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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lipitor
Attending: ___
Chief Complaint:
DOE, ___ edema
Major Surgical or Invasive Procedure:
cardiac catheterization -- ___
History of Present Illness:
___ with Hx HTN, HLD, chronic diastolic dysfunction presents
with increasing dyspnea on exertion, ___ edema, and chest
heaviness. She states that she first noticed lower extremity
edema in her left leg a few months ago. Prior to that time, she
had chronic swelling of her left foot for many years, which she
believes dates to a gout flare in her left great toe ___ years
ago. Over the last few months she has noticed slowly
progressive swelling of both legs up to the knees. Two weeks
ago she noticed dyspnea with her normal daily activities. She
normally can walk on flat surfaces without dyspnea, and has mild
dyspnea on one flight of stairs. Over the last two weeks she
has had progressive dyspnea and by the day of admission found
herself short of breath walking from the bed to the corridor.
At these times she also noted chest pressure. She denies chest
pressure at rest. Last ___ she felt "off", took 2 aspirin,
and felt better. She denies pain at that time.
.
She also notes that she sometimes has lightheadedness on
standing and turning, although some of this is due to her
left-sided vertigo. She believes the lightheadedness is new.
She denies falling or loss of balance.
.
Overnight she has been free of chest pressure, but has not
exerted herself. She was started on a heparin gtt, loaded with
600mg Plavix, and diuresed with Lasix 10mg IV. Her EKGs reveal
Q waves in 3 and aVF without ST segment changes; troponin
positive at 0.67. BNP 1121. She remained afebrile overnight
with SBP 120-150s and HR 60-80s. This morning she has no
complaints.
Past Medical History:
Hypertension
Hypercholesterolemia
Chronic kidney disease (baseline Cr 1.2-1.5)
Syncope (___)
Essential Tremor tx with Botox
Cataracts s/p lens replacement b/l
Anxiety
Depression (most recent PHQ-9 was 2)
Colonic polyps, last ___ ___, due ___
Low back pain
Nephrolithiasis s/p cystoscopy ___
Overactive bladder
Urinary Incontinence - requires 3 pads daily
Vertigo - left ear
Hard of hearing
Chronic anemia (baseilne Hb 10.5-12)
Osteoarthritis
h/o gout in left great toe, last attack ___ yrs ago
Social History:
___
Family History:
Mother with pig's valve, father with CAD, sister died of lung
cancer, daughter died of colon cancer metastatic to the liver.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 153/80 63 18 100% on RA ___ 67kg
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP at 4mm, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - +BS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, ___ edema bilaterally but left>right, left
leg chronically larger than right, 2+ peripheral pulses, neg
___
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
.
DISCHARGE PHYSICAL EXAMINATION:
98.6 120/70 67 18 97% RA weight 66.6kg
GENERAL: NAD. Alert and oriented x3. Mood, affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. MMM, OP clear.
NECK: Supple with JVP of 5-6 cm.
CARDIAC: RRR, normal S1 S2. No MRG. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
rales, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No HSM.
EXTREMITIES: No cyanosis or clubbing. Trace peripheral edema
Pertinent Results:
Admission Labs:
___ 06:30PM BLOOD WBC-6.2 RBC-4.24 Hgb-12.8 Hct-39.0 MCV-92
MCH-30.1 MCHC-32.8 RDW-14.5 Plt ___
___ 06:30PM BLOOD Neuts-64.0 ___ Monos-3.6 Eos-3.7
Baso-0.7
___ 08:05PM BLOOD ___ PTT-30.5 ___
___ 06:30PM BLOOD Glucose-104* UreaN-25* Creat-1.5* Na-142
K-3.6 Cl-103 HCO3-30 AnGap-13
___ 06:30PM BLOOD ALT-16 AST-22 CK(CPK)-101
Cardiac Labs:
___ 06:30PM BLOOD CK-MB-3 proBNP-1121*
___ 06:30PM BLOOD cTropnT-0.67*
___ 07:45AM BLOOD CK-MB-3 cTropnT-0.58*
Interim Labs:
___ 06:30PM BLOOD ALT-16 AST-22 CK(CPK)-101
___ 07:45AM BLOOD CK(CPK)-71
___ 06:21AM BLOOD %HbA1c-5.7 eAG-117
___ 07:45AM BLOOD Triglyc-129 HDL-68 CHOL/HD-3.4
LDLcalc-139* LDLmeas-163*
___ 07:45AM BLOOD Albumin-4.1 Calcium-10.5* Phos-3.1 Mg-1.9
Cholest-233*
___ 06:00AM BLOOD Calcium-9.4 Phos-2.3* Mg-2.5
___ 07:55AM BLOOD Calcium-10.0 Phos-2.4* Mg-2.3
___ 07:45AM BLOOD PTH-40
Discharge Labs:
___ 07:55AM BLOOD WBC-6.1 RBC-3.73* Hgb-11.2* Hct-34.9*
MCV-94 MCH-29.9 MCHC-32.0 RDW-15.0 Plt ___
___ 07:55AM BLOOD Glucose-139* UreaN-33* Creat-1.4* Na-146*
K-4.1 Cl-113* HCO3-26 AnGap-11
___ 07:55AM BLOOD Calcium-10.0 Phos-2.4* Mg-2.3
Microbiology:
URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000
ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Imaging:
CXR ___:
FINDINGS: Frontal and lateral views of the chest were compared
to previous exam from ___. The lungs are clear of
focal consolidation. Biapical pleural scarring is again seen.
There is no pleural effusion. Cardiac silhouette is enlarged
but stable. Osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Cardiac cath ___: ***Preliminary Report***
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary disease. The LMCA was
patent. The
LAD was patent, long, and tortuous and wrapped around the apex.
There
was a ___ plaque at the D2 takeoff and beyond. The D1 is a
2mm long
vessel and D2 is a small vessel. Septals collateralize the RCA.
The LCX
was patent. It gives rise to a high OM (functionally ramus
intermedius)
with 40-50% osteial and large long and tortuous OM2 that is free
from
significant disease. The RCA had a somewhat anterior takeoff. It
had a
99% distal lesion with TIMI2 flow proximal and TIMI 1 flow
distal to
this lesion. The Distal RCA was receiving moderate collaterals
mostly
from the LAD system.
2. Limited resting hemodynamics revealed systemic systolic
arterial
hypertension.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Systemic arterial hypertension.
TTE ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the basal inferior segment. Overall left
ventricular systolic function is normal (LVEF>55%). Diastolic
function could not be assessed. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is a very small pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of ___,
focal hypokinesis of the basal inferior segment. Diastolic
function cannot be assessed on the current study due to the
presence of multiple VPBs. Other findings are similar.
Medications on Admission:
amlodipine 5 mg Tablet daily
atenolol 25 mg Tablet daily
hydrochlorothiazide 25 mg Tablet daily
ibuprofen 800 mg Tablet prn LBP with food
trazodone 50 mg Tablet ___ Tablet(s) qhs prn insomnia
aspirin 81 mg Tablet daily
calcium carbonate-vitamin D3 500 mg (1,250 mg)-400 unit Tablet
bid
cholecalciferol (vitamin D3) 1,000 unit Capsule 2 daily
MVI
vit C 500 daily
Vit E 400 daily
Fibercon
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. trazodone 50 mg Tablet Sig: ___ Tablet PO at bedtime as
needed for insomnia.
4. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Vitamin C 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
6. FiberCon 625 mg Tablet Sig: One (1) Tablet PO once a day.
7. Vitamin D3 1,000 unit Capsule Sig: Two (2) Capsule PO once a
day.
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
11. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
non-ST elevation myocardial ischemia
mild chronic diastolic heart failure
chronic kidney disease
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 shortness of breath and dyspnea on exertion.
FINDINGS: Frontal and lateral views of the chest were compared to previous
exam from ___. The lungs are clear of focal consolidation.
Biapical pleural scarring is again seen. There is no pleural effusion.
Cardiac silhouette is enlarged but stable. Osseous and soft tissue structures
are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB/LE EDEMA
Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, HYPERTENSION NOS
temperature: 99.1
heartrate: 68.0
resprate: 16.0
o2sat: 99.0
sbp: 147.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ with Hx HTN, HLD, chronic diastolic dysfunction presents
with increasing dyspnea on exertion, ___ edema, and chest
heaviness, EKG changes and elevated troponin concerning for
NSTEMI, found to have 99% RCA lesion, s/p DES.
.
# NSTEMI: Found to have 99% RCA lesion, DES placed ___. No
further chest pain or dyspnea. LDL found to be 139, patient has
not been on statin therapy due to sensitivity to Lipitor (leg
pain). HDL good at 68. HbA1c 5.7%. Several medication
adjustments were made to provide her maximum medical therapy for
newly diagnosed ischemia and known heart failure. She was
discharged on ASA, statin, ACE, beta blocker. She will also be
on Plavix for prevention of restenosis. The patient recovered
rapidly from the procedure and was walking independently with no
chest pain or dyspnea at the time of discharge.
.
# PUMP: Prior echo showed mild chronic diastolic heart failure.
On admission she was slightly hypervolemic, however diuresis
was held for renal protection in light of contrast use during
PCI. She auto-diuresed and was euvolemic with weight 66.6kg at
the time of discharge. TTE showed new focal hypokinesis of
basal inferior segment, likely due to recent NSTEMI.
.
# RHYTHM: During her stay the patient remained in normal sinus
rhythm although with some ectopy. Metoprolol was uptitrated to
reduce this activity.
.
# HTN: BP well controlled with SBP 110-130s.
.
# CKD: Baseline Cr 1.2-1.4 by our records. During her stay she
was at the high end of this range, with no sign of increase by
the time of discharge. Nephrology appt pending as outpatient.
Mild hypernatremia and hyperchloremia on discharge, diuresis was
held. Her home NSAID was discontinued and atenolol switch to
metoprolol.
.
# Hypercalcemia: Persistent in ___ since ___ with normal
albumin. Etiology unknown. Phos normal. PTH normal, likely
inappropriately high given high Ca. ___ be etiology of CKD, as
both have been present since ___. Her calcium
supplementation was stopped and vitamin D supplementation
reduced. Nephrology appt pending.
.
# UA: UA ___ had moderate leuks, no bacteria. Culture revealed
E coli. She was provided 3 days treatment with Cipro, ___.
She was asymptomatic during her stay.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of RA, recent admission for pelvic fracture
and comminuted right L5 transverse process fracture, comminuted
sacral fractures, who presents from her rehab facility with
abnormal sodium level.
She was discharged from ___ ___ after admission for pain
and weakness in setting of L5 transverse process fx, pubic rami
fracture, and right comminuted sacral fractures after mechanical
fall. Deemed not to be an operative candidate, but pain remained
difficult to control, and she was d/c-ed on tylneol, MS contin,
dilaudid (breakthrough), gabapentin, and tizanidine.
Her discharge summary documented that she'd been hyponatremic
during a recent admission to ___, thought due to SIADH and HCTZ.
Na levels remained normal during her BI admission, and HCTZ was
continued.
At rehab, she recently finished course of antibiotics for
pneumonia. She continued to have ___ pain and numbness for which
she saw ortho ___, at which time repeat pelvic x rays showed
stable fractures.
She has had poor pain control and because of this has been
unable to eat no well for the last two weeks. She feels mildly
weak but has no acute chest pain, shortness breath, abdominal
pain, nausea, vomiting, diarrhea. Was supposed to have a spinal
outpatient appointment ___ but morning labs showed a sodium of
123 (compared to 134-136 on last admission) and she was sent
into the emergency department for further evaluation.
In ED initial VS: 98.1 80 103/50 17 95% RA
Exam: well appearing in NAD
Labs notable for:
120|84|13
-----------<113
2.8|27|0.5
Serum osm 253. Urine Osm 153. Urine Na < 20.
Patient was given IVF in the ED with gradual improvement to
serum sodium 129 over 24 hours.
Patient was given:
___ 18:41 IVF 40 mEq Potassium Chloride / NS
___ Started 150 mL/hr
___ 19:05 PO Potassium Chloride 40 mEq ___
___ 21:47 IVF 40 mEq Potassium Chloride / NS
___ Stopped - Unscheduled
___ 21:57 PO Morphine SR (MS ___ 15 mg ___
___ 23:26 PO/NG HYDROmorphone (Dilaudid) 2 mg
___
___ 06:05 PO/NG HYDROmorphone (Dilaudid) 2 mg
___
___ 09:02 PO/NG Gabapentin 600 mg ___
___ 09:02 PO/NG Levothyroxine Sodium 75 mcg
___
___ 09:04 PO Morphine SR (MS ___ 15 mg
___
___ 09:43 PO/NG HYDROmorphone (Dilaudid) 2 mg
___
___ 14:00 PO/NG Gabapentin ___ Not Given
___ 14:46 TD Lidocaine 5% Patch 2 PTCH ___
Applied
___ 17:13 PO/NG HYDROmorphone (Dilaudid) 2 mg
___
On arrival to the floor patient reports story as above.
Currently, pain is well controlled, and denies nausea, vomiting,
dizziness, lightheadedness. DOes report episode of diarrhe atwo
days ago, now resolved.
REVIEW OF SYSTEMS: (+) per HPI. otherwise negative in remaining
systems.
Past Medical History:
- Colon CA s/p local resection. Last colonoscopy ___
- Fibrocystic breast changes
- Hypothyroidism
- osteoporosis/ osteopenia
- Rheumatoid arthritis
- Hx of shingles
- HTN, HLD
- Bronchiectasis
Social History:
___
Family History:
Mother- lung disease.
Brothers with melanomas and prostate cancers
Physical Exam:
Admission
=========
VITALS: 98.3 128/69 82 20 94ra
GENERAL: Alert, oriented, no acute distress, but occasionally
trips over her words
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear (upper
dentures in place)
LUNGS: Clear to anterior auscultation bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AOx3, strength ___ in lower extremities but limited
slightly by pain, sensation to light touch intact
Discharge
=========
Vitals: 98.3, 112/61, 79, 16, 94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated.
Abdomen: soft, non-tender, non-distended
Ext: Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or
edema
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. Ankle dorsiflexion/plantarflexion ___
bilaterally, hip flexion and knee extension ___ bilaterally
Back: exam deferred due to severe pain
Pertinent Results:
Admission
=========
___ 04:00PM BLOOD WBC-11.1* RBC-4.03 Hgb-11.6 Hct-33.6*
MCV-83 MCH-28.8 MCHC-34.5 RDW-16.3* RDWSD-48.5* Plt ___
___ 04:00PM BLOOD Plt ___
___ 04:00PM BLOOD Glucose-113* UreaN-13 Creat-0.5 Na-120*
K-2.8* Cl-84* HCO3-27 AnGap-12
___ 04:00PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2
Discharge
=========
___ 06:50AM BLOOD WBC-5.3 RBC-4.11 Hgb-11.9 Hct-37.2 MCV-91
MCH-29.0 MCHC-32.0 RDW-17.9* RDWSD-59.0* Plt ___
___ 06:15AM BLOOD Glucose-92 UreaN-21* Creat-0.5 Na-135
K-4.3 Cl-98 HCO3-23 AnGap-18
___ 06:15AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0
Labs & Imaging
==============
MRI Pelvis ___
IMPRESSION:
1. Effacement of the bilateral S1 neural foramina secondary to
sacral
fracture fragments and callus.
2. Mild asymmetric narrowing of the right S2 foramen without
definite
compression of the nerve root.
3. Bilateral L5 nerves and proximal sciatic nerves contact the
anterior
aspect of the sacral fractures, without evidence of entrapment.
MR ___ ___
IMPRESSION:
Bone marrow signal changes related to acute to subacute sacral
fracture with blood products in the spinal canal. Mild
narrowing of the spinal canal due to thickening of the dura,
likely reactive. However, there is no evidence of neural
foraminal narrowing, though evaluation is limited due to acute
signal change in the sacrum.
CT ___ ___
IMPRESSION:
1. Comminuted fractures involving the sacrum bilaterally with
minimal interval sclerosis, representing healing. There is
interval anterior and inferior displacement at S1-S2 level,
contributing to central canal narrowing at this level
2. Fracture lines involving the neural foramina at S1 levels
bilaterally, with foraminal narrowing.
3. Right L5 transverse Proctor is more comminuted. Similar
posterior right iliac bone fracture.
4. Interval some healing with some sclerosis across fracture
planes.
5. Atelectasis at the lung bases bilaterally, right greater than
left.
6. Extensive atherosclerosis with ectasia of the infrarenal
abdominal aorta measuring up to 2.3 cm.
CT Head ___
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or large
territorial infarct.
Please note MRI of the brain is more sensitive for the detection
of acute
infarct.
2. Paranasal sinus disease, as described.
LEFT FOOT XR ___
FINDINGS:
There is deformity at the head of the fifth metatarsal with what
appears be well-defined bony erosions involving both the
mediolateral aspect of the metatarsal head. There is no
appreciable soft tissue swelling seen. No fracture seen. No
involvement of the adjacent metatarsals is seen. Small
subcortical lucencies in the base of the distal phalanx and head
of the proximal phalanx of the first toe likely reflect
subchondral cysts, erosions are considered less likely. There
are moderate degenerative changes in the midfoot predominately
in the talonavicular joint. Prominent steida process in the
talus.
IMPRESSION:
Probable chronic erosions at the head of the fifth metatarsal,
correlate with symptoms of gout
Microbiology
============
URINE CULTURES ___ and ___ NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Cyanocobalamin 500 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Lidocaine 5% Patch 2 PTCH TD QAM
7. Omeprazole 20 mg PO DAILY
8. Senna 17.2 mg PO QHS
9. Simvastatin 20 mg PO QPM
10. Tizanidine 4 mg PO TID
11. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
12. Lactulose 30 mL PO BID
13. Morphine SR (MS ___ 15 mg PO Q12H
14. Vitamin D 3000 UNIT PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. Hydrochlorothiazide 25 mg PO DAILY
17. Gabapentin 300 mg PO TID
18. Escitalopram Oxalate 10 mg PO DAILY
Discharge Medications:
1. Alendronate Sodium 70 mg PO QTHUR
2. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety Duration: 1 Week
RX *alprazolam 0.25 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*6 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
5. Sodium Chloride Nasal ___ SPRY NU TID:PRN dry nose
6. Gabapentin 600 mg PO QPM
7. Gabapentin 400 mg PO QAM AND QNOON
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Tizanidine 4 mg PO TID
10. Acetaminophen 1000 mg PO Q8H
11. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
12. Cyanocobalamin 500 mcg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Escitalopram Oxalate 10 mg PO DAILY
15. Lactulose 30 mL PO BID
16. Lidocaine 5% Patch 2 PTCH TD QAM
17. Omeprazole 20 mg PO DAILY
18. Senna 17.2 mg PO QHS
19. Simvastatin 20 mg PO QPM
20. Tiotropium Bromide 1 CAP IH DAILY
21. Vitamin D 3000 UNIT PO DAILY
22. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you meet with
your primary care doctor.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis
=============
Sacral fracture
Hyponatremia
Secondary Diagnoses
================
Anxiety
Bronchiectasis
Hypertension
Hyperlipidemia
Hypothyroidism
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: ___ year old woman with history of pelvic fracture, now with lower
extremity movements, altered. Evaluate for acute intracranial hemorrhage or
large territorial infarct.
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, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Prominent ventricles sulci compatible with age-related
involutional changes. Periventricular white matter hypodensities likely
represent chronic small vessel ischemic disease.
There is partial opacification of the bilateral sphenoid sinuses and mucosal
thickening in the bilateral ethmoid air cells. Air-fluid level is noted the
right sphenoid sinus. Mastoid air cells and middle ear cavities are well
aerated. The bony calvarium is intact.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or large territorial infarct.
Please note MRI of the brain is more sensitive for the detection of acute
infarct.
2. Paranasal sinus disease , as described.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331
INDICATION: ___ year old woman with known lumbar fractures with worsening back
pain.// evolution of spinal fractures/degeneration
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 7.3 s, 28.8 cm; CTDIvol = 31.0 mGy (Body) DLP = 891.3
mGy-cm.
Total DLP (Body) = 891 mGy-cm.
COMPARISON: CT L-spine dated ___.
FINDINGS:
The comminuted fractures involving the transverse process of L5 on the right,
as well as bilateral sacral ala are re-demonstrated. There is patchy
increased sclerosis within the sacrum bilaterally, compatible with minimal
interval healing. There is omental bilateral S1 foramina, better seen on the
right, which were probably involved on prior as well, fracture planes are more
distracted today in there is some sclerosis. The fracture also extends into
the posterior elements of S1 on the right.
There is interval anterior, inferior subluxation of the central sacrum along
the fracture lines, new since prior, with approximately 0.8 cm anterior
displacement, and approximately 0.8 cm inferior displacement, sagittal image
42.
A nondisplaced fracture involving the very posterior iliac bone on the right
is unchanged, extending to the SI joint (series 601, image 55). There is mild
loss of height of the L5 vertebral body, which is unchanged compared to prior.
Again seen is moderate degenerative changes are seen throughout the lumbar
spine, with multilevel probably mild central canal narrowing, and multilevel
probably moderate foraminal narrowing, most prominent at L4-5, L5-S1 levels,
similar.
Opacification at the lung bases bilaterally, right greater than left, likely
represents atelectasis. A partially imaged 1.8 cm hypodensity within the
right kidney likely represents a simple cyst. Extensive atherosclerotic
calcification with ectasia of the infrarenal abdominal aorta measuring up to
2.3 cm in maximal diameter. No other abnormalities within the partially
imaged chest and abdomen.
IMPRESSION:
1. Comminuted fractures involving the sacrum bilaterally with minimal interval
sclerosis, representing healing. There is interval anterior and inferior
displacement at S1-S2 level, contributing to central canal narrowing at this
level
2. Fracture lines involving the neural foramina at S1 levels bilaterally, with
foraminal narrowing.
3. Right L5 transverse Proctor is more comminuted. Similar posterior right
iliac bone fracture.
4. Interval some healing with some sclerosis across fracture planes.
5. Atelectasis at the lung bases bilaterally, right greater than left.
6. Extensive atherosclerosis with ectasia of the infrarenal abdominal aorta
measuring up to 2.3 cm.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE.
INDICATION: ___ year old woman with sacral fracture and L5 transverse process
fracture. Please evaluate for worsening fracture, displacement, neurovascular
compromise.
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 6 mL of
Gadavist contrast agent.
COMPARISON: CT lumbar spine from ___.
FINDINGS:
Again seen is comminuted fracture involving the sacrum bilaterally with
approximately 5 mm anterior displacement of the S1 vertebral body with respect
to the S2, overall unchanged from ___. Evaluation of the bony cortex
is better seen on the CT from ___. As previously noted, there is
evidence of some bony bridging along the fractured cortical margin. Fracture
line is seen along the anterior to posterior direction in the right ischium,
extending into the right sacroiliac joint (06:36). As expected, there is bone
edema pattern at inferior S1 and superior S2 vertebral body with associated T1
hypointense signal along the fracture line.
The spinal cord terminates at T12-L1. The visualized cord is unremarkable.
Blood products are seen in the sacral portion of the spinal canal.
Nonenhancing 2.4 cm hyperintensity on T2 weighted imaging in the interpolar
region of the right kidney likely represents a simple cyst.
There is mild degenerative changes of the lumbar spine. There is ___ type 2
change at L3-L4 and L4-L5 endplates, likely due to degenerative disease.
Otherwise, the vertebral body signals are overall unremarkable. Loss of
normal disc signal throughout the lumbar spine is likely related to
degenerative disease.
At T12-L1, L1-L2, and L2-L3, there is no significant the spinal canal or
neural foraminal narrowing.
At L3-L4, L4-5, and L5-S1, there is mild narrowing of the spinal canal and
subarticular recess due to disc osteophyte complex.
At S1-S 2, there is narrowing of the spinal canal due to anterior displacement
of the vertebral body and thickening of the dura.
Due to signal change in the the sacrum, evaluation of the exiting S1 nerve
roots are difficult to evaluate in its full extent. However, there is no
evidence of neuroforaminal narrowing.
IMPRESSION:
Bone marrow signal changes related to acute to subacute sacral fracture with
blood products in the spinal canal. Mild narrowing of the spinal canal due to
thickening of the dura, likely reactive. However, there is no evidence of
neural foraminal narrowing, though evaluation is limited due to acute signal
change in the sacrum.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman with sacral fracture and L5 TVP fracture.//
Please evaluate for pelvic fracture, neurovascular compromise.
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: None.
COMPARISON: CT of the lumbar spine from ___ and CT of the pelvis
from ___.
FINDINGS:
There is diffuse STIR signal abnormality in T1 hypointensity of the sacrum,
secondary to known comminuted fractures of the bilateral sacral ala, better
evaluated on prior CT of the lumbar spine from ___ and CT of the
pelvis from ___. The bilateral S1 foramina are completely effaced by
fracture fragments and callus. There is mild asymmetric narrowing of the
right S2 foramen without definite compression of the nerve root. The left S2
foramen is patent. The bilateral S3 and S4 nerves are normal in course,
caliber and signal intensity.
The bilateral L5 nerves and proximal sciatic nerves contact the anterior
aspect of the sacral fractures, without evidence of entrapment.
Known right-sided pubic rami fractures are incompletely covered.
Focal 2.2 x 1.5 cm T2 hyperintensity between the right iliacus and psoas
muscles (series 6, image 2) corresponds to callus and probable hematoma on the
prior CT of the lumbar spine from ___.
There is edema of the pyriformis muscles, right greater than left. There is
also edema of the right pectineus muscle associated with the pubic rami
fractures.
There is posterior and superior displacement of the sacrum relative to the L5
vertebral body seen on the scout localizer images.
IMPRESSION:
1. Effacement of the bilateral S1 neural foramina secondary to sacral
fracture fragments and callus.
2. Mild asymmetric narrowing of the right S2 foramen without definite
compression of the nerve root.
3. Bilateral L5 nerves and proximal sciatic nerves contact the anterior
aspect of the sacral fractures, without evidence of entrapment.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old woman s/p recent fall with pelvic and spinal
fractures. Now with left ___ toe pain.// Evaluate for fracture of left ___ toe
TECHNIQUE: Three views left foot
COMPARISON: Left ankle radiographs ___
FINDINGS:
There is deformity at the head of the fifth metatarsal with what appears be
well-defined bony erosions involving both the mediolateral aspect of the
metatarsal head. There is no appreciable soft tissue swelling seen. No
fracture seen. No involvement of the adjacent metatarsals is seen. Small
subcortical lucencies in the base of the distal phalanx and head of the
proximal phalanx of the first toe likely reflect subchondral cysts, erosions
are considered less likely. There are moderate degenerative changes in the
midfoot predominately in the talonavicular joint. Prominent steida process in
the talus.
IMPRESSION:
Probable chronic erosions at the head of the fifth metatarsal, correlate with
symptoms of gout
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal sodium level
Diagnosed with Hypo-osmolality and hyponatremia
temperature: 98.1
heartrate: 80.0
resprate: 17.0
o2sat: 95.0
sbp: 103.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | ___ with a history of RA, recent admission for pelvic fracture
and comminuted right L5 transverse process fracture, comminuted
sacral fractures, who presented from her rehab facility with
hyponatremia.
ACTIVE ISSUES
=============
# Sacral fractures: Severe back pain due to L spine, sacral, and
pelvic fractures. Lower extremity neuro exam was normal. CT
lumbar spine demonstrates comminuted fractures of sacrum with
interval anterior and inferior displacement contributing to
neuroforaminal narrowing. MRI shows S1-S2 anterior displacement
of vertebral body with some narrowing of spinal canal. Patient
was seen by spine surgery who recommended no surgical
intervention recommended with trial of conservative management
and LSO brace with follow up in 6 weeks. Her pain regimen was
titrated for following with input from chronic pain service: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / amitriptyline / gabapentin /
ACE Inhibitors / zinc
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
Endoscopy ___
Colonoscopy ___
History of Present Illness:
___ with PMH of PUD complicated by multiple GI bleeds, HTN,
psoriasis, depression, presenting with anemia and palpitations.
Patient reports that she has had ongoing dizziness since ___
which was thought to be due to vertigo, did ___ for this and it
improved. It then became worse about a week ago and she fell and
hit her shoulder, did not lose consciousness, "tapped" her head.
She went to her dermatologist on ___ for follow up of her
psoriasis and had a CBC checked because she takes Humira. She
was
called because her Hgb was found to be 7.1 and told to come to
the ED. She reports feeling well other than the dizziness. She
denies any reflux or heartburn, but does note that she feels
like
she is choking on food again, which happened the last time she
was diagnosed with PUD. She also notes a dark black BM on
___,
and since then her BMs have improved but still not back to
normal. She denies any abdominal pain, SOB, DOE, CP,
palpitations. She denies using NSAIDs, rare EtOH use.
Of note, patient also endorses pain/edema to her left foot as
well as frequent falls without head strike. Per ED ___,
"patient
is also endorsing transient thoughts of slitting her wrists when
her health gets really bad. She denies any suicidal ideation
today. She is followed by a therapist as an outpatient."
In the ED:
- Initial vital signs were notable for: T 97.2F, HR 75, BP
109/53, RR 18, 99% RA
- Exam notable for:
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Rectal- No gross blood, no stool sample for testing
- Labs were notable for:
Hgb 6.3 (from 7.1 on ___, and from baseline ___
Iron 18, Ferritin 12, Tsat 4%
- Studies performed include:
XR L foot: Calcific density adjacent to the tip of the medial
malleolus to be correlated
with physical exam regarding point tenderness in this area. A
small avulsion
fracture would be possible. Elsewhere, no evidence of fracture.
- Patient was given:
___ 19:01IVPantoprazole 40 mg
1 unit pRBCs
- Consults:
GI: Concern for UGIB. Stable. PPI, transfuse, good access. NPO
MN
for EGD tomorrow.
Vitals on transfer: T 97.8F, BP 164/98, HR 58, RR 18, 100% RA
Upon arrival to the floor, patient endorses the above history.
She reports that she is still a little dizzy, but otherwise
feels
well. Denies CP, SOB.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
-LLE DVT ___
-Hypertension
-Type 2 diabetes mellitus
-Osteoarthritis, s/p bilateral knee surgeries, right TKR
- Depression/Anxiety
- History of left leg fracture and chronic pain/foot drop.
- Left knee posterior dislocation s/p reduction ___
- Acute popliteal artery thrombosis s/p left popliteal artery
bypass ___
- s/p skin graft to the left lateral calf ___
- ORIF of patellar dislocation ___
- Right knee osteoarthritis s/p right knee subtotal lateral
meniscectomy ___ complicated by septic arthritis
- s/p right total knee replacement in ___, revision right
total knee replacement in ___, and status post revision of
the right tibial component and right tibial tubercle osteotomy
___.
- status post bilateral dorsal wrist ganglion excision
bilaterally
- status post right toe fifth PIP joint arthroplasty for
hammertoe ___.
Social History:
___
Family History:
Her mother died of cancer, but she is
unsure which type. Her sister died of a stomach or a bowel
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 353)
Temp: 97.0 (Tm 97.8), BP: 144/80 (144-164/80-98), HR: 60
(58-60), RR: 17 (___), O2 sat: 100%, O2 delivery: Cpap, Wt:
244.27 lb/110.8 kg
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. Sclera anicteric and without injection.
ENT: MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, mild tenderness to
deep palpation in the epigastric region.
EXTR: L>R nonpitting edema.
NEUROLOGIC: AOx3, moving all extremities spontaneously.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 821)
Temp: 98.1 (Tm 98.1), BP: 132/76 (132-159/76-91), HR: 60
(56-61), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: RA ,
Wt: 236.11 lb/107.1 kg
EYES: NCAT. Sclera anicteric and without injection.
ENT: MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, nontender
EXTR: L>R nonpitting edema
NEUROLOGIC: AOx3, moving all extremities spontaneously.
PSYCH: appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
===============
___ 06:56PM BLOOD WBC-6.0 RBC-3.35* Hgb-6.3* Hct-23.3*
MCV-70* MCH-18.8* MCHC-27.0* RDW-18.7* RDWSD-46.6* Plt ___
___ 06:56PM BLOOD Neuts-44.8 ___ Monos-13.4*
Eos-3.8 Baso-0.8 AbsNeut-2.70 AbsLymp-2.21 AbsMono-0.81*
AbsEos-0.23 AbsBaso-0.05
___ 06:51PM BLOOD Glucose-87 UreaN-15 Creat-0.7 Na-142
K-4.6 Cl-107 HCO3-25 AnGap-10
___ 06:51PM BLOOD Calcium-9.4 Phos-3.1 Mg-2.3
DISCHARGE LABS:
===============
___ 07:17AM BLOOD WBC-5.2 RBC-3.86* Hgb-7.6* Hct-26.8*
MCV-69* MCH-19.7* MCHC-28.4* RDW-19.8* RDWSD-48.6* Plt ___
___ 07:17AM BLOOD Glucose-88 UreaN-8 Creat-0.7 Na-142 K-3.8
Cl-106 HCO3-22 AnGap-14
___ 07:17AM BLOOD Calcium-10.2 Phos-3.1
IMAGING:
========
FOOT AP,LAT & OBL LEFT ___:
IMPRESSION:
Cortical irregularity adjacent to the medial malleolar tip and
along the
dorsum of the disc talus may reflect small fracture fragments.
These were not visualized on the foot radiographs from ___ or ___.
VENOUS DUP EXT UNI ___:
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
EGD ___: Normal
Colonoscopy ___: Normal mucosa. Mild diverticulosis of the
descending colon and sigmoid colon.
MICROBIOLOGY:
=============
None.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 200 mg PO DAILY
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
3. Cyanocobalamin 500 mcg PO EVERY OTHER DAY
4. Ascorbic Acid Dose is Unknown PO DAILY
5. adalimumab 40 mg/0.4 mL subcutaneous EVERY OTHER WEEK
6. Calcipotriene 0.005% Cream 1 Appl TP BID
7. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
8. HydrOXYzine ___ mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. CARVedilol 25 mg PO BID
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. adalimumab 40 mg/0.4 mL subcutaneous EVERY OTHER WEEK
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing, shortness of breath
4. Ascorbic Acid ___ mg PO DAILY
5. Calcipotriene 0.005% Cream 1 Appl TP BID
6. CARVedilol 25 mg PO BID
7. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
8. Cyanocobalamin 500 mcg PO EVERY OTHER DAY
9. Docusate Sodium 100 mg PO BID
10. HydrOXYzine ___ mg PO QHS
11. LamoTRIgine 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Acute on chronic anemia
Melena
Ankle sprain with small avulsion fracture
SECONDARY DIAGNOSIS:
====================
Depression
Suicidal ideation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: ___ with PMH of PUD complicated by multiple GI bleeds,
HTN,psoriasis, depression, presenting with melena and anemia likely in the
setting of recurrent UGIB, also with L ankle pain after fall last week.//
possible avulsion fracture possible avulsion fracture
TECHNIQUE: Three views of the left ankle were obtained
COMPARISON: Radiographs of the foot dated ___
FINDINGS:
Cortical irregularity along the medial malleolar tip is re-visualized as well
as cortical irregularity along the distal dorsal aspect of the talus. No
dislocation or additional fracture seen. There is diffuse soft tissue
swelling around the left ankle. There are no significant degenerative
changes. The mortise is congruent. The tibial talar joint space is preserved
and no talar dome osteochondral lesion is identified. No suspicious lytic or
sclerotic lesion is identified. No soft tissue calcification or radiopaque
foreign body is identified.
IMPRESSION:
Cortical irregularity adjacent to the medial malleolar tip and along the
dorsum of the disc talus may reflect small fracture fragments. These were not
visualized on the foot radiographs from ___ or ___.
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) LEFT
INDICATION: ___ year old woman here with likely upper GI bleed with L lower
extremity swelling.// 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.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Anemia, Palpitations
Diagnosed with Anemia, unspecified
temperature: 97.2
heartrate: 75.0
resprate: 18.0
o2sat: 99.0
sbp: 109.0
dbp: 53.0
level of pain: 7
level of acuity: 2.0 | ___ with PMH of PUD complicated by multiple GI bleeds, HTN,
psoriasis, depression, presenting with melena and anemia likely
in the setting of recurrent UGIB. EGD and colonoscopy were
normal, and Hemoglobin remained stable. She was discharged in
stable condition with close PCP ___. She was also seen by
orthopedic surgery for ankle sprain and small avulsion fracture
that will heal with time and for which she will wear a boot. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex Gloves, Small
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ known to me from admission in ___ of this year w/ hx
of autoimmune hepatitis c/b cirrhosis c/b grade I and III
esophageal varices on EGD in ___ now p/w GI bleed and
question of altered mental status.
Patient is a very poor historian but notes one-two days of
coffee ground dark but not bloody emesis as well as dark stools.
She thinks she vomited on either ___ or ___ (maybe both) but not
today. Thinks the black stools started over the weekend. Denies
any BRBPR or hematemesis. She also complains of abdominal pain
that seems to have sstarted yesterday. Denies fever, chills,
dysuria, lightheadedness, SOB, chest pain, constipation,
diarrhea. Endorses med compliance at home (has a ___ as well as
her daughter - says daughter administers her medications).
She presented to OSH today (___) where noted to
have hct 24 (last Hct here around 30), heme positive stool,
given 1 unit pRBCs, started on octreotide drip, and transferred
to ___ d/t patient being followed by hepatology here. During
transport she was stable but noted to have SBP 87 on arrival in
ED.
ED VS: 88 114/68 16 98% room. Initially systolics dropped to ___
but came back up with minimal intervention. On rectal had
melanotic stool. For some reason octreotide stopped for 3+ hours
and pantoprazole gtt not started. Given CTX 2g initially for SBP
but then CT scan didn't show ascites so SBP unlikely. Labs
significant for Hct 26 (recent baseline around 30), Plt 446, INR
1.7, Alb 2.9, AST 115, Tbili 2 (baseline 1). Lactate 2. BUN
elevated to 33 without Cr elevation (baseline BUN teens). Pt
reporting abdominal pain but CT scan showed no No acute process
to explain patient's pain. VS at transfer: 82 102/65 18 100%.
On arrival to the MICU, patient mostly concerned about her
pneumoboots which she says are bothering her and that she
refuses to wear. Also concerned about her abdominal pain and
asking for pain medications. Denies feeling nauseated or
lightheaded.
Past Medical History:
- stage IV autoimmune hepatitis, cirrhosis
--> 2 cords of non-bleeding grade I esophageal varices on EGD
___
- diabetes type II (last A1c 7.4% in ___
- diabetic neuropathy
- HTN
- dyslipidemia
- CAD s/p MI?
- essential thrombocytosis
- multiple personality disorder
- seizure disorder
- severe essential tremor which affects speech
- osteoporosis
- psoriasis
- chronic pain
- depression
- anxiety
- asthma
- renal tumor, followed by urology
- history of multiple mechanical falls
- compression fx s/p vertebroplasty ___
- diverticulitis s/p partial colectomy with Dr. ___ in ___
- s/p TAH/BSO
- urinary incontinence
Social History:
___
Family History:
mother: lupus
father: ulcers, stomach cancer
daugher: healthy
Physical Exam:
Admission PE:
Vitals: T: 99 BP: 93/50 P: 79 R: 9 O2: 96% on RA
General: Alert, somewhat oriented, odd affect, anxious
HEENT: Sclera anicteric, mildly dry MM with some cracking skin,
oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no cervical LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, patient
expressing pain somewhat inconsistent to palpation in a diffuse
pattern, no rebound or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, compression devices in place over both legs
Neuro: No asterixis, odd affect, slowed speech, no focal
deficits, some difficult with historical questions that seems
more effort related than truly memory related, from prior
experiences taking care of this patient, this is at her baseline
Discharge PE:
Pertinent Results:
Admission Labs:
___ 03:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 03:26PM LACTATE-2.0
___ 03:00PM GLUCOSE-182* UREA N-33* CREAT-0.4 SODIUM-138
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
___ 03:00PM ALT(SGPT)-32 AST(SGOT)-115* ALK PHOS-26* TOT
BILI-2.0*
___ 03:00PM LIPASE-38
___ 03:00PM ALBUMIN-2.9*
___ 03:00PM WBC-3.8* RBC-2.89* HGB-8.9* HCT-26.0* MCV-90
MCH-30.7 MCHC-34.1 RDW-21.5*
___ 03:00PM NEUTS-57 BANDS-0 ___ MONOS-6 EOS-0
BASOS-1 ___ MYELOS-0 NUC RBCS-3* PLASMA-1*
___ 03:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-1+
___ 03:00PM ___ PTT-39.0* ___
.
>> Imaging:
- CT abd ___:
1. No acute process in the abdomen or pelvis to explain
patient's abdominal pain.
2. Evidence of cirrhosis and portal hypertension including
slightly increased massive splenomegaly and paraesophageal
varices. Minimal perisplenic ascites. Areas of hypodensity and
heterogeneous enhancement are grossly similar compared to prior
MRI.
3. 4-mm right lower lobe pulmonary nodule, as seen on prior MRI
from ___, but new compared to prior CT from ___.
Recommend followup CT in one year.
4. 14 mm left hepatic lobe hypodensity, previously
characterized as a
hemangioma on MRI from ___, not significantly
changed in size.
.
EGD ___: 4 cords of grade I-II varices were seen in the lower
third of the esophagus. 2 of them had a red spot on them
(stigmata of recent bleeding). 2 bands were successfully placed,
one at 12 o'oclock and one at 9 o'oclock. Hemostasis was
achieved. Abnormal mucosa was noted in the stomach, consistent
with portal gastropathy. Normal mucosa in the duodenum
.
>> MICRO:
- ucx: pending
- bl cx: pending
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
2. Alendronate Sodium 70 mg PO QSUN
3. Aspirin 81 mg PO DAILY
4. Budesonide 3 mg PO BID
5. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. LeVETiracetam 1500 mg PO BID
7. PrimiDONE 100 mg PO QAM
8. PrimiDONE 125 mg PO QNOON
9. PrimiDONE 125 mg PO QPM
10. Rifaximin 550 mg PO BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. Vitamin D 800 UNIT PO DAILY
13. Lactulose 30 mL PO QID constipation
14. Gabapentin 600 mg PO TID
15. nystatin *NF* 100,000 unit/g Topical BID
16. Azathioprine 100 mg PO DAILY
17. Escitalopram Oxalate 20 mg PO DAILY
18. Furosemide 20 mg PO DAILY
19. Nadolol 20 mg PO DAILY
20. Spironolactone 50 mg PO DAILY
21. Sucralfate 2 gm PO BID Duration: 14 Days
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
RX *albuterol sulfate 90 mcg ___ puff IH Q4H PRN Disp #*1
Inhaler Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Azathioprine 100 mg PO DAILY
RX *azathioprine 50 mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
4. Budesonide 3 mg PO BID
RX *budesonide 3 mg 1 capsule by mouth twice a day Disp #*60
Capsule Refills:*0
5. Escitalopram Oxalate 20 mg PO DAILY
RX *escitalopram 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
7. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic ___ Active Test] 1 strip to
test blood sugar four times a day Disp #*120 Unit Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL 40 units 40 Units
before BED; Disp #*1200 Milliliter Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL Up to 12 Units per
sliding scale four times a day Disp #*1200 Milliliter Refills:*0
9. Lactulose 30 mL PO QID constipation
RX *lactulose 10 gram/15 mL 30 mL by mouth four times a day Disp
#*3600 Milliliter Refills:*0
10. LeVETiracetam 1500 mg PO BID
RX *levetiracetam 750 mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
11. Nadolol 40 mg PO DAILY
RX *nadolol 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. PrimiDONE 100 mg PO QAM
RX *primidone 50 mg 2 tablet(s) by mouth three times a day Disp
#*210 Tablet Refills:*0
13. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
14. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
15. Sucralfate 2 gm PO BID Duration: 14 Days
RX *sucralfate 1 gram 2 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
16. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule IH daily Disp #*30 Capsule Refills:*0
17. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
18. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp
#*3 Tablet Refills:*0
19. lactobacillus acidophilus *NF* 1 billion cell Oral daily
Reason for Ordering: to help prevent C. diff
RX *lactobacillus acidophilus 1 billion cell 1 tablet(s) by
mouth daily Disp #*15 Tablet Refills:*0
20. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
21. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H PRN Disp #*60 Tablet
Refills:*0
22. Alendronate Sodium 70 mg PO QSUN
RX *alendronate 70 mg 1 tablet(s) by mouth QSUN Disp #*4 Tablet
Refills:*0
23. nystatin *NF* 100,000 unit/g Topical BID
RX *nystatin 100,000 unit/gram apply to infected area twice a
day Disp #*1 Tube Refills:*0
24. PrimiDONE 125 mg PO QNOON
25. PrimiDONE 125 mg PO QPM
26. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*15
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- esophageal varices
- cirrhosis
- autoimmune hepatitis
Secondary:
- diabetes
- ulcerative colitis
- sacral ulcer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History of cirrhosis and encephalopathy, presenting with diffuse
abdominal pain, worst in the left upper and lower quadrants.
COMPARISON: CT abdomen and pelvis from ___. MRI abdomen from
___. CTA abdomen from ___.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following the administration of 100 cc of intravenous Omnipaque contrast
material. Multiplanar reformats were performed.
TOTAL DLP: 609 mGy-cm.
ABDOMEN CT: A 4-mm right lower lobe pulmonary nodule was identified on prior
MRI from ___, but is new compared to prior CT from ___ (2:5). There is minimal bilateral lower lobe dependent atelectasis.
Coronary artery calcifications are seen. The liver contour is mildly nodular,
in keeping with known cirrhosis. There is also mild hypoattenuation of the
liver parenchyma, consistent with fat deposition, as described on prior MRI.
A previously characterized hemangioma within the left hepatic lobe along the
falciform ligament was better seen on prior MRI but is not significantly
changed in size, measuring up to 14 mm (2:26). There is no suspicious liver
lesion identified. The portal vein is patent. There is recanalization of the
periumbilical vein. The patient is status post cholecystectomy. The spleen
is massively enlarged, measuring up to 23.8 cm, possibly slightly increased
compared to prior MRI. A 14-mm hypodense lesion within the posteromedial
aspect of the spleen is not significantly changed in size compared to prior
MRI, consistent with a cyst. Heterogeneous enhancement along the posterior
aspect of the spleen is similar in appearance to prior MRI from ___. The pancreas is unremarkable. The adrenal glands are normal. A 9-mm
simple cyst within the left lower renal pole is not significantly changed. An
11 x 4 mm hyperdense lesion within the left interpolar region is stable over
multiple prior studies, dating back through ___. The kidneys are
otherwise unremarkable, with symmetric excretion of contrast material. The
stomach is grossly normal. The small bowel is unremarkable. There is
scattered colonic diverticulosis, without evidence of diverticulitis. The
appendix is normal. There is mild mesenteric edema with minimal perisplenic
ascites. Large perisplenic/perigastric varices are increased compared to
prior CT from ___. Paraesophageal varices are new compared to prior CT. The
abdominal aorta is normal in caliber. There are no pathologically enlarged
abdominal lymph nodes.
PELVIS CT: The bladder is unremarkable. The uterus is not well seen and may
be surgically absent. There is no free fluid in the pelvis. No
pathologically enlarged pelvic lymph nodes are seen.
BONE WINDOW: No suspicious lytic or blastic lesions are identified. A
compression deformity of the L1 vertebral body with associated cement from
prior vertebroplasty is not significantly changed. Mild associated narrowing
of the spinal canal at this level, related to retropulsion of the fracture
fragments, is not significantly changed.
IMPRESSION:
1. No acute process in the abdomen or pelvis to explain patient's abdominal
pain.
2. Evidence of cirrhosis and portal hypertension including slightly increased
massive splenomegaly and paraesophageal varices. Minimal perisplenic ascites.
Areas of hypodensity and heterogeneous enhancement are grossly similar
compared to prior MRI.
3. 4-mm right lower lobe pulmonary nodule, as seen on prior MRI from ___, but new compared to prior CT from ___. Recommend followup CT in
one year.
4. 14 mm left hepatic lobe hypodensity, previously characterized as a
hemangioma on MRI from ___, not significantly changed in size.
Radiology Report
DATE: ___.
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ female patient with recent intubation, evaluate ETT
and lungs.
FINDINGS: AP single view of the chest has been obtained with patient in
supine position. The patient is now intubated. An ETT is seen to terminate
in the trachea 5 cm above the level of the carina. No pneumothorax has
developed. No new pulmonary infiltrates or evidence of pleural effusion when
comparison is made with the next preceding chest examination of ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI BLEED
Diagnosed with GASTROINTEST HEMORR NOS
temperature: nan
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 114.0
dbp: 68.0
level of pain: tolerable
level of acuity: 2.0 | ___ with Autoimmune hepatitis c/b by cirrhosis c/b
decompensations with infections and known varices, seizure
disorder, and DMII presenting with history concerning for a
upper GI bleed.
.
>> Active issues:
# Variceal bleed: Pt with known varices and missed repeat EGD on
___ for repeat banding. Pt with coffee grounds in last 48hrs
before presentation, followed by melena, all suggestive of UGIB.
In setting of poor historian, elevated BUN also supports history
of upper GI blood loss. Hemodynamically stable. Hcts remained
stable as well. Pt admitted to MICU, on PPI and octreotide gtt.
Had EGD showing varices with stigmata of recent bleed, which
were banded. PPI gtt transitioned to IV PPI daily and then to PO
PPI. Octreotide gtt x72hrs. Pt started on ceftriaxone for SBP
ppx, then transitioned to ciprofloxacin for total 7 day course
to be completed as outpatient. HCT was stable at ___ during
hospital stay (23.5 on day of discharge), and baseline was
___. Patient will have HCT checked by ___ (and sent to PCP) 4
days after discharged. She will have PCP and hepatology follow
up, including EGD in ___ weeks after discharge. Nadolol was
increased to 40mg daily from 20mg daily. Sucralfate and PPI to
be continued until pt sees hepatology.
.
>> Chronic issues:
# Chronic Abdominal Pain: Unclear etiology, chronic. CT in ER
didn't show a cause and there was no mentionable ascites. CBC w/
diff and LFTs fairly unremarkable. Exam benign other than
ill-defined pain. Has history of chronic pain complaints on
narcotics contract. During last admission determined that her
pain medications were probably causing more problems than they
were solving so they were stopped although it appears they have
been renewed in outpatient world. Pt continued on oxycodone and
then MS ___ was restarted. Outpatient providers can reassess
need for ongoing MS ___ and oxycodone.
.
# Autoimmune hepatatis, stage IV c/b cirrhosis: Complicated by
ascites, encephalopathy, and esopageal varices. Currently not
encephalopathic. Has been on immunosuppresion. Continued
lactulose/rifaximin. Azathioprine continued. Budesonide held
initially and restarted after EGD. Lasix held initially as well
in the setting of bleeding, but restarted prior to discharge.
.
# Diabetes II: Blood sugars currently stably controlled. On home
glargine dose of 40 units Qhs. Lantus, SSI. Continued gabapentin
600 TID for neuropathy.
.
# Asthma: Symptoms are stable. Continued albuterol inhaler,
Tiotropium Bromide 1 CAP.
.
# History of Falls: During admission in ___ there had been
issues with falls and her being more sedated so her narcotics
were actually stopped at that time but have been more recently
restarted. She was discharged with home ___ and OT.
.
# Hx compression fractures: The patient has been on Fosamax
since ___ with a plan to stop in ___ and check her bone
density at that time. Continued Alendronate Sodium and vitamin D
for now. See above under abdominal pain for explanation of pain
management.
.
# Decubitus Ulcer, stage III: Wound care made recommendations
that will be followed up by ___.
.
# Seizure disorder: Continued LeVETiracetam 1500 mg PO BID,
Primidone 100 mg PO QAM, 125 mg PO QNOON, 125 mg PO QPM.
.
# Anxiety/Depression: Continued citalopram 20mg daily.
.
# CAD: Continued ASA 81mg.
.
>> Transitional issues:
# EGD in ___ weeks to be scheduled at hepatology follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___: proximal splenic embolization
History of Present Illness:
___ male fell into a dumpster, presented to ___ complaining of left upper abdominal pain, CT
imaging demonstrated splenic laceration with hemoperitoneum.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Temperature: 98.2 F (36.8 C). Pulse:
82. Respiratory Rate: 20. Blood-pressure: 102/74. Oxygen
Saturation: 98% room air; Normal.
General Appearance: pale, clammy
Chest: non-labored
Cardiovascular: rrr
Abdomen: soft, Left sided abdominal tenderness
Extremities: no lower extremity edema
Neurological: A&O x3
Pulses: Palpable bilateral femoral pulses. Palpable bilateral
brachial/radial pulses
Discharge Physical Exam:
VS: 98.5, 136/78, 81, 18, 96 Ra
Gen: resting in bed, NAD
CV: HRR
Pulm: LS ctab
Abd: soft, mildly TTP
Ext: No edema
Pertinent Results:
___ 05:55AM BLOOD WBC-14.4* RBC-3.62* Hgb-11.6* Hct-33.0*
MCV-91 MCH-32.0 MCHC-35.2 RDW-13.3 RDWSD-44.6 Plt ___
___ 09:20AM BLOOD WBC-18.3* RBC-3.74* Hgb-11.8* Hct-33.5*
MCV-90 MCH-31.6 MCHC-35.2 RDW-13.5 RDWSD-44.1 Plt ___
___ 03:03AM BLOOD WBC-19.4* RBC-4.01* Hgb-13.0* Hct-36.0*
MCV-90 MCH-32.4* MCHC-36.1 RDW-13.2 RDWSD-43.6 Plt ___
___ 10:16PM BLOOD WBC-20.3* RBC-3.92* Hgb-12.5* Hct-35.9*
MCV-92 MCH-31.9 MCHC-34.8 RDW-13.2 RDWSD-44.2 Plt ___
___ 07:16PM BLOOD WBC-23.7* RBC-3.76* Hgb-12.2* Hct-34.3*
MCV-91 MCH-32.4* MCHC-35.6 RDW-12.9 RDWSD-42.5 Plt ___
Celiac arteriogram:
Celiac arteriogram demonstrated inferior splenic laceration.
Coil embolization of the proximal splenic artery. Post
embolization celiac arteriogram demonstrated collateral flow to
the spleen.
CT abd/pelvis (OSH)
Splenic laceration with active extravasation
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*20 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Grade III to IV splenic laceration and active extravasation
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 splenic laceration// active extravasation
COMPARISON: CT abdomen pelvis from earlier the same day
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure. Dr.
___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: 25 mcg fentanyl
CONTRAST: 55 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 7.2 min , 51 mGy
PROCEDURE:
1. Left radial artery access
2. Celiac arteriogram.
3. Coil embolization of splenic artery
4. Celiac arteriogram.
PROCEDURE DETAILS:
Following a discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. Left arm was
prepped and draped in the usual sterile fashion.
Using palpation, the left radial artery was identified. After injection of 1%
subcutaneous lidocaine, a micropuncture needle was advanced into the radial
artery until brisk blood return was identified. An 018 Nitinol wire was easily
advanced into the radial artery. The micropuncture needle was exchanged for a
5 ___ Glide sheath. The sheath was flushed and 3000 units of intra-arterial
heparin, 200 mcg of nitroglycerin and 2.5 mg of verapamil were injected into
the radial artery. The sheath was connected to a pressurized bag of
heparinized saline.
A 5 ___ ___ radial catheter, straight tip penumbra plantar and
microcatheter and double angled glide micro wire were simultaneously advanced
into the descending thoracic aorta and subsequently into the abdominal aorta,
using fluoroscopic guidance. Glide catheter and micro wire were removed.
___ radial Catheter was retracted to select the superior mesenteric artery,
followed by the celiac artery, with contrast injected to confirm position.
Once the celiac trunk was selected, a celiac arteriogram was performed which
demonstrated laceration of the inferior spleen . The microcatheter and micro
wire were then advanced into the proximal splenic artery, at which point he
micro wire was removed and a pod ___ mm by 60 cm framing coil was
deployed, followed by a 45 cm packing coil. Post embolization celiac
arteriogram was performed after removal of the microcatheter and demonstrated
mild migration of the coils, embolization of the proximal splenic artery and
only collateral perfusion of the spleen. The catheter was removed.
A TR band was placed over the patient's left wrist. After inflation of the
band with 18 cc of air, the sheath was removed. The band was slowly deflated
until bleeding was noted at the skin entry site. An additional 5 cc of air was
introduced into the band until hemostasis was achiieded. The total volume of
air in the band is 15 cc.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Left radial artery access
2. Celiac arteriogram demonstrated inferior splenic laceration.
3. Coil embolization of the proximal splenic artery
4. Post embolization celiac arteriogram demonstrated collateral flow to the
spleen..
IMPRESSION:
Successful proximal splenic artery embolization.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by UNKNOWN
Chief complaint: s/p Fall, Transfer
Diagnosed with Unspecified laceration of spleen, initial encounter, Fall on same level, unspecified, initial encounter
temperature: 98.2
heartrate: 82.0
resprate: 20.0
o2sat: 98.0
sbp: 102.0
dbp: 74.0
level of pain: 10
level of acuity: 2.0 | The patient presented to Emergency Department on ___. Upon
arrival to ED the patient was evaluated by ED and trauma
surgery. His eFAST was positive and CT scan revealed
hemoperitoneum with active extravasation of contrast from a
grade IV splenic laceration. He was urgently taken to ___ where
he underwent embolization of the splenic artery. He was then
admitted to the ___ for close monitoring of his blood counts
as well as hemodynamic monitoring. His hematocrits have all
been stable since ___ embolization. He reports mild LUQ pain
intermittently. He was advanced to a regular diet on ___
and tolerated it well. He was called out to the floor ___
and was transferred out of the TSICU.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with intermittent
Dilaudid boluses while the patient was NPO and then transitioned
to oxycodone once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Serial
hematocrits were stable. There was no evidence of bleeding in
the ICU.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO After three stable
hematocrits the diet was advanced sequentially to a Regular
diet, which was well tolerated. Patient's intake and output were
closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none after the splenic artery
embolization.
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. He received his
post-splenectomy vaccines at the time of discharge and
instructions on spleen injury care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Percocet
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ female with history of AF on coumadin
presenting after syncopal event at the local area at ___
CT head with evidence of trace SAH.
Per patient was in USOH this AM; went to local store and while
ambulating noted acute onset lightheadedness/shakiness and
briefly lost consciousness for seconds - minutes. Hit head with
fall. No bladder/bowel incontinence. No associated visual
changes, chest pain, palpations. No recent sick contacts or
recent travel. Notes episode of bronchitis ~2wks prior treated
with antibiotics with residual cough, no fevers, chills, sweats.
Tolerating PO without nausea, vomiting, loose stool. +
occassional feels lightheaded/dizziness when standing.
She initially presented to an OSH where CT head was read as
small bilateral SAH. She was transferred to ___ for further
evaluation and observation. On arrival, initial VS 99.1 80
159/68 18 95%. Neuro exam non-focal. EKG: Atrial fibrillation
rate of 78, no ischemic changes. VS prior to transfer 98.5 83
129/58 17 94%. Repeat head CT demonstrated . Neurosurgery was
consulted who saw the patient and documented an intact neuro
exam. Per neurosurgery, CT head with trace bilat SAH, stable to
resolving compared to prior scan from OSH. NSG recommeneded
syncope workup, Q4 neuro checks overnight, blood pressure
control less than 160, hold Coumadin for now and repeat head CT
in AM. These recommendations were discussedw with Dr. ___.
On arrival to the floor patient complains of mild scalp pain.
Denies chest pain, pleuritic pain, palpitations, nausea or
vomiting, numbness or weakness. Per patient she is able to
ambulate unassisted however cannot ambulate more than 1 block
without shortness of breath
Past Medical History:
# Atrial Fibrillation
# COPD
# RUE Arterial Clot, ___
# HTN
# AAA s/p endovascular repair
Social History:
___
Family History:
No history of blood clots
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 155/72 74AF ___ 92%RA
GENERAL: well appearing, speaking in full sentences
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: rhonchorus bs, no wheeze, moderate air movement, resp
unlabored, no accessory muscle use
HEART: irreg irreg , no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses; no edema palpable of upper and
lower extremities
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait stable
DISCHARGE PHYSICAL EXAM:
VS: 98.2, 112/52, 91, 20, 98% 2LNC
GENERAL: well appearing, speaking in full sentences, NAD
HEENT: NC/AT
NECK: supple
LUNGS: rhonchorus bs, no wheeze, poor air movement, resp
unlabored, no accessory muscle use
HEART: irreg irreg , no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses; no edema palpable of upper and
lower extremities
NEURO: awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 05:40PM ___ PTT-47.2* ___
___ 05:40PM WBC-8.5 RBC-4.44 HGB-14.7 HCT-46.7 MCV-105*
MCH-33.1* MCHC-31.5 RDW-14.4
___ 05:40PM DIGOXIN-1.1
___ 05:40PM ___
___ 05:40PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.9
___ 05:40PM CK-MB-4
___ 05:40PM cTropnT-<0.01
___ 05:40PM CK(CPK)-58
IMAGING STUDIES:
- CT HEAD (___): IMPRESSION: Linear hyperdensities in the
bilateral parietal regions, concerning for foci of subarachnoid
hemorrhage, unchanged from CT earlier today.
- CT C-SPINE (___): IMPRESSION: No acute fracture.
Moderate degenerative changes of the cervical spine. Grade 1
anterolisthesis of C7 on T1.
- TTE (___): Poor image quality. The left atrium is normal
in size. 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 regional left
ventricular systolic dysfunction suggested with basal to mid
inferior akinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal with borderline normal free
wall function. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. An
eccentric jet of at least moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
- CTPA (___): IMPRESSION: 1. No evidence of a pulmonary
embolism or acute aortic injury. 2. There is a combination of
consolidative opacities at bilateral lung bases with
ground-glass opacities at the left lung base with mild
mediastinal lymphadenopathy which raise suspicious for an
infection process (possibly due to aspiration) versus an
inflamatory process. Continued followup is recommended.
- CT HEAD (___): IMPRESSION: Linear hyperdensities in
biparietal regions, compatible with subarachnoid hemorrhage, are
less conspicuous since ___ exam. No new intracranial
hemorrhage.
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-7.1 RBC-3.62* Hgb-12.6 Hct-38.0
MCV-105* MCH-34.8* MCHC-33.1 RDW-14.9 Plt ___
___ 06:35AM BLOOD ___ PTT-42.0* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 3 mg PO MWF
2. Warfarin 4 mg PO TUETHURSSATSUN
3. Digoxin 0.125 mg PO DAILY Start: In am
4. Verapamil SR 180 mg PO Q24H Start: In am
Hold for SBP<100, HR<50
5. FoLIC Acid 1 mg PO DAILY Start: In am
6. Alphagan P *NF* (brimonidine) 0.1 % ___ BID
Apply to each eye BID
7. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q6HR:PRN SOB
Please take 2 puffs
8. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Verapamil SR 180 mg PO Q24H
Hold for SBP<100, HR<50
5. Alphagan P *NF* (brimonidine) 0.1 % ___ BID
Apply to each eye BID
6. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q6HR:PRN SOB
Please take 2 puffs
7. Outpatient Physical Therapy
Outpatient ___ for balance and strength training
8. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL Inject 1 Syringe Subcutaneously
every twelve (12) hours Disp #*40 Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Subarachnoid Hemorrhage, Syncope
Secondary: COPD, atrial fibrillation,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Syncope, fall.
___ at outside institution.
FINDINGS: Frontal and lateral views of the chest were obtained. No focal
consolidation, pleural effusion, or evidence of pneumothorax is seen. The
cardiac and mediastinal silhouettes are stable. No overt pulmonary edema is
seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: Syncope, on Coumadin, headache.
COMPARISON: CT head from earlier today.
TECHNIQUE: Contiguous axial images were obtained of the brain, no contrast was
administered. Coronal and sagittal images were obtained. Bone algorithm was
obtained.
FINDINGS: There are subtle areas of linear high density in the bilateral
parietal lobes (ie 2;18) which raise concern forsubarachnoid hemorrhage,
unchanged from study done earlier today at outside institution. There is no
evidence of edema, mass, mass effect, or acute territorial infarction. The
ventricles and sulci are normal in size and configuration for the patient's
age. The visualized paranasal sinuses and mastoid air cells are well aerated.
No fracture. Minimal white matter hypodensities consistent with small vessel
ischemic disease.
IMPRESSION:
Linear hyperdensities in the bilateral parietal regions, concerning for foci
of subarachnoid hemorrhage, unchanged from CT earlier today.
Updated findings discussed with ___. ___ on ___ at 8:30PM.
Radiology Report
HISTORY: Fall, on coumadin, 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 acute fracture. There is a grade 1 anterolisthesis of C7 on T1.
There are moderate degenerative changes of the cervical spine, most prominent
at C5-6, C6-7 and C7-T1 with disc space narrowing and osteophytes. The
vertebral heights are preserved. The visualized lung apices are grossly
clear. Of note are carotid artery calcifications.
IMPRESSION:
No acute fracture. Moderate degenerative changes of the cervical spine.
Grade 1 anterolisthesis of C7 on T1.
Radiology Report
INDICATION: Patient with history of subarachnoid hemorrhage. Assess for
interval change.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness.
DLP: 726 mGy-cm.
FINDINGS:
Linear hyperdensities in biparietal regions are compatible with subarachnoid
hemorrhage and are less conspicuous since ___ exam. No new focus of
intracranial hemorrhage is identified. There is no infarct. The sulci and
ventricles are slightly prominent, likely age-related involutional changes.
Confluent hypodensities in periventricular white matter likely reflect sequela
of small vessel ischemic disease. There is no hydrocephalus. Basilar
cisterns are patent. The paranasal sinuses and mastoid air cells are well
aerated. Orbits are normal in appearance.
IMPRESSION:
Linear hyperdensities in biparietal regions, compatible with subarachnoid
hemorrhage, are less conspicuous since ___ exam. No new intracranial
hemorrhage.
Radiology Report
HISTORY: Hypertension, a-fib, history of DVTs on Coumadin, with syncope and
hypoxia.
COMPARISON: Chest radiograph from ___.
TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet
to the base of the lungs after the uneventful administration of IV contrast.
Multiplanar reformatted images were prepared and reviewed.
FINDINGS:
Opacification of the pulmonary vasculature demonstrates no filling defects
suggestive of a pulmonary embolism. The heart is mildly enlarged but without
a pericardial effusion. Moderate atherosclerotic calcifications are noted
throughout the coronary arteries. Mild atherosclerotic calcifications are
noted throughout the thoracic aorta and at the takeoff of the great vessels
but the aorta is normal in caliber and contour. There is mediastinal
lymphadenopathy with a subcarinal lymph node measuring up to 1.1 cm in the
short axis (2: 46) and prominence of lower paratracheal lymph nodes (2: 36).
There is no pneumothorax.
There are trace bilateral pleural effusions. Consolidative opacities are
noted in the right lower lobe near the major fissure (3:158) as well as at the
the right base (3:174) and left base (3:201). Additionally, multiple
ground-glass opacities are noted in the left lower lobe and nonspecific in
etiology (3: 144, 153, 162, 181, 199).
This study is not tailored for evaluation subdiaphragmatic structures but
there is a small hiatal hernia. Otherwise, the visualized portions of the
upper abdomen are normal.
Osseous structures: There are no lytic sclerotic osseous lesions suspicious
for malignancy. Mild degenerative changes are visualized throughout the
thoracic spine.
IMPRESSION:
1. No evidence of a pulmonary embolism or acute aortic injury.
2. There is a combination of consolidative opacities at bilateral lung bases
with ground-glass opacities at the left lung base with mild mediastinal
lymphadenopathy which raise suspicious for an infection process (possibly due
to aspiration) versus an inflamatory process. Continued followup is
recommended.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 99.1
heartrate: 80.0
resprate: 18.0
o2sat: 95.0
sbp: 159.0
dbp: 68.0
level of pain: 3
level of acuity: 3.0 | ___ female with history of AF on coumadin presenting after
unwitnessed syncopal event at the local area ___ admission
CT head with evidence of trace SAH.
# Syncope: No additional episodes during this hospitalization.
Based on her presentation there was little to suggest that this
episode was associated with seizure. She underwent multiple
studies to attempt to determine the cause for her syncope,
including echo, CTPA, monitoring on telementry, and
orthostatics. None of these tests revealed an obvious cause for
her syncopal episode. She worked with physical therapy and they
felt that she was safe to be discharged home with outpatient
physical therapy.
# Subarachnoid Hemorrhage: Per neurosurgery it is unlikely that
this was the inciting event and rather occurred in the setting
of the fall/syncope. Her INR was 3.3 on admission, and her
coumadin was held, based on the recommendation by neurosurgery.
Also, her blood pressure was maintained at <140 systolic. On
repeat imaging, the SAH was stable to resolving. She had no
focal deficits on neuro exam. She was discharged on lovenox
until full resolution of her bleed was seen on more distant
repeat imaging scheduled as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Reglan / Adderall
Attending: ___.
Chief Complaint:
Unable to tolerate anything by mouth
Major Surgical or Invasive Procedure:
EGD (___)
History of Present Illness:
Mr. ___ is a ___ with severe GERD s/p fundoplication ___
and gastroparesis with rash to Reglan discharged on Erythromycin
___ now presenting with chest pain with swallowing. Since
discharge on ___, patient had been feeling well, but unable
to tolerate erythromcyin due to stomach upset and diarrhea.
Stopped medication on the ___. Since then had been doing well
and been able to eat well, including bread. For the past few
days, he has been having nausea and vomiting. On the day prior
to admission, he developed acute onset chest pain, that he feels
was eminating from his esophagous, with eating. Since then has
been unable to tolerate POs, including water. Never had this
kind of esophagous pain before. Went for urgent care appointmen
to PCP, who told him he was hypotensive to 90/50. Per patient,
EMS repeated vitals and BP 131/77.
Of note, pt was recently admitted from ___ for abdominal
pain, N/V. His symptoms were attributed to gastroparesis gastric
emptying results and a prior EGD showing significant food in the
stomach. Given rash with reglan, pt was discharged on
erythromycin with meals and pre-prandial zofran. Has not been
taking erythromycin, omeprazole, or pre-meal zofran since
discharge.
Prior to this, pt was admitted from ___ for abdominal pain,
nausea. He underwent EGD showing retained gastric contents
consistent with a potential functional gastric outlet
obstruction or gastroparesis. Pt was started on erythromycin
with good response.
In the ED, initial vitals were: T 95.2 P ___ BP 131/77 R 18 O2
Sat 99% RA
- Labs were significant for wbc 8.3, H/H 12.9/39.4, Plt 304,
normal chem 10, normal LFTs.
- Imaging revealed: CXR showed no acute process
- The patient was given 1L NS, zofran, sublingual nitro, NS,
lidocaine viscous, donnatol, and aluminum magnesium hydroxide
with simethicone. Patient unable to tolerate GI cocktail.
Vitals prior to transfer: 97.8 80 116/63 18 100% RA
Upon arrival to the floor, 98.6, 142/74, 65, 14, 99RA. Patient
feels comfortable, doesn't feel like he can tolerate any POs.
Denies pain. Does note some lightheadedness and dizziness with
sitting up and ambulating. Denies bloody vomit. Has interittent
coughing that he attributes to esophageal spasm. Denies any
asthma exacerbations. Occasional diarrhea.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-GERD s/p ___ fundoplication ___ at ___
by Dr. ___
-reported Pancreatic neuroendocrine tumor from ___ appears
to be not a previous diagnosis given records from ___
reports (please see note from ___. It was a duodenal polyp
with a small foci of bland cells (<0.1cm), removed.
-Asthma since age ___
-Adenomatous colonic polyp removal ___
-DJD of his spine
-Lt Ankle surgery ___
-Rt knee surgery ___
Social History:
___
Family History:
Mother had CAD at an old age. He otherwise denies any family
history of heart disease, lung disease, cancer.
Physical Exam:
ON ADMISSION
Vitals: 98.6, 142/74, 65, 14, 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: Supple
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: moving all extremities, gait deferred.
ON DISCHARGE
Vitals: 98.0-98.6 (109-138)/(65-82) 63-67 99-100%RA
Exam:
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- EOMI, tongue midline, face symmetric, motor function
grossly normal
Pertinent Results:
======= ON ADMISSION =======
___ 03:30PM BLOOD WBC-8.3 RBC-4.40* Hgb-12.9* Hct-39.4*
MCV-90 MCH-29.3 MCHC-32.7 RDW-13.4 RDWSD-43.8 Plt ___
___ 03:30PM BLOOD Plt ___
___ 03:30PM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-142
K-4.3 Cl-103 HCO3-25 AnGap-18
___ 03:30PM BLOOD ALT-12 AST-14 AlkPhos-72 TotBili-0.3
___ 03:30PM BLOOD Albumin-4.6 Calcium-10.1 Phos-4.4 Mg-2.1
======== ON DISCHARGE =======
___ 07:20AM BLOOD WBC-6.1 RBC-4.08* Hgb-12.1* Hct-37.4*
MCV-92 MCH-29.7 MCHC-32.4 RDW-13.5 RDWSD-45.6 Plt ___
___ 07:20AM BLOOD Plt ___
___ 06:16AM BLOOD Glucose-108* UreaN-6 Creat-0.8 Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
___ 06:16AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.0
___ 06:16AM BLOOD PTH-24
___ 06:16AM BLOOD TSH-PND
=========== GI REPORT BRIEF SUMMARY ===============
Findings: Esophagus:
Mucosa: Normal mucosa was noted. Cold forceps biopsies were
performed for histology at the lower third of the esophagus.
Cold forceps biopsies were performed for histology at the middle
third of the esophagus.
Stomach:
Other Extra folds seen at GE junction consistent with prior
Nissen fundoplication.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Normal mucosa in the esophagus (biopsy, biopsy)
Normal mucosa in the duodenum
Extra folds seen at GE junction consistent with prior Nissen
fundoplication.
Otherwise normal EGD to third part of the duodenum
Recommendations: Extra folds at GE junction consistent with
prior Nissen fundoplication. No evidence of food impaction,
inflammation, stricturing to explain his symptoms. Biopsies
taken at distal and mid esophagus to evaluate for eosiniphilic
esophagitis.
Follow-up biopsies.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
2. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 250 mg ORAL
DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8hr:PRN Disp #*21
Tablet Refills:*1
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q6H:PRN SOB
4. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 250 mg ORAL
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: odynophagia
Secondary: gastroparesis, asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with chest pain and hypotension. Evaluate for
pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS:
The heart size, mediastinal, and hilar contours are unchanged since the prior
radiographs. Conspicuity of the left hilum may be due to underlying vascular
structures. The lungs are clear without pleural effusion, focal
consolidation, or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ man status post Nissen fundoplication, with
persistent emesis. Evaluate for obstruction or perforation.
TECHNIQUE: Supine and upright abdominal radiographs.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air or pneumatosis coli.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of obstruction or perforation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Epigastric pain
Diagnosed with DYSKINESIA OF ESOPHAGUS, NAUSEA WITH VOMITING, GASTROPARESIS
temperature: 95.2
heartrate: 100.0
resprate: 18.0
o2sat: 99.0
sbp: 131.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | ___ is a ___ year old male with severe GERD s/p
fundoplication ___ and gastroparesis who presented with chest
pain from ___ clinic, and was admitted due to inability to
tolerate POs.
Please see OMR note "FURTHER INFORMATION ON ___ AND ADMISSION
___ for additional details and summary of OSH records.
# Substernal Pain/regurgitation:
He reports he was eating a normal diet up until one day prior to
admission, when he suddenly felt pain at the sternal area in his
esophagus after swallowing his hambuger, with immediate vomiting
afterwards (<1 minute). He could not tolerate any liquids, foods
or medications by mouth. A chest xray was unremarkable. An
endoscopy found no abnormalities aside from expected post
surgical changes. With staff keeping him company for meals, he
was quickly advanced to a regular diet without witnessed
regurigation or ongoing pain. He appears not to tolerate large
quantities of meat well, and we recommend avoiding dense foods
such as steaks and hambugers and to eat pasta/softer foods. This
could be related to his nissin funduplication, or due to
emotional stress/pressure from family. Initially he was trialed
on nitro for esophageal spasm, which made his pain worse and
gave him side effects (headache and infusion site discomfort).
# GERD:
Given his report of diarrhea and reported history of
neuroendocrine tumor, there was initially concern this could be
related to retained neuroendocrine tissue. After obtaining
___ EGD/EUS and path report from ___, it was not clear
he had a neuroendocrine tumor. There was a small duodenal polup
which had bland cells suggestive of neuroendocine origin, but
the focus was <0.1cm and unable to be confirmed with
immunohistochemical staining due to the small size. The US of
his pancreas was normal.
# Gastroparesis:
He has not been following prescribed GI regimen, as he has not
being taking any medications at all for the last week. He
reports being able to physically take them, but that he had
stopped and not renewed the prescriptions. Has not been taking
erythromycin, omeprazole, or ondansetron at home. He also
reports that the erythromycin caused diarrhea. He had no
problems tolerating regular consistency food after diet
advancement.
# asthma:
Albuterol neb was given 3x while inpatient for subjective
dyspnea and cough, but no signs of wheezing on exam and he
maintained normal sats and ambulatory sats.
# Developmental Delay/Emotional Stress:
Poor coping strategies appear to be playing a role. We reviewed
some preliminary strategies and recommended close follow up with
his therapist, ___ at ___
(___).
# Health Care Proxy:
He states he is not close with his family and would not want
either of his parents to be his health care proxy. He
___ his girlfriend of one month, ___
(___), as his preferred HCP. When she arrived to meet
with the team, HCP paperwork was deferred as she was unable to
demonstrate undestanding of his medical problems, symptoms, or
preferences. It will need to be reassessed whether she is
capable of serving as his HCP in the future. At this time, it
still defaults to his next of kin.
TRANSITIONAL ISSUES
- new meds: ondansetron, pantoprazole (both restarted after
self-discontinuation)
- stopped meds: none
- lab work: no addional laboratory monitoring recommended
- follow up appointments with GI
- TSH result pending at discharge
- follow up with outpatient therapist ___ at
___ regarding family stress regarding meals
- erythromycin 250 mg TID had been recommended at his last
discharge <2 weeks ago, however given he was not taking this and
did not want to take it, this was not restarted
- Consider ensure/supplement if ongoing poor PO intake or weight
loss
- His gastric emptying study should be repeated as an outpatient
- Please see note in OMR ("FURTHER INFORMATION ON PMH AND
ADMISSION ___ for summary of OSH medical records. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Protamine / piperacillin / amlodipine
Attending: ___.
Chief Complaint:
Dysphagia, Supratherapeutic INR
Major Surgical or Invasive Procedure:
AVJ Ablation ___
History of Present Illness:
___ PMH Aflutter s/p CTI ablation and PVI, HFrEF s/p BiV
___,
MGUS, CKD, PAD, DM who presents for evaluation after found to
have elevated INR on routine outpatient labwork.
Of note, since ___ he has had four
___.
___ He was admitted for necrotizing skin and soft for
debridement ___ and ___ and had an angioplasty on ___. The
wound culture had polymicrobial growth and he was originally put
on Zosyn but then switched to CTX, linezolid and metronidazole
because he developed AIN thought to be ___ abxs. He was followed
by OPAT with tentative plan to complete course on ___. Of note,
TTE done this admission also found newly reduced EF
___ He was admitted for ___ on CKD and was found to have
___ albicans fungemia. His PICC was removed, and he was
initially put on IV fluconazole but was switched to PO prior to
discharge for a planned 14d course following PICC removal
(___). Cause for his ___ was not entirely clear. It could
have potentially been prerenal and he received resuscitation
with
IVF and blood products as needed. There was potentially some
component of retention, foley was initially placed then removed
and he passed a voiding trial. Ultimately Cr was down-trending
on
discharge. Lasix was resumed on discharge given concern he could
develop volume overload with new HFrEF, but with instructions to
monitor Cr closely. Cardiology follow up was also recommended
given new HFrEF. He was discharged to rehab.
___ He was admitted for a planned skin flap to R foot
with
podiatry but course was complicated by decompensated HFrEF and
atrial tachyarrhtyhmia so he was transferred to cardiology. He
underwent cardioversion on ___ but on ___ atrial arrhythmia
returned. Medical options limited by CKD, HFrEF and previous
amiodarone pulmonary toxicity. He was discharged on metoprolol
succ 200mg daily. He was discharged to rehab. Of note, nuclear
perfusion stress was done this admission which showed no
ischemia
but he does have akinesis of basal inferoseptum, basal-mid
inferior and inferolateral walls.
___ He presented with lower extremity weakness and was
found to have symptomatic conversion pauses. He had a BiV placed
on ___. He was mildly volume overloaded, was diuresed, and was
discharged on 40mg PO Lasix. ___ recommended discharge to rehab
given unstable gait and falls riskbut he preferred to be
discharged home.
His current presentation, he was having his INR checked
routinely
and it was found to be elevated so he was referred to the ED. He
says that at home his biggest issue most recently has been
difficulty swallowing. He says that he swallows and then about 1
minute later the food comes back up, undigested. He denies any
trouble swallowing liquids. He has also had decreased appetite
and says he thinks he has been losing weight. He has also been
having a cough. He has also been feeling like his legs are weak
but denies any falls since he was last discharged. He also
denies
lightheadedness, dizziness, headache, chest pain, dyspnea,
nausea, constipation, diarrhea, abdominal pain, dysuria, urinary
frequency. Occasionally he feels as though he is unable to empty
his bladder completely.
On arrival to the ED initial VS were 97 93 142/111 16 100% RA.
Basic labs were obtained and were notable for Cr 4.9 (from
baseline 2.3-2.5), K 6.8, INR 9.7, mild transaminitis. CT head,
CXR, and RUQUS were all obtained. Renal was consulted for ___ on
CKD and as K had improved with IVF they planned to see him
formally in the AM. He was given 500cc NS, CTX 1g (for UTI
diagnosed on UA), diltiazem ER 120mg, metoprolol succinate 100mg
x2, phytonadione 2.5mg. At the time of transfer his VS were 98.8
94 145/97 19 100% RA.
Upon arrival to the floor, he says he is feeling tired and weak
and is wondering how long he will have to be in the hospital.
Past Medical History:
AFib/ATach s/p flutter ablation and PVI with persistent atrial
tachycardia
CHF
HLD
HTN
OSA on CPAP
Gout
T2DM
GERD
CKD
Anemia
MGUS
Acute interstitial nephritis on zosyn
R foot osteomyelitis x2
Social History:
___
Family History:
Family history is notable for dementia in his father with onset
in his ___. His father also had a myocardial infarction and
stroke. His mother had borderline diabetes. A brother had
substance abuse problems in the past.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 96.7AdultAxillary 149 / ___ 98 RA
GENERAL: Alert, sitting in bed, NAD
HEENT: atraumatic, normocephalic, EOMI, PERRL (2->1mm)
NECK: supple
CARDIAC: RRR, no murmurs, rubs, gallops
LUNGS: good inspiratory effort, no accessory muscle use, diffuse
ronchi and faint wheezes
BACK: Scar in L midback from prior spinal surgery
ABDOMEN: NABS, soft, NT, ND, no rebound or guarding
EXTREMITIES: wwp, 2+ pitting edema bilaterally to the knees. RLE
with well-healed skin flap without any erythema, fluctuance or
drainage
NEUROLOGIC: AAOx3, CN II-XII intact, strength ___ bilateral
upper
extremities, 4+/5 bilateral lower extremities
DISCHARGE PHYSICAL EXAM
GENERAL: Alert, sitting in bed, NAD, generalized weakness
NECK: JVP ~11 cm at 45 degrees
CARDIAC: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no increased work of breathing
ABDOMEN: Soft, non-tender, non-distended, normoactive BS
EXTREMITIES: Warm, DP pulses 2+ bilaterally, no edema, small
0.25
inch circular dry eschar on the tip of the left great toe,
severe
onychomycosis
Pertinent Results:
ADMISSION LABS:
===========
___ 06:43PM BLOOD WBC-12.4* RBC-3.75* Hgb-10.8* Hct-34.6*
MCV-92 MCH-28.8 MCHC-31.2* RDW-16.9* RDWSD-53.8* Plt ___
___ 06:43PM BLOOD Neuts-82.3* Lymphs-7.5* Monos-9.1
Eos-0.0* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-10.17*
AbsLymp-0.93* AbsMono-1.12* AbsEos-0.00* AbsBaso-0.01
___ 06:43PM BLOOD ___ PTT-35.0 ___
___ 07:49AM BLOOD Ret Man-3.5* Abs Ret-0.13*
___ 07:49AM BLOOD ___ 06:43PM BLOOD ALT-69* AST-75* AlkPhos-189* TotBili-0.6
___ 04:10PM BLOOD CK-MB-5 cTropnT-0.10*
___ 01:40PM BLOOD CK-MB-5 cTropnT-0.09*
___ 07:49AM BLOOD Albumin-3.1*
___ 04:10PM BLOOD Calcium-8.4 Phos-6.1* Mg-2.1
___ 07:49AM BLOOD Hapto-143
___ 07:49AM BLOOD CRP-8.7*
___ 05:20AM BLOOD HIV Ab-NEG
___ 06:57PM BLOOD Lactate-2.8*
DISCHARGE LABS:
=============
___ 06:15AM BLOOD WBC-7.5 RBC-2.86* Hgb-8.1* Hct-26.7*
MCV-93 MCH-28.3 MCHC-30.3* RDW-16.6* RDWSD-56.1* Plt ___
___ 06:15AM BLOOD ___ PTT-31.1 ___
___ 06:15AM BLOOD Glucose-89 UreaN-61* Creat-3.9* Na-142
K-4.4 Cl-102 HCO3-28 AnGap-12
___ 06:00AM BLOOD ALT-59* AST-53* AlkPhos-157* TotBili-0.5
___ 06:15AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0
STUDIES:
======
CHEST X RAY (___)
FINDINGS:
Left-sided pacer device is re-demonstrated with leads in
unchanged positions. Moderate cardiac enlargement is unchanged.
The mediastinal and hilar contours are similar to the prior
exam. There is mild pulmonary vascular congestion without frank
pulmonary edema. Small bilateral pleural effusions, slightly
larger on the left, appear slightly decreased in size from the
prior exam. Patchy atelectasis is noted in the lung bases. No
pneumothorax or new focal consolidation. Moderate multilevel
degenerative changes are seen in the thoracic spine.
IMPRESSION:
Mild pulmonary vascular congestion without frank pulmonary
edema. Small
bilateral pleural effusions, decreased in size from the prior
exam. Continued bibasilar atelectasis.
HEAD CT NON-CONTRAST (___)
FINDINGS:
There is a small area of hypodensity in the left internal
capsule, which is new since the ___ study, which likely
represents a chronic lacune. There is no evidence of acute
territorial infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are mildly prominent keeping with
age-related involutional change. Vascular calcifications are
again noted in the carotid siphons and distal vertebral
arteries. No acute fractures are seen. The paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits
are unremarkable.
IMPRESSION:
No acute intracranial process.
ABDOMINAL US (___)
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
trace ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening. A 0.4 cm gall bladder polyp is seen.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity. Spleen length: 7.0 cm
KIDNEYS: Again seen is a complex cyst with solid components in
the in the
upper pole of the right kidney measuring 2.6 x 2.0 x 2.6 cm,
previously 2.4 x 2.7 x 2.2 cm. A left parapelvic cyst is seen
measuring 3.7 x 3.5 x 3.7 cm.
Right kidney: 11.0 cm
Left kidney: 10.5 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
Bilateral pleural effusions are partially imaged.
IMPRESSION:
No definite ultrasound findings of cirrhosis. Trace ascites.
Bilateral
pleural effusions incompletely imaged. Again seen complex cyst
in the right upper pole, unchanged in size compared to prior.
TTE ___
IMPRESSION:
LVEF 15%.
Severe global left ventricular hypokinesis. Moderate to severe
global right ventricular hypokinesis. At least moderate to
severe tricuspid regurgitation. At least moderate pulmonary
hypertension. Moderate right ventricular dilation.
Compared with the prior TTE (images reviewed) of ___ ,
left pleural effusion is present, there is more tricuspid
regurgitation, left ventricular ejection fraction is slightly
lower and right ventricle is
larger all consistent with more volume overload.
Video Oropharyngeal swallow eval ___:
Trace aspiration with large sips of nectar thick liquids.
Please note that a detailed description of dynamic swallowing as
well as a
summative assessment and recommendations are reported separately
in a
standalone note by the Speech-Language Pathologist (OMR, Notes,
Rehabilitation
Services).
MICROBIOLOGY
=============
___ 6:43 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:52 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
___ 7:49 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
3. Finasteride 5 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Isosorbide Dinitrate 20 mg PO TID
6. Metoprolol Succinate XL 200 mg PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Pravastatin 40 mg PO QPM
10. Sodium Bicarbonate 650 mg PO BID
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
13. HydrALAZINE 25 mg PO Q8H
14. ___ MD to order daily dose PO DAILY16
15. Glargine 9 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Torsemide 40 mg PO DAILY
2. HydrALAZINE 100 mg PO Q8H
3. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Isosorbide Dinitrate 40 mg PO TID
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
7. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
8. Finasteride 5 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Pravastatin 40 mg PO QPM
12. Sodium Bicarbonate 650 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
15. ___ MD to order daily dose PO DAILY16
16.CPAP
Autoset CPAP settings
Autoset Cpap (x) ___ () Other
Mask: () Full (x) Nasal () Own
Humidity: () Yes (x) No
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
- Acute on chronic systolic heart failure
- Atrial tachycardia s/p AV nodal ablation
- Congestive hepatopathy
- Encephalopathy
SECONDARY
=========
- Normocytic anemia
- DM2
- Complex R renal cyst
- Foot ulcer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with ___ weakness, INR 8// Eval for bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.2 cm; CTDIvol = 47.1 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
There is a small area of hypodensity in the left internal capsule, which is
new since the ___ study, which likely represents a chronic lacune.
There is no evidence of acute territorial infarction, hemorrhage, edema, or
mass effect. The ventricles and sulci are mildly prominent keeping with
age-related involutional change. Vascular calcifications are again noted in
the carotid siphons and distal vertebral arteries.
No acute fractures are seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with elevated INR// right upper quadrant
ultrasound; any evidence of cirrhosis, liver dz that would explain elevated
INR (>9)
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is trace ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. A
0.4 cm gall bladder polyp is seen.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 7.0 cm
KIDNEYS: Again seen is a complex cyst with solid components in the in the
upper pole of the right kidney measuring 2.6 x 2.0 x 2.6 cm, previously 2.4 x
2.7 x 2.2 cm. A left parapelvic cyst is seen measuring 3.7 x 3.5 x 3.7 cm.
Right kidney: 11.0 cm
Left kidney: 10.5 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
Bilateral pleural effusions are partially imaged.
IMPRESSION:
No definite ultrasound findings of cirrhosis. Trace ascites. Bilateral
pleural effusions incompletely imaged. Again seen complex cyst in the right
upper pole, unchanged in size compared to prior.
Radiology Report
EXAMINATION: Video oropharyngeal swallow study
INDICATION: ___ year old man with coughing and dysphagia// evidence of
aspiration or other abnormalities in swallowing?
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: 03:26 min.
COMPARISON: None.
FINDINGS:
Penetration that cleared at the height of the swallow. Trace aspiration with
large the sips of nectar thick liquids.
IMPRESSION:
Trace aspiration with large sips of nectar thick liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Adult failure to thrive
temperature: 97.0
heartrate: 93.0
resprate: 16.0
o2sat: 100.0
sbp: 142.0
dbp: 111.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man with atrial flutter and
atrial arrhythmia s/p CTI line and PVI, DCCV, HFrEF (thought to
be tachyarrythmia induced on the basis of waxing/waning LVEF
corresponding with arrhythmia control, no prior cath),
tachy-brady syndrome with BIV-P implanted in ___, MGUS, CKD,
PAD, and recent pseudomonas osteomyelitis complicated by
fungemia who was admitted to medicine for supratherapeutic INR
(> 9), acute kidney injury on CKD, post-prandial emesesis and
dysphagia. He was transferred to the heart failure service for
management of acute-on-chronic systolic heart failure and
underwent uncomplicated His bundle ablation on ___ given his
difficulty with rate control.
# PUMP: LV 15%
# RHYTHM: Dual-V paced, A-flutter
ACTIVE ISSUES:
==============
#Acute on chronic systolic heart failure
#Cardiomyopathy, likely tachycardia induced
Patient was found to be cool on exam and likely in low-output
state at time of transfer to heart failure service. Lactate
initially elevated to 2.8 but normalized. He was diuresed with
IV Lasix, subsequently switched to PO Torsemide with stable
weight. Hydralazine was increased to 100 mg TID, isordil
increased to 40 mg TID. Underwent successful AV-nodal ablation
with Dr. ___ on ___. Patient has a BiV pacer. Euvolemic at
discharge.
Discharge Weight: 76.2kg (167.99 lbs) - felt to be euvolemic.
#Atrial tachycardia, hx Aflutter
Prior admission complicated by atrial arrhythmia s/p
cardioversion but converted back within 1 day. Most recently had
admission for BiV PPM ___ after he presented with lower
extremity weakness and was found to have symptomatic conversion
pauses. During this admission, home metoprolol was decreased
from 200mg succ BID to tartrate 50mg q6h given borderline
cardiogenic shock. Underwent successful AVJ ablation ___ and
re-programming of PPM. Transitioned to 200 mg Metoprolol
succinate daily post-procedure.
#Acute on chronic renal failure.
Patient has proteinuric CKD stage IV (baseline Cr 2.5-2.7), on
the basis of long standing T2DM, HTN, MGUS and cardiac disease.
Last urine ACR in ___ was 2183. Creatinine uptrended to the
5.0 but stayed mostly in the 4 range with downtrending BUN.
Nephrology was consulted. ___ was thought due to cardio-renal
physiology in the setting of worsening cardiac function.
Possibly worsened by poor PO intake. Creatinine downtrending but
remaining elevated above prior baseline; likely to have new
baseline after recent insult. Will need outpatient monitoring of
renal function.
Discharge Creatinine: 3.9
#Oropharyngeal dysphagia
#Malnutrition
Patient complained of mild dysphagia on video swallow with
possible esophageal dysmotility. GI was consulted, recommended
pantoprazole 40 mg BID, ___ clinic followup, and possibly
manometry outpatient. EGD was not urgently recommended given
recent prior which was reassuring, but nonurgent repeat was
recommended. He was started on a pureed diet. Nutrition was
consulted and he was started on nutritional supplements. Speech
and swallow reevaluated and upgraded to soft solids, thin
liquids. Patient accepted this diet as a way of reducing
aspiration risk.
#Acute Liver Injury
Likely congestive hepatopathy. Improving with aggressive
diuresis but did not completely resolve during admission. RUQUS
unremarkable. Will need outpatient monitoring.
#Coagulopathy
#Supratherapeutic INR
INR > 9 on admission due to malnutrition. Improved after 2.5 mg
PO VitK. Held warfarin until INR was <3.0, then resumed. Briefly
started on a heparin bridge to warfarin while awaiting ablation.
Heparin subsequently discontinued as no indication for bridging.
Discharged on warfarin 5MG, last dose was ___.
Discharge INR: 1.5
# Encephalopathy
# Deconditioning
Not fully oriented on exam and somewhat inattentive, suspect
some mild hospital associated delirium. Electrolytes are
acceptable, do not suspect uremia. No signs of infections.
Daughter noted that he gets confused in the hospital. ___ and OT
were consulted. Patient placed on delirium precautions. Required
2 person assist with standing. Had previously refused rehab. SW
was consulted regarding significant deconditioning and patient
decision making and he accepted discharge to rehab.
CHRONIC ISSUES:
==============
#Normocytic anemia
Likely due to anemia of CKD and chronic illness. Stable.
# Atrial fibrillation
Held home warfarin per above until INR back in therapeutic
range. Following improvement of INR after vitamin K, resumed
warfarin. Initially dosed 3MG on ___, increased to 3.5 on
___, subsequently on 5MG ___, and ___ (prior to
discharge).
# Diabetes mellitus
Given poor PO intake and ___, decreased long acting insulin from
9 to 6, held standing meal time Humalog. Started insulin sliding
scale.
# Complex R renal cyst
Needs follow up imaging because of small chance of being
malignant. Best imaging modality would be MRI, although this has
risks given his CKD.
TRANSITIONAL ISSUES
==============
[ ] Follow-up weight, volume status, adjust diuresis as needed.
Estimated dry weight is 76kg.
[ ] Consider consolidating isosorbide to mononitrate 120 once
daily on ___
[ ] Consider referral to sleep clinic for OSA evaluation
(previously was on CPAP for OSA but has not used since ___,
we placed an order for autoset 4mmHg-20mmHg given that this is
what he has used on prior recent admissions)
[ ] Next INR check ___, will need daily checks until
therapeutic x48hrs
[ ] Re-check creatinine, BUN
[ ] Re-checking liver enzymes to confirm resolution of
transaminitis
[ ] Consider repeat TTE in 3 months to re-evaluate ventricular
function after resolution of tachycardia
- Discharge weight: 76.2kg (167.99 lbs)
- Discharge creatinine: 3.9
- Discharge heart failure regimen:
PRELOAD: Torsemide 40 mg daily.
AFTERLOAD: Hydralazine 100mg q8h, isosorbide dinitrate 40MG
TID
Neurohormonal blockade: Metoprolol succinate 200MG daily
#CODE STATUS: Full code
#CONTACT: Daughter/HCP: ___, Phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Bentyl
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
ERCP
PTBD
History of Present Illness:
Ms. ___ is a ___ woman with history of HTN,
HLD, hemochromatosis presenting with abdominal pain and
jaundice,
found to have pancreatic mass.
The patient initially presented to her PCP for back pain. The
patient reports that her back pain began around Labor Day. No
trauma. The pain was in her midthoracic region, worse on the
left
side. She had several imaging tests that were unrevealing.
Flexeril and gabapentin were trialed without effect. She was
started on oxycodone, which helped somewhat with the pain, but
even doses of 7.5 mg only took the edge off the pain. She was
also taking Tylenol and ibuprofen; she is unsure how much, but
she reports that she used a bottle of 100 tablets of each in
about two weeks. No weight loss or gain, but she has not felt
like eating very much in the past few days.
At a recent PCP visit, she was noted to have scleral icterus.
She
reported decreased appetite, constipation, and abdominal pain in
the last two days prior to admission. outpatient labs were
obtained that were notable for Na 120, AST 156, ALT 118, Tb
10.4,
AP 400. The patient was directed to stop her
hydrochlorothiazide.
She was sent to ___ for abdominal imaging, which
demonstrated a pancreatic mass. She was then referred to ___
for further management. She denies any nausea, vomiting. No
fevers or chills. No dysuria.
She reports that she was diagnosed with hemochromatosis several
years ago; no known family history. She was undergoing
phlebotomy, but decided to discontinue this about ___ years ago.
In the ED, initial vitals: 8 97.4 79 132/82 18 99% RA
Labs notable for: WBC 8.3; Na 123, BUN/Cr ___ AST 112, ALT
168, AP 543, Tb 10.3, lipase 12
Patient given: Morphine 4 mgx2, 500 cc NS, nicotine patch
On arrival to the floor, the patient reports that she continues
to have severe epigastric abdominal pain that radiates to her
back. She denies any other complaints at present.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Hereditary hemochromatosis
- Hypertension
- Hyperlipidemia
- Insomnia
- Depression
- Thoracic back pain
Social History:
___
Family History:
- Father: ___. Colon cancer, pancreatic cancer, DMII
- Mother: CVA
- Brother: CAD/PVD
- Sister: CAD/PVD, HTN
- Son: ___ disorder
Physical Exam:
VITALS: 98.3 120/83 78 16 95 RA
GENERAL: Alert and in no apparent distress
EYES: Icteric, pupils equally round, mild proptosis
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation in
mid-epigastrium. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted; icteric skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
Pertinent Results:
___ 02:00AM BLOOD WBC-6.9 RBC-3.16* Hgb-10.1* Hct-29.7*
MCV-94 MCH-32.0 MCHC-34.0 RDW-17.2* RDWSD-58.9* Plt ___
___ 02:00AM BLOOD Neuts-68.3 Lymphs-16.8* Monos-8.8 Eos-4.3
Baso-0.6 Im ___ AbsNeut-4.71 AbsLymp-1.16* AbsMono-0.61
AbsEos-0.30 AbsBaso-0.04
___ 06:29AM BLOOD ___ PTT-29.8 ___
___ 02:00AM BLOOD Glucose-117* UreaN-2* Creat-0.4 Na-131*
K-3.9 Cl-97 HCO3-22 AnGap-12
___ 07:19AM BLOOD ALT-84* AST-54* AlkPhos-454* TotBili-5.0*
___ 02:00AM BLOOD Albumin-3.5 Calcium-9.0 Phos-4.1 Mg-1.5*
___ 04:18PM BLOOD calTIBC-345 Ferritn-450* TRF-265
___ 04:18PM BLOOD Osmolal-248*
___ 04:18PM BLOOD TSH-2.5
CT ABD:
IMPRESSION:
1. A 2.2 cm pancreatic head mass causes abrupt obstruction of
the common bile
duct resulting in moderate intrahepatic and extrahepatic biliary
dilation.
Mass abuts the second portion of the duodenum but does not
contact major
vessels.
2. Peripancreatic lymphadenopathy including a necrotic appearing
2.6 cm lymph
node just anterior to the third portion of the duodenum.
DIAGNOSIS:
POSITIVE FOR MALIGNANT CELLS.
Adenocarcinoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
2. Gabapentin 300 mg PO QAM
3. Gabapentin 600 mg PO QPM
4. Omeprazole 40 mg PO DAILY
5. TraZODone 150 mg PO QHS
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. Fenofibrate 160 mg PO DAILY
8. ClonazePAM 0.5 mg PO QHS:PRN insomnia/anxiety
9. FoLIC Acid 1 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Headache
over the counter. take no more than 3 grams per day
2. Bisacodyl ___AILY:PRN Constipation - Second Line
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*14 Suppository Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
through ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*3 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
avoid with alcohol or driving/machinery
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*100 Tablet Refills:*0
6. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray NAS ONCE Disp #*1
Spray Refills:*0
7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO BID
take ___ times per day to titrate to bowel movements
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 gram by
mouth three times a day Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
10. BuPROPion XL (Once Daily) 300 mg PO DAILY
11. ClonazePAM 0.5 mg PO QHS:PRN insomnia/anxiety
12. Fenofibrate 160 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Gabapentin 300 mg PO QAM
15. Gabapentin 600 mg PO QPM
16. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bile obstruction
Mass, pancreas
Acute pain
Constipation
Hyponatremia
Hypertension
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: ___ year old woman with new pancreatic mass and obstruction with
failed ERCP. Scan prior to PTBD placement. CT Abd/Pelvis with IV contrast only
please// CT Abd/Pelvis with IV Contrast Only
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.5 s, 48.7 cm; CTDIvol = 11.3 mGy (Body) DLP = 543.7
mGy-cm.
Total DLP (Body) = 544 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Numerous calcified granulomas noted in the lung bases. No pleural
or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is moderate diffuse intrahepatic
biliary dilation. Extrahepatic biliary dilation extends to the level of a
hypoenhancing pancreatic head mass described below. The gallbladder is
distended with mild gallbladder wall edema.
PANCREAS: A 2.1 x 2.2 x 2.0 cm (TV x AP x CC) hypoenhancing pancreatic head
mass causes obstruction of the common bile duct. There is mild pancreatic
ductal dilation and pancreatic parenchymal atrophy upstream of this mass.
This mass closely abuts the second portion of the duodenum, but does not
contact major vessels. Several enlarged peripancreatic lymph nodes are noted
and described below.
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: Uterus is unremarkable. No adnexal abnormalities are
seen.
LYMPH NODES: There are several enlarged peripancreatic lymph nodes measuring
up to 11 mm in the porta hepatis region (02:38). A large necrotic mesenteric
node measuring 2.6 x 2.6 cm is noted, anterior to the third portion of the
duodenum. Additional enlarged 10 mm node is noted adjacent to the SMA
(02:51). There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild to moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Bilateral pars defects at L5 are noted and there is associated grade 1
anterolisthesis of L5 on S1.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
PANCREATIC CANCER STAGING:
Morphologic Evaluation
Appearance (in the pancreatic parenchymal phase): hypoattenuating
Size (maximal axial dimension in cm): 2.2 cm
Location (head right of SMV, body left of SMV): head/uncinate
Pancreatic duct narrowing/abrupt cutoff with or without upstream dilatation:
present
Biliary tree abrupt cutoff with or without upstream dilatation: present
Arterial evaluation
SMA involvement: absent
Celiac Axis involvement: absent
Common hepatic artery involvement: absent
Variant anatomy: none
Venous evaluation
MPV involvement: absent
SMV involvement: absent
Focal vessel narrowing or contour irregularity (tethering or tear drop):
absent
Extension to first draining vein: absent
Thrombus within vein: absent; type of thrombus: None
Venous collaterals: absent
Extrapancreatic evaluation
Liver lesions: absent
Peritoneal or omental nodules: absent
Ascites: absent
Suspicious lymph nodes: Present
IMPRESSION:
1. A 2.2 cm pancreatic head mass causes abrupt obstruction of the common bile
duct resulting in moderate intrahepatic and extrahepatic biliary dilation.
Mass abuts the second portion of the duodenum but does not contact major
vessels.
2. Peripancreatic lymphadenopathy including a necrotic appearing 2.6 cm lymph
node just anterior to the third portion of the duodenum.
Radiology Report
INDICATION: ___ year old woman with new dx pancreatic mass, failed ERCP today,
12.15, could not cannulate. Requesting PTBD w/brushing of bile duct.// PTBD
w/Brushings of bile duct
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___, attending Interventional Radiologist
performed the procedure. ANESTHESIA: General, provided by the anesthesiology
team.
MEDICATIONS: Ceftriaxone 1 g
CONTRAST: 25 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 10.4 minute, 35 mGy
PROCEDURE:
1. Transabdominal ultrasound.
2. Ultrasound guided left percutaneous transhepatic bile duct access.
3. Left cholangiogram
4. ___ right biliary drain placement internal external.
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 abdomen was
prepped and draped in the usual sterile fashion.
Under Ultrasound guidance, a 21G Cook needle was advanced into leftbiliary
system. Images of the access were stored on PACS. Once return of bilious fluid
was identified, a Nitinol wire was advanced under fluoroscopic guidance into
the common bile duct. A skin ___ was made over the needle and the needle was
removed over the wire. An Accustick set was advanced over the wire and the
inner stiffener was withdrawn. A contrast injection was performed to confirm
biliary anatomy. A 7 ___ sheath was introduced and a Kumpe the wire to
gather with a Glidewire were used to cross the tight distal CBD occlusion into
the duodenum.
Brushings for cytology across the mass obstructing the distal CBD were
obtained and sent to the cytology lab. A 10 ___ internal external biliary
drainage catheter was then placed. A final cholangiogram was obtained
demonstrating appropriate position. The catheter was sutured and secured a
sterile dressing was applied there were no immediate complications.
FINDINGS:
Complete occlusion of the distal CBD leading to severe extra and intrahepatic
biliary dilation.
IMPRESSION:
Successful placement of the left ___ internal-external biliary drain and
cytology brushings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Abnormal CT, Jaundice
Diagnosed with Unspecified jaundice, Abn lev hormones in specimens from female genital organs, Dehydration, Alcohol-induced chronic pancreatitis, Other specified diseases of pancreas
temperature: 97.4
heartrate: 79.0
resprate: 18.0
o2sat: 99.0
sbp: 132.0
dbp: 82.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ woman with history of HTN, HLD,
hemochromatosis who presented with abdominal pain and jaundice,
found to have pancreatic mass and bile obstruction. s/p PTBD.
# Abdominal pain
# Bile obstruction
# Pancreatic mass concerning for adenoCA
Patient presenting with several months of thoracic back pain,
found on outside imaging to have pancreatic mass resulting in
biliary obstruction. The patient is a current smoker with
family history of pancreatic cancer; of additional note, she has
hereditary hemochromatosis which may confer an additional risk
of extrahepatic cancer. Patient has had MRI spine without acute
pathology to explain pain; suspect that this is referred. She
is now s/p failed attempt at ERCP. She had ongoing pain for
which she required opioids. ___ was consulted and PTBD was
performed successfully with brushings. CT scan was performed.
She improved clinically with improvement in her LFTs. She was
discharged home to follow up in ___ clinic on ___.
- ___ pending
- BRUSHING positive for adenocarcinoma on day of discharge
- Patient to follow up with ___ for ongoing PTBD management.
- Given Rx for dilaudid with stool softeners and narcan and
discussed specific instructions regarding proper management with
this medication
# Hyponatremia:
Patient noted to have asymptomatic Hyponatremia to 123 on
initial labs. Unknown chronicity, last Na from ___ within
normal limits. She was on HCTZ. Assessment was most consistent
with hypovolemic Hyponatremia in addition to effects of HCTZ.
She corrected vigorously with small amount of NS given at the
time of hospitalization. I reviewed with nephrology and we
tempered her correction with D5W over the last 24 hrs. Her Na
eventually stabilized and improved thereafter. Her HCTZ was
held on DC indefinitely.
# Anxiety:
- Continued Clonazepam. Increased to BID prn
# Nicotine dependence:
Patient current 1 ppd smoker.
- Counseled on smoking cessation
- Nicotine patch
# Asymptomatic bacteriuria:
- stable |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Biliary colic
Major Surgical or Invasive Procedure:
___ Laparoscopic Cholecystectomy
History of Present Illness:
2 weeks ago had back pain that woke patient from sleep. Pain
located primarily in the right mid back. Described as dull pain
that progressed to sharp over the course of the night.
Eventually pain progressed and saw physician, prescribed
flexeril. Pain continued to recur, usually only in the
evenings. Reports associated cramping in stomach area as well
as mild shortness of
breath. Denies nausea or vomiting, denies fevers or chills.
Denies sick contacts. PResented to PCP and was referred for a
CT scan.
Past Medical History:
PMH:
None
PSH:
1. Tonsillectomy/adenoids as a child
Social History:
___
Family History:
N/C
Physical Exam:
Physical Exam upon admmission:
PE: 98.85 87 122/75 16 96%
GEN: AOx3 NAD
HEENT: NC/AT no scleral icterus
COR: RRR S1S2
RES: normal respiratory effort
ABD: Soft, NT/ND, obese
EXT: WWP without edema
NEU: Without focal deficit
PSY: Without focal deficit
Physical Exam upon discharge:
PE: 98.2, 82, 110/67, 16, 98%/RA
Gen: NAD, resting in bed.
Heent: EOMI, MMM
Cardiac: Normal S1, S2.
Pulm: Lungs CTAB No W/R/R
Abd: S/ND/mildy tender at lap sites
Ext: + pedal pulses. No CCE
Neuro: AAOx4, normal mentation
Pertinent Results:
___ 04:05PM BLOOD WBC-10.1 RBC-4.54* Hgb-14.5 Hct-44.7
MCV-99* MCH-32.0 MCHC-32.5 RDW-12.5 Plt ___
___ 04:05PM BLOOD Neuts-49.0* ___ Monos-8.0 Eos-2.4
Baso-1.0
___ 04:05PM BLOOD Plt ___
___ 04:05PM BLOOD ___ PTT-31.9 ___
___ 04:05PM BLOOD Glucose-93 UreaN-10 Creat-0.9 Na-139
K-4.2 Cl-104 HCO3-30 AnGap-9
___ 04:05PM BLOOD ALT-23 AST-21 AlkPhos-63 TotBili-0.5
___ 04:05PM BLOOD Albumin-4.6
___ Radiology LIVER OR GALLBLADDER US
IMPRESSION:
Cholelithiasis with marked gallbladder wall edema, however
without gallbladder distension or pericholecystic fluid.
Findings likely reflect chronic cholecystitis, although
gallbladder wall edema can also be seen in the setting of third
spacing/hypoproteinemia, or hepatitis among other scenarios.
Medications on Admission:
Flexeril
Tylenol #3
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholecysytitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right upper quadrant pain.
TECHNIQUE: Transabdominal ultrasound.
COMPARISON: Outside CT from ___.
FINDINGS:
The liver is of normal echotexture without focal lesions. There is no
evidence of intra or extrahepatic ductal dilatation. The main portal vein is
patent. The common bile duct measures 3 mm.
The gallbladder wall is edematous and thickened up to 7 mm although it should
be noted that the gallbladder is not distended. There are several shadowing
calcified gallstones within it. No pericholecystic fluid is noted and there
was a negative sonographic ___ sign.
IMPRESSION:
Cholelithiasis with marked gallbladder wall edema, however without gallbladder
distension or pericholecystic fluid. Findings likely reflect chronic
cholecystitis, although gallbladder wall edema can also be seen in the setting
of third spacing/hypoproteinemia, or hepatitis among other scenarios.
Discussed updated findings with ___ at 10:25 pm, ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with CHOLELITHIASIS NOS
temperature: 98.85
heartrate: 87.0
resprate: 16.0
o2sat: 96.0
sbp: 122.0
dbp: 75.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ was admitted on ___ under the acute care
surgery service for management of his acute cholecystitis. He
was taken to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. He tolerated the procedure well and was extubated
upon completion. He was subsequently taken to the PACU for
recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of ___
to regular, which he tolerated without abdominal pain, nausea,
or vomiting. He was voiding adequate amounts of urine without
difficulty. He was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On ___, he was discharged home with scheduled follow up in
___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pedestrian struck with resulting L tibial plateau fx, b/l
acetabular fx, L ulna fx
Major Surgical or Invasive Procedure:
___
1. Open reduction internal fixation left ulnar fracture
with internal fixation.
2. Washout and debridement open tibial shaft fracture down
to and inclusive of bone.
3. Open reduction internal fixation left tibial plateau
fracture with internal fixation.
4. Open reduction internal fixation left tibial tubercle
fracture with internal fixation.
5. Open reduction internal fixation left tibial shaft
fracture with internal fixation.
6. Monitor interstitial compartment pressures, left tibia.
7. Four-compartment fasciotomy left tibia without
debridement.
8. Application VAC sponge, left leg.
9. Closed treatment left fibula fracture without
manipulation.
___
1. Repair dehiscence extensive, left lateral leg.
2. Repair dehiscence, left medial leg.
History of Present Illness:
___ ped struck by car while walking with GF at approx ___,
+ short LOC, GCS 15, tx from OSH for bilateral pelvic fx w/
hematoma, L tib/fib fx, L ulnar fx, L 8th rib fx, L heel
hematoma.
Injuries:
L 8th rib fx
bilateral acetab fx
L pelvic hematoma 7x5x2 cm
L sacral fx
L ulna fx
L tib plateau fx
L heel hematoma
Past Medical History:
PMH: basal cell ca
PSH: sternal basal cell ca excision, L frontal craniotomy
Social History:
___
Family History:
non-con
Physical Exam:
On arrival:
T 98.2 P 88 BP 130/72 RR 18 O2 96 RA
AOx3, GCS 15
airway intact, breathing stable, HD stable
abrasion L apical scalp
tender to palpation left hemithorax
left wrist tender, neurovascular intact
abdomen soft/nontender
pelvis sheeted
foley in place, no blood at meatus
left leg in splint, neurovascular intact
At discharge:
AVSS
NAD, A&O x3
CV: RRR
PULM: CTAB
MSK:
LUE with incision clean/dry/intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
Mild pain with passive motion at wrist
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Contralateral extremity examined with good range of motion,
SILT, motors intact and no pain or edema
LLE incisions clean/dry/intact with mild swelling and
ecchymosis, no induration, fluctuance or drainage.
Thighs and legs are soft
Mild pain with passive motion at knee and ankle
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Contralateral extremity examined with good range of motion,
SILT, motors intact and no pain or edema
Pertinent Results:
___ 06:20AM BLOOD WBC-4.7 RBC-3.86* Hgb-11.8* Hct-37.9*
MCV-98 MCH-30.6 MCHC-31.1 RDW-14.4 Plt ___
___ 06:20AM BLOOD Glucose-97 UreaN-11 Creat-0.9 Na-139
K-4.5 Cl-105 HCO3-26 AnGap-13
Medications on Admission:
MVI
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion .
3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*28 Syringe* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
8. Wheelchair with elevating leg rests , handrails on wheels
9. Walker with left arm platform
10. Bedside Commode
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Open left tibial shaft fracture.
2. Left lateral tibial plateau fracture.
3. Impending compartment syndrome of the left leg.
4. Left ulna fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Trauma.
COMPARISONS: None.
FINDINGS: A single frontal image of the chest shows no consolidation, edema,
pleural effusion, or pneumothorax. The cardiomediastinal silhouette is
normal. No displaced fracture is seen.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
LEFT LOWER EXTREMITY CT WITHOUT CONTRAST DATED ___.
CLINICAL INDICATION: ___ man with left tibial plateau fracture,
assess fracture.
COMPARISON: Reference knee radiographs from ___.
TECHNIQUE: Multiple contiguous axial MDCT images of the left knee were
acquired with soft tissue and bone algorithms with coronal and sagittal
reformations provided for interpretation.
FINDINGS: There is a comminuted fracture of the proximal tibia with fracture
lines extending towards the lateral tibial plateau with associated impaction
and approximately 3-4 mm of depression at the lateral tibial plateau.
Fracture lines also extend to the medial and lateral tibial metadiaphysis with
multiple comminuted fracture fragments. No definite fracture line is seen
towards the medial tibial plateau.
Acute comminuted fracture of the proximal fibula. Old osseous avulsion
fracture fragments at the fibular styloid ___, 105:118).
Though examination with CT is not sensitive and specific for the detection of
meniscal or ligamentous abnormalities, the anterior cruciate ligament and
posterior cruciate ligament are grossly intact. Medial collateral ligament
appears grossly maintained. The iliotibial band attaches to a lateral
proximal tibia fracture fragment. The biceps femoris and lateral collateral
ligament are grossly intact and attach at the proximal lateral fibula and old
osseous avulsion fragments at the fibular styloid.
Moderate knee joint lipohemarthrosis. Enostosis in the medial femoral
condyle. Degenerative changes are seen at the patellofemoral joint with
osteophyte marginal formation laterally. Mild narrowing of the medial
compartment knee joint space with associated subchondral sclerosis.
Subcutaneous soft tissue stranding is seen at the predominantly anterolateral
and lateral knee.
Punctate radiopaque densities in the anterior knee subcutaneous soft tissues
(107B:59, for example) could represent tiny radiopaque foreign bodies.
Calcified atherosclerotic vascular disease of the superficial femoral artery,
popliteal artery and branch vessels.
The patella and distal femur are grossly intact.
IMPRESSION:
1. Lateral tibial plateau fracture with mild impaction and 3-4 mm of
depression with fracture lines extending to both the medial and lateral tibial
metadiaphysis with multiple associated comminuted fracture fragments.
2. Comminuted fracture of proximal fibula.
3. Old osseous avulsion fracture fragments at fibular styloid.
4. Moderate lipohemarthrosis.
5. Mild-to-moderate degenerative changes of the patellofemoral compartment
and medial compartment of the knee.
6. Calcified atherosclerotic vascular disease of the superficial femoral
artery, popliteal artery and branch vessels.
7. Punctate radiopaque densities in the anterior knee subcutaneous soft
tissues may represent tiny foreign bodies.
Radiology Report
HISTORY: ORIF left tibia.
Fluoroscopic assistance provided without the radiologist present. 18 spot
views obtained. Fluoro time not recorded on the electronic requisition.
Views demonstrate steps related to hardware fixation about the hip, knee, and
ankle. Assessment of fine bony detail is limited by technique. Correlation
with real-time findings and when appropriate, conventional radiographs is
recommended for full assessment.
Radiology Report
HISTORY: C-arm ORIF left forearm, left tibia.
Fluoroscopic assistance provided to surgeon in the OR without the radiologist
present. Five spot views obtained. Views are of the wrist, with a sideplate
along the distal ulna. Side not indicated. Fluoro time not recorded on the
electronic requisition. Correlation with real-time findings and when
appropriate conventional radiographs recommended for full assessment.
Radiology Report
INDICATION: ___ man with polytrauma, question pneumothorax or
pneumonia.
COMPARISONS: Portable chest radiograph from ___.
FINDINGS: Since the prior radiograph, there is no significant interval change.
There is no focal consolidation, pleural effusion, or pneumothorax.
Visualized osseous structures are unremarkable. Cardiomediastinal silhouette
is normal.
IMPRESSION: No focal consolidation or pneumothorax.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Desaturation, postop.
Comparison is made with prior study, ___. Cardiac size is top normal.
New right perihilar opacities are concerning for aspiration. Left lung is
essentially clear aside from a small atelectasis in the base. There is no
pneumothorax or pleural effusion.
Radiology Report
LEFT TIBIA FIBULA RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior from ___.
CLINICAL HISTORY: Post-ORIF of a right tibial fracture, assess alignment and
hardware.
FINDINGS: Four views of the left tibia fibula were provided. A lateral
sideplate and multiple screws traverse the proximal tibia extending into the
mid diaphyseal region. The alignment is near anatomic. Fracture is known to
involve the lateral tibial plateau, though the articular surface appears
smooth. Fracture of the neck of the left fibula is displaced with overall
alignment unchanged.
IMPRESSION: Post-ORIF of the left tibial fracture with anatomic alignment
achieved.
Radiology Report
LEFT WRIST RADIOGRAPHS PERFORMED ON ___
Comparison is made with a prior study from ___.
CLINICAL HISTORY: Left ulnar fracture, status post ORIF, assess fracture for
healing and hardware position.
FINDINGS: AP, lateral, and oblique views of the left wrist were provided.
There is a side plate traversing the distal ulnar fracture which is in near
anatomic alignment. There is no sign of hardware failure. No new fractures
are seen.
Radiology Report
PELVIS RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior CT torso dated ___.
CLINICAL HISTORY: ___ man with bilateral pelvic fractures, managed
nonoperatively, assess alignment of the acetabular fractures as well as the
pubic ramus fractures.
FINDINGS: Three views of the pelvis were provided including Judet views. The
known fracture of the left sacral ala is suboptimally assessed. There is
displacement of the left superior ramus fracture which extends into the left
acetabulum. Also noted is inferior left pubic ramus fracture. The right
pubic ramus fractures are not significantly displaced. The proximal femurs
align normally.
IMPRESSION: Multiple pelvic fractures with displaced right pubic ramus
fractures and displaced left pubic ramus fractures. Please note, evaluation
is not sensitive to assess the degree of fracture displacement given the
comminuted nature of these fractures.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with FX TIBIA SHAFT-OPEN, FX UPPER END TIBIA-CLOSE, FRACTURE ACETABULUM-CLOS, FRACTURE OF PUBIS-CLOSED, FX SACRUM/COCCYX-CLOSED, FX DISTAL ULNA-CLOSED, FRACTURE ONE RIB-CLOSED, MV COLL W PEDEST-PEDEST
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr ___ was admitted to the trauma ICU from the ED following
his transfer from outside hospital. He was taken to the
operating room by orthopedic surgery that same day (___) for
ORIF left tibia & ulna, as well as 4-compartment fasciotomy of
left leg please see Dr ___ report for further
details. He was extubated in the operating room and remained HD
stable. He returned to the trauma ICU post-op for monitoring.
Overnight, he was HD stable, had no respiratory issues, had a
stable hematocrit and maintained adequate urine output. He was
kept NPO while in the ICU. His pain was well controlled with a
dilaudid PCA. On post-op day 1 (24 hours post admission), he was
transferred to the orthopedic service and out to the regular
floor. He was taken back to the OR on ___ for Repair of
dehiscence of left medial and lateral leg fasciotomy wounds. He
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: Left lower extremity: Touch down weight
bearing with ___ brace locked in extension when OOB, ok to
unlock from ___ when in bed; no active extension, ok to do
flexion exercises.
Left upper extremity: Non-weight bearing; ok to platform crutch
weight bear; sling when OOB, no splint
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 remained in
the hospital for a prolonged period of time secondary to
post-discharge placement difficulties as the patient was not
insured and not a MA resident. He ultimately was found to be
safe for discharge home with services. He was at that point
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 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
tachycardia/hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with PMH of HTN who was in her USOH until
1:30 ___ when she developed palpitations while at work as a
medical assistant. Pt reports 2 previous episodes of similar
symptoms where the last was in ___ and was while she was
on vacation with no inciting events. The episodes normally last
only <1 hr. She reports feeling the same way this time and that
if there hadn't been all of the "medical people around" it would
have resolved the same way it normally does with resting. She
reports feeling fine all weekend, no changes in diet, no alcohol
or increases in caffeine. She was at work feeling fine when all
of a sudden she developed the feeling that "her heart was
beating out of her chest", she asked to lie down and was found
to be tachycardic in the 200s. She works at a PCP office as ___
medical assistant and EKG showed afib. She was given 5mg IV dilt
there with reportedly little effect. She received an unclear
amount in the ambulance (14mg?). On arrival to the ED her EKG
showed Afib and she was given another 5mg of IV metoprolol and
converted to sinus rhythm.
In the ED her initial VS were 124 133/98 18 100% RA. She was not
lightheaded, HR in 140s, BP 150s. EKG showed afib with no ST
changes. Given IVF and metoprolol 5mg and HR went down to the
100s. CXR was normal. CBC, chem 10, and UA were normal. D-dimer
elevated to 750, CTA chest without sings of PE or acute aortic
syndrome.
Due to an unclear reason she received morphine in ED, and on
arrival to the floor reports feeling very flushed, weak,
nauseous and is dry heaving. She denies any chest pain. She
reports no longer feeling palpitations. She denies any worsening
shortness of breath (has noticed this over the past few years,
unchanged), no orthopnea, no peripheral edema. Denies any focal
weakness. Has intermittent headaches.
At baseline, she has sob with one flight of stairs but no other
cardiac symptoms. Has had occasional sob with exertion along
with headaches, and was started on metoprolol succinate 2 months
ago, but she has self-discontinued the medication 3 weeks ago
because she was feeling better.
Overnight, patient complaining of pruritus in b/l hands, but
this has completely resolved this morning. + 'a little bit of
nausea.' Denies pain, palpitations, pain in L arm/jaw, or sob.
REVIEW OF SYSTEMS:
(+) Per HPI.
(-) Cardiac: Denies chest pain, paroxysmal nocturnal dyspnea,
orthopnea, peripheral edema/swelling, syncope or presyncope.
(-) General: Denies weight change, fatigue, subjective fevers at
home, chills, rigors, night sweats, headache, diplopia,
odynophagia, dysphagia, lymphadenopathy, prior history of stroke
or TIA, cyanosis, cough, hemoptysis, diarrhea, melena,
hematochezia, hematemesis, known pulmonary embolism or DVT,
myalgias, joint pains, new brusing, new bleeding, dysuria,
exertional buttock or calf pain.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension diagnosed ___
2/. OTHER PAST MEDICAL HISTORY: headache, migraine, fatty liver,
obesity
3. PSH: R leg repair for polio and L leg repair ___ bus accident
Social History:
___
Family History:
Father: renal cancer
Mother: congenital heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.3, 113/78, 72, 18, 98RA Wt 79.8kg
GENERAL: Younger than stated age appearing white woman in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP not elevated, no carotid bruits
CARDIAC: RRR, no MRG appreciate, nondisplaced PMI
LUNGS: CTAB, no adventitious breath sounds bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. No femoral bruits. b/l trace ankle edema
L>R which is chronic and per patient secondary to b/l surgeries
(R for polio, L for bus accident). 2+ peripheral pulses, able to
move all extremities
NEURO: A&Ox3, sensation to soft touch intact, ___ strength
throughout
SKIN: No stasis dermatitis, ulcers, or xanthomas. b/l well
healed leg scars
DISCHARGE PHYSICAL EXAM
VS: 98.2, 135-137/75-81, 73, 18, 100%RA Wt 79.8kg
GENERAL: Younger than stated age appearing white woman in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP not elevated, no carotid bruits
CARDIAC: RRR, no MRG appreciate, nondisplaced PMI
LUNGS: CTAB, no adventitious breath sounds bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. No femoral bruits. b/l trace ankle edema
L>R chronic secondary to b/l surgeries (R for polio, L for bus
accident). 2+ peripheral pulses, able to move all extremities
NEURO: A&Ox3, sensation to soft touch intact, ___ strength
throughout
RECTAL: guaic negative
Pertinent Results:
ADMISSION LABS
___ 02:30PM BLOOD WBC-7.0 RBC-4.32 Hgb-13.4 Hct-39.9 MCV-93
MCH-30.9 MCHC-33.5 RDW-13.4 Plt ___
___ 02:30PM BLOOD Neuts-54.7 ___ Monos-5.6 Eos-1.4
Baso-1.0
___ 02:30PM BLOOD Glucose-156* UreaN-16 Creat-0.5 Na-144
K-3.7 Cl-106 HCO3-27 AnGap-15
___ 02:30PM BLOOD Calcium-9.4 Phos-2.6* Mg-1.9
___ 02:41PM BLOOD D-Dimer-750*
___ 02:30PM BLOOD TSH-1.4
DISCHARGE LABS
___ 07:00AM BLOOD WBC-8.1 RBC-4.00* Hgb-12.2 Hct-37.1
MCV-93 MCH-30.6 MCHC-33.0 RDW-13.6 Plt ___
___ 07:00AM BLOOD ___ PTT-29.6 ___
___ 07:00AM BLOOD Glucose-98 UreaN-16 Creat-0.6 Na-142
K-4.1 Cl-105 HCO3-30 AnGap-11
___ 07:00AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9
URINE
___ 02:00PM URINE Color-Straw Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
EKG ___: sinus rhythm, 65bpm, no ST-T wave abnormalities
Telemetry - rare PACs and PVCs, sinus rhythm, HR 61-104
IMAGING
___ CXR
IMPRESSION: No acute intrathoracic process.
___ CTA CHEST
1. No evidence of pulmonary embolus or acute aortic syndrome.
Clear lungs.
___ ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF 65%). Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: New onset AFib, RVR, assess pneumonia or CHF.
FINDINGS: Portable AP upright chest radiograph obtained. The lungs appear
essentially clear bilaterally without signs of pneumonia or CHF. No effusion
or pneumothorax. Cardiomediastinal silhouette appears grossly unremarkable.
Bony structures are intact.
IMPRESSION: No acute intrathoracic process.
Radiology Report
INDICATION: Patient with AFib. Assess for PE.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired images through the chest were obtained at 1.25 mm
slice thickness with intravenous contrast. Coronal and sagittal reformatted
images are provided.
FINDINGS:
The pulmonary artery is well opacified without perfusion defects to suggest
acute pulmonary embolus. The intrathoracic aorta is normal in caliber without
evidence of dissection. The great vessels are unremarkable. Heart is normal
in size with a trace pericardial effusion. There is no hilar or mediastinal
lymphadenopathy. No pathologically enlarged axillary lymph nodes are seen.
Lungs are essentially clear. There is mild centrilobular emphysema, most
pronounced at lung apices. No pleural effusion, focal consolidation or
pneumothorax is seen. No suspicious pulmonary mass or nodule is detected.
There is a punctate pleural-based nodular opacity in the right middle lobe
(2:60). Tracheobronchial tree is patent to subsegmental levels.
This study is not tailored for subdiaphragmatic evaluation, however, partially
imaged upper abdominal visceral organs are unremarkable.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen. An
osseous defect involving the sternum is noted, which is well corticated and
likely chronic.
IMPRESSION:
1. No evidence of pulmonary embolus or acute aortic syndrome. Clear lungs.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: TACHYCARDIA/HYPOTESION
Diagnosed with ATRIAL FIBRILLATION
temperature: nan
heartrate: 138.0
resprate: 18.0
o2sat: nan
sbp: 60.0
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ F with a history of HTN who presented with palpitations and
found to be in new onset Afib with RVR who is currently back
into sinus rhythm.
# Afib with RVR: patient has no documented history of afib
however she has had episodes of similar sensations which is
likely previous episodes of Afib. Lytes and UA were normal.
D-dimer was checked and it was elevated at 750; CTA was obtained
which showed no evidence of PE and clear lungs. She was given
5mg of IV metoprolol in the ED in addition to IV dilt in the
ambulance and returned back into sinus rhythm. She remained in
sinus rhythm with no cardiac symptoms for the rest of her
hospitalization. CHADS2VASc score is 3, thus with a 3.2% stroke
risk. Per discussion with patient regarding risks and benefits
of anticoagulation, decision was made to start warfarin 5mg
daily. She was guaic negative. Teaching regarding
anticoagulation with warfarin was performed with patient prior
to discharge. She will follow up with ___
___ clinic. TTE demonstrated LVEF 65%, LVH, Mild
(1+) aortic regurgitation, trivial mitral regurgitation, and
mild pulmonary artery systolic hypertension. Given mild
pulmonary artery systolic hypertension, will recommend
outpatient sleep study to r/o sleep apnea.
Patient has been off all of her medications including her
beta-blocker which is likely contributing to the afib. She was
restarted on metoprolol succinate 25mg daily and titrated up to
50mg daily.
#Hypertension- blood pressure remained in the 130s range
systolic. She had self-discontinued HCTZ three weeks ago. Given
the increase in metoprolol to 50mg daily, HCTZ was held until
further follow up with PCP.
#Nausea/itching- patient with significant dry heaving and
itching on arrival to the floor in the setting of getting
morphine in the ED. Given zofran for the nausea and her symptoms
resolved by the following day.
CHRONIC ISSUES
#Headache/migraine: has been prescribed metoprolol for this by
PCP. She self-discontinued the medication three weeks ago
because she was feeling better. Restarting metoprolol as per
above. No complaints of headaches during this hospitalization.
#TRANSITIONAL ISSUES
- Increased metoprolol succ from 25mg to 50mg daily for better
rate control
- Started anticoagulation with warfarin 5mg daily given
CHA2DS2VASc score of 3. Will follow up with ___
___ clinic
- Holding HCTZ given BP in 130s systolic and recent increase in
metoprolol
- TTE showed mild pulmonary hypertension; please consider
outpatient sleep study
- CODE: Full code (confirmed)
- CONTACT: Husband ___ ___ |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin / lisinopril / ibuprofen
Attending: ___.
Chief Complaint:
Headaches, right acute on chronic SDH
Major Surgical or Invasive Procedure:
___: Right middle meningeal artery embolization
History of Present Illness:
___ with history of motor vehicle accident ___, had a
non-surgical head CT at that time, read as small chronic SDH vs
hygroma. He additionally had a C7 articulating facet fracture,
which was treated conservatively with hard C-collar. Since then
he has been treated by his primary care physician for
___ syndrome -- however
his headaches and difficulty concentrating have persisted. He
was
last seen on ___ by his PCP, who ordered a repeat head CT,
which he had today. CT revealed new right acute on chronic SDH.
He was sent to the emergency department for neurosurgical
evaluation and management.
Past Medical History:
DIABETES TYPE II
NEUROPATHY
ASPIRIN ALLERGY
HYPERLIPIDEMIA
OBESITY
VARICOSE VEINS
TESTOSTERONE DEFICIENCY
ERECTILE DYSFUNCTION
? OCULAR MIGRAINE
NEPHROPATHY
PSORIASIS
HYPERTENSION
NEPHROLITHIASIS
HYPERPARATHYROIDISM
CORONARY ARTERY DISEASE
? EMPHYSEMA
ACTINIC KERATOSIS
PSORIASIS, VULGARIS
SEBORHEIC KERATOSIS, OTHER
TINEA UNGULUM
COLONIC ADENOMA
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission
------------
Vitals
O: T: 98.1F, BP: 131/65, HR: 85 RR:18, SpO2:100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs full without nystagmus
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
---------------
On Discharge
---------------
T 97.8 HR: 101 BP: 134/76 RR:20 Sat:95%
Bowel Regimen: [x]Yes [ ]No Last BM: PTA
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension intact: [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___
[x]Sensation intact to light touch
Dressing:
Angio Groin Site: [x]Soft, no hematoma [x]Palpable pulses
Dressing removed
Pertinent Results:
Please see OMR for pertinent lab/imaging studies.
Medications on Admission:
ATORVASTATIN - atorvastatin 80 mg tablet. TAKE ONE TABLET BY
MOUTH EVERY DAY
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 50 mg tablet. 1 (One)
tablet(s) by mouth once a day
KETOCONAZOLE - ketoconazole 2 % topical cream. Apply twice a day
to right plantar foot
KETOCONAZOLE - ketoconazole 2 % shampoo. three times a day as
needed for scalp and face rash lather and wash
LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth daily
METFORMIN - metformin ER 750 mg tablet,extended release 24 hr. 3
tablet(s) by mouth once a day
NORTRIPTYLINE - nortriptyline 25 mg capsule. 1 capsule(s) by
mouth daily
SITAGLIPTIN [JANUVIA] - Januvia 100 mg tablet. TAKE ONE TABLET
BY
MOUTH EVERY DAY
TADALAFIL [___] - Cialis 20 mg tablet. ___ tablet(s) by
mouth prior to anticipated sexual activity do not exceed 1 tab
in
24 hrs
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit capsule. 1 capsule(s) by mouth once a day
MULTIVITAMIN - Dosage uncertain - (OTC; mens formula)
PSYLLIUM HUSK [METAMUCIL] - Metamucil 0.52 gram capsule. 4
Capsule(s) by mouth daily - (OTC)
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
Do not exceed 6 tablets/day, do not exceed 3 grams of
Acetaminophen daily
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO QHS
5. Atorvastatin 80 mg PO QPM
6. Hydrochlorothiazide 50 mg PO DAILY
7. Januvia (SITagliptin) 100 mg oral daily
8. Losartan Potassium 25 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 2250 mg PO DAILY
Resume this medication on ___. Nortriptyline 25 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Right acute on chronic Subdural Hematoma
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: ___ year old man with MVC ___ with right sided headache
; subdural hematoma noted// evaluate for interval change of SHD vs hygroma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.1 cm; CTDIvol = 55.6 mGy (Head) DLP =
897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
A moderate-sized acute on chronic subdural hemorrhagic collection along the
right lateral convexity is substantially bigger, measuring up to 2.3 cm in
thickness. Associated mass effects include 6 mm rightward midline shift and
effacement of the right hemispheric sulci and right lateral ventricle. The
suprasellar and ambient cisterns remain patent. No frank herniation is seen.
A prominent retrocerebellar CSF space is again noted, likely representing a
___ cisterna magna.
There is no evidence of large territorial ischemic infarction.
There is no evidence of acute displaced 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:
Moderate-sized acute on chronic subdural hemorrhagic collection along the
right lateral convexity is substantially bigger from ___ and
measures up to 2.3 cm in thickness. This is associated with 6 mm rightward
midline shift. No herniation is seen.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:35 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with c7 fracture with MVC, s/p healing previously
on imaging, now with recurrent neck pain// r/o recurrent injury/ reinjury,
attention to c7. r/o recurrent injury/ reinjury, attention to c7.
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 5.6 s, 22.0 cm; CTDIvol = 26.1 mGy (Body) DLP = 574.0
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) = 634 mGy-cm.
COMPARISON: CT C-spine from ___.
FINDINGS:
Redemonstration of minimally displaced fractures of the left C7 transverse
process and facet. There has been no significant interval bridging or callus
formation.
Alignment remains anatomic.No new fractures are identified.There is no
prevertebral soft tissue swelling.
Multilevel degenerative changes are again noted in the cervical spine, most
severe at C5-6, notable for intervertebral disc height loss and endplate
degenerative changes. There is mild-to-moderate left neural foraminal
narrowing at C6-7.
The imaged thyroid and lung apices are unremarkable. There is no cervical
lymphadenopathy by CT size criteria.
Redemonstration of periapical lucency around the right posterior mandibular
molar (02:27), compatible with sequela of periodontal disease.
IMPRESSION:
1. Redemonstration of minimally displaced fractures of the left C7 facet and
transverse process, without significant interval callus formation or osseous
bridging.
2. No new fractures or malalignment.
3. Moderate degenerative changes of the cervical spine, most pronounced at
C5-6 and C6-7.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with right acute on chronic SDH. possible OR
tomorrow for evacuation// preop ACUTE SUBDURAL HEMATOMA
IMPRESSION:
Compared to chest radiographs ___.
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
and pleural surfaces are normal.
Radiology Report
EXAMINATION: Cerebral angiogram and right middle meningeal artery
embolization for chronic subdural hematoma
Following vessels were selectively catheterized and angiography was performed.
Right internal carotid artery
Right external carotid artery
Middle meningeal artery
Right common femoral artery
INDICATION: A ___ man who was previously healthy was an auto accident
late last year that time CT head performed did not demonstrate any subdural
hematoma appear her since that time he has continued to have headaches and is
not quite up to his normal cognitive ability per the patient. He visited his
PCP in underwent CT head imaging which demonstrated a right convexity chronic
subdural hematoma which measured 20 mm with 6 mm of midline shift. As he is
neurologically doing well and his current symptoms are currently headache is
felt it was safe to proceed with middle meningeal artery embolization.
ANESTHESIA: The patient was maintained under general endotracheal
anesthesia. Please see separately dictated anesthesia documentation. The
patient's hemodynamic and respiratory parameters were monitored continuously
throughout the entirety of the case by a trained and independent observer.
TECHNIQUE: Diagnostic cerebral angiogram, right internal carotid artery,
external carotid artery middle meningeal artery with middle meningeal artery
embolization
COMPARISON: None
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. He was transferred to the fluoroscopic table supine. After smooth
induction of general endotracheal anesthesia, bilateral groins were prepped
and draped in standard sterile fashion. A time-out was performed. The right
common femoral artery was identified using anatomic and radiographic
landmarks. The right common femoral artery was accessed using standard
micropuncture technique after infiltration of local anesthetic. A long 6
___ sheath was introduced, connected to continuous heparinized saline
flush, and secured.
Next a 5 ___ Berenstein 2 diagnostic catheter was introduced. It was
connected to continuous heparinized saline flush as well as the power
injector. It was advanced over 038 glidewire through the aorta into the aortic
arch. The wire was used to select right internal carotid artery. The catheter
was positioned over the wire into the right internal carotid artery. The wire
was removed. Vessel patency was confirmed via hand injection. Standard AP and
lateral views were obtained.
The catheter was withdrawn to the common carotid artery. A roadmap was
performed. The catheter was advanced in the right external carotid artery over
the wire using roadmap guidance. The wire was removed. Vessel patency was
confirmed via hand injection. Standard AP and lateral views were obtained.
The purpose of the diagnostic angiograms was to provide baseline images for
comparison to runs later in the case to rule out thromboembolic complications
as well as understand collateral flow and rule out any anastomosis between the
internal and external carotid artery circulation that would preclude
embolization. They were also used for selection of devices as well as working
angles. The diagnostic portion informed the interventional portion that
followed.
A smart mask was obtained from the previous run. Next an SL 10 microcatheter
loaded with a synchro 2 standard wire was introduced. It was advanced into the
right middle meningeal artery into the frontal branch. The microwire was
removed. Hand injection was performed via the microcatheter to confirm
positioning within the right middle meningeal artery. Next 2.1 Cc of 100-300
embosphere gold particles mixed with 50-50 contrast were injected under
continuous fluoroscopic guidance. Embolization was concluded when there was
sign of reflux and stasis of the contrast and particles. Next 2 mm x 4cm
helical coils were placed into the right middle meningeal artery. The coils
were detached. Next the Microcatheter was withdrawn into the main branch of
the middle meningeal artery. Roadmap angiography was performed. The synchro
2 wire was reintroduced and used to select the parietal branch of the middle
meningeal artery. The catheter was advanced over the wire and the wire was
withdrawn. Next 2.0 Cc of 100-300 embosphere gold particles mixed with 50-50
contrast were injected under continuous fluoroscopic guidance. Embolization
was concluded when there was sign of reflux and stasis of the contrast and
particles. Next a 2 mm x 4 cm helical coils were placed into the parietal
branch. The catheter was withdrawn into the middle meningeal artery origin.
Next a 3 mm by 6 cm helical coil was placed into the middle meningeal artery
origin and detached. The microcatheter was removed. Follow-up angiogram was
performed via the diagnostic catheter in order to confirm satisfactory
embolization of the middle meningeal artery on the right. As well as to rule
out additional embolic material that was not intended. The catheter was
withdrawn into the common carotid artery. Standard AP and lateral views were
obtained in order to rule out thromboembolic complications.
Next the diagnostic catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Perclose. After awakening from
general endotracheal anesthesia, the patient was removed from the fluoroscopy
table and remained at his neurologic baseline without any evidence of
thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Right internal carotid artery: Vessel patency smooth regular. There is
filling of the middle cerebral and anterior cerebral arteries. There is
filling of the ophthalmic artery. No aneurysms or AVMs are identified. There
is no intracranial extracranial anastomoses identified. Normal arterial
capillary and venous phase. There is concavity to the cerebral cortex at the
location of chronic subdural hematoma.
Right external carotid artery: Vessel patency smooth regular. There is
filling of the external carotid artery and its distal branches. There is no
intracranial or extracranial anastomosis identified
Middle meningeal artery: Filling of the middle meningeal artery. There is no
anastomoses with the ophthalmic artery or any intracranial anastomoses.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
Successful right middle meningeal artery embolization
RECOMMENDATION(S):
1. Follow up in clinic in 2 weeks
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with right acute on chronic SDH, POD1 from MMA
embolization.// please eval for change/stability of SDH. please perform at
0700.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head ___ 15:03
FINDINGS:
A moderately sized acute on chronic subdural hemorrhagic collection is again
seen along the right lateral convexity, not significantly changed in size from
the prior exam dated ___. This collection measures up to 2.7 cm
in thickness, similar to prior when accounting for differences in measurement
technique. There is persistent effacement of the right hemispheric sulci and
right lateral ventricle and 5 mm of leftward midline shift. No hydrocephalus.
A more lenticular component of this collection projects over the right frontal
lobe measuring 7 mm in thickness, unchanged from prior. The suprasellar
cistern remains patent. No frank herniation. A prominent CSF space is noted
posterior to the cerebellum, likely ___ cisterna magna.
Patient is now status post embolization of the right middle meningeal artery.
A new very hyperdense component of this extra-axial collection is felt to be
related to artifact from embolization coil. No evidence of interval large
territorial infarction.
No evidence of acute displaced fracture. There is mild thickening of the
anterior ethmoidal air cells. Otherwise the visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
Moderately sized acute on chronic subdural hemorrhagic collection along the
right lateral convexity is stable from the prior exam. There is 5 mm leftward
midline shift, similar to prior.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache, SDH
Diagnosed with Nontraumatic chronic subdural hemorrhage
temperature: 96.2
heartrate: 105.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 88.0
level of pain: 1
level of acuity: 2.0 | On ___, Mr. ___ was admitted from the ED to the ___ for
neurological monitoring and surgical planning. On ___, he was
consented for right middle meningeal artery aneurysm and brought
to the angio suite for the procedure. The procedure was
uncomplicated, please see OMR for separate procedure note. He
was extubated in the angio suite and transferred to the PACU for
post anesthesia monitoring. He remained hemodynamically and
neurologically stable and was transferred to the ___ for
continued monitoring. He was started on a methylprednisone
taper.
On ___ his A-line and foley were removed. His fingerstick
blood sugars were elevated in the 300s and he received RISS.
Metformin was held given the angio contrast load. After
discussion with the patient and his wife and confirmation with
Dr. ___ steroids were stopped as they likely contributed
to his elevated fingersticks and the plan was developed to
discharge today, restart Metformin on ___ (48 hours post angio)
and follow up with his PCP for ongoing management of his
hyperglycemia. Patient and wife expressed readiness and
understanding for discharge with PCP follow up as his blood
sugars have been elevated in the 200-300 range for some time at
home and his PCP is aware and managing. He restarted Januvia
prior to discharge.
At the time of discharge he was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Ativan / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
infected L humerus hardware
Major Surgical or Invasive Procedure:
___ ___ L humerus
History of Present Illness:
This is a ___ year-old gentleman s/p IMN for a midshaft humeral
fracture in ___ with hardware complication with
revision
to another IMN in ___. In ___ he demonstrated signs
of infection and the nail was removed followed with IV
Antibiotics. In ___, he underwent ORIF of the left arm
done
at the ___ in ___. He was seen by his orthopedist
who referred him for further treatment at the ___. He
complains
of ___ days of fevers, chills and worsening arm pain
Past Medical History:
h/o cocaine abuse, polysubstance abuse
depression
appendectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
on admit:
A&O x 3
Calm and comfortable
L UE notable for surgical nonerythematous wound.
Tenderness over the surgical wound.
Arms and forearm compartments soft
No pain with passive motion
Axillary, Radial, Median, Ulnar SILT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Elbow stable to varus, valgus, rotatory stresses.
on d/c:
AFVSS
A&O x 3
Calm and comfortable
incision c/d/i, sutures in place
Arms and forearm compartments soft
No pain with passive motion
Axillary, Radial, Median, Ulnar SILT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Elbow stable to varus, valgus, rotatory stresses.
Pertinent Results:
___ 06:11PM COMMENTS-GREEN TOP
___ 06:11PM LACTATE-2.2*
___ 06:05PM GLUCOSE-111* UREA N-11 CREAT-0.8 SODIUM-133
POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
___ 06:05PM estGFR-Using this
___ 06:05PM CRP-64.0*
___ 06:05PM WBC-6.5# RBC-3.88* HGB-11.5*# HCT-35.0*
MCV-90 MCH-29.6 MCHC-32.9 RDW-15.0
___ 06:05PM NEUTS-64.1 ___ MONOS-14.4* EOS-2.0
BASOS-0.7
___ 06:05PM PLT SMR-LOW PLT COUNT-81*#
___ 06:05PM ___ PTT-30.7 ___
___ 06:05PM SED RATE-40*
Radiology Report
HISTORY: Left arm pain with history of prior operative repair.
TECHNIQUE: Left shoulder, 3 views, left humerus, 2 views, left elbow, 3
views.
COMPARISON: None.
FINDINGS:
The patient is status post ORIF of a fracture involving the mid-diaphysis of
the left humerus transfixed by lateral plate with multiple screws. Several of
the screws appear to have backed out slightly, and there is extensive ___
hardware lucency along with heterotopic ossification. 2 screws are also seen
distally which appear to lie within the soft tissues. The fracture line
remains visible suggesting ___.
There is diffuse demineralization of the osseous structures. No acute
fracture or dislocation is identified clearly within the left shoulder or left
elbow. A joint effusion is not seen within the left elbow. There are mild to
moderate degenerative changes in the left elbow joint. Mild degenerative
spurring is also seen within the left acromioclavicular joint.
IMPRESSION:
Status post ORIF of a left mid diaphyseal humeral fracture with ___ hardware
lucency suggestive of loosening. Several screws also appear to be partially
backed out. No acute fracture or dislocation is clearly visualized.
Radiology Report
INTRAOPERATIVE RADIOGRAPHS OF THE LEFT HUMERUS
CLINICAL INDICATION: ___ male status post hardware removal.
TECHNIQUE: Five intraoperative radiographs of the left humerus were obtained.
___.
FINDINGS:
There has been interval removal of the plate and screws from the left humerus
when compared to the prior exam. There is a comminuted mid diaphyseal
fracture of the left humerus seen. Screw tracks are present throughout the
humerus. There is heterotopic ossification about the fracture site. The
fracture site is non-united.
IMPRESSION: Status post hardware removal for comminuted left mid diaphyseal
humeral fracture with nonunion of the fracture fragments. Please refer to the
intraoperative report for further details.
Radiology Report
HISTORY: Evaluation of PICC placement.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Multiple chest radiographs the most recent on ___.
FINDINGS:
The right-sided PICC is seen with its tip terminating in the middle SVC.
The lungs are clear. The cardiomediastinal silhouette and hilar contours are
normal. The pleural surfaces are normal without effusion or pneumothorax.
IMPRESSION:
Right-sided PICC seen with its tip terminating in the mid SVC. No evidence of
complication.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, L Shoulder pain
Diagnosed with JOINT PAIN-SHLDER
temperature: 100.0
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 168.0
dbp: 80.0
level of pain: 7
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have infected L humerus hardware and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for removal of L humerus hardware,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the LUE extremity, and will
be discharged on ASA 325 x2wks for DVT prophylaxis. The patient
will follow up in two weeks per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ibuprofen
Attending: ___.
Chief Complaint:
Angioedema
Major Surgical or Invasive Procedure:
___: Fiberoptic exam by ENT.
___: Fiberoptic exam by ENT.
History of Present Illness:
___ w/hx of likely acquired angioedema, recurrent facial
swelling most recently admitted from ___ - ___ for the same,
endometriosis, IBS, hypothyroidism, bipolar disorder, multiple
abdominal surgeries who presented on ___ to ___ ___. She
notes she was fine until this morning when she woke up with
tongue numbness, floor of mouth fullness, and anterior neck
swelling and a sensation of being unable to breathe.
Most recent hospital admission required icatibant, steroids, and
Benadryl and MICU surveillance overnight, but did not require
intubation for airway protection.
In ___ initial VS: 98.6 94 137/90 20 100% RA
___ scope exam apparently revealed glottic edema.
Patient evaluated by ENT; fiberoptic exam pertinent for
Hypopharynx: Watery edema of vallecula and L piriform sinuses,
effaced post-cricoid area; no erythema; no significant pooling
of secretions
Larynx: Significant watery edema of lingual epiglottic surface,
L>R A-E folds with effacement of L piriform, and L false VF
Patient given:
___
IV MethylPREDNISolone Sodium Succ 125 mg
IV DiphenhydrAMINE 25 mg
IV LORazepam .5 mg x 2
Oxymetazoline 1 SPRY
SC Icatibant 30 mg
___
Escitalopram Oxalate 10 mg
Lithium Carbonate 600 mg
Ranitidine 300 mg
IV Dexamethasone 10 mg q8hr
Aspirin 81 mg ___
___ Amoxicillin-Clavulanic Acid ___ mg
IVF ___ ( 1000 mL ordered)
Given c/f angioedema, originally planned for MICU admit.
Patient boarded in the ___ overnight. ENT re-evaluated on ___
with significant improvement from prior. Patient determined safe
for inpatient floor admission with continuous O2 monitoring.
On arrival to the floor, patient reports that her submental
fullness sensation is decreasing. Voice continues to be hoarse,
but also improving throughout the day. Requesting water to
drink. No problems with pill intake. Cannot think of any
exposures at home. She does have two cats and one dog that she
has had for many years. Denies fever. Has been on Augmentin for
sinusitis, no maxillary tenderness or drainaing.
Past Medical History:
-ANGIOEDEMA
-BIPOLAR DISORDER (on lithium)
-ANXIETY
-HYPOTHYROIDISM
-ASTHMA
-OBESITY
-SLEEP APNEA-not on CPAP currently
-IRRITABLE BOWEL SYNDROME
-ENDOMETRIOSIS
-ANGIOEDEMA SECONDARY TO ACQUIRED C1 ESTERASE INHIBITOR
DEFICIENCY: HOSPITALIZED IN ___, AND IN ___
-Angioedema: with low C4, C1INH, and C1Q level; thought to be
acquired rather than hereditary angioedema, given age of onset
of symptoms ___ years) and no clear family history. Followed by
Dr. ___ at ___
Social History:
___
Family History:
No history consistent with hereditary angioedema.
Father: CAD/PVD; Cancer
Mother: Cancer; ___ Disease; Macular degeneration; Allergic
to bees and wasps
Paternal Aunt: Cancer - ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.7 PO 157 / 83 79 19 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 97.3, 132/82, 66, 18, 99% on RA.
General: Resting comfortably.
HEENT: Sclerae anicteric, moist mucous membranes, oropharynx
clear, neck supple. No stridor, no lymphadenopathy.
Lungs: Breathing non-labored, no wheezing appreciated.
Cardiovascular: RRR, S1 and S2 present.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding.
Ext: Warm, well perfused, no edema.
Neuro: CNII-XII grossly intact, moving all extremities equally
Pertinent Results:
ADMISSION LABS
==============
___ 01:39AM BLOOD WBC-9.6 RBC-4.56# Hgb-12.6# Hct-40.6#
MCV-89 MCH-27.6 MCHC-31.0* RDW-13.4 RDWSD-43.6 Plt ___
___ 01:39AM BLOOD Neuts-80.8* Lymphs-17.5* Monos-0.6*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.73*# AbsLymp-1.68
AbsMono-0.06* AbsEos-0.01* AbsBaso-0.02
___ 01:39AM BLOOD ___ PTT-24.6* ___
___ 01:39AM BLOOD Glucose-272* UreaN-14 Creat-1.1 Na-139
K-4.2 Cl-101 HCO3-21* AnGap-21*
___ 01:39AM BLOOD ALT-13 AST-13 AlkPhos-90 TotBili-0.2
___ 01:39AM BLOOD Albumin-4.4
___ 05:40AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.4
DISCHARGE LABS
==============
___ 05:40AM BLOOD WBC-9.6 RBC-3.57* Hgb-10.0* Hct-32.1*
MCV-90 MCH-28.0 MCHC-31.2* RDW-13.4 RDWSD-44.0 Plt ___
___ 05:40AM BLOOD Glucose-120* UreaN-24* Creat-1.0 Na-141
K-4.0 Cl-107 HCO3-19* AnGap-19
___ 05:40AM BLOOD ALT-12 AST-10 LD(LDH)-171 AlkPhos-69
TotBili-0.2
___ 05:40AM BLOOD TotProt-5.4* Calcium-9.2 Phos-3.5 Mg-2.3
Iron-97
MALIGNANCY WORK-UP
==================
___ 05:40AM BLOOD calTIBC-274 VitB12-320 Folate-13
Hapto-200 Ferritn-219* TRF-211
___ 05:40AM BLOOD Iron-97
___ 05:40AM BLOOD Ret Aut-1.6 Abs Ret-0.06
___ 05:40AM BLOOD PEP-ABNORMAL B ___ FreeLam-12.9
Fr K/L-1.49 b2micro-2.9* IgG-542* IgA-54* IgM-33* IFE-MONOCLONAL
ANGIOEDEMA EVALUATION
=====================
___ 01:39AM BLOOD C3-146 C4-<2*
ESR
===
___ 05:40AM BLOOD ESR-11
CRP
===
___ 01:39AM BLOOD CRP-32.5*
URINE STUDIES
============
___ 12:00PM URINE Color-Straw Appear-Clear Sp ___
___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 12:00PM URINE RBC-<1 WBC-11* Bacteri-NONE Yeast-NONE
Epi-<1
UPEP
====
___ 12:00PM URINE U-PEP-NO PROTEIN
MICROBIOLOGY
============
___: C. DIFFICILE: NEGATIVE.
___: URINE CULTURE: NO GROWTH (FINAL)
IMAGING
=======
___: SKELETAL SURVEY
IMPRESSION:
No focal lytic or sclerotic bone lesions suggestive of myeloma.
Degenerative changes as described.
___: CT CHEST WITH CONTRAST
IMPRESSION: No evidence of malignant disease in the thorax. No
lymphadenopathy. No pleural effusions.
___: CT ABDOMEN AND PELVIS WITH CONTRAST
IMPRESSION:
1. No acute abdominopelvic pathology or malignancy.
2. Mild splenomegaly.
3. 2.1 cm right lower pole renal cyst now demonstrating
hyperdensity along the anterior wall, possibly hemorrhage,
however given the interval change,
warrants follow-up. Attention on follow-up imaging or further
evaluation with renal ultrasound is recommended.
RECOMMENDATION(S): Attention on follow-up of the right lower
pole renal
cystic lesion or renal ultrasound to further evaluate the
lesion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Lithium Carbonate 600 mg PO QHS
4. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
2. Icatibant 30 mg SC ONCE Duration: 1 Dose
Dose should be administered by subcutaneous injection given over
30 seconds in the abdominal area.
RX *icatibant [Firazyr] 30 mg/3 mL 3 mL SC episodes of severe
angioedema Disp #*2 Syringe Refills:*0
3. Lithium Carbonate 600 mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
-Acquired C1 Esterase deficiency complicated by angioedema.
-Normocytic Anemia
-Bipolar Disorder
-Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SKELETAL SURVEY (INCLUD LONG BONES)
INDICATION: ___ year old woman with concern for lymphoproliferative disorder
with IgG monoclonal protein. // Please perform skeletal survey to assess for
evidence of myeloma.
TECHNIQUE: 12 images obtained as part of a skeletal survey
COMPARISON: CT torso ___
FINDINGS:
Calvarium: No focal lytic or sclerotic bone lesions.
Bilateral humeri: No focal lytic or sclerotic bone lesions seen.
Thoracic spine: No focal lytic or sclerotic bone lesions. Mild degenerative
changes are seen in the thoracic spine.
Lumbar spine: There are rudimentary ribs at T12. There are then 5
non-rib-bearing lumbar-type vertebrae. There is preservation of the normal
lumbar lordosis. There is moderate multilevel degenerative disc disease most
prominent at L3-L4. No fracture seen. No destructive lytic or sclerotic bone
lesions.
Pelvis: There degenerative changes at the symphysis pubis. No fracture or
dislocation seen. No focal lytic or sclerotic bone lesion seen.
Bilateral femurs: Mild degenerative changes of the bilateral knee joints. No
focal lytic or sclerotic bone lesions.
IMPRESSION:
No focal lytic or sclerotic bone lesions suggestive of myeloma. Degenerative
changes as described.
Radiology Report
INDICATION: ___ year old woman with acquired angioedema with concern for
lymphoproliferative process. // Please evaluate for lymphadenopathy/evidence
of underlying malignancy. Please perform with and without 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) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.5 s, 71.4 cm; CTDIvol = 16.2 mGy (Body) DLP =
1,157.1 mGy-cm.
Total DLP (Body) = 1,170 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: 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 surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is mildly enlarged measuring 13.5 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are normal in size and enhancement bilaterally. Normal
contrast excretion. Millimetric hypodensities bilaterally are too small to
characterize. A dominant cystic lesion at the lower pole of the right kidney
measures 2.1 cm, unchanged in size since the prior study however there is mild
hyperdensity along the anterior wall of the lesion, possibly interval
hemorrhage.
GASTROINTESTINAL: The distal esophagus, stomach, and small bowel are normal in
caliber. The appendix is not visualized. There are multiple descending
colonic and sigmoid diverticula, without evidence of active inflammation. No
mesenteric edema or free fluid.
PELVIS: The urinary bladder is relatively decompressed however appears within
normal limits. There is no pelvic free fluid. The uterus is not visualized.
There are no adnexal masses.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Degenerative changes are seen in the lumbar spine.
SOFT TISSUES: There is a fat containing paraumbilical hernia and to the left
of midline (2:83).
IMPRESSION:
1. No acute abdominopelvic pathology or malignancy.
2. Mild splenomegaly.
3. 2.1 cm right lower pole renal cyst now demonstrating hyperdensity along the
anterior wall, possibly hemorrhage, however given the interval change,
warrants follow-up. Attention on follow-up imaging or further evaluation with
renal ultrasound is recommended.
4. Please see a separate report discussing findings within the chest.
RECOMMENDATION(S): Attention on follow-up of the right lower pole renal
cystic lesion or renal ultrasound to further evaluate the lesion.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Concern for lymphoproliferative disease.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: Given in abdominal CT report.
COMPARISON: No comparison.
FINDINGS:
Mildly enlarged thyroid. No supraclavicular infraclavicular or axillary
lymphadenopathy. No enlarged lymph nodes in the mediastinum. Several of the
normal sized mediastinal lymph nodes (2, 20) are calcified. Normal appearance
of the large mediastinal vessels. No substantial coronary calcifications, no
valvular calcifications. No pericardial effusion. No hiatal hernia. Normal
appearance of the posterior mediastinum. Status post cholecystectomy. Mild
splenomegaly Detailed abdominal findings are described in the abdominal CT
report. No osteolytic lesions at the level of the ribs, the sternum, or the
vertebral bodies. Mild degenerative vertebral disease. No vertebral
compression fractures. Mild paraseptal changes along the right minor fissure
(4, 106) and at the level of the right hilus. Non characteristic cystic
changes in the right lower lobe (4, 158). Minimal scarring in the left lower
lobe (4, 180). No pleural thickening, no pleural effusions.
IMPRESSION:
No evidence of malignant disease in the thorax. No lymphadenopathy. No
pleural effusions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Tongue swelling
Diagnosed with Angioneurotic edema, initial encounter, Oth places as the place of occurrence of the external cause
temperature: 98.6
heartrate: 94.0
resprate: 20.0
o2sat: 100.0
sbp: 137.0
dbp: 90.0
level of pain: 0
level of acuity: 3.0 | ___ w/hx of likely acquired angioedema, recurrent facial
swelling presenting with recurrent laryngeal swelling, now
improving with steroids and icatibant.
# Acquired C1 Esterase Inhibitor Deficiency: Patient has history
of acquired C1 esterase inhibitor with resultant angioedema with
hospitalizations secondary to the angioedema. Patient has been
evaluated as an outpatient with Allergy at ___
___ (Dr. ___. Outpatient evaluation
showed C1 inhibitor level of 8, C4 complement <10, C1Q
complement <50, consistent with acquired C1 esterase inhibitor
deficiency.
Presented with angioedema. Received methylprednisolone,
diphenhydramine, and icatibant in the Emergency Department with
improvement of symptoms. As an outpatient, patient had an IgG
kappa monoclonal protein detected (although quantification not
performed).
Patient evaluated by ENT with serial fiberoptic examinations
with improvement of angioedema. She received 5 day course of
prednisone and plan for 14 day course of augmentin.
As there is association with MGUS, myeloma, lymphoma,
Hematology/Oncology was consulted for evaluation. As part of the
evaluation, patient had CBC with normocytic anemia. Differential
on the CBC unremarkable. LFT's normal. C4 was <2 with C3 of 146.
SPEP showed abnormal band in gamma region with IgG kappa of 2%.
B2 macroglobulin was 2.9 with immunoglobulins with IgG 542, IgA
54, IgM 33.
CT chest showed "no evidence of malignant disease in the thorax.
No lymphadenopathy, No pleural effusions." CT Abdomen/Pelvis
showed "no acute abdominopelvic pathology or malignancy. Mild
splenomegaly." A skeletal survey was performed which showed no
focal lytic or sclerotic bone lesions suggestive of myeloma.
There was discussion regarding bone marrow biopsy between the
Heme/Onc team at ___ and the ___ Oncology team. As patient at
risk for developing angiodemea in the setting of tissue damage
(as in case of possible bone marrow biopsy), thorough discussion
took place regarding risks/benefits of bone marrow biopsy. After
discussion between ___ Heme/Onc, ___ Oncology, and patient,
decision was made to defer bone marrow biopsy to outpatient,
with plan to have scheduled bone marrow biopsy in a procedural
center with premedication prior to procedure. Patient was in
full agreement with this plan and did not sign a consent for the
bone marrow biopsy given risks associated with it.
A note was left by Allergy regarding pre-medication if a bone
marrow biopsy were to be performed. The note is located in OMR
on ___ and states:
1) Give Berinert 20 units/kg 30 minutes prior to the procedure
2) Can also consider administration of methylprednisolone,
diphenhydramine prophylactically as well but these are not
effective for C1 inhibitor deficiencies.
3) Standard anesthesia drugs can be used as would not be
exacerbating agents (as compared to patients with histaminergic
angioedema)
She is currently in the process of receiving prior approval for
Icatibant as an outpatient and will follow up with her
Allergist. A prescription for this medication was given to her
at the time of discharge, as her Allergist had submitted a prior
authorization on her behalf.
At the time of discharge, UPEP was pending and flow cytometry on
peripheral smear pending.
# Normocytic Anemia: Iron studies unremarkable with serum iron
of 97, TIBC 274, ferritin 219. As part of additional evaluation,
Haptoglobin normal, vitamin B12 320, folic acid 13.
# Bipolar Disorder: Continued on lithium carbonate 600 mg PO
daily. Continued escitalopram 20 mg PO daily.
# Hypothyroidism: Continued levothyroxine 25 mcg PO daily.
TRANSITIONAL ISSUES
===================
[] continue Augmentin with end date ___.
[] Please follow up UPEP, and flow cytometry as an outpatient.
[] Please arrange bone marrow biopsy as an outpatient (pending
repeat discussion with heme/onc as outpatient), with plan for
need to be performed in a procedural center with possible
anesthesia back-up given concern for possible development of
angioedema with bone marrow biopsy.
[] Prior to the bone marrow biopsy, patient will likely need to
be pre-medicated prior to the procedure. Input from patient's
outpatient Allergist, Dr. ___ would be beneficial. If
he is unable to be reached, a note regarding pre-treatment was
placed by Dr. ___ of ___ on ___ in ___.
[] Please note that on patient's CT Abdomen and pelvis without
contrast, patient was noted to have a "2.1 cm right lower pole
renal cyst, now demonstrating hyperdensity along the anterior
wall, possibly hemorrhage, however, given the interval change,
warrants follow-up." Please perform Renal Ultrasound as an
outpatient.
[] Follow up with Dr. ___ Ears/Nose/Throat given recurrent
episodes of presumed
angioedema. Call ___ to schedule an appointment ___
weeks after discharge
[] Patient will require outpatient follow up with ___ Heme/Onc
who specialize in Heme Malignancies.
[] Patient should have evaluation of splenomegaly as an
outpatient in correlation with evaluation by ___ Heme/Onc.
[] Please ensure up to date on mammogram and colonoscopy as
outpatient for routine healthcare maintenance.
[] Contact Information: ___ ___ (friend) |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
Reduction of gastric volvulus
GJ tube placement
History of Present Illness:
___ yo F, living in long term care facility ___ dementia and
severe weakness (question of MS vs. muscular dystrophy, history
not clear), developed 1 episode of coffee ground emesis at 2am
today. Her boyfriend last night at 10pm had noted that she had
"foam around her mouth" and that her upper extremities seemed
cold and clammy. After the emesis she was transferred to OSH,
and
a diagnosis of massive upper GI bleed was was presumed, based on
her coffee ground emesis, tachycardia, and hypotension.
Therefore
she received 1.7 L IVF, 2 u PRBC, 1 u FFP, and antibiotics. CT
showed massively dilated stomach with stomach in the chest,
transverse colon in the chest. She was transferred here for
management of gastric volvulus with hiatal hernia. En route she
developed increasing respiratory distress and was placed on
BiPAP.
ROS: UTO, dementia. Currently reports "pain in my bum", denies
any chest or abd pain. Reports trouble breathing.
Past Medical History:
hypercalcemia, metabolic encephalopathy
severe global weakness, MS vs muscular dystrophy of some sort?
dementia
DVT/PE ___, on xarelto
osteoarthritis (knees)
CKD, baseline Crt 1.01
dysphagia, puree diet
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
===================
Vitals: afebrile, tachy 130s, SBP 130s. tachypnic ___, BiPAP
transitioned to face tent. Sats >90%
GEN: Alert
HEENT: No scleral icterus, dentures, coffee ground emesis
material in mouth
CV: tachycardic, No M/G/R
PULM: coarse wheezes/rhochi bilaterally.
ABD: Soft, nondistended, nontender, no rebound or guarding,
no palpable masses
DRE: poor tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused.
Neuro: very week. 1+ strength bilateral upper extremities. No
movement in LEs. Unclear if sensation is intact in LEs.
Discharge Physical Exam:
===================
Vitals: T98.3 BP153/84 HR103 RR17 O2%99Ra
GEN:AxOx1. Confused but back to baseline. Asking about her
husband
___. PEERLA. No tongue deviation. Oral mucosa moist with
no teeth
CV: Normal S1/S2. No murmurs. No gallops
PULM: CTAB. No crackles. No dullness to percussion
ABD: Soft. Nondistended. Nontender. Midline laparotomy scar well
healed with staples removed.
Extremities: Thin and weak. No
Neuro: Very weak, ___ strength in lower extremities and upper
extremities. Unclear if sensation is intact. Resting bilateral
tremor
Pertinent Results:
ADMISSION LABS:
=============
___ 10:21AM BLOOD WBC-18.7* RBC-5.81* Hgb-17.3* Hct-54.0*
MCV-93 MCH-29.8 MCHC-32.0 RDW-19.4* RDWSD-64.5* Plt ___
___ 10:21AM BLOOD Neuts-86.2* Lymphs-6.0* Monos-6.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-16.08* AbsLymp-1.12*
AbsMono-1.22* AbsEos-0.01* AbsBaso-0.05
___ 03:07PM BLOOD ___ PTT-31.3 ___
___ 10:21AM BLOOD Glucose-298* UreaN-28* Creat-1.5* Na-140
K-7.9* Cl-106 HCO3-12* AnGap-21*
___ 10:21AM BLOOD ALT-26 AST-75* AlkPhos-48 TotBili-2.2*
___ 10:21AM BLOOD Lipase-548*
___ 10:21AM BLOOD cTropnT-0.03*
___ 10:21AM BLOOD Albumin-3.8 Calcium-11.9* Phos-4.7*
Mg-2.5
___ 10:21AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 10:45AM BLOOD Type-ART pO2-153* pCO2-32* pH-7.32*
calTCO2-17* Base XS--8
___ 10:33AM BLOOD Lactate-7.7*
___ 11:21AM BLOOD K-4.4
___ 10:45AM BLOOD O2 Sat-98
___ 04:49PM BLOOD freeCa-1.24
___ 10:21AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 10:21AM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 10:21AM URINE RBC-22* WBC->182* Bacteri-MOD* Yeast-NONE
Epi-3
___ 10:21AM URINE CastHy-22*
___ 10:21AM URINE AmorphX-RARE*
___ 10:21AM URINE WBC Clm-MANY* Mucous-FEW*
___ 10:21AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
INTERIM LABS:
===========
___ 07:35PM BLOOD ___ PTT-28.1 ___
___ 01:15AM BLOOD ___ PTT-26.9 ___
___ 01:50AM BLOOD ___ PTT-33.0 ___
___ 09:00AM BLOOD ___
___ 07:46AM BLOOD ___ PTT-28.4 ___
___ 06:30AM BLOOD ___ PTT-29.5 ___
___ 07:20AM BLOOD Glucose-70 UreaN-19 Creat-1.0 Na-145
K-5.4 Cl-108 HCO3-25 AnGap-12
___ 01:15AM BLOOD ALT-20 AST-32 AlkPhos-29* TotBili-1.0
___ 07:35PM BLOOD CK-MB-24* cTropnT-0.02*
___ 01:15AM BLOOD CK-MB-12* cTropnT-0.01
___ 06:00AM BLOOD CK-MB-1 cTropnT-0.02*
___ 03:21AM BLOOD CK-MB-1 cTropnT-0.02*
___ 07:20AM BLOOD TSH-2.9
___ 12:47PM BLOOD Lactate-5.3*
___ 04:49PM BLOOD Glucose-209* Lactate-4.4* Na-135 K-5.3*
Cl-107
___ 05:41PM BLOOD Glucose-160* Lactate-4.3* K-4.3
___ 01:31AM BLOOD Lactate-3.1*
___ 08:59AM BLOOD Lactate-1.9
___ 09:50AM BLOOD WBC-11.6* RBC-3.61* Hgb-10.9* Hct-34.6
MCV-96 MCH-30.2 MCHC-31.5* RDW-17.2* RDWSD-60.7* Plt ___
___ 03:21AM BLOOD WBC-11.9* RBC-3.69* Hgb-10.8* Hct-34.5
MCV-94 MCH-29.3 MCHC-31.3* RDW-17.2* RDWSD-59.2* Plt ___
___ 06:05AM BLOOD Glucose-136* UreaN-19 Creat-1.1 Na-145
K-2.8* Cl-101 HCO3-35* AnGap-9*
___ 06:48AM BLOOD Glucose-95 UreaN-17 Creat-1.0 Na-145
K-3.6 Cl-100 HCO3-33* AnGap-12
DISCHARGE LABS:
==============
___ 06:13AM BLOOD WBC-10.3* RBC-3.25* Hgb-9.7* Hct-31.4*
MCV-97 MCH-29.8 MCHC-30.9* RDW-17.2* RDWSD-61.1* Plt ___
___ 06:05AM BLOOD WBC-10.1* RBC-3.31* Hgb-10.2* Hct-32.2*
MCV-97 MCH-30.8 MCHC-31.7* RDW-17.0* RDWSD-60.6* Plt ___
___ 01:36AM BLOOD Neuts-79.0* Lymphs-15.3* Monos-4.8*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-16.26* AbsLymp-3.16
AbsMono-0.98* AbsEos-0.01* AbsBaso-0.04
___ 06:13AM BLOOD Plt ___
___ 06:13AM BLOOD Glucose-123* UreaN-26* Creat-1.1 Na-144
K-4.5 Cl-106 HCO3-27 AnGap-11
___ 06:05AM BLOOD Glucose-136* UreaN-19 Creat-1.1 Na-145
K-2.8* Cl-101 HCO3-35* AnGap-9*
___ 06:13AM BLOOD Albumin-3.0* Calcium-11.9* Phos-2.2*
Mg-2.4
___ 06:05AM BLOOD Calcium-12.4* Phos-1.8* Mg-2.3
MICROBIOLOGY:
============
___ 10:21 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 10:21 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:28 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:48 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 3:52 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 8:44 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 3:03 pm PLEURAL FLUID PLEURAL 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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING/STUDIES:
==============
CXR ___:
Large hiatal hernia.
CXR ___:
Enteric tube terminates in expected location of the stomach.
Unchanged small
bilateral pleural effusions. New right lower lobe collapse.
CXR ___:
Lungs continue to be low volume with moderate bilateral
effusions and mild to
moderate interstitial edema slightly worsened since the prior
study.
Cardiomediastinal silhouette is stable. No pneumothorax is
seen.
CXR ___:
Compared to chest radiographs ___ through ___.
Moderate bilateral pleural effusions and severe basal
atelectasis have
worsened. Previous enlargement of the cardiac silhouette and
mediastinal
vascular engorgement have resolved. Pulmonary vasculature is
mildly engorged
and edema is minimal if any. No pneumothorax.
CTAP W/CON ___:
1. Large pocket of fluid measuring at least 9 cm surrounding the
distal
esophagus at the site of the prior large hiatal hernia.
Nonspecific
postoperative pockets of loculated fluid in the lesser sac.
2. Interval postoperative changes in the stomach, however a
large
paraesophageal hernia remains and there is improved gastric
distension post
percutaneous gastrojejunostomy. The intrathoracic portion of
stomach is
mildly distended with oral contrast.
3. Evolving left retroperitoneal hematoma.
4. Endometrial thickening. This could be further evaluated
with nonemergent
pelvic ultrasound
CT CHEST W/CON ___:
1. Interval decrease in the gastric distension with persistent
hiatus hernia
containing significantly distended intrathoracic stomach.
2. Large rim enhancing loculated low-attenuation fluid
collection in the right
pleural space measuring upwards of 8.4 x 7.2 x 9.4 cm.
3. Significant atelectasis involving both lower lobes and
lingula. No
definite pneumonia. Intermediate attenuation bilateral pleural
effusions.
CT CHEST W/CON ___:
1. Re-demonstrated large pockets of fluid measuring up to 9 cm,
related to the
recent surgery. These probably represent postsurgical seromas.
However,
given increased rim of enhancement, superimposed infection is
highly
suspected.
2. Unchanged moderate size pleural effusions bilaterally with
bilateral lower
lobe collapse.
3. Smaller left paracolic organized fluid collection.
CTAP W/CON ___:
1. Re-demonstrated large pockets of fluid measuring up to 9 cm,
related to the
recent surgery. These probably represent postsurgical seromas.
However,
given increased rim of enhancement, superimposed infection is
highly
suspected.
2. Unchanged moderate size pleural effusions bilaterally with
bilateral lower
lobe collapse.
3. Smaller left paracolic organized fluid collection.
CXR ___:
Interval decrease of left pleural effusion status post drainage.
No
pneumothorax. Stable small right pleural effusion. Persistent
distention of
the stomach.
CXR ___:
Right pleural pigtail catheter remains in similar position. A
small to
moderate right-sided effusion is similar to minimally increased.
There is
associated atelectasis of the right lung base. Lung volumes are
lower than
the preceding examination. In addition, there is intrathoracic
stomach with
greater distention of the gastric bubble, and obstruction cannot
be excluded.
There is also compressive atelectasis of the left lung base.
There is
worsening vascular congestion with possible trace edema. No
other gross dense
consolidation is seen. There is no pneumothorax.
Cardiomediastinal
silhouette appears unchanged, though is difficult to fully
characterize given
the intrathoracic stomach and associated mass effect.
___ 06:13AM BLOOD WBC-10.3* RBC-3.25* Hgb-9.7* Hct-31.4*
MCV-97 MCH-29.8 MCHC-30.9* RDW-17.2* RDWSD-61.1* Plt ___
Final Report
CXR, ___
IMPRESSION:
Compared to the prior study, aeration of the right lung base has
improved.
There remains a small left-sided pleural effusion with adjacent
compressive
atelectasis which is mainly from a massive hiatal hernia. The
intrathoracic
stomach appears less distended than the prior examination.
Heart remains
moderately enlarged. Upper enteric tube is been removed. No
new
consolidation is seen. There is no pneumothorax.
Medications on Admission:
Alendronate 70mg - Please resume only after primary care
provider appointment
___ 25mg-Discontinued and started on amolodipine instead
(see below)
Xarelto 25mg-restart at rehab, see below)
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN Thick secretions
3. amLODIPine 5 mg PO DAILY Hypertension
4. Lidocaine 5% Ointment 1 Appl TP DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN Nausea Duration: 1 Dose
7. Pantoprazole 40 mg PO Q24H
8. Rivaroxaban 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Thiamine 100 mg PO DAILY Duration: 5 Doses
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dementia
Gastric volvulus
GJ tube placement
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Scratch ___ with sob pna?
TECHNIQUE: Single portable view of the chest
COMPARISON: Correlation is made to CT scan of the chest abdomen and pelvis
performed at an outside institution from ___.
FINDINGS:
Abnormality seen overlying the mediastinum with partially air-filled structure
compatible with known large hiatal hernia. This obscures detailed evaluation
of the adjacent lungs and the cardiac silhouette. Lung apices are clear.
IMPRESSION:
Large hiatal hernia.
Radiology Report
INDICATION: Scratch ___ with ng tube placement ng?
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from earlier the same day from 10:17.
FINDINGS:
There has been interval placement of an enteric tube with tip projecting over
the left aspect of the mid mediastinum, overlying patient's hernia. No other
change.
Radiology Report
INDICATION: ___ year old woman s/p reduction of gastric volvulus in hiatal
hernia// check ETT, evaluate for hemo/pneumothorax
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the endotracheal tube projects over the mid thoracic trachea.
There are layering bilateral pleural effusions with subjacent atelectasis. No
pneumothorax is identified. The appearance of the cardiac silhouette is
unchanged. The previously seen large hiatal hernia is not as conspicuous on
the current radiograph.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hiatal hernia s/p ex-lap with reduction of
hernia, currently intubated// ? interval change
IMPRESSION:
In comparison with the study ___, the the tip of the endotracheal tube
is unchanged, though it is again pointing directly toward the right lateral
wall. Cardiomediastinal silhouette is stable. The hazy opacification at the
left base with obscuration hemidiaphragm is again consistent with pleural
fluid and underlying compressive atelectasis. Less prominent changes are seen
at the right base.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with need for NG tube// NG tube placement
COMPARISON: Chest radiographs ___ through ___
FINDINGS:
Portable upright AP view of the chest provided.
New enteric tube terminates in the expected location the stomach.
Endotracheal tube terminates approximately 2.0 cm above the level of the
carina. Small to moderate bilateral pleural effusions are grossly stable
compared to prior. Increased opacification of the right base likely reflects
new right lower lobe collapse. Hiatal hernia is partially imaged. No
pneumothorax. Cardiomediastinal silhouette is unchanged
IMPRESSION:
Enteric tube terminates in expected location of the stomach. Unchanged small
bilateral pleural effusions. New right lower lobe collapse.
Radiology Report
INDICATION: ___ year old woman with leukocytosis, intubated// Pneumonia,
tubeplacement
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs continue to be low volume with moderate bilateral effusions and mild to
moderate interstitial edema slightly worsened since the prior study.
Cardiomediastinal silhouette is stable. No pneumothorax is seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pulmonary edema on prior CXR s/p diuresis,
now extubated// ? interval change ? interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild to moderate pulmonary edema has changed in distribution, but not in
overall severity. Severe left lower lobe atelectasis and moderate bilateral
pleural effusions are unchanged. No pneumothorax. Large cardiac silhouette
is stable, obscured by the intrathoracic portion of the upper stomach which is
not nearly as dilated today as it was on ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ F w/ h/o dementia, severe weakness, on Xarelto for DVT/PE,
p/w gastric volvulus s/p reduction of volvulus and GJ tube placement, now w/
AMS, desats while sleeping// Please eval for interval change Please eval
for interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate bilateral pleural effusions and severe basal atelectasis have
worsened. Previous enlargement of the cardiac silhouette and mediastinal
vascular engorgement have resolved. Pulmonary vasculature is mildly engorged
and edema is minimal if any. No pneumothorax.
The previous, distended intrathoracic stomach is no longer clearly identified.
Radiology Report
INDICATION: ___ p/w gastric volvulus now ___ s/p gastric volvulus reduction
now with rising leukocytosis.// Evaluate for abscesses, perforations or any
other acute concerns
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 4.1 s, 54.2 cm; CTDIvol = 19.7 mGy (Body) DLP =
1,068.2 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP =
16.8 mGy-cm.
Total DLP (Body) = 1,087 mGy-cm.
COMPARISON: Outside CT without contrast ___.
FINDINGS:
LOWER CHEST: There is mild dilatation of the distal esophagus. A large
paraesophageal hiatal hernia remains, however portions of the stomach have
been reduced into the abdomen. There are new small bilateral pleural
effusions with bibasilar segmental compressive atelectasis. There is a
discrete pocket of fluid measuring at least 9 cm surrounding the distal
esophagus, separate from the pleural effusions and atelectatic lung (series 2,
image 9).
ABDOMEN:
HEPATOBILIARY: The liver is unremarkable. No biliary ductal dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas is unremarkable.
SPLEEN: The spleen is unremarkable.
ADRENALS: Mild thickening of the adrenal glands is again noted.
URINARY: The kidneys are unremarkable except for a few hypodense lesions too
small to characterize. No hydronephrosis.
GASTROINTESTINAL: There is improved distension of the stomach post partial
reduction into the abdomen. A large paraesophageal hiatal hernia remains and
the intrathoracic portion of the stomach is mildly distended with oral
contrast. There is mild narrowing of the stomach at the level of the
diaphragm, however the distal stomach in the abdomen is not dilated. A
percutaneous gastrojejunostomy tube is in appropriate position without
surrounding fluid collection.
There are a few pockets of loculated fluid in the lesser sac measuring up to 2
cm, nonspecific in the postoperative setting. No additional fluid collections
are demonstrated.
No bowel obstruction or free air demonstrated. Large stool ball is again
noted in the rectum.
PELVIS: There is trace free fluid in the pelvis. There is endometrial
thickening. The adnexa are unremarkable for age.
LYMPH NODES: There is no abdominal or pelvic lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Low-density coursing in the
left anterior pararenal space likely corresponds to evolving hemorrhage seen
on prior CT.
BONES: There is no evidence of worrisome osseous lesions.
SOFT TISSUES: Mild diffuse subcutaneous edema is noted as well as midline
staples from recent intervention. Broad-based right inguinal hernia
containing nonobstructed cecum is again seen.
IMPRESSION:
1. Large pocket of fluid measuring at least 9 cm surrounding the distal
esophagus at the site of the prior large hiatal hernia. Nonspecific
postoperative pockets of loculated fluid in the lesser sac.
2. Interval postoperative changes in the stomach, however a large
paraesophageal hernia remains and there is improved gastric distension post
percutaneous gastrojejunostomy. The intrathoracic portion of stomach is
mildly distended with oral contrast.
3. Evolving left retroperitoneal hematoma.
4. Endometrial thickening. This could be further evaluated with nonemergent
pelvic ultrasound
RECOMMENDATION(S): Dedicated CT chest with contrast to assess the extent of
the fluid collection in the lower thorax.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman s/p reduction of gastric volvulus and
gastropexy, with rising leukocytosis and paraesophageal collection seen on
prior CT abd/pelvis today.// CT chest with IV contrast only to evaluate extent
of paraesophageal collection and to evaluate for pneumonia. DOES NOT NEED PE
PROTOCOL.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.3 s, 31.8 cm; CTDIvol = 16.8 mGy (Body) DLP = 508.6
mGy-cm.
Total DLP (Body) = 521 mGy-cm.
COMPARISON: Prior CT from ___.
FINDINGS:
The study is limited by significant motion artifact.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
HEART AND VASCULATURE: The thoracic aorta and the main pulmonary artery are
normal in caliber. Calcific atherosclerotic changes involving the thoracic
aorta. The heart, pericardium, and great vessels are within normal limits. No
pericardial effusion is seen.
MEDIASTINUM: No significantly enlarged axillary, mediastinal, or hilar lymph
nodes seen. Interval decrease in the gastric distension with persistent
hiatus hernia with significantly air and fluid distended intrathoracic
stomach.
LUNGS/AIRWAYS: There is significant atelectasis involving both lower lobes as
well as the lingula. The airways are patent to the level of the segmental
bronchi bilaterally.
PLEURAL SPACES: Intermediate attenuation (30 -35 ___ bilateral pleural
effusions seen with interval increase in amount compared to the prior study.
There is a large loculated low-attenuation fluid collection in the right
pleural space measuring 8.4 x 7.2 x 9.4 cm, corresponding to the collection
partially visualized on the earlier same day CT abdomen and pelvis exam.
ABDOMEN: Included portion of the upper abdomen shows bilateral adrenal
thickening which may represent adrenal hyperplasia. A percutaneous
gastrojejunostomy tube is seen in situ with edema and stranding in the
overlying soft tissues, in keeping with recent tube placement.
BONES: No suspicious osseous abnormality is seen.? Wedge compression involving
T7 vertebral body with greare than 50% height loss. There is no acute
fracture.
IMPRESSION:
1. Interval decrease in the gastric distension with persistent hiatus hernia
containing significantly distended intrathoracic stomach.
2. Large rim enhancing loculated low-attenuation fluid collection in the right
pleural space measuring upwards of 8.4 x 7.2 x 9.4 cm.
3. Significant atelectasis involving both lower lobes and lingula. No
definite pneumonia. Intermediate attenuation bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old woman with acute O2 desaturation, c/o abdominal pain
and pain with breathing, pain at PEG site// please evaluate for intrapulmonary
source of O2 desat, free air in abdomen
COMPARISON: Radiographs from ___ and CT scan from ___
IMPRESSION:
There is a very large hiatal hernia better seen on the prior chest CT. This
causes elevation of the left hemidiaphragm and there is large gastric bubble
projecting over the left lung base. There is a large left-sided pleural
effusion with fluid extending to the apex, better assessed on the prior CT
scan. Small right-sided pleural effusion is seen. There are no
pneumothoraces.
Radiology Report
EXAMINATION: CT CHEST, ABDOMEN AND PELVIS WITH CONTRAST
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the chest, 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 5.3 s, 70.2 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,421.0 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.8 mGy (Body) DLP =
8.4 mGy-cm.
Total DLP (Body) = 1,431 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST); Acquisition sequence:
1) Spiral Acquisition 5.3 s, 70.2 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,421.0 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.8 mGy (Body) DLP =
8.4 mGy-cm.
Total DLP (Body) = 1,431 mGy-cm.
COMPARISON: CT chest, abdomen and pelvis ___ and ___.
FINDINGS:
CHEST:
NECK: Visualized thyroid glands are unremarkable.
AIRWAYS: Major airways are clear. There is compression of the lower lobe
bronchi which are related to atelectasis and effusions.
MEDIASTINUM: Large hiatal hernia displaces the heart to the right. There is
no pericardial effusion and no cardiomegaly. There is no adenopathy.
LUNGS: Re-demonstrated is moderate to large size bilateral pleural effusions
with collapse of the lower lobes bilaterally. There is linear atelectasis of
the lingula. Other areas of ground-glass opacities have not significantly
changed mainly in the right upper lobe. Evaluation of the lungs are limited
due to motion.
PLEURA: There is unchanged moderate to large sized bilateral pleural
effusions. There is re-demonstration of a 9 cm right paraesophageal fluid
collection that appears unchanged in size at the site of hiatal hernia repair
within the right hemithorax. There is a smaller fluid collection measuring up
to 6 cm along the greater curvature of the stomach also appears similar. These
fluid collections demonstrate a thin rim of enhancement.
ABDOMEN:
HEPATOBILIARY: Hepatic attenuation is fairly homogeneous and is unchanged.
Portal vein appears patent. There is no obvious biliary ductal dilatation.
Gallbladder appears unremarkable.
PANCREAS: Pancreatic contours are unremarkable with no peripancreatic fat
stranding to suggest pancreatitis.
SPLEEN: No splenomegaly.
ADRENALS: Unchanged bilateral mild adrenal gland hyperplasia.
URINARY:There is no hydronephrosis. Renal enhancement is symmetric
bilaterally.
GASTROINTESTINAL: Status post reduction of a large hiatal hernia.
Intrathoracic stomach is again noted, appears unchanged in the degree of
distention as the post surgical CT on ___. Gastrostomy tube is in
good position as well as gastrojejunostomy tube small bowel loops are not
dilated. Interval reduction of the right hemicolon from the large hiatal
hernia with no large bowel wall thickening or pericolonic fat stranding to
suggest colitis.
PERITONEUM: There is re-demonstration of low-density fluid tracking along the
left paracolic gutter. It appears unchanged since ___. This tracks
from the inferior aspect of the pancreatic tail, measuring 13 cm cranio
caudally and 2 cm in thickness. Additionally, there is re-demonstration of a
9 cm right paraesophageal fluid collection that appears unchanged in size at
the site of hiatal hernia repair within the right hemithorax. There is a
smaller fluid collection measuring up to 6 cm along the greater curvature of
the stomach also appears similar. These fluid collections continue to have
thin rim of enhancement.
LYMPH NODES: No abdominopelvic adenopathy.
VASCULAR: Abdominal aorta is normal in caliber with patent intra-abdominal
branches.
PELVIS: Uterus is normal in size for age. Urinary bladder appears
unremarkable.
BONES:There are no new acute osseous abnormalities. There is a mid thoracic
spine compression deformity that appears unchanged.
SOFT TISSUES: Midline surgical wound with no subcutaneous fluid collections.
IMPRESSION:
1. Re-demonstrated large pockets of fluid measuring up to 9 cm, related to the
recent surgery. These probably represent postsurgical seromas. However,
given increased rim of enhancement, superimposed infection is highly
suspected.
2. Unchanged moderate size pleural effusions bilaterally with bilateral lower
lobe collapse.
3. Smaller left paracolic organized fluid collection.
Radiology Report
EXAMINATION: CT CHEST, ABDOMEN AND PELVIS WITH CONTRAST
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the chest, 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 5.3 s, 70.2 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,421.0 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.8 mGy (Body) DLP =
8.4 mGy-cm.
Total DLP (Body) = 1,431 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST); Acquisition sequence:
1) Spiral Acquisition 5.3 s, 70.2 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,421.0 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.8 mGy (Body) DLP =
8.4 mGy-cm.
Total DLP (Body) = 1,431 mGy-cm.
COMPARISON: CT chest, abdomen and pelvis ___ and ___.
FINDINGS:
CHEST:
NECK: Visualized thyroid glands are unremarkable.
AIRWAYS: Major airways are clear. There is compression of the lower lobe
bronchi which are related to atelectasis and effusions.
MEDIASTINUM: Large hiatal hernia displaces the heart to the right. There is
no pericardial effusion and no cardiomegaly. There is no adenopathy.
LUNGS: Re-demonstrated is moderate to large size bilateral pleural effusions
with collapse of the lower lobes bilaterally. There is linear atelectasis of
the lingula. Other areas of ground-glass opacities have not significantly
changed mainly in the right upper lobe. Evaluation of the lungs are limited
due to motion.
PLEURA: There is unchanged moderate to large sized bilateral pleural
effusions. There is re-demonstration of a 9 cm right paraesophageal fluid
collection that appears unchanged in size at the site of hiatal hernia repair
within the right hemithorax. There is a smaller fluid collection measuring up
to 6 cm along the greater curvature of the stomach also appears similar. These
fluid collections demonstrate a thin rim of enhancement.
ABDOMEN:
HEPATOBILIARY: Hepatic attenuation is fairly homogeneous and is unchanged.
Portal vein appears patent. There is no obvious biliary ductal dilatation.
Gallbladder appears unremarkable.
PANCREAS: Pancreatic contours are unremarkable with no peripancreatic fat
stranding to suggest pancreatitis.
SPLEEN: No splenomegaly.
ADRENALS: Unchanged bilateral mild adrenal gland hyperplasia.
URINARY:There is no hydronephrosis. Renal enhancement is symmetric
bilaterally.
GASTROINTESTINAL: Status post reduction of a large hiatal hernia.
Intrathoracic stomach is again noted, appears unchanged in the degree of
distention as the post surgical CT on ___. Gastrostomy tube is in
good position as well as gastrojejunostomy tube small bowel loops are not
dilated. Interval reduction of the right hemicolon from the large hiatal
hernia with no large bowel wall thickening or pericolonic fat stranding to
suggest colitis.
PERITONEUM: There is re-demonstration of low-density fluid tracking along the
left paracolic gutter. It appears unchanged since ___. This tracks
from the inferior aspect of the pancreatic tail, measuring 13 cm cranio
caudally and 2 cm in thickness. Additionally, there is re-demonstration of a
9 cm right paraesophageal fluid collection that appears unchanged in size at
the site of hiatal hernia repair within the right hemithorax. There is a
smaller fluid collection measuring up to 6 cm along the greater curvature of
the stomach also appears similar. These fluid collections continue to have
thin rim of enhancement.
LYMPH NODES: No abdominopelvic adenopathy.
VASCULAR: Abdominal aorta is normal in caliber with patent intra-abdominal
branches.
PELVIS: Uterus is normal in size for age. Urinary bladder appears
unremarkable.
BONES:There are no new acute osseous abnormalities. There is a mid thoracic
spine compression deformity that appears unchanged.
SOFT TISSUES: Midline surgical wound with no subcutaneous fluid collections.
IMPRESSION:
1. Re-demonstrated large pockets of fluid measuring up to 9 cm, related to the
recent surgery. These probably represent postsurgical seromas. However,
given increased rim of enhancement, superimposed infection is highly
suspected.
2. Unchanged moderate size pleural effusions bilaterally with bilateral lower
lobe collapse.
3. Smaller left paracolic organized fluid collection.
Radiology Report
EXAMINATION: CT-guided drainage
INDICATION: ___ year old woman with large right pleural fluid collection.//
Please drain the fluid pocket from the right pleural space.
COMPARISON: ___
PROCEDURE: CT-guided drainage of right pleural/mediastinal collection.
OPERATORS: Dr. ___ ___, radiology fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a right decubitus position on the CT scan table.
Limited preprocedure CT scan was performed to localize the collection. Based
on the CT findings an appropriate skin entry site for the drain placement was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 250 cc of straw-colored fluid was aspirated with a sample sent
for microbiology evaluation. The catheter was secured by a Flexitrack. The
catheter was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.2 s, 22.0 cm; CTDIvol = 12.2 mGy (Body) DLP = 252.4
mGy-cm.
2) Stationary Acquisition 2.5 s, 1.4 cm; CTDIvol = 19.0 mGy (Body) DLP =
27.4 mGy-cm.
3) Stationary Acquisition 8.0 s, 1.4 cm; CTDIvol = 84.0 mGy (Body) DLP =
121.0 mGy-cm.
Total DLP (Body) = 408 mGy-cm.
SEDATION: No moderate sedation was used for the procedure.
FINDINGS:
Limited preprocedure scan of the lower thorax re-demonstrated a small-moderate
right pleural effusion, with a more medially located loculated component.
This was targeted for aspiration and drainage.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with gastric volvulus s/p reduction with
pleural effusion s/p drainage// ?status of pleural effusion
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from ___, CT chest ___
FINDINGS:
There is a very large hiatal hernia with elevation of the left hemidiaphragm
and atelectasis of the left lower lobe. There has been interval decrease in a
left pleural effusion. There is a persistent small right pleural effusion
with right lung base atelectasis. There is no pneumothorax. The
cardiomediastinal silhouette is within normal limits. A drainage catheter
seen projecting over the gastric bubble.
IMPRESSION:
Interval decrease of left pleural effusion status post drainage. No
pneumothorax. Stable small right pleural effusion. Persistent distention of
the stomach.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with pigtail in chest.// Evaluate interval
change.
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: Chest radiograph ___. Chest CT ___.
IMPRESSION:
Right pleural pigtail catheter remains in similar position. A small to
moderate right-sided effusion is similar to minimally increased. There is
associated atelectasis of the right lung base. Lung volumes are lower than
the preceding examination. In addition, there is intrathoracic stomach with
greater distention of the gastric bubble, and obstruction cannot be excluded.
There is also compressive atelectasis of the left lung base. There is
worsening vascular congestion with possible trace edema. No other gross dense
consolidation is seen. There is no pneumothorax. Cardiomediastinal
silhouette appears unchanged, though is difficult to fully characterize given
the intrathoracic stomach and associated mass effect.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SOB and tachycardia// please evaluate for
interval change in chest xray please evaluate for interval change in
chest xray
IMPRESSION:
Compared to chest radiographs ___ through ___.
Hugely dilated stomach, substantially intrathoracic, is slightly smaller today
than on ___. It is responsible for severe atelectasis, left lower lobe.
Previous right basal consolidation and right pleural effusion have improved
substantially, and there is no longer any pulmonary edema. Small left pleural
effusion is stable. No pneumothorax. Cardiac silhouette is entirely
obscured. Small bore catheter projecting over the lower midline is not
identifiable.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old woman with new tachycardia, hypoxia, history of
DVT/PE// please evaluate for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 13.4 mGy (Body) DLP = 376.2
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 1.2 s, 0.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 3.3
mGy-cm.
Total DLP (Body) = 381 mGy-cm.
COMPARISON: CT dated ___
FINDINGS:
HEART/VASCULATURE:
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
visualized subsegmental pulmonary arteries. The main and right pulmonary
arteries are normal in caliber.
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation.
Cardiac chamber sizes are normal. There is no evidence of right ventricular
strain. There is no pericardial effusion.
AIRWAYS/LUNGS:
Upper airways are patent. There is bibasilar atelectasis. Subsegmental
atelectasis is also noted in the left upper lobe. Patchy airspace opacities
are seen in the apical segment of the left lower lobe and periphery of the
right upper lobe.
There is moderate bilateral pleural effusions.
MEDIASTINUM/LYMPH NODES:
Redemonstration of large hiatal hernia with herniation of a large portion of
the stomach into the mediastinum which is incompletely included in the field
of view. There has been interval placement of a mediastinal drainage catheter
through a right posterior approach. Right mediastinal fluid collect has
decreased in size now measuring 3.7 x 4.5 cm. The percutaneous catheter is
along the medial aspect of the collection.
There is no mediastinal lymphadenopathy.
BONES/CHEST WALL:
Sclerosis along the superior endplate of T7 vertebral body with mild
compression deformity is unchanged. No focal bone lesion identified.
UPPER ABDOMEN:
Limited images of the upper abdomen show no concerning findings.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Patchy opacities in the upper lobes may be secondary to aspiration.
3. Redemonstration of large hiatal hernia containing a large portion of the
stomach.
4. Right mediastinal collection has significantly decreased in size in
interval.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with hiatal hernia, stomach in chest, resp
distress earlier today were planning on NG but now seems better.// Is
intrathoracic stomach decompressed?
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: Same-day CTA chest. Chest radiograph ___.
IMPRESSION:
Massive hiatal hernia again distorts anatomy and degrades the examination.
Moderate bilateral pleural effusions were better seen on the prior chest CTA.
Hazy areas of density in the right upper lobe correspond to rightward
mediastinal shift and more lateralized view of the aortic arch when compared
to the CT. Otherwise no new consolidation is seen. There is no pneumothorax.
The large intrathoracic stomach appears moderately decreased in distention as
compared to the prior radiograph.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with new OGT// eval OGT
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___, 15:44.
IMPRESSION:
Upper enteric tube curls and terminates in the intrathoracic stomach. Lung
bases are slightly better aerated. No other interval changes are seen.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with gastric volvulus, s/p reduction of
volvulus, GJ tube, pleural tube for right pleural effusion. Pleural tube
removed// evaluate for interval change
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___.
IMPRESSION:
Compared to the prior study, aeration of the right lung base has improved.
There remains a small left-sided pleural effusion with adjacent compressive
atelectasis which is mainly from a massive hiatal hernia. The intrathoracic
stomach appears less distended than the prior examination. Heart remains
moderately enlarged. Upper enteric tube is been removed. No new
consolidation is seen. There is no pneumothorax.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: GI bleed, Transfer
Diagnosed with Sepsis, unspecified organism
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | ___ living in long-term care facility ___ dementia and severe
weakness who presented to OSH w/ episode of coffee-ground
emesis, where CT demonstrated massively dilated stomach with
stomach in the chest, transverse colon in the chest c/w gastric
volvulus, transferred to ___ after fluid overload causing
respiratory distress and pressor requirement. After being
evaluated in the ___ ED and urgent NGT placed for
decompression, the patient was consented and immediately taken
to the operating room for an exploratory laparotomy, gastric
reduction from chest, and GJ tube placement. The patient was
taken to the Surgical ICU for close monitoring afterwards and
remained intubated for fluid overload and pulmonary edema. She
was started on a PPI and the G-tube was placed to gravity to
decompress the stomach. She remained on levophed for a short
period of time given her volume overload. On POD2, the patient
was weaned off pressors and successfully extubated after some
diuresis and she was taken off of antibiotics. By POD3, the
patient was comfortable on room and air and transferred to the
floor. She was cleared to received tube feeds through the J-tube
and home meds through the G-tube. She was evaluated by
speech/swallow and cleared for puree/nectar-thick diet. By POD4,
the patient was able to take POs and her tube feeds were
advanced.
On POD#13 the patient underwent ___ drainage of right sided
pleural effusion.
On POD#14 the patient, who was on telemetry monitoring, became
markedly bradycardic. While she remained asymptomatic the
entire time, our team was concerned enough to consult
cardiology. Cardiology fully examined the patient and her
cardiac monitoring strips and determined there was no indication
for intervention. The patient then began showing prolonged
pauses in between heart beats, and out of an abundance of
caution she was transferred back to the trauma surgery ICU.
Cardiology re-evaluated the patient, and electrophysiology was
also consulted, and both teams decided since she was
asymptomatic there was nothing to do for this patient and they
recommended transferring her back to the floor and taking her
off telemetry.
On POD#19 in the early morning the patient was found to be in
respiratory distress. She was requiring increasing amount of
supplemental oxygen via nasal cannula and eventually was placed
on a non-rebreather. Because of her tenuous respiratory status,
she was sent again to the TSICU. Chest X-ray was unremarkable.
Her respiratory status and oxygen saturation were monitored
closely in the ICU, and she improved. Once her supplemental
oxygen needs were between 2 and 3 liters nasal cannula, she was
transferred back to the floor. She returned to the floor
POD#20.
On the floor her oxygen was weaned to ___. On ___ an NG
tube was placed for additional gastric decompression given the
GJ tube wasn't fully decompressing the stomach due to the
gastric herniation. The head of bed was elevated 30 degrees. On
___ her tube feeds were advanced and her G tube was put to
gravity. On ___ the nurse was concerned because of
increased secretions that weren't being drained through the NG
tube. An instruction was placed for frequent (q2h) flushing of
the tube. An order was also placed for mucormyst for possible
thickened respiratory secretions. This improved her secretions.
She was also hypertensive (170s/90s) in the setting of holding
her preadmission atenolol. Cardiology was previously on consult
was reconsulted and suggested we start amlodipine 5mg. Her
vitals improved after starting the amlodipine. On ___ the NG
tube was clamped given low output and removed. A pigtail
catheter that was placed to drain pleural effusions in the ICU
was also removed at that time. A follow up chest xray did not
reveal any new abnormalities. On ___ she was tolerating her
tube feeds at goal (Osmolite 1.5 @ 40cc/hr + beneprotein 3
packates a day) with no episodes of emesis. She was alert and
her mental status was at baseline (confused due to her
dementia). She was passing gas and not reporting any pain.
Speech and swallow had approved her for a 1:1 tolerating
puree/nectar diet and thin liquids as needed. Talked to Dr. ___
(___) at ___ and communicated information about restarting
xarelto, stopping the atenolol, restarting the amlodipine in the
setting of bradycardia per our formal cardiology recommendation.
The physician is aware that the patient was off xarelto while in
the hospital. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
umbilical pain
Major Surgical or Invasive Procedure:
Exploratory Laparotomy, Small Bowel Resection, Reduction and
Repair of Incarcerated Incisional Hernia
staples removed ___ with lower aspect of wound opening up,
serous large amount of serous fluid
History of Present Illness:
Ms. ___ is a ___ year old female with a past medical history of
CVA with right-side deficits, multiple prior surgeries including
ex lap for perforated ulcer, operative SBO who now presents with
acute on chronic painful umbilical bulge accompanied by new skin
changes. She reports baseline pain from a bulge at the
umbilicus
that worsened starting 1 week ago with non-bloody emesis at that
time. Her symptoms resolved for a time but she vomited 3 days
prior to today and then subsequently the next day. She reports
that her appetite decreased throughout the week and that she
lost
some weight.
Patient reported a sharp stabbing pain around her umbilicus
along with new redness and warmth of the overlying skin. The
pain was more severe than the pain she had experienced in the
past and sharper in quality. The pain did not
radiate. Moving around worsened the pain. She denied any
worsening of her pain
with eating. She reports having had a bowel movement and flatus
the morning of presentation. She denied any fevers or chills. Of
note, she also has a bulge more superiorly that does not cuase
her pain.
She reported to ___ this morning where a CT was
performed with concern for incarcerated verntral hernia
containing potentially compromised bowel. She was therefore
transferred to ___ for further work up and surgical evaluation.
Past Medical History:
COPD
CVA ___ w/ residual R-sided weakness and dysarthria
HTN
HLD
diabetes
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical exam: upon admission: ___:
Vitals-100.3 (OSH)/98.4 65 108/60 16 94% RA
General- non-toxic
HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes
Cardiac- RRR
Chest- no increased work of breathing on room air
Abdomen- soft, moderately distended. Soft and reducible
epigastric hernia that is nontender. ___ bulge that
is
not reducible, indurated, tender to palpation, with overlying
skin erythema. Midline laparotomy scar. No rebound or guarding.
Ext- WWP, no edema
Physical examination upon discharge: ___:
GENERAL: NAD
CV; ns1, s2, no murmurs
LUNGS: Diminished BS bases bil
ABDOMEN: soft, mid-abdominal tenderness, lower aspect of wound
open, wound edges pink, DSD
EXT: flaccid right arm, no lower ext tenderness bil.,muscle st
lower ext. +4/+5
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD
Plt Ct
___ 07:30 8.8 2.78* 7.5* 24.7* 89 27.0 30.4* 15.0
48.4* 460*
___ 11:05AM BLOOD WBC-12.7* RBC-3.11* Hgb-8.5* Hct-27.6*
MCV-89 MCH-27.3 MCHC-30.8* RDW-15.3 RDWSD-48.5* Plt ___
___ 07:40AM BLOOD WBC-9.6 RBC-2.92* Hgb-7.8* Hct-25.6*
MCV-88 MCH-26.7 MCHC-30.5* RDW-15.2 RDWSD-48.1* Plt ___
___ 07:43AM BLOOD WBC-14.6* RBC-3.27* Hgb-8.9* Hct-29.0*
MCV-89 MCH-27.2 MCHC-30.7* RDW-15.6* RDWSD-49.4* Plt ___
___ 07:45PM BLOOD WBC-16.4* RBC-4.51 Hgb-12.4 Hct-37.7
MCV-84 MCH-27.5 MCHC-32.9 RDW-13.9 RDWSD-42.4 Plt ___
___ 07:45PM BLOOD Neuts-87.9* Lymphs-4.3* Monos-6.6
Eos-0.2* Baso-0.3 Im ___ AbsNeut-14.44* AbsLymp-0.70*
AbsMono-1.09* AbsEos-0.03* AbsBaso-0.05
___ 11:05AM BLOOD Plt ___
___ 10:58AM BLOOD ___ PTT-27.4 ___
___ 11:05AM BLOOD Glucose-133* UreaN-13 Creat-0.6 Na-141
K-4.3 Cl-106 HCO3-22 AnGap-13
___ 07:40AM BLOOD Glucose-84 UreaN-11 Creat-0.6 Na-143
K-4.1 Cl-108 HCO3-23 AnGap-12
___ 07:45PM BLOOD Glucose-85 UreaN-24* Creat-1.0 Na-139
K-3.4* Cl-103 HCO3-22 AnGap-14
___ 11:05AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8
___ 11:05AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8
___ 07:50PM BLOOD Lactate-1.3
___: portable abdomen:
Mildly dilated loops of small bowel in the mid abdomen measuring
up to 3.1 cm. If there is a clinical concern for obstruction,
further evaluation with CT scan of the abdomen and pelvis is
recommended.
CXR:
Study is limited by body habitus. Lung volumes are low
accentuating the
cardiac silhouette and pulmonary vasculature. Heart size is
borderline.
There is unfolding of the thoracic aorta with knob
calcifications. There is central pulmonary vascular congestion
with possible trace interstitial edema.
Linear atelectasis is seen. There is an equivocal retro-cardiac
opacity which could represent a developing pneumonia along with
tiny bilateral effusions. There is no pneumothorax.
___: CT abdomen and pelvis:
1. Post midline laparotomy for repair of a strangulated ventral
hernia. There is a subcutaneous fluid collection measuring 3.3
x 2.4 cm to the left of the midline laparotomy site, compatible
with a small abscess. A second rim enhancing fluid collection
is seen within a left spigelian-type hernia measuring 4.5 x 1.9
cm.
2. Small rim enhancing collection in the small bowel mesentery
measuring 2.8 x 1.3 cm.
3. Dilated small bowel loops, with gradual tapering at the level
of the
terminal ileum, suggestive of ileus.
___: CXR:
1. Interval placement of NG tube which terminates within the
stomach.
2. Persistent vascular congestion and mild asymmetric pulmonary
edema.
___: portable abdomen:
Non-obstructive bowel gas pattern. Previously administered oral
contrast
reaches the rectum.
___ 6:22 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
MEROPENEM MIC <=1 MCG/ML SUSCEPTIBLE test result
performed by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
___ 10:35 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 25 mg PO DAILY
2. Gabapentin 100 mg PO DAILY
3. GlipiZIDE 5 mg PO DAILY
4. Lovastatin 20 mg oral DAILY
5. oxybutynin chloride 10 mg oral DAILY
6. Aspirin 81 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Famotidine 20 mg PO Q12H
please re-evaluate with PCP for indication to continue
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Aspirin 81 mg PO DAILY
7. Atenolol 25 mg PO DAILY
8. Gabapentin 100 mg PO DAILY
9. GlipiZIDE 5 mg PO DAILY
10. Lovastatin 20 mg oral DAILY
11. oxybutynin chloride 10 mg oral DAILY
12. Ranitidine 150 mg PO DAILY
13. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
incarcerated ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NGt// Evaluate NGT placement.
COMPARISON: Chest radiograph from ___
FINDINGS:
Portable supine view of the chest provided.
Interval placement of an NG tube is demonstrated which courses below the
diaphragm terminating in the stomach. Pulmonary vascular congestion with mild
asymmetric pulmonary edema persists. No focal consolidation, effusion, or
pneumothorax is identified. The cardiomediastinal silhouette is unchanged
with a top-normal heart size.
IMPRESSION:
1. Interval placement of NG tube which terminates within the stomach.
2. Persistent vascular congestion and mild asymmetric pulmonary edema.
Radiology Report
INDICATION: ___ year old woman with LOA, SBR, repair of ventral hernia, now
with n/v, placement of NGT tube// follow passage of contrast (Please do
imaging at ___
TECHNIQUE: Portable supine frontal view of the abdomen and pelvis.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
There is a nonobstructive bowel gas pattern. Ingested oral contrast partially
opacifies the entirety of the large bowel and rectum which is normal caliber.
There is no supine radiographic evidence of free air. There is no
pneumatosis. Midline skin staples are seen. Upper enteric tube terminates in
the proximal stomach.
IMPRESSION:
Nonobstructive bowel gas pattern. Previously administered oral contrast
reaches the rectum.
Radiology Report
INDICATION: ___ year old woman with s/p ex lap, LOA, SBR, repair enterotomy,
primary repair ventral hernia s/p large episode of emesis// Rule out
ileus/obstruction
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: CT scan from ___
FINDINGS:
Post midline laparotomy. A right-sided surgical drain is present, with the
tip projecting over the mid pelvis.
A suprapubic catheter is in place.
There are mildly dilated loops of small bowel in the mid abdomen measuring up
to 3.1 cm.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
IMPRESSION:
Mildly dilated loops of small bowel in the mid abdomen measuring up to 3.1 cm.
If there is a clinical concern for obstruction, further evaluation with CT
scan of the abdomen and pelvis is recommended.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with CVA, DM, p/w strangulated ventral
incisional hernia w/ bowel perf, now POD6 ex lap, LOA, SBR, repair enterotomy,
primary repair ventral hernia with rising WBC.// ?pneumonia
TECHNIQUE: AP and lateral views of the chest.
IMPRESSION:
Study is limited by body habitus. Lung volumes are low accentuating the
cardiac silhouette and pulmonary vasculature. Heart size is borderline.
There is unfolding of the thoracic aorta with knob calcifications. There is
central pulmonary vascular congestion with possible trace interstitial edema.
Linear atelectasis is seen. There is an equivocal retrocardiac opacity which
could represent a developing pneumonia along with tiny bilateral effusions.
There is no pneumothorax.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis with contrast
INDICATION: ___ year old woman with strangulated ventral hernia with bowel
perf., s/p exp lap, LOA, SBR, repair enterotomy, now with rising WBC//
evaluate for abdominal abscess (please do with po/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) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 53.0 mGy (Body) DLP =
26.5 mGy-cm.
2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 27.3 mGy (Body) DLP =
1,338.9 mGy-cm.
Total DLP (Body) = 1,365 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions, with subsegmental atelectatic
changes at both lung bases.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains gallstones
without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral renal cortical hypodensities are too small to characterize, however
likely represent cysts. There is no hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The patient is post midline laparotomy for repair of a
strangulated ventral hernia. Associated postsurgical changes with congestion
and stranding are seen in the subcutaneous tissues of the anterior abdominal
wall as well as in the mesentery. An enteroenteric anastomosis in the right
mid abdomen appears within normal limits for the early postsurgical setting.
The small bowel loops are mildly dilated up to 3.8 cm, with air-fluid levels,
with gradual tapering distal to the anastomosis, suggestive of ileus. There
is a small rim enhancing collection in the small bowel mesentery measuring 2.8
x 1.3 cm (2:60). The colon and rectum are unremarkable. There is a small
hiatal hernia.
PELVIS: Foley catheter is present in the urinary bladder which is collapsed.
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: Post midline laparotomy with expected postsurgical changes along
the anterior abdominal wall. A surgical drain is present in the a
subcutaneous fat along the anterior abdominal wall, with the tip terminating
deep to the midline laparotomy site. There is a organized fluid collection
measuring 3.3 x 2.4 cm to the right of the midline laparotomy site (02:34),
containing gas, compatible with a small abscess. A second rim enhancing
collection is seen within a left spigelian hernia, measuring 1.9 x 4.5 cm.
The spigelian hernia also contains omental fat, and non-organized fluid along
its dependent portion.
There is anasarca.
IMPRESSION:
1. Post midline laparotomy for repair of a strangulated ventral hernia. There
is a subcutaneous fluid collection measuring 3.3 x 2.4 cm to the left of the
midline laparotomy site, compatible with a small abscess. A second rim
enhancing fluid collection is seen within a left spigelian-type hernia
measuring 4.5 x 1.9 cm.
2. Small rim enhancing collection in the small bowel mesentery measuring 2.8 x
1.3 cm.
3. Dilated small bowel loops, with gradual tapering at the level of the
terminal ileum, suggestive of ileus.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Other and unsp ventral hernia with obstruction, w/o gangrene
temperature: 98.4
heartrate: 65.0
resprate: 16.0
o2sat: 94.0
sbp: 108.0
dbp: 60.0
level of pain: 8
level of acuity: 2.0 | ___ year old female admitted to the hospital with an umbilical
bulge and emesis. A cat scan of the abdomen was done with
concern for incarcerated verntral hernia concerning for a
comprised bowel. She was also noted to have an elevated white
blood cell count. Based on these findings, the patient was
transferred here for management. Upon admission, the patient
was made NPO, and given intravenous fluids. An NGT was placed
for bowel decompression.
She was taken to the operating room on HD #2 where she underwent
an exploratory laparotomy, SBR, enterotomy repair, and ventral
hernia repair. At the close of the procedure, ___ drain was
placed in the hernia sac. There was a 150cc blood loss. The
patient was extubated after the procedure and monitored in the
recovery room.
On POD #1, the NGT and foley catheter were removed and the
patient was started on clear liquids after return of bowel
function. Her white blood cell count was monitored. She resumed
her oral home medications. On POD #9, she reported nausea and
an NGT was replaced for bowel decompression. It remained in
place for ___ days. Prior to the removal of the NGT, the patient
underwent a gastrograffin study which showed contrast to the
rectum. The NGT was removed and the patient resumed clears and
advanced to a regular diet. She had no further episodes of
nausea or vomiting. She was reported to have a rising white
blood cell count. A c.diff culture was negative, but urine
culture grew proteus. The patient completed a course of
ceftriaxone. Her white blood cell count normalized at the time
of discharge.
In preparation for discharge, the patient was evaluated by
physical therapy. Recommendations were made for discharge to a
rehabilitation facility. On HD #15, the patient was discharged.
Her vital signs were stable and she was afebrile. She was
tolerating a regular diet and voiding without difficulty. She
had return of bowel function. Her abdominal staples were removed
and steri-strips applied. The lower aspect of her wound opened
after removal of the staples followed with a large amount of
sero-sanguinous. A DSD was applied and dressing changes
initiated. Discharge instructions were reviewed and questions
answered. A follow-up appointment was made in the Acute care
clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R leg wound dehiscence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
___ y.o. ___ Creole speaking female hx IDDM, CVA with
residual dysarthria, schizoaffective disorder, and
differentiated liposarcoma of the right thigh s/p neoadjuvant
radiotherapy and surgical resection by ortho onc (Dr. ___
___ with placement of a right femoral cephalomedullary
nail, now s/p free tissue transfer of anterolateral thigh and
vastus lateralis from left thigh to right thigh, in addition to
nerve coaptation for functional muscle transfer on ___.
Patient was discharged to rehab on ___. Presents to ER after
a witnessed fall while working with physical therapy at rehab.
Patient was wearing a knee-immobilizer, however ___ notes that
the sutures came out. No significant bleeding. No signs of
trauma/infection.
In ER, workup for AMS, including head CT were normal.
10-point ROS is otherwise normal.
Past Medical History:
1. Type 2 diabetes.
2. Depression.
3. Hypertension.
4. Left-sided cerebrovascular accident with resultant
neurological deficits on the right side including some speech
delay.
5. Hyperlipidemia.
6. Obesity.
7. Gastroesophageal reflux disease.
8. Conversion disorder, not otherwise specified.
9. Anxiety state, not otherwise specified.
10. Hyperopia and presbyopia.
Social History:
___
Family History:
The patient is unable to recount or recall her family history.
Physical Exam:
Admission Exam:
98.2 95 124/95 17 99% RA
gen: well-appearing, nad
cv: <2 sec cap refill
lungs: NWB
Ext: Falp is warm, well-perfused. Wound breakdown at distal end
of flap, at site of sutures; 4x1cm exposed
Discharge Exam:
Pertinent Results:
___ 04:45PM BLOOD WBC-9.7 RBC-3.99* Hgb-10.6* Hct-32.9*
MCV-82 MCH-26.5* MCHC-32.2 RDW-15.4 Plt ___
___ 04:45PM BLOOD Plt ___
___ 04:45PM BLOOD Glucose-153* UreaN-15 Creat-0.9 Na-137
K-4.9 Cl-99 HCO3-24 AnGap-19
___ 04:45PM BLOOD Calcium-9.4 Phos-3.3 Mg-2.4
CC6A ___ 9:22 AM
MR THIGH ___ CONTRAST RIGHT Clip # ___
Reason: Eval for ligamentous injury
UNDERLYING MEDICAL CONDITION:
___ year old woman with left ALT/vastus lateralis free flap 2
weeks ago. Now s/p
fall
REASON FOR THIS EXAMINATION:
Eval for ligamentous injury
CONTRAINDICATIONS FOR IV CONTRAST:
Wet Read by ___ on SAT ___ 1:41 ___
1. Edema within the right lateral compartment musculature likely
secondary to subacute postoperative state and component of
recent fall. Less extensive edema noted in the left lateral
compartment, also likely postoperative in etiology.
2. 4.2 x 2.7 cm near uniform signal intensity fluid collection
overlying the lateral compartment likely seroma.
3. No evidence of ligamentous, however subtle evaluation is
limited due to adjacent edema and postoperative state. The
distal aspect of the iliotibial band is not included in the
field of view.
The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 1:34 ___.
*** UNAPPROVED (PRELIMINARY) REPORT *** !! WET READ !!
Medications on Admission:
4. Clozapine 125 mg PO QHS
5. Cyanocobalamin 100 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Glargine 30 Units Dinner
Humalog 5 Units Breakfast
Humalog 10 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using REG Insulin
9. Lisinopril 10 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Succinate XL 100 mg PO DAILY
12. NIFEdipine CR 90 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
15. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxyCODONE 10 mgs by mouth every twelve (12) hours Disp #*28
Tablet Refills:*0
16. Senna 8.6 mg PO BID:PRN constipation
17. Milk of Magnesia 30 mL PO Q6H:PRN constipation
18. cefaDROXil 500 mg oral BID Duration: 10 Days
Maintain antibiotics while drains in place. Refill as needed.
Discharge Medications:
1. Clozapine 125 mg PO QHS
2. Insulin SC
Sliding Scale
Fingerstick QACHS, QPC2H, HS
Insulin SC Sliding Scale using REG Insulin
3. Lisinopril 10 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Metoprolol Succinate XL 100 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Aspirin 121.5 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth q6h;prn Disp #*20
Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
R leg wound dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with flap to RLE done 2 weeks ago. Fall today
// eval for RLE tendon injury under distal portion of flap
TECHNIQUE: LIMITED FOCUSED ULTRASOUND OF UPPER RIGHT THIGH SOFT TISSUE.
EXAMINATION was aborted prior to being completed due to technical difficulty.
COMPARISON: None.
FINDINGS:
3 images of the proximal right thigh, superior to bandage and surgical site
were submitted, which demonstrate no focal fluid collection or evidence of
discrete soft tissue mass. The study was aborted due to technical difficulty.
In discussion with musculoskeletal radiology, it was felt that MRI would be
the study of choice.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with somnolence, ?infection/pna // Eval for PNA
TECHNIQUE: AP and lateral views the chest
COMPARISON: None
FINDINGS:
Low lung volumes contribute to bibasilar atelectasis and bronchovascular
crowding. With this in mind, no acute cardiopulmonary process is identified.
No pleural effusion, no pneumonia and no pulmonary edema is identified.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
EXAMINATION:
CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall/headstrike, confusion // Eval for
intracranial hemorrhage
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1003 mGy-cm; CTDI: 55 mGy
COMPARISON: ___
FINDINGS:
There is no acute intracranial hemorrhage,acute infarction or midline shift.
Gray-white matter differentiation is preserved. There is no hydrocephalus.
There is no edema. There is no fracture.
Visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: NONCONTRAST MRI OF THE RIGHT THIGH
INDICATION: ___ woman with right ALT/vastus lateralis free flap 2
weeks ago now status post fall.
TECHNIQUE: A noncontrast MRI of the right thigh was performed on a 1.5 Tesla
magnet utilizing a full body high-definition coil. The following sequences
were obtained: Axial and coronal T1, sagittal and coronal STIR, and axial T2
fat saturated.
COMPARISON: Intraoperative fluoroscopic spot images of the right femur ___ and outside MRI of the right femur ___.
FINDINGS:
Evaluation is significantly limited by patient motion and hardware related
susceptibility artifact from the patient's right femoral intramedullary nail.
There is prominent intramuscular edema involving the anterolateral compartment
of the right thigh, which is likely a postoperative appearance given the
recent vastus lateralis flap transfer. Edema is also noted within the lateral
aspect of the left thigh likely reflecting the flap donor site.
Postsurgical changes are noted within the subcutaneous soft tissues of the
distal right thigh laterally with associated subcutaneous soft tissue edema
and fibrosis related to prior mass resection. There is limited evaluation for
residual or recurrent mass in the absence of administered intravenous
contrast.
There is a new 3.8 x 2.5 x 8.6 cm homogeneously T2 hyperintense fluid
collection within the subcutaneous soft tissues of the superolateral right
thigh without appreciable peripheral hemosiderin likely reflecting a
postoperative seroma. An additional thin, longitudinally extensive fluid
collection with similar imaging characteristics is noted interposed between
muscle bellies of the rectus femoris and vastus lateralis within the right
thigh measuring approximately 10.9 x 2.3 x 0.7 cm (series 7, image 8 and
series 4, image 51) likely reflecting an additional seroma. There is a
tubular structure extending along the soft tissues of the right thigh postero
laterally. This may represent a drain. Similarly, there may be a tubular
structure in the left lateral thigh, also not fully evaluated.
The visualized tendons including right and left hamstring and left gluteal
tendons are within normal limits. The right-sided gluteus minimus tendon
appears intact. The right-sided gluteus medius tendon is not optimally
visualized, in part due to susceptibility artifact, but cannot be confirmed to
be intact on this exam. Right rectus femorals tendon origin appears intact.
Left rectus femoris tendon origin is probably intact, though not optimally
visualized. There is more limited evaluation of the quadriceps tendons given
the large field of view of the current exam.
The bone marrow signal is within normal limits. There is no fracture or
avascular necrosis.
Limited evaluation of the pelvis demonstrates no gross abnormality on this
nondedicated exam. No free intrapelvic fluid is seen . There is no
significant inguinal lymphadenopathy.
IMPRESSION:
1. Status post right vastus lateralis flap transfer with postoperative edema
noted within the anterior compartment muscles of the right thigh and laterally
at the donor site from the left thigh.
2. Postoperative changes at the distal lateral right thigh within the region
of prior mass resection. Limited evaluation for residual or recurrent mass.
3. 3.8 x 2.5 x 8.6 cm postoperative seroma noted within the superolateral
subcutaneous soft tissues of the right thigh with a thin, more longitudinally
extensive seroma interposed between the bellies of the rectus femoris and
vastus lateralis of the right thigh measuring approximately 10.9 x 2.3 x 0.7
cm.
4. Limited evaluation of the quadriceps tendons given the large field of view
on this exam. Further evaluation, if clinically indicated, can be obtained
with small field-of-view images on a knee MRI.
5. Question bilateral drains. These are not effectively evaluated on these
images. If clinically indicated, radiographs and, if needed, CT, could help
for further assessment.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: WOUND EVAL S/P FALL
Diagnosed with DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, ABN REACT-SURG PROC NEC
temperature: 98.4
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 107.0
dbp: 87.0
level of pain: 13
level of acuity: 3.0 | The patient was admitted to the plastic surgery service on
___ for a R leg wound dehiscence. The patient underwent
repair of the wound in the emergency department and was
subsequently admitted for additional imaging and evaluation.
Neuro: The patient received pain medication with good effect and
adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
Imaging: The patient underwent a MRI of the R leg that showed
swelling within the right lateral compartment musculature but no
frank tear was visible.
At the time of discharge on HD#1, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. She will be discharged back to the rehab facility. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / naproxen
Attending: ___.
Chief Complaint:
Epigastric /chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
.
Date: ___
Time: ___
.
_
________________________________________________________________
PCP: Name: ___
___: ___ ASSOCIATES
Address: ___
Phone: ___
Fax: ___
_
________________________________________________________________
___ w MM s/p SCT in ___ at ___ now on daily Revlimid in
remission who presents with acute onset of epigastric pain with
nausea and vomiting x 2 hours. Pain radiates to the back. It is
difficult to breath because the pain is so intense. The pain is
constant. There have been no recent medication changes, nor
foreign travel. She has not had any insect/scorpion bites. She
has never experienced this pain before. She does not have
gallstones. Rare ETOH. No fevers or chills. She was in her
general state of good health with the exception of her chronic
msk aches and pains prior to this. She does not smoke.
In ER: (Triage Vitals:
10 |98.6 |122 |112/62 |18 |100% RA
Meds Given:
___ 15:40 SC Morphine Sulfate 4 mg
___ 16:05 IVF 1000 mL NS 1000 mL
___ 16:05 IV Ondansetron 4 mg
___ 16:08 IV Morphine Sulfate 4 mg
___ 17:50 IV HYDROmorphone (Dilaudid) 1 mg
___ 18:00 IV Metoclopramide 10 mg
___ 19:22 IV HYDROmorphone (Dilaudid) 1 mg
___ 23:36 IV HYDROmorphone (Dilaudid) 1 mg
___ 23:36 IVF 1000 mL LR 1000 mL ___
___ 23:46 IV Ondansetron 4 mg ___
>
Fluids given: as above
Radiology Studies: CXR and CTA
consults called None
.
PAIN SCALE: ___ pain in the epigastrum radiating in a band to
both sides and up to the L upper chest
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No recent weight loss and rest per HPI
HEENT: [X] All normal
RESPIRATORY: [+] SOB - pain taking her breath away
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [+] chronic muscle pains s/p transplant
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [] All normal
All other systems negative except as noted above
Past Medical History:
Colonic adenoma
Impaired glucose tolerance
SLEEP DISORDER / DISTURBANCE, UNSPEC
URINARY INCONTINENCE, UNSPEC
Pulmonary nodule/lesion, solitary
Thyroid nodule
Monoclonal (M) protein disease, multiple 'M' protein
Multiple myeloma
History of stem cell transplant
Neuropathy due to drugs
Dyspnea
Positive PPD
Cough
Chronic chest and rib pain, into anterior neck
Social History:
___
Family History:
Her father died in an accident. Her mother does not have any
medical problems.
Physical Exam:
Vitals: T 97.4 P ___ BP 143/88 RR 20 SaO2 100% on RA
GEN: uncomfortable female writing in pain.
HEENT: pin point putpils b/l
NECK: supple
CV: s1s2 tachy, rr no m/r/g
RESP: b/l ae no w/c/r
ABD: hypoactive but present bs, soft, + epigastric and RUQ
tenderness no guarding or rebound
back: No spinal tenderness
GU:
EXTR:no c/c/e 2+pulses
DERM: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
Pertinent Results:
___ 11:39PM ___ COMMENTS-GREEN TOP
___ 11:39PM LACTATE-3.7*
___ 09:04PM cTropnT-<0.01
___ 03:55PM GLUCOSE-186* UREA N-19 CREAT-0.8 SODIUM-142
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-24 ANION GAP-22*
___ 03:55PM estGFR-Using this
___ 03:55PM ALT(SGPT)-23 AST(SGOT)-26 ALK PHOS-55 TOT
BILI-0.7
___ 03:55PM ___
___ 03:55PM cTropnT-<0.01
___ 03:55PM ALBUMIN-4.8
___ 03:55PM WBC-14.2*# RBC-5.07# HGB-15.5# HCT-45.2*#
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.9 RDWSD-44.6
___ 03:55PM NEUTS-47.0 ___ MONOS-7.0 EOS-0.6*
BASOS-0.6 IM ___ AbsNeut-6.71*# AbsLymp-6.30* AbsMono-0.99*
AbsEos-0.08 AbsBaso-0.08
___ 03:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
=============================
CTA CHest
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Unchanged solid 5 mm left upper lobe nodule, stable from
___, and
compatible with a benign process.
3. Stable, T5 compression deformity, unchanged from ___.
Right lower
rib lesions, question multiple myeloma involvement.
4. Partially imaged abdominal ascites.
MRCP
1. Acute pancreatitis with an acute necrotic collection, as
described above.
2. Small-to-moderate amount of ascites and small bilateral
pleural effusions,
increased from the prior CT, suggestive of significant third
spacing.
3. No evidence of cholelithiasis or choledocholithiasis.
Medications on Admission:
-The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Baclofen 10 mg PO TID
3. Lenalidomide 5 mg PO DAILY
4. Cyclosporine 0.05% Ophth Emulsion 1 drop Other DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Gabapentin 600 mg PO TID
7. Hemorrhoidal Suppository 1 SUPP PR TID PRN rectal discomfort
8. Acyclovir 400 mg PO Q12H
9. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Cyclosporine 0.05% Ophth Emulsion 1 drop Other DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Hemorrhoidal Suppository 1 SUPP PR TID PRN rectal discomfort
5. Gabapentin 100 mg PO QHS
6. Acyclovir 400 mg PO Q12H
7. Baclofen 10 mg PO TID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with a59F chest pain x2h, yelling screaming
in pain // ___ chest pain x2h, yelling screaming in pain
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath is seen, terminating in the upper to mid SVC without
evidence of pneumothorax. No focal consolidation is seen. There is no
pleural effusion. The cardiac and mediastinal silhouettes unremarkable.
Chronic appearing deformity of the posterior left eighth rib suggests prior
trauma, also seen on chest CT from ___.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with with severe ___ chest pain that radiates into the
back, tachycardic, diaphoretic, history of multiple myeloma
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 217 mGy-cm.
COMPARISON: CTA chest dated ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
A right chest wall Port-A-Cath terminates at the cavoatrial junction.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland is persistently heterogeneous with numerous small nodules.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is no evidence of pulmonary parenchymal abnormality. A 5 mm left upper
lobe nodule (02:37) is unchanged from ___. The airways are patent to the
subsegmental level.
Limited views of the upper abdomen notable for ascites.
BONES: T5 compression deformity is chronic. Sclerotic foci involving the
right lower ribs may reflect multiple myeloma. Chronic left rib deformities
are noted inferiorly.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Unchanged solid 5 mm left upper lobe nodule, stable from ___, and
compatible with a benign process.
3. Stable, T5 compression deformity, unchanged from ___. Right lower
rib lesions, question multiple myeloma involvement.
4. Partially imaged abdominal ascites.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with acute pancreatitis. // Please assess for
cholelithiasis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CTA chest on ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is minimal ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 10 cm.
KIDNEYS: The right kidney measures 10.2 cm. The left kidney measures 10 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Minimal intra-abdominal ascites. Normal appearing gallbladder with no
evidence of cholelithiasis.
Radiology Report
EXAMINATION: MRCP
INDICATION: History of multiple myeloma, in remission. Presents with
pancreatitis. Evaluate for gallstone pancreatitis.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 6 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Right upper quadrant ultrasound from ___. CTA of the
chest from ___. PET-CT from ___.
FINDINGS:
Lower Thorax: There are small bilateral pleural effusions and bibasilar
atelectasis. Within the limitations of MRI, there are no large consolidations
or nodules at the lung bases. The base of the heart is normal in size. There
is no pericardial effusion.
Liver: The liver is normal in shape and contour without morphologic features
of cirrhosis. There is no significant hepatic steatosis. No focal liver
lesion is identified. The hepatic arterial anatomy is conventional. The
portal and hepatic veins are patent.
Biliary: There is no intrahepatic biliary duct dilation. The common bile duct
measures 6 mm, which is at the upper limits of normal for a patient of this
age. It tapers smoothly to the ampulla without evidence of
choledocholithiasis or mass. There is no abnormal enhancement around the bile
ducts. The gallbladder is not distended. There is minimal wall edema, which
is likely secondary to the surrounding ascites. There is no MRI evidence of
acute cholecystitis. No gallstones are identified.
Pancreas: The pancreatic parenchyma is edematous and enlarged, compatible with
acute pancreatitis. There is no duct dilation or mass. At the junction of
the head and neck, is a 30 x 13 mm ill-defined region of of T2 hyperintensity
that is nonenhancing (1203, 79). This is compatible with an acute necrotic
collection The splenic vein is normal and patent without evidence of a
thrombus. There is no evidence of a pseudoaneurysm.
Spleen: The spleen is normal in size, measuring 7.9 cm. There are no focal
lesions.
Adrenal Glands: The bilateral adrenal glands are normal.
Kidneys: The kidneys are normal in size. There are no renal lesions or
hydronephrosis. There is extensive edema in the left retroperitoneal space,
likely related to the pancreatitis.
Gastrointestinal Tract: The stomach and small bowel are normal in course and
caliber without evidence of obstruction. The imaged portions of the large
bowel are normal. There is a small-to-moderate amount of intra-abdominal
ascites, mostly centered around the liver.
Lymph Nodes: There is no periportal, retroperitoneal, or mesenteric
lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber without evidence of an
aneurysm or significant atherosclerotic plaque.
Osseous and Soft Tissue Structures: There are no concerning osseous lesions.
Mild multilevel degenerative changes are noted throughout the spine. The soft
tissues are unremarkable.
IMPRESSION:
1. Acute pancreatitis with an acute necrotic collection, as described above.
2. Small-to-moderate amount of ascites and small bilateral pleural effusions,
increased from the prior CT, suggestive of significant third spacing.
3. No evidence of cholelithiasis or choledocholithiasis.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with pancreatitis and hypoxia // rule out
pneumonia, vol overload
TECHNIQUE: Portable chest AP radiograph
COMPARISON: Prior chest radiograph from ___.
CTA chest with and without contrast from ___
FINDINGS:
Since ___, pulmonary vascular congestion, bilateral pleural
effusions, moderate on the right and small on the left, and mild to moderate
bibasilar atelectasis, left greater than right, are new. Lung volumes are
low. Cardiomediastinal silhouette is mildly enlarged since prior study. No
pneumothorax. Right Port-A-Cath is positioned in the right atrium.
IMPRESSION:
1. Pulmonary vascular congestion, bilateral pleural effusions, moderate on the
right and small on the left, and mild to moderate bibasilar atelectasis, left
greater than right, are new since ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with worsening SOB // pls eval for volume
overload, pna
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
There is a tiny left hydro pneumothorax as evidenced by the air-fluid level on
the right and subtle lateral pneumothorax visualized in the superior upper
lung. There are small to moderate bilateral pleural effusions right greater
than left. There is mild pulmonary vascular redistribution. There is volume
loss/infiltrate in both lower lungs.
IMPRESSION:
Small right hydropneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with worsening SOB, recent CXR with recent ?
air fluid levels in RLL, pls re-eval. PLEASE DO UPRIGHT (last film was
semi-upright) // eval for signs of abcess, hydropneumothorax
TECHNIQUE: Portable chest
COMPARISON: ___ at 230
FINDINGS:
There bilateral pleural effusions right greater than left. There is volume
loss in both lower lungs. A few air bronchograms are seen on the right.
There is fluid in the right major fissure. The air-fluid level seen on the
prior study is no longer as evident. It could have just been fluid in the
fissure rather than a hydro pneumothorax. The right central line is
unchanged. The upper lungs are clear
IMPRESSION:
No air-fluid level to suggest hydro pneumothorax. The previous appearance was
likely due to fluid in the major fissure
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with acute necrotizing pancreatitis now with
rapidly rising bilirubin of uncertain cause and change in character of pain.
Evaluate for arterial clot, CBD dilation, Portal/Splenic vein thrombosis.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 57.6 cm; CTDIvol = 6.2 mGy (Body) DLP = 326.2
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 1.9 s, 0.2 cm; CTDIvol = 31.6 mGy (Body) DLP =
6.3 mGy-cm.
4) Spiral Acquisition 8.0 s, 56.0 cm; CTDIvol = 6.5 mGy (Body) DLP = 333.6
mGy-cm.
5) Spiral Acquisition 8.0 s, 56.0 cm; CTDIvol = 6.5 mGy (Body) DLP = 333.6
mGy-cm.
Total DLP (Body) = 1,002 mGy-cm.
COMPARISON: MRCP from ___
FINDINGS:
VASCULAR:
The abdominal aorta is normal in caliber without aneurysmal dilatation. The
celiac axis, SMA, bilateral renal arteries, and ___ are widely patent.
Hepatic arterial anatomy is conventional. There is no evidence of splenic
artery aneurysm. Bilateral common, internal, and external iliac arteries are
widely patent.
The portal vein is patent, as is the splenic vein. The proximal SMV is also
patent.
LOWER CHEST: There are bilateral small nonhemorrhagic pleural effusions.
There is adjacent compressive atelectasis. There is also atelectasis at the
right frontal lobe. There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder contains high density
material, likely related to vicarious excretion of contrast from prior CTA
chest. It is not distended.
PANCREAS: There is low-density material replacing much of the pancreatic neck
and body compatible with necrotizing pancreatitis. There appears to be an
enhancing capsule surrounding this region measuring approximately 4.2 x 4.4 cm
concerning for walled-off necrosis. There is also moderate peripancreatic
fluid extending into abdominal cavity, bilateral paracolic gutters and the
retroperitoneum.
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 suspicious renal lesions, stones, or hydronephrosis.
Tiny cortically based hypodensity is seen in the interpolar region of the left
kidney, too small to fully characterize but likely represent a cyst. There is
no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is colonic wall thickening involving the
distal transverse colon extending to the descending colon and rectum, which
could reflect third spacing versus inflammatory changes from acute
pancreatitis. The appendix is visualized and normal. There is no evidence of
mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is moderate amount of
free fluid within the pelvis.
REPRODUCTIVE ORGANS: The uterus is not identified. No adnexal mass is seen.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Compression deformities at the superior endplate of L3 and inferior endplate
of T12 are likely degenerative in nature.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of biliary ductal dilatation, portal/ splenic vein thrombosis,
or major arterial thrombosis.
2. Necrotizing pancreatitis with walled off necrosis in the pancreatic neck
and body measuring approximately 4.2 x 4.4 cm.
3. Moderate amount of reactive intra-abdominal and pelvic ascites.
4. Descending colonic wall thickening, which could reflect inflammation from
acute pancreatitis or third spacing.
5. Small bilateral pleural effusions with adjacent compressive atelectasis.
NOTIFICATION: Findings discussed with ___ phone at 4:40pm on
___, 5 minutes following discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new dobhoff tube placement // evaluate
tube placement
IMPRESSION:
As compared to previous radiograph from earlier the same date, a Dobhoff tube
is been placed, with distal tip terminating in the region of the
gastroduodenal junction no other relevant change since recent radiograph.
Radiology Report
INDICATION: ___ year old woman with severe pancreatitis // location of tip of
dobhoff tube
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None.
FINDINGS:
A Dobhoff tube is seen in the stomach, with its tip terminating in the
pylorus/antrum. There are no abnormally dilated loops of large or small
bowel. There is no free intraperitoneal air.
Osseous structures are unremarkable. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies.
IMPRESSION:
Dobhoff tube in place with tip terminating in the pylorus/antrum.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ year old woman with history of multiple myeloma s/p SCT, on
maintenance Revlimid, now here w/ severe necrotizing pancreatitis but with new
neck pain. // ultrasound of soft tissues of neck. Has pain on left anterior
side, near hyoid, I think I feel a 1cm firm lymph node. Would like to eval
for lymphadenopathy.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left neck.
COMPARISON: CTA chest dated ___ and PET-CT dated ___.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left side of the neck. No sonographic abnormality is seen to correspond to
the area of pain. No lymphadenopathy.
Partially imaged thyroid gland demonstrates multiple nodules.
IMPRESSION:
1. No sonographic correlate to the area of pain in the left neck.
2. Partially imaged thyroid demonstrates multiple nodules. Recommend
non-urgent outpatient thyroid ultrasound for further evaluation of thyroid
nodules, if this has not already been performed.
RECOMMENDATION(S): Partially imaged thyroid demonstrates multiple nodules.
Recommend non-urgent outpatient thyroid ultrasound for further evaluation of
thyroid nodules, if this has not already been performed.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Acute pancreatitis, unspecified, Chest pain, unspecified, Unspecified abdominal pain
temperature: 98.6
heartrate: 122.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 62.0
level of pain: 10
level of acuity: 3.0 | The patient is a ___ year old female with h/o MM s/p SCT in ___
now maintained revlimid in remission who presents with acute
onset of n/v and severe abdominal pain found to have acute
pancreatitis.
# ACUTE PANCREATITIS - Lipase 28,000 with focal hemorrhagic
necrosis on MRCP otherwise negative for stone, ductal dilation,
third spacing noted. Most likely etiology is idiopathic vs.
Revlimid induced vs autoimmune. No evidence of end organ failure
but extensive third spacing with pulm edema and mild hypoxia
worsened by shallow breathing/splinting, tachycardia likely
exacerbated by dysautonomia from chemo (peripheral neuropathy,
resting heart rates in clinic ~100). She had significant
improvement after IV fluids and autodiuresis, with gradual
improvement in underlying pancreatitis on bowel rest. She was
started on enteral feeding via tube feeds, which she was
initially able to tolerate, however became increasingly
intolerant of the tube (throat pain). She pulled this out
herself. Thereafter, she was able to tolerate a PO diet without
difficulty, and was discharged on ___ with follow up planned
with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with recent dx of multiple
myeloma on Velcade and longer known AFIB on Xarelto presents to
ED dyspnea on exertion so severe that he can no longer function.
The dyspnea has been getting worse for weeks. He was scheduled
for a Cardiac MR in early ___ but his symptoms have become
so
bad, he presented to ED.
Work up in ED: negative. CTA/CXR: NO PE; No PNA; no edema.
Trops,
Lactate, WBC, HGB, vitals: WNL. Physcical exam/lung exam:
unremarkable other than some mild-mod ___ edema which could
certainly drug-related.
Pt reports worsening DOE over weeks and some moderate ___ edema.
Also reports episodic chills but not fevers. Complains of
constipation.
Denies: wheezes, cough, H/A, N/V, dysphagia, CP, palpitations,
Abd pain, dysuria, bleeding of any kind.
In the ED, initial vitals: T 97.3 HR 85 BP 113/79 RR ___ O2
96% on RA
Past Medical History:
PAST ONCOLOGIC HISTORY: (per outpatient note dated ___:
"Presented to hospital in early ___ with report of
6mths of progressive fatigue, DOE, and 10 day history of fevers,
sweats, body aches, and excessive thirst. Work-up revealed lytic
bone lesions, ___, anemia, monoclonal urine protein spike,
nephrotic range proteinuria and elevated serum light chains
concerning for multiple myeloma. Preliminary BM bx results from
___ showing lambda restricted plasma cell dyscrasia.
___: started on Velcade / Dex."
PAST MEDICAL HISTORY:
# Atrial fibrillation
# Seronegative inflammatory arthritis
# Prior hepatitis A
# Prior pneumonia (around the time swine flu was happening)
complicated by L empyema requiring VATS ___
# Prostate cancer s/p resection of the prostate ___ ago (with
no radiation or other treatment) ___
# Shingles ___ years ago, complicated by post-herpetic neuralgia
in
the R shoulder region
# Cataracts, macular fibrosis and degeneration
Social History:
___
Family History:
Mother had emphysema. Father had lung cancer.
Physical Exam:
VITAL SIGNS: 97.4 PO 100 / 64 ___ 77___
General: NAD
HEENT: MMM
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored no crackles no wheezing
ABD: BS+ SNT/ND
LIMBS: + distal ___, improving from prior, WWP
SKIN: No rashes on extremities
NEURO: Speech fluent, strength grossly intact
PSYCH: thought process logical, linear, future oriented
Pertinent Results:
___ 07:35AM BLOOD WBC-8.1 RBC-3.61* Hgb-11.2* Hct-34.4*
MCV-95 MCH-31.0 MCHC-32.6 RDW-14.6 RDWSD-51.7* Plt Ct-73*
___ 12:05AM BLOOD WBC-10.0 RBC-3.89* Hgb-12.0* Hct-36.4*
MCV-94 MCH-30.8 MCHC-33.0 RDW-14.6 RDWSD-50.2* Plt Ct-83*
___ 12:05AM BLOOD Neuts-80.9* Lymphs-8.6* Monos-8.4
Eos-0.1* Baso-0.2 NRBC-0.7* Im ___ AbsNeut-8.12*
AbsLymp-0.86* AbsMono-0.84* AbsEos-0.01* AbsBaso-0.02
___ 07:35AM BLOOD Glucose-67* UreaN-15 Creat-1.0 Na-139
K-3.8 Cl-105 HCO3-22 AnGap-12
___ 12:05AM BLOOD Glucose-107* UreaN-30* Creat-1.1 Na-138
K-4.0 Cl-107 HCO3-21* AnGap-10
___ 07:35AM BLOOD Glucose-67* UreaN-15 Creat-1.0 Na-139
K-3.8 Cl-105 HCO3-22 AnGap-12
___ 12:05AM BLOOD Glucose-107* UreaN-30* Creat-1.1 Na-138
K-4.0 Cl-107 HCO3-21* AnGap-10
___ 07:35AM BLOOD ALT-23 AST-20 LD(LDH)-212 AlkPhos-69
TotBili-0.4
___ 12:05AM BLOOD ALT-25 AST-21 AlkPhos-74 TotBili-0.3
___ 07:35AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.1 UricAcd-5.6
___ 12:05AM BLOOD Albumin-3.7 Calcium-8.7 Phos-4.3 Mg-2.0
___ 12:19AM BLOOD Lactate-1.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO BID
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Flecainide Acetate 100 mg PO Q12H
4. Rivaroxaban 15 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *bisacodyl 5 mg ___ tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Magnesium Citrate 300 mL PO ONCE:PRN constipation
3. Polyethylene Glycol 17 g PO BID
hold for loose stools
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 gm by mouth
twice a day Disp #*60 Packet Refills:*0
4. Senna 17.2 mg PO BID
hold for loose stools
RX *sennosides [Senokot] 8.6 mg 17.2 mg by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Acyclovir 400 mg PO BID
6. Diltiazem Extended-Release 180 mg PO DAILY
7. Flecainide Acetate 100 mg PO Q12H
8. Rivaroxaban 15 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Myeloma
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chills and left-sided rales, immunosuppressed
// Pneumonia?
COMPARISON: Chest radiograph from ___
FINDINGS:
PA and lateral views of the chest provided.
Hyperinflation with flattening of the diaphragms. There is no focal
consolidation, effusion, or pneumothorax. There are no signs of congestion or
edema. The cardiomediastinal silhouette is normal. Pectus excavatum
deformity is noted evidence of displaced fracture. Nipple shadows are noted.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with multiple myeloma, bilateral lower extremity
swelling // Blood 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 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.
Left-sided ___ cyst measuring approximately 4.9 x 1.7 x 5.9 cm.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Left-sided ___ cyst measuring up to 5.9 cm.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with multiple myeloma, worsening shortness of breath
// Pulmonary embolism?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.6 mGy (Body) DLP = 0.8
mGy-cm.
2) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 6.5 mGy (Body) DLP = 3.2
mGy-cm.
3) Spiral Acquisition 4.5 s, 35.3 cm; CTDIvol = 8.0 mGy (Body) DLP = 280.8
mGy-cm.
Total DLP (Body) = 285 mGy-cm.
COMPARISON: CT of the chest from ___..
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Ascending aorta is mildly dilated, measuring up to 4.0 cm. No evidence of
dissection or intramural hematoma. Right heart is enlarged, otherwise heart,
pericardium, and great vessels are within normal limits. Independent origin
of the left vertebral artery. 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: Lungs are clear without masses or areas of parenchymal
opacification. Bibasilar atelectasis. Right apical granuloma and pleural
scarring. The airways are patent to the level of the segmental bronchi
bilaterally. Mild airway wall thickening likely related to inflammation.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Diffuse osseous demineralization and mild degenerative changes of the
shoulders.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mildly thickened airway walls, may be secondary to inflammation.
3. Mild enlargement of the ascending aorta, up to 4 cm. Enlargement of the
right heart which may be related to underlying atrial fibrillation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Shortness of breath, Other specified abnormal findings of blood chemistry, Dyspnea, unspecified
temperature: 97.3
heartrate: 85.0
resprate: 24.0
o2sat: 96.0
sbp: 113.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ w/ MM on Velcade, Afib on Xarelto, who p/w
progressive DOE. Preceded his MM diagnosis but recently worse
and thought to be due to velcade. His vital signs were
underranged, normal O2 sats with ambulation and at rest. CTA
ruled out PE and PNA. Seen by cardiology who did not feel this
was related to the afib nor did they think there was a component
of CHF despite his ___. His EKG and labs were unremarkable. His
symptoms progressively improved spontaneously while inpatient
and was able to ambulate in the hallway. His ___ spontaneously
improved. Reviewed w/ BMT team and they feel this may be due to
an indiosyncratic velcade reaction however we will need to
evaluate for cardiac amyloidosis. A cardiac MRI was not able to
be arranged inpatient and will be able to have this done as an
outpatient, date TBD. He had good HR control and was not in RVR.
He had constipation attributed to his MM therapy and improved
with bowel regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
___ drainage of ___ fluid collection
History of Present Illness:
___ yo G3P2 woman s/p colposcopy with biopsy, ECC and mirena
exchange
___ who presented to the ED with diffuse abdominal pain and
fever starting ___. Reported abdominal pain is diffuse, not
localizing, overall feeling of tenderness, constant x 5 days
without acute change today. Reports intermittent fevers to 102
at
home. pain and fevers improve with ibuprofen/Tylenol. Also has
muscle soreness in thighs and arms. Feels occasional SOB due to
abdominal pain
with deep breaths. no CP. denies cough, rhinitis, dysuria.
occasional
nausea, no emesis. no diarrhea. reports BM.
She had small amount of vaginal spotting, brown colored, no
malodor.
Past Medical History:
OBHx:
- G3P2, SVD x 2, SAB x 1
GynHx:
- h/p colpo ___, LSIL, +hrHPV
- denies h/o fibroids, Gyn surgery, STIs
PMH:
- denies
PSH:
- none
Meds:
ranitidine
mirena IUD
Allergy:
NKDA
FHx: denies bleeding/clotting disorders, gyn/GI malignancies. FH
of breast cancer
SHx: ___
Family History:
denies bleeding/clotting disorders, gyn/GI malignancies. FH
of breast cancer
Physical Exam:
Physical exam on Admission:
VS:
3 99.8 102 112/48 18 100% RA
Gen: A&Ox3, NAD
CV: RRR
Pulm: no respiratory distress
Abd: soft, nondistended, + rebound, -guarding. diffuse abdominal
tenderness. no increased suprapubic pain.
Back: + b/l costovertebral angle TTP
Ext: no calf TTP/edema
Pelvic:
SSE: normal external female genitalia, cervical os visually
closed with small amount white/brown discharge. bx site at 12
o'clock mild bleeding ___ scopette, healthy appearing bed.
SVE: mild cervical tenderness to palpation, no uterine
tenderness, no adnexal tenderness
Physical Exam on Discharge:
O:
Vitals: ___ 0327 Temp: 99.1 PO BP: 107/68 R Lying HR: 90
RR:
16 O2 sat: 96% O2 delivery: Ra
PE:
Gen: NAD, resting comfortably in hospital bed.
CV: RRR
Pulm: LCTAB, no respiratory distresss or crackles
Abd: soft, no rebound tenderness or guarding from yesterday,
tender to deep palpation with most pain in RUQ.
Pertinent Results:
___ 06:22AM BLOOD WBC-7.7 RBC-3.79* Hgb-11.4 Hct-33.5*
MCV-88 MCH-30.1 MCHC-34.0 RDW-12.8 RDWSD-41.5 Plt ___
___ 10:20AM BLOOD WBC-9.2 RBC-3.62* Hgb-11.0* Hct-32.0*
MCV-88 MCH-30.4 MCHC-34.4 RDW-12.5 RDWSD-40.8 Plt ___
___ 06:15AM BLOOD WBC-9.5 RBC-3.59* Hgb-10.9* Hct-31.9*
MCV-89 MCH-30.4 MCHC-34.2 RDW-12.5 RDWSD-41.1 Plt ___
___ 05:45PM BLOOD WBC-11.2* RBC-4.29 Hgb-13.0 Hct-37.6
MCV-88 MCH-30.3 MCHC-34.6 RDW-12.4 RDWSD-39.7 Plt ___
___ 06:22AM BLOOD Neuts-81.6* Lymphs-9.2* Monos-6.4
Eos-0.7* Baso-0.3 Im ___ AbsNeut-6.25* AbsLymp-0.70*
AbsMono-0.49 AbsEos-0.05 AbsBaso-0.02
___ 10:20AM BLOOD Neuts-93* Bands-1 Lymphs-4* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.65*
AbsLymp-0.37* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.00*
___ 06:15AM BLOOD Neuts-89.0* Lymphs-3.6* Monos-5.6
Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.41* AbsLymp-0.34*
AbsMono-0.53 AbsEos-0.01* AbsBaso-0.03
___ 05:45PM BLOOD Neuts-88* Bands-4 Lymphs-2* Monos-6 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-10.30* AbsLymp-0.22*
AbsMono-0.67 AbsEos-0.00* AbsBaso-0.00*
___ 10:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Acantho-OCCASIONAL
___ 05:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Ovalocy-OCCASIONAL
___ 06:22AM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-141
K-3.6 Cl-103 HCO3-26 AnGap-12
___ 05:45PM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-140
K-3.5 Cl-100 HCO3-25 AnGap-15
___ 01:15AM BLOOD ___ PTT-33.1 ___
___ 12:46AM BLOOD ___ PTT-34.1 ___
___ 05:45PM BLOOD ALT-21 AST-21 AlkPhos-145* TotBili-0.8
___ 06:22AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2
___ 05:45PM BLOOD Albumin-3.2*
___ 05:52PM BLOOD Lactate-1.4
Imaging:
CT A/P ___:
1. 6.5 x 2.2 x 6.3 cm mildly complex focal fluid collection
adjacent to the
right lobe of the liver as well as a small amount of mildly
complex abdominal
and pelvic free-fluid. Findings could reflect hematoma and
hemoperitoneum,
though no source is evident, with infection also not excluded.
Correlation
with clinical history is recommended, and consider further
assessment with
MRI.
2. Appendix is not visualized and appendicitis cannot be
excluded. Consider
repeat CT with oral and intravenous contrast if appendicitis
remains of
clinical concern.
3. Smooth peritoneal enhancement suggests peritonitis.
4. Normal uterus with IUD in appropriate position. No free
intraperitoneal
air.
5. Trace left pleural effusion with mild bilateral lower lobe
atelectasis.
Chest X ray ___:
IMPRESSION:
Left lower lobe atelectasis and trace left pleural effusion.
Pelvic US ___:
1. Tubular structure within the right adnexa adjacent to the
ovary with
increased vascularity, likely representing salpingitis, and
raises concern for
pelvic inflammatory disease considering the findings on the
recent CT.
2. Normal uterus and ovaries. Satisfactory position of the IUD
within the
endometrial cavity.
3. Small volume free fluid within the pelvis.
US guided interventional radioalogy drainage of perihepatic
fluid:
Technically successful US-guided aspiration of right perihepatic
collection.
Samples sent to laboratory for microbiologic and cytologic
evaluation.
Medications on Admission:
ranitidine
mirena IUD
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
do not exceed 4g in 24 hours
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*25 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*37 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
may cause drowsiness, do not drive while taking
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pelvic inflammatory disease
perihepatic fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: please eval for iud placement, perforation
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
The uterus is anteverted and measures 9.0 x 4.7 x 6.1 cm. The endometrium is
homogenous and measures 7 mm. The IUD was demonstrated within the endometrial
cavity. The IUD appears satisfactorily placed. There is a small amount of
fluid within the endometrial canal.
The ovaries are normal. However, there is a tubular structure within the
right adnexa adjacent to the right ovary, which demonstrates increased
vascularity, likely representing the fallopian tube with salpingitis. Small
volume free fluid within the pelvis.
IMPRESSION:
1. Tubular structure within the right adnexa adjacent to the ovary with
increased vascularity, likely representing salpingitis, and raises concern for
pelvic inflammatory disease considering the findings on the recent CT.
2. Normal uterus and ovaries. Satisfactory position of the IUD within the
endometrial cavity.
3. Small volume free fluid within the pelvis.
Radiology Report
INDICATION: ___ year old woman with perihepatic fluid collection.// ?
hematoma, abscess?
COMPARISON: CT abdomen pelvis ___.
PROCEDURE: Ultrasound-guided drainage of perihepatic collection.
OPERATORS: Dr. ___ resident and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, 18- and subsequently 15-gauge
hypodermic needles were advanced into the collection. Collection was highly
viscous/thick, and only scant samples of the collection where able to be
obtained with a 15 gauge needle. The position of the needle was confirmed
within the collection via ultrasound.
<5 cc cc of thick, gelatinous fluid was drained with samples sent for
microbiology evaluation. The needle was removed and sterile dressings were
applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
FINDINGS:
Targeted grayscale and color Doppler ultrasound of the right upper quadrant
demonstrate a circumscribed, heterogeneously echogenic 6.0 x 2.9 x 5.1 cm
perihepatic collection along the anterolateral aspect of segment VI, exerting
medial mass-effect on the liver capsule. No internal vascularity is seen.
IMPRESSION:
Technically successful US-guided aspiration of right perihepatic collection.
Samples sent to laboratory for microbiologic and cytologic evaluation.
NOTIFICATION: The findings above were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:00 pm, 10 minutes
after discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Unspecified abdominal pain
temperature: 99.8
heartrate: 102.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 48.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a ___ G3P2 who presented to the ED with abdominal
pain and fever. She had undergone a colposcopy, Mirena IUD
removal/replacement on ___ and then presented on ___
with diffuse abdominal pain and ___ complex fluid
collection. She had a CT showing abdominal fluid collections
concerning for peritonitis. Surgery was also consulted to rule
our appendicitis. Surgery recommendations did not show concern
for appendicitis and did not recommend any further imaging or
procedures. Given recent instrumentation she was treated for
presumed pelvic inflammatory disease. She was treated with IV
ceftriaxone and then transitioned to PO doxycycline and flagyl.
With regard to the perihepatic collection, she underwent ___
guided drainage of the collection. ___ was only able to drain
about 5 cc of thick gelatinous fluid that did not appear to have
blood or to be infected. The specimens were sent off to
microbiology. Extensive review of the literature to investigate
the relationship between post procedure IUD and a RUQ
collection, it was determined that the RUQ collection was not
due to the recent IUD placement as ___ is an
adhesive disease. There was no suggestion of uterine perforation
based on the TVUS which showed the IUD to be in the correct
place and ___ drainage with no evidence of heme in the abdominal
cavity. IT was also found in her Atrius health records that she
was found to have a 6 cm perihepatic collection in ___
which confirmed that the IUD placement is not related to the RUQ
collection. While in the hospital, she remained afebrile. With
regard to her left pleural effusion, patient continued to have
normal 02 saturations with a clear lung sounds bilaterally thus
this incidental finding was not pursued further.
Per CDC guidelines, she was continued on PO doxycycline and
flagyl and discharged with these medications to complete a 14
day course. Her pain from the PID was controlled with
acetaminophen and oxycodone which she was discharged with. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lovastatin
Attending: ___.
Chief Complaint:
acute renal insufficiency, dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of atrial fibrillation on coumadin, prostate cancer,
TIA, HTN, HLD who was sent in by his primary care doctor for
admission because of increasing creatinine with unclear
etiology. In the ED the patient states that he has been having
some mild shortness of breath and otherwise is without other
symptoms. He denies any fevers, chills, chest pain. Otherwise
the patient does not have any abdominal pain. He does not have
any dysuria or oliguria.
.
He was recently admitted to ___
___ for pleuritic chest pain. He had some nocturnal fevers,
afebrile during the day. No etiology for the CP or the fever was
found. Since discharge the pain has resolved, but he remains
weak, with dyspnea on exertion and fatigue. Saw PCP ___ ___
found to have an elevated Cr and rechecked ___ was upto 2.9.
Given that the contrast was 2 weeks ago, it was thought that he
needed further evaluation for ___.
.
VS in the ED were initially 98.8 73 129/71 16 96% RA
.
VS prior to transfer: 75, RR: 24, BP: 122/58, Rhythm: Atrial
Fibrillation, O2Sat: 95, O2Flow
.
On the floor, patient reports that he last felt his usual self,
able to walk without dyspnea weeks ago before his
hospitalization. States cannot even tie his shoelaces without
dyspnea. Denies any chest pain currently, dyspnea. Denies PND or
orthopnea, sleeps on 1 pillow. No fevers since he left ___
hospital around ___.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
prostate cancer s/p XRT approx ___
atrial fibrillation
TIA
liver fibrosis secondary to etoh use
peripheral neuropathy
OSA on CPAP
spinal stenosis
HTN
HLD
h/o shoulder surgery
Social History:
___
Family History:
No history of kidney disease
Physical Exam:
Vitals: 97.9, 120/80, 85, 18, 96/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP to mandible
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, pitting b/l ___ edema to
thighs
Exam on discharge:
VS: 130s/80s HR ___, RR 16 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP noted 1-2 cm above clavicle
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi. Diminished breath sounds at bases, improved from prior
exam.
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, 1+ pitting b/l ___ edema to
knees
Pertinent Results:
On admission:
___ 11:20AM BLOOD WBC-7.7 RBC-2.90* Hgb-8.8* Hct-27.6*
MCV-95 MCH-30.4 MCHC-32.0 RDW-14.0 Plt ___
___ 11:20AM BLOOD Neuts-75* Bands-0 Lymphs-15* Monos-10
Eos-0 Baso-0 ___ Myelos-0
___ 11:20AM BLOOD ___ PTT-48.5* ___
___ 11:20AM BLOOD Glucose-103* UreaN-26* Creat-2.2* Na-138
K-5.2* Cl-106 HCO3-19* AnGap-18
___ 11:20AM BLOOD ALT-15 AST-37 AlkPhos-181* TotBili-0.9
___ 11:20AM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.3 Mg-2.2
___ 11:10AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 Iron-29*
___ 11:10AM BLOOD calTIBC-304 VitB12-1821* Folate-7.2
Ferritn-187 TRF-234
___ 12:30PM URINE Color-Straw Appear-Clear Sp ___
___ 12:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:30PM URINE Hours-RANDOM Creat-51 Na-10 K-25 Cl-15
TotProt-14 Prot/Cr-0.3
___ 10:28PM URINE Eos-NEGATIVE
Microbiology
___ URINE URINE CULTURE-FINAL INPATIENT
Imaging
Final Report
HISTORY: To evaluate pleural effusions.
FINDINGS: In comparison with the previous study, there are
moderate pleural
effusions bilaterally, more prominent on the left. Enlargement
of the cardiac
silhouette is unchanged. Retrocardiac opacification reflects
atelectasis as
well as effusion. No definite vascular congestion.
___. ___
___: SUN ___ 5:32 ___
creatinine 1.1 at discharge with diuresis
Hct 29.2
SPEP, UPEP (-), light chains pending (low suspicion)
urine culture (-)
Medications on Admission:
confirmed with patient's list
Vitamin D2 50,000 unit Cap Oral weekly
omeprazole 20 mg Cap, Delayed Release Oral BID
Neurontin 300 mg Cap Oral, 1 in am, 1 in pm, 2 at night
Betamethasone valerate .1% topical lotion BID
warfarin 2 mg daily
metoprolol tartrate 25 mg Tab Oral BID
nifedipine ER 30 mg Tab Oral daily
losartan 100 mg Tab Oral daily
aspirin 81 mg Tab Oral daily
Calcium 2 tablets daily
MVI daily
Ergocalciferol Vit D2
Flaxseed oil 1000mg
Discharge Medications:
1. betamethasone valerate 0.1 % Cream Sig: One (1) Appl Topical
BID (2 times a day).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
3. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime
as needed for foot pain.
6. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
9. losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: Two (2)
Tablet PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. flaxseed oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
acute kidney insufficiency,
Secondary:
anemia
pleural effusion
leg edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with shortness of breath, assess for pneumonia.
TECHNIQUE: Portable AP upright radiograph of the chest.
COMPARISONS: None available.
FINDINGS: Lungs are low in volume with dense retrocardiac and patchy right
basal opacities, which may reflect atelectasis; however, particularly on the
left, pneumonia would be difficult to exclude. Accompanying pleural effusions
may also be present. No pneumothorax is seen. The heart is moderately to
markedly enlarged.
IMPRESSION:
1. Dense retrocardiac opacity and bibasal opacities could reflect atelectasis
and pleural effusion; however, infectious process would be difficult to
exclude. Accompanying pleural effusion, particularly on the left, may also be
present. Consider PA and lateral examination with full inspiration to better
assess.
2. Moderate to marked cardiomegaly.
Radiology Report
HISTORY: To evaluate pleural effusions.
FINDINGS: In comparison with the previous study, there are moderate pleural
effusions bilaterally, more prominent on the left. Enlargement of the cardiac
silhouette is unchanged. Retrocardiac opacification reflects atelectasis as
well as effusion. No definite vascular congestion.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FOR ADMIT
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, ALCOHOL CIRRHOSIS LIVER, LONG TERM USE ANTIGOAGULANT
temperature: 98.8
heartrate: 73.0
resprate: 16.0
o2sat: 96.0
sbp: 129.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of atrial fibrillation on coumadin, prostate cancer,
TIA, HTN, HLD who was sent in by his primary care doctor for
admission because of increasing creatinine with unclear etiology
and subacute dyspnea.
# Acute kidney injury: Patient with acute kidney injury over
the past weeks (1.8 ___, 2.9 ___ in the seting of
recent hospitalization and contrast exposure (CTA and CT
neck/chest with contrast). After discharge on ___, first noted
worsened creatinine was ___, at least 8 days after contrast
exposure. If this was the first increase, it seems late for
contrast induced nephropathy, but still possible. No new
medications to suggest AIN. Did have recent pulmonary illness at
___ suggesting that post-viral glomerularnephritis
possible. Presence of anemia, low grade fevers, could suggest
underlying amyloidosis or myeloma, although not a significant
amount of proteinuria. U/S kidney from ___ and
primary care doctor suggests no hydronephrosis/obstruction.
Urine eos negative. Renal consulted and SPEP/UPEP negative,
light chains still pending [addendum, absolute light chains were
elevated, as to be expected in setting ___ but ratio was
normal]. Medications were renally doesed and PPI was stopped.
Creatinine improved to 1.1 at discharge with gentle diuresis.
Patient has outpatient nephrology follow up.
# Pleural effusions/DOE: Patient endorsed DOE since at least
___. Differential included anemia and with x-ray findings,
pulmonary effusions. He was recently treated for pneumonia at
OSH. The effusion was not thought to be parapneumonic given
lack of infectious sxs, fever, leukocytosis. It was thought
likely due to a new diagnosis of CHF versus ongoing chronic
liver diease. TTE showed preserved LVEF 55-60%, relatively
preserved valvular function (1+ MR). Working diagnosis included
possible viral myopericarditis in ___, with transient
cardiac dysfuction. In setting of temporary decline in GFR,
this likely led to progression of hypervolemia. He was treated
with furosemide, and symptoms improved. He was discharged on a
few more days of daily furosemide, and will follow up closely
with his PCP, ___.
# Atrial fibrillation: Rate controlled. CHADS score of 4
suggests high risk of clot. Continued home metoprolol and
intially held coumadin given possibility of upcoming renal
biopsy however this was restarted on ___. INR remained
therapeutic, rate well-controlled.
# Anemia: Patient was noted to have a new from the beginning of
___ at which time his Hct was 39. While hospitalized in
___ it had already dropped to 39. He reported a history of
colon damage/inflammation due to radiation therapy with history
of colonoscopy with polyps in ___ and planned outpatient
endo/colonoscopy. He was guaiac negative and iron, B12 and
folate labs were unremarkable. Favor marrow suppression in
setting of acute illness as etiology, lower suspicion for occult
GI bleed (only one out of many FOBT were positive). Patient
will follow up with Dr. ___.
# Peripheral neuropathy: He was continued on home gabapentin,
renally dosed.
# OSA on CPAP: He was ordered for CPAP.
# HTN: Continued home asa, nifedipine, metoprolol and held
losartan given ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
fish derived
Attending: ___
Chief Complaint:
Chest and abdominal pain with report of purulent drainage from L
knee
Major Surgical or Invasive Procedure:
___ Angiography
History of Present Illness:
Mr. ___ is a ___ yo man with history of DMII on metformin,
arthrodesis + ORIF of L knee w/ chronic draining sinus tract,
SCC
with diffuse cutaneous involvement, HLD, HTN, MDD vs BPAD, PTSD,
opiate use disorder in remission who originally presented to the
ED with abdominal and CP, n/v, found to have BCx with GPC.
Per history obtained in the ED, the patient reported substernal
8
out of 10 chest pain that started at 6 AM ___, constant, no
relieving factors. He also noted nausea and vomiting concurrent
with the symptoms, nonbloody, nonbilious. He noted a normal
bowel
movement ___ with no blood. He was passing gas. Denied fevers
or chills, changes in vision or hearing. He does not have a
history of MI or CAD or any stress testing in the past. No
history of DVT or PE. Denies urinary symptoms.
He described a recent fall at Stop and Shop with resultant right
knee and hip pain, imaged by x-ray several days ago without
evidence of fracture or dislocation. He has continued to
ambulate
at his baseline with a cane.
-Initial vitals in the ED were: 98.2 86 152/75 16 100% RA
-Exam revealed diffuse abdominal tenderness, reducible ventral
hernia, diffuse macular skin lesions. Nl cardiac + respiratory
exam.
- Troponins x 2 were flat, WBC 10.5, glucose 169, AG 18, lactate
4.5 -> 3.3 -> 3.0 -> 2.1, ALT 51 AST 45 AP 82. VBG
7.43/38/68/26.
UA with 100 prot 150 glu, + Ket. 1 bottle BCx GPC in clusters.
- CT A/P revealed no acute abnormality IDed to account for Sx.
CXR revealed no cardiopulmonary abnormalities. Hip xray revealed
no e/o fracture or dislocation. Received stress test with no EKG
changes. EKG sinus with RBB, LAD.
-The patient was given NG SL .4 mg, LR 1L x3, Lasix 40mg,
started
on an insulin sliding scale, vanc/cef, pain control with
Tylenol,
Ibuprofen, gabapentin, and morphine 4mg x 1, morphine 2mg x 1.
-Social Work was consulted for difficulty caring for himself at
home, recommended home services.
On arrival to the floor, the patient's CP had resolved. He
continued to have diffuse abdominal pain but no nausea or
emesis.
He endorses continued R hip pain making ambulation difficult. He
denies shortness of breath. He is tearful at times describing
his
home situation.
Of note, he has a history of ORIF and arthrodesis of open tibia
plateau fracture in ___, complicated by a sinus tract and
recurrent drainage. He had osteomyelitis requiring IV Nafcillin
treatment ___ years ago, multiple I&Ds, most recently in ___,
culture growing moderate staph aureus, treated with
Bactrim/Keflex.
The patient has a psychiatric history of MDD vs. BPAD and PTSD
and episodes of SI and receives psychiatric care at ___. Currently he denies suicidal ideation, violent thoughts,
or hallucinations.
He was recently diagnosed with DMII and begun on metformin
1000mg
QD by his PCP.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
-Diagnoses: bipolar disorder (diagnosed in ___ at age ___, in
the setting of cocaine use), anxiety, ptsd
-Hospitalizations: Several, per record, including at ___
and ___ within the past year. Hospitalized on Deac4 in
___ for suicidal ideation. Most recent
hospitalization
he reports was at ___ in ___.
-Current treaters and treatment:
---Currently attending a substance recovery group therapy at
___ on ___ from 1 to 2:30. He goes to acupuncture at
___ every morning.
---Therapist at ___: ___ (last saw on ___.
---Psychiatrist at ___: Dr. ___ (last saw him on
___.
---Reports he has follow up appointments with providers in 2
weeks.
-Medication and ECT trials: Alprazolam, Fluoxetine, Bupropion,
Fluoxetine, Depakote
-Currently on suboxone
-Self-injury: Denies.
-Harm to others: Denies.
-Access to weapons: Denies.
.
Substance Use History
-History of opiate use disorder (prescription opiates for
chronic pain) on suboxone
.
Past Medical History
1. Cholelithiasis; previous cholecystitis times three, s/p
laparoscopic cholecystectomy
2. Eczema.
3. Psoriasis
4. History of squamous cell cancer of the skin.
Social History:
Born and raised in ___, estranged from family. Mother died
in early ___.
-Went to ___ and worked as a ___ but lost everything due to
drug use.
-Previously worked as a ___ in the town of
___.
-Partner committed suicide ___ years ago (per previous notes,
patient reported in ___ that it was ___ years ago). He had
been living with that partner in ___ for ___ years and came
back to ___.
-He is currently living in a sober house in ___. He
describes feeling supported by one man at the sober house, but
otherwise feels threatened by other individuals there due to
negative remarks they make about sexual orientation (patient
identifies as gay). Note From ___ describes that he had
left a sober living house back then because he was feeling
threatened by other residents).
-Spirituality: Catholic
-Trauma: As child from father. States he was abused by a partner
who committed suicide.
---Has one friend whom he's known since ___ (___) who
lives in ___. Has not been returning ___ phone calls
in a few weeks since his depression worsened.
Family History:
-Father bipolar disorder, alcohol use
-Brother had accidental overdose (suspected cocaine)
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ Temp: 97.7 PO BP: 196/110 R Lying HR: 94
RR:
18 O2 sat: 96% O2 delivery: ra
GENERAL: Alert and interactive.
PSYCH: emotionally labile, tearful at times.
HEENT: EOMI. NC/AT.
NECK: No JVD, trachea is midline.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. no
g/m/r
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Soft, distended, midline ventral hernia that is
reducible. Tender to palpation diffusely.
SKIN: Diffuse macular lesions consistent with squamous cell
carcinoma. Bleeding from lesions on dorsal L foot and R knee. No
lesions between toes or foot ulcers. Full sensation in feet.
EXTREMITIES: L knee s/p arthrodesis. Full ROM in other joints.
NEUROLOGIC: AOx3. CN2-12 intact. R hip movement made difficult
due to pain, ___ strength otherwise. Normal sensation.
DISCHARGE PHYSICAL EXAM
========================
PHYSICAL EXAM:
========================
VS REVIEWED IN OMR
GENERAL: Alert and interactive, sitting up on edge of bed,
conversational, obese.
PSYCH: mood fine, consistent with affect
HEENT: EOMI. NC/AT.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. no
g/m/r
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Softly distended, tender to palpation midline with
Ventral abdominal hernia (reducible) otherwise nontender
SKIN: Diffuse macular lesions, particularly seen on extremities.
EXTREMITIES: L knee s/p arthrodesis with small circular scar.
b/l
___ edema, swollen. well healed scar on LLE, no drainage seen
NEUROLOGIC: AOx3. Normal sensation.
Pertinent Results:
ADMISSION LABS:
___ 04:43PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:43PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-100*
GLUCOSE-150* KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 04:43PM URINE RBC-5* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 04:43PM URINE MUCOUS-RARE*
___ 04:36PM LACTATE-4.5*
___ 03:53PM cTropnT-<0.01
___ 11:20AM PO2-68* PCO2-38 PH-7.43 TOTAL CO2-26 BASE
XS-0 COMMENTS-GREEN TOP
___ 11:20AM LACTATE-3.3*
___ 11:10AM GLUCOSE-169* UREA N-18 CREAT-0.9 SODIUM-141
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
___ 11:10AM ALT(SGPT)-51* AST(SGOT)-45* ALK PHOS-82 TOT
BILI-0.5
___ 11:10AM LIPASE-29
___ 11:10AM cTropnT-<0.01
___ 11:10AM ALBUMIN-4.6
___ 11:10AM WBC-10.5* RBC-5.52 HGB-15.6 HCT-49.8 MCV-90
MCH-28.3 MCHC-31.3* RDW-16.8* RDWSD-54.2*
___ 11:10AM NEUTS-78.4* LYMPHS-12.9* MONOS-7.2 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-8.25* AbsLymp-1.36 AbsMono-0.76
AbsEos-0.01* AbsBaso-0.04
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-8.5 RBC-5.20 Hgb-14.7 Hct-48.3 MCV-93
MCH-28.3 MCHC-30.4* RDW-16.0* RDWSD-54.8* Plt ___
___ 07:15AM BLOOD Glucose-132* UreaN-12 Creat-0.9 Na-139
K-4.8 Cl-97 HCO3-24 AnGap-18
___ 07:15AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.2
IMAGING/MICRO/STUDIES:
___ Cardiac Cath
No angiographically apparent coronary artery disease.
___ TTE
Suboptimal image quality. Mild symmetric left ventricular
hypertrophy with
preserved global biventricular systolic function. Mild tricuspid
regurgitation. Normal pulmonary
pressure.
___ MR CALF ___ CONTRAST
1. Diffuse left calf subcutaneous edema and mild diffuse
muscular atrophy
without drainable fluid collection. Given artifacts from
surgical hardware,
no evidence of osteomyelitis in the non obscured portions of the
femur and
tibia.
2. Status post left knee arthrodesis, with hardware better
evaluated on prior
radiograph.
3. Similar symmetric subcutaneous edema and mild muscle atrophy
of the
visualized right lower extremity.
___ Imaging CARDIAC PERFUSION PHARM
1. Mildly transiently dilated left ventricle during stress.
2. Moderate focal apical perfusion defect during stress with
reversibility on
rest, cannot rule out ischemia.
3. When compared to the prior study in ___, there is
interval increase
in LV end-diastolic volume. The reversible apical defect is
also new.
___ Cardiovascular STRESS
IMPRESSION: No angina symptoms. No ST segment changes. Nuclear
report
sent seperately.
___ EKG
Sinus rhythm
RBBB and LAFB
Possible lateral infarct
Compared with the previous tracing of ___
No significant change was found
___BD & PELVIS WITH CO
1. No acute abnormality identified to account for this patient's
symptoms. No
ventral hernia seen.
2. Colonic diverticulosis.
3. Hepatic steatosis. See recommendations below.
4. Indeterminate 3.1 cm right lower pole renal hypodense lesion
with internal
density values slightly higher than expected for a simple cyst.
This can be
further assessed with nonemergent renal ultrasound.
5. Severe spinal stenosis at L2-3 and L3-4.
RECOMMENDATION(S):
1. Nonemergent renal ultrasound.
2. Radiological evidence of fatty liver does not exclude
cirrhosis or
significant liver fibrosis which could be further evaluated by
___.
This can be requested via the ___ (FibroScan) or the
Radiology
Department with either MR ___ or US ___, in
conjunction with a GI/Hepatology consultation" *
___ Imaging CHEST (PA & LAT)
No acute cardiopulmonary abnormality.
___ Imaging HIP UNILAT MIN 2 VIEWS
No acute fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Testosterone Cypionate 100 mg IM EVERY 2 WEEKS (TH)
2. Losartan Potassium 25 mg PO DAILY
3. LamoTRIgine 100 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Trintellix (vortioxetine) 20 mg oral DAILY
8. Buprenorphine-Naloxone Film (4mg-1mg) .5 FILM SL Q6H
9. Atorvastatin 20 mg PO QPM
10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
12. QUEtiapine Fumarate 25 mg PO BID as needed for anxiety
13. Loratadine 10 mg PO DAILY
14. Sildenafil 100 mg PO .5 - 1 TAB PO ___ HRS
15. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
16. Gabapentin 800 mg PO QID
17. Acetaminophen 500 mg PO 2 TABS Q8HRS
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM shoulder pain
RX *lidocaine [Aspercreme (lidocaine)] 4 % Please apply to your
shoulder once a day Disp #*7 Patch Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet by mouth once a day Disp
#*30 Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM
4. Acetaminophen 500 mg PO 2 TABS Q8HRS
5. Aspirin 81 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Gabapentin 800 mg PO QID
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
9. LamoTRIgine 100 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. Losartan Potassium 25 mg PO DAILY
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. QUEtiapine Fumarate 25 mg PO BID as needed for anxiety
15. Sildenafil 100 mg PO .5 - 1 TAB PO ___ HRS
16. Testosterone Cypionate 100 mg IM EVERY 2 WEEKS (TH)
17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
18. Trintellix (vortioxetine) 20 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Chest pain
SECONDARY DIAGNOSIS:
Type 2 diabetes
s/p arthrodesis + ORIF of L knee w/ chronic draining sinus tract
SCC with diffuse cutaneous involvement
HLD
HTN
MDD vs BPAD
PTSD
opiate use disorder in remission
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: History: ___ with right hip pain s/p fall.// Fracture?
Dislocation?
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
cross-table lateral views of the right hip.
COMPARISON: None
FINDINGS:
There is no acute fracture or dislocation. Mild degenerative changes are seen
in the hips with mild joint space narrowing and lateral acetabular spurring.
No diastases of the pubic symphysis or sacroiliac joints. There is no
suspicious lytic or sclerotic lesion. There is no concerning soft tissue
calcification or radio-opaque foreign body.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with CP, palpitations, N/V, diaphoresis//
Pneumonia/Wide mediastinum?
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is borderline enlarged, unchanged. The mediastinal and hilar
contours are similar in configuration. The pulmonary vasculature is normal.
Mild streaky atelectasis in the lung bases without focal consolidation. No
pleural effusion or pneumothorax is seen. There are no acute osseous
abnormalities. Mild height loss of a vertebral body at the thoracolumbar
junction is unchanged. There are mild-to-moderate multilevel degenerative
changes seen in the thoracic spine. Cholecystectomy clips are noted in the
right upper quadrant of the abdomen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: +PO contrast; History: ___ with abdominal pain and ventral
hernia.+PO contrast// Bowel obstruction?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
3) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 27.7 mGy (Body) DLP =
1,444.2 mGy-cm.
Total DLP (Body) = 1,463 mGy-cm.
COMPARISON: MRI abdomen ___, CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Minimal atelectasis is noted in the lung bases visualized lung
fields are otherwise within normal limits. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous hypoattenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Within the posterior lower pole of the left kidney is a indeterminate
hypodense lesion measuring 3.1 x 2.9 cm, essentially new from prior exams, and
with internal density values higher than expected for a simple cyst (31 ___.
Other additional subcentimeter hypodensities are too small to fully
characterize in the right kidney. Within the upper pole the right kidney is a
2.4 x 2.2 cm simple appearing 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. Diverticulosis of
the colon is noted, without evidence of wall thickening or fat stranding. The
appendix is not visualized, but no secondary signs for appendicitis are
present.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: Periportal lymph nodes measure up to 11 mm, likely related to
underlying liver disease. There is no additional 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.
Multilevel degenerative changes are seen in the imaged thoracolumbar spine
with severe spinal stenosis seen at L2-3 and L3-4.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. No
ventral hernia identified.
IMPRESSION:
1. No acute abnormality identified to account for this patient's symptoms. No
ventral hernia seen.
2. Colonic diverticulosis.
3. Hepatic steatosis. See recommendations below.
4. Indeterminate 3.1 cm right lower pole renal hypodense lesion with internal
density values slightly higher than expected for a simple cyst. This can be
further assessed with nonemergent renal ultrasound.
5. Severe spinal stenosis at L2-3 and L3-4.
RECOMMENDATION(S):
1. Nonemergent renal ultrasound.
2. Radiological evidence of fatty liver does not exclude cirrhosis or
significant liver fibrosis which could be further evaluated by ___.
This can be requested via the ___ (FibroScan) or the Radiology
Department with either MR ___ or US ___, in conjunction with
a GI/Hepatology consultation" *
* Chalasani et al. The diagnosis and management of nonalcoholic fatty liver
disease: Practice guidance from the ___ Association for the Study of
Liver Diseases. Hepatology ___ 67(1):328-357
Radiology Report
EXAMINATION: ?acute infectious process/abscess given h/o arthrodesis + ORIF
of L knee with reported pus drainage nearby and GPC clusters in blood
INDICATION: ___ yo M with h/o DM2, arthrodesis + ORIF of L knee w/ chronic
drainage, SCC with diffuse cutaneous involvement, HLD, HTN, MDD vs BPAD, PTSD,
opiate use disorder in remission who was found to have BCx with GPC, with
reported pus coming from sinus track near L knee concerning for source//
?acute infectious process/abscess given h/o arthrodesis + ORIF of L knee with
reported pus drainage nearby and GPC clusters in blood
TECHNIQUE: Multiplanar multisequence MRI of the left calf was performed with
and without IV contrast.
COMPARISON: Left knee and tibia-fibula radiograph dated ___.
FINDINGS:
The patient is status post left knee arthrodesis with intramedullary rod and
interlocking screws within the distal femur and proximal tibia. Hardware
artifact limits diagnostic evaluation of the adjacent structures. Within the
limitation, the non obscured portions of the femur and tibia demonstrate no
bone marrow signal abnormalities to suggest osteomyelitis. Postoperative
appearance of the left knee is noted.
There is diffuse subcutaneous edema in the visualized left calf. No fluid
collection identified. Skin and subcutaneous irregularity in the
posteromedial lower thigh likely represent postoperative changes. No muscle
edema. There is diffuse muscle atrophy. The visualized tendons are grossly
intact. Coronal views of the right calf also demonstrates diffuse
subcutaneous edema without definite drainable fluid collection. There is a
small right knee joint effusion. There are moderate right knee degenerative
changes. There is diffuse muscle atrophy of the right thigh.
IMPRESSION:
1. Diffuse left calf subcutaneous edema and mild diffuse muscular atrophy
without drainable fluid collection. Given artifacts from surgical hardware,
no evidence of osteomyelitis in the non obscured portions of the femur and
tibia.
2. Status post left knee arthrodesis, with hardware better evaluated on prior
radiograph.
3. Similar symmetric subcutaneous edema and mild muscle atrophy of the
visualized right lower extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Chest pain, N/V
Diagnosed with Unspecified abdominal pain, Chest pain, unspecified
temperature: 97.7
heartrate: 85.0
resprate: 20.0
o2sat: 96.0
sbp: 181.0
dbp: 102.0
level of pain: 8
level of acuity: 3.0 | ====================
PATIENT SUMMARY:
====================
Mr. ___ is a ___ yo man with history of DMII on metformin,
arthrodesis + ORIF of L knee w/ chronic draining sinus tract,
SCC with diffuse cutaneous involvement, HLD, HTN, MDD vs BPAD,
PTSD, opiate use disorder in remission who originally presented
to the ED with abdominal and CP, n/v, found to have S. Epi in
___ BCx, thought to be contaminate. His antibiotics were
stopped. He was subsequently found to have a positive stress
test as an inpatient, notable for focal apical perfusion defect,
and completed a cardiac cath, neg for coronary artery disease.
At time of discharge, he did not endorse chest or abdominal
pain.
====================
TRANSITIONAL ISSUES:
====================
#stopped meds: Suboxone
#changed meds: atorvastatin 20 to 80 mg PO qHS
#new meds: metoprolol succinate 50 mg PO daily, lidocaine patch
[ ] Follow-up appointment with cardiology pending at time of
discharge. IF this appointment is not made within ___ days of
discharge, please call ___ to arrange.
[ ] CT ABD & PELVIS WITH CO found indeterminate 3.1 cm right
lower pole renal hypodense lesion with internal density values
slightly higher than expected for a simple cyst. This can be
further assessed with nonemergent renal ultrasound.
[ ] CT ABD & PELVIS WITH CO also found radiological evidence of
fatty liver that does not exclude cirrhosis or significant liver
fibrosis. Recommend further evaluation by ___. This can
be requested via the ___ (FibroScan) or the Radiology
Department with either MR ___ or US ___, in
conjunction with a GI/Hepatology consultation"
[ ] Pain control. He opted to stop suboxone due to vomiting.
Lidocaine patch worked for shoulder pain, but he would like to
consider steroid injections. Please discuss.
[ ] Ventral abdominal hernia, reducible. Towards the end of the
stay, he expressed a desire to discuss the management of this
hernia with the surgery team. His CT ABD & Pelvis did not show a
ventral hernia. Please follow up re: management.
====================
ACUTE ISSUES:
====================
# Chest Pain
Patient endorsed chest pain in the ED, which resolved by arrival
to the floor. His initial workup notable for negative troponins,
EKG with no changes on stress test. However, given multiple risk
factors, underwent cardiac pharmacologic stress test which
showed moderate focal apical perfusion defect. Cardiology
recommended TTE and CT coronary angiography, which were negative
for coronary artery disease. He was transitioned onto high dose
atorvastatin 80mg, metoprolol tartrate 12.5 Q6hrs (consolidated
to metoprolol succinate 50 every morning on discharge), and
continued on ASA 81mg daily per their recommendations.
# S epi containment in blood cultures
On admission, one blood culture bottle grew gram positive cocci,
with presumed source L knee s/p ORIF and arthrodesis (___)
given h/o Staph aureus infection ___ and patient report of
purulent drainage. He was started on vancomycin/ceftriaxone
empirically in the ED. HIP UNILAT MIN 2 VIEWS, CT ABD & PELVIS
WITH CO, and MR CALF ___ CONTRAST were taken, without signs of
acute infection. Antibiotics were stopped when S epi was grown,
thought to be contaminant. Admission UCx <10,000 CFU. He was
afebrile throughout admission and on discharge.
#Major depressive disorder
#Opiate use disorder in remission
#Generalized anxiety disorder
#Dependent personality traits
His mood fluctuated throughout admission; he was continued on
his home regimen, after his CM ___ was able to bring
his home Vortioxetine. Psych was also consulted given his
subjective worsening mood with history of SI, who did not
recommend changes in his home medications. He did not endorse
any SI during his stay, and his mood was at baseline at time of
discharge.
#Right hip and knee pain
Pt reports hip and knee pain after a fall over the weekend. He
reports pain with ambulation, can walk with help + with his
cane. X-rays with no evidence of fracture or dislocation. ___
consulted, recommended continued home OT, ___, and ___. Continued
pain management with standing Tylenol, Motrin, Gabapentin.
#Abdominal Pain
No e/o acute pathology on CT A/P. S/p ccy. WBC 10.1 on
admission. Mildly distended, passing gas. Reducible ventral
hernia w/ no e/o strangulation. AST/ALT mildly elevated - on
discharge, AST down trended to 39, ALT at 61.
====================
CHRONIC ISSUES:
====================
#Social Work
Pt describes difficulties with self-care at home. Social work
spoke with his ___ case manager to continue services at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
milk / soy / gluten / red dye / tetracycline / aspirin / Avelox
/ NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / anesthesia -
unknown agent
Attending: ___.
Chief Complaint:
Episodes concerning for seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ RH F w PMHx of epilepsy and multiple
concussions who presents to ___ ED with increased frequency of
events concerning for seizure.
Ms. ___ follows with Dr. ___ in neurology, and his notes
summarize Ms. ___ remote medical history. More recently,
Ms. ___ reports that for the past 6 months she has had
feelings of dizziness, disequilibrium, and fatigue, with
worsening of her jerks. She attributes this to an asthma attack
which required a 5 day burst of steroids. Approximately 1 week
after stopping steroids, she had the above symptoms. Her
oxcarbazepine was increased from 450mg BID to ___ with
modest improvement in the jerks only. In the months that
followed, she had various intermittent symptoms. She describes
going on a hike and feeling like she was drifting to the left
and going to pass out.
On ___, she started to become ill and had worsening
of her asthma.
She was again placed on prednisone, this time 60mg x4-5days with
no taper. She notes that while she was on the 60mg, all over her
symptoms resolved completely (dizziness, fatigue, and jerks).
When she stopped the prednisone, however, her
symptoms returned "with a vengeance."
Ms. ___ travels for work and on ___ while in
___ she went to urgent care for evaluation of her
symptoms. She was placed on a prednisone taper (40mg x3d, 30mg
x2d, 20mg x2d, 10mg x2d, off). Again, her symptoms improved with
the steroids and returned when she stopped.
After Ms. ___ returned to ___, she saw her PCP on ___
___ they discussed her symptoms. She was restarted on
?empiric steroids (prednisone 20mg qD) to see if it would help.
Unfortunately, she states that she had not gotten any relief
from the steroids this time, and in fact her jerks seem to be
increasing in frequency and are now causing her to have some
neck pain.
Regarding Ms. ___ jerks, she states that prior to 6 months
ago, she would have jerking of the RUE and R side of the neck "a
few times a week" usually at night while falling asleep, but
sometimes during the day. With the above described worsening of
her symptoms, that frequency changed to daily, with multiple
jerks occurring each night. Currently, she is having jerking of
the RUE, R side of the neck, and R leg >10x per hour (observed
during my interview). The RLE has only been involved for the
last ___ days. She states that the jerking of her neck is also
causing her some pain. She reports waking up a few nights ago
and noticed the jerking. She wonders if she is having jerks
during sleep. She denies ever waking up with urinary
incontinence or a tongue bite.
Normal c-section birth and development, though she was
"dyslexic". She states that she started trying to learn to write
with her left hand but would write in mirror image. She then
switched to using the right hand and has been a right-hander
ever since. Recalls having sensation of ___ when she was
younger,
not in many years. She does report having "random" occurrences
of abdominal rising sensation "a couple times a year." She has
never had a CNS infection.
ROS: +fatigue, dizziness, and disequilibrium. Denies focal
weakness or numbness. She has had a lingering cold and dry cough
with congestion.
Past Medical History:
PAST MEDICAL HISTORY:
- epilepsy
1.) staring spells, started in college
- never confirmed by EEG
- started on trileptal 450mg BID with resolution of events
2.) RUE jerking +/- RLE jerking
- no EEG correlate (OSH)
- multiple concussions
- asthma
HOME MEDICATIONS:
- levetiracetam 125mg qHS
- oxcarbazepine 450mg qAM, 600mg qPM
- prednisone 20mg qD
- singulair PRN
- Advair HFA PRN
- Zyrtec PRN
ALLERGIES:
- ASA
- Avelox
- gluten
- milk
- NSAIDs
- red dye
- soy
- tetracycline
Social History:
___
Family History:
Mother - "joint issues"
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VS T:98.0 HR:80 BP:155/91 RR:18 SaO2:100RA
GEN - well appearing, well developed
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - atraumatic, WWP
NEUROLOGICAL EXAMINATION:
MS - Awake, alert, oriented x 3. Attention to examiner easily
attained and maintained. Concentration maintained when recalling
months backwards. Recalls a coherent history. Structure of
speech
demonstrates fluency with full sentences, and normal prosody. No
paraphasic errors. Intact repetition, naming, reading, and
comprehension. No evidence of apraxia or neglect.
CN - [II] PERRL 3->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light
touch
bilaterally. [VII] No facial movement asymmetry with forced
eyelid closure or volitional smile. [VIII] Hearing intact to
finger rub bilaterally. [IX, X] Palate elevation symmetric. No
dysarthria. [XI] SCM/Trapezius strength ___ bilaterally. [XII]
Tongue midline with full ROM.
MOTOR - Normal bulk and tone. No pronation, no drift.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
Observed >10 jerks during the ~1hr spent with this patient.
Jerks
consisted of <1 second of R shoulder shrug +/- head turn/tilt to
the right. One episode consisted of what appeared to be a full
body jerk with both shoulders shrugging and a quick contraction
at both hips. The jerks do not occur during activation of the
muscles of the RUE or when she is walking.
SENSORY - No deficits to light touch throughout.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
COORD - No dysmetria with finger to nose or heel-shin testing.
Good speed and intact cadence with rapid alternating movements.
Negative Romberg.
GAIT - Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Able to tandem without
difficulty. No posturing with stressed gait.
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS Tm/Tc: 98.8/98.3 HR: 56-58 BP: ___ RR: 18 SaO2:
94-98RA
GEN - sleeping, but awakens easily to vocal stim; well
appearing, well developed
HEENT - NC/AT, EEG leads in place; MMM
NECK - full ROM, no meningismus
CV - RRR without murmur
RESP - CTAB, normal WOB
ABD - ND
EXTR - atraumatic, WWP
Neurologic Exam:
MS - Awake, alert, oriented x 3. Attention to examiner easily
attained and maintained. Structure of speech demonstrates
fluency with full sentences, and normal prosody. No paraphasic
errors. No evidence of apraxia or neglect.
CN - [II] PERRL 3->2 brisk. [III, IV, VI] EOMI, no nystagmus.
[VII] No facial movement asymmetry with forced eyelid closure or
volitional smile. [VIII] Hearing grossly intact. [IX, X] No
dysarthria. [XI] SCM/Trapezius strength ___ bilaterally. [XII]
Tongue midline with full ROM.
MOTOR - Normal bulk and tone.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
SENSORY - No deficits to light touch throughout.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
COORD - No dysmetria when reaching out for objects
GAIT - Deferred
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 04:10PM BLOOD WBC-6.0 RBC-4.63 Hgb-13.7 Hct-41.6 MCV-90
MCH-29.6 MCHC-32.9 RDW-12.7 RDWSD-41.5 Plt ___
___ 04:10PM BLOOD Neuts-81.2* Lymphs-15.0* Monos-3.2*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-4.89 AbsLymp-0.90*
AbsMono-0.19* AbsEos-0.00* AbsBaso-0.02
___ 04:10PM BLOOD Glucose-102* UreaN-9 Creat-0.6 Na-136
K-4.1 Cl-98 HCO3-24 AnGap-18
___ 04:10PM BLOOD Albumin-5.2 Calcium-9.5 Phos-3.0 Mg-2.2
___ 04:10PM BLOOD ALT-41* AST-35 AlkPhos-83 TotBili-<0.2
___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
===============
DISCHARGE LABS:
===============
___ 05:10AM BLOOD WBC-6.6# RBC-4.07 Hgb-12.7 Hct-36.5
MCV-90 MCH-31.2 MCHC-34.8 RDW-12.8 RDWSD-41.8 Plt ___
___ 05:10AM BLOOD Glucose-82 UreaN-12 Creat-0.6 Na-140
K-4.0 Cl-104 HCO3-23 AnGap-17
___ 05:10AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1
___ 05:10AM BLOOD tTG-IgA-1
========
IMAGING:
========
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
====
EEG:
====
___: IMPRESSION: This is a normal continuous EEG monitoring
study. No seizures, pushbutton activations or epileptiform
discharges are recorded.
___: IMPRESSION: This continuous EEG monitoring study
records 37 pushbutton activations for jerks which consist of ___
second episodes of rightward head turn, with or without flexion
of the hips. Movements are somewhat variable, and hip flexion
can be brief or last several seconds at a time. There is no
clear electrographic correlate with any of these events.
Background activity is otherwise normal with a well-organized
and symmetric 10 Hz posterior dominant rhythm. No electrographic
seizures, pushbutton activations or epileptiform discharges are
recorded.
___: IMPRESSION: This continuous EEG monitoring study
records 14 pushbutton activations for a variety of random
appearing movements. There is no clear electrographic correlate
with any of these events. Background activity is otherwise
normal with a well-organized and symmetric 10 Hz posterior
dominant rhythm. No electrographic seizures, pushbutton
activations or epileptiform discharges are recorded.
___: IMPRESSION: This is a normal continuous ICU monitoring
study. Six events are captured for variable jerking movement
involving one or both legs, whole body or head. There are no
electrographic correlate with any of these events. There are no
electrographic seizures or epileptiform discharges.
___: IMPRESSION: This is a normal continuous ICU monitoring
study. Several events are captured for sudden jerking movement
involving both legs and torso, but without electrographic
correlate. There are no electrographic seizures or epileptiform
discharges. Compared to the prior day s recording, there are no
significant changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 125 mg PO QHS
2. OXcarbazepine 450 mg PO QAM
3. OXcarbazepine 600 mg PO QPM
4. PredniSONE 20 mg PO DAILY
5. Cetirizine 10 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. ClonazePAM 0.5 mg PO BID:PRN leg spasm
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
2. PredniSONE 5 mg PO TAPER
take 3 tabs for 3 days, then 2 tabs for 3 days, then 1 tab for
three days.
Tapered dose - DOWN
RX *prednisone 5 mg 3 tablet(s) by mouth daily Disp #*18 Tablet
Refills:*0
3. Cetirizine 10 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abnormal body movements
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with worsening of myoclonic jerks and possible
seizure // PNA?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to suggest
pneumonia.
Gender: F
Race: PATIENT DECLINED TO ANSWER
Arrive by WALK IN
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 98.0
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 155.0
dbp: 91.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ RH F w PMHx of multiple concussions
who presented to ___ ED with increased frequency of events
described as right sided leg > arm jerks with side spasm. She
was evaluated for seizure with EEG, which was negative (multiple
events were captured). The etiology of the movements remained
unclear at the time of discharge; however, it was reassuring
that her EEG was normal and her past MRI brain and C-spine was
normal. Possible diagnosis of propriospinal myoclonus (with
possible functional etiology) was considered at discharge.
Of note, because her EEG was negative for seizure, her Keppra
and oxcarbazepine were discontinued at discharge. She was
started on clonazepam 0.5 BID PRN to see if this would improve
her symptoms.
She also was on chronic prednisone for asthma; we recommended a
taper of prednisone as she was having no asthma issues at this
time. Due to a low abnormal free cortisol in the past (although
this was checked while patient was on chronic prednisone), we
recommended follow-up with endocrinology.
Also, as pt described a history of rash related to gluten
exposure and joint aches (anti-tTG pending at discharge), we
recommended follow-up with rheumatology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / erythromycin base / mesalamine
Attending: ___.
Chief Complaint:
Left Knee Pain
Major Surgical or Invasive Procedure:
L knee joint aspiration
History of Present Illness:
This is an ___ w/Hx of rheumatoid arthritis who was transferred
from urgent care for L-knee pain. Pt had a mechanical trip and
fall ___ afternoon and twisted her L-knee. At the time, she
did not have significant pain but had swelling that worsened
throughout the day and was unable to bear weight secondary to
pain. She does not take medicines and does use a cane at
baseline. She does not have a PCP. She did not strike her head
and denies headache and neck pain. She was seen at urgent care
and had an equivical knee XR and was transferred for CT.
In the ED, initial VS were 99.3 95 171/66 16 100% RA .
Exam notable for L knee hemearthrosis; non-weightbearing.
Labs showed mild hypokalemia and pyuria/bacteriuria on UA
CT head and c-spine without acute abnormality. CT of the L knee
significant for nondisplaced medial tibial fracture
Received CeftriaXONE 1 g IV ONCE, Potassium Chloride 40 meq PO
x2, Nitrofurantoin Monohyd (MacroBID) 100 mg PO ONCE , Oxycodone
5mg x2, Acetaminophen 1000 mg x2, and tramadol 50mg
Ortho trauma were consulted and recommend non operative
management.
Decision was made to admit to medicine for further management.
On arrival to the floor, ___ reports minimal nausea,
otherwise comfortable. Daughter recounts that she is more alert
now.
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.
All other 10-system review negative in detail.
Past Medical History:
Rheumatoid Arthritis
Rotator Cuff repair
Calcium Pyrophosphate Deposition Disease
Social History:
___
Family History:
None per daughter.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.1 187/78 102 16 94%RA
GENERAL: NAD
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: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no suprapubic
tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. Left leg in brace.
PULSES: 2+ DP pulses bilaterally, neurovascularly intact
NEURO: CN II-XII grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 12:23AM BLOOD WBC-8.4 RBC-4.02 Hgb-11.6 Hct-34.9 MCV-87
MCH-28.9 MCHC-33.2 RDW-13.3 RDWSD-41.7 Plt ___
___ 12:23AM BLOOD Neuts-74.8* Lymphs-9.5* Monos-15.0*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.26* AbsLymp-0.80*
AbsMono-1.26* AbsEos-0.01* AbsBaso-0.02
___ 12:23AM BLOOD Glucose-143* UreaN-34* Creat-0.9 Na-136
K-3.2* Cl-101 HCO3-26 AnGap-12
___ 12:23AM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD cTropnT-<0.01
___ 02:23PM BLOOD Lactate-1.4
___ 08:15AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:15AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:15AM URINE RBC-2 WBC->182* Bacteri-MANY Yeast-NONE
Epi-1
MICRO:
___ Blood Culture: NGTD
___ 8:17 am URINE TAKEN FROM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 12:16 pm JOINT FLUID Source: Knee LEFT KNEE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
IMAGING:
CT Head ___
Area of encephalomalacia in the right anterior temporal lobe
likely from prior infarct or hemorrhage. No acute intracranial
abnormality.
CT C-spine ___
Multilevel degenerative changes of the cervical spine without
evidence of acute traumatic injury.
CT L Lower Extremity ___
Left knee lipohemarthrosis raising concern for fracture.
Diffuse
demineralization limits evaluation however there may be a
nondisplaced fracture involving the anterior aspect of the
medial tibial plateau, as above.
CXR ___
1. Low lung volumes with mild cardiomegaly, and mild prominence
of the bilateral interstitial lung markings, suggestive of mild
central pulmonary vascular congestion.
2. No focal consolidation concerning for pneumonia.
DISCHARGE LABS
___ 07:00AM BLOOD WBC-7.9 RBC-4.05 Hgb-11.7 Hct-36.2 MCV-89
MCH-28.9 MCHC-32.3 RDW-13.5 RDWSD-44.3 Plt ___
___ 07:00AM BLOOD Glucose-124* UreaN-24* Creat-0.7 Na-138
K-4.4 Cl-102 HCO3-25 AnGap-15
___ 07:00AM BLOOD Calcium-9.6 Phos-2.5* Mg-2.3
___ 12:16PM JOINT FLUID ___ HCT,Fl-8.5* Polys-71*
___ Macro-10
___ 12:16PM JOINT FLUID Crystal-FEW Shape-RHOMBOID
Locatio-INTRAC Birefri-POS Comment-c/w calcium pyrophosphate
crystals
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This ___ is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Amlodipine 2.5 mg PO DAILY
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Please take last dose in the evening of ___.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Non displaced left medial tibial plateau fracture and subsequent
hemarthrosis
Hypertension
Urinary Tract Infection
Hypokalemia
Rheumatoid Arthritis
Calcium Pyrophosphate Deposition Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with fatigue. Evaluate for pneumonia.
TECHNIQUE: Chest upright AP and lateral
COMPARISON: None.
FINDINGS:
Lung volumes are low, causing crowding of bronchovascular structures. There
is mild cardiomegaly, with mild prominence of the interstitial lung markings,
suggesting mild central pulmonary vascular congestion. No focal consolidation
or pneumothorax identified. No evidence of pleural effusions. Degenerative
changes of the visualized AC joints and bilateral glenohumeral joints are mild
to moderate.
IMPRESSION:
1. Low lung volumes with mild cardiomegaly, and mild prominence of the
bilateral interstitial lung markings, suggestive of mild central pulmonary
vascular congestion.
2. No focal consolidation concerning for pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall. Evaluate for 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: Total DLP (Head) = 742 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a moderate focus of encephalomalacia in the right frontotemporal
region due to prior infarction. There is resultant mild ex vacuo dilatation
of the frontal horn of the right lateral ventricle. Prominence of ventricles
and sulci is reflective of involutional change. There is no acute hemorrhage
or evidence of major acute infarction. No mass effect or edema. No skull
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:
Chronic right frontotemporal encephalomalacia. Involutional changes. No
acute hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall. Evaluate for fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 724 mGy-cm.
COMPARISON: None.
FINDINGS:
There are multilevel degenerative changes in the cervical spine with endplate
sclerosis and marginal osteophyte formation. There is resultant neural
foraminal narrowing at C6-7 on the right. There is no significant central
canal stenosis, fracture, or paraspinal hematoma. The thyroid gland is
homogeneous and there are no pathologically enlarged cervical lymph nodes.
The partially imaged lung apices demonstrate calcified and noncalcified
pleural thickening.
IMPRESSION:
Multilevel degenerative changes of the cervical spine without evidence of
acute traumatic injury.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: L Knee pain
Diagnosed with Displaced bicondylar fracture of left tibia, init, Fall on same level, unspecified, initial encounter, Urinary tract infection, site not specified, Hyperkalemia
temperature: 99.3
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 171.0
dbp: 66.0
level of pain: 9
level of acuity: 3.0 | ___ y.o F presenting with a mechanical fall and left knee
swelling, with CT evidence of a left nondisplaced medial tibial
fracture with associated hemarthrosis, admitted after increased
lethargy following multiple opiate medications. Orthopedics
recommended non-surgical intervention, weight bearing as
tolerated, knee brace, and rehab. EKG significant for t-wave
inversions in the precordial leads. Troponins negative x 2.
Adequate pain control achieved with 1000mg acetaminophen TID.
She was noted to have a UTI which grew pan-sensitive E.coli,
treated with 5 days of nitrofurantoin (___). ___
hypertensive with SBPs to 170-180 and was started on amlodipine
2.5 mg daily. ___ was discharged to rehab with intent to
find ___ PCP.
# Mechanical fall: ___ presenting with a mechanical fall,
without loss of consciousness, or worrisome history for cardiac
etiology. CXR without evidence of infection. UA grossly
positive. Orthostatics were negative.
# L Nondisplaced medial tibial fracture and subsequent
hemarthrosis: She presented with L knee swelling and pain, with
a CT significant for a left nondisplaced medial tibial fracture.
She was evaluated by orthopedic surgery in the ED, and was
placed in a knee immobilizer, with weight bearing as tolerated.
She will follow up with ortho trauma clinic as an outpatient.
Pain controlled with acetaminophen 1000 mg TID, lidocaine patch,
and tramadol for breakthrough pain. ___ discharged to rehab
facility with follow up in Orthopedic Trauma clinic.
# E.Coli urinary tract infection: ___ with a grossly
positive UA, for which she received macrobid and CTX in the ED.
Culture positive for E.Coli. She denies urinary symptoms. She
was treated with nitrofurantoin 100mg q12 for 5 days,
___.
# Lethargy: Per ED records, the ___ was given several opiate
medications for pain relief, vomited, and then became lethargic.
Of note, she had a low-grade temperature to 99.3 upon arrival to
the ED, which may be subsequently masked given Tylenol. UA
grossly positive. Neurology exam nonfocal. CT head negative.
Upon arrival to the floor, the ___ easily awakens to voice
and follows simple ___ commands. ___ discharged at
baseline per family. Suggest avoiding opiate therapy in future.
# HTN: ___ with elevated SBPs in the 180s, asymptomatic. Per
the daughter, the ___ has declined medical treatment and
will not take medications. EKG with t-wave inversions in
precordial lead and left ventricular hypertrophy consistent with
long term hypertension.
# Hypokalemia: Resolved. ___ with mild hypokalemia, for
which she was given 40 meQ of potassium in the ED.
CHRONIC ISSUES
#Rheumatoid Arthritis: Not on treatment.
#CPPD: Joint aspiration significant for positively bifringement
crystals. Can consider rheumatology referal as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
TEE/Cardioversion (___)
History of Present Illness:
___ yo M with history of Afib with RVR, CMP (last ECHO ___ EF
= 30%; thought to be multifactorial, tachycardia/poorly
controlled afib, alcohol intake and possibly HIV), Mitral
regurgitation, HIV who presents from ___ cardiology with
progressively worsening DOE and orthopnea over last month along
with 4 lb weight gain.
Patient has variable dyspnea with exertion, sometimes able to
walk ___ blocks, sometimes less, patient believes it's
associated with heart rate at the time. +palpitations,
lightheadedness, orthopnea at times (baseline 1 pillow at night,
can increase if dyspnea), PND. Denies fevers, chills, cough,
chest discomfort, lower extremity edema.
In ___ his EF was down to 25% but recovered to near normal and
he was switched from amiodarone to dronaderone 400 mg BID in
___ by Dr ___ due to efforts to avoid long term toxicity of
amiodarone. Cath in ___ was negative for CAD.
Early ___ had recurrent Afib that occurred in the setting of
not taking his medications as well as significant triggers of
poor oral intake, alcohol and substance use. Cardioversion was
attempted but was not successful. Then he also had another
recurrence in ___ possibly related to ? ETOH and/or not
taking multaq but he went back into NSR spontaneously. Per
cardiology note, his compliance with cardiac medications has
been marginal. Continuing ETOH consumption remains an issue.
In ___, he presented to ___ ED with atypical CP and had
MIBI test which showed diltated LV with severe systolic
dysfunction and subsequently dronaderone was discontinued and
ECHO showed EF 30%. Outpatient ETT-MIBI was not suggestive of
ischemia with exercise duration of 9 minutes. Rhythm was AF
(baseline HR ___ throughout the study without any awareness of
AF. Metoprolol was increased and plan was for another
cardioversion once INR was therapeutic x 1 month and initiation
of another antiarrythmic, possibly sotalol but then she presents
to her cardiology office as above.
In the ED, initial VS were: 97.6 117 ___ 97%RA. Labs were
remarkable for Na 138, K 4.5, Cr 1, INR: 1.7, H/H ___. EKG
showed Afib at rate 120bpm, left axis deviation and poor R wave
progression in V1-V3 and T wave inversion in V4-V5 (Unchanged
EKG from ___. CXR showed minimal patchy left basilar opacity
that could reflect atelectasis, may be infection. Pt received IV
metoprolol 5 mg x1 and IV lasix 20 mg x1. Pt was seen by
cardiology, who recommended admission, diuresis as needed, and
plan for TEE/cardioversion on ___. VS on transfer were: 95
113/68 16 97% RA. On the floor, patient states that he is
comfortable and without respiratory distress.
Past Medical History:
Dilated non-ischemic cardiomyopathy, presumed to be secondary to
alcohol intake versus multifactorial
Atrial fibrillation
Mitral regurgitation
Impaired Glucose Tolerance
PLANTAR WARTS
HIV INFECTION
ANXIETY
TENDON SHEATH GIANT CELL TUMOR
INSTABILITY - WRIST
OSTEOARTHRITIS, LOCALIZED PRIMARY - HAND
HERPES SIMPLEX
DERMATITIS - ATOPIC
Social History:
___
Family History:
colon cancer, premature CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9, BP 104/74, HR 110, RR 18, 99% RA, Wt. 80.9kg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Tachycardic, irregularly irregular rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Unchanged from admission
Pertinent Results:
ADMISSION LABS:
___ 01:47PM BLOOD WBC-4.9 RBC-4.33* Hgb-12.9* Hct-39.4*
MCV-91 MCH-29.8 MCHC-32.7 RDW-13.2 Plt ___
___ 01:47PM BLOOD Neuts-64.3 ___ Monos-6.6 Eos-1.0
Baso-0.9
___ 01:47PM BLOOD ___ PTT-39.2* ___
___ 01:47PM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-138
K-4.5 Cl-105 HCO3-26 AnGap-12
___ 06:40AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-5.6 RBC-4.65 Hgb-13.6* Hct-43.1
MCV-93 MCH-29.3 MCHC-31.5 RDW-13.1 Plt ___
___ 06:20AM BLOOD ___ PTT-97.4* ___
___ 06:20AM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-140
K-4.5 Cl-105 HCO3-27 AnGap-13
___ 06:20AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1
TEE ___:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). The right atrium is dilated. The right
atrial appendage ejection velocity is depressed (<0.2m/s). No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is moderate to severely
depressed. The right ventricular cavity is dilated with
depressed free wall contractility. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 35 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen.
IMPRESSION: No atrial or atrial appendage thrombus. Moderate to
severely depressed global biventricular systolic function.
Moderate mitral regurgitation. Mild tricuspid regurgitation.
DCCV ___:
Pre-DCCV ECG: Atrial fibrillation, 82 bpm
Post-DCCV ECG: Atrial fibrillation, 115 bpm
IMPRESSION:
Unsuccessful electrical cardioversion of atrial fibrillation.
RECOMMENDATIONS:
1. Continued inpatient management per cardiology service.
2. Would recommend loading patient with amiodarone and
attempting
DCCV again in one month.
3. Continue anticoagulation with heparin gtt bridging to
warfarin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 75 mg PO DAILY
2. Acyclovir 800 mg PO TID Eruptions
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. Lisinopril 5 mg PO DAILY
5. Warfarin 7.5 mg PO DAILY16
6. Vitamin B Complex 1 CAP PO DAILY
7. Atazanavir 300 mg PO DAILY
8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
9. RiTONAvir 100 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Multivitamins 1 TAB PO BID
Discharge Medications:
1. Outpatient Lab Work
Diagnosis: Atrial fibrillation
Lab Order: ___
Follow up provider: ___ ___
2. Atazanavir 300 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Lorazepam 0.5 mg PO HS:PRN insomnia
6. Multivitamins 1 TAB PO BID
7. RiTONAvir 100 mg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Acyclovir 800 mg PO TID Eruptions
11. Metoprolol Succinate XL 75 mg PO DAILY
12. Amiodarone 100 mg PO TID
RX *amiodarone 100 mg 1 tablet(s) by mouth three times daily
Disp #*60 Tablet Refills:*1
13. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular rate
Acute exacerbation of CHF (non-ischemic cardiomyopathy)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Atrial fibrillation with rapid ventricular rate, congestive heart
failure, HIV, worsening dyspnea on exertion over the last month.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___ and ___.
FINDINGS:
The heart size is moderately enlarged but unchanged. Mediastinal and hilar
contours are stable. The pulmonary vasculature is not engorged. Minimal
patchy opacity in the left lung base may reflect atelectasis though infection
is not completely excluded. No pleural effusion or pneumothorax is
visualized. There are no acute osseous abnormalities.
IMPRESSION:
Minimal patchy left basilar opacity could reflect atelectasis but infection is
not completely excluded.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with ATRIAL FIBRILLATION, CONGESTIVE HEART FAILURE, UNSPEC, ASYMPTOMATIC HIV INFECTION
temperature: 97.6
heartrate: 98.0
resprate: 16.0
o2sat: 97.0
sbp: 212.0
dbp: 146.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with history of Afib with RVR, non-ischemic CMY (last
ECHO ___ EF = 30%; thought to be multifactorial from
tachycardia, poorly controlled Afib, mitral regurgitation,
alcohol intake and possibly HIV), who presented with
progressively worsening dyspnea on exertion and orthopnea over
the last month likely related to AFib with RVR causing acute on
chronic congestive heart failure. Patient was given Lasix 20mg
IV in the ED with resolution of symptoms. He had two more
episodes of subjective dyspnea without respiratory distress in
the hospital for which he was given Lasix IV and increase in
metoprolol for rate control as patient continued to be
tachycardic to HR 100-110s. Patient had cardioversion attempts
x2 on ___ with prompt return of sinus rhythm but early
return of atrial fibrillation. Plan is to have patient loaded
with Amiodarone and reattempt of cardioversion in one month.
Because of interactions with Amiodarone and Ritonavir, patient
will be loaded with reduced dose of Amiodarone of 100mg TID x 3
weeks with close follow up by outpatient cardiologist. Patient
also anticoagulated with Coumadin and was subtherapeutic while
in the hospital. INR 1.6 on day of discharge so Coumadin
increased to 10mg daily. Patient will follow up with ___
___ on day after discharge for INR check and
Coumadin dosing. Recommended decrease in Coumadin dose by 30% on
day 3 after start of Amiodarone loading due to interaction of
Amiodarone and Coumadin. Patient was also started on Lasix 20mg
daily due to symptoms of heart failure, with close follow up by
Primary Care Provider. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Betalactams / Iodine-Iodine Containing / Meropenem
Attending: ___.
Chief Complaint:
dizziness, hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/PMHx CLL and ITP, DM tx from ___ due to
persistent weakness and dizziness x 2d. Pt found to have
persistent hypoglycemia while in ___. Pt presently on
actos, sulfonylurea, had 3 blood sugars in ___ while @ ___,
then BS in 200s after multiple doses of D50. Pt reports that she
has continued to have dull left sided abdominal pain; pt has had
a distended abdomen due to established adenopathy, and states
that there has been no change in abdominal girth. She reports
that she has had a mild decrease in appetite without significant
nausea, having only had a cup of coffee today. Reports
occasional chest pain that is non-radiating and non-exertional.
.
Vitals in the ER: 97.2 78 162/50 16 99% RA. She was given
Calcium Gluconate 2g IV for K 7.4 (5.4 at ___ previously)
and Kayexylate 30g PO x1.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
On ___, received fludarabine and rituximab. She went on
to receive 2 cycles of fludarabine and then received Rituxan
alone with four weeks of consolidation. She developed febrile
neutropenia with this regimen.
From ___ to ___, she received weekly Rituxan for
thrombocytopenia that was refractory to steroids and IVIG.
In ___, she started maintenance rituximab.
From ___ until ___, she was treated with
chlorambucil for painful adenopathy and IVC compression. Her
chlorambucil therapy was interrupted due to thrombocytopenia.
Ultimately chlorambucil was stopped on ___.
Hospitalization from ___ to ___ because of airway
compromise from her lymphadenopathy that required intubation and
radiation therapy.
On ___, she began cyclophosphamide for
progression of her CLL in the form of a rising white blood cell
count as well as Coombs positive hemolytic anemia and probable
autoimmune thrombocytopenia. Rituximab was held from the ___
cycle, but she then went on to receive 5 cycles of RCD
(rituximab, cyclophosphamide, and dexamethasone). She received
Neulasta throughout this course of therapy.
On ___, she began IVIG for hypogammaglobulinemia. She
had
another treatment with IVIG on ___.
On ___, she had further progression of her CLL in the
form
of increased adenopathy within the peritoneum, retroperitoneum,
and pelvis. She was subsequently started on rituximab and
dexamethasone on ___, as well as on ___.
On ___, she began pentostatin and rituximab with the
pentostatin given at a dose of 2 mg/m2 once every three weeks.
She received 2 cycles of this chemotherapy with Neulasta
support.
On ___, she presented with increased abdominal pain and
abdominal distention, and because of this pain she required
inpatient admission.
She received cycle 1 of bendamustine on ___ and
___ at a dose of 50 mg/m2 for relapsed CLL with bulky
disease. The bendamustine was dose reduced by 50% considering
her renal function and tendency for cytopenias.
___ - ___: hospitalized for neutropenic fever.
___ - ___: hospitalized for neutropenic fever, right foot
swelling and treated for right leg/foot cellulitis and gout.
___: Cycle 2 Bendamustine 50 mg/m2 (dose reduced)/Rituximab
375 mg/m2
___: Cycle 3 Bendamustine 50 mg/m2/Rituximab 375 mg/m2
___: Cycle 4 dose reduced ___ 50 mg/m2/Rituxan 375
mg/m2.
This cycle was complicated by an acute febrile illness -
pneumonia vs. UTI.
___: Patient admitted with fever, likely UTI, and
thrombocytopenia with vaginal bleeding.
.
___ - ___: Admitted with UTI and pneumonia; had a gout
flare
.
___ - ___ R upper maxillary dental infection, right
maxillary sinusitis treated with Clindamycin and tooth
extractions
.
PAST MEDICAL HISTORY:
- Chronic ITP
- CAD s/p stent to mid-proximal LAD in ___
- Diastolic dysfunction, last EF 65%, ___
- h/o hypertensive cardiomyopathy, now resolved
- AF
- CKD ___ hypertensive nephrosclerosis, baseline Cr 1.8
- DM, Type II
- GERD
- Gout
- Hypothyroidism
- Hypertension
- Dyslipidemia
- Secondary hyperparathyroidism
Social History:
___
Family History:
- The patient notes a mother with a myocardial infarction at the
age of ___.
- A sister with a myocardial infarction at the age of ___.
- Otherwise, denies any further family history.
Physical Exam:
ADMISSION
VS:98.2, 75, 149, 51, 97% RA
GEN: Elderly man in NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
DISCHARGE
Vitals: T98.5 HR 68 BP 151/93 (120s150s/40s-90s) RR20 O2 sat 98%
RA
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, scattered cervical LAD (tender
in L anterior cervical chain/superclavicular matted
lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
in the LUSB, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, mild tenderness to the left side abdomen,
distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred; no vertiginous symptoms
with head turning.
Pertinent Results:
ADMISSION
___ 04:50AM GLUCOSE-317* UREA N-54* CREAT-2.0* SODIUM-134
POTASSIUM-7.3* CHLORIDE-103 TOTAL CO2-19* ANION GAP-19
___ 04:50AM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-70 TOT
BILI-0.3
___ 04:50AM LIPASE-34
___ 04:50AM ALBUMIN-4.8
___ 04:50AM WBC-164.1* RBC-2.81* HGB-9.7* HCT-29.2*
MCV-104* MCH-34.4* MCHC-33.1 RDW-17.3*
___ 04:50AM PLT COUNT-29*
___ 07:31AM BLOOD %HbA1c-5.5 eAG-111
___ 04:50AM BLOOD ALT-14 AST-21 AlkPhos-70 TotBili-0.3
___ 07:31AM BLOOD cTropnT-<0.01
DISCHARGE
___ 08:30AM BLOOD WBC-147.9* RBC-2.65* Hgb-9.3* Hct-26.6*
MCV-100* MCH-35.2* MCHC-35.1* RDW-16.8* Plt Ct-34*
___ 08:30AM BLOOD Plt Smr-VERY LOW Plt Ct-34*
___ 08:30AM BLOOD Glucose-100 UreaN-40* Creat-1.8* Na-146*
K-4.8 Cl-110* HCO3-23 AnGap-18
___ 08:30AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
PORTABLE CXR ___:
IMPRESSION: Mild cardiomegaly. No acute intrathoracic process.
ECG Study Date of ___ 4:53:10 AM
Artifact is present. Sinus rhythm. Atrial ectopy. The P-R
interval is
prolonged. Non-specific ST-T wave changes. Compared to the
previous tracing of ___ there is no significant change.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Carvedilol 12.5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Doxepin HCl 50 mg PO HS
8. Fluoxetine 20 mg PO DAILY
9. Fluticasone Propionate 110mcg 1 PUFF IH DAILY
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Levothyroxine Sodium 137 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. Senna 2 TAB PO DAILY:PRN constipation
16. Simvastatin 40 mg PO DAILY
17. traZODONE 50 mg PO HS:PRN insomnia
18. GlipiZIDE XL 5 mg PO DAILY
19. Lisinopril 30 mg PO DAILY
20. Pioglitazone 15 mg PO DAILY
21. Torsemide 10 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Doxepin HCl 50 mg PO HS
7. Fluoxetine 20 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Senna 2 TAB PO DAILY:PRN constipation
13. Torsemide 10 mg PO DAILY
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. traZODONE 50 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hypoglycemia/Hyperglycemia, Hyperkalemia
Secondary: Chronic Lymphocytic Leukemia
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: CLL and other medical issues, presents with dizziness and
weakness.
COMPARISON: Multiple chest radiographs, the latest from ___.
ONE VIEW OF THE CHEST:
The lungs are well expanded and clear. The cardiac silhouette is enlarged.
The mediastinal silhouette and hilar contours are normal. No pleural effusion
or pneumothorax is present.
IMPRESSION:
Mild cardiomegaly. No acute intrathoracic process.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: HYPOGLYCEMI
Diagnosed with DIAB W MANIF NEC ADULT, CHEST PAIN NOS
temperature: 98.4
heartrate: 77.0
resprate: 16.0
o2sat: 99.0
sbp: 161.0
dbp: 64.0
level of pain: 6
level of acuity: 2.0 | ___ yo ___ speaking female with h/o relapsed CLL, chronic
ITP, DM, and CKD (baseline Cr 1.9-2.1) transferred from ___
___ for persistent weakness and dizziness for 2 days, found
to have hyperkalemia and hypoglycemia initially, transferred to
___ and found to be hyperglycemic and hyperkalemic. Was
treated for her electrolyte abnormalities and was D/C on her
diabetes medications and lisinopril with outpatient followup.
ACTIVE ISSUES
# Diabetes Mellitus type 2, with Hyperglycemia after 2 days of
hypoglycemia at outside hospital from probable Sulfonurea
overdose - Patient was treated with insulin initially and her
blood sugars stabilized. Pioglitazone and Glipizide were stopped
and she was diet controleld. Fingerstick glucoses day before/of
discharge ranges from 119-141. Was not requiring sliding scale
insulin. Advised her to followup with PCP before restarting any
of her DM medications.
# Hyperkalemia - Likely related to elevated glucose levels.
Patient received regular insulin 10 unit IVx1 and 10 units SC
x1, calcium gluconate 1 g x 2, dextrose 50% x 1, and Kayexalate
60 g. Potassium levels normalized upon correction of glucose
levels. Lisinopril was discontinued pending PCP ___.
CHRONIC ISSUES
# CLL - relapsed with worsening lymphadenopathy and
lymphocytosis. Cycle 4 of bendamustine (dose-reduced)/Rituximab
in ___. Patient to follow up with Dr. ___ Heme/Onc as
outpatient.
# CKD Stage III: Baseline Cr 1.9-2. Lisinopril was held at time
of discharge (as above)
# Chronic ITP: Platelets at baseline of high ___, low ___.
.
# Chronic diastolic CHF: Patient euvolemic during admission.
Continued home Imdur, Coreg. Held lisinopril for hyperkalemia.
# Hyperlipidemia: Continued home simvastatin
.
# HTN: Continued home amlodipine
# Hypothyroidism: continued home levothyroxine
# H/o gout: continued allopurinol
TRANSITIONAL ISSUES
1) Hypertension - Stopped Lisinopril due to hyperkalemia, and
patient was hypertensive during this admission. ___ need to
uptitrate or adjust regimen if Lisinopril continues to be held.
Carvedilol was not an option due to PR interval prolongation as
well as borderline bradycardia at times on telemetry. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with metastatic pancreatic
cancer
(on modified FOLFOX6 C1D14), DM, HTN, and known pulmonary emboli
on lovenox, transferred from ___ for evaluation of
abdominal pain, and portal venous thrombosis.
AJ Labs notable for:
1) Na 130
2) AST 152, ALT 118, AP 614
3) WBC 12.6, 13.6% monos
4) Lactic acid 2.7
He is reporting abdominal pain in the right upper quadrant. He
has had nausea and vomiting and weeks of constipation without
ability to pass stool. No bloody emesis, no coffee grounds. No
black or bloody stools. Transferred to us on heparin.
Pt patient says he felt warm at home, measured temperature to
100.3, and had subjective chills and diaphoresis for the past
2.5
months.
In the ED, initial vitals: 97.3 82 149/86 20 100% RA
Exam notable for: Notable for tender to palpation in the right
upper quadrant
Labs were notable for:
1) Coags: INR 2.0, PTT 32.4
2) CBC: WBC 10.4, Hb 11.2, plt 450
3) BMP: Na 134, K 4.9, Cl 93, HCO3 26, BUN 8, Cr 0.7, AG 15
4) Lactate: 1.5
Imaging:
1) RUQ U/S: Unlikely cholecystitis, if clinical concern obtain
HIDA. Multiple liver masses up to 4.2 cm. Mildly increased flow
in main portal vein may indicate focal stenosis.
Patient was given:
___ 07:29 IV Heparin Started 1100 units/hr
___ 08:42 IV HYDROmorphone (Dilaudid) 1 mg
___ 08:46 IV Ampicillin-Sulbactam
___ 09:10 IV Ampicillin-Sulbactam 3 g
___ 11:28 IVF NS
___ 11:28 IV HYDROmorphone (Dilaudid) .5 mg
___ 12:21 IV Heparin Increase Rate by 350 u/hr to 1450
u/hr
___ 12:21 IV Heparin 3300 UNIT
___ 12:22 IVF NS 1 mL
Consults:
1) Surgery: Pt does not have cholecystitis, may have PV focal
stenosis. No surgical intervention recommended.
Decision was made to admit to OMED for pain control and IV
heparin administration.
Vitals prior to transfer were: 82 158/85 18 100% RA
On arrival to the floor, he describes midline abdominal pain for
the past 3 days, now ___. He also describes RUQ and RLQ pain
radiating to R back and flank. His vomiting has improved from
yesterday. He endorses decreased appetite. Pt says he is not
passing flatus. Pt also says he has to take smaller breaths as
his abdominal pain worsens on deep breathing.
-He denies headaches and dizziness, chest pain, nausea, or
dysuria.
Past Medical History:
PMH: appendicitis
PSH: appendectomy (as a child), ex-lap (unclear reason, as a
child)
Liver cavernous hemangioma sp excision in ___ at ___
PAST ONCOLOGIC HISTORY:
Pancreatic cancer stage IV
- ___ Developed LLQ and generalized abdominal pain, fatigue,
night sweats w/o fevers, and decreased appetite resulting in 20
lbs weight loss followed by darker urine and acholic stools.
- ___ Due to persistent and worsening symptoms, he
presented to ___ and was found to have concern for
metastatic disease on CT scan (multiple liver lesions,
pancreatic
tail mass, and L adrenal mass). He was transferred to ___.
- ___ Underwent liver biopsy which revealed
poorly-differentiated carcinoma consistent with a pancreatic
primary
- ___ CT torso demonstrated extensive liver mets and
adenopathy as well as possible xyfoid met
- ___ C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125
mg/m2
D1,8,15 with ___ ___ 500 mg BID D1-___
- ___ C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125
mg/m2
D1,8,15 with ___ ___ 500 mg BID D1-___
- ___ CT torso showed substantial reduction in tumor
burden, partial response by RECIST criteria.
- ___ C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125
mg/m2
D1,8,15 with ___ ___ 500 mg BID D1-___ C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125
mg/m2
D1,8,15 with ___ ___ 500 mg BID D1-___
- ___ CT torso showed ongoing partial response but new
PE.
Held CCR2i for 1 week and started enoxaparin
- ___ Hold chemo per pt preference
- ___ C5D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125
mg/m2
D1,8,15 with ___ ___ 500 mg BID D1-___
- ___ C6D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125
mg/m2
D1,8,15 with ___ ___ 500 mg BID D___ Held all chemo for infected tooth needing
extraction
- ___ Resume CCR2i ___ ___ 500 mg BID, C6D15
gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2
- mg/m2
- ___ CT torso showed new liver mets
- ___ End of treatment on CCR2i on trial for PD
- ___ Offered consent for ___ ___
- ___ Signed consent for ___ ___ with
pharmacogenetics
study
- ___ C1D1 Irinotecan 75 mg/m2 D1,8 lubernectidin 2 mg/m2
D1
- ___ C2D1 Irinotecan 75 mg/m2 D1,8 lubernectidin 2 mg/m2
D1
- ___ Held chemo for abdominal pain, Neupogen use, recent
ED visit, constipation. Review of OSH scan shows progressive
disease.
- ___ C1D1 FOLFOX6
PAST MEDICAL HISTORY:
SBO
Cavernous hemangioma Liver
BPV
Pancreatic cancer
DM
HTN
HOME MEDICATIONS:
The Preadmission Medication list may be inaccurate and requires
futher investigation
1. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
2. Filgrastim 480 mcg SC DAY ___ AND DAY ___ OF EACH CYCLE
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Hydrochlorothiazide 12.5 mg PO QAM
5. HydrOXYzine 25 mg PO Q6H:PRN pruritis
6. Lactulose 15 mL PO Q6H:PRN constipation
7. Lidocaine-Prilocaine 1 Appl TP PRN 30 min before access port
8. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral QID with meals/snacks
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Morphine SR (MS ___ 60 mg PO Q12H
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Prochlorperazine 10 mg PO QID:PRN nausea
13. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
dental paste
15. Acetaminophen 500 mg PO PRN Pain - Mild
16. calcium carbonate-vitamin D3 unk unk oral unknown
17. magnesium hydroxide 400 mg (170 mg) oral TID:PRN
18. Senna 8.6 mg PO BID:PRN constipation
19. Simethicone 120 mg PO QD
Social History:
___
Family History:
No family history of premature CAD, SCD or
cardiomypathies. Father with pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
Vitals: 98.5 PO 161 / 100 86 18 98 Ra
GENERAL: Pleasant young man, Appears in pain, always changing
positions due to abdominal discomfort.
HEENT: PERRLA, anicteric sclera, pink conjunctiva, Dry mucous
membranes, oropharynx clear
NECK: supple, no LAD
LUNGS: CTAB, no wheezing, rales, or ronchi, good air movement.
pt
breathing comfortably on room air
CV: RRR, normal S1, S2, no murmurs rubs or gallos
ABD: soft, hypoactive bowel sounds. exquisitely tender in RUQ.
Mildly tender on RLQ. No tenderness on L abdomen. +guarding but
no rebound.
EXT: warm and well perfused, no clubbing cyanosis or edema
SKIN: No significant rashes.
NEURO: moving all 4 extremities
ACCESS: PIV
DISCHARGE PHYSICAL EXAM
==========================
Vitals: 97.8 PO 124 / 80 87 20 100 RA
GENERAL: Pleasant young man sitting comfortably in bed, in no
acute distress.
HEENT: PERRLA, anicteric sclera, MMM, oropharynx clear
NECK: supple
LUNGS: CTAB, no wheezing, rales, or ronchi, good air movement.
pt
breathing comfortably on room air
CV: RRR, normal S1, S2, no murmurs rubs or gallos
ABD: soft, trace tenderness on RUQ. Otherwise no tenderness in
rest of abdomen, no guarding and rebound
EXT: warm and well perfused, no clubbing cyanosis or edema
ACCESS: PIV AND PORT (deaccessed).
Pertinent Results:
ADMISSION LABS
=======================
___ 07:45AM BLOOD WBC-10.4* RBC-4.56* Hgb-11.2* Hct-34.4*
MCV-75* MCH-24.6* MCHC-32.6 RDW-17.2* RDWSD-46.6* Plt ___
___ 07:45AM BLOOD ___ PTT-32.4 ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-200* UreaN-8 Creat-0.7 Na-134
K-4.9 Cl-93* HCO3-26 AnGap-15
___ 07:45AM BLOOD ALT-95* AST-96* AlkPhos-521* TotBili-0.7
___ 07:45AM BLOOD Lipase-13
___ 07:45AM BLOOD Albumin-3.3*
___ 07:45AM BLOOD %HbA1c-8.2* eAG-189*
___ 07:52AM BLOOD Lactate-1.5
DISCHARGE LABS
==================
___ 07:40AM BLOOD WBC-7.6 RBC-4.43* Hgb-11.1* Hct-32.7*
MCV-74* MCH-25.1* MCHC-33.9 RDW-17.2* RDWSD-45.3 Plt ___
___ 11:45AM BLOOD ___ PTT-35.0 ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-29.3 ___
___ 07:40AM BLOOD Glucose-240* UreaN-8 Creat-0.7 Na-135
K-5.0 Cl-93* HCO3-24 AnGap-18*
___ 07:40AM BLOOD ALT-98* AST-96* LD(LDH)-260* AlkPhos-448*
TotBili-0.7
___ 07:40AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.2
MICROBIOLOGY
===================
__________________________________________________________
___ 8:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:44 am BLOOD CULTURE 1 OF 1.
Blood Culture, Routine (Pending):
IMAGING
====================
___ Imaging LIVER OR GALLBLADDER US IMPRESSION:
1. Sludge is seen within the gallbladder, with mild thickening
of the
gallbladder wall but no dilation of the gallbladder and absent
sonographic
___ sign, making cholecystitis unlikely. If there is
significant clinical concern, HIDA can be performed for further
evaluation.
2. Hepatic metastases measure up to 4.2 cm.
3. An area of mildly increased flow through the main portal vein
may indicate focal stenosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
2. Filgrastim 480 mcg SC DAY ___ AND DAY ___ OF EACH CYCLE
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Hydrochlorothiazide 12.5 mg PO QAM
5. HydrOXYzine 25 mg PO Q6H:PRN pruritis
6. Lactulose 15 mL PO Q6H:PRN constipation
7. Lidocaine-Prilocaine 1 Appl TP PRN 30 min before access port
8. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral QID with meals/snacks
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Morphine SR (MS ___ 60 mg PO Q12H
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Prochlorperazine 10 mg PO QID:PRN nausea
13. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
dental paste
15. Acetaminophen 500 mg PO PRN Pain - Mild
16. calcium carbonate-vitamin D3 unk unk oral unknown
17. magnesium hydroxide 400 mg (170 mg) oral TID:PRN
18. Senna 8.6 mg PO BID:PRN constipation
19. Simethicone 120 mg PO QD
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *magnesium hydroxide [Pedia-Lax] 400 mg (170 mg) 1 tab by
mouth every six (6) hours Disp #*90 Tablet Refills:*0
4. Acetaminophen 500 mg PO PRN Pain - Mild
5. calcium carbonate-vitamin D3 unk unk oral Frequency is
Unknown
6. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
7. Filgrastim 480 mcg SC DAY ___ AND DAY ___ OF EACH CYCLE
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Hydrochlorothiazide 12.5 mg PO QAM
10. HydrOXYzine 25 mg PO Q6H:PRN pruritis
11. Lactulose 15 mL PO Q6H:PRN constipation
12. Lidocaine-Prilocaine 1 Appl TP PRN 30 min before access
port
13. magnesium hydroxide 400 mg oral TID:PRN constipation
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Morphine SR (MS ___ 60 mg PO Q12H
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
18. Prochlorperazine 10 mg PO QID:PRN nausea
19. Senna 8.6 mg PO BID:PRN constipation
20. Simethicone 120 mg PO QD
21. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
dental paste
22. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000
unit oral QID with meals/snacks
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Abdominal pain
Constipation
Hyperkalemia
Transaminitis
Pulmonary embolus
Portal Vein Thrombosis
SECONDARY DIAGNOSIS
===================
Pancreatic Cancer
Microcytic Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with concern for cholecystitis*** WARNING ***
Multiple patients with same last name!// r/o cholecystiits
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. There are multiple
masses within the liver consistent with known metastatic disease, the largest
of which measures 4.2 x 4.2 x 3.7 cm in the right lobe. The main portal vein
is patent with hepatopetal flow. An area of mildly increased flow in the main
portal vein may indicate focal stenosis. Appropriate direction of flow is
seen in the anterior and posterior right portal vein. There is a trace amount
of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is sludge within the gallbladder, with mild thickening of
the gallbladder wall but no dilation of the gallbladder. The gallbladder is
folded.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 10 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. Sludge is seen within the gallbladder, with mild thickening of the
gallbladder wall but no dilation of the gallbladder and absent sonographic
___ sign, making cholecystitis unlikely. If there is significant clinical
concern, HIDA can be performed for further evaluation.
2. Hepatic metastases measure up to 4.2 cm.
3. An area of mildly increased flow through the main portal vein may indicate
focal stenosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: PE, Transfer
Diagnosed with Portal vein thrombosis
temperature: 97.3
heartrate: 82.0
resprate: 20.0
o2sat: 100.0
sbp: 149.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | ___ with metastatic pancreatic cancer (on modified FOLFOX6
C1D14), DM, HTN, and known pulmonary emboli on lovenox,
transferred from ___ for evaluation of abdominal
pain iso constipation, and portal venous thrombosis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Keflex / tetracycline
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a pleasant ___ yo woman
w/ h/o cervical cancer s/p hysterectomy, hidradenitis
superativa,
afib, NIDDM who p/w RLQ abdominal pain since ___ evening.
She also endorses 2 nonbloody loose stools yesterday, Fever to
101.9, + nausea, no vomiting. Denies cough, dyspnea, or chest
pain. No history of abdominal surgeries.
In the ED, initial vitals were: 100.4 102 130/76 22 96% RA.
Labs
were notable for WBC 15.2, sodium 134. CTAP showed acute
uncomplicated diverticulitis involving the mid descending colon
and probably hepatic steatosis. Pt was given nicotine patch and
lozenge, cipro, flagyl, Tylenol and 1 L NS.
On the floor, pt tells me her pain was ___ on arrival to the ED
but it has since resolved and she only has mild TTP. She
describes having had attacks like this in the past, however only
occurring every ___ years or so. She describes the pain as
feeling
like "someone twisting her intestines". She also endorses
thirst
and headache which ___, previously ___. She has not eaten
since yesterday however states that she now feels hungry and
wants to eat.
Past Medical History:
1. Recurrent Right breast infections consistent with epidermal
inclusion cysts x 2. Generally, she presents with breast
infections that are draining and are treated with Bactroban
ointment and Keflex
2. History of cervical cancer ___ status post TAH, followed by
Dr. ___, treated with XRT, complicated by radiation
dermatitis.
3. Status post appendectomy ___.
4. History of asthma, asymptomatic since ___.
5. History of palpitations with ___ of Hearts monitor showing
episodes of quadrigeminy.
6. History of left shoulder impingement, seen by Dr. ___
___ in ___, treated with physical therapy.
Social History:
___
Family History:
Son has atrial fibrillation
Physical Exam:
Constitutional: Alert, oriented, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: obese, soft, non-tender to palpation, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Pertinent Results:
___ 01:00AM BLOOD WBC-12.6* RBC-4.46 Hgb-11.6 Hct-34.2
MCV-77* MCH-26.0 MCHC-33.9 RDW-15.4 RDWSD-42.6 Plt ___
___ 01:00AM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-139
K-3.7 Cl-105 HCO3-24 AnGap-10
___ 02:50PM BLOOD ALT-6 AST-15 AlkPhos-96 TotBili-0.8
___ 01:00AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9
___ 01:23AM BLOOD Lactate-0.7
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with LLQ pain,
epigastric pain,
feversNO_PO contrast// Eval for diverticulitis, biliary
pathology,
intra-abdominal infxn
TECHNIQUE: Single phase contrast: MDCT axial images were
acquired through the
abdomen and pelvis following intravenous contrast
administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 51.2 cm; CTDIvol = 23.7 mGy
(Body) DLP =
1,211.0 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) = 1,228 mGy-cm.
COMPARISON: Prior CT ___
FINDINGS:
LOWER CHEST: Visualized lung fields demonstrate atelectasis
without focal
consolidation. There is no evidence of pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous hypoattenuation
relative to
the spleen 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.
Colonic
diverticula are seen within the descending and sigmoid colon.
Focal area of
wall thickening with adjacent stranding and fascial thickening
is seen within
the mid descending colon with an inflamed diverticulum
identified (601:38).
There is a small amount of fluid tracking along the left
pericolic gutter and
retroperitoneum, though no fluid collection or extraluminal foci
of gas are
seen to suggest perforation. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The 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. Moderate
atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Mild grade 1 L3 on L4 and L4 on L5 anterolisthesis is present
with moderate
central canal stenosis at L4-5.
SOFT TISSUES: A small umbilical hernia containing fat is noted.
IMPRESSION:
1. Acute uncomplicated diverticulitis involving the mid
descending colon. No
drainable fluid collections.
2. Probable hepatic steatosis.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
twice a day Disp #*14 Tablet Refills:*0
2. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Afib
DM
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with LLQ pain, epigastric pain,
feversNO_PO contrast// Eval for diverticulitis, biliary pathology,
intra-abdominal infxn
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 51.2 cm; CTDIvol = 23.7 mGy (Body) DLP =
1,211.0 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) = 1,228 mGy-cm.
COMPARISON: Prior CT ___
FINDINGS:
LOWER CHEST: Visualized lung fields demonstrate atelectasis without focal
consolidation. There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous hypoattenuation relative to
the spleen 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. Colonic
diverticula are seen within the descending and sigmoid colon. Focal area of
wall thickening with adjacent stranding and fascial thickening is seen within
the mid descending colon with an inflamed diverticulum identified (601:38).
There is a small amount of fluid tracking along the left pericolic gutter and
retroperitoneum, though no fluid collection or extraluminal foci of gas are
seen to suggest perforation. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The 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. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild grade 1 L3 on L4 and L4 on L5 anterolisthesis is present with moderate
central canal stenosis at L4-5.
SOFT TISSUES: A small umbilical hernia containing fat is noted.
IMPRESSION:
1. Acute uncomplicated diverticulitis involving the mid descending colon. No
drainable fluid collections.
2. Probable hepatic steatosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with Severe sepsis with septic shock, Dvtrcli of lg int w/o perforation or abscess w/o bleeding, Elevated white blood cell count, unspecified, Fever, unspecified, Type 2 diabetes mellitus without complications
temperature: 100.4
heartrate: 102.0
resprate: 22.0
o2sat: 96.0
sbp: 130.0
dbp: 76.0
level of pain: 9
level of acuity: 3.0 | Patient observed for diverticulitis. Upon arrival to the floor
already feeling better. In AM able to tolerate diet, antibiotics
changed to PO and patient will be discharged with PCP follow up
in ___ weeks. She will continue augmentin to finish 7d course. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transient right arm weakness, unsteadiness,
Major Surgical or Invasive Procedure:
None
History of Present Illness:
NEUROLOGY INITIAL CONSULT NOTE
CC: weakness
Reason for consult: Episode of bilateral leg weakness, dizziness
This was not a code stroke
NIHSS 0
HPI:
History was obtained from patient with the help of his wife at
bedside, who provided ___ translation
___ right-handed with PMH of diabetes c/b neuropathy,
nephropathy, retinopathy, hyperlipidemia, hypertension,
peripheral neuropathy who presents to the ED with transient
episode of bilateral lower extremity weakness, right arm
weakness, difficulty speaking, and dizziness.
Patient was recently briefly hospitalized after having 2 similar
episodes. He states that on day prior to presentation to the
ED,
he had another similar episode. He was working at his job as a
___, when he noticed that he was having bilateral leg
weakness, causing him to lose balance. No falls, as patient
states he was able to hold onto objects. At the same time that
he experienced leg weakness, he states that he also had right
arm
weakness, and noticed that he had difficulty speaking. He also
endorses "dizziness", the which he means that he has no strength
and feels tired. he denies lightheadedness, chest pain, nausea,
vision changes, numbness, tingling, room spinning. With regards
to his difficulty speaking, he states that he was still able to
understand what other people were saying to him; however he was
having trouble finding words, although he was still able to
speak. He was also having difficulty dialing a phone number
into
his phone. He was also having difficulty holding onto objects
in
his right hand. He states that his episode of difficulty
speaking lasted about 30 minutes. He states that the entire
episode of bilateral leg weakness and right arm weakness lasted
about 2 hours, similar to his prior 2 episodes. He states that
the only difference between the most recent episode in the
previous 2 episodes was that and the most recent episode, he had
trouble speaking. He states that he had bilateral leg weakness
and right arm weakness during the previous 2 episodes. He
states
that his symptoms appear all at the same time, but his leg
weakness would improve first. His symptoms do not fluctuate in
intensity during the episodes. He states that his most recent
episode occurred after he had been working as a ___ for 7
hours. He states that all 3 episodes occurred after he had been
working for many hours on his feet. He states that he drinks
plenty of water and stays hydrated.
Patient went to ___, where he was referred
to come to the ED. Per wife at bedside, patient has had trouble
walking for long time, thought to be due to his diabetes. Wife
states that they have many pairs of shoes at home.
Patient was recently admitted briefly to stroke service from
___ to ___ with similar symptoms. Per previous consult
note,
patient first experienced bilateral leg weakness on ___
___.
He was at work at the time when all of a sudden his legs felt
weak to the point where he almost fell over, but his coworker
caught him. At that time, he felt unsteady, but denies feeling
dizzy. The episode lasted about 20 minutes and he was back to
baseline. He was able to continue working until the following
___ when he had a recurrence of the above symptoms, in
addition to right arm weakness and numbness. It was difficult
for him to hold objects or lifted up in the air. This episode
lasted about 3 hours. He went to bed, but woke up the next day
with persistent weakness and numbness of his right arm. During
this admission, brain MRI showed no evidence of acute
infarction.
He did have small chronic lacunar infarcts in the bilateral
basal
ganglia and adjacent white matter. CTA showed 20 to 30%
stenosis
of left ICA as well as plaque causing severe stenosis of the
left
vertebral artery. Irregularity of the left posterior cerebral
artery, diminutive right vertebral artery. It was thought that
his symptoms were representative of fatigue or exertion. He
uses
his right arm to carry heavy loads in the context of his work as
___ at a ___. His atorvastatin was increased from 20
to 40 mg daily and his losartan was increased from 50 mg to 75
mg
daily. He was also started on aspirin 81 mg.
ROS:
Positive per above
Patient denies recent fevers, chills, chest pain, nausea,
vomiting, vision changes
Past Medical History:
PMH:
Hypertension
Diabetes
History of alcohol use disorder
Hyperlipidemia
Diabetic retinopathy, neuropathy, nephropathy
Social History:
___
Family History:
not applicable
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T: 96.1 BP: 143/78 HR: 82 RR: 18 SaO2: 98
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert. Able to relate history in ___.
Attentive, Language is fluent with intact repetition and
comprehension in ___. Normal prosody. Able to name both high
and low frequency objects in ___. No dysarthria. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm. EOMI without nystagmus. Normal
saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone throughout. No pronator drift.
Slight action tremor noted in hands
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
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 light touch or pinprick. Perception
intact in bilateral big toes. Patient did have decreased
sensation to vibration in bilateral toes, present at the
malleoli, although not to weak vibration. No extinction.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response -patient withdrew feet bilaterally as he was
ticklish
-Coordination: Symmetric finger-tap bilaterally. No dysmetria on
FNF or HKS bilaterally.
-Gait: Patient was able to get up and walk independently. He
had
a cautious gait, appearing nervous that he might fall. He
states
that when he sat up, he felt a little lightheaded. He had
trouble with tandem gait.
Pertinent Results:
___ 06:30AM BLOOD WBC-6.4 RBC-4.84 Hgb-15.5 Hct-46.5 MCV-96
MCH-32.0 MCHC-33.3 RDW-12.4 RDWSD-43.8 Plt ___
___ 04:10PM BLOOD ___ PTT-30.1 ___
___ 04:10PM BLOOD AT-PND ProtCFn-PND ProtSFn-PND
___ 04:10PM BLOOD Lupus-PND dRVVT-S-PND
___ 06:30AM BLOOD Glucose-131* UreaN-17 Creat-0.6 Na-140
K-4.4 Cl-103 HCO3-24 AnGap-13
___ 06:30AM BLOOD ALT-29 AST-21
___ 03:55PM BLOOD Lipase-51
___ 06:25AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
___ 10:33PM BLOOD cTropnT-<0.01
___ 04:10PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
___ 04:10PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND
___ 04:37PM URINE Blood-NEG Nitrite-NEG Protein-20*
Glucose-200* Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-5.5
Leuks-NEG
___ 04:37PM URINE RBC-0 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-0
===============
Final Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD.
INDICATION: ___ with history of T2DM, HTN, HLD who presents
with 2w of bl leg
weakness and new word finding difficulties. // assess for any
abnormality,
concern for recent tia/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 dated ___.
FINDINGS:
There is a small region of slow diffusion with associated high
T2/FLAIR signal
in the left corona radiata and body of the caudate, new from
prior study dated
___ and consistent with an acute infarction (302:18
and 17).
There is no evidence of hemorrhage, edema, midline shift, or
mass effect.
There is redemonstration of small bilateral chronic lacunar
infarcts in the
basal ganglia and adjacent white matter. There are mild
bilateral
periventricular and subcortical T2/FLAIR white matter
hyperintensities,
nonspecific but suggestive of chronic small vessel ischemic
disease. The
ventricles and sulci are normal in caliber and configuration.
Major vascular
flow voids are present.
There are no osseous abnormalities. There is a mucous retention
cyst and mild
mucosal thickening in the left maxillary sinus, unchanged.
Otherwise, the
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are
clear. The orbits are unremarkable.
IMPRESSION:
1. Acute infarction in the left corona radiata and body of the
caudate, new
from prior study dated ___. No evidence of
intracranial
hemorrhage.
2. Redemonstration of small chronic lacunar infarcts in the
bilateral basal
ganglia and adjacent white matter.
===========
Final Report
EXAMINATION: Carotid Artery ultrasound
INDICATION: ___ year old man with acute stroke. // Eval of
stroke. ICA plaque
seen on CTA.
TECHNIQUE: Real-time grayscale, color, and spectral Doppler
ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
There is mild homogenous atherosclerotic plaque in the right
carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
CCA ___: 136 cm/s / 18.7 cm/s
CCA Distal: 103 cm/s / 23 cm/s
ICA ___: 72.9 cm/s / 13.3 cm/s
ICA Mid: 71.4 cm/s / 16.9 cm/s
ICA Distal: 87.2 cm/s / 21.8 cm/s
ECA: 127 cm/s
Vertebral: 23.5 cm/s
ICA/CCA Ratio: 0.85
The right vertebral artery flow is antegrade with a normal
spectral waveform.
LEFT:
There is mild heterogenous atherosclerotic plaque in the left
carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
CCA ___: 122 cm/s / 17.6 cm/s
CCA Distal: 102 cm/s / 19.9 cm/s
ICA ___: 66.7 cm/s / 16.1 cm/s
ICA Mid: 81.9 cm/s / 22.2 cm/s
ICA Distal: 74.8 cm/s / 13.7 cm/s
ECA: 134 cm/s /
Vertebral: 44.5 cm/s /
ICA/CCA Ratio: 0.8
The left vertebral artery flow is antegrade with a normal
spectral waveform.
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
=======================
EKG Sinus
=============
TTE
CONCLUSION:
The left atrial volume index is normal. There is a small patent
foramen ovale with premature appearance
of a few (much less than 30) agitated saline microbubbles in the
left heart after maneuvers. There is
moderate symmetric left ventricular hypertrophy with a normal
cavity size. There is normal regional and
global left ventricular systolic function. Quantitative biplane
left ventricular ejection fraction is 59
% (normal 54-73%). Left ventricular cardiac index is normal
(>2.5 L/min/m2). There is no 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 a normal
ascending aorta diameter for gender. The
aortic valve leaflets (3) appear structurally normal. There is
no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is
trivial mitral regurgitation. 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: 1) Moderate symmetric left ventricular hypertrophy
wtih normal biventricular
(as measured by LVEF/radial contractile function)
regional/global systolic function. Mild
reduction in global LV systolic strain (an early marker of
cardiomyopathy). LVEF/global strain
ratio is < 4.1 suggestive of hypertension cardiomyopathy rather
then infiltrative cardiomyopathy.
However, there is mild apical sparing pattern. A finding that
can be seen in diffuse
cardiomyopathic process as well as infiltrative heart disease.
2) Small patent foramen ovale with
many fewer than 30 microbubbles seen in the left heart at rest
and with maneuvers.
==========
Final Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with stroke, PFO // rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation
was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral
doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal
color flow and
compressibility are demonstrated in the posterior tibial and
peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Repaglinide 4 mg PO DAILY
4. Losartan Potassium 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*1
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Losartan Potassium 75 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Repaglinide 4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Ischemic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD.
INDICATION: ___ with history of T2DM, HTN, HLD who presents with 2w of bl leg
weakness and new word finding difficulties. // assess for any abnormality,
concern for recent tia/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 dated ___.
FINDINGS:
There is a small region of slow diffusion with associated high T2/FLAIR signal
in the left corona radiata and body of the caudate, new from prior study dated
___ and consistent with an acute infarction (302:18 and 17).
There is no evidence of hemorrhage, edema, midline shift, or mass effect.
There is redemonstration of small bilateral chronic lacunar infarcts in the
basal ganglia and adjacent white matter. There are mild bilateral
periventricular and subcortical T2/FLAIR white matter hyperintensities,
nonspecific but suggestive of chronic small vessel ischemic disease. The
ventricles and sulci are normal in caliber and configuration. Major vascular
flow voids are present.
There are no osseous abnormalities. There is a mucous retention cyst and mild
mucosal thickening in the left maxillary sinus, unchanged. Otherwise, the
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The orbits are unremarkable.
IMPRESSION:
1. Acute infarction in the left corona radiata and body of the caudate, new
from prior study dated ___. No evidence of intracranial
hemorrhage.
2. Redemonstration of small chronic lacunar infarcts in the bilateral basal
ganglia and adjacent white matter.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 11:00 ___, 5 minutes after
discovery of the findings
Radiology Report
EXAMINATION: Carotid Artery ultrasound
INDICATION: ___ year old man with acute stroke. // Eval of stroke. ICA plaque
seen on CTA.
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
There is mild homogenous atherosclerotic plaque in the right carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 136 cm/s / 18.7 cm/s
CCA Distal: 103 cm/s / 23 cm/s
ICA ___: 72.9 cm/s / 13.3 cm/s
ICA Mid: 71.4 cm/s / 16.9 cm/s
ICA Distal: 87.2 cm/s / 21.8 cm/s
ECA: 127 cm/s
Vertebral: 23.5 cm/s
ICA/CCA Ratio: 0.85
The right vertebral artery flow is antegrade with a normal spectral waveform.
LEFT:
There is mild heterogenous atherosclerotic plaque in the left carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 122 cm/s / 17.6 cm/s
CCA Distal: 102 cm/s / 19.9 cm/s
ICA ___: 66.7 cm/s / 16.1 cm/s
ICA Mid: 81.9 cm/s / 22.2 cm/s
ICA Distal: 74.8 cm/s / 13.7 cm/s
ECA: 134 cm/s /
Vertebral: 44.5 cm/s /
ICA/CCA Ratio: 0.8
The left vertebral artery flow is antegrade with a normal spectral waveform.
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with stroke, PFO // rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with Cerebral infarction, unspecified
temperature: 96.1
heartrate: 82.0
resprate: 18.0
o2sat: 98.0
sbp: 143.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ YO M with PMH of hypertension, hyperlipidemia,
and diabetes who presented back to the hospital because of after
an episodes of right arm weakness, acute onset dysarthria, and
unsteadiness, after having more limited symptoms previously when
presented. His previous workup was more consistent with work
related and hypoglycemic symptoms, but during the most recent
episode, tried having a cut of juice didn't help. He was found
to have residual right handed weakness on presentation and
patient was found to have an acute stroke.
Stroke risk factors include diabetes and hyperlipidemia. A1C was
6.9 and LDL 171. Imaging revealed: CTA with some vertebral and
left ICA stenosis, with left ICA plaque, but carotid ultrasound
reporting less than 40% stenosis and adequate flow. MRI with
acute left corona radiata infarct, new since ___
study during last admission. Etiology of this acute stroke can
be both microvascular versus embolic. Less likely atheroembolic,
and most likely microvascular with concern for a stuttering
presentation. For cardioembolic workup, patient received an ECHO
and will discharged with a ziopatch. His ECHO demonstrated a
small PFO and so he underwent hypercoagulable work-up that
included lower extremity US which was negative for DVT as well
as hypercoagulable labs (lupus, APLS, anti-thrombin III, Protein
C, protein S). He will need Prothrombin and Factor V Leiden labs
drawn as outpatient for follow-up (Cannot be drawn as
inpatient). In his previous admission, he was started on ASA
81mg, and is now started on Plavix 75mg daily for DAPT. He was
started on Atorvastatin 40 mg during his last admission and
should follow up with his PCP to have his LDL checked. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Fistulogram ___
Dialysis ___
History of Present Illness:
___ h/o DM, CVA, presenting with lethargy and altered mental
status after dialysis. Pt complained of lower abdominal pain and
nausea. Started during dialysis. Completed full session.
Endorses chills but no fevers. Makes urine and denies dysuria.
Pt was not able to provide further history.
In the ED, initial VS: 98.6 72 196/78 18 97% RA. Labs notable
for AP 150, lipase 61, UA with moderate leuks, 100 protein, 6
WBC, few bacteria, no epis. CT abdomen with IV contrast showed
no acute abnormalities. CXR was unremarkable. NCHCT showed no
acute intracranial process. EKG unremarkable, SR ___hanges. Nephrology was consulted given the contrast load given
and they will see the patient in the morning. She was given
morphine 5mg IV x1 for LLQ pain. VS at transfer: 97.9 79 173/61
13 99%RA.
Currently, she complains of nausea only. Denies abdominal pain.
ROS:
+ per HPI, otherwise negative.
Past Medical History:
1. Coronary artery disease
- s/p cath (___): Mild epicardial disease, collalateral flow
to distal inferior wall, no intervention
2. Hypertension
3. Hyperlipidemia
4. Diabetes: complicated by retinopathy, neuropathy, and
nephropahy
5. ESRD on HD MWF
6. Stroke: left frontal MCA and occipital PCA stroke
7. Impaired memory s/p MVA
8. Anemia
9. History of MSSA PNA, ___. Treated for presumptive endocarditis, ___. H/o Upper GI bleed NOS, gastritis, duodenitis
Social History:
___
Family History:
-Father died in his ___ with heart disease
-Siblings (two sisters) with diabetes ___ (type II).
Physical Exam:
Admission:
VS - Temp 98.1F, BP 194/87, HR 77, R 16, O2-sat 99% RA
GENERAL - chronically ill appearing ___ female in
NAD, arousable to voice, inattentive
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 - WWP, no c/c/e, palp peripheral pulses (radials,
DPs)
NEURO - somnolent but arousable to voice, A&O to person, month,
year, hospital, CNs II-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout
Discharge:
VS Tm 99.3 BP 153-200/90 U PO 920 O urine incontinance
___ glucose:
GEN Alert, disoriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, ___ systolic fistula murmur
ABD soft NT ND normoactive bowel sounds, no r/g, well healed
midline scar.
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function ___ ___, patient did not
cooperate with f/n/f test. Reflexes 1+ ___ and down going
babinski.
SKIN no ulcers or lesions except for scabs on knees.
Pertinent Results:
ADMISSION LABS:
___ 06:00PM BLOOD WBC-5.0 RBC-3.73* Hgb-11.7* Hct-37.5
MCV-101* MCH-31.5 MCHC-31.3 RDW-13.8 Plt ___
___ 06:00PM BLOOD Neuts-71.8* ___ Monos-5.4 Eos-1.0
Baso-0.2
___ 06:00PM BLOOD ___ PTT-31.6 ___
___ 06:00PM BLOOD Glucose-107* UreaN-19 Creat-3.6*# Na-136
K-4.8 Cl-99 HCO3-26 AnGap-16
___ 06:00PM BLOOD ALT-20 AST-21 AlkPhos-150* TotBili-0.4
DISCHARGE LABS:
___ 08:10AM BLOOD WBC-6.0 RBC-3.46* Hgb-11.1* Hct-33.7*
MCV-98 MCH-32.2* MCHC-33.0 RDW-13.8 Plt ___
___ 08:10AM BLOOD Glucose-65* UreaN-28* Creat-5.9*# Na-132*
K-5.9* Cl-92* HCO3-25 AnGap-21*
___ 08:10AM BLOOD Calcium-9.3 Phos-5.5* Mg-2.2
MICRO DATA:
___ BLOOD CULTURE x2 - PENDING
___ 3:02 am
URINE Site: NOT SPECIFIED 1635S.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ECG ___ 5:13:32 ___
Sinus rhythm. Non-specific inferolateral ST-T wave
abnormalities. Compared to the previous tracing of ___, ST-T
wave abnormalities are new.
CHEST (PA & LAT) ___ 5:30 ___
No acute cardiopulmonary abnormality.
CT ABD & PELVIS WITH CONTRAST ___ 6:54 ___
1. No findings to explain the patient's symptoms. No evidence
of diverticulitis.
2. Small right renal cyst is unchanged.
3. Calcified fibroids in the uterus.
4. Moderate aortic and bi-iliac arterial calcifications.
AV FITULOGRAM ___ ___ 2:05 ___
Uncomplicated left upper extremity AV graft, outflow tract and
central venography with sequential 6 and 8 mm balloon dilatation
of 80% venous juxta-anastomotic stenosis (residue of 20%) and 6
mm balloon dilatation of focal arterial limb stenosis.
CT HEAD W/O CONTRAST ___ 6:55 ___
1. No acute intracranial process.
2. Stable left frontal and left occipital areas of
encephalomalacia.
3. Stable bilateral thalamic lacunar infarcts.
EEG ___
[final result pending]
Medications on Admission:
Humulin 70/30 10u QAM, 6u QPM
Lisinopril 40mg daily
Metoprolol succinate 150mg daily
Colace 200mg BID:PRN
Pravastatin 40mg QHS
Renvela 800mg TID w/ meals
Epogen 2200 units 2x/week
Plavix 75mg qd
Amlodipine 5mg qd
Coumadin 7mg daily stopped ___
Aspirin stopped ___
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Succinate XL 150 mg PO DAILY
3. Docusate Sodium 200 mg PO BID constipation
4. Pravastatin 40 mg PO HS
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. Epoetin Alfa 2200 UNIT IV 2X/WEEK (MO,FR)
7. Clopidogrel 75 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
HOld for SBP<100
9. Nephrocaps 1 CAP PO DAILY
RX *Nephrocaps 1 mg 1 Capsule(s) by mouth daily Disp #*30
Capsule Refills:*2
10. Finger sticks
Please check daily finger sticks, prefer in the morning fasting.
Goal sugars between 80 and 120s.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary:
hypoglycaemia
hypertension
hypotension
confusion
Secondary:
end stage renal disease
diabetes
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
HISTORY: Abdominal pain, end-stage renal disease on hemodialysis.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The heart size remains mildly enlarged. The mediastinal and hilar contours
are stable with mild aortic non calcifications demonstrated. The pulmonary
vascularity is normal. No focal consolidation, pleural effusion or
pneumothorax is present. There are mild degenerative changes in the thoracic
spine. A clip is seen within the right upper quadrant the abdomen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ female with abdominal pain, ESRD.
COMPARISON: CT on ___.
TECHNIQUE: MDCT images through the abdomen and pelvis were obtained following
administration of IV contrast. Coronal and sagittal reformations were
performed.
FINDINGS: The lung bases are clear. The visualized heart and pericardium are
unremarkable.
The liver enhances homogeneously and there are no focal liver lesions. The
patient is status post cholecystectomy. The pancreas is unremarkable. The
spleen is unremarkable. The adrenal glands are normal. There is a small
right renal cyst measuring 1.0 cm, unchanged compared to prior study.
Previously noted exophytic cyst off of the left kidney upper pole has
decreased in size, no measuring 12 x 14 mm. Otherwise the kidneys are
unremarkable and there is no evidence of hydronephrosis. The stomach and
small bowel are unremarkable. There is no mesenteric or retroperitoneal
lymphadenopathy. No free air or free fluid is present.
The colon is normal. There is no evidence of diverticulitis. The rectum is
unremarkable. There are calcifications throughout the uterus, likely reflect
fibroids. The adnexa are unremarkable. The bladder in normal. No evidence
of hernia. There is no free fluid.
There are aortic and bi-iliac atherosclerotic calcifications, similar to prior
study. The visualized vasculature appears patent.
BONES: Bones are unremarkable.
IMPRESSION:
1. No findings to explain the patient's symptoms. No evidence of
diverticulitis.
2. Small right renal cyst is unchanged.
3. Calcified fibroids in the uterus.
4. Moderate aortic and bi-iliac arterial calcifications.
Radiology Report
INDICATION: ___ female with confusion, evaluate for hemorrhage.
COMPARISON: CT head on ___.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
Bone algorithm was obtained.
FINDINGS: There is no evidence of acute hemorrhage, edema, mass, mass effect,
or acute territorial infarction. There are areas of encephalomalacia in the
left frontal and occipital lobes, unchanged compared to prior study. Focal
hypodensities in the bilateral thalami are consistent with lacunar
infarctions, unchanged. Confluent hypodensities in the periventricular and
deep white matter are consistent with chronic small vessel ischemic disease.
Ventricles and sulci are mildly enlarged consistent with age-related atrophy.
The visualized paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. No acute intracranial process.
2. Stable left frontal and left occipital areas of encephalomalacia.
3. Stable bilateral thalamic lacunar infarcts.
Radiology Report
AV GRAFT VENOGRAM AND ANGIOPLASTY
INDICATION: ___ woman with end-stage renal disease with concern for
stenosis in the left upper extremity AV graft.
OPERATORS: Drs. ___ (fellow) and ___ (attending
physician). Dr. ___ was present throughout the procedure.
CONTRAST: Sterile 135 mL Optiray 320.
SEDATION: Moderate sedation with divided doses of intravenous 75 mcg fentanyl
and 1 mg Versed over 50 minutes, during which patient's hemodynamic status was
continuously monitored by trained radiology nurse.
OTHER MEDICATION: IV ___ IU heparin.
PROCEDURE AND FINDINGS: Consent was obtained from the healthcare proxy after
explaining the benefits, risks, and alternatives. Patient was placed supine
on the imaging table in the interventional suite. Timeout was performed as
per ___ protocol.
Initial limited gray-scale and color sonogram was performed, which
demonstrated flow within the graft. On palpation, there was mild pulsation.
Under aseptic conditions, palpatory guidance, and after infiltrating the skin
with 1% lidocaine, a micropuncture needle was placed in the arterial limb of
the graft about 4 centimeters from the arterial anastomosis and with the tip
pointing towards the venous outflow tract. A 0.018 wire was advanced through
the needle and into the graft. Needle was removed to place a 4.5 ___
microsheath. After removing the inner cannula and wire, venogram was
performed for the outflow tract and central veins. It demonstrated about 80%
venous juxta-anastomotic stenosis and 40% focal stenosis in the arterial limb
of the graft. After exchanging the microsheath for a short 6 ___ ___ Tip
sheath over a 0.035 Glidewire, the Glidewire was exchanged for a 0.035 ___
wire with the help of a 5 ___ Kumpe catheter. Sequential dilatation of the
venous juxta-anastomotic stenosis was performed with 6 x 40 and 8 x 40 mm
balloons. Post-dilatation venography demonstrated significant improvement
with about 20% residual stenosis. Focal 40% stenosis was noted in the
arterial limb of the graft, which was balloon dilated with a 6 x 40 balloon.
Post-dilatation venography demonstrated mild improvement. Good thrill within
the graft was noted at the end of the procedure. After removing the wire and
subsequently the sheath, gentle pressure was applied to the access site for
about 10 minutes to achieve complete hemostasis. Site was dressed in a
sterile fashion. Patient tolerated the procedure well and no immediate
post-procedure complication was seen.
IMPRESSION: Uncomplicated left upper extremity AV graft, outflow tract and
central venography with sequential 6 and 8 mm balloon dilatation of 80% venous
juxta-anastomotic stenosis (residue of 20%) and 6 mm balloon dilatation of
focal arterial limb stenosis.
Radiology Report
INDICATION: Hypotensive episode. Now poorly responsive. Evaluate for
infarction or hemorrhage.
COMPARISONS: CT head ___. CT head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
new vascular territorial infarction. Encephalomalacia in the left frontal
lobe is unchanged and likely the sequelae of prior infarction. A smaller
region of encephalomalacia in the left occipital lobe is also stable. A
calcification in the right basal ganglia is present in an area of a prior
hemorrhage. Periventricular confluent white matter hypodensities are
consistent with chronic small vessel ischemic disease. The ventricles and
sulci are prominent, consistent with age-related atrophy. The basal cisterns
are patent.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The soft tissues are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Stable encephalomalacia in the left frontal and left occipital lobes,
likely due to prior infarctions.
3. Stable calcification in the right basal ganglia is likely the sequelae of
a prior hemorrhage.
4. Stable age-related atrophy and chronic small vessel ischemic disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: LETHARGIC
Diagnosed with ALTERED MENTAL STATUS , ABDOMINAL PAIN OTHER SPECIED
temperature: 98.6
heartrate: 72.0
resprate: 18.0
o2sat: 97.0
sbp: 196.0
dbp: 78.0
level of pain: 13
level of acuity: 2.0 | Ms. ___ is a ___ lady with ESRD on HD, diabetes, and h/o
CVA who presented with lethargy and abdominal pain from ___
clinic. During her stay, she was hypoglycemic which resolved
with stopping her insulin. This might have been contributing to
her confusion. In addition, she was evaluated for seizure after
a prolonged episode of being minimally responsive. With holding
her insulin she was much more alert and she was discharged home.
# Lethargy/ confusion: patient is alert upon discharge.
Likely related to hypoglycemia and exacerbating previous stroke/
neurological defecits. ABG with chronic compensated respiratory
acidosis. UTI could be contributing given positive UA, although
mixed flora on culture, borderline left shift without
leukocytosis. No other clear infectious source identified. No
metabolic abnormalities identified. Neuro exam non focal and
NCHCT and CT A/P unremarkable. Patient treated with Bactrim x2
day for ? UTI, stopped when mixed flora. No symptoms. Also,
insulin was stopped altogether (see below). She had HD on ___,
___, and ___. After HD on the day of discharge she was alert
and interactive, though disoriented - only slightly worse
orientation than baseline per daughter.
# Hypoglycemia: now off insulin.
Patient with diabetes and on insulin at home, although ___ not
routinely checked. Has been hypoglycemic in house despite
decreasing home dose to 3 units. A1C 5.4. Patient likely with
numerous hypoglycemic epidodes at home. During this admission,
her insulin was stopped with resulting fingerstick glucose
80-160. She was discharged off insulin with requests that her
fingerstick be checked at home and possibly also at HD.
# Episode of hypotension/lip-smacking at HD: possibly related to
hypotension +/- uremia.
On the morning of ___ at dialysis attempts were made to remove
fluid slightly more aggressively and she had hypotension to
___ with brief period of unresponsiveness during which she
was making writhing/lip-smacking movements. No new concerning
EKG changes. Patient recovered with 700cc NS and was confused
for a period after. Neurology consult was called and agreed
that she had no new focal neuro finding. CT head showed no
acute process. EEG (final result pending at discharge)
suggested toxic-metabolic encephalopathy which was felt by Neuro
to be related to her ESRD. Seizure felt to be unlikely; she
might have had some vertebrobasilar insufficiency with syncope
in the setting of the hypotension. She and her family knows to
seek help for any similar episode of diminished level of
consciousness.
# ESRD: MWF schedule was continued in house.
She continued Renvela 800mg TID w/ meals and Epogen 2200 units
2x/week. Started nephrocaps. She will f/u with her
Nephrologist at HD.
# Fistulogram: completed while in house.
Fistula dilated ___ with good thrill at end of procedure.
# HTN: hypertensive at baseline.
SBP mostly 140-190 this admission. She was continued on her
meds (Metoprolol succinate 150mg daily, Lisinopril 40mg,
Amlodipine 5mg). Outpatient providers might consider
uptitrating her BP meds (this was not pursued in house
especially because of her episode of hypotension (see above).
# HLD: stable.
She was continued on Pravastatin 40mg QHS.
# h/o CVA: No new deficit on exam.
She was continued on Plavix 75mg qd.
# Transitional
-Code Status: Full code
-Emergency contact: ___ (dtr) ___, ___ (dtr) ___
-Pending at the time of discharge: blood cultures x2 (___), EEG
final result (addendum: was normal)
-Hypertension: ongoing outpatient management of blood pressure
-Hypoglycemia: ___ to check fingersticks, also check PRN
symptoms including if at dialysis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history of HTN, HLD,
PVD, CKD, dilated CM presenting with cough.
The patient reports that he developed a nonproductive cough 4
days prior to admission. He denies any shortness of breath. He
denies chest pain. No fevers but reports night sweats and
malaise. He reports decreased oral intake. The patient initially
presented to ___ Urgent care, where he was hypoxic to 93% on
room air. He had a CXR that showed bronchial wall thickening and
EKG without acute ischemic changes. He was referred to the ___
ED for further care.
In the ED, vitals: 98.8 92 123/67 20 97% 2L NC
Exam notable for: Pulm: Unlabored breathing rhonchi decreased
breath sounds of the bilateral lower lobes
Labs notable for: WBC 12.9, Hb 11.8, BUN/Cr 44/2.6; trop 0.02,
BNPO 5589, lactate 1.9; flu negative
Patient given: ceftriaxone 1 gm, azithromycin 500 mg IV; ASA 324
mg, 1L LR
On arrival to the floor, the patient denies any shortness of
breath but reports ongoing cough. Reports difficulty sleeping
due
to cough. Denies any vision changes, eye itching or pain, but
states that he noticed a discharge from his left eye that began
today.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Dilated cardiomyopathy (EF 50%)
Hypertension
PAD (right SFA PTCA/stent ___
Hyperlipidemia
Chronic kidney disease (GFR 44)
Basal cell skin cancer
Back pain
Paget's disease
Social History:
___
Family History:
Mother died of rectal cancer in her ___. No other family history
of malignancy of CV disease.
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 99.0 168/70 97 20 94 2LNC
GENERAL: Alert and in no apparent distress
EYES: Anicteric, copious purulent discharge from eyes, L>>R
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs with rhonchi, intermittent dry cough during exam.
Breathing is non-labored.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, no peripheral edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 452)
Temp: 98.1 (Tm 98.4), BP: 139/54 (114-176/45-75), HR: 62
(52-67), RR: 18 (___), O2 sat: 95% (94-98), O2 delivery: RA,
Wt: 242.06 lb/109.8 kg
Fluid Balance (last updated ___ @ 448)
Last 8 hours Total cumulative -750ml
IN: Total 0ml
OUT: Total 750ml, Urine Amt 750ml
Last 24 hours Total cumulative -475ml
IN: Total 1000ml, PO Amt 770ml, IV Amt Infused 230ml
OUT: Total 1475ml, Urine Amt 1475ml
GENERAL: Well developed, well nourished man in NAD. Hard of
hearing. Oriented x3. Hard of hearing; right ear better than
left
per pt. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: JVP 7-8cm
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. no thrills or lifts.
LUNGS: CTAB, no wheezes/rales/rhonchi.
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: WWP, no ___ edema
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:47PM BLOOD WBC-12.9* RBC-5.31 Hgb-11.8* Hct-38.2*
MCV-72* MCH-22.2* MCHC-30.9* RDW-16.6* RDWSD-42.4 Plt ___
___ 07:47PM BLOOD Glucose-138* UreaN-44* Creat-2.6* Na-138
K-5.1 Cl-104 HCO3-15* AnGap-19*
___ 07:47PM BLOOD ___ PTT-26.4 ___
___ 07:47PM BLOOD proBNP-5589*
___ 07:47PM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8
INTERVAL LABS:
==============
Tast 19% Ferritin 583 UNa 26
Tpn 0.02-->0.01
BNP 5589 (no priors)
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-14.2* RBC-4.67 Hgb-10.5* Hct-33.1*
MCV-71* MCH-22.5* MCHC-31.7* RDW-15.9* RDWSD-39.8 Plt ___
___ 07:00AM BLOOD ___ PTT-26.1 ___
___ 07:00AM BLOOD Glucose-101* UreaN-60* Creat-1.9* Na-145
K-4.6 Cl-111* HCO3-16* AnGap-18
___ 07:00AM BLOOD ALT-18 AST-19 LD(LDH)-238 AlkPhos-197*
TotBili-0.3
___ 07:00AM BLOOD Albumin-2.8* Calcium-7.9* Phos-3.5 Mg-2.0
MICROBIOLOGY:
=============
___ 5:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 11:18 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 12:47 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
__________________________________________________________
___ 8:17 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:47 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES:
========
CXR: (initial)
FINDINGS:
The heart is mildly enlarged. The pulmonary vasculature is
normal. There is bronchial wall thickening. No pneumothorax,
effusion, or focal consolidation. Mild multilevel degenerative
changes of the thoracic spine.
IMPRESSION:
Mild bronchial wall thickening which can be seen in the setting
of small
airway disease
CXR: (interval) ___
Comparison to ___. The symmetrical parenchymal
opacities at the lung bases have minimally increased in extent
and severity. This change likely reflect increasing hydrostatic
pulmonary edema. A retrocardiac atelectasis is stable. No
pneumothorax. No pneumonia. Persistent mild cardiomegaly
Renal US (___)
IMPRESSION:
1. No hydronephrosis.
2. Feature suggesting chronic parenchymal nephropathy
TTE (___)
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size.
There is moderate global left ventricular
hypokinesis. There is beat-to-beat variability in the left
ventricular contractility due to the irregular rhythm.
Quantitative biplane left ventricular ejection fraction is 30 %
(normal 54-73%). Left ventricular
cardiac index is low normal (2.0-2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with mild global free wall
hypokinesis. 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 no 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 are
mildly thickened. There is moderate [2+] tricuspid
regurgitation.
There is moderate pulmonary artery systolic
hypertension. There is a trivial pericardial effusion.
IMPRESSION: Frequent ectopy. Mild symmetric left ventricular
hypertrophy with normal cavity size
and moderate global hypokinesis. Mild right ventricular free
wall
hypokinesis. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
Compared with the prior TTE (images reviewed) of ___,
frequent ectopy is noted; biventricular
systolic funciton is less vigorous and the degree of valvular
regurgitation and estimated PASP is higher
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Enalapril Maleate 10 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Spironolactone 100 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
10. Mirtazapine 7.5 mg PO QHS
11. Finasteride 5 mg PO DAILY
12. NIFEdipine (Extended Release) 60 mg PO QPM
13. NIFEdipine (Extended Release) 90 mg PO QAM
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN Shortness of breath
RX *albuterol sulfate 90 mcg 1 puff every four (4) hours Disp
#*1 Inhaler Refills:*0
2. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID Duration:
4 Days
RX *erythromycin 5 mg/gram (0.5 %) 1 drop both eyes four times a
day Refills:*0
4. Sodium Bicarbonate 650 mg PO TID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. Finasteride 5 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. melatonin 3 mg oral QHS
12. Mirtazapine 7.5 mg PO QHS
13. Polyethylene Glycol 17 g PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
16. TraZODone 25 mg PO Q6H:PRN sleep/agitation
17. HELD- Enalapril Maleate 10 mg PO DAILY This medication was
held. Do not restart Enalapril Maleate until PCP follow up
testing
18. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until PCP ___ up testing
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
==================
Acute on chronic mixed systolic/diastolic heart failure
Acute kidney injury on chronic kidney disease
SECONDARY DIAGNOSIS:
====================
Community acquired pneumonia
Bacterial conjunctivitis
Peripheral arterial disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Orthopnea
TECHNIQUE: Frontal and lateral chest radiographs
COMPARISON: ___ CT and radiograph dated ___
FINDINGS:
The heart is mildly enlarged. The pulmonary vasculature is normal. There is
bronchial wall thickening. No pneumothorax, effusion, or focal consolidation.
Mild multilevel degenerative changes of the thoracic spine.
IMPRESSION:
Mild bronchial wall thickening which can be seen in the setting of small
airway disease
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with several days of cough and SOB// eval for
interval development of infiltrate/PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Lung volumes are low bilaterally. Worsening bibasilar opacities. No
pulmonary edema. Cardiomediastinal silhouette is unchanged to likely normal.
There is new blunting of the costophrenic angle only seen in the lateral view,
likely on the left. There is no pneumothorax.
IMPRESSION:
New symmetrical opacities at both bases of the lungs. These could represent
aspiration/pneumonia however this could also represent early mild pulmonary
edema. Probable small left pleural effusion is new since yesterday.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with ___. R/o obstruction, hydro// Eval for
post-renal causes ___
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis or stones bilaterally. Both kidneys demonstrate
cortical atrophy and demonstrate hyperechoic parenchyma.
Right kidney: 12.3 cm. At the interpolar of the right kidney, there is a
simple cortical cyst measuring 2.9 x 1.8 x 2.6 cm.
Left kidney: 12.3 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. No hydronephrosis.
2. Feature suggesting chronic parenchymal nephropathy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ?CMY, PNA.// Eval for worsening pulmonary
vascular congestion Eval for worsening pulmonary vascular congestion
IMPRESSION:
Comparison to ___. The symmetrical parenchymal opacities at the lung
bases have minimally increased in extent and severity. This change likely
reflect increasing hydrostatic pulmonary edema. A retrocardiac atelectasis is
stable. No pneumothorax. No pneumonia. Persistent mild cardiomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Pneumonia, unspecified organism
temperature: 98.8
heartrate: 92.0
resprate: 20.0
o2sat: 97.0
sbp: 123.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES:
====================
#HFmEF (prev EF 55% in ___ -> visualized estimated EF 45%,
reported 30%)
Discharge weight: 242lb (110 kg)
Discharge Cr: 1.9
Discharge regimen:
-PRELOAD: None
-AFTERLOAD: STOPPED home nifedipine given reduced EF, STARTED
carvedilol 6.25mg BID
-NHBK: Carvedilol 6.25mg BID
[ ] Home enalapril 10mg daily and spironolactone 100mg HELD on
discharge given ___. Please restart enalapril once ___ has
resolved. If kidney function and BPs stable after restarting
enalapril, would then restart spironolactone at potentially a
lower dose.
[ ] Please follow up weights, BP, CMP at follow up appointment
and adjust medications as appropriate.
[ ] Consider outpatient ischemic work-up if with complaints of
angina and if within goals of care
___ on CKD
[ ] Cr on discharge 1.9 (prior baseline ~1.3-1.7). Set up with
outpatient nephrology follow-up.
[ ] Started on sodium bicarbonate 650mg TID. Please check CMP at
next follow up and uptitrate or discontinue sodium bicarbonate
as appropriate.
[ ] Please ensure follow up with Dr. ___ in ___ weeks from
discharge is scheduled.
#Bacterial conjunctivitis
[ ] To complete a 7 day course of erythromycin eye gtts from
___. Please ensure completion of this course and
resolution of symptoms. Consider additional course of treatment
if with continued symptoms.
#CAD/PAD
[ ] Patient taking full dose aspirin 325mg daily for unclear
indications. Dose was reduced to ASA 81mg daily. If with clear
indication for full dose aspirin please restart this.
BRIEF SUMMARY:
==============
Mr. ___ is a ___ y.o. gentleman w/ a h/o mild dilated
cardiomyopathy (prior 55% in ___ --> now EF 30% ___,
HTN, HLD, Paget's disease, benign ventricular ectopy, PAD s/p
stenting of R SFA ___ w/ re-stenting of mid and distal R SFA
___, CKD, and obesity who presented w/ several day h/o cough
and dyspnea, now being transferred to the cardiology service for
further management of newly reduced EF.
CORONARIES: Unknown, ETT ___ with no ischemic changes
PUMP: EF 30% 2+ TR
RHYTHM: Sinus with freq PVCs
===============
ACTIVE ISSUES:
===============
# Acute on chronic mixed systolic/diastolic HF (prev EF 55% ->
now visualized EF estimated ~45%, reported 30%)
Mr. ___ initially presented with ___ days SOB and cough and
was treated with CTX/Azithromycin for ? CAP given leukocytosis
and evidence of bronchial thickening on CXR though no obvious
consolidations. TTE in evaluation of dyspnea showed newly
reduced EF of 30% from prior EF of 55% in ___, w/ 2+ TR and
PASP, frequent PVCs with new RV hypokinesis and possible
inferior/posterior hypokinesis concerning for prior ischemia.
However, on review of his TTE on rounds, his systolic function
appears to be better than reported EF of 30%, and is estimated
to be closer to 45%. The calculated EF may seem abnormal in the
setting of frequent PVCs. He likely has mixed
ischemic/nonischemic cardiomyopathy with contributions from
underlying CAD given his hx of PAD (however per history does not
seem to have had a recent missed MI), ongoing HTN, as well as
ongoing benign ventricular ectopy. Ischemic workup was deferred
as patient had no symptoms of angina. TSH wnl, iron studies w/o
evidence of overload. After receiving 1L NS on ___ for presumed
pre-renal ___, patient had evidence of volume overload on CXR
and so was diuresed actively with Lasix 20mg + 40mg on ___. He
appeared relatively euvolemic after this and was trialed on PO
Lasix 40mg on ___ with good effect. He did not require any
further diuresis. His home nifedipine was discontinued given his
newly reduced EF and carvedilol 6.25mg BID was started for both
afterload and NHBK. His home enalapril and spironolactone were
held on discharge given his ___ and should be restarted with
resolution of his ___. His discharge weight was 242lb (110 kg),
discharge Cr 1.9. Ischemic workup should be considered if within
goals of care if patient has episodes of angina.
# ___ on CKD
Baseline Cr 1.3-1.7 (last Cr ___, presented with Cr 2.6,
uptrended to 2.8 with fluid administration. CXR w/ e/o possible
volume overload following 1L NS on ___. PVR not elevated. Renal
US ___ with no hydronephrosis, concerning for obstructive
uropathy. He was diuresed with good effect with Cr 2.5->2.0.
Home enalapril and spironolactone were HELD throughout admission
and on discharge in setting of his ___. He was seen by renal who
recommended starting sodium bicarbonate 650mg TID for metabolic
acidosis thought ___ renal dysfunction. His Cr on discharge was
1.9. He should follow up with Dr. ___ in ___ weeks as an
outpatient.
#Cough
#Community acquired PNA
#Acute hypoxic respiratory failure
Patient presented with cough and dyspnea as above. Initial CXR
without focal consolidation but repeat following IVFs with b/l
opacities with c/f infection +/- volume overload and worsening
WBC. He completed a 5 day course of CTX/azithromycin from
___ and was weaned to room air with improvement in his
symptoms of cough.
# Bacterial conjunctivitis:
Patient presented with copious purulent discharge in bilateral
eyes, left>right on presentation that rapidly reappears after
wiping eyes consistent with bacterial conjunctivitis. He was
treated with erythromycin eye gtts x7d (___).
#Anemia:
Hgb 10.5, low MCV which is chronic. Fe studies most c/w anemia
of chronic disease.
================
CHRONIC ISSUES:
================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, dizziness, nausea and vomiting
Major Surgical or Invasive Procedure:
___ Diagnostic cerebral angiography
___ Cerebral angiography (no intervention performed)
History of Present Illness:
___ yo M with sudden onset of HA, nausea and vomiting. This
morning at 0630 he bent over to feed his dog and felt a popping
sensation at the back of his head followed by severe headache,
dizziness, nausea and he vomited immediately. He took two Advil
and went to work. His headache and dizziness persisted and he
came home, rested for a couple hours and then his wife brought
him to OSH where head CT showed SAH. CTA was obtained without a
read and he was sent to ___ for further evaluation. Currently
he c/o only of a moderate headache and lightheadedness. He did
receive a dose of narcotic for his HA.
ROS: No chest pain, SOB, recent fevers, chills or sweats
Past Medical History:
high cholesterol, recent hernia repair at ___ 1 week
ago on ___
Social History:
___
Family History:
No hx aneurysm or intracranial hemorrhage
Physical Exam:
On Admission:
O: T: 99.4 BP:144/91 HR:95 R:18 O2Sats:97%
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 4mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally 2 beats of
nystagmus bilaterally.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Handedness Left
Upon discharge:
Neuro intact, MAE full motor
Pertinent Results:
___ 01:45PM ___ PTT-30.9 ___
___ 01:45PM PLT COUNT-343
___ 01:45PM WBC-11.2* RBC-4.56* HGB-14.4 HCT-42.9 MCV-94
MCH-31.5 MCHC-33.5 RDW-13.0
___ 01:45PM GLUCOSE-106* UREA N-16 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-21* ANION ___: CT/CTA head from OSH: Intraventricular hemorrhage within
the lateral, ___ and ___ ventricles without hydrocephalus.
Coronal and Sagittal views only are available for the CTA that
show a right AVM at the head of the caudate.
___: CT head noncontrast:
IMPRESSION:
Stable appearance of known intraventricular hemorrhage,
involving the lateral, ___ and ___ ventricles, stable
ventricular caliber. No evidence of hydrocephalus.
Radiology Report CHEST (PRE-OP AP ONLY) Study Date of ___
5:05 AM
IMPRESSION:
Hyperinflated lungs, otherwise no acute cardiopulmonary process.
___ CTA head:
Right caudate head arteriovenous malformation with
intraventricular
hemorrhage. Unchanged since the studies of ___.
Medications on Admission:
1. Atorvastatin 20mg PO DAILY
2. Viagra (sildenafil) unknown oral PRN intercourse
3. Nicotine Patch Dose is Unknown TD DAILY
4. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
4. Atorvastatin 20 mg PO DAILY
5. Nicotine Patch 14 mg TD DAILY
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*90 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right Arteriovenous Malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PROCEDURE PERFORMED: Diagnostic cerebral angiography, right internal carotid
artery, with 3D rotational angiography and processing on a separate
workstation, right external carotid artery, left common carotid artery, left
vertebral artery.
INDICATIONS: Mr. ___ is a ___ right-handed white male who
presented with a hemorrhage yesterday involving an intraventricular
hemorrhage. CTA demonstrated evidence of arteriovenous malformation. He
presents today in his baseline neurologic state which is neurologically
intact, although with headaches for a diagnostic cerebral angiogram.
ATTENDING: Dr. ___.
ASSISTANTS: Dr. ___.
ANESTHESIA: Conscious sedation provided by nursing.
MATERIALS EMPLOYED: 5 ___ sheath, 4 ___ Berenstein 2 catheter, 038
Terumo Glidewire.
DESCRIPTION OF PROCEDURE: The patient was brought to the neuro-angio suite
and his right groin was prepped and draped in usual sterile fashion as he had
just recently had a hernia surgery on the left side. A timeout was performed
and his right femoral artery was accessed using anatomic and radiographic
landmarks with a micropuncture needle kit. A 5 ___ sheath was placed into
the femoral artery, sutured in place and hooked up to a continuous heparinized
saline flush. A 4 ___ Berenstein catheter was hooked up to a RHV,
three-way stopcock and continuous heparinized saline flush and was placed
within the sheath. Once a good backflow of blood was obtained and then hooked
up to a contrast power injector. Using a Terumo Glidewire, the catheter was
then brought up over the aortic arch and used to access the right common
carotid artery. Under roadmap guidance, the right internal carotid artery was
selected and intracranial AP and lateral angiography was performed
demonstrating the AVM and a 3D rotational angiography was performed. Next,
the right external carotid artery was selected and intracranial AP and lateral
angiography was performed. Catheter was then brought back to access the left
common carotid artery as well as for AP and lateral angiography and then the
left subclavian artery under roadmap guidance to select the left vertebral
artery. After angiography was performed, the catheter was then removed, the
patient was assessed to be at the neurologic baseline and the sheath was
removed. 15 minutes of manual pressure were held on the artery.
DESCRIPTION OF FINDINGS:
RIGHT COMMON CAROTID ARTERY: There is no evidence of atherosclerotic plaque
or stenosis of the ICA bifurcation. The visualized branches of the internal
and external carotid arteries in the cervical area are normal.
RIGHT INTERNAL CAROTID ARTERY: There is good injection seen within the
internal carotid artery through the ICA bifurcation. The origins of the
ophthalmic, PCOM and anterior choroidal arteries appear normal. The ICA
bifurcation fills normally as are the ACA and MCA vessels. There is no
filling across the ACOM complex; however, there is some cross-filling of the
distal left pericallosal and callosal marginal arteries. There is an obvious
AVM in the deep right frontal area that is fed by multiple lenticulostriate
vessels. There is one larger feeding artery that originates from the A1-A2
junction consistent with the recurrent artery of ___. The avm nidus fills
rapidly and is small but mildly compact. The nidus measures 1.5 x 1.4 x 0.8
cm. The prominent feeding artery has a fusiform dilated aneurysm associated
with it that measures 7.4 x 2.7 x 3.3 mm. The nidus drains through a single
draining vein that is serpiginous in nature and drains into the internal
cerebral veins, basal vein ___ and out in the straight sinus. There
does not appear to be any feeding from the ACA vessels or distal MCA cortical
vessels. There is no associated venous stenosis with the AVM. Otherwise, the
parenchymal phases fill normally as does the normal venous egress.
RIGHT EXTERNAL CAROTID ARTERY: Good injection is seen within the distal
external carotid artery branches with no evidence of feeding the AVM or
arteriovenous shunting. The visualized branches of the ECA appear normal.
LEFT COMMON CAROTID ARTERY: The carotid bifurcation appears without stenosis
or atherosclerotic plaque and the visualized external and internal cervical
branches appear normal. Intracranial AP and lateral angiography demonstrates
good appearance of the ICA filling as well as the ECA filling into the cranial
space. Origins of the ophthalmic and anterior choroidal arteries appear
normal, although there is a fetal configuration to the left PCOM. Otherwise,
the ACA and MCA vessels fill normally with good parenchymal filling and normal
parenchymal and venous egress. There is no evidence of cross-filling into the
known AVM. There is no other aneurysm, arteriovenous malformation or
arteriovenous shunting.
LEFT VERTEBRAL ARTERY: Good injection was seen at the distal vertebral artery
to the basilar bifurcation with good reflux down into the right vertebral
artery. The origins of the bilateral PICAs are seen well and the bilateral
AICAs and bilateral SCAs and PCAs are seen. The left PCA is quite small in
nature, which is consistent with a known left fetal PCOM. Parenchymal phases
appear to fill normally as is the venous egress. There is no evidence of
arteriovenous shunting, aneurysm or feeding of the known AVM.
CONCLUSIONS:
1. Deep right frontal AVM fed by lenticulostriate vessels from the MCA and
one predominant vessel that originates from the recurrent artery of ___.
The nidus measures 1.5 x 1.4 x 0.8 cm. There is a single serpiginous dilated
draining vein that drains deep through the internal cerebral vein, basal vein
___ and ___ sinus. There is no associated venous stenosis.
There is a fusiform feeding artery aneurysm on the larger feeding vessel that
measures 7.4 x 2.7 x 3.3 mm. This is consistent with a ___ II AVM
due to less than 3 mm in size and deep venous drainage.
2. No evidence of thromboembolic complication.
Radiology Report
HISTORY: Intracerebral hemorrhage, AVM. Preop.
COMPARISON: None available.
TECHNIQUE: Semi-erect frontal chest radiographs.
FINDINGS:
The cardiac silhouette is mildly enlarged. The lungs are hyperinflated. There
is no focal consolidation, pleural effusion or pneumothorax.
IMPRESSION:
Hyperinflated lungs, otherwise no acute cardiopulmonary process.
Findings discussed with Dr. ___ by ___ via telephone on
___ at 7:38 AM.
Radiology Report
HISTORY: Known intraventricular hemorrhage, AVM. Evaluate for hydrocephalus.
COMPARISON: Outside head and neck CTA from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without IV contrast. Sagittal and coronal reformats were generated.
Total exam DLP: 892 mGy-cm.
CTDI: 52 mGy-cm.
FINDINGS:
As seen on prior head CT, there is redemonstration of hyperdense blood
products within the lateral ventricles, right worse than left, ___ and ___
ventricle, not significantly changed since prior examination. Blood is seen
layering within the occipital horns of the lateral ventricles bilaterally.
Increased density in the right caudate nucleus is compatible with known AVM,
and is causing mild effacement of the frontal horn of the right lateral
ventricle, not significantly changed since prior examination. Ventricle size
is stable, there is no evidence of hydrocephalus. There is major vascular
territory infarction or shift of normally midline structures. The basal
cisterns appear patent and there is preservation of gray-white matter
differentiation.
There is moderate mucosal thickening of the ethmoidal air cells. Mild mucosal
thickening of the right sphenoid sinus and maxillary sinuses bilaterally.
Otherwise, the remaining visualized paranasal sinuses, mastoid air cells and
middle ear cavities are clear. No fracture is identified.
IMPRESSION:
Stable appearance of known intraventricular hemorrhage, involving the lateral,
___ and ___ ventricles, stable ventricular caliber. No evidence of
hydrocephalus.
Radiology Report
HISTORY: Arteriovenous malformation.
TECHNIQUE: Contiguous axial images were obtained through the brain before
contrast administration. Subsequently, CT angiography was performed during
infusion of Omnipaque intravenous contrast. Images were reconstructed on a
separate workstation.
CTDIvol 163 mGy
DLP ___ mGy-cm.
COMPARISON: Head CT ___ and cerebral arteriography ___.
FINDINGS:
Again seen is hemorrhage within the right lateral ventricle, the ___
ventricle, and the ___ ventricle. There is no evidence of new hemorrhage
since the prior study. There is no hydrocephalus.
The CT examination again demonstrates an arteriovenous malformation in the
right caudate head. This receives arterial supply from the lenticulostriate
arteries and demonstrates deep venous drainage. An aneurysm arising from the
largest of the lateral lenticulostriate arteries measures approximately 2.5mm
and is unchanged.
IMPRESSION:
Right caudate head arteriovenous malformation with intraventricular
hemorrhage. Unchanged since the studies of ___.
Radiology Report
PREOPERATIVE DIAGNOSIS: Right basal ganglia arteriovenous malformation.
INDICATION: The patient had presented with a hemorrhage from this, a previous
diagnostic angiogram was done. He was brought back for definitive
intervention.
ATTENDING PHYSICIAN: ___, M.D.
ASSISTANT: ___, M.D. and ___, NP.
PROCEDURES PERFORMED: Right internal carotid artery arteriogram, right
recurrent artery of Heubner arteriogram.
ANESTHESIA: General.
DETAILS OF THE PROCEDURE: The patient was brought to the Angiography Suite.
anesthesia was induced in the supine position. Following this, both groins
were prepped and draped in a sterile fashion. Access was gained to the right
common femoral artery using a Seldinger technique and a 5 ___ vascular
sheath was placed in the right common femoral artery. We now catheterized the
above-mentioned vessels and AP, lateral filming was done. Now a
three-dimensional rotational angiography was done. The interpretation of this
revealed that the right basal ganglia AVM was fed by a recurrent artery of
Heubner. We now exchanged out the ___ 2 catheter in the right internal
carotid artery and a ___ 0.072 catheter was placed in the distal right
internal carotid artery. A 0.038 DAC x ___ cm was placed in the supraclinoid
carotid artery with continuous flush. Following this, using a marathon
catheter and a Mirage wire, the recurrent artery of Heubner was catheterized.
Injections were done. This revealed two branches, one feeding the AVM and
other most likely feeding the anterior limb of the internal capsule. I was
unable to catheterize the branch that leads into the AVM due to the
significant tortuosity despite trying for an hour. At this point, we decided
to abort the procedure. All catheters were taken out. The vascular sheath in
the right common femoral artery was left to be taken out and after the effects
of the heparin had worn off. A total of 6000 units of heparin were given
during the procedure.
FINDINGS: Right internal carotid artery arteriogram shows filling of the
right internal carotid artery along the cervical, petrous, cavernous and
supraclinoid portion. Anterior and middle cerebral arteries are seen well.
There is a large dilated recurrent artery of Heubner which divides into two
with one branch supplying the arteriovenous malformation, the nidus measures
approximately 3 cm x 2 cm x 2 cm. There is a large draining vein which drains
deep into the internal cerebral vein and finally into the straight sinus.
There is a small aneurysmal dilatation at the origin of the artery that feeds
the AVM after dividing from the recurrent artery of Heubner.
Recurrent artery of Heubner arteriogram demonstrates that the artery divides
into two. The anterior branch is seen to supply the AVM. A more posterior
and lateral branch is seen to be very large but does not involve the AVM
itself.
IMPRESSION: ___ underwent cerebral angiography and attempted
embolization of a right caudate head AVM that was unsuccessful.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH
Diagnosed with HEADACHE
temperature: 99.4
heartrate: 95.0
resprate: 18.0
o2sat: 97.0
sbp: 144.0
dbp: 91.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ was admitted to the Neurosurgical ICU for frequent
neuro checks and systolic ___ pressure control < 140. A
radial a-line was placed upon admissipon to the ICU for
persistent elevated SBP and he required nicardipine gtt, PRN
hydralazine and prn Labetolol for ___ pressure control.
Consent for diagnostic cerebral angiogram was obtained from both
the patient and the wife.
On ___, The patient had a NCHCT which was found to be stable.
The patient wnet for a diagnostic cerebral angiogram. The
patient was on flat bed rest for a total of 6 hours. The
patient was neurologically intact on exam following the cerebral
angiogram and was experiencing nausea and headache. The goal
SBP was less than 160.
Since that time, Mr. ___ was neurologically and
hemodynamically stable. On ___, the patient underwent an angio
with attempted embolization of his right caudate head AVM but
was unable to do so. Due to the tortuous nature of the vessel,
the patient's AVM could not be embolized or intervened on. He
was transferred back to floor, where his femoral sheath was
discontinued with no issue. ___ patient remained stable,
patient was seen for CyberKnife consideration and cleared for
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Chest tube placement ___
History of Present Illness:
Mr. ___ is a ___ with history of stroke ___ & ___,
HTN, HLD, carotid stenosis, BPH, and neurogenic bladder with
chronic foley who presents with shortness of breath and
pleuritic chest pain for the 3 days ago. The patient notes he
became short of breath suddenly while watching tv. He denies any
prior history of DVT, PE, or recent travel. He does note that at
baseline he is not very mobile due to his previous stroke
history and uses a walker to ambulate. Today while at his PCP's
office he had left calf tenderness. Given this and shortness of
breath and pleuritic chest pain, he was sent to the ED. He
endorses mild prodcutive cough. He denies any fevers, chills,
night sweats, chest pain, nausea, vomiting or diaphoresis. He
also denies any oprthopnea, PND and lower extremity edema. No
weight gain for weight loss. Patient used to used 2PPD x ___
years in ___.
In the ED, initial VS were 99.4 67 123/67 18 96% ra. Labs showed
WBC 12.9 (76.6), with normal BMP (BUN:Cr, 20:1.1). D Dimer 904.
UA from chronic foley notable for Lg leuk, neg nitr, RBC 5, WBC
> 182, many bacteria, 7 Epi.
Imaging showed no evidence of deep venous thrombosis in the left
lower extremity veins. CXR showed substantial left-sided pleural
effusion. He underwent CTA which showed large left sided pleural
effuion without pulmonary embolism. No mass lesions. Patient was
admitted for further work-up and management.
Past Medical History:
- PreDiabetes
- Hypertension
- Hyperlipidemia
- Vitamin D deficiency
- BPH
- Carotid Stenosis
- Stroke ___ and ___
- ___ disease, diagnosed ___
- Neurogenic Bladder s/p indeweling foley
- Depression
- Gout
- Ishemic optic neuropathy
- Vascular Cognitive Impairment
- Gait insability with recurrent falls
- Osteoarthritis
- s/p appendecctomy
Social History:
___
Family History:
Maternal grandmother - cancer (uncertain type)
Maternal grandfather - cancer (uncertain type)
Mother - died at age ___ of breast cancer
Father - died at age ___ uncertain cause
Siblings - all in good health
Physical Exam:
EXAM ON ADMISSION:
==================
VS - 98.6 170/92 82 96%RA
GENERAL: NAD, appears well, eating dinner
HEENT: anicteric sclera, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased breath sounds in the left lung without crackles
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: warm and well perfused trance edema, moving all 4
extremities with purpose
GU: foley in place
NEURO: CN II-XII intact, normal streght throughout, sensatio
intact throughout to light touch
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EXAM ON DISCHARGE:
==================
VS Tm 98 BP 132/67 HR66 RR20 Sat 95% on RA
Minimal output from chest tubes
GEN: A&Ox3 and in no apparent distress
HEENT: PERRL, able to direct gaze left and right on command but
unable to track eyes laterally towards the extreme periphery of
his view (unchanged from his admission exam). MMM, oropharynx
clear or erythema and exudate.
Neck: Supple, no LAD or masses
CV: Normal S1 and S2, RRR, No murmurs, rubs or gallops
Lungs: Decreased breath sounds in the left middle and lower lung
fields is stable and assymetric with right. No wheezes, rales,
or rhonchi. Otherwise CTAB.
Abdomen: Bowel sounds present. Soft, non-tender, non-distended
GU: Foley in place
Skin: Dry. Normal texture and temperature.
Extremities: Warm and well perfused. NO cyanosis, clubbing, or
edema.
Neuro: Cranial nerves II-XII intact (see HEENT above), ___ UE
strength bilaterally, ___ ___ strength bilaterally, sensations to
light touch grossly intact in face, UE, and ___ bilaterally
Pertinent Results:
LABS ON ADMISSION:
==================
___ 03:10PM BLOOD WBC-12.9* RBC-4.66 Hgb-14.2 Hct-41.8
MCV-90 MCH-30.5 MCHC-34.0 RDW-13.7 RDWSD-44.7 Plt ___
___ 03:10PM BLOOD Neuts-76.6* Lymphs-12.7* Monos-9.4
Eos-0.3* Baso-0.5 Im ___ AbsNeut-9.85* AbsLymp-1.63
AbsMono-1.21* AbsEos-0.04 AbsBaso-0.07
___ 03:10PM BLOOD ___ PTT-27.5 ___
___ 03:10PM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-135
K-4.0 Cl-102 HCO3-25 AnGap-12
___ 03:10PM BLOOD ALT-15 AST-13 LD(LDH)-173 AlkPhos-78
TotBili-0.9
___ 03:10PM BLOOD proBNP-85
___ 03:00PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 03:10PM BLOOD TotProt-6.9 Albumin-3.9 Globuln-3.0
Calcium-9.4 Phos-3.3 Mg-1.7
___ 04:50PM BLOOD D-Dimer-904*
PLEURAL FLUID ANALYSIS:
___ 03:41PM PLEURAL ___ RBC-3778* Polys-65*
Lymphs-30* Monos-3* Eos-1* Macro-1*
___ 03:41PM PLEURAL TotProt-4.7 Glucose-98 Creat-1.1
LD(LDH)-344 Amylase-34 Albumin-2.7 ___ Misc-PRO BNP =
LABS ON DISCHARGE:
==================
___ 05:59AM BLOOD WBC-9.9 RBC-3.96* Hgb-11.9* Hct-35.7*
MCV-90 MCH-30.1 MCHC-33.3 RDW-13.6 RDWSD-45.0 Plt ___
___ 05:59AM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-136
K-4.2 Cl-103 HCO3-25 AnGap-12
___ 05:59AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
MICROBIOLOGY:
=============
___ 3:41 pm PLEURAL FLUID LEFT PLEURAL.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
STUDIES/IMAGING:
================
___ of LLE ___: No evidence of deep venous thrombosis in
the left lower extremity veins.
CXR PA/LAT ___: Substantial left-sided pleural effusion.
CTA CHEST ___:
1. No evidence of pulmonary embolism.
2. Moderate to large pleural effusion with atelectasis on the
left; no
visible mass on the left. Loculated elements suggest longer
chronicity, at
least in part, to the pleural effusion. Substantial associated
atelectasis.
3. Flat, possibly enhancing or least a hyperdense, lesion along
the right
lateral chest wall. This overlies suggesting a prior fracture
involving the right lateral seventh rib so the finding may be
posttraumatic.
4. Erosive changes at the manubrial sternal joint suggesting
prior
inflammation, such as unusual presentation of inflammatory
arthropathy,
potentially sequela of prior infection.
CXR ___: No relevant change as compared to the previous
image. Constant position of the left pigtail catheter.
Constant extent of a small left pleural effusion with subsequent
retrocardiac atelectasis and elevation of the left
hemidiaphragm. Unchanged appearance of the heart and of the
right lung.
CT CHEST ___: Interval decrease in size in loculated left
pleural effusion after placement of the pigtail catheter.
Multiple loculated bubbles of air. Subcutaneous air. Left lower
lobe consolidation, most likely a combination of atelectasis or
infection with no possibility to exclude underlying mass.
Unchanged appearance of the right chest wall/pleural lesion.
Potentially as previously suggested 8 might be related to
previous fracture of the left seventh rib but followup is
required to exclude the possibility of neoplastic origin. No
changes in the intra-abdominal findings demonstrated but there
is higher elevation of left hemidiaphragm potentially due to
drainage of pleural effusion with more pronounced right
mediastinal shift.
CT Chest ___:
1. Slight interval decreased size of the nonhemorrhagic left
pleural effusion
with an appropriately positioned pigtail catheter at the left
lung base.
2. Newly demonstrated 5.2 x 4.4 cm blood and fluid-filled
structure in the
left midlung, either in the fissure or within the lung
parenchyma, concerning
for a hemato-pneumatocele or fissural pleural loculation.
3. Unchanged pleural lesion adjacent to the remote right ___
rib fracture,
possible a sequelae of trauma.
CT Chest ___:
IMPRESSION:
1. The fluid collection located either in the left upper lobe
or centered in the left major fissure is larger compared to ___. Appearance remains consistent with a hematocele, although
superinfection cannot be excluded. CT guided drainage of this
collection was performed on same date and reported
separately.
2. Small loculated left pleural effusion with catheter in place
is stable in size. There is better aeration of left lower lobe.
3. Unchanged deformity of the sternum with irregular lucent
sternal defect and surrounding sclerosis, soft tissue density
and extra osseous calcification. This may represent an ununited
fracture, although superimposed infection and or pathologic
fracture cannot be excluded. Please correlate with any history
of trauma.
4. 13 mm thyroid nodule or nodular configuration of the
inferior pole right thyroid lobe. If clinically indicated,
ultrasound can be obtained for further evaluation on a nonurgent
basis once current illness has resolved.
___ CXR
In comparison with the study ___, the larger pigtail
catheter has been removed. There is little overall change in
the opacification at the left base, consistent with some
combination of pleural effusion and underlying compressive
atelectasis. No evidence of pneumothorax.
The right lung remains clear.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Left-sided pleuritic chest pain and calf tenderness.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: None.
FINDINGS:
Cardiac borders are partly obscured by a moderate sized left-sided pleural
effusion with suspicion for substantial associated atelectasis involving the
inferior part of the lingula and basilar segments of the left lower lobe.
There is no net shift of midline structures. Aorta appears mildly tortuous.
Right lung appears clear, without pleural effusion.
IMPRESSION:
Substantial left-sided pleural effusion.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with complaint of pleuritic left chest pain and left calf
tenderness, evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CHEST CTA
INDICATION: Sudden dyspnea and positive D-dimer.
TECHNIQUE: Multidetector CT images of the chest were obtained with
intravenous contrast in the pulmonary arterial phase. Sagittal and coronal
reformations it would were performed in addition to the bilateral oblique MIP
reformations, which were performed and reviewed.
DLP: 447.0 mGy-cm.
COMPARISON: None.
FINDINGS:
There are mildly prominent central mesenteric lymph nodes although none are
enlarged by size criteria. The heart is borderline in size, perhaps with
apical thinning. Coronary artery calcifications are present. Gynecomastia is
moderate.
No filling defects are found among pulmonary arteries.
There is a sessile polypoid subpleural opacity of high density suggesting
possibility of enhancement that measures up to 22 x 19 mm in axial ___
(2:72) along the right lateral chest. This overlies an irregular remodeled
contour to the right lateral seventh rib with hypertrophy suggestive of prior
fracture.
On the left, there is a moderate to large pleural effusion with loculated
elements, but not defined walls, although much of it is probably free-flowing.
Parts of the left lower lung show associated atelectasis but there is no
visible mass in the left lung or hilum. There is no pleural effusion on the
right side. There is also a prior fracture involving the anterior right third
rib without displacement.
Limited views of the upper abdomen are unremarkable.
There are no suspicious bone lesions. Erosive changes are present at the
manubrial sternal joint.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Moderate to large pleural effusion with atelectasis on the left; no
visible mass on the left. Loculated elements suggest longer chronicity, at
least in part, to the pleural effusion. Substantial associated atelectasis.
3. Flat, possibly enhancing or least a hyperdense, lesion along the right
lateral chest wall. This overlies suggesting a prior fracture involving the
right lateral seventh rib so the finding may be posttraumatic.
4. Erosive changes at the manubrial sternal joint suggesting prior
inflammation, such as unusual presentation of inflammatory arthropathy,
potentially sequela of prior infection.
Final report discussed with Dr. ___ on ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with large left sided pleural effusion s/p chest
tube placement // r/o ptx
COMPARISON: ___
IMPRESSION:
As compared to the previous image, the patient has received a left-sided
pigtail catheter in the pleural space. The extent of the left effusion has
substantially decreased. No pneumothorax. Lower lung volumes. Moderate
cardiomegaly. Unchanged appearance of the right lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with large left pleural effusion now s/p chest
tube placement. // Please perform on ___ before 7AM. Assess for PTX.
COMPARISON: ___.
IMPRESSION:
No relevant change as compared to the previous image. Constant position of
the left pigtail catheter. Constant extent of a small left pleural effusion
with subsequent retrocardiac atelectasis and elevation of the left
hemidiaphragm. Unchanged appearance of the heart and of the right lung.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ year old man with new left-sided pleural effusion s/p chest
tube placement on ___. Pleural fluid analysis c/w parapneumonic effusion vs
malignancy. // Assess for interval change, underlying disease
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___
FINDINGS:
Since the prior study the has been insertion of pigtail catheter in the left
pleural space at the mid aspect. As a consequence there has been interval
substantial decrease in the amount of pleural effusion in particular at the
basal aspect of the pleura. Currently the effusion continues to be loculated
containing multiple foci of air, most likely trapped within the effusion. The
prior study there has been interval elevation of the hemidiaphragm, slight
potentially due to decrease in the amount of pleural fluid with subsequent
slight right mediastinal shift. Left chest wall air is demonstrated along the
tract of the catheter. No pneumothorax seen outside of the fluid collection.
No appreciable pericardial effusion is seen. Minimal amount of right pleural
fluid is demonstrated, increased since the prior study.
Imaged portion of the upper abdomen demonstrate large cortical cyst in the
left kidney as well as gallbladder sludge and foci of calcification in the
right kidney.
Airways are patent to the subsegmental level bilaterally except fall left
lower lobe and lingula where atelectasis is noted most likely due to
combination of effusion and elevated left hemidiaphragm. Except for minimal a
right lower lung atelectasis right lung is clear. Off note is soft tissue
lesion, 2.3 x 1.7 cm, pleural or extrapleural based, series 4, image 148,
unchanged in appearance since previous CT obtained 2 days ago.
No lytic or sclerotic lesions worrisome for infection or neoplasm
demonstrated. Erosive changes at the manubrial sternal joint suggesting prior
inflammation as previously. Septal thickening in the left upper lobe is
minimal. Besides left lower lobe atelectasis no new findings demonstrated.
IMPRESSION:
Interval decrease in size in loculated left pleural effusion after placement
of the pigtail catheter. Multiple loculated bubbles of air. Subcutaneous air.
Left lower lobe consolidation, most likely a combination of atelectasis or
infection with no possibility to exclude underlying mass.
Unchanged appearance of the right chest wall/pleural lesion. Potentially as
previously suggested 8 might be related to previous fracture of the left
seventh rib but followup is required to exclude the possibility of neoplastic
origin.
No changes in the intra-abdominal findings demonstrated but there is higher
elevation of left hemidiaphragm potentially due to drainage of pleural
effusion with more pronounced right mediastinal shift.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with effusion s/p chest tube // Please perform
by 6AM on ___
IMPRESSION:
Allowing for differences in technique and projection, there has not been a
substantial change in the appearance of the chest since recent study of ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pulmonary effusion // Chest tube pulled out
IMPRESSION:
As compared to prior study of several hr earlier, left pigtail pleural
catheter has been removed, with no substantial change in moderate partially
loculated left pleural effusion with adjacent lingular and left lower lobe
atelectasis and or consolidation.
Radiology Report
INDICATION: ___ year old man with chest tube placed // eval for pneumothorax
TECHNIQUE: Portable AP upright view of the chest
COMPARISON: ___
FINDINGS:
There is interval placement of a pigtail pleural catheter in the mid left
chest. The large left pleural effusion however has minimally changed. The
right lung is clear. The is no right pleural effusion. The cardiac
silhouette is partially obscured and difficult to evaluate. The visualized
mediastinal contours are otherwise stable.
IMPRESSION:
Interval placement of a left pleural catheter with minimal improvement in
large left pleural effusion.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with dyspnea from left sided pleural effusion,
likely infectious, status post 1 day of TPA/DNAse. Evaluate for size of
pleural effusion and for underlying pathology.
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. Due to injector malfunction, the first of
scans were obtained without intravenous contrast and and repeated following
proper intravenous contrast administration.
DOSE: DLP: 1641mGy-cm
COMPARISON: Chest CT from ___
FINDINGS:
Soft tissues: The thyroid is homogeneous. Numerous mediastinal lymph nodes are
noted but not pathologically enlarged. Heart size is mildly enlarged with a
small pericardial effusion, as before. Mild aortic annular and coronary
artery calcifications are noted. Limited images of the upper abdomen again
demonstrate a large cyst at the upper pole of the left kidney measuring up to
9.5 cm. No other significant abnormalities appreciated. Aorta and main
pulmonary artery are normal in caliber.
Lungs: Since the prior study there has been slight interval decrease in the
loculated left pleural effusion with a pleural catheter forming a pigtail in
the posterior aspect of the left lung base. Small hydropneumothorax is noted.
The adjacent left lower lobe demonstrates compressive atelectasis. Larger and
more apparent since the prior study is a fluid-filled structure measuring 5.2
x 4.4 cm (05:33), with a fluid-blood level internally. The collection is in
the region that was occupied by the previous pigtail catheter, seen on ___, and could be either fissural or in the lung. Narrowing of the lingular
and left lower lobe bronchi is noted, as a result of mass effect from the
collection. Trace right pleural effusion with adjacent compressive
atelectasis is noted. Subpleural lesion adjacent to the remote right seventh
rib fracture is unchanged.
Bones: Remote right lateral seventh rib fracture with adjacent pleural
changes. No concerning osseous lesion is seen. There is nonunion of the
remote sternomanubrial fracture.
IMPRESSION:
1. Slight interval decreased size of the nonhemorrhagic left pleural effusion
with an appropriately positioned pigtail catheter at the left lung base.
2. Newly demonstrated 5.2 x 4.4 cm blood and fluid-filled structure in the
left midlung, either in the fissure or within the lung parenchyma, concerning
for a hemato-pneumatocele or fissural pleural loculation.
3. Unchanged pleural lesion adjacent to the remote right 7th rib fracture,
possible a sequelae of trauma.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 5:30 ___, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion with chest tube in place.
Please complete before 6 am // Chest tube on left
COMPARISON: ___.
IMPRESSION:
As compared to the previous image, no relevant change is seen. The extent of
the left pleural effusion and the position of the pigtail catheter is
constant. No pneumothorax. Unchanged appearance of the right lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion with chest tube in place.
Please complete before 6 am. Evaluate pneumothorax and chest tube placement.
TECHNIQUE: Portable semi upright chest radiograph
COMPARISON: Multiple priors
FINDINGS:
Lung volumes are slightly lower, particularly on the right. Left chest tube
is unchanged. Left perihilar consolidation is increased since the prior study,
likely reflecting atelectasis. Previous moderate left pleural effusion is
smaller and the heterogeneous opacity at the left lung base is likely a
combination of atelectasis and edema. Increasing opacities at the right lung
base may reflect a developing pneumonia.
IMPRESSION:
Decrease in size of left pleural effusion, with bibasilar atelectasis, left
greater than right, and slight decrease in lung volumes.
Increasing opacities at the right lung base, while may reflect atelectasis,
raise the concern for pneumonia. Continued surveillance is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleaural effusion s/p chest tube. Please
complete exam by 0600 // empyema getting smaller? chest tube in place?
IMPRESSION:
As compared to previous study of earlier the same date, there has not been a
relevant change in the appearance of a moderate left pleural effusion with
adjacent left lower lobe atelectasis and or consolidation. Note is made of
improved aeration of the right lung base with resolving atelectasis and
decreased pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema with chest tube placed. Please
complete before 0600 // empyema getting smaller? chest tube in place?
IMPRESSION:
As compared to ___ radiograph, left pigtail pleural catheter remains
in place with slight decrease in size of partially loculated moderate left
pleural effusion with adjacent left basilar atelectasis and or consolidation.
Additionally, a very small right pleural effusion is accompanied by adjacent
minor right basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema s/p chest tube. Please complete
before 6 am // Chest tube in place. Size of effusion
TECHNIQUE: Portable chest
___
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with empyema. // Resolution of complicated
effusion?
TECHNIQUE: Multidetector helical scanning of the chest was performed after
the uneventful administration of IV contrast and reconstructed as contiguous
5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8
mm MIPs axial images.
DOSE: DLP: 718mGy-cm
COMPARISON: CT chest ___
FINDINGS:
There is a 13 mm nodule or nodular configuration of the inferior pole of right
thyroid lobe. Thoracic aorta and main pulmonary artery are normal size.
There is mild coronary artery and aortic valve calcification. Small
pericardial effusion is less. There are numerous prominent mediastinal lymph
nodes which are likely reactive.
Airways are patent to subsegmental levels on the right. Previously narrowed
airway in the lingula is improved. There is persistent narrowing of the left
lower lobe airways. Compared to ___, the small loculated left pleural
effusion is stable with left pigtail pleural catheter in unchanged position at
the posterior left lung base. There is better aeration of left lower lobe.
There are small pockets of air in the small left pleural effusion. The well
circumscribed round fluid collection with internal fluid blood level located
either in the left upper lobe or centered in the left major fissure measures
59 x 57 x 46mm, larger from prior (52 x 46 x 36 mm). This is consistent with
a hematocele although superinfection cannot be excluded. A tubular
hypodensity at the left lower lobe measuring 12 x 20 x 64 mm could be folded
atelectatic lung or loculation of pleural fluid, and less likely collection
within the parenchyma. . There small non loculated right pleural effusion.
BONES/ SOFT TISSUE: Again seen is the right pleural based lesion adjacent to
right 7th rib which is stable and likely related to prior rib fracture.
Unchanged deformity adjacent to the manubriosternal joint was previously
variably described as nonunion of fracture or erosive changes and again shows
irregularity, surrounding sclerosis with central lucency, and adjacent soft
tissue density and calcification. . There is bilateral gynecomastia.
ABDOMEN: This study was not designed for subdiaphragmatic evaluation.
Limited assessment of upper abdominal organs show large left simple renal cyst
which is partially imaged. Left adrenal myelipoma is unchanged.
IMPRESSION:
1. The fluid collection located either in the left upper lobe or centered in
the left major fissure is larger compared to ___. Appearance remains
consistent with a hematocele, although superinfection cannot be excluded. CT
guided drainage of this collection was performed on same date and reported
separately.
2. Small loculated left pleural effusion with catheter in place is stable in
size. There is better aeration of left lower lobe.
3. Unchanged deformity of the sternum with irregular lucent sternal defect and
surrounding sclerosis, soft tissue density and extra osseous calcification.
This may represent an ununited fracture, although superimposed infection and
or pathologic fracture cannot be excluded. Please correlate with any history
of trauma.
4. 13 mm thyroid nodule or nodular configuration of the inferior pole right
thyroid lobe. If clinically indicated, ultrasound can be obtained for further
evaluation on a nonurgent basis once current illness has resolved.
RECOMMENDATION: Please correlate with any history of trauma and/or concern
for infection as regards the indeterminate lesion of the sternum described
above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema s/p chest tube. Please complete
before 6 am // please eval chest tube placement and size of effusion
please eval chest tube placement and size of effusion
IMPRESSION:
In comparison with the study ___, there has been placement of a second
left chest tube. The degree of the opacification at the left base is
unchanged and there is no evidence of pneumothorax. Right lung remains clear.
Radiology Report
INDICATION: ___ year old man with picc // r picc 46cm ___ ___ Contact
name: ping, ___: ___
TECHNIQUE: Chest single view
___ at 05:50
FINDINGS:
There is a new right-sided PICC line with tip in the superior vena cava. The
left pleural effusion and pigtail catheter and left lower lobe volume loss are
unchanged there is a small right effusion with some compressive changes at the
right base. There is no pneumothorax
Radiology Report
INDICATION: ___ -year-old male with loculated left pleural effusion.
COMPARISON: Chest CT performed on ___.
PROCEDURE: CT-guided placement of pigtail catheter into a loculated left
pleural effusion.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan was performed to localize the collection. Based on the CT
findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
pigtail catheter into the collection. The metal stiffener and the wire were
removed. The pigtail was deployed. The position of the pigtail was confirmed
within the collection via CT fluoroscopy.
Approximately 70 cc of hemorrhagic fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to Pleurovac and left to water seal for transport to the floor.
Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 491 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 50 mcg fentanyl throughout the total intra-service time of
15 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
PREPROCEDURE:
Limited noncontrast chest CT performed for preprocedure evaluation
demonstrates a 5.7 x 4.4 cm collectionwith hematocrit level likely within the
left fissure. This fluid collection was targeted for drainage as described
above. In addition, there is a posterior approach pigtail catheter coiled
within the left pleural space. The continues to be a small amount of fluid
and air around the catheter. There is left lower lobe atelectasis. There is
a trace right pleural effusion with adjacent atelectasis. Note is made of
coronary artery vascular calcifications.
POSTPROCEDURE:
Limited noncontrast CT of the chest demonstrates the newly placed left lateral
intercostal approach pigtail catheter coiled within the now decompressed
left-sided pleural collection. There is a small amount of air around the
catheter. The left posterior approach pigtail catheter is again identified
within the pleural space with associated small foci air. There continues to
be atelectasis of the left lower lobe. Trace right pleural effusion with
adjacent atelectasis.
IMPRESSION:
Successful CT-guided placement of an 8 ___ pigtail catheter into the
loculated left likely pleural collection. A total of 70 cc of hemorrhagic
fluid was aspirated with sample submitted for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with parapneumonic effusion s/p pigtail. //
interval changes. interval changes.
IMPRESSION:
In comparison with the study ___, the larger pigtail catheter has been
removed. There is little overall change in the opacification at the left
base, consistent with some combination of pleural effusion and underlying
compressive atelectasis. No evidence of pneumothorax.
The right lung remains clear.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Calf pain, Dyspnea
Diagnosed with PLEURAL EFFUSION NOS, RESPIRATORY ABNORM NEC
temperature: 99.4
heartrate: 67.0
resprate: 18.0
o2sat: 96.0
sbp: 123.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with a remote 20 pack year
smoking history, multiple CVAs (___), HTN, HLD, carotid
stenosis, and neurogenic Bladder with chronic foley who
presented with SOB, found to have exudative pleural effusion. He
was treated with chest tube placement for fluid drainage with
improvement of his symptoms. His course was complicated by ___,
which was pre-renal in nature and improved with IVF.
#Exudative Pleural effusion: Pt presented with SOB found to have
large left-sided pleural effusion on CXR and CTA chest. Fluid
collection was unilateral and he had no history of heart failure
with negative BNP ruling out heart failure as etiology.
Interventional pulmonology was consulted who performed chest
tube placement on ___ revealing exudative pleural fluid. Based
on pleural fluid results, uptrending WBC count and incomplete
visualization of lung on imaging due to effusion underlying
pneumonia was considered (empyema). He was started on an empiric
antibiotic coverage with Vanc/Zosyn. Malignancy was also
considered given smoking history and elevated PSA. Following
initial chest tube placement more than 1.5L of fuid drained with
some improvement of his symptoms. While he was more comfortable
he still had persistent oxygen requirement. Given evidence of
loculations within effusion on repeat CT chest and residual
fluid, tPA/DNAse was placed in chest tube on ___ and more than
500cc of additional fluid was drained. . His course was
complicated by altered mental status, during his original chest
tube was pulled out. Chest tube was replaced. A follow up CT
chest showed fluid accumulating along a fissue, which needed to
be drained by ___ with CT guidance on ___. Ultrasound
evaluation on day of discharge showed resolution of effusion,
and his chest tube was subsequently pulled. He will require a 4
week course of antibiotics, and is being switched over to
ertapenum for daily dosing. He will need to follow up with IP in
4 weeks.
___: Cr 1.1 on admission. Cr rose to 1.5 several days on the
day after admission. Most likely pre-renal given FeNa of 0.1%
from restricted intake in the setting of stress of
hospitalization and chest discomfort due to pleural effusion.
Downtrended promptly following fluid resuscitation.
#Hyponatremia: Developed hyponatremia to 132 during this
admission. Likely hypovolemic given concentration on lab work
and ___. Improved with IVF.
#Leukocytosis: Leukocytosis to 12.9 on admission. Rose to 23.6
before downtrending. Possibly due to infection given suspected
pneumonia as above vs stress leukocytosis.
#Elevated PSA: PSA elevated to 9.7 in ___ when seen by Dr.
___ in ___ Urology Group. Needs follow-up in the
outpatient setting.
#Neurogenic bladder: Has chronic foley. Denies dysuria or acute
complaints. UA dirty but no need to treat in the setting of
indwelling foley without symptoms.
#History of CVA: Continue home ASA 325mg and atorvastatin.
#HTN: Continued home metoprolol and amlodipine.
#HLD: Continued home atorvastatin.
#Gout: Continued allopurinol.
#Depression and Anxiety: Continued home duloxetine and
clonidine.
TRANSITIONAL ISSUES:
====================
# Right-sided subpleural lesion noted on CT chest. Radiology
recommended 6 month f/u CT to assess for interval change.
# Further work-up for elevated PSA
# F/U video swallow study for evaluation of aspiration
# F/U with interventional radiology in 4 weeks, with CT scan at
that time
# Continue IV antibiotics for 4 weeks
# CODE: Full
# EMERGENCY CONTACT HCP: Daughter ___ ___ |
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 hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presents from ___ with a left acetabular fracture after a
fall. She slipped and fell in the bathroom landing on her left
side. No head strike or LOC. She has pain in the left hip that
is sharp and does not radiate. The pain is worse with movement
of the hip. She has not taken anything for the pain. No weakness
or numbness. She has had bilateral hip replacements and normally
walks with a walker.
Past Medical History:
Carotid stenosis: ___ had occluded left ICA with severe
narrowing of external carotid, 70% stenosis of right ICA
CKD, baseline creatinine 1.5 in ___
HTN
Peripheral vascular disease
Glaucoma
Hard of hearing
Right hip replacement ___
Social History:
___
Family History:
Mother had "blood disorder," father had kidney disease
Physical Exam:
Exam at discharge:
Medications on Admission:
metoprolol succinate 25mg daily
amlodipine 5mg daily
lisinopril 5mg daily
HCTZ 12.5mg daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
periprosthetic left acetabular fracture
Discharge Condition:
Mental Status: Confused - sometimes (baseline).
Level of Consciousness: Alert and interactive.
Activity Status:
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hip fx? // re eval fx? Please obtain Judet
views
TECHNIQUE: Pelvis four views
COMPARISON: ___
FINDINGS:
Patient is status post bilateral hip arthroplasties. Partially imaged medial
left acetabular fracture is seen. Fracture appears to involve the medial
acetabulum and extends superiorly. There may also be slight left acetabular
protrusio of the femoral head component of the left hip prosthesis. No
evidence of hardware fracture is seen. The very inferior aspects of the
femoral components of the hip prostheses are not included on the images. No
dislocation is seen. The pubic symphysis and sacroiliac joints are intact.
Possible heterotopic ossification is noted along the right greater trochanter.
Overall the bones are diffusely osteopenic. Degenerative changes are noted
along the partially imaged lower lumbar spine. There are vascular
calcifications.
IMPRESSION:
Left acetabular fracture.
Status post bilateral hip arthroplasties. No hardware fracture seen.
Radiology Report
INDICATION: History: ___ with hip fx // eval fx for operative mx
TECHNIQUE: Noncontrast enhanced MDCT images of the bony pelvis were obtained
without the administration of intravenous contrast. Reformatted coronal and
sagittal images were also obtained.
DOSE: Total exam DLP: 1379 mGy per cm.
COMPARISON: No prior CT available for comparison. Reference made to
radiographs performed earlier today, ___ at 09:10.
FINDINGS:
Patient is status post bilateral hip arthroplasties with prosthesis causing
streak artifacts through the lower pelvis. There is fracture through the
medial left acetabulum extending superiorly and possibly inferiorly. No
definite fracture of the orthopedic hardware is seen. There is no dislocation.
Chronic deformity of the inferior pubic ramus in medial superior right pubic
ramus may relate to prior trauma. Degenerative changes are seen along the
visualized lower lumbar spine, including disc space narrowing and vacuum
phenomenon, and osteophytosis.
Retroperitoneal hematoma is seen in the left pelvis extending superiorly to
approximately the level of L4, tracking superiorly along the anterior lateral
distal left psoas muscle and inferior to the left external iliac region.
Retroperitoneal hematoma spans approximately 9 x 4 cm.
The superior most image demonstrates a dilated distal abdominal aorta
measuring up to 3.8 cm in diameter, although not well evaluated. There is
borderline aneurysm of the right common iliac artery.
There is a 2.6 x 1.9 cm heterogeneous structure/ lesion in the right adnexa
located between the uterus and the right ovary, difficult to discern were the
uterine or ovarian in etiology. Followup pelvic ultrasound is recommended for
further evaluation. No drainable fluid collection is seen. There is no bowel
wall thickening or evidence of bowel obstruction in the pelvis. Colon
diverticulosis is noted. Arterial calcifications are seen.
IMPRESSION:
Bilateral hip prostheses cause streak artifacts through the lower pelvis.
Medial left acetabular fracture extends superiorly and inferiorly Associated
retroperitoneal hematoma in the left pelvis spanning 8.7 x 3.8 cm.
Superior most image shows distal aorta aneurysm to 3.8 cm, not well evaluated
or fully imaged. Borderline aneurysm of the right common iliac artery.
2.6 x 1.9 cm heterogeneous structure/ lesion in the right adnexa located
between the uterus and right ovary, difficult to discern whether uterine or
ovarian in origin. Recommend followup pelvic ultrasound for further
evaluation.
Discussed with Dr. ___ at 10:32 on ___
RECOMMENDATION(S): 2.6 x 1.9 cm heterogeneous structure/ lesion in the right
adnexa located between the uterus and right ovary, difficult to discern
whether uterine or ovarian. Recommend followup pelvic ultrasound for further
evaluation.
NOTIFICATION: Discussed with Dr. ___ at 10:32 on ___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with fall // ptx?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Patient is rotated somewhat to the left. No pleural effusion is seen. The
cardiac and mediastinal silhouettes are unremarkable. Patchy left suprahilar
opacity most likely represents vascular structures underlying consolidation
not excluded in the appropriate clinical setting. No definite evidence of
pneumothorax in this patient reportedly upright in position. No displaced
fracture identified.
Radiology Report
EXAMINATION: HAND (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ year old woman with bruisng and swelling s/p fall of ___
metacarpal head.
TECHNIQUE: Left hand, three views.
COMPARISON: ___.
FINDINGS:
Diffuse osteopenia is present. No fracture or dislocation is identified.
Severe degenerative changes are identified, slightly progressed from ___.
These changes are more prominent in the DIP and PIP joints of all digits as
well as in the first CMC, first MCP and triscaphe joints. There is bouttoniere
deformity of the index finger of the left hand. There is no radiopaque foreign
object.
IMPRESSION:
No evidence of fracture. Severe osteoarthritis is slightly progressed
compared with ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FRACTURE ACETABULUM-CLOS, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING
temperature: 97.8
heartrate: 70.0
resprate: 18.0
o2sat: 94.0
sbp: 157.0
dbp: 64.0
level of pain: 5
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 periprosthetic left acetabular fracture and was
admitted to the orthopedic surgery service for pain control and
a trial of nonoperative management. The patient's home diet was
continued. The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the left lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
TEE/DCCV (___)
History of Present Illness:
Mr. ___ is a ___ man with a PMH notable for
paroxysmal atrial fibrillation, who presents from his PCP's
office after being found to be tachycardic.
The history given by the patient is a bit vague. He reports
first having heart problems going back to the ___
when he had intermittent palpitations. In ___, he was
hospitalized for a lung infection. During that time, he was
diagnosed with atrial fibrillation that was thought to be
triggered by the infection. He also mentions having had
echocardiograms at that time to rule out vegetations. He was
discharged on clarithromycin and doxycycline for the pneumonia.
Prior to the New Year, he went down to ___ and started
feeling generally unwell. He started having malaise, coughing
with phlegm production, and shortness of breath. When he
returned to ___ earlier this week, he went to see his PCP ___
___. Earlier that day, he had a fever to 101 at home. On arrival
to the office, he was found to have a heart rate in the 140s,
and sent to the ED for further care.
In the ___ ED, he was given diltiazem boluses and placed on a
diltiazem drip that slowed his heart rate to the 110s. His BP
was normal in the 100s/70s. Because of his recent travel, a
d-dimer was checked, which was highly elevated. He had a CTA
that was negative for PE or clear consolidations. He was then
admitted to Cardiology for further management of his
tachyarrhythmia.
On arrival to the floor, patient reports feel somewhat better,
but still quite fatigued.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
denies headache, sinus tenderness, rhinorrhea or congestion.
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:
- Paroxysmal atrial fibrillation on aspirin only
- Hypertension
- Gout
- GERD
- Anxiety
Social History:
___
Family History:
Father had a MI and CABG in his ___.
Physical Exam:
==================
ADMISSION EXAM
==================
Vital Signs: T 97.8, HR 92, BP 132/66, RR 20, SAT 98% on RA
Weight: 118.8 kg
General: Alert, oriented, no acute distress, obese habitus
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP slightly elevated at 8-9 cm
CV: Tachycardic, irregularly irregular rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Lungs: Mostly clear to auscultation bilaterally with bibasilar
crackles, no wheezing
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, grossly normal motor function
==================
DISCHARGE EXAM
==================
Wt 113.9kg
VS: Afebrile, Tcurr 97.9F, bp 91-125/47-88, bpcurr= 103/66, HR
69-86, RR 16, 99% O2sat on RA
Tele: NSR since TEE cardiovrsion
General: Awake, alert, in no acute distress, sitting up in a
chair
HEENT: NC/AT, PERRLA, clear conjunctiva b/l, MMM
Neck: Supple, no cervical lymphadenopathy
CV: RRR, S1, S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes
Abdomen: Soft, obese, non-distended, +BS, non-tender to
palpation in all four quadrants
Ext: Warm, no edema, 2+ peripheral pulses
Pertinent Results:
=================
ADMISSION LABS
=================
___ 02:05PM BLOOD WBC-11.0* RBC-4.47* Hgb-11.7* Hct-37.8*
MCV-85 MCH-26.2 MCHC-31.0* RDW-14.0 RDWSD-43.2 Plt ___
___ 02:05PM BLOOD Neuts-79.3* Lymphs-13.4* Monos-5.6
Eos-0.8* Baso-0.4 Im ___ AbsNeut-8.71* AbsLymp-1.47
AbsMono-0.62 AbsEos-0.09 AbsBaso-0.04
___ 02:05PM BLOOD ___ PTT-29.1 ___
___ 02:05PM BLOOD Glucose-105* UreaN-16 Creat-1.2 Na-135
K-4.4 Cl-99 HCO3-22 AnGap-18
___ 02:05PM BLOOD Calcium-9.2 Phos-3.9 Mg-1.9
======================
PERTINENT RESULTS
======================
LABS
======================
___ 02:05PM BLOOD proBNP-1742*
___ 02:05PM BLOOD cTropnT-<0.01
___ 03:20PM BLOOD D-Dimer-3280*
___ 02:05PM BLOOD TSH-1.2
___ 06:05AM BLOOD CRP-138.4*
___ 07:10AM BLOOD SED RATE-79
======================
IMAGING/STUDIES
======================
CXR (___): No acute cardiopulmonary process.
---
CTA (___):
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Small pericardial effusion appears mildly complex without
evidence for abnormal pericardial enhancement or thickening.
3. Small left and trace right layering nonhemorrhagic pleural
effusions.
4. Prominent subcarinal and right hilar lymph nodes. Other
additional scattered mediastinal lymph nodes are mildly numerous
but not individually enlarged. These are likely reactive.
---
Bilateral lower extremity ultrasounds (___):
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
---
TEE (___):
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A very small left-to-right shunt
across the interatrial septum is seen at rest c/w a very small
secundum atrial septal defect. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: No spontaneous echo contrast or thrombus in the
___. Very small secundum type atrial septal defect
with left-to-right flow. Mild mitral regurgitation.
---
ECG (___):
Atrial fibrillation with a rapid response rate of 114 beats per
minute.
Non-diagnostic Q waves inferiorly. Non-specific ST segment
changes. Compared to the previous tracing of ___ the
ventricular response rate is slower and a regular narrow complex
tachycardia has been replaced by an irregular narrow complex
tachycardia likely consistent with atrial fibrillation versus
atrial flutter with a variable conduction.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
___ 243 22 -67
---
ECG (___):
Sinus rhythm with left atrial enlargement. There are small
inferior Q waves. Cannot rule out an old inferior wall
myocardial infarction. Non specific ST-T wave abnormalities most
marked in the apical leads. Compared to the previous tracing
sinus rhythm has replaced atrial flutter.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
75 160 96 422 448 34 43 -30
=================
DISCHARGE LABS
=================
___ 09:50AM BLOOD WBC-4.4 RBC-4.62 Hgb-11.7* Hct-38.4*
MCV-83 MCH-25.3* MCHC-30.5* RDW-13.9 RDWSD-41.3 Plt ___
___ 09:50AM BLOOD ___ PTT-38.0* ___
___ 09:50AM BLOOD Glucose-116* UreaN-11 Creat-1.0 Na-138
K-4.2 Cl-101 HCO3-23 AnGap-18
___ 09:50AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.4
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 12.5 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. ALPRAZolam 1 mg PO BID:PRN anxiety
5. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl [DILT-XR] 120 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*1
2. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily with
dinner Disp #*30 Tablet Refills:*3
3. Allopurinol ___ mg PO DAILY
4. ALPRAZolam 1 mg PO BID:PRN anxiety
5. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Atrial fibrillation/atrial flutter
SECONDARY:
- Anxiety
- Gastroesophageal reflux
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with dyspnea, fever, tachycardia // please evaluate
for acute infectious process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with tachycardia, +dimer // please evaluate for pulmonary
embolism
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 3.8 s, 29.9 cm; CTDIvol = 23.2 mGy (Body) DLP = 692.4
mGy-cm.
Total DLP (Body) = 704 mGy-cm.
COMPARISON: Chest x-ray ___.
FINDINGS:
CTA THORAX: The aorta and major thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the chest without evidence of
intramural hematoma or dissection. Major aortic arch branch vessels are
grossly patent and within normal limits. The pulmonary artery is normal
caliber. The pulmonary artery is well opacified to subsegmental levels.
There is no evidence of an intraluminal filling defect in the main, right,
left, lobar, or subsegmental pulmonary arterial branches. No arteriovenous
malformation is identified.
CT THORAX: The partially imaged thyroid gland is within normal limits. The
esophagus is otherwise normal. The heart is normal in size. There is a small
pericardial effusion which appears mildly complex ___ ___. There is mild
coronary artery calcification. The heart is otherwise unremarkable. A
prominent subcarinal lymph node measures up to 14 mm (2, 51) and a prominent
right hilar lymph node measures up to 10 mm. Additional scattered mediastinal
lymph nodes elsewhere are mildly abnormally numerous but not individually
pathologically enlarged. There is no axillary or visible supraclavicular
lymphadenopathy.
Major airways are patent to subsegmental levels bilaterally. There is mild
diffuse bronchial wall thickening. Bandlike opacity at the left lung base
likely reflects platelike atelectasis. There is no dense focal lung
consolidation. There is no worrisome lung nodule or mass. There are small
left and trace right layering nonhemorrhagic pleural effusions. There is no
pneumothorax.
Within the imaged upper abdomen, a tiny hiatal hernia is seen.
MUSCULOSKELETAL: There is no concerning focal subcutaneous or musculoskeletal
soft tissue abnormality. The imaged thoracic vertebral bodies are normally
aligned. There is mild multilevel degenerative change. Vertebral body heights
are preserved. No concerning focal lytic or sclerotic osseous lesions are
seen.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Small pericardial effusion appears mildly complex without evidence for
abnormal pericardial enhancement or thickening.
3. Small left and trace right layering nonhemorrhagic pleural effusions.
4. Prominent subcarinal and right hilar lymph nodes. Other additional
scattered mediastinal lymph nodes are mildly numerous but not individually
enlarged. These are likely reactive.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with PMH notable for paroxysmal atrial
fibrillation, Lyme disease, who presents with generalized malaise, cough, and
dyspnea, found to be in atrial flutter. Has lower extremity edema (asymmetric)
and an elevated D-Dimer (3280) // rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified, Fever, unspecified
temperature: 97.8
heartrate: 146.0
resprate: 22.0
o2sat: 100.0
sbp: 111.0
dbp: 81.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ man with a history of
paroxysmal atrial fibrillation, who presented with generalized
malaise, cough, and dyspnea, and was found to be in atrial
flutter with rapid rates. His rates were initially controlled
with diltiazem gtt and oral diltiazem, and he was anticoagulated
with a heparin gtt. On ___, he underwent successful TEE/DCCV to
normal sinus rhythm. Diltiazem ER 120 mg daily was continued,
and he was started on rivaroxaban 20 mg daily for
anticoagulation. The patient was in normal sinus rhythm at time
of discharge.
Of additional note, the patient has a several-month history of
migrating arthralgias, fevers, night sweats, and weight loss. A
month or so prior to presentation, he was seen by a doctor who
thought he had Lyme disease (reportedly confirmed with Western
blot), and started him on doxycycline, clarithromycin, nystatin,
and hydroxychloroquine. He initially felt better but on the day
prior to admission had a fever to 101 at home. Here, he was
afebrile and without leukocytosis. However, his inflammatory
markers including ESR/CRP (79/138) and D-dimer (3280) were
markedly elevated (CTA negative for PE). The patient's symptoms
warrant further outpatient evaluation by infectious disease and
rheumatology.
=========================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___
Chief Complaint:
Chest pain, hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old male with PMH of CAD s/p CABG (LIMA-LAD, SVG-OM,
SVG-diag, SVG-PDA ___, inferior MI in ___, stent of LCx and
___ RCA in ___, NSTEMI on ___ with PCI of the SVG to OM,
ESRD on HD, pAfib, HTN, and HLD with chief complaint of right
sided chest tightness on inspiration and weakness for 10 days.
He was referred here from clinic by Dr. ___. Per
report, O2 88% on ambulation, hypotensive to 100/60 and dizzy on
standing.
His chest pain is nonpleuritic and nonexertional. It is
intermittent, does not radiate to his arm or neck and is not
associated with nausea or diaphoresis. Chest pain does get worse
when patient lies on his left side or on his back. Has a
non-productive mild cough. Patient denies sick contacts,
fever/chills, abdominal pain, nausea/vomiting, diarrhea. No
lower
extremity edema or pain. No recent surgeries or hx of
malignancy.
Patient endorses a 40 pack year plus smoking history.
Patient does not require oxygen at home, but does endorse
needing
oxygen during his past 4 dialysis sessions. He has never been
formally diagnosed with COPD and does not use an inhaler. Denies
weight gain, but endorses a 25 kg weight loss over the past ___
years. Patient still urinates and denies any dysuria/hematuria
or
frequency.
Hx of pulmonary nodules, recent MRI with liver lesions.
In the ED:
Initial VS: 98.6F, HR 57, BP 142/52, RR 19, 96% RA
Pertinent labs notable for: WBC 6.2, Hgb 9.4. Negative UA. Blood
cultures x2 pending, urine culture pending. Negative troponin.
Studies notable for: CXR with subtle opacities in the RUL and
RLL
concerning for mild multifocal pneumonia.
Patient received: 1 g IV Ceftriaxone, 500 mg IV Azithromycin,
Clopidogrel 75 mg, Metropolol Succ 100 mg, Aspirin 81 mg
ROS: (+) per HPI
10 point ROS reviewed and negative other than those stated in
HPI.
Past Medical History:
HTN
Hyperdipidemia
Coronary artery disease
Gastroesophageal reflux disease
Chronic kidney diseas - Wegener's granulomatosis
Depression, currently working with counselor bimonthly
Appendectomy
Hernia repair in his 20s.
Leg cramps
Anemia
Social History:
___
Family History:
Mom: died at ___ of old age
Father, sister: died from lung CA
MGM: DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.3 F, HR 58, RR 18, BP 142/53, O2 98% on 2 L NC
General: NAD
HEENT: Dry mucous membranes
Neck: No JVD
Lungs: Coarse breath sounds throughout, inspiratory wheezing.
CV: ___ holosystolic murmur heard throughout. Soft diastolic
murmur.
GI: Soft, non-tender, non-distended. Bony protrusion below
sternum c/w post-op changes.
Ext: WWP. No pitting edema.
Neuro: A/ox3. Moving all extremities.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.0 F, HR 75, RR 18, BP 172/62, O2 97% on RA
General: NAD
HEENT: MMM
Neck: No JVD
Lungs: Coarse breath sounds throughout, inspiratory wheezing.
CV: ___ holosystolic murmur heard throughout. Soft diastolic
murmur.
GI: Soft, non-tender, non-distended. Bony protrusion below
sternum c/w post-op changes.
Ext: WWP. No pitting edema.
Neuro: A/ox3. Moving all extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:05PM BLOOD WBC-6.2 RBC-3.12* Hgb-9.4* Hct-29.7*
MCV-95 MCH-30.1 MCHC-31.6* RDW-14.9 RDWSD-51.8* Plt ___
___ 05:05PM BLOOD Neuts-53.3 ___ Monos-14.7*
Eos-2.3 Baso-0.5 Im ___ AbsNeut-3.29 AbsLymp-1.77
AbsMono-0.91* AbsEos-0.14 AbsBaso-0.03
___ 05:05PM BLOOD Glucose-88 UreaN-67* Creat-6.2* Na-134*
K-4.8 Cl-94* HCO3-24 AnGap-16
___ 05:05PM BLOOD cTropnT-0.10* proBNP->70000*
___ 10:59PM BLOOD cTropnT-0.09*
___ 08:00AM BLOOD cTropnT-0.09*
___ 05:05PM BLOOD Calcium-8.5 Phos-5.4* Mg-1.9
___ 05:05PM URINE Color-Straw Appear-Clear Sp ___
___ 05:05PM URINE Blood-TR* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:05PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS:
===============
___ 06:14AM BLOOD WBC-7.4 RBC-2.95* Hgb-8.9* Hct-28.4*
MCV-96 MCH-30.2 MCHC-31.3* RDW-15.2 RDWSD-53.1* Plt ___
___ 06:14AM BLOOD Glucose-84 UreaN-67* Creat-6.5*# Na-136
K-5.3 Cl-95* HCO3-25 AnGap-16
MICRO:
======
Sputum Culture (___): Contaminated
Blood cultures x2 (___): NGTD
Urine culture (___): < 10,000 CFU/mL.
IMAGING:
========
CT A/P (___):
IMPRESSION:
1. Numerous subcentimeter hypodense lesions throughout the liver
measuring up to 9 mm, indeterminate. Ultrasound-guided biopsy
is recommended.
CXR (___):
Mild cardiomegaly. Subtle opacities in the right upper and
lower lobe
concerning for mild multifocal 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. Nephrocaps 1 CAP PO DAILY
4. Cinacalcet 60 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
9. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
10. Aspirin 81 mg PO DAILY
11. Minoxidil 5 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q8H:PRN SOB
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff INH Q8H:PRN
Disp #*1 Inhaler Refills:*0
2. LevoFLOXacin 500 mg PO Q48H Duration: 3 Doses
RX *levofloxacin 500 mg 1 tablet(s) by mouth Q48H Disp #*2
Tablet Refills:*0
3. Minoxidil 5 mg PO DAILY
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Cinacalcet 60 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Multifocal pneumonia
Hepatic lesions
Secondary:
Coronary artery disease
End stage renal disease
Hypertension
Pulmonary hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest pain hypoxia// Pneumonia?
COMPARISON: CT of the chest from ___
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy wires are
noted. The lungs are hyperinflated. Subtle opacities in the right upper and
lower lobes may represent a very mild pneumonia. The left lung appears
relatively clear. The heart is mildly enlarged. Mediastinal contour is
stable. Bony structures are intact.
IMPRESSION:
Mild cardiomegaly. Subtle opacities in the right upper and lower lobe
concerning for mild multifocal pneumonia.
Radiology Report
EXAMINATION: CT ABD WANDW/O C
INDICATION: ___ year old man with ESRD on hemodialysis and new liver lesions
not fully visualized on MRI in ___, c/f metastatic malignancy.// ?Liver
malignancy. Please counsel patient to not breathe deeply during visualization
of liver.
TECHNIQUE: Multiphasic Liver: Multidetector CT of the abdomen was done
without and with IV contrast. Initially, the abdomen was scanned without IV
contrast. Subsequently, a single bolus of IV contrast was injected and the
abdomen was scanned in the early arterial phase, followed by a scan of the
abdomen in the portal venous phase, followed by a scan of the abdomen in
equilibrium phase (3-min delay).
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol =
3.4 mGy (Body) DLP = 117.6 mGy-cm. 2) Spiral Acquisition 1.9 s, 25.7 cm;
CTDIvol = 11.5 mGy (Body) DLP = 294.3 mGy-cm. 3) Spiral Acquisition 2.4 s,
31.7 cm; CTDIvol = 11.0 mGy (Body) DLP = 347.2 mGy-cm. 4) Spiral Acquisition
1.9 s, 25.7 cm; CTDIvol = 11.5 mGy (Body) DLP = 294.5 mGy-cm. 5) Stationary
Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 6)
Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.4 mGy (Body) DLP = 16.7
mGy-cm. Total DLP (Body) = 1,072 mGy-cm.
COMPARISON: MRI abdomen dated ___.
FINDINGS:
LOWER CHEST: There is right basilar atelectasis. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is normal in morphology. There are hypodense
subcentimeter hypodense lesions throughout the liver seen on the portal
venous and delayed phases, and without evidence of arterial enhancement,
nonspecific. There are no lesions meeting OPTN V criteria for ___. 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 atrophic bilaterally. There are numerous hypodense
lesions in the bilateral kidneys measuring up to 1.9 cm on the right and 2.0
cm on the left, compatible with a combination of simple and
proteinaceous/hemorrhagic cysts, as seen on prior MRI from ___.
There is redemonstration of a 2.7 cm exophytic, peripherally calcified cyst in
the upper pole of the right kidney. There is no hydronephrosis.
GASTROINTESTINAL: There is a small hiatal hernia. There is colonic
diverticulosis without evidence of diverticulitis. Visualized small and
large bowel loops are normal in caliber.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is redemonstration of chronic appearing compression deformities
of the T11 and L1 vertebral bodies, unchanged. Mild retrolisthesis at L1-L2,
likely degenerative and unchanged.
SOFT TISSUES: The abdominal wall is within normal limits.
IMPRESSION:
1. Numerous subcentimeter hypodense lesions throughout the liver measuring up
to 9 mm, indeterminate. Ultrasound-guided biopsy is recommended.
RECOMMENDATION(S): Ultrasound-guided biopsy the liver lesions is recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Hypoxia
Diagnosed with Chest pain, unspecified
temperature: 98.6
heartrate: 57.0
resprate: 19.0
o2sat: 96.0
sbp: 142.0
dbp: 54.0
level of pain: 1
level of acuity: 3.0 | ___ year old male with PMH of CAD s/p CABG (LIMA-LAD, SVG-OM,
SVG-diag, SVG-PDA ___, inferior MI in ___, stent of LCx and
___ RCA in ___, PCI on ___ with PCI of the SVG to OM, ESRD
on HD, pAfib, HTN, and HLD with radiographic evidence of
multifocal PNA as well as new liver lesions on MRI.
ACUTE ISSUES:
=============
# MULTIFOCAL PNA
# DYSPNEA
Patient presented with radiographic evidence of multifocal PNA
(RUL, RLL) with new-onset hypoxia and 10 days of chest pain. He
was initially given ceftriaxone and azithromycin, which was
transitioned to PO levofloxacin given continued clinical
stability and improvement (last day ___. He had wheezing on
exam, and likely had contribution from reactive airway disease
versus underlying COPD given remote history of smoking, which
improved with nebulizers. At the time of discharge, his cultures
showed no growth. He was afebrile and breathing well on room
air.
# HTN: Patient was continued on home amlodipine 5 mg qD, home
metoprolol succ 100 mg qD, home isosorbide mononitrate 120 mg qD
# ESRD on HD (___), due to ANCA associated GN (GPA), not
anuric. He continued to get hemodialysis while inpatient.
# NEW LIVER LESIONS: Visualized on MRI from early ___.
Underwent CT abdomen w/ and w/o contrast for better
visualization of lesions, which demonstrated "multiple
indeterminate subcentimeter hypodense lesions throughout the
liver measuring up to 9 mm, not meeting OPTN 5 criteria for HCC.
Ultrasound-guided biopsy is recommended". Decision to pursue
biopsy was deferred to the outpatient setting.
CHRONIC ISSUES:
===============
# CAD: CAD s/p CABG (LIMA-LAD, SVG-OM, SVG-diag, SVG-PDA ___,
inferior MI in ___, stent of LCx and ___ RCA in ___ (cath
showed occluded SVG-Diag and RPDA at that time). S/p
catheterization ___ for NSTEMI w/ DES to SVG-OM anastomosis
from prior vein graft. He has baseline stable angina ___ month.
HE was continued on his home regimen, including aspirin 81 mg
QD, clopidogrel 75 mg QD, atorvastatin 40 mg daily, and
metoprolol, amlodipine, and imdur as per above.
# HFrEF: Secondary to CAD. EF 45%. Last echo ___ notable for
"left ventricular systolic function is reduced, mitral
regurgitation is increased, and severe pulmonary hypertension is
now present." He has no current signs of heart failure.
Continued on home metop. Per outpatient cardiologist, there was
no need to add on an ___.
# PAROXYSMAL AF (provoked iso CABG in ___: He remains in sinus
rhythm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Remeron / Haldol / Ativan / codeine
Attending: ___
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a history of HCV cirrhosis, COPD, history
of polysubstance abuse, chronic back pain, who presents with
altered mental status.
Either his landlord or relative had called EMS because of
reported disorientation to time. The patient does take lactulose
and states that he has been taking it regularly. He also takes
oxycodone for chronic pain and states that he has not taken more
than usual. He denies fever or chills.
Per the patient's mother he has been confused for the past 2
days. He has been slurring his words. She thinks he had been
sleeping more than usual for the past few days. She does note
that about 2 weeks ago he was started back on some of his meds.
He was recently admitted to ___ ___ for
confusion
and slurred speech. On this admission he was diagnosed with
toxic
metabolic encephalopathy thought to be due to home opioid use in
the setting of his cirrhosis. He had no signs of infection on
that admission. He was treated for HE with increased lactulose
regimen but ultimately primary HE was felt to be less likely the
cause.
Since that admission per the chart review he recently was seen
in
clinic at ___ for chronic pain and was referred for a right knee
injection which was performed on ___.
He denies hematemesis, melena, or hematochezia. He denies chest
pain or cough. He denies recent travel. He states that he has
not
had any alcoholic beverages for the last ___ years. He denies any
other IV drug use currently. He states that he also may have
fallen and hit his head within the last 2 weeks. Denies headache
or dizziness. Had a very similar presentation about a month and
a
half ago and was found to have a UTI.
Past Medical History:
Hepatitis C genotype 2
Cirrhosis complicated by grade I varices in ___ and variceal
bleed ___
?Cryoglobulinemia
Colonic polyps
___ esophagus
Gunshot wounds to his lower legs
Fractured jaw
Polysubstance abuse
Chronic back pain
Social History:
___
Family History:
Father: CAD, stroke
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.9 BP 123/71 HR 55 RR ___ RA
GENERAL: obsess older male, lying in bed sleepy appearing
intermittently falling asleep during the interview
HEENT: EOMI, PERRL, anicteric sclera, poor dentition, MMM
NECK: supple, JVP at 10 cm H20
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: clear to auscultation in posterior lung fields, no
wheezes
rhonchi or crackles
ABDOMEN: obese abdomen, non-tender to palpation, no rebound or
guarding, no shifting dullness
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2 place and able to identify his mother on the phone,
strength is ___ in upper and lower extremities bilaterally,
CN2-12 intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 97.5 PO BP: 129/73 HR: 59 RR: 18 O2 sat: 95%
O2 delivery: ra
GENERAL: sleeping, awakens to sternal rub, when awake he says
his
whole name, is interactive but goes back to sleep
HEENT: EOMI, PERRL, anicteric sclera, MMM
HEART: RRR, no mgr
LUNGS: CTAB, no wrr
ABDOMEN: obese abdomen, nontender, nondistended, no
rebound/guarding
EXTREMITIES: wwp, no edema
NEURO: A&Ox2-3, PERRL, moves all extremities, very somnolent but
wakes when rolled over in bed
SKIN: warm, dry, no lesions
Pertinent Results:
ADMISSION LABS:
___ 09:09AM BLOOD WBC-4.4 RBC-4.95 Hgb-13.8 Hct-43.1 MCV-87
MCH-27.9 MCHC-32.0 RDW-16.4* RDWSD-51.6* Plt Ct-50*
___ 09:09AM BLOOD Neuts-54.8 ___ Monos-9.3 Eos-3.4
Baso-0.9 Im ___ AbsNeut-2.43 AbsLymp-1.39 AbsMono-0.41
AbsEos-0.15 AbsBaso-0.04
___ 09:09AM BLOOD ___ PTT-29.0 ___
___ 09:09AM BLOOD Glucose-147* UreaN-11 Creat-1.2 Na-135
K-6.1* Cl-100 HCO3-24 AnGap-11
___ 09:09AM BLOOD ALT-47* AST-135* AlkPhos-71 TotBili-1.4
___ 09:09AM BLOOD Lipase-34
___ 09:09AM BLOOD Albumin-3.4*
___ 07:25PM BLOOD Calcium-9.3 Phos-3.2 Mg-1.8
___ 09:09AM BLOOD %HbA1c-6.5* eAG-140*
___ 08:50AM BLOOD Ammonia-68*
___ 09:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:15AM BLOOD ___ pO2-55* pCO2-47* pH-7.40
calTCO2-30 Base XS-2
___ 09:15AM BLOOD K-3.4
___ 06:28PM BLOOD Lactate-2.4*
DISCHARGE LABS:
___ 09:05AM BLOOD WBC-3.7* RBC-5.18 Hgb-14.1 Hct-44.5
MCV-86 MCH-27.2 MCHC-31.7* RDW-16.6* RDWSD-51.4* Plt Ct-41*
___ 09:05AM BLOOD ___ PTT-34.1 ___
___ 09:05AM BLOOD Glucose-112* UreaN-5* Creat-0.8 Na-137
K-3.4* Cl-108 HCO3-20* AnGap-9*
___ 09:05AM BLOOD ALT-41* AST-59* AlkPhos-79 TotBili-1.5
___ 09:05AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.7
___ 01:16PM BLOOD pO2-156* pCO2-33* pH-7.45 calTCO2-24 Base
XS-0 Comment-GREEN TOP
___ 09:07AM BLOOD Lactate-1.7
MICROBIOLOGY:
___
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ CULTURE No growth to date x2
___ CULTURE No growth to date x2
___ No growth.
___ Legionella Ag Pending
IMAGING:
___ HEAD W/O CONTRAST
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
redemonstration of a small, 6 mm hyperdense focus within the
right putamen,
minimally more prominent when compared to CT from ___ but stable
compared to CT from ___. This was previously
evaluated with MRI
on ___ and likely represents occult vascular
formation with
chronic hemorrhage. No evidence of acute hemorrhage. The
ventricles and
sulci are normal in size and configuration. The basal cisterns
are preserved.
No new acute fractures identified. There is redemonstration of
previously
described fractures involving the left lateral orbit, orbital
floor, left
zygomatic arch, nasal bone, and left maxillary sinus. The
previously
described right maxillary fracture is not visualized on the
current study.
There is mild mucosal thickening in the paranasal sinuses and
ethmoidal air
cells. The mastoid air cells and middle ear cavities are clear.
The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute large territory infarction or acute intracranial
hemorrhage.
2. Similar appearance of small approximately 6 mm focal
hyperdense focus in
the right putamen. This was previously evaluated on MRI from ___, and likely represents an occult vascular malformation with
chronic
hemorrhage.
3. Re-demonstrated facial fractures, better evaluated on CT
facial bones from
___. No new acute fracture identified.
___ X-RAY (PA & LAT)
FINDINGS:
Cardiac silhouette size is mildly enlarged but unchanged. The
mediastinal and
hilar contours are similar. The pulmonary vasculature is not
engorged. There
is patchy parenchymal opacification within the right lung base,
similar
compared to the prior exam, with bronchial wall thickening,
findings which
could reflect infection. Streaky left basilar atelectasis is
noted. No
pleural effusion or pneumothorax. Remote right-sided posterior
rib fracture
is re-demonstrated.
IMPRESSION:
Similar appearance of patchy right basilar opacification when
compared to
prior chest radiograph from ___ which could reflect
ongoing
infection.
___ US
FINDINGS:
Study is limited due to difficulty with positioning.
LIVER: The liver is coarsened and nodular in echotexture. The
contour of the
liver is nodular, consistent with cirrhosis. In the left
hepatic lobe, there
is a 2.6 x 1.3 x 2.3 cm heterogeneously hypoechoic, avascular
structure,
incompletely characterized. The main portal vein is patent with
hepatopetal
flow. The left portal vein is patent, the right portal vein is
not seen.
There is a recanalized umbilical vein. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 6 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 17.7 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
1. Study limited due to difficulty with patient positioning.
2. Cirrhotic liver with sequela of portal hypertension
including splenomegaly
and recanalized umbilical vein.
3. No evidence of acute cholecystitis.
4. Incompletely characterized heterogeneous hypoechoic lesion
in the left
hepatic lobe measuring up to 2.6 cm. Recommend follow-up MRI
for further
characterization.
RECOMMENDATION(S): Follow-up nonemergent MRI with IV contrast
for further
characterization of left hepatic lobe lesion.
___ ABD & PELVIS W & W/O
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest
performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: Unchanged appearance of cirrhotic liver with
recannulization of
the umbilical vein. Stable exophytic cyst segment VI of the
liver (series
303, image 124) and additional stable tiny low attenuating
lesion segment VI
of the liver (series 301, image 39 also likely representing a
benign cyst or
biliary hamartoma. No new or enlarging liver lesions
identified. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder
is within normal limits.
PANCREAS: Stable punctate calcification within the head of the
pancreas. The
pancreas otherwise has normal attenuation throughout, without
evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: Stable splenomegaly with embolic material and areas of
chronic
infarction. No acute findings.
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.
Multiple bilateral low attenuating lesions within the kidneys
which are too
small to adequately characterize but statistically represent
benign cysts. No
suspicious cystic or solid mass. No hydronephrosis. There is
no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is 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: No acute fracture or suspicious osseous lesion.
SOFT TISSUES: Small fat containing periumbilical hernia.
Otherwise
unremarkable.
IMPRESSION:
1. Cirrhotic liver with secondary findings of portal venous
hypertension as
detailed above and unchanged from prior imaging. No suspicious
liver lesions
identified.
2. Additional chronic changes as above without significant
change from ___.
___ CHEST W/CONTRAST
FINDINGS:
Evaluation is limited due to respiratory motion.
HEART AND VASCULATURE: No central pulmonary artery filling
defect to suggest
emboli. The thoracic aorta is normal in caliber without
evidence of
dissection or intramural hematoma. Heart size is grossly is
normal. Dense
coronary artery calcifications. No pericardial effusion is
seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Evaluation is significantly limited due to
respiratory motion.
No significant pulmonary nodules, focal consolidation, or mass
identified.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: See separate CT abdomen report.
BONES: Chronic healed and ununited right posterolateral rib
fractures. No
acute fracture or suspicious osseous lesion.
IMPRESSION:
Limited CT of the chest due to respiratory motion without acute
intrathoracic
process or suspicious masses identified.
Coronary artery disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with altered mental status// Eval for acute
pathology
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 = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___ CT head
___ MRI head
___ CT head
___ CT facial bones
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
redemonstration of a small, 6 mm hyperdense focus within the right putamen,
minimally more prominent when compared to CT from ___ but stable
compared to CT from ___. This was previously evaluated with MRI
on ___ and likely represents occult vascular formation with
chronic hemorrhage. No evidence of acute hemorrhage. The ventricles and
sulci are normal in size and configuration. The basal cisterns are preserved.
No new acute fractures identified. There is redemonstration of previously
described fractures involving the left lateral orbit, orbital floor, left
zygomatic arch, nasal bone, and left maxillary sinus. The previously
described right maxillary fracture is not visualized on the current study.
There is mild mucosal thickening in the paranasal sinuses and ethmoidal air
cells. The mastoid air cells and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute large territory infarction or acute intracranial hemorrhage.
2. Similar appearance of small approximately 6 mm focal hyperdense focus in
the right putamen. This was previously evaluated on MRI from ___, and likely represents an occult vascular malformation with chronic
hemorrhage.
3. Re-demonstrated facial fractures, better evaluated on CT facial bones from
___. No new acute fracture identified.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with altered mental status// Eval for acute
pathology
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size is mildly enlarged but unchanged. The mediastinal and
hilar contours are similar. The pulmonary vasculature is not engorged. There
is patchy parenchymal opacification within the right lung base, similar
compared to the prior exam, with bronchial wall thickening, findings which
could reflect infection. Streaky left basilar atelectasis is noted. No
pleural effusion or pneumothorax. Remote right-sided posterior rib fracture
is re-demonstrated.
IMPRESSION:
Similar appearance of patchy right basilar opacification when compared to
prior chest radiograph from ___ which could reflect ongoing
infection.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with hx HCV cirrhosis, here with AMS// eval for
acute pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ ultrasound liver
FINDINGS:
Study is limited due to difficulty with positioning.
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. In the left hepatic lobe, there
is a 2.6 x 1.3 x 2.3 cm heterogeneously hypoechoic, avascular structure,
incompletely characterized. The main portal vein is patent with hepatopetal
flow. The left portal vein is patent, the right portal vein is not seen.
There is a recanalized umbilical vein. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 6 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 17.7 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Study limited due to difficulty with patient positioning.
2. Cirrhotic liver with sequela of portal hypertension including splenomegaly
and recanalized umbilical vein.
3. No evidence of acute cholecystitis.
4. Incompletely characterized heterogeneous hypoechoic lesion in the left
hepatic lobe measuring up to 2.6 cm. Recommend follow-up MRI for further
characterization.
RECOMMENDATION(S): Follow-up nonemergent MRI with IV contrast for further
characterization of left hepatic lobe lesion.
NOTIFICATION: The findings and recommendation of MRI were discussed with
___, M.D. by ___, M.D. on the telephone on ___ at
1:52 pm, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with CMV cirrhosis prior smoker and cirrhosis//
please eval for lung mass
TECHNIQUE: Helical images of the chest were obtained through the thorax after
the uneventful administration of intravenous contrast. Reformatted coronal,
sagittal, and axial maximal intensity projection images were submitted to PACS
and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 6.1 mGy (Body) DLP = 210.7
mGy-cm.
2) Spiral Acquisition 1.5 s, 19.7 cm; CTDIvol = 24.5 mGy (Body) DLP = 481.3
mGy-cm.
3) Spiral Acquisition 5.7 s, 74.9 cm; CTDIvol = 24.2 mGy (Body) DLP =
1,815.6 mGy-cm.
4) Spiral Acquisition 1.5 s, 19.7 cm; CTDIvol = 24.5 mGy (Body) DLP = 481.0
mGy-cm.
5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
6) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 20.1 mGy (Body) DLP =
10.1 mGy-cm.
Total DLP (Body) = 3,000 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: None
FINDINGS:
Evaluation is limited due to respiratory motion.
HEART AND VASCULATURE: No central pulmonary artery filling defect to suggest
emboli. The thoracic aorta is normal in caliber without evidence of
dissection or intramural hematoma. Heart size is grossly is normal. Dense
coronary artery calcifications. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Evaluation is significantly limited due to respiratory motion.
No significant pulmonary nodules, focal consolidation, or mass identified.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: See separate CT abdomen report.
BONES: Chronic healed and ununited right posterolateral rib fractures. No
acute fracture or suspicious osseous lesion.
IMPRESSION:
Limited CT of the chest due to respiratory motion without acute intrathoracic
process or suspicious masses identified.
Coronary artery disease.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old man with CMV cirrhosis prior smoker and cirrhosis//
triple phaseplease evaluate hepatic lesion seen on ultrasound and evaluate for
spontaneous shunts
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen without and with
IV contrast. Initially the abdomen was scanned without IV contrast.
Subsequently a single bolus of IV contrast was injected and the abdomen and
pelvis was scanned in the portal venous phase, followed by a scan of the
abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 6.1 mGy (Body) DLP = 210.7
mGy-cm.
2) Spiral Acquisition 1.5 s, 19.7 cm; CTDIvol = 24.5 mGy (Body) DLP = 481.3
mGy-cm.
3) Spiral Acquisition 5.7 s, 74.9 cm; CTDIvol = 24.2 mGy (Body) DLP =
1,815.6 mGy-cm.
4) Spiral Acquisition 1.5 s, 19.7 cm; CTDIvol = 24.5 mGy (Body) DLP = 481.0
mGy-cm.
5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
6) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 20.1 mGy (Body) DLP =
10.1 mGy-cm.
Total DLP (Body) = 3,000 mGy-cm.
COMPARISON: Ultrasound from ___ and CT abdomen from ___ and ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: Unchanged appearance of cirrhotic liver with recannulization of
the umbilical vein. Stable exophytic cyst segment VI of the liver (series
303, image 124) and additional stable tiny low attenuating lesion segment VI
of the liver (series 301, image 39 also likely representing a benign cyst or
biliary hamartoma. No new or enlarging liver lesions identified. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: Stable punctate calcification within the head of the pancreas. The
pancreas otherwise has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Stable splenomegaly with embolic material and areas of chronic
infarction. No acute findings.
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.
Multiple bilateral low attenuating lesions within the kidneys which are too
small to adequately characterize but statistically represent benign cysts. No
suspicious cystic or solid mass. No hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is 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: No acute fracture or suspicious osseous lesion.
SOFT TISSUES: Small fat containing periumbilical hernia. Otherwise
unremarkable.
IMPRESSION:
1. Cirrhotic liver with secondary findings of portal venous hypertension as
detailed above and unchanged from prior imaging. No suspicious liver lesions
identified.
2. Additional chronic changes as above without significant change from ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, Fatigue
Diagnosed with Other encephalopathy, Altered mental status, unspecified
temperature: 97.8
heartrate: 51.0
resprate: 18.0
o2sat: 94.0
sbp: 121.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | SUMMARY
====================
___ with hx of HCV cirrhosis (Childs B, MELD 12 on admission)
previously d/b ascites, varices, and HE, COPD, history of
polysubstance use, and chronic back pain, who presented with
altered mental status, somnolence, and slurred speech.
Ultimately felt to be multifactorial from oxycodone, hepatic
encephalopathy and possible underlying CAP which was treated on
this stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right sided sensory changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old left-handed man who presents
with one day of right-sided sensory changes. Yesterday while
playing ___-sack, he noticed that he rapidly developed a
"tingling" sensation from his right knee down to his toes,
rapidly followed by a sensation of "numbness" and
"hypersentivity
to pain." The sensation of touching his skin with his hand or
his
clothes rubbing along that part of his limb were accentuated and
felt uncomfortable. He tried to ignore this and went to baseball
practice (which he recently started). He did not have any injury
before or during this time, and he was able to function normally
during baseball practice. He had no preceding chest pain,
palpitations, dyspnea, headache or neck pain. However, his
sensory symptoms persisted and ascended up the right side of his
body to about ___ inches below the level of the nipple on his
chest, side and back. He felt a "tightness around the ribs" that
crawled up from his leg to the chest and back. He felt unsteady
on his feet when standing but did not have significant
difficulty
with walking. He otherwise had no other symptoms. The symptoms
stopped their progression, but they have plateaued in
distribution and severity and have not lessened or waxed and
waned.
He is healthy and has essentially no prior medical history
including no prior history of neurologic symptoms or deficits
(vision loss, diplopia, limb weakness or sensory changes,
vertigo, headache, etc.). He has been well and without signs or
symptoms of infection before this event. He has no prior history
of autoimmune disease or symptoms, including no rashes,
arthralgias, myalgias, dry eyes, or dry mouth. He has one great
aunt who had multiple sclerosis.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Endorses loss of sensation and hyperesthesia.
Denies bowel or bladder incontinence or retention.
Endorses difficulty with balance. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
None, besides lactose intolerance
Social History:
___
Family History:
Multiple sclerosis (maternal great aunt).
___ fever (maternal grandfather). ___ syndrome
(brother). Otherwise no other neurologic, autoimmune, or
autoinflammatory disease.
Physical Exam:
Physical Exam on Admission:
VS T: 97.9 HR: 88 BP: 132/71 RR: 18 SaO2: 100% RA
General: NAD, lying in bed comfortably, well-appearing young
man.
/ Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
/ Neck: Supple, no nuchal rigidity, no bruits, no L'hermitte's /
Cardiovascular: RRR, no M/R/G / Pulmonary: Equal air entry
bilaterally, no crackles or wheezes / Abdomen: Soft, NT, ND,
+BS,
no guarding / Extremities: Warm, no edema, palpable
radial/dorsalis pedis pulses / Skin: No rashes or lesions /
Back:
no focal spinal tenderness, no scoliosis
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Recalls a coherent
history. Structure of speech demonstrates fluency with full
sentences, intact repetition, and intact verbal comprehension.
Normal prosody. No dysarthria. No evidence of hemineglect. No
left-right agnosia.
- Cranial Nerves - [II] R 4->3, L 3->2 brisk. No APD. VF full to
number counting. Funduscopy shows crisp disc margins, no
papilledema. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch or pin bilaterally. [VII] No facial
movement asymmetry. [VIII] Hearing intact to finger rub
bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
orbiting with arm roll. No tremor or asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5] [L 5]
Biceps [C5] [R 5] [L 5]
Triceps [C6/7] [R 5] [L 5]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Extensor Digitorum [C7] [R 5] [L 5]
Flexor Digitorum [C8] [R 5] [L 5]
Leg
Iliopsoas [L1/2] [R 5] [L 5]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 5]
Tibialis Anterior [L4] [R 5] [L 5]
Gastrocnemius [S1] [R 5] [L 5]
Extensor Hallucis Longus [L5] [R 5] [L 5]
Extensor Digitorum Brevis [L5] [R 5] [L 5]
- Sensory - Describes hyperesthesia to pin and lingering of pin
sensation/pain from T5-T6 on the front and back down. Improved
sensation in the right leg (to left leg as compared to the
back).
No saddle anesthesia. Diminished proprioception at the first toe
on the right ___ correct), but intact on the left.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response equivocal on the right, flexor on the left. No
clonus. No ___ or Troemner signs.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements. Normal heel-shin testing.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway with normal gait, but sways to
the
right with tandem gait. Moderate sway with Romberg in all
directions.
Physical Exam on Discharge:
Physical Exam on Discharge:
T 98 BP 103/58 HR 70 RR 16 O2 99 RA
awake, alert, speech fluent
EOMI, face symmetric
full strength in UEs and ___
no pronator drift
crossed adducters, brisk but symmetric refelexes, toes flexor, 2
beats of clonus
hyperesthesia on right foot in S1 distribution
Pertinent Results:
Labs on Admission:
___ 01:50PM WBC-6.9 RBC-5.35 HGB-15.5 HCT-46.2 MCV-87
MCH-29.0 MCHC-33.6 RDW-12.1
___ 01:50PM PLT COUNT-271
___ 01:50PM GLUCOSE-81 UREA N-11 CREAT-0.7 SODIUM-142
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
___ 05:52PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
MRI brain w/ and w/o contrast
FINDINGS: There are no white matter signal abnormalities to
suggest a
demyelinating process. There is no evidence of intracranial
mass, edema,
blood products or abnormal diffusion. The ventricles, basal
cisterns and sulci are normal in size. Major vascular flow voids
are preserved.
IMPRESSION: Normal head MRI.
MRI C/T spine
1. Normal cervical and thoracic spinal cord, without evidence
of
demyelinating disease.
2. Mild mid thoracic disc and endplate degenerative changes,
unusual for age, without kyphosis. Early or atypical
Sc___'s disease cannot entirely be excluded.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
peripheral neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man, with right-sided thorax to leg sensory disturbance.
Assess for demyelinating disease.
COMPARISON: None.
TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were
acquired through the head before and after administration of IV gadolinium
contrast. Dedicated 3D volumetric FLAIR sequence was acquired.
Diffusion-weighted images and ADC maps were also obtained for evaluation.
FINDINGS: There are no white matter signal abnormalities to suggest a
demyelinating process. There is no evidence of intracranial mass, edema,
blood products or abnormal diffusion. The ventricles, basal cisterns and sulci
are normal in size. Major vascular flow voids are preserved.
IMPRESSION: Normal head MRI.
Radiology Report
HISTORY: ___ man, with right-sided thorax to leg sensory disturbance.
Assess for demyelinating lesion.
COMPARISON: None.
TECHNIQUE: Post-contrast multiplanar, multisequence T1- and T2-weighted
images were acquired through the cervical and thoracic spine.
FINDINGS:
CERVICAL SPINE: The vertebral body heights, alignment, and disc heights are
preserved. The cervical spinal cord is normal in morphology and signal
intensity, without abnormal enhancement. The cervical spinal canal is
capacious throughout. There are no significant degenerative changes. Bone
marrow signal is normal.
THORACIC SPINE: The vertebral body heights and alignment are preserved.
There is mild loss of intervertebral disc height, disc dessication, as well as
mild endplate irregularities and small Schmorl nodes at T7-8, T8-9, T9-10 and
T10-11, unusual for age. There is no associated kyphosis. There is no disc
herniation into the spinal canal. The thoracic spinal cord is normal in
morphology and signal intensity, without abnormal enhancement. The conus
medullaris terminates at T12-L1. Bone marrow signal is normal.
IMPRESSION:
1. Normal cervical and thoracic spinal cord, without evidence of
demyelinating disease.
2. Mild mid thoracic disc and endplate degenerative changes, unusual for age,
without kyphosis. Early or atypical Scheuermann's disease cannot entirely be
excluded.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NUMBNESS RIGHT SIDE
Diagnosed with SKIN SENSATION DISTURB
temperature: 97.9
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ with no PMH p/w a unilateral right-sided
ascending sensory disturbance from his foot to approximately
T5-T6, most concerning initially for a
Clinically Isolated Syndrome.
# Neuro: This sensory disturbance began with paresthesias
followed by numbness and hyperesthesia, gradually spreading
upwards over the course of hours between 1500 and ___ yesterday
before stopping at the mid chest. He describes a "tightness
around the ribs" on the right side. He describes some difficulty
with balance when standing. He has had no priorepisodes of
neurologic symptoms or dysfunction and has no other current
symptoms (except for a presyncopal/syncopal episode during
phlebotomy in the ED). His examination reveals a right-sided
sensory level on the back and torso with T5-T6 pin
hyperesthesia, impaired proprioception in the right foot, sway
with Romberg testing, and a tendency to lean to the right with
tandem gait. There was no preceding trauma or cardiopulmonary
symptoms prior to this episode, though he does note that he
recently started baseball practice. The progression of symptoms
stopped at the T5-T6 level, suspected lesion may be present in
the thoracic cord, although a thalamic location is also possible
(cervical spine is also possible, but the progression appears to
have stopped the night prior to this evaluation). MRI brain and
C/T spine were obtained with and without contrast and did not
show any demyelinating lesions. Morning after admission,
symptoms were largely resolved with only mild hyperesthesia in
right foot in S1 distribution. Did not pes cavus as well as
hammer toes on exam, so likely has Charcot ___ disease
and above presentation is consistent with peripheral neurpathy.
Patient will schedule EMG after discharge as well as neurology
clinic follow up (non urgently). Did discuss PCP referral to
podiatry for insoles given pes cavus. Also, MRI spine with Mild
mid thoracic disc and endplate degenerative changes, unusual for
age, without kyphosis. Early or atypical Scheuermann's disease
cannot entirely be excluded. Thus, should have repeat imaging in
___ year to reassess with PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with a h/o CVA, dementia, submassive PE, seizure D/O, and an
uncharacterized bladder stone, who presented with ___ years of
hematuria and 1 week of passing clots and dysuria. He was seen
in the ED earlier this week for similar symptoms and was
prescribed antibiotics for a UTI. His hematuria began about ___
years ago when he transitioned to a nursing facility, and his
family recently brought him home because they were concerned
that he was not receiving appropriate medical care. Over the
past week, he has complained of burning while urinating, and has
passed large clots in his urine. He is incontinent of urine at
baseline.
On ___ he presented to the ED with similar symptoms. At the
time he was generally well-appearing, had no CVA tenderness, and
had no abdominal tenderness. He reported that there were clots
in the blood, associated dysuria and dark urine. He denied any
change in UOP, flank pain, fever/chills, chest pain, dyspnea,
abdominal pain, ___ pain, rash, bruising/bleeding problems,
lightheadedness, or dizziness. A bedside US found no urinary
obstruction or hydronephrosis. He was given cefpodoxime PO 100mg
x2, and was discharged with a prescription for 10d of
cefpodoxime PO 100mg BID for a UTI. A UCx from ___ grew
cipro-resistant Proteus. Of note, he complained of intermittent
hematuria and dysuria on ___ at a neurology appointment.
Past Medical History:
- CAD
- submassive pulmonary embolism ___
- CVA ___ with residual L hemiparesis
- Essential Hypertension
- Advanced dementia
- Seizure Disorder
- BPH
- Depression
- GERD
- Osteoporosis
- cataracts, son reports cataract surgery
Social History:
___
Family History:
Patient denies a family history of hypertension, hyperlipidemia,
diabetes, cancers
Physical Exam:
Admission Exam:
===============
(Exam limited by language and baseline dementia)
Vitals: T 96.9, BP 135/82, HR 59, RR 20, O2 100% on RA
General: Alert, oriented only to self, no acute distress.
HEENT: Atraumatic, MMM, poor dentition.
Resp: Clear to auscultation anteriorly. No wheezes, rales, or
ronchi.
CV: RRR, normal S1/S2, no murmurs, rubs, gallops.
GI: Soft. +Bowel sounds. Some suprapubic fullness and tenderness
to palpation.
MSK: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, or
edema.
Neuro: Grossly intact. Unable to completely characterize due to
clinical situation.
Discharge Exam:
===============
General: Alert, not oriented, no acute distress, laying in bed.
HEENT: Atraumatic, MMM, poor dentition.
Resp: Clear to auscultation anteriorly. No wheezes, rales, or
ronchi.
CV: RRR, normal S1/S2, no murmurs, rubs, gallops.
GI: Soft. +Bowel sounds. Some suprapubic fullness and tenderness
to palpation.
MSK: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, or
edema.
Neuro: Grossly intact. Unable to completely characterize due to
clinical situation.
Pertinent Results:
Admission Labs:
===============
___ 04:31AM PLT COUNT-177
___ 04:31AM NEUTS-45.1 ___ MONOS-13.4* EOS-4.2
BASOS-0.4 IM ___ AbsNeut-3.55 AbsLymp-2.88 AbsMono-1.05*
AbsEos-0.33 AbsBaso-0.03
___ 04:31AM WBC-7.9 RBC-4.31* HGB-14.2 HCT-43.0 MCV-100*
MCH-32.9* MCHC-33.0 RDW-13.3 RDWSD-49.1*
___ 04:31AM GLUCOSE-75 UREA N-17 CREAT-1.1 SODIUM-145
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
___ 04:32AM URINE MUCOUS-MANY*
___ 04:32AM URINE RBC->182* WBC->182* BACTERIA-MOD*
YEAST-NONE EPI-0
___ 04:32AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-300*
GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 04:32AM URINE COLOR-Red* APPEAR-Cloudy* SP ___
Discharge Labs:
===============
___ 09:35AM BLOOD WBC-8.3 RBC-3.75* Hgb-12.3* Hct-37.3*
MCV-100* MCH-32.8* MCHC-33.0 RDW-13.6 RDWSD-49.7* Plt ___
___ 04:31AM BLOOD Neuts-45.1 ___ Monos-13.4*
Eos-4.2 Baso-0.4 Im ___ AbsNeut-3.55 AbsLymp-2.88
AbsMono-1.05* AbsEos-0.33 AbsBaso-0.03
___ 09:35AM BLOOD Plt ___
___ 06:23AM BLOOD ___ PTT-32.2 ___
___ 09:35AM BLOOD Glucose-135* UreaN-9 Creat-0.8 Na-144
K-3.9 Cl-106 HCO3-26 AnGap-12
Microbiology Labs:
==================
___ 8:57 pm URINE
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
CORYNEBACTERIUM UREALYTICUM SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| CORYNEBACTERIUM
UREALYTICUM SP.
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=2 S
MEROPENEM------------- 0.5 S
PENICILLIN G---------- =>16 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ <=1 S
Imaging:
========
GU Ultrasound (___):
1. 2.6 cm bladder stone.
2. Limited evaluation of the bladder due to decompression.
Within this
limitation, there is diffuse bladder wall thickening, with more
focal areas of thickening adjacent to the calculus, which may be
related to inflammation. Correlation with cystoscopy is
recommended.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Baclofen 5 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Tums (calcium carbonate) 200 mg calcium (500 mg) oral BID:PRN
6. Citalopram 10 mg PO DAILY
7. Dabigatran Etexilate 150 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Famotidine 20 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. LevETIRAcetam 1250 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Pyridoxine 50 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Valproic Acid ___ mg PO Q12H
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. Alendronate Sodium 70 mg PO QMON
18. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Alendronate Sodium 70 mg PO QMON
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Baclofen 5 mg PO BID
7. Calcium Carbonate (calcium carbonate) 200 mg calcium (500
mg) oral BID:PRN heartburn.
8. Citalopram 10 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Famotidine 20 mg PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. LevETIRAcetam 1250 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Pyridoxine 50 mg PO DAILY
15. Senna 8.6 mg PO BID:PRN Constipation - First Line
16. Tamsulosin 0.4 mg PO QHS
17. Valproic Acid ___ mg PO Q12H
18. HELD- Dabigatran Etexilate 150 mg PO BID This medication
was held. Do not restart Dabigatran Etexilate until your doctor
decides that you can restart it
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hematuria, bladder stone vs. mass
Secondary: UTI, Failure to thrive
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: COMPLETE GU U.S. (BLADDER AND RENAL)
INDICATION: ___ year old man with ?bladder mass on ___ ultrasound, now w/
persistent hematuria// evaluation for mass
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and
bladder were obtained.
COMPARISON: CT dated ___. Ultrasound dated ___.
FINDINGS:
The right kidney measures 8.4 cm. The left kidney measures 9.0 cm. There is no
hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
The bladder is only minimally distended and can not be fully assessed on the
current study. There is a 2.6 cm calculus in the bladder. The bladder wall
is thickened, with more focal regions of thickening adjacent to the bladder
stone.
IMPRESSION:
1. 2.6 cm bladder stone.
2. Limited evaluation of the bladder due to decompression. Within this
limitation, there is diffuse bladder wall thickening, with more focal areas of
thickening adjacent to the calculus, which may be related to inflammation.
Correlation with cystoscopy is recommended.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Hematuria
Diagnosed with Urinary tract infection, site not specified, Hematuria, unspecified
temperature: 97.3
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | ___ with a h/o CVA, dementia, submassive PE (___), seizure D/O,
and an uncharacterized 2.6cm bladder stone, who presented with
acute-on-chronic hematuria, with recent passing of clots and
pyuria, now with Foley in place without any bleeding, awaiting
urology outpatient followup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Worsening abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
He initially presented to an OSH complaining of 12 hours of
LUQ/flank pain and was transferred to our ED per family
preference as he is followed by GI here.He had nausea but no
vomiting or diarrhea. He reported chills and a temp of 100.7 on
the way to the hospital but was afebrile since arrival. He was
able to eat breakfast on date of admission. He reported mild
constipation and had not been taking laxatives/stool softeners
lately.
Labs at OSH were all WNL. CT suggested possible ileus, no other
findings.
In our ED initial vitals were 10 97.6 86 129/84 18 97%. Labs
showed WBC 5.9, hgb 13.2 with MCV of 91 (from 12.1 and MCV of
106 in ___, chem7/LFT's/lipase all WNL. Per ED, OSH CT was
reviewed with radiology here and pancreas looks improved from
prior. ___ have been in 700's in the past. In the ED he
received 1mg IV dilaudid x2 and 30mg ketorolac.
Past Medical History:
Anxiety
L labrum and pectoralis muscle repair
Alcohol and Percocet abuse
Chronic pancreatitis
Depression
Hx narcotic abuse
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission:
Vitals- 98.1, 71, 139/74, 16, 99%RA
General- Alert, oriented, grimacing. Parents at bedside.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen. He has active bowel sounds. I could not fully examine
his abdomen because he jumped and pushed my hand away when I
laid the stethescope over his abdomen (without applying any
pressure). He was diffusely exquistely tender.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge:
Vitals- 98.0, 72, 124/66, 16, 98%RA
General- Alert, oriented x 3. NAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm
Abdomen: Normoactive BS. mild diffuse tenderness to palpation
but soft without rebound. no guarding
Ext- no clubbing, cyanosis or edema
Pertinent Results:
___ WBC-5.9 RBC-4.07* Hgb-13.2* Hct-37.2* MCV-91# Plt
___
___ WBC-8.5 RBC-4.00* Hgb-12.7* Hct-36.3* Plt ___
___ Glucose-106* UreaN-9 Creat-1.0 Na-141 K-4.6 Cl-102
HCO3-28 AnGap-16
___ Glucose-107* UreaN-9 Creat-0.9 Na-140 K-4.6 Cl-102
HCO3-28 AnGap-15 ALT-15 AST-20 AlkPhos-71 TotBili-0.2
___ Glucose-105* UreaN-10 Creat-1.0 Na-141 K-3.9 Cl-102
HCO3-29 AnGap-14 Albumin-4.8 Calcium-9.4 Phos-4.5 Mg-2.2
ABDOMEN US (COMPLETE STUDY) ___
IMPRESSION:
Normal right upper quadrant ultrasound. Splenic vein is patent
at the hilum however the entire course is not visualized due to
overlying bowel gas. However, in reviewing the CT from the
prior day there did not appear to be any evidence of splenic
vein thrombosis at that time.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium 100 mg PO BID
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. CloniDINE 0.1 mg PO BID
4. Gabapentin 600 mg PO TID
5. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
6. Morphine SR (MS ___ 45 mg PO Q8H
7. Pregabalin 100 mg PO TID
8. QUEtiapine Fumarate 200 mg PO QHS
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. CloniDINE 0.1 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
6. Morphine SR (MS ___ 45 mg PO Q8H
7. Pregabalin 100 mg PO TID
8. QUEtiapine Fumarate 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain most likely due to opiate ileus
Secondary dx:
chronic pancreatitis
hx alcohol abuse
Discharge Condition:
alert and oriented
Comfortable.
Ambulatory
Followup Instructions:
___
Radiology Report
HISTORY: Pancreatitis now with persistent left upper quadrant pain. Concern
for splenic venous thrombosis.
TECHNIQUE: Right upper quadrant ultrasound
COMPARISON: CT from ___.
FINDINGS:
The liver is of normal echogenicity with no focal liver lesions. There is no
intra or extrahepatic ductal dilatation. The CBD is normal in caliber. The
main portal vein is patent. The gallbladder is distended but there is no
evidence of stones, sludge, mural edema, or pericholecystic fluid.
The pancreas is not well visualized due to overlying bowel gas.
The spleen measures 11.8 cm. No focal splenic lesions are seen. The distal
splenic vein is patent however the splenic vein is not seen throughout its
entire course due to overlying bowel gas.
IMPRESSION:
Normal right upper quadrant ultrasound. Splenic vein is patent at the hilum
however the entire course is not visualized due to overlying bowel gas.
However, in reviewing the CT from the prior day there did not appear to be any
evidence of splenic vein thrombosis at that time.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O PANCREATITIS
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 97.6
heartrate: 86.0
resprate: 18.0
o2sat: 97.0
sbp: 129.0
dbp: 84.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ with a history of pancreatitis requiring
admission this year, depression, anxiety, and a history of
alcohol and narcotic abuse who presents with abdominal pain.
Labs and CT done at OSH were unremarkable except for mild ileus
on CT. Abdominal ultrasound to look for splenic vein thrombosis
was negative.
Impression was that either the fatty meal of takeout food that
preceeded the admission or constipation was contributory to his
symptomatology
He was started on a bowel regimen for constipation, low fat
diet, reglan and home meds continued. No additional pain meds
were given during this hospital stay, other than routine home
meds. His symptoms improved with the above management. He will
follow up with his GI doctors to discuss further evaluation and
managementment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
ERCP with sphincterotome, common bile duct stent placement and
brushings sent for cytology
History of Present Illness:
Patient is a pleasant ___ year old male with history of stage
IIIB colorectal adenocarcinoma s/p resection and adjuvant
chemoradiation, oncologist Dr. ___ in ___, who
presents with one week of jaundice.
He notes low back pain over the past three weeks, which he
attributed to a muscle strain. The pain has occasionally
radiated to his epigastrium, but has been mild, and he has
sought OTC pain reliefHis appetite has been diminished over the
past few days. He went out to eat two days ago. Soon after
eating, he developed nausea and vomiting, and sought care at
___. In the ___, staff noted that he appeared
jaundice. Further questioning revealed that patient had lighter
color stools in addition to mild low back pain.
At the OSH ___, an abdominal ultrasound showed a dilated CBD with
possible obstruction, with bilirubin greater than 10. Patient
was transferred directly to ___ ___ for further evaluation.
In the ___:
VS: 96.8 69 136/89 18 97%
Imaging obtained, wet reads:
Abdominal ultrasound (wet read):
1. Distended gallbladder with sludge. Dilated CBD measuring up
to 1.6 cm,
also containing sludge.
2. Hypoechoic structure near the pancreatic head could represent
lymph node;
however, a pancreatic head lesion cannot be excluded. Given this
finding and
biliary dilation, a pancreatic mass protocol CT exam is
recommended.
CTA pancreas (wet read):
1. 3.2 x 2.5 pancreatic head mass with a large 3.9 x 2.8 cm
porta hepatis
lymph node conglomerate encasing the common hepatic artery and
portal vein.
2. Retroperitoneal lymphadenopathy abuts the celiac axis and
SMA.
3. Intra-, and extrahepatic biliary dilatation.
4. No portal vein or SMV thrombosis.
5. No evidence of liver metastasis or omental tumor deposits.
Patient was transferred to floor, during which time he reported
feeling fatigued without any other complaints. No fevers,
chills, no abdominal pain, no back pain.
ROS as noted above, remainder of 12 point ROS negative.
Past Medical History:
Stage IIIb colon cancer, s/p resection and adjuvant chemotherpy
- oncologist Dr. ___ in ___
iron deficiency anemia
Social History:
___
Family History:
Significant history: brother has gall bladder cancer, cousin
died of gall bladder cancer, and some first and second degree
relatives have colorectal cancer. Patient reports that he and
and his family have undergone genetic screening.
Physical Exam:
VS: 98.5 141/79 HR 75 RR 16 98% RA
General: very pleasant male, no distress
HEENT: icteric sclerae, clear oropharynx
Neck: no LAD, supple
CV: RRR, normal S1, S2, no m,r,g
Pulm: clear bilaterally
Abdomen: soft, mildly tender in epigastrium, no guarding or
rebound
Ext: no ___ edema, warm, well perfused
Neuro: CNs grossly intact
Psych: appropriate
Discharge Exam:
VSS, afebrile
icteric sclerae
minimal abdominal pain in epigastrium, no guarding or rebound
Pertinent Results:
___ 09:25AM PLT COUNT-246
___ 09:25AM WBC-7.3 RBC-4.12* HGB-12.8* HCT-37.9* MCV-92
MCH-31.0 MCHC-33.7 RDW-15.8*
___ 09:25AM CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-2.1
___ 09:25AM ALT(SGPT)-359* AST(SGOT)-206* ALK PHOS-420*
TOT BILI-11.6*
___ 09:25AM estGFR-Using this
___ 09:25AM GLUCOSE-95 UREA N-6 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
___ 10:10AM ___ PTT-33.5 ___
___ 10:10AM PLT COUNT-228
___ 10:10AM WBC-8.5 RBC-4.05* HGB-12.8* HCT-37.6* MCV-93
MCH-31.5 MCHC-34.0 RDW-16.0*
___ 10:10AM LIPASE-15
___ 10:10AM ALT(SGPT)-368* AST(SGOT)-212* ALK PHOS-427*
TOT BILI-11.6* DIR BILI-8.6* INDIR BIL-3.0
___ 10:10AM estGFR-Using this
___ 10:10AM UREA N-7 CREAT-0.8 SODIUM-140 POTASSIUM-3.8
CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
RUQ ultrasound
1. Distended gallbladder with sludge. Dilated CBD measuring up
to 1.6 cm,
also containing sludge.
2. Hypoechoic structure near the pancreatic head could
represent lymph node;
however, a pancreatic head lesion cannot be excluded. Given
this finding and
biliary dilation, a pancreatic mass protocol CT exam is
recommended.
CTA pancreas:
TECHNIQUE: CT angiography protocol of the pancreas was obtained
with initial
non-enhanced, and subsequent arterial and portal venous phase
MDCT images
through the abdomen. Axial, coronal, and sagittal reformats
were acquired.
COMPARISON: Liver and gallbladder ultrasound from ___.
FINDINGS:
Pancreatic Tumor Table:
I: Pancreatic tumor present: Yes.
a) Location: Pancreatic head.
b) Size: 3.2 x 2.5 cm.
c) Enhancement relative to pancreas: ___.
d) Confined to pancreas with clear fat planes (duodenum and IVC
do not apply):
No.
e) Remaining pancreas: No significant pancreatic duct
dilatation or atrophy.
II. Adenopathy present: Yes.
a) Size and location of largest lymph node: 2.8 x 1.7 cm, porta
hepatis.
b) Necrosis in lymph nodes: Yes.
c) Size of gastroduodenal artery node, "node of importance":
NA.
III. Metastatic disease, definitely present: Left paraortic
and retrocrural
lymph nodes.
IV: Ascites/peripancreatic fluid: No.
Pancreatic Vascular Table:
I: Vascular Tumor Involvement: Yes.
a) Celiac involvement: Surrounded by nodes
b) SMA involvement: Surrounded by nodes.
c) SMV involvement and percent encasement: No.
d) Less than 1 cm SMV between tumor and first major SMV branch:
Yes.
e) Portal vein involvement: Yes.
g) Splenic vein involvement: No.
h) Splenic artery involvement and distance from tumor to celiac
artery
bifurcation: Yes, 0 cm.
i) Vascular Involvement, Other: Hepatic artery.
II: Thrombosis, any vessel: No.
III: Aberrant Anatomy: No.
a) Replaced right hepatic artery: No.
There is a 3.2 x 2.5 cm ___ mass in the head of the
pancreas with
large porta hepatis lymph nodes, the largest measuring 2.8 x
1.7. The lymph
node conglomerates encase the hepatic artery and portal vein.
The portal vein,
SMV and splenic vein remain patent without thrombosis. There are
left
periaortic retroperitoneal lymph nodes with central necrosis,
the largest
measures about 12 x 22 mm (series 3B, image 159) abutting the
celiac axis and
SMA. Additional aortocaval lymph nodes are seen measuring up to
14 x 8 mm.
There is a small necrotic retrocrural lymph node. There is no
pancreatic duct
dilatation, or distal pancreatic atrophy. The CBD is dilated up
to 16 mm and
there is moderate intrahepatic biliary dilatation. The CBD is
deviated
slightly leftward with eccentric abrupt narrowing as it enters
the pancreas,
but the distal 1 cm of the CBD is normal in caliber below the
obstruction. In
segment VII and V of the right lobe, 5 mm hypoattenuating liver
lesions with
peripheral enhancement are seen, too small to characterize, but
likely a
hemangioma (se 3, 119). A segment VII hypoattenuating 16-mm and
adjacent 5 mm
lesions likely represent simple cysts. The spleen is normal.
The partially
visualized bowel demonstrates a transverse colon anastomosis
site and there
are non-pathologically enlarged mesenteric lymph nodes. No
omental or
peritoneal tumor deposits are demonstrated. The IVC is patent.
Both kidneys
are normally enhancing and excreting urine. The adrenal glands
are normal.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. 3.2 x 2.5 cm ___ mass in the medial head of the
pancreas with
large porta hepatis, hepatic artery, celiac artery, SMA,
aortocaval,
periaortic, and retrocrural pathologic lymph nodes. The mass in
the pancreas
could also be lymph nodes and so consideration not only include
pancreatic
adenocarcinoma and cholangiocarcinoma but metastases from
patient's know
colonic adenocarcinoma.
2. Moderate intra- and extrahepatic biliary dilation from CBD
obstruction in
the head of the pancreas.
3. No definite evidence of liver metastasis, but MRI might be
considered to
characterize small hypoattenuating hepatic lesions.
ERCP:
Normal major papilla.
.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
.
Contrast medium was injected resulting in complete
opacification.
.
A single irregular stricture of malignant appearance that was 1
cm long was seen at the middle third of the common bile duct.
.
A mild diffuse dilation was seen at the upper third of the
common bile duct and common hepatic duct measuring 10 mm.
.
Given CBD stricture, sphincterotomy was performed in the 12
o'clock position using a sphincterotome over an existing
guidewire.
.
Given CBD stricture cytology samples were obtained for histology
using a brush in the middle third of the common bile duct.
.
A 7cm by ___ Cotton ___ biliary stent was placed successfully
in the main duct. Good bile flow was noted.
Labs at discharge:
___ Hgb Hct MC___ ___
Plt Ct
9.63.93*12.1*35.8*9130.8 33.715.7*221
GlucoseUreaNCreatNa K ClHCO3AnGap
88 7 0.6 1373.4103 26
11
ALTAST AlkPhos ___
___ 4.2*
Medications on Admission:
clonazepam 1 mg HS
ferrous sulfate 325 mg daily
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *Cipro 500 mg 1 tablet(s) by mouth Q12 Disp #*10 Unit
Refills:*0
2. Ferrous Sulfate 325 mg PO DAILY
3. Clonazepam 1 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Common bile duct obstruction
Pancreatic head mass
Secondary Diagnosis:
Stage IIIb colon cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with jaundice, right upper quadrant pain.
TECHNIQUE: CT angiography protocol of the pancreas was obtained with initial
non-enhanced, and subsequent arterial and portal venous phase MDCT images
through the abdomen. Axial, coronal, and sagittal reformats were acquired.
COMPARISON: Liver and gallbladder ultrasound from ___.
FINDINGS:
Pancreatic Tumor Table:
I: Pancreatic tumor present: Yes.
a) Location: Pancreatic head.
b) Size: 3.2 x 2.5 cm.
c) Enhancement relative to pancreas: ___.
d) Confined to pancreas with clear fat planes (duodenum and IVC do not apply):
No.
e) Remaining pancreas: No significant pancreatic duct dilatation or atrophy.
II. Adenopathy present: Yes.
a) Size and location of largest lymph node: 2.8 x 1.7 cm, porta hepatis.
b) Necrosis in lymph nodes: Yes.
c) Size of gastroduodenal artery node, "node of importance": NA.
III. Metastatic disease, definitely present: Left paraortic and retrocrural
lymph nodes.
IV: Ascites/peripancreatic fluid: No.
Pancreatic Vascular Table:
I: Vascular Tumor Involvement: Yes.
a) Celiac involvement: Surrounded by nodes
b) SMA involvement: Surrounded by nodes.
c) SMV involvement and percent encasement: No.
d) Less than 1 cm SMV between tumor and first major SMV branch: Yes.
e) Portal vein involvement: Yes.
g) Splenic vein involvement: No.
h) Splenic artery involvement and distance from tumor to celiac artery
bifurcation: Yes, 0 cm.
i) Vascular Involvement, Other: Hepatic artery.
II: Thrombosis, any vessel: No.
III: Aberrant Anatomy: No.
a) Replaced right hepatic artery: No.
There is a 3.2 x 2.5 cm ___ mass in the head of the pancreas with
large porta hepatis lymph nodes, the largest measuring 2.8 x 1.7. The lymph
node conglomerates encase the hepatic artery and portal vein. The portal vein,
SMV and splenic vein remain patent without thrombosis. There are left
periaortic retroperitoneal lymph nodes with central necrosis, the largest
measures about 12 x 22 mm (series 3B, image 159) abutting the celiac axis and
SMA. Additional aortocaval lymph nodes are seen measuring up to 14 x 8 mm.
There is a small necrotic retrocrural lymph node. There is no pancreatic duct
dilatation, or distal pancreatic atrophy. The CBD is dilated up to 16 mm and
there is moderate intrahepatic biliary dilatation. The CBD is deviated
slightly leftward with eccentric abrupt narrowing as it enters the pancreas,
but the distal 1 cm of the CBD is normal in caliber below the obstruction. In
segment VII and V of the right lobe, 5 mm hypoattenuating liver lesions with
peripheral enhancement are seen, too small to characterize, but likely a
hemangioma (se 3, 119). A segment VII hypoattenuating 16-mm and adjacent 5 mm
lesions likely represent simple cysts. The spleen is normal. The partially
visualized bowel demonstrates a transverse colon anastomosis site and there
are non-pathologically enlarged mesenteric lymph nodes. No omental or
peritoneal tumor deposits are demonstrated. The IVC is patent. Both kidneys
are normally enhancing and excreting urine. The adrenal glands are normal.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. 3.2 x 2.5 cm ___ mass in the medial head of the pancreas with
large porta hepatis, hepatic artery, celiac artery, SMA, aortocaval,
periaortic, and retrocrural pathologic lymph nodes. The mass in the pancreas
could also be lymph nodes and so consideration not only include pancreatic
adenocarcinoma and cholangiocarcinoma but metastases from patient's know
colonic adenocarcinoma.
2. Moderate intra- and extrahepatic biliary dilation from CBD obstruction in
the head of the pancreas.
3. No definite evidence of liver metastasis, but MRI might be considered to
characterize small hypoattenuating hepatic lesions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: JAUNDICE, ERCP
Diagnosed with OBSTRUCTION OF BILE DUCT
temperature: 96.8
heartrate: 69.0
resprate: 18.0
o2sat: 97.0
sbp: 136.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | ___ yo male with history of stage IIIb colon cancer s/p resection
and adjuvant chemotherapy presents with obstructive jaundice
with endoscopic findings concerning for malignancy.
# Obstructive jaundice- Differential for mass:
cholangiocarcinoma vs. pancreatic adenocarcinoma vs. recurrence
of colon cancer. Patient informed of endoscopic findings, and
is aware of the possibility of either a new primary malignancy
or recurrence. No evidence of cholangitis given absence of
fever, elevated WBC. Continued IVF, NPO overnight after ERCP.
Advanced diet as tolerated to full diet later on day of
discharge. Contacted primary oncologist, Dr. ___. Will
need to follow up results of brushings after discharge. Will
complete short course of ciprofloxacin at home.
# Stage IIIb colon cancer- patient recently completed
chemotherapy, with CT scan in ___ that per patient did not show
any evidence of disease.
# Iron deficiency anemia- restarted iron once taking PO
# Anxiety/insomnia- restarted clonazepam once taking PO
# Full code
# HCP ___, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall from ___ story balcony, left frontal contusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with past medical history of
attention deficit disorder who presents via EMS to ___ for a
20 ft fall from balcony on to cement stairway in the setting of
intoxication (EtOH level on arrival ~180) at 0407am on
___. Patient reports being in USOH at party with friends
having drinks when he rolled back on the balcony railing and
fell impacting the ground. The patient notes his next
recollection was being in ___ and speaking with the ED
physicians.
He endorses right lower extremity pain where a laceration is
present on his right calf. He notes some neck stiffness and
headache, but denies any other complaints.
Past Medical History:
Attention Deficit Disorder
Social History:
___
Family History:
non-contributory
Physical Exam:
T: 98.2F, BP: 114/51, HR: 87, R: 12, O2Sats: 100%
Gen: In ___ C-Spine collar with laceration over left eye and
hematoma on left upper eyelid. Dried blood over the left orbit
HEENT: Pupils: ___ b/l, EOMs intact w/o nystagmus or
interrupted
saccades
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused, dressed wound on left calf with
serosanguinous drainage on bandage
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, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout, with exception of
right lower extremity which was limited by pain. No pronator
drift was evident.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Pertinent Results:
___ ___- IMPRESSION:Left frontal lobe contusion adjacent to
the left frontal bone. No fractures are identified.
___ CT C-spine- IMPRESSION: No acute fracture or
malalignment.
___ CXR- IMPRESSION: No acute intrathoracic process. No
fracture however a solitary chest radiograph is not designed to
evaluate for fracture. Dedicated views based on physical exam
findings can be done.
___ CT Torso- IMPRESSION: No acute intrathoracic or
intraabdominal injury.
___ TIB/FIB Xray- IMPRESSION: No acute fracture. Posterior
soft tissue defect.
___ KNEE (AP, LAT & OBLIQUE) RIGHT- IMPRESSION: No acute
fracture. Posterior soft tissue defect.
Medications on Admission:
Adderall XR 25mg daily
Adderall 20mg daily
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
2. Adderall XR *NF* (amphetamine-dextroamphetamine) 25 mg Oral
qAM Reason for Ordering: Wish to maintain preadmission
medication while hospitalized, as there is no acceptable
substitute drug product available on formulary.
3. Adderall *NF* (amphetamine-dextroamphetamine) 20 mg Oral qpm
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
4. Ibuprofen 800 mg PO Q8H:PRN pain
RX *ibuprofen 400 mg 2 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Brain Contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man status post fall, trauma.
COMPARISON: None available.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
Bone algorithm was obtained.
FINDINGS: There is an intracerebral contusion adjacent to the left frontal
bone (2, 18). No other areas of bleeding are identified. The ventricles and
sulci are normal in size and configuration. There is no shift of normally
midline structures. There is no hydrocephalus. There is a mucous retention
cyst in the left maxillary sinus. Otherwise, the paranasal sinuses and
mastoid air cells are well aerated. No fractures are identified. There is
soft tissue swelling overlying the left frontal bone.
IMPRESSION:Left frontal lobe contusion adjacent to the left frontal bone. No
fractures are identified.
Radiology Report
INDICATION: Trauma, fall.
COMPARISON: None available.
FINDINGS: AP view of the chest. There is no focal consolidation, pleural
effusion, or pneumothorax. The cardiomediastinal contours are normal. No
fracture is identified.
IMPRESSION: No acute intrathoracic process. No fracture however a solitary
chest radiograph is not designed to evaluate for fracture. Dedicated views
based on physical exam findings can be done.
Radiology Report
INDICATION: Trauma from fall.
COMPARISON: None available.
TECHNIQUE: MDCT images were obtained through the cervical spine. No contrast
was administered. Coronal and sagittal reformations were performed. Bone
algorithm was obtained.
FINDINGS: There is no evidence of acute fracture or malalignment. The
prevertebral soft tissues are normal. The aerodigestive tract is
unremarkable. The visualized lung apices are grossly clear.
IMPRESSION: No acute fracture or malalignment.
Radiology Report
INDICATION: ___ male with fall and trauma, evaluate for injury.
COMPARISON: None available.
FINDINGS: Three views of the right knee. AP and lateral views of the right
tibia. There is no acute fracture or dislocation. There is no joint effusion
in the knee. There is a soft tissue defect seen posterior to the knee.
IMPRESSION: No acute fracture. Posterior soft tissue defect.
Radiology Report
INDICATION: Trauma, fall.
COMPARISON: None available.
TECHNIQUE: MDCT images were obtained through the chest, abdomen and pelvis
following the administration of IV contrast. Coronal and sagittal
reformations were performed.
FINDINGS:
CHEST: There is no axillary, hilar, mediastinal, or supraclavicular
lymphadenopathy. The thyroid is normal. The esophagus is normal. The aorta
and pulmonary arteries are normal. The heart and pericardium are
unremarkable. There is no pericardial effusion. The airways are patent to
the subsegmental level. There is no pleural effusion. There is no focal
consolidation. No pneumothorax.
ABDOMEN: The liver enhances homogeneously and there are no focal liver
lesions or lacerations. The gallbladder is normal. The pancreas, spleen, and
adrenal glands are unremarkable. The kidneys are normal. There is no
mesenteric or retroperitoneal lymphadenopathy. There is no free air. The
stomach, small bowel, large bowel, and appendix are unremarkable.
PELVIS: There is no free fluid in the pelvis. The prostate and seminal
vesicles are normal. The rectum is normal. The bladder and terminal ureters
are unremarkable. There is no pelvic or inguinal lymphadenopathy. There are
no hernias identified.
The intra-abdominal vasculature is patent.
BONES: The bones are unremarkable. No fractures are identified.
IMPRESSION: No acute intrathoracic or intraabdominal injury.
Radiology Report
INDICATION: Left frontal contusion s/p fall, evaluate for interval change.
COMPARISON: CT head and cervical spine from ___.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared and
reviewed.
FINDINGS: Again visualized is a left frontal parenchymal contusion adjacent
to the left frontal bone (2:5), which appears denser but stable in size, with
minimal surrounding edema. No new foci of hemorrhage are identified. There
is no shift of normally midline structures or herniation. The ventricles and
sulci are normal in size and configuration.
No fracture is identified. Known mucus retention cyst in the left maxillary
sinus is not imaged on today's study. Visualized mastoid air cells and
paranasal sinuses are clear.
IMPRESSION: Left frontal lobe contusion adjacent to left frontal bone appears
denser but stable in size. No new foci of hemorrhage are identified.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with CEREBEL CONTUS-DEEP COMA, FALL-1 LEVEL TO OTH NEC, OPN WND KNEE/LEG W TENDN, OPEN WOUND OF SCALP, ALCOHOL ABUSE-UNSPEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Pt was admitted to the neurosurgery service, floor for
neurological observation. The patient had a 10 cm laceration
over the right superior calf, closed with sutures and two
parallel 2 cm lacerations in the occipital region of his scalp,
closed with staples. A repeat CT head the following morning
showed an unchanged left frontal contusion, with final
radiological read currently pending. He was seen by social work
due to his trauma in the setting of alcohol and cocaine
intoxication. He was counseled on the danger of substance abuse
and encouraged to abstain from further use. He was also referred
to ___ in ___ for treatment of his
substance use. He was ambulating at baseline and his
neurological examination remained normal. He will have his
sutures taken out in ___ days, follow up in concussion as well
as ___ clinic and have a repeat CT head prior to his
___ clinic vist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
airway watch, bleeding teeth and gums
Major Surgical or Invasive Procedure:
___ per OMFS (see note in OMR) - Clot washout, debridement
of extraction sockets and irrigation. Packed gelfoam/surgicell
and sutured in place
History of Present Illness:
___ w/ PMH of afib on coumadin, ___ body dementia presents as
transfer from ___ due to concern for Ludwig's angina.
Patient reportedly had a dental procedure 2 days ago with
extraction of 4 of his bottom teeth. He went into the OSH today
due to oropharyngeal bleeding. Bleeding was controlled with TXA.
There was also a large clot that formed over the teeth that were
extracted.
White blood cell count was 15. While in the emergency department
at OSH, patient had progression of his symptoms with development
of redness, warmth, and fullness of the right side of his neck
although he still had no airway concerns. Given there was
concern for concerning for early Ludwig's angina, he was given
unasyn and transferred to ___ for further management. In the
ED at ___ he remained hemodynamically stable. He was seen by
the ___ in the ED and subsequently came up to the SICU for
further management.
Patient denies any difficulty breathing, chest pain, shortness
of breath, difficulty swallowing.
Past Medical History:
PMH:
Afib on Coumadin
___ body dementia
Essential hypertension
PSH:
Melanoma removed from his forehead
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Constitutional / General appearance: Appears comfortable, Awake
and alert x ___
HEENT: EOMI
HEENT: Right pupil 5mm, briskly reactive to light, left pupil
3mm, sluggishly reactive to light
Neurologic: CN ___ intact, moves all limbs, sensation intact,
grip strength intact
Cardiovascular: Irregularly irregular
Respiratory: Good symmetric air entry throughout, clear to
auscultation
GI / Abdomen: Soft, nontender
GU / Renal: Clear urine
Extremities / MSK: Warm peripheries, no edema
DISCHARGE PHYSICAL EXAM:
=========================
Temp: 97.5 PO BP: 150/84 R Lying HR: 71 RR:
18 O2 sat: 98% O2 delivery: RA
GENERAL: Alert and interactive, in no acute distress
HEENT: NC/AT, R>L anisocoria (chronic), EOMI, sclera anicteric,
anterior mandible with ecchymoses bilaterally, teeth missing at
extraction site, no bleeding noted
NECK: Supple, notable for b/l submandibular lymphadenopathy with
bruises
CARDIAC: RRR, S1/S2 present, no murmurs appreciated
LUNGS: CTAB, no wheezing or crackles.
ABDOMEN: Normal bowels sounds, mildly distended, non-tender.
EXTREMITIES: Pneumoboots in place, no edema
SKIN: No rash, scattered ecchymoses on hands bilaterally
NEUROLOGIC: Flat affect, hypophonic, slowed speech; alert but
confused to situation at times
Pertinent Results:
PERTINENT RESULTS:
===================
___ 08:53PM BLOOD WBC-15.0* RBC-3.05* Hgb-10.8* Hct-33.7*
MCV-111* MCH-35.4* MCHC-32.0 RDW-17.9* RDWSD-73.2* Plt ___
___ 05:30AM BLOOD WBC-12.9* RBC-3.05* Hgb-10.8* Hct-33.3*
MCV-109* MCH-35.4* MCHC-32.4 RDW-17.8* RDWSD-71.3* Plt ___
___ 08:53PM BLOOD Neuts-78.3* Lymphs-13.8* Monos-6.6
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.76* AbsLymp-2.07
AbsMono-0.99* AbsEos-0.01* AbsBaso-0.05
___ 05:30AM BLOOD ___ PTT-46.3* ___
___ 08:53PM BLOOD ___ PTT-47.4* ___
___ 05:30AM BLOOD ___ 05:30AM BLOOD Glucose-147* UreaN-17 Creat-0.6 Na-139
K-4.3 Cl-104 HCO3-22 AnGap-13
___ 08:53PM BLOOD Glucose-99 UreaN-18 Creat-0.6 Na-139
K-4.1 Cl-105 HCO3-24 AnGap-10
___ 05:30AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.8
___ 08:53PM BLOOD Calcium-8.4 Phos-2.1* Mg-1.8
___ 08:58PM BLOOD Lactate-0.7
PERTINENT IMAGING:
==================
CT Neck
IMPRESSION:
1. SLIGHT ASYMMETRY TO THE VOCAL CORDS WITH SOFT TISSUE DENSITY
ASSOCIATED WITH THE RIGHT VOCAL CORD AND LARYNX. DIRECT
VISUALIZATION CLINICAL CORRELATION IS ADVISED.
2. SLIGHT INDURATION JUST SUPERIOR TO THE LEFT SUBMANDIBULAR
GLAND.
3. NO SIGNIFICANT HEMATOMA ENHANCING ABSCESS OR ACUTE
ABNORMALITY OTHERWISE PRESENT
Head CT scan:
ATROPHY AND MICROVASCULAR ISCHEMIC CHANGES. NO ETIOLOGY TO THE
PATIENT'S
ANISOCORIA AS QUESTIONED
CXR
IMPRESSION: Borderline cardiomegaly and vascularity with
blunting of the left anterior costophrenic angle. Possible mild
interstitial edema or interstitial infiltrate superimposed on
chronic obstructive pulmonary disease with findings most
pronounced in the left perihilar region and coarse interstitium
in the right lung base. Lateral view suggests interstitial
infiltrate.
ENT Fiberoptic Exam:
In the context of the patient's clinical presentation and the
need to visualize the regions in close proximity, the decision
was made to proceed with an endoscopic exam. Accordingly, after
verbal consent, the fiberoptic scope was passed to visualize the
regions of concern. The findings were:
Normal nasal cavity, no pus or polyps
Normal nasopharynx, no masses
Normal oropharynx
Epiglottis crisp
Supraglottic area normal
Right arytenoid complex and true vocal fold hypomobile relative
to the left with what appears to be height mismatch
True vocal folds with good apposition
No masses
CT CHEST W/CONTRAST ___:
No outside compression of the trachea. No masslike structures
at the
mediastinal or hilar level. Saber sheath trachea. Patulous
esophagus.
Bilateral basal areas of atelectasis without evidence of
suspicious pulmonary
nodules.
VIDEO SWALLOW STUDY ___:
1. No aspiration.
2. Leftward deviation of the cervical esophagus, unknown cause.
CT of the
neck may be obtained for further evaluation as clinically
indicated.
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).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Warfarin 5 mg PO 4X/WEEK (___)
4. Warfarin 2.5 mg PO 3X/WEEK (___)
5. Meclizine 25 mg PO TID:PRN dizziness
6. FLUoxetine 20 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Vitamin E 1000 UNIT PO DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
12. Vitamin B Complex 1 CAP PO DAILY
13. Carbidopa-Levodopa CR (___) 2 TAB PO BID 7 AM, 3 ___
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days
last date to be ___.
2. Ascorbic Acid ___ mg PO DAILY
3. Gabapentin 400 mg PO TID
4. Vitamin E 400 UNIT PO DAILY
5. Warfarin 2.5 mg PO DAILY
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
7. Carbidopa-Levodopa CR (___) 2 TAB PO BID 7 AM, 3 ___
8. FLUoxetine 20 mg PO DAILY
9. Meclizine 25 mg PO TID:PRN dizziness
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
11. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Tooth extraction socket bleeding/swelling
Right vocal cord hypomobility
Concern for Ludwig's angina requiring ICU admission for airway
monitoring
Leukocytosis
Supratherapeutic INR
Hypoechhoic right vocal cord
Zenker diverticulum with impaired relaxation of upper esophageal
sphyncter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with concerns for Ludwig's angina// Infiltrates?,
fluid overload?
TECHNIQUE: Chest AP
COMPARISON: None
FINDINGS:
Cardiac silhouette is enlarged mildly. Lung fields are within normal limits
without evidence of consolidation, pleural effusion or pneumothorax.
IMPRESSION:
Mildly enlarged cardiac silhouette.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with vocal cord paralysis// Eval for any mass
compressing laryngeal nerve given vocal cord paralysis
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 329 mGy-cm
COMPARISON: No comparison
FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. There is no thyroid compression of the trachea.
The middle parts of the trachea have a saber sheet appearance. No mass in the
mediastinum is compressing the trachea. Mediastinal lymph nodes are normal in
size. The esophagus, however, is very patulous. Moderate coronary
calcifications, no valvular calcifications, no pericardial effusion. Numerous
calcified gallstones. No osteolytic lesions at the level of the ribs, the
sternum, or the vertebral bodies. Moderate degenerative vertebral disease.
No vertebral compression fractures. Mild bilateral apical scarring. Several
millimetric pulmonary nodules, for example in the right upper lobe (302, 60)
are non suspicious. Mild atelectasis in both the right and the left lung
basis. Extensive respiratory motion artifacts limit the assessment of the
lower lobes. Small rounded atelectasis at the left lung basis (302, 159). No
pleural effusions. No diffuse lung disease.
IMPRESSION:
No outside compression of the trachea. No masslike structures at the
mediastinal or hilar level. Saber sheath trachea. Patulous esophagus.
Bilateral basal areas of atelectasis without evidence of suspicious pulmonary
nodules.
Radiology Report
EXAMINATION: SECOND OPINION CT NEURO PSO1 CT
INDICATION: ___ year old man with bleeding s/p extraction of teeth ___ with
post op bleeding dt supratherapeutic INR. CT neck at OSH noted vocal cord
asymmetry, confirmed with direct laryngoscopy.// CT neck from ___
review CT head/neck from OSH specifically in light of assessing for lesions
along the course of the vagus or recurrent laryngeal nerves.
TECHNIQUE: Imaging was performed after administration of 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: 1292.4 mGy cm
COMPARISON: None.
FINDINGS:
There is adduction of the right vocal cord, and enlargement of the right
piriform sinus suggestive of right vocal cord paralysis (401:212). No lesions
are identified along the course of the recurrent laryngeal nerves, although
the study does not include the aortic arch. Thus, the full course of the left
recurrent laryngeal nerve is not visualized. The full course of the right
nerve is visualized. There is a small amount of non occlusive secretion
within the upper thoracic trachea (41:250). Evaluation of the aerodigestive
tract demonstrates no mass and no areas of focal mass effect.
The salivary glands enhance normally and are without mass or adjacent fat
stranding. The thyroid gland appears normal. There is no lymphadenopathy by
CT criteria. The neck vessels are patent.
Aside from minimal left apical pleuroparenchymal scarring, the imaged portion
of the lung apices are clear and there are no concerning pulmonary
nodules.There are small right upper mediastinal lymph nodes, the largest
measuring approximately 9 mm in short axis dimension there are no osseous
lesions.
IMPRESSION:
Adduction of the right focal cord suggests right vocal cord paralysis.
No lesions are identified along the course of the right recurrent laryngeal
nerve.
Evaluation of the left recurrent laryngeal nerve is mildly limited as the
study does not include the aortic arch.
Radiology Report
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man with dysphagia// eval for cause of dysphagia
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: 01:45 min.
COMPARISON: None
FINDINGS:
There was no gross aspiration or penetration. There is leftward deviation of
the cervical esophagus, unknown cause.
IMPRESSION:
1. No aspiration.
2. Leftward deviation of the cervical esophagus, unknown cause. CT of the
neck may be obtained for further evaluation as clinically indicated.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Jaw pain, Transfer
Diagnosed with Postproc hemor of a dgstv sys org fol a dgstv sys procedure, Abnormal coagulation profile, Unspecified atrial fibrillation, Long term (current) use of anticoagulants
temperature: 97.9
heartrate: 77.0
resprate: 18.0
o2sat: 99.0
sbp: 130.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES:
=======================
[] Patient admitted on diuretic however no documented history of
heart failure no echo in our system. Noted to be orthostatic on
___ and Lasix held.
[] Weigh daily. If weight increases more than 3 lbs in 2 days,
restart PO Lasix at 40mg daily.
[] Will need to f/u with dentist regarding tooth extraction
[] Consider transition to DOAC given supratherapeutic INR and
ease of use.
[] Please repeat INR in ___ days and adjust warfarin dose as
necessary for goal INR ___
[] On videoswallow, noted to have Zenker diverticulum with
difficulty in UES relaxation, will need to follow up with Dr
___.
[] Intermittently orthostatic, but recovers and re-equilibrates
after several minutes. If orthostatic, encourage PO fluid
intake. Please ensure that he stands/sits up slowly with
something to hold onto
[]Discharge INR: 1.8
[]Discharge weight: 168.87 (___) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending: ___.
Chief Complaint:
cough, sent in from PCP
___ or Invasive Procedure:
none.
History of Present Illness:
Ms. ___ is ___ with h/o CAD s/p CABG, AAA rupture s/p repair,
HTN, HLD, in by PCP for productive cough, and FFT. The patient
initially presented to her PCP's office early ___ with a
productive cough and found to have e/o aspiration pneumonia on
CXR ___ and started on Clindamycin ___. The patient was
recently seen by her PCP ___ ___ and sent in from clinic with
worsening clincal condition, cough, as well as weight loss. As
per PCP referral, the patient reports feeling worse on
clindamycin. The patient reports having a cough productive of
white phlegm for the last couple of weeks. Her daughter also
reported some cough after eating or drinking. The patient
denies any pleuritic chest pain.
Of note, the patient is fully functional at her baseline, able
to drive and prepare meals for herself. She lives on the first
floor and her daughter and daughter's husband live on second
floor. There are three stairs that the patient has to climb to
enter house; no stairs inside.
Of note, the patient's weight decreased from 80 lbs (___) to
77 lbs now and the family is concerned about insufficient daily
food intake. As per the patient and her daughter, the patient
drinks boost, orange juice, and coffee daily. The patient will
eat oatmeal; will have about a half sandwich and maybe a few
bites of a steak with dinner.
On ROS, the patient denies any recent fevers/chills,
nausea/vomit/diarrhea, or dysuria. Denies any chest pain,
reports having some palpitations when she is nervous. Denies
any changes in her bowel movements or abdominal pain. Denies
any urinary symptoms.
While in the ED, initial vitals: 100.0 78 98/68 18 96% RA
Labs notable for white count of 10.6 and lactate of 2.7. CXR
with e/o possible early infection at R lung base. The patient
was given 1L IVF and one dose Levofloxacin. VS on transfer to
the floor: 98.4, 76, 20, 115/68, 96% on RA.
Past Medical History:
Atrophic vaginitis and cystocele
B12 anemia
CAD
HLD
HTN
dementia
OA
AAA
s/p cholecystectomy
nephrolithiasis
Social History:
___
Family History:
non contributory
Physical Exam:
Admission PE:
VS: 97.8 128/80 78 16 95RA
General: pleasant, thin, frail elderly woman, NAD, laying
comfortably in bed
HEENT: moist mucous membranes
CV: RRR S1, S2, +holosystolic murmur heard loudest at ___
lungs: decreased breath sounds at R base with scattered
inspiratory crackles at R base, slight decreased breath sounds
at L base, +cough with inspiration, junky sounding
abdomen: soft, nontender, nondistended, +BS
extremities: warm, well perfused, no ___ edema, 2+ DP pulses
Neuro: CN ___ grossly intact, normal muscle strength and
sensation throughout
Discharge PE:
unchanged, the patient left AMA the same day she was admitted
Pertinent Results:
Admissions labs:
___ 12:50PM BLOOD WBC-10.6 RBC-4.13* Hgb-12.3 Hct-38.4
MCV-93 MCH-29.9 MCHC-32.2 RDW-13.0 Plt ___
___ 12:50PM BLOOD Neuts-86.0* Lymphs-9.6* Monos-3.8 Eos-0.3
Baso-0.3
___ 12:50PM BLOOD ___ PTT-28.4 ___
___ 12:50PM BLOOD Glucose-136* UreaN-16 Creat-0.6 Na-140
K-4.6 Cl-103 HCO3-27 AnGap-15
___ 12:50PM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8
___ 01:09PM BLOOD Lactate-2.7*
CXR: IMPRESSION: Bibasilar airspace opacities which appears
mildly increased at the right lung base since ___ and may
represent early or developing infection in the appropriate
clinical setting.
Discharge labs:
unchanged, as the patient left AMA the same day she was admitted
Medications on Admission:
lipitor 20 mg daily
Diovan 160 mg daily
codeine-guaigenesin 1 teaspoon qhs
HCTZ 12.5 mg daily
clindamycin 150 mg q8h x 7day (STARTED ___
metoprolol 100 mg daily
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Guaifenesin AC ___ mg/5 mL Liquid Sig: One (1) tsp PO at
bedtime as needed for cough.
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 5 days.
Disp:*2 Tablet(s)* Refills:*0*
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman with malaise, shortness of breath.
Evaluate for infection.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. The lungs
are hyperextended suggestive of emphysema. Bibasilar airspace opacities are
redemonstrated, with increased opacity at the right lung base since ___.
Blunting of the costophrenic sulci is longstanding and may represent chronic
pleural thickening or scarring. The upper lung zones are clear. The cardiac
and mediastinal silhouettes are stable. Median sternotomy wires are intact.
Aortic tortuosity is unchanged with diffuse calcification. No pulmonary edema.
Wedge compression deformities in the thoracic spine are similar to the prior
study.
IMPRESSION: Bibasilar airspace opacities which appears mildly increased at
the right lung base since ___ and may represent early or developing
infection in the appropriate clinical setting.
Findings discussed with Dr. ___ by phone at 2:20 p.m. on ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN, WEIGHT LOSS
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 100.0
heartrate: 78.0
resprate: 18.0
o2sat: 96.0
sbp: 98.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is ___ with history of CAD s/p CABG, AAA rupture s/p
repair, HTN, HLD who initially presented to her PCP office in
early ___ with a cough, and found to have ? e/o aspiration on
CXR from ___ started on clindamycin who was sent in from clinic
with worsening clincal condition, cough, as well as weight loss.
# PNA: The patient has history of coughing while eating and
recent CXR done in the setting of a productive cough with e/o
aspiration PNA. She has been taking clindamycin since ___,
with no significant improvement in her symptoms. CXR on this
presentation with increasing opacity at R lung base. The patient
was continued on clinda, and levofloxacin was added for CAP
coverage in the setting of not improving on clinda alone. The
patient ultimately left AMA. She was given prescriptions to
continue these antibiotics for five days. She was also
instructed to follow up with PCP and get outpatient speech and
swallow evaluation to assess for any aspiration. She remained
afebrile and did not have white count.
# HTN: The patient was continued on her home valsartan,
metoprolol, and HCTZ.
# HLD: The patient was continued on lipitor.
# weight loss: The patient reports weight loss over the last one
month. Has declined colonoscopy in the past. The patient was
put in for nutrition c/s, but was never seen as she left AMA.
Goals of care and potential for further malignancy work up
should be addressed as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ - 1. Coronary bypass grafting x4 with the left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the right acute marginal artery,
the obtuse marginal artery, and the diagonal artery. 2.
Endarterectomy of the diagonal artery.
___ - Cardiac catheterization
History of Present Illness:
___ w/ PMH of type 2 diabetes c/b ESRD previously on peritoneal
dialysis, s/p kidney transplant on ___ for diabetic
nephropathy, atrial fibrillation on anticoagulation, HTN, HL now
presenting with chest pain and dysuria.
Patient had a living-related donor kidney transplant in ___ for diabetic nephropathy. Her course has been complicated
by urinary tract infections. Yesterday, she experienced dysuria
in the evening. The was then followed by an episode of
exertional chest pain when she ambulated to the bathroom and
while returning noted onset of palpitations accompanied by a
aching sensation in her back. After sitting down, her chest pain
resolved with 20 minutes of rest. She had some associated
dyspnea and diaphoresis during the event. She denies cough or
fevers. She went to sleep and later awoke with diaphoresis and
feeling unwell. She was concerned and presented to ___
___ for further evaluation where she was noted to have a
positive UA and was started on ceftriaxone for UTI. She was also
noted to have an elevated TnI of 3.741 with a nondiagnostic EKG.
She was treated with aspirin for presumed ACS and transferred to
___ for further management.
In the ED, her initial vitals were: 96.7F HR84 BP 105/51 RR 16
99% RA. ECG did not show ST elevations by report (not currently
available). Troponin 0.39, INR 2.9, WBCs 16.9k, Hct 31.7.
Lactate 1.9. Cardiology was consulted and felt that she was
having a NSTEMI. However, the patient was chest pain free and
due to her elevated INR from warfarin, she has high risk of
bleeding. Cardiology recommended admission to cardiology
service, holding warfarin, starting a heparin drip and planning
for catheterization tomorrow unless Pt develops worsening chest
pain or ECG changes. Pt was given clopidogrel 300mg po x 1 in
ED, started on heparin drip and admitted to cardiology service
for further management.
Past Medical History:
CAD
Atrial fibrillation on warfarin
Type II DM
CKD stage V previously on PD
living unrelated kidney transplant ___
Diabetic retinopathy
Vascular disease
Hypertension
Hypercholesterolemia
Social History:
___
Family History:
Father: DM, mother h/o DM, HTN, Psoriasis. Mother passed away in
___. She has no siblings.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 100.7, BP 141/56, HR 96, RR 18, 95% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, no oral flush
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, systolic murmur
appreciated throughout without radiation to carotids, no rubs or
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no femoral bruits bilaterally
Neuro- CNs2-12 intact, motor function grossly normal
Skin- Diaphoretic, no rashes or lesions
Discharge Exam:
VS: T 98.7 HR: 50-60 SR BP: 100-114/60 Sats: 98% RA
BS: 128-228 Wt: 84.7 Kg preop 89 Kg
General: ___ year-old female in no apparent distress
HEENT: normocephalic
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2
Resp: clear breath sounds throughout
GI: benign
Extr: warm no edema
Wound: sternal & right lower extremity clean dry intact
Neuro Awake, alert oriented
Pertinent Results:
ADMISSION LABS:
___ WBC-16.9*# RBC-3.54*# Hgb-10.3*# Hct-31.7*# MCV-90
MCH-29.2 MCHC-32.6 RDW-13.3 Plt ___
___ Neuts-95* Bands-1 ___ Monos-4 Eos-0 Baso-0 Atyps-0
Metas-0
___ ___ PTT-43.2* ___
___ Glucose-227* UreaN-22* Creat-1.2* Na-139 K-4.4 Cl-107
HCO3-26
___ CK-MB-16* MB Indx-5.9
___ cTropnT-0.39*
PERTINENT INTERVAL LABS:
___ %HbA1c-8.8* eAG-206*
___ CK-MB-44* MB Indx-6.9* cTropnT-1.20*
___ CK-MB-40* MB Indx-5.1 cTropnT-1.35*
___ CK-MB-24* MB Indx-4.3 cTropnT-2.21*
___ CK-MB-10 MB Indx-2.3 cTropnT-2.24*
___ CK-MB-11* MB Indx-2.6 cTropnT-2.89*
___ CK-MB-5 cTropnT-2.92*
Discharge Labs:
___ WBC-8.9 RBC-2.95* Hgb-8.6* Hct-27.2 Plt ___
___ ___
___ ___ PTT-31.2 ___
___ ___ PTT-26.5 ___
___ Glucose-91 UreaN-27* Creat-1.3* Na-138 K-4.6 Cl-105
HCO3-28
___ Glucose-135* UreaN-26* Creat-1.2* Na-135 K-4.6 Cl-102
HCO3-28
___ Phos-2.9 Mg-2.0
___ tacroFK-6.5
___ tacroFK-PND
CARDIAC CATHETERIZATION ___:
Coronary angiography: right dominant
LMCA: Distal 70% into true bifurcation involving LAD/Cx
LAD: Origin 95% with diffuse 50% calcific disease and TIMI 2
flow. Diagonal has calcific 50% stenosis.
LCX: Heavily calcified with origin 90% stenosis and long 60%
stenosis into OM1
RCA: Origin 50%. Mild luminal irregularities and heavy
calcification
CXR PORTABLE ___:
FINDINGS: As compared to the previous radiograph, the left PICC
line has been removed. Otherwise, no relevant changes noted.
The lung volumes are
constant. Borderline size of the cardiac silhouette without
pulmonary edema. No pleural effusion. Normal hilar and
mediastinal structures. No pneumonia.
CXR PORTABLE ___:
FINDINGS: Cardiomediastinal contours are within normal limits
allowing for
low lung volumes. Lungs and pleural surfaces are clear.
CXR PORTABLE ___:
Portable AP single view of the chest shows reduced lung volume
but
without consolidation. New left retrocardiac opacification is
likely due to atelectasis. No pleural effusion or pneumothorax.
Heart size is still
moderately enlarged. IJ catheter is unchanged with tip ending
in right
atrium.
IMPRESSION: New left base atelectasis. No pleural effusion.
1RENAL TRANSPLANT US ___:
IMPRESSION:
1. No hydronephrosis of the transplant kidney.
2. Patent transplant kidney vasculature. The resistive indices
are mildly
elevated, minimally increased compared with the prior study.
CAROTID US ___:
Impression: Right ICA 40-59% stenosis .
Left ICA 40-59% stenosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY16
2. Atorvastatin 20 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Mycophenolate Mofetil 1000 mg PO QAM
8. Tacrolimus 2.5 mg PO Q12H
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
10. Glargine 35 Units Breakfast
Glargine 40 Units Bedtime
Insulin SC Sliding Scale using Glulisine Insulin
11. Mycophenolate Mofetil 500 mg PO QPM
12. FoLIC Acid 1 mg PO DAILY
13. biotin unknown unknown oral daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Glargine 45 Units Breakfast
Glargine 40 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Mycophenolate Mofetil 1000 mg PO QAM
7. Mycophenolate Mofetil 500 mg PO QPM (___)
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tacrolimus 2.5 mg PO Q12H
10. Vitamin D 1000 UNIT PO DAILY
11. Acetaminophen 650 mg PO Q4H:PRN pain, fever
12. Docusate Sodium 100 mg PO BID
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
14. biotin 0 unknown ORAL DAILY
15. Lactulose 30 mL PO DAILY
16. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*5
17. Warfarin 5 mg PO DAILY16
Take as directed to maintain
INR 2.0-3.0
18. HYDROmorphone (Dilaudid) 2 mg PO Q4H pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Atrial fibrillation on warfarin
Type II Diabetes Mellitus
CKD stage V previously on PD
Living unrelated kidney transplant ___
Diabetic retinopathy
Vascular disease
Hypertension (of meds since transplant)
Hypercholesterolemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Diabetes, renal transplant, rule out infection.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the left PICC line has been
removed. Otherwise, no relevant changes noted. The lung volumes are
constant. Borderline size of the cardiac silhouette without pulmonary edema.
No pleural effusion. Normal hilar and mediastinal structures. No pneumonia.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: Radiograph of one day earlier.
FINDINGS: Cardiomediastinal contours are within normal limits allowing for
low lung volumes. Lungs and pleural surfaces are clear.
Radiology Report
HISTORY: ___ female with LURT now w/ NSTEMI and UTI.
COMPARISON: Transplant kidney ultrasound ___.
FINDINGS:
The transplant kidney is seen in the right lower quadrant measuring 12.3 cm in
length. There is no hydronephrosis and no perinephric fluid collection is
identified. A hypoechoic focus that may represent a cyst or calyceal
diverticulum is seen in the interpolar region of the transplant kidney
measuring 1.1 x 0.6 x 1.1 cm. The urinary bladder is minimally distended and
is normal in appearance.
DOPPLER EXAMINATION: Color Doppler and spectral waveform analysis was
performed. Appropriate arterial waveforms with sharp upstrokes are seen in
the main renal artery with peak systolic velocity of 27 cm/second.
Appropriate venous flow seen in the main renal vein. Resistive indices are
minimally increased and again noted to be mildly elevated measuring 0.79, 0.79
and 0.76 in the upper, mid and lower poles respectively.
IMPRESSION:
1. No hydronephrosis of the transplant kidney.
2. Patent transplant kidney vasculature. The resistive indices are mildly
elevated, minimally increased compared with the prior study.
Radiology Report
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old woman with severe CAD awaiting CABG. Pre-op.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is moderate heterogeneous plaque in the ICA. On the left there
is plaque in the moderate calcified ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 116/29, 103/28, 113/38 cm/sec. CCA peak systolic
velocity is 80/19 cm/sec. ECA peak systolic velocity is 71 cm/sec. The ICA/CCA
ratio is 1.45. These findings are consistent with 40-59% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 131/31, 75/25, 82/31 cm/sec. CCA peak systolic
velocity is 85/22 cm/sec. ECA peak systolic velocity is 58 cm/sec. The
ICA/CCA ratio is 1.54. These findings are consistent with 40-59% stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA 40-59% stenosis .
Left ICA 40-59% stenosis .
Radiology Report
AP CHEST, 6:40 P.M., ___
HISTORY: CABG fast-track.
IMPRESSION: AP chest compared to preoperative chest radiograph, ___.
ET tube, upper enteric drainage tube in standard placements. Midline and left
pleural drains in place. Swan-Ganz catheter ends in the proximal right
pulmonary artery. No pneumothorax or pleural effusion. Cardiomediastinal
silhouette has a normal postoperative appearance, and low lung volumes produce
vascular crowding, but there is no substantial atelectasis or pulmonary edema.
No pneumothorax.
Radiology Report
INDICATION: Status post CABG, chest tubes DC'd. Evaluate for pneumothorax.
COMPARISONS: Chest radiograph from ___.
FINDINGS: A left internal jugular sheath is present. There is no focal
consolidation, pleural effusion or pneumothorax. The heart is mildly
enlarged, consistent with a post-operative appearance. Median sternotomy
wires and clips are noted. There is no pleural effusion or focal
consolidation. Note is made of a distended stomach.
IMPRESSION: No evidence of pneumothorax.
Radiology Report
INDICATION: Status post CABG, left IJ Cordis changed to triple-lumen over a
wire.
COMPARISONS: Chest radiograph from ___.
FINDINGS: There is a left internal jugular central line that terminates
within the right atrium. The lungs are clear without focal consolidation,
pleural effusion or pneumothorax. The heart is enlarged. Median sternotomy
wires are intact. The stomach is distended.
IMPRESSION:
1. Left internal jugular central line terminates at the right atrium.
2. Distended stomach which may benefit from NG tube.
Radiology Report
PATIENT HISTORY: ___ woman status post CABG, evaluate for effusion.
COMPARISON: Exam is compared to chest x-ray of ___.
FINDINGS: Portable AP single view of the chest shows reduced lung volume but
without consolidation. New left retrocardiac opacification is likely due to
atelectasis. No pleural effusion or pneumothorax. Heart size is still
moderately enlarged. IJ catheter is unchanged with tip ending in right
atrium.
IMPRESSION: New left base atelectasis. No pleural effusion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE
temperature: 96.7
heartrate: 84.0
resprate: 16.0
o2sat: 99.0
sbp: 105.0
dbp: 51.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___ is a ___ y.o. female with PMHx of CAD, hypertension,
hyperlipidemia, diabetes mellitus type II c/b end-stage renal
disease now s/p renal transplant in ___, atrial fibrillation
on anticoagulation who presented with NSTEMI and found to have
severe 3-vessel disease necessitating surgical
revascularization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
allopurinol
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Successful CT-guided placement of an ___ pigtail
catheter into the collection.
History of Present Illness:
___ year old male with history of HTN and gout who p/w 1 month
history of abdominal pain. Patient states pain is mostly ___
lower abdomen and vague ___
terms of quality of pain. It has persisted for the month and was
not improving and he presented to ED for further evaluation. He
denies fevers, chills, nausea, vomiting. He has been tolerating
PO intake. He does report increasing frequency of urination but
no other issues with urination, including no painful urination
or
burning or obstruction. He has had normal appearing regular BMs
and continues to pass gas.
Past Medical History:
HTN, Gout
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical examination upon admission: ___
VS: 98.6 71 154/74 18 95% RA
Gen: NAD, A&Ox3, conversant
HEENT: EOMI, mmm, no sclera icterus
CV: RRR
Pulm: No distress
Abd: soft, non distended, mildly tender to palpation ___ lower
abdomen, no rebound or guarding
Ext: WWP, no edema
Discharge Physical Exam: ___:
VS: 98.6, 60, 122/46, 18, 94% RA
Gen: Dressing, walking around ___ room. Interactive and pleasant.
HEENT: No deformity, PERRL, EOMI. Neck supple, trachea midline.
CV: RRR
Pulm: Clear to auscultation bilaterally
Abdomen: Soft, tender to palpation at drain site as anticipated,
non-distended. Drain site CDI with stat lock dressing ___ place.
Serousanginous drainage ___ drain bag.
Ext: Warm and dry. No edema. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 04:20AM BLOOD WBC-10.1* RBC-4.79 Hgb-13.9 Hct-42.5
MCV-89 MCH-29.0 MCHC-32.7 RDW-12.5 RDWSD-41.1 Plt ___
___ 04:15AM BLOOD WBC-12.1* RBC-4.34* Hgb-12.4* Hct-38.9*
MCV-90 MCH-28.6 MCHC-31.9* RDW-12.5 RDWSD-41.6 Plt ___
___ 11:34AM BLOOD WBC-16.5*# RBC-4.96 Hgb-14.7 Hct-44.7
MCV-90 MCH-29.6 MCHC-32.9 RDW-12.9 RDWSD-42.3 Plt ___
___ 11:34AM BLOOD Neuts-77.5* Lymphs-10.6* Monos-9.4
Eos-1.3 Baso-0.5 Im ___ AbsNeut-12.75* AbsLymp-1.74
AbsMono-1.55* AbsEos-0.21 AbsBaso-0.08
___ 04:20AM BLOOD Plt ___
___ 04:50AM BLOOD ___ PTT-27.9 ___
___ 04:20AM BLOOD Glucose-96 UreaN-22* Creat-1.1 Na-140
K-4.1 Cl-101 HCO3-26 AnGap-17
___ 11:34AM BLOOD ALT-28 AST-39 AlkPhos-102 TotBili-1.0
___ 04:20AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1
___: cat scan abdomen and pelvis:
1. Acute sigmoid diverticulitis, complicated by a 4.4 x 3.6 x
3.5 cm
extra-luminal abscess ___ the mid lower right abdomen.
2. Extensive atherosclerotic calcifications involving the
abdominal aorta and bilateral iliac arteries.
___: CT guided drainage:
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
___ 11:22 am ABSCESS Source: pelvic abscess.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amlodipine-benazepril ___ mg oral DAILY
2. atenolol-chlorthalidone 100-25 mg oral DAILY
3. Colchicine 0.6 mg PO DAILY
4. Febuxostat 80 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
7. Fish Oil (Omega 3) 1000 mg PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
last dose
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. amlodipine-benazepril ___ mg oral DAILY
7. Aspirin 81 mg PO DAILY
8. atenolol-chlorthalidone 100-25 mg oral DAILY
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
10. Colchicine 0.6 mg PO DAILY
11. Febuxostat 80 mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO EVERY OTHER DAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
diverticulitis
pelvic abscess
Discharge Condition:
Mental Status: Clear and coherent ( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ man with abdominal pain. Evaluate for
diverticulitis.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 4.4 s, 47.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 631.6
mGy-cm.
Total DLP (Body) = 642 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 collapsed.
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 3.7 x 3.5 cm simple cyst in the lower pole the left kidney. There
is no perinephric abnormality. Incidental note of a circumaortic left renal
vein.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. In the right mid
to lower abdomen, there is severe inflammation of the sigmoid colon with
mucosal hyperemia, adjacent fat stranding, and wall thickening (2: 55-63).
An adjacent lobulated fluid collection with internal foci of air and an
enhancing rim measures 4.4 x 3.6 x 3.5 cm, concerning for an abscess. Mild
adjacent fat stranding around the medial appendix is thought to be reactive
from the adjacent colonic process.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Dense calcifications are identified in the prostate.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Lumbar spinal degenerative changes are mild-to-moderate.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Acute sigmoid diverticulitis, complicated by a 4.4 x 3.6 x 3.5 cm
extraluminal abscess in the mid lower right abdomen.
2. Extensive atherosclerotic calcifications involving the abdominal aorta and
bilateral iliac arteries.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 17:33 on ___, 5 min after discovery.
Radiology Report
EXAMINATION: CT-guided abscess aspiration and drainage
INDICATION: ___ year old man with diverticulitis w/ 4 cm pelvic abscess //
please eval to drain pelvic abscess from perf diverticulitis
COMPARISON: CT abdomen and pelvis ___
PROCEDURE: CT-guided drainage of diverticular abscess.
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during
the key components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the CT
findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 30 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam. !If this Fluency report was activated before the completion
of the dose transmission, please reinsert the token called CT DLP Dose to load
new data.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 26
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
The known diverticular abscess was aspirated and drained using an 8 ___
catheter. Approximately 30 cc of purulent fluid was aspirated. Fluid was sent
to the laboratory for analysis.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Urinary frequency, ABD DISCOMFORT
Diagnosed with Unspecified abdominal pain
temperature: 99.3
heartrate: 76.0
resprate: 16.0
o2sat: 98.0
sbp: 130.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | ___ year old male admitted to the hospital with abdominal pain.
Upon admission, the patient was made NPO, given intravenous
fluids, and underwent imaging. A CT scan of the abdomen and
pelvis showed acute sigmoid diverticulitis, complicated by a 4.4
x 3.6 x 3.5cm extra-luminal abscess ___ the mid lower right
abdomen. The patient was started on a course of ciprofloxacin
and flagyl. His white blood cell count was monitored.
On HD #2, the patient was taken to ___ for drainage of the
abscess and successful CT-guided placement of an ___
pigtail catheter into the collection with aspiration of 30 cc of
purulent material which was sent for culture.
The patient's vital signs remained stable and he was afebrile.
His white blood cell count normalized. He was tolerating a
regular diet and his pain was controlled with oral analgesia.
He was voiding without difficulty. The patient was discharged
home with ___ services on HD #3 ___ stable condition. Drain care
was reviewed. A follow-up appointment was made ___ the acute
care clinic and he was given a prescription for completion of
his antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dysuria, groin pain
Major Surgical or Invasive Procedure:
___ percutaneous nephrostomy
Central line placement and removal
History of Present Illness:
The patient is a ___ year-old male with a history of hypertension
and atrial fibrillation who presented to OSH with with groin
pain, dysuria, and diarrhea; now admitted to the MICU with acute
renal failure and likely urosepsis in the setting of bilateral
ureteral obstruction.
The patient reports that he began experiencing symptoms of
malaise and dysuria on ~ ___. He presented to a local
physician at that time, and was started on ciprofloxacin for
presumed cystitis/prostatitis. On ___, his cipro was stopped by
his PCP, and he was started on Bactrim for ongoing urinary
symptoms. On ___, the patient called his PCP's office with
persistent pain and burning with urination, frequency at night,
though without fever, chills, hematuria. He has also been
experiencing diarrhea over the last ___ days per his report. He
presented to an OSH ED given persistence of symptoms.
At the OSH, BMP revealed Na 120, bicarb 8, Cr 12.2, AG 23. CBC
showed WBC 20 and HCT 35.3. Urinalysis showed large leukocyte
esterase, large blood, nitrite negative, and protein 300. A
Foley catheter was placed early in the patient's course. The
patient was given 4 L of normal saline, 1 amp bicarbonate, and
Zosyn. CT of the abdomen showed diffuse abnormal bladder wall
thickening concerning for diffuse bladder malignancy or less
likely aggressive cystitis, causing significant bilateral
hydronephrosis despite the presence of a foley catheter. He was
transferred to ___ ED.
In the ED, initial VS were: P 80 BP 113/59. Labs were
significant for Na 125, HCO3 9, Cr 9.6. lactate 1.1. Blood
cultures and urine cultures were sent. Nephrology was consulted,
who felt that there was no emergent indication for dialysis.
Urology was consulted, they felt patient had bilateral
obstruction with concern for urosepsis and recommended bilateral
PCN placement. ___ was contacted for PCN placement. VS at the
time of transfer were: 97.9 90 109/53 20. RIJ was placed in the
ED given hypotension to SBP ___, and placement was confirmed
with CXR. The patient was started on levophed. The patient
subsequently went to the ___ suite, where b/l nephrostomy tubes
were placed.
On arrival to the MICU, the patient reports feeling tired, but
without pain. He denies any current urinary or GI symptoms.
Past Medical History:
Hypertension
Atrial Fibrillation
Subdural hematoma after a fall secondary to ETOH - s/p surgery
Left inguinal hernia repair
Resection of colon polyps
Alcohol Dependence
Social History:
___
Family History:
Patient denies any family history of medical conditions.
Physical Exam:
Exam on Admission:
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no tenderness over bladder
GU: foley in place, bilateral perc nephrostomy tubes draining
clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, no asterixis
Discharge:
Vitals: 98.4, 131/71, 78, 18, 98%ra
Today 8 hour: L700/R700
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no signs of hematoma of R IJ
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no tenderness over bladder
GU: bilateral perc nephrostomy tubes draining clear yellow
urine, No signs of infection around meatous.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
___ 05:39PM BLOOD WBC-17.8* RBC-3.38* Hgb-10.9* Hct-32.2*
MCV-95 MCH-32.3* MCHC-33.9 RDW-12.9 Plt ___
___ 05:39PM BLOOD Neuts-89.0* Lymphs-6.0* Monos-4.4 Eos-0.4
Baso-0.2
___ 01:34AM BLOOD ___ PTT-23.7* ___
___ 05:39PM BLOOD Glucose-123* UreaN-130* Creat-9.6*
Na-125* K-4.5 Cl-95* HCO3-9* AnGap-26*
___ 04:46PM BLOOD cTropnT-<0.01
___ 11:27AM BLOOD cTropnT-<0.01
___ 01:34AM BLOOD Calcium-7.5* Phos-7.9* Mg-2.0
Imaging:
___: Bilateral ultrasound and fluoroscopy-guided 8 ___
nephrostomy
tube placement.
FINDINGS:
1. Ultrasound demonstrated bilateral moderate hydronephrosis.
An initial
access demonstrated urine containing pus in both kidneys.
2. Minimal contrast injection was performed to confirm
location. No
antegrade nephrostogram was performed given the patient's
clinical condition
(over sepsis) and appearance of the urine.
___
1. Right internal jugular central venous catheter tip at the
junction of the SVC and proximal right atrium. No pneumothorax.
2. Nondisplaced right 1st rib fracture
MICRO:
___- negative
___- UA- NG
Discharge labs:
___ 08:35AM BLOOD WBC-14.7* RBC-3.60* Hgb-11.9* Hct-35.2*
MCV-98 MCH-33.0* MCHC-33.8 RDW-13.4 Plt ___
___ 07:50AM BLOOD WBC-18.4* RBC-3.64* Hgb-11.7* Hct-34.8*
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.2 Plt ___
___ 08:00AM BLOOD WBC-17.0* RBC-3.59* Hgb-11.4* Hct-34.3*
MCV-96 MCH-31.7 MCHC-33.1 RDW-12.8 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD PTT-28.4
___ 08:00AM BLOOD Glucose-126* UreaN-19 Creat-0.9 Na-136
K-3.7 Cl-101 HCO3-23 AnGap-16
___ 08:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.5*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Hydrochlorothiazide 50 mg PO DAILY
3. Labetalol 200 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*16 Tablet Refills:*0
4. Outpatient Lab Work
Complete Metabolic Panel
Please get drawn on ___. Fax results to PCP Dr ___.
5. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
6. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
RX *magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #*10
Capsule Refills:*0
7. Amlodipine 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Septic Shock
Bilateral hydronephrosis
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Right internal jugular central line placement.
TECHNIQUE: Portable AP view of the chest.
COMPARISON: None.
FINDINGS:
Right internal jugular central venous catheter tip terminates at the junction
of the SVC and proximal right atrium. No pneumothorax is present. The heart
size is mild to moderately enlarged. There is unfolding of the thoracic
aorta. Crowding of the bronchovascular structures is noted, as well as mild
pulmonary vascular engorgement with cephalization of the pulmonary
vascularity. No focal consolidation or large pleural effusion is present.
There is a nondisplaced fracture of the right lateral 1st rib.
IMPRESSION:
1. Right internal jugular central venous catheter tip at the junction of the
SVC and proximal right atrium. No pneumothorax.
2. Nondisplaced right 1st rib fracture.
Radiology Report
INDICATION: ___ gentleman with history of urosepsis, bilateral
moderate hydronephrosis on CT scan, for bilateral percutaneous nephrostomy
tube placement.
PHYSICIANS: Dr. ___, the attending radiologist, was present and
supervising. Dr. ___, fellow.
PROCEDURE: Bilateral ultrasound and fluoroscopy-guided 8 ___ nephrostomy
tube placement.
CONTRAST: 2 cc of contrast.
MODERATE SEDATION: Moderate sedation was provided with divided doses of 4 mg
IV Versed and 150 mcg IV fentanyl throughout the intra-procedure time of 1
hour 15 minutes, during which continuous hemodynamic monitoring was performed.
PROCEDURE: Prior to initiation of procedure, written informed consent was
obtained and preprocedure timeout was performed. The patient was placed prone
on the fluoroscopy table and his back and flanks were prepped in a sterile
manner. Under ultrasound guidance, initial 21-gauge Cook needle access was
obtained into the lower pole calix in the right kidney, and a 0.018 wire was
advanced into the kidney. The needle was exchanged for an AccuStick set,
through which a minimal contrast injection confirmed location. A ___ wire
was advanced into the kidney and proximal ureter, and an 8 ___ nephrostomy
tube was placed. This was secured to the skin with suture and StatLock.
Next, a similar procedure was performed on the left, with Cook needle access,
followed by nitinol wire placement and AccuStick set placement with contrast
confirmation. An 8 ___ nephrostomy tube was placed over ___ wire
following this. Samples from both sides were obtained for microbiology. The
patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Ultrasound demonstrated bilateral moderate hydronephrosis. An initial
access demonstrated urine containing pus in both kidneys.
2. Minimal contrast injection was performed to confirm location. No
antegrade nephrostogram was performed given the patient's clinical condition
(over sepsis) and appearance of the urine.
IMPRESSION: Successful bilateral 8 ___ nephrostomy tube placement.
Radiology Report
BLADDER ULTRASOUND
HISTORY: Question retention.
COMPARISONS: CT from ___.
TECHNIQUE: Ultrasound of the bladder.
FINDINGS: The bladder is only partly full with markedly thickened, as seen
previously, including a trabeculated pattern. The left distal ureter is
mildly dilated up to 15 mm in diameter, the right 9 mm. The estimated bladder
volume, based on measurements of 96 x 70 x 71 mm, is 251 cc. The patient was
not able to void at the time of the study. Transient color flow near the left
ureterovesical junction suggests a weak ureteral jet, although none is
demonstrated on the right side.
IMPRESSION: Partly full bladder, without substantial dilatation or
distention. The volume was 251 cc and the patient felt unable to void at that
volume. Marked bladder wall thickening is highly non-specific but could be
seen with post-obstructive or inflammatory etiologies.
Radiology Report
INDICATION:
___ male with history of urosepsis and placement of bilateral
percutaneous nephrostomy tubes 6 days ago. Comes today for nephrostomy
catheter check on the left due to absence of urine output.
OPERATORS:
Dr. ___, ___ fellow and Dr. ___, ___ attending.
ANESTHESIA:
Moderate sedation was provided by administering divided doses for a total of
75 mcg of fentanyl and 2 mg of Versed for this total intraservice time of 45
minutes, during which patient's hemodynamic parameters were continuously
monitored.
1% lidocaine was also used as a local anesthetic agent.
PROCEDURES:
1. Left percutaneous nephrostomy tube check.
2. Reaccess with a left percutaneous nephrostomy tube placement.
PROCEDURE DETAILS:
After explaining risks, benefits and alternatives to the procedure, written
informed consent was obtained from the patient. Patient was brought to the
angiography suite and placed prone on the imaging table. The left flank was
prepped and draped in the usual sterile fashion. Preprocedure timeout was
performed as per ___ protocol.
Initial scout image of the abdomen demonstrated the left percutaneous
nephrostomy tube significantly pulled back. Subsequently, a Glidewire was
attempted to navigate through the tube into the left kidney's collecting
system, however, the wire coiled in a non-anatomic position. Subsequently,
the wire was removed, and small amount of contrast injection through a ___
sheath demonstrated extravasation of contrast. Given these findings, a
decision to perform a new access into the left kidney was made.
Under ultrasound and fluoroscopic guidance, a left inferior pole calix was
cannulated using a 21-gauge Cook needle through which a 0.018 nitinol wire was
then advanced into the renal pelvis. The needle was exchanged for the inner
portion of the Accustick sheath to give further support and then wire was
navigated further down into the proximal ureter. Subsequently, the AccuStick
piece was withdrawn and four-set of the AccuStick was reformed. Following,
the four AccuStick system was then advanced over the wire into the renal
pelvis. The inner dilator, the wire and the metallic shaft of the AccuStick
were removed, and an Amplatz wire was advanced into the renal pelvis and
coiled within. Subsequently, an 8 ___ dilator was used to open the soft
tissue tract, and this was followed by successful placement of an 8 ___
nephrostomy tube with the pigtail locked within the renal pelvis of the left
kidney. Small amount of contrast injection demonstrated adequate positioning
of the tube. The catheter was secured to the skin with ___ silk suture and a
StatLock device. The catheter was attached to external bag drainage.
Following, decision was made to perform right nephrostogram, since the right
nephrostomy catheter also appeared displaced on the scout image. The
nephrostogram demonstrated the pigtail to be within the collecting system, and
the tube was slightly advanced under fluoroscopy. Adequate positioning was
achieved, and the tube was secured again with another suture and a StatLock
device.
Patient tolerated the procedure well without immediate complications.
FINDINGS:
1. Displaced nephrostomy tube of the left kidney, with its tip completely out
of the urinary collecting system. Mild-to-moderate hydronephrosis on this
side.
2. Slightly displaced pigtail of the right nephrostomy tube, which was
slightly repositioned and secured.
IMPRESSION:
There has been interval displacement of the left nephrostomy tube, which
required a new stick in the current procedure, with successful ___
placement of a left percutaneous nephrostomy tube (8 ___.
The right nephrostomy catheter also appeared to be slightly pulled back, which
was repositioned and secured again with 0 silk suture and a StatLock device.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIARRHEA
Diagnosed with DIARRHEA, HYPERTENSION NOS
temperature: nan
heartrate: 80.0
resprate: nan
o2sat: nan
sbp: 113.0
dbp: 59.0
level of pain: 4
level of acuity: 2.0 | The patient is a ___ year-old male with a history of hypertension
and atrial fibrillation who presented to OSH with with groin
pain and hypotension; admitted to the MICU with acute renal
failure, anion-gap metabolic acidosis, and sepsis in the setting
of bilateral ureteral obstruction.
#) Septic shock from urinary source: Likely secondary to sepsis
given positive UA, anatomical findings on CT, leukocytosis and
frank pus drained from L nephrostomy during ___ placement of
nephrostomy tube. Patient labs and clinical history (diarrhea,
poor POs) suggest contribution of hypovolemia as well. Patient
with adequate UOP and normal lactate, status-post fluid
resucitation. No evidence to suggest cardiogenic etiology, PE,
or adrenal insufficiency as cause of patient's hypotension. The
patient was started on levophed for BP support, though this was
weaned over the first 24 hours. Patient was started on cefepime
for broad-spectrum GN coverage. Urine culture was pending at the
time of transfer to the floor and showed no growth. While on the
medicine floor, his cultures returned no growth. In
consultation with infectious disease, he was placed on
Ciprofloxacin for a total of 14 days by mouth.
#) Obstructive acute renal failure: He was found to have
significant bilateral hydronephrosis on OSH CT. The patient's
creatinine trended downward following placement of bilateral PCN
by interventional radiology. On ___ it was noticed that pt
did not have any output from the Left PCN. ___ took pt and found
that the tube was displaced. ___ replaced tube and pt had good
drainage. On the day of discharge on ___ ___ tubes were
draining urine.
#) Atrial fibrillation: Patient had frequent runs of SVT/AFib in
the morning during his hospital course. He was started on
metoprolol during the course of his ICU stay, and this was
uptitrated on the medicine floor. At___ cardiology was
consulted and recommended putting pt on PO Mg and uptitrating
his Metoprolol with follow up as an out pt in ___ weeks. His
aspirin was restarted at discharge.
#) Abnormal bladder wall thickening: Concerning for diffuse
bladder malignancy or less likely aggressive cystitis, causing
significant bilateral hydronephrosis. Likely will need
cystoscopy/biopsy pending HD stability. Urology followed during
ICU stay and recommened out pt evulation. Cytology was negative
for malignant cells. He was scheduled for outpatient urology
evaluation.
#) Hyponatremia: Likely hypovolemic hyponatremia given response
to volume and recent history of diarrhea. Na improved to normal
range during course of ICU stay. While on the floor his sodium
stayed in the normal range.
#) Anemia: Unclear chronicity given lack of records in system.
No e/o active bleeding.
#) H/o hypertension: Held home anti-hypertensives in setting of
acute illness. His labetalol, HCTZ, and lisinopril were stopped.
He was started on metoprolol during the hopsitalization for the
AF. He was restarted on amlodipine at discharge.
#) Anion Gap Metabolic acidosis: Likely secondary to severe
renal failure. Lactate normal. No ketones on UA. No history or
evidence of intoxication. Improved in conjuction with
improvement in renal function. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Taxol
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of CHF, CAD, AV Block s/p PPM, breast Ca metastatic
to lung/liver, hypothyroid who presents with worsening DOE.
Patient reports symptoms began evening of ___ and have
gradually worsened. Worse with exertion, particularly when
walking up stairs. The patient additionally reports a recent
cough productive of sputum. She has also recently increased her
PO Lasix dose from 20 to 30mg qD. Finally, she noted mild
orthopnea the evening prior to admission. She denies any recent
fever, chills, chest pain, abdominal pain, vomiting, dysuria,
bowel changes. She does report that she has been quite active
over the past week but over the past day had difficulty walking
across the street.
Of note, patient recently had breast Ca restaged and noted to
have "progression of her disease back in her liver with increase
in size and number of multiple hepatic mets, the largest being
4.5 cm. In her chest CT, there has been slow growth of her
right hilar lower lobe soft tissue surrounding the right lower
lobe bronchi." The patient recently restarted her Afinitor +
exemestane for breast Ca. She took these in ___ but stopped -
it was unclear at that time if she developed true pulmonary
toxicity or had dyspnea ___ heart failure at that time. She
restarted these medications at reduced doses 3 weeks ago.
In the ED, initial vitals afebrile, HR 65, BP 120/89, RR 18,
96%RA. Initialy exam notable for "no evidence of fluid overload;
CTAB, no peripheral edema. Labs notable for unremarkable Chem 7
(Bun/Cr ___, negative troponin, BNP 16k. CBC with WBC 7.7,
Hgb 11, Plt 152. Patient given SL Nitro, Duonebs, Lasix 20mg x2.
EKG V-Paced with rate of 99. CXRx2 completed in ED with interval
worsening of pulmonary edema. Patient then developed transient
hypertension, tachypnea and hypoxia and placed on BiPAP and a
nitro gtt which was only needed for ~ 2 hours. Patient improved
and was taken of BiPAP and placed on NC, however patient
developed asymptomatic hypotension (low of ___ systolic) and was
not considered to be stable for the floor so was admitted to the
MICU.
On transfer, vitals were: afebrile, HR 84, BP 91/70, RR 18,
95%NC.
On arrival to the MICU, patient resting comfortably in bed in
NAD. She is requesting discharge as she "feels completely fine"
and is going to ___ this weekend.
Past Medical History:
- Metastatic ER+ Breast Cancer: s/p bilateral mastectomy,
Adriamycin x5, tamoxifen, Arimidex, exemestane, Faslodex, XRT to
left axillary nodes and subpectoralis nodes, Xeloda. Currently
on on everolimus and exemestane.
- 2:1 AV block s/p dual-chamber ___ PPM (___)
- Glaucoma
- Bladder suspension
- Cholecystectomy
Social History:
___
Family History:
Positive for breast cancer, and diabetes, and heart disease.
Physical Exam:
ADMISSION EXAM
==============
Vitals:97.5; 109/77; 55; 17; 100%4L NC; 60.7kg
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: crackeles at R base, otherwise 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
EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes/lesions noted
NEURO: A&Ox3. Moving all extremities with purpose
DISCHARGE EXAM
==============
Vitals: 97.7 128/64 97 20 97RA
General: Alert, oriented, appears reasonably well.
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at the bases bilaterally, left
breath sounds more absent than right, coarse rhonchi at the
bases, mild wheeze bilaterally.
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
head best of LL intercostal space.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions
Neuro: AOx3, CN ___ in tact, strength ___ upper and lower
extremities, sensation grossly in tact. Gait deferred.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 04:05PM WBC-7.7 RBC-3.85* HGB-11.0* HCT-34.8 MCV-90
MCH-28.6 MCHC-31.6* RDW-13.4 RDWSD-44.2
___ 04:05PM NEUTS-76.2* LYMPHS-15.3* MONOS-8.0 EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-5.88 AbsLymp-1.18* AbsMono-0.62
AbsEos-0.00* AbsBaso-0.03
___ 04:05PM PLT COUNT-152
___ 04:05PM ___
___ 04:05PM cTropnT-<0.01
___ 04:05PM estGFR-Using this
___ 04:05PM GLUCOSE-134* UREA N-26* CREAT-0.7 SODIUM-136
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16
==========
PERTINENT LABS
==========
___ 03:50PM PLEURAL WBC-1475* RBC-485* Polys-2* Lymphs-36*
Monos-0 Plasma-5* Meso-2* Macro-53* Other-2*
___ 03:50PM PLEURAL TotProt-3.1 Glucose-174 Creat-0.6
LD(LDH)-189 Amylase-93 Albumin-2.2 ___ Misc-PRO BNP =
==============
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-3.8* RBC-3.78* Hgb-10.9* Hct-37.0
MCV-98# MCH-28.8 MCHC-29.5* RDW-13.5 RDWSD-48.7* Plt ___
___ 01:10PM BLOOD ___ PTT-22.1* ___
___ 06:45AM BLOOD Glucose-103* UreaN-19 Creat-0.8 Na-136
K-4.3 Cl-101 HCO3-20* AnGap-19
___ 06:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
=====
MICRO
=====
___ 3:50 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 12:23 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
__________________________________________________________
___ 2:29 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
__________________________________________________________
___ 2:21 am MRSA SCREEN
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 9:20 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
PLEURAL FLUID
Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Note: WT1 and calretinin highlight a few mesothelial cells. The
majority of cells are CD-68 positive
macrophages. Stains for ER, Moc31 and B72.3 are negative.
=======
IMAGING
=======
CT Chest w/Contrast
1. Significant interval increase in size of the right perihilar
mass with
extension along the bronchovascular structures toward the
peripheral pleura and now also posteriorly with significant
narrowing but not obstruction of all the right lobar and
segmental bronchi, most consistent with a malignant hilar
lesion.
2. Interval increased bilateral pleural effusions, now moderate
on the right and small on the left.
3. Increased interlobular septal thickening and ground glass
nodules,
reflecting edema and/or lymphangitic carcinomatosis.
4. Several new opacities in the left lung, some of which may
reflect mucous plugging and others, perhaps malignant nodules.
5. Interval increased size of numerous hepatic hypodensities,
presumed
metastatic.
6. Interval increased soft tissue density in the left breast,
axilla, and
supraclavicular region with skin thickening.
TTE ___
The left atrial volume index is moderately increased. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the distal ventricle and apex. The remaining segments
contract normally (LVEF = 40 %). The right ventricular cavity is
mildly dilated with focal hypokinesis of the apical free wall.
The ascending aorta is mildly dilated. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
0.7-0.8cm2 with indexed valve area 0.44-0.5cm2/m2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is mild functional mitral stenosis (mean
gradient 6.8mmHg) due to mitral annular calcification. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular chamber size and systolic
function with mild regional systolic dysfunction c/w CAD in the
mid-LAD distribution. Severe calcific aortic valve stenosis.
Mild functional mitral stenosis from MAC. At least mild mitral
regurgitation.
Compared with the prior study (images reviewed) of ___ the
severeity of the aortic stenosis has increased partly on account
of a lower stroke volume. Mild functional mitral stenosis is now
seen. The distal inferior wall is now hypokinetic. There is now
mild pulmonary hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Atorvastatin 40 mg PO QPM
6. Furosemide 20 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. diclofenac potassium 50 mg oral QAM:PRN hip pain
9. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Everolimus 5 mg PO QD
12. Exemestane 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain
7. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
8. diclofenac potassium 50 mg oral QAM:PRN hip pain
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Furosemide 20 mg PO DAILY:PRN Weight gain >1lb
RX *furosemide 20 mg 1 tablet(s) by mouth daily in the morning
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Stage 4 Breast Cancer
Secondary Diagnosis
Anemia
Thrombocytopenia
Systolic congestive heart failure
Coronary artery disease
AV block
Hypothyroidism
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with DOE // CHF exacerbation?
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___ chest x-ray and chest CT from ___.
FINDINGS:
When compared to prior x-ray, there is more conspicuous opacity at the right
lung base medially with a more rounded configuration on the frontal views.
Increased less well the found surrounding opacity is also noted at the right
lung base as well. There is a small right pleural effusion. Biapical
scarring is again noted. The left lung is otherwise clear. There is
pulmonary vascular congestion without overt edema. Cardiomediastinal
silhouette is stable. No acute osseous abnormalities. Right chest wall dual
lead pacing device is again noted. Mid thoracic compression deformity is
unchanged from prior CT.
IMPRESSION:
Progression of opacity at the right lung base potentially in part due to post
obstructive atelectasis given known increasing infrahilar soft tissue on prior
CT scan. Superimposed infection would be possible. More rounded nodule at
the right lung base could represent a pulmonary nodule. Followup will be
necessary.
Radiology Report
INDICATION: ___ with sudden worsening SOB // CHF, PNA?
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Radiograph dated same day, ___ at approximately
16:39
FINDINGS:
Portable AP chest radiograph demonstrates stable cardiomediastinal silhouette.
A right chest dual lead pacing device is noted, of leads which appear intact
and in unchanged position. Relative to most recent examination, opacity
within the right lung base appears more confluent. There has been progression
of pulmonary vascular congestion. No new confluent consolidation identified
on the left. There persists blunting of the right costophrenic angle
consistent with a small pleural effusion. There is no pneumothorax.
IMPRESSION:
Worsening vascular congestion with developing more confluent right lung base
opacity, potentially due to blossoming infection or progressive atelectasis
although asymmetric edema is possible.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with a history of a hilar mass and new O2
requirement; evaluate for worsening hilar compression vs carcinamatosis as
etiology of new o2 requirement.
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 4.3 s, 34.0 cm; CTDIvol = 10.7 mGy (Body) DLP = 362.8
mGy-cm.
Total DLP (Body) = 363 mGy-cm.
COMPARISON: Chest CT dated ___.
FINDINGS:
The thoracic aorta is normal in caliber with a moderate, diffuse calcified and
noncalcified atherosclerosis. The main, left, and right pulmonary arteries
are mildly dilated, up to 3.2 cm, overall unchanged and likely suggesting
pulmonary hypertension. No evidence of an incidental central pulmonary
embolus. The heart is mildly enlarged, similar the prior exam. Coronary
artery calcifications are moderate. Aortic valve calcifications are mild. No
pericardial effusion.
The thyroid is unremarkable. No axillary lymphadenopathy by CT size criteria.
A 6 mm left supraclavicular node is unchanged from the prior exam, other left
supraclavicular nodes are more prominent (series 2, image 30). Several,
scattered mediastinal lymph nodes are prominent, most of which are overall
unchanged in size, including an 8 mm prevascular node (series 2, image 24).
Increased soft tissue prominence in the right hilum surrounding the right
mainstem bronchus and extending along the right upper lobe bronchus, bronchus
intermedius, and right lower lobe and middle lobe bronchi is difficult to
precisely measure but persists and has markedly increased in size. The right
hilar mass now has extension posteriorly and inferior into the right lower
lobe as well as more peripheral toward the pleural surface. There is
significant narrowing but no obstruction of the all the right lobar and
segmental bronchi. There is mild fullness of the hilar tissue on the left,
that is more conspicuous from the prior exam with narrowing but not
obstruction of the left lower lobe bronchus.
A moderate right nonhemorrhagic pleural effusion has increased in size in the
interim. A trace, non hemorrhagic left pleural effusion is new compared to the
prior exam. There is marked, bilateral increased interlobular septal
thickening and ground glass opacities. This may reflect edema and/or
lymphangitic carcinomatosis.
Biapical scarring and traction bronchiectasis as well as anterior scarring are
overall unchanged, likely secondary to history of radiation therapy (series 4,
image 40, 32). Focal ground-glass opacities in the left upper lobe may
reflect areas of focal air trapping for inflammatory change, not clearly seen
on the prior exam (e.g. Series 4, image 50, 52).
Several bilateral nodules are unchanged. However, at least 2 sub-3-mm left
upper lobe nodules are new (series 4, image 137). Other opacities such as in
the superior segment of the left upper lobe (series 4, image 105) may reflect
focal areas of bronchiole impaction. Several subpleural opacities in the left
lower lobe are also new, largest 1 mm (series 4, image 185, 190). There is
increased volume loss in the left lower lobe with peribronchiolar thickening,
mild bronchiectasis. A calcified granuloma in left upper lobe is unchanged
(series 4, image 80).
The patient is status post right breast reconstruction. There appears to be
increased breast density in the posterior left upper breast as well as soft
tissue density in the left axilla with new skin thickening since ___.
A 4-mm sclerotic lesion in the left lateral ninth rib is unchanged since at
least ___ (series 602b, image 125). Superior compression deformity
with less than 50% loss of vertebral body height in the T9 vertebral body is
overall unchanged since at least ___ (series 602b, image 69). No new or
suspicious lytic or sclerotic osseous lesion. Old rib fractures are
unchanged.
Multiple hepatic hypodensities persist, the largest in segment 6 now measuring
up to 4.7 x 2.9 cm, minimally changed from the prior exam where it measured
4.5 x 3.1 cm (series 2, image 59). A 3.9 x 2.6 cm hypodensity in segment ___
has perhaps slightly increased in the interim, previously measuring 3.5 x 2.6
cm (see series 2, image 54). A 2.5 x 2.1 cm segment 4B hypodense lesion has
also all slightly increased in the interim, previously measuring 2.4 x 1.7 cm
(series 2, image 52). A 2.6 x 2.1 cm segment 2 lesion is perhaps minimally
increased, previously measuring 2.3 x 2.2 cm (series 2, image 54). Other
smaller hypodensities persist. No definite new nodules within the limitations
of this incompletely visualized liver.
IMPRESSION:
1. Significant interval increase in size of the right perihilar mass with
extension along the bronchovascular structures toward the peripheral pleura
and now also posteriorly with significant narrowing but not obstruction of all
the right lobar and segmental bronchi, most consistent with a malignant hilar
lesion.
2. Interval increased bilateral pleural effusions, now moderate on the right
and small on the left.
3. Increased interlobular septal thickening and ground glass nodules,
reflecting edema and/or lymphangitic carcinomatosis.
4. Several new opacities in the left lung, some of which may reflect mucous
plugging and others, perhaps malignant nodules.
5. Interval increased size of numerous hepatic hypodensities, presumed
metastatic.
6. Interval increased soft tissue density in the left breast, axilla, and
supraclavicular region with skin thickening.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute dyspnea // effusions, edema.
effusions, edema.
COMPARISON: Chest radiographs since ___ most recently ___.
Mild pulmonary edema is unchanged. Consolidation in the right lower lobe is
more pronounced, could be collapse alone. Heart size top-normal unchanged.
Moderate right pleural effusion increased slightly. Left pleural effusion is
presumed, but not large. There is no pneumothorax. Left apical scarring
suggests prior radiation to the region.
Transvenous right atrial and right ventricular pacer leads are continuous from
the right pectoral generator.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with R sided pleural effusion s/p tap // r/o
PTX r/o PTX
COMPARISON: Comparison to ___ at 22:17
FINDINGS:
Portable upright chest radiograph ___ at 16:26 is submitted.
IMPRESSION:
A right-sided pacer remains in place with the leads intact and terminating
over the right atrium and right ventricle, respectively. There has been
interval decrease in size of a right pleural effusion status post
thoracentesis with improved aeration at the right base and no definite
pneumothorax identified. No pulmonary edema. Stable left apical opacity
likely reflecting post radiation changes. No focal airspace consolidation to
suggest pneumonia. Stable cardiac and mediastinal contours. Multiple
surgical clips overlying the right lower hemi thorax consistent with prior
mastectomy and reconstruction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chronic pulmonary edema
temperature: 98.3
heartrate: 65.0
resprate: 18.0
o2sat: 96.0
sbp: 120.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year female, with past history of metastatic
breast Ca with worsening metastasis, recently started on
chemotherapy 3 weeks ago, CHF, CAD, hypothyroidism, presenting
with worsening dyspnea on exertion.
=============
ACTIVE ISSUES
=============
# Dyspnea on Exertion
# Pleural Effusion
The patient presented with acute hypoxia and hypotension to the
MICU and briefly required BiPAP before being transitioned back
to nasal canula. She was transferred out of the MICU the
following morning to the general medicine floor. She was stable
on 4L NC but worsened transiently overnight in the setting of
being supine. A CT Chest was done which showed internal increase
in metastatic R hilar lesions with narrowing of right bronchi,
possible lymphangitic carcinomatosis, and likely malignant
pleural effusions v. pulmonary edema. Her presenting
dyspnea/hypoxia was thought to be multifactorial in the setting
of the above findings and less likely in the setting of
pulmonary toxicity from chemotherapy regimen. Her dyspnea and
hypoxia improved and she was weaned from o2. She was treated
with a 7 day course of Levofloxacin. Pulmonary and Radiation
Oncology were consulted. She underwent right sided thoracentesis
on ___, with 700cc fluid removed. Studies from the
thoracentesis showed an effusion, with cytology results not
showing malignant cells. She was discharged to home off oxygen
with close Hem/Onc follow up.
#Hypotension. She was transiently hypotensive in the setting of
being placed on nitro gtt in the MICU, which improved after
nitro gtt was discontinued. She was given home Lasix
intermittently for volume management and home metoprolol was
restarted.
# Metastatic Breast Cancer: Stage IV breast cancer: ER positive,
HER2 negative. She had been recently restarted on everolimus and
exemastane (___) given progression of her cancer. These
medications were held on admission. CT Chest w/ contrast was
done on admission which showed interval progression of R hilar
lesions, worsening pleural effusions, and possible lymphangitic
carcinomatosis as above. Outpatient oncologist Dr. ___ was kept
informed and was in agreement with the above plan. A
thoracentesis was performed, cytology withou malignant cells.
Radiation oncology was consulted and recommended ongoing
outpatient follow up.
==============
CHRONIC ISSUES
==============
# Normocytic Anemia: H/H was trended and was stable.
# Thrombocytopenia: Platelets were trended and were stable.
# CHF. TTE done during admission showed stable LVEF 40% with
slight worsening in severe aortic stenosis. She was initially
diuresed with 40mg IV Lasix in the MICU and transitioned to home
regimen of 20mg PO Lasix, given intermittently during admission
to maintain euvolemia. Discharge weight was 59.7kg
# CAD: s/p BMS to LAD ___. Home ASA and atorvastatin were
continued. Metoprolol was initially held in the setting of
hypotension but restarted.
# 2:1 AV block s/p PPM. ___ PPM (___). Stable.
# Hypothyroidism: TSH 3.5. Continued to levothyroxine 25 mcg
# Hip Pain: Continued home tramadol
# Depression. Continued home citalopram.
===================
TRANSITIONAL ISSUES
===================
- Discharge weight: 59.7KG
- Discharge diuretic regimen: Lasix 20mg PO, to be taken if
morning weight has increased by more than 1lb since the previous
day.
# Effusion: Unlikely infectious. Pleural cytology not malignant,
patient to f/u with IP as outpatient if needed for consideration
for pleurx catheter.
# Chemotherapy: Patient's affinitor and exemestane to be held
per primary oncologist ___.
# Diuretic: Patient with elevated LA, but also severe AS.
Discharged on 20 mg Lasix PRN for weight gain >1lb from previous
day, please continue to weigh patient and adjust as needed
# Communication: patient HCP: ___ (Daughter)
___
# Code: DNR/DNI - OK for BiPAP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
worsening pericardial effusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents from clinic with worsening chronic pericardial
effusion. Patient seen in outpatient ___ clinic today for
routine follow up and was noted to have bilateral lower
extremity edema along with weight gain and some dyspnea. He
underwent an echocardiogram which demonstrated a pericardial
effusion with mild tamponade physiology. At time of arrival in
the emergency department he states he is completely without
complaints.
In the ED intial vitals were: 16:42 0 97.4 92 127/61 18 99%
Labs notable for WBC 2.8 Ht 28 plat 27 Cr 2.1. CXR showed No
evidence of pulmonary edema. Persistent probable small right
pleural effusion and possible pleural-based scarring. Unchanged
enlargement of the cardiac silhouette likely in part due to the
patient's known pericardial effusion. Echo showed: Compared with
the prior study (images reviewed) of ___ the pericardial
effusion is slightly larger, and evidence of impaired right
ventricular filling is now present. Right heart chamber collapse
may be absent despite impaired ventricular filling in the
presence of severe pulmonary hypertension
Cardiology was consulted in the ER and felt there was no
clinical tamponade with pulsus of 7. Also noted significant risk
with emergent pericardiocentesis in setting of thrombocytopenia.
Recommended consideration of gentle diuresis, but will be
careful not to precipitate clinical tamponade. Patient admitted
to ___ for further management.
On the floor, he denies SOB, CP, palpitations. He does does
endorse progressive SOB with exertion and describes difficulty
walking 30 feet inside his house w/o mild respiratory distress.
He also reports mild orthostasis but denies pre-syncope or
syncope.
ROS: On review of systems, he denies any prior history of
stroke, TIA, deep venous thrombosis, myalgias, joint pains,
cough, hemoptysis or red stools. He denies recent fevers, chills
or rigors. All of the other review of systems were negative.
+ dark stools but not melenic, no hematochezia, no diarrhea or
abd pain
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
+ Notable for exertional dyspnea as noted above and mild ___
edema and weight gain of about 10lbs in 2 weeks
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
1) Lymphoblastic Lymphoma Dx ___ by ___ after years of low
grade pancytopenia and progressive fatigue
Treatment:
- Bendamustine C1 80mg/m2 x 2days ___
- R-bendamustine C2 ___ complicated by infusion reaction
with rituximab
- C1 R-velcade-dex ___
- C2 R- velcade-dex ___
- C3 R-velcade-dex ___
- C4 R-velcade-dex ___
- Chlorambucil -___
2) HTN
3) HLD
4) Dementia, patient reports trouble with memory
5) Pancytopenia
6) BPH
7) Cholecystectomy
8) Excision of scalp skin cancer
9) Foot drop
10) chronic pericardial effusion
11) chronic pleural effusion
12) pHTN
Social History:
___
Family History:
Father died at age ___ of presumed PE. Twin brother with colon
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 69.0, 109/49 70 20 95ra
General: well appearing laying flat in bed in NAD
HEENT: HEENT, no scleral icterus
Neck: supple, JVP to angle of mandible
CV: RRR, normal s1/s2, no mrg
Lungs: CTABL
Abdomen: mildly distended but = per patient; + splenomegaly, no
TTP
GU: no foley
Ext: 1+ ___ ___ edema, R>L
Neuro: grossly nonfocal, AAO x person, place, not date
Skin: scattered bruises
DISCHARGE PHYSICAL EXAM
VS: 97.7 100/55 (90s-100s/40s-50s) 87 (80s) 94% on RA Pulsus
6mmHg
Weight: 69.0kg
General: well-appearing elderly male, lying flat in bed,
breathing comfortably
HEENT: NC/AT, PERRL, sclera anicteric, no conjunctival
injection, oropharynx clear
Neck: supple, JVP at 8cm, no LAD
CV: RRR with extra beats, normal s1/s2, no m/r/g
Lungs: good effort, clear bilaterally
Abdomen: soft, nontender, mild distention, + splenomegaly,
normoactive bowel sounds
GU: no foley
Ext: 1+ bilateral ___ edema
Neuro: AAO x 3, ___ strength throughout, no dysmetria; can
immediately recall ___ words,
Skin: scattered bruises
Pertinent Results:
ADMISSION LABS
====================
___ 07:58PM BLOOD WBC-3.2* RBC-3.06* Hgb-9.7* Hct-31.3*
MCV-102* MCH-31.9 MCHC-31.2 RDW-16.2* Plt Ct-29*
___ 07:58PM BLOOD Neuts-38* Bands-1 Lymphs-48* Monos-2
Eos-1 Baso-0 Atyps-8* ___ Myelos-2*
___ 07:58PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr-1+
___ 07:58PM BLOOD ___ PTT-25.0 ___
___ 07:58PM BLOOD Glucose-129* UreaN-42* Creat-2.1* Na-139
K-3.5 Cl-102 HCO3-22 AnGap-19
___ 01:25PM BLOOD Calcium-8.8 Phos-4.2 Mg-2.3
IMAGING/STUDIES
====================
___ TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 60%). The right ventricular free wall is hypertrophied.
The aortic root is mildly dilated at the sinus level. There are
focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Severe [4+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a moderate sized pericardial effusion. The effusion appears
circumferential. No right atrial diastolic collapse is seen.
There is delayed right ventricular diastolic excursion,
consistent with impaired fillling. Echocardiographic signs of
tamponade may be absent in the presence of elevated right sided
pressures. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling.
___ CXR
No evidence of pulmonary edema. Persistent probable small right
pleural
effusion and possible pleural-based scarring. Unchanged
enlargement of the
cardiac silhouette likely in part due to the patient's known
pericardial
effusion.
___ ECG
NSR, rate 83, PVCs, low voltage in limb leads, no ST or T wave
changes
DISCHARGE LABS
========================
___ 06:00AM BLOOD WBC-2.7* RBC-2.34* Hgb-7.3* Hct-23.6*
MCV-101* MCH-31.3 MCHC-31.0 RDW-16.3* Plt Ct-28*
___ 06:00AM BLOOD ___ PTT-30.3 ___
___ 06:00AM BLOOD Glucose-124* UreaN-43* Creat-1.8* Na-140
K-3.1* Cl-105 HCO3-22 AnGap-16
___ 06:00AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Aspirin EC 81 mg PO DAILY
3. Cholestyramine 4 gm PO TID
4. Ferrous Sulfate 325 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. ipratropium bromide 0.06 % NU TID
9. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Cholestyramine 4 gm PO TID
3. Ferrous Sulfate 325 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Aspirin EC 81 mg PO DAILY
6. ipratropium bromide 0.06 % NU TID
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
primary: pericardial effusion, chronic diastolic congestive
heart failure
secondary: lymphoma, anemia, thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with pericardial effusion and dyspnea.
COMPARISON: Chest x-ray from ___ and MR from ___.
FINDINGS:
Frontal and lateral views of the chest. There is persistent blunting of the
right lateral costophrenic angle and trace blunting seen posteriorly. This
may be due to small pleural effusion with possible underlying pleural
thickening or scar laterally. Faint right basilar opacities have not
significantly changed since prior and may be due to scar. There is no
pulmonary vascular congestion. Cardiac silhouette is enlarged likely in part
due to pericardial effusion. No acute osseous abnormalities detected.
IMPRESSION:
No evidence of pulmonary edema. Persistent probable small right pleural
effusion and possible pleural-based scarring. Unchanged enlargement of the
cardiac silhouette likely in part due to the patient's known pericardial
effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WORSENING PERICARDIAL EFFUSION
Diagnosed with LYMPHOMA NEC UNSPEC SITE
temperature: 97.4
heartrate: 92.0
resprate: 18.0
o2sat: 99.0
sbp: 127.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ was admitted with recent dyspnea on exertion and
concern for increasing pericardial effusion. Pulsus remained
___, he was hemodynamically stable, and had no signs or
symptoms to suggest tamponade and was discharged sypmtom-free.
ACTIVE ISSUES
# Chronic Pericardial Effusion
Likely malignant. Initial concern for possible tamponade given
delayed right ventricular diastolic excursion consistent with
impaired filling on ehcocardiogram. Home torsemide initially
held gvien this finding. Pulsus was measured to be ___ on
serial measurements. He remained hemodynamically stable. There
was no evidence of tamponade and he was discharged symptom-free.
# dCHF with preserved EF
Dry weight 68kg. CXR without signs of pulmonary edema. No
evidence of decompnsation. His SOB is at baseline. Restarted
home medications that were held overnight.
# Lymphoplasmacytic lymphoma
Most recent therapy has been with chlorambucil. Last dose was on
___. Disease course has been complicated by CHF exacerbation as
well as pericardial effusion for which he is monitored very
closely by cardiology (see above). Has had several epidoses of
concern for tamponade but ultimately had never had intervention.
# Pancytopenia
In the late ___ had needed periodic blood
transfusions. Anemia felt to be multifactorial in part related
to his lymphoma, treatment for lymphoma, renal dysfunction and
cardiac disease. Was switched to Aranesp the day prior to
admission. Platelet count 27, basline has been in ___. Felt to
be in large part related to his splenomegaly. H/H decreased from
admission; patient had reported black stools for some time, but
stools were guiac negative, and he has been taking iron
supplementation. Was hemodynamically stable. Should have H/H
followed at outpatient follow-up.
# HTN
Home metoprolol and lisinopril initially held at admission given
concern for tamponade, but restarted at discharge.
TRANSITIONAL ISSUES
- F/u H/H after discharge at scheduled appointments
- F/u with outpatient providers as scheduled |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
mold
Attending: ___
Chief Complaint:
Jaundice, weakness
Major Surgical or Invasive Procedure:
Transjugular liver biopsy
History of Present Illness:
___ F PMhx of HTN, cholelithiasis s/p cholecystectomy, obesity
s/p gastric bypass, 6mo of increasing fatigue, 4 months of SOB,
1wk of increasing jaundice who initially presented to ___,
found to have markedly elevated LFTs, now transferred to ___
for further management.
.
Per patient report, beginning 6mo prior to admission (___), patient began to notice increasing fatigue. She denies
associated fevers, cough, SOB, BRBPR/melena/darkstools.
.
However, beginning 4mo prior to admission (___) patient
began to notice ___ with walking to the grocery store, not
associated w chest pain, palpitatations; was seen by PCP
___ (___) with above problems, and per
patient report, had blood tests that were all normal. However,
DOE continued to progress so that she was unable to walk up a
flight of stairs or walk a block without becoming extremely SOB;
During this time she also noted increased lower extremity edema;
edema was progressive, started out as mild swelling of her feed,
and progressed to go as high as her knees. No associated PND,
palpitations, chest pain.
.
Additionally, patient also reports that for the 1month prior to
her admission, she began to note increasing gait instability;
she felt unsteady on her feet and no longer partook in
activities that required she leave the house. She denied
asssociated paresthesias, sensory/motor deficits, HA, visual
changes.
.
1wk prior to current presentation, patient noted increasing
yellowness of her skin, not associated with abdominal pain or
confusion. She also reports increasing facial sweling during
that time as well. On day of admission, patient saw her mother,
who was surprised by SOB and gait instability (they attempted to
go to the mall, and patient was unable to walk there without
holding onto the wall, became very short of breath), and she
insisted that she be evaluated by a doctor.
.
Patient presented to ___ for further evaluation, where she
was found to have labs significant for WBC 12.1(N77), HCT 23.5,
PLT 132, ALT/AST 140/392, AP 383, Alb 1.8, Tbili 9.4, Dbili 5.5,
INR 3.49, lactate 4.0. RUQ u/s reportedly demonstrated normal
ducts, heterogenous liver. Patient was given 1g CTX for empiric
SBP coverage and was transferred to ___ for further
evaluation.
.
In ___ ___, initial vital signs were 97.7 90 ___ 100%RA.
Exam was notable for icterus, 2+ pitting edema to ankles. Labs
were notable for WBC 11.6, Hct 25, Plt 141, INR 3.4, ALT/AST
147/415, AP380, Tbili 8.9, Alb 2.5, Lip11, Cr 1.1, Lactate 3.2,
neg Stox.
CXR demonstrated a normal heart size, no acute pulm process.
Case was discussed w Liver who recommended admission for further
workup. Vital signs prior to transfer were 98.2 90 100/52 18
98%RA. Access was 20g PIVx1.
.
On arrival to the floor, vital signs were 98.2 115/75 100 20
95%RA 99.8kg. Patient confirmed above story, also reported
change in urine color x 1 week. Denied tylenol or herbal
supplement usage, no new medications; reported drinking ___
drinks four times per week;
On review of systems she denied chills / nightsweats, headache,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena, dysuria,
hematuria.
Past Medical History:
- HTN
- Depression / Anxiety
- s/p gastric bypass
- s/p cholecystectomy
Social History:
___
Family History:
The patient's father had what was appraently alcoholic
cirrhosis. No family history of heart disease, early MI.
Physical Exam:
Admission physical exam:
VS: 98.2 115/75 100 20 95%RA 99.8kg
GENERAL: middle-aged female, edematous / obese
HEENT: +icterus, EOMI, PERRL, + periorbital edema, MMM
NECK: +JVD to ear
HEART: RRR, no MRG, loud S4
LUNGS: CTA bilat, no rhonchi/rales/wheezes
ABDOMEN: Obese, difficult to assess for fluid ___ habitus, but
typmanitic accross abdomen, +HSM, no rebound/guarding, no CVA
tenderness
RECTAL: guaiac pos brown stool
EXTREMITIES: WWP, 2+ edema to knees bilaterally, 2+ ___ pulses
SKIN: No rashes, palmar erythema, or spider hemangiomas
NEURO: AOx3, CNs II-XII wnl, proximal muscle weakness, sensation
to light touch and proprioception intact, rapid alternating
motions intact, heel-shin intact, finger-nose finger intact, no
pronator drift, + short, staggering gait (unable to assess
further given concern for fall).
Discharge Exam:
VSS
Still mild facial asymmetry, with mild periorbital edema
Heart regular
Lungs clear
Abd soft, nontender, obese, no ascites appreciated
Ext: 2+ edema R>L
Pertinent Results:
ADMISSION LABS:
___ 08:00PM BLOOD WBC-11.6*# RBC-2.73*# Hgb-7.6*#
Hct-25.0*# MCV-92# MCH-27.7# MCHC-30.2* RDW-20.1* Plt ___
___ 08:00PM BLOOD ___ PTT-45.2* ___
___ 08:00PM BLOOD Glucose-70 UreaN-8 Creat-1.1 Na-133 K-4.1
Cl-98 HCO3-23 AnGap-16
___ 08:00PM BLOOD ALT-147* AST-415* AlkPhos-380*
TotBili-8.9*
___ 05:35AM BLOOD Calcium-7.8* Phos-1.8* Mg-1.8
DISCHARGE LABS:
___ 07:27AM BLOOD WBC-13.1* RBC-3.24* Hgb-9.1* Hct-31.6*
MCV-98 MCH-28.1 MCHC-28.7* RDW-20.6* Plt ___
___ 07:27AM BLOOD ___ PTT-58.9* ___
___ 07:27AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-139
K-3.6 Cl-103 HCO3-25 AnGap-15
___ 07:27AM BLOOD ALT-89* AST-148* LD(LDH)-632*
AlkPhos-269* TotBili-8.5*
___ 07:27AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
OTHER LABS:
___ 06:00AM BLOOD ESR-60*
___ 05:40AM BLOOD Ret Aut-4.6*
___ 08:00PM BLOOD calTIBC-90* Ferritn-2166* TRF-69*
___ 05:35AM BLOOD ___ Folate-3.9 Hapto-28*
___ 05:40AM BLOOD ___ Ferritn-1037*
___ 05:45AM BLOOD TSH-5.1*
___ 05:45AM BLOOD T4-2.7*
___ 08:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 05:35AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 06:00AM BLOOD ___ Titer-1:640 PAT
Cntromr-NEGATIVE
___ 06:00AM BLOOD dsDNA-NEGATIVE
___ 06:00AM BLOOD RheuFac-13 CRP-27.0*
___ 05:45AM BLOOD AFP-1.0
___ 05:45AM BLOOD IgG-___*
___ 05:40AM BLOOD C3-83* C4-23
___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:00PM BLOOD HCV Ab-NEGATIVE
___ 05:58AM BLOOD ERYTHROPOIETIN-Test
___ 06:00AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 05:45AM BLOOD HEREDITARY HEMOCHROMATOSIS MUTATION
ANALYSIS-Test
___ 12:42AM BLOOD CERULOPLASMIN-Test
Liver US:
IMPRESSION:
1. Extremely limited study due to patient body habitus. The
portal vein and
hepatic veins were not identified. Multiphasic CT or MRI is
recommended for
evaluation of intrahepatic vasculature. Findings were discussed
with Dr.
___ on ___ at 12:08.
2. Limited views of the spleen and both kidneys appear normal.
3. Trace ascites.
Liver Bx:
DIAGNOSIS:
Liver, needle core biopsy:
1. Established cirrhosis with prominent sinusoidal fibrosis.
Trichrome stain evaluated.
2. Severe, predominantly macrovesicular steatosis.
3. Frequent cells with balloon cell degeneration and
intracytoplasmic hyaline.
4. Mild septal inflammation with prominent neutrophils and
associated bile duct proliferation, which is likely related to
cirrhosis.
5. Iron stain shows focal minimal iron deposition in Kupffer
cells.
Note: The findings are consistent with toxic/metabolic injury.
Findings were discussed with Dr. ___ by Dr. ___ on ___.
CT face/neck/chest:
IMPRESSION:
1. No evidence of stenosis, occlusion or aneurysm in arteries
of neck.
2. No evidence of superior vena cava obstruction.
3. Mild dilatation of main pulmonary artery.
4. Defect in the floor and medial wall of the left orbit with
herniation of
the orbital fat into the left maxillary sinus. This is of
unknown chronicity
and may be post-traumatic or congenital.
CT chest:
IMPRESSION: Multifocal, panlobular ground-glass opacities that
are seen mainly in the periphery of the lungs and are more
prominent in the upper portions of the lungs. No evidence of
lung parenchymal architectural distortion.
These findings are nonspecific with broad differential that
includes infectious or inflammatory processes (such as COP),
hypersensitivity pneumonitis or vascular diseases.
Medications on Admission:
- HCTZ 25mg daily
- metoprolol succ 100mg daily
- omeprazole 20mg daily
- Ativan prn
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
7. Ensure Plus 0.05-1.5 gram-kcal/mL Liquid Sig: One (1) bottle
PO three times a day.
Disp:*90 bottles* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic cirrhosis
Anemia
Elevated ___
___ 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
ULTRASOUND DUPLEX DOPPLER DATED ___
INDICATION: ___ woman with worsening liver function, ? evidence of
portal vein thrombosis or other liver pathology.
COMPARISON: No previous studies available for comparison.
FINDINGS: The study is extremely limited due to patient's body habitus and
poor penetration. The visualized portions of the liver appear diffusely
echogenic. No focal liver lesions are identified on limited scanning. The
common bile duct could not be visualized. No definite intra- or extra-hepatic
duct dilation was identified. The gallbladder was not visualized. The spleen
is normal in size measuring 12.2 cm. The pancreas is not visualized. The
limited views of both kidneys appear normal without evidence of hydronephrosis
or large renal lesion. Trace perihepatic and perisplenic ascites.
DUPLEX ULTRASOUND:
Grayscale and color Doppler images were performed of the liver.
The main hepatic artery, right hepatic artery, and left hepatic artery are
patent. The main portal vein, left portal vein, and right portal vein could
not be visualized. The hepatic veins could not be visualized.
IMPRESSION:
1. Extremely limited study due to patient body habitus. The portal vein and
hepatic veins were not identified. Multiphasic CT or MRI is recommended for
evaluation of intrahepatic vasculature. Findings were discussed with Dr.
___ on ___ at 12:08.
2. Limited views of the spleen and both kidneys appear normal.
3. Trace ascites.
Radiology Report
TRANSJUGULAR LIVER BIOPSY
INDICATION: ___ woman with liver dysfunction, elevated INR.
OPERATORS: Drs. ___ (fellow), ___ (resident) and ___
___ (attending physician). Dr. ___ was present during key moments of the
procedure.
SEDATION: Moderate sedation in divided doses of intravenous ___ mcg fentanyl
and 2.5 mg of Versed over 50 minutes, during which patient's hemodynamic
status was continuously monitored by a trained radiology nurse.
PROCEDURE AND FINDINGS: Consent was obtained from the patient after
explaining the benefits, risks, and alternatives. The patient was placed
supine on the imaging table in the interventional suite. Timeout was
performed as per ___ protocol.
Under aseptic conditions, sonographic guidance, and after infiltrating the
skin and subcutaneous tissues with 1% lidocaine, a micropuncture needle was
placed in the patent right internal jugular vein. A 0.018 wire was advanced
through the needle and into the SVC. After making an incision, needle was
exchanged for a 4 ___ microsheath. Inner cannula and wire were removed to
place a 0.035 ___ wire, which was advanced into the IVC. After removing the
microsheath, the tract was dilated under fluoroscopy with a ___ dilator.
A ___ long ___ sheath was then placed over the wire and advanced
into the IVC. After removing the inner cannula, the sidearm was aspirated and
flushed. A trimmed 5 ___ C2 catheter was placed within the sheath and
advanced into the IVC. After retracting the ___ sheath to the right
atrium, the ___ wire was with a 0.035 angled Glidewire. Catheter-Glidewire
combination was then used to access the middle hepatic vein. The Glidewire
was then replaced with ___ wire, which was advanced into the middle hepatic
vein. The ___ sheath was then advanced into the middle hepatic vein.
Some sterile contrast material was injected into the catheter to confirm its
position within the middle hepatic vein (in AP and lateral projections). The
C2 catheter was then removed over the ___ wire to place the curved sheath
metallic cannula (mamba), which was advanced into the middle hepatic vein just
distal to the outer sheath tip. After removing the wire, a semi-automatic
biopsy needle was placed within the metallic cannula to obtain three passes of
core samples of liver tissue. After removing the needle and curved metallic
cannula, the outer sheath was removed over the ___ wire. Firm pressure was
applied to the venotomy site for about 15 minutes to achieve complete
hemostasis. Site was dressed in a sterile fashion. Liver tissue samples were
sent for laboratory analysis. Patient tolerated the procedure well and no
immediate post-procedure complication was seen.
IMPRESSION: Uncomplicated transjugular liver biopsy from the middle hepatic
vein. Three cores of liver tissue samples were obtained, which were sent for
analysis.
Radiology Report
CLINICAL HISTORY: ___ woman with new cirrhosis, asymmetrical swelling
of the right side of her face. Patient has history of smoking.
STUDY: CTA neck with contrast.
COMPARISON STUDY: None.
TECHNIQUE: Contiguous axial CT images were obtained from the aortic arch to
the skull base during intravenous administration of contrast. The images were
processed on a separate workstation with display of curved reformats, 3D
volume-rendered images and maximum intensity projection images.
FINDINGS: There is common origin of the brachiocephalic artery and the left
common carotid artery. The aortic arch and the origin of the great vessels
appear normal.
Bilateral common carotid arteries appear normal.
Calcified plaques are noted at the right common carotid bifurcation and the
proximal right internal carotid artery without significant stenosis.
Bilateral internal and external carotid arteries are patent.
The right proximal and distal internal carotid artery measure 7.4 and 4.3 mm
respectively. The left proximal and distal internal carotid artery measure
7.4 and 4.2 mm respectively.
Bilateral vertebral arteries are patent.
There is no evidence of stenosis, occlusion or aneurysm in arteries of neck.
There is dilatation of main pulmonary artery. There is no evidence of superior
vena cava obstruction.
Patchy ground glass opacities are noted in bilateral lung apices with mild
pleural thickening along right lung apex.
Defect is noted in the floor and medial of the left orbit with herniation of
the intraorbital fat into the left maxillary sinus. The visualized soft
tissues of the neck are unremarkable.
IMPRESSION:
1. No evidence of stenosis, occlusion or aneurysm in arteries of neck.
2. No evidence of superior vena cava obstruction.
3. Mild dilatation of main pulmonary artery.
4. Defect in the floor and medial wall of the left orbit with herniation of
the orbital fat into the left maxillary sinus. This is of unknown chronicity
and may be post-traumatic or congenital.
Radiology Report
INDICATION: ___ woman with probable consolidation seen in the upper
lobe on CT neck, evaluate extensive consolidation.
COMPARISONS: PA and lateral chest radiographs from ___ ER CTA of
the neck from ___.
FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax.
Cardiomediastinal silhoutte is unremarkable. Lung volumes are low. There are
no acute skeletal abnormalities.
IMPRESSION: No evidence of focal consolidation.
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ patient with ground-glass
opacities that were seen on prior CT of the neck. The patient presents with
new cirrhosis and DOE. The request is to further evaluate the opacities.
COMPARISON: Prior CT examination from ___.
TECHNIQUE: CT of the chest with IV contrast administration. Coronal and
sagittal reformations were made.
TOTAL EXAM DLP: 536.14 mGy-cm.
FINDINGS:
CHEST: Thyroid gland is within normal limits.
The heart is mildly enlarged. Calcifications are seen in the aortic valve.
No pericardial effusion is seen. The pulmonary artery is within normal
limits. No pulmonary emboli are identified (though this examination is not a
PE dedicated study). The airways are patent and of normal in caliber.
Reidentified are panlobular patchy ground-glass opacities that are seen mainly
in the periphery of the lungs.
No lung architectural abnormalities are seen. In comparison to the visualized
lung fields that were seen on prior examination from ___, these
findings are grossly unchanged. Subsegmental atelectases are seen in the
lower lobes of the lungs. No evidence of consolidation, pulmonary nodules or
pleural effusion.
Few prominent bilateral axillary lymph nodes are identified.
ABDOMEN: The patient is status post cholecystectomy and gastric bypass
surgery. The liver demonstrates significant hypoattenuation which is
consistent with liver steatosis. The spleen, visualized portion of pancreas,
visualized portion of the kidneys, both adrenals are unremarkable.
OSSEOUS STRUCTURES: No concerning lytic or osteoblastic lesions are seen.
IMPRESSION: Multifocal, panlobular ground-glass opacities that are seen
mainly in the periphery of the lungs and are more prominent in the upper
portions of the lungs. No evidence of lung parenchymal architectural
distortion.
These findings are nonspecific with broad differential that includes
infectious or inflammatory processes (such as COP), hypersensitivity
pneumonitis or vascular diseases.
Gender: F
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: WEAKNESS FOR MONTHS
Diagnosed with JAUNDICE NOS, OTHER MALAISE AND FATIGUE, HYPERTENSION NOS
temperature: 97.7
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 101.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | ___ yo F with history of HTN, cholelithiasis s/p cholecystectomy,
obesity s/p gastric bypass, who presents with fatigue and
jaundice diagnosed with alcoholic cirrhosis.
.
1. Alcoholic Cirrhosis: The patient presented with AST>ALT and
tbili 9.0. Based on history, serologies, and liver biopsy, the
diagnosis of alcoholic cirrhosis was made. The patient had only
trace ascites, no encephalopathy, and no other chronic stigmata
of liver disease. The patient had negative hepatitis serologies,
negative smooth muscle, negative AMA, negative iron stain, and
negative ceruloplasmin. The patient did have a positive ___ with
high titer, but liver biopsy did not show evidence of autoimmune
hepatitis. The patient was started on prednisone 40mg for acute
alcoholic hepatitis. The patient will continue the prednisone
for 30 days with a two week taper after that. The patient was
educated about the necessity of abstaining from alcohol,
maintaining her nutrition, and taking her medications as
prescribed. The patient was set up with follow up in the liver
clinic.
.
2. Anemia: The patient's Hct ranged from ___ on this
admission. She had no evidence of occult bleeding. Iron studies
were performed that were most consistent with anemia of chronic
inflammation. Her reticulocyte index was slightly low for her
level of anemia. Hemolysis labs were positive, but Coombs was
negative. Hematology was consulted who believed that the patient
had bone marrow suppression from alcohol abuse in the setting of
baseline microcytic anemia. An EPO level was sent that returned
normal. The patient was transfused one unit of blood during her
stay and responded appropriately to the transfusion. Her Hct on
discharge was 31, however, her baseline is closer to ___.
3. Positive ___: The patient had a positive ___ with 1:640 titer
during workup for autoimmune hepatitis. Rheumatology was
consulted. Other serologies were sent including dsDNA,
centromere, that returned negative. CK and muscle enzymes were
negative as well. The patient also endorsed weight loss (see
below). Rheumatology only recommended followup in clinic and no
further acute management.
4. Unsteady gait: Patient with proximal muscle weakness of both
upper and lower extremity on admission, with gait that reflects
this weakness. Patient also with slight sensory loss in
stocking/glove pattern, likely from alcohol v nutritional
deficiency given gastric bypass. CK normal. B12, folate normal.
Patient worked with Physical Therapy, who agreed with home
discharge.
.
5. Weight loss: Pt notes unintentional 50 pound weight loss over
a few months. The most likely diagnosis is poor nutritional
intake. CT neck/chest did not show Pancoast or SVC syndrome. TSH
c/w hypothyroidism, though in setting of acute illness, so
levothyroxine not started. The patient also had elevated ACE
level and ground glass opacities on chest CT, concerning for
sarcoid. The patient will f/u with rheumatology and her PCP.
.
6. HTN: Discharged on home metoprolol.
.
7. GERD: Continued home omeprazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache x2
Major Surgical or Invasive Procedure:
___ Right Craniotomy for Subdural Hematoma Evacuation
History of Present Illness:
___ y/o male on daily 81mg of ASA, who fell a month ago
striking his head, no LOC. He was doing well after this until 2
days ago when he developed a sudden headache that would not
subside. He presented to an OSH were a CT of the head was
obtained and showed a large acute on chronic SDH with 17mm MLS
and vasogenic edema. He was then transferred here to ___ for
further work up. The patient endorses headache, and nausea,
denies, blurred vision, vomiting, or dizziness.
Past Medical History:
HTN, HLD, MI, Gastric bypass, DM prior to weight loss.
Social History:
___
Family History:
NC
Physical Exam:
Upon admission:
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. No abnormal movements,
tremors. Strength full power ___ to right side, slight pronator
on the left, LUE 4+/5, and LLE Quad/Ham 4+/5 ___ ___.
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Upon discharge:
Alert & Oriented x3
PERRL
Face symmetric
Tongue midline
No pronator drift
___ strength throughout
Incision c/d/i closed with staples
Pertinent Results:
___ CT head
1. Interval decrease in a large right sided subdural fluid
collection status post catheter placement. Leftward shift of
normally midline structures is improved as described above. No
new hemorrhage or infarction is detected
Medications on Admission:
Atenolol 50mg QD, pravastatin 40mg QD, lisinopril 40mg QD,
amlodipine 7.5mg QD, ranitidine 75mg QHS, calcium citrate,
aspirin 81mg
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Amlodipine 7.5 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*8 Tablet Refills:*0
6. Lisinopril 40 mg PO DAILY
7. Pravastatin 40 mg PO QPM
8. Ranitidine 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with w acute on chronic right SDH w MLS, s/p R
crani for evacuation of hematoma. please evaluate post operative changes.
Please obtain by 10 pm. // ___ year old man with w acute on chronic right SDH w
MLS, s/p R crani for evacuation of hematoma. please evaluate post operative
changes. Please obtain by 10 pm.
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: This study involved 3 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 18.0 s, 18.7 cm; CTDIvol = 53.6 mGy (Head) DLP = 1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CT head performed at an outside institution on ___
FINDINGS:
Compared to the most recent prior examination, there has been interval
drainage of a the right subdural hematoma. The hematoma is smaller than on
the prior examination and measures 1.9 cm at its widest diameter (previously
2.5 cm). There is 7 mm of leftward shift of normally midline structures which
is improved from the prior study when midline shift measure 1.4 cm. There is
no evidence of new hemorrhage or of infarction. Mixed density fluid within
the subdural collection likely represents blood products of varying ages.
There is high-density blood around the catheter, likely related to recent
intervention.
IMPRESSION:
1. Interval decrease in a large right sided subdural fluid collection status
post catheter placement. Leftward shift of normally midline structures is
improved as described above. No new hemorrhage or infarction is detected
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: AMS
Diagnosed with SUBDURAL HEMORRHAGE, OTHER FALL, LONG TERM(CURRENT) USE ANTIPLATE/ANTITHROMB.
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ y/o male who was found to have a large right acute on chronic
SDH.Patient recieved 1 gram of Keppra in ED. He was prepped for
urgent OR for ___ evacuation. He was given 1 pack of platelets
prior to the OR. He underwent Right Craniotomy for ___
evacuation. He was extubated in the OR. He was transferred to
the ICU post operatively. A subdural drain was left in place.
On ___ Patient was neurologically intact. Subdural drain
remained in place with high output. His diet was advanced.
On ___ Patient was neurologically intact. Tolerating advanced
diet. Subdural drain was pulled after SQH was held. Suture was
tied down at drain site. Patient was mobilizing independently.
He was transferred from the ICU to the floor.
On ___ Patient's pain was well controlled. He was tolerating a
diet and ambulating independently. He was discharged home with
instructions for follow up. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / erythromycin base
Attending: ___
Chief Complaint:
L arm numbness
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Mr. ___ is a pleasant right-handed ___ man with
___ Syndrome (migraine-like headaches, focal neurologic
deficits, and CSF abnormalities) on verapamil and ?sarcoid
presents with subacute left hand/arm/ear numbness. He was sent
in by Dr. ___ evaluation.
He was last seen by Dr. ___ on ___ for follow-up of
___ Syndrome with visual symptoms. He initially presented
___ with visual symptoms that occurred more than
several times per day. He also had blinding headaches when he
was young between ages ___, which has since subsided. There
was also a question of sarcoid in his late ___ but he did not
have any treatment. ?repeat workup did not show anything in his
lungs. Had several of these episodes even before presentation in
his late ___ while traveling to ___. This
responded to verapamil, and symptoms subsided for ___ months.
They came back in two forms:
1. Speck that starts out on the left and grows in an arc-like
fashion (like the ___ logo) over to the left in a prismatic
fashion, expands, then flutters and blocks out L sided vision,
occur once per week sometimes followed by headache, last
___
2. R eye visual changes where he gets flickering linear light,
lasts ___, like he is being blinded by bright areas vs like
when one stands up too quickly, but this is not associated with
position change
3. L ear, torso, L arm numbness/clumsiness that did stop with
verapamil but is now back and progressively getting worse
On exam in ___, there was no visual field defect, cranial
nerves intact, +clumsiness in L arm and RAM/slowness in finger
to nose movements, LUE reflexes brisker than R. He had stopped
the verapamil prior to this visit and restarted it at 240mg with
ASA 325mg afterwards. He did not start the aspirin but has been
taking the verapamil.
He presents today because the numbness in his left arm has been
progressively getting worse since his MRI at ___
___ two weeks ago. This was reviewed by Dr. ___ told
the patient that there were more lesions seen. Initially, his
numbness only involved his middle, ring, and pinky fingers. Now
it involves both his index finger and thumb. The numbness is
circumferential and constant, and his dexterity is also
diminished. He is having trouble tying his ties and buttoning
shirts. He has not slept on his left arm or left it in one
position over a long period of time, no trauma to the arm.
He also reports the left side of his lips tingling like they are
about to go numb but are not numb yet. Left ear is numb as is
the area behind his left ear, neck is spared. He also reports
that he could be looking for something on his left but is unable
to see it but knows it is there because he would turn his head
more so he could see it with his right eye immediately. It is
like the sensation of knowing something is there but unable to
see it. Has baseline spot in his left eye that he cannot see.
Past Medical History:
___ Syndrome (no CSF in BI OMR, diagnosed by Dr. ___,
?sarcoid
Social History:
___
Family History:
no family history of stroke or blood clots
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___ ED,
___. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Speech is fluent
with full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. No dysarthria.
Normal prosody. No evidence of hemineglect. No left-right
confusion. Able to follow both midline and appendicular
commands.
- Cranial Nerves: L pupil 4mm->3mm, R pupil 3->2, VF full to
number counting, optic discs crisp bilaterally. EOMI but pt
reports diplopia on far left gaze that does not improve with
distance. Inside image disappears when he looks to the left with
left eye closed. No nystagmus. V1-V3 without deficits to light
touch, pin, or temperature bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor: Normal bulk and tone. LUE drift with pronation. No
tremor or asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 2+ 1
R 2+ 2+ 2+ 2+ 1
- Sensory: Decreased sensation to light touch and pin over left
ear and just behind the left ear, spares neck. Decreased light
touch and pin in entire left upper extremity circumferentially
to over the shoulder. Medial forearm seems to have more
sensation than lateral forearm but upper arm is entirely the
same decreased sensation. No finger proprioception in left pinky
all the way to the wrist, makes many mistakes when
proprioception tested in left index finger but is better than
left pinky finger. Sensation intact to LT, pin, temperature, and
proprioception elsewhere. There is no spinal level.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Decreased speed with rapid alternating movements in
LUE, LUE clumsy with trouble touching each individual finger to
thumb.
- Gait: deferred
DISCHARGE PHYSICAL EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
- Mental status: Awake, alert, oriented to person, place, date.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
No left-right confusion. Able to follow both midline and
appendicular commands. No evidence of apraxia or neglect.
- Cranial Nerves: Slight anisocoria w/ L 4mm->3mm, R 3mm->2mm,
VF full to number counting. EOMI, reports horizontal diplopia in
primary gaze and both R and L gaze, binocular with inside image
improving with L eye closed, improved with distance. V1-V3
without deficits to light touch, pin, or temperature
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. Slight LUE drift and pronation.
No tremor or asterixis. Strength full throughout UEs and ___
___.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 2+ 1
R 2+ 2+ 2+ 2+ 1
- Sensory: Decreased sensation to light touch and pin over left
ear and LUE, more prominent in medial hand near ___ digit. Lack
of proprioception throughout LUE, more prominent medially.
Otherwise, sensation intact to LT, PP and proprioception
throughout other extremities.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Dysdiadochokinesia noted in LUE w/ decreased speed
of RAM. Decreased finger tap on L.
- Gait: deferred
Pertinent Results:
___ 05:45AM BLOOD WBC-7.9 RBC-5.07 Hgb-16.6 Hct-46.7 MCV-92
MCH-32.7* MCHC-35.5 RDW-13.5 RDWSD-45.8 Plt ___
___ 02:40PM BLOOD WBC-7.4 RBC-4.94 Hgb-16.2 Hct-45.1 MCV-91
MCH-32.8* MCHC-35.9 RDW-13.2 RDWSD-45.1 Plt ___
___ 05:45AM BLOOD ___ PTT-28.0 ___
___ 05:45AM BLOOD Lupus-NEG
___ 05:45AM BLOOD Glucose-83 UreaN-10 Creat-0.8 Na-140
K-3.8 Cl-102 HCO3-23 AnGap-19
___ 02:40PM BLOOD Glucose-100 UreaN-11 Creat-0.8 Na-140
K-4.3 Cl-106 HCO3-21* AnGap-17
___ 02:40PM BLOOD ALT-36 AST-31 AlkPhos-86 TotBili-0.8
___ 02:40PM BLOOD cTropnT-<0.01
___ 05:10AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
___ 02:40PM BLOOD Albumin-4.2 Cholest-191
___ 02:40PM BLOOD Triglyc-170* HDL-55 CHOL/HD-3.5
LDLcalc-102
___ 02:40PM BLOOD TSH-0.96
___ 02:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:12PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-0 Polys-PND
Lymphs-PND Monos-PND
___
1. Late acute to subacute infarcts superimposed on chronic
infarcts in the right perrolandic region. No acute hemorrhagic
transformation. Given repeated infarcts within this region
dating back to ___, embolic source is considered highly
unlikely. This may represent inflammatory etiology or
potentially migrainous component although this typically affects
the posterior circulation. Vasculitis and vasospasm is
consideration although as noted below MRA of the head and neck
is unremarkable. No evidence of vascular malformation.
2. Unremarkable head and neck MRA.
___
Normal global and regional biventricular systolic function. No
ASD, PFO or LV thrombus seen.
___ C-Spine w/ and w/o
1. No abnormal cord signal on pre or postcontrast images.
2. Multilevel degenerative changes, worst at C6-7 where
posterior disc bulge
more prominent on the right causes mild canal narrowing and
moderate right
neural foraminal narrowing. There is also moderate left neural
foraminal
narrowing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 240 mg PO Q24H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Verapamil SR 360 mg PO Q24H
RX *verapamil 360 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
subacute infarcts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old man with ?sarcoid who presents with LUE
weakness/numbness// ?sarcoid vs pancoast tumor vs something compression on L
brachial plexus area
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
A few scattered areas of linear atelectasis/scarring are seen, particularly at
the left mid to lower lung. No definite focal consolidation is seen. No
pleural effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable. LINQ device is seen overlying the left
hemithorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with LUE weakness/numbness, please obtain images
with contrast as the differential is quite broad at this time// ?stroke vs
demyelinating process
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 18 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique. Postcontrast axial T1 and MP-RAGE sequences also
performed. Coronal and axial MP-RAGE reformats obtained.
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: ___ brain MRI/MRA and neck MRA
FINDINGS:
MRI BRAIN:
There is encephalomalacia and gliosis in the right MCA/PCA watershed zone and
right perirolandic region, consistent with a chronic infarcts dating back to ___. Superimposed on these areas are multiple foci of slow
diffusion with associated FLAIR hyperintense signal, some which demonstrate
associated enhancement, compatible with infarcts ranging from late acute to
subacute. The regions of chronic infarct demonstrates subtle T1 hyperintense
gyriform signal compatible with cortical laminar necrosis/mineralization.
There is no evidence of hemorrhage, mass, or mass effect. The ventricles and
sulci are age-appropriate and there is no hydrocephalus. Principal
intracranial vascular flow voids are preserved. The dural venous sinuses are
patent on postcontrast MP-RAGE. There is a mucous retention cyst in the left
maxillary sinus and there is mucosal thickening in the anterior ethmoid air
cells.
MRA BRAIN:
The intracranial vertebral and internal carotid arteries and their major
branches appear normal without evidence of stenosis, occlusion, or aneurysm
formation.
MRA NECK:
The common, internal and external carotid arteries appear normal. There is no
evidence of internal carotid artery stenosis by NASCET criteria. The origins
of the great vessels, subclavian and vertebral arteries appear normal
bilaterally. The vertebral arteries are patent.
IMPRESSION:
1. Late acute to subacute infarcts superimposed on chronic infarcts in the
right perrolandic region. No acute hemorrhagic transformation. Given
repeated infarcts within this region dating back to ___, embolic source is
considered highly unlikely. This may represent inflammatory etiology or
potentially migrainous component although this typically affects the posterior
circulation. Vasculitis and vasospasm is consideration although as noted
below MRA of the head and neck is unremarkable. No evidence of vascular
malformation.
2. Unremarkable head and neck MRA.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:34 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old man with left arm numbness and rare
inflammatory/stroke syndrome// ?radic ?inflammatory ___ disease
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. After administration
of 10 mL of Gadavist intravenous contrast, sagittal and axial T1 weighted
imaging was performed.
COMPARISON: CT ___ from ___ obtained at outside facility.
FINDINGS:
Cervical alignment is anatomic. Vertebral body heights are preserved. Mixed
___ type 1 and 2 C6-C7 endplate changes are identified, corresponding to
endplate sclerosis seen on prior CTA of ___. There is no suspicious
marrow lesion. Degenerative loss of disc height and signal is mild at C5-C6
and C6-C7. The visualized posterior fossa is unremarkable. There is no
abnormal signal or enhancement of the visualized cord. There is no evidence
of infection or neoplasm. There is no abnormal enhancement on postcontrast
images.
C2-3: No significant canal or neural foraminal narrowing.
C3-4: A small posterior disc protrusion causes negligible canal and minimal
right neural foraminal narrowing.
C4-5: A small posterior disc protrusion causes minimal canal narrowing and
mild right neural foraminal narrowing.
C5-6: A small posterior disc protrusion causes mild canal narrowing and
moderate right neural foraminal narrowing.
C6-7: A posterior disc protrusion more prominent on the right causes mild
canal narrowing with deformity of the thecal sac but does not contact cord.
There is moderate right neural foraminal narrowing secondary to the disc
bulge. There is also moderate left neural foraminal narrowing.
C7-T1: No significant canal or neural foraminal narrowing.
Visualized prevertebral and paraspinal soft tissues are unremarkable.
IMPRESSION:
1. No abnormal cord signal on pre or postcontrast images.
2. Multilevel degenerative changes, worst at C6-7 where posterior disc bulge
more prominent on the right causes mild canal narrowing and moderate right
neural foraminal narrowing. There is also moderate left neural foraminal
narrowing.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Hand numbness
Diagnosed with Weakness, Anesthesia of skin
temperature: 98.7
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 154.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | Pt is a ___ man who presented with subacute LUE numbness and
decreased coordination that has been worsening recently;
admitted for expedited workup to Stroke Service. He was
monitored on telemetry and continued on his home Verapamil and
Aspirin therapy. He underwent MRI/MRA Brain which showed
subacute on chronic infarcts in R perirolandic and watershed
region between PCA and MCA of unclear origin, similar to
infarcts seen on previous MRIs and suggesting a predilection for
ischemia in these areas over a span of time. Echocardiogram was
performed without abnormalities. Patient also underwent MRI
C-Spine with some minor cervical spondylosis but no acute
findings. He underwent lumbar puncture on ___ with no
pleocytosis seen on basic CSF studies and other studies pending
at time of discharge. Prior to discharge, his home Verapamil was
increased from 240mg to 360mg for attempt at better control of
potential vasospasm producing pt's infarcts and resultant
symptoms. He was started on low dose statin due to slightly
elevated LDL>100 seen on vascular risk factor workup. He
appeared clinically stable throughout admission and was
discharged home the same day due to pt not wanting to stay in
the hospital for further diagnostic and therapeutic
intervention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
amoxicillin
Attending: ___
___ Complaint:
Feculent drainage following I&D of colocutaneous fistula site
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman who was diagnosed with
Crohn's ileocolitis in ___ for which she has received several
medication regimens who presents 1 week status post incision and
drainage of a back abscess that for the past day has been
draining brown, feculent output. She states that one week ago
she developed a lump on her back (at approximately T10-T12 area)
that she thought was a pulled muscle. She subsequently went to
the emergency department at ___, where she was diagnosed
with an abscess and underwent incision and drainage. A wick was
placed at that time. She went for follow-up, and the wick was
removed 2 days ago. Then, the next day (___) at 9 ___
the character of the drainage, which had previously been milky
white/yellow changed to light to dark brown and was feculent
smelling. Therefore, she presented to the emergency department.
She denies fevers, chills, chest pain, shortness of breath,
nausea, vomiting, abdominal pain, changes to bowel function.
Ultimately, she reports that she feels otherwise well.
Past Medical History:
Past Medical History:
Crohn's disease
Iron deficiency anemia
Past surgical history:
___ Bedside incision and drainage of back abscess
Social History:
___
Family History:
Mother with juvenile arthritis
First cousin with ulcerative colitis
Physical Exam:
Discharge Physical Exam:
Temperature 99.3, heart rate 104, blood pressure 111/72,
respiratory rate 18, pulse ox 96% on room air
Gen: Underweight
CV: Mildly tachycardic otherwise regular rhythm
Resp: Comfortable on room air
GI: Soft nontender nondistended
Back: Crosshatch incision draining minimal thick yellow output.
No evidence of cellulitis.
Rectal: No evidence of fistula disease, no drainage, normal anal
tone, skin tag x1
Extremities: wwp
Pertinent Results:
___ 05:39AM BLOOD WBC-8.6 RBC-3.54* Hgb-8.8* Hct-30.9*
MCV-87 MCH-24.9* MCHC-28.5* RDW-15.2 RDWSD-48.2* Plt ___
___ 06:40AM BLOOD WBC-8.4 RBC-3.42* Hgb-8.5* Hct-29.5*
MCV-86 MCH-24.9* MCHC-28.8* RDW-14.9 RDWSD-47.0* Plt ___
___ 06:50AM BLOOD WBC-9.3 RBC-3.60* Hgb-8.8* Hct-30.8*
MCV-86 MCH-24.4* MCHC-28.6* RDW-14.9 RDWSD-46.5* Plt ___
___ 01:35AM BLOOD WBC-13.3* RBC-4.16 Hgb-10.3* Hct-35.2
MCV-85 MCH-24.8* MCHC-29.3* RDW-15.1 RDWSD-46.5* Plt ___
___ 01:35AM BLOOD Neuts-87.8* Lymphs-7.1* Monos-3.8*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.69* AbsLymp-0.95*
AbsMono-0.51 AbsEos-0.03* AbsBaso-0.03
___ 08:45AM BLOOD Glucose-87 UreaN-12 Creat-0.4 Na-142
K-4.3 Cl-107 HCO3-25 AnGap-10
___ 04:55AM BLOOD Glucose-1274* UreaN-10 Creat-0.5 Na-131*
K-7.3* Cl-97 HCO3-20* AnGap-14
___ 04:57AM BLOOD Glucose-126* UreaN-9 Creat-0.4 Na-141
K-3.7 Cl-108 HCO3-23 AnGap-10
___ 05:39AM BLOOD Glucose-102* UreaN-8 Creat-0.4 Na-139
K-4.1 Cl-104 HCO3-22 AnGap-13
___ 06:40AM BLOOD Glucose-170* UreaN-9 Creat-0.4 Na-136
K-4.2 Cl-104 HCO3-24 AnGap-8*
___ 06:50AM BLOOD Glucose-120* UreaN-9 Creat-0.5 Na-138
K-4.0 Cl-105 HCO3-23 AnGap-10
___ 01:35AM BLOOD Glucose-95 UreaN-20 Creat-0.6 Na-139
K-4.3 Cl-98 HCO3-26 AnGap-15
___ 05:39AM BLOOD ALT-10 AST-11 AlkPhos-70 TotBili-<0.2
___ 08:45AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.1
___ 04:55AM BLOOD Calcium-8.9 Phos-6.8* Mg-2.2
___ 04:57AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
___ 05:39AM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.5 Mg-2.1
Iron-24*
___ 06:40AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.3
___ 06:50AM BLOOD Albumin-3.3* Calcium-8.2* Phos-4.0 Mg-2.3
Iron-34
___ 01:35AM BLOOD Albumin-3.8
___ 05:39AM BLOOD calTIBC-243* VitB12-417 Ferritn-29
TRF-187*
___ 06:50AM BLOOD calTIBC-234* Ferritn-42 TRF-180*
___:39AM BLOOD Triglyc-151*
___ 06:50AM BLOOD Triglyc-204*
___ 05:39AM BLOOD 25VitD-29*
___ 05:39AM BLOOD CRP-5.9*
Medications on Admission:
(Stelara)
Prednisone 20mg Daily
Discharge Medications:
1. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
RX *ertapenem 1 gram 1 gram IV once a day Disp #*6 Vial
Refills:*0
2. PredniSONE 10 mg PO DAILY
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
3.Outpatient Lab Work
Labs to be drawn on ___ LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___. ERTAPEMEN: WEEKLY:
CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS, CRP.
TPN labs:Albumin, Phosphate, BUN, Calcium, Bicarbonate,
Chloride, Creatinine, Glucose Sodium , Potassium, Total
Bilirubin and Protein, LFTs
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Crohn's disease
Colocutaneous fistula
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: NO_PO contrast; History: ___ with chrons with abscess that is
draining brown, milky, malodorous fluid s/p I+DNO_PO contrast// ?possible
fistula in the low thoracic upper lumbar region to a skin abscess that is open
and draining odorous brown fluid
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 7.2 mGy (Body) DLP = 3.6
mGy-cm.
2) Spiral Acquisition 6.0 s, 47.6 cm; CTDIvol = 7.9 mGy (Body) DLP = 375.6
mGy-cm.
Total DLP (Body) = 379 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
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 contracted without
evidence of gallstones
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. A 1.8 cm splenule is incidentally noted.
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: There is extensive ileal, cecal, transverse colon and
splenic flexure hyperenhancement suggesting active Crohn's disease/flare.
There is extensive fibro stenosing disease within the mid lower abdomen and
right lower quadrant with multiple tethered loops of small-bowel and colon in
a stellate configuration (for example series 2, image ___ 62, 63 and 64 and
series 601, image 29). There are multiple enteric and entero-colic fistulas
(for example series 2, image 64). A linear high density structure is seen
within tethered loops of ileum of unclear clinical significance (2:60). There
is evidence of active disease in the transverse colon with pseudopolyps,
luminal stenosis and upstream bowel dilation (2:60). There is a segment of
dilated small bowel in the pelvis proximal to an area of stricturing measuring
up to 3.8 cm, suggestive of partial obstruction (02:63). There is no evidence
of intra-abdominal abscess.
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: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is an apparent ___ fistula with a tract
extending from the splenic flexure (02:30), and tracking along the
retroperitoneum to the posterior abdominal wall, terminating along the midline
at the level of the L3 vertebral body (02:33). Along the tract are multiple
ramifications with associated abscesses the largest in the left posterior
abdominal wall measuring 2.2 x 5.3 cm encasing the left eleventh and twelfth
ribs (series 2, image 28). There is apparent sclerotic change of the anterior
aspect of the left eleventh rib suggesting osteomyelitis (osteomyelitis of the
twelfth rib can not be excluded on CT). An addition small enhancing
collection is seen along the Left posterior abdominal wall subcutaneous soft
tissue (02:36).
IMPRESSION:
1. Hyperenhancement of the ileum, cecum, transverse colon and splenic flexure
suggesting active Crohn's flare.
2. Multiple abnormal, tethered loops of large and small-bowel in the mid lower
abdomen and right lower quadrant with associated interloop fistulas as well as
focal areas of stricturing and upstream bowel dilation involving the ileum and
transverse colon suggesting partial bowel obstruction.
3. No associated abscess in the lower abdomen
4. Colocutaneous fistula with a tract extending from the splenic flexure to
the posterior left abdominal wall with multiple ramifications and abscesses in
relation to the posterior abdominal wall as well as involvement of the left
eleventh and twelfth ribs.
5. Suspected left eleventh rib osteomyelitis is new compared to prior.
6. Interval resolution of bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new L PICC// 43cm L Basilic DL PICC ___
___ Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
FINDINGS:
The tip of the left PICC projects over the right atrium, approximately 1.5 cm
beyond the cavoatrial junction. No focal consolidation, pleural effusion or
pneumothorax. The size of the cardiac silhouette is within normal limits.
IMPRESSION:
The tip of the left PICC projects over the right atrium, approximately 1.5 cm
beyond the cavoatrial junction.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old woman with crohn's disease// possible thrombosis
causing failure of PICC placement. Please do right upper extremity u/s. Thank
you.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins. Left subclavian line is partially evaluated.
The right internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The right basilic,
and cephalic veins are patent, compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
INDICATION: ___ with advancec Crohn's disease(previously treated with
stelara, pred) p/w colocutaneous fistula from desc colon to back// evaluate
extent of osteomyelitis in 11th rib noted on recent CT- to determine Abx
duration
TECHNIQUE: Multiplanar multisequence MRI of the left-sided ribs was performed
with and without IV contrast.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
Again seen is the 10.8 x 1.7 x 6.8 cm (TV by AP by CC) rim enhancing fluid
collection centered at the level of the thoracolumbar junction tracking along
the left lower chest wall and extending inferiorly to the level of iliac bone
consistent with known abscess, similar to ___. The collection
communicates with the colon at the splenic flexure consistent with
colocutaneous fistula. The left eleventh and twelfth ribs course through the
abscess. The segments of the eleventh and twelfth ribs within the collection
demonstrate indistinct cortex and loss of T1 signal intensity, although no
substantial STIR hyperintensity or post-contrast enhancement is identified.
The visualized left lateral tenth, ninth, and eighth ribs are not involved by
the abscess. There is mild edema in the paraspinal muscles and in the left
gluteus minimus muscle.
The visualized spine demonstrate normal alignment and normal marrow signal.
Mild disc bulge is noted throughout the lumbar spine. No spinal canal or
neural foraminal narrowing. The abscess does not appear to involve the spine.
The intraabdominal and pelvic bowel loops are better evaluated on CT abdomen
pelvis from ___. The visualized liver, spleen, kidneys, pancreas,
gallbladder, and abdominopelvic vasculature are unremarkable.
IMPRESSION:
1. 10.8 x 1.7 x 6.8 cm abscess centered at the left thoracolumbar junction
tracking along the left chest wall and extending inferiorly to the level of
iliac bone communicating with a colocutaneous fistula from the splenic
flexure. Overall appearance is unchanged compared to ___.
2. Left eleventh and twelfth ribs course through the abscess with the
segments within the abscess demonstrating indistinct cortex and T1 hypointense
marrow signal intensity. No substantial marrow edema or postcontrast
enhancement is appreciated within the left eleventh and twelfth ribs given
surrounding abscess and size of the ribs. The appearance is not classic for
osteomyelitis but remains suspicious for early osteitis.
Radiology Report
EXAMINATION: MR ___
INDICATION: ___ with CD (stelara, pred) pw CCF from desc colon to back// eval
for severity of disease, eval for surgical planning
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic sequences performed
prior to, during, and following the administration of 0.1 mmol/kg of Gadavist
intravenous contrast (4 cc). Oral contrast consisted of 1000 mL of Breeza. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: ___ chest wall MRI and ___ CT abdomen/pelvis
FINDINGS:
MR ENTEROGRAPHY:
Examination is limited by mild motion degradation. Abnormal findings are not
as well demonstrated as on the recent CT due to motion artifact and limited
spatial resolution on this MR.
___ enhancement and mural edema involving loops of distal jejunum and
ileum is not as conspicuous as on the prior CT. Loops of distal jejunum and
ileum are tethered to the adjacent transverse colon, sigmoid colon, cecum,
appendix, urinary bladder, uterus, and right ovary.
There is mild mural edema and mucosal hyperenhancement extending from the
proximal to mid transverse colon through the splenic flexure. Pseudopolyps
seen on recent CT are obscured by fecalized luminal contents. Essentially at
the origin of the mural edema and mucosal hyperenhancement, the transverse
colon is tethered with apparent sinus tract(s) extending to adjacent loops of
distal jejunum and ileum (series 12, images 40-65).
There is mild mural edema and mucosal hyperenhancement at the splenic flexure
extending through the proximal to mid descending colon. There is a
colocutaneous fistula originating at the splenic flexure multiple small
collections of fluid and gas, better assessed on preceding chest wall MRI
performed 15 hours prior. While the dominant tract extends posteriorly, there
is a second tract extending anteriorly toward the anterior abdominal wall
without associated abscess formation (series 13, images 94-109). While there
is no mural edema or abnormal enhancement involving the sigmoid colon, the
distal sigmoid colon is tethered to adjacent bowel loops in the right pelvis
(series 12, images 64-70; series 1102, images ___.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
The liver is normal in signal, enhancement, and contour. No concerning
lesions. No intrahepatic or extrahepatic biliary ductal dilation. The
gallbladder is normal. The pancreas is normal in signal intensity and
enhancement. No focal lesions. The spleen is normal in size, signal
intensity, and enhancement. No focal lesions. Small accessory spleen. The
adrenal glands are normal in size and shape. No nodules. The kidneys are
normal and symmetric in size, shape, and nephrogram. No concerning lesions.
No hydronephrosis. No suspicious osseous lesions. The abdominal wall is
unremarkable.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The urinary bladder, uterus, and right ovary are tethered to adjacent loops of
bowel as described above. There is trace pelvic free fluid. No suspicious
osseous lesions. The pelvic wall is unremarkable.
IMPRESSION:
1. Examination is limited by motion degradation and limitations of spatial
resolution. Abnormal findings below are better demonstrated on prior chest
wall MRI and abdomen/pelvis CT.
2. Acute on chronic inflammatory bowel disease with tethering and possible
sinus tracts involving the distal jejunum, ileum, cecum, transverse colon,
appendix, urinary bladder, uterus, and right ovary. Difficult to distinguish
between loops of involved small-bowel and microabscesses.
3. Acute and chronic inflammatory bowel disease involving the splenic flexure
and proximal to mid descending colon with a colocutaneous fistula extending to
the left flank with multiple fluid and gas containing collections, better
assessed on chest wall MRI. An additional sinus tract extends anteriorly
toward the anterior abdominal wall without associated abscess formation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Cutaneous abscess of back [any part, except buttock]
temperature: 99.3
heartrate: 118.0
resprate: 18.0
o2sat: 96.0
sbp: 111.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | Ms ___ presented with a complex history of fistulizing
ileocolonic Crohn's disease since ___ and now a colocutaneous
fistula/abscess. At this of her admission it was clear that her
penetrating Crohn's disease had not been responding to Stelara
and her steroid dependence was potentially predisposing to
fistula/abscess formation.
In this current setting both Gastroenterology and Colorectal
surgery determined that there were limited medical options to
attempt to induce remission of her disease. It was recommended
that she receive total parenteral nutrition or enteral feeding-
although she initially declined, she eventually consented to a
PICC being placed so that she could receive TPN. TPN was
continued throughout this admission and by the time of
discharge, it was being cycled over 12hours and this was
tolerated well.
CT taken on ___ was indicative of an active Crohn's flare; MRE
was also obtained and demnstrated extensive acute on chronic
inflammation involving multiple loops of small bowel and large
bowel. Of particular note, on CT there was an area surrounding
the eleventh rib concerning for osteomyelitis. She underwent MRI
of chest to further characterise this. It demonstrated a
10x1.7x6.8cm abscess centered at the left thoracolumbar junction
tracking along the left chest wall and extending inferiorly to
the level of iliac bone in the setting of a colocutaneous
fistula.As a result infectious disease recommended daily
ertapenem infusions (1g daily for 7 days until surgery). She is
planned for an OR procedure on ___ for multiple resections to
get control of her fistulizing disease and possible ostomy
creation; the area surround the 11th rib will also be cultured. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Byetta / clonidine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of DM gastroparesis who presents w/ upper abdominal
pain, nausea/vomiting. Was just dc'd yesterday from ED for
gastroparesis.
Pt reports symptoms first started 3 days ago, mostly n/v,
epigastric pain. She went to the ED ___ and was feeling better
after. Yesterday, she had worsening epigastric pain. Pt reports
nausea as well with ___ total episodes of emesis. She reports
she also found out yesterday that her brother died; after that
she developed sternal chest discomfort, which she describes as a
dull pain. No associated dyspnea. No past episodes of chest
pain. She also reports 3 episodes of diarrhea yesterday,
otherwise no diarrea. No fevers. FSG running somewhat high into
the 200s, none into the 300s. She reports her symptoms are very
typical of a gastroparesis flare. She reports her last flare was
approx 2mo ago.
Pt recently admitted ___ for lethargy and AMS. Pt
represented to the ED ___ with n/v and thought ___
gastroparesis flair. Pt sent home after able to tolerate clear
liquids.
In the ED intial vitals were: 99.3 92 ___ 2L Nasal
Cannula. Repeat BP 227/110. Labs notable for WBC 12 (58%N), Hct
31.1, K 3.1, BUN/Cr ___, Mg 1.4, trop<0.01, LFTs normal. UA
negative, ucx sent. Patient was given: zofran, 10IV reglan, 40IV
K, and IV morphine 5mg IV x2. 1.5L NS given. RUQ U/S s/p
cholecystectomy and otherwise normal. CXR done. EKG: SR, L axis,
no change from previous EKG. ED reports pt CP free in the ED.
Symptoms not controlled so pt being admitted for symptom mgmt.
Vitals on transfer: 97.9 88 ___ 98% RA --> pt given 5 IV
metop before transfer.
On arrival to the floor, pt reports ___ chest discomfort and
___ epigastric discomfort. No HA or changes in vision.
Past Medical History:
#CHF: Diastolic, preserved EF
#CVAs: b/l lacunar infarcts in ___, R cerebellar infarct
___, residual weakness of right side
#DM2: c/b neuropathy, retinopathy, gastroparesis
#HTN
#chronic low back pain
#HCV, no prior treatment
#HBV
#mood disorder (depression, anxiety with psychotic features per
OMR)
#tardive diskinesia
#hiatal hernia
#colon polyps
#cervical degenerative disc disease
#benign thyroid nodules
#s/p cholecystectomy
#s/p c-section
Social History:
___
Family History:
+colon cancer, heart disease, DM, HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.7, 186/107, 97, 18, 99% RA
General- middle aged black woman, in NAD
Neck- supple
CV- regular, rate at 100, no murmurs
Lungs- CTAB, breathing comfortably
Chest- tenderness over sternum with reproducible pain
Abdomen- soft, ND, +BS, epigastric tenderness
Ext- warm, well perfused, no ___ edema
DISCHARGE PHYSICAL EXAM:
Vitals: T:98.6 ___ R:20 O2:100% on RA
General: Alert, oriented, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild tenderness to palpation in epigastrium,
non-distended, normal active bowel sounds, no rebound tenderness
or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes noted
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities
Pertinent Results:
LABS:
___ 08:45AM BLOOD WBC-9.4 RBC-3.69* Hgb-8.6* Hct-28.7*
MCV-78* MCH-23.4* MCHC-30.1* RDW-15.7* Plt ___
___ 08:20AM BLOOD WBC-6.9 RBC-4.12* Hgb-9.8* Hct-32.2*
MCV-78* MCH-23.7* MCHC-30.4* RDW-15.6* Plt ___
___ 08:45AM BLOOD Glucose-176* UreaN-11 Creat-0.8 Na-138
K-3.5 Cl-104 HCO3-27 AnGap-11
___ 08:20AM BLOOD Glucose-249* UreaN-13 Creat-0.9 Na-138
K-3.2* Cl-100 HCO3-30 AnGap-11
___ 05:25AM BLOOD cTropnT-<0.01
___ 08:45AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.7
___ 08:20AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.7
IMAGING:
RUQ U/S (___): IMPRESSION: Patient status post
cholecystectomy. No choledocholithiasis. Normal study.
ECG (___): Sinus rhythm. Borderline voltage criteria for left
ventricular hypertrophy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aripiprazole 15 mg PO QAM
3. Aspirin 325 mg PO DAILY
4. Citalopram 40 mg PO QAM
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 300 mg PO QHS:PRN pain
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 150 mg PO DAILY
9. Mirtazapine 7.5 mg PO HS
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. QUEtiapine Fumarate 300 mg PO DAILY
14. Senna 2 TAB PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. NovoLOG (insulin aspart) 100 unit/mL Subcutaneous PRN BG>180
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aripiprazole 15 mg PO QAM
3. Aspirin 325 mg PO DAILY
4. Citalopram 40 mg PO QAM
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 300 mg PO QHS:PRN pain
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 200 mg 1 tablet extended
release 24 hr(s) by mouth once a day Disp #*30 Tablet Refills:*3
9. Mirtazapine 7.5 mg PO HS
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. QUEtiapine Fumarate 300 mg PO DAILY
13. Senna 2 TAB PO BID
14. Vitamin D 1000 UNIT PO DAILY
15. NovoLOG (insulin aspart) 100 unit/mL Subcutaneous PRN BG>180
16. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*60 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gastroparesis flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY:
Right upper quadrant abdominal pain with nausea and vomiting. Assess for
cholelithiasis.
COMPARISON: Comparison is made to CT of the pelvis performed ___.
FINDINGS:
Liver is homogeneous in echotexture without discrete masses or lesions. There
is no intra or extrahepatic biliary ductal dilatation with the free portion of
the common bile duct measuring 7 mm. Patient status post cholecystectomy.
The evaluation of the pancreatic tail is obscured by bowel gas though the
demonstrated portions demonstrate normal pancreatic parenchyma. The main
pancreatic duct is prominent but within normal limits measuring 2 mm. The
right kidney demonstrates a 4.1 cm simple cyst extending from the upper pole,
unchanged compared to ___. No stones or hydronephrosis identified.
Limited assessment of the inferior vena cava and aorta demonstrate normal
caliber.
Doppler assessment of the portal vein shows patency and hepatopetal flow.
IMPRESSION:
Patient status post cholecystectomy. No choledocholithiasis. Normal study.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with DIAB NEURO MANIF IDDM, GASTROPARESIS
temperature: 99.3
heartrate: 92.0
resprate: 10.0
o2sat: 100.0
sbp: 214.0
dbp: 93.0
level of pain: 10
level of acuity: 2.0 | ASSESSMENT AND PLAN: ___ w/ hx of DM gastroparesis who presents
w/ upper abdominal pain, nausea/vomiting.
# Gastroparesis flare: Pt presented with epigastric pain,
nausea/vomiting that are characteristic of a gastroparesis
flare. RUQ U/S was without biliary process. LFTs and lipase were
wnl. Symptoms resolved with zofran prn and scheduled reglan.
Diet was advanced as tolerated. On hospital day #2 patient was
able to tolerate lunch without nausea/vomiting, was at baseline,
was discharged to home.
# HTN urgency: BP to 227/110 in the ED. Did report CP briefly,
however trops were negative and ECG was reassuring. CP may have
been d/t anxiety as patient found out her brother died day
before admission or perhaps MSK pain. HTN likely due to patient
being unable to take PO meds d/t nausea/vomiting from
gastroparesis flare. Was hypertensive to 200s overnight during
her hospitalization as well. She was continued on her home meds
- amlodipine, lisinopril, metoprolol. Was discharged on an
increased dose of metoprolol (200 mg qd).
# Chest pain: atypical and reproducible on exam. EKG without
changes and trop neg x2. Pain onset after finding out about
brother's death yesterday. It may be anxiety or MSK pain. Pain
was controlled with tylenol. Had no further CP during
hospitalization.
# Leukocytosis: may be reactive from gastroparesis flair per
above. No current evidence of infection by symptoms and negative
UA and CXR.
# Family loss: brother passed away on day of presentation.
Social work was consulted. Reported that "Assessment: Pt
exhibits strong resiliency. Has supports in family and friends,
but it is hard to ask for help. She has aftercare services in
place."
# Hypokalemia: likely ___ emesis. Repleted in ED. Was monitored
daily.
# IDDM: Managed with sliding scale
# Anemia: Hct close to recent baseline on last admission.
Checked daily.
# H/o CVA: Was continued on ASA.
# Depression: Continued citalopram, mirtazepine, abilify and
seroquel. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending: ___.
Chief Complaint:
R flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx HTN, HLD, & h/o stage IIIc endometrial adenoCa who
presents with right-sided squeezing flank pain, worsening since
yesterday.
Patient reports that right flank pain began all of a sudden on
___ and 2 hour later, she took ibuprofen 800mg which brought
down the pain from ___ to ___. She went to the ED and was
diagnosed with pyelonephritis and given cipro to complete a 10
day course. Since that day, she has had intermittent pain that
was relieve with Alleve (she took 3 alleves from ___ to ___.
Yesterday, her right flank pain woke her up from sleep and she
took alleve which brought the pain down from ___ to ___. The
pain lasted for about 45 minutes, but occurred about 5 times and
as a result she took 5 Alleve (per the box instructions, the
maximum was 2 pills/day). She came in to the ED yesterday night.
Denies any fever, chills, dysuria, chest pain, shortness of
breath, or abdominal pain. Of note, patient has baseline level
of urinary and bowel urge incontinence ___ radiation for
endometrial cancer, and reports that she restricts her fluid
intake during the day to avoid wetting herself.
In the ED, initial VS were 97.8, 66, 145/76, 16, 100% RA. Labs
were notable for new renal failure with Cr 1.5 (up from 0.8 on
___ and negative urinalysis. Prelim read of renal
ultrasound showed mild right hydronephrosis, new from ___,
but otherwise normal U/S with no stones or no perinephric fluid
collection. Patient received 1L NS, dilaudid 1mg IV x 2, and
ketorolac 15mg IV x 1 (despite ___. Non-contrast CT abd/pelvis
showed 5mm obstructing stone in the proximal right ureter. She
was admitted to medicine for further work up of acute renal
failure. Vital signs on transfer were 98.3 62 113/65 18 99% RA.
On arrival to the floor, patient continued to complain of right
flank pain that she describes as a squeezing feeling with
intermittent radiation to her right groin. She never had this
pain before or history of kidney stones. It is now ___. Pain
is worse with palpation and laying still. Reports occasional dry
heaves, but no vomiting, diarrhea, abdominal pain, f/c, night
sweats, dysuria, gross hematuria, frequency.
REVIEW OF SYSTEMS:
(+) Per HPI, chronic back pain with numbness on L lower
extremity and foot drop.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Hypertension
-Hypercholesterolemia
-Depression
-S/p lacunar stroke 10 to ___ years ago
-Stage IIIC grade 3 endometrial adenocarcinoma (ER/PR positive)
dx ___ (had TAH-BSO, omental biopsy, washings, and lymph
node dissection by Dr. ___, last radiation in ___, last
chemo in ___
-urine and bowel incontinence post radiation
-Obesity
-Back pain with grade ___ left foot drop
-H/o radiation colitis
-L4-L5 annular rupture, disk herniation.
-L4-L5 recurrent spinal stenosis, far lateral.
PAST SURGICAL HISTORY:
___: Anterior lumbar interbody fusion, left transpsoas
approach, L4-L5
___: Posterolateral fusion, decompression and
instrumentation, ___: L4-L5 posterior decompression
Social History:
___
Family History:
Includes cancer, diabetes, heart disease, lung disease, kidney
disease, and dementia. Her daughter has systemic lupus. 3
maternal aunts with carcinoma - 2 with ovarian CA and 1 with
endometrial CA.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98, 133/53, 59, 18, 97% RA, wt: 90.1kg
GEN: A+Ox3, NAD
HEENT: NCAT. EOMI. PERRL. MMM. no LAD. no JVD. neck supple.
CV: RRR, normal S1/S2, ___ systolic murmur best heart at the
RUSB, no rubs or gallops.
LUNG: CTAB, no wheezes, rales or rhonchi
BACK: R flank tenderness with palpation
ABD: soft, NT/ND, +BS. no rebound or guarding. neg HSM.
EXT: W/WP, no edema, no C/C. 2+ ___ pulses bilaterally.
NEURO: CNs II-XII grossly intact. ___ strength in U/L
extremities throughout except for L foot flexion/extension which
is ___. Decreased sensation to soft touch in L lower extremity.
DISCHARGE PHYSICAL EXAM
VS: Tmax 98.6, Tc 97.9 116/43, 62, 20, 96% RA
GEN: A+Ox3, NAD
HEENT: NCAT. EOMI. PERRL. MMM. no LAD. no JVD. neck supple.
CV: RRR, normal S1/S2, ___ systolic murmur best heart at the
RUSB, no rubs or gallops.
LUNG: CTAB, no wheezes, rales or rhonchi
BACK: R flank tenderness with palpation
ABD: soft, NT/ND, +BS. no rebound or guarding. neg HSM.
EXT: W/WP, no edema, no C/C. 2+ ___ pulses bilaterally.
NEURO: CNs II-XII grossly intact. ___ strength in U/L
extremities throughout except for L foot flexion/extension which
is ___. Decreased sensation to soft touch in L lower extremity.
Pertinent Results:
ADMISSION LABS
___ 05:54AM BLOOD WBC-6.9 RBC-4.68 Hgb-13.7 Hct-40.9 MCV-87
MCH-29.2 MCHC-33.4 RDW-14.6 Plt ___
___ 05:54AM BLOOD Neuts-70.5* Lymphs-17.7* Monos-8.2
Eos-3.3 Baso-0.3
___ 06:40AM BLOOD ___ PTT-28.9 ___
___ 05:54AM BLOOD Glucose-127* UreaN-29* Creat-1.5* Na-137
K-4.4 Cl-100 HCO3-26 AnGap-15
DISCHARGE LABS
___ 12:45PM BLOOD WBC-4.2 RBC-3.74* Hgb-11.1* Hct-33.1*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.7 Plt ___
___ 12:45PM BLOOD UreaN-19 Creat-1.4*
___ 06:40AM BLOOD Glucose-149* UreaN-20 Creat-1.3* Na-142
K-4.4 Cl-110* HCO3-25 AnGap-11
___ 06:40AM BLOOD Calcium-7.5* Phos-2.9 Mg-2.0
URINE
___ 05:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:55AM URINE Eos-NEGATIVE
___ 05:55AM URINE Hours-RANDOM Creat-47 Na-154 K-35 Cl-143
Phos-43.5
___ 05:55AM URINE Osmolal-574
___ 05:55AM URINE Color-Straw Appear-Clear Sp ___
MICRO
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
___ RENAL ULTRASOUND
IMPRESSION:
1. Mild right hydronephrosis, new from ___. No stones
identified. No perinephric fluid collection.
2. Echogenic liver consistent with hepatic steatosis,
incompletely imaged.
Other forms of liver disease including steatohepatitis and more
advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
___ CT ABD AND PELVIS W/O CONTRAST
IMPRESSION:
1. 5-mm obstructing calculus within the proximal right ureter
resulting in
mild hydronephrosis. Mild perinephric fluid may indicate
forniceal rupture.
No perinephric abscess.
2. Unchanged bilateral parapelvic renal cysts.
3. Fatty liver; steatohepatitis cannot be excluded.
4. Post-radiation changes in the pelvis of this patient with
prior
endometrial carcinoma. No suspicious adenopathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxazepam 15 mg PO BID
2. Propranolol 80 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN sob
5. Aspirin 325 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH BID:PRN sob
7. Fluoxetine 20 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Divalproex (DELayed Release) 250 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Divalproex (DELayed Release) 250 mg PO TID
5. Fluoxetine 20 mg PO DAILY
6. Oxazepam 15 mg PO BID
7. Propranolol 80 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH BID:PRN sob
9. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN sob
10. Ciprofloxacin HCl 500 mg PO Q12H
please take for a total of 10 days (last day on ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*6 Tablet Refills:*0
11. Tamsulosin 0.4 mg PO HS
please take for one month
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at night Disp #*30
Capsule Refills:*0
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q8 Disp #*10 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: mild right hydronephrosis, 5mm obstructing calculus in
proximal right ureter
SECONDARY: pyelonephritis, depression, hypertension, history of
stage IIIc grade 3 endometrial adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right-sided flank pain. Treated for pyelonephritis on ___.
COMPARISON: US ___, CT ___.
FINDINGS: The right kidney is 13.4 cm and the left kidney is 14.5 cm, both
normal in size and echogenicity without stone or mass identified. Mild right
hydronephrosis is new from ___. No stones are seen bilaterally. There
is no perinephric fluid collection. Numerous renal pelvic cysts are again
noted.
The study is performed with a full, normal-appearing bladder. Bilateral
ureteral jets are seen.
The imaged portions of the liver are echogenic.
IMPRESSION:
1. Mild right hydronephrosis, new from ___. No stones identified. No
perinephric fluid collection.
2. Echogenic liver consistent with hepatic steatosis, incompletely imaged.
Other forms of liver disease including steatohepatitis and more advanced liver
disease including significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
Radiology Report
HISTORY: ___ female with clinical pyelonephritis, now with increasing
right-sided flank pain and new hydronephrosis seen on recent renal ultrasound.
Assess for obstructing stone or abscess.
COMPARISON: Renal ultrasounds from ___ and ___, and CT
torso from ___
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness. No intravenous contrast
was administered. Coronal and sagittal reformations were prepared.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Lung bases are clear without
consolidation or pleural effusion. No suspicious pulmonary nodule is
identified. The imaged cardiac apex is within normal limits.
Complete evaluation of the abdominal viscera is limited secondary to the
non-contrast technique. There is diffuse fatty liver without focal lesion.
Geographic hyperattenuation surrounding the gallbladder fossa is unchanged
from prior and likely reflects focal fatty sparing (2:25). No intra- or
extra-hepatic biliary ductal dilatation is identified. The gallbladder,
spleen, pancreas, and adrenal glands appear normal. The abdominal aorta and
its branch vessels demonstrate mild atherosclerotic calcifications, though are
non-aneurysmal. Stomach and small bowel loops are normal in caliber and
configuration without evidence of obstruction or acute inflammation. Mild
bowel wall thickening and fascial thickening in the lower right pelvis is
unchanged from prior examination and likely reflects post-radiation changes in
this patient with known prior endometrial carcinoma. Surgical clips are seen
in the retroperitoneum, likely secondary to prior lymph node dissection
(2:53). No pathologically enlarged mesenteric or retroperitoneal lymph nodes
are identified. There is no abdominal free fluid or free air.
GU: Redemonstrated are numerous bilateral parapelvic cysts. However, there
is new mild right hydroureteronephrosis and a small obstructing stone within
the proximal right ureter measuring 5 mm (601B:26). No other stones are
visualized within the kidneys, ureters or bladder. There is no organized
perinephric fluid collection or abscess. A mild amount of free fluid
surrounding the right kidney suggests forniceal rupture (2:39). Assessment
for pyelonephritis is limited on this non-contrast examination.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: Mild wall thickening of the
rectosigmoid junction is similar to prior and likely related to post-radiation
changes. The remainder of the colon is normal in caliber and configuration
without evidence of obstruction or inflammation. Numerous surgical clips are
seen within the pelvis secondary to prior hysterectomy. Fascial thickening as
described above is unchanged. Presacral soft tissue thickening is consistent
with radiation changes. There is no pelvic free fluid. No pathologically
enlarged pelvic or inguinal lymph nodes are identified.
BONES AND SOFT TISSUES: The patient is status post interval posterior spinal
fusion at L4 and L5 with interbody spacer. Hardware appears in expected
position without evidence of loosening or failure. Spinal alignment is
preserved. No bone destructive lesion or acute fracture is identified.
IMPRESSION:
1. 5-mm obstructing calculus within the proximal right ureter resulting in
mild hydronephrosis. Mild perinephric fluid may indicate forniceal rupture.
No perinephric abscess.
2. Unchanged bilateral parapelvic renal cysts.
3. Fatty liver; steatohepatitis cannot be excluded.
4. Post-radiation changes in the pelvis of this patient with prior
endometrial carcinoma. No suspicious adenopathy.
DLP: 831.84 mGy-cm
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FLANK PAIN
Diagnosed with CALCULUS OF KIDNEY, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.8
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 145.0
dbp: 76.0
level of pain: 6
level of acuity: 3.0 | ___ with PMHx HTN, HLD, & h/o stage IIIc endometrial adenoCa who
presents with right-sided flank pain, worsening since the day
prior to admission and found to have ___.
# ___ renal calculi: creatinine is
1.5 from baseline 0.8. Per renal ultrasound, likely post-renal
given new onset of mild hydronephrosis on R kidney. CT scan was
obtained which showed a 5mm obstructing stone in the proximal
right ureter that is the likely cause of the mild
hydronephrosis, flank pain, and ___. In addition, likely some
contribution from NSAIDs as patient states that she has been
taking more than the recommended dose due to the right flank
pain. BUN/Cr ratio ~ 20:1 which suggest possible prerenal
azotemia, however FeNa was 3%. UA was negative for UTI. Urology
was consulted who recommended trial of passage of stone with
aggressive fluid hydration and flomax for 1 month. She was given
about ___ of fluids and flomax 0.5mg HS. At discharge, she
stated that her flank pain has improved. Her creatinine also
trended down to 1.4. She has follow up with her PCP ___ ___.
Patient was instructed to look at her urine and attempt to
collect the stone if it passes.
# Bacterial UTI with Right flank pain: previously came to ED on
___ with urine culture growing pan sensitive E-coli and sent
home with 10 days course of ciprofloxacin. UA is negative during
this admission. No fevers or leukocytosis. Most likely etiology
of R flank pain is obstruction secondary to renal calculi as it
presents with the classic symptom of pain radiation to the
ipsilateral groin. She was continued on her prescribed 10 days
course of cipro (complicated given prior history of radiation to
the area). Her last day is on ___. Pain was controlled with
oxycodone as needed. She was advised to stay away from NSAIDs
given ___.
CHRONIC ISSUES
# Hypertension: continued with amlodipine, propranolol
# essential tremor: continued with propanolol
# Hypercholesterolemia: patient prescribed statin, but refuses
to take
# Depression: continued with fluoxetine, depakote, oxazepam
# Stage IIIC grade 3 endometrial adenocarcinoma s/p
surgery/radiation/chemo: stable
# TRANSITIONAL ISSUES:
-please recheck creatinine and ensure it is trending down
-please evaluate right flank to ensure that pain is improving
-If creatinine or symptoms worsen, consider referral to urology
-patient in process of completing 10 days course of cipro for
pyelo (last day on ___
-patient will need to continue with aggressive hydration and
flomax for one month, consider discontinuing flomax if stone
passes or symptoms resolve |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levaquin / aspirin / ibuprofen
Attending: ___
Chief Complaint:
Chest discomfort and cold symptoms
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ with PMH of HTN, MI s/p 2 stents, SVT s/p ablation, colon
CA, reflux who presents with chest pressure. States that he had
central chest pressure that felt like a heavy weight lasting
several hours. Called PCP and was advised to present to ED for
evaluation. Pain has since resolved. Denies radiation, N/V,
associated diaphoresis, back pain, palpitations. Says that the
pain is very different from his myocardial infarction pain, and
notes that the pain was not positional and has since dissipated.
Pt also has 2d hx of a "cold" with non-productive cough,
rhinorrhea and ST. Denies fever, but notes positive chills.
Denies any sick contacts.
EKG in ER: New TWI III, prolonged PR interval suggestive of ___
degree AV block. As compared to ___ EKG, new TWI, but
continuing AV block.
In the ED, initial vitals were: 98.3 92 147/57 16 98% ra. CXR
with questionable infiltrate.
Treatment in ED:
___ 16:37 PO Aspirin 243 mg
___ 17:44 oral Tessalon Perles *NF* (benzonatate) 100 mg
___ 18:32 IV CeftriaXONE 1 gm
___ 18:57 IV Azithromycin 500 mg
Review of systems:
(+) Per HPI
Otherwise a 10 point ROS is negative.
Past Medical History:
Hypertension
CAD s/p MI in ___ and ___
Glaucoma
Sinus bradycardia
1st degree AV block
Hyperlipidemia
Colon ca s/p sigmoidectomy
BPH s/p TURP
AVNRT
Social History:
___
Family History:
Both of his parents died from heart conditions, possible MI
and/or stroke. He does not know their exact diagnosis, as they
both passed away in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
Vitals: 98.5, rr20, pulse 104, 97% on RA
General: Alert, oriented, uncomfortable appearing
HEENT: Sclera anicteric, MMM, oropharynx erythematous with
exudates present. Rhinorrhea present.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, 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 visible rashes
Neuro: No focal deficits.
DISCHARGE PHYSICAL EXAM:
==================
Vitals: 98.4-101.3, 120/55, 97 pulse, rr20, 100% on RA
General: Alert, oriented, uncomfortable appearing
HEENT: Sclera anicteric, MMM, oropharynx erytehmatous with
exudates present. Rhinorrhea present.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, 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 visible rashes
Neuro: No focal deficits.
Pertinent Results:
ADMISSION LABS:
==============
___ 04:01PM BLOOD WBC-8.5 RBC-3.97* Hgb-11.5* Hct-35.1*
MCV-89 MCH-29.0 MCHC-32.8 RDW-14.2 Plt ___
___ 04:01PM BLOOD Neuts-89.0* Lymphs-5.5* Monos-4.5 Eos-0.9
Baso-0.2
___ 04:01PM BLOOD Glucose-97 UreaN-25* Creat-1.2 Na-140
K-4.2 Cl-104 HCO3-27 AnGap-13
___ 04:01PM BLOOD proBNP-329
___ 04:01PM BLOOD Calcium-9.5 Phos-3.0 Mg-2.0
OTHER PERTINENT LABS:
================
___ 07:30AM BLOOD WBC-6.0 RBC-3.97* Hgb-11.8* Hct-35.1*
MCV-88 MCH-29.8 MCHC-33.7 RDW-14.4 Plt ___
___ 07:30AM BLOOD Glucose-95 UreaN-19 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
___ 07:30AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.0
CARDIAC ENZYMES:
=============
___ 04:01PM BLOOD cTropnT-<0.01
IMAGING:
======
CXR ___ (PA/LAT):
A left base opacification, not clearly seen on the lateral
radiograph is new since ___ and could represent
atelectasis or infection in the appropriate clinical setting.
There is persistent right mid lung opacity laterally which has
persisted since ___. The lungs are otherwise clear without
pulmonary edema, pleural effusion or pneumothorax. The the
heart size is top normal. The aorta is tortuous. There is no
free air.
IMPRESSION:
A left base opacity, not clearly seen on the lateral radiograph,
is new since ___ could represent atelectasis or infection
in the appropriate clinical setting.
MICROBIOLOGY:
===========
Blood cultures - ___ - NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 12.5 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Zolpidem Tartrate 2.5 mg PO HS:PRN insomnia
8. bimatoprost 0.01 % ophthalmic 1 gtt HS
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
11. Acetaminophen 650 mg PO Q6H:PRN fever, pain
12. Omeprazole 40 mg PO BID
13. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
5. Losartan Potassium 12.5 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Simvastatin 40 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Cepastat (Phenol) Lozenge 2 LOZ PO Q4H:PRN throat pain
RX *phenol [Cepastat] 14.5 mg Take 1 lozenge by mouth q4h:prn
Disp #*42 Lozenge Refills:*0
13. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth
q6h:prn Disp ___ Milliliter Milliliter Refills:*1
14. bimatoprost 0.01 % ophthalmic 1 gtt HS
15. Zolpidem Tartrate 2.5 mg PO HS:PRN insomnia
16. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
RX *azithromycin 250 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
possible community-acquired pneumonia
Viral upper respiratory infection
1st degree AV block
CAD
Secondary:
Hypertension
Hyperlipidemia
Benign prostatic hypertrophy
Colon cancer s/p sigmoidectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with chest pain // ?pna
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___. ___.
FINDINGS:
A left base opacification, not clearly seen on the lateral radiograph is new
since ___ and could represent atelectasis or infection in the
appropriate clinical setting. There is persistent right mid lung opacity
laterally which has persisted since ___. The lungs are otherwise clear
without pulmonary edema, pleural effusion or pneumothorax. The the heart size
is top normal. The aorta is tortuous. There is no free air.
IMPRESSION:
A left base opacity, not clearly seen on the lateral radiograph, is new since
___ could represent atelectasis or infection in the appropriate clinical
setting.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Cough, Chest pain
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.3
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 147.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH of HTN, MI s/p 2 stents, SVT s/p ablation, colon
CA, reflux who presents with chest discomfort different from his
prior myocardial infarction discomfort, in the context of
rhinorrhea/cough/sore throat, and a CXR concerning for
atelectasis vs PNA, consistent with viral infection and
potential underlying pneumonia.
# URI vs PNA
Patient had multiple URI sx at admission including rhinorrhea,
cough and sore throat with erythematous oropharynx. One day hx
of symptoms. Because his symptoms were associated initially with
chest discomfort, he received a chest xray. This CXR indicated
possible pneumonia. On ___, patient had a fever to 101.3.
Due to the possible pneumonia in the left lower lobe, he was
treated with ceftriaxone and azithromycin x 2 days. Given no
recent healthcare exposures, and likely community acquired
pneumonia he was discharged on Azithromycin for a total of a 5
day course. The ceftriaxone was discontinued. In addition to
the antibiotics, the patient was encouraged to take in ample
non-caffeinated, non-alcoholic fluids, and to seek urgent
medical care if any worsening of symptoms or increasing fevers.
- Acetaminophen 650 mg PO Q6H:PRN fever, pain
- Cepastat (Phenol) Lozenge 2 LOZ PO Q4H:PRN throat pain
- Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN
# Chest Pain
Possibly ___ mild demand ischemia in the context of a pneumonia,
or more likely is ___ costochondritis/MSK from patient's
repeated coughing. Troponin x 1 <0.01. EKGs showed non-specific
changes. Patient maintained on telemetry with no acute events
for 24 hours. Note that he has chronic 1st degree AV block on
EKG.
# Thrombocytopenia:
Thrombocytopenic dating back to ___ be a chronic
thrombocytopenia, may be medication related, or may be related
to splenic sequestration or underproduction. To be followed as
outpatient.
# chronic normocytic anemia: Anemic on labs dating back to ___,
presumed seconary to chronic disease.
# CAD:
As noted above, continued home medications, received ASA in ED
and patient ruled out for ACS.
- Aspirin 81 mg PO DAILY
- Losartan Potassium 12.5 mg PO DAILY
- Metoprolol Succinate XL 12.5 mg PO DAILY
# HTN: continue home meds.
# Glaucoma:
Stable. Continue home meds.
Timolol Maleate 0.5% 1 DROP BOTH EYES BID
bimatoprost 0.01 % ophthalmic 1 gtt HS
Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
#BPH
Stable, patient voiding without assistance, no hesistancy.
Tamsulosin 0.4 mg PO HS
# Hyperlipidemia:
Stable. Continue home meds.
- Simvastatin 40 mg PO DAILY
# GERD
Stable. Continue home meds.
- Omeprazole 40 mg PO BID
#Colon cancer s/p sigmoidectomy.
Stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aureomycin / Dilantin Kapseal / Bactrim / Augmentin / Penicillin
V / Amoxicillin / Aspirin
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old woman with a history of
complex-partial seizures w/ secondary generalization, congenital
blindness, NCSE, and recent admissions for decompensation due to
environmental stressors with catatonia. She was at her baseline
over the past few days while at her nursing home and then today
was scheduled for her usual appointment at clinic but was more
confused and less responsive. She was reported to have a
low-grade fever on ___ and was started on doxycycline for a
presumptive RLE cellulitis. In the office she was minimally
responsive and was slumped over in her wheelchair.
She was admitted to the neurology service between ___ and
___ for an acute decompensation while at rehab in which she
became less responsive and had speech arrest. She was monitored
on EEG and had a toxic/metabolic w/u including LP which was
unrevealing. Additional history was obtained that there was a
major change in her living situation whil she was hospitalized
which coincided with her symptoms. It was felt that she was
having an emotional decompensation and was catatonic.
She is unable to detail any additional aspects of her history
including whether she had a fever or rash. She keeps repeating
phrases such as "I'm at ___.
ROS unobtainable given level of interaction
Past Medical History:
-Complex partial seizures with secondary generalization
-History of NCSE (most recently ___, presents with confusion
and sometimes "limited language".
-History of prematurity, born at 6 months GA with retrolental
hypoplasia and congenital blindness
-Hypertension
-Pitting edema
-Bilateral carpal tunnel syndrome
-Chronic urticaria of unknown etiology
-Prior admissions for gait instability ___ and ___ due to
depakote and lamictal toxicity
-s/p right radial fracture and dislocation of thumb joint s/p
hematoma block and closed reduction/splinted of distal radius
fracture, s/p right thumb reduction and wash out with placement
of removable splint
-Large left paracentral disc osteophyte at C5-6 level
-Right ankle sprain ___
-Bilateral hypoattenuating thyroid nodules
-Esophagitis
-s/p TAH/BSO in ___
-s/p trigger release of right ring finger in ___ and left in
___
Social History:
___
Family History:
no hx of seizures
Physical Exam:
Vitals: 98.2 77 116/38 20 99%
General: eyes open, minimally interactive, roving eyes
movements, NAD
HEENT: NC/AT 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: 4 cm rash over the right anterior lower leg, no
surrounding erythema, warm to touch
Neurologic:
-Mental Status: alert, oriented to BI, not to date. Unable to
spell WORLD or recite ___. Minimal language output, but states
that "I am blind" and "I'm in ___. Lifts hands up to
command. Will not follow more complex commands. Unable to
determine praxis or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2mm and minimal reactivity. Clouding of corneas..
Blind - no detection of shadows
III, IV, VI: looking mostly left but does conjugately move eyes
in all directions. R eye occassionall adducts without left eye
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Diminsihed bulk in distal extremities b/l. Lifts arms
antigravity symmetrically and then has good resistance in the
triceps b/l. Lifts the legs symmetrically and antigravity off
the
bed. Normal tone. No adventitious movements.
-Sensory: No deficits to light touch, b/l.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was flexor bilaterally.
-Coordination: unable to assess given minimal movement.
-Gait: deferred
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Discharge Exam: She is awake and alert. She knows her name ___
___.
Her speech is fluent without paraphasic errors, and she says hi
to each examiner after asking his/her name. She counts from 1
to 10, but then perseverates repeatedly when asked to do other
tasks. Follows simple commands. Corneal clouding as before.
Face symmetric, no obvious dysarthria. MAEs well. Mental status
is notably improved from admit
Pertinent Results:
___ 07:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:30PM GLUCOSE-124* UREA N-19 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
___ 01:30PM ALT(SGPT)-17 AST(SGOT)-18 ALK PHOS-67 TOT
BILI-0.2
___ 01:30PM LIPASE-29
___ 01:30PM ALBUMIN-4.0 CALCIUM-8.6 PHOSPHATE-4.5
MAGNESIUM-2.1
___ 01:30PM VALPROATE-97
___ 01:30PM WBC-3.6* RBC-4.98 HGB-14.4 HCT-42.4 MCV-85
MCH-28.9 MCHC-34.0 RDW-14.1
___ 01:30PM NEUTS-88* BANDS-0 LYMPHS-7* MONOS-5 EOS-0
BASOS-0 ___ MYELOS-0
___ 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 01:30PM PLT SMR-LOW PLT COUNT-138*
___ 01:30PM ___ PTT-32.5 ___
EEG: final report pending. Video-EEG telemetry from past 24 hrs
shows no pushbutton activations and no electrographic seizures.
Interictal left
temporal sharp waves were seen, phase-reversing at T3, unchanged
from before. Background was still slow, 6 Hz maximum,
indicative
of mild-to-moderate encephalopathy, with focal left temporal
intermittent slowing, as before.
CT head ___: No acute intracranial process.
Medications on Admission:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. divalproex ___ mg Tablet Extended Release 24 hr Sig: 1.5
Tablet Extended Release 24 hrs PO QHS (once a day (at bedtime)).
5. divalproex ___ mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QAM (once a day (in the
morning)).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO Q 24H (Every
24 Hours).
7. lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO Q 24H (Every 24
Hours).
8. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: ___ puffs inh Inhalation Q6H (every 6 hours)
as needed for wheeze, sob.
17. ipratropium bromide 0.02 % Solution Sig: One (1) puff inh
Inhalation Q6H (every 6 hours) as needed for wheeze, sob.
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. divalproex ___ mg Tablet Extended Release 24 hr Sig: 1.5
Tablet Extended Release 24 hrs PO QHS (once a day (at bedtime)).
5. divalproex ___ mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QAM (once a day (in the
morning)).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO Q 24H (Every
24 Hours).
7. lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO Q 24H (Every 24
Hours).
8. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: ___ puffs inh Inhalation Q6H (every 6 hours)
as needed for wheeze, sob.
17. ipratropium bromide 0.02 % Solution Sig: One (1) puff inh
Inhalation Q6H (every 6 hours) as needed for wheeze, sob.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered Mental Status
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
CLINICAL HISTORY: ___ woman with altered mental status. Evaluate for
pneumonia.
COMPARISON: Chest radiograph ___.
FINDINGS: Frontal and lateral views of the chest were obtained. The study is
somewhat limited by patient's lordotic position and low lung volumes. A vagal
stimulator projects over the left hemithorax with a catheter extending to the
neck. There is no focal consolidation, pleural effusion, or pneumothorax.
Mild bibasilar atelectasis is noted. The cardiac silhouette is mildly
enlarged, unchanged. Mediastinal silhouette and hilar contours are normal
allowing for low volumes.
IMPRESSION: Limited study. Mild bibasilar atelectasis. No acute
cardiopulmonary process.
Radiology Report
INDICATION: Altered mental status in a patient with history of seizures.
Evaluate for intracranial hemorrhage or cerebrovascular accident.
COMPARISON: NECT of head from ___.
TECHNIQUE: Non-contrast contiguous axial images were obtained through the
brain and reformatted into coronal and sagittal planes.
FINDINGS: There is no intracranial hemorrhage, edema, mass, mass effect, or
vascular territorial infarct. There is stable prominence of ventricles and
sulci consistent with age-related involutional changes.
The orbits again demonstrate bilateral phthisis bulbi. There is mucosal
thickening involving the right sphenoidal sinus, slightly more prominent than
on the prior study. Otherwise, the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MS CHANGES
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.2
heartrate: 77.0
resprate: 20.0
o2sat: 99.0
sbp: 116.0
dbp: 38.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted for altered mental status from baseline.
During her hospital course, she was evaluated for increased
seizure activity, infection, and psychiatric problems leading to
this alteration, with no clear etiology determined. However, she
clinically improved with time and is now near baseline and is
clear for discharge back to her facility.
1. Neurologic: CT head performed in ED was unremarkble. Video
EEG monitoring then performed for 3 days with no seizures
captured. There was slowing consistent with diffuse mild to
moderate encephalopathy with focal left temporal sharp waves. No
electrographic or clinical seizures during hospitalizaiton. EEG
was not markedly different from prior studies. Her mental status
markedly improved during hospitalization. No medication changes
were made
2. Psychiatric: Psychiatry was asked to consult. They
recommended infectious workup which was in progress but had no
further recommendations during course of acute illness and felt
her symptoms were due to delirium. As she has had multiple
evaluations in the hospital for concern of underlying
psychiatric disease without any clear diagnosis, we arranged
outpatient follow-up for her at the ___.
3. Infectious disease: Patient arrived on course of doxycycline
for concern of cellulitis over right anterior leg. This region
on exam was not concerning for cellulitis and was more
consistent with a contact dermatitis. Regardless, a 5 day course
of doxycycline was completed. The leg erythema was markedly
improved by discharge. Infectious workup including CBC, CXR, and
UA were all unremarkable. She had no fevers or other
signs/symptoms of infections during hospitalization.
4. Cardiovascular: Hemodynamically stable throughout
hospitalization
5. Respiratory: Stable on room air throughout hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Mr. ___ is a ___ year old male with history of
hypertension and hyperlipidemia, recent admission ___ for
obstructive jaundice s/p ERCP and stent placement, with recent
stent removal who presents with 5 days of abdominal pain,
jaundice, pale stools.
This is similar to his previous biliary obstruction episode.
In the ED, RUQUS was done which showed new mild intrahepatic and
extrahepatic biliary dilation. Cholelithiasis without
cholecystitis. CT A/P showed intrahepatic and extrahepatic
dilation with distal bile duct measuring up to 1.3 cm in
diameter. Cholelithiasis without cholecystitis.
No medications were given in the ED. Admitted for ERCP eval.
On interview he reports that he started having abdominal pain
last ___ (about 5 days ago) that was very uncomfortable. He
says that it's more of an ache with bloating and feels like he
has to burp. He didn't have nausea or vomiting or diarrhea. He
had some constipation and light stools but not as light as prior
episode. The abdominal discomfort got better but he noticed the
jaundice getting worse and his doctor told him to come to the
hospital for evaluation. Denies fevers/chills, lower extremity
edema, confusion.
Was supposed to see surgery for evaluation of cholecystectomy
this ___.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hyperlipidemia
Intermittent abdominal pain as above
Psoriasis
Intermittent long standing vertigo
Biliary stricture s/p stent and stent removal
Social History:
___
Family History:
Mother with lymphoma at age ___
Father died at age ___ from complications of COPD, smoker
Son died at age ___ from leukemia
Brother with DM2
Sister with fibromyalgia
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: scleral icterus, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Jaundiced.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 03:27PM BLOOD WBC-7.3 RBC-4.90 Hgb-15.4 Hct-42.7 MCV-87
MCH-31.4 MCHC-36.1 RDW-12.9 RDWSD-40.6 Plt ___
___ 03:27PM BLOOD Neuts-66.8 ___ Monos-8.7 Eos-3.7
Baso-0.7 Im ___ AbsNeut-4.89 AbsLymp-1.44 AbsMono-0.64
AbsEos-0.27 AbsBaso-0.05
___ 07:31AM BLOOD ___ PTT-33.8 ___
___ 03:27PM BLOOD ___ PTT-33.5 ___
___ 07:31AM BLOOD Glucose-79 UreaN-11 Creat-0.9 Na-142
K-3.9 Cl-102 HCO3-24 AnGap-16
___ 03:27PM BLOOD Glucose-81 UreaN-10 Creat-0.9 Na-140
K-3.9 Cl-103 HCO3-22 AnGap-15
___ 03:27PM BLOOD ALT-345* AST-150* AlkPhos-162*
TotBili-8.6* DirBili-7.3* IndBili-1.3
___ 07:31AM BLOOD ALT-272* AST-138* LD(LDH)-196
AlkPhos-170* TotBili-7.8*
___ 07:31AM BLOOD Albumin-4.1 Calcium-9.9 Phos-3.7 Mg-2.0
Final Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with abdominal pain RLQ jaundice// appendicitis
biliary
obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were
obtained.
COMPARISON: Reference CT abdomen pelvis ___, ___ ___
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: Compared with recent MRCP, there is new mild
intrahepatic and
extrahepatic biliary dilation.
CHD: 7 mm
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured
by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 12.8 cm
KIDNEYS: Limited views of the kidneys show no evidence of
hydronephrosis.
Right kidney: 11.0 cm
Left kidney: 12.1 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
RIGHT LOWER QUADRANT: On dedicated images of the right lower
quadrant, the
distal portion of the appendix is seen without significant wall
thickening and measuring up to 7 mm in diameter.
IMPRESSION:
1. New mild intrahepatic and extrahepatic biliary dilation.
2. Cholelithiasis without ultrasound findings of cholecystitis.
3. Partially visualized appendix without ultrasound findings of
appendicitis.
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with abdominal pain
RLQ
jaundiceNO_PO contrast// appendicitis ?
TECHNIQUE: Single phase contrast: MDCT axial images were
acquired through the
abdomen and pelvis following intravenous contrast
administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy
(Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 21.7 mGy
(Body) DLP =
1,064.5 mGy-cm.
Total DLP (Body) = 1,077 mGy-cm.
COMPARISON: Abdominal ultrasound ___ from 1 hour prior,
reference CT
abdomen pelvis ___
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.
Redemonstration of a rounded hypodense structure within segment
2 of the
liver, unchanged in size or appearance since prior exam and may
represent a
hepatic cyst or biliary hamartoma. There is mild intrahepatic
and
extrahepatic biliary dilation, with the distal common bile duct
measuring to
1.3 cm in diameter (series 2, image 25). Although no definite
radiodense
stones are seen within the the common bile duct, unable to rule
out
choledocholithiasis. The gallbladder contains gallstones
without wall
thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
Redemonstration of a 1.8 cm simple right renal cyst (series 2,
image 38),
unchanged in size or appearance since prior exam. There is no
evidence of
additional focal renal lesions or hydronephrosis. There is no
perinephric
abnormality.
GASTROINTESTINAL: No bowel obstruction is seen. Pancolonic
diverticulosis is
noted, without evidence of wall thickening and fat stranding.
The appendix is
top-normal in diameter, similar to prior (series 2, image 60).
PELVIS: Urinary bladder is relatively decompressed. There is no
free fluid in
the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Intrahepatic and extrahepatic biliary dilation, with the
distal bile duct
measuring up to 1.3 cm in diameter. Recommend ERCP/MRCP for
further
assessment for distal obstructing lesion/process.
2. Cholelithiasis without acute cholecystitis.
3. No evidence of acute appendicitis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Fenofibrate 145 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q4H:PRN Pain
3. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 4 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*8 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H Duration: 4 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*12 Tablet Refills:*0
3. Acetaminophen 325-650 mg PO Q4H:PRN Pain
4. Fenofibrate 145 mg PO DAILY
5. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Gangrenous cholecystitis with cholelithiasis
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: ___ with abdominal pain RLQ jaundice// appendicitis biliary
obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Reference CT abdomen pelvis ___, MRCP ___
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: Compared with recent MRCP, there is new mild intrahepatic and
extrahepatic biliary dilation.
CHD: 7 mm
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 12.8 cm
KIDNEYS: Limited views of the kidneys show no evidence of hydronephrosis.
Right kidney: 11.0 cm
Left kidney: 12.1 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
RIGHT LOWER QUADRANT: On dedicated images of the right lower quadrant, the
distal portion of the appendix is seen without significant wall thickening and
measuring up to 7 mm in diameter.
IMPRESSION:
1. New mild intrahepatic and extrahepatic biliary dilation.
2. Cholelithiasis without ultrasound findings of cholecystitis.
3. Partially visualized appendix without ultrasound findings of appendicitis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with abdominal pain RLQ
jaundiceNO_PO contrast// appendicitis ?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 21.7 mGy (Body) DLP =
1,064.5 mGy-cm.
Total DLP (Body) = 1,077 mGy-cm.
COMPARISON: Abdominal ultrasound ___ from 1 hour prior, reference CT
abdomen pelvis ___
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.
Redemonstration of a rounded hypodense structure within segment 2 of the
liver, unchanged in size or appearance since prior exam and may represent a
hepatic cyst or biliary hamartoma. There is mild intrahepatic and
extrahepatic biliary dilation, with the distal common bile duct measuring to
1.3 cm in diameter (series 2, image 25). Although no definite radiodense
stones are seen within the the common bile duct, unable to rule out
choledocholithiasis. The gallbladder contains gallstones without wall
thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Redemonstration of a 1.8 cm simple right renal cyst (series 2, image 38),
unchanged in size or appearance since prior exam. There is no evidence of
additional focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: No bowel obstruction is seen. Pancolonic diverticulosis is
noted, without evidence of wall thickening and fat stranding. The appendix is
top-normal in diameter, similar to prior (series 2, image 60).
PELVIS: Urinary bladder is relatively decompressed. There is no free fluid in
the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Intrahepatic and extrahepatic biliary dilation, with the distal bile duct
measuring up to 1.3 cm in diameter. Recommend ERCP/MRCP for further
assessment for distal obstructing lesion/process.
2. Cholelithiasis without acute cholecystitis.
3. No evidence of acute appendicitis.
RECOMMENDATION(S): Recommend ERCP for further evaluation of intrahepatic and
extrahepatic biliary dilation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Jaundice
Diagnosed with Unspecified abdominal pain
temperature: 97.4
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 87.0
level of pain: 1
level of acuity: 3.0 | Mr. ___ is a ___ year old male with
history of hypertension and hyperlipidemia, recent admission
___
for obstructive jaundice s/p ERCP and stent placement, with
recent stent removal who presents with 5 days of abdominal pain,
jaundice, pale stools.
#Obstructive jaundice
#Cholelithiasis: Presents with similar symptoms to prior
admission and has evidence of biliary obstruction on labs and on
CT A/P. No evidence of infection. Brushings from cytology at
last
ERCP were negative for malignancy. CA ___ was elevated, but is
likely a false positive as there is no mass appreciated on CT
imaging. He had ERCP on ___ which could not remove large stone
but did
place stent. ACS plans to do inpatient cholecystectomy ___
since he is
having frequent, recurrent episodes.
#HTN: not on any medications at the moment
#Obesity - outpatient exercise program
#HLD: continue simvastatin 10 mg QHS |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Atorvastatin / gabapentin
Attending: ___.
Chief Complaint:
vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year old woman with PMH significant for
cervical radiculopathy, HLD, hyperparathyroidism, HTN, migraine,
mitral regurgitation, seizures, Waldenstrom's, presenting to the
ER with nausea, vomiting since ___ pm.
Patient woke up from sleep and was helped to the bathroom where
she threw up. Family called an ambulance and patient was brought
to the ER. Patient has thrown up multiple times with what looks
to be nonbloody nonbilious emesis in the room. Of note patient
is
hard of hearing as well as husband who is there, so obtaining a
full and accurate history is difficult. Patient denies any sick
contacts, fever, chills, chest pain, shortness of breath,
abdominal pain, dysuria. Patient states that she feels
generalized weakness and states that this is new since last
night.
In the ED, initial vitals: 97.6 80 140/66 18 96% RA. With normal
exam.
Labs were significant for: Na 133, Cl 94, Calcium 10.8, Phos
2.0,
Lactate 3.9-->3.2, negative UA, negative flu. Blood and urine
cultures pending.
EKG: normal sinus rhythm without ST changes.
Imaging showed CXR: Low lung volumes with bibasilar opacities,
may represent atelectasis or infection.
NCHCT: No acute intracranial process.
CT-A:
1. No pulmonary embolism or acute aortic abnormality.
2. No acute process in the abdomen or pelvis.
3. Small right basilar consolidation likely represents
atelectasis, however
superimposed infection is difficult to completely exclude.
4. Small hiatal hernia.
In the ED, pt received:
Zofran IV 4 mg, 1.5 mL IVF NS, 500 mg Azithromycin, 1g IV
Ceftriaxone.
Vitals prior to transfer: 85 129/64 17 96% RA.
Currently, she reports that she is feeling very nauseous. Feels
dry mouth. Denies fevers/chills, chest pain/pressure, SOB,
cough.
Has a slightly sore throat. Denies abdominal pain. Denies
diarrhea/constipation. Last BM yesterday. She denies joint
pains,
weakness. Feels generally tired and weak but no specific
weakness. Has a headache. A couple of days ago had one of her
migraine episodes. Has no neck pain or stiffness. She denies any
vision loss or changes. Has chronic hearing loss that has not
changed.
Of note, has a tooth that was supposed to be pulled but she kept
refusing. She does not remember exactly what they said about the
tooth.
Past Medical History:
BPPV
Carpal Tunnel Syndrome
Cervical Radiculopathy
Cholecystits s/p ERCP sphincterotomy
Urinary frequency
HLD
Hyperparathyroidism
HTN
Migraines
Mitral regurgitation
MGUS
OA
Seizure d/o, grand mal
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ON ADMISSION:
GEN: Alert, lying in bed, no acute distress, uncomfortable and
nauseous, spitting up at times
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor. Has
left sided decaying tooth.
NECK: Supple. Cervical lymphadenopathy non-tender on left side.
No tenderness or stiffness.
PULM: Generally CTA b/l 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, ___ strength throughout.
ON DISCHARGE:
Vitals: ___ ___ Temp: 98.9 PO BP: 152/73 R HR: 84 RR: 16
O2 sat: 93% O2 delivery: Ra
General: alert, confused, NAD, sitting in bed
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: supple, no LAD
Resp: clear to auscultation bilaterally
CV: regular rate and rhythm,
GI: soft, non-tender, non-distended
Integument: PIV R arm
Pertinent Results:
___ 02:00AM BLOOD WBC-8.9 RBC-3.91 Hgb-12.1 Hct-36.4 MCV-93
MCH-30.9 MCHC-33.2 RDW-12.5 RDWSD-42.7 Plt ___
___ 02:00AM BLOOD Neuts-63.7 ___ Monos-5.4 Eos-1.1
Baso-0.3 Im ___ AbsNeut-5.68 AbsLymp-2.60 AbsMono-0.48
AbsEos-0.10 AbsBaso-0.03
___ 02:00AM BLOOD ___ PTT-25.9 ___
___ 02:00AM BLOOD Glucose-170* UreaN-12 Creat-0.8 Na-133*
K-4.3 Cl-94* HCO3-23 AnGap-16
___ 02:00AM BLOOD ALT-16 AST-22 LD(LDH)-195 CK(CPK)-57
AlkPhos-57 TotBili-0.4
___ 02:00AM BLOOD Albumin-3.7 Calcium-10.8* Phos-2.0*
Mg-2.0
___ 02:00AM BLOOD PTH-195*
___ 07:03AM BLOOD %HbA1c-5.3 eAG-105
___ 02:30AM BLOOD Lactate-3.9*
___ 04:08PM BLOOD Lactate-2.6*
REPORTS:
CXR ___
Low lung volumes with bibasilar opacities, may represent
atelectasis or
infection.
CT HEAD ___
No acute intracranial process.
Brain parenchymal atrophy is mild.
Moderate chronic small vessel ischemic changes.
Extensive periodontal disease posterior right mandibular molar,
possible
subclinical infection on the right, dental consult recommended.
CTA Chest and ABDOMEN ___. No pulmonary embolism or acute aortic abnormality.
2. No acute process in the abdomen or pelvis.
3. Small right basilar consolidation likely represents
atelectasis, however
superimposed infection is difficult to completely exclude.
4. Small hiatal hernia.
Blood/urine cultures - no growth
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 2.5 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gastroenteritis
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with hypoxia, elevated lactate, nausea// ?pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Multiple prior chest radiographs, most recently on ___
FINDINGS:
Lung volumes are low, crowding bronchovascular structures, with bibasilar
opacities. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable. There are degenerative changes in
the bilateral shoulders.
IMPRESSION:
Low lung volumes with bibasilar opacities, may represent atelectasis or
infection.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with lethargy, vomiting// ro 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 16.0 s, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MRI head on ___
FINDINGS:
There is no evidence of ACUTE infarction,hemorrhage,edema, or mass. Dilated
perivascular spaces in the bilateral basal ganglia are unchanged. There are
moderate chronic small vessel ischemic changes. Mild generalized brain
parenchymal atrophy. There are atherosclerotic calcifications in the
bilateral cavernous carotids.
A 1.3 cm hyperdense ovoid lesion in the right occipital parietal soft tissue
likely represent a epidermal inclusion cyst with proteinaceous material, also
present on prior. There is no evidence of fracture. There is mild mucosal
thickening in the right maxillary sinus and ethmoid air cells. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Patient is status post left lens replacement. The visualized
portion of the orbits are otherwise unremarkable. Periapical lucencies
involving posterior mandibular molars, consistent with extension of
periodontal disease, with irregularity of the tip of the roots of the right
posterior molar tooth apex, suggesting underlying probably subclinical
infection, clinically correlate, dental consult recommended. No definite
communication with the adjacent right maxillary sinus, which is partially
opacified. Degenerative arthritis bilateral temporomandibular joints.
IMPRESSION:
No acute intracranial process.
Brain parenchymal atrophy is mild.
Moderate chronic small vessel ischemic changes.
Extensive periodontal disease posterior right mandibular molar, possible
subclinical infection on the right, dental consult recommended.
RECOMMENDATION(S): Dental consult
Radiology Report
EXAMINATION: CTA chest and CT abdomen and pelvis with contrast
INDICATION: History: ___ with n/v, hypoxia// ?infection ?PE
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 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3
mGy-cm.
2) Spiral Acquisition 3.4 s, 27.1 cm; CTDIvol = 12.2 mGy (Body) DLP = 329.4
mGy-cm.
3) Spiral Acquisition 5.9 s, 46.1 cm; CTDIvol = 14.6 mGy (Body) DLP = 671.4
mGy-cm.
Total DLP (Body) = 1,003 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___
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 great vessels are within normal limits. The heart
is normal in size with coronary artery calcifications in the LAD and left
circumflex. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Evaluation of the lung parenchyma slightly limited by
respiratory motion. A small right basilar consolidation likely represents
atelectasis. There is minimal left basilar atelectasis. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal 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 a simple cyst arising from the right upper pole measuring up to 3.8
cm. There is no hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon is within normal limits. There is a moderate stool ball in the rectum.
The appendix is normal (2:139). There is no free intraperitoneal fluid or
free air.
PELVIS: Evaluation of the pelvis is slightly limited in the setting of streak
artifact from left hip arthroplasty.
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no
evidence of adnexal abnormality bilaterally.
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 AND SOFT TISSUES: Severe degenerative changes of the right shoulder are
partially visualized. There are degenerative changes in the thoracolumbar
spine, including mild anterolisthesis of L4 on L5. Patient is status post
left hip arthroplasty. There is no evidence of worrisome osseous lesions or
acute fracture. The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No pulmonary embolism or acute aortic abnormality.
2. No acute process in the abdomen or pelvis.
3. Small right basilar consolidation likely represents atelectasis, however
superimposed infection is difficult to completely exclude.
4. Small hiatal hernia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Vomiting
Diagnosed with Nausea with vomiting, unspecified
temperature: 97.6
heartrate: 80.0
resprate: 18.0
o2sat: 96.0
sbp: 140.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ year old woman with PMH significant for cervical
radiculopathy, HLD, hyperparathyroidism, HTN, migraine, mitral
regurgitation, seizures, Waldenstrom's, who presented with
nausea and vomiting. She was found to have an elevated lactate
level. She was treated with IV fluids with improvement in
lactate level.
She underwent imaging of the head, chest, and abdomen, which
revealed no acute process or explanation for lactic acidosis and
vomiting.
On the day of discharge she was symptomatically improved and
asked to go home. Her family came in and asked that she could go
home. ___ services were arranged and she was discharged.
TRANSITIONAL ISSUES
=====================
- Recommend she sees a dentist (dental disease noted on CT)
- Family has noted recent memory and cognitive decline and
functional decline. Further services and evaluation should be
considered as outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
"Headache."
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
OMED admit note Pt seen and evaluated ___ 2300
___ year-old woman with h/o of grade III anaplastic
oligoastrocytoma in the right temporal lobe, s/p resection who
presented today with 2 weeks of progressive headache and
tinnitus. Pt describes R sided and frontal pressure headache,
sore to touch. She has taken tyelnol and advil w/o improvement.
She also has pain with chewing. She initially had c/o tinnitus
started 2 weeks ago and saw her ENT dr ___ not find any
problems. This has not improved and is constant. Over the last
3 days, now having vertigo, + nausea, no vomiting, no problems
with gait.
.
She denies fevers, chills, night sweats, seizures. Also denies
CP, SOB, abd pain, vmiting, diarrhea, constipation. full ten
point ROS otherwise negative.
Past Medical History:
1. Grade III anaplastic oligoastrocytoma of the right temporal
lobe:
#Gross total resection ___ by ___, MD
#Involved-field cranial irradiation to 6,000 cGy ending ___
#4 cycles of Temodar ending ___
#SRS to 1,800 cGy ___ posterior medial cavity
#One cycle of CPT-11 ended ___, pt decided to stop
#Craniotomy with Gliadel wafers ___ by ___, MD
#CPT-11 restarted ___ - ___ cycles
2. ? History of Seizures - Unobserved falls in the past w prior
EEG suggestive of possible seizure activity
3. Panic disorder
4. EtOH abuse
5. Suicide attempt by medication overdose
6. Irritable bowel syndrome
7. Right ovarian cyst resection (___)
Social History:
___
Family History:
Sister with diabetes. Parents with HTN.
Physical Exam:
Admission PE
Exam
VS T current 97.8 BP118/67 HR 55 RR 18
O2sat 97% RA pain ___
Gen: In NAD.
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3, seems to have slight
facial assymetry, ? droop right side, EOMI, decreased sensation
over V1-V3, other CN intact on my exam, difficulty with tandem
gait, Romberg ok, finger to nose ok
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
.
Discharge PE
Tm: 98.2 Tc: 98.0 BP:120/62 HR:62 RR:16 O2 Sats 87 on RA
I/O ___
.
pain: per above
GEN: AAOX3 nad
HEENT: CN ___ grossly intact, frontal portion of skull midly
TTP, double vision when glasses are off (chronic)
NECK: ROM is close to full, no lad and no obvious thyroid masses
CV: RRR, no rmg
RESP: CTAB no wrr
ABD: NTND, active BS
back: LP site is CDI, minimal erythema and ttp
EXTR: WWP, no edema, pulses 2+ and equal
DERM: no obvious rashes
neuro: CN grossly intact (but chronic double vision) MS wnl,
strength and sensation wnl
PSYCH: mood and affect wnl
Pertinent Results:
___ 08:00AM BLOOD WBC-5.3 RBC-4.16* Hgb-11.1* Hct-33.5*
MCV-81* MCH-26.8* MCHC-33.3 RDW-15.0 Plt ___
___ 06:30AM BLOOD WBC-6.1 RBC-4.16* Hgb-11.2* Hct-33.4*
MCV-80* MCH-27.0 MCHC-33.6 RDW-14.9 Plt ___
___ 08:00AM BLOOD Glucose-83 UreaN-14 Creat-0.9 Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
___ 06:30AM BLOOD Glucose-97 UreaN-12 Creat-0.9 Na-137
K-3.9 Cl-102 HCO3-25 AnGap-14
___ 02:10PM BLOOD Glucose-84 UreaN-8 Creat-0.9 Na-137 K-5.0
Cl-103 HCO3-23 AnGap-16
___ 08:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.9
___ 06:30AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
.
CT ___ head:
IMPRESSION:
1. Stable postsurgical changes from prior right temporal
oligoastrocytoma
resection.
2. Minimal hypoattenuation in the cerebellum on the right seen
in area of
possible cavernoma with edema seen on prior MR.
3. Subcentimeter hyperdense focus in the left sylvian fissure
corresponds
with prior probable cavernoma. No surounding edema in this area.
4. No new hemorrhage, new vasogenic edema or mass effect.
.
MRI/MRI brain ___:
IMPRESSION:
1. Post-surgical changes as described above.
2. No new lesions. Stable nodular enhancement medial to surgical
bed.
3. Stable areas of magnetic susceptibility in left sylvian
fissure, right
frontal, and right temporal lobes likely represent cavernomas.
4. Stable enhancing area of magnetic susceptibility in right
cerebellum,
likley cavernoma, however given history cannot completely rule
out metastasis. Attention on follow up.
5. Normal MRA of the head.
.
___ EKG:
Sinus bradycardia. Low precordial voltage. RSR' pattern in lead
V1.
Since the previous tracing of ___ the rate is slower. ST-T
wave
abnormalities are improved.
.
___ Spinal fluid
Cerebrospinal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Monocytes and lymphocytes.
Radiology Report
HISTORY: ___ female with history of resection of a right temporal
grade 3 oligoastrocytoma, status post radiation and chemotherapy. Patient now
presenting with headache.
COMPARISON: MRI of the brain from ___.
TECHNIQUE: ___ MDCT axial images of the brain were obtained without
intravenous contrast. Coronal and sagittal reformations were prepared.
NONCONTRAST HEAD CT: The patient is status post resection of a large tumor
from the right temporal lobe. The resection cavity appears similar compared
to recent prior MR examination. The right temporal craniotomy sites and
metallic plates appears stable. Hypodensity in the cerebellum on the right
corresponds with a region of FLAIR hyperintensity with central focus of
enhancement and susceptibilty on prior MR. ___ punctate ___ in the
posterior left sylvian fissure corresponds with a region of probable
post-radiation cavernoma seen previously. Additional areas of enhancement
along the medial resection margin are not well characterized on this
non-contrast CT examination. There is no evidence of acute hemorrhage. No
focus of new vasogenic edema is identified to suggest new mass lesion. There
is no shift of the usually midline structures. Suprasellar and basilar
cisterns are widely patent. No scalp hematoma or acute osseous abnormality is
evident. The visualized paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
1. Stable postsurgical changes from prior right temporal oligoastrocytoma
resection.
2. Minimal hypoattenuation in the cerebellum on the right seen in area of
possible cavernoma with edema seen on prior MR.
3. Subcentimeter hyperdense focus in the left sylvian fissure corresponds
with prior probable cavernoma. No surounding edema in this area.
4. No new hemorrhage, new vasogenic edema or mass effect.
Radiology Report
INDICATION: ___ woman with oligoastrocytoma status post resection,
possible cavernomas, now with right-sided headache and tinnitus, evaluate for
intracranial lesion, cavernoma versus other lesion.
COMPARISON: MRI of the head on ___.
TECHNIQUE: MRI of the head with and without contrast. MRA of the head.
FINDINGS: Post-surgical changes are again seen in the right temporal fossa
with similar configuration of the surgical bed and stable medial nodular
enhancement. The areas of magnetic susceptibility in the left sylvian fissure
and right frontal and right temporal lobes are less apparent however this
could be due to difference in technique as this study was done on a 1.5 tesla
magnet and the most recent study was done on a 3 tesla magnet. There is no
diffusion abnormality to suggest acute ischemia. There is no acute
hemorrhage. The area of susceptibility that enhances is again seen with
vasogenic surrounding edema in the right cerebellum, unchanged. No new
lesions.
MRA: The left vertebral artery is dominant. The right vertebral artery is
hypoplastic. The intracranial anterior and posterior circulation arteries are
patent without evidence of stenosis. There is no aneurysm or vascular
malformation. The right posterior communicating artery is patent.
IMPRESSION:
1. Post-surgical changes as described above.
2. No new lesions. Stable nodular enhancement medial to surgical bed.
3. Stable areas of magnetic susceptibility in left sylvian fissure, right
frontal, and right temporal lobes likely represent cavernomas.
4. Stable enhancing area of magnetic susceptibility in right cerebellum,
likley cavernoma, however given history cannot completely rule out metastasis.
Attention on follow up.
5. Normal MRA of the head.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HEADACHE
Diagnosed with BRAIN NEOPLASM NOS
temperature: 97.3
heartrate: 56.0
resprate: 20.0
o2sat: 100.0
sbp: 107.0
dbp: 73.0
level of pain: 10
level of acuity: 2.0 | Pt is a ___ y.o female with h.o anaplastic oligoastrocytoma s/p
resection and XRT, seizures, ETOH abuse, IBS who presents with
headache and tinnitus
.
##headache/tinnitus/unsteadiness
Pt reported progressively increasing symptoms over the last 2
weeks. No fever or other infectious symptoms. No signs of
encephalitis or meningismus. Primary concern would be for return
of malignancy given that symptoms correspond to apparent area of
prior cancer. In addition, other considerations could include
posterior stroke or TIA, but otherwise neurologically intact.
Could consider migraine, headache, post XRT effect, BPPV
(unlikely) etc. MRA negative, MRI showed edema in the
R.cerebellum cannot r/o metastasis other possibility including a
cavernoma. Pt's neuro signs were monitored closely. She was
given tordol, Tylenol and oxycodone prn pain. Neuro
oncology/neurology was consulted and performed an LP that was
negative for malignant cells. The patients headache recurred
after a day or so free of symptoms. She was tried on diamox,
which was not effective. She was given a headache cocktail of
phenergan, depakote, dexamethasone, IVF and caffeine and the
headache resolved. The patients headache seemed to recur in the
morning when she woke up. Dr. ___ back and saw the
patient and felt as thought this headache is chronic, could be
managed with NSAID's, vicodin and tylenol and the patient could
be sent home. The leading cause of these headache were thought
to be vascular headaches vs. tension headaches. The patient was
sent home on amitriptyline 10 QHS.
.
##Ataxic gait
The patient was initially evaluated by ___ and they recommended
ambulating with a walker vs. inpatient ___. The following day,
___ re-evaluated her and her gait was within normal limits. She
was given a prescription for outpatient ___.
.
## Positive Urine culture
The patient UA was negative and she denies symptoms. Her UC
grew out alpha strep vs. lactobaccilus. This is likely a
contaminant and/or reflects the normal vaginal flora. Elected
to not treat, but if develops symptoms in the future, would
consider repeating UA/UC.
.
##Constipation
The patient was sent home on po and pr bowel medications.
.
##h.o anaplastic oligoastrocytoma
No known recurrence as the cause of this headache. Will
continue to follow with Dr. ___
.
##Transitional Issues:
-VDRL CSF is pending, please follow up
-Patient needs to follow up with her PCP and ___
Dr. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female, previously healthy presents with sharp/dull
periumbilical pain nowlocalized to RLQ starting this morning.
She reports having
generalized malaise, nausea (no emesis), anorexia and diarrhea
for the past 3 days. She didn't have fevers at home but 102 in
the ED. Her last episode of diarrhea was this morning. LMP 2
days
ago.
Past Medical History:
Anemia of unknown origin
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: ___ upon admission:
___ 18 96RA
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, RLQ tenderness to palpation.
+McBurney's
point tenderness, + Rovsings
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___:
vital signs:
t=98.4, hr=55, bp=100/69, rr=18, 97% room air
GENERAL: NAD
CV: ns1, s2
LUNGS: clear
ABDOMEN: hypoactive BS, soft, tender, no rebound, no guarding
EXT: no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 06:19AM BLOOD WBC-9.1 RBC-3.47* Hgb-8.8* Hct-28.5*
MCV-82 MCH-25.4* MCHC-30.9* RDW-16.9* RDWSD-51.0* Plt ___
___ 05:25AM BLOOD WBC-9.9 RBC-3.32* Hgb-8.9* Hct-27.4*
MCV-83 MCH-26.8 MCHC-32.5 RDW-16.8* RDWSD-50.4* Plt ___
___ 11:25AM BLOOD WBC-14.2* RBC-3.98 Hgb-10.5* Hct-32.9*
MCV-83 MCH-26.4 MCHC-31.9* RDW-16.5* RDWSD-50.1* Plt ___
___ 06:19AM BLOOD Plt ___
___ 06:44PM BLOOD ___ PTT-30.0 ___
___ 06:19AM BLOOD Glucose-91 UreaN-4* Creat-0.6 Na-143
K-4.0 Cl-106 HCO3-23 AnGap-14
___ 11:25AM BLOOD ALT-10 AST-15 AlkPhos-47 TotBili-0.5
___ 06:19AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
___: CT abd and pelvis:
Acute appendicitis, likely complicated by micro perforation. No
evidence of drainable fluid collection.
___: CT abd and pelvis:
1. No significant interval change in acute appendicitis with
surrounding
inflammatory changes/phlegmon. No formed abscess or drainable
fluid
collection.
2. Trace bilateral pleural effusions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
___ last dose
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*13 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Perforated appendicitis with phlemgmon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with severe abdominal pain, intermittent,
epigastric// biliary colic
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 2 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.5 cm.
KIDNEYS: Limited views of the right kidney shows no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal abdominal ultrasound.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ with sever abdominal pain, now worse. diarrhea. no recent
travel. // ? colitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.Oral contrast was not administered.Coronal and
sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 462 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 an
inflamed hyperemic tubular structure arising from the cecum measuring up to 17
mm (2:68). There is adjacent free fluid as well as mild thickening of the
adjacent distal/terminal ileum. The extent of inflammation suggests at least
micro perforation. No drainable fluid collections are identified. Adjacent
right lower quadrant prominent lymph nodes likely reactive. No evidence of
adjacent peritoneal thickening or hyperemia. The remaining colon and rectum
are within normal limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small free fluid in the pelvis in the right lower quadrant extending to the
pelvis.
REPRODUCTIVE ORGANS: The uterus and left adnexae are within normal limits.
The right ovary abuts the inflammatory changes in the right lower quadrant.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Acute appendicitis, likely complicated by micro perforation. No evidence of
drainable fluid collection.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS
INDICATION: ___ year old woman with perforated appendicitis, w/ phlegmonon//
Previous CT from ___ showed no abscess, is there an abscess now?
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 = 6.5 mGy (Body) DLP = 343.3
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 8.4 s, 0.5 cm; CTDIvol = 42.7 mGy (Body) DLP =
21.3 mGy-cm.
Total DLP (Body) = 366 mGy-cm.
COMPARISON: CT abdomen and pelvis performed on ___
FINDINGS:
LOWER CHEST: There are trace bilateral pleural effusions, new from ___.
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 in appearance. Small bowel
loops are normal in caliber. Again seen is a markedly dilated appendix
measuring up to 1.5 cm, compatible with known acute appendicitis. There is
wall hyperemia with extensive surrounding inflammatory and phlegmonous
changes, appearing overall similar in extent and morphology compared to ___. There is no organized drainable fluid collection. No pneumoperitoneum.
PELVIS: Urinary bladder is unremarkable in appearance. An oval-shaped
hypodensity in the region of the right adnexa measuring up to 4.5 cm most
likely represents the right ovary (2:75). This is more apparent on the
coronal images, where it is morphologically similar to the contralateral
ovary.
REPRODUCTIVE ORGANS: Uterus is unremarkable in appearance.
LYMPH NODES: Retroperitoneal and mesenteric lymph nodes are not enlarged by
size criteria. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No significant interval change in acute appendicitis with surrounding
inflammatory changes/phlegmon. No formed abscess or drainable fluid
collection.
2. Trace bilateral pleural effusions.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Unspecified abdominal pain
temperature: 99.0
heartrate: 91.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | ___ year old female admitted to the hospital with ___
pain. Upon admission, the patient was made NPO, given
intravenous fluids and underwent imaging which showed acute
appendicitis, likely complicated by micro perforation. The
patient underwent serial abdominal examinations along with
monitoring of the white blood cell count. She was started on a
course of intravenous antibiotics. During her hospitalization,
she experienced bouts of nausea and vomiting while on the
antibiotics and her abdominal pain continued. A repeat cat scan
was done which showed no abdominal abscess or fluid collection.
The patient's abdominal pain began to resolve and she was
transitioned to oral antibiotics. Her white blood cell count
normalized. The patient was started on a regular diet. She was
ambulatory and voiding without difficulty. Bowel function was
slow to return. The patient was discharged from the hospital
on HD #5 in stable condition. Discharge instructions were
reviewed and questions answered. A follow-up appointment was
made in the acute care clinic. The patient was given a
prescription to complete a 7 day course of antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / Bactrim / donepezil / ibuprofen / lactulose /
montelukast / Mucinex / nifedipine / tramadol / Vicodin
Attending: ___.
Chief Complaint:
COUGH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/asthma and COPD presenting with progressive dry cough x 4
days. Patient went to PCP initially who prescribed azithromycin
and nebulizer every 4 hours. This AM, the patient's son noted
wheezing and brought her to the ED.
Patient denies fevers, chills. Cough is productive of minimal
sputum. Of note, patient had a sinus infection 1 month ago, but
no sinus tenderness or post-nasal drip. Patient denies smoking
and sick contacts.
No Chest pain, no shortness of breath, abdominal pain, n/v/d. No
myalgia. No sore throat.
Past Medical History:
GERD
Gout
COPD
CKD
Alzheimer's
HTN
Latent TB
Social History:
___
Family History:
History of DM
No h/o lung CA
Physical Exam:
ADMISSION
Vitals: T 98.2 BP 147/76 HR 99 R 18 SpO2 96 ra
GEN: NAD, coughing
HEENT: Sclera anicteric, no rhinorrhea
___: Regular, no MRG, difficult to auscultate over coughing
Lungs: No increased WOB, diffuse inspiratory and expiratory
wheezing in all fields. No rhonchi, no crackles
Abd: NTND
Ext: Warm, trace edema b/l
DISCHARGE
VS: 98.0 104/65 100 18 92%RA Amb sat: 95%
GEN: nontoxic, appears comfortable, sitting up
HEENT: NC/AT
CV: RRRR
Lungs: fair to good air exachange. Sparse wheezing
Abd: soft NTND
Exrem: wwp
Psych: AAOx2, pleasant
Pertinent Results:
ADMISSION
___ 09:33AM BLOOD WBC-5.2 RBC-4.56 Hgb-13.6 Hct-42.1 MCV-92
MCH-29.8 MCHC-32.3 RDW-14.6 RDWSD-49.0* Plt ___
___ 09:33AM BLOOD Neuts-83.5* Lymphs-12.4* Monos-1.4*
Eos-1.7 Baso-0.2 Im ___ AbsNeut-4.30 AbsLymp-0.64*
AbsMono-0.07* AbsEos-0.09 AbsBaso-0.01
___ 06:00AM BLOOD Glucose-105* UreaN-12 Creat-1.0 Na-140
K-3.9 Cl-104 HCO3-24 AnGap-16
PERTINENT
___ 09:33AM BLOOD Neuts-83.5* Lymphs-12.4* Monos-1.4*
Eos-1.7 Baso-0.2 Im ___ AbsNeut-4.30 AbsLymp-0.64*
AbsMono-0.07* AbsEos-0.09 AbsBaso-0.01
___ 05:31AM BLOOD Neuts-66.6 ___ Monos-7.8 Eos-1.1
Baso-0.2 Im ___ AbsNeut-6.19* AbsLymp-2.22 AbsMono-0.73
AbsEos-0.10 AbsBaso-0.02
DISCHARGE
___ 05:31AM BLOOD WBC-9.3# RBC-4.98 Hgb-14.7 Hct-46.3*
MCV-93 MCH-29.5 MCHC-31.7* RDW-14.6 RDWSD-49.3* Plt ___
___ 05:31AM BLOOD Neuts-66.6 ___ Monos-7.8 Eos-1.1
Baso-0.2 Im ___ AbsNeut-6.19* AbsLymp-2.22 AbsMono-0.73
AbsEos-0.10 AbsBaso-0.02
___ 05:32AM BLOOD Glucose-99 UreaN-21* Creat-1.1 Na-140
K-3.7 Cl-103 HCO3-25 AnGap-16
STUDIES
___ CXR
IMPRESSION: No acute cardiopulmonary process.
MICROBIOLOGY
none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Allopurinol ___ mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Furosemide 10 mg PO 3X/WEEK (___)
5. Docusate Sodium 100 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Bisacodyl 10 mg PR QHS:PRN constipation
8. Tiotropium Bromide 1 CAP IH DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
11. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Docusate Sodium 100 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Furosemide 10 mg PO 3X/WEEK (___)
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Vitamin D ___ UNIT PO DAILY
10. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
11. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb ih every four
(4) hours Disp #*42 Vial Refills:*0
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
ih every six (6) hours Disp #*28 Ampule Refills:*0
14. PredniSONE 40 mg PO DAILY Duration: 2 Doses
RX *prednisone [Deltasone] 20 mg 2 tablet(s) by mouth daily Disp
#*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
COPD Exacerbation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with wheezing, cough, SOB // evaluate for
pneumonia, acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs the most recent on ___
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. The aorta
is tortuous and shows mural calcification. The lungs are clear without focal
consolidation, pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 96.6
heartrate: 108.0
resprate: 18.0
o2sat: 96.0
sbp: 144.0
dbp: 107.0
level of pain: 0
level of acuity: 3.0 | ___ with h/o Asthma/COPD presents with COPD exacerbation. VSS,
afebrile, no signs of PNA and satting well on room air.
BRIEF HOSPITAL COURSE
#COPD exacerbation: Patient has had progressive, non-productive
cough x1 week. She denies fevers/chills, no vomiting,
rhinorrhea, ST or muscle aches make a viral URI unlikely as the
exacerbating factor. Patient is afebrile with clear CXR which
rules out PNA. Of note the patient has a remote history of a
sinus infection which may have been the exacerbating factor.
Given that the patient is satting 96% on RA she does not need O2
at this time. Patient has h/o latent TB though no concerning
findings on CXR. Coughing had some relief with benzonatate,
however is still very distressing for the patient and her son.
The patient was given scheduled duonebs and albuterol. In
addition a prednisone taper was started at 60mg PO, patient
given script to finish 5 day prednisone burst and she was
started on azithromycin. She did not have any oxygen requirement
during her hospitalization; sats and ambulatory sats within
normal limits on day of discharge.
#Neutrophilia: patient has no leukocytosis and is afebrile but
has 83% PMNs on diff. CXR does not show PNA. Afebrile, UA
negative. no other signs of infection at this time. Repeat diff
shows resolution.
#GERD: Patient continued on home PPI
#ESRD: Cr 1.0, baseline unknown; continued on home furosemide |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
My ___ is a ___ male hx CVA and vascular dementia who presents to
___ on ___ with a mild TBI on Aspirin 81mg. Pt
with multiple falls over the past 3 days. The patient had a
recent admission for lethargy and falls with left sided weakness
and found to have multiple right sided strokes, likely
cardioembolic. Family reports he has become increasingly weak on
his right side since discharge which has lead to the
falls. + headstrike, no LOC. Family at bedside also reports
increased confusion and agitation since discharge. Currently he
is undergoing evaluation with a Holter monitor for Afib. In the
ED, his systolic pressure remained elevated to 200 and he was
started on nicardipine.
Past Medical History:
PMHx:
Ischemic stroke ___
BPH s/p surgery in ___ ___
Hyperlipidemia
Glucose intolerance
Possible psoriasis vs. eczema based on R elbow rash
PSHx:
Prostate surgery as noted above
Social History:
___
Family History:
FHx:
No family history of dementia, memory problems or strokes
Physical Exam:
Exam on Admission:
=================
Gen: WD/WN, comfortable, NAD.
HEENT: small amount of right periorbital ecchymosis
Neck:
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, attentive but poor effort with exam
Orientation: Oriented to person, ___ but not date, answers
___ for year
Language: Speech is fluent per daughter
___:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual not tested due to pt cooperation.
III, IV, VI: Extraocular movements appear intact bilaterally but
pt does not follow full exam.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors.
On Drift testing the right arm drops intermittently but then
corrects.
Pt does not complete formal muscle group testing but is at least
antigravity throughout. Right UE appears slightly weaker than
left. Right Grip ___, left Grip 4+/5
Sensation: Intact to light touch
Exam on Discharge
=================
Vitals: T 97.5 PO 126 - 153/66-79, 93 18 93 Ra
General: no acute distress
HEENT: sclerae anicteric
Neck: Supple
___: RRR, normal S1/S2, no r/g/m
Pulmonary: CTA anteriorly
Abdomen: Soft, non-distended
Extremities: WWP, no peripheral edema
Neuro: ___ strength in R extremities, ___ in left extremities
Skin: No rashes or lesions
Pertinent Results:
ADMISSION LABS:
==================
___ 05:55PM BLOOD WBC-8.8 RBC-5.35 Hgb-15.4 Hct-46.7 MCV-87
MCH-28.8 MCHC-33.0 RDW-14.8 RDWSD-46.8* Plt ___
___ 05:55PM BLOOD Neuts-64.3 ___ Monos-7.6 Eos-1.8
Baso-0.3 Im ___ AbsNeut-5.66 AbsLymp-2.24 AbsMono-0.67
AbsEos-0.16 AbsBaso-0.03
___ 05:55PM BLOOD ___ PTT-35.5 ___
___ 05:55PM BLOOD Glucose-172* UreaN-18 Creat-0.9 Na-138
K-3.5 Cl-99 HCO3-25 AnGap-18
___ 07:30PM BLOOD cTropnT-<0.01
___ 05:55PM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
___ 08:59PM BLOOD Lactate-1.5
___ 08:30PM URINE Color-Straw Appear-Clear Sp ___
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
OTHER RELEVANT LABS:
=====================
___ 12:36AM BLOOD WBC-11.3* RBC-5.11 Hgb-14.6 Hct-44.6
MCV-87 MCH-28.6 MCHC-32.7 RDW-14.7 RDWSD-47.3* Plt ___
___ 07:05AM BLOOD WBC-10.4* RBC-4.84 Hgb-14.1 Hct-42.4
MCV-88 MCH-29.1 MCHC-33.3 RDW-14.8 RDWSD-47.6* Plt ___
___ 06:10AM BLOOD WBC-8.0 RBC-4.40* Hgb-12.7* Hct-38.9*
MCV-88 MCH-28.9 MCHC-32.6 RDW-15.0 RDWSD-48.4* Plt ___
___ 05:51AM BLOOD ___ PTT-32.9 ___
___ 07:05AM BLOOD ___ PTT-30.5 ___
___ 05:37AM BLOOD Glucose-142* UreaN-14 Creat-0.8 Na-138
K-3.4 Cl-99 HCO3-25 AnGap-17
___ 07:54AM BLOOD Glucose-154* UreaN-25* Creat-0.9 Na-141
K-3.6 Cl-106 HCO3-25 AnGap-14
___ 06:10AM BLOOD Glucose-143* UreaN-21* Creat-1.0 Na-140
K-3.9 Cl-99 HCO3-22 AnGap-23*
___ 02:54AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
___ 05:37AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.9*
___ 07:54AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9
___ 06:10AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
___ 06:05AM BLOOD Cortsol-15.9
___ 06:10AM BLOOD HIV Ab-Negative
___ 12:10PM BLOOD Type-ART O2 Flow-3 pO2-102 pCO2-41
pH-7.39 calTCO2-26 Base XS-0 Intubat-NOT INTUBA Comment-NASAL
___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
==================
___ CT C-spine
No evidence of fracture or traumatic malalignment.
___ ___
Acute subarachnoid hemorrhage within a left frontal lobe sulcus.
While there is no evidence of acute territorial infarction, MRI
is more
sensitive for the detection of acute infarction.
___ ___
IMPRESSION:
Subarachnoid hemorrhage along a left frontal sulcus, not
appreciated on the current examination. No new hemorrhage.
___ CXR
IMPRESSION:
No acute cardiopulmonary abnormality.
CVEEG (___): IMPRESSION: This is an abnormal continuous ICU
monitoring study because of a slow and disorganized background,
indicative of a mild to moderate encephalopathy, which is
nonspecific with regard to etiology. There are frequent bursts
of generalized delta frequency slowing as well as frontal
predominant slowing, suggestive of subcortical dysfunction.
There are no clear epileptiform discharges or electrographic
seizures.
CXR (___):
IMPRESSION: Comparison to ___. No relevant change
is seen. Moderate cardiomegaly with elongation of the
descending aorta and enlargement of the left ventricle. No
pulmonary edema. No pneumonia, no pleural effusions.
DISCHARGE LABS:
====================
___ 07:20AM BLOOD WBC-9.6 RBC-4.40* Hgb-12.9* Hct-39.8*
MCV-91 MCH-29.3 MCHC-32.4 RDW-15.4 RDWSD-50.7* Plt ___
___ 07:20AM BLOOD Glucose-107* UreaN-25* Creat-0.8 Na-144
K-4.0 Cl-103 HCO3-28 AnGap-17
___ 07:20AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Naproxen 500 mg PO Q12H:PRN Pain - Mild
3. Colchicine 0.6 mg PO BID:PRN gout attack
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*42 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
3. Atorvastatin 80 mg PO QAM
RX *atorvastatin 80 mg 1 tablet(s) by mouth every morning Disp
#*14 Tablet Refills:*0
4. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
5. Docusate Sodium 100 mg PO DAILY
RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*14
Capsule Refills:*0
6. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. Senna 8.6 mg PO DAILY
RX *sennosides 8.6 mg 1 tablet by mouth daily Disp #*14 Tablet
Refills:*0
8. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
10. Colchicine 0.6 mg PO BID:PRN gout attack
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Subarachnoid hemorrhage
Toxic metabolic encephalopathy
Hypertension
Constipation
Secondary:
Gout
Discharge Condition:
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with increasing falls, weakness // evaluate for
pneumonia
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: ___ chest radiograph
FINDINGS:
Mild cardiomegaly with a left ventricular predominance is not changed from the
previous study. The mediastinal and hilar contours are similar with mild
atherosclerotic calcifications noted at the aortic arch. Pulmonary
vasculature is not engorged. Patchy left lower lobe opacity could reflect an
area of atelectasis, but infection or aspiration is not excluded. No pleural
effusion or pneumothorax is seen. No acute osseous abnormality is visualized.
IMPRESSION:
Left lower lobe patchy opacity could reflect atelectasis, but infection or
aspiration is not excluded in the correct clinical setting.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall 3 days ago, on ASA, increasing confusion
and right sided weakness. Patient has history of stroke
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) = 803 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
There is a small amount of acute subarachnoid blood within a left frontal
sulcus (series 2, image 26). There is no evidence of large acute territory
infarction, hemorrhage, edema, or mass. Subcortical, deep, and
periventricular white matter hypodensities in both cerebral hemispheres are
nonspecific, but likely represent the sequela of chronic microvascular
ischemic disease. There is prominence of the ventricles and sulci suggestive
of involutional changes. Mild atherosclerotic calcifications are noted within
the distal vertebral arteries and cavernous carotid arteries.
There is no evidence of fracture. Mild mucosal thickening is seen within the
bilateral maxillary sinuses and scattered ethmoid air cells. Otherwise, the
visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The patient is status post bilateral lens resections.
IMPRESSION:
Acute subarachnoid hemorrhage within a left frontal lobe sulcus.
While there is no evidence of acute territorial infarction, MRI is more
sensitive for the detection of acute infarction.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall 3 days ago, on ASA, increasing confusion
and right sided weakness. Patient has history of stroke.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 790 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified. There is no prevertebral
soft tissue swelling. There is no evidence of infection or neoplasm.
Extensive nuchal ligament ossification is noted.
Multilevel mild degenerative disc disease is demonstrated with small posterior
intervertebral osteophytes causing mild narrowing of the spinal canal, most
pronounced at C5-6. No high-grade spinal canal or neural foraminal stenosis.
No thyroid nodules. No cervical lymphadenopathy. The partially visualized
lung apices are within normal limits. Incidental note is made of a
right-sided, ovoid, air and fluid containing structure (03:56) at the thoracic
inlet adjacent to the right lateral aspect of the proximal esophagus,
potentially a ___ diverticulum.
IMPRESSION:
No evidence of fracture or traumatic malalignment.
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) RIGHT
INDICATION: History: ___ with right arm pain // fracture?
TECHNIQUE: Frontal and lateral view radiographs of the right forearm.
COMPARISON: None.
FINDINGS:
No fracture is detected in the radius or ulna. The proximal or distal
radioulnar joints are congruent. No suspicious lytic or sclerotic lesion or
periosteal new bone formation is detected. No soft tissue calcification is
seen. Limited assessment of the elbow and wrist joint demonstrates no gross
acute abnormality. Mild degenerative spurring is seen involving the ulnar
trochlear joint. Enthesophyte is noted at the insertion of the triceps upon
the olecranon.
IMPRESSION:
No fracture.
Radiology Report
INDICATION: History: ___ with right arm pain // fracture?
TECHNIQUE: Right shoulder, three views, right humerus, two views
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is present. Mild degenerative changes are
noted involving the glenohumeral joint with joint space narrowing and minimal
spurring. The acromioclavicular joint demonstrates minimal spurring. There
are no amorphous soft tissue calcifications. No concerning lytic or sclerotic
osseous abnormalities are detected. The imaged right lung is clear.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH and delirium // please assess for
infiltrate please assess for infiltrate
IMPRESSION:
In comparison with the study of ___, the patient has taken a better
inspiration. Cardiac silhouette is at the upper limits of normal and there is
mild tortuosity of the descending thoracic aorta. No evidence of pulmonary
vascular congestion, pleural effusion, or acute focal pneumonia at this time.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST
INDICATION: ___ year old man with left traumatic SAH post fall on ASA 81mg,
evaluate subarachnoid hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 1060 mGy-cm.
COMPARISON: Head CT ___ he and ___
FINDINGS:
Focus of subarachnoid hemorrhage along a left frontal sulcus at the vertex,
not well seen on the current study. No new hemorrhage identified. Ventricles
and sulci are enlarged suggesting age related atrophy. Periventricular and
subcortical white matter hypodensities are nonspecific, but likely sequela of
chronic small vessel disease. Chronic lacune noted in the right corona
radiata. Basal 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 visualized
portion of the orbits are unremarkable. There been bilateral lens
replacements.
IMPRESSION:
Subarachnoid hemorrhage along a left frontal sulcus, not appreciated on the
current examination. No new hemorrhage.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old man with hx of dementia w/ tSAH, now resolved //
Evaluate for pulmonary source of infection
TECHNIQUE: Multiple AP views
COMPARISON: Chest radiograph ___
FINDINGS:
The heart measures at the upper limits of normal. Lung volumes are mildly
decreased in comparison the prior examination. Subtle increased patchy
opacity at the right lung base is stable from multiple prior radiographs
dating back to ___ and likely represents a combination of
atelectasis and pulmonary vessels. There is no pneumothorax. No pleural
effusion.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man s/p resolved SAH, with somnolence. interval
change? // interval change?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
2) Sequenced Acquisition 12.0 s, 13.1 cm; CTDIvol = 45.8 mGy (Head) DLP =
602.1 mGy-cm.
3) Sequenced Acquisition 3.0 s, 6.6 cm; CTDIvol = 45.8 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CTs head ___ and ___
FINDINGS:
Small amount of subarachnoid hemorrhage along a left frontal sulcus (02:24) is
decreased as compared to CT head ___. There is no evidence of new
intracranial hemorrhage. There is a chronic lacunar infarct noted in the
right corona radiata. Prominent ventricles and sulci are compatible with
age-related global atrophy. Periventricular and subcortical white matter
hypodensities are nonspecific but likely sequelae of chronic small vessel
ischemic disease.
Limited evaluation of the paranasal sinuses due to motion artifact but no
gross abnormality. Patient is status post lens replacements. Mastoid air
cells and middle ear cavities are well aerated. Limited evaluation of the
temporal bone due to motion artifact but there is no fracture within the
limitations.
IMPRESSION:
Small left subarachnoid hemorrhage is decreased as compared to head CT ___. No evidence of worsening or new intracranial hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Mr. ___ is an ___ year old ___ man with previous
history of CVAx2 of uncertain etiology, presumed embolic, with declining
baseline mental status over past year, admitted after a fall with L
subarachnoid hemorrhage and now transferred to Medicine for management of
delirium. T101 overnight// eval for PNA eval for PNA
IMPRESSION:
Comparison to ___. No relevant change is seen. Moderate
cardiomegaly with elongation of the descending aorta and enlargement of the
left ventricle. No pulmonary edema. No pneumonia, no pleural effusions.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: R Weakness, Altered mental status
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified
temperature: 98.1
heartrate: 96.0
resprate: 16.0
o2sat: 95.0
sbp: 170.0
dbp: 101.0
level of pain: unable
level of acuity: 2.0 | Mr. ___ is an ___ ___ man with previous
history of CVAx2 of uncertain etiology, presumed embolic, with
declining baseline mental status over past year, admitted after
a fall with L subarachnoid hemorrhage.
The patient was admitted to the stepdown unit for management of
blood pressure. He was originally on nicardipine in the ED, but
experienced rebound tachycardia and switched effectively to a
Lopressor drip. The Lopressor drip was stopped on the morning of
___. No further imaging of his head was needed as he was
neurologically stable. He was transferred to the Medicine
service upon transfer out of the Neuro ICU for management of
delirium on ___.
#Encephalopathy: Patient presented with progressively worsening
mental status and falls over past year. He was agitated during
admission and unable to tolerate MRI. There was also likely a
component of underlying dementia. Patient had EEG on prior
admission (___) indicating focal slowing c/f deep midline
subcortical dysfunction but without evidence of seizure. Tox
screen and lyme serology were negative. Patient's HIV was
negative and cultures were negative. No seizure activity noted
on CVEEG during this admission. Pt required olanzapine while in
the step down unit, but this made him more somnolent. He
required no further doses of olanzapine while on the medicine
service. His mental status improved with frequent reorientation.
#HTN: Patient with persistent hypertension. Patient was started
on lisinopril and amlodipine, which were slowly uptitrated with
goal of maintaining SBP <160 given SAH. His blood pressures
remained stable on these doses. Discharge BP **** Patient's Cr
was checked 1 week after starting lisinopril and was wnl.
#Constipation- Patient was continue docusate, senna, bisacodyl
daily. These medications were transitioned to once a day dosing
for ease of medication administration for family upon discharge.
Patient routinely had BMs every ___ days.
#History of embolic stroke: Patient underwent evaluation for
etiology of embolic strokes on recent admission (___). TTE
with no evidence of endocarditis. He underwent holter monitoring
and was on telemetry with no evidence of atrial fibrillation.
Patient was restarted on aspirin 81 mg daily on ___, 14 days
post- SAH.
#Gout: Continued allopurinol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ancef / Bactrim / latex / doxycycline
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ yo M w/ ___ chronic venous ulcerations
followed by wound care at ___, A. Fib on
Metoprolol/digoxin/warfarin, who came in with atypical chest
pain.
Mr. ___ reports intermittent c/p with exertion and at rest
chronically over the last several weeks. The pain is usually
left sided and associated with palpitations and SOB this AM. ___
reported pt initially declined to go to ED for eval, BP 108/70,
HR 80-101. After calling outpatient cardiologist Dr.
___ was referred to ___ ED. He is chronically on
digoxin and metoprolol XL 50mg. He has multiple hospitalizations
in the past from ___ for afib with RVR requiring
amiodarone in ___ and uptitration of digoxin and metoprolol in
___.
He was in A. Fib w/ RVR w/ rates in 140s-150s and was
hypotensive w/ SBPs ___. It was unclear if he was hypotensive
from infected wounds (feet) v. unstable A. fib. Levophed was
started in the ED, but he did not receive pressors in MICU. He
was loaded with amiodarone overnight.
He is still in A. fib but rates are better controlled now.
Questionable medication compliance prior to admission. Dig level
was undetectable on admission. He received 150 mg amiodarone
overnight and was getting 0.5 mg infusion over ___ hours.
Digoxin was restarted.
Past Medical History:
Dyslipidemia
Hypertension
Nondisplaced fracture of greater trochanter of left femur
Status post skin graft
Compression fracture of L4 lumbar vertebra
Esophagitis
Depression
Peripheral Edema
Orthostatic Hypotension
Obesity
COLONIC ADENOMA
ANEMIA, UNSPEC
ATRIAL FLUTTER
ESOPHAGEAL ATRESIA/STENOSIS/TE FISTULA - CONGEN
ATRIAL FIBRILLATION
OSTEOARTHRITIS - KNEE, left
PSORIASIS
CELLULITIS (SPECIFY SITE)
PROSTATIC HYPERTROPHY - BENIGN
STASIS ULCER
THROMBOPHLEBITIS/PHLEBITIS OF DEEP VEINS
PERIPHERAL VASCULAR DISEASE
h/o ALCOHOL DEPENDENCE
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
VITALS: T 97.5 119/68 126 ___ RA
GENERAL: lying comfortably in bed, no apparent distress, A/Ox3,
affect appropriate, wearing in glasses
HEENT: sclera anicteric, EOMI, CN II-XII grossly intact, line
dressing in place on R side of neck
NECK: JVD ~9 to 10 cm this morning
LUNGS: right lower lobe crackles, left side clear to
auscultation, unlabored breathing
HEART: irregularly irregular rhythm, JVP difficult to assess
with line dressing in place, 2+ radial pulses, unable to assess
DP pulses with lower extremity dressings in place, no murmurs,
rubs, or gallops
ABDOMEN: soft, non-distended, + BS, no tenderness to palpation
EXTREMITIES: LLE dressing wrapped to just below knee with
discoloration of ankle dressing from wound weeping, RLE dressing
to mid-shin, diffuse erythema of lower extremities to knee,
could
not assess edema due to dressings
DISCHARGE PHYSICAL EXAM
===========================
VITALS: Tc 97.8 100/60 99 18/ 94% RA
GENERAL: lying comfortably in bed, no apparent distress, A/Ox3,
affect appropriate
HEENT: sclera anicteric, EOMI, CN II-XII grossly intact, R neck
dressing intact, no ecchymosis
NECK: JVD ~8 cm this morning
LUNGS: CTAB, no wheezes or rales, unlabored respirations
HEART: irregularly irregular rhythm, JVD 8 cm, 2+ radial
pulses,
unable to assess DP pulses with lower extremity dressings in
place, no murmurs, rubs, or gallops
ABDOMEN: soft, non-distended, + BS, no tenderness to palpation
EXTREMITIES: LLE dressing around the mid-calf, RLE dressing
around ankle, diffuse erythema of lower extremities to knee
Pertinent Results:
ADMISSION LABS
======================
___ 12:10PM BLOOD WBC-6.6 RBC-3.40* Hgb-9.7* Hct-30.9*
MCV-91 MCH-28.5 MCHC-31.4* RDW-15.4 RDWSD-50.7* Plt ___
___ 12:10PM BLOOD ___ PTT-37.2* ___
___ 12:10PM BLOOD proBNP-1598*
___ 12:10PM BLOOD cTropnT-<0.01
___ 12:10PM BLOOD Glucose-95 UreaN-20 Creat-0.8 Na-136
K-3.8 Cl-98 HCO3-24 AnGap-18
___ 12:10PM BLOOD TSH-3.9
___ 12:10PM BLOOD Digoxin-<0.2*
RELEVANT LABS
======================
___ 12:10PM BLOOD TSH-3.9
___ 12:10PM BLOOD Digoxin-<0.2*
___ 02:26PM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:10PM BLOOD cTropnT-<0.01
PERTINENT STUDIES
======================
CTA CHEST ___: No evidence of pulmonary embolism or
aortic
abnormality. Mild pulmonary vascular congestion. Main pulmonary
artery is dilated up to 3.7 cm, consistent with pulmonary
hypertension. 6 mm left upper lobe pulmonary nodule.
___ TTE: The left atrial volume index is moderately
increased. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
Tissue Doppler imaging suggests a normal left ventricular
filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
arch is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally
normal. Mild to moderate (___) mitral regurgitation is seen.
The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. There is a round, 4.2-cm echogenic
lesion in the liver, likely simple cyst.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild to moderate mitral regurgitation. Probable liver
cyst - if clinically-indicated, recommend correlation with
dedicated liver imaging.
MICRO RESULTS
======================
___ Blood cx x 2: negative
___ Blood cx: BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from only one set in the previous five days.
DISCHARGE LABS
======================
___ 06:35AM BLOOD WBC-6.1 RBC-3.69* Hgb-10.6* Hct-33.7*
MCV-91 MCH-28.7 MCHC-31.5* RDW-14.9 RDWSD-49.8* Plt ___
___ 06:35AM BLOOD Glucose-95 UreaN-23* Creat-0.9 Na-141
K-4.2 Cl-102 HCO3-25 AnGap-14
___ 06:35AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Warfarin 6.25 mg PO 5X/WEEK (___)
4. Lisinopril 2.5 mg PO DAILY
5. desoximetasone 0.25 % topical DAILY
6. econazole 1 % topical BID
7. Furosemide 20 mg PO DAILY
8. Gabapentin 100 mg PO BID
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Micro-Guard (miconazole nitrate) 2 % topical BID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Clobetasol Propionate 0.05% Cream 1 Appl TP 3X/WEEK
(___)
15. Digoxin 0.125 mg PO 4X/WEEK (___)
16. Digoxin 0.25 mg PO 3X/WEEK (___)
17. Warfarin 7 mg PO 2X/WEEK (WE,SA)
Discharge Medications:
1. Digoxin 0.25 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. Metoprolol Succinate XL 100 mg PO BID
4. Warfarin 4 mg PO DAILY16
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Clobetasol Propionate 0.05% Cream 1 Appl TP 3X/WEEK
(___)
7. desoximetasone 0.25 % topical DAILY
8. Docusate Sodium 100 mg PO BID
9. econazole 1 % topical BID
10. Furosemide 20 mg PO DAILY
11. Micro-Guard (miconazole nitrate) 2 % topical BID
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO BID
14. Tamsulosin 0.4 mg PO QHS
15. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctors ___ to do so,
because your blood pressure was low
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation with rapid ventricular response
Secondary diagnosis:
HFpEF
Chronic venous ulceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with chest ___ for pna or edema*** WARNING
*** Multiple patients with same last name!// chest ___ for pna or edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___ and CT dated ___.
FINDINGS:
There is a 5 mm calcified granuloma in the left lower lobe as on prior CT. No
focal consolidation is seen. The pulmonary vasculature are unremarkable.
There is no pleural effusion or pneumothorax. Mild cardiomegaly is grossly
unchanged accounting for technique differences and patient positioning. No
fracture.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Unchanged mild cardiomegaly.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with chest pain, hypotension. Evaluate for aortic
dissection.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 447 mGy-cm.
COMPARISON: Chest CT ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
main pulmonary artery is dilated up to 3.7 cm, suggestive of pulmonary
hypertension. The thoracic aorta is normal in caliber without evidence of
dissection or intramural hematoma. There is moderate calcific atherosclerosis
along the aortic arch and at the origin of the neck vessels. The heart is
within normal limits.. Trace pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There are many prominent but not pathologically
enlarged mediastinal lymph nodes. Calcified hilar lymph nodes may reflect
prior granulomatous disease or treated lymphoma. No axillary lymphadenopathy.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Peribronchial thickening suggest chronic small airways disease.
At the lung bases, there is thickening of the septa, which may suggest mild
pulmonary vascular congestion. There may be early fibrotic changes along the
periphery of the upper lobes. There is a calcified granuloma in the left
lower lobe (3:116). A 6 mm nodule is present in the left upper lobe (3:90).
There is no focal consolidation.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: The esophagus is patulous and probably slightly thickened, consistent
with the patient's history of esophagitis. Multiple hepatic hypodensities are
incompletely characterized, most likely represent cysts. There is a small
hiatal hernia.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
DISH is noted in the thoracic spine.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Mild pulmonary vascular congestion.
3. Main pulmonary artery is dilated up to 3.7 cm, consistent with pulmonary
hypertension.
4. 5 mm left upper lobe pulmonary nodule. 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 recommend in a high-risk
patient.
5. Prominent but nonenlarged mediastinal lymph nodes are nonspecific.
Calcified hilar lymph nodes may suggest prior granulomatous disease.
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 recommend in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hypotension s/p CVL// eval line placement
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. Right IJ central venous catheter
terminates in the mid SVC. No pneumothorax. Peripheral fibrotic changes are
better assessed on same-day CT exam. Calcified granuloma projects over the
left mid lung. No large effusion or pneumothorax.
IMPRESSION:
Appropriately placed right IJ central venous catheter.
Radiology Report
EXAMINATION: ANKLE (AP, LAT AND OBLIQUE) BILATERAL
INDICATION: ___ year old man with extensive chronic lower extremity venous
ulcers, c/f bacteremia from SSTI// gas? osteo? would like to visualize medial
malleolus gas? osteo? would like to visualize medial malleolus
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left foot
COMPARISON: None available
FINDINGS:
The bones are diffusely demineralized. Degenerative changes are present
around the tibiotalar joint, midfoot and hindfoot. There is no acute
displaced fracture identified. No obvious erosions. There are soft tissue
defects over both medial and lateral malleoli without obvious underlying
subcutaneous gas. Extensive mineralized densities project over the lower left
extremity, likely related to chronic venous insufficiency. Vascular
calcification is also present.
IMPRESSION:
Skin defects over both medial and lateral malleoli without evidence of
subcutaneous gas. No radiographic evidence of osteomyelitis however if there
is continued clinical suspicion, further evaluation with MRI or bone
scintigraphy is recommended.
Extensive mineralization of the subcutaneous tissues of the left lower
extremity likely related to chronic venous insufficiency.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Tachycardia
Diagnosed with Chest pain, unspecified
temperature: 98.0
heartrate: 146.0
resprate: 16.0
o2sat: 98.0
sbp: 134.0
dbp: 75.0
level of pain: 0
level of acuity: 1.0 | ___ is an ___ yo M w/ ___ atrial fibrillation on
metoprolol, digoxin, and warfarin who presented with atypical
chest pain and found to have A. fib w/ RVR to 140-150s and
hypotension. He had been grieving his brother's recent death and
admitted to medication non-compliance. Digoxin levels were not
measurable upon admission.
He was admitted to the ICU because of hypotension and he had a
positive blood culture which later proved to be contaminant. He
was started on broad spectrum antibiotics and loaded with
amiodarone and metoprolol. HR improved and hypotension resolved.
Patient was transferred to general cardiology. His antibiotics
were discontinued as his hypotension was thought to be due to A.
Fib w/ RVR.
He was volume overloaded and diuresed. Digoxin was restarted and
his metoprolol was titrated with improvement in rate control. ___
evaluated Mr. ___ and determined he would benefit from rehab
prior to returning home. His INR was supratherapeutic and his
home warfarin was decreased to 4 mg daily. |
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 shoulder pain
Major Surgical or Invasive Procedure:
Left proximal humerus ORIF
History of Present Illness:
___ transfer from ___ who presents with L
shoulder pain after fall outside earlier today. Pt was walking
outside when she was knocked over by the wind, falling onto her
L shoulder. Possible headstrike but no LOC. Recalls all events.
Denies numbness/tingling. Pain w/ shoulder ROM.
Past Medical History:
depression/anxiety; GERD, HL; UGIB
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
A&O x 3
Calm and comfortable
LUE skin clean and intact
Tenderness over proximal shoulder. Arms and forearms are soft
Shoulder ROM deferred.
No pain with wrist or digit ROM
A R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
RUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
BLE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
PHYSICAL EXAM ON DISCHARGE:
A&O x3, calm and pleasant
LUE: Incision clean, dry, and intact. Fingers warm and
well-perfused, with palpable radial pulse. Moves all fingers;
+EPL/FPL/DIO/FDS fire. Left hand swollen, with edema glove in
place. Sensation intact to light touch over
SPN/DPN/TN/saph/sural.
Pertinent Results:
___ 05:47AM BLOOD WBC-9.2 RBC-3.08* Hgb-9.3* Hct-27.5*
MCV-89 MCH-30.2 MCHC-33.8 RDW-15.6* Plt ___
___ 05:47AM BLOOD Glucose-90 UreaN-19 Creat-0.4 Na-142
K-3.9 Cl-111* HCO3-25 AnGap-10
___ 05:47AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.0
Medications on Admission:
citalopram 1.5mg qhs, clonapin 1mg daily, zantac 1 tab daily,
simvastatin, Vit D
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
4. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for Anxiety.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Injection TID (3 times a day).
12. oxycodone 5 mg Capsule Sig: 0.5 Tablet PO ONCE (Once) as
needed for pain: HOLD if somnolent, confused, agitated, or RR
<12.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left proximal humerus fracture
Discharge Condition:
Currently alert and oriented x3.
Ambulatory - requires assistance or aid (walker or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with reported shoulder fracture on outside
hospital.
COMPARISON: No relevant comparisons available.
THREE VIEWS OF THE LEFT SHOULDER AND THREE VIEWS OF THE LEFT HUMERUS:
There is a comminuted fracture of the humeral head, with surgical neck and
greater tuberosity components. There is also a comminuted fracture of the
proximal humeral shaft with a 5.3 cm butterfly fragment. There is
anteroinferior dislocation of the humeral head with respect to the glenoid.
Radiology Report
INDICATION: ___ woman with fall today. Preop film.
COMPARISON: Outside hospital chest radiograph.
ONE VIEW OF THE CHEST:
The lungs are hyperexpanded and show a focal opacity overlying the right ___
rib. The cardiomediastinal silhouette, hilar contours and pleural surfaces
are normal. No pleural effusion or pneumothorax is present. The left humeral
head is dislocated. Clips are noted in the left upper quadrant.
IMPRESSION:
No acute intrathoracic process. Dislocated left humeral head.
Focal opacity overlies the right first rib. Apical lordotic views are
recommended for further evaluation.
These findings were communicated via telephone to ___ at 11:48 pm on
___.
Radiology Report
INDICATION: ___ woman with left humeral fracture and dislocation on
x-ray.
COMPARISON: Radiographs from ___ at 8:00 p.m.
TECHNIQUE: MDCT images were acquired through the left shoulder without
contrast. Standard bone and soft tissue algorithms and multiplanar
reformations were obtained and reviewed.
FINDINGS:
There is an acute fracture/dislocation of the left proximal humerus.
The articular portion of the humeral head is dislocated anteroinferiorly with
respect to the glenoid. There is slight ill-definition of the anteroinferior
corner of the glenoid (2:27), without other evidence of a bony Bankart injury.
There is a large joint
effusion, with fat/fluid level and considerable surrounding edema.
Significant soft tissue stranding seen inferior to the deltoid.
The proximal humerus has a comminuted fracture with components involving both
the anatomic and surgical necks, comminuted greater tuberosity, and a larger
anterior fragment including the lesser tuberosity and portions of the greater
tuberosity.
In addition, there is a comminuted fracture of the left proximal humeral
diaphysis with a 5-cm butterfly fragment.
The AC joint remains congruent. The partially imaged lungs are clear. The
partially imaged ribs are intact.
IMPRESSION:
1. Persistent ___ dislocation of the humeral head with respect to
the glenoid. Equivocal tiny bony Bankart injury.
2. Comminuted fracture of the humeral head.
3. Comminuted fracture of the proxial humeral diaphysis.
Radiology Report
HISTORY: Focal opacity overlying first right rib. Apical lordotic views
recommended.
CHEST, SINGLE AP VIEW WITH APICAL ANGULATION:
An AP film from ___ at 20:45 p.m. demonstrated a focal opacity at the
right lung apex laterally. This is not well visualized on the current image.
It remains unclear, however, whether this lies within the lung or a rib and
the possibility of a right apical lung nodule cannot be conclusively excluded
on this view. No acute pulmonary process is identified. Background
hyperinflation suggestive of COPD and minimal atelectasis in the right
cardiophrenic region are suggested.
IMPRESSION: Focal nodular density less well seen on this apical view, but not
clearly localized to bone. Additional assessment either with two right and
left shallow oblique radiographic views of the chest or, alternatively, chest
CT is recommended for further assessment.
Radiology Report
HISTORY: Fracture.
FINDINGS: Images from the operating suite show fixation of a previously
described fracture. Further information can be gathered from the operative
report.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LEFT SHOULDER FX/DISLOCATION
Diagnosed with FX UP END HUMERUS NOS-CL, UNSPECIFIED FALL, HYPERCHOLESTEROLEMIA
temperature: 99.4
heartrate: 62.0
resprate: 18.0
o2sat: 96.0
sbp: 124.0
dbp: 53.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left proximal humerus fracture. She was taken to
the Operating Room on ___ and underwent ORIF of the left
proximal humerus. She tolerated the procedure well, and there
were no complications. Please see Operative Report for full
details. Post-operatively, the patient was taken to the
recovery room before being transferred to the floor in the usual
fashion. On POD #1, she was seen by ___ and OT. Her PCA was
discontinued and transitioned to oral medications, and she was
transfused 1 unit of packed red blood cells for acute blood loss
anemia.
Overnight between ___, the patient became acutely delirious
and paranoid. She reported visual hallucinations and expressed
her concern that someone was "trying to kill [her];" in
particular, she mentioned being concerned that a woman named
___ was trying to harm her. The Geriatric Medicine team was
consulted, saw and evaluated the patient, and provided a
thorough assessment and recommendations. She was given oral
Haldol and Zyprexa and responded well. Her delirium, confusion,
and paranoia continued to improve over the next few days. She
continued to be followed by the ___, OT, and Geriatric Medicine
services, who noted steady improvement and progress. She was
transfused 1 unit of blood on ___, and ___ for acute
blood loss anemia, and her hematocrit stabilized by the day of
discharge. Her mental status continued to improve. Given her
recent mental status changes (though much improved) as well as
the fact that her gait was unsteady on account of her left arm
injury and need for use of a cane, it was recommended that she
be discharged to a ___ rehabilitation facility prior to
being discharged home. This plan was discussed at length with
her family, and on ___ she was discharged to a rehabilitation
facility. She was given detailed precautionary instructions as
well as instructions for follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / metformin / Vicodin / Toradol / oxycodone /
hydrocodone
Attending: ___.
Chief Complaint:
- Right flank pain
Major Surgical or Invasive Procedure:
Fibulectomy of left residual limb on ___
History of Present Illness:
Ms. ___ is a ___ year old woman with insulin-dependent
DM,
CAD (s/p CABG), vascular disease s/p bilateral BKAs and prior
DVT
who presents with flank pain.
Ms. ___ has had a week of nausea and for two days has
experienced nonbilious emesis and nonbloody diarrhea. For one
day, she experienced sharp right flank pain radiating to the RLQ
and a pressure sensation in her bladder. She denies fevers
chills, chest pain, dyspnea, hematuria, vaginal bleeding.
Of note, Ms. ___ was discharged from rehab in ___ after
spending about three months there following an infection of her
left leg that eventually led to a BKA. Last year she had a 4-V
CABG (unknown vessels) that was complicated by graft harvest
site
of the RLE which also led to a BKA. Since leaving rehab about a
week ago and moving to ___, she has only been able to take a
few of her medications, and her last long-acting insulin was
nearly 5d ago due to severely reduced oral intake.
Past Medical History:
PMH:
- recurrent abscesses (hand, thigh)
- insulin-dependent DM II
- migraines
- missed abortion x2
- legal blindness
- neuralgia
- acute on chronic pancreatitis
- peripheral vascular disease
- nephrolithiasis
- ovarian cyst, ectopic pregnancy
- Bipolar disorder
- PTSD
PSH:
- I&D of left thigh abscess (___)
- D&C x2 (___)
- cholecystectomy
- Right ___ and ___ toe amputations
- Left ___ and ___ amputations
Social History:
___
Family History:
FAMILY HX: Multiple family members with various malignancies.
Physical Exam:
===========================
ADMISSION PHYSICAL
===========================
Initial vital signs were notable for:
- T97.7, HR 102, BP 157/93, RR 20, O2 99% RA
- Con: Appears uncomfortable, in no acute distress
- HEENT: NCAT. PERRLA, no icterus. EOMI
- Neck: no JVD
- Resp: No incr WOB, CTAB.
- CV: RRR. Normal S1/S2. 2+ radial pulse bilaterally
- Abd: Soft, right lower quadrant tenderness without rebound or
guarding, Nondistended.
- Back: R CVA tenderness
- MSK: bilateral BKA.
- Skin: No rash, Warm and dry, No petechiae
- Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
- Psych: Normal mentation
===========================
DISCHARGE PHYSICAL
===========================
97.5 116 / 82 ___
Gen: sitting comfortably in bed
HEENT: anicteric sclera, poor vision (reports being legally
blind), +strabismus
CV: distant heart sounds, S1S2 present, stable ___ systolic
murmur heard beast at LUSB
Chest: +well healed sternotomy scar; normal WOB, CTAB
MSK/Skin: b/l BKA. L distal residual limb now with removed wound
vac, no tenderness to palpation, no surrounding erythema or
exudate.
Neuro: awake, alert, conversant with clear speech
Pertinent Results:
=====================================
ADMISSION LABS
=====================================
___ 12:00PM PLT COUNT-381
___ 12:00PM NEUTS-75.3* LYMPHS-16.5* MONOS-5.0 EOS-2.0
BASOS-0.5 IM ___ AbsNeut-11.08* AbsLymp-2.43 AbsMono-0.73
AbsEos-0.30 AbsBaso-0.07
___ 12:00PM WBC-14.7* RBC-4.18 HGB-12.7 HCT-37.0 MCV-89
MCH-30.4 MCHC-34.3 RDW-14.3 RDWSD-45.1
___ 12:00PM HCG-<5
___ 12:00PM ALBUMIN-4.0
___ 12:00PM ALT(SGPT)-18 AST(SGOT)-11 ALK PHOS-144* TOT
BILI-0.2
___ 12:00PM GLUCOSE-328* UREA N-25* CREAT-0.8 SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-17
___ 03:20PM URINE RBC-1 WBC-29* BACTERIA-MANY* YEAST-NONE
EPI-<1
___ 03:20PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-300*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD*
___ 03:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS*
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:20PM URINE UCG-NEGATIVE
___ 06:13PM %HbA1c-8.4* eAG-194*
___ 06:13PM GLUCOSE-152* UREA N-24* CREAT-0.5 SODIUM-139
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-18* ANION GAP-14
=====================================
PERTINENT INTERVAL LABS
=====================================
___ 07:57AM BLOOD calTIBC-226* VitB12-647 Folate-6
Hapto-330* Ferritn-195* TRF-174*
___ 06:13PM BLOOD %HbA1c-8.4* eAG-194*
___ 07:14AM BLOOD Triglyc-1319* HDL-25* CHOL/HD-12.4
LDLmeas-126
___ 07:14AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 12:00PM BLOOD HCG-<5
___ 07:14AM BLOOD HCV Ab-POS*
___ 07:14AM BLOOD CHCV VL-NOT DETECT
=====================================
DISCHARGE LABS
=====================================
___ 06:45AM BLOOD WBC-6.7 RBC-2.73* Hgb-8.2* Hct-26.2*
MCV-96 MCH-30.0 MCHC-31.3* RDW-15.5 RDWSD-53.1* Plt ___
___ 06:45AM BLOOD Neuts-56.2 ___ Monos-8.3 Eos-4.8
Baso-0.6 Im ___ AbsNeut-3.77 AbsLymp-1.87 AbsMono-0.56
AbsEos-0.32 AbsBaso-0.04
___:18AM BLOOD Glucose-147* UreaN-22* Creat-0.7 Na-138
K-4.9 Cl-102 HCO3-23 AnGap-13
___ 07:57AM BLOOD LD(LDH)-255* TotBili-<0.2 DirBili-<0.2
___ 07:18AM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8
=====================================
PROCEDURES/STUDIES/IMAGING
=====================================
Fibulectomy of left residual limb on ___
The patient was prepped and draped in standard fashion in supine
position. A timeout was performed. A 15-blade was used to
excise the ulcer on the lateral part of the BKA stump, following
which electrocautery was used to dissect out the subcutaneous
tissues. Cultures were sent. After cultures were sent, the
head of the fibula was noted to protrude into the wound and we
did a partial fibulectomy using a rongeur. After the rongeur
fibulectomy, we ended up irrigating and closing the wound with
___ nylon sutures and ended up placing a Prevena VAC.
Hemostasis was achieved. There were no intraoperative
complications.
CT ABD/PELVIS IMPRESSION:
1. No bowel obstruction or bowel wall thickening. Normal
appendix. Status
post cholecystectomy.
2. Urinary bladder not well distended; apparent diffuse mild
urinary bladder
wall thickening may relate to underdistention. Correlate with
urinalysis to
assess for infection.
3. No hydronephrosis or hydroureter.
4. Stable 5 mm left lower lobe pulmonary nodule. Previously
seen right lower
lobe pulmonary nodules are not fully imaged on the current
study. There is
suggestion of at least 1 on the superior most image, series 2,
image 1, not
appreciably changed in size, but again, not fully imaged.
Duplex of right leg IMPRESSION:
Patent right lower extremity arteries from the common femoral to
distal
superficial femoral arteries without hemodynamically significant
stenosis
identified.
Duplex of left leg IMPRESSION:
Mild atherosclerosis without hemodynamically significant
stenosis identified
in the left common femoral, deep femoral, superficial femoral
arteries.
=====================================
MICRO
=====================================
SUPERFICIAL WOUND SWAB
___ 3:45 pm SWAB LEFT BELOW KNEE AMPUTATION WOUND.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Final ___:
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
ACID FAST CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levemir 40 Units Breakfast
Levemir 30 Units Bedtime
Novolog 8 Units Breakfast
Novolog 8 Units Lunch
Novolog 8 Units Dinner
2. CarBAMazepine (Extended-Release) 100 mg PO BID
3. Excedrin Migraine (aspirin-acetaminophen-caffeine)
___ mg oral QHS:PRN headache
4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
5. Furosemide 40 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Escitalopram Oxalate 10 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. QUEtiapine extended-release 300 mg PO DAILY
11. Nortriptyline 25 mg PO QHS
12. CARVedilol 6.25 mg PO BID
13. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Moderate
14. Gabapentin 800 mg PO QID
15. Temazepam 15 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO QID
RX *acetaminophen 650 mg 1 tablet(s) by mouth four times a day
Disp #*40 Tablet Refills:*0
2. Alcohol Pads (alcohol swabs) 1 pad topical 5X/DAY
RX *alcohol swabs [Alcohol Pads] use as directed 5 times per
day Disp #*100 Pad Refills:*0
3. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. HYDROmorphone (Dilaudid) 4 mg PO Q6H
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth q6H x 3d
then q8H x3d, then Q12h x 1d Disp #*23 Tablet Refills:*0
6. Lidocaine 5% Patch 5 PTCH TD QAM posterior calf pain, right
flank pain, left hand pain
RX *lidocaine 5 % apply 1 patch once a day Refills:*0
7. LORazepam 0.5 mg PO TID:PRN anxiety/anxiety exacerbating
pain
RX *lorazepam 0.5 mg 1 tablet by mouth three times a day Disp
#*10 Tablet Refills:*0
8. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine [Nicoderm CQ] 21 mg/24 hour 1 patch once a day Disp
#*10 Patch Refills:*0
9. Pen Needle (pen needle, diabetic) 30 gauge x ___ SQ 5 times
per day
ok to substitute length/size per patient preference
RX *pen needle, diabetic ___ Tier Unifine Pentips] 29 gauge X
___ use as directed 5 times per day Disp #*50 Box Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 scoop by
mouth every day dissolved in water Refills:*0
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
12. Tizanidine 2 mg PO TID
RX *tizanidine 2 mg 1 tablet(s) by mouth three times a day Disp
#*10 Tablet Refills:*0
13. Escitalopram Oxalate 20 mg PO DAILY
RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
14. Glargine 50 Units Breakfast
Glargine 50 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
15. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
17. Gabapentin 800 mg PO QID
RX *gabapentin 800 mg 1 tablet by mouth four times a day Disp
#*15 Tablet Refills:*0
18. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine [Euthyrox] 88 mcg 1 tablet(s) by mouth every
morning 30 minutes before food or other medications Disp #*30
Tablet Refills:*0
19. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
20. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
21. QUEtiapine extended-release 300 mg PO DAILY
RX *quetiapine 300 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
22.DME
Standard Commode
DX: ___
PX: good
___ 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Non-healing right residual limb surgical wound
-Difficult to control diabetes
-Acute on chronic mechanical back/flank pain
-Anxiety
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: NO_PO contrast; History: ___ with right flank, right lower
abdominal pain, nausea, vomiting, history of nephrolithiasisNO_PO contrast//
eval for nephrolithiasis, intra-abdominal process
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 7.1 s, 56.1 cm; CTDIvol = 27.8 mGy (Body) DLP =
1,557.8 mGy-cm.
3) Spiral Acquisition 0.8 s, 6.6 cm; CTDIvol = 22.8 mGy (Body) DLP = 151.2
mGy-cm.
Total DLP (Body) = 1,727 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: 5 mm left lower lobe pulmonary nodule on series 2, image 8 is
stable. Previously seen right lower lobe pulmonary nodules are not fully
imaged on the current study. There is suggestion of at least 1 on the
superior most image, series 2, image 1, not appreciably changed in size, but
again, not fully imaged. No pleural or pericardial effusion is seen. Patient
is status post median sternotomy, partially imaged.
ABDOMEN:
HEPATOBILIARY: Focal calcification in the left lobe of the liver is stable,
likely consistent with a calcified granuloma. There is no evidence of focal
lesions. No intrahepatic biliary ductal dilatation is seen. Mild prominence
of the common bile duct, similar to slightly less conspicuous compared the
prior study in this patient status post cholecystectomy. The gallbladder
surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No hydronephrosis is seen bilaterally. Punctate calcifications seen near the
renal collecting systems bilaterally may be vascular. No obstructing
nephroureterolithiasis seen. There is no perinephric abnormality.
GASTROINTESTINAL: Stomach is relatively collapsed. No bowel obstruction or
bowel wall thickening is seen. The appendix is normal in caliber.
PELVIS: The urinary bladder is not well distended. Apparent diffuse mild
urinary bladder wall thickening may relate to underdistention; correlate with
urinalysis. There is no free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
Mildly prominent left external iliac lymph node measures 1 cm in short axis
and appears to contain fatty hilum.
VASCULAR: There is no abdominal aortic aneurysm. Moderate to severe
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Few scattered nodular opacities in the subcutaneous tissue
anteriorly likely relate to subcutaneous injections.
IMPRESSION:
1. No bowel obstruction or bowel wall thickening. Normal appendix. Status
post cholecystectomy.
2. Urinary bladder not well distended; apparent diffuse mild urinary bladder
wall thickening may relate to underdistention. Correlate with urinalysis to
assess for infection.
3. No hydronephrosis or hydroureter.
4. Stable 5 mm left lower lobe pulmonary nodule. Previously seen right lower
lobe pulmonary nodules are not fully imaged on the current study. There is
suggestion of at least 1 on the superior most image, series 2, image 1, not
appreciably changed in size, but again, not fully imaged.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with history of IDDM, CAD (s/p CABG), vascular
disease s/p bilateral BKAs and prior DVT who is being treated for presumed
UTI, noted to have a purulent-draining 3 cm ulcer on the lateral aspect of the
distal BKA stump, patient also complaining of a cough, need to r/o PNA.// ?PNA
IMPRESSION:
No previous images. There is evidence of previous CABG procedure with intact
midline sternal wires. Cardiac silhouette is mildly enlarged without vascular
congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
EXAMINATION: ART DUP EXT LO UNI;F/U LEFT
INDICATION: ___ year old woman with DM, legal blindness, CAD s/p CABG, PVD s/p
bilateral BKA, who presented with flank pain and admitted for treatment of
UTI. Upon exam, found to have a left BKA ulcer draining purulent fluid// Eval
SSA and profunda
TECHNIQUE: Grayscale and color Doppler with pulse wave ultrasound images were
obtained of the left lower extremity arteries.
COMPARISON: None
FINDINGS:
Mild atherosclerosis in the left common femoral, deep femoral, superficial
femoral arteries.
Left peak systolic velocities:
Common femoral artery: 120 centimeters/second
Deep femoral artery: 124, 72 centimeters/second
Superficial femoral artery the proximal thigh: 208 centimeters/second
Superficial femoral artery in the midthigh: 145 centimeters/second
Superficial femoral artery in the distal thigh: 148 centimeters/second
Diastolic forward flow is noted throughout the left lower extremity arteries.
IMPRESSION:
Mild atherosclerosis without hemodynamically significant stenosis identified
in the left common femoral, deep femoral, superficial femoral arteries.
Radiology Report
EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT
INDICATION: ___ year old woman with PVD s/p b/l BKA. Vascular requesting
ultrasound assessment of both lower extremities.// arterial assessment of
right leg
TECHNIQUE: Grayscale and color Doppler with pulse wave ultrasound images were
obtained of the right lower extremity arteries.
COMPARISON: None
FINDINGS:
Mild atherosclerosis noted in the right lower extremity arteries monophasic
waveforms throughout.
Peak systolic velocities in the right lower extremity arteries:
Common femoral artery: 94 centimeters/second
Deep femoral artery: 81 centimeters/second
Proximal superficial femoral artery: 124 centimeters/second
Mid superficial femoral artery: 80 centimeter/second
Distal superficial femoral artery: 58 centimeters/second
IMPRESSION:
Patent right lower extremity arteries from the common femoral to distal
superficial femoral arteries without hemodynamically significant stenosis
identified.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Flank pain
Diagnosed with Type 2 diabetes mellitus with hyperglycemia, Long term (current) use of insulin
temperature: 97.7
heartrate: 102.0
resprate: 20.0
o2sat: 99.0
sbp: 157.0
dbp: 93.0
level of pain: 10
level of acuity: 3.0 | ========================
TRANSITIONAL ISSUES
========================
[ ] Patient is a double amputee with legal blindness who lives
in a ___ floor ___ apartment with her boyfriend who works on
most days. In order to be transported to and from outpatient
visits, the outpatient team must call ___
(___) the day before the appointment and ask for
"wheelchair van with lift assist", which should be covered by
her Mass Health.
[ ] Patient would likely benefit from a comprehensive care group
for her numerous medical, psychological, and social issues. We
suggest a referral to the ___.
[ ] Patient has a goal to wean off the hydromorphone and
lorazepam completely, please support her in this goal and
connect with a psychiatry and chronic pain doctor as indicated.
[ ] Vascular surgery wound check and suture removal with Dr.
___.
[ ] Patient to follow with the ___ for ongoing diabetes
management.
[ ] Severe hypertriglyceridemia, would repeat test and consider
starting triglyceride-specific therpay in addition to her statin
if still severely elevated.
[ ] Smoking cessation
===========================
BRIEF SUMMARY
===========================
___ is a ___ year old women with a very complicated
medical and psychosocial history notable for diabetes, tobacco
use, and obesity leading to legal blindness and severe vascular
disease s/p CABG and bilateral below the knee amputations, in
addition to depression, anxiety, and PTSD. She had just spent ___
years in ___ recovering from numerous medical problems, and
has been in ___ for 1 week living with her boyfriend without
any medical care or prescriptions.
She initially presented to ___ on ___ after calling an
ambulance with acute on chronic right lower back and right flank
pain, and was initially admitted with concern for
pyelonephritis. We did not feel like her presentation was
consistent with pyelonephritis, but rather acute on chronic
mechanical back pain.
However, once admitted she was noted to have a non healing ulcer
of the left residual limb. She underwent fibulectomy with
vascular surgery (Dr. ___ with the hope being she
will have better biomechanics to promote wound healing. She was
managed with a wound vac and also completed a 14 day course of
antibiotics per our infectious disease consultants.
She experienced significant post-operative left residual limb
pain which required narcotics as part of a multi-modal regimen.
The pain service helped with management, and over a 2 week
period we were able to wean off IV hydromorphone and at the time
of discharge planned to wean oral hydromorphone over the 6 days
leading up to her primary care follow up. The patient was in
agreement with this goal. She remains very convinced that she
will require an above the knee amputation to fully resolve her
pain. The vascular team was hesitant to offer this operation
without allowing her some time to recover from this operation
and she has outpatient follow up scheduled for further
discussions.
Given her significant anxiety and somewhat poor coping skills
with pain, we had the psychiatry team evaluate her. They made
adjustments to her prior regimen and recommended temporarily
starting a benzodiazepine until she settles out from a
post-operative pain standpoint. We discussed tapering the ___
(like the opiates) but she felt like her anxiety is actually
worse at home when she is alone compared to when she is in the
hospital. As such, we decided to continue on her current dose.
Of note, her diabetes was very poorly controlled and required
extremely high doses of insulin per day (270 units per day at
one point) and the ___ diabetes team followed along during
her stay. We felt like dietary choices contributed heavily (i.e.
was eating oreo milkshakes and fast food brought in from
visitors) but given that she endorsed home dietary habits of
much less food, we sent her home on a lower dose than she
required in house (but higher than her pre-admission
prescription) in hopes of preventing hypoglycemia in the short
term. We also started aspirin and statin for primary prevention
(lipid panel ___ 1319, HDL 25, TC 310, LDL 126)
We had numerous conversations regarding placement. We explained
that the best plan from a purely medical standpoint would be a
skilled nursing facility given her blindness, mobility
limitations, severe diabetes with need for 4 times per day
insulin, and dependence (at least in the post operative setting)
on opiates and benzodiazepines. After speaking with our case
managers, she felt like going home with a slightly "less safe"
medical plan would be overall more beneficial to her as she
could be with her family more consistently. Fortunately we were
able to secure a close follow up at the ___ and have
a transportation plan (see transitional issues).
Attending addendum:
I have seen and examined the patient on the day of discharge and
agree with the note by the medical resident. This patient poses
numerous challenges in having all of her needs met. We
recommended residing in a skilled facility to accomplish this,
but even though she understood the risks and benefits, she
elected to go back home. We make every possible attempt to
connect her with the maximum number of resources that are
available, and communicated with her diabetes provider to ensure
she had adequate doses if insulin on discharge. Ultimately, our
team spent 6 hours in discharge planning and coordination of
care, and I easily spent > 30 min in these activities as well. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
diarrhea, self-neglect
Major Surgical or Invasive Procedure:
Straight catherization
History of Present Illness:
___ M p/w several days incontinent ?diarrhea w/o fever or abd
pain, comes from wife's nursing home, sent by doctors there with
___ self-neglect and need for greater community support. Here
for observation, IVF, and SW/CM for evaluation of level of care
needed at d/c.
He was sent from his wife's nursing home after the physician
there called ___ to report patient had "moved into
his wife's room" and was incontinent of stool and urine. Prior
to ED arrival, pt reports diarrhea alternating with solid stool
for "several days" but was unable to further quantify.
In the ED, he presented with two episodes of diarrhea during the
day. Denies black or bloody stools, abdominal pain, or fever. He
was kept in the ED overnight ___ and during AM ___ he
complained of vague abdominal pain and appeared more withdrawn.
He received head, abd and pelvis CTs, which were not concerning.
UA negative. BCx neg so far. UCx grew 10k-100k proteus mirabilis
likely colonizer.
In the ED: T 98.1 HR 89 BP 110/65 RR 16 Sat 100%RA
- Imaging notable for: CT head with no acute process, CT Abd
and Pelvis with no acute process, CXR with hyperinflation but no
acute process
- Pt given:
___ 00:07 PO/NG Atorvastatin 10 mg
___ 09:16 PO Acetaminophen 650 mg
___ 09:16 IV Ondansetron 4 mg
___ 13:08 IVF NS
- Vitals prior to transfer: 97.2 95 96/60 18 98% RA
**Per ___ note**
On the floor, pt's main concern is that he has not been able to
access any of his medications as his wife's care facility will
not let him bring them and he did not want to leave her to get
them from home. He has not taken any of his medications for a
week. He is concerned that his wife will not allow help into
their house, as she is ___ and very independent" but he is
open to the discussion.
Past Medical History:
PAST MEDICAL HISTORY:
- Atrial fibrillation, warfarin held since ___
- Chronic systolic CHF
- hypotension
- hyperlipidemia
- h/o b/l pulmonary embolism and R popliteal DVT ___
(___), unprovoked, treated with Lovenox and
warfarin
- schizophrenia was on olanzapine (but patient denies taking
this)
- dementia
- prostate cancer s/p brachytherapy ___
- s/p ORIF R olecranon fx ___
- s/p left ankle fx, remote
Social History:
___
Family History:
Not contributory.
Physical Exam:
============================
ADMISSION PHYSICAL EXAM
============================
Vital Signs: 97.7PO 97/65 100 16 99 Ra
General: AOx3, NAD, cachectic
Mental status: Pt oriented to current events. Was able to list
all medications and many of the doses. Occasionally answers
questions tangentially but did not appear confused.
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRL, neck
supple, JVP not elevated, superficial cervical LAD bilaterally,
largest node 2-3cm. All mobile and soft.
CV: Irregular rhythm, normal rate, no murmurs, rubs, gallops
Lungs: Mild wheezes diffusely
Abdomen: Soft, mildly tenderness to palp over umbilical and LLQ
areas, non-distended, bowel sounds present, no organomegaly, no
rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
============================
DISCHARGE PHYSICAL EXAM
============================
AOx4, ___ backwards with ease, able to tell me he was admitted
for diarrhea and good to go back today.
Vitals: 97.7
PO 120 / 73 82 18 94 Ra
HEENT: MMM, oropharynx clear
Neck: supple
Lungs: CTAB no W/R/R
CV: normal rate, regular rhythm today. palpable heart beat
through precordium, no murmur appreciated.
Abdomen: soft, non-tender, non-distended.
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: clear speech, moving all extremities.
Pertinent Results:
=======================
ADMISSION LABS
=======================
___ 07:56PM BLOOD WBC-8.7# RBC-3.74* Hgb-12.0* Hct-38.1*
MCV-102* MCH-32.1* MCHC-31.5* RDW-14.2 RDWSD-52.9* Plt ___
___ 07:56PM BLOOD Glucose-96 UreaN-29* Creat-1.0 Na-135
K-8.5* Cl-104 HCO3-23 AnGap-17
___ 07:56PM BLOOD Albumin-3.5
___ 07:15AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.0 Mg-1.9
=======================
DISCHARGE LABS
=======================
___ 07:50AM BLOOD WBC-6.5 RBC-3.19* Hgb-10.2* Hct-32.3*
MCV-101* MCH-32.0 MCHC-31.6* RDW-14.3 RDWSD-53.0* Plt ___
___ 07:50AM BLOOD Glucose-81 UreaN-25* Creat-0.9 Na-139
K-4.5 Cl-103 HCO3-25 AnGap-16
___ 07:50AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1
=======================
MICROBIOLOGY
=======================
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Negative stool cultures including c.diff , blood cultures
=======================
IMAGING
=======================
___BD & PELVIS WITH CO
IMPRESSION:
1. Fluid within the colonic lumen compatible with the history of
diarrhea. No evidence of colitis. No acute intra-abdominal
pathology.
2. Coarse calcifications within the pancreas consistent with
chronic pancreatitis.
3. Mild cardiomegaly with trace pericardial effusion.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial including no intracranial hemorrhage or
acute large vascular territory infarction.
2. No acute fracture identified.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Hyperinflation without definite superimposed acute
cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Atorvastatin 10 mg PO QPM
3. Ferrous Sulfate 325 mg PO DAILY
4. OLANZapine 10 mg PO DAILY
5. Lumigan (bimatoprost) 0.01 % ophthalmic DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
glaucoma
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. LOPERamide 2 mg PO QID:PRN diarrhea
3. Multivitamins 1 TAB PO DAILY
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
5. Atorvastatin 10 mg PO QPM
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
glaucoma
7. Ferrous Sulfate 325 mg PO DAILY
8. Lumigan (bimatoprost) 0.01 % ophthalmic DAILY
9. OLANZapine 10 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dementia
Urinary Retention
Diarrhea with fecal incontinence
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 Dyspnea, crackles at right base, evaluate for pneumonia
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are relatively hyperinflated. There is no focal consolidation.
There may be trace left pleural fluid effusion. Cardiac silhouette is
enlarged, unchanged. No acute osseous abnormalities.
IMPRESSION:
Hyperinflation without definite superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with depression, ?increased confusion as well as
abdominal pain and diarrhea// ?ICH/mass. Also ?colitis
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.1 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of acute large vascular territory
infarction,hemorrhage,edema, or mass effect. There is prominence of the
ventricles and sulci suggestive of involutional changes. Periventricular and
subcortical hypodensities are nonspecific but suggest chronic small vessel
ischemic changes.
There is no evidence of fracture. Mild mucosal thickening of the ethmoid and
frontal sinuses as well as the right sphenoid sinus. Mucous retention cysts
noted in the maxillary sinus bilaterally. The visualized portion of the
remaining paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits demonstrate bilateral lens
replacements.
IMPRESSION:
1. No acute intracranial including no intracranial hemorrhage or acute large
vascular territory infarction.
2. No acute fracture identified.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ; History: ___ with depression, ?increased confusion as well as
abdominal pain and diarrhea// ?ICH/mass. Also ?colitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 4.9 s, 53.9 cm; CTDIvol = 10.3 mGy (Body) DLP = 557.0
mGy-cm.
Total DLP (Body) = 567 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Minimal left basilar atelectasis. Mild cardiomegaly with trace
pericardial effusion noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: Pancreas is atrophic with coarse calcifications noted within the
pancreatic head and tail consistent with chronic pancreatitis. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout. There is
re-demonstration of 4.2 x 4.7 cm cystic lesion within the spleen with
calcified septations, likely posttraumatic (3; 14).
ADRENALS: The right adrenal gland is normal in size and shape. The left
adrenal gland is thickened without focal lesion.
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. Colon is filled
with fluid compatible with history of diarrhea. Otherwise, the colon and
rectum are within normal limits without evidence of colitis. The appendix is
not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Brachytherapy seeds are noted within the prostate.
Seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild multilevel degenerative changes of the thoracolumbar spine is noted most
notable at L5-S1.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Fluid within the colonic lumen compatible with the history of diarrhea. No
evidence of colitis. No acute intra-abdominal pathology.
2. Coarse calcifications within the pancreas consistent with chronic
pancreatitis.
3. Mild cardiomegaly with trace pericardial effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea
Diagnosed with Diarrhea, unspecified, Unsteadiness on feet, Headache
temperature: 97.2
heartrate: 84.0
resprate: 22.0
o2sat: 98.0
sbp: 112.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ M p/w several days incontinent ?diarrhea w/o fever or abd
pain, comes from wife's nursing home, sent by doctors there with
___ self-neglect and need for greater community support. Here
for observation, IVF, and SW/CM for evaluation of level of care
needed at d/c. Found to be retaining, being treated for UTI.
# Concern for self-neglect and cognitive impairment:
Pt has been living in his wife's nursing home, despite not being
a resident. States that at home, he and his wife take care of
each other, which contradicts reports that she has dementia and
required placement herself. Lately has been incontinent of stool
and urine. Likely not able to care for himself in the community.
Had not been taking his medications for weeks and was sent in by
staff at his wife nursing home for incontinence and being
disheveled.
# Urinary retention
# UTI
Has a history of prostate cancer with brachytherapy, although is
not on any prostate meds as an outpatient. There was reports of
urinary incontinence prior to admission. Home meds that are
likely to cause retention include his glaucoma eyedrops
(although minimal systemic absorption) and olanzapine. He
reports he has been on olanzapine for many years and initially
it was prescribed from a psychiatrist. He endorses schizophrenia
as the reason why, and stated he was diagnosed with this in his
___. Given importance of his psych meds, started on PVR bladder
scans BID with straight catheterization for >300. Treated for
urinary tract infection ___.
# Diarrhea. Guaiac and C. diff neg. Given lack of fever and
abdominal pain, does not appear to be need for infectious stool
workup otherwise. Improved with loperamide.
# Hx GIB. Was hospitalized in ___ for UGIB, had endoscopy and
was found to have peptic ulcer. Anticoagulation was discontinued
at this point (was on them for both afib and unprovoked DVT/PE).
# AFib. Long-standing hx afib, was on rate controllers and
anticoagulation prior but was stopped by his doctor due to UGIB
and several episodes of hypotension. Currently pt in afib per
EKG but rate is normal.
# Schizophrenia. Per chart he has a history of schizophrenia and
patient endorses this was diagnosed in his ___ and he was
prescribed olanzapine by a psychiatrist. Continue home
olanzapine.
============================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Painless jaundice and Hematuria
Major Surgical or Invasive Procedure:
___- ERCP Dr. ___, Fellow (fellow)
___ CBD brushings sent by ___, MD ___
___, Fellow (fellow)
___ TRANSHEPATIC INTERNAL / EXTERNAL BILIARY
DRAINAGE CATHETER PLACEMENT by Dr. ___ ___ fellow)
Dr. ___ ___ attending),
Dr ___ ( ___ attending)
___-
1. Percutaneous transhepatic cholangiogram. 2. Placement of 8
cm x 12 mm Luminexx stent. 3. Balloon plasty of stent to 10mm.
4. Placement of 8 ___ Amplatz Anchor drain.
___- CT guided lung bx ___. ___
___. ___
___ of indwelling Amplatz Anchor drain by Dr. ___
___ (fellow) and Dr. ___ (attending present and
supervising
History of Present Illness:
The patient is an ___ year old male with atrial fibrillation,
CHF, COPD, and residual left sided paralysis after distant
traumatic head injury who was transferred from ___
after presenting with five days of painless jaundice and
hematuria. He was treated for a UTI on ___ with Cephalexin
after developing hematuria without any other urinary symptoms.
He completed the antibiotics, but noticed persistent dark urine
which he initially thought was continued blood from the UTI.
Additionally, his daughter noted that he was becoming jaudiced
and urged him to present for evaluation. He denied any abdominal
pain, nausea, vomiting, diarrhea, fevers, chills, or recent
weight loss.
He was evaluated at ___ where a CT was obtained
which showed diffuse intra and extra hepatic biliary dilatation.
CBD with irregular margins suggestive of mass. There was no
focal pancreatic mass, but a left bladder wall mass was seen.
Labs were notable for TBili 15 and Dbili 9.5. He was given
Unasyn and transferred to ___ for possible ERCP.
Initial vitals in ED triage were T 95.8, BP 132/79, HR 87, RR
18, and SpO2 99% on RA. He remained asymptomatic with benign
exam except for jaundice. Labs were notable for TBili 16.5, ALK
882, ALT 128, AST 126, and Lipase 77. Urinalysis showed RBC
>182, WBC 5, few bacteria, and moderate bilirubin. RUQ
ultrasound showed prominent intrahepatic and extrahepatic
biliary dilatation, CBD dilation to 18 mm, and GB sludge.
He was admitted to medicine for further management of painless
jaundice and biliary obstruction. Vitals ___ to floor transfer
were T 97.8, BP 118/84, HR 107, RR 16, and SpO2 97% on RA. On
reaching the floor, he reported feeling well with no current
medical complaints besides jaundice and dark urine.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary Artery Disease: denied history of MI, chest pain, or
cardiac catheterization
2. Congestive Heart Failure: has had TTE several times, but
patient does not remember details
3. Atrial Fibrillation
4. Permanent Pacemaker: placed ___ years ago
5. Hypertension
6. HYperlipidemia
7. Abdominal Aortic Aneurysm: infrarenal, 4.1 cm, peripheral
thrombus on CT abdomen (___)
8. COPD: (DO WE HAVE FEV1/FVC) rarely uses inhaler, no longer
smokes
9. Traumatic Head Injury: car accident in ___ residual left
arm and leg paralysis
10. Left Hip Replacement
11. Lumbar Spondylosis
12. Cataract Surgery -- bilateral
13. Appendectomy -- age ___
14. Tonsillectomy
Social History:
___
Family History:
-Mother: died from MI at age ___
-Father: died from stroke at age ___
-Brother: died from pancreatic and liver cancer at age ___ Uncle
also died of pancreatic cancer
-Son and daughter: healthy at ___ and ___, respectively
-No other known family history of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.1, BP 158/92, HR 86, RR 16, SpO2 98% on RA
Gen: Elderly male in NAD. Oriented x3.
HEENT: Right side of skull indented. Icteric sclera. Surgical
pupils, equal and responsive to light, EOMI. MMM, OP benign.
Neck: JVP not elevated. No cervical lymphadenopathy.
CV: Irregular rate. No M/R/G.
Chest: Somewhat decreased air movement throughout. Few crackles
at right base. No wheezes or rhonchi.
Abd: Active bowel sounds. Soft, NT, ND. No organomegaly or
masses appreciated.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: Jaundiced. Few ecchymoses at IV sites.
Neuro: CN II-XII intact except for slight left facial droop.
Strength ___ on right. Left foot drop. Left arm contractures.
Normal speech.
DISCHARGE PHYSICAL EXAM:
VS: T 98.3 BP 120/60 HR 67 RR 16 O2 sat 95% RA.
Gen: Elderly male in NAD. Oriented x3. Jaundiced
HEENT: Icteric sclera. Surgical pupils, equal and responsive to
light, EOMI. MMM, OP benign.
CV: Irregular rate. No M/R/G.
Chest: Mild crackles noted diffusely. No wheezing, rhonchi or
labored breathing.
Abd: Soft, ND, NTTP. No organomegaly or masses appreciated. No
tenderness around area where drain was located.
Ext: WWP. No C/C/E. Distal pulses intact radial 2+, DP 2+, ___
2+.
Skin: Jaundiced.
Neuro: Muscle atrophy and contractures evident on L side in
upper and lower extremities. A&O x3, normal speech, goal
oriented.
Pertinent Results:
ADMISSION LABS
___ 07:30PM BLOOD WBC-6.2 RBC-4.61 Hgb-13.7* Hct-42.2
MCV-92 MCH-29.6 MCHC-32.3 RDW-16.6* Plt ___
___ 07:30PM BLOOD Neuts-77* Bands-0 Lymphs-11* Monos-11
Eos-1 Baso-0 ___ Myelos-0
___ 07:30PM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-136
K-3.8 Cl-100 HCO3-25 AnGap-15
___ 07:30PM BLOOD ALT-128* AST-126* AlkPhos-882*
TotBili-16.5*
___ 07:30PM BLOOD Lipase-77*
___ 07:30PM BLOOD Albumin-4.0 Calcium-9.8 Phos-3.3 Mg-2.0
___ 07:45PM BLOOD Lactate-1.0
___ 07:30PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.0 Leuks-TR
___ 07:30PM URINE RBC->182* WBC-5 Bacteri-FEW Yeast-NONE
Epi-0
PERTINENT LABS RESULTS
___ 06:50AM BLOOD WBC-5.5 RBC-3.75* Hgb-11.4* Hct-34.8*
MCV-93 MCH-30.3 MCHC-32.6 RDW-17.0* Plt ___
___ 06:50AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-135
K-4.2 Cl-98 HCO3-28 AnGap-13
___ 06:50AM BLOOD ALT-61* AST-88* AlkPhos-318* TotBili-4.6*
___ 06:50AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
___ 08:00AM BLOOD Digoxin-0.7*
___ 07:10AM BLOOD CA ___ 5347*
___ 07:05AM BLOOD CEA-4.9*
RELEVANT STUDIES:
Imaging
___ GU U/S:
Polypoid calcified mass in the left bladder wall apparently
arising from the region of the left ureterovesical
junction,highly concerning for primary bladder neoplasm (2.4 x
1.0 x 2.1 cm). Direct visualization via cystoscopy is
recommended for further evaluation.
___ RUQ US:
1. Moderate intrahepatic and extrahepatic biliary dilatation,
with CBD dilated to 18 mm.
2. Limited assessment for choledocholithiasis; the mid to lower
common bile duct and pancreatic head are not visualized.
3. Cholelithiasis without specific sonographic evidence to
suggest acute inflammation.
___ CT Abdomen Pelvis:
1. Diffuse intrahepatic and extrahepatic biliary ductal dilation
with abrupt termination/narrowing of the common bile duct in the
region of the pancreatic head. No pancreatic ductal dilatation.
The pancreatic head is bulky and heterogeneous, and it is
difficult to exclude infiltrative or ill defined obstructive
mass, although no discrete mass is detected. However, there is
an
enhancing 1 cm nodular mass in the second portion of the
duodenum
which could represent a hypertrophic ampulla or ampullary mass.
ERCP and/or endoscopic ultrasound may be helpful in further
evaluation.
2. Peripancreatic, celiac axis, and retroperitoneal
lymphadenopathy.
3. Multiple small pancreatic hypodensities likely represent
sidebranch IPMN.
4. Fusiform infrarenal abdominal aortic aneurysm with intramural
thrombus, ulcerated plaques, and focal chronic dissection. No
aneurysm rupture.
5. Tiny right renal cortical hypodensity, likely a cyst, however
too small to characterize.
6. Indeterminate 2 mm pulmonary nodule in the right middle lobe.
7. Multilevel vertebral body compression fractures of
indeterminate age.
___ Chest CT-Scan:
1. Severe emphysema.
2. Left lower lung spiculated nodule is suspicious for primary
lung
malignancy and is probably invading the left upper lobe through
an incomplete fissure.
3. Multiple other less than 1 cm nodules are of indeterminate
significance and could be metastasis from any other known
malignancies.
Procedure Reports:
___ ERCP:
-Normal major papilla.
-Cannulation of the biliary duct was not possible with free-hand
technique.
-Multiple attempts were made.
-Cannulation attempts resulted in submucosal injection.
-Limited cholangiogram of bile duct suggest dilated bile duct
and
a possible stricture.
-However a guidewire could not be advanced through possible
stricture.
-Limited pancreatogram is normal.
___ ERCP:
-Mild congestion/edema of the major papilla was noted.
-Cannulation of the biliary duct was not possible despite
multiple attempts.
-Complete obstruction of the bile duct was noted.
-Recommended ___ consult
___ PTBD:
1. Marked intra and extrahepatic biliary dilatation with a tight
stenosis of the distal CBD.
2. Satisfactory brush and core biopsy of the strictured segment.
3. Contrast was seen to opacify the dilated gall bladder in
keeping with a patent cystic duct.
4. Opacification of the left duct system was noted via our right
sided access.
Pathology
___ Urine Cytology: ATYPICAL.
Rare atypical degenerated urothelial cells. Squamous cells,
anucleate squames, histiocytes, neutrophils, eosinophils, and
red
blood cells.
___: Distal common bile duct, mucosal biopsies:
Distorted biliary-type mucosa with markedly atypical glands and
single cells consistent with adenocarcinoma (confirmed by
cytokeratin cocktail immunostain); crush artifact limits
evaluation of the degree of differentiation of the tumor. Note:
Given the patient's imaging data and markedly elevated ___, a
primary biliary or pancreatic tumor is likely
___ Lung nodule biopsy pathology report:
Lung, left lobe, core needle biopsy (A): Adenocarcinoma. The
tumor cells stain positive for CK-7, but negative for CK-20 and
TTF-1. The morphology and staining profile is compatible with
metastasis from pancreaticobiliary site favored, however a lung
primary can not be completely ruled out. Clinical and radiologic
correlation are advised.
Radiology Report
INDICATION: ___ male with jaundice. Question choledocholithiasis.
COMPARISON: None available at the time of interpretation.
FINDINGS: Current exam is highly limited due to suboptimal penetration and
acoustic window. Allowing for such, the liver demonstrates no definite focal
or textural abnormality. There is moderate intrahepatic biliary dilatation.
The common bile duct is dilated to 18 mm, however not well enough visualized
to assess optimally for choledocholithiasis. The gallbladder is markedly
distended and contains sludge but without wall thickening or pericholecystic
fluid. The cystic duct also appears prominent. The pancreas is poorly seen.
The spleen measures approximately 7 cm. The main portal vein demonstrates
normal hepatopetal flow.
IMPRESSION:
1. Moderate intrahepatic and extrahepatic biliary dilatation, with CBD
dilated to 18 mm.
2. Limited assessment for choledocholithiasis; the mid to lower common bile
duct and pancreatic head are not visualized.
3. Cholelithiasis without specific sonographic evidence to suggest acute
inflammation.
Radiology Report
CTA ABDOMEN WITH AND WITHOUT CONTRAST
INDICATION: ___ male with painless jaundice and direct
hyperbilirubinemia. Evaluate for pancreatic mass.
COMPARISON: Outside CT dated ___ from ___.
TECHNIQUE: Multiple axial CT images were obtained through the abdomen before
and after the administration of 200 cc of Omnipaque IV contrast.
Post-contrast images were obtained in the arterial and portal venous phase per
pancreatic protocol. Sagittal and coronal reconstructions were obtained. No
adverse contrast reactions were reported.
FINDINGS:
LOWER LUNGS: There is a 2mm nodule in the right middle lobe. Bilateral
basilar subsegmental atelectasis. No pleural effusion. Cardiomegaly. The
distal aspect of a right ventricular chamber cardiac pacer lead is noted. No
pericardial effusion or thickening. There is significant biatrial
enlargement. Dense atherosclerotic calcifications of the coronary arteries
and calcifications of the mitral valve. Atherosclerotic calcifications of the
aortic root.
ABDOMEN: No free air. No abdominal ascites or fluid collection.
The liver demonstrates homogeneous enhancement without focal lesions.
Hyperdense fluid dependently layering along the common hepatic and common bile
ducts is likely related to reflux of oral contrast, limiting evaluation for
biliary ductal stones. There is diffuse intrahepatic and extrahepatic biliary
ductal dilatation, most pronounced centrally. The common bile duct is
dilated, measuring 1.3 cm and remains dilated to the level of the pancreatic
head where it abruptly narrows and is not visible distally within the
pancreatic head. The gallbladder is markedly distended. Enhancing round 1 cm
nodular structure within the second portion of the duodenum may represent a
portion of the duodenal papilla, however raises consideration for an
periampullary mass in the setting of the above findings. The pancreatic duct
is mildly prominent measuring approximately 2 mm, however is not dilated. The
pancreatic head is bulky and heterogenous, however no discrete hypoenhancing
pancreatic mass is detected. Multiple subcentimeter hypodense foci are seen,
however, within the inferior aspect of the pancreatic head, uncinate process,
and tail, the largest measuring 3 mm, possibly representing side branch
intraductal papillary mucinous neoplasms (IPMN).
Mulitple enlarged ___, celiac axis, and retroperitoneal lymph
nodes are identified. Enlarged left para-aortic lymph node measures 0.9 x 1.0
cm. Peripancreatic lymph node interposed between the pancreatic head and left
renal vein measures 1.2 x 1.3 cm (3b:142). Additional left paraaortic lymph
node measures 0.8 x 1.0 cm (3b:151).
The spleen demonstrates homogeneous enhancement without focal lesions.
Adrenal glands are normal in size without nodularity. Tiny cortical
hypodensities in the right kidney likely represent cysts, however, are too
small to characterize. Otherwise, the kidneys demonstrate symmetric
enhancement and excretion without hydronephrosis or hydroureter. The visible
bowel loops are normal in caliber. There has been interval transit of enteric
contrast now to the level of the distal colon. Mild colonic diverticulosis
without diverticulitis in the visible bowel loops.
The abdominal aorta is diffusely atherosclerotic with a fusiform infrarenal
aneurysm extending to the level of the aortic bifurcation, measuring 4.3 cm in
greatest dimension (AP). There is circumferential mural thrombus surrounding
the aneurysmal sac with focal areas of plaque ulcerations. There is a focal
chronic dissection within the aneurysm, approximately 5 cm proximal to the
distal aortic bifurcation. No evidence of aortic aneurysm rupture. Limited
evaluation of the common iliac arteries demonstrate diffuse atherosclerotic
calcification.
BONES AND SOFT TISSUES: The osseous structures are diffusely osteopenic.
Superior endplate depression of multiple vertebral bodies including T10, T11,
L2, and L4 are most likely related to compression fractures of indeterminate
age. Multilevel degenerative disc disease with facet arthrosis.
IMPRESSION:
1. Diffuse intrahepatic and extrahepatic biliary ductal dilation with abrupt
termination/narrowing of the common bile duct in the region of the pancreatic
head. No pancreatic ductal dilatation. The pancreatic head is bulky and
heterogeneous, and it is difficult to exclude infiltrative or ill defined
obstructive mass, although no discrete mass is detected. However, there is an
enhancing 1 cm nodular mass in the second portion of the duodenum which could
represent a hypertrophic ampulla or ampullary mass. ERCP and/or endoscopic
ultrasound may be helpful in further evaluation.
2. Peripancreatic, celiac axis, and retroperitoneal lymphadenopathy.
3. Multiple small pancreatic hypodensities likely represent sidebranch IPMN.
4. Fusiform infrarenal abdominal aortic aneurysm with intramural thrombus,
ulcerated plaques, and focal chronic dissection. No aneurysm rupture.
5. Tiny right renal cortical hypodensity, likely a cyst, however too small to
characterize.
6. Indeterminate 2 mm pulmonary nodule in the right middle lobe.
7. Multilevel vertebral body compression fractures of indeterminate age.
Radiology Report
COMPLETE GU ULTRASOUND
HISTORY: ___ man with history of AFib, CHF, COPD, former smoker,
question bladder mass on outside facility CT. Gross and microscopic
hematuria, evaluate for GU malignancy.
COMPARISON: Outside facility CT abdomen and pelvis of ___.
FINDINGS: Mild fullness of the right renal calyces without pelvic dilatation.
The right kidney measures 9.0 cm in length. The left kidney measures 9.5 cm
in length. No evidence of renal mass.
Full urinary bladder. Adherent to the bladder wall is a polyploid mass,
nonmobile, with shadowing thick calcification, the polyploid portion of the
mass measures approximately 2.4 x 1.0 x 2.1 cm. The mass contains some
internal flow, and appears to arise from the region of the left ureterovesical
junction. No ureteral jets evident. Slightly heterogeneous prostate
containing coarse calcification measuring 3.5 x 3.1 x 3.5 cm.
IMPRESSION: Polypoid calcified mass in the left bladder wall apparently
arising from the region of the left ureterovesical junction, highly concerning
for primary bladder neoplasm. Direct visualization via cystoscopy is
recommended for further evaluation.
Radiology Report
1. PERCUTANEOUS TRANSHEPATIC INTERNAL / EXTERNAL BILIARY DRAINAGE CATHETER
PLACEMENT
2. BRUSH AND FORCEP BIOPSIES OF DISTAL ___
MEDICAL HISTORY: ___ male with history of painless jaundice for two
weeks with intra and extrahepatic biliary dilatation on CT.
ERCP were unable to access ampulla and today patient comes in today for a
percutaneous biliary drain placement.
PROCEDURES:
1. Percutaneous transhepatic cholangiogram via right posterior duct access.
2. Placement of ___ internal/external biliary drain.
3. Forcep and brush biopsises from the distal CBD stricture.
MEDICATION: General anesthesia was induced by the anesthesiology team.Please
see relevant documentation. 2g of IV ceftriaxone was administered at induction
of anesthesia . In addition the patient received 8cc of 0.5% Marcaine along
the cutaneous drain placement tract at the end of the procedure
OPERATORS: Dr. ___ ___ fellow) Dr. ___ ___ attending),
Dr ___ ( ___ attending). The attending was present and supervised the
entire procedure.
PROCEDURE:
After discussion of the risks, benefits and alternatives to this procedure
written informed consent was obtained. Patient was brought to the angiography
suite and placed supine on the imaging table. A preprocedure timeout was
performed as per ___ protocol.
General anesthesia was induced. The right flank and upper abdomen was prepped
and draped in the usual sterile fashion.
Ultrasound was used to identify a peripheral dilated segment VI duct in the
right-sided biliary tree. Using a 21-gauge Cook needle a right posterior duct
was punctured and the dilated biliary tree was opacified. Dark bile was
immediately obtained. An 0.018 nitinol wire was advanced into the dilated
common bile duct. A accustick sheath was advanced over the nitinol wire and
used to exchange for an 035 angled glide A 6 ___ 25 cm ___ sheath
was advanced into the junction of the intrahepatic right and left biliary
ducts. Using a 5 ___ Kumpe catheter and the Terumo Glidewire, the system
was then advanced through the common bile duct. With some manipulation the
guide wire was passed through the tight distal CBD stenosis, into the
duodenum. At this moment, the Glidewire was exchanged into a super stiff
straight Amplatz 0.035 wire. Subsequently, a "pull-back" cholangiogram was
performed.
A tight beak like stenosis was seen in the distal comon bile duct.
At this point,follwing placement of a safety wire, a brush biopsy from the
CBD stricture was performed via the shaeth . Subsequently, a radial jaw forcep
biopsy of the same area of strictured distal CBD was performed with retrieval
of 4 sizeable tissue fragments. Relevant flouroscopic images were strored to
document position.
Following biopsy the ___ sheath was removed and an ___ internal / external
biliary drain was placed with the dital pigtail optimally formed in the bowel.
Injection of contrast confirmed satisfactory position and the catheter was
flushed and secured to the skin with a 0-silk suture and stat-lock device.
The patient was extubated and transferred in stable condition to the post
anaesthesia care unit.
IMPRESSION:
1. Marked intra and extrahepatic biliary dilatation with a tight stenosis of
the distal CBD.
2. Satisfactory brush and core biopsy of the strictured segment.
3. Contrast was seen to opacify the dilated gall bladder in keeping with a
patent cystic duct.
4. Opacification of the left duct system was noted via our right sided access.
Radiology Report
CHEST CT WITHOUT CONTRAST
INDICATION: Patient with history of AFib, CHF, COPD presenting pancreatic
adenocarcinoma and bladder mass concerning for malignancy. Evaluation for
metastasis AND nodes.
COMPARISON: Abdominal CT of ___. No prior chest CT.
FINDINGS:
AIRWAYS AND LUNGS:
Paraseptal and centrilobular emphysema is severe most predominant in upper
lobes. The airways are mildly thickened diffusely.
Spiculated left lower lobe nodule measuring 18 x 15 mm is concerning for a
primary lung malignancy. The lesion is in superior segment and is retracting
the major fissure. There is a high suspicion of contiguous spread to left
upper lobe by an incomplete fissure.
A few other lung nodules are seen. There are in series 4, image 44, 53, 57,
91, 100, 109, 133. One is in right middle lobe measuring 6 mm, another one in
the right lower lobe in subpleural lung is measuring 9 mm. They are
indeterminate and could be metastasis from his multiple malignancies.
MEDIASTINUM:
The thyroid is unremarkable. There is no pathologic, superclavicular,
axillary, or mediastinal lymph node enlargement by CT size criteria.
The aorta is moderately calcified with a small focal aneurysm in mid aortic
arch up to 3.3 cm.
Mild dilatation of pulmonary artery is seen with right pulmonary artery
measuring 2.9 cm. Left atrium is severely dilated and coronary arteries are
moderately calcified. There is no pleural or pericardial effusion.
OSSEOUS STRUCTURES: There is no bony lesion concerning for malignancy.
Multiple compression fractures are in the thoracic spine.
UPPER ABDOMEN: This unenhanced study is not tailored for assessment of
intraabdominal organ. The patient has a biliary catheter. Please refer to
recent abdominal CT for the details.
CONCLUSION:
1. Severe emphysema.
2. Left lower lung spiculated nodule is suspicious for primary lung
malignancy and is probably invading the left upper lobe through an incomplete
fissure.
3. Multiple other less than 1 cm nodules are of indeterminate significance
and could be metastasis from any other known malignancies.
Radiology Report
CT-GUIDED TARGETED BIOPSY
INDICATION: ___ year old newly diagnosed pancreatic adeno and ?primary bladder
malignancy now with new lung nodule Left lobe concerning for primary
malignancy vs mets
PHYSICIANS: ___
PRE PROCEDURE FINDINGS: There is severe aortic atherosclerosis. There is
coronary artery calcification, specifically within the LAD. The
tracheobronchial tree is patent. The pleura are clear. There is background
emphysema in the lungs.
There is a spiculated nodule in the left lower lobe, abutting the fissure.
This was targeted for biopsy.
PROCEDURE:
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. A preprocedure timeout was
performed discussing the planned procedure, confirming the patient's identity
with three identifiers, and reviewing a checklist per ___ protocol.
Under CT guidance, an entrance site was selected and the skin was prepped and
draped in the usual sterile fashion. 1% lidocaine buffered with sodium
bicarbonate were instilled for local anesthesia.
Using a coaxial technique, an outer 19G coaxial needle was introduced into the
left lower lobe. A 20-gauge biopsy needle was advanced into the lesion with CT
guidance and 4 core biopsy samples were obtained followed by ___ FNA.
Moderate sedation was provided by administering divided doses of 1 mg versed
and 50 mcg fentanyl throughout the total intra-service time of 53 minutes
during which the patient's hemodynamic parameters were continuously monitored
by radiology nursing personnel.
The patient tolerated the procedure well. There was a small amount of post
biopsy hemorrhage aroeund the lesion. There also was a small left
pneumothorax. Estimated blood loss was minimal.
Dr. ___ , the attending radiologist, was present throughout the entire
procedure. Post-procedure instructions were written in the ___ medical
record.
IMPRESSION:
CT-guided biopsy. Pathology pending.
Small left pneumothorax will be followed with serial radiographs.
Radiology Report
INDICATION: ___ man with newly-diagnosed pancreatic adenocarcinoma
status post placement of internal-external drain, now for placement of CBD
stent.
COMPARISON: Cholangiogram dated ___.
OPERATORS: Dr. ___ (fellow) and Dr. ___ (attending,
present and supervising) performed the procedure. Dr. ___, attending,
supervising.
PROCEDURES:
1. Percutaneous transhepatic cholangiogram.
2. Placement of 8 cm x 12 mm Luminexx stent.
3. Balloon plasty of stent to 10mm.
4. Placement of 8 ___ Amplatz Anchor drain.
ANESTHESIA: Moderate sedation was obtained by providing divided doses of 2.5
mg of Versed and 125 mcg of fentanyl during which the patients hemodynamic
paramaters were continuously monitored. In addition the patient received 10cc
of 1% buffered lidocaine to the skin surrounding the drain site.
PROCEDURE DETAILS: After discussing the risks, benefits and alternatives to
the procedure, written informed consent was obtained. The patient was brought
to the angiography suite and placed supine on the imaging table. A
preprocedure timeout was performed as per the ___ protocol. The right upper
groin was prepped and draped in the usual sterile fashion.
Initial scout images confirmed unchanged position of the indwelling 8 ___
internal-external drain with its tip placed in the duodenum. Following
injection of small amount of contrast through the catheter to confirm its
patency, the catheter was cut and ___ wire introduced into the duodenum.
The indwelling catheter was removed and a 7 ___ sheath inserted. A Kumpe
catheter was then used to exchange the ___ for an Amplatz wire and,
eventually, a pullback cholangiogram performed. The latter redemonstrated
tight stenosis of the common bile duct in its distal portion. After inserting
a 5 ___ measuring catheter, another pullback cholangiogram was performed
and measurements obtained to select an appropriate common bile duct stent.
The measurement catheter was removed and a 12 mm diameter, 8 cm Luminexx stent
advanced over the Amplatz wire so that its tip would be located in the
duodenum and distal end just disatl to the insertion site of the cystic duct.
The stent was then deployed without difficulty and dilated using a 4 cm x 10
___ balloon. A tight waist was noted at the level of the known CBD
tumor. A subsequent cholangiogram performed over the sheath, proximal to the
indwelling stent, suggested some compromise of outflow suggesting blood clots
within the stent which were subsequently addressed by repeated ballooning of
the lumen. A final cholangiogram demonstrated patency of the stent.
Access for a final cholangiogram in 48 hrs was secured by inserting an 8
___ Amplatz Anchor drain with its tip in the upper CBD, above the stent.
The anchor was locked, the catheter attached to the skin with 0 silk and
further secured using a StatLock. It was connected to a bag and should be
capped in about 12 hours.
IMPRESSION:
1. Successful placement of 12 mm, 8 cm Luminexx stent through the distal CBD
stenosis extending into the CBD with plasty to 10mm with good cholangiographic
result.Flow of contrast was seen throuh the stent following the procedure.
Of note the patient has a duodenal malrotation.
2. Placement of 8 ___ Anchor Amplatz drain to secure access for final
cholangiogram which should be performed in about two days. The drain is
connected to a bag and should be capped in about 12 hours.
The findings were communicated to Dr. ___ immediately following the
procedure.
Radiology Report
CLINICAL HISTORY: Status post biopsy of left lung nodule under CT guidance.
Evaluate for pneumothorax.
A small apical pneumothorax is present. Opacity is seen in the left mid lung.
IMPRESSION: Small pneumothorax.
Radiology Report
Status post biopsy of left lung nodule, evaluate for pneumothorax.
CHEST: Small apical pneumothorax persists marginally less than on the prior
chest x-ray. No other changes are otherwise seen.
Radiology Report
CLINICAL HISTORY: Status post left lung biopsy with resultant pneumothorax,
re-evaluate chest.
CHEST: The left pneumothorax has resolved. Left lung mass again noted. Lung
fields otherwise clear.
IMPRESSION: Resolution of left pneumothorax.
Radiology Report
CLINICAL HISTORY: COPD, atrial fibrillation status post lung biopsy on left
side, evaluate for pneumothorax.
CHEST: No evidence for pneumothorax is currently seen on the left side. The
left lung mass is less apparent. Right lung appears clear.
Radiology Report
CLINICAL HISTORY: Decreased output of biliary drainage tube. Evaluate for
perforation.
ABDOMEN SUPINE: No evidence of free air is seen under either hemidiaphragm on
semi-erect chest film. The abdomen was taken in supine position. Some areas
of air are seen across the upper abdomen, but it is impossible to know on this
film whether these lie within or outside of the bowel.
Radiology Report
INDICATION: History of pancreatic adenocarcinoma and lung/bladder mass.
Looking for metastatic disease. Of note, the patient has a remote history of
traumatic head injury from a car accident in ___ with residual left arm and
leg paralysis.
COMPARISON: None.
TECHNIQUE: Sequential axial images were acquired through the head following
the administration of intravenous contrast for a preceding contrast-enhanced
chest CTA. Multiplanar reformations were performed.
FINDINGS: There is a large region of confluent hypodensity within the right
frontoparietotemporal region, with associated ex vacuo dilatation of the
adjacent right lateral ventricle, consistent with encephalomalacia, underlying
a craniectomy defect.
There is no intracranial enhancing lesion concerning for a metastasis.
Assessment for intracranial hemorrhage is limited secondary to administration
of intravenous contrast material. However, no hemorrhage is identified. There
is no evidence of recent infarction. The anterior and posterior intracranial
arterial circulations are grossly patent. The orbits are unremarkable.
Minimal mucosal thickening is seen within the posterior aspect of the left
maxillary sinus. The remainder of the visualized portions of the paranasal
sinuses and mastoid air cells are well aerated. No suspicious lytic or
blastic lesions are identified.
IMPRESSION:
1. No evidence of metastasis. If there is continued concern for metastatic
disease, further evaluation could be performed with MRI.
2. Large region of encephalomalacia within the right frontoparietotemporal
region underlying a craniectomy defect. This is compatible with the patient's
history of remote traumatic brain injury and left-sided extremity paralysis.
Radiology Report
INDICATION: ___ man with pancreatic adenocarcinoma and lung mass,
concern for PE, given back pain and new hypoxia with ECG changes.
COMPARISON: CT CHEST ___ and CTA abdomen ___
FINDINGS:
CHEST:
There is no abnormal mediastinal lymphadenopathy.
Again appreciated is a small aneurysm within the aortic arch. The aorta
demonstrates moderate atherosclerosis. Moderate coronary artery calcification.
There is mild dilatation of the right and left pulmonary arteries. Enlarged
right and left atrium.
There has been interval development of a left-sided small pneumothorax. The
pericardial spaces are clear.
The central tracheobronchial tree is patent.
There is paraseptal and centrilobular emphysema. There is a spiculated lung
nodule within the left lower lobe with resolving perilesional hemorrhage.
There is bibasal atelectasis. Otherwise, the lung parenchyma is unchanged
from the ___ CT scan.
ABDOMEN: There has been interval insertion of an internal-external biliary
drain with resultant decompression of the biliary tree. Expected pneumobilia
is seen.
The pancreatic duct is mildly prominent. The pancreatic head is bulky, however
no discrete pancreatic mass is detected. There are also multiple subcentimeter
hypodense foci are seen, within the head, uncinate process and tail,
representing side branch IPMN.
Mulitple enlarged ___, celiac axis, and retroperitoneal lymph
nodes are again identified.
The liver, spleen, adrenals are unremarkable. Tiny right renal cortical
hypodensities are too small to characterize. Otherwise, the kidneys
demonstrate symmetric enhancement and excretion. The visible bowel loops are
normal in caliber. There is mild colonic diverticulosis.
The abdominal aorta is diffusely atherosclerotic with a fusiform infrarenal
aneurysm. There is a left iliac artery aneurysm.
PELVIS:
Beam hardening artifact from the left hip metallic hardware limits the
assessment of the pelvis. There is focal mass-like thickening of the left
bladder wall with overlying calcification, measuring 3.9 x 2 cm. There is air
in the bladder from recent foley catheter insertion.
There is sigmoid diverticulosis.
BONES: The bones are osteopenic. Again no suspicious bony lesions are seen
concerning for malignancy. Multiple compression fractures are again
appreciated. There has been a left total hip arthroplasty.
IMPRESSION:
1. There is no evidence of pulmonary embolism. There is, however, a small
left-sided pneumothorax related to the recent procedure.
2. There has been interval insertion of an internal-external biliary drain
with resultant decompression of the biliary tree.
3. Little change to the underlying pancreatic mass lesion.
4. There is focal bladder wall thickening and calcification, suggesting an
underlying mass lesion.
Radiology Report
INDICATION: Pancreatic bladder and lung malignancies with episode of
desaturation and negative chest CTA, now with possible filling defect in
common femoral vein on CT of ___. Evaluate for DVT.
COMPARISON: CT of ___.
TECHNIQUE: Bilateral lower extremity venous ultrasound.
FINDINGS: Grayscale, color, and spectral Doppler images were obtained of the
right and left common femoral, femoral, and popliteal veins. Normal flow,
compressibility, augmentation, and waveforms demonstrated. No intraluminal
thrombus is identified. Color flow is seen within the posterior tibial and
peroneal veins bilaterally. The area of dilation and hypodensity in the right
common femoral vein seen on the prior CT, which was suspected to represent
mixing artifact, is included in the imaged portion of the vessels and shows no
evidence of thrombus.
IMPRESSION: No deep venous thrombosis in right or left lower extremity.
Radiology Report
INDICATION: ___ man with recently diagnosed pancreatic adenocarcinoma
and distal CBD obstruction. CBD stent placement two days ago. Final
cholangiogram and possible removal of indwelling Anchor Amplatz drain.
COMPARISON: Cholangiogram dated ___.
OPERATORS: Dr. ___ (fellow) and Dr. ___ (attending
present and supervising) performed the procedure.
PROCEDURES:
1. Percutaneous transhepatic cholangiogram.
2. Removal of indwelling Amplatz Anchor drain.
3. Sealing of access tract with Gelfoam.
ANESTHESIA: Moderate sedation was obtained by providing divided doses of 1 mg
of Versed and 50 mcg of fentanyl during which the patient's hemodynamic
parameters were continuously monitored.
PROCEDURE DETAILS: After discussing the risks, benefits and alternatives to
the procedure, written informed consent was obtained.
COMPARISON: The patient was brought to the endoscopy suite and placed supine
on the imaging table. A preprocedural timeout was performed as per ___
protocol. The right upper quadrant was prepped and draped in the usual
sterile fashion.
Initial scout images confirmed unchanged position of the recently placed CBD
stent as well as the indwelling 8 ___ Amplatz Anchor drain with its tip in
the central right posterior bile duct. A cholangiogram performed over the
indwelling drain demonstrated patency of the stent with rapid clearance of
injected contrast through the stent into the duodenum. There was no residual
dilatation of the intrahepatic ducts.
The indwelling catheter was cut, ___ wire introduced and the catheter
eventually removed. A ___ sheath was inserted into the duct, the dilator
end withdrawn, its tip cut, contrast injected into the indwelling sheath and
the Gelfoam torpedo then loaded. Using the modified dilator, the Gelfoam
torpedo was then positioned in the distal portion of the sheath and finally
depolyed in the hepatic parenchyma along the access tract.
There was no leaking from the skin and a sterile dressing was applied.
The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION:
1. Followup transhepatic cholangiogram demonstrating patency of the recently
placed Luminexx CBD stent with rapid clearance of injected contrast and no
dilatation of the intrahepatic ducts.
2. Removal of indwelling Anchor Amplatz drain and sealing of the path of
access by Gelfoam.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PAINLESS JAUNDICE
Diagnosed with DIS OF BILIARY TRACT NEC, CAD UNSPEC VESSEL, NATIVE OR GRAFT, CHRONIC AIRWAY OBSTRUCTION, HYPERTENSION NOS
temperature: 95.8
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 132.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with history significant for atrial
fibrillation, CHF, COPD, and residual left sided paralysis after
distant traumatic head injury who presented with five days of
painless jaundice and hematuria. He was found to have intra and
extra hepatic bile duct dilation on imaging as well as a left
bladder wall mass.
Active Issues:
# Metastatic Pancreatic adenocarcinoma with bile obstruction-
The patient was admitted with 5 days of painless jaundice with
diffuse intra and extra hepatic biliary dilatation and CBD with
irregular margins suggestive of mass on CT abdomen from ___
___. The patient had a subsequent CT abdomen at ___ with
pancreas protocol which significant for a bulky and heterogenous
pancreatic head. Additionally, an enhancing 1 cm nodular mass in
the second portion of the duodenum was identified. An ERCP was
twice unsuccessful in relieving the CBD obstruction. The patient
was maintained on PO Cipro/IV Flagyl for cholangitis
prophylaxis, and remained afebrile with no leukocytosis. ___ was
subsequently consulted to place an internal-external
percutaneous transhepatic biliary drain and obtain cell
brushings and biopsy. After placement of drain,the patient's
LFTs and Tbili decreased dramatically (see labs). The Pathology
report described distorted biliary-type mucosa with markedly
atypical glands and single cells consistent with adenocarcinoma
(confirmed by cytokeratin cocktail immunostain); crush artifact
limited evaluation of the degree of differentiation of the
tumor. Given the patient's imaging data and markedly elevated
___, a primary biliary or pancreatic tumor is strongly
suspected. On ___ ___ placed a stent in the common bile duct,
and his LFTs and T Bili continued to downtrend. On ___ the
drain was removed. The patient tolerated the procedures well
with some right side pain at the site of the procedure. His
pain was well controlled with PO Dilaudid. A CT scan of the
patient's chest was notable for several pulmonary nodules, which
were consistent with metastatic pancreatic adenocarcinoma ( see
below). The patient's PCP ___ help coordinate follow up with
oncology near the patient's home. The patient has been given a
copy of his scans and pathology reports. It should be noted
that hepatobiliary surgery was consulted, and felt that his
tumor was unresectable.
# Lung Masses/Probable Metastatic pancreatic adenocarcinoma
A CT chest on ___ was notable for 16 mm left lower lobe
nodule with spiculated margins (with two 2mm satellite nodules)
which was read as highly concerning for a primary lung cancer
in addition to 3mm and 6 mm subpleural nodules in the right
lower lobe concerning for metastasis. A CT guided transthoracic
needle biopsy was performed on the 16mm nodule in the left lobe
on ___. Pathology from the biopsy was consistent with
pancreaticobiliary metastasis. The CT guided biopsy was
complicated by a small pneumothorax that remained stable and did
not require chest tube placement.
# Hematuria /Bladder Mass:
The patient presented to the OSH with hematuria in the setting
of a recently treated UTI. His UA was notable for hematuria with
RBC >100, WBC ___, and positive nitrites. He did not complain
of any urinary symptoms and recently completed a course of
Cephalexin. A CT scan of the pelvis at the OSH revealed a
bladder wall mass, which was ill defined with artifact from the
patient's hip replacement. A ___ ultrasound at ___ confirmed a
polypoid calcified mass in the left bladder wall arising from
the region of the left ureterovesical junction, highly
concerning for primary bladder neoplasm. Urine cytology was
obtained, which showed atypical cells. Given the patient's age
and smoking history the mass is concerning for transitional cell
carcinoma. Urology was consulted and deferred further workup of
the bladder mass as an outpatient, pending the work of for the
pancreatic mass. During his hospital course, the patient
maintained good urine output with no evidence of urinary
obstruction or gross hematuria. His urine remained dark, however
this was most likely ___ to increased urobilinogen in the
setting of CBD obstruction. The patient's PCP ___ help
coordinate outpatient follow up with urology for possible
cystoscopy and further evaluation of the bladder mass.
Inactive issues:
# Chronic Systolic CHF w/ LVEF 50% ( from echo ___- Lasix
was held in the setting of hypovolemic hyponatremia, which
resolved after holding the Lasix. ___ be restarted at discretion
of PCP if patient has evidence of volume overload. He was
continued on digoxin.
# CAD, native: The patient's pravastatin was held in the setting
of his abnormal LFTs. He was continued on Diltiazem
# Atrial Fibrillation: stable. He was continued on aspirin for
stroke prophylaxis and Diltiazem for rate control.
# Hypertension: Continued on diltiazem
# Hyperlipidemia: Pravastatin was held in the setting of
abnormal LFTs.
# COPD: Stable during hospital course. The patient did not
require inhalers or nebulizers. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
Parotitis
Major Surgical or Invasive Procedure:
laryngoscopy on ___
History of Present Illness:
___ w/ a hx of reactive airway disease presented to OSH with 3
day hx of painful swelling of the parotid region. Symptoms
originally started on the right side but swelling subsequently
involed left side the follwing day. Yesterday, the pain and
swelling as become confluent between the two regions. He went to
the ___ ___ and there was concern for Mumps, but he left
AMA. He felt much worse this AM and returned. He has taken
tylenol with minimal relief over last few days. He denies any
SOB, wheezing,or dysphagia. He denies any additional
consitutional symptoms. At ___, he received a dose of
dexamethasone and vanc and was transferred to ___ for further
management.
In the ___, vitals T:38.1 HR:100 BP:122/71 RR12. CT with
contrast showed diffuse fat stranding of superficial neck no
obvious abscess or infection. Notable LNA with swelling ofs
surrounding the upper airway. In ___ pt noted to be spitting up
white pus, not clear whether from oral cavity or oropharynx. ENT
scoped patient and could not visualize source. On FO exam,
oropharynx slightly compressed. Mucosa looks fine, swallowing
secretions, no stridor, mouth floor soft w/ patent airway. He
was started on the ceftriaxone and clindamycin in ___ and
dexamethasone was continued. He is transferred to the MICU for
further management.
On arrival to the MICU, pt is comfortable,in no acute distess.
Vitals 98.6, HR88, 140/84 96%on RA
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Reactive airway disease
Social History:
___
Family History:
Non contributory. No hx of airway disease.
Physical Exam:
Admission Physical Exam:
Vitals: 98.6, HR88, 140/84 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Diffuse neck swelling in region between b/l parotids with
overlying erythema. Mild ttp. Neck supple.
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
Discharge Physical Exam:
VS:97.8, 97.8, 122/82, 68, 16, 96RA
General: Alert, oriented, no acute distress, walking back from
the bathroom after shaving
HEENT: Sclera anicteric, diffuse swelling of the neck in a beard
like distribution, improved compared to yesterday, No white
plaque visible in his oropharygnx
CV: RRR no MRG
Lungs: CTAB 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: nonfocal
Pertinent Results:
Admission Labs:
___ 04:45PM BLOOD WBC-7.0 RBC-4.75 Hgb-15.0 Hct-43.2 MCV-91
MCH-31.6 MCHC-34.7 RDW-13.3 Plt ___
Admission Labs:
___ 04:45PM BLOOD Neuts-84.4* Lymphs-11.2* Monos-3.0
Eos-0.8 Baso-0.5
___ 04:45PM BLOOD ___ PTT-29.6 ___
___ 04:45PM BLOOD Plt ___
___ 04:45PM BLOOD Glucose-131* UreaN-7 Creat-1.1 Na-137
K-4.6 Cl-102 HCO3-26 AnGap-14
___ 04:56AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
___ 04:56AM BLOOD Vanco-<1.7*
___ 04:46PM BLOOD Lactate-1.1
___ 05:30PM URINE Color-Straw Appear-Clear Sp ___
___ 05:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Discharge labs:
___ 06:45AM BLOOD WBC-11.6* RBC-4.90 Hgb-15.1 Hct-45.0
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.4 Plt ___
___ 06:25AM BLOOD Glucose-129* UreaN-18 Creat-1.0 Na-139
K-4.3 Cl-102 HCO3-27 AnGap-14
___ 06:25AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2
Micro:
Mumps Ig MPending
Blood culture NEGATIVE
Urine culture NEGATIVE
EBV IgG-POSITIVE IgM- NEGATIVE
CMV- IgG and IgM NEGATIVE
Mumps IgM- NEGATIVE
HIV Ab-NEGATIVE
Imaging:
CT Neck
IMPRESSION: Diffuse bilateral symmetric edema in the deep and
and superficial soft tissues of the anterior neck.
Additionally, there are multiple enlarged lymph nodes throughout
nearly all stations in the neck measuring up to 1.6 cm (5:55).
There is, however, no evidence of a drainable collection. The
oropharynx is significantly narrowed but patent. Close continued
followup is recommended. Findings could be in the spectrum of
ludwig's angina.
Medications on Admission:
Albuterol prn
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth twice a day Disp #*17 Tablet Refills:*0
2. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Disp
#*200 Milliliter Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
Discharge Disposition:
Home
Discharge Diagnosis:
Parotitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluation of the patient with anterior neck swelling.
COMPARISON: Outside hospital neck radiographs from ___.
TECHNIQUE: MDCT-acquired axial images were obtained through the neck after
administration of intravenous contrast. Multiplanar reformatted images were
prepared and reviewed.
FINDINGS: There is diffuse bilateral symmetric edema in the deep and and
superficial soft tissues of the anterior neck. Additionally, there are
multiple enlarged lymph nodes throughout nearly all stations in the neck
measuring up to 1.6 cm (5:55). The combination of these findings is most
likely representative of an infectious process. There is, however, no
evidence of a discrete collection at this time. There is significant
narrowing of the oropharynx but the oropharynx is patent. The visualized
intracranial contents are normal. The visualized mastoid air cells and
paranasal sinuses are clear.
IMPRESSION: Diffuse bilateral symmetric edema in the deep and and superficial
soft tissues of the anterior neck. Additionally, there are multiple enlarged
lymph nodes throughout nearly all stations in the neck measuring up to 1.6 cm
(5:55). There is, however, no evidence of a drainable collection. The
oropharynx is significantly narrowed but patent. Close continued followup is
recommended. Findings could be in the spectrum of ludwig's angina.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NECK SWELLING/PAIN
Diagnosed with CELLULITIS/ABSCESS MOUTH
temperature: 38.1
heartrate: 100.0
resprate: 12.0
o2sat: nan
sbp: 122.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | ___ w/ a hx of reactive airway disease presents with 3 day hx of
progressively worsening painful swelling of the b/l parotid
region. Physical exam findings consistent with parotitis with no
airway compromise who was originally monitored in the ICU and
received high dose IV steroids and then transferred to the floor
where he was switched from IV abx to po abx and was stable at
the time of discharge.
#Parotitis: Still unclear what the etiology of this was. His
exam was consistent with a bilateral parotitis however his CT
scan did not show diffuse enlargement of the parotids and
isntead showed anterior neck phlegmon which was also apparent on
exam. He was originally treated with IV steroids and iV Abx int
he MICU and was scoped by ENT who found now airway compromise.
After transfer tot he flor further workup for the cause of the
parotitis was pursued and all results were negative including
HIV ab, CMV, EBV. The Mumps IgG was positive consistent with
previous immunity and his IgM was pending at the time of
discharge. HE responded well to the IV steroids and it was
decided not to give oral steroids, he was monitored for >24 hour
after his last day of steroids and was stable. He was also
switched form IV abx to augmentin to complete a 14 day course.
He was given ENT information for a follow-up and instructed with
call or present to the ___ if he devleoped dyspnea,
whistelingwhen he breathed or other danger signs.
-Augmentin x 10 more days at the time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Gadolinium-Containing Contrast Media / Iodinated
Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
bilateral leg weakness and numbness
Major Surgical or Invasive Procedure:
bilateral groin cutdown and bilateral thromboembolectomy
___
History of Present Illness:
Ms. ___ is a ___ year old female with history of asthma who is
transferred from ___ for vascular surgery evaluation of a
proximal descending aorta thrombus. She states she was diagnosed
with pneumonia last week and was not improving on the prescribed
antibiotics. She went to her PCP today with worsening cough and
dyspnea, but while waiting, she began having lower back pain,
bilateral calf pain, leg weakness, and numbness & tingling. She
presented to ___ and CTA there showed a irregularly
bordered thrombus in the proximal descending thoracic aorta
without evidence of PE. She was evaluated by vascular surgery
there who recommended initiation of heparin gtt and transfer to
___. On arrival, she still had low back pain (new for her),
but the weakness & numbness/tingling had resolved. She had an
episode of urinary incontinence with movement and cough (known
history of stress incontinence). In the ED, a code cord was
called given her symptoms. On evaluation, she reported back pain
and bilateral calf pain. She no longer felt weak or had any
additional
numbness/tingling in her feet. She still has a cough and some
shortness of breath from her known community acquired pneumonia,
but has no chest pain, nausea, vomiting, or abdominal pain.
Past Medical History:
Cervical herniated disc, anxiety, asthma, morbid obesity, stress
incontinence, prediabetes, Laparoscopic cholecystectomy (Dr.
___
___ History:
___
Family History:
Mother - heart disease
Physical Exam:
Admission Physical Exam:
VS: T 98, HR 86, BP 112/48, RR 20, SaO2 100% RA
GEN: Uncomfortable appearing, anxious
HEENT:
CV: Regular rate and rhythm
PULM: Easy work of breathing
ABD: Soft, obese, nontender, nondistended, no guarding or
rebound
tenderness.
MSK: Bilateral feet cool to touch to ankle. Cap refill ___
seconds, slightly mottling of the toes and heel. Initially could
not Doppler DP signal bilaterally. Bilateral calf and thigh
tenderness to palpation.
PULSES: ___
Initially: R: d/d/-/d L: d/d/-/d
repeat pulse exam: R: d/d/d/d L: d/d/d/d
NEURO: CII-XII intact. Bilateral lower extremity strength and
sensation symmetrical and intact.
PSYCH: Appropriate mood and effect
Discharge Physical Exam:
VS - 98.7 78 95/60 20 92% RA
Gen - NAD
CV - RRR
Pulm - mildly labored breathing, not in resp distress
Abd - b/l stapled groin
MSK & extremities/skin - palpable R DP, L ___ dopplerable R ___,
L DP
Pertinent Results:
MR CODE CORD ___
No evidence of high-grade spinal canal or neural foraminal
stenosis within the thoracic or lumbar spine. Cord signal is
within normal limits. Edema within the subcutaneous tissues of
the lower lumbar spine.
CTA A/P W/ B/L RUNOFFS ___
1. The previously identified clot in the descending thoracic
aorta is not
imaged as this area is superior to our current field of view.
2. Disruption of flow in the bilateral popliteal arteries with
lack of flow in a 7 cm segment on the right and a 6 cm segment
on the left. There is reconstitution of flow with 3 vessel
runoff into the calf bilaterally.
3. Bilateral peroneal arteries are patent to level of the distal
calf
4. No flow seen in the bilateral dorsalis pedis arteries..
5. Interruption of contrast in the deep femoral artery on the
right which may represent filling defect versus mixing.
6. Lingular and bibasilar atelectasis.
CXR ___
The tip of the right central venous catheter projects over the
mid to distal SVC. New and increased bilateral patchy airspace
opacities, suspicious for multifocal infection or atelectasis.
CXR ___
1. Progression of the right lower lobe opacity, concerning for
pneumonia.
2. Persistent similar opacities in the right upper and mid and
left lower
lungs. No evidence of pneumothorax.
TTE ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF = 70%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
CXR ___
In comparison with the study of ___, the patient has
taken a better inspiration. Cardiac silhouette is within normal
limits and there is mild elevation of pulmonary venous pressure.
Continued increased opacification at the bases, especially on
the right above the elevated hemidiaphragm, are consistent with
pleural fluid and atelectatic change. In the appropriate
clinical setting, it would be difficult to exclude superimposed
pneumonia, especially in the absence of a lateral view.
CXR ___
Compared to chest radiographs ___. Large area of right lower lobe consolidation has
not improved since and ___, accompanied by at least a
small right pleural effusion. Smaller regions of parenchymal
abnormality in the left lung are due in part to atelectasis, but
conceivably also contralateral pneumonia, particularly in the
left upper lobe. Heart size is normal. No pneumothorax
Medications on Admission:
Duo-Neb 0.5 mg-3 mg/3mL solution neb
codeine-guaifenesin 10 mg-100 mg/5 mL
flunisolide 25 mcg nasal spray
fluticasone 220 mcg/actuation
doxycycline 100 mg QD (take for 7 days)
cefuroxime 500 mg tablet BID (take for 10 days)
ibuprofen 600 mg tablet
tizanidine 2 mg tablet
diphenhydramine 25 mg prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 325 mg 2 capsule(s) by mouth every six hours
Disp #*120 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth two
times a day Disp #*60 Capsule Refills:*0
5. Enoxaparin Sodium 130 mg SC BID prevention of arterial
thromboembolism
Start: Today - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 150 mg/mL 1 INJ subq twice a day Disp #*30
Syringe Refills:*0
6. Levofloxacin 750 mg PO Q24H
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*7 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every six hours Disp
#*30 Tablet Refills:*0
8. 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
9. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Senokot] 8.6 mg 1 tablet by mouth two times a
day Disp #*60 Tablet Refills:*0
10. Warfarin 5 mg PO DAILY16
titrate up or down depending on daily INR till at goal INR of
___
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*1
+ home meds
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute bilateral lower extremity ischemia due to embolization.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR CODE CORD COMPRESSION
INDICATION: ___ with leg weakness and back pain with known aortic thrombus.
// Non contrast MRI of T and L spine
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: Outside hospital CT a chest of ___.
FINDINGS:
THORACIC SPINE:
Thoracic alignment is anatomic. Vertebral body heights are preserved. There
is no focal suspicious marrow lesion. There is no definitive cord signal
abnormality. There is no significant spinal canal or neural foraminal
narrowing.
LUMBAR SPINE:
Lumbar alignment is anatomic. Vertebral body heights are preserved. ___
type 2 L5-S1 endplate changes are noted. There is no focal suspicious marrow
lesion. Degenerative loss of disc height and signal at L5-S1 is severe. The
conus medullaris terminates at the L1 level, within expected limits. There is
no signal abnormality of the terminal cord or conus.
L1-L2 through L3-L4: No significant canal or neural foraminal narrowing.
L4-L5: A central protrusion with annular fissure does not significantly narrow
the spinal canal. In combination with mild facet arthropathy there is minimal
bilateral neural foraminal narrowing.
L5-S1: A central protrusion does not significantly narrow the spinal canal
but minimally narrows the subarticular zones without displacement of the
traversing nerve roots. In combination with facet arthropathy, there is mild
to moderate left and mild right neural foraminal narrowing.
OTHER:
There is mild T2 hyperintense signal along the anterior aspect of the
descending aorta (series 13, image 16) which likely represents previously
described thrombus. There is bilateral atelectasis.
The common bile duct is mildly prominent measuring up to 6 mm, compatible with
prior history of cholecystectomy. Otherwise, visualize prevertebral
paraspinal soft tissues are well.
IMPRESSION:
1. Allowing for motion artifact, mid of cord signal abnormality is identified.
2. There is no significant spinal canal or neural foraminal narrowing of the
thoracic spine.
3. Degenerative changes at L5-S1 with central protrusion and small annular
fissure minimally narrows the subarticular zone without significant spinal
canal narrowing. There is mild right and mild-to-moderate left neural
foraminal narrowing.
4. T2 hyperintense signal along the anterior aspect of the descending aorta
likely represents previously described thrombus.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: *** CODE CORD *** History: ___ with read of aortic thrombus from
OSH but unable to see on our read. ___ weakness. Please obtain with runoffs
into lower extremities // ?thrombus. Please obtain with lower extremity
runoffs
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 18.1 s, 142.1 cm; CTDIvol =
5.8 mGy (Body) DLP = 820.5 mGy-cm. 2) Stationary Acquisition 3.5 s, 0.5 cm;
CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 3) Spiral Acquisition 18.0 s,
141.6 cm; CTDIvol = 17.4 mGy (Body) DLP = 2,466.3 mGy-cm. 4) Spiral
Acquisition 8.8 s, 69.1 cm; CTDIvol = 6.3 mGy (Body) DLP = 434.9 mGy-cm. Total
DLP (Body) = 3,730 mGy-cm.
COMPARISON: Reference CT chest from ___ at 2100
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is minimal calcium burden in the
abdominal aorta and great abdominal arteries. The previously identified clot
in the descending thoracic aorta is not imaged as this area is superior to our
current field of view. There is disruption of flow in the popliteal arteries
bilaterally with lack of flow in a 7 cm segment on the right side and a 6 cm
segment on the left. There is reconstitution with three-vessel runoff
bilaterally into the calf. The bilateral peroneal arteries are seen in the
distal calf with no definite flow seen in the bilateral dorsalis pedis
arteries. An area of decreased enhancement is noted in the right deep femoral
artery which may represent filling defect versus contrast mixing.
LOWER CHEST: Lingular atelectasis and bibasilar 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 is resected.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small fat containing periumbilical hernia.
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. There is no evidence of
mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture. 2
surgical screws noted in the medial malleolus on the right.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. The previously identified clot in the descending thoracic aorta is not
imaged as this area is superior to our current field of view.
2. Disruption of flow in the bilateral popliteal arteries with lack of flow in
a 7 cm segment on the right and a 6 cm segment on the left. There is
reconstitution of flow with 3 vessel runoff into the calf bilaterally.
3. Bilateral peroneal arteries are patent to level of the distal calf
4. No flow seen in the bilateral dorsalis pedis arteries..
5. Interruption of contrast in the deep femoral artery on the right which may
represent filling defect versus mixing.
6. Lingular and bibasilar atelectasis.
Radiology Report
INDICATION: ___ year old woman with new TLC // new TLC Contact name: ___,
___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Interval placement of a right central venous catheter, the tip projecting over
the mid to distal SVC.
Patchy bilateral airspace opacities involving the right upper and mid lung
zones as well as the lung base have progressed. There is new fullness along
the left mediastinal border which may reflect collapsed lung or or pneumonia.
No pleural effusion or pneumothorax is identified. The size of the cardiac
silhouette is mildly enlarged.
IMPRESSION:
The tip of the right central venous catheter projects over the mid to distal
SVC.
New and increased bilateral patchy airspace opacities, suspicious for
multifocal infection or atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pneumonia and proximal descending aortic
thrombus s/p b/l groin cutdowns and thromboembolectomy with new higher o2
requirements. Evaluate for pneumonia.
TECHNIQUE: Single portable AP view of the chest.
COMPARISON: Chest radiographs from ___.
FINDINGS:
Compared to the prior radiograph, there has been interval removal of the right
IJ central venous catheter.
Patchy bilateral airspace opacities in the right lower lobe have progressed.
There are persistent similar opacities in the right upper and mid and left
lower lungs. No evidence of pneumothorax or pleural effusion.
Cardiomediastinal silhouette is slightly enlarged, but unchanged.
IMPRESSION:
1. Progression of the right lower lobe opacity, concerning for pneumonia.
2. Persistent similar opacities in the right upper and mid and left lower
lungs. No evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PNA, hx of asthma, smoking s/p b/l groin
cutdown and thromboembolectomy // evaluate resolving PNA, atelectasis
evaluate resolving PNA, atelectasis
IMPRESSION:
In comparison with the study of ___, the patient has taken a better
inspiration. Cardiac silhouette is within normal limits and there is mild
elevation of pulmonary venous pressure. Continued increased opacification at
the bases, especially on the right above the elevated hemidiaphragm, are
consistent with pleural fluid and atelectatic change. In the appropriate
clinical setting, it would be difficult to exclude superimposed pneumonia,
especially in the absence of a lateral view.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with pna // Please evaluate lung fields
Please evaluate lung fields
IMPRESSION:
Compared to chest radiographs ___.
Large area of right lower lobe consolidation has not improved since and
___, accompanied by at least a small right pleural effusion. Smaller
regions of parenchymal abnormality in the left lung are due in part to
atelectasis, but conceivably also contralateral pneumonia, particularly in the
left upper lobe. . Heart size is normal. No pneumothorax
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Elevated D-dimer
Diagnosed with Embolism and thrombosis of other parts of aorta
temperature: 98.0
heartrate: 86.0
resprate: 20.0
o2sat: 100.0
sbp: nan
dbp: nan
level of pain: 9
level of acuity: 2.0 | ___ was taken to the OR ___ for bilateral groin
cutdowns and bilateral thromboembolectomies. Both of her groin
incisions were closed and prevena VACs were place bilaterally.
On POD1 she advanced to a regular diet and was started on
aspirin and atorvastatin. On POD2 her right IJ CVL was pulled
and she desated to 88% and was short of breath, and was titrated
up to a nonrebreather with no improvement in her sats. She was
given several rounds of DuoNebs and a flutter valve, after which
her sats and symptoms improved. She was noted to have pneumonia
on levaquin on admission, a history of asthma and smoking ___
pack per day. A chest X ray showed progression of right lower
lobe opacity suggestive of worsening pneumonia vs. atelectasis.
She was broadened from levaquin to vancomycin and meropenem
(history of penicillin allergy). She desated once more to ___ on
___ and improved after DuoNebs and placement of face tent.
Her heparin drip was discontinued at this time and was switched
to Xarelto. Given Pharmacy's concern of using xarelto for
arterial thromboembolism, she was switch to a lovenox to
Coumadin bridge on ___. The rest of her hospitalization she
required intermittent oxygen. ___ was consulted, and recommended
rehab. She was switch back to levaquin ___. She was
discharged to rehab with follow up in the Vascular Surgery
Clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy, small bowel resection with
primary anastomosis
History of Present Illness:
PMHx: HBV, DM2, HTN, HL, prostate CA s/p radiation, esophageal
varices ___ cirrhosis, gout
PSHx: appendectomy, cholecystectomy, b/l rotator cuff repairs,
LIH repair (___)
Past Medical History:
1. Hepatitis B
2. DM II
3. HTN
4. Dyslipidemia
5. Prostate cancer s/p radiation
6. Arthritis right ankle
7. Pancytopenia (___)
8. Adenomatous polyps at 70 cm (___)
9. Esophageal varix s/p banding ___
10. Gastric ulcer
11. Small hiatal hernia
12. Portal hypertensive gastropathy
13. Small right pleural effusion (ultrasound ___
14. Gout
15. Cirrhosis
PAST SURGICAL HISTORY
1. Appendectomy
2. Cholecystectomy
3. Bilateral rotator cuff repairs
Social History:
___
Family History:
Son died from ruptured aortic dissection and cardiac tamponade.
Daughter is healthy. No history of liver disease.
Physical Exam:
Admission Physical Exam:
VS - 98.3 94 91/51 25 98% RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress
Abd - soft, severe distension, diffuse ttp w/ mild guarding, no
rebound, R inguinal incision c/d/I w/ surrounding swelling, no
erythema
MSK & extremities/skin - no leg swelling observed b/l
Discharge Physical Exam:
VS: 98.8 PO 93/55 L Lying 80 18 96 Ra
GEN: no acute distress. Pleasant and interactive.
CV: irregular rhythm.
Resp: Clear bilaterally, diminished in the bases.
ABD: Soft, mild distention, mild pain to palpation RLQ and
incisionally. Midline abdominal surgical incision with staples,
CDI. Small amount of serous drainage.
EXT: Warm and dry. 2+ ___ pulses. scant edema.
Pertinent Results:
___ 06:42AM BLOOD WBC-4.4 RBC-2.71* Hgb-7.9* Hct-24.9*
MCV-92 MCH-29.2 MCHC-31.7* RDW-17.7* RDWSD-59.7* Plt ___
___ 05:07AM BLOOD WBC-5.3 RBC-2.81* Hgb-8.3* Hct-25.7*
MCV-92 MCH-29.5 MCHC-32.3 RDW-17.6* RDWSD-59.5* Plt ___
___ 01:02AM BLOOD WBC-3.8* RBC-2.63* Hgb-7.7* Hct-24.3*
MCV-92 MCH-29.3 MCHC-31.7* RDW-18.0* RDWSD-60.2* Plt ___
___ 05:15AM BLOOD WBC-4.3 RBC-2.59* Hgb-7.6* Hct-23.9*
MCV-92 MCH-29.3 MCHC-31.8* RDW-18.1* RDWSD-60.4* Plt ___
___ 04:48AM BLOOD WBC-5.1 RBC-2.60* Hgb-7.7* Hct-23.9*
MCV-92 MCH-29.6 MCHC-32.2 RDW-18.3* RDWSD-60.3* Plt ___
___ 06:53AM BLOOD WBC-6.6 RBC-2.80* Hgb-8.2* Hct-25.6*
MCV-91 MCH-29.3 MCHC-32.0 RDW-18.0* RDWSD-59.7* Plt ___
___ 05:00AM BLOOD WBC-4.4 RBC-2.44* Hgb-7.0* Hct-21.9*
MCV-90 MCH-28.7 MCHC-32.0 RDW-18.6* RDWSD-61.1* Plt Ct-83*
___ 06:00AM BLOOD WBC-5.6 RBC-2.70* Hgb-7.8* Hct-24.4*
MCV-90 MCH-28.9 MCHC-32.0 RDW-18.5* RDWSD-59.7* Plt Ct-92*
___ 05:44AM BLOOD WBC-4.8 RBC-2.66* Hgb-7.7* Hct-24.1*
MCV-91 MCH-28.9 MCHC-32.0 RDW-18.4* RDWSD-59.7* Plt Ct-91*
___ 05:40AM BLOOD WBC-5.3 RBC-2.68* Hgb-7.8* Hct-24.0*
MCV-90 MCH-29.1 MCHC-32.5 RDW-18.2* RDWSD-59.1* Plt Ct-89*
___ 02:04AM BLOOD WBC-5.2 RBC-2.57* Hgb-7.5* Hct-23.0*
MCV-90 MCH-29.2 MCHC-32.6 RDW-18.0* RDWSD-58.6* Plt ___
___ 01:51AM BLOOD WBC-5.5 RBC-2.66* Hgb-7.6* Hct-23.7*
MCV-89 MCH-28.6 MCHC-32.1 RDW-18.0* RDWSD-57.1* Plt ___
___ 03:48AM BLOOD WBC-4.7 RBC-2.74* Hgb-8.1* Hct-24.5*
MCV-89 MCH-29.6 MCHC-33.1 RDW-18.0* RDWSD-57.6* Plt ___
___ 01:59AM BLOOD WBC-4.6 RBC-2.57* Hgb-7.4* Hct-22.9*
MCV-89 MCH-28.8 MCHC-32.3 RDW-17.7* RDWSD-56.4* Plt ___
___ 11:04PM BLOOD WBC-7.9 RBC-2.70* Hgb-7.7* Hct-23.3*
MCV-86 MCH-28.5 MCHC-33.0 RDW-17.5* RDWSD-54.3* Plt ___
___ 04:03AM BLOOD WBC-6.5 RBC-2.45* Hgb-6.9* Hct-21.5*
MCV-88 MCH-28.2 MCHC-32.1 RDW-17.7* RDWSD-56.3* Plt Ct-97*
___ 12:53AM BLOOD WBC-8.7 RBC-2.80* Hgb-8.0* Hct-25.0*
MCV-89 MCH-28.6 MCHC-32.0 RDW-17.0* RDWSD-55.1* Plt ___
___ 02:02PM BLOOD WBC-6.7 RBC-2.73* Hgb-7.8* Hct-23.9*
MCV-88 MCH-28.6 MCHC-32.6 RDW-16.9* RDWSD-54.1* Plt Ct-83*
___ 01:09AM BLOOD WBC-5.2 RBC-2.42* Hgb-6.8* Hct-21.4*
MCV-88 MCH-28.1 MCHC-31.8* RDW-17.0* RDWSD-54.4* Plt Ct-88*
___ 02:17AM BLOOD WBC-4.3 RBC-2.49* Hgb-7.0* Hct-21.9*
MCV-88 MCH-28.1 MCHC-32.0 RDW-17.1* RDWSD-53.7* Plt Ct-78*
___ 02:11AM BLOOD WBC-3.9* RBC-2.48* Hgb-7.1* Hct-21.7*
MCV-88 MCH-28.6 MCHC-32.7 RDW-17.0* RDWSD-53.2* Plt Ct-77*
___ 02:09AM BLOOD WBC-4.8 RBC-2.77* Hgb-7.8* Hct-24.4*
MCV-88 MCH-28.2 MCHC-32.0 RDW-16.6* RDWSD-53.1* Plt Ct-90*
___ 12:38AM BLOOD WBC-6.7 RBC-3.75* Hgb-10.7* Hct-33.0*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.7* RDWSD-53.1* Plt ___
___ 05:15AM BLOOD ___
___ 04:48AM BLOOD ___
___ 05:00AM BLOOD ___ PTT-38.4* ___
___ 06:00AM BLOOD ___ PTT-48.4* ___
___ 05:44AM BLOOD ___ PTT-47.2* ___
___ 05:40AM BLOOD ___ PTT-54.6* ___
___ 03:48AM BLOOD ___ PTT-48.4* ___
___ 03:58PM BLOOD ___ PTT-40.1* ___
___ 01:59AM BLOOD ___ PTT-39.1* ___
___ 06:41PM BLOOD ___ PTT-41.4* ___
___ 04:19PM BLOOD ___ PTT-37.2* ___
___ 12:03PM BLOOD ___
___ 11:04PM BLOOD ___ PTT-49.7* ___
___ 04:03AM BLOOD ___ PTT-50.7* ___
___ 04:59AM BLOOD ___ PTT-49.1* ___
___ 04:25AM BLOOD ___ PTT-50.2* ___
___ 02:02PM BLOOD ___ PTT-46.7* ___
___ 01:09AM BLOOD ___ PTT-40.4* ___
___ 03:07PM BLOOD ___ PTT-45.8* ___
___ 02:11AM BLOOD ___ PTT-46.1* ___
___ 01:36PM BLOOD ___ PTT-150* ___
___ 02:09AM BLOOD ___ PTT-48.7* ___
___ 01:13PM BLOOD ___ PTT-34.6 ___
___ 06:42AM BLOOD Glucose-129* UreaN-21* Creat-0.9 Na-134*
K-5.6* Cl-98 HCO3-23 AnGap-13
___ 12:00PM BLOOD Glucose-171* UreaN-18 Creat-0.8 Na-130*
K-5.3 Cl-96 HCO3-26 AnGap-8*
___ 05:07AM BLOOD Glucose-134* UreaN-15 Creat-0.8 Na-131*
K-5.6* Cl-96 HCO3-24 AnGap-11
___ 01:02AM BLOOD Glucose-117* UreaN-12 Creat-0.7 Na-131*
K-4.8 Cl-95* HCO3-26 AnGap-10
___ 05:15AM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-133*
K-4.9 Cl-97 HCO3-25 AnGap-11
___ 04:48AM BLOOD Glucose-124* UreaN-11 Creat-0.6 Na-134*
K-4.8 Cl-100 HCO3-24 AnGap-10
___ 06:53AM BLOOD Glucose-139* UreaN-11 Creat-0.6 Na-135
K-4.5 Cl-97 HCO3-23 AnGap-15
___ 05:00AM BLOOD Glucose-157* UreaN-12 Creat-0.7 Na-133*
K-4.5 Cl-98 HCO3-25 AnGap-10
___ 06:00AM BLOOD Glucose-122* UreaN-10 Creat-0.6 Na-134*
K-4.7 Cl-97 HCO3-25 AnGap-12
___ 05:44AM BLOOD Glucose-143* UreaN-10 Creat-0.5 Na-134*
K-4.1 Cl-97 HCO3-26 AnGap-11
___ 05:40AM BLOOD Glucose-123* UreaN-11 Creat-0.5 Na-134*
K-4.4 Cl-99 HCO3-28 AnGap-7*
___ 02:04AM BLOOD Glucose-123* UreaN-10 Creat-0.6 Na-135
K-4.3 Cl-99 HCO3-28 AnGap-8*
___ 01:51AM BLOOD Glucose-171* UreaN-12 Creat-0.6 Na-133*
K-4.1 Cl-97 HCO3-25 AnGap-11
___ 02:04AM BLOOD ALT-6 AST-11 AlkPhos-56 TotBili-1.6*
DirBili-0.7* IndBili-0.9
___ 01:51AM BLOOD ALT-7 AST-12 AlkPhos-55 TotBili-1.8*
DirBili-0.9* IndBili-0.9
___ 03:48AM BLOOD ALT-7 AST-11 AlkPhos-56 TotBili-1.9*
DirBili-0.9* IndBili-1.0
___ 01:59AM BLOOD ALT-6 AST-11 AlkPhos-50 TotBili-2.5*
DirBili-1.2* IndBili-1.3
___ 12:38AM BLOOD Lipase-42
___ 06:42AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8
___ 12:00PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0
___ 05:07AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
___ 01:02AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8
___ 05:15AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.4*
___ US:
Scant intra-abdominal ascites is not amenable to paracentesis.
Small
bilateral pleural effusions are noted.
___ 1. New large amount of ascites with findings of
peritonitis and
pneumoperitoneum. Given the large amount of free air, colonic
or gastric
perforation are stronger possibly distal small bowel perforation
and of the three, colonic perforation is favored.
2. Post mesh plug repair of right inguinal hernia with new right
groin 9 cm hematoma.
3. Cirrhotic liver with splenomegaly and sequelae of portal
hypertension and redemonstration of nonocclusive thrombus in
the left common femoral vein.
___ ECCHO: The left atrial volume index is mildly
increased. The right atrium is moderately dilated. Left
ventricular wall thicknesses are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF = 65%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is moderately
dilated with borderline normal free wall function. The aortic
root is mildly dilated at the sinus level. The ascending aorta
is mildly dilated. The aortic arch is mildly dilated. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion. Ascites is present.
___: No radiographic evidence for ileus
___: The right PICC extends to the mid clavicle, then
subsequently curls back toward the right lateral chest.
Recommend re-placement.
___ Paracentisis:
1. Technically successful ultrasound guided diagnostic
paracentesis.
2. 15 cc of fluid were removed, and sent for microbiology,
chemistry and
hematology.
___ US
Scant intra-abdominal ascites is not amenable to paracentesis.
Small
bilateral pleural effusions are noted.
___ 11:33 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 3:04 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 2:00 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
Reported to and read back by ___ ___
___ 12:25PM.
LACTOBACILLUS SPECIES. 1 COLONY ON 1 PLATE.
___ 1:56 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ with diffuse abd tendernessNO_PO contrast// ?mesenteric
ischemia, ?sbo
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.6 cm; CTDIvol = 16.4 mGy (Body) DLP = 896.7
mGy-cm.
Total DLP (Body) = 907 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Mild bibasilar subsegmental atelectasis..
ABDOMEN: Cirrhotic liver with multiple stable subcentimeter hypodense lesions,
some of which are cysts while others are too small to characterize or
indeterminate, amenable to follow-up on routine ___ screening. No biliary
dilatation. Cholecystectomy.
Large volume ascites, increased from prior, with peritoneal enhancement
concerning for peritonitis. There are findings of portal hypertension with
extensive periesophageal and gastric varices and patent paraumbilical vein, as
on prior. Again seen is an aneurysmal coronary vein (2; 27). Hepatic
vasculature is patent.
PANCREAS: The pancreas is unremarkable except for a stable 1.1 cm distal
cystic lesion, possibly a side-branch intraductal papillary mucinous neoplasm
(2; 36).
SPLEEN: Mild splenomegaly is again seen.
ADRENALS: Unremarkable.
URINARY: The kidneys are unremarkable except for stable hypodense lesions too
small to characterize, stable.
GASTROINTESTINAL: An end clip is again seen. There is no intestinal
obstruction.
Previously seen wall edema of the small bowel adjacent to the right inguinal
region is no longer visualized.
There is extensive new pneumoperitoneum, which could be seen with gastric or
colonic perforation favored or small bowel perforation. Although the site of
perforation is not elucidated, the majority of the free air is seen in the
right upper abdomen.
PELVIS: Peritoneal enhancement in the cul-de-sac is suggestive of peritonitis.
LYMPH NODES: No enlarged abdominal or pelvic lymph nodes.
VASCULAR: Re-demonstration of nonocclusive deep venous thrombosis within the
left common femoral vein, similar to prior. Right common iliac aortic
aneurysm again noted measuring up to 2.3 cm, similar to prior.
BONES: No aggressive osseous lesions.
SOFT TISSUES: In the right inguinal region, there is interval development of a
3.6 x 9.3 x 4.6 cm hematoma (2; 79). Postsurgical changes are noted
bilaterally from mesh plug repair.
IMPRESSION:
1. New large amount of ascites with findings of peritonitis and
pneumoperitoneum. Given the large amount of free air, colonic or gastric
perforation are stronger possibly distal small bowel perforation and of the
three, colonic perforation is favored.
2. Post mesh plug repair of right inguinal hernia with new right groin 9 cm
hematoma.
3. Cirrhotic liver with splenomegaly and sequelae of portal hypertension and
redemonstration of nonocclusive thrombus in the left common femoral vein.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. in person on ___ at 2:07 am, 1 minutes after discovery of the
findings.
The findings were discussed with Dr. ___. by ___, M.D. in person
on ___ at 2:18 am, 10 minutes after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with HBV cirrhosis with concern for ileus//
Assess for ileus/infection/ascites. Please perform supine and erect
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: None available.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Air is seen
within the colon, in a nonspecific bowel gas pattern.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Surgical staples are seen in the midline abdomen. Cholecystectomy surgical
clips are seen, as well as clips overlying the mid pelvis. Spinal fixation
hardware is seen within the lumbar spine. An IVC filter overlies the mid
abdomen.
IMPRESSION:
No radiographic evidence for ileus.
Radiology Report
EXAMINATION: DX CHEST 2 VIEW PICC LINE PLACEMENT
INDICATION: ___ year old man with right PICC// Right 43cm PICC ___ ___
Contact name: ___: ___. Evaluate PICC.
TECHNIQUE: Frontal views of the chest.
COMPARISON: Chest x-ray ___.
FINDINGS:
The right PICC extends to the mid clavicle, then subsequently curls back
toward the right lateral chest. The heart size is normal. The lung volumes
are low, but the lungs are clear. No pleural effusion or pneumothorax.
IMPRESSION:
The right PICC extends to the mid clavicle, then subsequently curls back
toward the right lateral chest. Recommend re-placement.
NOTIFICATION: The findings were discussed by ___ with ___,
RN on the telephone on ___ at 1:13 pm, 3 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ PMH of HBV/NASH cirrhosis c/b esophageal varices s/p banding,
T2DM, and HTN recently admitted to ___ ___ w/ strangulated R inguinal
hernia s/p open repair with mesh c/b R CFV thrombus on systemic A/C +IVC
filter, now readmitted ___ with severe abdominal pain, hypotension and
pneumoperitoneum on CT s/p ex-lap, small bowel resection, primary
anastomosis.// check PICC position Contact name: ___: ___ check
PICC position
IMPRESSION:
Compared to chest radiographs ___ through ___.
Right PIC line loops in the right subclavian vein and returns to the right
axilla, unchanged since ___ on ___.
Increased pulmonary vascular engorgement and borderline edema at the left lung
base are new since earlier in the day. Mild cardiomegaly is stable. Right
infrahilar consolidation could be pneumonia but is more likely atelectasis.
Pleural effusion small if any. No pneumothorax.
Radiology Report
INDICATION: ___ PMH of HBV cirrhosis (MELD-Na 19) c/b esophageal varices s/p
banding, T2DM, and HTN recently admitted to ___ ___ w/ strangulated
right inguinal hernia s/p open repair with mesh, now readmitted ___ with
severe abdominal pain, hypotension and pneumoperitoneum on CT s/p ex-lap,
small bowel resection, primary anastomosis.// reposition PICC s/p insertion by
___ nurse
COMPARISON: Cnest x-ray from yesterday
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure.
ANESTHESIA: None.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.1 min, 1 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and successfully repositioned into the
SVC. The position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip successfully repositioned
following power flush with tip in the distal SVC.
IMPRESSION:
Successful repositioning of right arm approach double lumen PowerPICC with tip
in the distal SVC. The line is ready to use.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ w/ PMHx HBV/NASH cirrhosis w/ recent small bowel perforation
s/p exlap p/w leaking clear fluid from incision c/f ascites// please evaluate
for ascites
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: Ultrasound from ___
FINDINGS:
Grayscale ultrasound images were obtained in all 4 quadrants of the abdomen to
assess for ascites. A small to moderate amount of ascites is seen.
IMPRESSION:
Small to moderate amount of ascites.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ w/ cirrhosis c/b ascites now w/ increasing abd girth// please
do diagnostic paracentesis
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Ultrasound from ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a
small-moderate amount of ascites. A suitable target in the deepest pocket in
the right lower quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 1.3 L of clear, straw-colored fluid were removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 1.3 L of fluid were removed, and sent for hematology and microbiology.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old man with cirrhosis c/b ascites, increasing
distention// Please do paracentesis to remove ascites
TECHNIQUE: Ultrasound guided therapeutic paracentesis
COMPARISON: Paracentesis dated ___. CT scan dated ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the left mid
abdomen was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 5 cc 2% lidocaine was
instilled for local anesthesia.
Under continuous ultrasound guidance, 5 ___ catheter was advanced into the
largest fluid pocket in the left mid abdomen and 0.5 L of clear, straw-colored
fluid were removed. Postprocedure ultrasound demonstrated only minimal
residual fluid. The initial fluid pocket demonstrated multiple internal
septations.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided therapeutic paracentesis.
2. 0.5 L of serous straw-colored fluid were removed.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis with intravenous contrast
INDICATION: ___ year old man p/w perforated bowel now s/p ex-lap/SBR now with
hypotension, tachycardia// please assess for anastomotic leak vs drainable
collection/abscess***PLEASE USE 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) Spiral Acquisition 4.1 s, 53.7 cm; CTDIvol = 19.5 mGy (Body) DLP =
1,045.5 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.9 mGy (Body) DLP =
18.4 mGy-cm.
Total DLP (Body) = 1,066 mGy-cm.
COMPARISON: CT scan of the abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Bibasal atelectasis. Small bilateral pleural effusions. These
findings are new from prior study.
ABDOMEN:
HEPATOBILIARY: Morphologic features of cirrhosis. Hypodense liver lesions,
largest measuring 1.6 cm in the caudate lobe are present dating back to ___ and likely represent small cysts or hamartomas. No solid liver mass.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: Homogeneous enhancement of the pancreatic parenchyma. Again
identified is an 11 mm hypoattenuated lesion at the pancreatic tail.
SPLEEN: The spleen is enlarged, measuring 17.9 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Bilateral renal cortical cysts. No hydronephrosis.
GASTROINTESTINAL: There is a metallic clip within the stomach. Small and
large bowel are normal in caliber. There has been a prior small bowel
resection with enteroenteric anastomosis in the right hemipelvis (axial series
2, image 69) oral does not extend to the level of the anastomosis, which
limits evaluation. However, there is no definite evidence of perianastomotic
collection or discontinuity. Scattered colonic diverticula.
Moderate to large volume ascites, with ascites extending into midline
___ hernia. The ascites is predominantly fluid attenuation (<10
___ without localized pocket or rim enhancing collection. Previously
visualized pneumoperitoneum has resolved. There is some peritoneal hyper
enhancement in the pelvis compatible with peritonitis, similar to prior study.
PELVIS: The bladder is decompressed with a Foley catheter in situ. Moderate
pelvic free fluid.
REPRODUCTIVE ORGANS: Fiducial markers are noted within the prostate.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. IVC filter in situ. The portal and hepatic venous circulations are
patent. There are multiple portosystemic collaterals with large recanalized
paraumbilical vein, para-/periesophageal varices, and multiple additional
upper abdominal collateral vessels.
BONES: Compression deformity of the L4 vertebral body appears similar to
previous. There has been a previous posterior spinal fusion with L1-2 S1
transpedicular screws and bilateral rods.
SOFT TISSUES: Diffuse body wall edema. Right-sided inguinal fluid collection,
likely hematoma has decreased in size, measuring 8.5 cm, previously 9.3 cm.
IMPRESSION:
1. Findings from prior small bowel resection with right lower quadrant
anastomosis. Evaluation for anastomotic leak is limited as oral contrast did
not reach the anastomotic site, however there is no definite perianastomotic
collection or discontinuity to suggest anastomotic leak. There is no
organized fluid collection within the abdomen or pelvis.
2. Moderate volume ascites similar to prior. Persistent peritoneal
enhancement in the pelvis compatible with peritonitis.
3. Morphologic features of cirrhosis and portal hypertension.
4. Basal effusions and atelectasis has worsened compared to the prior study.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:11 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man s/p ex-lap/SBR for bowel perf now with
hypotension/tachycardia s/p oral contrast load// please assess for
extra-luminal contrast
TECHNIQUE: Supine frontal views of the abdomen and pelvis.
COMPARISON: Same-day CT abdomen and pelvis.
FINDINGS:
There are mildly distended small bowel loops, though there was no evidence of
obstruction on the same day earlier CT examination. Air is seen within the
large bowel. There is no supine radiographic evidence of free air. There is a
layering left-sided pleural effusion. Posterior lumbar fusion hardware is
seen. Skin staples are seen. Centralization of bowel loops suggesting at
least small to moderate volume ascites, as seen on the preceding CT
examination.
IMPRESSION:
Mildly distended small bowel loops, though there is no evidence of obstruction
on the preceding CT examination. Ascites. No supine radiographic evidence
free air, though this is relatively on sensitive, and upright or lateral
decubitus view should be obtained if there is high concern. No radiodense oral
contrast is seen.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old man with NASH cirrhosis and ascites s/p scheduled
paracenteses// please perform therapeutic paracentesis
TECHNIQUE: Ultrasound guided therapeutic paracentesis
COMPARISON: CT scan from ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the left lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the left
lower quadrant. Approximately 15 cc of fluid was removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Limited paracentesis due to small volume of ascites in the abdomen. Only
15 cc of ascitic fluid could be aspirated.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man with cirrhosis and massive ascites s/p failed
paracentesis// please assess for large pocket amenable to large volume
drainage
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___
FINDINGS:
LIVER: Limited examination of the liver demonstrates a nodular, irregular
contour, compatible with cirrhosis.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: Patient has had a previous cholecystectomy.
SPLEEN: There is splenomegaly at 17.7 cm.
KIDNEYS: Limited evaluation of the kidneys does not demonstrate
hydronephrosis.
A small volume of ascites is present, with small fluid pockets in both the
right and left lower quadrant, containing multiple septations.
Right pleural effusion.
IMPRESSION:
Small volume of ascites with small fluid pockets in the lower quadrants of the
abdomen, containing multiple septations.
Right pleural effusion.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old man with NASH cirrhosis and regular therapeutic
paracentesis (last performed ___. Now just needing diagnostic fluid for
repeat culture.// Diagnostic fluid. One sample purely sent for stat gram
stain. Other sent for culture.
TECHNIQUE: Ultrasound guided diagnostic paracentesis
COMPARISON: ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated trace
ascites. A suitable target in the deepest pocket in the left lower quadrant
was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the left
lower quadrant and 15 cc of straw-colored/serosanguineous fluid were removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic paracentesis.
2. 15 cc of fluid were removed, and sent for microbiology, chemistry and
hematology.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ PMH cirrhosis (MELD-13) w incarcerated RIH and SBO s/p open
RIH repair w plug ___ and mesh and IVC filter, d/c'ed on lovenox, now w small
bowel perf s/p ex-lap, SBR// Therapeutic Paracentesis. patient on hep gtt
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: Prior abdominal ultrasound dated ___.
FINDINGS:
Turning views in 4 quadrants demonstrate minimal loculated fluid with
insufficient fluid to safely perform therapeutic or diagnostic paracentesis.
IMPRESSION:
Insufficient fluid to safely perform paracentesis.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ PMH cirrhosis (MELD-13) w incarcerated RIH and SBO s/p open
RIH repair w plug ___ and mesh and IVC filter, d/c'ed on lovenox, now w small
bowel perf s/p ex-lap, SBR// Abdomen US to asses ascites and potential need
for para
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: Limited abdominal ultrasound ___
FINDINGS:
Evaluation of the 4 quadrants and midline abdomen reveal no drainable ascites.
Trace ascites interspersed under overlying bowel is noted, and not accessible.
Bilateral pleural effusions are noted.
IMPRESSION:
Scant intra-abdominal ascites is not amenable to paracentesis. Small
bilateral pleural effusions are noted.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Sepsis, unspecified organism, Severe sepsis with septic shock, Perforation of intestine (nontraumatic)
temperature: 98.1
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 111.0
dbp: 93.0
level of pain: 10
level of acuity: 2.0 | The patient presented to the SICU after exploratory laparotomy
his post op course in the PACU was significant for phenylephrine
requirement and Afib with RVR.
On his POD 1 he underwent an ECHO which showed EF=65%, dilated
atria, moderate ___, and severe 3+ TR. Heparin gtt was
initiated for his Hx of DVT. He received several doses of IV
Lopressor and eventually broke back to sinus several hours
later. During his ICU course he had several episodes of Afib
again with RVR which were treated with lopressor and volume
repletion with albumin.
The Neo was switched to NE from which he was weaned off with
volume repletion using PRBC as needed and Alb and was put on
midodrine.
His NGT was self d/c'd and was not renewed. The patient started
passing Gas but still showed abdominal distention secondary to
re accumulation of his ascites, his home
rifaximin/spironolactone were renewed. US showed mild to
moderate ascites.
Although he was kept NPO he started having bilious vomiting. a
picc was inserted in anticipation for the need for TPN. The
patient exhibited spont increase in his INR probably from
nutritional derangement. He was treated with FFP and Vit K and
his ascites was drained after his INR was normalized. 1.3 lit
was removed. The patient felt better after this procedure and
was able to tolerate diet which was advanced slowly.
of note Psych were involved in his care for suicidal ideation
and the patient had a 1:1 sitter until he had a discussion w/
wife after which he wished to remain full code.
on the day he was transferred out of the SICU he was ambulating
OOB to chair, worked w/ ___ ___ rehab and his diet was
advanced to regular passing Gas and having BM. his HR was better
controlled. His MELD when transferred was 20. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Heparin Agents
Attending: ___
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Trans-esophageal Echocardiogram (___)
History of Present Illness:
___ hx of DM and CHF prsents from assisted living with 1 day of
dyspnea, productive cough, and emesis x3 today. She is a poor
historian and recurrently falls asleep frequently. The majority
of her history is provided from the ED and SNF record. She had 1
day of dyspnea and was found to have aRA sat of 88%. They
performed a CXR showing mild pulmonary edema. The patient is on
coumadin for a ?history of acute VTE according to ___ records.
She is non-ambulatory at baseline ___ her diabets and uses a
wheelchair. She think that her legs may have become more swollen
over the past several week.
A&O, crackles at bases, 1+ BLE edema
ED COURSE
In the ED intial vitals were: 100.4 123 183/96 20 97% 3L Nasal
Cannula. Labs were notable for negative rapid flu test, INR 1.9,
BNP 1391, and troponin of 0.02. She was subsequently febrile to
101 in the ED. Patient was given: 1000mL NS, acetamiophen, and
ASA 324
On the floor the patient is somnolent and easily awakens for
short periods to talk.
REVIEW OF SYSTEMS: On review of systems, denies any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. Denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
- Acute VTE
- DM2
- Peripheral neuropathy
- Cervical spondylosis
- HTN
- CKD
- HLD
- Hypothyroidis
- Osteoarthritis
- GERD
- Constipation
- PVD
- Venous stasis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=98.4 BP=125/81 HR=108 RR=20 O2 sat=95%2l
GENERAL: WDWN woman in NAD. Oriented x3. Somnolent, awakens
easily but falls back asleep.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Bibasilar crackles R > L
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c. Trace bilateral edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.4 ___ 82-115 ___ 91-100/RA
Weight: 133.8kg (134.0kg on ___ (Admission weight 131kg [bed])
24H I+O: 220/660
8H I+O: (Not recorded)
___: ___ 172
Telemetry: Patient in variable aflutter. No pauses or tachy runs
GENERAL: WDWN woman in NAD. AAOx3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 9 cm.
CARDIAC: Faint heart sounds RR, nl S1/S2. No m/r/g. No T/L/S3/S4
LUNGS: Bibasilar crackles R > L, mild diffuse rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c. WWP, no evidence of peripheral edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-7.4 RBC-4.24 Hgb-12.1 Hct-37.7 MCV-89
MCH-28.5 MCHC-32.1 RDW-15.0 Plt ___
___ 05:00PM BLOOD ___ PTT-36.4 ___
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-108* UreaN-16 Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
___ 05:00PM BLOOD CK(CPK)-231*
___ 05:00PM BLOOD CK-MB-3 proBNP-1391*
___ 05:00PM BLOOD cTropnT-0.02*
___ 05:34AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1
___ 12:39AM BLOOD D-Dimer-356
IMAGING/STUDIES:
___: PA CXR:
FINDINGS: The heart is mildly enlarged, unchanged from prior.
There is no pleural effusion or pneumothorax. Mild fullness of
the right hilum is seen dating back to ___. No focal
consolidation is seen. Linear opacity at the left lung base
likely represents atelectasis. There is no acute osseous
abnormality. IMPRESSION: No definite signs of pneumonia. Lateral
view may aid in overall assessment if there is strong clinical
concern.
TRANS-THORACIC ECHOCARDIOGRAM ___:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45 %). Doppler parameters are indeterminate for left
ventricular diastolic function. Right ventricular chamber size
is normal. with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: Suboptimal image quality. Mild
left ventricular systolic dysfunction. Preserved right
ventricular systolic function. Moderate pulmonary hypertension.
TRANS-ESOPHAGEAL ECHOCARDIOGRAM ___:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage, though image quality of the lower half of the ___ was
suboptimal. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is
depressed. There is considerable beat-to-beat variability of the
left ventricular ejection fraction due to an irregular
rhythm/premature beats. Mild right ventricular free wall
hypokinesis. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 38 cm from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. IMPRESSION: Suboptimal image quality. No
left atrial body/appendage thrombus identified in the top half
of the appendage. Lower aspect ___ partially obscured by
shadowing. Depressed biventricular systolic function. Mild
mitral regurgitation. Mild tricuspid regurgitation
DISCHARGE LABS:
___ 05:25AM BLOOD WBC-8.6 RBC-3.83* Hgb-11.4* Hct-33.5*
MCV-88 MCH-29.8 MCHC-34.0 RDW-14.6 Plt ___
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD ___ PTT-34.9 ___
___ 05:25AM BLOOD Glucose-90 UreaN-37* Creat-1.4* Na-141
K-4.1 Cl-101 HCO3-33* AnGap-11
___ 05:25AM BLOOD ALT-21 AST-23 LD(LDH)-193 AlkPhos-61
TotBili-0.3
___ 05:25AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 200 mg PO BID
2. Fluoxetine 20 mg PO DAILY
3. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Levothyroxine Sodium 137 mcg PO DAILY
5. Nortriptyline 75 mg PO QHS
6. Simvastatin 10 mg PO QPM
7. Warfarin 4.5 mg PO DAILY16
8. Furosemide 20 mg PO DAILY
9. Acetaminophen 325 mg PO Q6H:PRN Pain / Fever
10. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
11. Calcium Carbonate 1250 mg PO BID
12. Bisacodyl 10 mg PR QHS:PRN Constipat
13. Lactulose 15 mL PO DAILY:PRN Constipation
14. Fleet Enema ___AILY:PRN Constipation
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB / Wheezing
16. Meclizine 25 mg PO Q8H:PRN Dizziness / Vertigo
17. Milk of Magnesia 30 mL PO DAILY:PRN Constipation
18. Multivitamins 1 TAB PO DAILY
19. Nystop (nystatin) 100,000 unit/gram topical Q12H:PRN
Reddened Skin
20. Omeprazole 20 mg PO DAILY
21. Guaifenesin ___ mL PO Q6H:PRN Cough
22. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN Pain / Fever
2. BuPROPion (Sustained Release) 200 mg PO BID
3. Fluoxetine 20 mg PO DAILY
4. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB / Wheezing
6. Lactulose 15 mL PO DAILY:PRN Constipation
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Meclizine 25 mg PO Q8H:PRN Dizziness / Vertigo
9. Milk of Magnesia 30 mL PO DAILY:PRN Constipation
10. Multivitamins 1 TAB PO DAILY
11. Nortriptyline 75 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. Senna 8.6 mg PO BID
14. Warfarin 5 mg PO DAILY16
15. Amiodarone 400 mg PO BID Duration: 2 Days
Lsat dose ___ of ___
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*3
Tablet Refills:*0
16. Amiodarone 400 mg PO DAILY
Please start this medication on ___
RX *amiodarone 400 mg 1 tablet(s) by mouth DAILY Disp #*60
Tablet Refills:*2
17. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth DAILY Disp #*90 Tablet
Refills:*2
18. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth DAILY Disp #*90
Tablet Refills:*2
19. Levofloxacin 750 mg PO DAILY Duration: 7 Days
Last dose ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth DAILY
Disp #*2 Tablet Refills:*0
20. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth DAILY Disp
#*90 Tablet Refills:*2
21. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
22. Bisacodyl 10 mg PR QHS:PRN Constipat
23. Calcium Carbonate 1250 mg PO BID
24. Fleet Enema ___AILY:PRN Constipation
25. Furosemide 20 mg PO DAILY
26. Guaifenesin ___ mL PO Q6H:PRN Cough
27. Nystop (nystatin) 100,000 unit/gram topical Q12H:PRN
Reddened Skin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Atrial Flutter
Congestive Heart Failure
Pneumonia
Urinary Tract Infection
Secondary Diagnosis:
Diabetes
Hypertension
Acute Kidney Injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough and fever.
COMPARISON: Comparison is made to chest radiograph from ___.
TECHNIQUE Portable view of the chest.
FINDINGS:
The heart is mildly enlarged, unchanged from prior. There is no pleural
effusion or pneumothorax. Mild fullness of the right hilum is seen dating back
to ___. No focal consolidation is seen. Linear opacity at the left lung base
likely represents atelectasis. There is no acute osseous abnormality.
IMPRESSION:
No definite signs of pneumonia. Lateral view may aid in overall assessment if
there is strong clinical concern.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough, fever // r/o PNA
COMPARISON: ___ and prior portable radiograph performed earlier
today.
FINDINGS:
PA and lateral views of the chest provided. Evaluation is markedly limited
due to large body habitus and low lung volumes. There is mild hilar
engorgement and possible mild pulmonary edema. No convincing signs of
pneumonia, effusion or pneumothorax. The heart is mildly enlarged. The
mediastinal contour appears somewhat prominent likely due to position and AP
technique. Otherwise no change
IMPRESSION:
Mild congestion/edema. No convincing evidence for pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Vomiting, Productive cough
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 100.4
heartrate: 123.0
resprate: 20.0
o2sat: 97.0
sbp: 183.0
dbp: 96.0
level of pain: 13
level of acuity: 2.0 | PATIENT:
Mrs ___ is a ___ year old female with a PMH of recent
DVT, DM2 p/w cough, hypoxia, and fever without clear infiltrate
on her CXR. Found to be newly in aflutter with mild congestive
symptoms and a UTI.
ACUTE ISSUES
# AFlutter: Patient was identified as having aflutter with
vaiable conduction on admission. INR was noted to be
subtherapeutic so patient underwent TEE which demonstrated no
thrombosis. Warfarin was increased to 5mg daily. Started on
amiodarone, but patient remained in aflutter for duration of
hospitalization. Discahrged home on antiarrhythmics, metoprolol,
and warfarin, with intent to return for electrical cardioversion
in one month.
# Pneumonia: Patient without clear bacterial infiltrate on
imaging, but patient with a new oxygen requirement, febrile, and
a productive cough. Originally started on vencomycin and
cefepime but downtitrated to levofloxacin soon after admission.
Patient's fevers resolved, cough improved, and able to be weaned
off oxygen. Dishcarged with intent to compelete a 7 day course
of antibiotics.
# Congestive Heart Failure: Patient newly diagnosed with CHF
with elevated BNP and radiographic evidence of mild hilar
engorgement and possible mild pulmonary edema. Patient did not
appear volume overloaded by exam. Patient with small troponin
leak which peaked and fell; attributed to congestion. Etiology
of CHF throught to be multifactorial, including concurrent
infection and new atrial arrhythmia. Initially diuresed, but
patient soon developed ___ and diuresis was halted. TTE
demonstrated LVEF of 40-45%. Patient started on metoprolol, but
pressures initially low so not initiated on an ACE inhibitor.
CHRONIC ISSUES
# Diabetes: Home insulin regimen was continued while
hospitalized, blod sugars were well controlled during admission.
# Hypertension: Patient started on metoprolol
# Hyperlipidemia: Patient started on atrovastatin
# Peripheral Vascular Disease: Patient started on aspirin
# Hypothyroidism: Continued home levothyroxine
# Depression: Continued home buproprion |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ M w PMHx HTN, HLD, DM2, CKD, and
vascular dementia who presents to ___ ED with at least 12
hours of unsteady gait and pain in the L>R thigh.
Mr. ___ reports that his gait difficulties began "a few
days ago". He says his balance was off, but is unable to
describe his difficulties in any more detail. His wife did not
notice an issue until around midnight on the evening prior to
presentation. She states that when Mr. ___ was up walking,
he was holding onto objects to keep himself steady. At 0300, he
awoke to go to the bathroom and again had to hold onto the walls
and furniture to steady himself. When he came back to bed, he
was unable to pull his legs into the bed. She helped him in, but
recalls that when she lifted up his left leg, he appeared to
grimace in pain.
When the couple awoke the next morning at 0800, Mr. ___ was
still having gait difficulties. He also reports some pain in his
thighs, the left more so than the right. His wife tried to give
him a massage, but this seemed to cause him even more pain.
Given his difficulty with mobility, they decided to come to the
ED.
On ROS, Mr. ___ and his wife report a history of falls, the
most recent one being ~1 month ago. The falls appear to have
been mechanical. Mr. ___ also suffers from urinary urge
incontinence >6 months, and at least 3 months of difficulty
controlling his bowel movements. His wife also reports a "step
down" decline in Mr. ___ thinking and general functioning.
She recalls on ___, she thought Mr. ___ was "foggy" and
forgot to take all his pills. She states that she thought
perhaps he had a stroke. Since that time his short term memory
has been very poor and he will ask her
Past Medical History:
- HTN
- HLD
- CKD stage IV
- DM2 c/b peripheral neuropathy and CKD
- CABG s/p bypass ___ years ago
- osteoarthritis
- s/p L hemiarthropathy after L femoral neck fx in ___
- urinary urge incontinence and nocturia
- fecal incontinence
- MCI, "vascular dementia"
- follows with Dr. ___ in CNU
- glaucoma
- s/p B/L cataract extraction
- "multiple TIAs"
- L arm weakness ___
- vertigo, gait unsteadiness ___
- OSA on CPAP
Social History:
___
Family History:
Mother - died age ___ of an MI
Father - died age ___ MI
Sibs - 2 brothers died one with MI age ___ and other with CAD s/p
PPM and ___ disease; 1 sister died after complications
of a fall and had CAD
Children - 3 all well
Physical Exam:
ADMISSION EXAM:
VS: 98.5 152/62 ___ 100% on RA
GEN: Alert, lying in bed, no acute distress.
HEENT: Moist MM, anicteric sclera
NECK: Supple without LAD
PULM: Generally CTA b/l 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 intact. Strength and sensation preserved in
upper extremities and right lower extremity. Strength ___ in
LLE. Left quads possibly in spasm compared with R thigh, though
without edema, tenderness to palpation, or sensory loss.
DISCHARGE EXAM:
Vitals- T98.6 BP110/58(106-126/48-62) HR64(64-83) RR:19 SaO2:
98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, aniscoric, R
pupil keyhole and non-reactive, left pupil reactive.
Neck- supple, JVP not elevate
Lungs- Bibasilar crackles ___ way up
CV- Irreg rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, no
tenderness to palpation
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-11.4*# RBC-3.06*# Hgb-9.4*#
Hct-28.6*# MCV-94 MCH-30.7 MCHC-32.9 RDW-14.6 RDWSD-49.7* Plt
___
___ 11:30AM BLOOD Neuts-83.2* Lymphs-8.0* Monos-7.8
Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.50* AbsLymp-0.91*
AbsMono-0.89* AbsEos-0.03* AbsBaso-0.03
___ 11:30AM BLOOD Glucose-168* UreaN-68* Creat-3.1* Na-138
K-4.7 Cl-105 HCO3-19* AnGap-19
CARDIAC ENZYMES
___ 11:30AM BLOOD CK-MB-11* MB Indx-3.4 cTropnT-0.07*
___ 05:13AM BLOOD CK-MB-6 cTropnT-0.09*
___ 05:15AM BLOOD CK-MB-6 cTropnT-0.10*
___ 01:25PM BLOOD CK-MB-5 cTropnT-0.09*
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-6.8 RBC-2.57* Hgb-7.8* Hct-24.3*
MCV-95 MCH-30.4 MCHC-32.1 RDW-14.4 RDWSD-49.2* Plt ___
___ 05:15AM BLOOD Glucose-182* UreaN-80* Creat-3.4* Na-140
K-4.4 Cl-109* HCO3-19* AnGap-16
___ 05:15AM BLOOD Calcium-8.3* Phos-5.3* Mg-2.0
___ 05:13AM BLOOD calTIBC-252* Ferritn-184 TRF-194*
___ 05:15AM BLOOD TSH-2.7
___ 05:13AM BLOOD CRP-74.5*
___ 11:40AM BLOOD Lactate-1.0
SED RATE:
Test Result Reference
Range/Units
SED RATE BY MODIFIED 48 H < OR = 20 mm/h
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Amlodipine 10 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Humalog 4 Units Breakfast
Humalog 6 Units Dinner
Humalog ___ 4 Units Breakfast
Humalog ___ 2 Units Dinner
6. FLUoxetine 40 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. FLUoxetine 40 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Humalog 4 Units Breakfast
Humalog 6 Units Dinner
Humalog ___ 4 Units Breakfast
Humalog ___ 2 Units Dinner
8. FoLIC Acid 1 mg PO DAILY
9. Outpatient Physical Therapy
ICD 9: 781.2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atrial Fibrillation
Musculoskeletal pain
Secondary:
Vascular Dementia
DM
HTN
CKD
HLD
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: ___ w/left leg weakness, please eval for stroke.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.9 cm; CTDIvol = 47.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, mass, or mass effect.
The ventricles and sulci are stable in size, mildly prominent, consistent with
age-appropriate global atrophy. Subcortical right frontal lobe focal
hypodensity adjacent to but not appearing to involve the right caudate head is
unchanged from multiple prior exams, possibly related to the focal white
matter microangiopathy. Elsewhere, symmetric periventricular white matter is
nonspecific however compatible sequelae of chronic white matter
microangiopathy.
Again seen is ventricular enlargement out of proportion to the sulci, possibly
reflecting communicating hydrocephalus.
There is no evidence of fracture or soft tissue injury. There is mild ethmoid
air cell mucosal thickening ; otherwise, the imaged paranasal sinuses and
mastoid air cells are clear. Extensive carotid siphon calcifications are
unchanged. The patient is status post bilateral lens removal; otherwise, the
globes and bony orbits are intact and unremarkable.
IMPRESSION:
1. No acute intracranial process. No hemorrhage or evidence of recent
infarction.
2. Stable chronic findings including white matter small vessel microangiopathy
most prominent in the right subcortical frontal lobe, vascular calcifications,
and age-appropriate global atrophy.
3. Dilated ventricles possibly reflecting communicating hydrocephalus.
Radiology Report
EXAMINATION: Chest radiographs.
INDICATION: ___ w/unsteady gait, bibasilar crackles, please eval for occult
PNA // ___ w/unsteady gait, bibasilar crackles, please eval for occult PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
The patient is status post CABG with multiple clips identified in unchanged
position from the prior examination. The lungs are grossly clear without
focal consolidation, pleural effusion, pneumothorax, or pulmonary edema. The
cardiomediastinal silhouette is unchanged.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ w/left leg pain and unsteady gait, falls, h/o left partial
hip, please eval left hip and knee for fracture
COMPARISON: Prior CT abdomen pelvis from ___
FINDINGS:
A total of 8 images provided including views of the pelvis and left hip. Left
hip hemi arthroplasty is noted which appears anatomically aligned without
signs of hardware failure. There is no acute fracture involving the bony
pelvic ring though portions of the iliac crests are excluded. The right hip
aligns normally. Vascular calcifications are present. Lower lumbar spine
degenerative disease is noted.
IMPRESSION:
No acute findings.
Radiology Report
INDICATION: ___ w/left leg pain and unsteady gait, falls, h/o left partial
hip, please eval left hip and knee for fracture
COMPARISON: None
FINDINGS:
AP, lateral and obliques views of the left knee were provided. No acute
fracture or dislocation. No joint effusion is seen. Vascular calcifications
are present. Minimal osteoarthritis with tiny joint line spurs noted. Bones
appear somewhat demineralized.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT pelvis
INDICATION: ___ s/p partial left hip replacement w/pain with ROM of left hip,
xrays negative, please eval for occult left hip fx.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,157 mGy-cm.
COMPARISON: CT pelvis ___.
FINDINGS:
BONES: The patient is status post total left hemiarthroplasty. The left hip
prosthetic components appear well-seated without evidence of loosening or
other hardware related complication, however assessment is mildly limited due
to the presence of extensive hardware related artifact. There is diffuse
osteopenia. There is severe a lower lumbar degenerative change, with L4-L5
and L5-S1 intervertebral vacuum disc phenomenon. No concerning focal lytic or
sclerotic osseous lesions are seen. There is no SI joint or symphysis pubis
diastasis. Grade 1 retrolisthesis of L5 with respect to L4 and S1 appears
degenerative in nature, and is stable since ___.
SOFT TISSUES: There is a small fat containing left inguinal hernia.
Otherwise, the imaged subcutaneous soft tissues of the pelvis are
unremarkable.
PELVIS: The partially visualized small and large bowel are unremarkable. The
urinary bladder and distal ureters are unremarkable. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged. Otherwise, the imaged
reproductive organs are unremarkable.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Moderate to severe atherosclerotic disease is noted. The imaged
abdominal aorta and iliac arterial vasculature is normal in caliber.
IMPRESSION:
1. Hardware artifact limits evaluation. Within limitation, no evidence of
fracture, dislocation, or hardware related complication involve the left hip
at site of hemi-arthroplasty. Prosthetic components appear well-seated
without evidence of loosening.
2. Small fat containing left inguinal hernia.
3. Enlarged prostate.
4. Severe aortoiliac atherosclerotic calcification.
5. Severe lower lumbar spine degenerative change. Stable L5 grade 1 listhesis
with respect to L4 and S1, unchanged since ___, likely degenerative in
nature.
Radiology Report
EXAMINATION: STROKE PROTOCOL (BRAIN W/O) T7___ MR HEAD
INDICATION: ___ year old man with PMHx HTN, HLD, DM2, CKD, and vascular
dementia who presents to ___ ED with at least 12 hours of unsteady gait and
pain in the L>R thigh // New Left ___ weakness, r/o central cause/CVA
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Nonenhanced MR head dated ___ a.m. nonenhanced head
CT dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or acute infarction. There stable is prominence of the ventricles and sulci
suggestive involutional changes. The ventricles appear enlarged out of
proportion to the sulci. Scattered foci and confluent areas of T2/FLAIR
hyperintensity are noted in the periventricular and subcortical white matter
which are nonspecific but suggestive of chronic small vessel ischemic disease.
The overall appearance is unchanged from prior.
IMPRESSION:
1. No evidence of acute infarct.
2. Stable chronic involutional and likely small vessel ischemic changes.
3. Prominence of the ventricles somewhat out of proportion to the sulci could
be seen in the setting of communicating hydrocephalus.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Leg weakness
Diagnosed with Weakness
temperature: 97.2
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 152.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
Mr. ___ is an ___ M w PMHx HTN, HLD, DM2, CKD, and
vascular dementia who presents to ___ ED with at least 12
hours of unsteady gait and pain in the left thigh.
# Left Thigh Pain: Pt initially complained of extreme left thigh
pain, completely resolved without trace prior to evaluation by
the medicine team on the floor. He did not have any cellulitic
changes, skin breakdown, and does not usually inject his insulin
in that region. Full range of motion without signs of fracture
or infection on imaging. Likely an acute musculoskeletal pain
with possible muscle spasm component. MR stroke protocol was
negative for any acute/subacute changes which would explain this
phenomenon. Of not CRP was elevated to 74, in isolation with no
other signs of infection this is difficult to interpret.
# Atrial fibrillation: Pt noted to have a brief episode of
asymptomatic atrial fibrillation with no tachycardia. One
episode in ___ which resolved without treatment, but none
documented/known by patient since then. Not currently
anticoagulated. CHADS2 score of 5 currently which would carry a
12.5% risk of stroke per year. Recommended anticoagulation given
high CHADS2, but patient and wife preferred to discuss with
outpatient cardiologist tomorrow before proceeding. Had planned
to get ECHO during admission however patient and wife declined
in favor of follow up with established cardiologist.
# Troponemia: Patient completely asymptomatic, EKG without
obvious ischemic changes but with new RBBB since ___. Likely
mild demand ischemia in setting of anemia and CKD stage 4.
Troponin max 0.10, down trending prior to discharge 0.09.
# Subacute on chronic anemia: Normocytic. Most recent Hgb from
___ was 11, so this is a subacute decrease. Likely related to
his renal failure. Currently HDS with no signs of bleeding.
Guaiac negative stools in ED
CHRONIC PROBLEMS:
# HTN: Continued amlodipine, imdur. His PCP has been holding
losartan given worsening renal function for the past 3 months.
# CAD: Continued atorvastatin and clopidogrel.
# CKD: Cr 3.1 which is at recent baseline in 3s. Being followed
by transplant surgery for fistula placement. Cr 3.4 on
discharge.
# Diabetes: Most recent A1c 7.7% ___ per ___ records. Per
___ records, takes Humalog ___ 4 units + 4 units Humalog
with breakfast and Humalog ___ 2 units + 6 units Humalog with
dinner. Held Humalog ___ mix for ISS while admitted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Daypro / Lanolin
Attending: ___
Chief Complaint:
diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ W with
hypertension, prior ischemic stroke, "baseline dementia",
"Sjogren's syndrome" (per chart diagnoses), prior left leg
sqaumous cell cancer and breast cancer s/p lumpectomy who
presents to the ED from her retirement community with a chief
complaint of diplopia that she noticed when she awoke this
morning.
Her health has been well lately. At her community, she states
that she doesn't need much assistance. She takes her own
medications which include lisinopril, aspirin and multiple other
vitamin supplementations. She awoke with diplopia this morning
without a headache, slurred speech or dysphagia. She states that
it is horizontal and better when she closes one eye; in fact,
during my history, she routinely tries to close her left eye
while talking to me to avoid the diplopia. She has never
experienced anything like this before. She has chronic hearing
impairment and is not wearing her hearing aids today. She also
requires a walker at baseline to ambulate.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Neurological Review of Systems: No headache, head trauma or
falls. No problems with asymmetric weakness or numbness. She
requires a walker for ambulating.
Past Medical History:
- Hypertension
- SCC
- Prior ischemic infarction: "Several years ago, I had a stroke
and I couldn't walk or talk for MONTHS". Not much more is
documented in our medical records. "Thank God, I recovered
completely".
- Breast Cancer s/p lumpectomy
- Sjogren's syndrome
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
V/s: 98.1, 140-180s SBP, HR 53-62, 95% on RA, 20
General: Thin, frail, short elderly woman who appears younger
than her stated age, hearing impairment
HEENT: NC/AT, no conjunctival icterus noted but with pallor,
MMM,
no lesions noted in oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Slow, regular, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: warm and well perfused, right knee has a brace
Neurologic:
-Mental Status: Alert, oriented to ___. "I know that next week
is ___, so it must be ___. Able to relate history
without
difficulty. Inattentive, only able to relate ___ forwards, but
struggles backwards. Language is fluent with intact repetition
and comprehension. No anomia. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV and VI: No nystagmus. At primary gaze, eyes are
conjugate. On looking to the right, her left eye cannot adduct
completely and her diplopia is present and horizontal. On
looking
to the left, both eyes are conjugate and diplopia resolves.
Looking directly up and down, diplopia is present as is on
primary gaze. Similarly, looking up and down to the left -> no
diplopia, while looking up and down to the right --> there is
diplopia.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Diffuse atrophy. No pronator drift bilaterally. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch
-DTRs:
Bi ___ Pat Ach
L 3 2 2 2
R 3 2 2 2
Plantar response: Up bilaterally
-Coordination: Dysmetric on finger-nose but improves when
covering one eye.
-Gait: Deferred
DISCHARGE PHYSICAL EXAM:
GEN: sitting in bed
HEENT: OP clear
CV: RRR
PULM: CTAB
ABD: soft, NT, ND
EXT: no edema
NEURO EXAM:
MS - AAOx3, speech fluent
CN - improved adduction of L eye from admission, EOM otherwise
intact, face symmetrical, tongue midline, facial sensation
intact
MOTOR - ___ throughout
COORDINATION - with one eye closed FNF was accurate
SENSATION - intact to light touch bilaterally
GAIT - narrow based, independent
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-4.6 RBC-3.80* Hgb-12.0 Hct-37.0
MCV-97 MCH-31.7 MCHC-32.5 RDW-12.7 Plt ___
___ 11:00AM BLOOD Neuts-54.3 ___ Monos-5.7 Eos-7.2*
Baso-1.1
___ 11:00AM BLOOD ___ PTT-35.8 ___
___ 11:00AM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-140
K-4.4 Cl-103 HCO3-28 AnGap-13
DISCHARGE LABS:
___ 07:15AM BLOOD ___ PTT-37.3* ___
___ 07:15AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-139
K-4.0 Cl-102 HCO3-28 AnGap-13
___ 07:15AM BLOOD ALT-14 AST-19 LD(LDH)-195 AlkPhos-71
TotBili-0.5
___ 07:15AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.4 Mg-2.0
Cholest-237*
___ 07:15AM BLOOD %HbA1c-5.5 eAG-111
___ 07:15AM BLOOD Triglyc-111 HDL-107 CHOL/HD-2.2
LDLcalc-108 LDLmeas-113
MICROBIOLOGY:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN AND/OR GENITAL CONTAMINATION.
REPORTS:
CT HEAD ___: IMPRESSION: No evidence of hemorrhage or
infarction. Unchanged since ___.
CTA ___: IMPRESSION:
1. Occlusion of the left vertebral artery in its distal V4
segment.
2. No evidence of stenosis, occlusion, or aneurysm along the
basilar and
bilateral posterior cerebral arteries.
3. Moderate stenosis of the left A1 origin.
4. Complex, predominantly noncalcified plaque with ulcerative
morphology
involving the right ICA bifurcation.
MRI ___: IMPRESSION:
1. No evidence of acute or subacute stroke.
2. Chronic small vessel ischemic disease in the periventricular
white matter and brainstem.
3. No evidence of hemorrhage.
4. Loculated fluid in the sphenoid sinus.
5. Severe multilevel degenerative change of the cervical spine,
appears
slightly worse in comparison to the prior CT of the cervical
spine from ___.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 Tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
2. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 Tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 Tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*6
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
Last evening of dose ___
RX *Bactrim DS 800 mg-160 mg 1 Tablet(s) by mouth twice a day
Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Brainstem stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
NEURO EXAM: AAOx2, difficulty adducting L eye looking to right,
___ strength throughout
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with history of stroke, with horizontal
diplopia.
TECHNIQUE: Contiguous MDCT data were acquired through the head without
intravenous contrast. Images were displayed in multiple planes.
COMPARISON: ___.
FINDINGS: There is no evidence of hemorrhage, infarction, edema, mass, or
shift of normally midline structures. Mild periventricular hypodensities are
consistent with small vessel ischemic changes. Calcifications along the
tentorium are unchanged since ___ and likely represent dural
calcifications. Mild prominence of ventricles and sulci is consistent with
age-related atrophy. Visualized paranasal sinuses and mastoid air cells are
clear. There is no soft tissue hematoma or fracture.
IMPRESSION: No evidence of hemorrhage or infarction. Unchanged since ___.
Radiology Report
INDICATION: ___ female with history of stroke, now presenting with
partial third nerve palsy, concerning for underlying aneurysm.
COMPARISON: CT head dated ___. Cervical CT from ___.
TECHNIQUE: CTA of the head and neck was performed with contrast.
FINDINGS:
CTA HEAD: There is a moderate stenosis of the left A1 segment origin. The
left PCom artery has fetal origin. No aneurysms are identified along the
bilateral PCom or superior cerebellar arteries.
The left vertebral artery demonstrates a discrete change of luminal caliber at
the level of the C1 arch with what appears to be a fatty plaque in the vessel
wall. In the distal V4 segment of the left vertebral artery, there is
occlusion proximal to the junction with the right artery. The basilar artery
is patent.
Atherosclerotic disease is involving the bilateral cavernous, clinoid and
ophthalmic ICA segments without causing significant stenosis. The anterior,
middle and posterior cerebral arteries are patent with normal contrast
enhancement and branching pattern. No aneurysms are identified.
CTA OF THE NECK: The origins of the common carotid and vertebral arteries are
patent without significant stenosis. The bilateral common carotid arteries
demonstrate a tortuous retro-laryngeal course. A complex primarily
noncalcified plaque with possible ulceration is involving the right carotid
artery bifurcation, causing about ___ stenosis. Mild calcified plaque
without associated luminal narrowing is seen at the left ICA bifurcation. The
bilateral internal carotid arteries as well as vertebral arteries demonstrate
normal flow-related enhancement.
Note is made of a left-sided thyroid nodule that may be further characterized
by ultrasound. The lung apices are clear.
Multilevel degenerative changes are seen in the cervical spine, lucency within
the dens and periodontoid pannus are unchanged in comparison with the CT from
___.
IMPRESSION:
1. Occlusion of the left vertebral artery in its distal V4 segment.
2. No evidence of stenosis, occlusion, or aneurysm along the basilar and
bilateral posterior cerebral arteries.
3. Moderate stenosis of the left A1 origin.
4. Complex, predominantly noncalcified plaque with ulcerative morphology
involving the right ICA bifurcation.
Radiology Report
INDICATION: New onset third cranial nerve palsy. Evaluate for stroke.
COMPARISONS: CTA head and neck ___. CT head ___. CT of
the cervical spine ___.
TECHNIQUE: Routine enhanced ___ MRI examination of the brain was performed
after the uneventful intravenous administration of 6 mL of Gadavist contrast.
Multiplanar T1-weighted, T2-weighted, FLAIR, and susceptibility images were
obtained. Sagittal MP-RAGE images were obtained with coronal and axial
reformats.
FINDINGS: There are no foci of restricted diffusion to suggest an acute or
subacute infarction. Specifically, the brainstem is unremarkable. There are
multiple periventricular FLAIR hyperintensities consistent with chronic small
vessel ischemic disease. FLAIR hyperintensities are also present in the
brainstem, particularly in the pons (10, 9). This is also consistent with
chronic small vessel ischemic disease. There is no evidence of hemorrhage.
There are no regions of abnormal enhancement to suggest an underlying mass.
There are no extra-axial fluid collections or hemorrhage.
The posterior fossa and cervicomedullary junction are preserved. The orbits
and periorbital spaces are normal. There is no abnormality of the skull base
or calvaria. The major intracranial vessel flow voids are preserved.
There is a small amount of loculated fluid within the sphenoid sinus. The
remainder of the paranasal sinuses are clear.
There are significant degenerative changes of the cervical spine, including an
inflammatory pannus and erosions at the atlantoaxial junction. There is
cervical kyphosis, peaked at C5 and C6. There is retrolisthesis of C5 on C6
with associated spinal canal narrowing. In comparison to the prior CT of the
cervical spine, this appears slightly worse. This may be due to patient
positioning. No fracture is identified.
IMPRESSION:
1. No evidence of acute or subacute stroke.
2. Chronic small vessel ischemic disease in the periventricular white matter
and brainstem.
3. No evidence of hemorrhage.
4. Loculated fluid in the sphenoid sinus.
5. Severe multilevel degenerative change of the cervical spine, appears
slightly worse in comparison to the prior CT of the cervical spine from ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIPLOBIA
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS
temperature: 98.1
heartrate: 62.0
resprate: 18.0
o2sat: 98.0
sbp: 146.0
dbp: 84.0
level of pain: 0
level of acuity: 1.0 | ___ is a ___ woman with hypertension, a prior ischemic
stroke, baseline mild dementia, Sjogren's syndrome, prior left
leg sqaumous cell cancer and breast cancer s/p lumpectomy who
presented with diplopia and was found on exam to have an
incomplete CN III palsy on the left with MRI showing no stroke,
but clinical suspicion remained high for a stroke too small to
be seen on MRI.
# NEURO: during her admission her difficulty with adducting her
L eye improved as did her double vision. She did not return to
baseline, however, by the day of discharge. Her ASA was
increased from 81mg to 325mg. She will see neuro-opthalmology
as an outpatient. During her stay she was mildly disoriented at
times, which we attributed to a UTI (see below), and which
improved with ABx.
# CARDS: she was monitored on telemetry without any noted
events. However, while here she had an episode of hypotension
after going to the bathroom (SBP in the ___), so we decreased
her lisinopril to 2.5mg (from 40mg QD). She may need to have
this re-uptitrated as an outpatient if she has hypertension
again in the future.
# ENDO: her LDL was 113 and her HgA1C was 5.5. We started her
on simvastatin 20mg QD sa her goal LDL was now < 70 given her
prior stroke. ISS was started while she was here, but once her
HgA1C returned WNL it was stopped.
# ID: U/A was positive for UTI, and pt was started on bactrim
for a 3 day course (___). Her UCx showed genital
contamination, but we continued her course as she became less
confused on ABx.
# CODE: DNR, okay to intubate unless thought to be for a chronic
condition
PENDING RESULTS: None |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / novacaine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of remove MVA and subsequent chronic
pain, breast cancer s/p lumpectomy in ___, transferred from
___ for L1 vertebral body fracture with
retropulsion.
The patient remembers slipping on a wet floor several days ago
and bumping her flank. She also reports frequent falls. Today,
she reports pain to her lower back, difficulty ambulating due to
pain and difficulty standing from seated. She denies pain
radiating down her legs, but has nerve pain in her legs at
baseline. She has also had constipation for the past week
resulting in worsened back pain. She has occasional urinary
incontinence at baseline. No worsening bladder incontinence or
bowel incontinence.
Most of the history is obtained from the patient's niece. She
reports that patient is currently being worked up for dementia
and has been noted to have "sundowning" and visual
hallucinations in recent weeks. She has a history of chronic
pain since a remove MVA in ___. She was diagnosed with breast
cancer recurrence in ___ and is s/p lumpectomy, but declined
chemotherapy.
In the ED, initial vitals: 95.6 85 157/61 16 98% RA
Labs were significant for leukocytosis of 13, UA dirty.
Imaging significant for:
MRI showed L1 burst fracture, CT C spine negative.
CT Lumbar Spine: Burst fracture of L1 vertebral body with
retropulsed fracture fragment causing moderate spinal canal
narrowing.
CT Head: Sphenoid sinusitis. Mild cortical atrophy. Chronic
lacunar infarcts cannot be excluded.
In the ED, she received
___ 09:19 PO/NG Pregabalin 25 mg
___ 09:21 PO/NG FLUoxetine 20 mg
___ 09:22 PO/NG Atenolol 50 mg
___ 09:22 PO Naproxen 500 mg
___ 09:22 PO/NG Aspirin 81 mg
___ 09:23 PO/NG LORazepam .5 mg
___ 13:19 PO/NG LORazepam .5 mg
___ 13:46 IVF 1000 mL NS 500 mL
___ 16:23 PO/NG Ciprofloxacin HCl 500 mg
___ 16:23 IVF 1000 mL NS
Neurosurgery was consulted and recommended discharge with TLSO
brace and outpatient followup given the burst fracture appeared
chronic.
She was admitted to Medicine for pain control and ___ eval
Currently, patient reports that her pain is well controlled and
would like to sleep.
Past Medical History:
MVA with multi trauma ___
Fibromyalgia
Cervical spine surgery, unspecified
MI with stents
colitis
Breast cancer recurrence in ___, s/p lumpectomy
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T99 BP 153/87 HR 87 RR 20 Sats 99 RA
GEN: Alert, lying in bed, no acute distress. Diffuse
excoriations around her skin
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l 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: Patient has ptosis of left eye (Chronic from previous
eye surgery) CN II-XII otherwise grossly intact, motor function
grossly normal in upper extremities. ___ exam limited by pain
DISCHARGE PHYSICAL EXAM:
Weight: NR
VS: 97.9 157/77 (130-170; avg 130-150s) 86 18 99
I/O: ___ x1 large BM; 24h-560/950
GEN: Alert, lying in bed, mildly uncomfrotable. Diffuse
excoriations around her skin and face.
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l 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: Patient has ptosis of left eye (Chronic from previous
eye surgery) CN II-XII otherwise grossly intact, motor function
grossly normal in upper extremities. ___ exam limited by pain
Pertinent Results:
ADMISSION LABS:
==============
___ 04:08AM BLOOD WBC-13.0* RBC-4.00 Hgb-12.1 Hct-36.5
MCV-91 MCH-30.3 MCHC-33.2 RDW-12.5 RDWSD-41.2 Plt ___
___ 04:08AM BLOOD Neuts-73.5* Lymphs-15.8* Monos-9.4
Eos-0.2* Baso-0.5 Im ___ AbsNeut-9.59* AbsLymp-2.06
AbsMono-1.22* AbsEos-0.02* AbsBaso-0.07
___ 04:08AM BLOOD ___ PTT-34.5 ___
___ 04:08AM BLOOD Glucose-109* UreaN-35* Creat-1.0 Na-140
K-4.8 Cl-101 HCO3-27 AnGap-17
___ 04:08AM BLOOD estGFR-Using this
___ 06:02AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.8
___ 04:10AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:10AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 04:10AM URINE RBC-1 WBC-8* Bacteri-MANY Yeast-NONE
Epi-<1
___ 04:10AM URINE Mucous-FEW
DISCHARGE LABS:
==================
___ 06:43AM BLOOD WBC-11.9* RBC-4.06 Hgb-12.1 Hct-37.3
MCV-92 MCH-29.8 MCHC-32.4 RDW-12.4 RDWSD-41.2 Plt ___
___ 06:43AM BLOOD Plt ___
___ 06:43AM BLOOD Glucose-101* UreaN-23* Creat-0.8 Na-139
K-3.5 Cl-102 HCO3-28 AnGap-13
___ 06:43AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8
PERTINENT IMAGING:
==================
___-SPINE W/O CONTRAST
IMPRESSION:
1. No acute fracture or malalignment of the cervical spine.
2. Severe multilevel multifactorial degenerative changes
described.
___ Imaging MR ___ SPINE W/O CONTRAST
IMPRESSION:
1. Study is severely degraded by motion.
2. L1 vertebral body burst fracture with 7 mm retropulsion of
the inferior
posterior fracture fragment resulting in moderate spinal canal
stenosis.
3. Moderate to severe multilevel degenerative changes as
described.
4. Small nonspecific L2-3 level intervertebral disc space fluid
without
definite epidural collection. While findings may be
degenerative in nature, infectious or inflammatory etiologies
are not excluded on the basis examination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 25 mg PO BID
2. Atenolol 100 mg PO DAILY
3. FLUoxetine 20 mg PO DAILY
4. Naproxen 500 mg PO Q12H
5. Atorvastatin 40 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. LORazepam 0.25 mg PO QHS
8. Ferrous Sulfate 325 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Codeine Sulfate 30 mg PO Q12H
12. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE Q24H
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
14. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Anacin (aspirin-caffeine) 400-32 mg oral QHS:PRN pain
17. LORazepam 0.25 mg PO QAM
18. Psyllium Wafer ___ WAF PO DAILY
19. Nortriptyline 10 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE Q24H
5. Codeine Sulfate 30 mg PO Q12H
6. Ferrous Sulfate 325 mg PO DAILY
7. FLUoxetine 20 mg PO DAILY
8. LORazepam 0.25 mg PO QHS
RX *lorazepam 0.5 mg 0.5 (One half) by mouth qHS PRN Disp #*10
Tablet Refills:*0
9. Losartan Potassium 100 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Nortriptyline 10 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
14. Pregabalin 25 mg PO BID
15. Psyllium Wafer ___ WAF PO DAILY
16. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
17. Anacin (aspirin-caffeine) 400-32 mg oral QHS:PRN pain
18. LORazepam 0.25 mg PO QAM
RX *lorazepam 0.5 mg 0.5 (One half) by mouth qAM Disp #*10
Tablet Refills:*0
19. Naproxen 500 mg PO Q12H:PRN pain
Please do not take > 7 days in a row. If so call PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
L1 fracture
Hypertension
SECONDARY DIAGNOSES:
Constipation
Dementia
Hyperlipidemia
Depression
History of breast cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. IN TLSO BRACE AT ALL TIMES WHEN MOBILE, INCLUDES
PASSENGER IN VEHICLE.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ female status post fall. Evaluate for cervical 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 5.3 s, 20.8 cm; CTDIvol = 37.0 mGy (Body) DLP = 772.2
mGy-cm.
Total DLP (Body) = 772 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
There is minimal C3 on C4 anterolisthesis, unchanged compared to prior exam
(see 602 B image 26 on current study and series 1A image 1 on prior). There
is no evidence of acute fracture. A left scapular 80 enostosis is partially
visualized (see 601b:21).
Endplate sclerosis and Schmorl's nodes are noted at C4-5 and C5-6. There are
severe multilevel degenerative changes including loss of intervertebral disc
space, subchondral sclerosis, subchondral cyst formation, and osteophyte
formation. There is no bony vertebral canal stenosis. Uncal hypertrophy and
facet arthropathy cause moderate to severe left-greater-than-right multilevel
neural foraminal stenosis. There is no prevertebral soft tissue swelling.
Limited imaging of the lungs demonstrate left upper lobe emphysematous changes
and biapical scarring.
IMPRESSION:
1. No acute fracture or malalignment of the cervical spine.
2. Severe multilevel multifactorial degenerative changes described.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ female with at L1 burst fracture. Evaluate cord
compression.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: Outside lumbar spine CT from ___.
FINDINGS:
Study is severely degraded by motion, especially on axial imaging.
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
There is grade 1 anterolisthesis of L4 on L5, unchanged. There is
redemonstration of an L1 comminuted fracture which predominantly involves the
inferior endplate with associated vertebral body height loss and 7 mm
retropulsion of the inferior posterior fracture fragment into the spinal canal
causing moderate spinal canal stenosis.
There is minimal cortical irregularity of the superior endplate of L2, as seen
on prior dedicated CT examination. At L2-3 endplates type ___ ___ changes are
noted.
The visualized portion of the spinal cord is grossly preserved in signal.
There is loss of intervertebral disc signal at all levels. There is near
complete loss of intervertebral disc height at L2-3 and L5-S1. Small
nonspecific fluid is noted within the L2-3 intervertebral disc space.
Within the limits of this noncontrast study there is no paravertebral or
paraspinal mass identified and there is no evidence of neoplasm. The
visualized portion of the sacroiliac joints are grossly preserved.
At the T12-L1 level, there is minimal disc protrusion causing mild spinal
canal stenosis. There no neural foraminal narrowing.
At the L1-L2 level, there is moderate spinal canal stenosis secondary to a
retropulsed inferior posterior fracture fragment. There is facet arthropathy
and moderate neural foraminal narrowing, worse on the right.
At the L2-L3 level, there is moderate intervertebral osteophytosis causing
severe spinal canal narrowing. There is facet arthropathy and moderate
bilateral neural foraminal narrowing, more severe on the left.
At the L3-L4 level, there is minimal disc protrusion causing effacement of the
anterior thecal sac. There is moderate facet arthropathy and moderate
bilateral neural foraminal narrowing.
At the L4-L5 level, there is significant intervertebral osteophytosis and
thickening of the ligamentum flavum causing severe spinal canal stenosis.
There is severe facet arthropathy and bilateral neural foraminal narrowing,
moderate in the left and severe in the right.
At the L5-S1 level, there is no spinal canal stenosis. There is mild facet
arthropathy with mild left neural foraminal narrowing.
IMPRESSION:
1. Study is severely degraded by motion.
2. L1 vertebral body burst fracture with 7 mm retropulsion of the inferior
posterior fracture fragment resulting in moderate spinal canal stenosis.
3. Moderate to severe multilevel degenerative changes as described.
4. Small nonspecific L2-3 level intervertebral disc space fluid without
definite epidural collection. While findings may be degenerative in nature,
infectious or inflammatory etiologies are not excluded on the basis
examination.
Radiology Report
INDICATION: ___ year old woman with fall // ?acute process
COMPARISON: The comparison is made with prior studies including the exam from
Steward ___ hospital dated ___.
IMPRESSION:
There is linear atelectasis or scarring in the left lung base. Within the
adjacent soft tissue there surgical clips present. There is no pneumothorax
or CHF.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Back pain
Diagnosed with Stable burst fracture of first lumbar vertebra, init, Exposure to other specified factors, initial encounter
temperature: 95.6
heartrate: 85.0
resprate: 16.0
o2sat: 98.0
sbp: 157.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | ___ with history of breast cancer presents with
chronic-appearing L1 fracture and grade 1 L4-5 spondylosis.
# L1 fracture: Neurosurgery evaluated the patient and felt no
surgical intervention was required at this time. She was
instructed to wear a TLSO brace at all times and follow up with
neurosurgery in 4 weeks. Etiology of repeated falls is unclear
but most likely mechanical secondary to ___ body dementia. ___
evaluated patient and recommended rehab which patient initially
refused, however after lengthy discussion with family and
patient, she was agreeable to discharge to rehab. She was
treated with Tylenol, naproxen, and codeine (home medication)
for pain relief. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
wound infection
Major Surgical or Invasive Procedure:
angiography of RLE with angioplasty and stent placement
(___)
right ___ toe amputation (___)
History of Present Illness:
Mr ___ is a ___ M with PMH of CAD s/p CABG at age ___,
ischemic CHF (EF 35%), PEA arrest in ___ s/p ICD, IDDM, PVD,
afib (on metop and Eliquis), HTN, HLD, presenting as a transfer
from ___ with concern for osteomyelitis
Of note, patient was recently hospitalized earlier this year
with first toe infection. He was at an outside hospital where
he underwent surgery with podiatry and suffered a PEA arrest,
where ROSC was achieved within 5 minutes, and the patient was
transferred to ___ where an ICD was successfully placed.
Rather than having any surgery, long-term antibiotics were
completed as an outpatient.
Patient notes he was doing well in the months since discharged
and successfully completed antibiotics a few months ago.
However,
over the last 2 weeks has had increasing redness and pain in his
first toe on the right. He went to ___ where he had imaging
concerning for osteomyelitis, and received abx for multiple days
as an inpatient. They were awaiting a bed for transfer to ___,
however the patient elected to leave and presented to the ___
ED for admission.
Past Medical History:
- DM2
- HTN
- HLD
- post four-vessel CABG in ___ (LIMA to LAD, SVG to OM1, SVG
to OM 2, SVG to RCA) c/b anicteric LAD to ___ (___) and
occluded SVG to OM1 with multiple prior left main stents ___,
___.
- Heart failure with reduced EF: EF 35-40%
- Atrial fibrillation
- Prior NSTEMI
- CKD III
- PVD status post multiple digital amputation and foot
infections
- Pulmonary hypertension
- Substance abuse, in remission
- necrotizing fasciitis with osteomyelitis
Social History:
___
Family History:
___ includes diabetes and heart disease
Physical Exam:
ADMISSION EXAM
==============================
___ 1139 Temp: 97.9 PO BP: 155/92 HR: 88 RR: 17 O2 sat: 98%
O2 delivery: Ra FSBG: 192
GEN: Well appearing, NAD
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD.
LUNGS: CTAB
HEART: Irregular, nl S1, S2. No m/r/g.
ABD: NT/ND, normal bowel sounds.
EXTREMITIES: Trace ___ edema. WWP. Right foot dressed without
significant drainage or malodor.
SKIN: No rashes.
NEURO: AOx3.
DISCHARGE EXAM
==============================
VITALS: Temp: 97.5 PO BP: 153/95 L Lying HR: 87 RR: 16 O2 sat:
98% O2 delivery: Ra FSBG: 169
GENERAL: Well appearing man in no acute distress. Comfortable.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: NCAT. EOMI. MMM.
CARDIOVASCULAR: Regular rate & rhythm. Normal S1/S2. No murmurs,
rubs, or gallops. ICD present over left chest.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Right foot with overlying dressing clean, dry,
intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
==============================
___ 10:53PM BLOOD WBC-11.6* RBC-4.26* Hgb-9.4* Hct-31.3*
MCV-74* MCH-22.1* MCHC-30.0* RDW-19.2* RDWSD-50.0* Plt ___
___ 10:53PM BLOOD Neuts-68.5 Lymphs-18.0* Monos-7.3 Eos-4.6
Baso-0.6 Im ___ AbsNeut-7.94* AbsLymp-2.08 AbsMono-0.84*
AbsEos-0.53 AbsBaso-0.07
___ 10:53PM BLOOD Glucose-89 UreaN-25* Creat-1.7* Na-134*
K-5.5* Cl-103 HCO3-21* AnGap-10
___ 10:53PM BLOOD ALT-94* AST-45* AlkPhos-270* TotBili-0.2
___ 10:53PM BLOOD Lipase-24
___ 10:07AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1
___ 10:53PM BLOOD Albumin-3.0*
PERTINENT LABS
==============================
___ 06:29AM BLOOD WBC-10.2* RBC-3.41* Hgb-8.3* Hct-27.5*
MCV-81* MCH-24.3* MCHC-30.2* RDW-24.0* RDWSD-68.6* Plt ___
___ 06:29AM BLOOD Glucose-150* UreaN-38* Creat-1.7* Na-139
K-5.3 Cl-106 HCO3-22 AnGap-11
___ 05:57AM BLOOD ALT-48* AST-29 AlkPhos-208* TotBili-0.2
___ 06:18AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.5 Iron-28*
___ 06:18AM BLOOD calTIBC-222* Ferritn-168 TRF-171*
___ 10:07AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 10:07AM BLOOD HCV Ab-NEG
DISCHARGE LABS
==============================
___ 06:29AM BLOOD WBC-10.2* RBC-3.41* Hgb-8.3* Hct-27.5*
MCV-81* MCH-24.3* MCHC-30.2* RDW-24.0* RDWSD-68.6* Plt ___
___ 06:29AM BLOOD ___ PTT-29.5 ___
___ 06:29AM BLOOD Glucose-150* UreaN-38* Creat-1.7* Na-139
K-5.3 Cl-106 HCO3-22 AnGap-11
___ 06:29AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.5
MICRO
==============================
___ 1:37 pm TISSUE PROXIMAL MARGIN.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
BACILLUS SPECIES; NOT ANTHRACIS. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
__________________________________________________________
___ 1:37 pm TISSUE Site: TOE BONE,RIGHT BIG TOE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
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------------- 2 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
PERTINENT STUDIES
==============================
RIGHT FOOT X-RAY (___)
Heterogeneous lucency in the lateral aspect of proximal phalanx
of the first toe associated with cortical irregularity is
concerning for osteomyelitis. A less conspicuous cortical
irregularity is also seen in the lateral aspect of distal first
metatarsal. Soft tissue swelling along the medial aspect of the
first metatarsophalangeal joint with probable small foci of air
noted within the soft tissues.
NON-INVASIVE ARTERIAL STUDIES (___)
-Significant aorto right iliac disease with additional
multifocal level disease.
-Moderate left SFA and tibial disease.
-Severe peripheral arterial disease in the right lower extremity
with a right TBI of 0.26 and ABI of 0.66.
-Moderate peripheral arterial disease in the left lower
extremity with a left ABI of 0.72.
TTE (___)
IMPRESSION: Small oscillating mass on the left ventricular
aspect of the aortic valve most c/w a Lambl's excrescence but a
small vegetation cannot be excluded in the appropriate clinical
context. Mild symmetric left ventricular hypertrophy with normal
normal cavity and mild regional and global systolic dysfunction
c/w a mixed cardiomyopathy. Increased PCWP. Grade III/IV
diastolic dsyfunction. Restrictive filling pattern. Normal right
ventricular cavity size with mild global systolic dysfunction.
Mild to moderate mitral regurgitation. Mild tricuspid
regurgitation. Severe pulmonary artery systolic hypertension.
Pulmonary artery diastolic hypertension.
NON-INVASIVE ARTERIAL STUDIES (___)
Normal right ABI and TBI, with suggestion of mild obstructive
tibial disease based on waveforms. Mildly abnormal left ABI with
waveform suggestive of proximal superficial femoral disease.
When compared to ___, the right ABI and TBI are
significantly improved. Findings on the left are overall
similar.
RIGHT FOOT X-RAY (___)
There has been amputation of the great toe at the head of the
proximal phalanx. There is an overlying soft tissue defect.
Prior amputations of the fourth and fifth toes are again
visualized.
RENAL US (___)
Normal renal ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. Collagenase Ointment 1 Appl TP DAILY
6. Senna 17.2 mg PO QHS
7. Vitamin D ___ UNIT PO DAILY
8. Metoprolol Succinate XL 100 mg PO BID
9. multivitamin with iron 1 tablet oral DAILY
10. Glargine 30 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
11. Apixaban 5 mg PO BID
12. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
continue taking until directed to stop by your podiatrist
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY Duration: 19 Days
Stop taking on ___ and take aspirin instead
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*19
Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO BID
continue taking until directed to stop by your podiatrist
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*20 Capsule Refills:*0
4. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Glargine 30 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
6. Senna 17.2 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Apixaban 5 mg PO BID
9. Collagenase Ointment 1 Appl TP DAILY
10. Furosemide 20 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO BID
12. multivitamin with iron 1 tablet oral DAILY
13. Vitamin D ___ UNIT PO DAILY
14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart baby aspirin until ___ (after completing your
course of clopidogrel)
15. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you see your
regular doctor
16.durable equipment
Rx: medium crutches
Dx: R foot osteomyelitis M86.171
Px: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
# RIGHT ___ TOE OSTEOMYELITIS
SECONDARY DIAGNOSES:
# PERIPHERAL ARTERIAL DISEASE
# ACUTE ON CHRONIC KIDNEY DISEASE
# ATRIAL FIBRILLATION
# ANEMIA
# URINARY RETENTION
# ABNORMAL LIVER CHEMISTRIES
# CHRONIC SYSTOLIC HEART FAILURE
# ISCHEMIC CARDIOMYOPATHY
# CAD s/p CABG
# INSULIN DEPENDENT DIABETES
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: History: ___ with R diabetic foot ulcer and fevers// r/o
osteomyelitis
TECHNIQUE: AP, lateral, and oblique views of the right foot.
COMPARISON: Radiographs from ___.
FINDINGS:
Status post amputation of the fourth and fifth toes at the level of proximal
phalanges.
Heterogeneous lucency in the proximal phalanx of the first toe lucency
associated with cortical irregularity is concerning for osteomyelitis. A less
conspicuous cortical irregularity is also seen in the distal first metatarsal.
Vascular Monckeberg calcifications. Small dorsal and Achilles calcaneal
enthesophytes. Soft tissue swelling along the medial aspect of the first
metatarsophalangeal joint with probable small foci of air noted within the
soft tissues.
IMPRESSION:
Heterogeneous lucency in the lateral aspect of proximal phalanx of the first
toe associated with cortical irregularity is concerning for osteomyelitis. A
less conspicuous cortical irregularity is also seen in the lateral aspect of
distal first metatarsal. Soft tissue swelling along the medial aspect of the
first metatarsophalangeal joint with probable small foci of air noted within
the soft tissues.
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
Lower extremity arterial Doppler. Rest only.
INDICATION: ___ year old man with hx PVD, s/p stent in left leg, with right
hallux wound// eval for PVD in right leg
TECHNIQUE: Doppler ultrasound and pulse volume recordings were obtained at
multiple levels in both lower extremities
Grayscale ultrasound, color Doppler, and spectral Doppler waveforms of the
bilateral lower extremities were obtained.
COMPARISON: None.
FINDINGS:
Significant aorto right iliac disease with additional multifocal level
disease, moderate left SFA and tibial disease.
On the right side, monophasic doppler waveforms are seen in the femoral,
popliteal, posterior tibial and dorsalis pedis arteries.
On the left side, triphasic Doppler waveforms are seen in the femoral artery.
Monophasic waveforms are seen in the popliteal, posterior tibial, and dorsalis
pedis arteries.
The right ABI is 0.66 and the left ABI is 0.72. Pulse volume recordings
demonstrate symmetric amplitudes at the levels studied.
The right TBI is 0.26
IMPRESSION:
-Significant aorto right iliac disease with additional multifocal level
disease.
-Moderate left SFA and tibial disease.
-Severe peripheral arterial disease in the right lower extremity with a right
TBI of 0.26 and ABI of 0.66.
-Moderate peripheral arterial disease in the left lower extremity with a left
ABI of 0.72.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old man with PVD, DM s/p SFA PTA/stent, TPT and ___ PTA.//
Lower extremity perfusion given PVD and following procedure
TECHNIQUE: Noninvasive evaluation of the arterial system of the lower
extremities was performed with Doppler signal recordings, pulse volume
recordings and segmental limb the pressure measurements at rest.
COMPARISON: ___
FINDINGS:
On the right-side, triphasic Doppler waveforms were seen at the right femoral,
popliteal arteries, and monophasic posterior tibial, and dorsalis pedis
arteries. The right ABI was 0.91 with a toe pressure of 123 mm Hg and TBI of
0.83. Pulse volume recordings demonstrate mildly abnormal waveforms in the
thigh, calf, ankle, moderately abnormal at the metatarsal and digit.
On the left-side, triphasic Doppler waveforms were seen at the left common
femoral artery, monophasic in the superficial femoral, popliteal, posterior
tibial, and dorsalis pedis arteries. The left ABI was 0.78, toe pressure was
not performed pulse volume recordings demonstrate mildly abnormal waveforms
the thigh, moderately abnormal at the calf, ankle, moderate to severely
abnormal at the metatarsal.
IMPRESSION:
Normal right ABI and TBI, with suggestion of mild obstructive tibial disease
based on waveforms.
Mildly abnormal left ABI with waveform suggestive of proximal superficial
femoral disease.
When compared to ___, the right ABI and TBI are significantly
improved. Findings on the left are overall similar.
Radiology Report
INDICATION: ___ year old man s/p R first ray resection// post op eval
COMPARISON: Radiographs from ___
IMPRESSION:
There has been amputation of the great toe at the head of the proximal
phalanx. There is an overlying soft tissue defect. Prior amputations of the
fourth and fifth toes are again visualized.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with CKD and worsening ___// evidence of hydronephrosis,
other cause for ___?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 11.3 cm
Left kidney: 11.6 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound.
Gender: M
Race: HISPANIC/LATINO - SALVADORAN
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Fever, unspecified
temperature: 99.0
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 139.0
dbp: 72.0
level of pain: 5
level of acuity: 3.0 | ___ with history of CAD s/p CABG at age ___, ischemic CMP (LVEF
35%), PEA arrest (___) s/p ICD, IDDM, PVD, and atrial
fibrillation who initially presented with worsening right first
toe redness and pain, found to have severe RLE arterial disease
and RLE osteomyelitis. During this admission, he underwent
angioplasty and stent placement to the RLE, as well as right ___
toe amputation. Final operative pathology pending at the time
of discharge. Patient will follow-up closely with podiatry to
determine final length of antibiotic course and for ongoing
management of foot infection.
# RIGHT ___ TOE OSTEOMYELITIS
Longstanding issue with prior culture data at ___
notable for MRSA and Pseudomonas. He was recently admitted at
___ but left the facility in favor of seeking further care at
___. He was started on broad spectrum antibiotics initially
with vancomycin, ceftazidime, and metronidazole until he
underwent ___ toe amputation on ___ without complication. He
was subsequently narrowed to Cipro/Doxy based on prior culture
data. Tentative plan is to continue oral antibiotics until time
of podiatry follow up. Of note, the proximal margin culture was
growing coag-negative staph and bacillus species, though unclear
as to whether these are true pathogens vs. contaminants. Final
operative pathology was pending at the time of discharge. If
final pathology shows inadequate margins or if wound appears to
have recurrent infection, would advise outpatient ID referral
for consideration of long term antibiotics. From a wound
standpoint, he appeared to have clean and well perfused tissue
with post-op course notable only for persistent bleeding &
oozing which did require pRBC transfusion (in setting of Plavix
+ anti-coagulation due to co-morbidities). Wound was kept
wrapped with steady improvement in bleeding, and he was able to
ambulate with assistance using crutches prior to discharge.
# PERIPHERAL ARTERIAL DISEASE
Presented with known history of severe peripheral vascular
disease likely contributing to ongoing foot wounds. Evaluated by
vascular surgery and underwent angiography with angioplasty and
stent placement on ___ without complication. Subsequently
with significant improvement in distal blood flow on repeat
non-invasive studies. Plan is to continue Plavix + apixaban for
30-days post-procedure then switch back to aspirin + apixaban
thereafter. He will follow up with vascular surgery and have
repeat non-invasive studies as an outpatient.
# ACUTE ON CHRONIC KIDNEY DISEASE
Fluctuating baseline though acutely worsened following toe
amputation. Most likely due to ATN or pre-renal physiology at
this time; notably with urine microscopy showing some brown
casts. Renal US was normal. Renal function steadily improved
with discharge Cr 1.7. Resumed home PO Lasix prior to discharge.
# ATRIAL FIBRILLATION
Well controlled throughout admission. He was briefly on heparin
gtt in setting of ___, later resumed home apixaban.
# ANEMIA
Acute on chronic due to blood loss related to right toe
amputation. Received 1u pRBC with appropriate H/H response over
course of admission. Of note he does appear to have chronic
microcytic anemia with iron studies showing transferrin
saturation 12% consistent with iron deficiency. He will need
outpatient workup for this including colonoscopy.
# URINARY RETENTION
Developed in post-operative setting, most likely from
anesthesia. Resolved without issue.
# ABNORMAL LIVER CHEMISTRIES
Possibly due to atorvastatin which was temporarily held,
subsequently dose reduced. LFTs down-trended thereafter.
Hepatitis serology negative.
# CHRONIC SYSTOLIC HEART FAILURE
# ISCHEMIC CARDIOMYOPATHY
Continued metoprolol succinate and home PO Lasix. Losartan was
held in setting of acute on chronic renal disease but can be
resumed as outpatient once Cr normalized.
# CAD s/p CABG
Occurred in ___ at age ___. Stable. Continued medical
management.
# INSULIN DEPENDENT DIABETES
Continued insulin scales in house.
TRANSITIONAL ISSUES
=================================
[ ] Monitor right foot wound closely and continue antibiotic
course as necessary. If pathology report shows contaminated
margins or otherwise concerned for persistent infection would
recommend outpatient ID consultation to discuss need for long
term antibiotics.
[ ] Noted to have microcytic anemia with transferrin saturation
12%, consistent with iron deficiency anemia. He will need
outpatient workup including colonoscopy.
[ ] Will remain on clopidogrel + apixaban for 30 days
post-angioglasty (Last day ___. Thereafter switch to
aspirin + apixaban indefinitely.
[ ] Will need repeat arterial non-invasive studies in 2 weeks
around time of vascular surgery follow up.
[ ] Patient requesting evaluation for erectile dysfunction
likely related to known vascular disease. Please follow up as
outpatient and refer to urology if needed.
[ ] Repeat CBC, chemistry, LFTs at time of PCP follow up to
ensure normalized. If persistent AST/ALT elevation will need
additional workup. Can resume ___ once renal function
normalized. |
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, dizziness
Major Surgical or Invasive Procedure:
None during this admission.
History of Present Illness:
___ w/hx of HTN, HLD, anemia who presents with 3 weeks of
"dizziness" with intermittent HA. Pt reports this happening
suddenly, and that it is worse with changing positions (lying to
sitting, sitting to standing). Also endorses feeling lightheaded
but states the room is not spinning. Reports a HA on the left
side for 2 days but not today. He also notes feeling week in
arms and legs. There is no recent trauma or neck pain, however
he reports some nausea and some gait imbalance/wobbling. No
numbness or tingling. No fevers, chills, CP, SOB, abdominal
pain, diarrhea, urinary symptoms. Not on blood thinners. Got
TDAP 1 month ago for a laceration. Takes Losartan, HCTZ,
beta-blocker.
Labs were drawn and largely normal with exception of Cr 2.2 and
H/H 11.2/33.9. Head CT was normal. Has ___ to 2.2 up from 1.7
baseline, and patient has no knowledge of prior renal disease.
In the ED, initial vitals were: 97.1 123/88 60 16 100RA
Exam notable for cranial nerves intact, atraumatic head, some
tenderness in the left posterior part of the neck without
midline tenderness of neck. Full ROM. ___ strength bilaterally.
No sensory deficits. 2+ patellar reflexes bilaterally. Negative
___ maneuver - no nystagmus.
Labs notable for: BMP WNL except for BUN2.2; CBC WNL except
H/H=11.2/___.9 PLT168
Imaging notable for CT Head w/o contrast: IMPRESSION: 1. No
acute intracranial process. Specifically, no intracranial
hemorrhage or
large mass 2. Of note MR is more sensitive detection of subtle
mass lesions
Patient was given APAP PO 1000mg, 2L IV NS
Patient was seen by neurology who recommended consult not needed
in ED, but if further concern for primary team to re-consult
Decision was made to admit for ___ with Cr 2.2 from baseline of
1.7
Vitals notable for: 97.1 151/102 60 18 99RA
On the floor, the patient confirms his previous history of ___
weeks of headaches and lightheadedness/dizziness with changes in
position, especially with rising from bed or seated position. He
also reports ringing in his ears when having the headaches and
lightheadedness. He has had decreased fluid intake orally for
the past several weeks, and has been walking every morning and
evening. He has some chills and occasional night sweats but no
cough or weight loss.
Review of systems:
(+) Per HPI
(-) Denies fever or recent weight loss. Denies 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:
-hypertension
-hyperlipidemia
-anxiety
-insomnia
-GERD
Social History:
___
Family History:
Father died form alcohol complications. Other family members
with palpitations. No h/o sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
VS: 97.7 144/99 60 18 100RA
GEN: NAD, lying and sitting in bed in no apparent distress
HEENT: AT/NC; anicteric sclera, EOMI, PERRL; no LAD, throat
supple
CV: RRR, (+)S1/S2, no M/R/G
PULM: CTAB, no W/R/R
ABD: S/NT/ND, (+)BS, no organomegaly
GU: no Foley
EXT: NT, nonedematous
SKIN: multiple scars ___ stab wounds ___ prior to admission
NEURO: A/Ox3, motor and sensory exams, including cerebellar and
gait, tested and ___ globally; CNII-XII intact
PSYCH: normal mood/affect
DISCHARGE EXAM:
VS: 98.6 138/90 59 18 100RA - orthostatics performed and normal
GEN: NAD, lying and sitting in bed in no apparent distress
HEENT: AT/NC; anicteric sclera, EOMI, PERRL; no LAD, throat
supple
CV: RRR, (+)S1/S2, no M/R/G
PULM: CTAB, no W/R/R
ABD: S/NT/ND, (+)BS, no organomegaly
GU: no Foley
EXT: NT, nonedematous
SKIN: multiple scars ___ stab wounds ___ prior to admission
NEURO: A/Ox3, motor and sensory exams, including cerebellar and
gait, tested and ___ globally; CNII-XII intact
PSYCH: normal mood/affect
Pertinent Results:
ADMISSION LABS:
___ 03:18PM BLOOD WBC-5.7 RBC-3.49* Hgb-11.2* Hct-33.9*
MCV-97 MCH-32.1* MCHC-33.0 RDW-12.5 RDWSD-43.9 Plt ___
___ 03:18PM BLOOD Neuts-61.7 ___ Monos-8.0 Eos-4.6
Baso-1.1* Im ___ AbsNeut-3.49 AbsLymp-1.37 AbsMono-0.45
AbsEos-0.26 AbsBaso-0.06
___ 03:18PM BLOOD Glucose-102* UreaN-17 Creat-2.2* Na-137
K-5.1 Cl-103 HCO3-24 AnGap-15
___ 04:28PM URINE Color-Straw Appear-Clear Sp ___
___ 04:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
DISCHARGE LABS:
___ 06:38AM BLOOD WBC-5.2 RBC-3.28* Hgb-10.5* Hct-32.2*
MCV-98 MCH-32.0 MCHC-32.6 RDW-12.3 RDWSD-44.2 Plt ___
___ 06:38AM BLOOD Glucose-87 UreaN-13 Creat-1.8* Na-141
K-4.3 Cl-107 HCO3-23 AnGap-15
___ 06:38AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.4*
MICRO:
___ BCx (x2): NG final
STUDIES:
___ EKG:
Sinus rhythm with normal intervals and no diagnostic
abnormalities. No previous tracing available for comparison.
IMAGING:
___ CT Head w/o Contrast:
IMPRESSION:
No acute intracranial process. Specifically, no intracranial
hemorrhage or large mass.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Propranolol 40 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Propranolol 40 mg PO BID
2. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was
held. Do not restart Hydrochlorothiazide until you follow up
with your primary care doctor on ___
3. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you follow up with
your primary care doctor on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
-acute kidney injury
-dehydration
Secondary diagnosis:
-hypertension
-hyperlipidemia
-normocytic anemia
-generalized anxiety disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with new onset dizziness + HA for 3 weeks. Assess for bleed
or mass
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) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or large 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:
No acute intracranial process. Specifically, no intracranial hemorrhage or
large mass.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Headache, Dizziness
Diagnosed with Headache
temperature: 97.1
heartrate: 60.0
resprate: 16.0
o2sat: 100.0
sbp: 123.0
dbp: 88.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with history of HTN, HLD, and
normocytic anemia who presented with 3 weeks dizziness and
intermittent headache who was also found to have ___ with Cr 2.2
up from baseline of Cr 1.7. In the ED the patient was given IV
fluids and had a head CT which was normal. On the floor he was
encouraged to take copious PO fluids. By the AM of the day after
admission, the patient was feeling significantly improved, with
no complaints of positional dizziness. Similarly, his Cr
improved to his baseline. He was encouraged to continue to keep
drinking fluids, especially when walking outside. He will be
seen by his PCP as an outpatient for labs and to follow up on
his elevated baseline Cr. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"Headache"
Major Surgical or Invasive Procedure:
R craniotomy for ___ ___ Dr. ___
___ of Present Illness:
This is a ___ year old female who stood up suddenly from bed
on ___ and became dizzy, fell striking her head, and had
loss of consciousness. She attributes her fall to not feeling
well for several days prior and possibly being dehydrated.
Since
that time she has had persistent headache that is generally a
level ___ on a ___ pain scale. She states that it is worse in
the early morning and after a full day of work reaching to a
level of 10 on a ___ pain scale. The patient states that she
is
a pharmacist and after working all day, she is dizzy and has
difficulty with concentration. In addition she has experienced
intermittent periods of decreased hearing. The patient has been
followed by her PCP for these headaches and had been recommended
to have a Head CT prior to an elective surgery at ___
___ for lower body lift later this week. A Head CT was
performed today which was consistent with a subacute on chronic
SDH and that patient was brought here for further evaluation nd
treatment.
The patient denies weakness, numbness, tingling sensation, bowel
or bladder deficit, vision changes
Past Medical History:
HTN, gastric bypass ___, cholecystectomy ___
Social History:
___
Family History:
non contributory
Physical Exam:
O: T:98.8 BP: 138/83 HR:68 R: 16 O2Sats:100%
Gen: NO otorrhea, NO rhinorrhea, NO raccoons eyes or Battle sign
comfortable, NAD.
HEENT: Pupils: 4-3mm EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
On Discharge: non focal. sutures c/d/i
Pertinent Results:
CT HEAD W/O CONTRAST ___
Bilateral subdural hematomas on the right greater than the left
with no change in size or evidence of acute bleeding from
___. There is 5-mm of leftward midline shift, which is
stable.
___ CXR: FINDINGS: No previous images. The heart is normal in
size and lungs are clear without evidence of vascular congestion
or pleural effusion.
___ CT Head- IMPRESSION:
1. Expected postoperative appearance status post right
craniotomy and
evacuation of large right subdural hematoma from ___ with no
evidence of acute bleeding and slightly decreased leftward
midline shift from the prior study.
2. Stable small left subdural hematoma.
Medications on Admission:
Toprol XL 100 mg qd, cozaar 50 mg qd
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Fioricet 50-325-40 mg Tablet Sig: ___ Tablets PO every six
(6) hours as needed for headache: use to wean off dilaudid.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
R SDH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female status post fall and head strike on ___
now with subacute on chronic subdural hemorrhage, here to evaluate for
interval changes.
COMPARISON: Outside CT of the head performed on ___.
TECHNIQUE: MDCT-acquired axial images were obtained through the head without
intravenous contrast.
CT HEAD WITHOUT CONTRAST: There is a relatively large and faintly hyperdense
right subdural hematoma which is unchanged in size with no evidence of acute
bleeding from ___. There is stable, moderate local mass effect with
compression of the right cerebral hemisphere and 5-mm of leftward midline
shift, unchanged from ___. There is no evidence of herniation. A small
left subdural hematoma appears more hyperdense on today's exam from the
preceding CT without evidence of increased size or acute bleeding. There is
no evidence of intraventricular extension. The ventricles and sulci are
normal in size and configuration. The gray-white matter interface is well
preserved with no evidence of acute major vascular territorial infarct. The
visualized paranasal sinuses and mastoid air cells are well pneumatized. The
bony calvarium appears intact.
IMPRESSION: Bilateral subdural hematomas on the right greater than the left
with no change in size or evidence of acute bleeding from ___. There is
5-mm of leftward midline shift, which is stable.
Radiology Report
HISTORY: Subdural hematoma, to assess for pneumonia.
FINDINGS: No previous images. The heart is normal in size and lungs are
clear without evidence of vascular congestion or pleural effusion.
Radiology Report
INDICATION: ___ female with right subdural hematoma status post
evacuation via craniotomy with subgaleal drainage, here to evaluate for
interval changes.
COMPARISON: Non-contrast head CT last performed on ___.
TECHNIQUE: MDCT-acquired axial images were obtained through the head without
intravenous contrast.
CT HEAD WITHOUT CONTRAST: There are expected postoperative changes and right
pneumocephalus status post craniotomy and evacuation of the relatively large
right subdural hematoma seen on ___. Minimal residual fluid and blood
products are noted along the right cerebral convexity. No significant edema
is detected. There is residual 4-mm leftward shift of normally midline
structures, decreased from ___. There is no evidence of herniation. A
small left subdural hematoma is slightly more hyperdense on today's study
compared to the most recent prior CT without evidence of increase in size or
acute bleeding. The ventricles and sulci are normal in size and
configuration. The gray-white matter interface is well preserved without
evidence of acute major vascular territorial infarct. The visualized
paranasal sinuses and mastoid air cells are well pneumatized. The bony
calvarium shows four burr holes in the right parietal bone at the site of
craniotomy.
IMPRESSION:
1. Expected postoperative appearance status post right craniotomy and
evacuation of large right subdural hematoma from ___ with no evidence of
acute bleeding and slightly decreased leftward midline shift from the prior
study.
2. Stable small left subdural hematoma.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SDH
Diagnosed with SUBDURAL HEM W/O COMA, UNSPECIFIED FALL, HYPERTENSION NOS, AORTOCORONARY BYPASS
temperature: 98.8
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 138.0
dbp: 83.0
level of pain: 5
level of acuity: 2.0 | This is a ___ year old woman presents s/p fall after standing
with dizziness striking her head a month ago. Head CT reveals a
right SDH with minimal midline shift. She was admitted to the
floor for further neurosurgical monitoring and evaluation. On
___, repeat head CT was stable and her PO dilaudid was added to
her pain medication regimen with success. She was consented for
OR procedure and pre-oped. On ___, patient remains stable and
awaits surgical procedure. She proceeded to the OR on ___ for a
right craniotomy. The patient tolerated the procedure well and
was extubated and taken to the SICU. Post-op CT head was without
hemorrhage and she was neurologically intact. On ___ she was
neurologically stable and cleared for transfer to the floor. She
was tolerating a PO diet and pain was controlled.
After remaining stable overnight she was cleared for discharge
home on ___. She was ambulating independently and voiding
without difficulty. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
___: diagnostic paracentesis
___: EGD with NJ tube placement
attach
Pertinent Results:
ADMISSION LABS:
___ 10:40AM BLOOD WBC-9.2 RBC-2.94* Hgb-10.4* Hct-32.9*
MCV-112* MCH-35.4* MCHC-31.6* RDW-16.5* RDWSD-67.8* Plt Ct-88*
___ 10:40AM BLOOD Neuts-81.6* Lymphs-8.6* Monos-8.1
Eos-0.7* Baso-0.2 Im ___ AbsNeut-7.48* AbsLymp-0.79*
AbsMono-0.74 AbsEos-0.06 AbsBaso-0.02
___ 10:40AM BLOOD ___ PTT-38.1* ___
___ 10:40AM BLOOD Plt Ct-88*
___ 10:40AM BLOOD Glucose-109* UreaN-7 Creat-0.5 Na-141
K-3.8 Cl-101 HCO3-24 AnGap-16
___ 10:40AM BLOOD ALT-37 AST-114* AlkPhos-179* TotBili-4.1*
___ 10:40AM BLOOD Albumin-3.3* Iron-63
___ 10:40AM BLOOD calTIBC-122* TRF-94*
___ 10:40AM BLOOD Smooth-POSITIVE*
___ 10:40AM BLOOD antiTPO-32
___ 10:40AM BLOOD IgG-2292*
PERTINENT LABS:
___ 06:00AM BLOOD VitB12-705 ___ Ferritn-575*
___ 06:00AM BLOOD AMA-NEGATIVE
___ 06:00AM BLOOD ___ Titer-1:320* AFP-3.6
___ 06:00AM BLOOD IgM-224
DISCHARGE LABS:
___ 06:52AM BLOOD WBC-9.8 RBC-2.69* Hgb-9.4* Hct-30.3*
MCV-113* MCH-34.9* MCHC-31.0* RDW-16.2* RDWSD-66.8* Plt Ct-99*
___ 06:52AM BLOOD Plt Ct-99*
___ 06:52AM BLOOD ___ PTT-41.2* ___
___ 06:52AM BLOOD Glucose-136* UreaN-13 Creat-0.4 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-9*
___ 06:52AM BLOOD ALT-30 AST-93* LD(LDH)-229 AlkPhos-234*
TotBili-2.5*
___ 06:52AM BLOOD Albumin-2.8* Calcium-8.3* Phos-2.9 Mg-1.9
___ 06:00AM BLOOD VitB12-705 ___ Ferritn-575*
MICRO:
___ 9:49 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING:
___ Imaging LIVER OR GALLBLADDER US
1. Cirrhotic liver, without evidence of focal lesion,
splenomegaly or ascites.
2. The bladder is decompressed and full of gallstones.
Gallbladder wall
thickening may relate to the patient's volume status, and the
decompressed
gallbladder.
3. Splenomegaly.
4. Patent hepatic vasculature.
___ Imaging DUPLEX DOPP ABD/PEL
1. Cirrhotic liver, without evidence of focal lesion,
splenomegaly or ascites.
2. The bladder is decompressed and full of gallstones.
Gallbladder wall
thickening may relate to the patient's volume status, and the
decompressed
gallbladder.
3. Splenomegaly.
4. Patent hepatic vasculature.
___ Imaging PARACENTESIS DIAG/THERA
1. Technically successful ultrasound guided diagnostic
paracentesis.
2. 15 cc of fluid were removed and sent for analysis.
___ Gastroenterology EGD
Varices in the distal esophagus. No evidence of gastric varices.
Oozing portal hypertensive gastropathy. NJ tube placed
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL
INDICATION: cholelithiasis vs cholestasis; PVT?
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON:
None available.
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 moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD is borderline
enlarged measuring 6 mm.
GALLBLADDER: The gallbladder is decompressed, and filled with stones. There is
gallbladder wall thickening. ___ sign is negative.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Spleen is enlarged with normal echogenicity.
DOPPLER EVALUATION:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 15.6 cm/sec.
Right and left portal veins are patent, with antegrade flow.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
Paraumbilical vein is recannulized and patent.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion, splenomegaly or ascites.
2. The bladder is decompressed and full of gallstones. Gallbladder wall
thickening may relate to the patient's volume status, and the decompressed
gallbladder.
3. Splenomegaly.
4. Patent hepatic vasculature.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL
INDICATION: cholelithiasis vs cholestasis; PVT?
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON:
None available.
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 moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD is borderline
enlarged measuring 6 mm.
GALLBLADDER: The gallbladder is decompressed, and filled with stones. There is
gallbladder wall thickening. ___ sign is negative.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Spleen is enlarged with normal echogenicity.
DOPPLER EVALUATION:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 15.6 cm/sec.
Right and left portal veins are patent, with antegrade flow.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
Paraumbilical vein is recannulized and patent.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion, splenomegaly or ascites.
2. The bladder is decompressed and full of gallstones. Gallbladder wall
thickening may relate to the patient's volume status, and the decompressed
gallbladder.
3. Splenomegaly.
4. Patent hepatic vasculature.
Radiology Report
INDICATION: ___ year old woman with new cirrhosis with ascites unable to tap
at bedside // please perform diagnostic para
TECHNIQUE: Ultrasound-guided diagnostic paracentesis
COMPARISON: ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated moderate
ascites. A suitable target in the deepest pocket in the right upper quadrant
was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic paracentesis
Location: Right upper quadrant
Fluid: 15 cc of cloudy, yellow fluid
Samples: None
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic paracentesis.
2. 15 cc of fluid were removed and sent for analysis.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: Abnormal CT, Abnormal labs, Jaundice
Diagnosed with Unspecified cirrhosis of liver
temperature: 97.6
heartrate: 100.0
resprate: 15.0
o2sat: 100.0
sbp: 118.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ year old healthy female with no known medical history who is
presenting with significant weight loss, malaise and fatigue
with Atrius labs/imaging consistent with new diagnosis of
cirrhosis due to possibly autoimmune vs alcohol. |
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, left chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M healthy male who presents with one week of cold like sx
and worsening cough with left chest pain.
Pt reports that one week ago he had cold like sx with cough,
runny nose and sore throat. Did not measure his temperature at
home. Says he has had episodes of "bronchitis" or "asthma"
before that were treated with antibiotics but never felt how he
does today. Says that all of the sudden yesterday (___) he was
in a meeting at work and suddenly felt shaky and cold. After
leaving work, he was unable to drive home due to fatigue and
slept a couple of hours in his car before getting home. Says
that his left chest pain started yesterday. Describes as
intermittent and feels "achy and muscle like". It is worse with
breathing and coughing. It kept him up all night and this is
ultimately what brought him to the ED. Cough has gotten worse.
It is productive-initially has blood tinge to it but then turns
clear. Also describes neck pain that was brief yesterday and has
now resolved- is achy and muscle-like in origin but he thinks he
may have been related to a strain while bending over in the
shower.
On ROS, denies vomiting, diarrhea, head ache, neck stiffness,
new rashes or changes in his skin, leg swelling, calf pain, new
weakness, new numbness or tingling, angina, orthopnea,
depression, anxiety, black stools, bloody stools. No visual
changes, recent travel, muscle aches outside of that described
above, recent sedentary behavior, calf pain.
Does endorse mild dysuria, nausea and feeling SOB with his pain,
feeling as though he can't breath.
In the ED, initial VS were T 101.3, HR 132, BP 155/76, RR 20 and
97% on room air. Patient was given Tylenol and oxycodone,
ceftriaxone and azithromycin, 2 liters IVF, Ua and ucx were sent
and CXR was performed. CBC note-able for a white count of 23.6,
H/H 12.5/36.0. CXR demonstrated evidence a LLL PNA with
effusion.
Past Medical History:
Dyslipidemia
Anxiety
(**Recently stopped metformin and atenolol)
Social History:
___
Family History:
Mother-breast cancer
Father- COPD, ___ Mellitus, hypertension
Physical Exam:
Upon admission:
VS - 97.7 128 141/66 18 93 r/a
GENERAL: NAD
HEENT: brown skin discoloration on forehead, MMM, no erythema or
exudate of the oropharynx, neck ROM is intact
NECK: supple, non tender, no lymphadenopathy, no JVD
CARDIAC: Tachycardic, RRR, s1 and s2 are nl, no m/r/g
LUNG: Diffuse coarse breath sounds w/inspiration expiration with
wheezing heard b/l in the bases
CHEST: No pain with palpation of the left chest
ABDOMEN: obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, no calf pain with
palpation
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Upon discharge:
VS - 99.2 147/90 109 20 96%
GENERAL: NAD
HEENT: brown skin discoloration on forehead, MMM, no erythema or
exudate of the oropharynx, hyperpigmented skin along back of
neck (looks like acanthosis nigrans)
CARDIAC: Tachycardic, RRR, s1 and s2 are nl, no m/r/g
LUNG: Improved aeration bilaterally, no wheezes, some rhonchi in
bases
CHEST: No pain with palpation of the left chest
ABDOMEN: obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, no calf pain with
palpation
PULSES: 2+ DP pulses bilaterally
SKIN: warm, well perfused, no excoriations or lesions, no rashes
Pertinent Results:
LABS UPON ADMISSION:
--------------------
___ 02:30PM BLOOD WBC-23.6*# RBC-4.17* Hgb-12.5* Hct-36.0*
MCV-86 MCH-30.0 MCHC-34.7 RDW-13.5 RDWSD-42.3 Plt ___
___ 02:30PM BLOOD Glucose-111* UreaN-20 Creat-1.2 Na-134
K-4.0 Cl-94* HCO3-26 AnGap-18
___ 06:09PM BLOOD Lactate-1.4
LABS UPON DISCHARGE:
--------------------
___ 07:37AM BLOOD WBC-16.3* RBC-4.23* Hgb-12.3* Hct-37.1*
MCV-88 MCH-29.1 MCHC-33.2 RDW-13.5 RDWSD-43.3 Plt ___
___ 07:37AM BLOOD Glucose-123* UreaN-12 Creat-1.0 Na-138
K-4.0 Cl-100 HCO3-27 AnGap-15
IMAGING:
CXR ___:
FINDINGS:
Heart size is accentuated by low lung volumes and appears mildly
enlarged. Mediastinal and hilar contours are unremarkable.
Pulmonary vasculature is not engorged with crowding of the
bronchovascular structures due to low lung volumes. Left
basilar consolidative opacities concerning for pneumonia. There
may be a small left pleural effusion. No pneumothorax is
identified. No acute osseous abnormalities detected.
IMPRESSION:
Left basilar opacification concerning for pneumonia with small
left pleural effusion. Followup radiographs after treatment are
recommended to ensure resolution of this finding.
MICRO:
___ 2:05 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
MEROPENEM <=0.06 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- S
PENICILLIN G----------<=0.06 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- 8 R
VANCOMYCIN------------ <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Cough Syrup] 100 mg/5 mL 5 -10 mL by mouth q 6
hour Refills:*0
6. Levofloxacin 750 mg PO DAILY Duration: 10 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Community acquired pneumonia
Bacteremia
Secondary diagnoses:
Dyslipidemia
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with cough, fever
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: ___
FINDINGS:
Heart size is accentuated by low lung volumes and appears mildly enlarged.
Mediastinal and hilar contours are unremarkable. Pulmonary vasculature is not
engorged with crowding of the bronchovascular structures due to low lung
volumes. Left basilar consolidative opacities concerning for pneumonia.
There may be a small left pleural effusion. No pneumothorax is identified.
No acute osseous abnormalities detected.
IMPRESSION:
Left basilar opacification concerning for pneumonia with small left pleural
effusion. Followup radiographs after treatment are recommended to ensure
resolution of this finding.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough, ILI, Chest pain, Fever
Diagnosed with Pneumonia, unspecified organism, Sepsis, unspecified organism
temperature: 101.3
heartrate: 132.0
resprate: 20.0
o2sat: 97.0
sbp: 156.0
dbp: 78.0
level of pain: 10
level of acuity: 1.0 | ___ yo M who presents with cough, fever and left pleuritic pain
found to have LLL opacity concerning for community acquired
pneumonia.
1. S. Pneumoniae Pneumonia/Bacteremia
Patient febrile with white count (neutrophilia, bandemia),
opacity on CXR, and sx of pneumonia. CURB 65 score 1, risk of
death 0-6% in next thirty days. Bacteremia speciated to
S.pneumo. Pt initially treated with ceftriaxone and
azithromycin, which was changed to vancomycin and ceftriaxone
when patient found to be bacteremic. Then switched to
levofloxacin upon discharge. Cough was treated with guafenisin
and tensilon pears for symptoms. Pain treated with IV morphine
and oxycodone.
**Upon writing this discharge summary, strep pneumo found to be
resistant to levofloxacin. Patient will be readmitted later
today for IV antibiotic administration and possible PICC
placement.
2. Constipation: On senna, Colace. Still no BM in setting of
recent narcotic use
-Add miralax
--Chronic issues--
2. Hyperlipidemia
-Continue on home statin
3. Anxiety
-Continue on home citalopram |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
amlodipine / Augmentin / Cipro / Macrobid / Salicylates /
Beta-Blockers (Beta-Adrenergic Blocking Agts) / tetracycline
Attending: ___.
Chief Complaint:
RLE pain
Major Surgical or Invasive Procedure:
Right ankle open reduction internal fixation
History of Present Illness:
___ w/hx of HTN and vWF disease who presents as transfer from ___
___ s/p fall down stairs with right ankle fracture. Fracture
was reduced and splinted at OSH and transferred to ___ for
definitive care given patients history of vWF disease. Denies
HS/LOC. Complains of significant pain in right ankle.
Past Medical History:
___ Disease
HTN
HLD
Depression
Anxiety
Physical Exam:
RLE in splint:
Splint c/d/I
SILT SP/DP/T
Firing ___
+2 pulses distally
Medications on Admission:
Benicar HCT 40 MG - 12.5 MG daily
Amlodipine 5 MG BID
Bupropion 75 MG daily
Fluoxetine 60 MG daily
Neurontin 600 MG TID
Lorazepam 0.5 MG QPM PRN anxiety
Lorazepam 1 MG BID
Omeprazole 20 MG daily
Simvastatin 20 MG QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. amLODIPine 5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. DiphenhydrAMINE 12.5 mg PO Q8H:PRN itch
6. Docusate Sodium 100 mg PO BID constipation
7. Enoxaparin Sodium 30 mg SC Q12H
8. FLUoxetine 60 mg PO DAILY
9. LORazepam 1 mg PO TID
10. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. TraZODone ___ mg PO QHS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right ankle trimalleolar fracture-dislocation
Discharge Condition:
AAOx3, mentating appropriately, NVI
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with fall// eval for pneumonia
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. Overlying EKG leads are present.
There is exclusion of the right CP angle. There is platelike atelectasis at
the right lung base, otherwise lungs are clear. No consolidation concerning
for pneumonia. No congestion or edema. No large effusion or pneumothorax is
seen. The cardiomediastinal silhouette is normal. Imaged osseous structures
are intact.
IMPRESSION:
No pneumonia. Platelike right basal atelectasis. Excluded right CP angle.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: RT ANKLE FX.ORIF
IMPRESSION:
Fluoroscopic images show placement of fixation devices about fractures of the
distal fibula and medial malleolus. Further information can be gathered from
the operative report.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with r ankle fracture s/p fixation// pulmonary
edema? pulmonary edema?
IMPRESSION:
___ in to ___. Decreased lung volumes. Mild fluid overload but
no overt pulmonary edema. No pneumonia. Mild retrocardiac atelectasis. No
larger pleural effusions.
Radiology Report
INDICATION: ___ year old woman s/p ankle ORIF.// desat
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
Increased interstitial markings bilaterally may reflect pulmonary interstitial
edema. Opacities at both lung bases likely reflect atelectasis. No pleural
effusion or pneumothorax. The size of the cardiac silhouette is mildly
enlarged.
IMPRESSION:
Interval development/worsening of pulmonary interstitial edema.
Radiology Report
EXAMINATION: CT angiogram of the chest
INDICATION: ___ year old woman w/ hx of vWB dx s/p R ankle ORIF today.// acute
desat to 50% and tachycardia. R/o 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 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 3.3 s, 25.4 cm; CTDIvol = 11.5 mGy (Body) DLP = 292.5
mGy-cm.
Total DLP (Body) = 296 mGy-cm.
COMPARISON: None.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. Ductus diverticulum
noted (image 37, series 2) there is no evidence of penetrating atherosclerotic
ulcer or aortic arch atheroma present. 2 vessel arch noted.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There a few nonspecific prominent mediastinal lymph nodes measuring up to 1
cm. No enlarged axillary or hilar lymph nodes are seen. The thyroid gland
appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There are bibasilar consolidations and atelectasis, as well as consolidation
dependently in the right upper lobe. Interlobular septal thickening and
diffuse ground-glass opacities likely represent an element of pulmonary edema.
There is mild centrilobular emphysema. The airways are patent to the
subsegmental level. Lung bases are partly excluded from the examination.
Limited images of the upper abdomen are unremarkable.
No aggressive osseous lesions are demonstrated..
IMPRESSION:
Limited examination due to incomplete visualization of the lung bases:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bibasilar atelectasis and consolidations. Additional consolidation in the
dependent right upper lobe. Findings may be secondary to aspiration.
3. Mild pulmonary edema and few nonspecific prominent mediastinal lymph
nodes.
NOTIFICATION: Final report communicated to ___, M.D. ___
at 09:20.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute hypoxemia requiring transfer to
SICU, s/p diuresis// eval known pulmonary edema eval known pulmonary
edema
IMPRESSION:
In comparison with the study of ___, the patient has taken a slightly
better inspiration. Cardiac silhouette is within upper limits of normal in
size and there has been substantial improvement in the pulmonary vascular
congestion. Mild atelectatic changes are seen at the bases.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 97.6
heartrate: 81.0
resprate: 18.0
o2sat: 95.0
sbp: 127.0
dbp: 58.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right ankle trimalleolar fracture-dislocation and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for right ankle open
reduction internal fixation, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in the right lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ (___) per routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M discharged from the hospital 8 days ago with pneumonia,
returned to the ED today with dyspnea. He had been feeling well
since his discharge until this morning. While walking around the
house he noted a gradual shortness of breath, noting that his
"breath felt shallower." Dyspnea was worst when he arrived at
the ED but resolved with sitting up. No chest pain or any other
constitutional symptoms. No calf pain, abd pain, urinary
symptoms. He notes that he had packaged pasta last night with a
cream sauce and is unsure of the sodium content.
.
In ED VS were 97.8 70 155/71 18 96% on RA. Labs were remarkable
for worsening BNP and a troponin of 0.06. Vitals on transfer
were 97.2, 62SR, 140/56, 19, 100 on 3L. On arrival to the floor,
patient denies dyspnea and is resting comfortably. He has no
complaints.
Past Medical History:
- CABG (LIMA to LAD, SVG to OM)
- dCHF per OMR, last Mibi in ___ with no perfusion defects and
LVEF 68%, baseline weight 120 lbs
- Sleep apnea, on CPAP since ___
- Tracheal bronchomalacia
- Hypertension
- Hyperlipidemia
- Glaucoma
- Carpal tunnel syndrome
- s/p hernia repair
Social History:
___
Family History:
Brother: CAD
Father: CAD
Sisiter: Cancer
Physical Exam:
VS: 97.2, 62SR, 140/56, 19, 100% on 3L
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. JVP elevated to mandible.
CV: RRR, no murmurs, audible S3
LUNGS: clear to auscultation bilaterally
ABD: soft, non-tender, non-distended
EXT: 1+ edema bilaterally
Pertinent Results:
___ 07:35AM BLOOD WBC-8.5 RBC-3.42* Hgb-10.2* Hct-31.6*
MCV-93 MCH-29.8 MCHC-32.3 RDW-14.7 Plt ___
___ 07:35AM BLOOD Glucose-85 UreaN-23* Creat-1.4* Na-142
K-3.8 Cl-108 HCO3-24 AnGap-14
___ 09:20PM BLOOD cTropnT-0.04*
___ 12:04PM BLOOD proBNP-___*
___ CXR:
The patient is status post coronary artery bypass graft surgery.
The heart is mildly enlarged. The aortic arch is calcified. The
mediastinal and hilar contours appear unchanged. Opacities in
the right upper lobe have improved substantially and are mostly
resolved. Patchy right infrahilar and left basilar opacities
appear more chronic and are similar to earlier radiographs from
___. A calcified granuloma in the left lower lobe is
likewise unchanged. There is no definite pleural effusion or
pneumothorax. Minimal anterior wedging of a lower thoracic
vertebral body and mild degenerative changes are similar.
IMPRESSION: Marked improvement and nearly resolved right upper
lobe
pneumonia. Otherwise, stable background findings.
Medications on Admission:
atorvastatin 20 mg Tablet daily
aspirin 81 mg Tablet daily
multivitamin daily
cholecalciferol (vitamin D3) 1,000 unit daily
metoprolol succinate 25 mg daily
spironolactone 25 mg daily
brinzolamide 1 % Drops Ophthalmic BID
azithromycin 250 mg daily for 7 days (finished)
cefpodoxime 100 mg daily for 7 days (finished)
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. brinzolamide 1 % Drops, Suspension Sig: One (1) drops
Ophthalmic twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute exacerbation of chronic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Recent pneumonia with symptoms that of fail to improve.
COMPARISONS: Chest radiographs from ___ and ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The patient is status post coronary artery bypass graft surgery.
The heart is mildly enlarged. The aortic arch is calcified. The mediastinal
and hilar contours appear unchanged. Opacities in the right upper lobe have
improved substantially and are mostly resolved. Patchy right infrahilar and
left basilar opacities appear more chronic and are similar to earlier
radiographs from ___. A calcified granuloma in the left lower lobe is
likewise unchanged. There is no definite pleural effusion or pneumothorax.
Minimal anterior wedging of a lower thoracic vertebral body and mild
degenerative changes are similar.
IMPRESSION: Marked improvement and nearly resolved right upper lobe
pneumonia. Otherwise, stable background findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SHORTNESS OF BREATH
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.8
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 155.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | ___ yo M with dCHF, HTN, HL, s/p CABG, presenting with gradual
dyspnea this morning that has since resolved. He was recently
discharged from the hospital after a pneumonia. Concern in the
ED was for PE and he was given lovenox however his exam is more
consistent with a heart failure exacerbation
.
# Acute exacerbation of diastolic congestive heart failure -
This seems to be the most likely cause of his symptoms given
exam, but was resolved by the time he arrived to the floor. He
was given lasix 10mg IV and diuresed about 500cc. He felt even
more improved in the morning. He did not require oxygen and on
ambulation his O2 sat remained arounf 95%. He was discharged
home and will followup with his cardiologist.
.
# CAD - continued metoprolol, statin, and aspirin
TRANSITIONAL
___ - His last echo was performed in ___. A mibi was last
performed in ___. If this is truly his second episode of heart
failure in 6 months, he may need a repeat echo. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
OxyContin / lactose
Attending: ___.
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with medical history COPD on home O2, CHF with preserved EF
presenting with SOB and cough. He has had 8 days of cough and
SOB. His cough was initially productive of blueish sputum which
progressed to yellow and is now ___. He returned from
___ yesterday and his daughter made him come to the ER. Hx
frequent pneumonias. Most recent admission here in ___ for
CHF/COPD exacerbations. He notes he had a tactile fever in
___ which has resolved. Denies CP. +bilateral leg swelling.
Takes 100mg Lasix a day and has been taking as directed. Pt
supposed to be on home O2 but his machine broke in ___ and
he went 2 weeks without his oxygen but his daughter notes "his
saturations were just fine."
In the ED, patient was deemed to have CHF exacerbation.
Ambulatory sat was down to low ___. He was also noted to have a
history of COPD and thought to have a likely mixed CHF/COPD
exacerbation. He was admitted to cardiology for diuresis and
persistent ambulatory hypoxia with CHF exacerbation.
In the ED, initial vitals: 98.1 81 141/78 20 94% RA.
- Exam notable for: Lungs with significant crackles @ bases, 2+
bilateral pedal edema.
- Labs notable for: wbc 11.3, K 3.2 (repleted in ED), Cr 1,
pro-BNP 161, Trop <0.01, UA negative.
- EKG: sinus at 84, LAD, RSR' with ___lev in V1, V2
similar to prior.
- Imaging notable for: CXR with Mild to moderate interstitial
edema.
- Patient given: lasix 40 IV and Kcl 40 meq.
- Vitals prior to transfer: 97.1 87 145/92 24 94% RA.
On arrival to the floor, pt reports that he has had increased
dyspnea on exertion over the last two weeks. He must also sleep
sitting up and endorses worsening lower extremity edema. He has
not noted any wheezing or cough and feels that his current
presentation is consistent with volume overload. He reports
adherence to daily Lasix, and weighs himself daily. Dry weight
per patient is ___ kg and he is 3kg above that today. He does not
deny dietary indiscretion.
Past Medical History:
- diastolic CHF
- DMII
- HTN
- tobacco abuse
- HLD
- chronic LBP with lumbar spondylosis and stenosis s/p L3-L5
laminectomy and posterior spinal fusion in ___
- nodular goiter
- Stage III COPD on home O2
- peripheral vascular disease s/p endovenous ablation of the
left leg ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 97.8, 144/81, 88, 18, 92% 2L NC weight: 96kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Lungs: fine crackles throughout, no wheezes or decreased breath
sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis, 2+ pitting edema to the
knees with weeping of shins
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
LABS: reviewed in ___, see below
MICROBIOLOGY: attached
EKG: sinus at 84, LAD, RSR' with ___lev in V1, V2
similar to prior
DISCHARGE PHYSICAL EXAM
========================
VS: 98.2 156/86 (100-150s/60-80s) 92 (80-90s) 20 95% 2L
(91-95%)
I/O: 340/825; ___
Wt: 93.7<--95.1
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: Mild bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS
==============
___ 05:10PM WBC-11.3* RBC-5.16 HGB-12.4* HCT-40.7 MCV-79*
MCH-24.0* MCHC-30.5* RDW-15.8* RDWSD-44.9
___ 05:10PM NEUTS-61.0 ___ MONOS-9.9 EOS-4.4
BASOS-1.1* IM ___ AbsNeut-6.87* AbsLymp-2.62 AbsMono-1.12*
AbsEos-0.50 AbsBaso-0.12*
___ 05:10PM GLUCOSE-87 UREA N-13 CREAT-1.0 SODIUM-145
POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-29 ANION GAP-19
___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:10PM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-2.0
___ 05:10PM proBNP-161
___ 05:10PM cTropnT-<0.01
DISCHARGE LABS
===============
___ 06:05AM BLOOD WBC-12.9* RBC-4.92 Hgb-12.5* Hct-39.1*
MCV-80* MCH-25.4* MCHC-32.0 RDW-15.8* RDWSD-44.4 Plt ___
___ 06:05AM BLOOD Glucose-281* UreaN-18 Creat-1.0 Na-136
K-3.9 Cl-96 HCO3-27 AnGap-17
___ 06:05AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
IMAGING
========
CXR ___
FINDINGS:
Diffuse increase in interstitial markings bilaterally is
worrisome for mild to
moderate interstitial edema. Linear right middle lobe
atelectasis/scarring is
seen. There is no pleural effusion or pneumothorax. The
cardiac and
mediastinal silhouettes are grossly stable.
IMPRESSION:
Mild to moderate interstitial edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Humalog 40 Units Breakfast
Humalog 30 Units Lunch
Humalog 30 Units Dinner
NPH 40 Units Breakfast
NPH 70 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Lisinopril 20 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Torsemide 80 mg PO DAILY
6. ALPRAZolam 0.25 mg PO Q4H:PRN anxiety
7. Aspirin 81 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain
- Moderate
11. Potassium Chloride 20 mEq PO DAILY
12. Pravastatin 40 mg PO QPM
13. Pregabalin 100 mg PO BID
14. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
15. Senna 17.2 mg PO BID:PRN constipation
16. Tamsulosin 0.4 mg PO QHS
17. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp
#*60 Tablet Refills:*0
2. Humalog 40 Units Breakfast
Humalog 30 Units Lunch
Humalog 30 Units Dinner
___ U300 80 Units Breakfast
3. Levofloxacin 750 mg PO DAILY Duration: 4 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*4 Tablet Refills:*0
4. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
5. Torsemide 80 mg PO BID
RX *torsemide 20 mg 4 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*0
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
7. ALPRAZolam 0.25 mg PO Q4H:PRN anxiety
8. Aspirin 81 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Lisinopril 20 mg PO DAILY
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Metoprolol Succinate XL 100 mg PO DAILY
14. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
Pain - Moderate
15. Potassium Chloride 20 mEq PO DAILY
Hold for K >
16. Pravastatin 40 mg PO QPM
17. Pregabalin 100 mg PO BID
18. Senna 17.2 mg PO BID:PRN constipation
19. Tamsulosin 0.4 mg PO QHS
20. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute on chronic CHF exacerbation
Secondary: Chronic obstructive pulmonary disease, Diabetes
Mellitus II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with hx CHF, COPD with SOB. // CHF?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Diffuse increase in interstitial markings bilaterally is worrisome for mild to
moderate interstitial edema. Linear right middle lobe atelectasis/scarring is
seen. There is no pleural effusion or pneumothorax. The cardiac and
mediastinal silhouettes are grossly stable.
IMPRESSION:
Mild to moderate interstitial edema.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with fever, chills, ?SOB that is worsening. //
?pneumonia
TECHNIQUE: Chest two views
COMPARISON: ___ 16:31
FINDINGS:
Heart size and pulmonary vascularity have mildly improved since prior. Strand
of retrosternal fibrosis. There is no effusion. No pneumothorax. No
consolidations. Mild interstitial prominence bilateral lungs, may be
inflammatory or infectious.
IMPRESSION:
Mild interstitial prominence bilateral lungs, may be inflammatory or
infectious. No consolidation.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ with HFpEF and COPD on home oxygen presenting with SOB and
weight gain c/f acute on chronic CHF exacerbation and home oxygen
noncompliance, now concerning for sepsis of unknown etiology. // Eval for
sites of infection. Only localizing symptom is back pain.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 8.0 s, 0.5 cm; CTDIvol = 38.5 mGy (Body) DLP =
19.3 mGy-cm.
2) Spiral Acquisition 6.2 s, 67.5 cm; CTDIvol = 16.4 mGy (Body) DLP =
1,108.5 mGy-cm.
Total DLP (Body) = 1,128 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is 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 3 point cm cyst in the midpole of the left kidney. 1.3 and 1.7 cm
cysts are seen projecting from upper pole of left kidney. Additional
subcentimeter hypoattenuating lesions are seen both kidneys, too small to
completely characterize, statistically most likely to represent simple cysts.
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.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: Inguinal lymph nodes measure up to 13 mm on the left 15 mm on the
right. Enlarged external iliac nodes are seen bilaterally. For example:
There is 13 mm left external iliac node seen on image 100 of series 2. 11 mm
right external iliac node is seen on image 99 of series 2.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture,
noting levo scoliotic deformity of the spine, centered around L1-L2. Fixation
hardware is seen extending from L3 to S1. Benign-appearing sclerotic lesion
in the left femoral neck seen on image 117 series 2 most likely represents a
bone infarct.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra- abdominal findings.
2. Enlarged bilateral inguinal internal iliac lymph nodes, of uncertain
clinical significance.
NOTIFICATION: Impression #2, above, was entered by Dr. ___ on
___ at 10:46 into the Department of Radiology critical communications
system for direct communication to the referring provider.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ with HFpEF and COPD on home oxygen presenting with SOB and
weight gain c/f acute on chronic CHF exacerbation and home oxygen
noncompliance, now concerning for sepsis of unknown etiology.// Eval for sites
of infection. Only localizing symptom is back pain.
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, was
reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm
thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning
of the abdomen and pelvis and/or neck will be reported separately. All images
of the chest were reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 8.0 s, 0.5 cm; CTDIvol = 38.5 mGy (Body) DLP =
19.3 mGy-cm.
2) Spiral Acquisition 6.2 s, 67.5 cm; CTDIvol = 16.4 mGy (Body) DLP =
1,108.5 mGy-cm.
Total DLP (Body) = 1,128 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Compared to chest CT scanning since ___, most recently ___.
FINDINGS:
12 mm left supraclavicular lymph node, 04:18, was 10 mm in ___ ; the
growth is probably not clinically significant. Right supraclavicular and
axillary nodes, although numerous in both axillae, are not pathologically
enlarged. Moderate gynecomastia, bulkier on the left has progressively
increased in that asymmetric fashion since ___. It would be difficult
to exclude malignancy without mammography, but there are no findings to
suggest a. elsewhere in the chest wall are no soft tissue abnormalities
concerning for malignancy. Findings below the diaphragm will be reported
separately.
Moderate enlargement of the thyroid gland, left greater than right has
improved slightly since ___. Low-attenuation areas and calcifications
are stable. Thyroid has been most recently evaluated with a radionuclide scan
in ___.
Atherosclerotic calcifications are mild in head neck vessels, distributed
through most coronary artery branches. Aorta and pulmonary arteries are
normal size. There is no pericardial or pleural abnormality.
There are no new or pathologically enlarged central lymph nodes. Numerous
mediastinal lymph nodes are not pathologically enlarged and most are smaller
today than in ___ and a pair of 11 mm right hilar nodes were smaller in
___.
Lungs:
There are no new or growing lung lesions or any lung nodules of sufficient
size to warrant concern for malignancy. 4 mm left lower lobe nodule, 4:91,
for example, has not changed since at least ___.
Emphysema is moderate to severe in the lung apices, milder elsewhere. There
is no pulmonary edema.
Regions of scarring in the middle lobe, lingula, and the right lower lobe are
unchanged since ___ and similar in appearance to ___.
A new crescentic high attenuation lesion in the posterior basal segment of the
left lower lobe, maximum diameter 12 mm, 4:143-150, is probably atelectasis.
Although the configuration is consistent with pulmonary infarction, this study
is sufficient to show that there is no central pulmonary embolus and the
patient has had multiple chest CTA examination is negative for pulmonary
embolus in the past.
There are no bone lesions in the chest cage suspicious for malignancy.
.
IMPRESSION:
No pulmonary edema or other diffuse pulmonary abnormality. Moderate emphysema
is chronic.
Atherosclerotic calcification is moderate in head and neck and coronary
arteries.
No evidence of intrathoracic malignancy. Borderline central
Many mildly or borderline enlarged lymph nodes have been larger in the past.
No new or growing lung lesions. Chronic multifocal subsegmental atelectasis,
new region left lower lobe. Only if there is strong clinical concern for
pulmonary embolus would I consider another chest CTA.
Moderate, chronic goiter, recently larger.
Progressive gynecomastia.
RECOMMENDATION(S): Only if there is strong clinical concern for pulmonary
embolus would I consider another chest CTA.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF now with fever and leukocytosis //
Please assess for pneumonia, worsening pulmonary edema Please assess for
pneumonia, worsening pulmonary edema
IMPRESSION:
In comparison with the study of ___, there are increased streaks of
atelectasis especially at the right base. Only minimal elevation of pulmonary
venous pressure in this patient with enlargement the cardiac silhouette and
some tortuosity of the aorta.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 98.1
heartrate: 81.0
resprate: 20.0
o2sat: 94.0
sbp: 141.0
dbp: 78.0
level of pain: 6
level of acuity: 2.0 | ___ with HRREF and COPD on home oxygen presenting with acute on
chronic CHF exacerbation.
# CHF exacerbation: preserved EF but clinically volume
overloaded on exam. Last TTE ___ with no valvular disease.
Today he endorses DOE, orthopnea and is 3 kg above his dry
weight. He reports adherence to home torsemide but may have
committed dietary indiscretions while abroad. No recent viral
illnesses to contribute to decompensation. Initially on a Lasix
gtt at 5/hr for three days with notably aggressive diuresis at
-2 to -2.5L. Transitioned to 100mg torsemide po (home dose) but
still aggressively diuresis. Pt then transitioned to 80mg
torsemide bid.
-Discharge weight: 93.3kg
-Discharge Cr: 1.3
#fever, leukocytosis, CT opacities: concern for HCAP pneumonia,
however CT read as atelectasis > pneumonia and confirmed with
radiology, unclear infectious source given rapid onset of fever
103 when there was initial plan to discharge day of fever, also
tachycardia HR > 130s, SBPs low to ___, however, lactate
found to be normal. C diff wnl, UA unrevealing. Pt noted that on
history he had pneumonias in the past and every year in
___, had episodes of rigoring, coughing and that this
episode was not new. Ntoably, pt says he has been on levaquin
with relief in the past for pneumonias. On this episode, he had
similar symptoms of rigoring even up to the day of his discharge
but fevers have been resolved (afebrile x 72 hours),
leukocytosis mostly resolved (~13 at time of discharge with zero
bands) and mostly asymptomatic. Pt initila on vanc/zosyn and
then narrowed to levaquin (___nd ___, patient
given Rx for this), No growth on BCx/sputum Cx/UCx.
# T2DM:
Holding home metformin, Continued on ISS with humalog and
standing glargine while in house, however, difficult to control
sugars and ___ was consulted. At discharge, diabetes
management was as follows: tuoseo 300u 80u qam, Humalog 40u
qbreakfast, 30u qlunch, 30u qdinner.
While hospitalized, notably lantus increased to 40 --> 50 --> 60
--> 70 bid in setting of infection. Pt notes that with prior
pneumonias, has had very elevated sugars and expects this to
resolve given that his sugars are resolving. pt with very close
follow-up ___ with ___ to manage diabetes but
___ recommended discharging on original home regimen of
insulin.
# COPD: no evidence of exacerbation at this time, on baseline
home oxygen requirement. Pt with ambulatory sats down to 83-85%
without oxygen. Continued on home advair, tiotropium and
albuterol with duonebs while in house prn. Patient will continue
home O2 at 2L with goals between 88-92%. Pt aware that he needs
to continue oxygen, given that he was off of oxygen while abroad
and notably feeling weak. Pt irritated by nasal dryness and thus
given nasal spray with minimal relief and sneezing. Pt said he
has something OTC at home that will help with this.
# HTN:
Continued on home lisinopril, metoprolol
# CAD:
Continued on home ___, metoprolol and pravastatin
# Anxiety:
Continued on home PRN alprazolam
# PAIN:
Continued on home gabapentin, Percocet. Required ocassiaonl
oxycodone 5mg x 1 in addition to Percocet and not worsened at
time of discharge.
# BPH:
Continued on home flomax
CORE MEASURES |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS, hypoxia, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old ___ woman with PMH
notable for mild aortic stenosis and aortic regurgitation s/p
cardiac pacemaker, NIDDM, anemia, mild reactive airway disease,
HTN, and paroxysmal atrial fibrillation presenting from home
rehab facility with altered mental status, cough, and hypoxia.
Daughter was present at bedside for translation. At baseline
patient lives in long term facility, speaks ___ only, and
has dementia. She reports that patient was in usual state of
health until 4 days prior to admission when patient was noted to
be more lethargic with decreased appetite. She developed a cough
and watery discharge from her eyes 2 days ago and was evaluated
by physicians at the facility and noted on CXR to have RLL
pneumonia (confirmed with nursing staff) but was given
supplemental oxygen but not started on antibiotics. She was
prescribed erythromycin ointment for the eyes. Daughter reported
one fever yesterday and denies nausea, vomiting, diarrhea, chest
pain.
In the ED, initial vitals: 97.9 87 178/88 30 SaO2 95% on RA
- Labs notable for: WBC 18.0 with 94.5% neutrophils, lactate
2.5, UA with many bacteria, BUN/Cr 60/1.4
- Imaging notable for: prelim read of CXR new mild-moderate
pulmonary edema. EKG NSR with PACs
- Pt given: vancomycin 1000mg IV, methylprednisolone 125mg IV,
albuterol/ipratroprium nebs, and levofloxacin 750mg IV
- Vitals prior to transfer: 97.9 86 170/79 22 95% NC
On arrival to the floor, pt complaining of thirst and has
productive cough.
ROS:
No chills, night sweats, or weight changes. No changes in vision
or hearing, no changes in balance. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
Hypertension
Type 2 Diabetes
Hyperlipidemia
Colon cancer
Valvular heart disease
Anemia
Falls
Atrophic vaginitis
Paroxysmal atrial fibrillation
Pacemaker
Social History:
___
Family History:
There was a lung cancer in her mother as well as
heart disease. Family history is otherwise unavailable or
non-contributory.
Physical Exam:
ADMISSION EXAM
==============
Vitals- 97.4 168/68 80 18 99% on 3L
General- Alert, sleeping but rousable, no acute distress
HEENT- Sclerae anicteric, MM dry, oropharynx clear, edentulous,
crusting around both eyes R>L
Neck- supple, JVP not elevated but limited exam, no LAD
Lungs- CTAB no wheezes, rales, rhonchi, some crackles in
bibasilar bases but limited exam
CV- RRR, Nl S1, S2, II/VI systolic murmur loudest at axilla
Abdomen- obese, soft, NT/ND bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU- +foley
Ext- warm, well perfused, 2+ pulses, no clubbing, 1+ pitting
edema to ankles
Neuro- CNs ___ intact, motor function grossly normal
DISCHARGE EXAM
==============
Vitals- 98.5 157/80 98 20 93%2L
General- Alert, sleeping but rousable, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear, edentulous
Neck- supple, JVP not elevated but limited exam, no LAD
Lungs- CTAB no wheezes, rales, rhonchi, some crackles in
bibasilar bases but limited exam, less breath sounds R > L
CV- RRR, Nl S1, S2, II/VI systolic murmur loudest at axilla
Abdomen- obese, soft, NT/ND bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, 1+ pitting
edema to ankles
Neuro- CNs ___ intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
==============
___ 02:52PM BLOOD WBC-18.0*# RBC-4.04* Hgb-12.2 Hct-37.1
MCV-92 MCH-30.1 MCHC-32.8 RDW-16.6* Plt ___
___ 02:52PM BLOOD Neuts-94.5* Lymphs-2.8* Monos-2.0 Eos-0.4
Baso-0.2
___ 02:52PM BLOOD Plt ___
___ 02:52PM BLOOD ___ PTT-31.0 ___
___ 05:05PM BLOOD Glucose-531* UreaN-60* Creat-1.4* Na-134
K-5.5* Cl-99 HCO3-26 AnGap-15
___ 05:05PM BLOOD ___
___ 03:02PM BLOOD Lactate-2.5*
DISCHARGE LABS
==============
___ 07:40AM BLOOD WBC-13.7* RBC-4.45 Hgb-13.2 Hct-40.4
MCV-91 MCH-29.6 MCHC-32.7 RDW-15.2 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-205* UreaN-38* Creat-0.9 Na-142
K-4.1 Cl-96 HCO3-34* AnGap-16
___ 07:40AM BLOOD Calcium-9.5 Phos-2.2* Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 200 mg PO BID chronic pain
2. Atenolol 25 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
9. Amlodipine 5 mg PO HS
Discharge Medications:
1. Amlodipine 5 mg PO HS
2. Cyanocobalamin 500 mcg PO DAILY
3. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Acetaminophen 650 mg PO Q8H:PRN pain
9. Levofloxacin 500 mg PO Q24H HCAP Duration: 3 Days
Please take one pill daily, the last pill on ___.
10. Metoprolol Tartrate 12.5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
-Health care associated pneumonia
-Decompensated congestive heart failure
Secondary diagnosis:
-Acute kidney injury
-Hypoxia
-Type II diabetes
-Hypertension
-Anemia
-Hyperlipidemia
-Valvular 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 (PORTABLE AP)
INDICATION: ___ with dyspnea // evidence of pnumonia or effusion
COMPARISON: Chest radiograph from ___
FINDINGS:
AP view of the chest provided.
Bilateral mild-moderate pulmonary edema is new since prior study from ___. There is associated increased in width of vascular pedicle. Cardiac
size may be slightly larger. Obscuration of the left hemidiaphgram likely
reflects atelectasis and probably small amount of overlying pleural effusion.
Pacemaker wire is in unchanged location.
IMPRESSION:
New mild-moderate pulmonary edema. Follow-up with conventional radiograph is
recommended.
Radiology Report
INDICATION: Evaluate for interval change/resolution of pneumonia versus CHF,
in a patient with altered mental status, cough, hypoxia, and leukocytosis.
COMPARISON: Chest radiographs from ___, and ___.
FINDINGS:
A portable frontal chest radiograph again demonstrates a left chest wall pacer
device with the single lead overlying the right ventricle, unchanged in
position. Moderate cardiomegaly is unchanged, as is retrocardiac opacity
which is likely related to atelectasis and possible small left pleural
effusion. No definite focal consolidation is identified. Moderate pulmonary
edema is persistent, but improved compared to the prior radiograph. There is
no pneumothorax.
IMPRESSION:
Persistent but mildly improved moderate pulmonary edema.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Cough, Altered mental status
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOXEMIA, DEHYDRATION, ALTERED MENTAL STATUS
temperature: 97.9
heartrate: 87.0
resprate: 30.0
o2sat: 95.0
sbp: 178.0
dbp: 88.0
level of pain: 13
level of acuity: 2.0 | Ms. ___ is a ___ year old ___ woman with PMH
notable for valvular disease, s/p cardiac pacemaker, NIDDM,
anemia, HTN, and paroxysmal afib presenting from home rehab
facility with AMS, cough, and hypoxia most likely due to health
care associated pneumonia and decompensated CHF.
# AMS, cough, hypoxia: She had an elevated WBC and report of CXR
at rehab showing pneumonia so she was started on levofloxacin
750mg q48h (renally dosed) from ___ then switched to
levofloxacin 500mg qd ___ with resolving acute kidney
injury. She was given one dose of vancomycin in the ED, which
was discontinued on floor and supplemental oxygen and
albuterol/ipratropium nebulizers for symptomatic relief. She was
successfully weaned from 3L to 2L. Her hypoxia could also be due
to fluid overload, with CXR showing signs of new pulmonary edema
and BNP elevated to 39,322. She was diuresed with toresemide
10mg one time with good urine output. Repeat CXR showed improved
pulmonary edema.
# ___: On admission, creatinine was elevated to 1.4 from
baseline around 1.0 most likely due to hypoperfusion in setting
of illness and poor PO intake. It improved with 500cc bolus of
fluids.
# Hyperkalemia: On admission, potassium was up to 5.5 at
admission most likely due to ___. Patient was asymptomatic with
no changes on EKG. It resolved with decreasing creatinine.
# ?UTI: UA with many bacteria and some WBC concerning for UTI.
Urine culture was pending at discharge. Possible UTI should be
covered by levofloxacin for HCAP. Please follow up final urine
culture and ensure that any UTI is adequately treated.
# NIDDM not on any medications: On admission, blood glucose
elevated to 531, likely in setting of infection. She was placed
on regular insulin sliding scale with good glucose control.
# Anemia: Stable at baseline. She was continued on home vitamin
B12, iron, and folate supplements.
# HTN: Persistently elevated in 160s-180s with no signs of end
organ damage. Home atenolol was held in setting ___ and she
was started on metoprolol 12.5 mg twice a day. She was continued
on home amlodipine. Due to age, no additional antihypertensives
were given.
# Paroxysmal afib: Not currently anticoagulated. Rate control
improved with metoprolol 12.5mg twice a day. Home atenolol
stopped due to ___ as above.
# Other: Patient was continued on home pureed diet (confirmed
with rehab).
TRANSITIONAL ISSUES
===================
[] Please follow up on urine culture and if positive, broaden
antibiotic coverage.
[] Patient had significant pulmonary edema on admission. It may
be helpful to weigh Ms. ___ every few days and to give
occasional doses of lasix to help remove excess fluid if needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / codeine
Attending: ___.
Chief Complaint:
Abdominal distention
Major Surgical or Invasive Procedure:
None on this admission
History of Present Illness:
___ s/p ex-lap/lysis of adhesions for SBO on ___ by Dr. ___,
___ w increasing abdominal distension/decrease in bowel
function with abdominal x-ray concerning for small bowel
obstruction. Patient reports she has had persistent left-sided
abdominal pain since the surgery which has not improved, and has
had minimal appetite. She noticed increasing abdominal
distension overnight and felt nauseous this morning (but no
vomiting), prompting her to come to the ED for further
evaluation. Last passed flatus yesterday afternoon, although did
have a small semi-formed bowel movement this morning. Denies
fever, chills, bloody stools, or dysuria.
Past Medical History:
PHM: Celiac, Hemorrhoids, constipation
PSH: Intussuception repair at 5 mos, exlap/LOA (___) for SBO;
Hemorrhoidectomy x3
Social History:
___
Family History:
Uncle with colon cancer. Father has had a " bowel obstruction".
Physical Exam:
Physical exam on admission
Physical Exam:
Vitals: T 98.2 HR 80 BP 132/74 RR 16 O2sat 98RA
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, minimally distended; mildly tender to palpation in
epigastrium and LUQ, no rebound/guarding
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Physical exam on discharge (changes only):
VS: 98.9, 70, 130/85, 18, 100%RA
Abd exam: small slightly right of midline vertical incision
healing & covered with steri-strips; abd soft, nondistended;
minimal tenderness to plapation in epigastrium, no
rebound/guarding
Medications on Admission:
VitaminD, MVI, Prilosec 20 mg qd
Discharge Medications:
1. Amitriptyline 10 mg PO HS abdominal visceral hypersensitivity
RX *amitriptyline 10 mg 1 tablet(s) by mouth ___ day Disp #*30
Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
Please don't take the Prilosec you were previously taking; this
is the same type of medication
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
3. Vitamin D 0 UNIT PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with nausea, vomiting and abdominal distention
after recent abdominal surgery.
COMPARISON: ___.
TECHNIQUE: Frontal, supine and upright abdominal radiograph.
FINDINGS: There is diffuse small bowel dilatation with the paucity of bowel
gas in the colon and pelvis, with associated air-fluid levels throughout the
abdomen. No abdominal free air is identified. No abnormal calcification is
present. The visualized lung bases are clear.
IMPRESSION: Findings compatible with small-bowel obstruction.
Radiology Report
HISTORY: Status post exploratory laparotomy and on ___ for small bowel
obstruction
COMPARISON: Abdominal radiographs on ___ and ___
FINDINGS:
There are multiple air-fluid levels seen within the small bowel. There is
very little air in the large bowel, with the exception of a small amount of
air in the rectum. The abdomen appears more hazy than on previous exam.
There is bulging of the flanks, which may represent increasing ascites. The
bowel gas pattern is nonspecific, with no evidence of improvement compared to
prior study.
Bony structures are unremarkable.
IMPRESSION:
1. Increased abdominal haziness, which may represent increasing ascites since
prior exam.
2. Bowel gas pattern is relatively nonspecific, and unchanged from previous
examination. Small-bowel obstruction cannot be excluded.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HERE FOR BLOODWORK
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.2
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 74.0
level of pain: 3
level of acuity: 3.0 | After presentation to the ER, patient was made NPO and started
on IVF. NGT was placed in ER. Patient was admitted to colorectal
surgery. The next day, she was passing gas so the NGT was
clamped, then removed. She tolerated this well. She had a slight
headache that resolved and some chest pain. An EKG was stable
and she was given protonix, which helped. She was ambulating,
passing gas, and had a bowel movement. Her diet was advanced to
sips. In addition, she was started on amytriptyline 10 mg for
her chronic abdominal pain. A nutrition consult was ordered for
her celiac disease for advice on eating habits. On ___, she was
advanced to clear liquids plus boost, which she tolerated well.
A follow up with her GI physician, ___, was recommended.
She continued to pass gas and deny N/V and so she was discharged
home, doing well. KUB showed a few air-fluid levels. She was
advised to advance her diet from clears with Boost as tolerated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Penicillins / morphine / Erythromycin Base /
aspirin / IV Dye, Iodine Containing Contrast Media / Reglan
Attending: ___
Chief Complaint:
Impending DKA, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a past medical history
significant for ___ syndrome (albinism, platelet
storage disorder), uncontrolled IDDM s/p pancreatectomy, islet
cell transplant (___), asthma, severe gastroparesis, bezoars
and multiple abdominal surgeries presenting with ___ weeks of
hyperglycemia ___ 300-400), polyuria, poldipsia, abdominal pain,
nausea and vomiting. She has unintentionally lost 15 lbs in the
past several weeks. The patient states that her hyperglycemia
has been worsening for the past couple years. Over the past few
months though, it seems to have been very
uncontrolled. Her most recent fingsticks have been in the
300-400 range; and as high as 600. During this time she has
experienced intermittent diarrhea. She has been using 15 units
of insulin glargine daily, and a Humalog sliding scale without
success. She was sent in from ___ for impending DKA. She was
found to have large ketones on UA and 456 BSG. She denies
fevers, chills, chest pain, shortness of breath, or cough. She
does have abdominal pain but this is somewhat chronic in nature.
Her abdominal pain is mostly epigastric, intermittently severe
and non-radiating. The pain feels like a distension or pressure.
She attributes her abdominal pain to gastroparesis, but
unfortunately has not tolerated erythromycin or metoclopramide.
She has no known history of heart failure.
In the ED, initial VS were: 98.6 90 123/74 16 100%. The
following interventions/therapies were performed: 3L normal
saline, 2 mg IV Zofran and 5 units regular insulin.
On arrival to the floor, the patient complains of chronic
abdominal pain and the inability to control her blood sugar.
Past Medical History:
___ Syndrome with associated blindness
IDDM uncontrolled s/p pancreatectomy
Asthma
Gastroparesis
Bezoars
Numerous abdominal surgeries
Depression
Anxiety
Seasonal allergies
Constipation
Eczema
Lactase insufficiency
Irritable bowel syndrome
PSH:
Appendectomy
Cholecystectomy
___ fundoplication
Islet cell transplant
Hernia repairs
Hysterectomy
Oopherectomy
Jaw surgery for DMJ
Splenectomy
Pancreatectomy (for pancreatic divisum)
Celiac plexus neurolysis
Social History:
___
Family History:
Sister with ___ syndrome. Multiple family members
with T2DM and thyroid disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.1 122/80 80 18 99/RA
GEN: Well-appearing, resting in bed.
HEENT: NCAT, MMM
NECK: Supple.
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB, no c/w/r
___: +NABS in 4Q, soft, mild epigastric tenderness to
palpation, ND
EXT: WWP, no c/c/e.
NEURO: MAEE
DISCHARGE PHYSICAL EXAM:
97.9 127/69 75 18 97% RA ___ 78-150s
GEN: Awake/alert Ox3. Albino. Well-appearing, resting in bed. No
rhythmic movements.
HEENT: PERRL, EOMI, NCAT, MMM
NECK: Supple, no lymphadenopathy
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB, no c/w/r
___: +NABS in 4Q, soft, moderate epigastric/right sided
tenderness, ND, surgical scars noted
EXT: WWP, no c/c/e.
NEURO: CN II-XII grossly intact, ___ upper extremity and lower
extremity strength bilaterally, cerebellar exam within normal
limits, symmetric DTRs
Pertinent Results:
ADMISSION LABS:
___ 04:45PM BLOOD WBC-9.3 RBC-4.02*# Hgb-11.8* Hct-38.0
MCV-95# MCH-29.4# MCHC-31.1 RDW-16.1* Plt ___
___ 04:45PM BLOOD Neuts-50 Bands-0 Lymphs-43* Monos-6 Eos-1
Baso-0 ___ Myelos-0
___ 04:45PM BLOOD Glucose-370* UreaN-14 Creat-0.8 Na-133
K-4.1 Cl-95* HCO3-18* AnGap-24*
___ 04:45PM BLOOD Calcium-9.2 Phos-4.2 Mg-1.5*
___ 06:43AM BLOOD %HbA1c-14.7* eAG-375*
___ 05:00PM BLOOD Glucose-356* Lactate-1.2 Na-134 K-3.7
Cl-102 calHCO3-17*
___ 01:52AM BLOOD ALT-67* AST-36 AlkPhos-78 TotBili-0.2
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-8.0 RBC-3.65* Hgb-11.0* Hct-34.8*
MCV-96 MCH-30.1 MCHC-31.6 RDW-16.7* Plt ___
___ 06:30AM BLOOD Glucose-52* UreaN-13 Creat-0.5 Na-139
K-4.4 Cl-103 HCO3-32 AnGap-8
___ 06:30AM BLOOD Calcium-9.0 Phos-4.6* Mg-1.7
CXR
___
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. Lungs
are clear and the pulmonary vascularity is normal. No pleural
effusion or pneumothorax is present. Multiple clips in the
right upper quadrant of the abdomen indicate prior
cholecystectomy. There are no acute osseous abnormalities.
IMPRESSION: No acute cardiopulmonary process.
XR ABD
___
IMPRESSION: Upright and supine views of the abdomen show
stomach distended with food and colon distended with stool, and
no appreciable small bowel dilatation. There is no free
intraperitoneal gas and no evidence of ascites. Vascular clips
denote prior right upper quadrant and paramedian surgery.
Radiopaque pills are present in either the small bowel or a very
distended stomach.
CT HEAD
___
FINDINGS: There is no hemorrhage, edema, mass, mass effect, or
evidence of infarction. The ventricles and sulci are normal in
size and configuration. The basal cisterns are patent and
gray-white matter differentiation is preserved. The calvaria
are unremarkable. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. IMPRESSION: No acute
intracranial abnormality.
NOTE ADDED IN ATTENDING REVIEW: There is moderate mucosal
thickening with likely mucus-retention cyst formation involving
the limited included superior portion of the maxillary sinuses,
as well as scattered anterior and posterior ethmoidal air cells,
bilaterally. There may have been prior partial ethmoidectomy and
uncinectomy, incompletely demonstrated. The frontal and sphenoid
air cells are clear. These findings should be correlated with
detailed history.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
2. Creon 12 3 CAP PO TID W/MEALS
3. Doxepin HCl 100 mg PO HS
4. Escitalopram Oxalate 30 mg PO DAILY
5. Estrogens Conjugated 0.625 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 100 mg PO TID
8. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Lorazepam 0.5 mg PO TID PRN anxiety
10. omeprazole *NF* 10 mg Oral QD
11. Bisacodyl ___AILY
12. Lubiprostone 24 mcg PO BID
13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 2 TAB PO BID
Discharge Medications:
1. Bisacodyl ___AILY
RX *bisacodyl 10 mg 1 Suppository(s) rectally daily Disp #*30
Suppository Refills:*0
2. Creon 12 3 CAP PO TID W/MEALS
3. Docusate Sodium 100 mg PO BID
4. Doxepin HCl 100 mg PO HS
5. Escitalopram Oxalate 30 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Gabapentin 200 mg PO Q8H
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*0
8. Lubiprostone 24 mcg PO BID
RX *lubiprostone [___] 24 mcg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
10. Estrogens Conjugated 0.625 mg PO DAILY
11. Lorazepam 0.5 mg PO TID PRN anxiety
12. Omeprazole *NF* 10 mg ORAL QD
13. Glargine 14 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Q6H:PRN Disp #*20 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 2 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
diabetic ketoacidosis
Secomdary diagnoses:
DM type I uncontrolled with complications
Gastroparesis
Constipation
___ Syndrome
pseudoseizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Diabetic ketoacidosis.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. Lungs are clear and
the pulmonary vascularity is normal. No pleural effusion or pneumothorax is
present. Multiple clips in the right upper quadrant of the abdomen indicate
prior cholecystectomy. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
ABDOMEN, 3:42 P.M., ___
HISTORY: ___ woman with abdominal pain after multiple abdominal
surgeries.
IMPRESSION: Upright and supine views of the abdomen show stomach distended
with food and colon distended with stool, and no appreciable small bowel
dilatation. There is no free intraperitoneal gas and no evidence of ascites.
Vascular clips denote prior right upper quadrant and paramedian surgery.
Radiopaque pills are present in either the small bowel or a very distended
stomach.
Radiology Report
INDICATION: New onset seizure. Evaluation for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, thin-section bone reconstruction algorithm
images were acquired. Repeat images were acquired from the skull base due to
beam hardening artifact.
COMPARISON: None.
FINDINGS: There is no hemorrhage, edema, mass, mass effect, or evidence of
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent and gray-white matter differentiation is
preserved. The calvaria are unremarkable. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality.
NOTE ADDED IN ATTENDING REVIEW: There is moderate mucosal thickening with
likely mucus-retention cyst formation involving the limited included superior
portion of the maxillary sinuses, as well as scattered anterior and posterior
ethmoidal air cells, bilaterally. There may have been prior partial
ethmoidectomy and uncinectomy, incompletely demonstrated. The frontal and
sphenoid air cells are clear. These findings should be correlated with
detailed history.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPERGLYCEMIA
Diagnosed with IDDM, UNCONTROLLED
temperature: 98.6
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 123.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with a past medical history significant for
___ syndrome (albinism, platelet storage disorder),
uncontrolled IDDM s/p pancreatectomy, islet cell transplant
(___), asthma, severe gastroparesis, bezoars and multiple
abdominal surgeries presenting with ___ weeks of hyperglycemia
___ 300-400), polyuria, polydipsia, abdominal pain, nausea and
vomiting.
# RHYTHMIC MOVEMENTS
Episodes of rhythmic upper and lower extremity movements were
witnessed several times during the patient's hospitalization.
The movements occurred during a semi-conscious state in which
the patient was able to willfully close her eyes and answer
selective questions. IV Ativan was administered during several
of the events but did not result in cessation of the activity.
The neurology consult team witnessed several of the events and
determined the movements were not consistent with seizures due
to her purposeful activities, normal O2 saturations, lack of
tongue biting and absence of incontinence or post-ictal state. A
CT Head was performed which revealed no acute pathology
accounting for the seizure like activity. The patient's blood
glucose levels were occasionally, but not consistently low
during the episodes ranging from 72-130.
# UNCONTROLLED IDDM/IMPENDING DKA
Ms. ___ presented with weeks to months of finger sticks
ranging from 300-600 associated with polyuria and weight loss.
Unclear precipitant, however the patient did receive an islet
cell transplant in ___ which appears to have failed. No acute
infectious process was discovered during her hospitalization.
The infectious workup included CXR, UA, urine culture and blood
culture. Ketones and glucosuria were discovered on her initial
UA. Presenting glucose was 458 with an AG of 20. A1C: 14.7. Her
admission insulin regimen included 15U Lantus QAM and Humalog
sliding scale. Her anion gap closed with only 5 units in the ED.
She was placed on BID Lantus and a more aggressive sliding
scale. Initially glucose was checked q2 hours and chem7 q4
hours. IV fluids were continued and potassium was supplemented
as necessary. During the later half of her hospitalization she
experienced morning, fasting glucose levels between 50-70. Her
Lantus dosing and sliding scale were adjusted accordingly. She
was discharged on Lantus 14U QAM and 10U QPM. She was instructed
to call the ___ main number if she has difficulty controlling
her glucose levels including ___ <70 or >300.
# ABDOMINAL PAIN:
Ms. ___ suffers from gastroparesis and chronic abdominal
pain. She has a known gastric bezoar and diffuse fecal loading.
She complained of intermittent nausea, but no vomiting. She
denied diarrhea, melena and hematochezia. Her LFTs and lipase
were within normal limits. H. pylori was negative. KUB with
stomach distended w/ food and colon distended w/ stool. Per the
patient her symptoms and findings are all chronic in nature.
There was no apparent worsening of her symptoms during this
hospitalization. She reliably states that her pain feels like
distension and pressure and occurs most frequently after meals.
Her chronic constipation appears to be the result of diffuse
intestinal slowing, potentially a result of a autonomic
neuropathy. She takes intermittent opioids for the pain and is
on a fairly robust bowel regimen including Senna, Colace,
Miralax and Amitiza. Unfortunately there is no great solution to
her gastroparesis as she has been intolerant to metoclopramide
and erythromycin. She could not afford domperidone which her
gastroenterologist at ___ recommended. Ms. ___ had regular
bowel movement during her hospitalization. She was given
intermittent PO Dilaudid for what she described as severe
abdominal pain. Her dosing of gabapentin was increased to 200mg
TID. She was discharged with appropriate GI follow up (Dr.
___.
# ___ SYNDROME: Responsible for the patient's
albinism and blindness. Platelets within normal limits this
admission. No mucosal bleeding or ecchymoses.
# PANCREATIC INSUFFICIENCY
Pancrelipase continued.
# DEPRESSION:
Escitalopram continued.
TRANSITIONAL ISSUES
*******************
-blood cultures pending at discharge negative
-___, PCP and GI follow up
-patient to contact ___ main number if difficulty controlling
blood sugars |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Colchicine
Attending: ___.
Chief Complaint:
Back pain, s/p fall
Major Surgical or Invasive Procedure:
None
Past Medical History:
1. Coronary artery disease status post stenting of the right
coronary artery, ___, with a 2.0 x 18 Vision bare
metal stent. His risk factors are under good control. Off
Plavix.
2. Prior history of low ejection fraction, now resolved - EF
70%.
3. Hypertension.
4. Atrial fibrillation (not on warfarin due to fall hx).
Other History
5. Gout
6. Inclusion body myositis diagnosed ___, patient currently
on steroids and methotrexate with recent dose changes
7. Benign prostatic hypertrophy s/p TURP
8. CVA ___ with no sequela or neuro deficits
9. Pre Diabetes mellitus - Not on Meds
10. Obesity
11. Fatty liver
12. Positive PPD in the past
13. Restrictive pattern on PFTs (likely ___ to myositis)
Social History:
___
Family History:
His mother died at ___, cause is not known. Father died at ___ of
lung cancer and jaw cancer. He has a sister and a brother with
thyroid problems. Three daughters with thyroid problems. A son
who died a year ago at the age of ___ after a hypertensive stroke
in his brain.
Physical Exam:
INITIAL PHYSICAL EXAM
=======================
97.3 ___ 20 96RA (of note patient did not take any of
his medicines today)
GEN: NAD, AOx3
CV: Irregularly irregular, No MRG, No peripheral edema
RESP: Poor air movement bilaterally, no crackles
MSK: ___ flexor strength in UE bilaterally. Poorer ___ grip
strength in fingers bilaterally. Hip flexors 4+/5. Dorsiflexion
and Plantarflexion intact. L ___ finger missing from childhood
accident, no obvious atrophy in upper extremities
ABD: Distended, soft, NT, Hypoactive BS
DISCHARGE PHYSICAL EXAM
=======================
T 97.8 BP ___ P ___ R 22 O2Sat 99% on 2 L
GEN: NAD, AOx3
HEENT: EOMI, NC/AT, sclera anicteric
CV: RRR, No MRG, No peripheral edema
RESP: Clear to ausculation anteriorly and posteriorly
ABD: Soft. NT. ND, bowel sounds present
Extremities: warm and well perfused, no clubbing, cyanosis, or
edema
Neuro: MAE, answers questions appropriately
Psych: appropriate mood and affect
Pertinent Results:
INITIAL LAB RESULTS
======================
___ 04:18PM BLOOD WBC-8.7 RBC-4.40* Hgb-13.9* Hct-43.7
MCV-99* MCH-31.6 MCHC-31.9 RDW-15.1 Plt ___
___ 04:18PM BLOOD Glucose-208* UreaN-23* Creat-0.9 Na-143
K-4.0 Cl-96 HCO3-40* AnGap-11
___ 04:18PM BLOOD ALT-82* AST-41* CK(CPK)-32* AlkPhos-44
TotBili-0.7
___ 04:18PM BLOOD Lipase-52
___ 04:18PM BLOOD CK-MB-4
___ 04:18PM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.4 Mg-2.2
___ 04:18PM BLOOD TSH-0.69
___ 04:18PM BLOOD Digoxin-2.2*
___ 04:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
___ 04:40PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 04:40PM URINE CastHy-10*
___ 04:40PM URINE Color-Yellow Appear-Clear Sp ___
IMAGING
========
___ CT A/P
IMPRESSION:
1. No evidence of obstruction.
2. L3 compression deformity of the superior endplate with
approximately 20% height loss with mild prevertebral soft tissue
stranding. No evidence of retropulsion.
___ CXR
IMPRESSION:
No focal consolidation. Bibasilar atelectasis. Trace pleural
effusions would be difficult to exclude, although no large
pleural effusion is seen.
DISCHARGE LAB RESULTS
======================
___ 07:00AM BLOOD WBC-7.7 RBC-4.21* Hgb-13.6* Hct-42.0
MCV-100* MCH-32.2* MCHC-32.3 RDW-15.1 Plt ___
___ 07:00AM BLOOD Glucose-73 UreaN-22* Creat-1.0 Na-145
K-3.9 Cl-100 HCO3-39* AnGap-10
___ 07:00AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Digoxin 0.25 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 80 mg PO DAILY
5. Detemir 36 Units Breakfast
Humalog 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Methotrexate 12.5 mg SC 1X/WEEK (WE)
7. Metoprolol Tartrate 100 mg PO HS
8. Nitroglycerin SL 0.4 mg SL PRN cp
9. Omeprazole 40 mg PO DAILY
10. PredniSONE 30 mg PO DAILY
11. Simvastatin 10 mg PO HS
12. Terazosin 5 mg PO HS
13. Aspirin 325 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Fish Oil (Omega 3) 1200 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Metoprolol Tartrate 50 mg PO QAM
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Digoxin 0.25 mg PO DAILY
4. Fish Oil (Omega 3) 1200 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 80 mg PO DAILY
7. Methotrexate 12.5 mg SC 1X/WEEK (WE)
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN cp
10. Omeprazole 40 mg PO DAILY
11. PredniSONE 30 mg PO DAILY
12. Simvastatin 10 mg PO HS
13. Terazosin 5 mg PO HS
14. Vitamin D 1000 UNIT PO DAILY
15. Senna 8.6 mg PO BID
16. Polyethylene Glycol 17 g PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Bisacodyl 10 mg PO DAILY
19. TraMADOL (Ultram) 50 mg PO Q4H:PRN back pain
20. Acetaminophen 650 mg PO Q8H
21. Detemir 36 Units Breakfast
Humalog 18 Units Dinner
22. Metoprolol Tartrate 50 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. L3 compression fracture
2. Inclusion Body Myositis
3. Failure to Thrive
SECONDARY DIAGNOSIS
1. Coronary Artery Disease
2. Atrial Fibrillation
3. Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Back pain status post fall.
TECHNIQUE: Single AP supine portable view of the chest.
COMPARISON: ___.
FINDINGS:
There are areas of bibasilar atelectasis without definite focal consolidation.
No large pleural effusion is seen although trace pleural effusions would be
difficult to exclude. The cardiac silhouette is top-normal to mildly
enlarged. The aorta is calcified. No pulmonary edema is seen. No obvious
displaced fracture is seen. Degenerative changes at the acromioclavicular
joints.
IMPRESSION:
No focal consolidation. Bibasilar atelectasis. Trace pleural effusions would
be difficult to exclude, although no large pleural effusion is seen.
Radiology Report
HISTORY: History of inclusion body myositis on chronic steroids with severe
constipation and lower back pain. Status post fall at home for 10 days.
Evaluate for fracture or obstruction.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis following the administration of 150 cc of Omnipaque intravenous
contrast material. Reformatted coronal and sagittal axis images were
obtained.
COMPARISON: CT from ___ and ___.
FINDINGS: The visualized lungs are clear of any focal opacities, pleural
effusions or pneumothorax. Coronary calcifications are identified, and no
pericardial effusion is seen.
CT ABDOMEN: Hypoattenuation of the liver is consistent with fatty deposition.
A 2.0 x 2.2 cm cyst is noted in the left hepatic lobe (2:11). The intrahepatic
veins and portal veins appear patent. The gallbladder is nondistended without
any radiopaque gallstones. The spleen is normal in size and shape. The
pancreas enhances homogeneously without any ductal dilation or focal
pancreatic lesions.
The adrenal glands are normal in size and shape bilaterally. The kidneys are
normal in size and shape bilaterally. Appropriate contrast excretion is seen,
and the kidneys enhance symmetrically. There is no evidence of
hydronephrosis.
The stomach is decompressed and not well evaluated. The small bowel does not
have any wall thickening or evidence of obstruction. The appendix is not well
visualized, but there are no secondary findings to suggest appendicitis. The
large bowel contains stool without evidence of wall thickening or obstruction.
There is no intra-abdominal free air or free fluid.
CT PELVIS: The bladder is mildly distended and appears unremarkable. The
prostate gland appears normal. A large amount of fecal load is seen within
the rectum. There is no pelvic free fluid. There are no pelvic sidewall or
inguinal lymph node enlargement by CT size criteria.
The abdominal aorta has extensive atherosclerotic disease with ectasia noted.
The aorta and its major branches appear patent, though no mesenteric or
retroperitoneal lymph nodes are enlarged by CT size criteria. No anterior
abdominal wall hernias are noted.
BONES: No suspicious lytic or sclerotic osseous lesions are noted. There is
interval compression deformity of the L3 vertebral body superior endplate with
approximately 20% height loss. Subtle prevertebral soft tissue stranding is
noted. There is no evidence of retropulsion.
IMPRESSION:
1. No evidence of obstruction.
2. L3 compression deformity of the superior endplate with approximately 20%
height loss with mild prevertebral soft tissue stranding. No evidence of
retropulsion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Constipation
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL
temperature: 99.0
heartrate: 81.0
resprate: 18.0
o2sat: 93.0
sbp: 142.0
dbp: 82.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ gentleman with hx of inclusion body
myositis who presented with weakness, s/p fall, and failure to
thrive at home, found to have an L3 compression fracture without
need for surgical intervention.
ACUTE ISSUES
# WEAKNESS:
Patient's weakness was most likely due to known inclusion body
myositis in addition to deconditioning/failure to thrive and
some component of hypovolemia. Digoxin toxicity was thought to
be less likely given EKG changes not c/w this condition. Steroid
induced myopathy unlikely given normal CK. Infectious etiology
also less likely given lack of fevers, and no leukocytosis.
Lack of focality on exam argued against a primary neurologic
process such as stroke. On exam muscle weakness is predominantly
proximal--which can be consistent with includion body myositis
which is the only rheumatologic myositis with proximal and
distal muscle group findings. TSH was within normal limits. He
was continued on his home regimen of Prednisone nad
Methotrexate. The patient was evaluated by physical therapy with
recommendations for discharge to a rehab facility.
# COMPRESSION FX:
The patient c/o back pain s/p fall. He was found to have an L3
compression fx on CT A/P. He was evaluted by neurosurgery who
determined that surgical intervention was not needed and
recommended LSO brace to be worn whenever the patient is out of
bed or weight bearing. He was evaluated by ___ as above. He
receieved standing tylenol, a lidocaine patch, and tramadol PRN
for pain management. The patient should have neurosurgery f/u
upon discharge.
# CONSTIPATION:
The patient presented with constipation stating he had not had a
bowel movement in 14 days. Most likely due to inactivity given
he had spent most of his time in a recliner s/p fall due to back
pain. CT Abd/Pelvis showed significant fecal loading. He
received bisacodyl, docusate, senna, miralax standing, in
addition to bisacodyl PR and had a few small bowel movement in
addition to one large bowel movement with signficant relief in
constipation.
# Tachycardia
The patient was noted to be tachycardic to the 130s with
movement. At rest his HR was in the ___. This was felt to be
multi-factorial due to deconditioning, dehydration, and pain.
His home metoprolol was up-titrated to Metoprolol 50mg Q6HR as
above. On discharge his HR was mostly in the ___ though he was
intermittently tachycardic. His HR should be monitored as an
out-patient and additional medications should be titrated or
added if necessary.
CHRONIC ISSUES
# ELEVATED BICARBONATE:
Patient presented with elevated bicarbonate to 40 on admission.
Most likely due to compensation for a primary respiratory
acidosis as this seems to be a longstanding finding since ___
and patient with stated dx of COPD in addition to PFT finding of
a concomitant restrictive process. Bicarbonate was trended and
remained stably elevated between 37-40.
# TRANSAMINITIS:
The patient presented with a transaminitis at his baseline. This
was likely attributable to his known fatty liver disease.
# CAD s/p BMS to RCA:
The patient is not on Plavix. He was continued on his home
Simvastatin and Aspirin.
# DIASTOLIC CHF:
The patient has a history of diastolic CHF. It is unclear if his
digoxin is being used for CHF or for Afib. On exam the patient
appeared euvolemic to dry. His home Digoxin and Furosemide were
continued. His Metoprolol Tartrate was up-titrated to 50mg Q6HR
from his home regimen given tachycardia during admission.
# AFIB:
The patient is not on warfarin due to fall history. He was
continued on Digoxin as above, and his Metoprolol was
up-titrated due to tachycardia as above.
# GOUT:
The patient was continued on allopurinol ___ daily
# BPH s/p TURP:
The patient was continued on Terazosin 5mg HS
# DM:
The patient received NPH QHS in addition to an insulin sliding
scale. He received a diabetic diet.
TRANSITIONAL ISSUES
[] Pls monitor HR and consider adding additional medications
such as calcium channel blocker if clinically indicated and pt
becomes persistently tachycardic.
[] change from Metoprolol Tartrate 50mg Q6HR to Metoprolol
Succinate 200mg QD when clinically appropriate
[] Pt should wear LSO brace whenever out of bed or weight
bearing
[] Out-patient physical therapy
[] recommend obtaining hepatitis serologies and vaccinating for
Hep A and B if necessary given fatty liver disease
[] pls monitor blood sugars and titrate insulin as needed
[] pt has out-patient neurosurgery follow up scheduled for ___
[] pls monitor bowel movements and titrate bowel regimen PRN |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
lumbar puncture
left shoulder aspiration and steroid injection
History of Present Illness:
___ with hx of frequency/urgency syndrome s/p sacral
neuromodulator placement, hx of L choleastoma s/p bilateral
mastoidectomy, recent ED visits for UTI and L ear bleeding p/w
confusion.
Per ED notes, per the pts family, the pt was found to have new
onset confusion. The pt was last seen by her family ___ at
which point she was performing all her IADLs. Yesterday she was
very tired and didn't get out of bed all day. Today she couldn't
remember the code for voicemail, thought she stole neighbor's
paper, and was having some word finding difficulty.
Of note, the pt was seen ___ the BID-N ED ___ for some
lightheadedness and fall after standing. She was diagnosed with
a UTI and treated per the note with macrobid (though per family
txed with cipro?). She also presented to the ___ ED on ___
for bleeding from the L ear after removal of her hearing aid. At
the time she was thought to have otitis externa and was treated
with ciprodex x10 day and recommended not wear her hearing aid.
___ the ED, initial VS were: 98.1 80 16 166/64 98%RA. She denied
any pain at that time and was A&Ox2 (didn't know the date). She
received 1L NS. U/a showed large leuks, few bacteria. On exam
there was concern for green purulent material ___ the R tympanic
canal. She was given zosyn 4.5g IV x1.
On arrival to the floor, the pt was 97.8 170/65 82 20 97%RA. She
denied any pain or discomfort. She stated she was brought to the
hospital by her children because they were concerned about an
infection ___ her foot. She did endorse some urinary frequency
without dysuria. She denied fevers, chills, abd pain, HA, visual
changes.
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:
Past history of 2 pneumonias over ___ years ago.
Left ear cholesteatoma resected at ___ ___ ___.
Hypertension.
frequency/urgency syndrome s/p sacral neuromodulator placement
Essential Thrombocythemia
Social History:
___
Family History:
Her father died of heart disease at age ___. Her
mother died of breast cancer at age ___. 2 Brothers ___ their
___.
She has 2 sons (1 ___ ___, the other ___ ___ and 1 daughter
___ ___, all ___ good health.
Physical Exam:
Admission:
VS - ___.8 170/65 82 20 97%RA
GENERAL - Elderly female, well appearing, NAD
HEENT - R surgical pupil, L pupil reactive, L ear with partial
tympanic membrane, purulent appearing, with some granulation
tissue at the floor of the auditory canal, nontender on exam,
mild mastoid tenderness, R ear with some greenish material at
the TM, also non-tender. L hearing aid initially ___ place, on
removal had some dried blood.
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 - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - fluent speech, difficulty with hearing, A&Ox2, ___
strength, CN ___ intact. symmetric reflexes. no cerebellar
signs.
Discharge:
VS: Tmax 98.4 Tcur 97.3 BP137-166/62-74 HR60-101 RR16 O2
95-98%RA
General: Laying ___ bed naked with EEG leads on her head. Unable
to talk to her due to hearing machine defect. She seems to be
more confused than usual. When returned with the team, she was
sleepy but arousable.
Neuro: Right side facial drop which seems to be new.
Cardiovascular: RRR. Normal S1 and S2. No m/g/r.
Respiratory: CTAB with normal breath sounds.
Abdomen: Soft, NTND with +BS
Extremities: Warm, well perfused with 2+ distal pulses. No
erythema, swelling, or rash. Increased ROM of L arm - able to
lift up to 90 degrees. RUE decreased ROM, mild tenderness.
Pertinent Results:
Admission:
___ 05:02PM WBC-11.0 RBC-3.85* HGB-11.7* HCT-35.7* MCV-93
MCH-30.3 MCHC-32.8 RDW-13.3
___ 05:02PM NEUTS-65.2 ___ MONOS-7.9 EOS-2.4
BASOS-0.8
___ 05:02PM PLT COUNT-566*#
___ 05:02PM SED RATE-25*
___ 05:02PM GLUCOSE-109* UREA N-23* CREAT-0.6 SODIUM-143
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-30 ANION GAP-13
___ 05:02PM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-101 TOT
BILI-0.3
___ 05:02PM ALBUMIN-3.8 CALCIUM-9.6 PHOSPHATE-4.1
MAGNESIUM-1.9
___ 06:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 06:20PM URINE RBC-2 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 06:20PM URINE MUCOUS-RARE
___ 05:06PM LACTATE-1.2
Interim:
___ 06:00AM BLOOD VitB12-616
___ 06:00AM BLOOD ___
FTA-ABS, SERUM NONREACTIVE NONREACTIVE
JOINT FLUID
JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos
___ 16:21 ___ 82* 1 17
LEFT SHOULDER
JOINT FLUID Crystal Shape Locatio Birefri Comment
___ 16:21 FEW RHOMBOID I/E1 POS c/w calciu2
Discharge:
___ 08:00AM BLOOD WBC-17.5* RBC-3.94* Hgb-11.9* Hct-35.8*
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.3 Plt ___
___ 08:00AM BLOOD Glucose-122* UreaN-33* Creat-0.7 Na-138
K-4.3 Cl-100 HCO3-29 AnGap-13
Micro:
___ 2:36 pm URINE Source: Catheter. **FINAL REPORT
___
URINE CULTURE (Final ___: NO GROWTH.
___ 7:20 pm BLOOD CULTURE **FINAL REPORT ___ Blood
Culture, Routine (Final ___: NO GROWTH.
___ 4:22 pm
JOINT FLUID LEFT SHOULDER. **FINAL REPORT
___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 7:15 pm CSF;SPINAL FLUID Source: LP TUBE #3.
VIC ADDED PER ___ 1819 ___.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer tohematology for a quantitative white blood cell
count..
FLUID CULTURE (Final ___: NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
___ 10:00 am SWAB Site: EAR Source: right ear.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
___ AUREUS COAG +. HEAVY GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
___ AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Herpes Virus 6 DNA, Quant To Qual Real-Time PCR
HHV-6 DNA Not Detected
Herpes Simplex Virus PCR
Specimen Source CSF
Result Negative
Imaging:
CT HEAD W/O CONTRAST Study Date of ___
FINDINGS: There is no evidence of hemorrhage, edema, large
mass, mass effect or acute infarct. Gray-white matter
differentiation is preserved. Confluent subcortical and
periventricular white matter hypodensities are noted, consistent
with small vessel ischemic disease. Bilateral basal ganglia
calcifications are evident. Carotid siphons and bilatral
vertebral arteries demonstrate atherosclerotic calcifications.
Redemonstration of bilateral mastoidectomies. Middle ear
cavities and
visualized paranasal sinuses are clear. No soft tissue swelling
noted.
IMPRESSION: No acute intracranial process. No subdural
hematoma evident.
___ Radiology CHEST (PA & LAT)
FINDINGS: Frontal and lateral views of the chest are compared
to previous exam from ___. The lungs are clear.
Cardiomediastinal silhouette is within normal limits. Right
posterior healed rib fracture is new since prior but appears
old. Osseous and soft tissue structures are otherwise
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
CHEST (PORTABLE AP) Study Date of ___
FINDINGS: The lungs are clear without consolidation or edema.
There is no pleural effusion or pneumothorax. Since the prior
exam, lung volumes are lower. The cardiomediastinal silhouette
is normal. An old healed right rib fracture is unchanged.
Degenerative changes are noted ___ the bilateral shoulders.
IMPRESSION: No acute cardiopulmonary process.
PENDING LABS/STUDIES:
CAROTID SERIES COMPLETE Study Date of ___
Impression: Right ICA 40-59% stenosis.
Left ICA 40-59% stenosis.
___RAIN PERFUSION and CTA: final PND
FINDINGS: A more conspicuous hypodensity is seen within the
left basal
ganglia, compatible with an evolving, subacute infarct. This
hypodensity
involves the left caudate, putamen and globus pallidus. There
is no evidence for hemorrhagic conversion. Slight mass effect
from the edema minimally narrows the left lateral ventricle.
Prominence of the ventricles and sulci is again compatible with
age-related volume loss. There are confluent white matter
hypodensities ___ a
periventricular distribution, again compatible with chronic
small vessel
ischemic disease. Bilateral basal ganglia senescent
calcifications are
present. Dense calcifications are again seen ___ the carotid
siphons and
bilateral vertebral arteries. The lenses and globes are normal.
Bilateral mastoidectomies are again seen. There is no acute
fracture. Note is again made of plagiocephaly.
IMPRESSION: Subacute left basal ganglia infarct.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Study Date of
___
FINDINGS: There are severe end-stage osteoarthritic changes
involving the left glenohumeral joint with bone-on-bone contact,
subchondral sclerosis and large osteophytes. Degenerative
change of the AC joint is also seen. The visualized left lung
apex is clear.
FOOT AP,LAT & OBL LEFT Study Date of ___
Soft tissue calcification and mild swelling surrounding the
first
metatarsophalangeal joint. No acute fracture detected.
SHOULDER ___ VIEWS NON TRAUMA RIGHT Study Date of ___
Wet Read: ___ WED ___ 8:41 ___
Degenerative changes. No acute fracture detected.
Continuous EEG Study Date of ___
Abnormal continuous EEG because of asymmetric mild left
hemispheric background theta slowing, along with frequent left
hemispheric intermittent delta slowing, most prominent
temporally consistent with focal left hemispheric dysfunction.
There are no definite epileptiform abnormalities. There are no
electrographic seizures.
___ Neurophysiology EEG
IMPRESSION: Abnormal EEG due to the bursts of focal delta
slowing ___ the left as to her quadrant with occasional spread
more generally. This suggests a focal subcortical abnormality ___
the left hemisphere likely slowing although cannot specify an
etiology. Vascular disease is a common cause of this age.
Nevertheless, there were no epileptiform features. Finally, the
normal background argues against a major metabolic or other
encephalopathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Docusate Sodium 100 mg PO BID
6. losartan-hydrochlorothiazide *NF* 50-12.5 mg Oral daily
7. Polymyxin B Sul-Trimethoprim *NF* (trimethoprim-polymyxin B)
0.1-10,000 %-unit/mL ___ daily
8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
9. CIPRODEX *NF* (ciprofloxacin-dexamethasone) 0.3-0.1 % AU 5
drops TID L ear
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Polymyxin B Sul-Trimethoprim *NF* (trimethoprim-polymyxin B)
0.1-10,000 %-unit/mL ___ daily
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
7. Acetaminophen 650 mg PO Q6H:PRN pain
not to exceed 3g/day
8. Hydroxyurea 500 mg PO DAILY
9. PredniSONE 30 mg PO DAILY Duration: 4 Days
To start ___
10. Colchicine 0.6 mg PO EVERY OTHER DAY
To start ___
11. Atorvastatin 40 mg PO DAILY
12. Aspirin 325 mg PO DAILY
13. losartan-hydrochlorothiazide *NF* 50-12.5 mg Oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: confusion, possible multi-infarct dementia
Secondary: hearing loss, acute pseudogout flair
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
CHEST, TWO VIEWS: ___
HISTORY: ___ female with acute onset of confusion.
FINDINGS: Frontal and lateral views of the chest are compared to previous
exam from ___. The lungs are clear. Cardiomediastinal silhouette is
within normal limits. Right posterior healed rib fracture is new since prior
but appears old. Osseous and soft tissue structures are otherwise
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Remote fall on ___, presents confusion, rational
thoughts, please evaluate for subdural hematoma or mass-occupying lesion.
COMPARISON: Comparison is made to head CT performed ___.
TECHNIQUE: Non-contrast axial images were obtained through the brain.
Coronal and sagittal reformations were provided.
FINDINGS: There is no evidence of hemorrhage, edema, large mass, mass effect
or acute infarct. Gray-white matter differentiation is preserved. Confluent
subcortical and periventricular white matter hypodensities are noted,
consistent with small vessel ischemic disease. Bilateral basal ganglia
calcifications are evident. Carotid siphons and bilatral vertebral arteries
demonstrate atherosclerotic calcifications.
Redemonstration of bilateral mastoidectomies. Middle ear cavities and
visualized paranasal sinuses are clear. No soft tissue swelling noted.
IMPRESSION: No acute intracranial process. No subdural hematoma evident.
Radiology Report
INDICATION: Confusion and right facial droop. Concern for stroke.
COMPARISON: CT head ___. CT head ___.
TECHNIQUE: Contiguous axial images were obtained through the brain without
administration of contrast material. Subsequently, axial helical MDCT images
were obtained through the head using a CTA protocol after the uneventful
administration of 110 cc of Omnipaque IV contrast. Curved reformats,
volume-rendered reformations and CTA maximum intensity projection images were
generated on an independent workstation. In addition, CT perfusion was
performed with blood flow, blood volume, and mean transit time maps created on
an independent workstation.
FINDINGS:
HEAD CT: There is no evidence of hemorrhage, edema, mass, or infarction. The
ventricles and sulci are prominent, suggesting age-related volume loss.
Periventricular white matter hypodensities are consistent with chronic
microvascular ischemic disease. No fractures are seen, however, there is
prominent plagiocephaly which is likely congenital or developmental. The
basal cisterns appear patent and there is preservation of gray-white
differentiation.
CT PERFUSION: The perfusion maps appear normal and there is no evidence of
delayed transit time or reduced blood flow or blood volume.
HEAD CTA: Atherosclerotic mural calcifications are seen in the cavernous
carotid arteries. There is mild irregularity of the right MCA and focal
stenosis of the distal left vertebral artery likely secondary to both soft and
calcified atherosclerotic mural plaques. However, the major branches of the
circle of ___ including the basilar artery are well opacified with
contrast. There is no evidence for aneurysm formation greater than 2 mm or
other vascular abnormality.
IMPRESSION:
1. No perfusion abnormalities to suggest stroke. No hemorrhage. Chronic
small vessel ischemic disease
2. Diffuse atherosclerotic plaques cause irregularity of the right MCA and
stenosis of the distal left vertebral artery. There is no aneurysm greater
than 2 mm.
Radiology Report
STUDY: Left shoulder, ___.
CLINICAL HISTORY: ___ woman with osteoarthritis of left shoulder and
limited range of motion. Status post fall three weeks ago.
FINDINGS: There are severe end-stage osteoarthritic changes involving the
left glenohumeral joint with bone-on-bone contact, subchondral sclerosis and
large osteophytes. Degenerative change of the AC joint is also seen. The
visualized left lung apex is clear.
Radiology Report
HISTORY: ___ female with left shoulder pain.
STUDY: CT of the left shoulder without contrast; images were acquired in soft
tissue and bone algorithms. Coronal and sagittal reformatted images were also
generated.
COMPARISON: Shoulder radiographs from ___ at 15:20.
FINDINGS: Minimal degenerative change is present at the AC joint. Severe
degenerative changes are seen in the glenohumeral joint in the form of joint
space narrowing, subchondral sclerosis, and subchondral cysts exchange, as
well as large peripheral osteophytes. Additionally, there is a large joint
effusion with multiple punctate calcified bodies within the joint space.
These likely represent either loose bodies or less likely chondrocalcinosis.
Additionally, in the subscapular recess, there is a large calcified loose body
measuring 19 x 16 mm in axial plane (2:21). The muscles and tendons of the
rotator cuff appear grossly intact.
Degenerative changes are present along the left facets of the lower cervical
spine. The visualized portion of the left rib cage is intact. Multiple
levels of vertebral osteophytes are seen throughout predominantly the lower
thoracic spine.
Prominent lymph nodes are present in the left axilla, but none meet pathologic
size criteria for CT. The visualized portion of the left lung demonstrates
mild apical scarring as well as minimal dependent atelectasis along the major
fissure and posterior base. Scattered punctate areas of calcified
atherosclerotic disease are seen in the descending aorta. Calcified
atherosclerotic disease is also present in the left coronary artery.
The visualized portion of the left upper quadrant of the abdomen demonstrates
calcified atherosclerotic disease of the splenic artery. The stomach and
splenic flexure of colon are distended with ingested/fecalized contents.
IMPRESSION: Severe degenerative changes of the left glenohumeral joint with
large joint effusion and loose bodies; intraarticular calcifications likely
represent tiny loose bodies rather than chondrocalcinosis.
Radiology Report
FLUOROSCOPIC-GUIDED ASPIRATION, LEFT SHOULDER
HISTORY: ___ woman with left shoulder effusion on CT examination.
Evaluation for possible septic joint.
COMPARISON: CT examination of left shoulder performed ___.
Radiographs of left shoulder performed that same day.
TECHNIQUE:
Risks, benefits, and alternatives of the procedure were discussed with the
patient's daughter. Written informed consent was then obtained.
Patient was laid supine on the fluoroscopic table. Anterior aspect of the
left shoulder was then prepped and draped using the usual sterile fashion. 1%
lidocaine without epinephrine was then utilized for local subcutaneous and
deep soft tissue local analgesia.
18-gauge spinal needle was then introduced in the left glenohumeral joint
under direct fluoroscopic visualization. Approximately 4 cc of
serosanguineous fluid was then aspirated from the left glenohumeral joint.
Needle was removed, hemostasis achieved, and a sterile bandage applied.
Patient tolerated the procedure well and was transferred to the floor without
indicent.
Fluid was sent to the laboratory for cell count, crystal, and culture and
sensitivities.
___, attending physician, was present throughout this procedure.
FINDINGS:
Severe joint space narrowing, subchondral sclerosis, and osteophyte formation
is again present at the left glenohumeral joint indicative for severe
degenerative joint disease.
IMPRESSION:
1. Successful fluoroscopic aspiration of the left glenohumeral joint.
2. Severe degenerative joint disease of the left glenohumeral joint.
Radiology Report
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old woman with AMS and TIA.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is moderate heterogeneous plaque in the ICA. On the left there
is moderate heterogeneous plaque seen in the ICA, and ECA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 134/19, 118/23, 84/19, cm/sec. CCA peak systolic
velocity is 116 cm/sec. ECA peak systolic velocity is 167 cm/sec. The ICA/CCA
ratio is 1.1. These findings are consistent with 40-59% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 143/38, 104/21, 51/14, cm/sec. CCA peak systolic
velocity is 137 cm/sec. ECA peak systolic velocity is 204 cm/sec. The ICA/CCA
ratio is 1.0 . These findings are consistent with 40-59% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA 40-59% stenosis.
Left ICA 40-59% stenosis.
Radiology Report
INDICATION: Altered mental status.
COMPARISONS: Chest radiograph ___. Chest radiograph ___.
FINDINGS: The lungs are clear without consolidation or edema. There is no
pleural effusion or pneumothorax. Since the prior exam, lung volumes are
lower. The cardiomediastinal silhouette is normal. An old healed right rib
fracture is unchanged. Degenerative changes are noted in the bilateral
shoulders.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with altered mental status and concern for a
stroke.
COMPARISONS: CTP/CTA, ___ and non-contrast enhanced head CT,
___.
TECHNIQUE: MDCT-acquired axial images were obtained through the brain without
the administration of IV contrast.
DLP: 936.52 mGy-cm.
CTDvol: 58.53 mGy.
FINDINGS: A more conspicuous hypodensity is seen within the left basal
ganglia, compatible with an evolving, subacute infarct. This hypodensity
involves the left caudate, putamen and globus pallidus. There is no evidence
for hemorrhagic conversion. Slight mass effect from the edema minimally
narrows the left lateral ventricle.
Prominence of the ventricles and sulci is again compatible with age-related
volume loss. There are confluent white matter hypodensities in a
periventricular distribution, again compatible with chronic small vessel
ischemic disease. Bilateral basal ganglia senescent calcifications are
present. Dense calcifications are again seen in the carotid siphons and
bilateral vertebral arteries. The lenses and globes are normal. Bilateral
mastoidectomies are again seen. There is no acute fracture. Note is again
made of plagiocephaly.
IMPRESSION: Subacute left basal ganglia infarct.
These findings were discussed by phone with ___, M.D. by Dr. ___
at 15:30 hours on ___, immediately at the time of discovery.
Radiology Report
EXAM: Radiographs of the right shoulder
CLINICAL INDICATION: ___ woman with history of CPPD, presenting with
new right shoulder pain. Evaluation for involvement of CPPD in the right
shoulder.
COMPARISON: There are no comparisons for this exam.
FINDINGS: AP internal and external rotation views as well as a scapular Y
views show severe degenerative disease involving the glenohumeral joint, with
joint space narrowing, articular surface sclerosis and marginal osteophytes.
There are faint calcifications within the glenohueral joint. Prominent
spurring is also noted at the greater tuberosity. Mild degenerative disease
involving the acromioclavicular joint is present. There is an old healed
fracture involving the fifth posterior rib. No acute fracture is seen. The
visualized right hemithorax appears normal otherwise. Regional soft tissues
are within normal limits.
IMPRESSION:
1. Severe degenerative disease involving the right glenohumeral joint, with
faint intraarticular calcifications. Finding may represent CPPD arthropathy
or just Osteoarthritis.
2. Old right posterior rib fracture (fifth rib) as described.
Radiology Report
EXAM: Radiographs of the left foot.
CLINICAL INDICATION: ___ woman with left foot pain. Evaluation for
fracture. Also, concern for CPPD.
COMPARISON: None.
FINDINGS: AP, lateral, and oblique views show moderate degenerative disease
involving the first tarsometatarsal joint (with sclerosis, joint space
narrowing, and small marginal osteophyte). Additionally, there is mild amount
of degenerative disease involving the first metatarsophalangeal joint, with
scattered areas of calcification. Additionally, there is severe degenerative
disease involvong the articulation of the sesamoid and base of the first
metatarsal. No evidence of fracture or dislocation. There is a prominent
inferior calcaneal spur. Mild degenerative disease involving the tibiotalar
joint is present with marginal osteophytes. The visualized soft tissues are
within normal limits.
IMPRESSION:
1. Severe degenerative disease involving the articulation of the sesamoid and
base of the first metatarsal.
2. Moderate degenerative disease involving the first metatarsophalangeal
(MTP) and first tarsometatarsal joints. Non-specific calcification
surrounding the first MTP joint may represent dystrophic calcifications, and
can be seen in the setting of CPPD and/or osteoarthritis. No acute pathology
is seen.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CONFUSION
Diagnosed with SEMICOMA/STUPOR, ALTERED MENTAL STATUS , OTITIS MEDIA NOS
temperature: 97.8
heartrate: 77.0
resprate: 18.0
o2sat: 97.0
sbp: 144.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of frequency/urgency syndrome s/p sacral
neuromodulator placement, hx of L choleastoma s/p bilateral
mastoidectomy, recent ED visits for UTI and L ear bleeding p/w
confusion.
# Stroke: The patient presented with acute change ___ mental
status from her baseline level of functioning. She had been
living on her own, driving and shopping etc. Initial
differential included infection, seizure, infarct. Infectious
workup did not reveal a source: CXR negative, blood and urine
cultures negative, CSF with no evidence of infection, L shoulder
tap no infection. She was being treated for an ear infection on
arrival, however there was no evidence of inflammation on exam.
A culture was done of her ear which showed likely normal flora.
Her ciprodex was discontinued after she completed a ten day
course. She was initially also treated for a urinary tract
infection as UA showed some pyuria, however this was
discontinued with a normal culture. Head CTA and brain
perfusion scan was done on ___ to rule out stroke; this showed
no acute changes. A lumbar puncture was done on ___ due to
altered mental status with decreased level of responsiveness.
This did not show any infectious process; bacterial culture
negative and viral culture preliminary negative at time of
discharge. An EEG was performed due to concern for seizure and
preliminary results showed L sided slowing, no evidence of
seizure. A repeat CT was performed on ___ which showed
chronic L sided lacunar infarcts which explained the R sided
asymmetry seen on exam. A TSH, B12 and treponemal antibody were
checked and normal/negative. Neurology was consulted who
recommended a continuous EEG and treatment of HSV pending
testing. Continuous EEG showed L sided slowing. She was treated
with acyclovir ___ house until HSV serology came back negative.
A repeat CT was done ___ which showed hypodensity within
the left basal ganglia, compatible with an evolving, subacute
infarct. The stroke involved the left caudate, putamen and
globus pallidus. There was no evidence for hemorrhagic
conversion. The patient was seen by the stroke service; she was
started on atorvastatin and aspirin was increased to 325mg
daily. She was seen by physical therapy who recommended
rehabilitation.
# Pseudogout: Patient developed acute L sided shoulder pain. She
has a history of osteoarthritis, now with decreased ROM and pain
___ L shoulder joint s/p injection ___ ___. Joint aspiration done
on ___- few rhomboid crystals + birefringent, 14K WBC
consistent with pseudogout flair, no organisms on GM stain.
Patient received a steroid injection and naproxen to treat her
acute pseudogout flair. Symptoms improved, however on ___ she
developed L foot and R shoulder pain concerning for
polyarticular pseudogout. Rheumatology recommended prednisone 30
mg daily and colchine 0.6 mg every other day which were started
on ___.
# Otitis externa/media: The pt presented to the ED on ___ with
complaints of bleeding from the L ear after removal of hearing
aid. At the time it was felt that she had e/o otitis externa
which was treated with ciprodex drops and recommended cessation
of hearing aid use. Patient had R sided green/purulent discharge
on exam, however neither ear has evidence of inflammation. CT
did not identify any abscess or soft tissue swelling, and so it
seems unlikely that this represents malignant otitis externa.
Further, the patient denies pain. Patient completed 10 days of
ciprodex.
# Possible UTI: The pt had large leukocytes and few bacteria on
urinalysis at presentation. She did not endorse symptoms,
however daughter stated that she typically does not have
symptoms. She was recently treated for a urinary tract
infection due to pan sensitive E. Coli. She was initially
treated with ceftriaxone, which was discontinued after a 5 day
course. Repeat urine culture negative.
# Leukocytosis: No fevers and extensive negative infectious
workup which makes our suspicion for infection low. She was
diagnosed with JAK2 mutation ___ ___ when she presented to a
___ hospital with FUO, leukocytosis and thrombocytenia. She
was started on ___ and had to have the dose adjusted
multiple times due to thrombocytopenia. According to her ___
PCP, ___ was fully discontinued ___ the ___. Her
last visit with her ___ PCP ___ ___, she had WBC 8.9, Hct
37, Platelets 490. Patient was seen by hematology-oncology who
started her on hydroxyruea. Luekocytosis and thrombocytosis is
not felt to be contributing to her presentation. A follow up
appointment was made with hematology oncology.
# Thrombocytosis: Per ___ note the pt has essential
thrombocythemia for which she takes aspirin. See description
above. Hematology-oncology did not feel that her confusion was
related to her thrombocytosis.
# HTN: continued home amlodipine, losartan, hctz
# Glaucoma: continued home timolol, polymixin b sul-trimethoprim |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 07:05PM BLOOD WBC-30.3* RBC-3.22* Hgb-10.4* Hct-33.5*
MCV-104* MCH-32.3* MCHC-31.0* RDW-15.5 RDWSD-58.4* Plt ___
___ 07:05PM BLOOD Neuts-6* Lymphs-93* Monos-0* Eos-1 Baso-0
AbsNeut-1.82 AbsLymp-28.18* AbsMono-0.00* AbsEos-0.30
AbsBaso-0.00*
___ 07:05PM BLOOD Anisocy-1+* Poiklo-2+* Macrocy-1+*
Microcy-1+* Ovalocy-1+* Echino-2+* Acantho-1+* RBC Mor-SLIDE
REVI
___ 07:05PM BLOOD Plt Smr-LOW* Plt ___
___ 07:05PM BLOOD Glucose-76 UreaN-27* Creat-0.9 Na-144
K-3.6 Cl-107 HCO3-20* AnGap-17
___ 07:05PM BLOOD ALT-11 AST-18 LD(LDH)-206 AlkPhos-86
TotBili-0.4
___ 07:05PM BLOOD Albumin-4.3 Cholest-234*
___ 07:05PM BLOOD VitB12-1035* Folate->20
___ 07:05PM BLOOD Triglyc-151* HDL-45 CHOL/HD-5.2
LDLcalc-159*
___ 07:05PM BLOOD TSH-0.79
___ 07:05PM BLOOD 25VitD-58
___ 07:37AM BLOOD CRP-2.2
___ 01:35AM BLOOD SED RATE-Test
IMAGING:
========
Chest Xray ___:
No acute cardiopulmonary abnormality
DISCHARGE LABS:
================
___ 07:39AM BLOOD WBC-23.5* RBC-3.11* Hgb-10.1* Hct-32.4*
MCV-104* MCH-32.5* MCHC-31.2* RDW-15.5 RDWSD-58.4* Plt ___
___ 07:39AM BLOOD Glucose-81 UreaN-29* Creat-1.0 Na-142
K-3.7 Cl-105 HCO3-25 AnGap-12
___ 07:39AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Clopidogrel 75 mg PO DAILY
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. DULoxetine ___ 60 mg PO QAM
8. DULoxetine ___ 20 mg PO QPM
9. melatonin 3 mg oral QHS
10. Vitamin D 1000 UNIT PO DAILY
11. Mirtazapine 7.5 mg PO QHS
12. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Moderate
13. Phospholine Iodide (echothiophate iodide) 0.125 % ophthalmic
(eye) BID
14. TraZODone 50 mg PO QHS:PRN insomnia
15. Modafinil 200 mg PO DAILY
16. Lumigan 0.03% Ophth (*NF*) 0.01 % Other daily
Discharge Medications:
1. BuPROPion XL (Once Daily) 150 mg PO QAM
2. Gabapentin 100 mg PO QHS
3. Gabapentin 25 mg PO QAM Headache
4. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Multivitamins W/minerals 1 TAB PO DAILY
6. TraZODone 50 mg PO QHS:PRN insomnia
7. Lisinopril 5 mg PO DAILY
8. Ramelteon 8 mg PO QPM Insomia
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
10. Clopidogrel 75 mg PO DAILY
11. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
12. DULoxetine ___ 60 mg PO QAM
13. Levothyroxine Sodium 75 mcg PO DAILY
14. Lumigan 0.03% Ophth (*NF*) 0.01 % Other daily
15. Phospholine Iodide (echothiophate iodide) 0.125 %
ophthalmic (eye) BID
16. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Failure to thrive
Malnutrition
Major Depressive Disorder
History of aspiration
SECONDARY DIAGNOSES:
====================
Chronic lymphocytic leukemia
Hypothyroidism
Coronary artery disease
Heart failure with preserved ejection fraction
History of supraventricular tachycardia
Obstructive sleep apnea
Insomnia
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with failure to thrive // ?pna
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is mildly enlarged, unchanged. The mediastinal and hilar contours
are similar to prior with tortuosity of the thoracic aorta again noted. Mild
crowding of bronchovascular structures without frank pulmonary edema. Mild
atelectasis in the lung bases, but no focal consolidation. No pleural
effusion or pneumothorax is seen. There are no acute osseous abnormalities.
Chronic left proximal humeral fracture is demonstrated. Multilevel
degenerative changes in the thoracic spine are noted along with posterior
fusion hardware which is incompletely visualized.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Depression, Failure to thrive
Diagnosed with Adult failure to thrive
temperature: 98.4
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 113.0
dbp: 52.0
level of pain: 0
level of acuity: 3.0 | TRANSLATIONAL ISSUES:
===================
[ ] Patient had recent changes to his psych meds, primarily
which times of days he is taking them. We saw some improvement
in his headache and jaw pain w/ ___ of gabapentin in the
morning. Continue to monitor and adjust as needed.
[ ] Follow up with heme/onc as outpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Mycin drugs
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ y/o F w/PMHx Alzheimer's
dementia and history of recurrent candidiasis who was referred
to ___ for evaluation of FTT. Pt's history was discussed with
her son and husband who were at bedside. Per their report, pt
has had decreased appetite for ___ months. She has had little
appetite. When she does eat, she often regurgitates food,
including pills. Per her son, there have been times when emesis
seemed red or maroon colored. Pt has lost a significant amount
of weight, possibly as much as 50 pounds. Pt reports herself
that she often gets the feeing of food getting stuck in her
esophagus and has some anxiety about swallowing. She gets some
lower abdominal pain with eating, but no odynophagia. Otherwise,
no recent fevers, chills. Pt has also noticed some
light-headedness. There was some report of a fall from the ED,
although there was no mention of this by pt's family or in the
PCP's note.
With regards to her dementia, pt is verbal and conversive. She
is able to clean, but needs help showering and eating.
In the ED, initial vitals:
97.4; 76; 147/113; 18; 100% RA
- Labs notable for:
CBC: 15.2>11.7/36.3<253
Cr: 0.7
LFTs WNL
UA negative
- Imaging notable for:
CT C-spine w/o contrast:
1. No acute fracture.
2. Equivocal mild anterolisthesis of C4 on 5 is likely due to
degenerative change. Alignment is otherwise normal.
NCHCT:
No acute intracranial process.
CXR
Hyperinflated lungs, mild cardiomegaly.
- Patient given:
500cc IV NS
- Vitals prior to transfer: 77; 164/72; 18; 100% RA
On arrival to the floor, pt reports feeling similar as compared
with prior. She denied any pain or discomfort. She noted that
she has some SOB, which has been ongoing for ___ months. She
does note some dizziness that has been getting worse for several
weeks. This improved after IVF.
REVIEW OF SYSTEMS: Per HPI
Past Medical History:
Esophageal candidiasis
Alzheimer's disease
HTN
GERD
Osteoporosis
Asthma
Right-sided trigeminal neuralgia
Appendectomy
Septoplasty
Hysterectomy
Left THA
Right TKA
Social History:
___
Family History:
Hypertension
Physical Exam:
ADMISSION EXAM:
===================================
VS- T=97.7, BP=159/85, HR=81, RR=16, O2 Sat=99 on RA
General: Not in acute distress, cachectic
HEENT: very dry mucous membranes, with dried yellow and moist
white plaques extensively covering the tongue and oropharynx. No
supraclavicular lymphadenopathy
Axilla: No lymphadenopathy
CV: S1 and S2 present, systolic murmur and late systolic click,
regular rhythm
Lungs: Lungs were auscultated anteriorly because the patient
indicated that she was unable to get up. Lungs were clear to
auscultation bilaterally.
Abdomen: Soft and nondistended. Pain to palpation in all four
quadrants, but the pain was particularly pronounced in the left
lower and right lower quadrants. Bowel sounds present in all
four quadrants.
GU: Deferred
Ext: DP pulses present bilaterally with no ___ edema
Neuro: Oriented to name ___ but she was unable to
exactly recall her middle name). Not oriented to time (indicated
it was ___. Was able to say that she was in a hospital but
thought that the hospital was ___.
Skin: Full skin exam deferred.
DISCHARGE EXAM:
===================================
VS 97.6 151 / 82 77 20 97 RA
GENERAL: Not in acute distress, cachectic
HEENT: Mucous membranes moist today, very small glossy white
plaques c/w thrush persist but are significantly improved. No
supraclavicular/cervical lymphadenopathy
HEART: S1 and S2 present, systolic murmur and late systolic
click, regular rhythm
LUNGS: Lungs were clear to auscultation bilaterally anteriorly.
No wheezes
ABDOMEN: Deferred because the patient's food was there.
EXT: DP pulses present bilaterally
SKIN: Full skin exam deferred
NEURO: When asked to spell out her full name, she indicated
___. However, she was unsure of her exact
middle name as there appears to have been some debate about it
in the past, and it is unclear whether she is not recalling her
exact middle name or whether there was genuine debate and
uncertainty about it in the past about it. When asked where she
was, she said hospital, but she said that the name of the
hospital is ___. She said that it is ___.
Pertinent Results:
ADMISSION LABS:
===========================
___ 06:15PM WBC-15.2* LYMPH-6.4* ABS LYMPH-973 CD3-88
ABS CD3-858 CD4-57 ABS CD4-552 CD8-31 ABS CD8-304 CD4/CD8-1.81
___ 06:28PM LACTATE-1.4
___ 06:15PM GLUCOSE-81 UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
___ 06:15PM ALBUMIN-3.8 CALCIUM-9.2 PHOSPHATE-3.2
MAGNESIUM-2.1
MICRO:
===========================
___ 9:45 am SWAB Site: THROAT
MYCOLOGY CULTURE FOR SPECIATION PLEASE SPECIATE.
FUNGAL CULTURE (Preliminary):
YEAST, PRESUMPTIVELY NOT C. ALBICANS.
IMAGING:
===========================
___ BARIUM SWALLOW:
1. Diffusely shaggy appearance of esophageal mucosa likely
represents diffuse esophagitis.
2. Hold up of barium tablet and proximal esophagus, likely due
to narrowed
esophagus distally.
DISCHARGE LABS:
===========================
___ 07:20AM BLOOD WBC-8.4 RBC-4.08 Hgb-11.1* Hct-36.3
MCV-89 MCH-27.2 MCHC-30.6* RDW-16.1* RDWSD-52.6* Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Valsartan 40 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Sertraline 50 mg PO DAILY
5. Fluconazole 50 mg PO Q24H
Discharge Medications:
1. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
2. Donepezil 10 mg PO QHS
3. Sertraline 50 mg PO DAILY
4. Valsartan 40 mg PO DAILY
5.Walker
ROLLING WALKER. Diagnosis: Failure to thrive/R62.7, Prognosis:
good, Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===============================
- Failure to thrive
- Alzheimer's dementia
- Candidial esophagitis
- Benign paroxysmal positional vertigo
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. (cane sometimes)
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with AD, falls // ?cpd
COMPARISON: None
FINDINGS:
AP upright and lateral views of the chest provided. The lungs appear
hyperinflated. No focal consolidation, effusion or pneumothorax. No signs of
congestion or edema. Heart size is mildly prominent. Mediastinal contour is
normal. No acute osseous abnormality. Widened right AC joint likely reflects
old injury. No displaced rib fracture seen. No free air below the right
hemidiaphragm.
IMPRESSION:
Hyperinflated lungs, mild cardiomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with dizziness and fall // ?bleed or fx
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) = 803 mGy-cm.
COMPARISON: MR head ___
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
large mass. Periventricular and subcortical white matter hypodensities are
nonspecific, but likely represent chronic small vessel ischemic disease. There
is prominence of the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. Patient is status post bilateral maxillary
sinus surgery. There is scattered mucosal thickening in ethmoid air cells.
The visualized portion of the mastoid air cells and middle ear cavities are
clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with dizziness and fall
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 864 mGy-cm.
COMPARISON: None available.
FINDINGS:
Evaluation at the level of the maxilla and lower teeth is somewhat limited due
to metal artifact from maxillary and mandibular hardware. Minimal
anterolisthesis of C4 on 5 is likely chronic and due to degenerative disease.
Alignment is otherwise normal. No fractures are identified. There is moderate
severe degenerative change, worst from C5-C7, where there is disc space
narrowing, anterior and posterior osteophytes, and moderate spinal canal
stenosis. There is no prevertebral soft tissue swelling.
IMPRESSION:
No acute fracture. Minimal anterolisthesis of C4 on 5 is likely degenerative
in nature. Alignment is otherwise normal.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with PMHx esophageal candidiasis p/w dysphagia
// Is there e/o stricture, motility problems?
TECHNIQUE: Barium esophagram.
DOSE: Acc air kerma: 50.8 mGy; Accum DAP: 1032.5 uGym2; Fluoro time: 6
minutes
COMPARISON: None
FINDINGS:
The esophagus was not well distended and had a diffusely shaggy appearance.
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass.
The primary peristaltic wave was normal, with contrast passing readily into
the stomach. The lower esophageal sphincter opened and closed normally.
A 13 mm barium tablet was administered, which did not pass beyond the proximal
esophagus and was held up at that level despite multiple swallows.
There was no gastroesophageal reflux. There was no hiatal hernia.
No overt abnormality in the stomach or duodenum on limited evaluation.
IMPRESSION:
1. Diffusely shaggy appearance of esophageal mucosa likely represents diffuse
esophagitis.
2. Hold up of barium tablet and proximal esophagus, likely due to narrowed
esophagus distally.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Decreased PO intake
Diagnosed with Adult failure to thrive, Syncope and collapse
temperature: 97.4
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 113.0
level of pain: 0
level of acuity: 3.0 | ___ is an ___ y/o F w/PMHx of Alzheimer's disease and
history of recurrent candidiasis who presented to ___ for
evaluation of failure to thrive. This was determined to be
secondary to poor patient follow up outpatient and she was noted
to have severe thrush and candidial esophagitis on admission
(support by physical exam, barium swallow, and mycotic throat
culture). She was also complaining of dizziness here, and while
she did not have a positive Dixx-Hallpike test, the Epley
maneuver helped her vertigo immensely, and thus we believe that
she has benign paroxysmal positional vertigo. The patient
complained of intermittent hematuria, which was not noted on UA.
She also complained of mild abdominal pain with symptoms waxing
and waning. Both of these issues were not acute and will be
transitional.
The patient's individual problems were assessed, diagnosed, and
treated as follows:
ACTIVE PROBLEMS:
=============================
#ESOPHAGEAL CANDIDIASIS:
The patient has a PMHx of severe esophagitis due to ___
since ___. Recurrent, but responsive to fluconazole in the
past, has been on prophylaxis but dose/compliance unclear.
Improving on therapeutic doses here since admission.
In the past, her upper mouth plate has been considered as a
nidus for the recurrent infections. Past HIV test was negative
and past CD4 count was within normal limits. CD4 count on this
admission was within normal limits. HIV Ab and HCV Ab tests on
this admission were both negative.
Barium swallow from ___ revealed diffuse shaggy esophagus
consistent with esophagitis, as well as distal narrowing. Per
discussions with GI, endoscopy not necessary with patient's
current status. ID recommends endoscopy given c/f underlying
malignancy and could repeat biopsy with CMV/HSV/AFB, biopsy
sample for candid to investigate fluconazole resistance.
- Fluconazole 200 mg PO/NG Q24H to complete two week course w/
plans for outpatient f/u.
#FAILURE TO THRIVE:
The patient had a failure to thrive presentation that included
little appetite, food regurgitation, feeling of food getting
stuck in her esophagus, weight loss, abdominal pain, and
potentially bloody hematemesis. Felt to be secondary to her
esophagitis. Was eating much better by discharge.
#VERTIGO:
Orthostatics were positive (patient very dehydrated on
admission) here which may have been contributing at first.
Atenolol may have been worsening orthostatic hypotension as
well. However, given that the patient's symptoms resolved with
Epley maneuvers, the primary underlying cause appears to be BPPV
- STOPPED atenolol on ___, pressures stable
- Patient education on Epley maneuver to use PRN at home
#ABDOMINAL PAIN:
The patient had abdominal pain on palpation. Given her
presentation there was initial concern for chronic mesenteric
ischemia, although this seems highly unlikely as she has no risk
factors, and that her serial abdominal exams and reports of
abdominal pain are inconsistent. ___ need to be worked up
outpatient for malignancy given patient's intermittent complaint
of hematuria, although no hematuria noted on UA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
CEFUROXIME
Attending: ___.
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female with obesity, hypertension,
hyperlipidemia, anxiety/depression who presented to her PCP
yesterday with increased thirst and weakness in her legs for ___
weeks. A the PCP's office she was found to be hyperglycemic a
596. She was given 10 units regular insulin in office. Also
found to have high BUN/Cr (46/1.5), and hyponatremia to 128.
She was subsequently sent to the ED where BG was initially in
the high 300s. Initial vitals in ED triage were T 98.4, HR 73,
BP 118/100, RR 18, and SpO2 100% on RA. She was started on an
insulin sliding scale, and subsequently received 21 units of
humalog over the night and this morning. Blood glucose in the
ED decreased from ___ to high 100s by this morning. She
was given a total of 1L NS though the time period over which
this was administered is not clear. She also had a negative CXR
and a positive UA for 17 WBCs, small leuk esterase, and was
given Bactrim for UTI.
The patient was seen by ___ this morning who recommended
Lantus 12units with SSI and glimepiride.
Notably, the patient has had a couple of falls over the last
several weeks. The first was when she was getting out of bed
and slipped; she did not have any head strike. The second was
in the bathroom and the patient cannot recall the details
surrounding this. She had a CT of the head and C-spine in the
ER and these were both negative.
She was admitted to medicine for further management of new onset
diabetes and UTI. Vitals prior to floor transfer were 98.1 62
135/91 18 97%.
On reaching the floor, though the patient denies polyuria, her
partner reports she is incontinent at baseline and has also had
increased urine output. She denies burning or hesitancy. The
weakness in her legs was gradual; it is not associated with any
loss of sensation. In the ED she endorsed "peculiar aches and
pains" since the prior afternoon in legs and thighs. Denies
fevers, chills, cough, chest pain, shortness of breath. She
denies sick contacts. Had the flu vaccine this year.
Past Medical History:
# Morbid Obesity
# Hypertension
# Hypercholesterolemia
# Hypothyroidism
# Asthma
# Sleep Apnea
# Hereditary Spherocytic Hemolytic Anemia
# Irritable Bowel Syndrome
# Osteoarthritis
# Urinary Incontinence
# Uterine Leiomyoma
# Basal Cell Carcinoma
# Anxiety / Depression
# Neuropathy
Social History:
___
Family History:
FAMILY HISTORY: Patient does not recall most of family's medical
history; believes some relatives in "distant past" had diabetes.
# Mother: "No significant medical problems"
# Father: ___ aneurysm
# ___: Brother with "weak heart," ?diabetes
Children are healthy.
Physical Exam:
ADMISSION EXAM
VS: T 98.2, BP 104/68, HR 79, RR 20, SpO2 96% RA
Gen: Elderly female in NAD. Oriented to self and place, cannot
name date and angers when asked.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MM dry, OP benign.
Neck: Supple.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use.
Inconsistent effort but clear without crackles, wheezes or
rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. 1+ pitting edema in ___ bilaterally. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: +Tenting. Scaly skin with scattered seborrheic keratoses
on legs, arms, face.
Neuro: CN II-XII grossly intact. Repetitive lip and right face
movements. Strength ___ in all extremities. Sensation intact to
light touch throughout.
DISCHARGE EXAM
Tc 97.9 Tm 98.2 100-116/60-70 64-71 18 96% RA
General: Comfortable, NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Breathing comfortably, no accessory muscle use, scattered
exp wheeze with some limited air movement.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, slightly distended and tympanic to
percussion, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes
Neuro: AAOx3
Pertinent Results:
ADMISSION LABS
___ 06:00PM WBC-8.1 RBC-3.94* HGB-10.9* HCT-31.7* MCV-80*
MCH-27.6 MCHC-34.4 RDW-19.0*
___ 06:00PM NEUTS-70.5* ___ MONOS-4.7 EOS-2.5
BASOS-0.6
___ 06:00PM GLUCOSE-385* UREA N-46* CREAT-1.4* SODIUM-133
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
___ 07:03PM ___ TEMP-36.7 PO2-48* PCO2-48* PH-7.37
TOTAL CO2-29 BASE XS-1
___ 06:00PM ALT(SGPT)-17 AST(SGOT)-14 ALK PHOS-100 TOT
BILI-0.6
___ 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
___ 06:00PM URINE RBC-1 WBC-17* BACTERIA-FEW YEAST-NONE
EPI-4
DISCHARGE LABS
___ 05:37AM BLOOD WBC-7.6 RBC-3.90* Hgb-10.8* Hct-32.1*
MCV-82 MCH-27.7 MCHC-33.8 RDW-18.8* Plt ___
___ 05:37AM BLOOD Glucose-180* UreaN-24* Creat-1.4* Na-141
K-4.8 Cl-108 HCO3-28 AnGap-10
___ 05:37AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
___ 10:23AM BLOOD %HbA1c-9.1* eAG-214*
MICRO
___ 8:00 am URINE Site: NOT SPECIFIED
HEME S# ___ UCU ADDED ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
CXR ___: No acute process.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
4. Simvastatin 40 mg PO QHS
5. Levothyroxine Sodium 50 mcg PO DAILY
6. oxybutynin chloride *NF* 15 mg Oral DAILY
Extended Release
7. Gabapentin 300 mg PO DAILY
8. Gabapentin 900 mg PO HS
9. spironolacton-hydrochlorothiaz *NF* ___ mg Oral QMWF
10. BuPROPion (Sustained Release) 150 mg PO QAM
11. Cephalexin 250 mg PO QHS
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Apply to affected area
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Cephalexin 250 mg PO QHS
4. Gabapentin 300 mg PO DAILY
5. Gabapentin 900 mg PO HS
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Simvastatin 40 mg PO QHS
9. Vitamin D 1000 UNIT PO DAILY
10. oxybutynin chloride *NF* 15 mg Oral DAILY
Extended Release
11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Apply to affected area
12. FreeStyle Lancets *NF* (lancets) 1 lacet Miscellaneous QAC,
QHS
RX *lancets [FreeStyle Lancets] Use for blood glucose testing
QAC, QHS Disp #*1 Box Refills:*0
13. FreeStyle Lite Strips *NF* (blood sugar diagnostic) 1 strip
Miscellaneous QAC, QHS blood glucose testing
RX *blood sugar diagnostic [FreeStyle Lite Strips] Use 1 strip
for blood glucose testing QAC, QHS Disp #*1 Box Refills:*0
14. 70/30 26 Units Breakfast
70/30 16 Units Dinner
RX *insulin NPH & regular human [Humulin 70/30 Pen] 100 unit/mL
(70-30) 26 Units before BKFT; 16 Units before DINR; Disp #*1
Box Refills:*0
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
RX *albuterol ___ PUFFS inhaled Q6h prn Disp #*1 Inhaler
Refills:*0
16. BD Insulin Pen Needle UF Orig *NF* (insulin needles
(disposable)) 29 x ___ Miscellaneous BID
RX *insulin needles (disposable) [BD Insulin Pen Needle UF Orig]
29 gauge x ___ Use for administratio of insulin twice a day
Disp #*1 Box Refills:*0
17. glimepiride *NF* 4 mg ORAL DAILY Reason for Ordering: ___
recommendations
RX *glimepiride 4 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with myalgias, hyperglycemia.
COMPARISON: ___.
FINDINGS:
Two AP and one lateral view of the chest. The lungs are essentially clear
noting left basilar linear opacities most suggestive of atelectasis. There is
no effusion or pulmonary vascular congestion. Cardiomediastinal silhouette is
within normal limits. No acute osseous abnormality detected.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Fall.
TECHNIQUE: Contigous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared and
reviewed.
COMPARISON: Head CT from ___
FINDINGS:
There is no evidence of an acute intracranial hemorrhage, edema, mass, large
vessel territorial infarction, or shift of the midline structures. The
ventricles and sulci are prominent in size and configuration, likely
representing age-related cortical atrophy. Bilateral periventricular white
matter hypodensities are noted and likely sequela of chronic small vessel
ischemic changes. No acute fractures are identified. The visualized mastoid
air cells and paranasal sinuses are clear.
IMPRESSION:
No acute intracranial injury.
Radiology Report
HISTORY: Fall.
COMPARISON: CT head from same day.
TECHNIQUE: MDCT-acquired axial images were obtained through the cervical
spine without IV contrast. Multiplanar reformatted images were prepared and
reviewed.
FINDINGS:
There is no evidence of an acute fracture or subluxation. There is
straightening of the normal cervical lordosis. There is no prevertebral soft
tissue swelling. Moderate multilevel degenerative changes are visualized with
loss of disc height, uncovertebral joint hypertrophy and posterior osteophytes
causing at least mild canal narrowing at C4-C5 and C5-C6. There is also
moderate to severe, left greater than right neural foraminal narrowing at
C4-C5, and moderate left foraminal narrowing on the left at C3-C4, C5-C6 and
C6-C7. The visualized lung apices are clear. The thyroid gland is
unremarkable.
IMPRESSION:
Moderate degenerative changes with no acute fracture or subluxation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HYPERGLYCEMIA
Diagnosed with URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT
temperature: 98.4
heartrate: 73.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | This is a ___ woman with h/o obesity, HTN, HLD, hypothyroidism,
anemia, anxiety/depression who presents with nonketotic
hyperglycemia without acidosis or hyperosmolarity.
ACTIVE ISSUES
# New Onset Diabetes Mellitus: Patient presented to PCP's office
with BG in 500s. She was not acidotic and did not have an
elevated gap, serum osms have been wnl. Other electrolytes were
also wnl. She was hydrated o/n. She was seen by ___ in the ER
and started on a regimen of glargine and humalog SS; however,
BGs remained elevated to 300s despite glargine, and given that
patient was not felt likely to be able to handle a sliding scale
at home, she was started on a regimen of 70/30. Her glucose
came down to the high 100s and she was discharged on 70/30 at 26
units in the AM and 16 units in the ___. She received teaching
about diabetic testing and insulin administration by ___
teaching nurse.
# Urinary Tract Infection: It was difficult to tell if she was
symptomatic given baseline incontinence. However, given her
severe hyperglycemia in setting of possible underlying
infection, she was initially treated with Bactrim. When urine
culture came back with only normal flora/contamination, Bactrim
was stopped.
CHRONIC ISSUES
# ___ on CKD: Pts baseline creatinine seems to be 1.3-1.5, and
Cr here was 1.3-1.4, so not significantly different. However,
she did have an elevated BUN/Cr ratio and was dry on exam, now
s/p fluid resuscitation. At baseline.
# Anemia: Pt has underlying hereditary spherocytic hemolytic
anemia. Her baseline Hct has been ___ for last several years.
Her Hct at this admission was at or above baseline throughout
the stay.
# Hypothyroidism: continued home levothyroxine dose.
# Sleep Apnea: not on CPAP at home. No episodes of desaturation
during hospitalization.
# Asthma: not on medications for this at home. Given she did
have some scattered wheezing on exam, though no symptoms of
dyspnea or wheezing, she was discharged with albuterol inhaler
for PRN use.
# Hypertension: Continued on metoprolol. Home diuretics were
initially held due to concerns for dehydration, and the fact
that her BPs were well-controlled without the
spironolactone-HCTZ. They were held on discharge given SBPs in
100s-110s and given her baseline incontinence was likely
exacerbated by diuretics.
# Hyperlipidemia: Continued home statin
.
# Depression: Continued home bupropion
TRANSITIONAL ISSUES
-anti-GAD pending at time of discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / horse vaccine
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Patient is a ___ year old male with a history of NIDDM, HTN, PMR
who presented to the ED s/p syncopal episode yesterday. He
states that before the episode, he felt blood rushing in his
head while in the kitchen. He sat down for about half an hour,
then when he got
up, went to the kitchen, he recalls opening the cabinet and then
waking up on the floor, he is not sure how long he was out. No
prodrome. He got himself up, called his wife because he felt
well, but did not elect to seek any medical care at that time,
he
was confused after falling. He did not check his fingerstick
after the fall, but did check his blood pressure at 30 minutes
after the fall and says it was 149/83 with a pulse of 94. He
denies any headache or neck pain or any traumatic injuries. He
denied any precipitating palpitations, shortness of breath or
headache or chest pain. Since then, he has felt diffuse weakness
without any focal weakness numbness or tingling. He denies any
recent fevers, chills, cough, abdominal pain, nausea, vomiting,
changes in his bowel or bladder habits. This morning he was
lying in bed and stood up suddenly to answer the phone when he
felt lightheaded but did not pass out. He saw his PCP today, who
referred him to the ER for evaluation.
In the ED, initial vs were: 98.2 80 159/65 16 97%. Labs notable
for a lactate of 2.9, K 5.4, Calcicum 10.5, troponin negative.
CT head and CXR were both negative. ECG showed very small
inferior Q waves, NSR, very mild ST flattening in inferior and
lateral leads, no major ischemic changes, c/w prior. Vitals on
transfer were 98.4 88 137/98 16 99%.
On the floor, patient is alert and comfortable.
Past Medical History:
Diabetes mellitus type II
HTN (hypertension)
Obesity
Erectile dysfunction
Monoclonal gammopathy
PMR (polymyalgia rheumatica)
Kidney stone
Social History:
___
Family History:
No history of early CAD or sudden cardiac death.
Physical Exam:
ADMISSION:
Vitals: 97.8 140/75 86 18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA, EOMs
intact
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grosly intact
DISCHARGE:
Unchanged from admission.
Pertinent Results:
ADMISSION:
___ 04:05PM BLOOD WBC-8.9 RBC-4.50* Hgb-13.4* Hct-42.6
MCV-95 MCH-29.9 MCHC-31.5 RDW-13.7 Plt ___
___ 04:05PM BLOOD Neuts-60.4 ___ Monos-6.6 Eos-2.2
Baso-0.9
___ 04:05PM BLOOD ___ PTT-29.9 ___
___ 04:05PM BLOOD Glucose-102* UreaN-17 Creat-1.2 Na-138
K-5.8* Cl-105 HCO3-23 AnGap-16
___ 04:05PM BLOOD Albumin-4.1 Calcium-10.5* Phos-4.1 Mg-1.9
___ 04:11PM BLOOD Lactate-2.9* K-5.4*
PERTINENT:
___ 04:05PM BLOOD cTropnT-<0.01
___ 12:29AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:30AM BLOOD CK-MB-4 cTropnT-<0.01
DISCHARGE:
___ 06:30AM BLOOD WBC-7.2 RBC-4.26* Hgb-13.6* Hct-41.0
MCV-96 MCH-31.9 MCHC-33.1 RDW-13.5 Plt ___
___ 06:30AM BLOOD Glucose-148* UreaN-15 Creat-1.3* Na-139
K-4.2 Cl-107 HCO3-24 AnGap-12
___ 06:30AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7
___ 10:00AM BLOOD Lactate-1.5
STUDIES:
___ EKG:
Sinus rhythm. Non-specific ST-T wave changes, although ischemia
or infarction cannot be excluded. No previous tracing available
for comparison.
___ CXR:
IMPRESSION:
No acute cardiopulmonary process.
___ CT HEAD:
IMPRESSION: No acute intracranial process. Prominent volume
loss for
patient's age.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
hold for sbp < 100
2. Vitamin D 1000 UNIT PO DAILY
3. saxagliptin *NF* 5 mg Oral QD
4. docosahexanoic acid-epa *NF* 120-180 mg Oral QD
5. resveratrol *NF* 250 mg Oral QD
6. Allopurinol ___ mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. docosahexanoic acid-epa *NF* 120-180 mg Oral QD
4. Lisinopril 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. resveratrol *NF* 250 mg Oral QD
7. saxagliptin *NF* 5 mg Oral QD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- syncope, likely orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with syncope.
COMPARISON: ___.
FINDINGS:
Frontal and lateral views of the chest. Again seen is elevation of the left
hemidiaphragm. The lungs are clear of focal consolidation, effusion, or
pulmonary vascular congestion. Again seen is elevation of the left
hemidiaphragm. No acute osseous abnormality detected. Surgical clips seen in
the abdomen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Syncope.
COMPARISON: None.
TECHNIQUE: Non-contrast-enhanced MDCT axial images through the head were
obtained. Coronal, sagittal and thin section bone algorithm reconstructed
images were obtained.
FINDINGS: There is no evidence of acute intracranial hemorrhage, midline
shift, mass effect, or acute large vascular territorial infarction.
Prominence of the ventricles and sulci reflects age-related involutional
changes. Gray-white matter differentiation is preserved. The basal cisterns
are patent. There is minimal mucosal thickening in the paranasal sinuses and
sphenoid sinus. The mastoid air cells are clear. No fractures seen.
IMPRESSION: No acute intracranial process. Prominent volume loss for
patient's age.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: SYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.2
heartrate: 80.0
resprate: 16.0
o2sat: 97.0
sbp: 159.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with past medical history of NIDDM,
hypertension, and recent urologic intervention for kidney stones
on ___ presenting s/p syncopal episode. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pleuritic chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p renal transplant in ___ (unable to obtain IV dye), afib
on coumadin recently sub-therapeutic, who presents with ___ days
of pleuritic chest pain under her left breast. She denied any
pain at rest, dyspnea or lower extremity pain or swelling. She
was seen at ___ on ___ where she reported a recent car trip to
___ in the middle of last week ___ach way). Her
INR was found to be 1.2. She also notes recent exercise which
she thinks may have contributed to the pain. She currently feels
at baseline, with no pain. No recent fevers/chills. No chest
pain or abdominal pain. No shortness of breath.
- Initial vitals: 98.4 88 145/72 99% RA
- Labs were notable for UA neg for infection. INR was 1.2. Chem7
was notable Cr of 1.4, Trop negative. Alb 3.1, AP 133. CBC: 7.9
/ 10.1 /
- Studies performed include CXR showing stable small to moderate
bilateral pleural effusions and stable mild cardiomegaly and
pulmonary artery enlargement. Bilateral LENIS were negative
- Patient was given 1mg warfarin
On the floor patient feels well, no pleuritic pain, no shortness
of breath.
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:
ATRIAL FIBRILLATION
CHRONIC KIDNEY DISEASE
DIABETES TYPE II
HYPERLIPIDEMIA
HYPERTENSION
GALLSTONE PANCREATITIS S/P SPHINCTEROTOMY
S/P RENAL TRANSPANT
SYSTOLIC CONGESTIVE HEART FAILURE EF ___
SHINGLES - FOREHEAD
DIABETES MELLITUS
MITRAL REGURGITATION
URINARY TRACT INFECTION
RENAL TRANSPLANT ___
BILATERAL NEPHRECTOMIES ___
SPHINCTEROTOMY
BREAST AUGMENTATION
Social History:
___
Family History:
Sister RENAL TRANSPLANT
Daughter POLYCYSTIC KIDNEYS
Physical Exam:
Physical exam on admission:
=================================
Vitals: 99.1 162/97 96 16 99% RA blood sugar 371
General: comfortable, in NAD
HEENT: MMM, PERRL, oropharynx clear
Neck: supple
CV: RRR, normal s1 and s2
Lungs: CTAB
Abdomen: soft, nontender, nondistended
Ext: warm, well perfused, no ___ edema
Neuro: alert and oriented x 3, moving all extremities with
purpose. CN II-XI intact
Physical exam on discharge:
=================================
Vitals: 98.5 (101.0) 158/99 86 16 99% RA
General: comfortable, in NAD
HEENT: MMM, PERRL, oropharynx clear
Neck: supple
CV: RRR, normal s1 and s2
Lungs: CTAB
Abdomen: soft, mild ttp over transplanted kidney in RLQ, no RUQ
tenderness, nondistended
Ext: warm, well perfused, no ___ edema
Neuro: alert and oriented x 3, moving all extremities with
purpose. CN II-XI intact
Pertinent Results:
Labs on admission:
=========================
___ 12:24PM BLOOD WBC-9.8 RBC-3.44* Hgb-10.5* Hct-30.2*
MCV-88 MCH-30.5 MCHC-34.8 RDW-12.7 RDWSD-40.1 Plt ___
___ 12:24PM BLOOD Neuts-88.4* Lymphs-7.1* Monos-3.8*
Eos-0.2* Baso-0.1 Im ___ AbsNeut-8.70* AbsLymp-0.70*
AbsMono-0.37 AbsEos-0.02* AbsBaso-0.01
___ 12:24PM BLOOD ___
___ 12:24PM BLOOD Plt ___
___ 12:24PM BLOOD UreaN-21* Creat-1.2* Na-132* K-4.4 Cl-97
HCO3-24 AnGap-15
___ 12:24PM BLOOD ALT-15 AST-20
___ 12:24PM BLOOD Lipase-35
___ 12:24PM BLOOD Calcium-9.1
___ 03:30PM BLOOD Albumin-3.1* Calcium-9.0 Phos-2.6*#
Mg-1.8
___ 02:43PM BLOOD D-Dimer-___*
___ 03:35PM BLOOD Lactate-1.8
Reports:
=========================
IMPRESSION:
1. Multiple liver cysts and tortuous anechoic structures in the
central liver
which may represent additional cysts and/or saccular dilation of
bile ducts,
several with either intraductal stones or parenchymal
calcifications. MRCP is
suggested for further delineation and to exclude a common
hepatic duct stone
or other central cause of apparent biliary dilation, versus
intrinsic biliary
dilation such as could be due to ___'s disease or
cholangiohepatitis.
2. Trace perihepatic ascites and small left pleural effusion.
RECOMMENDATION(S): MRCP is recommended for further evaluation.
V/Q Scan
IMPRESSION: Low likelihood ratio for acute pulmonary embolism.
By electronically signing this report, I, the attending
physician, attest that I have
reviewed the images associated with the above examination(s) and
agree with the findings as documented above.
Microbiology:
=========================
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine: Pending x3
Labs on discharge:
=========================
___ 07:15AM BLOOD WBC-5.3 RBC-2.89* Hgb-8.6* Hct-25.1*
MCV-87 MCH-29.8 MCHC-34.3 RDW-12.6 RDWSD-40.1 Plt ___
___ 07:15AM BLOOD Glucose-151* UreaN-19 Creat-1.4* Na-135
K-3.5 Cl-101 HCO3-23 AnGap-15
___ 07:15AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.6
___ 07:15AM BLOOD ___ PTT-87.9* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Mycophenolate Mofetil 250 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Metoprolol Succinate XL 100 mg PO BID
5. Losartan Potassium 25 mg PO DAILY
6. Lorazepam 0.5 mg PO QHS:PRN anxiety
7. GlipiZIDE XL 5 mg PO DAILY
8. Furosemide 20 mg PO DAILY:PRN leg swelling
9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
10. Diltiazem Extended-Release 120 mg PO DAILY
11. Atorvastatin 10 mg PO QHS
12. Ezetimibe 10 mg PO DAILY
13. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
14. Warfarin 1 mg PO DAILY16
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral 2 tablets once a day
Discharge Medications:
1. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
5. Furosemide 20 mg PO DAILY:PRN leg swelling
6. Lorazepam 0.5 mg PO QHS:PRN anxiety
7. Metoprolol Succinate XL 100 mg PO BID
8. Losartan Potassium 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Mycophenolate Mofetil 250 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*3 Tablet Refills:*0
13. Atorvastatin 10 mg PO QHS
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral 2 tablets once a day
15. GlipiZIDE XL 5 mg PO DAILY
16. Warfarin 1 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fevers
Chest pain
Commmunity acquired pneumonia
Secondary:
status post renal transplant
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with L chest pain, c/f PE // Eval for acute process
TECHNIQUE: Upright PA and lateral chest
COMPARISON: Chest radiographs ___ through ___
FINDINGS:
Lung volumes are normal. Small to moderate bilateral pleural effusions are
unchanged since yesterday. Left retrocardiac opacity likely reflects
atelectasis. There is no new worrisome pulmonary opacity. Mild cardiomegaly
is unchanged. As before the main pulmonary artery is enlarged. There is no
pneumothorax.
IMPRESSION:
1. Stable small to moderate bilateral pleural effusions.
2. Stable mild cardiomegaly and pulmonary artery enlargement.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with chest pain, elevated D-dimer, unable to
CTPA // Eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with polycystic kidney disease presenting with
fevers, history of infected liver cysts.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
There is a small left pleural effusion.
LIVER: There are multiple liver cysts which appear simple. In addition,
there are tortuous anechoic structures in the central aspect of the liver
which appear compatible with saccular dilation of bile ducts. There are
number of associated echogenic foci which are either intraductal stones or
parenchymal calcifications. The main portal vein is patent with hepatopetal
flow. There is trace perihepatic ascites.
BILE DUCTS: The extrahepatic bile ducts appear nondilated and the CBD
measures 5 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, with top-normal size measuring 13.1 cm.
KIDNEYS: Survey evaluation of the transplant kidney reveals no
hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Multiple liver cysts and tortuous anechoic structures in the central liver
which may represent additional cysts and/or saccular dilation of bile ducts,
several with either intraductal stones or parenchymal calcifications. MRCP is
suggested for further delineation and to exclude a common hepatic duct stone
or other central cause of apparent biliary dilation, versus intrinsic biliary
dilation such as could be due to Caroli's disease or cholangiohepatitis.
2. Trace perihepatic ascites and small left pleural effusion.
RECOMMENDATION(S): MRCP is recommended for further evaluation.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Elevated D-dimer
Diagnosed with CHEST PAIN NOS, ATRIAL FIBRILLATION, KIDNEY TRANSPLANT STATUS, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 98.4
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 145.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ s/p renal transplant in ___ (unable to obtain IV dye), on
immunosuppresion, s/p bilateral nephrectomies, afib on coumadin
recently sub-therapeutic, who presents with ___ days of
pleuritic chest pain under her left breast after 12 hours
driving which resolved upon presentation. CP was of unclear
cause. VQ scan was low probability. Patient notes some exercise
recently and thinks this may have caused her pain. cardiac
enzymes negative, EKG reassuring for ACS. patient was
subtherapeutic on coumadin and has CHADS2 score of 3, and was
treated with heparin gtt. Patient had fevers of unknown
etiology, blood cultures were drawn which were pending at time
of discharge. The patient remained afebrile for 24 hours and
was treated for presumed community acquired pneumonia given her
subjective symptoms of pleuritic chest pain and pleural effusion
on admission CXR.
# FEVERS - Pt admitted for chest pain but spiked low grade
fevers during admission. Initially placed on empiric vancomycin
and zosyn, but continued spiking fevers without apparent source.
CXR showed minor pulmonary effusion on the R side. No
localizing infectious symptoms, and fever resolved. Has
reportedly had history of liver cyts which were again
demonstrated on RUQ US without RUQ tenderness to palpation, thus
not believed to be the source of intermittent fevers. The
patient remained afebrile for 24 hours and was treated for
presumed community acquired pneumonia given her subjective
symptoms of pleuritic chest pain and pleural effusion on
admission CXR without obvious localizing infectious signs, clear
V/Q scan, and negative urine and blood cultures at the time of
discharge.
# CP: The patient had an admission EKG and troponins reassuring
for ACS, but reported pleuritic chest pain on admission. Given
a sub-therapeutic INR the patient was begun on a heparin drip,
and with a recent history of travel and elevated d-dimer a V/Q
scan was ordered which showed low probability of a pullmonary
embolism. The patient's chest pain resolved completely by
hospital day 2. Given that her only subjective complaint on
admission was pleuritic chest pain, it was believed that her
pain likely stemmed from a parapneumonic effusion and the
patient was treated for community acquired pneumonia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrocodone / acetaminophen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENTING ILLNESS:
___ h/o HCV/EtOH, cirrohsis w/HCC, hepatic encephelopathy, COPD
on 3L home O2 presents with shortness of breath and abdominal
pain. Patient was admitted to ___ ___ for fatigue. Treated
with cipro/flagyl, changed to cipro 500mg for SBP prophylaxis,
discharged on this. Patient felt "great" all of ___, and
around 11pm-12am he developed bloating "gas like" abdominal pain
in his mid abdomen. He could not burp or fart and developed
worsening pain and abd distention. He said the pain did not
radiate. Associated nausea. The distention got to the point that
it was interfering with his breathing. He took a nebulizer and
inhaler, but his symptoms persisted. He called his ___ this
morning who evaluated him and decided to send him to the ED. He
said that his pain is resolving and his breathing is improved
and back to baseline.
The patient was a little upset this afternoon because of the
discouraging news he received during his last admission that he
would not be a transplant candidate secondary to his
comorbidities. He is also frustrated how often he comes to the
hopsital and his goal is to be home with his family. He has had
experienced with hospice in the past when his first wife passed
and they were good experiences.
In the ED, initial vitals were pain ___, T97.9, HR74, BP97/74,
RR20, O2sat:98% 6L NC. Labs were notable for BNP of 269, Hct
29.8 (baseline). He was noted to have an in respiratory effort,
and was unable to get through a full sentence with a single
breath. He had poor air movement on physical exam, but no
wheezes, rales or rhonchi. His CXR was negative for focal
consolidation or evidence of volume overload. He was treated
with nebulizers, lasix, and some zofran.
Upon arrival to the floor the patient felt that his breathing
was back to his baseline and his abdominal symptoms were
improving.
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:
#HCV Cirrhosis
- S/P 6 months of interferon
- Last VL ___ was 219,000 IU/mL.
- Not a transplant candidate here due to positive tox screen
- Undergoing transplant eval at ___ (per ___,
pulmonary HTN may be impediment to transplant)
-c/b ___ s/p CPK ___, HE, fluid overload, secondary SBP
(complication from prior paracentesis) and renal dysfunction.
# Pulmonary hypertension (followed by pulmonary at ___ and at
___)
# Substance abuse-quit ETOH ___, IV drugs in ___
# Hypertension
# OSA (not on CPAP)
# COPD (most recent PFTs with only mild obstruction)
# Hx CAD, MI in ___ on anti-platelet agents due to
thrombocytopenia
# Thrombocytopenia
# dCHF
# ___ trauma-Reconstructive leg surgery after fall from building
# Chronic musculoskeletal pain on narcotics as an outpatient
# Gunshot wound to head ___
# Erectile dysfunction
# Basal cell carcinoma
.
Past Surgical History:
# S/p R TKR (poly liner exchange) ___
# ___ Closed reduction right knee dislocation with
anesthesia
# Appendectomy
# Avulsion fracture of R ___ metatarsal
# S/P Right TKR (poly liner exchange) ___
# ___ Closed reduction right knee dislocation with
anesthesia and manipulation
Social History:
___
Family History:
Mother with ___. Maternal grandmother with MI. No known
family history of cancer. Brother with CAD at age ___. Brother
s/p heart transplant
Physical Exam:
VS: T: 98.4, HR: 76, BP: 140/78, RR: 16 ___ when talking,
98%2L . 6'3" 264.6lbs
General: Chronically ill appearing man lying in bed, short of
breath near the end of his sentence
HEENT: Sclera anicteric, conjunctiva pink
Neck: JVP just above the clavicle when sitting at 90 degrees
Heart: ___ holosystolic murmur at left lower sternal border
Lungs: clear bilaterally after cough
Abdomen: Soft, non-distended, tender in the epigastric region,
no shifting dullness, ro fluid wave
Extremities: 2+ radial pulses, ecchymoses on left forearm, 3+
edema to ankles and tapers to mid shin bilaterally
Neurological: CN II-XII intact, no asterixis
.
On Discharge:
I/O: 8hr 340/BR +0BM
VS: Tm 98.7 Tc 98.1 110/70 77 22 97% 3L; weight 120kg
GEN: Chronically ill-appearing man sitting up in bed in NAD,
alert, interactive
HEENT: Sclera anicteric, conjunctiva pink
Heart: ___ holosystolic murmur, Normal rate, reg rhythm
Lungs: Faint crackles at bases b/l, otherwise clear
Abdomen: Soft, non-distended, nontender, no shifting dullness,
ro fluid wave
Extremities: 2+ radial pulses, ecchymoses on left forearm, 3+
edema to ankles and tapers to mid shin bilaterally
Neurological: CN II-XII intact, no asterixis
Pertinent Results:
CBC Trend
___ 11:45AM BLOOD WBC-6.1 RBC-2.77* Hgb-10.1* Hct-29.8*
MCV-108* MCH-36.6* MCHC-34.0 RDW-17.7* Plt Ct-70*
___ 07:30AM BLOOD WBC-5.8 RBC-2.66* Hgb-9.8* Hct-28.3*
MCV-106* MCH-36.7* MCHC-34.5 RDW-18.0* Plt Ct-71*
.
Coags
___ 07:30AM BLOOD ___ PTT-31.4 ___
.
Chemistry
___ 11:45AM BLOOD Glucose-136* UreaN-19 Creat-0.8 Na-133
K-3.5 Cl-100 HCO3-25 AnGap-12
___ 07:30AM BLOOD Glucose-161* UreaN-19 Creat-0.8 Na-133
K-3.5 Cl-98 HCO3-27 AnGap-12
.
LFT trend
___ 11:45AM BLOOD ALT-46* AST-81* LD(LDH)-376* AlkPhos-134*
TotBili-3.1*
.
Lactate
___ 11:55AM BLOOD Lactate-1.7
.
CXR:
FINDINGS: AP upright and lateral views of the chest are
provided. Lung
volumes are low. Lungs are essentially clear with mild vague
opacity in the lower lungs which likely represents chronic
scarring or atelectasis. The heart and mediastinal contours
appear stable. No pneumothorax or pleural effusion. Bony
structures are intact.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB?Wheezing
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Ciprofloxacin HCl 500 mg PO Q24H
4. GlipiZIDE XL 10 mg PO DAILY
5. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Lactulose 30 mL PO TID
7. Mirtazapine 15 mg PO HS
8. Nadolol 40 mg PO DAILY
9. Nystatin Oral Suspension 5 mL PO TID
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
12. Pantoprazole 40 mg PO Q12H
13. Potassium Chloride 20 mEq PO DAILY
14. Rifaximin 550 mg PO BID
15. Sildenafil 20 mg PO TID
16. Torsemide 20 mg PO DAILY
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/Wheezing
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB?Wheezing
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Lactulose 30 mL PO TID
6. Mirtazapine 15 mg PO HS
7. Nadolol 40 mg PO DAILY
8. Nystatin Oral Suspension 5 mL PO TID
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
11. Pantoprazole 40 mg PO Q12H
12. Potassium Chloride 20 mEq PO DAILY
13. Rifaximin 550 mg PO BID
14. Sildenafil 20 mg PO TID
15. Torsemide 20 mg PO DAILY
16. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/Wheezing
17. Simethicone 80 mg PO QID:PRN abdominal pain
RX *simethicone 80 mg 1 mg by mouth every 6hours Disp #*60
Tablet Refills:*0
18. GlipiZIDE XL 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cirrhosis
Pulmonary Artery 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
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___ and ___.
CLINICAL HISTORY: Short of breath, question pneumonia or edema.
FINDINGS: AP upright and lateral views of the chest are provided. Lung
volumes are low. Lungs are essentially clear with mild vague opacity in the
lower lungs which likely represents chronic scarring or atelectasis. The
heart and mediastinal contours appear stable. No pneumothorax or pleural
effusion. Bony structures are intact.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, ALCOHOL CIRRHOSIS LIVER, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 97.9
heartrate: 74.0
resprate: 20.0
o2sat: 98.0
sbp: 97.0
dbp: 74.0
level of pain: 4
level of acuity: 2.0 | ___ year old with HCV/EtOH cirrhosis w/ HCC, hepatic
encephalopathy, gastric varices on EGD this year, secondary
bacterial peritonitis (complication of paracentesis), DM, renal
dysfunction, COPD, who is presenting with SOB.
ACTIVE ISSUES
# Chronic dyspnea on exertion: He has had multiple recent
admissions for treatment of SOB and etiology is likely
multifactorial but largely secondary to his severe pulmonary
hypertension. He is on continuous 3L NC home O2 and on admission
to the floor was on ___, at his baseline. On his last admission
with SOB/hypoxia, he was seen by pulm, and he underwent diuresis
and was treated with sildenafil, which improved his respiratory
status. CXR on this admission was essentially clear, without
evidence of CHF. His weight is actually down from recent weights
in clinic, and up 1.6pbs since admission on ___. He had some
mild elevated JVP and persistent lower extremity edema, however
BNP not significantly elevated. After the patient passed flatus
and his abdominal distention related to bloating resolved, his
breathing became much more comfortable. He was also given a
slightly higher dose of 30mg torsemide on the evening of
admission. This was switched back to 20mg torsemide as his home
dose on discharge.
# Abdominal Pain: Resolved on admission. Differential diagnosis
on admission included SBP, abdominal cramping secondary to
indigestion/gas. On admission exam was without appreciable
ascites and bedside ultrasound devoid of tap-able fluid
collection. Patient treated symptomatically with simethicone
with resolution of symptoms. Surmised that cramping may have
ensued due to bloating caused by aggressive lactulose use. At
time of discharge patient was without pain. He was continued on
cipro for SBP prophylaxis, lactulose for prevention of hepatic
encephalopathy with instruction for prpoer titration. In
addition he was given a prescription for simethicone for future
symptomatic treatment of gas/bloating
CHRONIC ISSUES
# Cirrhosis: Compensated without encephalopathy. Grade I varices
on last EGD in ___. MELD 16 on admission. In house he was
continued on nadolol 40 mg, Lactulose 30ml TID, rifaximin 550mg
PO BID, Cipro 500mg PO Daily for SBP prophylaxis
# GAVE like appearance of the antrum seen on EGD in ___ and no evidence of bleeding. Patient continued on PPI
# Hx CAD, MI in ___ on anti-platelet agents due to
thrombocytopenia. Patient was without cardiac complaint in
house.
# dCHF: Mildlty decompensated as above. Torsemide was increased
to 30mg PO on admission. Patient restarted on home 20mg QD prior
to discharge. At time of discharge he was oxygenating >95% on
home 3L with a discharge weight of a 120kg (standing scale).
# Chronic musculoskeletal pain. Patient was continued on home
Oxycontin and oxycodone.
# DMII. ___ well controlled in house on home glipizide 10mg PO
Daily in addition to home insulin regimen
TRANSITIONAL ISSUES
None. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
adhesive tape / Iodine-Iodine Containing / Latex / Penicillins
Attending: ___
Chief Complaint:
SOB, DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ male with a past medical history
of hepatitis C, COPD, Sarcoidosis decompensated with
gastrointestinal bleeding, status post TIPS and encephalopathy
presenting from clinic with worsening DOE, cough, Abd pain
acutely for the last 2 weeks, but with flares in SOB often in
the past. His cough is productive of whiteish phlegm and he
endorces SOB while lying flat and with minimal exertion. Prior
to this, he only rarely had DOE and never dyspnea at rest. No
N/V, hematemsis, melena, sick contacts. He does endorce
occasional chest pain and pain in both legs with ambulation. His
PO2 on ___ was 72, today ___ is 60, which is close to
meeting exception points for HPS.
Past Medical History:
(1) Diabetes
(2) Hypertension
(3) Sarcoidosis
(4) OSA
(5) Depression
(6) HCV cirrhosis, c/b esophageal varices s/p TIPs,
encephalopathy, and ascites, currently on transplant list.
Social History:
___
Family History:
NC
Physical Exam:
General: NAD
HEENT: NO LAD or thyromegaly, No JVD
CV: RRR, no m/r/g, S1, S2
Lungs: Course breath sounds with fine crakles
Abdomen: Soft, NT, ND, +BS
Ext: MAE, warm, well profused, 2+ DP pulses bilaterally.
Neuro: CN II-XII intact.
Skin: severe finger clubbing.
Discharge:
VS: 98 102 122/62 20 94 2L
General: NAD
HEENT: NO LAD or thyromegaly, No JVD
CV: RRR, no m/r/g, S1, S2
Lungs: Course breath sounds with fine crakles
Abdomen: Soft, NT, ND, +BS
Ext: MAE, warm, well profused, 2+ DP pulses bilaterally.
Neuro: CN II-XII intact.
Skin: severe finger clubbing.
Pertinent Results:
___ 11:27AM URINE HOURS-RANDOM
___ 11:27AM URINE HOURS-RANDOM
___ 11:27AM URINE UHOLD-HOLD
___ 11:27AM URINE GR HOLD-HOLD
___ 11:27AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:27AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 11:27AM URINE RBC-4* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:27AM URINE MUCOUS-RARE
___ 11:02AM TYPE-ART PO2-60* PCO2-29* PH-7.47* TOTAL
CO2-22 BASE XS-0
___ 11:02AM O2 SAT-89
___ 10:07AM ___ COMMENTS-GREEN TOP
___ 10:07AM LACTATE-1.9
___ 09:55AM GLUCOSE-135* UREA N-8 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16
___ 09:55AM estGFR-Using this
___ 09:55AM ALT(SGPT)-57* AST(___)-115* ALK PHOS-92 TOT
BILI-2.7*
___ 09:55AM ALT(SGPT)-57* AST(SGOT)-115* ALK PHOS-92 TOT
BILI-2.7*
___ 09:55AM LIPASE-72*
___ 09:55AM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.6
MAGNESIUM-1.7
___ 09:55AM WBC-4.2 RBC-4.04* HGB-14.4 HCT-40.3 MCV-100*
MCH-35.7* MCHC-35.8* RDW-17.1*
___ 09:55AM NEUTS-74.6* LYMPHS-14.9* MONOS-6.0 EOS-3.9
BASOS-0.6
___ 09:55AM PLT COUNT-104*
___ 09:55AM ___ PTT-35.1 ___
Final Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with hx of sarcoidosis, pulmonary
hypertension
now with hypoxemia and shortness of breath. Diffuse crackles in
the lower half
of lung. Improved somewhat with diuresis but BNP normal. Please
eval for
pulmonary edema versus interstitial lung disease. // eval for
pulmonary edema
versus interstial lung disease
TECHNIQUE: Multidetector helical scanning of the chest was
reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and
parasagittal,
and 8 x 8 mm MIPs axial images
DOSE: DLP: Not yet avail
COMPARISON: Chest x-ray ___ and chest CTA ___
FINDINGS:
Subcentimeter mediastinal lymph nodes most prominent in the
prevascular region
are similar to prior CT. Main pulmonary artery is enlarged at
3.5 cm
suggesting pulmonary arterial hypertension. Heart is upper
limits of normal in
size. There is no pericardial or pleural effusion. The right
pericardial lymph
node is similar to the prior CT. Small hiatal hernia is
incidentally noted, as
well as possible paraesophageal varices.
Exam was not tailored to evaluate the subdiaphragmatic region,
but note is
made of a TIPS T IPS, cirrhotic appearing liver, and
splenomegaly. Several
cystic lesions are present in the kidneys and have been more
fully
characterized on previous ultrasound exams.
There are no suspicious lytic or blastic skeletal lesions in the
thorax.
The lungs appear heterogeneous with a widespread ground-glass
opacities as
well as extensive areas of reticulation. The reticular opacities
have an upper
and mid lung predominance, but the lower lobes are also
involved. Distribution
is subpleural and peribronchovascular. Mild traction
bronchiectasis is also
demonstrated. The lungs are otherwise remarkable for mild
centrilobular
emphysema with upper lung predominance.
The patient is had a previous left lower lobe wedge resection,
with stable
postoperative appearance.
IMPRESSION:
1. Diffuse interstitial lung disease, with upper and mid lung
predominance.
Appearance is nonspecific, but is most likely due to provided
history of
sarcoidosis. Differential diagnosis includes chronic
hypersensitivity
pneumonitis.
2. Mild emphysema.
3. Enlarged pulmonary artery consistent with history of
pulmonary
hypertension.
4. Cirrhosis and findings consistent with portal hypertension.
___. ___
___: FRI ___ 1:04 ___
Imaging Lab
There is no report history available for viewing.
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Moderately increased LA volume index.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Estimated cardiac
index is normal (>=2.5L/min/m2). Doppler parameters are most
consistent with Grade I (mild) LV diastolic dysfunction. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
TASPE normal (>=1.6cm)
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. Normal mitral valve
supporting structures. No MS.
___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. The end-diastolic PR velocity is
increased c/w PA diastolic hypertension.
Conclusions
The left atrial volume index is moderately increased. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Doppler parameters are most
consistent with Grade I (mild) left ventricular diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. Tricuspid annular plane systolic excursion is normal
(2.1 cm; nl>1.6cm) consistent with normal right ventricular
systolic function. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is mild
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension.
IMPRESSION: Normal biventricular regional/global systolic
function. There is mild pulmonary artery systolic and diastolic
hypertension. Type I pattern diastolic dysfunction with
prolonged isovolumic relaxation pattern. However, with E/e' of 8
and E wave velocity of < 0.5 m/s elevated LVEDP is unlikely.
Mild ascending aorta dilation.
Compared with the prior study (images reviewed) of ___,
findings are similar.
Electronically signed by ___, MD, Interpreting
physician ___ ___ 14:53
Final Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with TIPS procedure presenting with
ABD pain,
SOB, and cough. // Eval for TIPS patency
TECHNIQUE: Grey scale ultrasound images of the abdomen were
obtained. Color
Doppler and spectral waveform analysis was performed.
COMPARISON: Liver ultrasound ___
FINDINGS:
LIVER: The hepatic architecture is coarsened in appearance.
There is no focal
liver mass. There is no ascites in the right upper quadrant.
BILE DUCTS: There is no intrahepatic biliary dilation.
DOPPLER EXAMINATION: The main portal vein is patent with
hepatopetal flow at a
velocity of 30 cm/sec. The TIPS shunt is patent with wall to
wall flow and
velocities of 138, 117, and 123 cm per second in the proximal,
mid and distal
portions respectively. Flow within the left portal vein is
minimal and is
toward the TIPS shunt. The right portal vein is aneurysmal with
helical flow.
The flow appears to be predominantly away from the TIPS shunt.
IMPRESSION:
1. Patent TIPS shunt with stable velocities.
2. Coarsened hepatic architecture. No focal liver lesion
identified.
The study and the report were reviewed by the staff radiologist.
___, ___
___. ___
___ ___ 4:29 ___
Imaging Lab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO BID
2. Valsartan 160 mg PO DAILY
3. Magnesium Oxide 400 mg PO TID
4. Rifaximin 550 mg PO BID
5. Glargine 47 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. ProAir HFA (albuterol sulfate) 108 mcg inhalation BID
8. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Glargine 47 Units Breakfast
3. Lactulose 30 mL PO BID
4. Magnesium Oxide 400 mg PO TID
5. Rifaximin 550 mg PO BID
6. Valsartan 160 mg PO DAILY
7. ProAir HFA (albuterol sulfate) 108 mcg inhalation BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Home O2
Patient's ambulatory O2 sat is 87%. Please provide patient with
2L continuous O2 with ambulation.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Intersitial Lung Disease
2. Hepatopulmonary syndrome
3. Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Shortness of breath. Question pneumonia.
COMPARISON: Scout view from CT performed on ___.
TECHNIQUE: Chest, AP and lateral.
FINDINGS:
A mild to moderate interstitial abnormality is most suggestive of interstitial
pulmonary edema. The cardiac, mediastinal and hilar contours appear stable.
There is no pleural effusion or pneumothorax. A TIPS shunt projects over the
right upper quadrant and there are also surgical clips. In addition
embolization coils are noted immediately to the right of midline as well as in
left upper quadrant, all unchanged findings.
IMPRESSION:
Findings suggesting mild to moderate pulmonary edema. Other etiologies such
as atypical pneumonia could be considered, however, depending on clinical
circumstances.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with TIPS procedure presenting with ABD pain,
SOB, and cough. // Eval for TIPS patency
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained. Color
Doppler and spectral waveform analysis was performed.
COMPARISON: Liver ultrasound ___
FINDINGS:
LIVER: The hepatic architecture is coarsened in appearance. There is no focal
liver mass. There is no ascites in the right upper quadrant.
BILE DUCTS: There is no intrahepatic biliary dilation.
DOPPLER EXAMINATION: The main portal vein is patent with hepatopetal flow at a
velocity of 30 cm/sec. The TIPS shunt is patent with wall to wall flow and
velocities of 138, 117, and 123 cm per second in the proximal, mid and distal
portions respectively. Flow within the left portal vein is minimal and is
toward the TIPS shunt. The right portal vein is aneurysmal with helical flow.
The flow appears to be predominantly away from the TIPS shunt.
IMPRESSION:
1. Patent TIPS shunt with stable velocities.
2. Coarsened hepatic architecture. No focal liver lesion identified.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with hx of sarcoidosis, pulmonary hypertension
now with hypoxemia and shortness of breath. Diffuse crackles in the lower half
of lung. Improved somewhat with diuresis but BNP normal. Please eval for
pulmonary edema versus interstitial lung disease. // eval for pulmonary edema
versus interstial lung disease
TECHNIQUE: Multidetector helical scanning of the chest was reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images
DOSE: DLP: Not yet avail
COMPARISON: Chest x-ray ___ and chest CTA ___
FINDINGS:
Subcentimeter mediastinal lymph nodes most prominent in the prevascular region
are similar to prior CT. Main pulmonary artery is enlarged at 3.5 cm
suggesting pulmonary arterial hypertension. Heart is upper limits of normal in
size. There is no pericardial or pleural effusion. The right pericardial lymph
node is similar to the prior CT. Small hiatal hernia is incidentally noted, as
well as possible paraesophageal varices.
Exam was not tailored to evaluate the subdiaphragmatic region, but note is
made of a TIPS T IPS, cirrhotic appearing liver, and splenomegaly. Several
cystic lesions are present in the kidneys and have been more fully
characterized on previous ultrasound exams.
There are no suspicious lytic or blastic skeletal lesions in the thorax.
The lungs appear heterogeneous with a widespread ground-glass opacities as
well as extensive areas of reticulation. The reticular opacities have an upper
and mid lung predominance, but the lower lobes are also involved. Distribution
is subpleural and peribronchovascular. Mild traction bronchiectasis is also
demonstrated. The lungs are otherwise remarkable for mild centrilobular
emphysema with upper lung predominance.
The patient is had a previous left lower lobe wedge resection, with stable
postoperative appearance.
IMPRESSION:
1. Diffuse interstitial lung disease, with upper and mid lung predominance.
Appearance is nonspecific, but is most likely due to provided history of
sarcoidosis. Differential diagnosis includes chronic hypersensitivity
pneumonitis.
2. Mild emphysema.
3. Enlarged pulmonary artery consistent with history of pulmonary
hypertension.
4. Cirrhosis and findings consistent with portal hypertension.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC, ACUTE LUNG EDEMA NOS
temperature: 99.4
heartrate: 95.0
resprate: 20.0
o2sat: 90.0
sbp: 173.0
dbp: 85.0
level of pain: 7
level of acuity: 2.0 | ASSESSMENT AND PLAN
___ is a ___ male with a past medical history of
hepatitis C, decompensated with gastrointestinal bleeding,
status post TIPS and encephalopathy presenting from clinic with
worsening DOE, and cough.
## SOB - Multiple etiologies for SOB including Cardiac (excess
preload from TIPS malfunction), paraenchymal disease from
Sarcoid, Pulmonary HTN from TIPS malfuntion, and HPS. ABG
showing P02 of 60. PE excluded. Pt fluid overloaded on exam with
crakles, ___ edema, and orthopnea. Appears to be worsening
Pulmonary HTN based on workup.
Pt was diuresed with 40 mg IV Lasix and improved. Pulm consulted
and requested ECHO to assess for worsening of pulmonary HTN
since TIPS redo, Chest CT to better characterize lung disease,
PFTs, and full rheum panel for autoimmune diseases.
Sats fell to 80% with ambulation(according to pt, already has
home ___ daily)
## HEPATIC ENCEPHALOPATHY: H/O.
--- Lactulose 30mL TID and titrate to 3BM daily
--- Rifaximin 550 BID
## COPD:
Continue Home
- Ipratropium Bromide Neb 1 NEB IH Q6H
- Fluticasone-Salmeterol Diskus (250/50) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ambien / Cipro
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w history of CAD s/p DES x6 to RCA (most recently ___ here
with ___ chest pain that awoke her from sleep at 3a. She
describes her pain as pressure-like, radiating throughout her
precordium and towards her left arm, and was associated with
mild dyspnea and nausea. She took 2 sublingual nitroglycerin
tablets at home without relief. Her pain lasted until 530a,
leading her to call ___ for transportation to the ED. She last
experienced similar symptoms 6 months ago; a discharge summary
from ___ notes chest pain which resolved with naproxen. She
called her cardiologist this morning (she had a scheduled
appointment today and was intending to cancel her visit); her
cardiologist called ___ ED and suggested possible elective
catheterization. She denies recent URI, lymphadenopathy,
palpitations, cough, subjective fevers, diaphoresis, worsening
dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,
peripheral swelling, or changes in diet/fluid intake. She has
gained several pounds recently, attributed to the "holidays".
At her baseline, she is able to walk ___ blocks without
difficulty. She makes a point to walk the halls of her apartment
complex ___ times per day as well as perform choreographed
exercise routines at home. She notes walking approximately 2.5
mi/day in ___, and progressive decline since then.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
In the ED, initial vitals were 98.6, 76, 118/76, 18, 99% 2L NC.
Labs were significant for a troponin of <0.01 and an INR of 2.2.
She had a CXR which was initially read as normal, but a wet read
audit later showed question of retrocardiac pneumonia. She
received 0.4mg SL NTG (which she reports resulted in minimal
pain relief), 2.5mg of morphine (made her feel "... like I was
flying", and 2mg of ondansetron. She was admitted for rule-out
of ACS.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS:
- HTN
- HLD
2. CARDIAC HISTORY:
- Coronary artery disease ___: DES x3 to RCA; ___
after positive stress: 90% focal and 60% diffuse ISR of mRCA
stent s/p DES x2; ___ relook after similar symptoms:
patent
RCA stents; ___ with DOE: 70% ISR of mRCA stent bilayer s/p
DES x1; ___ after presumed UA presentation: all stents
patent; ___: mild ___ RCA ISR and stable 50% mLAD and
50% dLAD, mean PCWP 9 mmHg)
- atrial fibrillation s/p DCCV in ___, on dronedarone and
warfarin
- valvular heart disease (mild AS, 1+ MR, 1+ TR in ___
3. OTHER PAST MEDICAL HISTORY:
- GERD
- IBS
- costochondritis
Social History:
___
Family History:
Brother has ___, had CVA in his ___. Mother lived until
age ___, father died in his ___ of ruptured gallbladder.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS on arrival to floor: 97.7, 147/84, 63, 0.95ra
Gen: NAD, AAOx3, sitting in chair comfortably
HEENT: NC/AT, PERRLA, EOMI, mucosa moist and pink, oropharynx
clear without exudate or erythema,
CV: irregularly irregular, II-III/VI late peaking systolic
murmur at RUSB radiating throughout precordium
Pulses: carotid, subclavian, radial, dorsalis pedis 2+
bilaterally
Pulm: CTAB
Abd: BS+, soft, NT, ND
MSK: pulses as above, trace ___ PE to mid-shins bilaterally
Neuro: CNII-XII intact, moving all extremities, sensation to
light touch intact peripherally
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.3, 103-132/46-75, 57-80, 0.97ra
I/O: 290po/850urine
Gen: NAD, AAOx3, sitting in chair comfortably
HEENT: NC/AT, PERRLA, EOMI, mucosa moist and pink, oropharynx
clear without exudate or erythema,
CV: irregularly irregular, II-III/VI late peaking systolic
murmur at RUSB radiating throughout precordium
Pulses: carotid, subclavian, radial, dorsalis pedis 2+
bilaterally
Pulm: CTAB
Abd: BS+, soft, NT, ND
MSK: pulses as above, trace ___ PE to mid-shins bilaterally
Neuro: CNII-XII intact, moving all extremities, sensation to
light touch intact peripherally
Pertinent Results:
ADMISSION LABS:
___ 08:05AM BLOOD WBC-7.2 RBC-4.20 Hgb-12.6 Hct-39.9 MCV-95
MCH-30.0 MCHC-31.5 RDW-14.8 Plt ___
___ 08:05AM BLOOD Glucose-122* UreaN-17 Creat-1.1 Na-140
K-4.1 Cl-102 HCO3-29 AnGap-13
___ 08:05AM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD cTropnT-<0.01
___ 01:37AM BLOOD cTropnT-<0.01
___ 05:00AM BLOOD CK-MB-4 cTropnT-<0.01
___ 08:05AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
DISCHARGE LABS:
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD Glucose-105* UreaN-22* Creat-1.0 Na-141
K-4.4 Cl-102 HCO3-29 AnGap-14
EKG ___ Sinus rhythm with premature atrial complexes.
Non-specific ST segment flattening. Compared to the previous
tracing of ___ the atrial ectopy is F314 new.
CXR ___: IMPRESSION: Subtle retrocardiac opacity may reflect
early pneumonia in the appropriate clinical setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Dronedarone 400 mg PO BID
4. Warfarin 1 mg PO DAYS (___)
5. ___ Oil (Omega 3) 1000 mg PO BID
6. Lisinopril 2.5 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL PRN CP
8. Ranitidine 300 mg PO DAILY
9. Sertraline 25 mg PO DAILY
10. Warfarin 0.5 mg PO DAYS (___)
11. Estradiol 0.1 mg PO 2X/WEEK (___)
Insert 1 g per vagina twice a week at bedtime
12. Acetaminophen ___ mg PO Q8H:PRN pain
13. Multivitamins 1 TAB PO DAILY
14. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY
5. Dronedarone 400 mg PO BID
6. Estradiol 0.1 mg PO 2X/WEEK (___)
Insert 1 g per vagina twice a week at bedtime
7. ___ Oil (Omega 3) 1000 mg PO BID
8. Lisinopril 2.5 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.3 mg SL PRN CP
11. Ranitidine 300 mg PO DAILY
12. Sertraline 25 mg PO DAILY
13. Warfarin 1 mg PO DAYS (___)
Instructed to hold until after cathterization on ___
14. Warfarin 0.5 mg PO DAYS (___)
Instructed to hold until after cathterization on ___
15. ALPRAZolam 0.25 mg PO TID:PRN anxiety
RX *alprazolam 0.25 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- chest pain
SECONDARY:
CAD
HTN
dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with chest pain. Question of pneumonia.
COMPARISON: Chest radiograph from ___
AP AND LATERAL CHEST RADIOGRAPHS: A subtle retrocardiac opacity could reflect
early pneumonia in the appropriate clinical setting. There is no interstitial
edema or pleural effusions. Mediastinal and hilar contours are within normal
limits. Mild cardiomegaly is similar to prior examination. Calcifications of
the descending thoracic aorta are again noted. There is no pneumothorax.
IMPRESSION: Subtle retrocardiac opacity may reflect early pneumonia in the
appropriate clinical setting.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.6
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 76.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ was admitted to ___ on ___ for rule-out MI
after she presented with chest pain in the setting of known
coronary artery disease. She had serial troponins which were
negative. Given her history of 6 DES to the RCA, she was
scheduled for left-heart catheterization with coronary
angiography. This unfortunately was unable to be performed due
to prolonged INR on the day of scheduling. She was discharged
with plans to return for elective cathterization on ___.
Her brief and uneventful hospital course, by problems, is as
follows:
1) Chest pain in setting of known CAD and s/p 6 DES to RCA, most
recently in ___ - Last coronary angiography ___ showing
mild ___ RCA ISR and stable 50% mLAD and 50% dLAD stenosis.
Sx c/w unstable angina (occurred at rest). Troponins negative.
TIMI score equal to 3, suggesting invasive approach with early
elective catheterization. LHC to be delayed until ___,
___, given elevated INR. Patient instructed to hold warfarin
on discharge. Continue ASA 81mg and clopidogrel 75mg on
discharge.
2) Atrial fibrillation s/p DCCV in ___ - INR 2.6 on day of
planned catheterization, thus this procedure was deferred. She
was scheduled to undergo cath on ___. She was instructed to
hold warfarin on discharge. She would continue to take
dronedarone as below. Her next INR check will be on ___.
3) Valvular heart disease (mild AS, 1+ MR, 1+ TR in ___ -
AS c/w murmur docuemnted on physical exam. Continued HTN and
afterload optimization.
4) HTN - Continued Lisinopril 2.5 mg PO DAILY
5) HLD - Continued ___ Oil (Omega 3) 1000 mg PO BID
6) GERD - Stable. Chest pain does not appear to be secondary to
GI causes. Continued H2 blockade with Ranitidine 300 mg PO
DAILY.
7) Anxiety - Thought to play a significant role in her chest
pain symptoms. She was prescribed alprazolam on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
this is a ___ yo male with MS presenting from home complaining of
weakness, diarrhea and hematuria. On presentation from the ED,
patient found to be septic with tachycardia to 125, rectal temp
to 102.5 F, a leukocytosis to 35K, and hemoconcentrated with a
HCT of 50.5K. Transferred to the ICU for further management.
In the ICU, he was empirically started on cefepime and
vancomycin for a known history of P.Aeuriginosa UTIs as well as
Vancomycin senstiive entercoccus infections in the past. The
patient was fluid resuscitated with approximately 9 L of IVF
with improvement in his hemodynamics and WBC count. Regarding
diarrhea, noted to be C.Diff negative. Transferred to the floor
for further management as sepsis had improved. Upon transfer to
the floors, BP was 119/69, HR of 81, RR 16, O2 sat 97% on RA.
LOS fluid balance is 8.2 L positive.
Of note, this is Mr. ___ ___ admission in past 6 months for
UTI. ID was consulted in the ICU regarding ppx of UTIs,
although formal evaluation is still pending at time of transfer.
Appears patient was on methenamine for urine acidifcation to
prevent UTIs previously. Additionally, urology was emailed
regarding possible benefit for suprapubic catheter and the
medical team is awaiting a reply.
ROS: per HPI. Has been having frequent diarrhea at home prior
to presentation with hematuria as well. Diarrhea has been
improving since hospitalization. Otherwise denies vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea,
vomiting,constipation, BRBPR, melena, hematochezia.
Past Medical History:
- Multiple sclerosis (clinically definite since ___ secondary
progressive type with gait disorder, limited mobility to
wheelchair)
- Neurogenic bladder and chronic indwelling Foley
catheterization
- Multiple urinary tract infections (Pseudomonas, E.coli,
Enterococcus, Klebsiella); followed by Dr. ___ (Urology)
- History of depression ___ to ___, currently
well-controlled)
- History of alcoholism (last drink was greater than ___
ago)
- Hyperlipidemia
- Greater trochanteric ulcers
- Status-post ADCF C5-7 (___)
Social History:
___
Family History:
- No family history of MS.
- No history of MI, CVA
- Father and mother with alcohol abuse, father with diabetes,
cousin with ___ disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Tmax: 37 °C (98.6 °F)
Tcurrent: 37 °C (98.6 °F)
HR: 122 (122 - 123) bpm
BP: 120/77(86) {120/77(86) - 120/77(86)} mmHg
RR: 32 (32 - 41) insp/min
Heart rhythm: ST (Sinus Tachycardia)
General: Emaciated middle aged man is somewhat agitated but in
no acute distress.
HEENT: EOMI, PERRLA, mucous membranes dry, patient asking for
water, moderate dentition.
Neck: No JVD, erythema present on neck. No goiter.
CV: Tachycardic. Regular rhythm. No M/R/G.
Lungs: Clear in all lung fields.
Abdomen: Nontender, nondistended. Hyperactive bowel sounds.
Mass present in ___ patient reports is a baclofen pump. No
other masses or organomegaly appreciated.
GU: Foley in place, no erythema, blood, or discharge apparent.
Foley draining dark urine.
Ext: Nonedematous. Warm, well perfused.
Neuro: Alert and oriented x 3. CN II-XI grossly intact.
Strength ___ and equal in bilateral handgrip, UE flexion &
extension, shoulder shrug. ___ strength ___ in RLE and ___ in
LLE. Patient refuses finger-nose-finger, other cerebellar
tests.
On discharge:
VS: T 98.2, BP 127/86 (112-135), HR 103 (76-110), RR 18, O2 sat
94% on RA I/O: 23L/3.7L in 24h
General: Emaciated middle aged man, in no acute distress.
Appears more alert and interactive.
CV: Regular rate, rhythm. No M/R/G.
Lungs: diminished breath sounds to RLL, but no crackles,
wheezes, rhonchi.
Abdomen: Nontender, ND, soft, normal bowel sounds. Solid, round
structure present right under skin in LLQ - patient reports is a
baclofen pump. No other masses or organomegaly appreciated.
GU: Foley in place, no erythema, blood, or discharge apparent.
Foley draining yellow/clear urine.
Ext: Warm, well perfused. Muscle atrophy noted in both ___, 2+
pedal edema b/l.
Neuro: Alert and oriented x 3. CN II-XI grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 01:15PM GLUCOSE-165* UREA N-27* CREAT-1.2 SODIUM-142
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-22*
___ 05:08PM LACTATE-3.1*
___ 01:15PM ALT(SGPT)-17 AST(SGOT)-20 LD(LDH)-238 ALK
PHOS-66 TOT BILI-0.6
___ 01:15PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-5.3*#
MAGNESIUM-2.6
___ 01:15PM LACTATE-4.6*
___ 01:15PM WBC-35.1*# RBC-5.39# HGB-16.5# HCT-50.5#
MCV-94 MCH-30.5 MCHC-32.6 RDW-13.1
___ 01:15PM NEUTS-94.5* LYMPHS-1.5* MONOS-3.6 EOS-0.1
BASOS-0.2
___ 12:30PM URINE COLOR-DkAmb APPEAR-Cloudy SP ___
___ 12:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-LG
___ 12:30PM URINE RBC-79* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 12:30PM URINE HYALINE-33*
IMAGING:
___ CTA
IMPRESSION:
1. No evidence of pulmonary embolism, cavitary lesion or septic
emboli.
2. Moderate slightly asymmetric (left greater than right)
pulmonary edema and
small bilateral pleural effusions consistent with hypervolemia.
3. Slightly distended colon, nonspecific and similar compared
___.
___ ___
Final Report
HISTORY: ___ man with history of multiple sclerosis,
neurogenic
bladder, lower GI bleed presents with worsening abdominal
distention and
nausea.
COMPARISON: CT abdomen and pelvis, ___ CT abdomen
and pelvis, ___.
FINDINGS:
Again seen are diffusely dilated loops of large bowel with air
fluid levels
with a maximal diameter of 8.5 cm. There is no clear evidence of
pneumoperitoneum or pneumatosis. Multiple surgical clips are
seen in the left
lower quadrant.
IMPRESSION:
Multiple severely dilated loops of large bowel with air-fluid
levels unchanged
from prior examination.
___ CT Abdomen
IMPRESSION:
1. Fluid-filled diffusely distended colon, unchanged from prior
examination.
2. No active extravasation of contrast in the bowel lumen to
suggest source
for new brisk lower GI bleed.
3. Ground-glass opacities in the bilateral lung bases have
increased on the
left. Though non-specific in appearance, findings could be
related to
pneumonia in the appropriate clinical setting.
___ Cystogram
FINDINGS: Intravenous contrast fills the bladder without
evidence of leak.
No contrast is seen within the rectum. Contrast is seen in the
right seminal
vesicle, possibly secondary to retrograde flow. The fat plane
between the
bladder and rectum is obscured. A Foley catheter is seen within
the bladder.
The bladder wall is trabeculated, likely secondary to neurogenic
bladder. Air
layering anteriorly within the bladder is likely due to
instrumentation.
Residual enteric contrast is seen within the cecum. Visualized
portion of the
colon is distended with air, as seen yesterday. Evaluation of
intrapelvic
organs is limited in the absence of intravenous contrast.
IMPRESSION: No definitive colovesicular fistula detected on
this study.
Contrast seen in the right seminal vesicle, of indeterminate
etiology,
possibly secondary to retrograde flow.
___ CT abdomen
FINDINGS: There is an enlarging right-sided pleural effusion as
well as a small left pleural effusion. The right lung base
demonstrates patchy
ground-glass opacity.
A lack of contrast administration limits adequate assessment of
the solid
viscera. The liver demonstrates no focal abnormality. The
kidneys, adrenals,
spleen, pancreas are unremarkable. The gallbladder and biliary
tree are
nondistended.
The small bowel is unremarkable. The large bowel contains a
significant
amount of air. The rectosigmoid demonstrates mural thickening
and contains a large amount of fecal material.
PELVIS:
The bladder is not well distended and contains a Foley catheter.
Air is noted within the bladder. There are calcifications noted
at the posterior aspect of the bladder, likely calculi. No
definite colovesicular fistula is appreciated; however, this
would be difficult to exclude.
Skin staples are noted within the left inguinal region likely
related to a previous hernia repair.
BONES: There are no ominous bony abnormalities. There is
electrical hardware
in the left lower quadrant with wires extending up into the
spinal canal,
related to a spinal stimulator.
IMPRESSION:
1. Thick-walled rectum and distal sigmoid compatible with
proctitis.
2. The bladder contains multiple calculi. There is air in the
bladder,
secondary to the foley. A colovesicular fistula is not
excluded.
3. Bilateral pleural effusions and new right lower lobe
airspace ground-glass
opacity concerning for pneumonia.
___ Renal U/S
FINDINGS: The right kidney measures 10.6 cm and the left kidney
measures 10.9
cm. There is no hydronephrosis. No stone or concerning solid
renal mass is
visualized. No perinephric fluid collection is identified. A
tiny cyst is
seen at the upper pole of the right kidney measuring 0.5 x 0.5 x
0.4 cm. The
bladder is collapsed on a Foley catheter. A scant trace of
ascites is seen in
the pelvis.
IMPRESSION: Unremarkable appearance of the kidneys with no
findings to
indicate an abscess. A scant trace of ascites is noted in the
pelvis, of
unknown etiology. A tiny simple right renal cyst is noted.
- CXR (___): IMPRESSION: No acute intrathoracic process.
MICRO:
- C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Labs on discharge:
___ 05:36AM BLOOD WBC-6.1 RBC-3.03* Hgb-8.9* Hct-27.9*
MCV-92 MCH-29.4 MCHC-32.0 RDW-13.2 Plt ___
___ 05:36AM BLOOD Glucose-104* UreaN-8 Creat-0.3* Na-137
K-4.0 Cl-103 HCO3-27 AnGap-11
___ 05:36AM BLOOD Calcium-7.2* Phos-3.2 Mg-2.2
___ 12:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ ___ (___) ___ REQUESTED WORK-UP OF ALL
ORGANISMS.
___ ___ ALSO REQUESTED FOSFOMYCIN AND TETRACYCLIN
SENSITIVITIES ___.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
FOSFOMYCIN SENSITIVE sensitivity testing performed by
___
___. TETRACYCLINE sensitivity testing performed by
___.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
ZONE SIZE FOR FOSFOMYCIN IS 6 MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution. ZONE SIZE FOR TETRACYCLINE IS 6 MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/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. ZONE SIZE FOR FOSFOMYCIN IS 27 MM.
Zone size determined using a method that has not been
standardized
for this drug-.
organism combination and for which no CLSI or
FDA-approved
interpretative standards exist. Interpret results with
caution.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
ZONE SIZE FOR FOSFOMCIN IS 15 MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
FOSFOMYCIN SENSITIVE sensitivity testing performed by
___.
TETRACYCLINE sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| | STAPH AUREUS
COAG +
| | |
ENTEROCOCCUS SP.
| | | |
___
| | | |
|
AMPICILLIN------------ =>32 R 16 R
=>32 R
AMPICILLIN/SULBACTAM-- 4 S
4 S
CEFAZOLIN------------- =>64 R
=>64 R
CEFEPIME-------------- 2 S <=1 S
2 S
CEFTAZIDIME----------- 4 S <=1 S
4 S
CEFTRIAXONE----------- =>64 R
=>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
=>4 R
GENTAMICIN------------ <=1 S <=1 S <=0.5 S
<=1 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM-------------<=0.25 S 0.5 S
<=0.25 S
NITROFURANTOIN-------- <=16 S 32 S
<=16 S
OXACILLIN------------- <=0.25 S
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- R <=1 S =>16 R
R
TOBRAMYCIN------------ <=1 S <=1 S
<=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S
=>16 R
VANCOMYCIN------------ 1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Ezetimibe 10 mg PO DAILY
4. Fluoxetine 20 mg PO BID
5. Oxybutynin 10 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. baclofen (bulk) *NF* 100 % Miscellaneous infusion
last filled 1 week ago, baclofen pump * Patient Taking Own Meds
*
9. methenamine mandelate *NF* 1 gram Oral daily
Discharge Medications:
1. methenamine mandelate *NF* 1 gram Oral daily
2. Ascorbic Acid ___ mg PO BID
RX *ascorbic acid ___ mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. baclofen (bulk) *NF* 100 % Miscellaneous infusion
last filled 1 week ago, baclofen pump * Patient Taking Own Meds
*
4. Thiamine 100 mg PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Fluoxetine 20 mg PO BID
7. Ezetimibe 10 mg PO DAILY
8. Calcium Carbonate 500 mg PO BID
9. Aspirin 325 mg PO DAILY
10. Bisacodyl ___AILY
RX *bisacodyl 10 mg 1 Suppository(s) rectally Daily Disp #*30
Suppository Refills:*0
11. 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
12. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 Tab by mouth BID: PRN Disp #*60
Tablet Refills:*0
13. Simethicone 40 mg PO TID
RX *simethicone 180 mg 1 capsule by mouth Daily Disp #*30
Capsule Refills:*0
14. Phosphorus 250 mg PO TID
RX *sod phos,di & mono-K phos mono [Phospha 250 Neutral] 250 mg
1 tablet(s) by mouth three times a day Disp #*90 Tablet
Refills:*0
15. Device: ___ Lift
___ Lift with Pads for Dependent Transfer
Discharge Disposition:
Home With Service
Facility:
___
___:
Sepsis of urinary origin
Urinary tract infection, recurrent
Hospital acquired pneumonia
Proctitis
Constipation, Ileus
Lower gastrointestinal bleeding
Multiple sclerosis
Neurogenic bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Bedridden with white blood cell count of 35, question pneumonia.
COMPARISON: Chest x-ray from ___.
FINDINGS: AP semi-upright and lateral views of the chest were obtained.
There are low lung volumes, though allowing for this, the lungs are clear
bilaterally with no focal consolidation, effusion, or pneumothorax. A small
calcified granuloma in the right lower lung is re-demonstrated with a stable
appearance. There is no evidence of CHF. Cardiomediastinal silhouette is
normal. Fixation hardware is noted in the lower C-spine. Bony structures
appear intact.
IMPRESSION: No acute intrathoracic process.
Radiology Report
HISTORY: ___ man with MS, indwelling Foley, recurring UTIs and
sepsis.
COMPARISON: Thyroid ultrasound ___.
FINDINGS: The right kidney measures 10.6 cm and the left kidney measures 10.9
cm. There is no hydronephrosis. No stone or concerning solid renal mass is
visualized. No perinephric fluid collection is identified. A tiny cyst is
seen at the upper pole of the right kidney measuring 0.5 x 0.5 x 0.4 cm. The
bladder is collapsed on a Foley catheter. A scant trace of ascites is seen in
the pelvis.
IMPRESSION: Unremarkable appearance of the kidneys with no findings to
indicate an abscess. A scant trace of ascites is noted in the pelvis, of
unknown etiology. A tiny simple right renal cyst is noted.
Radiology Report
INDICATION: ___ man with MS, neurogenic bladder with chronic Foley
and recurrent UTIs. Here with urosepsis. Is there abscess or colovesicular
fistula?
Comparison is made with ___.
TECHNIQUE: Axial CT images through the abdomen were obtained following oral
contrast administration. No intravenous contrast was administered. Sagittal
and coronal reformats were obtained.
FINDINGS: There is an enlarging right-sided pleural effusion as well as a
small left pleural effusion. The right lung base demonstrates patchy
ground-glass opacity.
A lack of contrast administration limits adequate assessment of the solid
viscera. The liver demonstrates no focal abnormality. The kidneys, adrenals,
spleen, pancreas are unremarkable. The gallbladder and biliary tree are
nondistended.
The small bowel is unremarkable. The large bowel contains a significant
amount of air. The rectosigmoid demonstrates mural thickening and contains a
large amount of fecal material.
PELVIS:
The bladder is not well distended and contains a Foley catheter. Air is noted
within the bladder. There are calcifications noted at the posterior aspect of
the bladder, likely calculi. No definite colovesicular fistula is
appreciated; however, this would be difficult to exclude.
Skin staples are noted within the left inguinal region likely related to a
previous hernia repair.
BONES: There are no ominous bony abnormalities. There is electrical hardware
in the left lower quadrant with wires extending up into the spinal canal,
related to a spinal stimulator.
IMPRESSION:
1. Thick-walled rectum and distal sigmoid compatible with proctitis.
2. The bladder contains multiple calculi. There is air in the bladder,
secondary to the foley. A colovesicular fistula is not excluded.
3. Bilateral pleural effusions and new right lower lobe airspace ground-glass
opacity concerning for pneumonia.
Radiology Report
INDICATION: Evaluate left PICC.
COMPARISONS: Chest radiograph ___. Multiple chest radiographs
dating to ___.
FINDINGS: A new left PICC terminates in the mid SVC. A small calcified
granuloma is unchanged at the right base. The lungs are otherwise clear
without consolidation or edema. There is no pleural effusion or pneumothorax.
Multiple loops of dilated bowel are incompletely evaluated.
IMPRESSION:
1. Left PICC terminates in the mid SVC.
2. No acute cardiopulmonary process.
3. Multiple loops of dilated bowel are incompletely evaluated.
Results were discussed with ___ of the IV team at 11:00 a.m. on ___
via telephone by Dr. ___ at that time the findings were discovered.
Radiology Report
INDICATION: ___ male with multiple sclerosis, chronic indwelling
Foley catheter, recurrent urinary tract infections, now with urosepsis and
clinical concern for colovesicular fistula.
COMPARISON: ___.
TECHNIQUE: Axial CT images through the pelvis were acquired after
instillation of 400 cc of contrast into the urinary bladder. Coronal and
sagittal reformatted images were reviewed.
FINDINGS: Intravenous contrast fills the bladder without evidence of leak.
No contrast is seen within the rectum. Contrast is seen in the right seminal
vesicle, possibly secondary to retrograde flow. The fat plane between the
bladder and rectum is obscured. A Foley catheter is seen within the bladder.
The bladder wall is trabeculated, likely secondary to neurogenic bladder. Air
layering anteriorly within the bladder is likely due to instrumentation.
Residual enteric contrast is seen within the cecum. Visualized portion of the
colon is distended with air, as seen yesterday. Evaluation of intrapelvic
organs is limited in the absence of intravenous contrast.
IMPRESSION: No definitive colovesicular fistula detected on this study.
Contrast seen in the right seminal vesicle, of indeterminate etiology,
possibly secondary to retrograde flow.
Preliminary findings discussed with ___ by ___ phone at
10:05 p.m. on ___.
Radiology Report
HISTORY: ___ male admitted with urosepsis, recently status post enema
for constipation, now presenting with brisk lower GI bleed. Assess for
source.
COMPARISON: CT abdomen and pelvis from ___
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 2.5- and 5-mm slice thickness. Initial axial
images were acquired in a non-contrast phase followed by arterial and delayed
phase imaging. Coronal and sagittal reformations were prepared.
CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: Irregular non-specific
ground-glass opacities within the bilateral lung bases have increased,
particularly in the left lung base. Differential considerations include
infectious and inflammatory etiologies, including pneumonia. There is no
pleural effusion. The imaged cardiac apex is within normal limits.
The liver appears homogeneous without focal lesion. No intra- or
extra-hepatic biliary ductal dilatation is identified. The gallbladder,
spleen, pancreas, and adrenal glands appear within normal limits. There is
symmetric enhancement of the kidneys without suspicious focal lesion or
hydronephrosis. Stomach and small bowel loops are normal in caliber and
configuration without evidence of obstruction or inflammation. The colon
remains diffusely dilated and filled with stool and fluid. Retained barium is
seen in the right colon and cecum. A spinal stimulator device along the left
abdominal side wall results in streak artifact in the left lower quadrant.
CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: A Foley catheter and a small
amount of air is seen within a decompressed bladder. There are numerous
dilated pelvic veins and the IMV is also prominent. Skin staples are seen in
the left inguinal region likely from prior hernia repair.
MESENTERIC CTA: No active extravasation of contrast is seen within the bowel
lumen to suggest site of new lower GI bleed. However, evaluation is limited
due to high-density oral contrast in the right colon and streak artifact from
stimulator device in the left abdominal wall. The celiac axis, SMA, renal
arteries, and ___ are widely patent. There is minimal atherosclerotic plaque
in the infrarenal abdominal aorta, which is non-aneurysmal. Bilateral common
iliac arteries, external iliac, and internal iliac arteries are widely patent.
IMPRESSION:
1. Fluid-filled diffusely distended colon, unchanged from prior examination.
2. No active extravasation of contrast in the bowel lumen to suggest source
for new brisk lower GI bleed.
3. Ground-glass opacities in the bilateral lung bases have increased on the
left. Though non-specific in appearance, findings could be related to
pneumonia in the appropriate clinical setting.
Radiology Report
AP CHEST, 5:03 A.M. ON ___
HISTORY: ___ man with bright red blood per rectum after NG tube
placement.
IMPRESSION: AP chest compared to ___, 9:54 a.m.:
Lung volumes are low, making it difficult to distinguish right basal vascular
crowding from mild interstitial edema. Heart is normal size and there is no
mediastinal vascular engorgement or any pleural effusion, so edema is less
likely. There is a new left perihilar pulmonary opacity partially obscured by
overlying EKG leads, but I suspect there is substantial atelectasis or new
pneumonia. Left PICC line ends in the mid to low SVC as before and an upper
enteric tube ends in the stomach, which is not particularly distended despite
severe gaseous distention of the rest of the intestinal tract in the upper
abdomen. No pneumothorax.
Dr. ___ was paged at 10:35 a.m. and I discussed the findings by telephone
with the house officer covering the patient at 10:50 a.m.
Radiology Report
HISTORY: ___ man with history of multiple sclerosis, neurogenic
bladder, lower GI bleed presents with worsening abdominal distention and
nausea.
COMPARISON: CT abdomen and pelvis, ___ CT abdomen and pelvis, ___.
FINDINGS:
Again seen are diffusely dilated loops of large bowel with air fluid levels
with a maximal diameter of 8.5 cm. There is no clear evidence of
pneumoperitoneum or pneumatosis. Multiple surgical clips are seen in the left
lower quadrant.
IMPRESSION:
Multiple severely dilated loops of large bowel with air-fluid levels unchanged
from prior examination.
Radiology Report
AP CHEST, 10:54 A.M.
HISTORY: ___ man. Recurrent UTIs and urosepsis. Hospital-acquired
pneumonia, now with worsening hypoxia.
IMPRESSION: AP chest compared to ___:
What was relatively limited left perihilar consolidation on ___, now
involves a good deal more of the left lung. There may also be new cavitary
lesions in the right lung, suggesting sepsis. Pleural effusion is small if
any. Heart size top normal. No pulmonary edema.
Dr. ___ was paged at 2:30 p.m. when the findings were recognized.
Radiology Report
INDICATION: ___ man with multiple sclerosis, urosepsis, hypoxia and
shortness of breath. Please assess for PE, cavitary lesions or septic emboli.
TECHNIQUE: CT angiography protocol of the chest was obtained with contiguous
images in the arterial phase. Axial, coronal, sagittal, and oblique reformats
were acquired.
COMPARISON: Chest x-rays from ___ and CT abdomen and pelvis from
___.
CTA OF THE CHEST:
There is no pneumomediastinum, mediastinal hemorrhage, or pericardial
effusion. The pulmonary artery and the aorta are normal without evidence of
pulmonary embolism. Diffuse and slightly asymmetric (left greater than right)
ground-glass opacities and interlobular septal thickening are seen in both
lungs, predominantly in the upper lobes, consistent with moderate pulmonary
edema. There are small bilateral, left greater than right pleural effusions.
The partially visualized upper abdomen demonstrates a slightly distended
colon, similar compared to ___.
There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. No evidence of pulmonary embolism, cavitary lesion or septic emboli.
2. Moderate slightly asymmetric (left greater than right) pulmonary edema and
small bilateral pleural effusions consistent with hypervolemia.
3. Slightly distended colon, nonspecific and similar compared ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WEAKNESS
Diagnosed with URIN TRACT INFECTION NOS, OTHER MALAISE AND FATIGUE, DIARRHEA, MULTIPLE SCLEROSIS
temperature: 99.2
heartrate: 125.0
resprate: 16.0
o2sat: 94.0
sbp: 112.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with MS, neurogenic bladder (Foley-dependent),
multiple recent admissions for UTIs presented with weakness,
diarrhea, and hematuria found to have urosepsis, course
complicated by lower GI bleed and hospital acquired pneumonia.
MICU COURSE: Empirically started on cefepime and vancomycin.
The patient was fluid resuscitated with approximately 9 L of IVF
with improvement in his hemodynamics and WBC count. C. diff
negative. Transferred to medicine floor, hemodynamically stable
and afebrile. Found to have proctitis on CT abdomen/pelvis and
had lower GIB. Sent back to MICU.MICU Course: continued vanc and
cefepime and given 2u blood. Transferred back to Medicine to
complete vanc/cefepime course, ending on ___.
#) GI BLEED/Acute blood loss anemia: Prior to and during this
admission, he had been having non-bloody diarrhea x6 days which
required a flexiseal placement while he was in the unit. C diff
PCR was negative. A CT abdomen pelvis demonstrated proctitis on
___. Upon arrival to the unit, he is no longer having bright
red blood per rectum, he is talkative/conversant with BP
preserved 130s/80s, but persistent tachycardia. NG tube was
placed and he was given bowel prep via the tube. His bleeding
stopped and it was felt that this prep was curative for the
bleed. He remained hemodynamically stable, and was called out to
the normal medical floor with plan for colonoscopy at a later
date. At midnight of ___ the patient had an episode of BRPPR,
and was tachycardic to 120s, although with stable blood
pressure, and was admitted back to the MICU. Hct at that time
was 29.7 (baseline appears to be ~33-39). He was transfused 2
units w/ post transfusion Hct of 29.1 although subsequent
hematocrits were stable. NG lavage did not reveal any blood. The
patient was seen by GI in the unit, with plan for colonoscopy,
however after the Movi prep the patient had no subsequent
episodes of BRBPR or bloody stools. This, combined with the fact
that the patient declined colonoscopy resulted in the decision
to transfer the patient back to the general medicine floor on
___. Patient transfused a 3rd unit of pRBCs on the medicine
floor and hct remained stable at 28 and hematocrits were then
checked daily instead of BID. As GI bleed was likely lower, IV
Protonix was discontinued. Heparin SC and aspirin were held
initially while patient with labile hct and guaiac positive
stool. Hct at time of discharge was 27.9. Patient was discharged
with instructions to schedule outpatient colonoscopy for both
screening and diagnostic purposes.
#) SEPSIS DUE TO CATHETER-ASSOCIATED UTI: The patient has had
recent admissions for UTIs with ESBL, E.coli, VSE, and
Pseudomonas, and as such the decision was made to cover broadly
with vancomycin and cefepime until urine culture speciation and
sensitivity return. Patient initially presented with sepsis of
urinary origin, called out of MICU back to floor and course was
complicated by GIB and transferred back to MICU. ID followed
patient and recommended multiple imaging modalities and ruled
out enterovesicular fistula. Urine culture grew out Pseudomonas
and E. coli sensitive to cefepime and enterococcus sensitive to
vancomycin. Cefepime and vancomycin were continued for two week
course and ended on ___ via PICC line as per ID recs. Upon
coming back to medicine floor, patient's leukocytosis eventually
resolved and remained afebrile. Patient is followed by Dr. ___
(___) and has been refusing clean intermittent
catheterization. Patient is to followup with Dr. ___ as
outpatient to discuss possible suprapubic cath placement. ID
consulted and did not recommend prophylactic antibiotics; ID
team recommended urine acidification with Vitamin C and
methenamine. Patient is to followup with ID in ___ clinic.
#Ileus: Patient found to have stool throughout bowel on CT and
stercoral ulcer was considered as cause of lower GI bleed.
Patient was passing very little stool upon returning to medical
floor from MICU s/p 3u RBCS and was having worsening abdominal
distention and patient was having nausea. KUB showed bowel
distention with gas and was then manually disimpacted and
started on daily suppositories which helped patient pass stool
regularly on daily basis. Given history of MS, patient was at
risk of constipation and will need chronic bowel regimen. At
time of discharge, patient was regularly passing BMs and had
benign abdominal exam.
#)Hospital acquired bacterial pneumonia: Patient found to be
hypoxic after lower GIB and required 2L of O2. Was symptomatic
feeling dyspneic. Imaging revealed new ground glass opacities
suggesting pneumonia. Patient was treated with vanc and cefepime
as above which resolved leukocytosis and hypoxia and dyspnea.
Vanc trough checked and found to be subtherapeutic and
uptitrated dose for trough of ___. Patient continued
antibiotics through ___ until ___. Patient is to followup
with ID in clinic.
#) TACHYCARDIA: Most likely differential was volume depletion.
Given persistence after 5L IVF repletion, considered other
etiologies such as supraventricular tachycardia, pulmonary
embolism, oxybutynin side effect, hypervolemia. At the time of
transfer out of the MICU, he remained tachycardic into the
100-120s, although asymptomatic and without any other signs of
hemodynamic instability. As patient had persistent tachycardia
and hypoxia on medicine floor, CXR was done which was concerning
for possible cavitary lesions. CTA was done to rule out PE and
clarify infiltrates which did not show PE and confirmed
pneumonia (without cavitations). Pleural effusions and pulmonary
edema were found on imaging as well which was consistent with
hypervolemia. Pt received two doses of IV 10mg Lasix and had
copious urine output. Patient's hypoxia and tachycardia
improved. In addition, pt's oxybutynin was discontinued due to
anticholinergic effects which may have helped improve
tachycardia. HR at time of discharge ranged from ___ to low
100s.
#Malnutrition, severe: Patient with poor PO intake throughout
course and had dramatically worsened with development of HAP.
Albumin of 2.5. Patient made NPO with recent GI bleed and with
ileus requiring disimpaction. Following resolving ileus, patient
was encouraged to improve PO intake and nutrition was consulted.
Patient refused TID Ensure Plus supplementation as it caused
diarrhea historically. At time of discharge patient was taking
in better PO, tolerating solids well and was no longer
complaining of dry mouth. He was discharged with phosphorus
supplementation.
#) ACUTE KIDNEY INJURY: Cr 1.2 on admission up from baseline of
0.5-0.6. Received 5L NS in ED as well as fluid resuscitation
while in the MICU. On the medicine floor, patient received IVF
maintenance while being treated for HAP and had decreased
appetite. At the time of discharge his creatinine had resolved
to 0.3.
#) ACUTE, COMMUNITY-ACQUIRED DIARRHEA: Differential was broad,
although most acute diarrheas are caused by viruses. Recent
antibiotics and chronic prophylactic antibiotics raised
suspicion for clostridium difficile colitis which was negative x
2 separate tests during admission.
CHRONIC PROBLEMS
================
#) MULTIPLE SCLEROSIS, SECONDARY PROGRESSIVE: Followed by Dr.
___ in neurology, complicated by ileus and neurogenic
bladder. Gets methylprednisolone 1000mg injections 3 days
monthly. Oxybutynin (given originally for bladder spasms) was
discontinued as patient was complaining of dry mouth and had
persistent tachycardia.
#) DEPRESSION: Continue fluoxetine.
#) OSTEOPOROSIS: Continue calcium and vitamin D.
#) DYSLIPIDEMIA: Continue ezetimibe.
TRANSITIONAL ISSUES:
-PICC was pulled on day of discharge ___
-Foley was replaced on day of discharge
-Patient was discharged with ___ services including home ___ and
___ lift prescription
-Patient finished 14 days of vanc/cefepime for UTI and hospital
acquired pneumonia.
-Patient has followup with PCP ___ is to followup in ___
-Patient is to followup with urology to discuss CIC vs
suprapubic catheterization
-Patient is to continue methenamine and Vit C for urine
acidication (UTI prophylaxis)
-Given patient with ileus/constipation, he is to continue bowel
regimen daily
-Oxybutynin was stopped on this admission as patient with dry
mouth and tachycardia
-Patient continued on Phosphorus supplementation as had
chronically low phos levels |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bleeding, Syncope
Major Surgical or Invasive Procedure:
Central Line Placement
Bone Marrow Biopsy ___
Bone Marrow Biopsy ___
Bone Marrow Biopsy ___
History of Present Illness:
Mr. ___ is a ___ yo M with no significant PH presenting with
bleeding and syncope following tooth extraction. Patient was in
his normal state of health until approximately 1 month prior to
admission when he noticed atraumatic ecchymosis on his lower
extremities. He had a dental procedure performed on ___ after
which he noted persistent bleeding. On ___, patient was
upstairs
in the bathroom when he endorsed lightheadedness and ultimately
syncopized. He denied any chest pain prior to the incident. He
presented to ___ where he was noted to have
platelet
count 2 with WBC 31, transferred to ___ ED for further
evaluation.
He presented to the ___ ED on ___ with WBC 42.1 with 38 other
and plt <5. He was evaluated by ___ who reviewed
peripheral blood smear consistent with many blasts with Auer
rods
and atypical lymphocytes, suspicious for AML vs. APL. Given this
suspicion, he received ATRA 40mg po once. He was transfused 1U
PRBC and 1 bag platelets. Patient had BM biopsy performed prior
to transfer.
In the ED:
Initial vital signs were notable for:
-T96.5, HR 88, BP 128/64, RR 16, POx 98% RA
Exam notable for:
-Oozing from tooth 9, ecchymosis on lower extremities,
neurologically intact
Labs were notable for:
-WBC 42.1, 38 other, ANC 2.11, Abslymph 15.58
-___: 13.3/22.4/1.2
-D-dimier 1264
-Fibrinogen 280
-Plt <5 --> 27
-Hgb 6.0 --> 8.8
-HIV AB negative; HBsAg negative, HBsAB negative, HBc-Ab
negative
-LDH 360
Studies performed include:
-CT Head w/o Contrast: No acute intracranial process
-CXR: No focal consolidation
Patient was given:
-ATRA 40mg po
Consults:
-Heme/Onc, as above
Vitals on transfer: T98.7, HR 93, BP 109/50, RR 18, POx 98% RA
Upon arrival to the floor, patient denies any dizziness,
lightheadedness, shortness of breath, chest pain, headaches,
n/v,
fevers chills. Corroborated HPI as above, saying that he noted
continuous bleeding and collapsed with preceding
dizziness/lightheadedness. Lost consciousness for a few seconds
before being awoken by his step-son. Had episode of presyncope
5
days prior to admission. Additional syncopal episode ___ years
ago, though medical work-up at that point unremarkable. Not sure
if he feels more fatigued than normal, as works 2 jobs,
including
one at night shift and often feels fatigued.
Past Medical History:
N/A
Social History:
___
Family History:
Sister with colon cancer. Brother died of alcoholic cirrhosis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.8 PO 114 / 65 100 20 98 RA
Gen: sitting upright in NA
NEURO: A&Ox3.
HEENT: No conjunctival pallor. No scleral icterus. Congealed
blood in left upper molars. No active bleeding.
NECK: JVP not elevated
LYMPH: No cervical or supraclav LAD
CV: Tachycardic regular rhythm. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: ND, nl bowel sounds, NT, no HSM.
EXT: WWP. Trace bilateral ___ edema .
SKIN: Nontender, non-pruritic petechial rash in bilateral ___
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 502)
Temp: 98.1 (Tm 98.3), BP: 109/63 (102-117/62-71), HR: 80
(77-88), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra,
Wt: 146.2 lb/66.32 kg Gen: lying comfortably in NAD
NEURO: A&Ox3
HEENT: No conjunctival pallor. No ulcerations in mouth, very
poor
dentition. No scleral icterus. No evidence of abscess.
LINE: Temp R CVL, no signs of infection, no tenderness at
insertion site, covered with tegaderm c/d/I after removal
CHEST: No rash
CV: Regular rate and rhythm. No MRG.
LUNGS: No increased WOB. CTAB, no r/r/w
ABD: Soft, NTND, BS+, no HSM.
EXT: WWP. No BLE edema.
SKIN: no rashes/lesions
Pertinent Results:
ADMISSION LABS:
==============
___ 01:10AM BLOOD WBC-42.1* RBC-1.89* Hgb-6.0* Hct-20.3*
MCV-107* MCH-31.7 MCHC-29.6* RDW-20.3* RDWSD-71.4* Plt Ct-<5*
___ 01:10AM BLOOD Neuts-5* ___ Monos-20* Eos-0*
Baso-0 NRBC-1.0* Other-38* AbsNeut-2.11 AbsLymp-15.58*
AbsMono-8.42* AbsEos-0.00* AbsBaso-0.00*
___ 01:10AM BLOOD ___ PTT-22.4* ___
___ 01:10AM BLOOD Plt Smr-RARE* Plt Ct-<5*
___ 01:10AM BLOOD ___ D-Dimer-1264*
___ 05:05PM BLOOD Ret Aut-4.3* Abs Ret-0.12*
___ 01:10AM BLOOD Glucose-118* UreaN-19 Creat-0.8 Na-137
K-3.6 Cl-105 HCO3-20* AnGap-12
___ 01:10AM BLOOD ALT-10 AST-13 LD(LDH)-360* AlkPhos-56
TotBili-0.8
___ 01:10AM BLOOD Albumin-3.8 Calcium-8.3* Phos-2.9 Mg-2.1
UricAcd-6.0
___ 02:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 02:30AM BLOOD HIV Ab-NEG
___ 05:05PM BLOOD HCV Ab-NEG
INTERVAL LABS:
==============
___ 12:00AM BLOOD Osmolal-277
___ 12:00AM BLOOD TSH-0.37
___ 07:00AM BLOOD Cortsol-21.9*
___ 12:00AM BLOOD CRP-83.2*
___ 05:10PM BLOOD CMV VL-NOT DETECT
BONE MARROW BIOPSY REPORTS:
===========================
___ Bone Marrow Biopsy
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS: ACUTE MYELOID LEUKEMIA, SEE NOTE:
Note: The blasts comprise 66% of the aspirate differential
count. By immunohistochemical staining, CD34 highlights 70-80%
of the marrow cellularity as blasts. By flow cytometry (see
separate report ___ these blasts express myeloid lineage
antigens and are negative for B- and T- cell lineage defining
antigens. Taken together these findings are consistent with a
diagnosis of acute myeloid leukemia. Correlation with clinical,
flow cytometry, and cytogenetic findings is recommended.
MICROSCOPIC DESCRIPTION
Peripheral blood smear:
The smears are adequate for evaluation. Erythrocytes are
decreased in number, normochromic, macrocytic and have
anisopoikilocytosis, including ovalocytes, eliptocytes,
acanthocytes, and rare tear drop cells. The white blood cell
count is increased. The platelet count is decreased. A 100 cell
differential shows 5% neutrophils, 2% lymphocytes, 6% monocytes,
0% eosinophils, 0% basophils, and 87% blasts.
Bone marrow aspirate:
The aspirate material is adequate for evaluation and consists of
numerous cellular spicules. Erythroid precursors are decreased
in number and exhibit normal maturation. Maturing myeloid
precursors are decreased in number and show normal maturation.
Megakaryocytes are decreased in
number; abnormal forms are not seen. There is an infiltrate of
immature cells that have immature chromatin, moderate amounts of
cytoplasm and prominent nucleoli with rare forms having auer
rods consistent with blasts. A 300 cell differential shows 66%
blasts, 3% promyelocytes, 4% myelocytes, 2% metamyelocytes, 1%
bands/neutrophils, 0% eosinophils, 23% erythroids, 0%
lymphocytes, and 1% plasma cells
The core biopsy material is adequate for evaluation. It consists
of two fragments of core one measuring 1.5 cm and the second
measuring 0.6cm. The biopsy is composed of periosteum, cortical
bone and trabecular marrow with a cellularity of >95%. There is
an interstitial infiltrate of immature
mononuclear cells consistent with blasts involving 70-80% of the
total cellularity. Erythroid precursors are decreased in number
and have overall normoblastic maturation. Myeloid precursors are
decreased in number with normal maturation. Megakaryocytes are
rare; abnormal forms are not
seen. A clot section shows similar findings.
SPECIAL STAINS:
Iron stain performed on aspirate material is adequate for
evaluation. Storage iron is present.
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
___, nTdT, cMPO, cCD79a, cCD3, cCD22, and CD antigens 2, 3,
4, 5, 7, 8, 10, 11b, 11c, 13, 14, 16, 19, 20, 23, 33, 34, 38,
45, 56, 64, 117 and 123.
RESULTS:
10-color analysis with CD45 vs. side-scatter gating is used to
evaluate for leukemia/lymphoma.
Approximately 95.9% of total acquired events are evaluable
non-debris events.
The viability of the analyzed non-debris events, done by 7-AAD
is 98.1%.
CD45-bright, low side-scatter gated lymphocytes comprise 3.5% of
total analyzed events.
B cells comprise 22.2% of lymphoid gated events and are
polyclonal.
T cells comprise 67.5% of lymphoid gated events and express
mature lineage antigens (CD3, CD5, CD2 and CD7).
A minor subset of T cells shows dim/variable loss of CD7
(non-specific finding).
T cells have a CD4:CD8 ratio of 0.9.
CD56 positive, CD3 negative natural killer cells represent 2.8%
of gated lymphocytes. They co-express CD2, CD7 and CD8 (subset).
Cell maker analysis demonstrates that the majority (75%) of the
cells isolated from this bone marrow aspirate are in the
CD45-dim/low side-scatter blast region. They co-express CD38,
CD34, ___, CD117, CD33, CD11b (subset), CD11c (subset), CD13,
CD64 (subset dim) and cMPO. They are negative for CD14, CD16,
CD2, CD3, CD5, CD7, CD56, CD10, CD19, CD20, CD4, CD8, Kappa,
Lambda, nTDT, cCD79a, cCD3, cCD22 and CD123.
INTERPRETATION:
Immunophenotypic findings consistent with involvement by acute
myeloid leukemia. Correlation with clinical, morphologic (see
separate pathology report ___ and other ancillary (see
separate cytogenetics report ___-___) findings is recommended.
Flow cytometry immunophenotyping may not detect all abnormal
populations due to topography, sampling or artifacts of sample
preparation.
Bone Marrow Cytogenetics:
SPECIMEN: BONE MARROW
FINDINGS: An apparently normal 46,XY male chromosome complement
was observed in 20 mitotic cells examined in detail. Chromosome
band resolution was 400-450. A karyogram was prepared on 4
cells.
CYTOGENETIC DIAGNOSIS: 46,XY[20] Normal male karyotype.
1) FISH: NEGATIVE for PML/RARA. No evidence of interphase bone
marrow cells with the PML/RARA gene rearrangement.
2) FISH: NEGATIVE for BCR/ABL. No evidence of interphase bone
marrow cells with the BCR/ABL1 gene rearrangement.
3) FISH: NEGATIVE MDS PANEL. No evidence of interphase bone
marrow cells with the common cytogenetic abnormalities observed
in myelodysplastic syndrome. These include deletion 5q31,
deletion 7q31, monosomy 7, trisomy 8 and deletion 20q12.
4) FISH: NEGATIVE for CBFB REARRANGEMENT. No evidence of
interphase bone marrow cells with rearrangement of the CBFB
gene.
5) FISH: NEGATIVE for MLL REARRANGEMENT. No evidence of
interphase bone marrow cells with rearrangement of the MLL gene.
6) FISH: NEGATIVE for RUNX1T1/RUNX1. No evidence of interphase
bone marrow RUNX1/RUNX1T1 gene rearrangement.
Myeloid Sequencing: CEBPA exon 1 frameshift deletion V95fs and
inframe insertion K313dup and frameshift, IKZF1 R274P, and IDH2
R140Q
mutations were DETECTED by targeted next generation sequencing.
-----
___ Bone Marrow Biopsy:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, nTdT,
cMPO, cCD79a, cCD3, cCD22, and CD antigens 11b, 13, 14, 16, 19,
33, 34, 45, 64, 117 and 123.
INTERPRETATION:
Diagnostic immunophenotypic features of involvement by leukemia
are not seen in this specimen. Correlation with clinical,
morphologic (see separate pathology report ___ and other
ancillary (see separate cytogenetics report ___) findings
is recommended. Flow cytometry immunophenotyping may not detect
all abnormal populations due to topography, sampling or
artifacts of sample preparation.
HEMATOPATHOLOGY REPORT
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS: HYPOCELLULAR BONE MARROW CONSISTENT WITH
CHEMOABLATION
MICROSCOPIC DESCRIPTION
Peripheral blood smear: The smears are adequate for evaluation.
Erythrocytes are moderately decreased in number, normochromic,
normocytic and have slight anisopoikilocytosis, including rare
dacrocytes and echinocytes. The white blood cell count is
markedly decreased. The platelet count is markedly decreased. A
limited differential shows: 2% blasts, 0% neutrophils, 96%
lymphocytes, 2% monocytes, 0% eosinophils and 0% basophils.
Bone marrow aspirate: The aspirate material is inadequate for
evaluation due to a lack of spicules and hemodilution.
The core biopsy material is adequate for evaluation. It consists
of a 1.2 cm long core biopsy composed of cortical bone,
cartiladge, skeletal muscle and trabecular marrow with a
cellularity of 5%. The majority of the cellular elements present
are plasma cells, histiocytes lymphocytes and stromal cells.
Maturing erythroid and myeloid elements are not appreciated. A
discrete blast population is not present. Megakaryocytes are
absent.
KEY IMAGING:
============
___ CXR: No focal consolidation
___ CT Head w/o Contrast: No acute intracranial process.
___ Transthoracic Echo
IMPRESSION: Normal study. Normal biventricular cavity sizes and
regional/global biventricular
systolic function. No valvular pathology or pathologic flow
identified
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler.
The estimated right atrial pressure is ___ mmHg. There is
normal left ventricular wall thickness with a normal cavity
size. There is normal regional and global left ventricular
systolic function. The visually estimated left ventricular
ejection fraction is 60%. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. No ventricular septal defect is seen.
There is normal diastolic function. Normal right ventricular
cavity size with normal free wall motion. Tricuspid annular
plane systolic excursion (TAPSE) is normal. 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. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) appear
structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral regurgitation. 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: Normal study. Normal biventricular cavity sizes and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified.
___ CXR:
IMPRESSION:
In comparison with the study of ___, there is little change
and no
evidence of acute cardiopulmonary disease. No pneumonia,
vascular congestion, or pleural effusion.
There has been placement of right IJ catheter that extends to
the mid to lower SVC with no evidence pneumothorax.
___ CT Sinus:
IMPRESSION:
1. Left lateral incisor periapical lucency with erosion through
the maxilla in close proximity to the nasal cavity and adjacent
6 x 8 mm rim enhancing collection concerning for a buccal
odontogenic abscess.
2. Severe dental disease with multiple periapical lucencies and
caries.
Dental exam recommended.
3. Minimal maxillary sinus mucosal thickening without
significant sinus
disease there or elsewhere. No evidence of invasive sinus
infectious origin.
___ CT Torso
IMPRESSION:
1. Uncomplicated colitis involving the ascending and transverse
colon.
Differential includes infectious or inflammatory etiologies.
Ischemic colitis far less likely given patent vasculature and
distribution.
2. Small volume free fluid in the right paracolic gutter. No
abscess or
perforation.
3. Trace ground-glass and nodular opacities in left lung measure
up to 4 mm, nonspecific, possibly infectious or inflammatory
foci. No lobar pneumonia.
___ CXR
IMPRESSION:
Bilateral increased pulmonary opacities with small bilateral
pleural effusions and normal heart size. Pulmonary edema versus
pneumonia.
___ CT Sinus:
IMPRESSION:
1. Redemonstration of a periapical lucency surrounding a left
lateral
maxillary incisor with erosion through the maxilla, in close
proximity to the nasal cavity. A faintly rim enhancing
collection anterior to the maxilla has decreased in size, now
measuring 3 x 3 mm, previously 6 x 8 mm. No new collections are
identified.
2. Redemonstration of severe dental disease with multiple
periapical
lucencies and caries.
3. Unchanged minimal mucosal thickening in the maxillary
sinuses and ethmoid air cells.
___ CT Head:
IMPRESSION:
No acute intracranial process.
___ CXR
IMPRESSION:
Compared to chest radiographs since ___ most recently
___.
Previous moderate pulmonary edema has improved, now mild.
Previous severe
right basal consolidation has also substantially decreased. No
pneumothorax
or appreciable pleural effusion. Heart size normal. Right
jugular line ends in the low SVC.
___ CT Abd/Pelvis:
IMPRESSION:
1. Persistent ascending colon colitis with improved appearance
of the
transverse colon (either improved colitis vs less decompression
on current
study). Differential diagnosis includes infectious,
inflammatory or ischemic
etiology. Associated inflammatory changes include small amount
of peritoneal fluid and thickening of the peritoneal fascia,
similar to prior.
2. New gas outlining the wall of the cecum is concerning for
developing
pneumatosis. No evidence of perforation. Correlation with
lactic acid is
recommended.
3. Fluid-filled colon in keeping with history of diarrhea.
4. No abdominal or pelvis fluid collections.
5. Please refer to separately reported chest CT for thoracic
findings.
___ CT Chest:
IMPRESSION:
1. No evidence of pneumonia.
2. The small ground-glass opacities in the lingula have
resolved.
3. Unchanged 2 mm pulmonary nodule in the right upper lobe. A
new 4 mm
ground-glass nodule in the middle lobe. These may be followed
on normal
routine oncologic surveillance studies.
4. New trace right pleural effusion.
Investigation of transfusion reaction (___)
Transfusion restrictions: Leukoreduced, irradiated
Transfusion restrictions met: Yes
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. ___
developed chills
and rigors five minutes after completion of a leukoreduced,
irradiated
platelet product. Laboratory workup revealed no evidence of
hemolysis.
Given that the patient has spiked multiple fevers during his
hospital
course that were not in the setting of transfusion, his
chills/rigors
after transfusion are more likely related to his underlying
medical
condition and not to transfusion. As leukoreduction
significantly
reduces the incidence of febrile non-hemolytic transfusion
reactions
(FNHTRs), other potential causes for his symptoms should be
investigated.
No changes in standard transfusion practices are recommended in
this
patient at this time.
DICSHARGE LABS:
===============
___ 12:00AM BLOOD WBC-9.6 RBC-2.79* Hgb-8.7* Hct-27.4*
MCV-98 MCH-31.2 MCHC-31.8* RDW-16.6* RDWSD-55.8* Plt ___
___ 12:00AM BLOOD Neuts-41 Lymphs-13* Monos-40* Eos-0*
___ Metas-3* Myelos-1* Blasts-1* NRBC-0.8* AbsNeut-3.94
AbsLymp-1.25 AbsMono-3.84* AbsEos-0.00* AbsBaso-0.10*
___ 12:00AM BLOOD ___ PTT-30.0 ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-148* UreaN-19 Creat-0.8 Na-141
K-4.8 Cl-102 HCO3-26 AnGap-13
___ 12:00AM BLOOD ALT-85* AST-54* AlkPhos-159* TotBili-<0.2
___ 12:00AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.3
___ 12:00AM BLOOD TotProt-6.2* Calcium-9.2 Phos-3.1 Mg-2.3
UricAcd-3.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin 500 mg PO Q8H
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
twice a day Disp #*21 Tablet Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Rinse your mouth with 15 mL
after brushing your teeth. twice a day Disp ___ Milliliter
Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
AML
Neutropenic Fevers
Odontogenic Abscess
SECONDARY DIAGNOSIS:
===================
Colitis
Poor Dentition
Vitreous and retinal hemorrhages
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 no significant PMH p/w leukcytosis c/f
AML.// Requesting placement double lumen central venous line
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ radiologist, performed the
procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: 1% lidocaine
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 42 seconds, to mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right neck was prepped and draped in the
usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath.
The Nitinol wire was removed and a short J wire was advanced into the IVC. A
triple-lumen central venous catheter (16 cm) was advanced over the wire into
the superior vena cava with the tip in the cavoatrial junction. All 3 access
ports were aspirated, flushed and capped. The catheter was secured to the skin
with a 0 silk suture and sterile dressings were applied. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The patient tolerated the procedure well without immediate
complications.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing triple
lumen central venous catheter with catheter tip terminating in the distal
superior vena cava.
IMPRESSION:
Successful placement of a temporary triple lumen catheter via the right
internal jugular venous approach. The tip of the catheter terminates in the
distal superior vena cava. The catheter is ready for use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new AML on induction chemo. New fever.//
Eval fever
IMPRESSION:
In comparison with the study of ___, there is little change and no
evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,
or pleural effusion.
There has been placement of right IJ catheter that extends to the mid to lower
SVC with no evidence pneumothorax.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST Q1217 CT HEADSINUS
INDICATION: ___ M on induction chemo for AML, spiking fevers to 102 on ___,
has chronic sinusitis sxs and now worsening running nose iso worsening
fevers// Evaluate for abscess, any evidence of sinusitis
TECHNIQUE: Axial images were acquired through the paranasal sinuses. Bone
and soft tissue reconstructed images were generated. Coronal reformatted
images were then produced.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 15.8 cm; CTDIvol = 29.9 mGy (Head) DLP = 453.4
mGy-cm.
Total DLP (Head) = 453 mGy-cm.
COMPARISON: Head CT from ___
FINDINGS:
Streak artifact from dental amalgam moderate to severely limits assessment of
the oropharynx. There is notable dental disease, partially visualized, with
periapical lucency and severe ___ involving the left second molar (7:105;
7:101). Additional periapical lucency involves the right lateral incisor.
Appear apical lucency involving the left lateral incisor extends superiorly
where there is a 1 cm defect in the left maxilla with extension in close
proximity to the nasal cavity (09:19; 03:11). Anterior to the defect, an 8 x
5 x 7 mm collection is faintly rim enhancing and slightly centrally hypodense
(04:11; 09:14). There is minimal dependent maxillary sinus mucosal thickening
bilaterally. The remaining paranasal sinuses are normally aerated, with no
mucosal thickening or air-fluid levels identified. The ostiomeatal units are
patent. The cribriform plates are intact. The lamina papyracea are intact.
IMPRESSION:
1. Left lateral incisor periapical lucency with erosion through the maxilla in
close proximity to the nasal cavity and adjacent 6 x 8 mm rim enhancing
collection concerning for a buccal odontogenic abscess.
2. Severe dental disease with multiple periapical lucencies and caries.
Dental exam recommended.
3. Minimal maxillary sinus mucosal thickening without significant sinus
disease there or elsewhere. No evidence of invasive sinus infectious origin.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:18 pm, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST; CT CHEST W/CONTRAST
INDICATION: ___ year old man with AML, neutropenic fevers, persistent
diarrhea// Evaluate for infectious foci, abscess, evidence of colitis
TECHNIQUE: Axial multidetector CT images were obtained through the torso
after the uneventful administration of intravenous contrast. 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: Total DLP (Body) = 751 mGy-cm.
COMPARISON: Chest radiograph from ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: Right internal jugular approach central venous catheter
terminates in the cavoatrial junction. No central pulmonary embolus. The
segmental and subsegmental pulmonary arteries are not well assessed due to
bolus timing. 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: In the lingula and subpleural superior left upper lobe, subtle
ground-glass opacities are nonspecific measure up to 4 mm (___).
Linear high-density branching structure in right upper lobe is nonspecific may
represent calcifications, and of unlikely clinical significance (4:153).
Otherwise the lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal 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 distal
ascending colon at the hepatic flexure and majority of the transverse colon
demonstrates wall thickening and mucosal hyperenhancement. There is trace
low-density free fluid along the right paracolic gutter. No evidence of
abscess or perforation. The descending and sigmoid colon are within normal
limits. The apparent slight rectal wall thickening likely reflects
underdistention. The appendix is normal. 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 and seminal vesicles appear normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: Patent visualized abdominopelvic vasculature including the SMA, SMV,
celiac origin, ___ and IMV. 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. An umbilical hernia containing fat is noted.
IMPRESSION:
1. Uncomplicated colitis involving the ascending and transverse colon.
Differential includes infectious or inflammatory etiologies. Ischemic colitis
far less likely given patent vasculature and distribution.
2. Small volume free fluid in the right paracolic gutter. No abscess or
perforation.
3. Trace ground-glass and nodular opacities in left lung measure up to 4 mm,
nonspecific, possibly infectious or inflammatory foci. No lobar pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:31 pm, 2 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with AML, neutropenic fevers, getting IVF, now w/
crackles on exam c/f volume overload// Evaluate for pulmonary edema, pleural
effusions Evaluate for pulmonary edema, pleural effusions
COMPARISON: Chest x-ray ___
FINDINGS:
Single portable frontal view of the chest shows the distal tip of the right IJ
central venous catheter overlying the caval atrial junction. The heart is
normal in size. There is a are small bilateral pleural effusions. There is
increased pulmonary opacities bilaterally worse at the right lung base than
the left. This could represent pulmonary edema or pneumonia. No
pneumothorax.
IMPRESSION:
Bilateral increased pulmonary opacities with small bilateral pleural effusions
and normal heart size. Pulmonary edema versus pneumonia.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST
INDICATION: ___ year old man with AML, on induction chemo, with severe
thrombocytopenia, c/o headache and new left-sided blurry vision. Also known
buccal abscess and maxillary erosions noted on prior head CT, with persistent
fevers// Change in appearance/severity of tooth abscess, maxillary erosion
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 20.7 cm; CTDIvol = 29.9 mGy (Head) DLP = 600.1
mGy-cm.
Total DLP (Head) = 600 mGy-cm.
COMPARISON: CT maxillofacial dated ___.
FINDINGS:
Similar to prior, streak artifact from dental amalgam moderate to severely
limits assessment of the oral cavity.
A periapical lucency of the left lateral incisor, which has been extracted,
extends superiorly through a 1.0 cm defect in the alveolar ridge of the left
maxilla with dehiscence of the bony floor of the nasal cavity. Anterior to
this defect, there is persistent fat stranding, as well as a subtle, faintly
rim enhancing collection measuring 3 x 3 mm, previously 8 x 5 mm (4:77). No
new collections are identified.
Periapical lucency and a severe caries involving the left third maxillary
molar (4:67) appear similar to prior.
Periapical lucency around the left maxillary canine is unchanged.
A periapical lucency involving the right maxillary canine is unchanged.
A caries and a periapical lucency involving the right second mandibular
premolar was not included in the field of view on the prior study.
A large dental caries involving the right second mandibular molar is also
noted.
Additional scattered smaller dental caries are noted.
There is no facial bone fracture. Pterygoid plates are intact. There is no
mandibular fracture and the temporomandibular joints are anatomically aligned.
The orbits are intact. The globes and extra-ocular muscles are unremarkable.
There is no orbital hematoma.
Aside from minimal mucosal thickening in the bilateral ethmoid air cells and
bilateral maxillary sinuses, the included paranasal sinuses are clear.
IMPRESSION:
1. Redemonstration of a periapical lucency surrounding a left lateral
maxillary incisor with erosion through the maxilla, in close proximity to the
nasal cavity. A faintly rim enhancing collection anterior to the maxilla has
decreased in size, now measuring 3 x 3 mm, previously 6 x 8 mm. No new
collections are identified.
2. Redemonstration of severe dental disease with multiple periapical
lucencies and caries.
3. Unchanged minimal mucosal thickening in the maxillary sinuses and ethmoid
air cells.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with AML, on induction chemo, with severe
thrombocytopenia, c/o headache and new left-sided blurry vision// Evaluate for
evidence of hemorrhage or new lesion
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
752.0 mGy-cm.
Total DLP (Head) = 752 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
There is no evidence of acute territorial infarction,hemorrhage,edema,or mass
effect. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with AML, spiked fever to 100.6 with some SOB//
Evaluate for consolidation, edema Evaluate for consolidation, edema
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Previous moderate pulmonary edema has improved, now mild. Previous severe
right basal consolidation has also substantially decreased. No pneumothorax
or appreciable pleural effusion. Heart size normal. Right jugular line ends
in the low SVC.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with AML, neutropenic fevers. Unclear infectious
source, and had been afebrile since ___, but spiked new fevers on ___. Chief
concern is for worsening colitis (has intermittent diarrhea) vs worsening
pulmonary infectious process.// Evaluate for infectious nidus that could be
causing neutropenic fevers
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 5.7 s, 0.2 cm; CTDIvol = 97.8 mGy (Body) DLP =
19.6 mGy-cm.
3) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol = 10.9 mGy (Body) DLP =
713.6 mGy-cm.
Total DLP (Body) = 735 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Please refer to separately reported CT of the chest performed at
the same time for thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is 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 filled with contrast and other content.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Mild mucosal thickening and fat stranding surrounding the
ascending colon from the cecum to the hepatic flexure with associated
thickening of the adjacent peritoneum and small amount of fluid in the right
paracolic gutter is overall unchanged since ___. New dependent and
non-dependent gas outlining the cecal wall could represent pneumatosis.
Transverse colon and descending colon contain fluid (likely reflective of
diarrhea) but otherwise appear normal. Rectum is normal. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are 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. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Persistent ascending colon colitis with improved appearance of the
transverse colon (either improved colitis vs less decompression on current
study). Differential diagnosis includes infectious, inflammatory or ischemic
etiology. Associated inflammatory changes include small amount of peritoneal
fluid and thickening of the peritoneal fascia, similar to prior.
2. New gas outlining the wall of the cecum is concerning for developing
pneumatosis. No evidence of perforation. Correlation with lactic acid is
recommended.
3. Fluid-filled colon in keeping with history of diarrhea.
4. No abdominal or pelvis fluid collections.
5. Please refer to separately reported chest CT for thoracic findings.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:46 pm, 50 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST WITH CONTRAST
INDICATION: ___ year old man with AML, neutropenic fevers. Unclear infectious
source, and had been afebrile since ___, but spiked new fevers on ___. Chief
concern is for worsening colitis (has intermittent diarrhea) vs worsening
pulmonary infectious process.// Evaluate for infectious nidus that could be
causing neutropenic fevers
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 5.7 s, 0.2 cm; CTDIvol = 97.8 mGy (Body) DLP =
19.6 mGy-cm.
3) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol = 10.9 mGy (Body) DLP =
713.6 mGy-cm.
Total DLP (Body) = 735 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Prior chest CT from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. No abnormalities on the chest wall. No atherosclerotic
calcifications in the head and neck arteries.
HEART AND VASCULATURE:
The heart is normal in size and shape. No pericardial effusion. Mild
atherosclerotic calcifications in the coronary arteries, none in the cardiac
valves or aorta. The aorta and pulmonary arteries are normal in caliber
throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes, none
pathologically enlarged by CT size criteria. No hilar lymphadenopathy.
PLEURA:
Small right pleural effusion the, new since prior. No effusion to the left..
Mild bilateral apical scarring.
LUNGS:
The airways are patent to the subsegmental levels. No bronchial wall
thickening, bronchiectasis or mucus plugging. Linear calcification in the
middle lobe (5:144), unchanged, likely sequela. A 2 mm pulmonary nodule in
the right upper lobe (5:111) is unchanged. A 4 mm ground-glass nodule in the
middle lobe (5:159). Mild compressive atelectasis of the right lower lobe.
Previously mentioned small ground-glass opacities in the lingula have
resolved.
CHEST CAGE:
No acute fractures. Mild dorsal spondylosis. No suspicious lytic or sclerotic
lesions.
UPPER ABDOMEN:
Please refer to same day abdominal CT report for subdiaphragmatic findings.
IMPRESSION:
1. No evidence of pneumonia.
2. The small ground-glass opacities in the lingula have resolved.
3. Unchanged 2 mm pulmonary nodule in the right upper lobe. A new 4 mm
ground-glass nodule in the middle lobe. These may be followed on normal
routine oncologic surveillance studies.
4. New trace right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with anemia, cough// leukemia, infection
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Lungs are expanded and without focal consolidation. There is no pleural
effusion or pneumothorax. Cardiomediastinal silhouette is within normal
limits. No acute fracture is identified. The upper abdomen is unremarkable.
IMPRESSION:
No focal consolidation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, platelets 2// eval brain bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of territorial infarctionacute hemorrhageedema,or mass.
The ventricles and sulci are normal in size and configuration.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Acute myeloblastic leukemia, not having achieved remission
temperature: 96.5
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 128.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
========
Mr. ___ is a ___ yo M with no significant PMH who presented
with bleeding and syncope, found to have leukocytosis with
elevated blast count, anemia and thrombocytopenia, diagnosed
with AML after a bone marrow biopsy. Started on induction
chemotherapy with 7+3, and had appropriately ablated marrow on
D14 bone marrow biopsy. Hospital course complicated by
neutropenic fevers, suspected to be secondary to colitis or an
odontogenic abscess, as well as bilateral retinal hemorrhages
due to thrombocytopenia. Bone marrow bx ___ reassuring. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cough, malaise
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
103 pmh COPD, hypertension, HLD presents with 5 days of
malaise, poor PO intake, cough. Per son, he visited his mother
at her assisted living home on ___ and note she has a chest
cold with a deep cough. Nurses called the patient's PCP ___.
___ went to visit the patient and give cough, crackle on
lung exam patient was sent into the ED by ambulance for further
evaluation.
Per the son, patient eats/drinks normal diet, no issues with
pills, ambulates with a walker, is very hard of hearing (good
ear is left ear) and does not wear dentures or hearing aide. No
major past hospitalizations.
In the ED, initial vitals were: Temp 99.8F HR 74 BP 174/71 RR
18
97% RA
Exam notable for: crackles in left lower lung base.
Labs notable for:
Na+ 129 K+ 4.8 BUN 19 Cr 0.7
TropT <0.01 BNP 2432 Lactate 1.4
UA Mod blood neg nitrate positive ketones 40 <1 WBC, few
bacteria
FluA/B PCR negative
EKG: SR, normal axis, submili elevation V2
Patient was given furosemide 40 mg IV.
Upon arrival to the floor, patient reports that she is feeling
well except for a deep cough.
Past Medical History:
HTN
S/P cholecystectomy
S/P hysterectomy
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DIVERTICULOSIS
HIP REPLACEMENT (L)
OSTEOPOROSIS
Social History:
___
Family History:
Son also has hypertension, no family history of gastrointestinal
disease.
Physical Exam:
ADMISSION EXAM
==============
VITAL SIGNS 97.4F 169/86 HR 78 RR 18 95 RA
GENERAL A&O3X
HEENT No teeth, mucous membranes moist, PEERL
NECK Supple, JVD is not elevated
CARDIAC RRR no mrg
LUNGS Crackles at bases bilaterally, moving air well
ABDOMEN Soft, NT, ND, normoactive bowel sounds
EXTREMITIES trace pitting edema bilaterally
NEUROLOGIC CNII-XII, 4+/5 UE, 4+/5 ___ strength
SKIN - warm, dry intact
DISCHARGE EXAM
==============
VITALS: Tmax 98.5 BP 120-160/60-70s HR 60-80s RR ___
on r
GENERAL Alert, oriented to place (hospital) and time (___) but
not month
HEENT: No teeth, mucous membranes moist, PEERL
CARDIAC RRR no mrg
LUNGS No adventitious lung sounds on anterior auscultation
ABDOMEN Soft, NT, ND, normoactive bowel sounds
EXTREMITIES trace edema bilaterally
NEUROLOGIC CNII-XII grossly intact
SKIN - warm, dry, intact; has 3x6cm erythematous, raised patch
of ___ skin without drainage, no fluctuance, not painful
to palpation
Pertinent Results:
ADMISSION LABS
==============
___ 06:08PM BLOOD WBC-5.8 RBC-4.70 Hgb-13.1 Hct-40.4 MCV-86
MCH-27.9 MCHC-32.4 RDW-15.2 RDWSD-47.7* Plt ___
___ 06:08PM BLOOD Neuts-78.5* Lymphs-9.9* Monos-10.8
Eos-0.0* Baso-0.3 Im ___ AbsNeut-4.57 AbsLymp-0.58*
AbsMono-0.63 AbsEos-0.00* AbsBaso-0.02
___ 06:08PM BLOOD Plt ___
___ 06:08PM BLOOD Glucose-89 UreaN-19 Creat-0.7 Na-129*
K-4.8 Cl-95* HCO3-22 AnGap-17
___ 06:08PM BLOOD proBNP-2432*
___ 06:08PM BLOOD cTropnT-<0.01
___ 05:28AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:08PM BLOOD Albumin-3.7
___ 06:08PM BLOOD Osmolal-280
___ 06:08PM BLOOD TSH-2.1
___ 06:22PM BLOOD Lactate-1.4
MICRO
=====
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTURE-FINALEMERGENCY WARD
IMAGING
=======
___ CXR
IMPRESSION:
Bilateral pleural effusions left greater than right with
associated
compressive lower lobe atelectasis.
DISCHARGE LABS
==============
___ 05:28AM BLOOD WBC-6.9 RBC-4.96 Hgb-14.0 Hct-42.9 MCV-87
MCH-28.2 MCHC-32.6 RDW-15.1 RDWSD-47.8* Plt ___
___ 05:28AM BLOOD Neuts-74.8* Lymphs-12.3* Monos-12.1
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.17 AbsLymp-0.85*
AbsMono-0.84* AbsEos-0.01* AbsBaso-0.02
___ 05:28AM BLOOD Plt ___
___ 05:28AM BLOOD ___ PTT-36.4 ___
___ 05:28AM BLOOD Glucose-76 UreaN-21* Creat-0.8 Na-136
K-4.0 Cl-93* HCO3-24 AnGap-23*
___ 05:28AM BLOOD CK(CPK)-60
___ 05:28AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Spironolactone 25 mg PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Spironolactone 25 mg PO EVERY OTHER DAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses
- Upper respiratory infection
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 (AP AND LAT)
INDICATION: ___ with cough, congestion, generalized weakness.
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided.
Bilateral small pleural effusions are noted, left greater than right with
associated compressive lower lobe atelectasis. No definite signs of pneumonia
or overt edema. No pneumothorax. Heart size cannot be assessed. Mediastinal
contour is unchanged with calcified thoracic aorta.
IMPRESSION:
Bilateral pleural effusions left greater than right with associated
compressive lower lobe atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cough, Lethargy
Diagnosed with Pneumonia, unspecified organism, Heart failure, unspecified
temperature: 95.2
heartrate: 81.0
resprate: 20.0
o2sat: 100.0
sbp: 193.0
dbp: 78.0
level of pain: 5
level of acuity: 2.0 | HOSPITAL COURSE
===============
Ms. ___ is a ___ year old lady with pmh COPD, hypertension,
HLD, who presented with 5 days of malaise, poor PO intake, and
cough. Per son, he visited his mother at her assisted living
home on ___ and noted she had a chest cold with a deep
cough. She had no fever or leukocytosis, and her CXR was
significant for small bilateral pleural effusions seen on prior
but no focal consolidations or pulmonary edema. The patient was
treated symptomatically and improved by the time of discharge.
She was also found to have a small right ___ gluteal
abscess that drained without intervention and prior to discharge
had minimal surrounding induration but no pain, fluctuance, or
discharge.
ACTIVE ISSUES
=============
# Upper respiratory infection
5 days non-productive cough, no evidence of pneumonia on CXR.
Flu A/B PCR negative. CXR with a worsening left sided pleural
effusion likely secondary to compressive atelectasis; of note,
pleural effusions and atelectasis long standing dating back to
___. Afebrile and white count within normal limits. Likely
upper respiratory virus. Treated symptomatically with duonebs,
tesslon pearls, guaifenesin. Improved by time of discharge.
# Left pleural effusions: CXR with a worsening left sided
pleural effusion likely secondary to compressive atelectasis; of
note, pleural effusions and atelectasis long standing dating
back to ___. Possible fluid overload, no history of CHF though
BNP elevated. Given stable respiratory status, no SOB, no
further workup as inpatient.
# Failure to thrive: One week of poor PO intake in the setting
of malaise, fatigue likely secondary to viral syndrome. Evidence
of ketones in urine without an anion gap and in the setting of
normal glucose evidence of starvation ketosis. Seen by
nutrition, supplemented with Frappes. Continue to encourage PO.
# Thrombocytopenia: Mild, stable, no evidence of bleeding,
likely from acute viral illness. Stable.
# *Resolved* Hyponatermia: Urine osm inappropriately high
compared to serum osm. Diuresed with 40 mg IV Lasix and
hyponatremia resolved. Recommend repeat lytes in follow up with
PCP.
# Left gluteal abscess, self-drained, small remaining ulcer: No
signs of infection or drainage. Not painful to palpation, not
affecting patients bowel movements. ___ to provide wound care
after discharge. Hot compresses, ___ baths recommended.
TRANSITIONAL ISSUES
===================
[] Follow up with PCP ___ at 10:00am
[] Follow up gluteal ulcer to ensure it does not worsen of
become infected
[] Repeat sodium at next PCP ___ (initially noted to be
hyponatremic but rapidly corrected after admission, patient
refused labs on day of discharge)
[] Consider stopping spironolactone pending outpatient blood
pressure trends, repeat lytes
# CODE: DNR/DNI (confirmed with son and patient)
# CONTACT: ___ son ___ |