hyperK resolved with
HD. She will resume her ___ outpatient HD schedule. Continued
on calcium acetate with meals.
# Paroxysmal atrial fibrillation:
# SVT, likely AVNRT:
# Sinus bradycardia:
Hx of pAF, for which anticoagulation previously deferred by her
cardiologist Dr. ___ last seen ___. Appears
she
is maintained on BID metoprolol and low-dose ASA as outpatient.
ED reported afib with RVR during her prolonged stay there, which
could not be confirmed as it was not captured on EKG. Suspect
her
tachycardia was, in fact, a regular SVT (likely AVRT) based on
EKG and telemetry information available since admission, likely
in setting of missing her home beta blocker. Home metoprolol
(50mg BID) was resumed, resulting in sinus bradycardia with HRs
in the ___ (without hypotension; difficult to determine
whether symptomatic in setting of dementia). Metoprolol was
therefore decreased to 12.5mg TID, which she appeared to be
tolerating well at the time of discharge. ___ need further
titration at rehab. Given absence of clear recurrent afib this
admission and decision by outpatient providers to defer
therapeutic anticoagulation (particularly in setting of GI
bleeding ___, was not addressed this admission. Would
benefit from additional consideration as outpatient with
cardiology f/u.
# Dementia:
Based on review of prior notes and discussions with patient's
husband son, ___, baseline AOx0-2 in setting of long-standing
dementia. Appeared to be at her baseline this admission with
non-focal neurologic exam.
# Dysphagia:
Previously thought to have mild dysphagia and increased risk of
aspiration; outpatient diet pureed solids, thin liquids. On
admission patient noted to be "cheeking" medications, unable or
unwilling to swallow. ___ have been a volitional component, as
she subsequently tolerated medications crushed without
difficulty. Diet continued as pureed solids, thin liquids on
discharge.
# Hypoglycemia:
Noted in the ED, for which she received dextrose. Not a known
diabetic and not on home insulin. A1c 4.9% this admission. ___
have been due to decreased PO intake, which has now improved,
with no further hypoglycemia since admission.
# Microcytic anemia:
Appears to be at baseline without e/o bleeding or hemolysis.
Received Epo with HD.
# Glaucoma
Continued home Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH
EYES Q12H and Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES
QHS
# Depression
Continued home Paroxetine 20 mg PO DAILY
# HLD
Continued home Pravastatin 10 mg PO QPM
# IBS
Continued home Cholestyramine 4 gm PO DAILY:PRN diarrhea
# Dispo:
Back to rehab today.
** TRANSITIONAL **
[ ] monitor HRs, may need to titrate metoprolol; if ongoing
difficulty with SVT and bradycardia, would consider EP
evaluation for consideration of PPM
[ ] consider further discussions regarding anticoagulation in
setting of pAF (no afib documented this admission) |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin / clindamycin / ___ Reductase
Inhibitors / ACE Inhibitors / valsartan
Attending: ___.
Chief Complaint:
delirium, wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ woman with a history of recent
hemorrhagic stroke 1 month ago, HTN, HLD, and T2DM, now residing
at a nursing facility, who presented with respiratory distress.
At her nursing home, the patient was found to have wheezes
bilaterally. She was given DuoNebs and had improvement. She
recently was found to have DVT at the nursing facility, so was
started on twice daily Lovenox. At the outside hospital today,
the patient was found to have pulmonary emboli. CT head showed
subacute cerebellar hematoma. She was transferred to ___ for
further management at her family's request.
The patient was unable to participate in any of the history in
the ED. Per the patient's daughter who is present, she will
usually make eye contact and can speak to a certain extent,
although she has been more sleepy lately. She reports that
beginning on ___, the patient developed a progressively
worsening cough and became more fatigued. This continued until
the day of admission.
In the ED:
Initial vital signs were notable for: T 98.6, HR 75, BP 135/90,
RR 28, O2 sat 93% on 2L NC
Exam notable for: Exam is remarkable for an agitated elderly
appearing Asian woman, she moves all extremities, there is some
expiratory wheezing audible externally, lungs are overall
generally clear to auscultation there is a PEG tube in place
abdomen is soft and nontender.
Labs were notable for: Hgb 7.8, BNP 1495, UA with large leuks,
19
WBCs, few bacteria
Studies performed include: CT head there is a hematoma within
the right cerebellar hemisphere measuring up to 3.0 ×2.5 cm
which is an appearance compatible with subacute blood products.
This should be correlated with prior imaging. This hematoma
mildly effaces the fourth ventricle there is no additional site
of hemorrhage or ___. Additional findings prior
bilateral lens replacements moderate global cerebral volume
loss. Mild
chronic microvascular ischemic white matter disease.
Mineralization along the falx CT PE. Possible filling defect
within a left upper lobe pulmonary
branch near a branch point between segmental and subsegmental
vessel this scan is degraded by motion and this could
potentially represent a pulmonary embolism or artifact. There is
an additional suspected filling defect within the adjacent left
upper lobe segmental branch these findings are favored to
represent pulmonary emboli over artifact a repeat study could be
considered for confirmation small bilateral pleural effusions
with adjacent atelectasis additional findings; heterogeneous
thyroid gland. Aortic calcifications. Coronary artery
calcifications. Partially visualized gastrostomy tube. Multiple
old ___ rib fractures. Thoracic spine degenerative
changes
Patient was given: IV Haloperidol 1 mg x2, Albuterol 0.083% Neb
Soln, Omeprazole 20 mg, Senna 8.6 mg, Acetaminophen IV 1000 mg,
SC Enoxaparin Sodium 60 mg, IV CefTRIAXone 1g, LR at 125cc/hr
Consults: Neurology- RECOMMENDATIONS:
- Treat DVT and PE as medically indicated.
- She was started on lovenox ___ days ago, and head CT today had
no hemorrhage.
- Neurology stroke team will follow while Mrs. ___ is inpatient.
- If any changes in neurologic exam, please repeat stat NCHCT.
Neurosurgery- At this time there is no contraindication to
anticoagulation for treatment of pulmonary embolus. However,
given that the patient was previously admitted to Neurology Dr
___ service - consider consulting Neurology for
anticoagulation preferences.
Vitals on transfer: T 98.7, HR 78, BP 137/70, RR 15, O2 sat 99%
on NC
Upon arrival to the floor, the patient states that she is
feeling fine and has no particular complaints. Does not report
fevers, chills, chest pain, shortness of breath, nausea,
vomiting, abdominal pain, and changes in bowel or bladder
habits. As per her daughter, her mother now appears much
improved and is more
alert. She still notes a persistent, harsh cough.
Past Medical History:
HTN
HLD
T2DM
Cerebellar hemorrhagic stroke
Social History:
___
Family History:
___
___
Physical Exam:
Admission Physical Exam:
========================
VITALS: T 98.2 PO, BP 189 / 69, HR 82, RR 16, O2 sat 94% on 2L
NC
GENERAL: Pleasant, alert and interactive. In no acute distress.
Intermittently pulling at oxygen and IV.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally (___), extraocular muscles intact. Sclera
anicteric and without injection. Dry mucous membranes. Tongue
with ___ material on surface.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Somewhat uncooperative during exam. Upper airway sounds
heard in upper lung fields. No crackles.
ABDOMEN: Normal bowels sounds, non distended, ___ to deep
palpation in all four quadrants. No organomegaly. PEG tube in
place under abdominal binder.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: ___ intact. ___ strength throughout. Normal
sensation. AOx1 (self, "IB").
DISCHARGE PHYSICAL EXAM:
=======================
VITALS:
___ ___ Temp: 97.6 PO BP: 174/66 R Lying HR: 66 RR: 16 O2
sat: 96% O2 delivery: Ra FSBG: 323
___ Total Intake: 1351ml PO Amt: 100ml TF/Flush Amt: 330ml
IV Amt Infused: 921ml
GENERAL: Sleeping, arousable, and intermittently interactive. In
no acute distress. Both hands in mitts and intermittently trying
to remove. Joined by daughter at bedside.
HEENT: Normocephalic, atraumatic. Pupils constricted s/p
bilateral cataract surgery. Sclera anicteric and without
injection. Dry mucous membranes. Tongue with dry, ___
material on surface.
NECK: Supple.
CARDIAC: RR, normal rate. Audible S1 and S2. No mrg.
LUNGS: Rhonchi b/l diffuse. No crackles.
ABDOMEN: S/ND, epigastric TTP. No HSM, PEG tube in place with
cap/attachment broken off.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses Radial 2+
and DP 1+ bilaterally.
SKIN: Warm. No rash. Brown macule on back.
NEUROLOGIC: Intermittently alert. CN ___ intact, strength ___
in
all 4 extremities, Face symmetric with no droop. finger to nose
intact bilaterally
Pertinent Results:
ADMISSION LABS:
___ 06:15AM BLOOD ___
___ Plt ___
___ 06:15AM BLOOD ___
___ Im ___
___
___ 06:15AM BLOOD ___ ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___
___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD ___
DISCHARGE LABS:
___ 07:00AM BLOOD ___
___ Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___
___
___ 07:55AM BLOOD ___
MICRO:
_______________________________________________________
___ 9:05 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:55 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:12 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:49 am URINE Site: CLEAN CATCH Source:
Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
Susceptibility testing performed on culture # ___
___.
__________________________________________________________
___ 2:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING/RESULTS:
___: CXR
Bilateral pleural effusions right greater than left are
unchanged.
Cardiomediastinal silhouette is stable. There is
atherosclerotic changes
involving the aorta. Pulmonary edema is unchanged. No
pneumothorax is seen
___: PORTABLE ABDOMEN
1. PEG tube is seen in the left upper quadrant overlying the
expected
location of the stomach.
2. Small, bilateral pleural effusions.
___: TTE
Normal left ventricular wall thickness, cavity size, and
regional/global systolic function (LVEF = >55 %). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. The pulmonary artrery systolic
pressure could not be quantified. There is no pericardial
effusion.
IMPRESSION: Mild aortic regurgitation with normal valve
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function.
Compared with the prior stress echo of ___, mild aortic
regurgitation is now seen.
___: RENAL US
1. No evidence of renal abscess or overt infectious process.
2. Debris within the right side of the bladder, possibly within
a wide necked
bladder diverticulum.
Radiology Report
INDICATION: ___ year old woman with hypoxemia and recent PE// Please eval for
pneumonia, pleural effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Bilateral pleural effusions right greater than left are unchanged.
Cardiomediastinal silhouette is stable. There is atherosclerotic changes
involving the aorta. Pulmonary edema is unchanged. No pneumothorax is seen
Radiology Report
INDICATION: ___ woman with a history of recent hemorrhagic stroke 1
month ago, HTN, HLD, and T2DM, now residing at a nursing facility, who
presented with respiratory distress.// confirm PEG placement
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None
FINDINGS:
A PEG tube is seen in the left upper quadrant overlying the expected location
of the stomach. There are no abnormally dilated loops of large or small
bowel. Limited views of the thorax demonstrate bilateral, small pleural
effusions.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
A metallic rod is seen to the left of the spine, denoting the patient's back
brace. Vascular calcifications are seen in the left upper quadrant. There
are no unexplained soft tissue calcifications or radiopaque foreign bodies.
IMPRESSION:
1. PEG tube is seen in the left upper quadrant overlying the expected
location of the stomach.
2. Small, bilateral pleural effusions.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ woman with a history of recent hemorrhagic stroke 1
month ago, HTN, HLD, and T2DM, now residing at a nursing facility with MRSA in
urine.// any renal abscess or focal areas of infection
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.3 cm. The left kidney measures 9.6 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended. There is an outpouching from the
right posterior bladder which might represent a broad necked diverticulum and
contains layering internal debris. No overt vascularity.
IMPRESSION:
1. No evidence of renal abscess or overt infectious process.
2. Debris within the right side of the bladder, possibly within a wide necked
bladder diverticulum.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Wheezing, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale
temperature: 98.6
heartrate: 75.0
resprate: 28.0
o2sat: 93.0
sbp: 135.0
dbp: 90.0
level of pain: unable
level of acuity: 2.0 | Ms. ___ is an ___ woman with a history of recent
hemorrhagic stroke 1 month ago, HTN, HLD, and T2DM, now residing
at a nursing facility, who presented with respiratory distress. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / ampicillin
Attending: ___
Chief Complaint:
sensory changes
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Mr. ___ is a ___, left-handed man who in ___
began to have episodes of sudden confusion and was found to have
cerebral amyloid angiopathy (biopsy proven) with marked
improvement after being treated with a steroid taper (four days
of 1 g Solu-Medrol followed by prednisone oral taper 40mg x2w,
30mg x2w, 20mgx2w, currently on 10mgx2w). Approximately two
weeks
ago (when he decreased from 20mg daily to 10mg daily), he
developed intense unilateral pain on his right flank which
wrapped around his back. He went to his PCP who prescribed
___ for concern of a developing shingles outbreak but told
him to wait on taking the medication until he developed a rash.
He never developed the rash but his pain quickly extended around
the body to the left side to uniformly include his chest and
back
from just below the collar bones around the top of the shoulder
blades down to the fold of the groin around to just above the
gluteal fold and buttocks. It has now become uncomfortable for
him to even wear a shirt or lightly touch the area. He feels as
if the skin on his truck has a terrible sunburn although he
denies any skin changes or rash. He denies any recent sick
exposures or insect bites. He has not been in the wilderness
lately. He has had several months of daily frontal headaches
since his hospitalization in ___ and takes ~3g of Tylenol for
this pain which he is now taking to also help the burning
sensation on his trunk. He has been previously been diagnosed
with a synovial cyst at L4-5 level which causes him pain on
movement and ambulation but he is not interested in any
intervention at this time. His wife called his outpatient
Neurologist, Dr ___ recommended evaluation in the ED.
Neurology was consulted for workup and management
recommendations.
On neuro ROS, (+) hyperesthesia of the trunk, (+) chronic
bifrontal headaches since his hospitalization in ___, (+)
chronic floaters in his vision. The pt denies diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness. (+)
chronic urinary urgency which he feels has increased recently
now
he has to get up ~ 4 times in the night (used to get up 2 times
in the night). No bowel or bladder incontinence or retention.
(+)
chronic pain with ambulation from the synovial cyst.
On general review of systems, (+) mild chronic constipation, (+)
urinary urgency. The pt denies recent fever or chills. No
weight
loss (may have gained in the setting of increased PO with
steroids). Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
or abdominal pain. No recent change in bowel or bladder habits.
Denies rash.
PMHx (per OMR, confirmed with patient):
History of migraine headache with aura.
History of prostate cancer status post brachytherapy, ___.
History of irritable bowel syndrome with predominantly
constipation.
Hyperlipidemia.
Gastroesophageal reflux disease.
Osteoarthritis, status post total knee replacement on the left
in
___.
Status post hernia repair x 2.
History of perforated bowel related to chronic constipation with
resection of 9 inches of bowel.
Status post appendectomy in ___.
Cerebral amyloid angiopathy/angiitis with brain biopsy ___.
Past Medical History:
Prostate CA
HLD
GERD
Social History:
___
Family History:
No known history of strokes or autoimmune disease. Was
raised by grandmother .
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL EXAM:
- Vitals: 98.2 80 152/90 18 100%RA
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple. No nuchal rigidity
- Pulmonary: no increased WOB
- Abdomen: soft, nontender, nondistended
- Extremities: no edema
- Skin: no rashes or lesions noted in the oropharynx, the groin,
the back or abdomen although he does have a fair number of
cherry
hemagiomas and some erythematous changes, he states this is
nothing new. There are no areas of skin breakdown or sores.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history with some difficulty with details looking to his wife to
fill in the gaps. Attentive, able to name ___ backward with
minimal difficulty (misses ___. Language is fluent with
intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Able to register 3 objects and recall
___ and ___ with prompting at 5 minutes.
- Cranial Nerves:
PERRL 2.5 to 2mm and brisk. VFF to confrontation. EOMI without
nystagmus. Normal saccades. Facial sensation intact to light
touch and pinprick. No facial droop. Hearing intact to room
voice. Palate elevates symmetrically. ___ strength in trapezii
and SCM bilaterally. Tongue protrudes in midline.
- Motor: Normal bulk and paratonia arms>legs. No pronator drift
bilaterally. Action tremor worse with reaching for objects L>R.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[EDB]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory: no deficits to LT and pin prick in the face, arms,
and
legs. He reports hyperesthesia to pinprick starting several
inches above the nipple line around the armpits and across the
back above the shoulder blades. This persists down to the crease
in the groin around the buttocks to about ~1inch above the start
of the gluteal fold. He has marked hyperesthesia to ice in a bag
in the same distribution and is noted to writhe in discomfort
during testing. He thinks that perhaps there is a gradient of
sensation, worse around the umbilicus but then improves up to
the
collar bones and down to the thighs (the distribution does
include the very proximal aspect of the lateral thighs) but this
variation in intensity is subtle. He feels the parasthesias
albeit mildly even with just gentle blowing of air on the area.
+deficits to vibration in the toes (+5 seconds) better at the
ankles. Does not report any gradient of sensation to pin prick
up
the legs. Proprioception intact at the toes.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was flexor bilaterally.
- Coordination: Action tremor with FNF. No resting tremor.
Although he has lots of paratonia and can not relax, no marked
rigidity with and without augmentation. Finger tap with normal
width and good cadence (no decrement). Alternating hand
movements
slow but on target. Mild bilateral dysmetria with HKS
bilaterally
(L>R).
- Gait: Somewhat antalgic with a mild right limp. Good
initiation
mildly wide based. Able to toe walk but has missteps with heel
walk. Unable to tandem. Romberg is positive with marked sway and
misstep with pull.
DISCHARGE PHYSICAL EXAM:
Vitals within normal limits
Gen: well appearing male in no distress, comfortable
HEENT: Normocephalic atraumatic
CV: warm, well perfused
Pulm: breathing non labored
Abdomen: soft, nontender
Neurology:
-MS: awake, alert, oriented to self, ___, date and situation.
Easily maintains history to examiner. Recalls a clear and
coherent history. Speech fluent with no dysarthria. No evidence
of hemineglect.
-CN: gaze conjugate, EOMI with no nystagmus, face symmetric,
tongue midline
-Motor: normal bulk and tone. Muscle strength ___ throughout. No
tremor or asterixis. Mild paratonia in arms>legs.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was flexor bilaterally.
-Sensory: hyperesthesia and allodynia present anteriorly and
posteriorly extending from ___ inches above nipple area (T3-T4)
to 1 inch below umbilical area (T10), to light touch and
pinprick. There is a gradient of hyperesthesia, more intense in
umbilical area and less intense moving superiorly and
inferiorly.
-Gait: Mildly antalgic. Good initiation. Able to toe walk but
has occassional misstep with heel
walk. No ataxia or sway.
Pertinent Results:
___ 08:00AM BLOOD WBC-9.4 RBC-4.43* Hgb-13.3* Hct-40.4
MCV-91 MCH-30.0 MCHC-32.9 RDW-14.1 RDWSD-46.5* Plt ___
___ 06:25PM BLOOD Neuts-71.0 ___ Monos-6.6 Eos-1.4
Baso-0.4 Im ___ AbsNeut-5.60 AbsLymp-1.59 AbsMono-0.52
AbsEos-0.11 AbsBaso-0.03
___ 08:00AM BLOOD Plt ___
___ 09:26PM BLOOD Parst S-NEGATIVE
___ 08:00AM BLOOD Glucose-132* UreaN-14 Creat-0.8 Na-138
K-3.7 Cl-98 HCO3-23 AnGap-21*
___ 01:09PM BLOOD LD(LDH)-168
___ 08:00AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.0
___ 03:14PM BLOOD Cryoglb-NO CRYOGLO
___ 07:24AM BLOOD VitB12-566 Folate->20
___ 07:24AM BLOOD %HbA1c-6.4* eAG-137*
___ 06:25PM BLOOD TSH-1.0
___ 07:24AM BLOOD ANCA-NEGATIVE B
___ 01:09PM BLOOD dsDNA-NEGATIVE
___ 01:09PM BLOOD RheuFac-<10
___ 07:24AM BLOOD ___
___ 06:25PM BLOOD CRP-2.8
___ 07:24AM BLOOD PEP-NO SPECIFI IgG-581* IgA-129 IgM-67
IFE-NO MONOCLO
___ 06:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:40AM BLOOD BORRELIA MIYAMOTOI -CANCELLED
___ 09:26PM BLOOD BORRELIA MIYAMOTOI, PCR-PND
___ 09:26PM BLOOD BORRELIA MIYAMOTOI -CANCELLED
___ 09:21AM BLOOD HEAVY METAL SCREEN-Test
___ 01:09PM BLOOD RO & ___
___ 01:09PM BLOOD NEURONAL NUCLEAR (___) ANTIBODIES-Test
___ 01:09PM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-Test Name
___ 07:24AM BLOOD SED RATE-Test
___ 07:24AM BLOOD VITAMIN B6 (PYRIDOXINE)-Test
___ 07:24AM BLOOD VITAMIN B1-WHOLE BLOOD-Test
___ 07:24AM BLOOD METHYLMALONIC ACID-Test
___ 07:24AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO QHS:PRN insomnia
2. NexIUM (esomeprazole magnesium) 20 mg oral DAILY
3. PredniSONE 10 mg PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Rosuvastatin Calcium 10 mg PO QPM
6. Tamsulosin 0.4 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
4. Gabapentin 900 mg PO TID
RX *gabapentin 300 mg 3 capsule(s) by mouth three times a day
Disp #*270 Capsule Refills:*1
5. Glucocard 01 Meter (blood-glucose meter) 1 glucoter
miscellaneous As directed
Please dispense the above glucometer or similar
RX *blood-glucose meter Disp 1 glucomtere as directed Disp #*1
Kit Refills:*0
6. Glucocard 01 Normal Control (blood glucose control, normal)
120 Lancets miscellaneous As directed
RX *blood glucose control, normal Check BS as directed 3 times
daily (before meals) Disp #*120 Strip Refills:*1
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1
8. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
9. ClonazePAM 0.5 mg PO QHS:PRN insomnia
10. Multivitamins 1 TAB PO DAILY
11. NexIUM (esomeprazole magnesium) 20 mg oral DAILY
12. Ranitidine 150 mg PO DAILY
13. Rosuvastatin Calcium 10 mg PO QPM
14. Sertraline 50 mg PO DAILY
15. Tamsulosin 0.4 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Truncal hyperesthesia of unclear etiology- HSV/VSV negative.
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 truncal hyperesthesias // eval pulmonary
process
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
No consolidation. The hila and pulmonary vasculature are normal. No pleural
effusions or pneumothorax. The heart size is normal. Air is seen in the
esophagus. The hiatal hernia is small.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old man with vest pattern of hyperesthesias from collar
bone to groin front to back after steroid taper // eval for cord lesion, ?
high cervical lesion sensory ganglionopathy?
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 10 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: MRI T and L-spine from ___.
MRI head from ___.
FINDINGS:
CERVICAL:
Vertebral body alignment is preserved. Vertebral body heights are preserved.
In the left anterior C6 vertebral body is an area demonstrate hyperintense T2
and FLAIR signal corresponding to heterogeneous signal intensity on T1
precontrast sequence which enhances (06:10, 15:10). No other areas of
abnormal marrow signal are seen in cervical spine. No other enhancing lesions
are identified. The visualized portion of the spinal cord is preserved in
signal and caliber.
Degenerative loss of disc height at C4-C5 and C5-C6 is mild.
There is no prevertebral soft tissue swelling..
The visualized portion of the posterior fossa and cervicomedullary junctionare
unremarkable.
At C2-3 there is uncovertebral hypertrophy and facet arthropathy causing
moderate right neuroforaminal narrowing but no vertebral canal or left neural
foraminal narrowing.
At C3-4 there is a disc bulge, uncovertebral hypertrophy and facet
arthropathy, causing mild vertebral canal narrowing which indents the thecal
sac but does not flatten the cord and moderate to severe bilateral neural
foraminal narrowing.
At C4-5 there is a disc bulge and facet arthropathy causing mild vertebral
canal narrowing, which indents the thecal sac but does not flatten the cord,
and moderate to severe bilateral neural foraminal narrowing.
At C5-6 there is a disc bulge and facet arthropathy causing mild vertebral
canal narrowing, which indents the thecal sac but does not flatten the cord,
and moderate bilateral
At C6-7 and C7-T1, there is no vertebral canal or neural foraminal stenosis.
THORACIC:
Alignment is normal.Mild widening of the T7 vertebral body is unchanged ___.
Vertebral body heights are otherwise maintained.T2 and FLAIR hyperintense
signal in the vertebral bodies of T7 and L1 are nonenhancing, unchanged from
___, and consistent with hemangiomas. The spinal cord appears normal in
caliber and configuration.
At T7-T8, right paracentral disc bulge cause mild vertebral canal narrowing,
indenting the thecal sac and mildly effacing the cord without underlying cord
signal abnormality or significant neuroforaminal narrowing.
At T8-T9 and T10-T11, disc bulges causes mild vertebral canal narrowing,
indenting the thecal sac without effacing the cord or causing significant
neural foraminal narrowing. A T12-L1 right neural foraminal 5 mm perineural
cyst is identified.
There are multiple T2 hyperintense nonenhancing parenchymal cystic lesions of
both kidneys measuring up to 1.7 cm, statistically most likely representing
simple cysts. The remainder the visualized prevertebral and paraspinal soft
tissues are grossly unremarkable.
IMPRESSION:
1. No evidence of intraspinal mass or cord signal abnormality.
2. C6 vertebral body enhancing lesion is indeterminate and could represent an
atypical hemangioma. Noncontrast CT scan of the C-spine is recommended for
further evaluation to evaluate for bony trabeculation.
3. Multilevel degenerative changes, described above, cause up to moderate to
severe neural foraminal narrowing but no spinal canal stenosis in the cervical
spine. No neural foraminal or spinal canal stenosis in the thoracic spine.
RECOMMENDATION(S): Noncontrast CT scan of the C-spine is recommended for
further evaluation to evaluate for bony trabeculation of the C6 vertebral body
lesion.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:59 ___, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION:
CT chest abdomen pelvis
INDICATION: ___ year old man with hx of amyloid angiitis, presents with
truncal hyperesthesia of unclear cause. ? paraneoplastic // eval for
underlying malignancy, concern for paraneoplastic process
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: CT chest abdomen pelvis from ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Subsolid nodule 5 mm right upper lobe (6:103). Scarring of the
inferior lingula. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
Focus of calcification at the diaphragmatic hiatus between the aorta and the
stomach is likely a calcified lymph node
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: Fatty replacement of the pancreas. No 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 are multiple simple cysts noted bilaterally largest is on the right and
measures 3.7 x 2.7 cm at the lateral interpolar region. There are also
multiple additional subcentimeter hypodense lesions which are too small to
characterize. No hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. The colon and rectum are
within normal limits. The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Enlarged prostate with numerous brachytherapy seeds, some
of which are just outside the prostate capsule on the right.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute
fracture.Hemangiomas at the L1 and T7 vertebra bodies. There is a bone island
at the T7 vertebral body also.
IMPRESSION:
No mass to explain neurologic symptoms as questioned.
There is a right upper lobe 5 mm sub solid pulmonary nodule. Follow-up
non-contrast CT the chest in ___ months based on risk factors is recommended
Radiology Report
EXAMINATION:
CT chest abdomen pelvis
INDICATION: ___ year old man with hx of amyloid angiitis, presents with
truncal hyperesthesia of unclear cause. ? paraneoplastic // eval for
underlying malignancy, concern for paraneoplastic process
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: CT chest abdomen pelvis from ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Subsolid nodule 5 mm right upper lobe (6:103). Scarring of the
inferior lingula. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
Focus of calcification at the diaphragmatic hiatus between the aorta and the
stomach is likely a calcified lymph node
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: Fatty replacement of the pancreas. No 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 are multiple simple cysts noted bilaterally largest is on the right and
measures 3.7 x 2.7 cm at the lateral interpolar region. There are also
multiple additional subcentimeter hypodense lesions which are too small to
characterize. No hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. The colon and rectum are
within normal limits. The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Enlarged prostate with numerous brachytherapy seeds, some
of which are just outside the prostate capsule on the right.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute
fracture.Hemangiomas at the L1 and T7 vertebra bodies. There is a bone island
at the T7 vertebral body also.
IMPRESSION:
No mass to explain neurologic symptoms as questioned.
There is a right upper lobe 5 mm sub solid pulmonary nodule. Follow-up
non-contrast CT the chest in ___ months based on risk factors is recommended
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BURNING OF CHEST, NO VISIBLE RASH
Diagnosed with Anesthesia of skin
temperature: 98.4
heartrate: 101.0
resprate: 18.0
o2sat: 96.0
sbp: 141.0
dbp: 78.0
level of pain: 5
level of acuity: 3.0 | ___, left-handed man with a pmx of Amyloid Angiitis who
presents with truncal hyperesthesia in the setting of steroid
taper.
#Truncal hyperesthesia: Patient reported a 10 day history of
dysthesia and allodynia, which spread slowly until it involved
his entire trunk, front and back, from about the level of the
armpits to the level of the upper border of the pelvis on the
back and inguinal creases on the front. Pain began with
dermatomal pain on right flank, extending to entire trunk front
and back. Patient underwent MRI of cervical, thoracic spines and
brain with and without contrast, which was negative, with no
evidence of mass or cord signal abnormality. Patient then had a
lumbar puncture which was inflammatory (tube 1: WBC: 20, 93%
lymphs, 6 monos, 1 eos; tube 4: WBC: 9, 94% lymphs, 5 monos),
and a number of inflammatory and autoimmune studies were sent
(see full labs below). Infectious Disease consult was placed to
assist was management.
Given the inflammatory CSF with sensory changes, patient was
started empirically on Acyclovir. However, this was discontinued
following negative CSF HSV and VZV PCR. As the symptoms started
in setting of steroid taper, his home prednisone was increased
from 10mg to 40mg QD with plans to follow up with neurology on
an outpatient basis. For pain control, patient was started on
Gabapentin for neuropathic pain, which controlled his symptoms.
By the time of discharge, patient reported truncal hyperesthesia
extending from the nipple area (T4) to T10 anteriorly and
posteriorly, but symptoms were mild and well controlled.
Overall, the etiology for patient's symptoms was uncertain, but
patient was considered stable for discharge because he
clinically had significant improvement and the broad workup was
sent. Differential included small fiber neuropathy, dorsal root
ganglionopathy secondary to autoimmune, rheumatologic,
infectious, or paraneoplastic etiologies. Patient's history was
initially concerning for disseminated zoster, HSV, myelitis, or
dorsal root ganglionopathy. Zoster and HSV were negative. Cannot
rule out worsening cerebral amyloid angiitis or small fiber
neuropathy, although normal MR ___- and ___ makes worsening
angiitis less likely. The clinical course was concerning for
autoimmune given recent spread to C3-C4 of neck and shoulders
with sparing of C5-T1, no involvement of arms, and onset after
prednisone was tapered from 20mg to 10mg. No signs of spinal
cord lesions on MRI C- and ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CC: Altered mental status, apnea, intubated
REASON FOR MICU: Altered mental status, apnea, intubated
Major Surgical or Invasive Procedure:
Intubation ___
Lumbar puncture
History of Present Illness:
Mr. ___ ___ gentleman with a history of PTSD and
schizophrenia/bipolar on seroquel, who presents unresponsive and
apneic, intubated on site, and transferred for further workup.
The patient lives in group home and was reportedly in usual
state of health until ___, when he reported headache. Since
that time, he has been acting oddly and not returned to
baseline. On the day prior to admission, the patient was
confused and "spacing out," and pacing the halls all night. The
morning of admission, he was seated in chair in the hallway with
garbled speech and appeared confused. He subsequently was found
in the hallway presumed to have fallen, reporting difficulty
breathing and bilateral ___ weakness preventing him from walking.
EMS was called and he was taken to ___. Per EMS, he was
lucid and responsive en route.
At ___, he was triggered on arrival for apnea, but had
pulses. He appeared pale and cyanotic, and was unresponsive,
with O2 at of 40% and hypothermic. His pupils were pinpoint, ans
so he was given narcan without effect. He did not regain
respiratory drive, and was therefore intubated without issue.
His labs were notable for leukocytosis to 45.1, VBG with
7.24/68, and ABG post-intubation 7.35/47/89. He had normal
chemistry and a lactate of 2.9. His urine and drug screen were
negative. He had CT head, C-spine, CTA chest/abdomen/pelvis
which were unremarkable aside from possible lower lobe
"irregular consolidation." He was given vancomycin, zosyn,
ceftriaxone 2g, acyclovir, and solumedrol for empiric CNS
infection. LP was attempted 5 times, but unsuccessful due to
body habitus. Neurology and ICU were consulted and planned for
transfer to ___ for continued workup, including possible EEG.
Upon arrival to the ED, his vital signs were normal with T 98.4,
HR 76, BP 105/76, and sat 100% on ventilator. Labs notable for
leukocytosis improving to 27.2 with neutrophilic predominance.
Serum tox negative, urine tox pending. Chemistry unremarkable
aside from bicarb 33, lactate normal 1.2, and VBG 7.42/53.
troponin negative x1. LP attempted once and failed.
EKG with normal sinus rhythm at 79, normal axis, normal
chambers, early RWP, no Q waves or ST elevations/depressions or
TWI.
On arrival to the MICU, patient was intubated and sedated. His
___ mother was contacted, who essentially confirmed history
mentioned, that he has not been himself for the past few days,
and has had garbled speech and headache. She reports that he
coughs at baseline from smoking, and that this didn't seem worse
than baseline. No urinary symptoms, n/v/d, abdominal pain,
rashes, pain anywhere. No recent travel or sick contacts. He
smokes cigarettes and vapes unknown substances. No ETOH use. Has
history of depression/schizophrenia per ___ mother (bipolar
per chart), but she reports that he has never been suicidal and
she doesn't think he ingested anything.
Upon arrival, sedation was weaned off and patient was answering
questions and following commands. He confirmed that he was
feeling short of breath before, and denied any chest pain or
pain anywhere else. He does endorse coughing. He confirms
medication of Seroquel 100 qhs. Upon waking up, patient was
having difficulty moving RLE, so code stroke was called.
However, this resolved after some time.
REVIEW OF SYSTEMS: See above.
Past Medical History:
- PTSD on Seroquel
- Bipolar disorder
- Schizophrenia (per ___ mother)
- History of ortho surgery: RT fx tibia
- R. ear infection
- Insomnia
- Smoker
Social History:
___
Family History:
Mother passed away from AIDS. No other known family history.
Physical Exam:
ADMISSION PHYSICAL EXAM
GENERAL: Alert, answering yes/no questions while intubated, no
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PEERL, EOMI
NECK: JVP unable to assess
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
SKIN: No rash
NEURO: RLE difficult for patient to move (able to move toes, but
not bend knee or hip), moving LLE on command, able to squeeze
hands, but R hand-grip is weaker than L. PEERL, EOMI, able to
smile symmetrically, facial sensation in tact. In tact sensation
throughout.
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: Temp: 98.3 PO BP: 105/64 HR: 62 RR: 16 O2 sat: 99%RA
HEENT: Neck supple, no meningismus
Pulm: breathing comfortably on room air, lungs clear
Abd: soft
Skin: PICC removed. There is a diffuse macular rash primarily
over the torso and upper arms, more confluent but less
erythematous than before.
Mental status- Awake, interactive. Attentive to interview.
Follows multistep commands. Language is fluent without
paraphasias. No dysarthria.
Cranial nerves- pupils equal and briskly reactive. Eye movement
full without nystagmus. Face symmetric. Tongue midline.
Motor- bulk, tone normal throughout. Asterixis absent. No
pronation. Full strength, slightly deconditioned
Sensation- grossly intact to light touch, proprioception in
upper
extremities intact
Coordination- intact finger to nose bilaterally
Reflexes- 2+ and symmetric throughout. No clonus.
Gait- not tested
Pertinent Results:
ADMISSION/IMPORTANT LABS
___ 04:20PM BLOOD WBC-27.2* RBC-4.08* Hgb-11.7* Hct-35.6*
MCV-87 MCH-28.7 MCHC-32.9 RDW-15.2 RDWSD-48.6* Plt ___
___ 04:20PM BLOOD Neuts-88.7* Lymphs-4.4* Monos-5.3
Eos-0.0* Baso-0.2 Im ___ AbsNeut-24.07* AbsLymp-1.20
AbsMono-1.45* AbsEos-0.00* AbsBaso-0.05
___ 04:20PM BLOOD ___ PTT-28.4 ___
___ 04:20PM BLOOD Glucose-142* UreaN-16 Creat-0.7 Na-145
K-4.1 Cl-101 HCO3-33* AnGap-11
___ 04:20PM BLOOD ALT-15 AST-12 AlkPhos-64 TotBili-0.4
___ 02:34AM BLOOD ALT-13 AST-10 CK(CPK)-180 AlkPhos-60
TotBili-0.3
___ 04:20PM BLOOD cTropnT-<0.01
___ 12:07AM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:34AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 04:20PM BLOOD Albumin-3.7 Calcium-9.0 Phos-1.8* Mg-2.1
___ 04:06PM BLOOD HIV Ab-NEG
___ 10:49PM BLOOD Vanco-19.8
___ 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:20PM BLOOD GreenHd-HOLD
___:35PM BLOOD ___ pO2-58* pCO2-53* pH-7.42
calTCO2-36* Base XS-7
___ 02:16AM BLOOD ___ pO2-73* pCO2-56* pH-7.39
calTCO2-35* Base XS-6
___ 04:35PM BLOOD Lactate-1.2
___ 04:35PM BLOOD O2 Sat-89
REPORTS/IMAGING
------------------
___ Imaging MR HEAD W/O CONTRAST
1. Complex fluid within the occipital horns of the lateral
ventricles, without evidence for blood products, concerning for
pus.
2. Chiari 1 malformation with effacement of CSF around the
medulla and upper cervical spinal cord.
3. Right mastoid air cell opacification of unknown chronicity.
4. New fluid and mucosal thickening in the paranasal sinuses,
likely secondary due to endotracheal intubation and prolonged
supine positioning in the inpatient setting.
RECOMMENDATION(S):
1. Given the recent LP, recommend follow-up head CT to assess
for any change in the position of the cerebellar tonsils.
2. Non urgent cervical spine MRI should be considered to assess
for a syrinx in the setting of the ___ 1 malformation.
___ Imaging CTA CTV HEAD
1. Layering complex fluid in the occipital horns of the lateral
ventricles, suggestive of pus, unchanged from ___.
2. Mild to moderate atherosclerotic narrowing involving the V4
segments of
the vertebral arteries, bilaterally. No evidence of vasospasm or
venous
thrombosis.
3. No interval change in ventricle morphology from ___.
4. Re-demonstrated Chiari I malformation.
5. Unchanged near-complete opacification of the right mastoid
air cells.
___ Imaging CT HEAD W/O CONTRAST
1. No new acute intracranial abnormality.
2. Previously noted complex fluid in the occipital horns of the
lateral
ventricles is not well seen on the current study. Ventricles
are unchanged in size.
3. Re-demonstration of known Chiari 1 malformation.
___ CT HEAD W/O CONTRAST
1. No evidence for increasing ventricular size or
ventriculomegaly.
2. Minimal residual complex material layering dependently in the
occipital
horns, similar from the previous examination and better
characterized on prior MRI.
3. No evidence for acute intracranial hemorrhage or vascular
territorial
infarction.
4. Unchanged appearance of a Chiari 1 malformation.
___ CT HEAD W/O CONTRAST
1. No evidence of hemorrhage or infarction.
2. Unchanged findings suggesting increased pressure, presumably
related to
meningitis..
3. Minimal residual complex material layering dependently in the
occipital
horns.
4. Unchanged appearance of Chiari malformation.
___ CT HEAD W/O CONTRAST
1. No acute hemorrhage or infarct..
2. Significant tonsillar descent, crowding at foramen magnum,
stable since
prior. Stable sulcal effacement and reticular size. No
hydrocephalus.
3. No CT evidence of abnormal intraventricular fluid collection.
___ RIGHT UPPER QUADRANT ULTRASOUND
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.
Gallbladder sludge, without evidence of cholecystitis.
MICROBIOLOGY
----------------
CSF STUDIES
___ 11:30AM CEREBROSPINAL FLUID (CSF) ___-___* RBC-___*
Polys-76 ___ ___ 11:30AM CEREBROSPINAL FLUID (CSF) TNC-___* RBC-336*
Polys-82 ___ ___ 11:30 am CSF;SPINAL FLUID Source: LP.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by ___ ___ 14:45.
FLUID CULTURE: NO GROWTH
FUNGAL CULTURE (Preliminary):
Enterovirus Culture: NEGATIVE
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
___ 4:39 am SPUTUM Source: Endotracheal.
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 100 mg PO QHS insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Divalproex (DELayed Release) 1000 mg PO BID
3. QUEtiapine Fumarate 25 mg PO QHS
4. Sarna Lotion 1 Appl TP BID:PRN itch
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pyogenic ventriculitis, presumed secondary to strep pneumoniae
Acute hypoxic respiratory failure
Septic shock
Dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with intubation evaluate and tracheal tube placement.
TECHNIQUE: Single upright AP chest radiograph
COMPARISON: None.
FINDINGS:
The endotracheal tube terminates 2.8 cm from the carina on this expiratory
study. The endotracheal tube courses below the diaphragm and into the
stomach, likely with the side-port in the distal esophagus. This could be
advanced slightly for optimal positioning. Low lung volumes cause
bronchovascular crowding and bibasilar atelectasis. There is no pleural
effusion or pneumothorax.
IMPRESSION:
1. Very low lung volumes causing bibasilar atelectasis and bronchovascular
crowding.
2. Endotracheal tube terminates 2.8 cm from the carina.
3. Enteric tube terminates within the stomach, likely with the side-port in
the distal esophagus. Consider advancing slightly.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man found down and apneic, now with right lower
extremity weakness. Assess for mass/stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT from ___ performed on ___ at 09:24.
FINDINGS:
There is layering FLAIR hyperintense, T2 intermediate, T1 intermediate
material with high signal on diffusion tracer sequence and ADC map in the
occipital horns of the lateral ventricles, without susceptibility artifact on
gradient echo images. The ventricles are normal in size. Cerebral sulci,
suprasellar, perimesencephalic, and prepontine cisterns are normal in size.
There is Chiari 1 malformation with approximately 18 mm descent of the
cerebellar tonsils into the foramen magnum, with effacement of CSF around the
medulla and upper cervical spinal cord. No acute infarction, edema, evidence
for blood products, or other signal abnormalities in the brain parenchyma.
Right mastoid air cells are opacified, as seen on the CT from approximately 12
hours earlier. There is fluid and mucosal thickening in the sphenoid sinuses
and inferior frontal sinuses, with opacification of the frontoethmoidal
recesses, new since the earlier CT, likely secondary to endotracheal
intubation and prolonged supine positioning in the inpatient setting. There
is mild mucosal thickening in the ethmoid air cells and right greater than
left maxillary sinuses.
IMPRESSION:
1. Complex fluid within the occipital horns of the lateral ventricles, without
evidence for blood products, concerning for pus.
2. Chiari 1 malformation with effacement of CSF around the medulla and upper
cervical spinal cord.
3. Right mastoid air cell opacification of unknown chronicity.
4. New fluid and mucosal thickening in the paranasal sinuses, likely secondary
due to endotracheal intubation and prolonged supine positioning in the
inpatient setting.
RECOMMENDATION(S):
1. Given the recent LP, recommend follow-up head CT to assess for any change
in the position of the cerebellar tonsils.
2. Non urgent cervical spine MRI should be considered to assess for a syrinx
in the setting of the ___ 1 malformation.
NOTIFICATION: The intraventricular findings were discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at 10:11 pm, 2
minutes after discovery of the findings. Final impression items 1 and 2, and
the recommendations above, were reported over the telephone by Dr. ___ to
Dr. ___ at 17:00 on ___, 10 minutes after discovery.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old man with apnea, AMS, hypothermia, leukocytosis, c/f
meningitis.// LP
TECHNIQUE: After informed consent was obtained from the patient's healthcare
proxy explaining the risks, benefits, and alternatives to the procedure, the
patient was laid in prone position on the fluoroscopic table. A pre-procedure
time-out was performed confirming the patient's identity, relevant history,
procedure to be performed and labs.
Puncture was performed at L3-4.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 6 cm spinal needle was inserted into
the thecal sac. There was good return of straw-colored CSF. An opening
pressure of 27 mm hg was obtained. 13 mL of CSF were collected in 4 tubes and
sent for requested analysis.
COMPARISON: None.
FINDINGS:
12 mL of CSF were collected in 4 tubes.
IMPRESSION:
1. Lumbar puncture at L3-L4 without complication.
2. Opening pressure of 27 mm Hg.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Radiology Report
EXAMINATION: CTA CTV HEADPQ152CTHEAD
INDICATION: ___ year old man presenting with apnea, MRI showing Chiari I
malformation and pyogenic ventriculitis// please perform CTA AND CTV to look
for vasospasm and venous sinus thrombosis. also eval for change in ventricle
size after LP
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the intravenous administration of 70 mL of Omnipaque350
nonionic contrast material. Three-dimensional angiographic volume rendered and
segmented images were then 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 2.6 s, 20.5 cm; CTDIvol = 27.2 mGy (Head) DLP = 556.8
mGy-cm.
3) Spiral Acquisition 2.6 s, 20.5 cm; CTDIvol = 27.2 mGy (Head) DLP = 556.8
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.8
mGy-cm.
5) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.8
mGy-cm.
6) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 22.7 mGy (Body) DLP =
11.4 mGy-cm.
Total DLP (Body) = 17 mGy-cm.
Total DLP (Head) = 2,048 mGy-cm.
COMPARISON: MR head ___, CT head ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is diffuse effacement of the sulci and mild narrowing of the lateral
ventricles as well as the perimesencephalic cisterns, however, no evidence of
ischemia, or mass effect. Layering fluid which is isodense to the white matter
is unchanged in amount from MR ___ and again is compatible with pus
based on the MR findings, suggesting infectious ventriculitis.
Re-demonstrated Chiari I malformation with effacement of the CSF surrounding
the medulla and the upper cervical spinal cord, unchanged.
No interval change in ventricle morphology from ___.
A 5 mm pedunculated, superficial soft tissue anterior scalp lesion (series 2
image 27) is unchanged from ___.
Endotracheal tube is partially imaged. A second likely orogastric tube coils
in the oropharynx and is only partially imaged.
There is layering fluid in the ___ and oropharynx with a small amount of
layering fluid in the sphenoid and right maxillary sinuses, likely secondary
to intubation.
Almost complete opacification of the mastoid air cells on the right is
unchanged from ___. The mastoid air cells on the left are clear.
CTA/CTV HEAD:
The study is slightly limited due to delay in the bolus timing injection,
within this limitation, there is punctate focus of high attenuation consistent
with average volume from the adjacent bone structures, grossly there is no
evidence of vasospasm, flow stenotic lesions or aneurysms, the left vertebral
artery is dominant. The major dural venous sinuses are patent with no
evidence of dural venous sinus thrombosis.
IMPRESSION:
1. Layering complex fluid in the occipital horns of the lateral ventricles,
suggestive of pus, unchanged from ___. There is diffuse effacement
of the sulci, cisterns and ventricles suggesting mild brain edema, close
follow-up is advised.
2. There is no evidence of flow stenotic lesions throughout the vessels of
the circle of ___. No evidence of vasospasm or venous thrombosis.
3. Re-demonstrated Chiari I malformation.
4. Unchanged near-complete opacification of the right mastoid air cells.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with meningitis, respiratory failure// ?evidence
of new respiratory process ?evidence of new respiratory process
IMPRESSION:
Compared to chest radiographs and chest CT ___.
Previous mild pulmonary edema has improved. Right middle lobe atelectasis has
worsened. Consolidative volume loss, left lower lobe, is probably unchanged,
visible only on the prior CT scan.
Pleural effusions are small if any. Heart size is top-normal but improved.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with meningitis, ventriculitis, worsened mental
status// ?evidence of hydrocephalus or herniation
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 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
186.8 mGy-cm.
Total DLP (Head) = 1,121 mGy-cm.
COMPARISON: CTA and CT head from ___. MR head from ___.
FINDINGS:
The previously noted complex fluid in the occipital horns of the lateral
ventricles is not well seen on the current study.
There is no evidence of acute large territorial infarction,hemorrhage,edema,or
mass-effect. The ventricles are unchanged in size. Redemonstration of known
Chiari 1 malformation. No herniation.
There is no evidence of acute fracture. There is mild mucosal thickening of
the ethmoid air cells and right maxillary sinus. The visualized portion of
the left mastoid air cells and middle ear cavities are clear. Partial
opacification of the right mastoid air cells is again noted. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No new acute intracranial abnormality.
2. Previously noted complex fluid in the occipital horns of the lateral
ventricles is not well seen on the current study. Ventricles are unchanged in
size.
3. Re-demonstration of known Chiari 1 malformation.
Radiology Report
INDICATION: ___ year old man with new dobhoff tube// Eval dobhoff location
TECHNIQUE: Serial portable frontal views of the chest.
COMPARISON: Subsequent abdominal radiograph. Chest radiograph same day.
IMPRESSION:
The second image demonstrates the Dobhoff tube in the right mainstem bronchus.
The final image demonstrates the Dobhoff tube pulled back, likely within the
airway at the level of the carina as the tip is varying to the right in the
direction of the mainstem bronchus. It is noted that the Dobhoff was replaced
on the subsequent examination and was appropriately positioned. Otherwise the
lungs are slightly better aerated than the earlier same day examination with
mild platelike residual atelectasis in the right mid to lower lung field. No
other short-term change.
Radiology Report
INDICATION: Chest and abdominal radiograph
TECHNIQUE: 3 serial frontal views of the abdomen and upper abdomen.
COMPARISON: ___ 16:42.
IMPRESSION:
The final image demonstrates the top off tube tip in the proximal stomach,
satisfactory. Otherwise no short-term interval changes are seen. There
remains low lung volumes with at least mild cardiomegaly and central pulmonary
vascular congestion with perhaps trace interstitial edema. Mild platelike
atelectasis in the right mid to lower lung field is re-demonstrated. There is
no new consolidation, large effusion, or pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with bacterial ventriculitis// Eval for
hydrocephalus
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. CT head ___, CTA head
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
186.8 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head ___, CTA head ___, MR head ___.
FINDINGS:
The patient's known complex fluid in the occipital horns is minimally seen,
better characterized on prior MRI examination. The ventricles and sulci are
unchanged in size and configuration. No evidence for ventriculomegaly.
There is no acute intracranial hemorrhage or large vascular territorial
infarction identified. No mass, mass effect, edema, or midline shift. A
known Chiari 1 type malformation is again seen.
There is no evidence for acute displaced calvarial fracture. Mild mucosal
thickening is seen in scattered ethmoid air cells and within the inferior
posterior left maxillary sinus. The mastoid air cells are underpneumatized
bilaterally, with unchanged partial opacification on the right. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence for increasing ventricular size or ventriculomegaly.
2. Minimal residual complex material layering dependently in the occipital
horns, similar from the previous examination and better characterized on prior
MRI.
3. No evidence for acute intracranial hemorrhage or vascular territorial
infarction.
4. Unchanged appearance of a Chiari 1 malformation.
Radiology Report
EXAMINATION: Portable AP chest
INDICATION: ___ year old man with meningitis, respiratory failure, new
dobhoff// eval dobhoff location
TECHNIQUE: Sequential portable AP chest radiographs acquired at 09:31 and
09:34
COMPARISON: Chest radiograph dated ___. CT chest
dated ___.
FINDINGS:
Sequential radiographs demonstrate interval placement of a Dobhoff enteric
tube, with tip projecting over the lower esophagus at 09:31, and projecting
over the left upper quadrant, in the expected location of the stomach at
09:34. There is a streak of probable atelectasis in the right mid lung. In
the lateral aspect of the left hemithorax is not included in the field of
view. No right pleural effusion. No pneumothorax is visualized. The
cardiomediastinal silhouette is similar to prior, with borderline
cardiomegaly.
IMPRESSION:
Sequential radiographs demonstrating a Dobhoff enteric tube, with tip
initially projecting over the lower esophagus, with final radiograph
demonstrating the tip projecting over the expected location of the stomach in
the left upper quadrant. Streak of atelectasis in the right midlung. Please
note that the lateral aspect of the left hemithorax is not included on the
field of view.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC// 50 cm R basilic DL PICC- ___
___ Contact name: ___: ___
TECHNIQUE: 2 frontal views of the chest
COMPARISON: ___
FINDINGS:
Mild interstitial prominence and vascular congestion suggesting mild edema.
This is stable. Previous bandlike opacity right midlung has resolved.
Moderate cardiomegaly again noted
No significant pleural effusion or pneumothorax.
There is a new right-sided PICC line terminating at cavoatrial junction. An
NG or Dobhoff tube is at least in the stomach but tip is off the film.
IMPRESSION:
Mild edema stable. New right-sided PICC line terminating at the cavoatrial
junction. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ventriculitis, incr cough and secretions//
eval PNA
TECHNIQUE: 2 frontal views of the chest
COMPARISON: ___
FINDINGS:
Low lung volumes. No dense infiltrate or edema. Linear atelectasis right
midlung.
Moderate cardiomegaly stable.
No significant pleural effusion or pneumothorax. Right-sided PICC line
terminating at the cc. The Dobhoff 4 or NG tube is at least in the stomach
but its tip is off the film.
IMPRESSION:
No acute pulmonary disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with meningitis, ventriculitis// eval for
interval change, hydro
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 47.4 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 843 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
As compared to the prior examination, there has been no significant interval
change. Again, there is no evidence of hemorrhage or infarction. The sulci
are effaced, the ventricles are small and the foramen magnum appears crowded.
These are findings of increased intracranial pressure, unchanged since the
prior study.
The ventricles and sulci are unchanged and normal in size and appearance.
Minimal dependently layering complex fluid within the occipital horns
bilaterally is minimally conspicuous, better seen on prior MRI examination.
There is no evidence for fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Unchanged findings suggesting increased pressure, presumably related to
meningitis..
3. Minimal residual complex material layering dependently in the occipital
horns.
4. Unchanged appearance of Chiari malformation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with leukocytosis, cough// Eval for pneumonia
Eval for pneumonia
IMPRESSION:
Compared to chest radiographs ___ through ___.
Heart size is normal. Pulmonary vascular engorgement has improved. Lungs
clear of focal abnormality. No pleural effusion or pneumothorax.
Feeding tube passes below the diaphragm and out of view.
Radiology Report
INDICATION: ___ year old man with cough, leukocytosis, evaluate for pneumonia
TECHNIQUE: Single upright AP chest radiograph
COMPARISON: Multiple prior chest radiographs dating back to ___,
most recently ___.
FINDINGS:
New hazy opacification of the left lower lung is suggestive of a moderate
layering pleural effusion with associated atelectasis. There is no
right-sided pleural effusion or consolidation. There is no pneumothorax or
pulmonary edema. The cardiomediastinal silhouette is stable. A right PICC
terminates in the low SVC.
IMPRESSION:
New hazy opacification of the left lower lung suggesting moderate layering
pleural effusion with atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ventriculitis// Eval for interval change in
pyogenic ventriculitis
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 747 mGy-cm.
COMPARISON: Multiple prior head CTs most recent dated ___
FINDINGS:
There is no evidence of acute large territory infarction or hemorrhage. The
ventricles and sulci are stable in size and configuration. Diffuse sulcal
effacement. Crowding at foramen magnum with tonsillar descent below foramen
magnum, stable. No periventricular edema.
There is no evidence of fracture. Mild volume fluid is visualized within the
right mastoid air cells otherwise the visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute hemorrhage or infarct..
2. Significant tonsillar descent, crowding at foramen magnum, stable since
prior. Stable sulcal effacement and reticular size. No hydrocephalus.
3. No CT evidence of abnormal intraventricular fluid collection.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with unexplained leukocytosis// Eval for
acalculous cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT scan of the chest from ___.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: Layering sludge is present in the gallbladder, without evidence
of cholecystitis.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.9 cm.
KIDNEYS: The right kidney measures 10.5 cm and the left kidney measures 11.4
cm. There is no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
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.
Gallbladder sludge, without evidence of cholecystitis.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ua
level of acuity: 2.0 | Mr. ___ ___ year-old gentleman with a history of PTSD
and schizophrenia/bipolar on seroquel, who presented with 3 days
headache and encephalopathy. At an outside hospital he became
unresponsive and apneic, was intubated, found to have bacterial
meningitis and pyogenic ventriculitis.
# Bacterial Meningitis / Pyogenic Ventriculitis: Likely S.
pneumoniae based on gram stain.
#) Toxic metabolic encephalopathy
Initially altered as below, and intubated in that setting.
Purulent LP and MRI concerning for pyogenic ventriculitis, with
gram stain on CSF likely consistent with S. pneumo. However,
cultures from CSF (obtained after antibiotics were given),
showed no growth. HIV negative. He was initially covered broadly
with vancomycin/cefepime/acyclovir, infectious disease and
neurology were consulted, neurology exams trended carefully,
including with CT scans to rule out obstructive hydrocephalus.
He was narrowed to meningitis coverage with
vancomycin/ceftriaxone 2g as well as dexamethasone (dose:
0.15mg/kg q6hr x4 days 20 IV q6, ending ___. Given the
presumed S. pneumonia meningitis, he completed a 14 day of
Ceftriaxone. EEG monitoring was performed given his
encephalopathy, and showed diffuse slowing with occasional
periodic sharp waves, though no seizures. However, he was felt
to be at high risk for seizures given his bacterial meningitis.
Lacosamide was started initially but then switched to Keppra as
Lacosamide was denied by insurance. He subsequently developed a
rash after starting Keppra, prompting a switch to Depakote. He
should continue on Depakote until follow-up with neurology.
Neurologic exam on discharge was non-focal.
#) Apnea
#) Hypoxic respiratory failure
#) Pneumonia
Apneic upon arrival to OSH ED, likely in setting of CNS
infection. He initially had persistently high O2 requirement
even after apneic episodes resolved. Seems related to depressed
mental status/poor cough and inability to clear secretions and
atelectasis. Covered with vanc/CTX in case of co-existing strep
pneumo pulmonary infection, then Ceftriaxone monotherapy. On
discharge, he was breathing on room air.
#) Dysphagia
After extubation, he has persistent oropharyngeal dysphagia,
requiring placement of an NG tube for feeding. However, with
time, his swallowing improved and he was able to tolerate a
pureed diet.
#) Leukocytosis
He initially presented with a white count of 27, which improved
with antibiotics. WBC count was 9.8 on ___, but then
subsequently rose to as high as 18.8. Repeat infectious work-up,
including blood and urine cultures, head CT, chest x-ray, and
right upper quadrant ultrasound were unrevealing for an acute
infectious process. He remained afebrile and well-appearing
during this time. WBC trended to normal prior to discharge.
#) Rash
As above, he developed a diffuse macular rash on ___. This was
suspected to be a drug rash, with likely culprits either
Ceftriaxone or Keppra. As his course of Ceftriaxone course
finished the next day, no changes were made to antibiotics.
Keppra was switched to Depakote. Liver function tests were
normal. He was treated symptomatically for pruritis with sarna
lotion.
#) PTSD/Bipolar/Schizophrenia/Depression
Unclear what his exact psychiatric history is, but patient is on
100mg seroquel qhs. On disability and lives in ___ ___
___ next door to his ___ mother who is currently acting as
HCP, but does not have paperwork herself. Held quetiapine while
still ongoing encephalopathy. Can restart in rehab with plan to
increase back to previous dose.
#Chiari 1 malformation with effacement of CSF around the
medulla: stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Codeine / bupropion / cefpodoxime / azithromycin
Attending: ___.
Chief Complaint:
Gross hematuria
Major Surgical or Invasive Procedure:
Catheter insertion with continuous bladder irrigation
History of Present Illness:
This is a ___ year old male who
presents with 1 day of painless gross hematuria. Patient has
history of BPH s/p TURPx2, most recently in approx ___ years
ago,
CKD stage III, ___. He presents with 1 day of
hematuria associated with clots. He awoke yesterday morning and
urinated without issues but when he looked in the toilet saw
that
it was bright red with blood, does not remember if there were
clots. He voided again several hours later, again without
difficulty but since it continued to be bloody he presented to
the ER. He denies dysuria, suprabupic pain, fever, chills, chest
pain, shortness of breath. He has chronic constipation. He does
not recall ever having hematuria before. He denies LUTS at
baseline, has ocassional incontinence overnight.
3-way catheter was inserted in the ER and he was started on CBI
but urine did not clear with large clots. There he was afebrile
with stable vitals. UA appeared grossly positive, concerning for
infection. CT was performed showing new asymmetric bladder wall
thickening and concern for active bleeding. He was therefore
admitted to continue CBI.
Past Medical History:
___ familial
Hypertension
BPH s/p TURP x2
Urinary Retention
Chronic Constipation
GERD w/ small hiatal hernia
Melanoma s/p excision
Anxiety/Depression
L hip fracture (___)
OA
Restrictive lung disease
Chronic pain
Insomnia
Social History:
___
Family History:
His mother, sister, and maternal uncle have ___.
Physical Exam:
GEN -- NAD, AAO
Abd -- SNT, distended
Urine -- rust colored urine in urinal
Pertinent Results:
___ 06:35AM BLOOD WBC-5.9 RBC-2.55* Hgb-7.8* Hct-25.1*
MCV-98 MCH-30.6 MCHC-31.1* RDW-18.4* RDWSD-64.8* Plt ___
___ 01:15PM BLOOD Glucose-97 UreaN-27* Creat-1.1 Na-145
K-4.5 Cl-107 HCO3-27 AnGap-11
___ 2:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO TID
3. Fentanyl Patch 50 mcg/h TD Q72H
4. Gabapentin 100 mg PO TID
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. PARoxetine 20 mg PO DAILY
7. Sucralfate 2 gm PO BID
8. Vitamin D ___ UNIT PO DAILY
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Lactulose 30 mL PO BID constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Terazosin 10 mg PO QHS
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Docusate Sodium 100 mg PO TID
3. Fentanyl Patch 50 mcg/h TD Q72H
4. Gabapentin 100 mg PO TID
5. Lactulose 30 mL PO BID constipation
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. PARoxetine 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Sucralfate 2 gm PO BID
10. Terazosin 10 mg PO QHS
11. Vitamin D ___ UNIT PO DAILY
12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until urine has cleared
Discharge Disposition:
Home
Discharge Diagnosis:
Gross hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ with hx of ___, stage III CKD, hypertension
who presents with gross hematuria for 1 day. Etiology of painless gross
hematuria
TECHNIQUE: A CT U protocol was employed: Noncontrast CT through the abdomen
pelvis was initially performed. Following this, IV contrast administration
was performed and a split bolus CT was performed followed by a delayed 3
minutes series through the abdomen and pelvis. Multiplanar reformations
provided.
DOSE: Total DLP (Body) = 1,680 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Bibasilar subsegmental atelectasis. Otherwise, visualized lung
bases are clear. There is no pleural or pericardial effusion. Trace
pericardial effusion is noted. There is a small hiatal hernia. The heart is
top-normal in size.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Subtle hypoenhancement of the a patent parenchyma suggests steatosis. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is mildly enlarged measuring approximately 14 cm. No
discrete focal splenic lesion.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: No kidney stone, ureteral stone or hydronephrosis. Several small
renal cortical cysts are noted bilaterally, several appear too small to
characterize. No worrisome renal lesion.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout.
Diverticulosis of the colon is noted, without evidence of wall thickening and
fat stranding. The appendix is normal.
PELVIS: Again demonstrated, is a large superior urinary bladder diverticulum.
Hyperdense material within this bladder diverticulum is consistent with blood
products. There is contrast extravasation within this large diverticulum on
the arterial phase CT, series 5 image 158 through 168 concerning for active
bleeding from the wall of the bladder diverticulum.
In addition, there is asymmetric soft tissue thickening along the left urinary
bladder wall best seen on series 5, image 172-182, nonspecific though
correlation with cystoscopy is recommended as a neoplasm is not excluded.
Foley catheter balloon terminates in the urinary bladder lumen. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is a left hip fixation without evidence of hardware complication.
There is no evidence of worrisome osseous lesions or acute fracture. Stable
multilevel degenerative changes of the visualized thoracolumbar spine are
noted.
SOFT TISSUES: Small fat containing bilateral inguinal hernias. Otherwise, the
abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Active bleeding from the wall of the urinary bladder diverticulum with
large volume hematoma within the urinary bladder and urinary bladder
diverticulum.
2. Asymmetric thickening along the urinary bladder wall requires cystoscopy to
exclude malignancy.
3. Small hiatal hernia.
4. Diverticulosis without evidence of acute diverticulitis.
5. Mild splenomegaly.
RECOMMENDATION(S): Consider interventional radiology consult given active
bleeding and nonemergent cystoscopy to further evaluate asymmetric thickening
along the left urinary bladder wall.
NOTIFICATION: Changes to initial preliminary read were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 10
30 pm, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: BLADDER US
INDICATION: ___ year old man with gross hematuria// Eval for residual clot
burden
TECHNIQUE: Grey scale and color Doppler ultrasound images of the bladder were
obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Bladder contains a Foley catheter. A large bladder diverticulum arises from
the dome of the bladder. Moderate amount of heterogeneous echogenic material
measuring approximately 3.6 x 1.9 x 3.1 cm seen within this bladder
diverticulum, consistent with clot as seen on recent CT. Extent appears
overall decreased compared to the CT.
IMPRESSION:
Moderate clot burden within the known bladder diverticulum. Clot burden
appears decreased compared to recent CT.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematuria
Diagnosed with Cystitis, unspecified with hematuria
temperature: 98.3
heartrate: 90.0
resprate: 16.0
o2sat: 97.0
sbp: 121.0
dbp: 96.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ was admitted to the urology service for management of
gross hematuria. A three-way catheter was placed and he was
initiated on continuous bladder irrigation. Substantial clot
was hand irrigated out on his first day of hospitalization.
Hematuria continued on hospital day 2 requiring further hand
irrigation. An ultrasound was performed on hospital day 3
demonstrating significant residual clot in the bladder
diverticulum. Ultimately his urine cleared, his catheter was
removed, and he was able to void without difficulty.
On hospital day 4 the patient was tolerating good p.o. intake,
was at his baseline functional status and was voiding without
difficulty. He was deemed stable for discharge home. He will
follow-up as an outpatient for cystoscopy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
___ Extubation
History of Present Illness:
___ woman with history of new hypertension,
hypothyroidism, migraines (not on medications), and no history
of
seizures/TIA/CVA/MI who comes in with unresponsiveness and
intubated on arrival to OSH.
History obtained from: Two daughters (___), and two
sons (___), and grandson (___)
Regarding her current presentation-
This AM while at home (she lives in elderly housing), neighbors
heard her calling for help. When EMS arrived, she was noted to
have rectal temp of 91, O2 sat or 94%, SBP 220, was talking and
noted that she did not feel well. There was no evidence of
trauma. En route to the OSH, she was noted to be vomiting and
was
intubated. On arrival to OSH, she had BP 199/105. She had a
negative CT ___, and she was transferred here for further
management. At OSH, her labs were significant for K 3.1, trop <
0.01, normal ammonia level, lactate of 3.4, glucose of 135. She
was loaded with keppra. Noted to have no nuchal rigidity.
She is now being admitted to ICU for altered mental status of
unclear etiology.
Her recent history is notable for:
She was in her usual state of health until ___ when she had
been complaining of headaches. She was seen at ___,
had a 1-day stay in the ED, was seen by an ophthalmologist and
notably had a negative eye exam, had a negative ___ CT, and was
discharged. She had nonfocal neuro exam at the time but had
numbness in her leg, hand, and face (right hand) and at that
time
also documented a history of vertigo about ___ years prior.
On ___, she was seen by her PCP for ___ similar presentation of
headache, intermittent paresthesias on the right side of her
body
and facial paresthesias, as well as some confusion. She was also
noted to be disoriented with respect to time ___ instead of
___. She reported intermittent headache, squiggly lines
affecting her left eye without temporal pain, jaw claudication,
vision loss, and she also endorsed a bump on her ___ in the
last
couple days. She had a CT ___ which was negative for acute
findings. Her chemistries were normal with chronic renal
insufficiency stable, and her CBC was unremarkable. She was
recommended admission but declined reporting that she wanted to
go home to take care of her dog. She was deemed to have
capacity,
started on lisinopril, and discharged.
She reports that recently she had her levothyroxine increased
from 125mcg daily to 137.5 mcg daily.
In the ED,
Initial Vitals:
T 96 HR 117 BP 154/113 RR 14 O2 Sat 98% Intubation
Exam:
Con: Intubated, unresponsive initially however then responding
to
pain by moving arms and legs
HEENT: Small amount of crusted blood at left nares however no
septal hematoma, Pupils equal, round and reactive to light and 2
mm bilaterally
Resp: Symmetric ventilated breath sounds bilaterally
CV: Irregular and mildly tachycardic, 2+ femoral and carotid
pulses bilaterally
Abd: Soft, nondistended
MSK: No deformity or edema
Skin: No rash, Warm and dry
Neuro: Intubated and unresponsive initially however when
propofol
weaned did start moving extremities
Psych: Intubated and unresponsive
Labs:
pH 7.29 pCO2 51
Lactate 1.8
UTox negative
CBC within normal limits
Coags: ___ 11.6, PTT 22.3, INR 1.1
UA glucose 100, 10 ketone, 30 protein, few bacteria
Other:
Chem panel - Cr 1.0, normal anion gap
Trop - 0.04
Serum tox- normal
LFTs- normal
EKG with afib HR 110
Imaging:
- CT ___ without Contrast ___
1. No acute intracranial process.
2. No calvarial fracture.
- CT C-spine without contrast ___
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes of the cervical spine worst
at
C3-4 and C5-6.
- CXR ___
The endotracheal tube terminates approximately 3.5 cm above the
carina. No acute cardiopulmonary process.
Consults: None
Interventions:
- Propofol drip
- Fentanyl drip
- Pt placed on CMV 420 X 18 40% 5 PEEP.
RR was increased to 20 after VBG was 7.29, 51.
ET is at 24@ incisor 7.5
VS Prior to Transfer:
HR 93 BP 125/83 RR 18 O2 Sat 100% Intubation
She has never filled out a HCP form.
Upon extubation, further history is obtained. Patient reports
shortness of breath ongoing for weeks and abdominal pain for a
couple of months. She reports issues with significant nausea on
and off for the last month.
She reports her first symptom today was nausea followed by
unilateral numbness, tingling and paresthesias (although she
does
not recall which side this was felt on). Despite this, she feels
that she remembers the events clearly and denies any confusion.
She denies any headache or visual changes. She did not have any
dysarthria, incontinence, or tongue biting during these
episodes.
She reports difficulty opening her eyes because it worsens her
dizziness, although she denies any sensation of spinning and
denies any photophobia. She reports compliance with her
medications although is suspicious of her thyroid hormone
medication, which she believes is dosed too highly. She takes
her
synthroid on an empty stomach every morning with one hour gap
before breakfast. She reports good appetite recently and states
she eats normally without any changes in weight.
She reports an episode of vertigo several years ago, but this
feels much worse and not that similar.
She does have an episode of emesis today shortly after
extubation
with small amount of coffee ground. She is hemodynamically
stable
during this episode.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Hypertension
Hypothyroidism
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: BP 120/99 HR 85 RR 20 O2 99% Intubated
GEN: Intubated, sedated, follows commands
HEENT: PERRL, EOMI. No tongue lacerations, no bleeding.
NECK: Difficult to assess nuchal rigidity. No thyroid nodules,
no lymphadenopathy.
CV: Irregularly irregular rhythm, no heart murmurs
RESP: Normal work of breathing, clear bilaterally
GI: Soft, nontender, nondistended.
GU: Foley in place
MSK: Moves both extremities equally, squeezes hands on both
sides. No appreciable edema.
SKIN: No bruises or rashes.
NEURO: Intubated and sedated as above. When extubated--
Able to move all extremities equally, intact sensation equally,
CN II-XII intact
DISCHARGE PHYSICAL EXAM:
==========================
24 HR Data (last updated ___ @ 919)
Temp: 98.1 (Tm 98.7), BP: 141/97 (105-141/69-97), HR: 93
(85-93),
RR: 18 (___), O2 sat: 96% (95-97), O2 delivery: Ra
General: Uncomfortable, endorses nausea and
dizziness
HEENT: NCAT, no oropharyngeal lesions, neck supple
Pulmonary: Unlabored work of breathing
Extremities: Warm, no edema
Psych: flat affect
Neurologic Examination:
- Mental status: Awake, alert and oriented x4, Speech is sparse
but fluent, with intact comprehension. No dysarthria. Hypophonia
- Cranial Nerves: PERRL (4 to 2 mm ___. VF full to number
counting. EOMI without nystagmus. V1-V3 without deficits to
light
touch bilaterally. No facial movement asymmetry. Palate
elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: Normal bulk and tone. No pronator drift. Fine postural
tremor.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
- Sensory: No deficits to light touch bilaterally. No extinction
to DSS.
- Coordination: Mild dysmetria and FNF on right and difficulties
mirroring on right. Right finger taps slightly slower than left
- Gait: slow to rise, wide based and unsteady. +Romberg
Pertinent Results:
ADMISSION LABS:
===============
___ 02:05PM WBC-9.7 RBC-3.85* HGB-12.0 HCT-37.1 MCV-96
MCH-31.2 MCHC-32.3 RDW-13.3 RDWSD-47.3*
___ 02:05PM NEUTS-87.4* LYMPHS-7.3* MONOS-4.1* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-8.49* AbsLymp-0.71* AbsMono-0.40
AbsEos-0.01* AbsBaso-0.03
___ 02:05PM PLT COUNT-151
___ 02:05PM ___ PTT-22.3* ___
___ 02:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-100* KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 02:05PM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 02:05PM URINE MUCOUS-RARE*
___ 02:05PM GLUCOSE-168* UREA N-17 CREAT-1.0 SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-19* ANION GAP-15
___ 02:05PM ALT(SGPT)-23 AST(SGOT)-39 CK(CPK)-110 ALK
PHOS-57 TOT BILI-0.3
___ 02:05PM LIPASE-29
___ 02:05PM cTropnT-0.04*
___ 02:05PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-1.7 CHOLEST-263*
___ 02:05PM %HbA1c-5.1 eAG-100
___ 02:05PM TRIGLYCER-79 HDL CHOL-104 CHOL/HDL-2.5
LDL(CALC)-143*
___ 02:05PM PROLACTIN-57* TSH-7.1*
___ 02:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 02:16PM LACTATE-1.8
___ 02:16PM O2 SAT-64
LAST SET OF LABS PRIOR TO DISCHARGE:
========================================
___ 05:30AM BLOOD WBC-5.8 RBC-3.56* Hgb-11.3 Hct-33.6*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.4 RDWSD-46.6* Plt ___
___ 05:30AM BLOOD ___ PTT-26.4 ___
___ 05:30AM BLOOD Glucose-87 UreaN-15 Creat-1.0 Na-135
K-3.8 Cl-102 HCO3-24 AnGap-9*
___ 03:36AM BLOOD CK-MB-4 cTropnT-0.02*
Imaging/Studies:
================
EEG ___
It showed a normal background in wakefulness except for the
frequent bursts of generalized ___ Hz slowing. These findings
indicate a dysfunction in midline structures but are not
specific with regard to etiology. Vascular disease is among many
possible causes. Nevertheless, there were no areas of persistent
focal slowing, and there were no epileptiform features or
electrographic seizures.
CT ___ without contrast ___
1. No acute findings.
2. Severe chronic small vessel ischemic change. Parenchymal
atrophy.
3. Mild paranasal sinus disease.
CT C-spine without contrast ___
1. No acute findings.
2. Cervical spine degenerative changes.
CXR ___
The endotracheal tube terminates approximately 3.5 cm above the
carina. No
acute cardiopulmonary process.
MR ___ W and Without Contrast ___
1. Large early subacute infarct involving the right cerebellar
___ territory, sparing the medulla. No mass-effect or evidence
for associated blood products.
2. Punctate focus of slow diffusion in the left medial temporal
lobe and more extensive T2/FLAIR hyperintensity in the medial
left temporal lobe along the left temporal horn. This most
likely represents an early subacute infarct superimposed upon
chronic changes.
3. Linear focus of high signal on diffusion tracer in the right
paracentral
centrum semiovale, within an area of extensive confluent
T2/FLAIR
hyperintensity, could represent T2 shine through from chronic
small vessel
ischemic disease, versus a late subacute infarct.
4. Extensive T2/FLAIR signal abnormalities in the supratentorial
white matter, nonspecific but likely sequela of chronic small
vessel ischemic disease in this age group. Multiple small
chronic infarcts in the basal ganglia, corona radiata, and
centrum semiovale. Lobulated 15 x 15 mm cystic structure with
at least two thin enhancing septations centered in the putamen,
likely a congenital cyst versus a large Virchow ___ space.
5. Small amount of fluid in the sphenoid sinuses, simple on the
right and
complex on the left. Please correlate clinically with any
symptoms of active
sinusitis.
TTE ___:
The visually estimated left ventricular ejection fraction is
70%. There is
no resting left ventricular outflow tract gradient. Mildly
dilated right ventricular cavity with normal free wall motion.
Tricuspid annular plane systolic excursion (TAPSE) is normal.
The aortic sinus diameter is normal for gender with mildly
dilated ascending aorta. The aortic arch diameter is normal with
a mildly dilated descending aorta. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is trace aortic regurgitation. The mitral valve leaflets
are mildly thickened with no mitral valve prolapse. There is
mild [1+] mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is moderate [2+] tricuspid regurgitation. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mildly dilated right ventricle. Normal
regional/global biventricular systolic function. Moderate
tricuspid regurgitation. Mild pulmonary hypertension.
MEASUREMENTS:
LEFT ATRIUM ___ ATRIUM (RA)
___: 3.4cm (nl<=4.0)
___ 4Chamber Length: 4.6cm (nl<5.2)
___ Volume: 59mL
___ Volume Index: 35mL/m² (nl <35)
RA 4Chamber Length: 5.0cm (nl<5.2)
Inferior vena cava
diameter: 2.1cm
LEFT VENTRICLE (LV)
Septal Thickness:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Levothyroxine Sodium 137 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ischemic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ with history of HTN and hypothyroidism, unresponsive and
intubated at OSH, found to have new onset atrial fibrillation, concerning for
embolic stroke or seizure activity.
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: CT head without contrast ___.
FINDINGS:
There is a large area of slow diffusion with mild associated T2/FLAIR
hyperintensity involving the right posterior inferior cerebellar hemisphere
and right inferior vermis, in the ___ territory, without associated medullary
involvement. No evidence for associated blood products, mass effect, or
contrast enhancement.
There is a punctate focus of slow diffusion in the left medial temporal cortex
(6:13, 5:13). There is more diffuse T2/FLAIR hyperintensity in the left
medial temporal lobe extending along the temporal horn, without mass effect,
and with fast diffusion on the ADC map, images 11:11, 5:13. This most likely
represents an early subacute infarct superimposed upon chronic changes. No
associated blood products or contrast enhancement.
There is a linear focus high signal on diffusion tracer image 6:22 in the
right paracentral centrum semiovale, without low signal on the ADC map. This
is within an area of extensive confluent T2/FLAIR hyperintensity in the right
centrum semiovale and could represent T2 shine through, versus a late subacute
infarct.
There is extensive confluent T2/FLAIR hyperintensity in the periventricular,
deep, and subcortical white matter of the cerebral hemispheres, nonspecific
but likely sequela of chronic small vessel ischemic disease given the
patient's age and cardiovascular risk factors. There are scattered small
chronic infarcts in the basal ganglia, centrum semiovale, and corona radiata.
There is a 15 x 15 mm lobulated cystic structure with at least two thin
enhancing septations centered in the putamen (14:88, 100:92), likely a
congenital cyst versus a large Virchow ___ space.
No evidence for an enhancing mass. No evidence for pathologic leptomeningeal
or pachymeningeal contrast enhancement.
Intracranial left vertebral artery appears hypoplastic, suggesting non
dominant status. Major vascular flow voids are otherwise grossly preserved.
Dural venous sinuses appear patent on postcontrast MP RAGE images.
There is a small amount of fluid within bilateral sphenoid sinuses, simple on
the right and complex on the left, and mild mucosal thickening in the left
sphenoid sinus. There is also minimal mucosal thickening in the bilateral
ethmoid air cells. There is trace fluid in the right mastoid air cells.
Sagittal T1 weighted images demonstrate incompletely evaluated degenerative
changes in the included upper cervical spine.
IMPRESSION:
1. Large early subacute infarct involving the right cerebellar ___ territory,
sparing the medulla. No mass-effect or evidence for associated blood
products.
2. Punctate focus of slow diffusion in the left medial temporal lobe and more
extensive T2/FLAIR hyperintensity in the medial left temporal lobe along the
left temporal horn. This most likely represents an early subacute infarct
superimposed upon chronic changes.
3. Linear focus of high signal on diffusion tracer in the right paracentral
centrum semiovale, within an area of extensive confluent T2/FLAIR
hyperintensity, could represent T2 shine through from chronic small vessel
ischemic disease, versus a late subacute infarct.
4. Extensive T2/FLAIR signal abnormalities in the supratentorial white matter,
nonspecific but likely sequela of chronic small vessel ischemic disease in
this age group. Multiple small chronic infarcts in the basal ganglia, corona
radiata, and centrum semiovale. Lobulated 15 x 15 mm cystic structure with at
least two thin enhancing septations centered in the putamen, likely a
congenital cyst versus a large Virchow ___ space.
5. Small amount of fluid in the sphenoid sinuses, simple on the right and
complex on the left. Please correlate clinically with any symptoms of active
sinusitis.
RECOMMENDATION(S): Consider follow-up brain MRI with and without contrast in
3 months to confirm expected stability of the left putaminal cystic lesion.
NOTIFICATION: According to the ___ Neurology Stroke Attending
Initial Note in the ___ medical record, the infarcts described in
impression items 1 through 3 are already known to the Neurology attending.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ woman with history of new
hypertension,hypothyroidism, migraines (not on medications), and no history
ofseizures/TIA/CVA/MI who comes in with unresponsiveness requiring intubation
at OSH, transferred to ___ for ICU level care. Found to have R PICU infarct
on MRI// eval for source of stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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 5.2 s, 41.1 cm; CTDIvol = 13.3 mGy (Body) DLP = 545.2
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 32.7 mGy (Body) DLP =
16.3 mGy-cm.
Total DLP (Body) = 563 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: MRI head with without contrast ___
CT head without contrast ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
A late subacute infarct involving the right ___ territory is re-demonstrated.
No hemorrhage is seen.
The ventricles and sulci are prominent, consistent global cerebral volume
loss. Extensive periventricular hypodensities are most consistent with
chronic microvascular ischemic disease. A large prominent perivascular spaces
seen in the left basal ganglia.
There is moderate mucosal thickening of the left sphenoid sinus and mild
mucosal thickening of the right sphenoid sinus. Chronic left sphenoid sinus
periostitis.. The mastoid air cells,and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
CTA HEAD:
Attenuated distal branch right ___.
Otherwise, the vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion, or aneurysm
formation. There is fetal origin of the left posterior cerebral artery.
There is near complete ___ termination of the left vertebral artery with a
diminutive distal V4 segment. The dural venous sinuses are patent.
CTA NECK:
Atherosclerotic changes of the carotid bifurcations are seen without narrowing
of the internal carotid arteries, by NASCET criteria. The vertebral arteries
appear normal with no evidence of stenosis or occlusion. A dominant right
vertebral artery is seen, with very small caliber left vertebral artery
throughout its length.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Degenerative changes of the cervical spine are seen.
IMPRESSION:
1. Early subacute infarct right ___ territory, stable. No hemorrhage..
2. Attenuated very distal branch right ___.
3. Severe chronic small vessel ischemic change..
4. Findings consistent with acute on chronic sphenoid sinusitis.
5. Otherwise normal CTA neck, CTA head.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ETT*** WARNING *** Multiple patients with same
last name!// eval ETT
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: None available.
FINDINGS:
The endotracheal tube terminates approximately 3.5 cm above the carina.
No focal consolidation or pulmonary edema. No pleural abnormalities. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
The endotracheal tube terminates approximately 3.5 cm above the carina. No
acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ unresponsive patient intubated and transferred to
BI*** WARNING *** Multiple patients with same last name!// Intracranial bleed,
fracture, c-spine fracture?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 8.0 s, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of large territorial infarction,hemorrhage,edema,or mass.
Brain parenchymal atrophy. Severe chronic small vessel ischemic change.
Prominent prevascular space inferior left basal ganglia.
There is no evidence of fracture. Small amount of fluid is noted in the
bilateral sphenoid sinuses. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
1. No acute findings.
2. Severe chronic small vessel ischemic change. Parenchymal atrophy.
3. Mild paranasal sinus disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ unresponsive patient intubated and transferred to
BI*** WARNING *** Multiple patients with same last name!// Intracranial bleed,
fracture, c-spine fracture? Intracranial bleed, fracture, c-spine
fracture?
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 21.3 cm; CTDIvol = 22.7 mGy (Body) DLP = 482.2
mGy-cm.
Total DLP (Body) = 482 mGy-cm.
COMPARISON: None available.
FINDINGS:
Alignment is normal. No fractures are identified.The vertebral body heights
are preserved. There is moderate to severe loss of disc heights at C3-4, C5-6
and C6-7. Anterior posterior osteophytes are seen throughout the cervical
spine, worst at C3-C6. Multilevel mild central canal narrowing. Multilevel
moderate to severe foraminal narrowing.
No prevertebral edema..The thyroid is unremarkable. Biapical scarring is
noted. The patient is intubated. Few air bubbles within left neck veins,
likely iatrogenic from IV line use, of doubtful significance.
IMPRESSION:
1. No acute findings.
2. Cervical spine degenerative changes.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ett
level of acuity: 1.0 | Ms. ___ is a ___ woman with history of new hypertension,
hypothyroidism, migraines (not on medications), and no history
of seizures/TIA/CVA/MI who comes in with unresponsiveness
requiring intubation at OSH, transferred to ___ for ICU level
care.
ACUTE ISSUES
===============
# Unresponsiveness
# Altered mental status
# Respiratory failure requiring intubation
Her initial presentation of unresponsiveness was cocnerning for
seizure (keppa loaded at OSH, prolactin elevated, and possibly
clinically consistent given her rapid improvement in mental
status, although she has not had prior seizure history) vs.
stroke (ischemic with her hypertension vs. embolic from new
onset atrial fibrillation-- see below regarding atrial
fibrillation.) An acute aspiration event in the setting of
vomiting was considered, as was infection (CXR clear, UA without
infection, no symptoms reported to family in the day preceding
presentation) so these were thought less likely. Acute coronary
syndrome (trop elevation, but no ST changes) was also considered
but ultimately lower suspicion. She has no known history of
diabetes to suggest hypoglycemia and her fingerstick
measurements were noted to be normal. Of note, her prior history
also may be significant for complex migraines given her
aura-like symptoms and unilateral paresthesias. Serum and utox
negative. She was intubated for altered mental status and
concern for airway at OSH but on same day of ICU admission on
___, she was successfully extubated. EEG revealed no seizure
activity so Keppra was not continued. Given low concern for
infection, no antibiotics were initiated. An initial CT revealed
no bleed but subsequent MRI revealed acute right cerebellar
stroke. CTA of ___ and neck without thrombus, specifically in
posterior circulation. It is possible her transient episode of
altered mental status was caused by a thrombus which traveled
through vertebral system before breaking apart.
#Acute Right Cerebellar Stroke, with smaller left mesial
temporal infarct
Etiology of stroke is likely cardioembolic given atrial
fibrillation captured on telemetry this admission vs. less
likely atheroembolic. CTA did not reveal dissection of posterior
circulation or occlusion. Stroke risk factors include A1c of
5.1, LDL of 143, TSH: 7.1. She was started on apixaban 5 mg BID
for anticoagulation given new diagnosis of atrial fibrillation
as well as atorvastatin 80 mg qHS. TTE was without structural or
cardioembolic source of infarct. Patient had significant nausea,
vertigo, and disqueilibrium while in the hospital which has been
slowly improving. Currently with schedule prochlorperazine 10mg
q6h and Zofran 4mg as needed for breakthrough nausea. QTc on
___ of 412.
# Vision change (intermittent difficulty with reading up close)
and headaches, subacute
Most likely related to history of long standing migraines as she
does endorse headache. Screened for temporal arteritis, which is
unlikely given normal ESR/CRP. Her convergence is intact so does
not appear to be related to cranial nerves. Would follow up with
optometry/ophthalmology as outpatient if symptoms continue.
# Hypothermia: Noted to be hypothermic with T = 91 per EMS, on
arrival to ___ still low temp of 96. Concerning for
sepsis/infection vs hypothyroidism (TSH elevated) vs.
___ trauma vs. panhypopituitarism (seems unlikely given
hypertensive, not consistent with adrenal insufficiency); could
also be related to sedation but of note her hypothermia seemed
to precede sedatives. No known prior cold exposure, no burns.
Resolved to normal temperature in ICU.
# Atrial fibrillation: New onset, patient reports no prior
history of atrial fibrillation but with palpitations over
preceding month. Given new stroke, she was started on apixaban 5
mg BID as well as metoprolol 12.5 mg twice daily. TTE revealed
___ is not dilated.
# Metabolic acidosis: pH 7.29 on arrival, improved to 7.38 on
recheck. Repeat blood gas with lactate also improved, no need to
further monitor.
# Troponinemia: Negative at OSH, present on admission here with
0.04->0.05->.02. Repeat EKG was without ST changes.
# Hypothyroidism: TSH elevated but patient reports compliance
with her thyroid medication.
- Should follow up as outpatient to rule out nonthyroidal
illness
TRANSITIONAL ISSUES:
======================
[] Neurology Follow up
- Apixaban given newly diagnosed atrial fibrillation
- Started atorvastatin 80 mg qHS
[] Patient will need to schedule PCP appointment for the next
___ weeks
- repeat TSH when acute illness resolved
- Metoprolol started in patient
[] Monitor qtc when on standing Compazine and Zofran for nausea
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? x() Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 143 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - If no, why not (I.e.
bleeding risk, etc.) () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cyclosporine
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
Mrs. ___ is a ___ with SLE previously on steroids but not
currently, seen today by surgery consultation for RLQ abdominal
pain.
She notes that the pain started two days ago and was somewhat
diffuse in nature but now is present primarily in the right
lower
quadrant and has escalated to ___ in severity. It's associated
with nausea, malaise, anorexia, chills, and bloating. She denies
any changes in bowel habits.
Past Medical History:
SLE, migraine headaches, submandibular stones, hypothyroidism
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: upon admission:
T: 98.6; HR: 82; BP: 111/65; RR: 18; O2: 100 RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: CTAB, normal excursion, no respiratory distress
Back: no vertebral tenderness, no CVAT
Abdomen: soft, tender to palpation in RLQ, Rovsing's sign
present
Neuro: strength intact/symmetric, sensation intact/symmetric
Extremities: WWP, no CCE, no tenderness, 2+ B ___
Skin: no rashes/lesions/ulcers
Pyschiatric: normal judgment/insight, normal memory, normal
mood/affect
Physical examination upon discharge: ___:
vital signs: t=97.9 hr=78, bp=105/61, rr=20
CV: ns1, s2, no murmurs
LUNGS: clear
ABDMEN: soft, tender, port sites clean and dry
EXT: no pedal edema bil, no calf tenderness bl
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 03:37PM BLOOD WBC-9.6# RBC-4.49 Hgb-14.3 Hct-42.0
MCV-94 MCH-31.8 MCHC-34.0 RDW-11.9 RDWSD-41.1 Plt ___
___ 03:37PM BLOOD Neuts-80.7* Lymphs-12.2* Monos-5.7
Eos-0.6* Baso-0.5 Im ___ AbsNeut-7.77*# AbsLymp-1.18*
AbsMono-0.55 AbsEos-0.06 AbsBaso-0.05
___ 03:37PM BLOOD Glucose-87 UreaN-7 Creat-0.8 Na-141 K-3.8
Cl-102 HCO3-25 AnGap-18
___ 03:37PM BLOOD ALT-20 AST-19 AlkPhos-69 TotBili-1.3
___ 03:37PM BLOOD Albumin-5.1 Calcium-10.0 Phos-3.6 Mg-2.3
___ 03:41PM BLOOD Lactate-1.2
___: cat scan of abdomen and pelvis:
1. Acute uncomplicated appendicitis.
2. 1.9 cm left ovarian cyst may represent follicular activity.
However, if the patient is postmenopausal, a follow-up pelvic
ultrasound is recommended on a non-urgent basis.
Medications on Admission:
levothyroxine 75', sumutriptan
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
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 right lower quadrant pain
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: Total DLP: 527 mGy-cm
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is bibasilar dependent atelectasis. No pleural effusions.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Multiple hepatic lesions are scattered throughout the liver, the largest of
which is a 1.6 cm simple cyst in hepatic segment VI (02:23). The sub-cm
lesions are too small to characterize. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
Portal venous system is patent.
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.
A 4 mm hypodensity in the upper pole of the left kidney is too small to
characterize (601b:36). No other renal parenchymal lesions are identified.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. Appendix is fluid-filled and abnormally
dilated, measuring up to 1.1 cm (601b:21). There is also mucosal
hyperenhancement, periappendiceal fat stranding and adjacent free fluid,
findings consistent with acute appendicitis. No evidence of perforation or
adjacent abscess formation.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is unremarkable. There is a 1.9 cm cyst in the
left ovary that may represent follicular activity (___:30). However, if the
patient is postmenopausal, follow-up pelvic ultrasound should be performed.
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.
Degenerative changes throughout the thoracolumbar spine are mild. There is
mild retrolisthesis of L5 on S1. Transitional anatomy noted at the
lumbosacral junction.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute uncomplicated appendicitis.
2. 1.9 cm left ovarian cyst may represent follicular activity. However, if
the patient is postmenopausal, a follow-up pelvic ultrasound is recommended on
a nonurgent basis.
RECOMMENDATION(S): Pelvic ultrasound if the patient is postmenopausal.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: RLQ abdominal pain, Dizziness, EXHAUSTION
Diagnosed with Unspecified acute appendicitis
temperature: 98.3
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 74.0
level of pain: 7
level of acuity: 3.0 | ___ year old female admitted to the hospital with right lower
quadrant pain. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging. A cat scan of the
abdomen was done which showed a fluid filled, dilated appendix
without perforation. Based on these findings, the patient was
taken to the operating room for a laparoscopic appendectomy.
The operative course was stable. The patient was extubated
after the procedure and monitored in the recovery room. Her
incisional pain was controlled with oral analgesia. She resumed
a regular diet and was voiding without difficulty. She was
ambulatory. The patient was discharged home on POD #1 in stable
condition. She was informed of the finding of a 1.9 left
ovarian cyst and the need for follow-up with her primary care
provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / morphine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
XRT to spine (T5, T11) and pelvis
History of Present Illness:
Ms. ___ is a ___ woman with metastatic BRCA1 mutant
breast cancer, estrogen receptor positive presenting for pain
control.
.
She was recently hospitalized at ___ for excruciating back
pain, at which time an MRI showed new and extensive involvement
of T11 and T12 with impingement of the spinal cord with
metastatic disease. Dr. ___ had recommended radiation
treatments to this area, T10-L1 (previous radiation was to lower
lumbar spine), however this has been deferred due to patient
concerns about bowel symptoms ___ radiation. Per documented
clinic notes, it was explained to the patient that she is at
risk for neurological compromise, including paralysis, with
untreated spinal disease, however she continued to decline
radiation. She did express an interest in ongoing chemotherapy.
.
She has had one week of increasing back pain, radiating to her
left hip and down to her left knee, as well as new onset LLE
weakness. She reports that she began noticing increased pain
last ___, which has gradually worsened throughout the week.
This morning she could not lift her left leg off her bed, which
worried her and she called her oncologist. Over the last few
days, she has been taking increasing doses of oxycodone and
dilaudid, in addition to her oxycontin and cyclobenzaprine. She
had planned to begin XRT of the T11/12 lesions on ___, but her
pain became unbearable and she came in to ___ from the ___
___ today and was sent over from ___ clinic.
.
In the ED, initial vitals were 97.8 98 138/99 18 100%RA. Code
cord was called on arrival. Labs showed WBC count of 19K with
unremarkable differential. Patient was hyperglycemic to 190 on
Chem7. 10 mg of IV dexamethasone was administered for possible
cord compression. She received a total of 7 mg IV
hydromorphone, 2 mg IV lorazepam x 1 and 2 mg ondansetron IV x
1. MRI of the T/L spine showed a new extradural mass at T5-6
displacing the cord anteriorly, as well as extensive advanced
metastatic disease at T11-12 and stable metastatic disease at
L5. Spine saw patient and stated findings limited to left leg
with L5 weakness and back pain, no sensory level and upgoing
toes bilaterally. Rectal exam was deferred due to patient
request. Hip and pelvic X-rays showed numerous sclerotic
lesions consistent with metastatic disease, but no definitive
fracture. Significant amount of stool in the cecum was also
seen. Vitals upon transfer were 97.6 ___ 16 99%RA.
.
On arrival to the floor, the patient is in ___ pain, writhing
in bed, finding it difficult to get comfortable. She reports
pain radiating to her left hip from her back. She feels very
constipated and is frustrated that she has not been able to
rest. There is no urinary hesitancy or incontinence, no bowel
incontinence. She has longstanding constipation, for which she
undergoes colonic hydrotherapy and takes polyethylene glycol.
There is no saddle anesthesia.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, recent weight loss or gain. Denies
blurry vision, diplopia, loss of vision, photophobia. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain or tightness, palpitations, lower extremity edema.
Denies cough, shortness of breath, or wheezes. Denies nausea,
vomiting, diarrhea, melena, hematemesis, hematochezia. Denies
dysuria, stool or urine incontinence. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. All other systems negative.
.
Past Medical History:
PAST ONCOLOGIC HISTORY:
# ___: pt noted nipple discharge. Mammogram showed 1cm cyst -
pt recommended surgical excision but pt deferred
# ___: R breast turned hard and nipple inverted, ongoing bloody
discharge
# ___: bilateral mammograms showed widespread abnormality in
the right breast with diffuse abnormal skin thickening, multiple
irregular hypoechoic masses extending between the 1o'clock and 6
o'clock positions, one of them being at least 6 cm longest
dimension. Largest lymph node was 2.7 cm in its largest
extension. ___ o'clock biopsy benign sclerotic breast tissue
with microcalcification, columnar cell change and an area
suggestive of LVI with cancer. The second biopsy yielded an
infiltrating ductal
carcinoma, histologic grade 2. IHC was positive for estrogen
receptor, progesterone receptor, and HER-2/neu negative. In
addition, an FNA of the right axillary lymph node was positive.
# ___: anastrozole and ovarian suppression started; bilateral
MRI of the breast that confirmed a multicentric disease
infiltrating the entire right breast. She has 2 metastatic liver
lesions (confirmed by biopsy)
# ___: switch from Arimidex to Exemestane given increasing
size of R breast mass
# ___: started Faslodex
# ___: PET scan done showed an increase in the size of the
breast mass and the right axillary LN, not really any change in
the liver mets. There is a new avidity in the posterior mid-back
localized to a rib.
# ___: due to clinical progression, taken off hormonal
treatment
# ___: started on Xeloda
# ___: PET with increased widespread osseous metastasis, a
lesion at L5 that now largely replaces a vertebral body and
could predispose to fracture. There was confirmation of the
overall progression in the right breast that appears to invade
the pectoralis muscle. There was decrease in the size of the
axillary lymphadenopathy and decreased uptake in the liver.
# ___: L5: palliative course of radiation to the area
consisting of 20 Gy in five fractions
# ___: started taxol
# ___: Started doxil
# ___ MRI done at ___->contiguous neoplastic
lesions at T11 and T12 invading the pedicles and dorsal elements
and invading the vertebral bodies but to a greater degree at T12
where there is associated soft tissue component entering the
canal on the right and displacing the spinal cord without cord
compression.
PAST MEDICAL HISTORY:
Vertebral disk issues in ___ and ___ that has been treated
conservatively.
s/p Hysterectomy in ___ at ___ for benign
fibroids
Social History:
___
Family History:
The patient has a striking history of breast cancer. Her mother
was diagnosed with breast cancer at age ___ ___s at age ___
with two separate primaries. She was then diagnosed with
ovarian cancer at age ___ and thereafter had a BRCA testing,
which was positive for mutation. The patient is uncertain
whether it is BRCA1 or BRCA2. The patient also has a half aunt
(common grandfather) who was diagnosed with breast cancer. The
patient is not of ___ extraction.
Physical Exam:
*ADMISSION EXAM*
Vitals - T: 98.3 BP: 159/107 HR: 86 RR: 20 02 sat: 99% RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing, uncomfortable, writhing in bed
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p
clear, MM dry.
Neck: Supple, no JVD.
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, tachycardic, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, distended, hypoactive bowel sounds.
BACK: No tenderness to palpation over spinous processes
EXTR: No lower leg edema, no clubbing or cyanosis
MSK: no pain to palpation of hip bilaterally
DERM: No active rash.
Neuro: muscle strength ___ in lower extremities, sensation to
light touch intact in lower extremities, 3+ reflexes in lower
extremities bilaterally, upgoing toes bilaterally
RECTAL: deferred due to patient insistence
PSYCH: Appropriate and calm.
.
*DISCHARGE EXAM*
VS - T 98.1 BP 115/80 HR 82 RR 18 99% RA
General: lying in bed, no acute distress
HEENT: EOMI, oropharynx clear, MMM. 3cm indurated nodule on top
of head on right, nontender.
Neck: supple, no cervical or supraclavicular lymphadenopathy
CV: r/r/r, no m/r/g
Lungs: CTA bilaterally
Abdomen: moderately distended, soft, nontender, normoactive
bowel sounds
Ext: no edema, cyanosis, 2+ distal pulses
Neuro: AAOx3, CN II-XII grossly intact, strength ___ in all
extremities, sensation grossly intact
Skin: intact, well perfused, mild radiation dermatitis on back
Pertinent Results:
*ADMISSION LABS*
___ 07:30PM BLOOD WBC-19.0* RBC-4.55 Hgb-12.4 Hct-37.2
MCV-82 MCH-27.3 MCHC-33.4 RDW-14.5 Plt ___
___ 07:30PM BLOOD Neuts-60.0 ___ Monos-3.7 Eos-0.2
Baso-1.1
___ 07:30PM BLOOD Glucose-191* UreaN-13 Creat-0.6 Na-136
K-4.0 Cl-99 HCO3-23 AnGap-18
RELEVANT LABS:
___ 07:10AM BLOOD CEA-608* ___
*DISCHARGE LABS*
___ 05:30AM BLOOD WBC-15.4* RBC-4.27 Hgb-11.7* Hct-34.5*
MCV-81* MCH-27.4 MCHC-33.8 RDW-15.8* Plt ___
___ 05:30AM BLOOD Glucose-207* UreaN-23* Creat-0.6 Na-135
K-5.1 Cl-99 HCO3-26 AnGap-15
___ 05:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2
*IMAGING*
MRI head ___ Preliminary report"
IMPRESSION:
1. Large osseous lesion at the vertex with a
subgaleal/subperiosteal component. There is associated invasion
and compression of the superior
Preliminary Reportsagittal sinus with significant narrowing. No
occlusion of the sinus is seen at present time.
2. Additional osseous lesions are demonstrated in the right
temporal and right temporo-occipital region with underlying
dural component.
3. Left occipital lesion measuring 8mm, and punctate left
cerebellar and right thalamic lesion are also noted.
CT torso ___:
IMPRESSION:
1. Multiple metastases in the liver and bilateral adrenal glands
as well as a retroperitoneal metastasis superior to the left
kidney.
2. Enlargement of the portacaval lymph node with invasion of
tumor into the portal vein resulting in tumor thrombus.
3. Lytic lesions involving the T11 spinous process, T12
vertebral body, pedicle, and spinous process, and the left
ischial spine extending to the posterior column of the left
acetabulum. The acetabular lesion has caused a partially
displaced pathological fracture of the left acetabulum. There is
also involvement of the right pubic symphysis with disruption of
the cortex.
CT head ___:
IMPRESSION:
1. Numerous lytic lesions within the right parietal/temporal
bones, right occipital bone, as well as at the cerebral
convexity, with extra-axial extension are concerning for
metastatic disease.
2. Small hyperdense/enhancing region in the left occipital
lobe at is concerning for metastitic disease. It is difficult to
assess if this lesions is intra-axial or extra-axial based on
this study. Recommend MRI with contrast for additional
evaluation, if clinically indicated.
MR ___ ___
IMPRESSION:
1. Multifocal metastatic disease within the visualized bones
including compression deformity of L5, as well as marrow
replacement by tumor at the left iliac wing, right superior
pubic rami, right femoral head, right lesser trochanter, as well
as the left acetabulum with soft tissue extension through the
cortex consistent with pathologic fracture.
2. Edema within the gluteal compartments bilaterally.
Hip Xray ___
FRONTAL AND LATERAL VIEWS OF THE LEFT HIP: Again, mixed
sclerotic and lucent
lesions are seen within the right superior pubic ramus and left
inferior pubic
ramus extending to the left acetabulum. There is no definite
pathologic
fracture. The bones are osteopenic, and if concern for fracture
persists,
cross-sectional imaging would be recommended.
There is a significant amount of stool seen within the cecum.
No bowel
obstruction.
MR ___ &W/O CONTRAST Study Date of ___
IMPRESSION:
1. Metastasis centered in the posterior elements of T5 with a
large posterior epidural component, which severely compresses
the spinal cord. No evidence of cord edema. The osseous
component has progressed since ___, and the epidural
component is likely new.
2. Interim enlargement of the large metastasis involving the
anterior and posterior elements of T11 and T12, with a large
circumferential epidural component which severely compresses the
spinal cord, resulting in cord edema. Right T11-T12 neural
foramen is obliterated with encasement of the T11 nerve root.
The right T12-L1 neural foramen is severely narrowed, with
inferior displacement of the T12 nerve root. Left T11-T12
neural foramen is mildly narrowed, with abutment of the left T11
nerve root. The mass has progressed since ___. Pathologic
fracture of T12 vertebral body is new.
3. Metastatic lesion at L5 appeared stable in extent compared
to ___, without epidural extension. Pathologic fracture of
L5 vertebral body is new since ___ it is not clear whether
it was present on ___.
4. Degenerative disease with moderate bilateral L5-S1 neural
foraminal narrowing and impingement of the exiting L5 nerve
roots, and mild bilateral L4-L5 neural foraminal narrowing.
5. Cervical spondylosis with encroachment on the spinal canal
is noted on the localizer sequence but incompletely evaluated.
6. Ill-defined and inadequately evaluated lesions in the imaged
portion of the right hepatic lobe, which were last assessed on
the ___ abdominal MRI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO HS:PRN pain
2. Dexamethasone 4 mg PO Q12H
3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
5. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
6. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
7. Nephrocaps 1 CAP PO DAILY
8. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral BID
9. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
10. Docusate Sodium 100 mg PO BID
11. Senna 1 TAB PO BID
12. Polyethylene Glycol 17 g PO DAILY
13. Milk of Magnesia 30 mL PO PRN constipation
14. Ibuprofen 400 mg PO Q8H
Discharge Medications:
1. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone [OxyContin] 30 mg 1 tablet extended release 12
hr(s) by mouth every twelve (12) hours Disp #*14 Tablet
Refills:*0
2. Cyclobenzaprine 10 mg PO TID:PRN pain
3. Docusate Sodium 200 mg PO BID
4. Lorazepam 0.5-1 mg PO TID:PRN anxiety
5. Milk of Magnesia 30 mL PO Q6H:PRN constipation
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 1 TAB PO BID
8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
9. Acetaminophen 1000 mg PO Q12H
10. Aquaphor Ointment 1 Appl TP QID:PRN xrt burns on back
11. Atenolol 25 mg PO DAILY
12. Bisacodyl 10 mg PO DAILY constipation
13. Bisacodyl ___AILY
14. Famotidine 20 mg PO Q12H
15. Fentanyl Patch 62 mcg/h TD Q72H
RX *fentanyl 50 mcg/hour Apply patch to skin every 72 hours Disp
#*5 Transdermal Patch Refills:*0
RX *fentanyl 12 mcg/hour Apply patch to skin every 72 hours Disp
#*5 Transdermal Patch Refills:*0
16. Furosemide 20 mg PO DAILY
17. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain
RX *hydromorphone 0.5 mg/0.5 mL 0.5-1 mg IV every three (3)
hours as needed Disp #*10 Syringe Refills:*0
18. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. Lactulose 30 mL PO DAILY:PRN constipation
20. Multivitamins W/minerals 1 TAB PO DAILY
21. Simethicone 80 mg PO QID:PRN bloating
22. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral BID
23. Nephrocaps 1 CAP PO DAILY
24. Dexamethasone 4 mg PO Q12H
Taper: 4 mg BID for 5 days, 4 mg once daily for 5 days, 2 mg
daily for 5 days, then off.
25. OxycoDONE Liquid ___ mg PO Q3H:PRN pain
hold for sedation, RR < 12
RX *oxycodone 5 mg/5 mL ___ mg by mouth every three (3) hours
as needed Disp #*1 Bottle Refills:*0
26. Peridex *NF* (chlorhexidine gluconate) 0.12 % Mucous
Membrane daily Reason for Ordering: Pt having gum irritation
from radiation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Spinal cord compression
Pathologic left hip fracture
Secondary:
Metastatic breast cancer
Steroid-induced hyperglycemia
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: Known left hip metastases. Evaluate for worsening metastatic
disease or pathologic fracture.
COMPARISON: ___, and CT torso, ___.
FRONTAL AND LATERAL VIEWS OF THE LEFT HIP: Again, mixed sclerotic and lucent
lesions are seen within the right superior pubic ramus and left inferior pubic
ramus extending to the left acetabulum. There is no definite pathologic
fracture. The bones are osteopenic, and if concern for fracture persists,
cross-sectional imaging would be recommended.
There is a significant amount of stool seen within the cecum. No bowel
obstruction.
Radiology Report
MRI EXAMINATION OF THE LEFT HIP WITHOUT GADOLINIUM CONTRAST
CLINICAL INDICATION: ___ female with metastatic breast cancer
presenting with severe left hip pain.
TECHNIQUE: MRI examination of the left hip was performed without gadolinium
contrast in the following sequences: Coronal T1, coronal STIR, coronal proton
density fat saturation, axial oblique proton density fat saturation, and
sagittal proton density fat saturation.
COMPARISON: Pelvis and left hip radiography dated ___.
FINDINGS:
There is decreased T1 bone marrow signal intensity that is isointense to
muscle within the L5 vertebral body, left iliac wing, right superior pubic
rami, right femoral head, right lesser trochanter, as well as within the left
acetabulum. All of these regions have increased bone marrow signal intensity
on the STIR sequence. Additionally, within the left acetabulum, there is
cortical breakthrough with soft tissue extension measuring 6.7 x 4.2 cm
consistent with pathologic fracture, best seen on series 3, image 16. The
posterior left iliac lesion also shows evidence of soft tissue extension
(3:22). Additionally, the lesion within the L5 vertebral body results in
compression deformity.
Nonspecific edema is present within the gluteal muscles bilaterally.
The gluteus medius tendon, adductor tendons, iliopsoas tendons, and hamstring
tendons are grossly intact.
The labrum appears intact. Visualized bowel loops demonstrate no evidence of
obstruction.
IMPRESSION:
1. Multifocal metastatic disease within the visualized bones including
compression deformity of L5, as well as marrow replacement by tumor at the
left iliac wing, right superior pubic rami, right femoral head, right lesser
trochanter, as well as the left acetabulum with soft tissue extension through
the cortex consistent with pathologic fracture.
2. Edema within the gluteal compartments bilaterally.
These critical findings were reported to Dr. ___ by telephone by Dr. ___
at 10:07 am on ___.
s
Radiology Report
HISTORY: ___ female with metastatic breast cancer. Single-lumen port
a catheter requested for chemotherapy.
COMPARISON: PET-CT ___.
CLINICIANS: Dr. ___ (attending physician) and Dr. ___
(fellow). The attending was present throughtout the entirety of the
procedure.
Anesthesia: Moderate sedation was provided by administering divided doses of
fentanyl and Versed throughout the total intra-service time of 94 minutes.
The patient's hemodynamic parameters were continuously monitored. A total
dose of 125 mcg fentanyl and 2.5 mg versed was used. 1% lidocaine and
lidocaine mixed with epinephrine were used for local anesthesia.
PROCEDURE:
1. Left internal jugular venous access.
2. Subcutaneous pocket creation over the left upper anterior chest wall.
3. Placement of a single-lumen chest port via the left IJV.
FINDINGS:
The procedure was discussed in detail with the patient and risks and benefits
emphasized. Informed written consent was obtained.
When the patient arrived in the angio suite, she was placed supine on the
procedure table. The left upper chest was prepped and draped in usual sterile
fashion. A preprocedural time out was performed per ___ protocol.
Under continuous ultrasound guidance, the left internal jugular vein which was
patent and compressible was accessed using a micropuncture needle. A Nitinol
wire was then passed into the right side of the heart and the needle exchanged
for a micropuncture sheath. The inner dilator and Nitinol wire were removed
and ___ wire was advanced through the heart into the IVC. A measurement was
obtained from this wire and the wire was then secured to the drape.
The location of the port pocket was determined and the pocket was created in
the subcutaneous tissues. At this time the catheter was tunneled through
subcutaneous tissues from the port pocket to the puncture site in the internal
jugular vein. The catheter was attached to the port hub and was flushed with
saline to assure there were no leaks.
At this time the port was sutured into the pocket using 0 Prolene. Attention
was brought back to the neck puncture site where the micropuncture catheter
was exchanged for a dilator and peel-away sheath using fluoroscopic guidance.
The catheter was then cut to length and inserted into the internal jugular
vein through the peel-away sheath. The peel-away sheath was removed and
fluoroscopy was used to verify positioning of the catheter and the catheter
tip.
The pocket was closed using Vicryl interrupted subcutaneous sutures and a
running subcuticular stitch. The neck puncture site was closed using
Steri-Strips. Steri-Strips were also placed over the port pocket incision.
The port was accessed using a non-coring ___ needle and could be aspirated
and flushed easily. The area was cleaned and dressed per protocol.
The patient left the department in stable condition. No complications.
IMPRESSION:
Uncomplicated placement of a left-sided Port-A-Cath with the tip terminating
in the right atrium. Port ready to use at this time. Port was left accessed
per request.
Radiology Report
HISTORY: History of metastatic BRCA1 mutant breast cancer, ER/PR positive,
Her 2-negative, with metastases to the spine who presented with severe back
pain, found to have 2 sites of cord compression and extensive metastatic
disease in the pelvis along with a pathologic fracture. Evaluate for staging
of patient's cancer to determine chemotherapy regimen.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after administration of 130 cc of Omnipaque. Multiplanar
reformatted images in coronal and sagittal planes were generated. 3 min
delayed images were acquired.
DLP: 1192.74 mGy-cm
COMPARISON: CT torso dated ___.
FINDINGS:
Lungs and heart: Please see separate report discussing the findings in the
thorax.
Liver: The liver is normal in size and homogeneous in attenuation and
contains contains numerous hypodense, peripherally enhancing lesions that
become isodense in the equilibrium phase, consistent with metastases. There
is no intrahepatic biliary duct dilatation. The hepatic vein is patent. The
portal vein contains a central filling defect just distal to the portal
confluence (series 2, image 52) consistent with a tumor thrombus extending
from the portacaval lymph node. The portacaval lymph node is enlarged,
measuring 1.7 cm (in the short axis) and contains metastasis extending into
the portal vein. The splenic vein and IMV are patent with no thrombus seen.
Gallbladder: The gallbladder is normal appearing without stones. The common
bile duct is normal in caliber.
Pancreas: The pancreas is normal appearing without duct dilatation or
peripancreatic fat stranding.
Spleen: The spleen is normal in size and homogeneous in attenuation without
mass lesions. There are two accessory spleens near the splenic hilum, which
were seen on the prior study.
Adrenals: The right adrenal contains two hypodense, peripherally enhancing
nodules measuring 9.4 mm and 5.1 mm. The left adrenal contains a 1.7 cm
peripherally enhancing hypodense nodule. These adrenal lesions are consistent
with metastases.
Kidneys: The kidneys are normal in size and display symmetric nephrograms and
contrast excretion. In the interpolar region of the right kidney and there is
a 1.1 cm hypodensity, which likely represents a simple cyst. The left kidney
shows no mass lesions. There is no evidence of hydronephrosis bilaterally.
The ureters are normal bilaterally.
Bowel: The esophagus is normal in caliber with no hiatal hernia. The stomach
is normal appearing without wall thickening or abnormal dilatation. The small
bowel is opacified with contrast and does not show abnormal dilatation or wall
thickening. The large bowel is normal appearing without obstructive mass
lesions, diverticula, or abnormal wall thickening. There is no
intraperitoneal free air or free fluid.
Lymph nodes: As mentioned above there is enlargement of the portacaval lymph
node measuring 1.7 cm. Superior to the left kidney and there is a 1.1 cm soft
tissue nodule which likely represents retroperitoneal metastasis (2:58).
There are no pathologically enlarged periaortic or mesenteric lymph nodes.
Pelvis: The bladder is under distended and normal appearing with no wall
thickening. The uterus is unremarkable, with size consistent with the
patient's age. The adnexae are unremarkable. There are no pathologically
enlarged pelvic or inguinal lymph nodes. There is no free fluid in the
pelvis.
Vessels: There is no aneurysmal dilatation of the abdominal aorta. The aorta
and its major branches are patent.
Osseous structures: There is a lytic lesion involving the T11 spinous process
and T12 vertebral body, right pedicle, and spinous process with invasion into
the spinal canal and likely spinal cord compression. There is lytic lesion
involving the L5 vertebral body with loss of height and possible extension
into the spinal canal but no clear evidence of cord compression. There is a
lytic lesion involving the left ischial spine resulting in partially displaced
pathological fracture of the posterior column of the left acetabulum. This
lesion contains a soft tissue component which extends medially into the
obturator internus muscle. Metastatic involvement of the right pubic symphysis
is identified.
IMPRESSION:
1. Multiple metastases in the liver and bilateral adrenal glands as well as a
retroperitoneal metastasis superior to the left kidney.
2. Enlargement of the portacaval lymph node with invasion of tumor into the
portal vein resulting in tumor thrombus.
3. Lytic lesions involving the T11 spinous process, T12 vertebral body,
pedicle, and spinous process, and the left ischial spine extending to the
posterior column of the left acetabulum. The acetabular lesion has caused a
partially displaced pathological fracture of the left acetabulum. There is
also involvement of the right pubic symphysis with disruption of the cortex.
Findings were discussed with Dr. ___ by Dr. ___ telephone at ___ on
___, 5 minutes after discovery.
Radiology Report
HISTORY: ___ female with metastatic breast cancer, cord compression,
pathologic hip fracture. Evaluate for brain metastases.
TECHNIQUE: Contiguous axial multi detector CT images were obtained through
the brain following the administration of IV contrast. Reformatted coronal
and sagittal and thin section bone algorithm-reconstructed images were
acquired.
Total exam DLP: 1040.21 mGy/cm
CTDIvol: 62.80 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, edema, or infarction. The ventricles and
sulci are normal in size and configuration.
There is a small area of hyperdense enhancement noted within the left
occipital lobe which measures approximately 7 x 3 mm. It is difficult to
assess if this lesions is intra-axial or extra-axial based on this study.
There are multiple lytic lesions noted within the right parietal/temporal bone
and right occipital bone, with small associated extra-axial enhancement,
suggesting extra-axial extension. Additionally, there is a large soft tissue
mass located at the convexity with complete underlying erosion of the bone at
this point with associated extra-axial extension.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation. The dural venous sinuses and vessels of the circle of
___ enhance normally and grossly symmetrically. The visualized paranasal
sinuses, mastoid air cells, middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
1. Numerous lytic lesions within the right parietal/temporal bones, right
occipital bone, as well as at the cerebral convexity, with extra-axial
extension are concerning for metastatic disease.
2. Small hyperdense/enhancing region in the left occipital lobe at is
concerning for metastitic disease. It is difficult to assess if this lesions
is intra-axial or extra-axial based on this study. Recommend MRI with
contrast for additional evaluation, if clinically indicated.
Radiology Report
CHEST CT, ___
HISTORY: Breast carcinoma.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
scanning of the abdomen and pelvis to be reported separately and intravenous
infusion of 130 cc Omnipaque nonionic iodinated contrast agent reconstructed
as contiguous 5- and 1.25-mm thick axial and 5 mm thick coronal and
parasagittal and 8 x 8 mm MIPs projections, compared to chest CT scanning
since ___ most recently PET CT scan ___.
FINDINGS: 12 x 17 mm prevascular and 9 x 11 mm internal mammary lymph nodes
are new since ___. Other hilar and mediastinal lymph nodes are not
pathologically enlarged. A large expansile metastasis of a left lower
posterior rib is more sclerotic, indicating interval therapeutic response, but
there is an increase in associated soft tissue thickening of the pleura and
submuscular nodularity, 2:30. There is no pleural or pericardial effusion.
New yperenhancing subcutaneous nodules at the lower margin of the mastectomy
field in the right chest wall extend into the anterior axillary line, ___
and nodules in the subjacent anterior costal pleural surface, 2:26; and
enlarged internal mammary lymph nodes, 2:27, are also new.
Circumferential wall thickening of the distal esophagus is longstanding, and
could be either chronic esophagitis or a small hiatus hernia, unchanged since
at least ___. Left lobe of the thyroid gland is chronically enlarged.
A central lucency is new or newly apparent since ___, could be metastasis or
primary thyroid nodule. A geographic soft tissue abnormality in the inferior
segment of the lingula, 4:126-135, could be atelectasis, but since there was a
small lesion in that location on ___, raises concern for an
unusuallt shaped pulmonary metastasis. Irregular subpleural opacification in
both lower lungs is more likely microatelectasis than interstitial lung
disease.
Findings in the liver will be reported separately.
Extensive metastasis in the T12 vertebra involves both the partially collapsed
body and posterior elements and invades the spinal canal, displacing the cord
to the left. It is more extensive today than it was on ___.
IMPRESSION:
1. Metastatic breast carcinoma, progressive in multiple areas, most
significantly T12 vertebra with invasion of the spinal canal, loss of height
and impending collapse. Also new or increased are soft tissue invasion around
large metastasis to left lower posterior rib, subcutaneous and internal
mammary and pleural metastases at the level of mastectomy, and upper
mediastinal prevascular and internal mammary adenopathy.
2. Newly apparent lesion, left thyroid lobe.
Dr. ___ I discussed the findings by telephone at 12:30pm.
Radiology Report
HISTORY: Metastatic breast cancer. Evaluate for brain metastasis.
COMPARISON: CT head ___.
TECHNIQUE: Sagittal T1-weighted sequence, axial FLAIR, axial T2, magnetic
susceptibility and diffusion-weighted images were obtained. MPRAGE and axial
T1 post gadolinium images were also obtained.
FINDINGS:
The ventricles are normal in caliber and configuration. No shift of the
midline structures is demonstrated.
The dominant lesion is seen at the vertex centered in the right parietal bone
with minor involvement of the left pariteal bone. The lesion is lobulated and
extends through the inner and outer table of the bone and measures 5.3 cm
transverse x 4 cm AP x 3.2 cm craniocaudal. There is enhancement of the lesion
and slow diffusion demonstrated suggesting hypercellularity. There is a large
subperiosteal/subgaleal component, and an extra axial component that is
compressing and invading the superior sagittal sinus. There is associated
local mass effect/ sulcal effacement. Although significantly narrowed there
is no occlusion of the superior sagital sinus and no propagating clot is
demonstrated.
Additional osseous lesions are present as seen on CT, including a right
temporal-occipital lesion with an underlying enhancing dural component that
measures 14 mm AP x 6 mm transverse, and a right temporal bone lesion with an
underlying dural component that measures 3.8 cm AP x 8 mm transverse. An
additional small paramedian lesion is demonstrated in the left frontal bone
superiorly measuring 6 mm. There is patchy bone marrow signal particularly
within the clivus, making assessment of the enhancement challenging.
There is an enhancing left occipital lobar lesion measuring 8 mm transverse x
7 mm AP with associated FLAIR-hyperintensity. The lesion is favored to be
dural-based, with a subarachnoid and parenchymal component. Punctate enhancing
lesion in the right thalamus measuring 3 mm is noted, and there is a 2 mm
intraaxial lesion in the left cerebellar hemisphere, inferomedially.
The orbits are unremarkable. Linear enhancing focus in the left frontal lobe
is in keeping with a developmental venous anomaly. There is some adjacent
FLAIR hyperintensity which may reflect minor associated venous ischemia.
IMPRESSION:
1. Large osseous lesion at the cranial vertex with a subgaleal/subperiosteal
component. There is associated intracranial extension, with invasion and
compression of the superior sagittal sinus with significant narrowing. No
occlusion of the sinus is seen at present time.
2. Additional osseous lesions are demonstrated in the right temporal and
right temporo-occipital bones with underlying dural components.
3. Left occipital lesion measuring 8 mm, dural-based, transgressing the
subarachnoid space.
and punctate left cerebellar and right thalamic lesions, represent parenchymal
metastatic disease.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, CANCER
Diagnosed with LUMBAGO, SECONDARY MALIG NEO BONE
temperature: 97.8
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 99.0
level of pain: 10
level of acuity: 2.0 | Impression: ___ yo woman with metastatic BRCA1 mutant breast
cancer (ER/PR positive, HER-2 negative) presenting with back
pain, found to have 2 sites of spinal cord comperssion and
extensive metastatic disease in hip.
.
*ACTIVE ISSUES*
# Spinal cord compression: MRI spine on admission showed new
metastatic lesions at T5-6 and T11-12 with spinal cord
compression at both sites. She was loaded with dexamethasone and
then continued on a maintenance dose throughout hospital stay.
No neurologic deficits were noted. Radiation oncology
recommended a course of 10 fractions, which she started on ___
and completed ___. Neurosurgery was consulted and recommended
surgery, but patient preferred to defer surgical intervention at
the time of consultation. They recommended a brace only if
patient desired one for stability. Patient remained ambulatory
with these spinal lesions until pelvic fracture was illucidated.
.
# Pelvic metastases with left acetabular fracture: Patient's
left hip pain was unrelenting during first part of hospital
course. Plain films of hip and pelvis on admission did not
suggest fracture but MRI on ___ showed extensive metastatic
disease throughout pelvis as well as a left acetabular fracture.
Orthopedic surgery was consulted and did not believe surgical
intervention would be beneficial. They recommended patient
remain non-weight bearing on the left. Radiation oncology
recommended a course with 5 fractions, began on ___ and
completed on ___. Pt will go to rehab for physical therapy,
should use standard walker and touch-down weightbearing left
leg.
.
# Pain control: Patient presented from clinic to ED for severe,
uncontrollable pain in her back, radiating to her legs. Given
her metastatic disease and pathologic fractures in both her
spine and pelvis, opioid pain relief was rapidly escalated. At
discharge, she required Fentanyl patches at 62mcg/h and
oxycodone 5mg for breakthrough pain. She continued home Flexeril
of 10mg TID. Occassionally required dilaudid 1mg IV for
procedures.
.
# Constipation: On admission, aggressive bowel regimen was
instituted to address one of the patient's main personal
concerns. She had standing orders for Colace 200mg BID, Senna 1
tab QD, Miralax 1 packet QD, bisacodyl 10mg PO; starting
Bisacodyl PR daily. She used as needed, lactulose 30ml PO,
lactulose enema, MOM. For bloating, she used simethicone. At
discharge, patient had daily bowel movements. Given her
increasing opioid requirements, constipation likely to remain a
chronic issue.
.
#. Leukocytosis: Patient with elevated WBC for duration of
hospital course, thought to be steroid-related demarginization.
Infectious causes were ruled out with normal blood cultures and
urine cultures. Patient remained afebrile and clinically did not
appear infected with clear lungs and no new murmurs.
Leukocytosis most likely ___ steroids and some component of a
leukemoid reaction. Patient has extensive metastatic disease in
her bones.
.
# Hypercalcemia: Patient first noted to have hypercalcemia on
___, most likely ___ metastatic disease to bone. She was given
palmidronate 60mg IV and hydrated.
.
# Hyperkalemia: Patient intermittantly hyperkalemic to high of
6.0. Patient's kidney function remained normal. She did not have
symptoms or EKG changes. Treated with lasix as needed, and then
started on standing dose of lasix 20mg PO daily.
.
# Steroid-induced hyperglycemia: Pt was started on glargine at
night and insulin sliding scale, adjused as necesary.
.
# Anxiety: Patient regularly tearful and anxious throughout
hospital stay. Received Ativan 0.5-1mg PO for anxiety
.
*CHRONIC ISSUES*
# Breast cancer: progressive disease to spine and pelvis noted
during this hospital stay. CT torso and head for disease
staging ___ showed showed several new metastasis and
progressive disease throughout abdomen (liver, adrenals, portal
vein tumor thrombus) and lytic lesions in skull. MRI brain ___
showed several osseous lesions with a subgaleal/subperiosteal
component and associated invasion and compression of the
superior sagittal sinus with significant narrowing. Dr. ___,
___ oncologist, followed closely throughout hospital stay.
Pt had port placement ___ to receive palliative chemo in
future. Will follow-up in clinic with Dr. ___ to
receive chemotherapy is ~10 days after discharge (Dr. ___
___ will call pt with appointment).
.
*TRANSITIONAL ISSUES*
- Pt had hypercalcemia and hyperkalemia, received bisphosphonate
and improved with lasix. Started standing lasix 20mg PO daily to
help with hyperkalemia. PLEASE CHECK POTASSIUM EVERY OTHER DAY
- Pt was found to have diffuse metastatic disease. Plan to start
chemo in a few weeks with Dr. ___.
- Pt should continue steroid taper for cord compression as
follows: 4 mg BID for 5 days, 4 mg once daily for 5 days, then 2
mg daily for 5 days, then off.
- Please continue her insulin glargine and sliding scale and
adjust as needed given her steroids are currently being tapered.
- Pt should follow up with a dentist regarding her gums. She
was started on peridex. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Perihepatic/pelvic fluid collections
Major Surgical or Invasive Procedure:
___ - CT-guided perihepatic and pelvic fluid collection
drainage
___ - ERCP
History of Present Illness:
___ y/o F with hx of prothrombin gene mutation, recurrent PE/DVT,
thrombocytopenia, s/p laparoscopic CCY at ___ on ___
for porcelain GB with complicated post op course including
medflight to ___, intubation, and multiple organ failure who
presents today as transfer from ___ with
complaints of suprapubic pain, elevated temp to 100.6, and CT
findings of fluid collection in the pouch ___ as well as
in the perihepatic region.
Of note on last hospitalization was noted to become hypotensive
post lap CCY, required pressors and ICU stay. During that time
she was also found to have PNA, ___, and transient respiratory
failure. She had a prolonged ICU stay and was found to have
large fluid collection perihepatic and pelvic during that
hospitalization that was thought to be hemorrhagic. She was sent
to rehab restarted on her coumadin with known fluid in her
abdomen. GI was consulted before discharge for persistently
elevated LFTS and there was concern for hepatic
necrosis/ischemia and that her LFTs would be trended.
Currently complains of suprapubic discomfort with urination and
defecation. Was constipated in rehab, given laxative and has
had large amounts of loose stools that are dark in color,
although patient notes that she is taking iron supplements.
Past Medical History:
- Rectal bleeding: ___ tx'd DDAVP
- Thrombocytopenia: ___ BM biopsy with erythroid
hyperplasia and granulocytic hypoplasia
- History of DVT/PE on coumadin
- Hypothryoidism
- Fe deficiency Anemia
- Porcelain gallbladder now s/p cholecystectomy ___
- Hyperlipidemia
- HTN
- s/p exploratory laparoscopy ___
- s/p tubal ligation ___
- osteoarthritis
Social History:
___
Family History:
Father (deceased) colon ca, Mother (deceased) liver ca, one
brother treated for colon ca.
Physical Exam:
Physical Exam upon presentation:
VS - 97.8 80 122/50 96%RA
___ - elderly woman, tired, NAD
CARDIAC - RRR, no m/r/g
CHEST - CTAB
ABDOMEN - surgical incision sites clean with steri strips
present, soft, non-distended, tenderness to deep palpation in
suprapubic region > LUQ and RUQ
NEURO - alert, oriented
Physical Exam upon discharge:
VS: 97.8, 129/76, 73, 18, 97/RA
GEN: Resting comfortably in bed, NAD.
HEENT: Mucus membranes moist, EOMI
CARDIAC: Normal S1, S2. RRR No MRG
PULM: Lungs diminished at bases. No W/R/R
ABDOMEN: Soft/nontender/mildly distended.
EXT: + pedal pulses. No CCE
NEURO: AAOx4, normal mentation.
Pertinent Results:
___ 03:55AM ___ PTT-25.5 ___
___ 03:55AM PLT SMR-VERY LOW PLT COUNT-27*
___ 03:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 03:55AM NEUTS-64 BANDS-0 LYMPHS-16* MONOS-13* EOS-5*
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 03:55AM WBC-9.4 RBC-3.89* HGB-11.5* HCT-35.3* MCV-91
MCH-29.6 MCHC-32.5 RDW-14.7
___ 03:55AM ALBUMIN-3.1*
___ 03:55AM LIPASE-33
___ 03:55AM ALT(SGPT)-15 AST(SGOT)-28 ALK PHOS-101 TOT
BILI-1.3
___ 03:55AM estGFR-Using this
___ 03:55AM GLUCOSE-131* UREA N-13 CREAT-0.6 SODIUM-133
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-16
___ 03:59AM LACTATE-1.3
___ 03:59AM ___ COMMENTS-GREEN TOP
___ 05:34AM BLOOD WBC-7.0 RBC-3.43* Hgb-10.0* Hct-31.3*
MCV-91 MCH-29.0 MCHC-31.8 RDW-15.1 Plt Ct-25*
___ 12:16AM BLOOD WBC-8.8 RBC-3.51* Hgb-10.1* Hct-32.0*
MCV-91 MCH-28.8 MCHC-31.6 RDW-14.9 Plt Ct-34*
___ 02:50AM BLOOD WBC-8.3 RBC-3.61* Hgb-10.5* Hct-32.8*
MCV-91 MCH-29.1 MCHC-32.0 RDW-14.7 Plt Ct-23*
___ 03:55AM BLOOD Neuts-64 Bands-0 Lymphs-16* Monos-13*
Eos-5* Baso-0 Atyps-2* ___ Myelos-0
___ 05:34AM BLOOD Glucose-119* UreaN-6 Creat-0.5 Na-135
K-3.6 Cl-104 HCO3-22 AnGap-13
___ 12:16AM BLOOD Glucose-119* UreaN-7 Creat-0.6 Na-137
K-3.9 Cl-105 HCO3-22 AnGap-14
___ 02:50AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-136
K-3.7 Cl-105 HCO3-24 AnGap-11
___ 05:34AM BLOOD Calcium-7.5* Phos-2.2* Mg-1.5*
___ 12:16AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.7
___ 02:50AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8
___ 03:55AM BLOOD Albumin-3.1*
___ 03:59AM BLOOD Lactate-1.3
___ GALLBLADDER SCAN
IMPRESSION: No evidence of bile leak or biliary obstruction.
Surgically absent gallbladder.
___ DRAINAGE HEMATOMA/FLUID
IMPRESSION:
1. Satisfactory placement of pigtail catheter within the pelvic
hematoma. If the catheter does not continue to drain, it should
be removed. Sample sent for culture.
2. Aspiration of thick clotted blood from perihepatic
collection. This is felt to represent a clotted hematoma and,
therefore, a catheter was not left in situ.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Warfarin ___ mg PO DAILY16
3. Ferrous Sulfate 65 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Tucks Hemorrhoidal Oint 1% 1 Appl PR TID PRN hemorrhoids
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 20 mg PO HS
9. Vitamin D 400 UNIT PO DAILY
10. Acetaminophen 650 mg PO Q8H pain
11. Captopril 12.5 mg PO TID
12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/WHEEZE
13. OxycoDONE (Immediate Release) 2.5 - 5 mg PO Q4H:PRN pain
14. Senna 1 TAB PO HS Constipation
15. Docusate Sodium 100 mg PO BID
16. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Captopril 12.5 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 65 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Pravastatin 20 mg PO HS
7. Tucks Hemorrhoidal Oint 1% 1 Appl PR TID PRN hemorrhoids
8. Vitamin D 400 UNIT PO DAILY
9. Senna 1 TAB PO HS Constipation
10. Omeprazole 20 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/WHEEZE
13. Heparin IV
No Initial Bolus
Initial Infusion Rate: 600 units/hr
14. Warfarin ___ mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Perihepatic and pelvic fluid collections
Stent removal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Perihepatic and pelvic fluid collections after laparoscopic
cholecystectomy. Please drain fluid collections.
PROCEDURE: CT-guided drainage of pelvic and perihepatic collections.
FINDINGS:
written informed consent was obtained. A pre-procedure time-out was performed
confriming identity of the patient using two identifiers and type of
procedure to be performed. The patoetn was prepped and draped in the usual
sterile fashion.
DRAINAGE OF PELVIC COLLECTION:
The patient was positioned prone. 8 mL of 1% lidocaine was administered
subcutaneously for local anesthesia. Using CT guidance and aseptic technique,
an 18 gauge ___ needle was advanced into the collection 5cc of bloody
fluid were aspirated. a 0.35 ___ wire was advanced into the collection and
coiled freely within it. 7 and 8 ___ dilators were used prior to insertion
of an 8 ___ ___ catheter. 100 mL of dark red bloody fluid was
aspirated. The pigtail catheter was left in situ. A sample was sent to
microbiology for culture and to biochemistry for bilirubin.
DRAINAGE OF PERIHEPATIC COLLECTION:
The patient was turned supine. 8 ml of 1% lidocaine was administered
subcutaneously for local anesthesia. Using CT guidance and aseptic technique,
an 18 gauge ___ needle was advanced into the collection. Placement in the
collection was confirmed with CT fluoroscopy. No fluid could be aspirated. A
0.35 ___ wire was then advanced into the collection. The wire could not be
advanced easily but there was some resistance. The wire was then seen coiling
around itself in a small area. An 8 ___ catheter was advanced over the wire
and coiled. No fluid could be aspirated. The wire was then repositioned ans 2
cc of bloody fluid were aspirated. The collection was felt to represent
clotted hematoma (___ unit = 56). Therefore, the catheter was removed
without complication. The sample was sent to microbiology for culture.
IMPRESSION:
1. Satisfactory placement of pigtail catheter within the pelvic hematoma. If
the catheter does not continue to drain, it should be removed. Sample sent for
culture.
2. Aspiration of thick clotted blood from perihepatic collection. This is
felt to represent a clotted hematoma and, therefore, a catheter was not left
in situ.
Management was discussed with Dr. ___ at the time of the procedure.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD DISCOMFORT
Diagnosed with OTHER DIGESTIVE SYSTEM COMPLICATIONS, DIS OF BILIARY TRACT NEC, OTHER POST-OP INFECTION, PERITONEAL ABSCESS, ABN REACT-SURG PROC NEC, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT
temperature: 97.9
heartrate: 78.0
resprate: 19.0
o2sat: 95.0
sbp: 115.0
dbp: 60.0
level of pain: 4
level of acuity: 2.0 | ___ admitted for abdominal pain secondary to perihepatic/pelvic
fluid collections after undergoing elective laparoscopic
cholecystectomy at OSH on ___. Upon admission her INR was
2.4, and her platelets 27, so on ___ she was unable to undergo
drainage as her anticoagulated state needed to be reversed and
her platelets restored. To this end, she was given vitamin K, a
heparin drip started at 600 units/hr for a PTT goal of 50-70,
and she was scheduled to undergo drainage on ___, which she
did. She tolerated the procedure well, and her regular diet was
resumed. On ___, she was evaluated by a nutritionist after
she stated that she had not been eating well; they recommended
Ensure daily with meals. Her albumin came back as 3.1. On
___, she had a HIDA scan that showed "no evidence of bile
leak or biliary obstruction. Surgically absent gallbladder".
On ___, the patient's pelvic drain was removed due to
minimal drainage, and the culture and gram stain of the fluid
was negative for bacterial growth. Blood cultures were also
negative. Antibiotics were discontinued at this time.
On ___, the patient was transfused with one unit of
platelets in order to undergo a previously scheduled ERCP for
stent removal. She tolerated the procedure without any
complications: "The prior placed plastic stent was removed using
a snare. Cannulation of the biliary duct was successful and deep
with a balloon catheter using a free-hand technique. The
intrahepatics were normal. The common bile duct was normal in
size. Small filling defects seen in the common bile duct. The
cystic duct stump was visualized along with RUQ surgical clips
from the prior cholecystectomy. Sludge was extracted
successfully using a extraction balloon. An occlusion
cholangiogram showed no further filling defects. There was
excellent flow of bile and contrast."
After her procedure, her heparin gtt was held for 6 hours and
she was discharged back to ___ with plan to restart
her heparin gtt at 1700 pm (___). She was started back on
her coumadin as well in order to obtain a therapeutic INR level.
She was discharged on ___ with scheduled followup in the
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
outpatient labs with ___, hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with
a history of recently diagnosed Child's class B alcoholic
cirrhosis complicated by ascites, recent hospitalization for
alcoholic hepatitis discharged ___, alcohol-induced
polyneuropathy, psoriasis, hypertension, and hypothyroidism, who
presents after routine outpatient follow-up labs showed elevated
creatinine, hyperkalemia, and elevated white blood cell count.
The patient was recently hospitalized at ___ from
___. He was initially admitted to the MICU for
alcohol
withdrawal and received a loading dose of phenobarbital. He was
found to have peripheral polyneuropathy secondary to alcohol use
and vitamin deficiencies. He was also found to have alcoholic
hepatitis and new cirrhosis. He received adequate nutrition
therapy and was discharged with hepatology follow up.
The patient states that he has been getting intermittent
low-grade fevers since he was discharged from the hospital, but
has otherwise been feeling improved. He does not report
abdominal
pain, vomiting, diarrhea, blood in the stool, cough, congestion,
sore throat, chest pain, shortness of breath, dysuria,
hematuria,
joint pains, headaches, neck pain or stiffness. He feels that
his
abdominal distention is much improved since leaving the
hospital,
and also reports that his jaundice is improving. He has been
monitoring himself for hepatic encephalopathy.
He went to his PCP to establish care and have post-discharge
follow-up. Routine labs showed an elevated potassium to 6.3,
creatinine of 1.7 (baseline 0.7-0.8), and WBC count of 22.0. He
was referred to the ___ for further evaluation.
In the ED initial vitals: T 99.4, HR 103, BP 115/79, RR 18, O2
sat 97% RA
- Exam notable for:
General: Comfortable, lying in bed, awake and alert
Head/eyes: Normocephalic/atraumatic. Pupils equal round and
reactive to light. + Scleral icterus
ENT/neck: Oropharynx within normal limits. Neck supple.
Chest/Resp: Breathing comfortably on room air. Lungs clear to
auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2.
GI/abdominal: Soft, nontender
GU/flank: No CVA tenderness
Musc/Extr/Back: No peripheral edema. Moving all extremities
Skin: Warm and dry, psoriatic rash
Psych: Normal mood, normal mentation
- Labs notable for:
CBC: WBC 22.0-->17.3, Hgb 10.1-->8.8, platelets 273-->175
Chem7: Na 131-->125-->130; K 6.3-->5.0; Cr 1.7-->1.9-->1.6
LFTs: ALT 140-->112; AST ___ Tbili 6.6-->5.8
Coags: INR 1.3-->1.5
Lactate: 2.0
UA: Trace leukesterase; trace protein; 19 WBCs; few bacteria
- Imaging notable for: Bedside ultrasound without significant
ascites
CXR- No acute cardiopulmonary process.
RUQUS- 1. Cirrhotic liver with sequela of portal hypertension
including marked splenomegaly. No focal hepatic lesions are
identified. There is no ascites.
2. The portal and hepatic veins are patent, although the left
portal vein demonstrates reversal flow.
3. Small amount of gallbladder sludge within unchanged 5 mm
gallbladder polyp.
- Consults: Hepatology- Recs:
sepsis work up, urine, blood cultures
Abdominal US
start IV cefrt
stop diuretics
- Patient was given:
Insulin (Regular) for Hyperkalemia 10 units
IV Dextrose 50% 25 gm
IV Calcium Gluconate ___ Started
IV Calcium Gluconate 1 g
IV CefTRIAXone 2 gm
IVF LR 250 mL/hr
Allopurinol ___ mg
amLODIPine 10 mg
FoLIC Acid 1 mg
Gabapentin 300 mg
Levothyroxine Sodium 88 mcg
Metoprolol Tartrate 25 mg
IVF LR 1000 mL
- ED Course: Given the patient's hyperkalemia, he was given
insulin, dextrose, and calcium gluconate with improvement.
Diuretics were held and the patient was given LR at 250cc/hr, as
well as a 1L bolus. He was also given a dose of ceftriaxone
given
his elevated WBC count and possible concern for SBP.
On arrival to the floor, the patient reports that he is
generally
doing well. He feels his abdomen is improved from his last
admission, though a little bit bigger in the setting of getting
IV fluids in the ED. Otherwise, he continues to note pain in his
feet. The pain in his legs is beginning to improve. He does not
report fevers, chills, chest pain, shortness of breath, nausea,
vomiting, abdominal pain, and changes in bladder habits. He is
having ___ formed bowel movements daily.
Past Medical History:
Psoriasis
Hypothyroidism
Hypertension
Anemia
Thrombocytopenia
Asthma
Social History:
___
Family History:
No FHx bleeding disorders, malignancy, or liver disease.
MI in father and grandfather
___ abuse in family
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2 PO 118 / 75 80 18 98 RA
GENERAL: pleasant young man, lying in bed, in no acute distress
HEENT: AT/NC, EOMI, icteric sclera, mild conjunctival pallor,
moist mucous membranes
NECK: supple, no LAD, no JVD
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, nontender in all quadrants, no
rebound/guarding, palpable hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused; numerous regions of large, pink,
plaques with silvery scale on arms, legs, abdomen; mildly
jaundiced
DISCHARGE PHYSICAL EXAMINATION:
___ ___ Temp: 98.5 PO BP: 120/77 R Lying HR: 89 RR: 18 O2
sat: 95% O2 delivery: Ra
GENERAL: pleasant man looks older than stated age, lying in bed,
in no acute distress
HEENT: AT/NC, EOMI, icteric sclera, moist mucous membranes
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, nontender in all quadrants, no
rebound/guarding, palpable hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
SKIN: warm and well perfused; numerous regions of large, pink,
plaques with silvery scale on arms, legs, abdomen; mildly
jaundiced
Pertinent Results:
ADMISSION LABS:
___ 05:26PM BLOOD WBC-22.0* RBC-2.97* Hgb-10.1* Hct-30.8*
MCV-104* MCH-34.0* MCHC-32.8 RDW-15.0 RDWSD-56.6* Plt ___
___ 05:26PM BLOOD ___ PTT-33.6 ___
___ 05:26PM BLOOD UreaN-57* Creat-1.7* Na-131* K-6.3*
Cl-88* HCO3-23 AnGap-20*
___ 05:26PM BLOOD ALT-140* AST-192* AlkPhos-129
TotBili-6.6*
___ 05:26PM BLOOD Calcium-10.2 Phos-6.0* Mg-2.6
___ 09:57PM BLOOD Lactate-2.0 K-5.9*
IMAGING:
RIGHT UPPER QUADRANT ULTRASOUND:
___:
IMPRESSION:
1. Cirrhotic liver with sequela of portal hypertension
including marked
splenomegaly. No focal hepatic lesions are identified. There
is no ascites.
2. The portal and hepatic veins are patent, although the left
portal vein
demonstrates reversal flow.
3. Small amount of gallbladder sludge with an unchanged 5 mm
gallbladder
polyp.
CXR ___:
FINDINGS:
Lungs are well expanded and clear. No pulmonary edema, pleural
effusion or pneumothorax. Cardiomediastinal silhouette is
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
MICRO:
___ 9:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 11:33 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
DISCHARGE LABS:
___ 06:31AM BLOOD WBC-15.3* RBC-2.77* Hgb-9.3* Hct-29.6*
MCV-107* MCH-33.6* MCHC-31.4* RDW-14.8 RDWSD-58.7* Plt ___
___ 06:31AM BLOOD ___ PTT-31.4 ___
___ 06:31AM BLOOD Glucose-93 UreaN-37* Creat-1.1 Na-135
K-5.0 Cl-96 HCO3-21* AnGap-18
___ 06:31AM BLOOD ALT-112* AST-140* AlkPhos-108
TotBili-5.8*
___ 06:31AM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.4 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Ascorbic Acid ___ mg PO BID
4. Desonide 0.05% Cream 1 Appl TP DAILY
5. Fluocinonide 0.05% Cream 1 Appl TP BID
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Thiamine 100 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (SA)
11. Spironolactone 100 mg PO DAILY
12. Lactulose ___ mL PO DAILY:PRN hepatic encephalopathy
13. Gabapentin 300 mg PO TID
14. Furosemide 40 mg PO DAILY
15. Levothyroxine Sodium 88 mcg PO DAILY
16. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
two times per day Disp #*30 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Ascorbic Acid ___ mg PO BID
5. Desonide 0.05% Cream 1 Appl TP DAILY
6. Fluocinonide 0.05% Cream 1 Appl TP BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 300 mg PO TID
9. Lactulose ___ mL PO DAILY:PRN hepatic encephalopathy
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Thiamine 100 mg PO DAILY
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
14. Vitamin D ___ UNIT PO 1X/WEEK (SA)
15. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until you speak with your PCP and the
liver team
16. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until you speak with your
PCP and the liver team
17.walker
Dx: Neuropathy
Rx: walker
Prognosis good
Length of need: 13 months
18.Outpatient Lab Work
Please obtain CBC, chem-10 (Na, K, Cl, HCO3, BUN, Cr, glucose,
Ca, Mg, phos), and LFTs (AST, ALT, alk phos, Tbili) on ___.
Results should be given to ___ team to continue to monitor. They
will be notified as such.
ICD-10: ___.60
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute kidney injury
Alcoholic cirrhosis
Alcoholic hepatitis
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: DUPLEX DOP ABD/PEL LIMITED
INDICATION: ___ man with history of cirrhosis, eval for portal vein
thrombosis
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Abdominal ultrasound dated ___.
FINDINGS:
Liver: The hepatic parenchyma is coarsened and echogenic in keeping with
history of cirrhosis. No focal liver lesions are identified. There is no
ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
CHD: 3 mm
Gallbladder: Re-demonstrated is a 5 mm gallbladder polyp, unchanged. There
is a small amount of sludge within the gallbladder. There is persistent
gallbladder wall thickening, although this is likely secondary to chronic
liver disease.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture.
Spleen length: 19.0 cm
Kidneys: No stones, masses, or hydronephrosis are identified in either kidney.
Right kidney: 11.9 cm
Left kidney: 12.8 cm
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Right portal veins are patent, with antegrade flow. The left portal vein is
patent, but demonstrates reversal of flow.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein is patent, with antegrade flow.
IMPRESSION:
1. Cirrhotic liver with sequela of portal hypertension including marked
splenomegaly. No focal hepatic lesions are identified. There is no ascites.
2. The portal and hepatic veins are patent, although the left portal vein
demonstrates reversal flow.
3. Small amount of gallbladder sludge with an unchanged 5 mm gallbladder
polyp.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs, Hyperkalemia
Diagnosed with Acute kidney failure, unspecified
temperature: 99.4
heartrate: 103.0
resprate: 18.0
o2sat: 97.0
sbp: 115.0
dbp: 79.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ man with a history of recently
diagnosed Child's class B alcoholic cirrhosis complicated by
ascites, recent hospitalization for alcoholic hepatitis
discharged ___, alcohol-induced neuropathy, psoriasis,
hypertension, and hypothyroidism, who presented after routine
outpatient follow-up labs showed elevated creatinine,
hyperkalemia, and elevated white blood cell count.
ACUTE ISSUES
# ___: The patient's ___ was felt to be most likely pre-renal in
etiology in
the setting of over-diuresis. This is corroborated by the fact
that it improved with IV fluids/albumin and holding diuresis.
The patient's creatinine rapidly downtrended and was nearing his
baseline at the time of discharge. Discharge creatinine: 1.1.
# Hyperkalemia: Given the patient's recent start on
spironolactone, this was likely in the setting of over-diuresis
and starting this medication. It responded rapidly to corrective
therapy in the ED and remained stable as an inpatient without
further interventions. No evidence of ECG changes or symptoms.
# Leukocytosis: The etiology of the patient's leukocytosis is
less obvious. It is possible that this is related to his
alcoholic hepatitis that was diagnosed during his recent
admission. However, he never had a leukocytosis prior to his
current admission. Infection is possible, though there are
currently no localizing sources. Ultrasound did not show
ascites,
so SBP is less likely. No evidence of pneumonia or GI infection.
Urine with few bacteria, but patient is asymptomatic. Blood
cultures and urine culture negative at the time of discharge. He
did receive one dose of ceftriaxone in the ED. His WBC count
downtrended by the time of discharge.
# Alcoholic cirrhosis: Child's B alcoholic cirrhosis was
diagnosed during last admission in ___. Complicated by
ascites. MELD 28 on admission. His underlying alcoholic
hepatitis
appears to be improving, which is reassuring. His elevated WBC
count could be related to this, though of note he did not have a
leukocytosis during his last admission. Bilirubin continues to
improve. Diuretics held as above.
# Alcohol induced polyneuropathy: Continues to have pain, though
improved from prior admission. Continued home gabapentin,
dose-reduced for renal function.
# EtOH use disorder: Last drink on ___. Seeking outpatient
therapist and management. Continued foalte, thiamine, and
multivitamin.
# Severe protein-calorie malnutrition: In the setting of
prolonged alcohol use disorder. Kept on high calorie, low sodium
diet with nutrition supplementation.
# Coagulopathy: Likely from synthetic dysfunction in the setting
of cirrhosis. No evidence of bleeding at this time.
CHRONIC ISSUES
# Psoriasis: Continued home fluocinonide, triamcinolone,
desonide creams.
# Hypertension: Normotensive in-house. Decreased metoprolol
tartrate to 12.5mg BID given normotension. Continued amlodipine.
# Gout: Continued home allopurinol.
# Hypothyroidism: Continued home levothyroxine.
TRANSITIONAL ISSUES
[]Discharge creatinine: 1.1
[]Discharge sodium: 135
[]Discharge potassium: 5.0
[]Discharge WBC count: 15.3
[]Continue to hold home diuretics (Lasix and spironolactone)
until appointment with PCP and liver team, as patient may not
require this in the future
[]Labs should be checked on ___ including CBC, chem-10, and
LFTs; has PCP appointment on ___
# CODE: Presumed FULL
# CONTACT: ___ ___ (mother) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaw pain
Major Surgical or Invasive Procedure:
ORIF Right PS and Right Angle fracture and ext #17.
History of Present Illness:
___ y/o M with no significant PMH presented to the ED with left
Jaw pain and difficulty biting s/p assault. neg LOC,
CT can showed Right PS and Left Mandible Angle Fracture
Past Medical History:
non-contributory
Social History:
___
Family History:
non-contributory
Physical Exam:
Gen: NAD
HEENT: post-op hardware. PERRL, EOMI
CV: reg
Pulm: CTAB, no distress
Abd: soft, NT, ND.
Neuro: alert and oriented. Normal gait.
Pertinent Results:
CT MaxF: ___
Several fractures through the mandibular bone including two
nondisplaced
Preliminary Reporthairline fracture lines to the right of the
midline within the symphysis of
Preliminary Reportthe mandible extending to the incisors.
Slightly displaced left mandibular
Preliminary Reportangle fracture extending to the most distal
mandibular molar with resulting
Preliminary Reportair tracking within the medial most aspect of
the masticator space
Radiology Report
HISTORY: Right PS and left mandible ankle fracture status post assault, now
status post ORIF and extraction #17, evaluate postop changes.
COMPARISON: Targeted review of CT of the sinus, mandible and maxilla from
___ at 22:02 p.m.
PANOREX, SINGLE VIEW: The patient is status post ORIF of right parasymphyseal
fractures, transfixed by two reconstruction plate and screws, in overall
anatomic alignment, and a left mandibular angle fracture, also transfixed by
plate and screws, with very slight distraction and minimal displacement. Jaws
are now wired shut.
The mandibular molar adjacent to the left mandibular angle fracture is no
longer visualized. Again seen is lucency around the partially erupted right
mandibular molar. In addition to this, the patient is partially edentulous.
TM joints appear congruent on these views. No fluid identified in the
dependent portion of either maxillary sinus.
IMPRESSION: Wiring of mandible and maxilla and ORIF of parasymphyseal and
left mandibular angle fractures, in overall anatomic alignment. Slight
distraction and minimal displacement at the left mandibular angle fracture is
noted.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Assault, MANDIBLE FX
Diagnosed with MANDIBLE FX NOS-CLOSED, ASSAULT NEC
temperature: 98.0
heartrate: 76.0
resprate: 15.0
o2sat: 98.0
sbp: 166.0
dbp: 86.0
level of pain: 10
level of acuity: 3.0 | The patient presented to Emergency Department on ___. Pt
was evaluated by upon arrival to ED and found to have facial
fractures on CT. Given findings, the patient was taken to the
operating room on ___ by ___. Please see the operative
note for details.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV opioids
and then transitioned to oral analgesic once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-op, patient tolerated full liquid diet as
recommended by ___. Patient was voiding independently without
problem.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Aphasia and question of right leg weakness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ right-handed woman presenting
with aphasia and right leg weakness in the context of recent
headache and on a background of numerous stroke risk factors and
a family history of hemiplegic migraine.
She has been well recently except for some intermittent new
headache that is severe and was kept secret, per her daughter.
Her daughter states that headache was mostly nuchal with
radiation vertically, this was present a few days earlier, as
well as last night. There was no associated fever.
Yesterday she was to undergo scheduled cataract surgery. This
was stopped in process, per her daughter, given high intraocular
pressure. This was of the right eye and she has been wearing a
patch until arriving here.
Last night she had a bad headache, but the patient cannot
presently provide details owing to her language difficulties.
She went to bed and slept, but later managed to say that she had
a rough night (translated from ___ by her daughter).
This morning she was seen sleeping at 8 AM, not unusual for her.
At 9 AM, her son, who lives in the same building, noted that she
was very confused. She would speak unintelligibly without
slurring words, but would not make sense - there was
substitution
of words as well as non-sense words. Her daughter also heard
this when her son placed the patient on the phone with her
daughter. Her son also thought that her right leg seemed weak
and that the patient had at one point called her leg numb.
EMS were called based on the concerns of son and daughter and
she
was brought to ___ were neurology consult was called on
arrival.
The patient has at no time been febrile to the family's
knowledge. She has otherwise been well. Paroxysmal atrial
fibrillation had recently been found and DC cardioversion
considered. Althought she had a several day admission for
bleeding gastric ulcers in ___, the reason Coumadin was
not
started was that she plans a trip to ___ soon and her
physicians felt that monitoring would be difficult and further
bleeding even more dangerous. Ulcers alone were also considered
a risk, as per Dr. ___ of ___. Further review
of systems was limited by the patient's aphasia.
Past Medical History:
- Anxiety and Depression
- Diabetes, type II
- Hypertension
- Hypercholesterolemia
- Obesity
- Cholecystectomy
- Prior gastric ulcers, including bleeding with admission in
___ (___)
- GERD
- Prior diagnosis of BPPV
- Atrial fibrillation
- Cataract surgery
- Total hysterectomy
Social History:
___
Family History:
Daughter with hemiplegic migraine and TIAs.
Physical Exam:
ADMISSION EXAM
Vitals: T ___ F; HR 70 BPM; BP 153/76 mmHg; O2Sat 100 % RA; RR 20
BPM
She is lying still, mostly looking straight ahead with some mild
preference to attention to the left. She is tearful. Her
daughters are at the bedside.
The right pupil is irregular and not round after surgery
yesterday. Her mouth is moist. Her neck seems slightly stiff,
but she is not uncomfortable when it is moved and flexion does
not result in any leg movement. Lung sounds are vesicular and
heart sounds are dual, but there are occasional ectopy. Her
abdomen is soft and bowel sounds are present. Extremities are
of
normal appearance, but for varicose veins and trace edema in her
legs.
She is awake and alert, but seems to be with her own thoughts.
She can say her first name but did not provide her last name.
She did not answer when asked where she was or the date. She
occasionally reaches to her right thigh and calls this her arm
(in ___ and said something to the effect that her arm has
no
foot. She can recite parts of prayers but not the one that her
daughter attempts to have her repeat. She mixes fragments of
prayers, but does not make errors with the words. She called
aspirin her uterus. She called a pen and pencil, but did not
name other presented objects. She is upset and says 'oh my
god'.
Olfactation was not tested. She blinks to threat from all four
quadrants. The right pupil is irregular and post-surgical and
does not react. The left is 4 to 2 and round. Her gaze is
conjugate and is full to left and right, with some limitation of
upgaze. There is trace nasolabial fold flattening on the right
(her family agree). Hearing intact to voice.
Sternocleidomastoid seems strong. No dysarthria, tongue
medially
placed.
Tone is normal in arms and legs. There is no pronator drift.
She can open her hand fully on the right and finger extension is
strong. She can lift both arms against gravity and strength is
symmetrical. Both legs can be lifted from the bed against
resistance, but it was not possible to get her to dorsiflex the
foot fully or extend the toes.
Reflexes:
B T Br Pa Ac
R ___ 1 0
L ___ 1 0
Toes upgoing on the right and down on the left.
Sensation: More marked affective response to nailbed pressure on
the left
than the right, but withdrawal throughout.
Coordination and Cerebellar Function: Good alternating movements
with both hands.
Gait: Not tested - kept patient flat.
**************
DISCHARGE EXAM
**************
Tc 97.8, BP 123/79, HR 89 (intermittent afib), RR 18, O2 95%
Gen: Well appearing, sitting in chair
HEENT: MMM, anicteric
CV: Irregular, no murmurs
Resp: CTAB
GI: +BS, soft, NTND
Ext: WWP, varicosities on LLE
Neuro:
MS: Awake and oriented to name and place, follows 1-step but not
2-step commands; cannot follow commands that cross midline;
speech somewhat improved but continued paraphasic errors and
mild anomia; cannot repeat
CN: R surgical pupil, pupils reactive, face symmetric, tongue
midline, SCM/Trap equal strength
Motor: Normal bulk and tone; Strength full on left side, 4+ in
right delt with mild right pronation on drift; otherwise full
strength
___: Reports equal sensation to light touch bilaterally;
Coord: Mild increased rebound on right
Pertinent Results:
Admission Laboratory Data:
139 99 22
------------< 160 AGap=18
3.6 26 0.8
Ca: 9.2 Mg: 2.0 P: 3.2
ALT: 11 AP: 93 Tbili: 0.4 Alb: 4.2 AST: 19
___: 12.3 PTT: 76.1 INR: 1.1
95 ___
8.0 12.6 292
38.6
N:72.5 L:20.3 M:6.9 E:0.2 Bas:0.2
IMAGING STUDIES:
CT Head (___): 1) No evidence of acute intracranial process.
2) Small infarct in the posterior left frontal lobe, at least
subacute and likely older. 3) Chronic sinus disease as detailed
above.
CTA Head and Neck (___):
1) Normal intracranial circulation. No dissection or flow
limiting stenosis of the arteries of the neck. 2) Chronic
inflammatory sinus disease as detailed above, predominantly on
the right, which may be odontogenic in origin. NOTE ADDED IN
ATTENDING REVIEW: Upon review of this study in tandem with the
MRI from ___, there is an abrupt interruption ("cut-off")
of the opacified distal branches of the inferior division of the
left middle cerebral artery (M3 segment), most apparent on the
3D volume-rendered images (355:1). This finding corresponds to
the vascular territory demonstrating slow diffusion on the MRI
and likely represents thrombo-embolic occlusion of these
vessels. The intracranial circulation is otherwise
unremarkable.
MRI (___): 1. Acute/subacute infarcts involving the left
parietal cortex extending inferiorly into the insular cortex and
a smaller focus in the left caudate head. 2. Extensive
right-sided sinus disease as described. Correlation with direct
visualization to exclude an underlying obstructing lesion is
advised.
ECHO (___): The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is moderately dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. There is no pericardial effusion. IMPRESSION: No
cardiac source of embolism identified. Preserved global and
regional biventricular systolic function. Mild dilatation of the
aortic root with moderate enlargement of the ascending aorta.
DISCHARGE LABS
___ 05:00AM BLOOD WBC-5.5 RBC-3.55* Hgb-11.0* Hct-33.6*
MCV-95 MCH-31.1 MCHC-32.9 RDW-14.8 Plt ___
___ 05:00AM BLOOD ___ PTT-76.9* ___
___ 05:00AM BLOOD Glucose-121* UreaN-17 Creat-0.7 Na-142
K-3.1* Cl-102 HCO3-29 AnGap-14
___ 05:00AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.0 Cholest-PND
___ 12:35PM BLOOD %HbA1c-6.4* eAG-137*
___ 12:35PM BLOOD HDL-53 CHOL/HD-3.5 LDLmeas-114
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Cholestyramine 4 gm PO BID diarrhea
Mix with 8 oz. fluid
3. Fluoxetine 20 mg PO DAILY --> PATIENT NOT ACTUALLY TAKING
4. Furosemide 40 mg PO BID
5. ketorolac *NF* 0.4 % ___ 1 drop in RIGHT eye 4 times a day for
1 week, 3 times a day for 1 week, twice a day for 1 week, daily
for 1 week then stop
1 drop in RIGHT eye 4 times a day for 1 week, 3 times a day for
1 week, twice a day for 1 week, daily for 1 week then stop
6. Losartan Potassium 50 mg PO BID
7. MetFORMIN (Glucophage) 850 mg PO DINNER
after supper
8. Metoprolol Tartrate 100 mg PO BID
9. moxifloxacin *NF* 0.5 % ___ 1 drop in RIGHT eye 4 times a day
for 1 week; 3 times a day for 1 week then stop
10. Omeprazole 40 mg PO BID
11. Potassium Chloride 20 mEq PO DAILY
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE FOR 1
WEEK, 3 TIMES A DAY FOR 1 WEEK, TWICE A DAY FOR 1 WEEK, ONCE A
DAY FOR 1 WEEK THEN STOP
Discharge Medications:
1. Furosemide 40 mg PO BID
2. Ketorolac *NF* 0.4 % ___ 1 DROP IN RIGHT EYE 4 TIMES A DAY FOR
1 WEEK, 3 TIMES A DAY FOR 1 WEEK, TWICE A DAY FOR 1 WEEK, DAILY
FOR 1 WEEK THEN STOP
3. Metoprolol Tartrate 100 mg PO BID
4. Omeprazole 40 mg PO BID
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE FOR 1
WEEK, 3 TIMES A DAY FOR 1 WEEK, TWICE A DAY FOR 1 WEEK, ONCE A
DAY FOR 1 WEEK THEN STOP
6. Aspirin EC 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. Lorazepam 2 mg PO BID
8. Vigamox *NF* (moxifloxacin) 0.5 % OD TID Duration: 1 Weeks
9. Warfarin 5 mg PO DAILY16
10. Amlodipine 5 mg PO DAILY
11. Cholestyramine 4 gm PO BID diarrhea
12. MetFORMIN (Glucophage) 850 mg PO DINNER
13. moxifloxacin *NF* 0.5 % ___ 1 DROP IN RIGHT EYE 4 TIMES A DAY
FOR 1 WEEK; 3 TIMES A DAY FOR 1 WEEK THEN STOP
14. Potassium Chloride 20 mEq PO DAILY
Hold for K >
15. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
16. Outpatient Physical Therapy
Diagnosis: ischemic stroke with aphasia and weakness. Please
evaluate and treat.
17. Outpatient Speech/Swallowing Therapy
Diagnosis: ischemic stroke with aphasia and weakness. Please
evaluate and treat.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1) Ischemic stroke
2) Atrial fibrillation
3) Hypertension
4) Diabetes
5) Hyperlipidemia
Discharge Condition:
Mental Status: Clear but with continued aphasia, with difficulty
with naming, repeating and following 2-step commands. Still
intermittently frustrated.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Has mild right sided weakness.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with altered mental status and right leg
weakness.
COMPARISON: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass
effect, or infarction. There is an area of hypodensity with loss of gray
matter in the posterior left frontal lobe, which likely represents an
infarction that is at least subacute and likely even older. The ventricles
and sulci are normal in size and configuration. The basal cisterns appear
patent and there is preservation of gray-white matter differentiation.
No fracture is identified. There is complete opacification of the right
maxillary sinus. The right ethmoid air cells are almost completely opacified
and the left ethmoid air cells are partially opacified. The sphenoid sinus is
completely opacified. The right frontal sinus is partially opacified. There
is thickening of the bone surrounding the right maxillary sinus, consistent
with chronic bone reaction due to chronic inflammation. This chronic
inflammation may be secondary to a polyp, although no polypoid masses seen on
this exam. The mastoid air cells and middle ear cavities are clear. Patchy
vascular calcifications are seen in the internal carotid arteries. The globes
are intact.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Small infarct in the posterior left frontal lobe, at least subacute and
likely older.
3. Chronic sinus disease as detailed above.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Confusion.
COMPARISONS: ___.
TECHNIQUE: Chest, portable AP upright.
FINDINGS: The cardiac, mediastinal, and hilar contours appear unchanged. The
lungs appear clear. There are no pleural effusions or pneumothorax. There
has been no significant change.
IMPRESSION: No evidence of acute disease.
Radiology Report
HISTORY: ___ female with aphasia and right leg weakness. Evaluation
for evaluation for thalamic hemorrhage or vascular stenosis.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of intravenous contrast initially. Subsequently,
helically acquired axial images were obtained through the head and neck using
a CTA protocol after the uneventful administration of 70 cc of Omnipaque
intravenous contrast. Curved reformats and volume rendered reformation
generated on an independent work station.
COMPARISON: Comparison is made to non-contrast CT of the head from ___.
FINDINGS:
Head CT: There is no evidence of hemorrhage, edema, mass, mass effect, or
acute vascular territorial infarction. The ventricles and sulci are normal in
size and configuration. No fracture is identified.
There is complete opacification of the right maxillary sinus and near complete
opacification of the right ethmoid air cells along with the frontal ethmoidal
recess with chronic osteitis of the anterior and lateral walls of the right
maxillary sinus, consistent with chronic inflammatory disease. Calcified
contents of the right maxillary sinus are likely also the sequelae of chronic
inflammation and may be secondary to a polyp, although no polypoid masses are
seen and sinonasal polyposis is unlikely given the predominantly right-sided
findings. Slight mucosal thickening of the left maxillary sinus is noted.
Bilateral periapical lucency of maxillary teeth ___ numbers 3, 4 and 14) is
noted. These findings could be related to the chronic sinus inflammatory
disease previously described. The mastoid air cells and middle ear cavities
are clear.
Head and neck CTA: The carotid and vertebral arteries and their major
branches are patent with no evidence of stenosis. The bilateral vertebral and
carotid arteries are tortuous with medialization of the common carotids, left
more than right. Calcifications are seen at the level of the carotid
bifurcations bilaterally with no evidence of flow-limiting stenosis. The left
internal carotid artery measures 8.5 mm proximally and 5.0 mm distally. The
right internal carotid artery measures 7.8 mm proximally and 5.5 mm distally.
IMPRESSION:
1. Normal intracranial circulation. No dissection or flow limiting stenosis
of the arteries of the neck.
2. Chronic inflammatory sinus disease as detailed above, predominantly on the
right, which may be odontogenic in origin.
The above findings were communicated to Dr. ___ by Dr.
___ at 1545H on ___, 5 minutes after discovery.
NOTE ADDED IN ATTENDING REVIEW: Upon review of this study in tandem with the
MRI from ___, there is an abrupt interruption ("cut-off") of the
opacified distal branches of the inferior division of the left middle cerebral
artery (M3 segment), most apparent on the 3D volume-rendered images (355:1).
This finding corresponds to the vascular territory demonstrating slow
diffusion on the MRI and likely represents thrombo-embolic occlusion of these
vessels. The intracranial circulation is otherwise unremarkable.
Radiology Report
HISTORY: Stroke, evaluate for territory.
TECHNIQUE: Multiplanar multisequence MRI of the brain was obtained without IV
gadolinium.
COMPARISON: CT head noncontrast of ___ and CTA of ___.
FINDINGS:
There is slow diffusion involving the left parietal cortex, extending
inferiorly into the insular cortex, consistent with acute/subacute infarct in
the territory of the inferior division of the left middle cerebral artery.
There is abnormal FLAIR hyperintensity corresponding to this abnormality. In
addition, there is a small focus of slow diffusion involving the left caudate
head consistent with an additional small infarct. There is no evidence of
midline shift or mass effect. There is no evidence of hemorrhage.
The ventricles are normal in size. There is mild prominence of the
extra-axial CSF spaces.
There are scattered minimal T2 hyperintensities in the periventricular and
subcortical white matter which are nonspecific but could be seen with chronic
microangiopathy.
There is extensive mucosal thickening of the right maxillary sinus with fluid.
There is also extensive opacification of the right sphenoid and right ethmoid
air cells with mucosal thickening of the right frontal sinuses.
IMPRESSION:
1. Acute/subacute infarcts involving the left parietal cortex extending
inferiorly into the insular cortex and a smaller focus in the left caudate
head.
2. Extensive right-sided sinus disease as described. Correlation with direct
visualization to exclude an underlying obstructing lesion is advised.
These findings were discussed with Dr. ___, at 1:50 pm, on ___ via
phone, and they were aware of the findings.
Gender: F
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by AMBULANCE
Chief complaint: R LEG WEAKNESS
Diagnosed with MUSCSKEL SYMPT LIMB NEC, APHASIA, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.0
heartrate: 70.0
resprate: 20.0
o2sat: 100.0
sbp: 153.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | NEUROLOGY ___ 11 COURSE (___)
Neuro: Ms. ___ was admitted with a Broca's aphasia
(difficulty generating speech, paraphasic errors, difficulty
repeating, naming, reading or writing) as well as mild right
sided weakness and some cerebellar signs. She was quite
frustrated and anxious at admission. Her MRI revealed a left MCA
stroke (mostly inferior division) but without severe vessel
cut-off on CTA.
The etiology of her stroke was felt to be most likely
cardioembolic given her atrial fibrillation without coagulation.
ECHO showed normal ventricular function and no PFO/ASD; no
obvious thrombus was visualized. She was therefore started on
Coumadin and kept on Aspirin 325mg with plans to stop this once
her INR is therapeutic. Dr. ___ will follow her
INR as an outpatient.
Her HgbA1c was 6.4% (per recent PCP notes, goal was for A1c
closer to 7) and her LDL was elevated at 114, so we started
Simvastatin 40mg to reduce her risk of future stroke.
Physical and speech therapy recommended discharge home with the
family with a walker and outpatient physical and speech therapy.
CV: We allowed Ms. ___ blood pressures to autoregulate
and held the home amlodipine and losartan and continued the
Metoprolol and Furosemide at lower doses. Her SBPs were
appropriate in the 100-120s. We recommended she restart her home
doses of Metoprolol, Furosemide, and Amlodipine at home, but not
take the Losartan until she has a recheck of her blood pressure
by her PCP.
ENDO: Metformin was held and she was on an insulin SS with
glucose in the 130-220s. She was told to restart her Metformin
at discharge. Lastly, Simvastatin was started for the elevated
LDL of 114 (Goal for secondar stroke prevent <100).
HEME: Her Hct decreased from 38 to 33 over her hospital stay.
Her guaiac was negative. We recommended she recheck this at the
PCPs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Naproxen / Tetracycline / Barium Sulfate / Morphine / Iodinated
Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
___: laparopscopic cholecystectomy
History of Present Illness:
___ year old female who complains of
Cholecystitis, Transfer. This is a ___ female with
stage IV renal cancer on chemotherapy who presents as a
transfer from out of hospital for acute cholecystitis. The
patient reports 2 weeks of right upper quadrant abdominal
pain. It is intermittent. She also endorses vomiting. The
pain does not radiate. She presented to the ___
and underwent a CT scan and ultrasound that reportedly
showed cholecystitis. She was given cefoxitin. She was given
dilaudid for her pain. After discussion with her oncologist,
she was transferred here given her care is here, for
surgical evaluation. She denies a chest pain or shortness of
breath. She is on Cipro for a UTI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Oncologic history began in ___ with right abdominal pain
with a CT scan demonstrating a left kidney mass. She underwent
laparoscopic radical nephrectomy on ___ and pathology
revealed clear cell renal cell carcinoma 5 cm in size, firm, and
grade 2 with extensive necrosis. There was no lymphovascular
invasion and all resection margins were negative for tumor.
She was observed, and in ___, she was found to have a
right adrenal mass which on follow-up scans grew. On ___,
she underwent laparoscopic right adrenalectomy with pathology
confirming metastatic renal cell carcinoma. Surveillance was
continued, and in ___, she was found to have a new left
8-mm left adrenal abnormality. She underwent a brain MRI for
headache which demonstrated an abnormality prompting a brain
biopsy in ___, with pathology negative. Surveillance CT
in ___ revealed further left adrenal enlargement.
She was seen at ___ and several treatment options were
presented. She was referred here for consideration for high-dose
IL-2 therapy. She passed eligibility testing and completed week
1 of IL-2 therapy and was admitted ___ for week 2. She had
difficulty tolerating IL-2, and was suggested to have surgery.
======================
.
PAST MEDICAL HISTORY: MVA in ___ with multiple orthopedic
injuries requiring hardware placement and subsequent removal;
asthma; ectopic pregnancy; early menopause; obesity and renal
cell carcinoma as above.
====================
Social History:
___
Family History:
FAMILY HX: She has a strong family history of cancer. Her father
died of pancreas cancer, her mother has bladder cancer, her
paternal
grandmother died of gall bladder cancer and her paternal
grandfather died of throat cancer.
Physical Exam:
DISCHARGE EXAM
Vitals: 98.6 69 115/76 18 93 2L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, appropriately tender at incisions, no
rebound or guarding, normoactive bowel sounds, no palpable
masses. Port site wound with dressings c/d/I. JP drain in place
in RUQ, serosanguinous output.
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 08:10PM BLOOD WBC-6.7 RBC-3.94 Hgb-13.8 Hct-41.2
MCV-105* MCH-35.0* MCHC-33.5 RDW-12.0 RDWSD-46.4* Plt ___
___ 05:52AM BLOOD WBC-7.7# RBC-3.56* Hgb-12.5 Hct-36.9
MCV-104* MCH-35.1* MCHC-33.9 RDW-11.6 RDWSD-44.3 Plt ___
___ 08:10PM BLOOD Glucose-119* UreaN-18 Creat-1.4* Na-136
K-4.8 Cl-100 HCO3-25 AnGap-16
___ 05:52AM BLOOD Glucose-168* UreaN-7 Creat-1.1 Na-135
K-5.1 Cl-98 HCO3-26 AnGap-16
___ 08:10PM BLOOD ALT-72* AST-63* AlkPhos-79 TotBili-0.7
___ 06:08AM BLOOD ALT-81* AST-74* AlkPhos-89 TotBili-0.9
___ 08:10PM BLOOD Lipase-109*
___ 09:00AM BLOOD Lipase-99*
___ 06:08AM BLOOD Lipase-59
RUQ US ___:
1. Findings compatible with early acute cholecystitis. Positive
sonographic ___ sign.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
Medications on Admission:
MEDICATIONS:
AMLODIPINE - amlodipine 5 mg tablet. 2 tablet(s) by mouth daily
-
(Prescribed by Other Provider)
EPINEPHRINE - epinephrine 0.3 mg/0.3 mL injection,
auto-injector.
as needed for allergic reaction - (Prescribed by Other
Provider)
FLUDROCORTISONE - fludrocortisone 0.1 mg tablet. 1 tablet(s) by
mouth M, W, F - (Prescribed by Other Provider)
HYDROCORTISONE SOD SUCCINATE [SOLU-CORTEF] - Solu-Cortef
Act-O-Vial 100 mg/2 mL solution for injection. Use as directed
in
case of emergency
LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth Take
___ tablet by mouth 30 minutes prior to Scan as needed for
anxiety
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth twice daily - (Prescribed by Other
Provider)
ONDANSETRON HCL - ondansetron HCl 4 mg tablet. 1 tablet(s) by
mouth three times a day as needed for nausea for 3 days of chemo
PAZOPANIB [VOTRIENT] - Votrient 200 mg tablet. 3 tablet(s) by
mouth once a day
PREDNISONE - prednisone 2.5 mg tablet. 2 Tablet(s) by mouth
daily
Increase during illness as discussed. - (Prescribed by Other
Provider)
Medications - OTC
ACETAMINOPHEN - acetaminophen 325 mg tablet. ___ Tablet(s) by
mouth prn - (OTC)
ALCOHOL SWABS [ALCOHOL PADS] - Alcohol Pads. Use to clean skin
prior to injection
LOPERAMIDE [IMODIUM A-D] - Imodium A-D 2 mg tablet. 1 tablet(s)
by mouth four times a day as needed for diarrhea
Discharge Medications:
1. Clotrimazole Cream 1 Appl TP BID
apply to perineal area
RX *clotrimazole 1 % apply externally to perineal area twice a
day Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. amLODIPine 5 mg PO BID
6. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___)
7. Omeprazole 20 mg PO BID
8. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: Evaluate for cholecystitis versus cholelithiasis, in a
___ woman with right upper quadrant pain.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital abdominal ultrasound and CT abdomen/ pelvis from
the same day.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: Nonmobile stones are seen within the neck of the distended
gallbladder. There is no gallbladder wall thickening or edema. A sonographic
___ sign is present.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 13.0 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. Findings compatible with early acute cholecystitis. Positive sonographic
___ sign.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:54 ___, 15 minutes
after discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cholecystitis, Transfer
Diagnosed with Acute cholecystitis
temperature: 97.4
heartrate: 97.0
resprate: 16.0
o2sat: 94.0
sbp: 137.0
dbp: 84.0
level of pain: 2
level of acuity: 2.0 | The patient was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis. She was
initially treated with antibiotics for two days as her lipase,
which was initially elevated, downtrended. She was then taken to
the operating room on ___ and underwent a laparoscopic
cholecystectomy that was uncomplicated. One JP drain was left in
place in the RUQ. Please see operative report for details of
this procedure. She tolerated the procedure well and was
extubated upon completion. She was subsequently taken to the
PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the evening of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed. On
___, she was discharged home with scheduled follow up in ___
clinic in one week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope vs seizure
Major Surgical or Invasive Procedure:
Pacemaker placement ___
Pacemaker revision ___
History of Present Illness:
Ms. ___ is a ___ year-old ?ambidextrous (does most things right
but plays tennis with left) woman with history of orthostatic
hypotension (?pseudopheochromocytoma) who was brought in from
her
PCP's office with multiple seizures today.
The history is relayed by her son at the bedside, who is a
physician and has been closely involved in her care.
He reports that she was previously healthy and living
independently up until around ___ of this year. Around that
time, she began complaining of "clanging" sounds that she would
hear even though there was no sounds. She did not have other
symptoms associated with the sounds at that time. The sounds
resolved on their own - though might have lasted couple of days
per patient.
On ___, she was in the car with her son and daughter-in-law and
they were going to dinner, and she had LOC lasting 10 seconds.
She was brought to ED and they found her to have supine
hypertension and orthostatic hypotension (per DC summary, SBP
170->101). She had cardiac work up and then discharged home.
On ___, she went to the market, felt lighteaded, fell and hit
her
head, though she did not have loss of consciousness. She was
again brought to ED and had head CT which showed only subgaleal
hematoma. Admitted to medicine for observation overnight, again
found to have orthostatic hypotension (170 -> 140s)
Afterwards, her son began monitoring her blood pressure more
carefully at home and found that she had significant supine
hypertension with lying SBP up to 200s, and relative orthostatic
hypotension with SBP in 150s and symptomatic. Her son brought up
question of pseudopheochromocytoma and empiric treatment was
started with atenolol 50 mg and doxazosin 4 mg at 9 AM daily. He
feels that these medications has helped her and there has been
fewer episodes of presyncopal or syncopal episodes.
Pheochromocytoma work up was done and showed normetanephrine of
1.2 (normal < 0.9) and normal metanephrine.
End of ___, she had severe GI illness with n/v/diarrhea. They
obtained 24 hour care giver to keep her at home with very
frequent PO hydration. During this illness, they noted that she
had frequent seizures, with eyes rolling up and tonic/clonic
movement of her arms/legs. She would wake up confused and
agitated. There was no tongue biting or urinary incontinence.
They estimate about ___ short seizures in the ___ day period
during her illness. She also had some confusion vs.
hallucination
as she was recovering, but essentially recovered to baseline per
her son.
2 weeks ago, she had one brief seizure while she was out with a
family member to get coffee. she had just gotten some coffee and
had a similar episode of convulsion.
For the last week, she has been feeling fatigued with some
diarrhea, and had one seizure yesterday. This morning, between
5:45 and 6:16, she had 7 episodes of either rolling or shaking
that was witnessed by the caregiver at home. She seemed confused
afterwards with possible hallucinations. They took her to her
PCP's office to get labs drawn and she had 2 more episodes, so
was brought to ED. Her hallucinations seem to be both auditory
(hearing ___ baritone singing") and formed/visual variety,
usually involving people (she was seen talking to empty space,
and when asked she said she was talking to the caregiver).
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Some 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. +Mild diarrhea, no vomiting. No recent change in
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
AORTIC REGURGITATION
BICUSPID REGURGITATION
Ductal carcinoma in situ s/p lumpectomy, no radiation or
chemotherapy needed
Chronic hearing loss
HLD
Supine hypertension and orthostatic hypotension as per HPI
Osteoporosis
Shingles in left back (___)
Squamous cell carcinoma s/p removal
Social History:
___
Family History:
Father had history of myocardial infarction, atrial
fibrillation, hypertension, and stroke. He passed away when he
was ___ years old. Mother had a history of endometriosis and
dementia and died at the age of ___. No history of seizures.
Physical Exam:
Admission Physical
====================
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, warm to palpation
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, place but not to date
(says ___. Able to relate history when asked. Attentive,
able to name ___ backward slowly, but correctly. Language is
fluent with intact repetition and comprehension. There was mild
stuttering. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of neglect. There was no evidence of left-right
confusion as the patient was able to accurately follow the
instruction to touch left ear with right hand.
Cube 3D copying was intact. She was able to fill in all the
numbers on clockface correctly but could not place the hands in
the correct position.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Slightly hard of hearing.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk. Some difficulty relaxing but normal tone
throughout. No pronator drift bilaterally but mild orbiting
around the left forearm. No adventitious movements, such as
tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4+ 4+ 5- 5- ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch throughout. Slight
hypersensitivity to pinprick from midshin and further distally.
Decreased cold sensation in the same area. Decreased vibration
at
the toes R>L. Unable to test proprioception reliably. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3+ 2
R 2 2 2 3+ 2
Brisk withdrawal with plantar stimulation.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Deferred.
Discharge Exam
===============
VS:(refused vitals multiple times) 98.1 ___ 16 100%RA
Orthostatics 142/60 54 while lying, 92/40 68 while standing
Gen: Pleasant, appearing to be in NAD
NECK: Supple, JVP low. Normal carotid upstroke without bruits.
No thyromegaly or LAP
CV: RRR, PMI normal position, no parasternal lift; normal S1/S2,
chest with pacer in place no TTP
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: Soft, NT/ND, +BS. No HSM. No abdominal bruits.
EXT: WWP, no LEs edema. Full distal pulses bilaterally. No
femoral bruits.
NEURO: alert, responsive and conversant. Moving all extremities.
Pertinent Results:
Admission Labs
=============
___ 02:31PM ___ PTT-24.9* ___
___ 01:18PM GLUCOSE-119* UREA N-20 CREAT-1.1 SODIUM-135
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-27 ANION GAP-12
___ 01:18PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-2.1
___ 01:18PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:18PM WBC-7.7# RBC-4.09* HGB-13.7 HCT-41.6 MCV-102*
MCH-33.5* MCHC-32.9 RDW-12.1
___ 01:18PM NEUTS-82.0* LYMPHS-9.4* MONOS-8.1 EOS-0.4
BASOS-0.1
___ 01:18PM PLT COUNT-167
___ 11:00AM GLUCOSE-117*
___ 11:00AM UREA N-21* CREAT-1.2* SODIUM-137
POTASSIUM-4.1 CHLORIDE-102
___ 11:00AM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-85
___ 11:00AM CALCIUM-9.2 MAGNESIUM-2.1
___ 11:00AM WBC-7.2# RBC-4.15* HGB-13.9 HCT-42.3 MCV-102*
MCH-33.5* MCHC-32.9 RDW-12.5
Discharge Labs
===============
___ 09:00AM BLOOD WBC-5.9 RBC-4.25 Hgb-13.6 Hct-42.8
MCV-101* MCH-32.1* MCHC-31.9 RDW-12.2 Plt ___
___ 12:50PM BLOOD Glucose-120* UreaN-20 Creat-1.1 Na-137
K-4.2 Cl-103 HCO3-27 AnGap-11
Imaging
==========
CT Head ___
IMPRESSION: No acute intracranial abnormality.
MRI Head ___
IMPRESSION:
1. There is no evidence of acute intracranial process, no
significant changes are present since the prior MRI examination
on ___.
2. Unchanged left-sided intra orbital/ intraconal 9 mm nodule,
probably
consistent with hemangioma.
EEG ___
IMPRESSION: This telemetry captured no pushbutton activations.
Background
showed fairly well-organized moderate amplitude theta frequency
slowing. These findings are etiologically non specific but could
reflect a mild
encephalopathy.
Chest Xray ___
IMPRESSION:
Appropriate position of right ventricular lead. No pneumothorax.
PPM ___
Generator Brand: ___
Model Name: ___
Model Number: ___
Presenting rhythm: high grade AVB
Intrinsic Rhythm: SR with high grade AV block
Programmed Mode: VVI 50
RV lead
Model Brand/Number: ___ ___
Intrinsic amplitude:14.6mV
Pacing impedance: 658 ohms
Pacing threshold: 0.4 @ 0.4 ms
%pacing: 30%
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Doxazosin 4 mg PO QAM
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Cephalexin 500 mg PO Q8H Duration: 1 Day
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*2 Capsule Refills:*0
3. QUEtiapine Fumarate 50 mg PO 5PM
RX *quetiapine 50 mg 1 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Syncope
- Second Degree Heart Block
Secondary Diagnosis
- Orthostatic Hypotension
- Hypertension
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
HISTORY: Multiple seizures. Evaluate for acute process.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DLP: 891.9 mGy-cm.
COMPARISON: Noncontrast CT head from ___.
FINDINGS: There is no acute large territorial infarct, hemorrhage, edema, or
mass effect. The ventricles and sulci are prominent, suggestive of
age-related involutional change. Mild periventricular hypodensities are
consistent with chronic small vessel ischemic disease. The basal cisterns are
patent and there is preservation of gray-white matter differentiation.
No fracture is identified. There are aerosolized secretions within the right
sphenoid sinus; the other visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRASTMRI of the head with and without contrast.MR
HEAD W/O CONTRAST
INDICATION: ___ year old woman with orthostatic hypotension, new seizures //
evaluate for abnormality, new seizures
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial FLAIR,
axial diffusion weighted and axial gradient echo images.
COMPARISON: Prior MRI of the brain dated ___, and prior head CT
dated ___.
FINDINGS:
No significant changes are demonstrated since the prior examination. There is
no evidence of intracranial hemorrhage, mass, mass effect or shifting of the
normally midline structures. The ventricles and sulci are prominent,
suggesting cortical volume loss, probably age related and involutional in
nature. Multiple scattered foci of high signal intensity are again seen on T2
and FLAIR sequences, distributed in the subcortical and periventricular white
matter, which are nonspecific and may reflect changes due to small vessel
disease. No diffusion abnormalities are detected. The major vascular flow
voids are present and demonstrate normal distribution. The orbits are notable
for a left-sided 9 x 7 mm retrobulbar/intraconal nodule, abutting the optic
nerve and the adjacent lateral rectus muscle and mild restricted diffusion,
there is no evidence of proptosis or significant enlargement since the prior
examination, the paranasal sinuses and the mastoid air cells are clear.
IMPRESSION:
1. There is no evidence of acute intracranial process, no significant changes
are present since the prior MRI examination on ___.
2. Unchanged left-sided intra orbital/ intraconal 9 mm nodule, probably
consistent with hemangioma.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p ppm // ___ year old woman s/p ppm
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
New left chest wall pacemaker with single ventricular leads appropriately
positioned. No pneumothorax. Heart size is enlarged but stable. Lungs are
clear and there is no pleural abnormality.
IMPRESSION:
Appropriate positioning of single cardiac lead with no pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p pacemaker // confirm lead placement
TECHNIQUE: Chest PA and lateral
COMPARISON: 1 day prior
FINDINGS:
The left chest wall pacemaker and right ventricular leads are stable. Heart
size and mediastinal contours are stable. No pneumothorax or pleural
effusion.
IMPRESSION:
Appropriate position of right ventricular lead. No pneumothorax.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Seizure
Diagnosed with OTHER CONVULSIONS
temperature: 96.8
heartrate: 61.0
resprate: 18.0
o2sat: 100.0
sbp: 162.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | ___ with a history of aortic regurgitation, ductal carcinoma in
situ s/p lumpectomy, supine HTN and orthostatic hypotension
presenting with recurrent episodes of syncope found to be in
second degree heart block now s/p pacemaker placement and
revision.
# Second Degree Heart block, Type 2 - Found to have high grade
block on telemetry. This was thought to be contributing to many
of her symptoms. The etiology of this block was unclear as
patient does not have known CAD or chest pain consistent with
ischemic events. She had a pacemaker placed on ___ and that
night was delirious and the lead became dislodged. She went for
revision on ___ and follow up chest xray showed the pacer in
good position with interrogation showing normal functioning. Her
pacemaker was ___ with one RV lead.
- Follow up in device clinic on ___.
- She was given Keflex to take through ___.
# Syncope - Patient with multiple episodes of syncope and
previous admission for syncopal events. Initially she was
admitted to the neurology service and started on Keppra
empirically for possible seizure disorder. CT Head, MRI Head,
and EEG did not show any abnormality consistent with seizures.
She was found to have high degree heart block on telemetry.
Neurology then recommended discontinuing her Keppra. She
underwent pacemaker implantation as above. She did have a known
history of orthostati hypotension that could be contributing to
her symptoms. Her doxazosin was stopped. Her symptoms may have
slightly improved but she continued to have orthostatic
hypotension on day of discharge.
# HTN - Patient was hypertensive while lying flat but
symptomatically orthostatic when upright. She was maintained on
her anti-hypertensives and remained with some symptoms of
orthostasis and also with occasionally elevated pressures. She
was recommended to follow up with her PCP for further blood
pressure control.
# Dementia - She had an unclear etiology, perhaps ___ body
dementia given her autonomic dysfunction vs alzheimers. Her
dementia likely contributed to her delirium and sundowning. She
got seroquel one night with improved results. She was discharged
with a few seroquel for PRN use.
- She was setup with close neurology follow up.
# Diarrhea - Patient with diarrhea prior to arrival which
improved in hospital. She was monitored but not further workup
was necessary. |