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Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with a history of hypertension, hematuria, hyperlipidemia and abnormal stress test done years ago at ___ who presents with syncope. Per patient and her daughter, this is the fourth time this has occurred since ___. In ___, patient fainted while in the bathroom having a bowel movement and urinating, a few years ago, she had it in the kitchen while working, the third time was in the bathroom as well and she had a seizure at that time, the fourth time is what is bringing her in today. Patient was having some abdominal pain, so she went to the bathroom to evacuate her bowels. In the bathroom while actively having a bowel movement and urinating when she started to feel a prodrome of weakness, fogginess, dizziness, she called her daughter into the bathroom and told her "I feel like I am going to pass out", her daughter held her up and tried to wake her up but then per daughter, he body went limp. Her daughter then started to rub her face and make her smell perfume. When the patient woke up seconds later, she still complained of dizziness. After the patient fainted again, this time with her head up and one arm to her chest while the other arm out and per her daughter, she started to shake in a seizure like movement, at this time her daughter heard the patient loose control of her bowel and bladder. Then the patient woke up and was confused and disoriented, she was guided by her daughter to the living room, but then fainted again. Finally the daughter helped the mother to the couch, After laying down, she suddenly felt better, and per daughter, looked less pale. Her daughter called the ambulance who performed orthostatics on her, patient shares that she could barely stand up to get her vitals checked as she was so dizzy. ROS: negative chest pain, shortness of breath with exertion (stairs, walking), abdominal pain, dysuria, melena, BRBPR, leg swelling, PND/orthopnea, palpitations, fevers, chills. In the ED, initial vital signs were: 98.0 65 125/48, 16, 95% on RA - Exam notable for: neuoro intact though did not test gait CTAB RRR NT ND abdomen - Studies performed include CXR Top-normal heart size unchanged EKG: sinus at 64 with TWIs in I an daVL new from prior on ___ ___s JPE in V3 similar to prior. CT scan of head with no intracranial process - Vitals on transfer: 98.4, 81, 137/47, 16, 97% on RA Upon arrival to the floor, the patient confirms this history above and states shes had no further episodes or symptoms. Past Medical History: Hematuria HTN HLD Positive stress test done years ago at ___ Social History: ___ Family History: mom - htn, CAD, father- died cause unknown Physical Exam: Admission physical exam: Vitals- 97.9 PO 152 / 68 77 18 96 RA GENERAL: AOx3, NAD, AOX3 HEENT: Normocephalic, atraumatic, right scab on lateral inferior portion of skull, sparse hair distribution. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. NECK: Supple, no nodules palpated, no cervical LAD . CARDIAC: RUSB with holosystolic murmur with early peak, radiating to carotid, no tardes et parvus. Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. BACK: Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. Discharge physical exam: Vitals- 98.5 ___ RA GENERAL: AOx3, NAD, AOX3 HEENT: Normocephalic, atraumatic, right scab on lateral inferior portion of skull, sparse hair distribution. NECK: Supple, no nodules palpated, no cervical LAD . CARDIAC: RUSB with holosystolic murmur with early peak, radiating to carotid. Regular rhythm, no JVD. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. Pertinent Results: Admission labs: =============== ___ 11:10AM BLOOD WBC-6.5 RBC-3.99 Hgb-11.9 Hct-36.4 MCV-91 MCH-29.8 MCHC-32.7 RDW-14.0 RDWSD-47.0* Plt ___ ___ 11:10AM BLOOD Neuts-58.7 ___ Monos-8.3 Eos-1.1 Baso-0.8 Im ___ AbsNeut-3.83 AbsLymp-1.99 AbsMono-0.54 AbsEos-0.07 AbsBaso-0.05 ___ 11:10AM BLOOD Glucose-123* UreaN-18 Creat-0.7 Na-140 K-3.6 Cl-103 HCO3-23 AnGap-18 ___ 11:10AM BLOOD ALT-17 AST-20 CK(CPK)-151 AlkPhos-60 TotBili-0.2 ___ 11:10AM BLOOD CK-MB-3 ___ 11:10AM BLOOD cTropnT-<0.01 ___ 11:10AM BLOOD Albumin-4.1 Calcium-9.8 Phos-4.0 Mg-2.2 ___ 11:10AM BLOOD Free T4-1.2 ___ 11:10AM BLOOD TSH-3.3 Discharge labs: =============== ___ 07:55AM BLOOD WBC-6.2 RBC-4.27 Hgb-12.8 Hct-38.8 MCV-91 MCH-30.0 MCHC-33.0 RDW-14.3 RDWSD-47.2* Plt ___ ___ 07:55AM BLOOD Neuts-36.6 ___ Monos-9.4 Eos-1.5 Baso-0.6 Im ___ AbsNeut-2.27 AbsLymp-3.20 AbsMono-0.58 AbsEos-0.09 AbsBaso-0.04 ___ 07:55AM BLOOD Glucose-92 UreaN-20 Creat-0.6 Na-142 K-3.8 Cl-106 HCO3-24 AnGap-16 ___ 07:55AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.1 Diagnostics: ============= ___ Chest x ray Compared to chest radiographs since ___ most recently ___. Top-normal heart size unchanged. Pulmonary, hilar, and mediastinal vasculature are unremarkable. Lungs are mildly hyperinflated, suggesting small airway obstruction, but clear of any focal abnormality. No pleural effusion. ___ CT head without contrast There is no evidence of infarction, hemorrhage, edema, or mass. Minimal periventricular and subcortical white matter hypodensities are nonspecific but likely sequelae of chronic small vessel ischemic disease. 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. A sclerotic focus within the clivus is unchanged since ___, likely a benign bone island. IMPRESSION: No evidence of intracranial hemorrhage or large territorial infarction. ___ EEG IMPRESSION: This is a normal continuous EMU monitoring study. There are no focal findings, epileptiform discharges or electrographic seizures. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 320 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Simvastatin 40 mg PO QPM 5. Vitamin D 800 UNIT PO DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Simvastatin 40 mg PO QPM 5. Valsartan 320 mg PO DAILY 6. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis ================= Vasovagal syncope Convulsive syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with cough// PNA? PNA? IMPRESSION: Compared to chest radiographs since ___ most recently ___. Top-normal heart size unchanged. Pulmonary, hilar, and mediastinal vasculature are unremarkable. Lungs are mildly hyperinflated, suggesting small airway obstruction, but clear of any focal abnormality. No pleural effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ with syncope though possible c/f seizure. 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, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: ___ noncontrast head CT. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. Minimal periventricular and subcortical white matter hypodensities are nonspecific but likely sequelae of chronic small vessel ischemic disease. 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. A sclerotic focus within the clivus is unchanged since ___, likely a benign bone island. IMPRESSION: No evidence of intracranial hemorrhage or large territorial infarction. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Syncope Diagnosed with Syncope and collapse temperature: 98.0 heartrate: 65.0 resprate: 16.0 o2sat: 95.0 sbp: 125.0 dbp: 48.0 level of pain: 0 level of acuity: 2.0
___ woman with a history of hypertension, hematuria, hyperlipidemia and abnormal stress test done years ago at ___ who presents with syncope. History notable for prodromal symptoms of lightheadedness, dizziness followed by syncope while evacuating bowels and bladder in the restroom, followed by convulsions ( shaking movements with loss of bladder and bowels but no tongue biting). VSS, physical exam unremarkable with negative orthostatics, labs unremarkable with negative troponin, EKG with TWI but unchanged, images notable for no acute intracranial process in CT head, CXR within normal limits. EEG done to rule out seizure, no asymmetry seen and neurology not concerned for seizure, telemetry for 1 night with no events. Symptoms consistent with convulsive syncope brought on by vasovagal syncope. Patient was educated on the condition and discharged with specific instructions to follow when she gets the prodromal symptoms.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: nausea, fatigue, abdominal pain Major Surgical or Invasive Procedure: R arm PICC placed R sided nephrostomy replaced History of Present Illness: Mr. ___ is an ___ yo M w/ PMH Of CAD s/p CABG and stents, sCHF (EF ___, ulcerative colitis, mesenteric ischemia s/p stenting of SMA and R renal artery ___ with multiple presentations for abdominal pain this month. He was admitted ___ to the CCU with stenting for abdominal pain thought to be ___ mesenteric ischemia, then readmitted ___ with abdominal pain of unclear etiology. Previous w/u during last ___/P, HIDA scan, and abdominal US prompting stenting of his SMA and right renal artery. In addition he was found to be H pylori positive and was started on a 2 week course of triple therapy (clarithyromycin, amoxicillin and PPI BID). MRCP during his most recent admission showed abnormal inflammatory process in the area of the R kidney: "Unchanged moderate right hydronephrosis with a right percutaneous nephrostomy tube terminating appropriately within the pelvis. Continued tethering of the ascending colon towards the mass with extension towards the pancreatic head". GI did not recommend ERCP or further studies at this time and the patient's pain resolved allowing discharge home. He was then just seen in the ED ___ at which time CT a/p w/o contrast did not show any acute intraabdominal process. He was admitted for 24 hrs and discharged ___ when walking around and feeling better after IVF. Prior to recent admission he had several days of increasing fatigue, decreased PO intake, and mild abdominal pain not associated with PO and controlled w/ oxycodone. He has had nausea <24 hrs. Last BM yesterday was soft brown stool. He denies CP/sob, presyncope, dysuria, confusion, HA, pleurisy, melena/hematochezia. ED course On arrival, patient was triggered for hypotension in the setting of emesis. He was pink/warm/dry, vomited 60 cc of bile without compromise of airway. Triage 01:05 0 97.0 73 73/37 18 97% 2L Today 01:37 0 82 ___ 99% RA Today 01:40 72 125/57 Today 02:09 0 98.1 92 108/47 18 99% RA Today 02:36 3 98 100 127/64 18 98% RA -blood cx x2 -CXR -CT a/p w/o contrast -18g x2 -1L NS -NGT placed and to suction -fentanyl 100mcg -Vancomycin 1g -Azithromycin 500mg -Ceftriaxone 1g On arrival to the MICU, patient is sleepy and has nausea, but otherwise is comfortable. Past Medical History: #CAD s/p CABG in ___ (LIMA-LAD, SVG-OM1, SVG-RPDA, and SVG-D1), post-operative MI s/p PCI ___ with placement of 3 BMS in the SVG-OM (other 2 SVGs were occluded, chronic total occlusion of RCA and LCx, as well as CTO of LAD after D1) #sCHF: EF ___ #Mesenteric ischemia: PTA/stent of the right renal artery and PTA/Stent of the SMA ___ #PVD #CKD #GERD #Ulcerative Colitis - was started on pentasa recently but discontinued early ___ given cramps. Asacol was held over the last 1 month given insurance issues #colonic polyps - adenomatous #DJD of back #spinal stenosis #anxiety/depression #arthritis hip s/p L hip replacement #s/p Left and Right CEA #chronic impingement left shoulder w arthritis s/p acromioplasty ___ #carpal tunnel surgery #bladder cancer - TCC s/p BCG at OSH, plus R ureteral TCC vs. stricture s/p R PCN placement ___ #right ureter stricture s/p right nephrostomy tube ___ Social History: ___ Family History: Mom died s/p appy Father died s/p MI brother w ___, 4-vessel CABG Physical Exam: ADMISSION EXAM -------------- Vitals: T:98.6 BP:115/60 P:83 R:24 O2:94% 2L NC General- somnolent, oriented, mild respiratory distress HEENT- Sclera anicteric, MM dry, NGT in place draining bilious liquid Neck- Normal carotid upstroke, no JVD Lungs- faint rales at L base, otherwise clear. ___ breathing CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops; occasional irregular beat Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- R NU tube, no CVAT, no Foley Ext- warm, dry, 1+ DP pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, 4+/5 strength throughout, normal sensation to light touch throughout. Decreased muscle bulk throughout. DISCHARGE EXAM -------------- Vitals: T 97.8, Tmax afebrile, BP 147/71, HR 63, RR 18, sat 97% on RA I/Os: 550cc of UOP, and 100cc through the R sided nephrostomy HEENT: anicteric, PERRL, MMM, clear oropharynx Chest: equal chest rise, CTAB posteriorly, no cough or work of breathing Heart: regular, no obv m/r/g on limited exam Abd: slightly distended, but soft, non-tender GU: no CVAT, R sided nephrostomy with amber colored urine Extr: WWP, no edema Skin: no rashes on limited exam Neuro: speaking easily, moving all 4 extremities Psych: normal affect Pertinent Results: ADMISSION LABS -------------- ___ 08:00AM BLOOD WBC-5.2 RBC-3.39* Hgb-8.1* Hct-27.2* MCV-80* MCH-24.0* MCHC-29.9* RDW-18.6* Plt ___ ___ 01:15AM BLOOD WBC-3.5* RBC-3.76* Hgb-9.1* Hct-30.4* MCV-81* MCH-24.2* MCHC-29.9* RDW-18.6* Plt ___ ___ 01:15AM BLOOD ___ PTT-31.4 ___ ___ 08:00AM BLOOD Glucose-75 UreaN-23* Creat-2.0* Na-139 K-3.9 Cl-104 HCO3-24 AnGap-15 ___ 01:15AM BLOOD Glucose-94 UreaN-23* Creat-2.0* Na-137 K-3.5 Cl-103 HCO3-21* AnGap-17 ___ 08:00AM BLOOD ALT-19 AST-29 AlkPhos-129 TotBili-0.4 ___ 08:00AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.1 Mg-1.7 ___ 10:35PM BLOOD Lactate-0.9 PERTINENT LABS -------------- ___ 08:00AM BLOOD Lipase-60 ___ 06:53AM BLOOD cTropnT-0.01 ___ 08:00AM BLOOD TSH-11* ___ 09:46AM BLOOD Lactate-1.5 ___ 01:27AM BLOOD Lactate-2.6* CT ABDOMEN AND PELVIS: IMPRESSION: 1. Small consolidation and heterogeneous opacities in the lingula are new since ___, and likely represent aspiration given rapid development. Persistent ___ opacities in the right middle ___ be infectious or inflammatory in nature. 2. Stable appearance of the known right ureteral mass which closely abuts the duodenum and inferior aspect of the pancreas without discernable fat plane. Focal thickening of the ascending colon, which remains tethered to this mass. Stable appearance of intrahepatic and extrahepatic biliary ductal dilatation. 3. Right nephrostomy tube is in place. Mild hydronephrosis is stable. Mild-to-moderate hydroureter is also unchanged. 3. Right renal artery and SMA stents are in place. The patency of the vessels cannot be assessed due to lack of intravenous contrast. 4. Moderate hiatal hernia. CXR ___ FINDINGS: The patient is status post coronary bypass surgery. The cardiac, mediastinal and hilar contours appear stable. A patchy but extensive opacity in the left upper lobe suggesting pneumonia has improved to some extent. The right lung remains clear. There is perhaps a trace pleural effusion on the left, but no definite right-sided effusion. There is a moderate hiatal hernia. The cardiac, mediastinal and hilar contours appear stable. IMPRESSION: Improvement in left upper lobe consolidation. Follow-up radiographs within eight weeks are recommended to show resolution. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H pain 2. Ascorbic Acid 80 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Cyanocobalamin 100 mcg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Metoprolol Succinate XL 50 mg PO DAILY 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN abdominal pain 10. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 11. Pantoprazole 40 mg PO Q12H 12. Polyethylene Glycol 17 g PO DAILY 13. Rosuvastatin Calcium 40 mg PO DAILY 14. Senna 2 TAB PO BID 15. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H pain 3. Ascorbic Acid 80 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Citalopram 20 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Cyanocobalamin 100 mcg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN abdominal pain 10. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 11. Pantoprazole 40 mg PO Q12H 12. Polyethylene Glycol 17 g PO DAILY 13. Rosuvastatin Calcium 40 mg PO DAILY 14. Senna 2 TAB PO BID 15. Vitamin E 400 UNIT PO DAILY 16. CefePIME 2 g IV Q24H Finish ___fter doses on ___. 17. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN wheezing 18. Vancomycin 1000 mg IV Q48H Finish ___fter doses on ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis - Health Care Associated Pnuemonia - Chronic Systolic CHF - CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: The patient with hypotension and abdominal pain. COMPARISONS: ___. FINDINGS: Supine portable view of the chest demonstrates low lung volumes. Left lung opacities are new since prior. There is relative sparing of the left upper lung. No pleural effusion is seen. No pneumothorax. Hilar and mediastinal silhouettes are unchanged. Heart size is top normal. Post-surgical changes related to median sternotomy and CABG are stable. IMPRESSION: Left lung opacities new since ___, most likely aspiration given rapid developmemt of these findings. Radiology Report INDICATION: Abdominal pain and hypotension. Assess for acute intra-abdominal process. COMPARISONS: ___. MRCP of ___ and CT abdomen and pelvis of ___. TECHNIQUE: MDCT-acquired contiguous images through the abdomen were obtained without intravenous or oral contrast at 5-mm slice thickness. Coronally and sagittally reformatted images are provided. DLP: 478 mGy-cm. FINDINGS: CT OF THE ABDOMEN: Small consolidation and heterogeneous opacities in the lingula are new since prior exam. There are persistent ___ opacities in the right middle lobe, which may represent infection or inflammation (2:6). No pleural effusion. Heart is normal in size without pericardial effusion. There is moderate hiatal hernia. Evaluation for visceral organs is limited due to lack of intravenous contrast. Within this limitation, the liver demonstrates homogeneous attenuation without suspicious focal lesions. Mild intrahepatic biliary ductal dilatation is unchanged. The gallbladder is incompletely distended. There is no gallbladder wall edema or pericholecystic fluid collection to suggest acute inflammation. The CBD remains dilated to 13 mm. The spleen is unremarkable. The pancreas demonstrates homogeneous attenuation without ductal dilatation or peripancreatic fluid collection. The adrenal glands are unremarkable. Right nephrostomy tube is in place. Mild hydronephrosis is stable. Small locules of gas within the right kidney, presumably relates to nephrostomy tube placement. The left kidney is unremarkable. There is no left hydronephrosis. Mild-to-moderate left hydroureter is stable. There is a soft tissue mass arising from the right ureter, which measures approximately 2.7 x 2.3 cm (2:41). The mass is seen closely adjacent to the duodenum and the inferior aspect of the pancreas without discernible fat planes. There is similar appearance of focal wall thickening involving the ascending colon which appears tethered to the mass and medially deviated (601B:22). There is persistent fat stranding involving the mesentery, not significantly changed since prior exam. There is no evidence of small bowel obstruction. No free air or free fluid in the abdomen. There is no evidence of bowel perforation. There are scattered mesenteric and retroperitoneal lymph nodes, unchanged. SMA and right renal stents are in place, the patency of these vessels cannot be assessed due to lack of intravenous contrast. Intra-abdominal aorta and its branches demonstrate severe calcified atherosclerotic disease. The focal ectasia of the infrarenal aorta is again noted measuring approximately 2.6 cm in its maximum diameter. There is no free air or free fluid within the abdomen. CT OF THE PELVIS: The bladder, seminal vesicles and rectum are unremarkable. The prostate gland is slightly enlarged. Oral contrast material is seen within the large bowel, which relates to oral contrast administered for CT yesterday. Post-surgical changes related to bilateral inguinal hernia repair with mesh placement is noted. No inguinal lymphadenopathy. No pathologically enlarged pelvic lymph nodes are seen. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion is seen. Focal hypodensity within the sacrum is likely a bone island. Left hip prosthesis is in place. There is no evidence of hardware-related complications. IMPRESSION: 1. Small consolidation and heterogeneous opacities in the lingula are new since ___, and likely represent aspiration given rapid development. Persistent ___ opacities in the right middle ___ be infectious or inflammatory in nature. 2. Stable appearance of the known right ureteral mass which closely abuts the duodenum and inferior aspect of the pancreas without discernable fat plane. Focal thickening of the ascending colon, which remains tethered to this mass. Stable appearance of intrahepatic and extrahepatic biliary ductal dilatation. 3. Right nephrostomy tube is in place. Mild hydronephrosis is stable. Mild-to-moderate hydroureter is also unchanged. 3. Right renal artery and SMA stents are in place. The patency of the vessels cannot be assessed due to lack of intravenous contrast. 4. Moderate hiatal hernia. Radiology Report CHEST RADIOGRAPH INDICATION: Suspected pneumonia seen on chest x-ray, evaluation for progression. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is progression of disease, with an increase in size and extent of the pre-existing left-sided pneumonia. The lesion is also slightly denser than previously. No other signs of parenchymal infection. No pleural effusions. Moderate cardiomegaly. No pneumothorax. Radiology Report CHEST RADIOGRAPHS HISTORY: Pneumosepsis. COMPARISONS: Prior day. TECHNIQUE: Chest, PA and lateral. FINDINGS: The patient is status post coronary bypass surgery. The cardiac, mediastinal and hilar contours appear stable. A patchy but extensive opacity in the left upper lobe suggesting pneumonia has improved to some extent. The right lung remains clear. There is perhaps a trace pleural effusion on the left, but no definite right-sided effusion. There is a moderate hiatal hernia. The cardiac, mediastinal and hilar contours appear stable. IMPRESSION: Improvement in left upper lobe consolidation. Follow-up radiographs within eight weeks are recommended to show resolution. Radiology Report INDICATION: ___ male with right ureteral obstruction and chronic nephrostomy. Nephrostomy tube dislodged yesterday and there is new drainage around the catheter. Catheter check and change requested. In addition, PICC placement requested for antibiotics. RADIOLOGISTS: Drs. ___ and ___ (attending) performed the procedure. ANESTHESIA: Local anesthesia was provided with 1% lidocaine and lidocaine gel. In addition, 50 mcg of fentanyl was administered during the nephrostomy exchange. Patients he modynamic parameters were continuously monitored by an independent radiology nurse during the total procedure time of 1 hour. RADIATION: 1 minute 12 seconds, 44 Gy*cm2. TECHNIQUE: After explanation of 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 angiography table. The right arm was prepped and draped in usual sterile fashion. A preprocedure timeout and huddle was performed as per ___ protocol. Using local anesthesia, the patent and compressible right basilic vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guide wire and a single-lumen PICC line measuring 39 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guide wire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. We next turned our attention to the nephrostomy catheter. The patient was placed prone on the imaging table. The right flank and indwelling catheter were prepped in usual sterile fashion. A spot fluoroscopic image demonstrates that the catheter had been pulled back with the pigtail in the subcutaneous tissues. A Glidewire was advanced through the catheter and into the collecting system without difficulty. The indwelling catheter was then removed. A 5 ___ Kumpe catheter was then advanced over the Glidewire into the expected position of the renal pelvis. The Glidewire was then removed and an injection of contrast confirmed its position in the renal pelvis. Next, a ___ wire was advanced into the renal pelvis and coiled. The Kumpe catheter was removed and an attempt was made to pass the new 10 ___ nephrostomy catheter over the wire into the collecting system. However, there was some resistance and a decision was made to exchange the ___ wire for an Amplatz wire using the Kumpe catheter. Next, the tract was dilated with 8 and 10 ___ dilators without difficulty. The new 10 ___ nephrostomy catheter was then advanced over the Amplatz wire into the collecting system. The plastic stiffener and wire were removed. The pigtail was formed and locked into position. A contrast injection confirmed its position. The catheter was secured to the skin with a 0 silk suture and StatLock device. A dry sterile dressing was applied. The patient tolerated the procedure well. IMPRESSION: 1. Uncomplicated ultrasound and fluoroscopically guided 4 ___ single-lumen PICC line placement via the right basilic venous approach. Final internal length is 39 cm, with the tip positioned in SVC. The line is ready to use. 2. Uncomplicated replacement of a 10 ___ right nephrostomy catheter via the existing tract. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: WEAKNESS Diagnosed with HYPOTENSION NOS, PNEUMONIA,ORGANISM UNSPECIFIED temperature: 97.0 heartrate: 73.0 resprate: 18.0 o2sat: 97.0 sbp: 73.0 dbp: 37.0 level of pain: 0 level of acuity: 1.0
Mr. ___ is an ___ yo man with CAD s/p CABG and stents, sCHF (EF ___, ulcerative colitis, bladder TCC and R ureteral stricture (negative for malignancy @ ___ s/p renal perc nephrostomy, and mesenteric ischemia s/p stenting ___ who presents to the ED with abdominal pain, nausea, fatigue in the setting of multiple recent evaluations and found to have new left sided lung consolidation. # HCAP: Patient was admitted to ___ ICU with a new Left sided PNA. He was treated with Vanc/Cefepime and Azithromycin as well as given IVF and 1 pRBC. Following discharge from the ICU to the floor he reported his symptoms were improving. He should finish an 8 day course of cefepime and vancomycin (started ___, finish ___ -- he completed 5 days of azithromycin while inpatient. #Weakness/Malaise: Patient was discharged from the ___ medical floor < 24hrs before representation to the ER. While admitted he improved significantly with 1L of IV fluid. He had looked hypovolemic. He reported feeling normal after eating in the AM and was discharged feeling better. He represented to the ER later the same day with abdominal pain, nausea, and ongoing weakness. He was very fatigued initially, and again looked hypovolemic (not on diuretics for CHF), so he was given more IVF (500mL x2) in the ICU. He felt significantly better. His exam showed no focal neurologic deficits, though he was cachectic and had diffusely decreased strength likely related to low muscle bulk. #Abdominal Pain: This has been an ongoing issue for the past ___ weeks. He was treated with stents to the SMA and R renal artery in ___ for presumed mesenteric ischemia. He has had ongoing, intermittent, cyclical pain since then with seemingly little relation to PO intake, though this has been marginal. He has had multiple reassuring abdominal CTs, negative HIDA scan, and is now s/p treatment for H pylori. He is without diarrhea or evidence of colitis, has a benign abdomen, and showed no elevation in lactate to indicate ischemic bowel tissue. It is possible that his severe LV dysfunction is not able to regularly provide adequate bowel perfusion in the setting of his vasculopathy/atherosclerosis, though it is unclear why his lactate would not be consistently elevated. He has reportedly not missed doses of clopidogrel. Apparently his pain is less severe than 1 month ago. It is unlikely to represent severe constipation given more than one BM day prior to admission. Currently it is unclear what to attribute his ongoing pain to as he does not have consistent symptoms that point to mesenteric ischemia (pain with eating). Notably, MRCP ___ showed a known soft tissue mass near R ureter extending superiorly to surround the duodenum at the junction of the ___ and ___ portions and abut the pancreatic head with tethering of the adjacent ascending colon. This finding had progressed since the month prior. However, urology felt this not to be malignant given ___ biopsy at ___, though the biopsy reports indicate that it was very difficult to interpret the pathology based on crush artifact. Other possibilities for malignant retroperitoneal mass would be sarcoma, lymphoma, though pathology ___ was at least confirmatory of urologic histologic origin, making sarcoma/lymphoma unlikely. Pain medications are working well for his pain, and he has GI follow up next week. He was instructed to stay well hydrated.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ Cardiac Catheterization History of Present Illness: ___ yo man with CAD s/p MI and CABG ___ w/ 90% RMA to RCA not amenable to PCI despite multiple attempts, CHF (EF 25% on TTE ___ s/p ___ dual chamger ICD implant ___ at ___ ___, PAD s/p R leg stent ___ at ___, CKD (baseline creatinine 1.8-2.3), HTN, presents with 24 hrs of CP to OSH. Peaked 4 hrs PTA at ___, improved to ___ after SL nitro. Cards consulted for question STEMI given widened LBBB (QRS of 128->150's today). Trop at OSH was 0.03 (nl 0.00-0.029) after 18hrs of CP. Given ASA, nitrox2, and started on heparin gtt prior to transfer. In the ___ ED, initial VS are 99.2 90 125/90 18 95% 2L. Labs notable for negative trop (08:00), BUN/Cr 46/2.2, EKG showed sinus rhythm, LBBB with QRS 158, LAD. Recieved Nitrox2. On arrival to the floor, pt reports symptoms have largely resolved in the emergency department following administration of nitro. Reports baseline chest pain (___) as chronic issue for years. Wonders what next steps will be in his care. Past Medical History: -Cardiac risk factors: hypertension, hyperlipidemia, smoking -Myocardial infarction: ___ yrs ago PAST SURGICAL HISTORY: -CABG ___ in ___ (___ to RCA, SVG to OM1, SVG to diag w/ Y ___ with a free LIMA to LAD) -Defibrillation and ?stent s/p MI EF 25% -R popliteal angiography and stenting -Cervical discectomy Social History: ___ Family History: -Mother had MI at age ___ -Father and 2 brothers committed suicide Physical Exam: ADMISSION: VS: 98.2 130/93 78 20 98% on 2L O2 General: WDWN man sitting comfortably in bed in NAD w/ nasal canula in place HEENT: NCAT, PERRL, EOMI Neck: supple, JVD 2-3 cm above clavicle, Kussmaul negative CV: regular rate and rhythm, no m/r/g Lungs: CTAB, no w/r/r Abdomen: soft, NT/ND, BS+ Ext: WWP, no clubbing, cyanosis or edema, 2+ L DP pulse, faint DP pulse on R w/ cap refill w/in 2 seconds Neuro: AAOx3, 3+ strength throughout, sensation to light touch throughout. DISCHARGE: General: WDWN man sitting comfortably in bed in NAD. Notable facial and chest plethora HEENT: NCAT, PERRL, EOMI Neck: supple, JVD 2 cm above clavicle, Kussmaul negative CV: regular rate and rhythm, HS 1 and 2 audible. No m/r/g Lungs: faint bibasilar crackles Abdomen: soft, NT/ND, BS+ Ext: no clubbing, cyanosis or edema. dilated superficial veins on lower extremities bilaterally. Skin: no visible hematoma at right groin cath site- no palpable thrill or audible bruit on auscultation Pulses: 1+ R and L dorsalis pedis pulses. Difficult to assess R femoral pulse due to presence of dressing. Capillary refill < 3 sec Neuro: AAOx3, 3+ strength throughout, sensation to light touch throughout. Pertinent Results: ADMISSION ___ 07:51AM BLOOD WBC-9.9 RBC-4.12* Hgb-13.8* Hct-41.0 MCV-100* MCH-33.4* MCHC-33.6 RDW-15.2 Plt ___ ___ 07:51AM BLOOD Neuts-85.8* Lymphs-8.2* Monos-4.3 Eos-1.4 Baso-0.3 ___ 07:51AM BLOOD ___ PTT-83.7* ___ ___ 07:51AM BLOOD Plt ___ ___ 07:51AM BLOOD Glucose-109* UreaN-46* Creat-2.2* Na-140 K-4.9 Cl-102 HCO3-22 AnGap-21* ___ 08:55PM BLOOD CK(CPK)-25* ___ 07:51AM BLOOD ___ ___ 07:51AM BLOOD cTropnT-<0.01 ___ 02:50PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 08:55PM BLOOD CK-MB-3 cTropnT-0.01 ___ 06:35AM BLOOD cTropnT-<0.01 ___ 02:30PM BLOOD cTropnT-<0.01 ___ 08:55PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:15AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 07:51AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1 DISCHARGE ___ 06:15AM BLOOD WBC-9.2 RBC-3.99* Hgb-13.4* Hct-40.6 MCV-102* MCH-33.7* MCHC-33.1 RDW-15.1 Plt ___ ___ 06:15AM BLOOD Glucose-86 UreaN-47* Creat-2.1* Na-139 K-4.8 Cl-103 HCO3-26 AnGap-15 ___ 06:15AM BLOOD CK(CPK)-26* ___ 06:15AM BLOOD CK-MB-3 cTropnT-<0.01 STUDIES ___ ECG Sinus rhythm. Right bundle-branch block. Left anterior fascicular block. Left ventricular hypertrophy with secondary repolarization abnormalities. No previous tracing available for comparison. ___ CXR IMPRESSION: No acute cardiopulmonary process. ___ ECHO FOCUSED STUDY/LIMITED VIEWS. The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis with regional variation including akinesis of the inferior wall, severe hypokinesis of the lateral wall, and hypokinesis of the mid to distal septum and anterior wall (LVEF = ___ %). Systolic function of apical segments is relatively preserved. Overall left ventricular systolic function is severely depressed. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. The study is inadequate to exclude significant aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Moderate left ventricular cavity dilation with severe global hypokinesis with regional variation. ___ CARDIAC CATHETERIZATION REPORT: Cardiac Catheterization & Endovascular Procedure Report Patient Name ___, ___ MRN ___ Study Date ___ Study Number ___ Date of Birth ___ Age ___ Years Gender Male Race Height 183 cm (6'0'') Weight 77.10 kg (170 lbs) BSA 1.99 M2 Procedures: Catheter placement, LIMA-LAD graft angiography; pressure wire interrogation of LAD; Angioseal femoral closure Indications: CAD, unstable angina Staff Nurse ___, RN Technologist ___, RT(R) Fellow ___, MD ___ ___, MD ___ ___, MD ___ ___, MD ___ ___, MD ___ ___, MD ___: Local Specimens: None Catheter placement via right femoral artery, 6 ___ Coronary angiography using 6 ___ AL1 guide Hemodynamic Measurements (mmHg) Baseline Site ___ ___ End Mean A Wave V Wave HR ___ Contrast Summary Contrast Total (ml): Optiray (ioversol 320 mg/ml)105 Radiology Summary Total Runs Total Fluoro Time (minutes) 53.6 Effective Equivalent Dose Index (mGy) 1876 Medication Log Start-StopMedicationAmountComment 01:45 ___ Heparin in NS 2 units/ml (IA) IA0 mlunable to quanitfy catheter flush amount 01:56 ___ Fentanyl IV50 mcg 01:56 ___ Versed IV1 mg 01:59 ___ Lidocaine 1% Subcut5 ml 02:19 ___ Fentanyl IV25 mcgback pain 02:20 ___ Versed IV0.5 mg 02:28 ___ Bivalirudin bolus IV55 mg 02:28 ___ Bivalirudin drip IV134.5 mg per hr 02:33 ___ Fentanyl IV25 mcg 02:33 ___ Versed IV0.5 mg 02:41 ___ Fentanyl IV25 mcgincreased back pain 03:27 ___ Fentanyl IV25 mcg 03:50 ___ Fentanyl IV25 mcg 04:08 ___ Adenosine drip IV140 mcg per kg per min 04:09 ___ Adenosine drip IV200 mcg per kg per min 04:12 ___ Adenosine drip IV0 mcg per kg per min 04:14 ___ Bivalirudin drip IV0 mg per hr Materials ManufacturerItem Name ___ ___ MEDICAL PROD & sCUSTOM STERILE KIT(STERILE PACK) COOKJ WIRE 180cm.035in ___ SCIENTIFICFL 4 DIAGNOSTIC5fr ___ SCIENTIFICFR 4 DIAGNOSTIC5fr ___ MEDICALLEFT HEART KIT TERUMOPINNACLE SHEATH 10cm5 Fr TYCO ___ 320200ml COOKMICROPUNCTURE INTRODUCER SET5fr ___ SCIENTIFICAR 2 DIAGNOSTIC5fr TERUMOPINNACLE SHEATH 10cm6 Fr ABBOTTP-PACKS ___ (INDEFLATORS) NAVILYSTPRESSURE MONITORING LINE 12" CORDISAR 26fr ABBOTTPROWATER WIRE180CM CORDISAL 16fr ___ SCIENTIFICAPEX RX 12mm2.0mm ___ SCIENTIFICPREMIER RX ___ ***NOT DEPLOYED*** VASCULAR SOLUTIONSGUIDELINER6fR ___ SCIENTIFICPREMIER RX ___ ___ SCIENTIFICNC QUANTUM APEX MR 08mm2.5mm MEDTRONICNC SPRINTER RX 09mm2.75mm ___ SCIENTIFICPREMIER RX ___ ___ SCIENTIFICPREMIER RX ___ ST JUDEAERIS 175mm PRESSURE WIRE.014in ST JUDEANGIOSEAL VIP 6FR6fr Findings ESTIMATED blood loss: 40 cc Hemodynamics (see above): Coronary angiography: right dominant LMCA: known occluded LAD: known occluded; distal vessel fills via graft with no significant disease LCX: known occluded SVG RCA: known occluded; distal vessel fills via graft to LAD LIMA-LAD: reported as free LIMA-LAD. This is a Y graft with anastomoses to LAD and diagonal. 80% lesion at diagonal stenosis; this is followed by prior patent stent and beyond this segment up 80% disease. Disease at origin of arm of graft to LAD which did not appear significant but was interrogated with pressure wire. Lowest FFR with adenosine infusion was 0.87 indicative of insignificant disease. Interventional details Using AL1 guide, lesion in diagonal distal to graft crossed with wire and dilate with 2 mm balloon. Because of tortuosity 2.25 stent could not be advanced to distal diagonal lesion and therefore guideliner was used. With distal lesion still not able to be crossed with 2.25x12 Premier stent, this was deployed at the anastomotic lesion and postdilated to 2.75 mm at 18 atm. Still unable to use 20 mm stent, distal lesion was stented with overlapping 2.25x8 and 2.25x12 Premier stents. Final result with no residual, normal flow at all sites. Angioseal femoral closure. Potential for Radiation Injury This patient underwent a procedure performed under fluoroscopic (X-ray) guidance. Procedures involving lengthy exposures to X-rays may cause damage to the skin and/or hair. These adverse effects may be increased if one has had previous (especially recent) radiation exposure to the same skin area. Radiation injury to the skin can take many forms, including an area of redness, blistering, hair loss, or ulceration. These effects may appear after a few weeks or even after several months. If an of these occur on the side and back of the torso (or elsewhere), please contact the Interventional Cardiology Section at ___ to arrange further evaluation. Assessment & Recommendations 1. Successful drug-eluting stent of distal anastomosis of graft to diagonal and of native diagonal distal to graft. 2. Negative pressure wire satudy of graft arm to LAD 3. RIMA graft to RCA not engaged due to concern about contrast but is likely occluded in presence of collaterals to distal RCA from LAD. 4. Monitor renal function 5. Continue aspirin indefinitely, clopidogrel minimum ___ year Attending Electronic Signature attests that the attending was present for the key components of this procedure. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 2. Allopurinol ___ mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 10. Lorazepam 0.5 mg PO Q6H:PRN anxiety 11. Metoprolol Succinate XL 75 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Potassium Chloride 20 mEq PO DAILY 14. PredniSONE 40 mg PO DAILY 15. Spironolactone 25 mg PO DAILY 16. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough 17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 18. Amiodarone 200 mg PO DAILY 19. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 2. Allopurinol ___ mg PO DAILY 3. Amiodarone 200 mg PO DAILY RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Lorazepam 0.5 mg PO Q6H:PRN anxiety 11. Metoprolol Succinate XL 75 mg PO DAILY RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 12. Multivitamins 1 TAB PO DAILY 13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 14. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain 15. PredniSONE 40 mg PO DAILY 16. Spironolactone 25 mg PO DAILY RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 17. Vitamin D 1000 UNIT PO DAILY 18. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 19. Potassium Chloride 20 mEq PO DAILY Hold for K > Discharge Disposition: Home Discharge Diagnosis: Acute Coronary Syndrome Extensive CAD s/p CABG, multiple catheterizations Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with cp/sob known CAD // acute pulm process TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: The lungs are well expanded. There is no focal consolidation, pleural effusion or pneumothorax. A left chest wall pacemaker is present with leads in the right atrium and right ventricle. Median sternotomy wires are intact. The cardiomediastinal silhouette is within normal limits and the aorta is tortuous. Cervical spine fusion hardware is present and hypertrophic changes are noted in the thoracic spine. Imaged upper abdomen is unremarkable. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH temperature: 99.2 heartrate: 90.0 resprate: 18.0 o2sat: 95.0 sbp: 125.0 dbp: 90.0 level of pain: 2 level of acuity: 2.0
___ yo man with CAD s/p MI and CABG ___ w/ 90% RMA to RCA not amenable to PCI despite multiple attempts, CHF (EF 25% on TTE ___ s/p ___ dual chamger ICD implant ___ at ___ ___, PAD s/p R leg stent ___ at ___, CKD (baseline creatinine 1.8-2.3), HTN. Worked up for UA/NSTEMI following ___nd developed anginal-equivalent symptoms following administration of regular anti-hypertensives. Catheterized on ___ showed known multivessel disease, 3x stent placement. Pt reported baseline chest pain resolved after intervention. Discharged to f/u with PCP + cardiologist. #Unstable angina s/p intervention: Pt originally presented with chest pain, on a background of baseline ___ chest pain. Troponins negative, started on heparin drip. Pt reports resolution of prior baseline symptoms s/p cardiac catheterization. Pt already on Aspirin and Clopidogrel and should be advised to continue these medications accordingly following placement of 3 drug eluting stents. -Continue Clopidogrel 75 mg PO daily -Continue Metoprolol XL 75 mg PO daily -Continue ASA 325 mg daily -Continue Atorvastatin 80 mg PO daily -Continue Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain -Continue Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY -Consider ___ after exploration of documentation from outside facilities #Chronic Sytolic CHF, compensated EF 25% on ___ ECHO. BNP elevated but pt does not appear volume overloaded, w/ minimal signs of retention, CXR showing no acute cardiopulmonary process. -Continued furosemide 40 mg PO daily -Continued spironolactone 25 mg PO DAILY #Paroxysmal Ventricular Tachycardia Unclear history of Amiodarone use, was planning to discuss use with cardiologist at next appointment-Continue Amiodarone 200 mg PO DAILY #CKD Baseline creatinine 1.8-2.3. Discharge creatinine 2.1. -Monitored daily lytes #COPD Pt reports being placed on steroids in past, having stopped then restarted on pred 40 mg. Unclear history which requires further exploration. -Continued Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB -Continued Ipratropium-Albuterol Neb 1 NEB NEB Q6H -Continued PredniSONE 40 mg PO DAILY #Anxiety -Continued Lorazepam 0.5 mg PO Q6H:PRN anxiety #Back Pain -Continued OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain TRANSITIONAL ISSUES -Smoking cessation imperative and patient interested in possible therapies in attempts to quit. Considering medication use for aid in quitting (?Chantix). -Pt found to be orthostatic, held lasix day before and day of discharge. Pt to restart day after discharge. Please f/u blood pressure -Patient on high dose steroids at home for unclear reason to inpatient team, patient unable to describe indication. Please follow-up high dose steroid use and consider taper if not indicated or already planned
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx of large B cell lymphoma s/p R-CHOP x3 cycles and IF radiation, s/p bilateral hip fxs with b/l THRs presenting with L hip pain after fall. History is obtained from patient's daughter, ___, at bedside. ___ reports at baseline her mother is able to ambulate up 2 flights of stairs, gets around with walker, and can perform most ADLs with minimal assistance. ___ provides essentially 24 hour supervision since her mother stopped spending ___ in ___ ___ years ago. On the day of presentation, ___ was with her mother in the "breakfast room," when her mother stated that she needed to use the bathroom, which she typically does without assistance. ___ assisted her in rising from the chair. She then turned around, and her mother yelled ___ When she turned back around, her mother was on the floor. She denies preceding chest pain, cough, reports of dysuria, melena or hematochezia. She denies LOC or head trauma around the time of the fall. Her mother reported L hip pain when being moved onto stretcher by EMS. In the ED: 98.2, 70, 155/75, 16, 91% RA->99% RA Labs notable for BUN 21, Cr 0.8, Hb 11.5, WBC 6.3 Shoulder, hip, pelvis xrays negative for fx CT pelvis: no e/o fracture CT head/c-spine: No acute process Received Tylenol ___ mg x1 and tramadol 25 mg PO x1 Admitted to medicine for further evaluation and pain control On arrival to floor, pt initially denies pain, but subsequently yelps and moans out in pain for pain in L hip ROS: Limited by mental status Past Medical History: large B cell lymphoma s/p R-CHOP x3 cycles and IF radiation treated by Dr. ___ s/p bilateral hip fractures and b/l THRs (in ___ and at ___ ___) Anxiety Hypertension Social History: ___ Family History: Noncontributory to hip pain after fall in ___ Physical Exam: VS: 98.4, 124/70, 77, 18, 94% RA Gen: elderly, frail appearing female, appears younger than stated age, initially appears comfortable, subsequently calling out in pain. Intermittently talking out loud while falling asleep HEENT: PERRL, EOMI, no cervical or supraclavicular adenopathy, dry MM CV: RRR, ___ systolic murmur loudest at RUSB and radiating to apex Lungs: CTAB anteriorly Abd: soft, nontender, nondistended, no rebound or guarding Ext: WWP, 1+ PTs bilaterally. TTP over L hip, full ROM exam deferred ___ pain, no overlying ecchymoses GU: No foley Neuro: A+O to person, date (when prompted), not place (although subsequently states, "I know this is a hospital). Hard of hearing. Full strength exam deferred in setting of significant pain. d/c 97.6 124/59 77 91%ra Gen: NAD, siting in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: Left hip tender, left leg tender as well when rolling leg. Skin: No visible rash. No jaundice. Neuro: AAOx2-3 (at baseline per daughter). No facial droop. Psych: Full range of affect Pertinent Results: ___ 12:50AM GLUCOSE-95 UREA N-21* CREAT-0.8 SODIUM-140 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12 ___ 12:50AM estGFR-Using this ___ 12:50AM WBC-6.3 RBC-3.64* HGB-11.5 HCT-33.8* MCV-93 MCH-31.6 MCHC-34.0 RDW-13.0 RDWSD-43.9 ___ 12:50AM NEUTS-78.8* LYMPHS-12.5* MONOS-6.0 EOS-1.7 BASOS-0.2 IM ___ AbsNeut-4.96 AbsLymp-0.79* AbsMono-0.38 AbsEos-0.11 AbsBaso-0.01 ___ 12:50AM PLT COUNT-153# d/c labs ___ 07:30AM BLOOD WBC-7.3 RBC-3.35* Hgb-10.7* Hct-30.9* MCV-92 MCH-31.9 MCHC-34.6 RDW-12.9 RDWSD-43.4 Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD Glucose-90 UreaN-22* Creat-0.8 Na-140 K-4.1 Cl-101 HCO3-32 AnGap-11 ___ 07:30AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.6 Imaging CT pelvis ___. No evidence of fracture or dislocation. Extensive hardware artifact somewhat limits assessment. 2. Unremarkable appearance of bilateral hip prosthetic hardware. 3. Diffuse osteopenia. CT C spine ___. No fracture or prevertebral fluid. No malalignment. 2. Moderate multilevel cervical spine degenerative change. No spinal canal narrowing. ___ femur Xray 1. No evidence of acute fracture. 2. Osteopenia. 3. Degenerative change and chondrocalcinosis at the knee. ___ pelvis xray No definite fracture. Bilateral hip hardware in place. If there is further concern for fracture, CT may be performed. ___ shoulder xray 1. Old fractures of left humerus and posterior ribs. 2. No acute fracture is seen ___ CT head 1. No acute intracranial process. No fracture. 2. Chronic findings including pansinus mucosal thickening, vascular calcifications, and age appropriate global atrophy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion 75 mg PO DAILY 2. Potassium Chloride 10 mEq PO Frequency is Unknown 3. Escitalopram Oxalate 30 mg PO DAILY 4. Furosemide 20 mg PO 3X/WEEK (___) MWF 5. Furosemide 10 mg PO 3X/WEEK (___) 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Metoprolol Succinate XL 37.5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO QHS 9. Carbidopa-Levodopa (___) 0.5 TAB PO Frequency is Unknown 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 12. Docusate Sodium 200 mg PO BID 13. Citrucel (methylcellulose (laxative);<br>methylcellulose (with sugar)) 500 mg oral QHS 14. Vitamin D 1000 UNIT PO DAILY 15. krill oil 500 mg oral QAM 16. Cyanocobalamin 1000 mcg PO DAILY 17. cranberry 400 mg oral DAILY 18. ALPRAZolam 0.25 mg PO BID:PRN anxiety Discharge Medications: 1. BuPROPion 75 mg PO DAILY 2. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY 3. Docusate Sodium 200 mg PO BID 4. Escitalopram Oxalate 30 mg PO DAILY 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. cranberry 400 mg oral DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. krill oil 500 mg oral QAM 12. Vitamin D 1000 UNIT PO DAILY 13. Acetaminophen 650 mg PO Q6H 14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 15. Senna 8.6 mg PO DAILY 16. Polyethylene Glycol 17 g PO DAILY 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: hip contusion fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with ground level fall with left sided pain, Evaluate for ICH, fracture. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 702 mGy-cm. COMPARISON: Unenhanced head CT ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is mild prominence of the ventricles and sulci suggestive of involutional changes, appropriate for age. There is no evidence of fracture. There is ethmoid air cell, frontal sinus, and right greater the left maxillary sinus mucosal thickening. Mastoid air cells are clear. The patient is status post bilateral lens removal; otherwise, the globes and bony orbits are intact and unremarkable. Carotid siphon calcifications are noted. IMPRESSION: 1. No acute intracranial process. No fracture. 2. Chronic findings including pansinus mucosal thickening, vascular calcifications, and age appropriate global atrophy. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ with ground level fall with left sided pain, 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) = 703 mGy-cm. COMPARISON: None. FINDINGS: There is no fracture or prevertebral soft tissue fluid. There is normal alignment within the cervical spine. There is diffuse osteopenia. There is moderate cervical spine degenerative change, with multilevel disc height loss and anterior and posterior intervertebral osteophytes. There is no significant spinal canal narrowing. Moderate neural foraminal narrowing is worst on the right at C3-4 (series 3, image 31). The thyroid is unremarkable. Carotid bulb calcifications are noted. There may be minimal interlobular septal thickening at the lung apices. There is no lung nodule or mass seen. IMPRESSION: 1. No fracture or prevertebral fluid. No malalignment. 2. Moderate multilevel cervical spine degenerative change. No spinal canal narrowing. Radiology Report EXAMINATION: CT PELVIS W/O CONTRAST INDICATION: ___ with recent fall, left sided pain, evaluate for hip or pelvic fracture. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast utilizing bone algorithm reconstruction. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,320 mGy-cm. COMPARISON: None. FINDINGS: 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 reproductive organs are unremarkable. LYMPH NODES: There is no pelvic or inguinal lymphadenopathy. VASCULAR: Mild atherosclerotic disease is noted. BONES: There is no evidence of fracture. There is a left total hip arthroplasty in grossly appropriate orientation without evidence of complication. An irregular appearance of the lower left anterior iliac wing near the prosthesis appears well corticated, chronic in nature, without acute fracture. Right hip femoral head fixation hardware is unremarkable in appearance. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of fracture or dislocation. Extensive hardware artifact somewhat limits assessment. 2. Unremarkable appearance of bilateral hip prosthetic hardware. 3. Diffuse osteopenia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, L Hip pain Diagnosed with Pain in left hip, Fall on same level, unspecified, initial encounter temperature: 98.2 heartrate: 70.0 resprate: 16.0 o2sat: 91.0 sbp: 155.0 dbp: 75.0 level of pain: 5 level of acuity: 3.0
___ with hx of large B cell lymphoma (s/p R-CHOP x3 cycles), prior bilateral hip fxs with b/l THRs presents with L hip pain after fall. #L hip pain, likely contusion: In the setting of a mechanical fall. Xrays and CT scans showed no acute fracture. Orthopedics evaluated the patient and felt no intervention was needed. Evaluated by ___, and she will need rehab. Pain under control with Tylenol lidocaine patch, ultram. # HTN/hypotension: Pt was at one point hypotensive and Lasix was held and metop evening dose and since those adjustments BPs were stable. She has been euvolemic. # Delirium: Pt was delerius at times during hospital stay but improved with her daughter there. Day of d/c MS was at baseline # Mild hypoxia: 90s on RA during hospital course. Lung sounds clear. No SOB or CP. Suspect atelectasis from bedbound state. Unclear if she carries prior dx of COPD as she is on flovent at home. Continued here. #Depression/Anxiety - Continued Lexapro and Wellbutrin - held Xanex as not taking at home and high risk med in this elderly patient #Constipation -bowel regimen was given # Code status: FULL again addressed with Daughter, she is not ready to make any decisions. # Contact: ___, husband ___, daughter ___ ___ TRANSITIONAL -consider restarting home Lasix as needed, trend CEM to see if needs K repletion
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Oxycodone Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Laparoscopic converted to open cholecystectomy, lysis of adhesions, cholangiogram and repair of hepatic duct. History of Present Illness: This is ___ years old female with past medical history of obesity, GERD, HLD who now presented with abdominal pain and nausea. Patient reports epigastric pain since yesterday 5PM, continuous, dull in character now increasing and mostly in RUQ since last 4 hours. Patient reported nausea, no emesis, no change in BM, no dysuria, no prior similar pain. Patient reports no chills, no fevers. Patient had colonoscopy ___ years ago with negative findings. Patient reports passing flatus and having BM. Upon evaluation in ED patient comfortable in the bed, in no apparent distress with epigastric/RUQ discomfort. Past Medical History: GYN HISTORY: In terms of her GYN history, the patient has a history of normal periods, though over the last one to ___ years, they have become less frequent. Her last menstrual period was on ___ and the period prior to that was in ___. When her periods do come, they are very light with only a few days of spotting. She denies any heavy bleeding or irregular intermenstrual bleeding. She also complains of urinary frequency and the feeling of incomplete bladder emptying when she does void likely associated with the increasing size of her uterine mass. PAST MEDICAL HISTORY: Notable for obesity as well as seasonal asthma. PAST SURGICAL HISTORY: Notable for dental surgery in ___. Social History: ___ Family History: Significant for breast cancer in her mother as well as a maternal grandmother. Her father has cardiac disease. She does also note a significant family history for uterine fibroids with a sister and a mother who had undergone hysterectomy for this condition. Physical Exam: Physical exam on admission ___: Vitals: afebrile, hemodynamically stable, Gen: NAD, A&O x 3 CV: no cardiac distress Pulm: breathing comfortably on room air Abd: soft, nondistended, tender in epigastric/RUQ pain with minimal guarding, ___ sign, no palpable masses or hernias, old midline incision healed, Ext: warm and well perfused Physical exam on discharge ___: Vitals: afebrile, hemodynamically stable, Gen: NAD, A&O x 3 CV: no cardiac distress Pulm: breathing comfortably on room air Abd: soft, nondistended, nontender, dressings c/d/i Ext: warm and well perfused Pertinent Results: ___ 07:40PM BLOOD WBC-10.8* RBC-4.77 Hgb-14.5 Hct-43.5 MCV-91 MCH-30.4 MCHC-33.3 RDW-12.4 RDWSD-41.2 Plt ___ ___ 07:40PM BLOOD Neuts-82.1* Lymphs-12.5* Monos-4.4* Eos-0.2* Baso-0.6 Im ___ AbsNeut-8.86* AbsLymp-1.35 AbsMono-0.47 AbsEos-0.02* AbsBaso-0.07 ___ 07:40PM BLOOD Glucose-176* UreaN-11 Creat-0.8 Na-138 K-4.9 Cl-100 HCO3-22 AnGap-16 ___ 07:40PM BLOOD ALT-73* AST-53* AlkPhos-140* TotBili-0.6 ___ 07:40PM BLOOD Lipase-27 ___ 07:40PM BLOOD cTropnT-<0.01 ___ 05:58AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0 ___ 11:39PM BLOOD Lactate-2.5* ___ 02:03AM BLOOD Lactate-1.7 IMAGING: ___ RUQUS 1. Mildly distended gallbladder with a large gallstone near the gallbladder neck and a positive sonographic ___ sign. Findings are highly concerning for acute cholecystitis. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. ___ CT ABDOMEN AND PELVIS 1. No evidence of acute abnormality in the abdomen or pelvis. Specifically no evidence of vascular injury in the liver. 2. Status post open cholecystectomy with postsurgical intra-abdominal air and changes to the anterior abdominal wall. 3. Diffuse geographic hypodensity within segment ___ likely due to geographic steatosis versus retraction contusion of the liver. Medications on Admission: 1. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q6H RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute cholecystitis Injury of right hepatic duct Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with epigastric RUQ pain. // gallstones or cholesystitis? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen and pelvis dated ___ and renal ultrasound dated ___ FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The common bile duct is not adequately visualized. GALLBLADDER: The gallbladder is mildly distended with a large gallstone near the gallbladder neck measuring up to 2.7 cm. No definite gallbladder wall thickening, mural edema, or pericholecystic fluid. Sonographic ___ sign is positive. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 9 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis.Left peripelvic renal cysts redemonstrated. Right kidney: 10.3 cm Left kidney: 11.9 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Mildly distended gallbladder with a large gallstone near the gallbladder neck and a positive sonographic ___ sign. Findings are highly concerning for acute cholecystitis. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. RECOMMENDATION(S): Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the ___ (FibroScan), or the Radiology Department with MR ___, in conjunction with a GI/Hepatology consultation" * * ___ 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: ABDOMEN (SUPINE ONLY) INDICATION: Intraoperative fluoroscopy. TECHNIQUE: Intraoperative fluoroscopy. COMPARISON: None FINDINGS: 175 intraoperative images were acquired without a radiologist present. Please refer to operative note for details of the procedure. IMPRESSION: Intraoperative images were obtained during cholecystectomy. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: US ABD LIMIT, SINGLE ORGAN INDICATION: ___ year old woman with lap chole, right hepatic duct injury s/p repair // biliary dilation? arterial blood flow? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound ___ FINDINGS: Please note that this is an extremely limited exam due to overlying bandages (we were asked not to remove them), intervening bowel gas, and pain. Within these limitations, there is no definite large focal abnormalities within the liver parenchyma. Unable to assess for biliary dilation and hepatic artery blood flow given technical limitations of the study. There is no ascites in the right lower quadrant. IMPRESSION: Extremely limited exam due to multiple technical limitations. Unable to evaluate for biliary dilation or hepatic artery blood flow. If there is high clinical concern, consider evaluation with contrast enhanced CT. Radiology Report EXAMINATION: CT ABD WANDW/O C INDICATION: ___ year old woman with cholecystitis s/p open chole with right hepatic duct injury // Triple phase liver CT, in particular assess blood flow to right hepatic lobe, biliary ducts 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 not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 1.9 s, 29.7 cm; CTDIvol = 5.8 mGy (Body) DLP = 172.5 mGy-cm. 2) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 24.4 mGy (Body) DLP = 686.7 mGy-cm. 3) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 24.4 mGy (Body) DLP = 723.9 mGy-cm. 4) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 24.4 mGy (Body) DLP = 687.0 mGy-cm. 5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 6) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.4 mGy (Body) DLP = 6.7 mGy-cm. Total DLP (Body) = 2,279 mGy-cm. COMPARISON: Ultrasound of the liver from ___. CT of the abdomen pelvis from ___. FINDINGS: LOWER CHEST: The lung bases are clear aside from mild dependent changes. ABDOMEN: HEPATOBILIARY: The liver has diffusely low density consistent with steatosis. There is no suspicious focal lesion. There is a diffusely hypoechoic attenuating region segment ___ which likely represents a region of retraction contusion after the given history of open cholecystectomy. There is no evidence of intrahepatic or extrahepatic biliary dilatation. Postsurgical changes are seen in the right upper quadrant with locules of intraperitoneal air. No evidence of discrete fluid collection. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of solid renal lesions. A left-sided extrarenal is noted. There is no perinephric abnormality. There is no hydronephrosis or hydroureter. GASTROINTESTINAL: Small hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement. The colon and rectum are within normal limits. LYMPH NODES: No evidence of retroperitoneal or mesenteric lymphadenopathy. VASCULAR: The common, left and right hepatic arteries are patent without evidence of dissection or occlusion. No evidence of injury to the hepatic or portal veins. No significant atherosclerotic disease is noted. There is no abdominal aortic aneurysm. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Ankylosis is noted of the anterior thoracic spine. SOFT TISSUES: Postsurgical changes are seen along the anterior abdominal wall. No evidence of discrete fluid collection. IMPRESSION: 1. No evidence of acute abnormality in the abdomen or pelvis. Specifically no evidence of vascular injury in the liver. 2. Status post open cholecystectomy with postsurgical intra-abdominal air and changes to the anterior abdominal wall. 3. Diffuse geographic hypodensity within segment ___ likely due to geographic steatosis versus retraction contusion of the liver. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Epigastric pain Diagnosed with Calculus of gallbladder w acute cholecyst w/o obstruction temperature: 97.8 heartrate: 72.0 resprate: 16.0 o2sat: 96.0 sbp: 142.0 dbp: 70.0 level of pain: 8 level of acuity: 2.0
Ms. ___ was admitted under the acute care surgery service for management of her acute cholecystitis. She was taken to the operating room and underwent a laparoscopic converted to open cholecystectomy. Her OR course was complicated by injury to the hepatic duct. Please see operative report for details of this procedure. She tolerated the procedure well and was extubated upon completion. She was subsequently taken to the PACU for recovery. She was transferred to the surgical floor hemodynamically stable. Her vital signs were routinely monitored and she remained afebrile and hemodynamically stable. She was initially given IV fluids postoperatively, which were discontinued when she was tolerating PO's. Her diet was advanced slowly to regular, which she tolerated without abdominal pain, nausea, or vomiting. She was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently. Her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. Due to the nature of her hepatic injury, she was followed by the liver transplant service. She had a RUQUS which was limited, so she then had a triple phase liver CT to assess blood flow to her right hepatic lobe and biliary ducts. CT imaging revealed no evidence of vascular injury in the liver. Throughout her hospitalization, she had progressively elevating alk phos but normalizing transaminase. On ___, she was discharged home with scheduled follow up in ___ clinic with repeat LFTs.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness in ___ ___ Surgical or Invasive Procedure: T6 Laminectomy History of Present Illness: ___ h/o metastatic prostate cancer, afib (on rivaroxaban) p/w ___ weakness. Pt reports that for the past 12 days he has had a sensation of weakness in both legs. He denies numbness, bowel/bladder changes. His symptoms started while he was traveling abroad. He got up to use the bathroom when his knees gave out on him (fell to knee, no head strike). Since then this has been the typical pattern. He will frequently while ambulating, espeically after having been seated/lying for an extended period, feel his legs go weak and that he is unable to walk. Pt called his oncologist to discuss. Bone scan done yesterday shows multiple metastatic lesions throughout skeleton. She recommended pt come in for an MRI. . In the ED: 98.1 58 129/64 16 96%. cbc, lytes ok. U/a with 14 rbcs, 98 wbcs, few bact, neg nitr. Spine consulted and recommeded imaging. CT head negative. MR spine showed: "No enhancing lesions within the cord. Multilevel degenerative changes and diffuse metastatic disease to the vertebral bodies are present...At T7, there is extension of metastatic disease into the posterior epidural space with anterior displacement of the thecal sac and mass effect on the cord. Focal increased T2 signal within the spinal cord at this level is concerning for cord compression/edema." Neuro involved and recommended re-eval by spine given the above findings. Admitted to OMED. . ROS: as above; otherwise complete ROS negative. Past Medical History: PMH: BPH Prostate Cancer, ___ 9 Right ureteral stone ? previous granulomatous disease with calcified nodes in lungs and pericardium PSH: Radical retropubic prostatectomy, Dr. ___, ___ Umbilical hernia Right percutaneous nephroureterostomy tube placement Extraction of ureteral calculus from upper pole on ___ Social History: ___ Family History: No known h/o neurologic disease Physical Exam: Admission Physical Exam: t97.4 bp134/76 hr56 rr20 sat97%ra GENERAL: Elderly gentleman, laying in bed in NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: irregular rhythm, normal S1/S2, no mrg LUNG: decreased breath sounds at the bases , no w/r/r ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: non-tender to palpation in the T and L spine, no step offs or deformities. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation grossly intact . Discharge Physical ___ General: Elderly man in NAD, sitting up in bed Heart: RRR Lungs:CTAB, no adventitious breath sounds Abdomen:soft,nt,nd,+bs's Extremities:2+rad/2+dp pulses/brisk capillary refill ___ BLE ___ +SILT BLE Pertinent Results: Admission Labs: ___ 12:30AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 12:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 12:30AM URINE MUCOUS-RARE ___ 05:00PM GLUCOSE-102* UREA N-19 CREAT-0.8 SODIUM-136 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-26 ANION GAP-10 ___ 05:00PM estGFR-Using this ___ 05:00PM WBC-6.9 RBC-4.06* HGB-13.2* HCT-38.7* MCV-95 MCH-32.6* MCHC-34.2 RDW-13.0 ___ 05:00PM NEUTS-74.7* LYMPHS-15.8* MONOS-6.5 EOS-1.8 BASOS-1.2 ___ 05:00PM PLT COUNT-186 . Discharge Labs: . Microbiology: # Urine Culture (___): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. . Pathology: Pending. . Imaging/Studies: # MRI T and L spine (___): 1. In the thoracic spine at the level of T7, there is extension of metastatic disease into the posterior epidural space, causing anterior displacement of the thecal sac and mass effect on the cord. Focal increased T2 signal within the spinal cord at this level is present, concerning for cord compression/edema. 2. Multilevel degenerative changes throughout the cervical and lumbar spine as described in detail above . # CT Head without cancer (___): IMPRESSION: 1. No acute intracranial abnormality. 2. Relatively mild bifrontal cortical atrophy, allowing for age. . # CT T-spine w/o contrast (___): 1. Diffuse osseous metastatic disease of the thoracic spine. 2. Osseous expansion of the T7 vertebral body and its posterior elements, with bony excresences causing severe canal narrowing and marked compression of the thecal sac at this level. Medications on Admission: 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Sotalol 120 mg PO BID 3. Rivaroxaban 20 mg PO DAILY Discharge Medications: 1. Sotalol 120 mg PO BID 2. Acetaminophen 1000 mg PO Q8H:PRN pain/fever 3. Diazepam 2.5 mg PO Q6H:PRN pain, spasm Please do not operate heavy machinery, drink alcohol or drive RX *diazepam 5 mg 0.5 (One half) tablet by mouth every six (6) hours Disp #*40 Tablet Refills:*0 4. enzalutamide 160 mg oral DAILY home med 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Rivaroxaban 20 mg PO DAILY 7. Heparin 5000 UNIT SC TID dvt prophylaxis 8. Docusate Sodium 100 mg PO BID 9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain Please do not operate heavy machinery, drink alcohol or drive RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*75 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: 1. Metastatic prostate carcinoma. 2. Thoracic spinal canal lesion consistent with metastatic disease. 3. Thoracic spinal stenosis. 4. Thoracic spinal cord compression, myelopathy. 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: Acute-onset gait abnormality, due to proprioceptive deficit. Please evaluate for evidence of subdural. COMPARISON: None. TECHNIQUE: Axial MDCT images were obtained through the brain without IV contrast. Multiplanar axial, coronal, sagittal and thin-section bone algorithm reconstructed images were generated. TOTAL BODY DLP: 780 mGy-cm CTDIvol: 53 mGy FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect or large vascular territorial infarction. The bifrontal extra-axial CSF spaces and cortical sulci are slightly prominent, suggesting atrophy. The basal cisterns are patent. There is preservation of gray-white differentiation. There is no fracture. There is extensive atherosclerotic calcifications of the carotid siphons, which appear tortuous. The partially visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. No acute intracranial abnormality. 2. Relatively mild bifrontal cortical atrophy, allowing for age. Radiology Report INDICATION: ___ year old man with thoracic epidural metastasis, pre-operative planning TECHNIQUE: MDCT images were obtained through the thoracic spine without administration of contrast. Axial images were interpreted in conjunction with sagittal and coronal reformats. DLP: 1473 mGy-cm COMPARISON: MRI thoracic spine ___. FINDINGS: There is diffuse osseous metastatic disease of the thoracic spine, with primarily sclerotic lesions. There are non acute wedge deformities most pronounced at T6 through T9. Severe multilevel degenerative disease with anterior osteophyte complexes and disk space narrowing are detailed in the thoracic spine MRI from ___. The T7 body appears expanded by cloud-like osseous material emanating from the dorsal cortex and extending circumferentially . The bony excrescences involve the dorsal aspect of the vertebral body with a large osseous component arising from the junction of the laminae (3:52). IMPRESSION: 1. Diffuse osseous metastatic disease of the thoracic spine. 2. Osseous expansion of the T7 vertebral body and its posterior elements, with bony excresences causing severe canal narrowing and marked compression of the thecal sac at this level. Radiology Report EXAMINATION: THORACIC SINGLE VIEW IN OR INDICATION: Thoracic epidural metastases TECHNIQUE: Plain film COMPARISON: Thoracic spine CT from ___ FINDINGS: A single portable lateral view of the mid and lower thoracic spine and upper lumbar spine shows radiodense screws projected over the posterior elements of T7 and T8. The most severe intervertebral disk space narrowing is seen at T9-T10. Thinner, needle-like markers are projected posterior to the T12-L1 and L1-L2 intervertebral disk spaces. The bones appear irregularly sclerotic consistent with the patient's known metastatic disease. IMPRESSION: Intraoperative markers positioned as described Radiology Report EXAMINATION: T-SPINE INDICATION: ___ year old man with s/p thoracic decompression // Standing AP, Lateral eval alignment s/p thoracic decompression COMPARISON: ___. IMPRESSION: Comparison is made to the intraoperative radiograph. Status post decompression. The alignment of the vertebral bodies is similar to the previous imaging material. Clips are visualized, paralleling the right margin of the spine on the frontal image. The frontal standing image shows a moderate" scoliosis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: WEAKNESS BOTH LEGS Diagnosed with LUMBOSACRAL NEURITIS NOS, SECONDARY MALIG NEO BONE, ABNORMALITY OF GAIT temperature: 98.1 heartrate: 58.0 resprate: 16.0 o2sat: 96.0 sbp: 129.0 dbp: 64.0 level of pain: 8 level of acuity: 2.0
___ h/o metastatic prostate cancer, afib (on rivaroxaban) p/w ___ weakness, found to have cord compression on imaging. .
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: phenobarbital Attending: ___. Chief Complaint: Left Hip Pain Major Surgical or Invasive Procedure: left acetabular ORIF History of Present Illness: ___ ped struck by truck going ~30mph on L side, BIBA c/o L hip pain. Patient denies HS or LOC. He c/o no other pain, no neck pain, no HA. Past Medical History: GERD, osteoporosis, HLD, BPH, anemia Social History: ___ Family History: NC Physical Exam: A&O, NAD, Pain Controlled AFVSS LLE: Incision d/c/i without erythemia, +gs/ta/efl/fhl silt s/s/sp/dp/pt Pertinent Results: xray and ct of pelvis showing left acetabular fx and s/p surgical fixation Medications on Admission: omeprazole, naproxen, alendronate, ferrous sulfate, tamsulosin, simvastatin Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Start: ___, First Dose: Next Routine Administration Time 5. Famotidine 20 mg PO Q12H 6. Metoprolol Tartrate 6.25 mg PO Q6H 7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 8. Senna 8.6 mg PO BID 9. Simvastatin 10 mg PO QPM 10. Tamsulosin 0.4 mg PO QHS 11. Phosphorus 500 mg PO BID Duration: 6 Doses Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: left acetabular fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with assistance Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with left hip fracture // left hip fracture COMPARISON: Same-day CT torso. FINDINGS: AP and bilateral Judet views of the pelvis were provided. Contrast filled urinary bladder is noted without definite signs of extravasation. There is a comminuted fracture involving the left acetabulum with medial protrusion of the left femoral head. Disruption of the anterior and posterior column is better assessed on same-day CT. Mild to moderate degenerative disease of the right hip noted. IMPRESSION: Comminuted fracture of the left acetabulum with medial protrusion of the femoral head. Radiology Report INDICATION: ___ year old man with left hip fracture // needs traction for hip fracture . COMPARISON: None Available. TECHNIQUE Frontal, oblique, and cross table lateral view of the knee. FINDINGS: There is no evidence of left knee fracture. There is no joint effusion. No concerning lytic or sclerotic lesions. No soft tissue abnormality. IMPRESSION: No fracture. Radiology Report INDICATION: ___ with left hip fx s/p traction // now left hip fx with traction . COMPARISON: Comparison made to pelvic radiograph from ___ and CT Torso ___ TECHNIQUE AP view of the pelvis. FINDINGS: Radiographs with the hip in traction demonstrate a comminuted fracture involving the left acetabulum, iliac wing and inferior pubic ramus. Traumatic protrusio again demonstrated. Alignment similar to prior. Contrast is seen filling the bladder without evidence of extravasation. IMPRESSION: Similar appearance to previous. Radiology Report INDICATION: ___ with left hip fx s/p traction. COMPARISON: Prior exam from earlier tonight. FINDINGS: Three views of the left knee were provided. No fracture or dislocation is seen. External fixation device is seen in the distal femur. No joint effusion. No significant degenerative disease. Radiology Report INDICATION: Left acetabular fracture ORIF. TECHNIQUE: Several intraoperative fluoroscopic spot images of pelvis were acquired, without a radiologist present. COMPARISON: Pelvis radiographs from ___. FINDINGS: The provided fluoroscopic spot images demonstrate ORIF of a left periacetabular fracture with 2 malleable plates and several screws. There is no evidence of hardware complication. For additional details, please see the operative report in the ___ medical record. The total fluoroscopic time was 38.6 seconds. IMPRESSION: As above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with L hip ORIF, post op s/p OG placement. OG placement. TECHNIQUE: Single portable AP view of the chest. COMPARISON: Chest radiograph from ___. FINDINGS: The new OG tube terminates in the upper stomach and would need to be advanced approximately 10 cm to position all of the sideholes in the stomach. Lungs are hyperinflated, but clear without effusion or consolidation. Heart, mediastinum, hila, and pleural surfaces are normal. Old healed left rib fractures are unchanged. The endotracheal tube terminates 5 cm above the carina and should not be withdrawn any further. The caliber of the endotracheal ET cuff exceeds that of the native trachea. IMPRESSION: 1. OG tube terminates in the upper stomach and would need to be advanced approximately 10 cm to position all of the sideholes in the stomach. 2. Caliber of the ET tube cuff exceeds that of the native trachea. It would be important to determine if this degree of overinflation is necessary from a clinical standpoint. Radiology Report INDICATION: ___ year old man with trauma, multisystem injuries, R-foot edema and warmth // evaluate for acute injury COMPARISON: None. IMPRESSION: There is a corticated osseous density along the medial base of the first proximal phalanx. The chronicity of this injury is unclear. Please correlate with focal pain at this location as this may represent an acute fracture. Equivocal lucency involving the base of the fourth metatarsal is likely due to variations in bony mineralization. There are degenerative changes of several DIP and PIP joints and of the first IP and MTP joints. There is a prominent calcaneal spur. Soft tissues are within normal limits. Radiology Report INDICATION: ___ year old man with ?fracture, lisfranc injury // ?lisfranc TECHNIQUE: Multiplanar, multisequence imaging was acquired through the right foot on a 3 Tesla magnet without the administration of intravenous contrast material. COMPARISON: Foot radiographs from ___. FINDINGS: Images are targeted to the mid and forefoot. The hindfoot is not included on these images. There is a nondisplaced comminuted intra-articular fracture through the base of the fourth metatarsal with mild associated marrow edema (09:25). There is also a slightly comminuted fracture along the dorsal aspect of the lateral cuneiform, without significant displacement (09:20). There is mild edema in the lateral aspect of the cuboid, without a fracture line identified. There is also subtle marrow edema within the base of the second metatarsal, without a definitive fracture line, although a subtle nondisplaced fracture cannot be excluded (08:13). There are mild degenerative changes at the first metatarsophalangeal joint. The Lisfranc ligament is intact. There is mild soft tissue edema surrounding the Lisfranc ligament, possibly due to a mild ligament sprain. The imaged tendons about the foot are within normal limits. There is no significant joint effusion. There is diffuse mild to moderate intramuscular edema. There is also marked subcutaneous edema, most prominent along the dorsal aspect of the foot. Note is made of close proximity of the lateral navicular bone to the anterior calcaneus, with fluid in the joint space and subchondral cyst. The appearance raises the question of a forme fruste calcaneonavicular coalition (08:16). IMPRESSION: 1. Nondisplaced comminuted intra-articular fracture through the base of the fourth metatarsal. 2. Slightly comminuted fracture along the dorsal aspect of the lateral cuneiform. 3. Intact Lisfranc ligament, although mild surrounding soft tissue edema is suggestive of a sprain. 4. Subtle marrow edema along the base of the second metatarsal near the insertion site of the Lisfranc ligament. Given that a nondisplaced fracture cannot be excluded, further evaluation with CT is recommended. 5. Mild edema within the lateral aspect of the cuboid, without a fracture identified, compatible with a contusion. 6. Probable contusion distal first metatarsal medially. 7. Findings suggestive of a forme fruste calcaneonavicular coalition. Please see report of foot CT obtained on ___, which demonstrates additional findings. RECOMMENDATION(S): Impression point #3 was discussed with Dr. ___ by Dr. ___ at 14:36 via telephone on ___, 5 min after discovery. Radiology Report INDICATION: ___ year old man with right ___ metatarsal injury and right ?2 metatarsal injury based off xrays. Please r/o Lisfranc injury // ?Lisfranc injury of R foot TECHNIQUE: Contiguous helical M CT images were obtained through the right foot without IV contrast. Multiplanar axial, coronal, sagittal and thin section bone algorithm reconstructed images were generated. DOSE: Total body DLP: 467 mGy-cm COMPARISON: Radiographs of the right foot ___. MRI of the right foot ___. FINDINGS: There is nondisplaced fracture of the medial malleolus (506b:175). There is small fracture fragment arising from the lateral metaphysis of the distal tibia (506b:146). The distal fibula appears intact. The tibial plafond is intact. There is comminuted fracture of the lateral cuneiform (3:74). There is a comminuted fracture at the base of the fourth metatarsal without minimal plantar displacement of the proximal fracture fragment. There is osseous fragmentation in the Lisfranc interval with cortical disruption of the lateral aspect of the medial cuneiform (3:84). The medial base of the ___ metatarsal appears intact. There is a nondisplaced fracture of the cuboid (3:82). There is comminuted fracture along the medial aspect at the base of the first and second proximal phalanges (3:126). There is fracture of both the medial and lateral sesamoids (504B:95 and 86). There is calcaneonavicular coalition. There is dorsal plantar calcaneal spurring. There is extensive subcutaneous edema throughout the foot most notably over the dorsum. The flexor and extensor tendons appear intact without evidence of entrapment. Mild edema about the Achilles without evidence of tear. IMPRESSION: 1. Fractures of the medial malleolus, lateral metaphysis of the distal tibia, lateral cuneiform, cuboid, and base of the fourth metatarsal. 2. Avulsion fragments arising from the lateral aspect of the medial cuneiform in the Lisfranc interval suggesting disruption of the Lisfranc ligament. 3. Fractures of base of the first and second proximal phalanges. Fractures of both the medial and lateral sesamoids. 4. Calcaneonavicular coalition (non-osseous). Radiology Report INDICATION: Pedestrian hit by truck. COMPARISON: None. FINDINGS: Portable supine AP view of the chest provided. Underlying trauma board is in place. Lungs are clear and hyperinflated. Cardiomediastinal silhouette appears normal. No acute bony injuries. IMPRESSION: No acute findings. Please refer to subsequent CT of the torso for further details. Radiology Report EXAMINATION: CT HEAD WITHOUT CONTRAST INDICATION: ___ male pedestrian struck by a truck, here to evaluate for acute intracranial injury. TECHNIQUE: Contiguous axial images were obtained through the head without the administration of intravenous contrast. Coronal and sagittal reformatted images as well as thin section images in a bone window algorithm were generated and reviewed. The examination was partially repeated due to motion degradation. DOSE: DLP: 1405 mGy-cm. COMPARISON: No prior studies available. FINDINGS: HEAD CT: There is no evidence of acute intracranial hemorrhage, edema, mass effect or shift of normally midline structures. The gray-white matter interface is preserved without evidence of acute major vascular territorial infarct. The ventricles and sulci are slightly prominent, compatible with age related parenchymal volume loss. The basal cisterns appear patent. The orbits and globes are unremarkable. The imaged paranasal sinuses, middle ear cavities and mastoid air cells are clear bilaterally. The bony calvaria appear intact. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE WITHOUT CONTRAST INDICATION: History: ___ ped vs truck c/o abdominal, hip pain // Evaluation of traumatic injuries TECHNIQUE: 2.5 mm helical axial MDCT sections were obtained from the skull base through the cervical spine. Axial images were interpreted in conjunction with coronal and sagittal reformats. DLP: 1014 MGy-cm CTDIvol: 37 MGy COMPARISON: None available. FINDINGS: Vertebral body heights are maintained and there is no evidence of fracture in the cervical spine. There is anterior wedging of the superior endplate of T1, which is age indeterminate. There are superior endplate compression fracture deformities of the T2 and T4 vertebral bodies with associated sclerosis and less than 25% loss of height, which appear remote. Intervertebral disc space heights are maintained. No acute alignment abnormality is identified. There is no prevertebral soft tissue abnormality. Multilevel degenerative changes are present with narrowing of intervertebral disc spaces most pronounced at the C5-T1 levels and flowing anterior osteophytes from the C4 level through the imaged portion of the upper thoracic spine. The thyroid is grossly unremarkable in appearance. No lymphadenopathy is present by CT size criteria. The visualized lung apices demonstrate pleuroparenchymal scarring. IMPRESSION: 1. No acute fracture or traumatic malalignment of the cervical spine. 2. Anterior wedging of the superior endplate of T1 with minimal associated sclerosis is age indeterminate. No evidence of surrounding hematoma. 3. Chronic appearing superior endplate compression fracture deformities of T2 and T4. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST INDICATION: ___ ped vs truck c/o abdominal, hip pain // Evaluation of traumatic injuries TECHNIQUE: Helically-acquired multidetector CT axial images were obtained through the maxillofacial bones and mandible. Intravenous contrast was not given. Axial images reconstructed with soft tissue and bone algorithm to display images with 1.25 mm slice. Coronal and sagittal reformations also constructed. DOSE: DLP: 606 mGy-cm. CTDIvol: 26 mGy. COMPARISON: None available. FINDINGS: SOFT TISSUES: There is no stranding, fluid collection, hematoma, or other soft tissue abnormality. MAXILLOFACIAL BONES: The maxillofacial bones are intact, without acute fracture. The zygomatico-maxillary complex is intact. The lateral pterygoid plates are intact. MANDIBLE: The mandible is without fracture or temporomandibular joint dislocation. The temporomandibular joints are symmetric, without significant degenerative change. DENTITION: There are no dental fractures. There are multiple periapical lucencies. SINUSES: The paranasal sinuses are intact and clear. The ostiomeatal units are patent. The mastoid air cells and middle ear cavities are clear. NOSE: There is no nasal bone fracture. Nasopharyngeal soft tissues are unremarkable. There is no nasal septal hematoma. ORBITS: The orbits, including the laminae papyracea, are intact. The globes are intact with non-displaced lenses and no intraocular hematoma. There is no preseptal soft tissue edema. There is no retrobulbar hematoma or fat stranding. Allowing for helical acquisition, reconstruction algorithm, and section thickness, the limited included portion of the brain is grossly unremarkable. IMPRESSION: 1. No evidence of facial fracture. 2. Dental caries. Recommend correlation with dental exam. Radiology Report EXAMINATION: CT TORSO WITH CONTRAST INDICATION: ___ male pedestrian struck by truck with abdominal and hip pain, here to evaluate for extent of traumatic injuries. TECHNIQUE: TECHNIQUE: MDCT images were obtained from the thoracic inlet to the pubic symphysis. IV Omnipaque contrast was administered. Oral contrast was not administered. A delayed series performed to assess urinary bladder. Axial images were interpreted in conjunction with sagittal and coronal reformats. DLP: 655 mGy-cm COMPARISON: None. FINDINGS: CHEST: The thyroid is normal. Axillary, supraclavicular, mediastinal, and hilar lymph nodes are not pathologically enlarged. The great vessels are unremarkable. The heart and mediastinum are normal. No pericardial effusion. The airways are patent to the subsegmental levels. The lungs are clear without focal or diffuse abnormality. The pleura is intact without effusion. No pneumothorax or pneumomediastinum. The esophagus is unremarkable except to note a small hiatal hernia. ABDOMEN: The liver, gallbladder, intra- and extra-hepatic bile ducts, spleen, adrenal glands, kidneys, and ureters are normal. The pancreas is atrophic with diffuse coarse calcifications throughout suggesting chronic pancreatitis. The stomach is normal. The small and large bowel enhance homogeneously and have a normal course and caliber. No retroperitoneal or mesenteric lymphadenopathy. The portal and intra-abdominal systemic vasculature are normal. No abdominal wall hernia, pneumoperitoneum, or free abdominal fluid. PELVIS: There is a left anterior extraperitoneal hematoma without evidence of active extravasation with adjacent pelvic fractures. There is mass effect from the extraperitoneal hematoma on the urinary bladder,with rightward displacement. The bladder is largely distended without evidence of rupture on delayed imaging. The terminal ureters are normal. No pelvic side-wall or inguinal lymphadenopathy. There is trace free fluid between loops of small bowel superior to the dome of the urinary bladder. OSSEOUS STRUCTURES: There is a comminuted displaced fracture of the left acetabulum disrupting both anterior and posterior columns with impaction and medial displacement of the intact left proximal femur. There is widening of the left sacroiliac joint. There are displaced fractures of the left superior and inferior pubic rami. There is a vertically oriented, nondisplaced left parasymphyseal fracture without widening of the pubic symphysis. There is an obliquely oriented fracture through the right sacral ala extending into the midline, which does not extend to involve either SI joint. A sclerotic focus in the right iliac wing measures 1.6 x 1.3 cm (601b:45). There are healed fractures of the left eighth, ninth and tenth ribs. There are sclerotic compression fracture deformities of the superior endplates of T2 and T4. Minimal sclerosis associated with anterior wedging of the superior endplate of T1 is age indeterminate. IMPRESSION: 1. Comminuted fracture of the left acetabulum through the anterior and posterior columns with impaction of the proximal femur, which is displaced medially but remains intact. Left extraperitoneal hematoma in the pelvis without evidence of active extravasation. No evidence of bladder rupture. 2. Displaced fracture of the left superior and inferior pubic rami. Nondisplaced left parasymphyseal fracture without diastasis of the pubic symphysis. Nondisplaced obliquely oriented fracture of the right sacral ala extending into the midline which does not involve either SI joint; however, there is widening of the left sacroiliac joint. 3. No evidence of solid organ injury. NOTIFICATION: The findings were discussed by Dr. ___ with the trauma surgery team in person on ___ at 7:00 ___, during discovery of the findings. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: PED/BICYLE STRUCK Diagnosed with FRACTURE ACETABULUM-CLOS, MV COLL W PEDEST-PEDEST, DTP/DTAP, COMBINED temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan
The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left acetabular fx and right foot lisfranc injury and was admitted to the orthopedic surgery service after LLE extremity traction was placed in the ED. The patient was taken to the operating room on ___ for left acetabular ORIF 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 TDWB in the left lower extremity and nwb in RLE, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Intentional Overdose Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M pmhx depression, OSA, and PTSD presenting with intentional Tylenol overdose. His reported time of ingestion was sometime in the morning ___. He brought to the ED after being found difficult to arouse by his family. At the OSH, he had a cxr which showed no acute intrapulmonary findings. Labs were significant for ALT 74, AST 61, troponin nonelevated, Tylenol 30.6, WBC 7.5 bili 0.9. Acetylcysteine was initiated at the OSH prior to transfer where he received stage I and II. In the ED, he was nauseous and vomited multiple times. He stated that he took the Tylenol in an attempt to commit suicide after a conflict with his wife. He had no additional complains besides nausea. There was concern that he had ingested amlodipine, Zoloft, aspirin, atorvastatin, and Ritalin. Per ED Nursing documentation, these medications belong to his wife. He denied f/c/cp/abdominal pain/diarrhea He was admitted to the ICU for frequent EKG monitoring per posion control. His QT on arrival was 413/ -Initial Vitals: 98 175/99 68 12 99% RA -Exam: Abd soft, nondistended -Labs: CBC wnl, Chem 10 notable for Bicarb 18 and Mg 1.2, ALT: 51 AST 45, lactate 2.9 Venous Gas: 7.45 pco2 34 hco3 24 Urine drug screen negative for benzos/barbituates, opiates, cocaine, amphetamines, methadone, oxycodone -Imaging: None -Consults: None -Patient was given: ___ ___ mg, mag sulfate 2 g IV On arrival to the ___, the patient confirmed the above history. Reports feeling bloated but not n/v. He states that he and his wife had an argument ___. He states that he "needed to get out" and that that is why he took the medications. He primarily took his wifes medications because he thought they had a better chance of killing himself. He has never attempted suicide before. He denies current SI/HI. Denies f/c/cp/sob/cough/abd pain/diarrhea/constipation/dysuria/myalgia. Past Medical History: -Depression -Gout -OSA -Prostate Cancer -Celiac Sprue -PTSD -ADHD -DM2 Social History: ___ Family History: Noncontributory Physical Exam: Admission Physical Examination: =============================== VS: 98 155/95 73 14 98% RA GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Gait is normal. AOx3. No asterixis Discharge Physical Examination: =============================== 97.9 125/77 65 18 98 RA GENERAL: Alert and in no apparent distress EYES: Anicteric ENT: MMM CV: Heart regular, soft murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation, no w/r GI: obese, soft, NTTP, NABS GU: no foley SKIN: No jaundice EXTR: warm, no edema NEURO: alert, appropriate PSYCH: calm, without psychomotor agitation Pertinent Results: Admission Labs: ================ ___ 11:41PM LACTATE-2.5* ___ 11:35PM URINE HOURS-RANDOM ___ 11:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 11:35PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:35PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-1000* KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 11:35PM URINE RBC-73* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 11:35PM URINE HYALINE-1* ___ 11:35PM URINE MUCOUS-RARE* ___ 09:05PM ___ PO2-40* PCO2-34* PH-7.45 TOTAL CO2-24 BASE XS-0 ___ 09:05PM LACTATE-2.9* ___ 09:00PM GLUCOSE-245* UREA N-20 CREAT-0.8 SODIUM-139 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-18* ANION GAP-18 ___ 09:00PM estGFR-Using this ___ 09:00PM ALT(SGPT)-51* AST(SGOT)-45* ALK PHOS-63 TOT BILI-0.9 ___ 09:00PM LIPASE-26 ___ 09:00PM LIPASE-26 ___ 09:00PM ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-1.6* MAGNESIUM-1.2* ___ 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-16 tricyclic-NEG ___ 09:00PM WBC-8.1 RBC-4.52* HGB-13.8 HCT-40.2 MCV-89 MCH-30.5 MCHC-34.3 RDW-14.0 RDWSD-45.1 ___ 09:00PM NEUTS-82.0* LYMPHS-12.3* MONOS-4.5* EOS-0.4* BASOS-0.4 IM ___ AbsNeut-6.64* AbsLymp-0.99* AbsMono-0.36 AbsEos-0.03* AbsBaso-0.03 ___ 09:00PM PLT COUNT-216 ___ 09:00PM ___ PTT-30.2 ___ Discharge Labs: =============== ___ 06:00AM BLOOD WBC-7.9 RBC-4.64 Hgb-14.4 Hct-43.5 MCV-94 MCH-31.0 MCHC-33.1 RDW-14.4 RDWSD-49.1* Plt ___ ___ 06:00AM BLOOD Glucose-145* UreaN-17 Creat-0.9 Na-140 K-3.6 Cl-101 HCO3-23 AnGap-16 ___ 07:42AM BLOOD ALT-40 AST-31 AlkPhos-79 TotBili-0.9 ___ 07:42AM BLOOD Calcium-9.8 Phos-3.0 Mg-2.0 ___ 05:21AM BLOOD Acetmnp-NEG ___ 11:18AM BLOOD Acetmnp-NEG ___ 03:33PM BLOOD ___ pO2-119* pCO2-37 pH-7.44 calTCO2-26 Base XS-1 ___ 03:33PM BLOOD Lactate-2.0 RUQ U/S IMPRESSION: Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on this examination. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Prazosin 3 mg PO QAM 4. BusPIRone 20 mg PO BID 5. Enalapril Maleate 40 mg PO DAILY 6. MethylPHENIDATE (Ritalin) 10 mg PO BID 7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN itching 8. Ketoconazole Shampoo 1 Appl TP ASDIR 9. Allopurinol ___ mg PO DAILY 10. Prazosin 6 mg PO QHS 11. Aspirin 81 mg PO DAILY 12. Ferrous Sulfate 325 mg PO DAILY 13. Cyanocobalamin 500 mcg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. DULoxetine ___ 120 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line 2. Docusate Sodium 100 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 4. Senna 8.6 mg PO BID 5. Prazosin 4 mg PO QHS 6. Prazosin 1 mg PO BREAKFAST 7. Allopurinol ___ mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. BusPIRone 20 mg PO BID 11. Cyanocobalamin 500 mcg PO DAILY 12. DULoxetine ___ 120 mg PO DAILY 13. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN itching 14. Vitamin D 1000 UNIT PO DAILY 15. HELD- Chlorthalidone 25 mg PO DAILY This medication was held. Do not restart Chlorthalidone until you are seen by your primary care 16. HELD- Enalapril Maleate 40 mg PO DAILY This medication was held. Do not restart Enalapril Maleate until you are seen by your primary care 17. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was held. Do not restart Ferrous Sulfate until you are seen by primary care and constipation resolves 18. HELD- MethylPHENIDATE (Ritalin) 10 mg PO BID This medication was held. Do not restart MethylPHENIDATE (Ritalin) until you are evaluated by psychiatry Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Tylenol overdose with multidrug ingestion 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: ___ year old man with history of PTSD and depression, presenting with intentional acetaminophen overdose, now with transaminitis of unclear etiology. Eval for biliary/liver pathology. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. Hypoechoic focus along the gallbladder fossa probably reflects fatty sparing. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 4 mm GALLBLADDER: There is a 5 mm gallbladder wall polyp. There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 10.5 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. Small left pleural effusion is noted. IMPRESSION: Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on this examination. RECOMMENDATION(S): Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the ___ (FibroScan) or the Radiology Department with either MR ___ or US ___, in conjunction with a GI/Hepatology consultation" * * Chalasani et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the ___ Association for the Study of Liver Diseases. Hepatology ___ 67(1):328-357 Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Overdose, Suicide attempt, Transfer Diagnosed with Poisoning by 4-Aminophenol derivatives, self-harm, init, Poisn by slctv serotonin reuptake inhibtr, self-harm, init, Poisn by antihyperlip and antiarterio drugs, self-harm, init, Poisoning by calcium-channel blockers, self-harm, init, Vomiting without nausea, Oth places as the place of occurrence of the external cause temperature: 98.0 heartrate: 68.0 resprate: 12.0 o2sat: nan sbp: 175.0 dbp: 99.0 level of pain: 0 level of acuity: 2.0
Patient was admitted to the ICU s/p intentional multi-drug overdose, most notable acetaminophen. He initially went to an OSH where he received stages 1 and 2 of NAC. He was then transferred to ___ ED where he was continued on stage 3 of NAC. He was admitted to the FICU for close monitoring of his QTc with q4h EKGs as per the recommendation of poison control. After 2 stable EKGs, he was able to be called out to the floor. Suicide attempt/Intentional overdose: Pt was placed under ___ with 1:1 sitter. His LFTs have normalized and EKGs were reassuring. Pt was monitored on telemetry without any events. Pt had transient N/V related to gluten sensitivity and dietary exposure but labs were all reassuring with normal lactate and venous blood gas. Symptoms resolved entirely and pt was ready/willing to transfer to inpt psych for ongoing care. Pt was continued on home duloxetine, buspirone and a decreased dose of PRazosin 4mg qhs and 1mg qam. Orthostatic hypotension: Pt had orthostatic hypotension on home doses of prazosin. He was given IVF and BP/symptoms resolved. Pt was restarted on a lower dose of Prazosin at 4mg qhs & 1mg in morning. Pt did well on this regimen with normal blood pressure and no orthostatic symptoms. We have been holding home anti-hypertensives and would recommend deferring rechallenge until pt is seen by PCP. Lactic acidosis: resolved after admission and was likely related to multidrug ingestion. Repeat VBG normal with lactate of 2. #Hypertension. Holding home chlorthaliadone & enalapril. - defer rechallenge to outpt f/u with PCP as BP has been normal while inpatient. #Constipation: pt was treated with multidrug bowel regimen, would try Bisacodyl PR if pt is unable to have BMs on this regimen. #Gout. Continue home allopurinol #OSA. Cont home CPAP #ADHD. Holding home Ritalin until evaluated in inpt psych facility Transition issues: - PCP to reassess need for anti-hypertensives after discharge from inpt psych - outpt follow up of likely steatohepatitis, pt is at high risk for NASH and may benefit from outpatient hepatology referral
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Peanut / Soy / Detrol / baclofen Attending: ___ Chief Complaint: Right foot numbness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a past medical history of NMO (followed here by Dr. ___ who presents with right foot numbness. She states that last night before bed she noticed had burning in her right foot (just the sole near the toes), so she put fan on to help out with this. This morning when she woke up, she felt that in addition to right foot burning, she had leg weakness more than baseline, not related to pain. She says she knows that her right leg is normally slightly weaker than the left, but that it was worse. She was having trouble ambulating due to pain and weakness and so she called Dr. ___ was told to come in to the emergency room. Of note, she had been off Cellcept ___ - last week due to insurance issues, and she had missed her neurology appointment several weeks ago. When she did come in to clinic last week, she was complaining of generalized fatigue/malaise, and dizzy episodes. The dizzy episodes are simultaneous lightheadedness + vertigo. She has a history of lightheadedness/syncope, but the vertigo is new - it would happen upon sitting up in bed, last for under a minute, and go away. She reports still having this. Last week in clinic, Dr. ___ her exam to be stable with no concerning findings re: vertigo, and so she was restarted on cellcept and no imaging studies were ordered. She endorses some stress when asked - she is about to graduate college and is interviewing for a job, she is concerned these symptoms will get in the way of this. NMO History: Was first diagnosed in ___ with LETM from C5-T11, manifested by sensory symptoms in bilateral feet followed by right leg weakness which remains to some degree. She was started on Cellcept. In ___ she was admitted for with ___ weeks of progressively worsening bilateral foot burning pains and paresthesias exacerbated by warmth, MRI C, T, & L spine with and without contrast showed no new lesions and she was not given steroids. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - NMO - recurrent syncope - migraines - alpha thalassemia - vitamin D insufficiency - fibroadenoma of breast Social History: ___ Family History: Father with diabetes ___. Mother died in ___ of a "stomach infection." Physical Exam: ========================== ADMISSION PHYSICAL EXAM ========================== Vitals: 99.0 75 111/62 16 100% RA 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 C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. No paraphasic errors. Naming intact to both high and low frequency objects. Reads without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes. Good knowledge of current events. No apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. ___ L eye, ___ left eye w/out glasses. No red desaturation, no APD. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 4 4 4 5 5 5 5 *RLE pain limited. -Sensory: Decreased sensation to pin throughout the right leg, 70% compared to the left. On abdomen, has hyperesthesia on the right, up to level of T8 anteriorly and posteriorly. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 3 3 R 2 2 2 3 3 R patellar with crossed adduction. Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, short stride and not stepping on right toes ___ pain. Unable to walk in tandem. Sways with Romberg. . . ========================= DISCHARGE PHYSICAL EXAM ========================= VS 98.6F, 95-121/52-60, HR 56-74, RR ___, 100% on RA, FSG 181 max General - NAD Mental status - Alert and oriented x3 CN - face symmetric, EOMI, PERRL Motor - IP, Hamstring, TA, ___ - ___ bilaterally Sensory - Stable mild hyperesthesia in left leg compared to right Pertinent Results: ==================== ADMISSION LABS ==================== ___ 03:10PM BLOOD WBC-4.3 RBC-5.13 Hgb-12.1 Hct-40.5 MCV-79* MCH-23.6* MCHC-29.9* RDW-13.1 RDWSD-37.3 Plt ___ ___ 03:10PM BLOOD Neuts-62.7 ___ Monos-8.9 Eos-0.2* Baso-0.2 Im ___ AbsNeut-2.67 AbsLymp-1.17* AbsMono-0.38 AbsEos-0.01* AbsBaso-0.01 ___ 03:10PM BLOOD Glucose-87 UreaN-13 Creat-0.8 Na-138 K-4.0 Cl-105 HCO3-24 AnGap-13 ___ 03:10PM BLOOD ALT-12 AST-27 AlkPhos-53 TotBili-0.5 ___ 05:30AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0 ___ 03:10PM BLOOD Albumin-4.6 ___ 03:10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 03:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 03:10PM URINE Hours-RANDOM ___ 03:10PM URINE UCG-NEGATIVE . URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. . ====================== DISCHARGE LABS ====================== ___ 05:05AM BLOOD WBC-14.8*# RBC-4.44 Hgb-10.6* Hct-34.6 MCV-78* MCH-23.9* MCHC-30.6* RDW-13.1 RDWSD-37.0 Plt ___ ___ 05:05AM BLOOD Glucose-146* UreaN-10 Creat-0.8 Na-139 K-4.3 Cl-102 HCO3-26 AnGap-15 . . ================== MRI C AND T SPINE ================== IMPRESSION: 1. In comparison with the prior MRI examination of the spine dated ___, no significant changes are identified, there is minimal disc bulge at C3/C4, with no evidence of nerve compression or neural foraminal narrowing. 2. There is no evidence of spinal canal stenosis, nerve root compression or signal abnormalities throughout the cervical and thoracic spinal cord, there is no evidence of abnormal enhancement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mycophenolate Mofetil 500 mg PO QAM 2. Mycophenolate Mofetil 1000 mg PO QPM 3. Levonorgestrel 1.5 mg PO DAILY 4. OxycoDONE (Immediate Release) 5 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Mycophenolate Mofetil 1000 mg PO BID 2. Vitamin D 1000 UNIT PO DAILY 3. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 capsule(s) by mouth daily Disp #*14 Capsule Refills:*0 4. Levonorgestrel 1.5 mg PO DAILY 5. OxycoDONE (Immediate Release) 5 mg PO DAILY 6. MethylPREDNISolone Sodium Succ 1000 mg IV DAILY Duration: 3 Doses RX *methylprednisolone sodium succ [Solu-Medrol] 1,000 mg 1000 mg IV once Disp #*1 Vial Refills:*0 RX *methylprednisolone sodium succ [Solu-Medrol] 500 mg 500 mg IV daily for 3 doses Disp #*3 Vial Refills:*0 RX *methylprednisolone sodium succ [Solu-Medrol] 500 mg 250 mg IV daily for 3 doses Disp #*3 Vial Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1.) Neuromyelitis Optica Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI CERVICAL AND THORACIC. INDICATION: ___ year old woman with NMO, RLE weakness // Cause for RLE weakness. TECHNIQUE: Sagittal T1, T2 and sagittal STIR sequences were obtained through the cervical and thoracic spine, axial gradient echo and T2 T2 weighted images were also obtained. The T1 weighted images were repeated after administration of 7 mL of Gadavist intravenous gadolinium contrast in axial sagittal projections. COMPARISON: MRI of the total spine dated ___, prior MRI of the total spine dated ___. FINDINGS: MRI of the cervical spine. The visualized elements of the posterior fossa and the craniocervical junction appear normal and unchanged. The signal intensity throughout the cervical spinal cord is normal with no evidence of focal or diffuse lesions to indicate spinal cord edema or cord expansion. There is no evidence of abnormal enhancement. In comparison with the prior examination dated ___, again there is minimal and unchanged posterior disc bulging at C3/C4, with no evidence of nerve root compression or spinal canal stenosis the visualized paravertebral structures are unremarkable. MRI of the thoracic spine. In comparison with the prior examination dated ___, no significant changes are demonstrated, the signal intensity throughout the thoracic spinal cord is normal, the conus medullaris terminates at the level of T12/L1 and is unremarkable. There is no evidence of abnormal enhancement. The intervertebral disc spaces appear maintained with no evidence of neural foraminal narrowing or spinal canal stenosis, the visualized paravertebral structures are grossly unremarkable. IMPRESSION: 1. In comparison with the prior MRI examination of the spine dated ___, no significant changes are identified, there is minimal disc bulge at C3/C4, with no evidence of nerve compression or neural foraminal narrowing. 2. There is no evidence of spinal canal stenosis, nerve root compression or signal abnormalities throughout the cervical and thoracic spinal cord, there is no evidence of abnormal enhancement. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Leg weakness Diagnosed with Weakness, Headache temperature: 99.0 heartrate: 75.0 resprate: 16.0 o2sat: 100.0 sbp: 111.0 dbp: 62.0 level of pain: 6 level of acuity: 3.0
Ms. ___ is a ___ year old woman with a hx of NMO diagnosed in ___, AQ Ab+ followed here by Dr. ___ presents with right foot parasthesias. On initial exam, she had RLE numbness new from prior exam, limiting ambulation, with mild weakness of right leg compared to left on admission exam. . While her MRI C and T spine imaging with contrast did not show any new lesion to explain her symptoms, her primary neurologist Dr ___ felt that given her recent interruption in her Cellcept and the aggressive nature of NMO, a course of steroids was still warranted. The pt was started on Methylprednisolone 1000mg IV over 8 hours x 3 doses with planned taper: 500mg over ___ hrs for 3 days, 250mg over ___ hrs for 3 days. She had a midline placed prior to discharge with home ___ to complete this therapy at home. . Her Cellcept was increased at an increased dose of 1000mg BID which had been planned as an outpatient. . During her stay, she also had a ___ minute episode of decreased responsiveness with intermittent ability to respond quietly to questions that was very consistent with known anxiety induced non-epileptiform spells. This slowly resolved and she was back to baseline after the event. . She will call Dr ___ office to schedule 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: Fever Major Surgical or Invasive Procedure: ___ Removal infected left forearm arteriovenous graft. History of Present Illness: Of importance, patient has HCV cirrhosis with recurrent stage II HCV cirrhosis ___ his allograft and was started on a 24-week course of Harvoni ___. Patient is also ___ hep c cirrhosis s/p liver transplant ___, DM2/ESRD on HD (___) via LUE Left loop forearm arteriovenous graft who was transferred from ___ for fever of 102 weakness.currently on transplant list. Patient presentd to ___ on ___ for complaints of fever to 102, as well as nausea, overall feeling unwell. Per-report, patient's family also noticed that his is having progressive memoral loss. Patient currently states that he feels febrile and naseous. Past Medical History: PMH: hepatitis C cirrhosis s/p liver transplant ___ ___ with recurrent hepatitis C and stage 2 fibrosis undergoing Harvoni treatment, liver transplant c/b hepatic vein stenosis status post stent with recurrent stenosis on Coumadin, DM2, HTN, OSA, Vit D deficiency, h/o large pericardial effusion without tamponade requiring pericardiocentesis 1L PSH: umbilical hernia s/p repair ___ liver transplant c/b hepatic vein stenosis status post stent with recurrent stenosis on Coumadin. uvulectomy, deviated septum repair esophageal variceal banding, exploratory laparotomy with resection of terminal ileum, appendectomy and ventral hernia repair ___ Social History: ___ Family History: Non-contributory Physical Exam: 102.1 ___ 18 97% RA General: AAOx3, but states he is becoming more forgetful Cardiac: WNL Respiratory: Breathing comfortably on room air Abdomen: Soft, distended, no rebound or guarding Extremity: left upper extremity AV graft site erythema, indurated, more swollen than right, warm to palpation. Pertinent Results: Labs on Admission: ___ WBC-5.2 RBC-3.88* Hgb-11.2*# Hct-33.0* MCV-85 MCH-28.9 MCHC-33.9 RDW-19.2* RDWSD-58.5* Plt Ct-87* ___ PTT-43.0* ___ Glucose-140* UreaN-62* Creat-5.3* Na-126* K-4.3 Cl-88* HCO3-20* AnGap-22* ALT-30 AST-27 AlkPhos-104 TotBili-1.7* tacroFK-2.0* . Labs at discharge: ___ WBC-6.8 RBC-3.27* Hgb-9.1* Hct-28.0* MCV-86 MCH-27.8 MCHC-32.5 RDW-18.2* RDWSD-56.8* Plt ___ Glucose-204* UreaN-59* Creat-5.0*# Na-132* K-3.4 Cl-94* HCO3-22 AnGap-19 ALT-7 AST-10 AlkPhos-129 TotBili-0.5 Calcium-7.9* Phos-4.0 Mg-1.7 tacroFK-3.9* ___ 5:35 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT 0130. GRAM POSITIVE COCCI ___ CLUSTERS. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI ___ CLUSTERS. ___ 1:15 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 4:30 pm SWAB Site: ARM ___ ABSCESS LEFT ARM. **FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ___ 4:55 pm FOREIGN BODY EXPLANTED GRAFT LEFT ARM. **FINAL REPORT ___ WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ___ 9:07 am BLOOD CULTURE #1. Blood Culture, Routine (Pending): ___ 6:20 am BLOOD CULTURE Source: Line-vip port Random. Blood Culture, Routine (Pending): Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tacrolimus 3 mg PO Q12H 2. Atovaquone Suspension 750 mg PO DAILY 3. Labetalol 300 mg PO TID 4. OxycoDONE (Immediate Release) 20 mg PO BID 5. NIFEdipine CR 90 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. Ledipasvir/Sofosbuvir 1 TAB PO DAILY Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Labetalol 300 mg PO TID 3. Ledipasvir/Sofosbuvir 1 TAB PO 6X/WEEK (___) 4. NIFEdipine CR 90 mg PO DAILY 5. Omeprazole 20 mg PO 6X/WEEK (___) 6. OxycoDONE (Immediate Release) 20 mg PO Q8H:PRN pain 7. Tacrolimus 3 mg PO Q12H 8. Venlafaxine XR 75 mg PO DAILY 9. Acetaminophen 325-650 mg PO Q8H:PRN pain do not exceed 2000mg per day 10. CefazoLIN 2 g IV POST HD (___) 11. CefazoLIN 3 g IV POST HD (SA) MSSA bacteremia last dose ___ week course from 1 set of negative blood culture ___. Warfarin 5 mg PO DAILY16 13. Calcitriol 0.5 mcg PO DAILY RX *calcitriol 0.5 mcg 1 capsule(s) by mouth 3x a week on dialysis day Disp #*12 Capsule Refills:*4 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Infected left forearm arteriovenous graft. MSSA bacteremia h/o liver transplant HCV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with RUQ pain // eval transplant TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___ FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. There is no ascites, right pleural effusion or sub- or ___ fluid collections/hematomas. The spleen measures 17.9 cm and has normal echotexture. DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 88 cm/sec. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.51, and 0.46, respectively. The main portal vein, right and left portal veins are patent with hepatopetal flow with normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: Patent hepatic vasculature with appropriate waveforms. Radiology Report EXAMINATION: ___ AVF/DUPLEX HEMO/DIAL ACCESS INDICATION: History: ___ with ?clot // eval fistula TECHNIQUE: Grayscale, color and spectral Doppler ultrasound images were obtained of the left forearm fistula. COMPARISON: None FINDINGS: The left forearm fistula is patent to with wall to wall color flow and an appropriate waveform. IMPRESSION: Patent left forearm fistula Radiology Report INDICATION: ___ M h/o liver transplant, ESRD on HD, p/w fever, also has some cough/sob // e/o pna TECHNIQUE: Frontal and lateral views the chest. COMPARISON: ___. FINDINGS: Prior right-sided central venous catheter is no longer visualized. There has been interval clearance of the dense retrocardiac opacity since prior exam. Minimal bibasilar opacities are noted. Superiorly the lungs are clear of consolidation and there is no effusion. There is however nodular opacity projecting over the anterior right second rib. Additional nodular opacities 1 projecting over each lung base are presumably nipple shadows but can be followed at time of subsequent exam. Moderate cardiomegaly is noted. No acute osseous abnormalities. TIPS identified in the right upper quadrant. IMPRESSION: Interval resolution of dense retrocardiac opacity seen on previous exam. There are bibasilar opacities presumably atelectasis noting that infection cannot be entirely excluded. An 8 mm nodule at the right upper lung. NOTIFICATION: Nonurgent chest CT is suggested for evaluation of suspected pulmonary nodule. Radiology Report EXAMINATION: US UPPER EXTREMITY, SOFT TISSUE LEFT INDICATION: ___ h/o liver transplant on immunosuppression, ESRD on HD, p/w fever to 102.5 and exquisite tenderness to palpation over L graft site // please eval soft tissue around graft site for e/o infection TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the -. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the left forearm. Along the course of and abutting the AV graft is a heterogeneous collection with internal echoes, which does not contain flow. In one location it measures approximately 4.5 x 1.3 x 3.6 cm. There is moderate soft tissue edema. Flow seen within the graft. For findings regarding the AV graft, please see report from ultrasound examination from 6 hr prior. IMPRESSION: Heterogeneous echogenic collection surrounding the left forearm AV graft with moderate subcutaneous edema, may represent hematoma, though infection is not excluded by imaging. Radiology Report INDICATION: ___ year old dialysis-dependent man with infected LUE AVG s/p excision. Please place temporary HD line on right side. COMPARISON: None TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. Anesthesia; Local lidocaine, with and without epinephrine. No moderate sedation was provided. Anxiety control was achieved by administrating asingle dose of 1 mg of midazolam throughout the total intra-service time of 25 min during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: See above CONTRAST: None. FLUOROSCOPY TIME AND DOSE: 0.20 min, 2 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 neckand upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a 0.018 wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The micro wire was removed and a short ___ wire was advanced into the IVC. A triple-lumen central venous catheter was advanced over the wire into the 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. The patient tolerated the procedure well without immediate complications. FINDINGS: Patent right internal jugular vein. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking and catheter tip terminating in the cavoatrial junction. Catheter aspirates and flushes well. IMPRESSION: Successful placement of a temporary triple lumen catheter via the right internal jugular venous approach. The tip of the catheter terminates in the cavoatrial junction. The catheter is ready for use. Radiology Report INDICATION: ___ hep c cirrhosis s/p liver transplant ___, DM2/ESRD on HD (___) via LUE Left loop forearm arteriovenous graft who was transferred from ___ for fever of 102 weakness. He is now s/p AV graft excision as well as R temp dialysis placement // Tunnel line placement COMPARISON: ___. TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 17 min during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. FLUOROSCOPY TIME AND DOSE: 1.4 min, 3 mGy PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right upper chest and existing temporary right internal jugular catheter was prepped and draped in the usual sterile fashion. A short ___ wire was advanced through the existing temporary dialysis catheter to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 19cm tip-to-cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. The temporary dialysis catheter was removed over the wire. The venotomy tract was dilated with a 14 ___ dilator. Following this, the peel-away sheath was placed over the ___ wire through which the catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. ___ subcuticular Vicryl sutures and Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Final fluoroscopic image showing 19 cm cuff to tip tunneled dialysis catheter with tip terminating in the right atrium. IMPRESSION: Successful exchange of a temporary dialysis catheter to a 19 cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Lower back pain, Transfer Diagnosed with DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT, ACCIDENT NOS, END STAGE RENAL DISEASE, LIVER TRANSPLANT STATUS, LONG TERM USE ANTIGOAGULANT temperature: 102.1 heartrate: 110.0 resprate: 18.0 o2sat: 97.0 sbp: 98.0 dbp: 57.0 level of pain: 5 level of acuity: 2.0
___ y/o male s/p liver transplant with renal dysfunction that ultimately led to need for dialysis, and patient currently listed for kidney transplant presents with arm swelling, erythematous over the dialysis graft. Of note he had a fistulagram with dilation of an outflow lesion on ___. Since this procedure, the patient reports no problems with HD including a session on the previous ___. It appeared ___ the ED that he had a cellulitis and he was started on IV Vanco, with an initial favorable response of over the graft. We decided to watch it very carefully with decreasing erythema. However, blood cultures drawn ___ the emergency room came back with gram-positive cocci the following morning so the decision was made to remove the graft. He was taken to the OR with Dr ___ ___ for removal of the infected left forearm arteriovenous graft. Cultures were sent from the graft material at the time of the OR, and both blood and graft material grew MSSA. At the time of surgery, there was evidence of pus within the graft lumen itself and all but 2-3 mm ends were left at the arterial and venous anastomoses and the rest of the graft excised. Initially wicks were placed to the three separate incisions. He received IV Vanco until the culture data was finalized and he was changed to Cefazolin with HD administration schedule. Discussion regarding HD access plan was reviewed with patient and his wife. ID was also consulted due to the bacteremia. After much discussion, a temporary line was placed and the patient was able to received dialysis. The line was exchanged on ___ for a tunneled dialysis catheter as he continued the IV antibiotics and most recent positive culture was from the day the graft was removed on ___. Wicks were removed on POD 1, and the arm swelling was decreasing and the erythema was greatly improved. Dressings were continued and the incision beds were clean with healthy appearing wound beds. Per the ID consult recommendations, a TEE was performed with no evidence of vegetations. He is recommended to complete a 6 week course of the IV Cefazolin at his ___ clinic. ___ was engaged to provide wound care. Warfarin was restarted once the dialysis tunneled line was placed. Tacro dosing was adjusted per level and he was kept on single immunosuppressant therapy.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Didanosine / Raltegravir Attending: ___. Chief Complaint: Generalized weakness, hypotension Major Surgical or Invasive Procedure: Subclavian central line History of Present Illness: This is a ___ yo M with PMH significant for HIV that presents with generalized weakenss and hypotension following acute episode of epistaxis last ___. During this episode, he states that blood was "pouring out of his nose". He was evaluated by ___ where his nose was packed with a nasal tampon. This did not stop the bleed, so he was re-evaluated the following day, and had bleed stopped with a balloon catheter. He does not know of any provocation for bleed, though does not that he takes SQ lovenox for a h/o PE in the past. Lovenox was not held at the ___. Since his packing, patient has felt progressively weak and reports myalgias. He describes shortness of breath with exertion, though this is not a new finding. Also reports large volume diarrhea since last admission. He was recently admitted to ___ within the last 2 weeks for abdominal pain and found to have diverticulitis on CT. He was treated with ciprofloxacin and developed diarrhea. For this, he was placed empirically on flagyl due to a h/o severe c.diff colitis in the past. C. diff studies negative during that admission. There was some concern for GIB, as he had an acute hct drop from 40->28, and was trasnfused 2U pRBC. GI consulted and performed EGD which showed esophagitis, but no bleed. Colonoscopy also unrevealing. The possibly etiologies for the patients anemia included a bleeding diverticula, slow bleeding due to duodenitis and esophagitis. He was scheduled for outpatient capsule endoscopy, but has not completed this yet. Fe studies significant for anemia of chronic disease. Placed on iron supplementation. In the ___, initial vs were: 98.2 79 84/48 18 99%. Initial labs significant for WBC 15, H/H 11.5/33.9,Plt 238. Chem-7 significant for Na 133, K 5.4, Cl 108, HCO3 17, BUN 47, Cr 2.2. INR 1.1. ABG with 7.___. Lactate 1. UA negative. He was given 2L NS which temporarily improved BP, however, pressure dropped again. Also given zosyn 4.5g, vanco 1g, and ativan 2g. Blood cultures sent x2. A subclavian central line was placed in the ___, and there was some concern for arterial placement. Transduced CVP was 9 and CXR read as placed in the innominate. On the floor, patient reports continual generalized weakness, though nothing focal. Also reports chills this morning and low grade subjective fever. He has had decreased PO intake since last admission. Since last admission, he continues to have ~4 loose, large volume, dark bowel movements daily. Past Medical History: -HIV Asthma -IgA deficiency with h/o multiple sinus/pulm infections, severe otitis media with mastoiditis -Lipodystrophy -HAV (___) -Depression -C. difficile colitis (___) -H. pylori gastritis (sp rx) -Migrained headache -Nephrolithiasis -Cervical disc disease -Giardia (___) -Hypokalemia (thought to be ___ HCTZ) -DJD of cervical spine (per pt) Social History: ___ Family History: Prostate Ca - father and brother Physical Exam: Admission: Vitals: 98.5 74 94/51 16 96%RA General: Alert, oriented, no acute distress HEENT: Nasal balloon catheter in place in R. nares. No evidence of ongoing bleed in oropharynx. Sclera anicteric, Dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: VS: 98.9/99.0 ___ 18 96% RA General: Alert, oriented, no acute distress HEENT: Balloon catheter removed. No evidence of further epistaxis Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neu: Upper extremity strength ___ b/l. RLE ___ strength, LLE 4+/5 with more give-way weakness. Sensation intact grossly b/l. Pertinent Results: ADMISSION LABS ___ 02:00PM BLOOD WBC-15.0*# RBC-3.68* Hgb-11.5* Hct-33.9* MCV-92 MCH-31.3 MCHC-33.9 RDW-16.5* Plt ___ ___ 03:29AM BLOOD WBC-7.9 RBC-3.12* Hgb-9.9* Hct-29.4* MCV-94 MCH-31.9 MCHC-33.8 RDW-17.0* Plt ___ ___ 03:29AM BLOOD ___ PTT-36.7* ___ ___ 02:00PM BLOOD Glucose-106* UreaN-47* Creat-2.2*# Na-133 K-5.4* Cl-108 HCO3-17* AnGap-13 ___ 03:29AM BLOOD Glucose-94 UreaN-29* Creat-1.4* Na-141 K-4.5 Cl-118* HCO3-18* AnGap-10 ___ 02:09PM BLOOD Glucose-109* UreaN-21* Creat-1.1 Na-140 K-4.2 Cl-114* HCO3-17* AnGap-13 ___ 07:42PM BLOOD Type-ART pO2-34* pCO2-34* pH-7.28* calTCO2-17* Base XS--10 ___ 09:23PM BLOOD ___ pO2-193* pCO2-35 pH-7.26* calTCO2-16* Base XS--10 ___ 09:57PM BLOOD ___ pO2-45* pCO2-32* pH-7.25* calTCO2-15* Base XS--11 ___ 03:53PM BLOOD Lactate-1.0 RELEVANT INTERIM LABS ___ 03:15PM BLOOD WBC-7.5 Lymph-31 Abs ___ CD3%-88 Abs CD3-2041* CD4%-21 Abs CD4-488 CD8%-66 Abs CD8-1524* CD4/CD8-0.3* DISCHARGE LABS ___ 06:50AM BLOOD WBC-7.2 RBC-3.06* Hgb-10.0* Hct-28.3* MCV-92 MCH-32.6* MCHC-35.3* RDW-16.6* Plt ___ ___ 06:50AM BLOOD Glucose-94 UreaN-10 Creat-1.1 Na-142 K-3.9 Cl-107 HCO3-27 AnGap-12 ___ 06:50AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.8 CHEST RADIOGRAPH PERFORMED ON ___ IMPRESSION: No definite signs of pneumonia. Lung volumes are low. MRI BRAIN AND C-SPINE ___: IMPRESSION: Except for a few nonspecific foci of T2 hyperintensity due to early changes of small vessel disease and mild thickening of the mucosa of the maxillary sinuses, no other significant abnormalities are seen on MRI of the brain with and without gadolinium. No evidence of mass effect, hydrocephalus or enhancing lesions. No acute infarcts seen. No evidence of brain atrophy. IMPRESSION: Progression of degenerative changes predominantly at C4-5 and C5-6 levels. Mild to moderate spinal stenosis at C4-5 and moderate spinal stenosis at ___ narrowing at both these levels have also increased. Degenerative changes at other levels as described above. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 2. Atazanavir 300 mg PO DAILY 3. Citalopram 40 mg PO DAILY 4. Doxepin HCl 10 mg PO HS:PRN insomnia 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 6. Fexofenadine 60 mg PO BID 7. Fluticasone Propionate NASAL 2 SPRY NU BID 8. Montelukast Sodium 10 mg PO DAILY 9. RiTONAvir 100 mg PO DAILY 10. Rosuvastatin Calcium 10 mg PO DAILY 11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 12. traZODONE ___ mg PO HS:PRN insomnia 13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 14. Amiloride HCl 5 mg PO DAILY 15. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 16. Ascorbic Acid ___ mg PO TID 17. Docusate Sodium 100 mg PO BID 18. Ferrous Sulfate 325 mg PO TID 19. Omeprazole 20 mg PO BID 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation 21. Diltiazem Extended-Release 240 mg PO DAILY 22. Sodium Chloride Nasal ___ SPRY NU QID Discharge Medications: 1. Ascorbic Acid ___ mg PO TID 2. Atazanavir 300 mg PO DAILY 3. Citalopram 40 mg PO DAILY 4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 5. Ferrous Sulfate 325 mg PO TID 6. Montelukast Sodium 10 mg PO DAILY 7. RiTONAvir 100 mg PO DAILY 8. Rosuvastatin Calcium 10 mg PO DAILY 9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 10. Sodium Chloride Nasal ___ SPRY NU QID 11. Sodium Bicarbonate 650 mg PO BID RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Fexofenadine 60 mg PO BID 17. Doxepin HCl 10 mg PO HS:PRN insomnia 18. Docusate Sodium 100 mg PO BID 19. Amiloride HCl 5 mg PO DAILY 20. Diltiazem Extended-Release 240 mg PO DAILY 21. diflunisal *NF* 500 mg Oral BID: PRN neck pain 22. SUMAtriptan *NF* 5 mg NU X1: PRN headache At onset of headache 23. Enoxaparin Sodium 120 mg SC DAILY 24. Warfarin 5 mg PO DAILY 25. Omeprazole 20 mg PO DAILY ***patient is not taking diflusinal for back pain, so it was eliminated from his medication list. Given recent GI bleed, an NSAID is contraindicated. Moreoever, patient states that he stopped it on his own some time ago Discharge Disposition: Home Discharge Diagnosis: Primary: Weakness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: Prior exam from ___. CLINICAL HISTORY: Elevated WBC with hypotension, assess for pneumonia. FINDINGS: PA and lateral views of the chest were provided. There is mild basal atelectasis in the setting of low lung volumes. No signs of pneumonia or CHF. No effusion or pneumothorax. Cardiomediastinal silhouette is normal and stable. No bony abnormalities. IMPRESSION: No definite signs of pneumonia. Lung volumes are low. Radiology Report HISTORY: A right subclavian line placed. COMPARISON: ___ FINDINGS: There is a new right subclavian line with tip crossing into the left innominate. This wet reading was provided by Dr. ___ on ___ at 7:29 p.m. There is no pneumothorax. There is mild cardiomegaly and minimal pulmonary vascular redistribution. IMPRESSION: right subclavian line crosses into left innominate Radiology Report HISTORY: Patient with known cervical disk disease, now with new pain rule out progression. TECHNIQUE: T1-T2 and inversion recovery sagittal and gradient echo axial images cervical spine. COMPARISON: Comparison was made to the MRI of ___. FINDINGS: At the craniocervical junction and C2-3 level, mild degenerative changes seen. From C3-4 and C5-6, there is thickening of the posterior longitudinal ligament. At C3-4, there is disc bulging and mild to moderate bilateral foraminal narrowing. At C4-5 disk bulging and uncovertebral degenerative change seen with moderate right-sided and moderate to severe left-sided foraminal narrowing and mild to moderate spinal stenosis and indentation on the spinal cord. At C5-6 and left-sided disc osteophyte is seen with moderate spinal stenosis and deformity predominantly on the left-side of spinal cord with severe left-sided and moderate right-sided foraminal narrowing. At C6-7 and inferiorly toT2-3, ild degenerative change seen. The spinal cord shows normal intrinsic signal. IMPRESSION: Progression of degenerative changes predominantly at C4-5 and C5-6 levels. Mild to moderate spinal stenosis at C4-5 and moderate spinal stenosis at C5-6. Foraminal narrowing at both these levels have also increased. Degenerative changes at other levels as described above. Radiology Report HISTORY: Patient with generalized weakness and history of HIV for further evaluation. The patient has unsteady gait. TECHNIQUE: T1 sagittal and axial FLAIR, T2, susceptibility and diffusion axial images of the brain were acquired before gadolinium. T1 axial and MPRAGE sagittal images were also obtained with axial and coronal reformats. COMPARISON: There are no prior brain MRI studies for comparison. FINDINGS: The ventricles and extra-axial spaces are normal in size without midline shift, mass effect or hydrocephalus. A few nonspecific foci of T2 hyperintensity are seen in the white matter in the supra and infratentorial regions likely due to early changes of small vessel disease. There is no evidence of brain atrophy is seen. There is no evidence of atrophy of the corpus callosum. There are no territorial infarct. There is no evidence of blood products. Following gadolinium administration, there is no evidence of parenchymal, meningeal or vascular enhancement seen. IMPRESSION: Except for a few nonspecific foci of T2 hyperintensity due to early changes of small vessel disease and mild thickening of the mucosa of the maxillary sinuses, no other significant abnormalities are seen on MRI of the brain with and without gadolinium. No evidence of mass effect, hydrocephalus or enhancing lesions. No acute infarcts seen. No evidence of brain atrophy. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: WEAKNESS Diagnosed with HYPOTENSION NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 98.2 heartrate: 79.0 resprate: 18.0 o2sat: 99.0 sbp: 84.0 dbp: 48.0 level of pain: 0 level of acuity: 1.0
___ yo M with PMH for HIV and recent admission for diverticulitis and ?GIB with chronic diarrhea presents with weakness and hypotension. #Hypotension/weakness: Most likely etiology is hypovolemia ___ ongoing diarrrhea, decreased PO intake, and recent epistaxis. Physical exam showed dry MM consistent with hypovolemia. Also with elevated BUN:Cr and element ___ c/w pre-renal from hypovolemia. Responded well to 2L NS in the ___, and in the MICU had BP 120/70s. Cr trended down to baseline with IVF. Chem-7 shows non-anion gap metabolic acidosis consistent with diarrhea. Infectious workup for diarrhea and other sources was negative. Was initially given vanco/zosyn in ___ however this was discontinued given low concern for infectious etiology. Also concern for occult GI blood loss given recent h/o hct drop and ?GIB during last admission. H/H was trended and stable and patient had no signs of GI bleeding. He was transferred to the floor where his BP's remained stable without further need for transfusion or fluid boluses. The ___ weakness itself was concerning for clonus found on exam, though actual strength was intact, the patient did have a good deal of tremor/shaking. He was seen by neurology who recommended CT C-spine and brain. These were unremarkable for findings to explain his symptoms. CD4 was checked for concern for OI within CNS possibly causing symptoms, but this was found not to be depressed, at 488. It was determined that the clonus was likely a physiologic variant, and shakiness and generalized weakness was likely due to deconditioning from repeated illnesses in last two months. Cortisol was checked for concern for adrenal insufficiency and was pending at the time of discharge. #Diarrhea: History c/w acute on chronic picture. Infectious workup negative. Symptoms improved during stay. ___ consider checking IgG TTG for concern for celiac disease given pt's IgA deficiency. Sodium bicarbonate was started given patient's loss of bicarb with diarrhea leading to non-AG metabolic acidosis. #Epistaxis: Nasal balloon packing kept in place until ___ and removed without further bleeding. ___: Patient with increase in Cr to 2.2 from baseline 1.1. BUN:Cr >20 consistent with pre-renal picture. Creatinine decreased to his baseline with fluids. He had good urine output. #H/o PE: Patient maintained intially on heparin drip given possibility of bleeding with recent epistaxis. Once nasal balloon packing removed without signs of bleeding, switched to warfarin with enoxaparin bridging. He was scheduled for appointment with PCP early the following week for INR check. CHRONIC ISSUES #Anemia: Patient with stable hct since last discharge. Previous iron studies consistent with anemia of chronic disease. H/H trended and stable. #HIV: No history of AIDS defining illnesses in the past. CD4 checked at 488. Patient is currently on HAART therapy. #Asthma: Fluticasone stopped due to severe interaction with HAART medications and increased systemic absorption of corticosteroids. Remainder of home medications continued. #GIB: Recent upper endoscopy that revealed duodenitis, esophagitis. He refused a recommended capsule enteroscopy. This was not an active issue at this admission. Omeprazole dose was decreased to 20mg daily (rather than BID) due to concerns about drug interaction with atazanavir. #Hypertension: Diltiazem and lisinopril initially held given hypotension. Diltiazem restarted for rate control of afib. Lisinopril held on discharge given BPs well controlled with systolics in low 100s. #Migraines: patient had headaches for which he was given his home percocet during hospitalization. TRANSITIONAL ISSUES # Cortisol pending at time of discharge should be followed up by PCP for ___ adrenal insufficiency as cause of overall fatigue and weakness # Pt needs INR check for titration of warfarin dosing and to determine when to stop enoxaparin
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: headache, nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F with history of migraines (for 40+ years but none in last ___ years), HTN, sciatica and lower back pain s/p spine surgery (no records), presents with headache, nausea/vomiting, dizziness and lightheadedness as well as a constellations of other neurological symptoms. Patient was in her usual state of health until last ___. It was her birthday and sometime during day she noticed the onset of progressive headache. She describes it as her typical migraines with R sided throbbing and retroorbital pain. However, given that she had not had a migraine in ___ years, she was somewhat puzzled by the reemergence of these symptoms. Although the headache felt similar in location and quality and intensity, she had increased nausea, and dizziness with generalized weakness on standing which was not typical of her migraine symptoms. Her headache and other symptoms gradually subsided though and by ___ she felt that she was back to her baseline. ___ she felt good but ___ her typical migraine pain recurred as did her nausea/vomiting and dizziness (which she describes intermittently either as lightheadedness or room-spinning vertigo). She felt that she could not walk and was confined to her wheelchair and although her gait has been progressively more impaired over the last several months- requiring the use of walker or wheelchair- she endorses feeling more weakness than normal and perhaps a slight "funny" feeling in her right leg. She cannot tell whether this weakness has persisted since she has not stood for 24hrs at this point. During the recurrence of the headache yesterday, she also noticed intermittent R-sided facial dysesthesia noting that the lower part of her face felt cool. This symptom has subsided. She also noted some pins/needles in her right hand and the above mentioned "funny feeling" in her R leg both of which have persisted and are new for her. She was taken to ___ at which time she underwent ___ which was read as normal. She was then transfered here for further Neuro workup. In the ED she received morphine and reglan both of which improved her symptoms although not entirely. She denies visual symptoms, GI complaints or antecedent infectious symptoms. She does note some chronic left-sided numbness in her arm and leg since the back surgery. Past Medical History: HTN Chronic lower back pain s/p surgery 3 months prior (details unknown) Migraine (40+ years although none in the past ___ years) Hypothyroidism Anxiety and Depression with Suicidal attempt ___ years ago Social History: ___ Family History: No family history of neurological disease, no strokes, seizures, brain tumors, Physical Exam: Vitals: 98 72 140s-160s sbp/60s-80s 16 98% ra General: Awake, eyes, closing, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: slight crackles at lung bases b/l Cardiac: irregular rhythm, normal rate, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert but closing eyes repeatedly during examination, oriented x 3. Able to relate history but extremely dysarthric. Speech is slurred, writes down answers for questions on a sheet of paper. Able to name high/low frequency items. Can follow simple commands. Does not recognize his own left hand when held up. Identifies only one person on the cookie jar picture. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: restricted gaze without movement past the midline to the left. V: diminished sensation on left face to pinprick. VII: left sided facial droop with decreased excursion. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii on the right , not raising the left. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 3 ___ ___ 4 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: significantly diminished sensation to pinprick on the left side over face/arm/leg. -DTRs: Bi Tri ___ Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was flexor bilaterally. -Coordination: No movement of the left arm to check, but otherwise, No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS. -Gait: deferred Discharge PE: good strength throughout. sensory loss L>R to pinprick in LUE and LLE. Pertinent Results: Labs ___ WBC-7.4 RBC-4.10* HGB-12.4 HCT-35.7* MCV-87 MCH-30.1 MCHC-34.6 RDW-13.2 ___ TRIGLYCER-275* HDL CHOL-38 CHOL/HDL-5.1 LDL(CALC)-99 ___ %HbA1c-5.7 eAG-117 ___ ALT(SGPT)-9 AST(SGOT)-12 LD(LDH)-167 CK(CPK)-49 ALK PHOS-62 TOT BILI-0.4 ___ GLUCOSE-106* UREA N-11 CREAT-0.7 SODIUM-137 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 Imaging CTA Head and Neck: IMPRESSION: 1. Occlusion of the V2 segment of the right vertebral artery with reconstitution at the V4 segment, mainly from flow from the left vertebral artery. 2. No CT evidence of acute infarct or hemorrhage. MR ___ IMPRESSION: 1. Multilevel, multifactorial degenerative changes in the cervical spine, with mild-to-moderate canal stenosis and deformity on the ventral thecal sac and on the ventral cord, multilevel mild-to-moderate foraminal narrowing with deformity on the nerves, most prominent at C5-6 and C6-7 levels. Osseous details are better assessed on the prior CTA study. 2. Focus of T2 increased signal intensity in the right cervicomedullary junction and in the right cerebellar hemisphere, corresponding to the known acute infarcts, better assessed on the concurrent MR study. 3. Right vertebral artery flow void is not well seen, related to the known occlusion, better assessed on the prior CTA and the concurrent MRA studies. MRI/A Head and Neck: IMPRESSION: 1. Small acute infarcts in the right cerebellar hemisphere and the right cervicomedullary junction in the territory of the posterior inferior cerebellar artery and the right vertebral artery. No surrounding mass effect or edema around the infarcts. 2. Non-visualization of flow in the right vertebral artery, from the V2 segment at C5 level upwards to the distal V4, here a short segment close to the formation of the Basilar artery appears to have enhancement. Occlusion may relate intraluminal and/or intramural thrombosis, assessment is somewhat limited on the fat sat sequences due to artifacts. Mild contour irrgeualrity with mild narrowing of the left V4 segment. 3. Minimal mucosal thickening in the left mastoid air cells. See other details as above. MRI Thoracic and Lumbar Spine: Wet Read 1. Significant anterior wedge deformity at T11, and mild-to-moderate at T12. No prior study available for comparison, and chronicity of fracture indeterminate, but no acute T2 hyperintensity in the bone marrow to suggest acute nature, but subacute compression fractures cannot excluded. 2. Grade 1 anterolisthesis at L4 on L5. Moderate disc extrusion, R > L, resulting in moderate bilateral neural foraminal narrowing. 3. Moderate S-shape thoracoscoliosis. 4. Small Tarlov cysts. 5. Small left renal cyst. Echocardiogram: IMPRESSION: Suboptimal image quality. No intracardiac source of thromboembolism identified. Medications on Admission: Gabapentin 400mg TID Fentanyl 50mcg/hr patch Lisinopril 5mg daily Synthroid ___ Remeron 45 Trazodone 50mg TID Zyprexa 10mg daily Percocet 4 tabs/ day Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. olanzapine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. trimethobenzamide 100 mg/mL Solution Sig: Two (2) Intramuscular Q6H (every 6 hours) as needed for nausea. 8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for Nausea. 10. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: medullary stroke and cervical stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with headache and right sided numbness COMPARISON: none. TECHNIQUE: Continuous axial CT images were obtained through the brain without intravenous contrast material. Subsequently, rapid axial imaging was performed from the aortic arch through the brain during infusion of intravenous contrast material. Images were processed on a separate workstation with display of curved reformats, 3D volume-rendered images, and maximum intensity projection images. FINDINGS: CT: The ventricles, sulci, and cisterns are age appropriate. There is no evidence of intracranial hemorrhage, mass or infarction. There is no apparent extra-axial collection. The osseous structures are unremarkable. The paranasal sinuses are clear. The orbits are normal. The soft tissues are unremarkable. There is scarring at the lung apices. The thyroid gland is normal in appearance. The soft tissues of the neck are normal appearing. There are degenerative changes of the spine. CTA: Arch & Neck: There is calcification of the aortic arch. The brachiocephalic artery, the bilateral carotid arteries and subclavian arteries are patent and of normal course and caliber. The origin of the left vertebral artery is patent and of normal course and caliber. There is occlusion of the V2 segment of the right vertebral artery with reconstitution at the V4 segment, mainly from flow from the basilar/left vertebral artery. Circle of ___: The petrous, cavernous, and supraclinoid internal carotid arteries are of normal course and caliber. The anterior, middle and posterior cerebral arteries are of normal course and caliber. The basilar artery is of normal course and caliber. There is no gross deep or dural venous sinus thrombosis. IMPRESSION: 1. Occlusion of the V2 segment of the right vertebral artery with reconstitution at the V4 segment, mainly from flow from the left vertebral artery. 2. No CT evidence of acute infarct or hemorrhage. Radiology Report INDICATION: Evaluation of patient with stroke. COMPARISON: None available. FINDINGS: Single portable semierect chest radiograph is obtained. The lungs are clear with no evidence of a consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette is normal. Dextroscoliosis of the mid thoracic spine is noted, though this may be positional. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Cervical spondylosis, with myelopathy, to evaluate for spinal disease. COMPARISON: CTA neck done on ___. TECHNIQUE: MR of the cervical spine without contrast. FINDINGS: Somewhat limited due to motion-related artifacts. There is heterogeneous signal intensity of the marrow, likely related to scattered fat deposition. Multilevel anterior and posterior osteophytes are noted. There is mild anterior wedging of the C4 and C5 and C6 vertebral bodies. Disc desiccation is noted at all levels. Multi-level disc bulges and disc osteophyte complexes and facet degenerative changes and ligamentum flavum thickening are noted, indenting the ventral and the posterior thecal sac at multiple levels. This is most prominent from C3-C7 levels. However, there is no compression on the upper cervical cord. Mild deformity of ventral cord is noted at multiple levels. Multilevel moderate-to-severe foraminal narrowing is noted from disc and uncovertebral changes with possible deformity on the nerves, in particular at C5-6 and C6-7 levels. Pulsation artifacts are noted in the thecal sac, limiting assessment. A T2 hyperintense focus is noted in the cervicomedullary junction and right cerebellar hemisphere, corresponding to the known infarct better identified on the concurrent MR study. No pre or para-vertebral soft tissue swelling or masses are noted. Fluid is noted in the the hypopharynx and upper esophagus, limiting accurate assessment. IMPRESSION: 1. Multilevel, multifactorial degenerative changes in the cervical spine, with mild-to-moderate canal stenosis and deformity on the ventral thecal sac and on the ventral cord, multilevel mild-to-moderate foraminal narrowing with deformity on the nerves, most prominent at C5-6 and C6-7 levels. Osseous details are better assessed on the prior CTA study. 2. Focus of T2 increased signal intensity in the right cervicomedullary junction and in the right cerebellar hemisphere, corresponding to the known acute infarcts, better assessed on the concurrent MR study. 3. Right vertebral artery flow void is not well seen, related to the known occlusion, better assessed on the prior CTA and the concurrent MRA studies. Radiology Report INDICATION: Headache, nausea, vertigo, right vertebral artery occlusion, evaluate for stroke and etiology of vertebral lesion to perform with T1 fat sat sequences. COMPARISON: CTA head and neck done on ___. TECHNIQUE: MR of the head without contrast; MR angiogram of the head with IV contrast, including T1 pre-contrast fat sat sequences of the neck. 3D TOF MR angiogram of the head without contrast. FINDINGS: MR OF THE HEAD WITHOUT CONTRAST: There are few small foci of slow diffusion in the right cerebellar hemisphere posteroinferiorly and in the right side of the cervicomedullary junction. These demonstrate slight decreased signal on the ADC sequence and represent acute infarcts. There is no surrounding significant edema or mass effect. Mildly hyperintense signal on the FLAIR sequence is noted. There are multiple FLAIR hyperintense foci, scattered in the cerebral white matter, subcortical and periventricular in location, likely nonspecific in appearance. No associated negative susceptibility is noted. There is increased signal intensity noted in the mastoid air cells on both sides from fluid and mucosal thickening. The left vertebral artery is dominant and patent. The right vertebral arterial flow void is not well seen. There is mild mucosal thickening in the ethmoid air cells and in the left side of the sphenoid sinus posteriorly. 3D TOF MR ANGIOGRAM OF THE HEAD: Right vertebral artery is not seen except for a very short segment close to the basilar artery formation. The left vertebral artery is dominant. The anterior, inferior and the superior cerebellar arteries are seen. The A1 segments of the anterior cerebral arteries are diminutive in size. The intracranial internal carotid arteries and the middle cerebral arteries are patent without focal flow-limiting stenosis, occlusion or obvious aneurysm. MR ANGIOGRAM OF THE NECK: On the fat sat sequences of the neck, there is increased signal intensity, noted intermittently in the right vertebral artery more distally, concerning for thrombosis with/without a small component of dissection. The images of the lower neck are suboptimal. MR ANGIOGRAM OF THE NECK: The origins of the arch vessels are patent. The common carotid and the cervical internal carotid arteries are patent. The left vertebral artery is patent with a tortuous course. There is mild contour irregularity of the left V4 segment. The right vertebral artery is not seen, from the mid cervical segment from C5 levl upwards to the distal V4 segment, where there is some flow noted, likely from the Basilar artery. IMPRESSION: 1. Small acute infarcts in the right cerebellar hemisphere and the right cervicomedullary junction in the territory of the posterior inferior cerebellar artery and the right vertebral artery. No surrounding mass effect or edema around the infarcts. 2. Non-visualization of flow in the right vertebral artery, from the V2 segment at C5 level upwards to the distal V4, here a short segment close to the formation of the Basilar artery appears to have enhancement. Occlusion may relate intraluminal and/or intramural thrombosis, assessment is somewhat limited on the fat sat sequences due to artifacts. Mild contour irrgeualrity with mild narrowing of the left V4 segment. 3. Minimal mucosal thickening in the left mastoid air cells. See other details as above. Radiology Report HISTORY: ___ woman with back discomfort and difficulty in standing and walking. Evaluate for spondylosis or canal stenosis. COMPARISON: Only limited comparison from prior chest radiograph on ___. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired through the thoracic and lumbar spine. No IV contrast was administered. THORACIC SPINE MRI WITHOUT CONTRAST: There is an overall mild-to-moderate S-shape thoracolumbar scoliosis. T11 vertebral body demonstrates a severe anterior wedge compression deformity, but without intense marrow T2-signal hyperintensity, representing an old compression fracture. T12 demonstrates a mild anterior wedge compression fracture with a prominent Schmorl's node, also chronic in appearance. Neither compression fracture demonstrates significant retropulsion into the canal. The thoracic cord is normal in signal intensity. LUMBAR SPINE MRI WITHOUT CONTRAST: In the lumbar spine, there are mild-to-moderate multilevel degenerative changes with facet arthropathy, but no spinal stenosis. At L2-3, there is no neural foraminal narrowing. At L3-4, there is no neural foraminal narrowing. At L4-5, there is a moderate disc bulge, resulting moderate left and mild-to-moderate right neural foraminal narrowing. No nerve root encroachment is noted. At L5-S1, there is mild disc bulge, but no significant neural foraminal narrowing. Small Tarlov cysts are noted in the sacral region. Incidental finding is made of a 2.1 cm left renal cyst in the localizer image. The urinary bladder is significantly distended. IMPRESSION: 1. Chronic severe T11 and mild T12 compression fractures without significant retropulsion into the canal. 2. Moderate disc bulge at L4-5, resulting in moderate left and mild-to-moderate right neural foraminal narrowing. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: HA Diagnosed with OCCLUS VERTEBRAL ART W/INFARCT, SKIN SENSATION DISTURB, HEADACHE, HYPERTENSION NOS, HYPOTHYROIDISM NOS temperature: 98.6 heartrate: 52.0 resprate: 16.0 o2sat: 95.0 sbp: 143.0 dbp: 63.0 level of pain: 7 level of acuity: 2.0
The patient was admitted to the Neurology Service at ___ on ___ for headache, nausea and vomiting. The workup included several imaging modalities which showed an occluded right vertebral artery and infarct in the right medulla. An echo was also done which showed no cardioembolic source of thromboembolism. MR of the cervical spine showed mild to moderate cervical stenosis most pronounced in the C5-7 area. The patient was placed in a soft C-collar for this. It is difficult to say if her cervical stenosis may be producing some degree of myelopathy (eg. she has diffuse mild weakness in the bilateral arms and legs in an upper motor neuron pattern, as well as increased reflexes in the arms). MR of thoracolumbar area showed multiple deformities in the T11-12 areas and also disk herniation in the L4-5 area, and there is no imaging for comparison, but no acute abnormalities were noted. Records from ___ Neurosurgery indicate the patient had a left L4-L5 decompressive hemilaminectomy for L4-L5 spondylolisthesis and left leg radicular pain. The patient is a poor historian and even after discussing the patient with her PCP, it is difficult to assess her baseline motor and sensory losses. She has an orthopedic surgeon and will need to followup with him considering our findings during this admission. Labwork was significant for hemoglobin A1c 5.7 normal, Cholesterol 192, Triglyceries 275, HDL 38, LDL 99. The patient is a high fall risk so anticoaguation with heparin or coumadin was avoided. She was started on aspirin 325mg daily, which she will be discharged on. Simvastatin 10mg was also started. Otherwise, the patient will continue all other ___ medications. The patient was admitted from ___ which has extensive rehab services. She will be discharged to her SNF for continued treatment of her stroke and cervical stenosis. She should followup with orthopedic surgeon Dr. ___ PCP, and has a scheduled neurology followup with Dr. ___.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___ Chief Complaint: lethargy, hyperkalemia Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: ___ year old man with Hx prostate cancer, rectal adenocarcinoma, HLD and HTN who presented to ___ from ___ with general lethargy with hyperkalemia of 7.0, found to be hyperkalemic and with ___. Transferred to ___ for possible need for urgent HD. Prior to presentation, he was given 15 g of Kayexalate for K of 7 and transferred to ___. On presentation to ___, the patient reported generalized malaise, fatigue. He denied any CP/SOB, abdominal pain, N/V, urinary symptoms. He had no specific complaints and did not know why he was sent to the hospital. He was found to have K 7.4 and Cr 3.7, ECG with wide complex rhythm with widening of QRS complex and peaked T waves c/w critical hyperkalemia. He was treated with Albuterol 10 mg neb, 10 units of Insulin, 2 g of Ca-Gluconate. Foley catheter placed with resulting purulent urine, thus broad coverage with vancomycin and cefepime was initiated. Blood and urine cultures sent. Initial BP was low, however SBP up to ___ with 2L NS bolus. Given difficulty with IV access, emergent left groin line placed. Given concern for hyperkalemia in the setting of ___ and potential need for emergent dialysis, the patient was transferred to ___. On transfer to ___ ___, initial vitals were T99, 70/43, 93, 28, 100% 10L NRB. K 5.5, Cr 2.7, BUN 132. Completed vancomycin and cefepime doses initiated at ___. Started on norepinephrine for hypotension (SBP 70-80s), most recently at 0.25 mcg/hr. Received a total of 4L IVF between ___ and ___. EKG showed sinus rhythm, improved but still tall TWs, RBBB with QRS 146. The patient's respiratory status remained good, breathing comfortably on RA. Prior to transfer, vitals 90/60, 79, 18, 99% 4L NC. On arrival to the ICU, patient is alert but disoriented and unable to provide history. Of note regarding recent medical history per OSH records ___, ___, patient was living independently and using a walker in a senior living facilty until about 3 months ago. He was hospitalized at ___ in ___ for diarrhea, and has been in and out of the hospital since then for various reasons including falls, UTI, and bradycardia with trifascicular block. Most recent admission in ___ to ___ with UTI due to resistant E Coli requiring ertapenem. Noted on D/C summary then were sacral decubitous ulcer evaluated by surgery and referred to wound clinic, and chronic constipation due to rectal mass known to be adenocarcinoma. Past Medical History: Prostate cancer, s/p brachytherapy Rectal adenocarcinoma, not considered a good surgical candidate. HLD HTN Aortic stenosis Trifascicular block: evaluated by Cardiology at ___ during hospitalization. PPM indicated but deferred as patient with infection at the time and requiring further discussion regarding prognosis with rectal cancer Anemia lower back pain ___ lumbosacral disc degeneration s/p ___ TKR Social History: ___ Family History: Patient unable to provide Physical Exam: ADMISSION: Vitals- T: 98.6 BP: 123/68 P: 102 R: 22 O2: 100% 3L General: Awake, answers selectively but not oriented. Not following commands. HEENT: Sclera anicteric, purulent discharge L eye. PERRLA. Dry mucous membranes Neck: supple, JVP not elevated, no LAD Lungs: Crackles at bilateral bases, otherwise clear CV: Regular rhythm, early systolic murmur best at RUSB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining purulent urine. Ext: warm, ___ pulses present by doppler, no clubbing, cyanosis or edema Skin: deep sacral ulcer, non-purulent, probes >1cm with hard endpoint. multiple erythematous blanching Stage ___ on buttocks and heels. DISCHARGE: General: Awake, alert and oriented to name, hospital, day, and date HEENT: Sclera anicteric, scant purulent discharge R eye, MMM Neck: supple, JVP not elevated, no LAD Lungs: CTAB CV: Regular rhythm, early systolic murmur best at RUSB, normal s1, very faint s2 but audible Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly or masses GU: Foley with clear yellow urine Ext: warm, cannot palpate ___ pulses, edema, RUE PICC without surrounding erythema or tenderness Skin: Dry, thin Pertinent Results: ADMISSION LABS: ___ 08:40PM BLOOD WBC-12.4* RBC-2.58* Hgb-7.2* Hct-24.3* MCV-94 MCH-27.8 MCHC-29.5* RDW-16.4* Plt ___ ___ 08:40PM BLOOD Neuts-89.5* Lymphs-4.7* Monos-4.5 Eos-1.2 Baso-0.1 ___ 08:40PM BLOOD Glucose-156* UreaN-132* Creat-2.7* Na-137 K-5.5* Cl-107 HCO3-17* AnGap-19 ___ 08:56PM BLOOD Lactate-2.2* K-5.5* ___ 08:40PM URINE Color-YELLOW Appear-Cloudy Sp ___ ___ 08:40PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 08:40PM URINE RBC-179* WBC->182* Bacteri-MANY Yeast-NONE Epi-24 . OTHER PERTINENT LABS: ___ 10:00PM URINE Color-Straw Appear-Hazy Sp ___ ___ 10:00PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 10:00PM URINE RBC-51* WBC-70* Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 . DISCHARGE LABS: ___ 01:52AM BLOOD WBC-7.5 RBC-2.69* Hgb-7.6* Hct-24.6* MCV-91 MCH-28.3 MCHC-31.0 RDW-17.2* Plt ___ ___ 01:52AM BLOOD Glucose-89 UreaN-41* Creat-1.2 Na-140 K-4.1 Cl-113* HCO3-19* AnGap-12 ___ 01:52AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.6 . MICRO: BLOOD CULTURE ___: NO GROWTH TO DATE URINE CULTURE ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. SACRAL DECUBITUS ULCER WOUND CULTURE ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. . IMAGING: CXR ___ IMPRESSION: As compared to the previous radiograph, there is a newly appeared. Minimal atelectasis in the retrocardiac lung regions and at the left lung bases. No other relevant changes are noted as compared to the previous image from to hr ago. Low lung volumes. Massive scoliosis with asymmetry of the ribcage. Mild cardiomegaly without pulmonary edema. . Renal U/S ___ FINDINGS: The right kidney measures 12.2 cm. The left kidney measures 12.4 cm. There is mild fullness of the left renal pelvis. The right renal collecting system is not very well evaluated but does not show evidence of dilation. There is loss of cortical thickness in both kidneys. The bladder is moderately well seen and normal in appearance. . IMPRESSION: Mild fullness of the left renal pelvis and Loss of cortical thickness in both kidneys. . CXR ___ FINDINGS: Comparison is made to prior study from ___. There has been placement of a right-sided central venous line with the distal lead tip within the mid-to-distal SVC. This could be pulled back 4 cm for more optimal placement. The heart size is within normal limits. There are no pneumothoraces. There is some atelectasis at the lung bases. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 2.5 mg PO HS 2. FoLIC Acid 1 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Lovastatin 20 mg oral daily 5. Multivitamins 1 TAB PO DAILY 6. melatonin 3 mg oral HS 7. lactobacillus acidophilus oral BID 8. Ascorbic Acid ___ mg PO BID 9. Benefiber (guar gum) (guar gum) 40 mg oral BID 10. Escitalopram Oxalate 15 mg PO DAILY 11. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN abdominal pain 12. Bismuth Subsalicylate 30 mL PO Q6H:PRN GI upset Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hyperkalemia Acute renal failure Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with sob // eval pneumonia COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, there is a newly appeared. Minimal atelectasis in the retrocardiac lung regions and at the left lung bases. No other relevant changes are noted as compared to the previous image from to hr ago. Low lung volumes. Massive scoliosis with asymmetry of the ribcage. Mild cardiomegaly without pulmonary edema. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with hx prostate cancer, here with UTI and ___. // assess for hydro, pyelo TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 12.2 cm. The left kidney measures 12.4 cm. There is mild fullness of the left renal pelvis. The right renal collecting system is not very well evaluated but does not show evidence of dilation. There is loss of cortical thickness in both kidneys. The bladder is moderately well seen and normal in appearance. IMPRESSION: Mild fullness of the left renal pelvis and Loss of cortical thickness in both kidneys. Radiology Report STUDY: AP chest, ___. CLINICAL HISTORY: Patient with PICC line placement. FINDINGS: Comparison is made to prior study from ___. There has been placement of a right-sided central venous line with the distal lead tip within the mid-to-distal SVC. This could be pulled back 4 cm for more optimal placement. The heart size is within normal limits. There are no pneumothoraces. There is some atelectasis at the lung bases. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hyperkalemia, Hypotension Diagnosed with URIN TRACT INFECTION NOS, HYPERKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: nan heartrate: 93.0 resprate: 28.0 o2sat: 100.0 sbp: 70.0 dbp: 43.0 level of pain: 0 level of acuity: 1.0
___ year old gentleman with Hx prostate and rectal cancer, HLD, and HTN presents from SNF with general lethargy, found to be hyperkalemic, with ___ and concern for sepsis due to E.coli UTI. . # Sepsis: Patient had leukocytosis and tachycardia on admission, with hypotension requiring pressor support; grew ESBL E.coli in urine at ___. He also has a sacral decubitus ulcer, but urine is most likely source of sepsis. Started on Vanc/cefepime at OSH, then transitioned to meropenem ___ once urine culture results from ___ were finalized. - Continue Meropenem for 7 day course (Day 1: ___ . # Hyperkalemia: Potassium 7s at OSH with associated EKG changes on presentation. POtassium 5.5 on admission to ___ following acute treatment. Etiology likely due to ___. Also appears to have been receiving Lisinopril 40mg at SNF, which was supposed to be discontinued for hyperkalemia during recent hospitalization. Peaked T waves resolved and wide QRS is baseline due to known tri-fascicular block. Lisinopril was discontinued. . # ___: Likely combination of prerenal in setting of infection and hypotension, as well as post-renal with UTI. Renal US with slight dilation of renal pelvis. Cr improved with IVFs. A Foley catheter was placed for monitoring and decompression. . # Decubitus ulcer: Multiple decubitus ulcers on sacrum, buttocks and heels. Sacral ulcer concerning for probe to bone, though non-purulent. Was evaluated by surgery at ___ in ___, not thought to have surgical indication at the time. Wound care consulted for management. . # Anemia, acute on chronic: Underlying anemia likely combination of nutritional and blood loss from known rectal mass. Received 1u PRBCs on admission since and stable since without further transfusion needs. . # Aortic stenosis: Per OSH report. Appeared dry on exam, without e/o heart failure. No acute decompensations this admission. . # HTN: Held lisinopril for hyperkalemia, ___. . # Depression: Continued home lexapro and olanzapine. . # h/o prostate and rectal cancer: Remote history of prostate cancer treatment, apparently in remission. Rectal mass consistent with adenocarcinoma, reportedly not a surgical candidate. TRANSITIONAL ISSUES: # Continue Meropenem for total 7 day course (Day 1: ___ # Continue wound care management of sacran and heel decubitous ulcers # Lisinopril discontinued on this admission. If hypertensive, consider other agents due to hyperkalemia with Lisinopril.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Splenic trauma, Left renal laceration, SDH, Tri-Malleolar ankle fracture. Major Surgical or Invasive Procedure: ___: Exploratory laparotomy, splenectomy ___: 1. Open reduction, internal fixation distal tibia intra- articular fracture with medial plating. 2. Examination under anesthesia with external rotation stress. 3. Closed distal fibular fracture. History of Present Illness: Patient is a ___ year old male who was involved in a MVC as the driver of a motorcycle in the setting of likely alcohol intoxication. A c-collar was placed in the field, and he was brought to ___ ED where workup revealed no signs of head or Cspine trauma, but did show a grade V splenic laceration and low grade left renal laceration. Per verbal report, he was awake and alert at the time, only complaint was LUQ abdominal pain, specifically, denied any neck pain. Did have some hypotension, further details unknown. Given severity of splenic injury and concern for hemodynamic compromise he was taken to the OR for exlap and splenectomy. OR course significant for 5L crystalloid, 2u PRBCs, 2L EBL. He was admitted to the ___. Past Medical History: Depression Social History: ___ Family History: noncontributory Physical Exam: Physical exam ___ T99.3 HR 94 BP 134/80 RR 16 Sat 97% GEN: NAD, comfortable, complaining of frequent loose stools. CV: RRR, peripheral pulses intact, Left lower extremity in cast has good capillary refill PULM: CTAB, no respiratory distress GI: Soft, NTTP, no guarding. Midline abdominal incision intact, no erythema along the staple line. EXT: Left lower extremity in cast, motor/sensation intact, good cap refill NEURO: AAOx3, CNII-XII intact. Pertinent Results: Admission labs ___ WBC-9.7 RBC-4.39* Hgb-14.8 Hct-42.3 MCV-96 MCH-33.7* MCHC-35.0 RDW-13.2 Plt ___ PTT-24.8* ___ Glucose-149* UreaN-13 Creat-1.1 Na-138 K-3.5 Cl-101 HCO3-25 AnGap-16 Discharge labs ___ WBC-20.7* RBC-3.14* Hgb-9.9* Hct-30.4* MCV-97 MCH-31.7 MCHC-32.7 RDW-13.4 Plt ___ BLOOD ___ PTT-27.5 ___ Glucose-100 UreaN-9 Creat-0.7 Na-137 K-4.0 Cl-102 HCO3-24 AnGap-15 Calcium-9.3 Phos-4.9* Mg-2.3 Medications on Admission: none Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain 2. Bacitracin Ointment 1 Appl TP BID 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drink alcohol or drive while taking Discharge Disposition: Home Discharge Diagnosis: Polytrauma: 1. Left distal tibia intra-articular fracture and 2. Distal fibular fracture 3. Grade 5 splenic injury with hemoperitoneum 4. Right tentorial subdural hematoma 5. Inner lower lip laceration/mucosal degloving injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (crutches) Left Lower Extremity: Touchdown weight bearing only Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ man status post motorcycle accident. TECHNIQUE: Contiguous multidetector CT scan through the head was performed without intravenous contrast. Axial images displayed as separate 5 mm and 2.5 mm bone algorithm image series. Multiplanar reformation was performed to construct coronal and sagittal images. DOSE: The patient was scanned twice due to motion artifact. DLP: 2650.07 mGy-cm. CTDIvol: 53.59 mGy and 81.81 mGy. COMPARISON: None available. FINDINGS: Limited examination due to patient motion. The examination was repeated, there is a persistent linear high attenuation area along the right leaflet of the tentorium cerebelli (images 13 through 15, series 2 and series 5), likely consistent with a subdural hematoma with no significant mass effect or shifting of the adjacent structures, otherwise, the ventricles and sulci are normal in size and configuration. There is no fracture. The imaged paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Limited examination due to patient motion, high attenuation area along the right leaflet of the tentorium cerebelli (images 13 through 15, series 2 and series 5), likely consistent with a subdural hematoma with no significant mass effect or shifting of the adjacent structures. NOTIFICATION: These findings were discovered and communicated via phone call by Dr. ___ to Dr. ___ at 9:38 am., on ___. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ man status post motorcycle accident. Unable to reliably report symptoms secondary to intoxication. TECHNIQUE: Non-contrast multidetector helical CT scan through the cervical spine was performed. Image data processed to generate 2.5 mm axial soft tissue algorithm, 2.5 mm axial bone algorithm, coronal, and sagittal image series. DOSE: DLP: 925.70 mGy-cm; CTDIvol: 37.26 mGy. COMPARISON: None. FINDINGS: There is no acute fracture or alignment abnormality. There is no prevertebral soft tissue swelling. Limited, non-contrast appearance of the included soft tissues is unremarkable. No concerning abnormality is seen in the included upper lungs. CT is not able to provide intrathecal detail comparable to MRI; within this limitation, the outline of the thecal sac appears normal. IMPRESSION: No evidence of acute cervical spine injury. Radiology Report EXAMINATION: CT TORSO W/CONTRAST INDICATION: ___ man status post motorcycle crash, with intra-abdominal free fluid on FAST. TECHNIQUE: MDCT acquired axial images of the chest, abdomen, and pelvis were obtained after administration of 130 mL Omnipaque intravenous contrast. Enteric contrast was not given. Coronal and sagittal reformats prepared and reviewed. DOSE: DLP: ___ MGy-cm. COMPARISON: None. FINDINGS: CT CHEST WITH CONTRAST: There is no evidence of vascular injury or mediastinal hematoma. The imaged thyroid is normal. There is no axillary, supraclavicular, mediastinal, or hilar lymphadenopathy by CT size criteria. The heart is structurally normal and there is no pericardial effusion. The lungs are clear without parenchymal or interstitial abnormality. The airways are patent. There are no concerning pulmonary nodules. There is no pneumothorax or pleural effusion. ABDOMEN: The spleen is shattered, with only minimal profusion of the disparate fragments. There are multiple foci of active extravasation. There is moderate hemoperitoneum. There are two renal lacerations with a small amount of perinephric blood (602b: 55, 59). There is no leakage of excreted contrast from renal collecting system or ureter. The right kidney is uninjured. The liver enhances homogeneously, without concerning focal lesion. The gallbladder and biliary tree are normal. The pancreas is normal, without focal injury or duct dilation. The adrenal glands are normal. The stomach and duodenum are normal. The small bowel and large bowel are normal in caliber, without wall thickening or mass. There is no intra- or retroperitoneal lymphadenopathy. There is no fluid collection or pneumoperitoneum. The abdominal aorta is normal caliber, with patent main branches. The portal vein and IVC are patent. PELVIS: The urinary bladder is without wall thickening or mass. The rectum is unremarkable. There is no pelvic mass. There is a small amount of hemoperitoneum tracking down into the pelvis. There is no pelvic or inguinal lymphadenopathy. The prostate and seminal vesicles are unremarkable. BONES AND SOFT TISSUES: There is no acute fracture. There are no destructive osseous lesions concerning for malignancy or infection. There are no soft tissue masses. IMPRESSION: 1. High-grade splenic injury, at least grade 4, with profusion of only a small number of the disparate fragments and multiple sites of active extravasation. 2. Two left renal lacerations without evidence of ureteral injury. NOTIFICATION: Preliminary findings were discussed with the trauma team in person at the time of interpretation. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST INDICATION: ___ man, status post motorcycle accident, presenting with soft tissue facial injuries. Evaluate for fracture. TECHNIQUE: Non-contrast multidetector CT helical scan through the paranasal sinuses was performed. Axial images displayed with soft tissue and bone algorithm technique. Coronal and sagittal reformats provided. DOSE: DLP: 582.42 mGy-cm; CTDIvol: 25.88 mGy COMPARISON: None. FINDINGS: There are no facial fractures. The mandible and dentition are intact. The imaged paranasal sinuses are clear. The globes and orbital soft tissues are normal. There is soft tissue swelling of the chin and lips, with several small radiopaque foreign bodies imbedded in the soft tissues (401b:42,49,53). IMPRESSION: There are no facial fractures. Soft tissue swelling of the changes loops with several small radiopaque foreign bodies as above. Radiology Report EXAMINATION: TRAUMA #3 (PORT CHEST ONLY) PORT INDICATION: ___ man status post motorcycle accident. COMPARISON: None available. FINDINGS: The lungs are clear. The hilar and cardiomediastinal contours are normal. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. No osseous injury is seen. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p trauma splenectomy // eval ETT position, lines, etc COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, no relevant change is noted. Borderline size of the cardiac silhouette. The patient is now intubated. The tip of the endotracheal tube projects 5 cm above the carinal. The course of the new nasogastric tube is normal, the tip projects over the middle parts of the stomach, the side port is at the gastroesophageal junction. No larger pleural effusions. No pneumonia, no pneumothorax. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with trauma // Eval for interval change, right SDH TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: CTDIvol: 54 mGy DLP: 1003 mGy-cm COMPARISON: CT head without contrast ___ 02:39 FINDINGS: There is persistent linear high density along the right tentorium (602b: 31), likely representing subdural hematoma. There is no evidence of new intracranial hemorrhage, mass effect or infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. Mucosal thickening is noted in the bilateral sphenoid sinus, ethmoid air cells, and maxillary sinuses. The mastoid air cells, and middle ear cavities are clear. IMPRESSION: Stable appearance of right tentorial subdural hematoma compared to 12 hr prior. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ male status post advancement of endotracheal tube. TECHNIQUE: Portable AP radiograph of the chest from ___. COMPARISON: ___ at 06:10 hr. FINDINGS: There is no significant interval change in the position of the endotracheal tube as compared to the prior exam. A terminates at the level of the thoracic inlet. An enteric tube courses below the hemidiaphragms into the stomach. The lungs are clear. There is no pneumothorax. The heart and mediastinum are magnified by the projection. Regional bones and soft tissues are unremarkable. IMPRESSION: No significant interval change in position of the endotracheal tube. Clear lungs. Radiology Report EXAMINATION: ANKLE (AP, LAT AND OBLIQUE) LEFT INDICATION: ___ year old man with trauma, pain // Eval for fx TECHNIQUE: Plain film COMPARISON: None. FINDINGS: 3 portable views of the left ankle show acute transverse fracture through the distal fibula and vertical fracture through the distal tibia separating the medial malleolus from the main body of the tibia and questionable lucency through the distal posterior tibia (posterior malleolus) The medial in tibial fracture extends through the articular surface of the distal tibia and the fibular fracture probably extends to the region of the talofibular ligament. Soft tissue swelling is most marked laterally. Apparent fractures of the third and fourth metatarsal heads may be more apparent than real, related to unusual projection but if there are physical signs suggesting fracture here, foot films are recommended IMPRESSION: At least bimalleolar and possible tri malleolar acute left ankle fractures as described. Radiology Report INDICATION: Small right-sided subdural hematoma after motor vehicle collision. Evaluate for interval change. TECHNIQUE: Helical axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted images in coronal and sagittal axes were generated. DOSE: DLP: 1003.4 mGy-cm; CTDIvol: 55.0 mGy. COMPARISON: Noncontrast CT head from ___. FINDINGS: Again seen is the subdural hematoma along the right tentorium, unchanged in size and distribution. No new focus of hemorrhage is identified. There is no acute large territorial infarct, edema, mass effect, or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent and there is preservation of gray-white matter differentiation. Mucosal thickening of the bilateral maxillary and sphenoid sinuses as well as the ethmoid air cells is unchanged. IMPRESSION: Unchanged subdural hematoma along the right tentorium. No new focus of hemorrhage identified. Radiology Report INDICATION: Left ankle fracture ORIF. TECHNIQUE: Fluoroscopic assistance was provided to the surgeon without the radiologist present. A total of 4 intraoperative fluoroscopic spot films were obtained. Total fluoroscopy time was 11.4 seconds. Total dose was 28.8 mrad. COMPARISON: ___ left ankle radiographs. FINDINGS: Four spot fluoroscopic views demonstrate ORIF of bimalleolar fracture with fixation plate along the distal medial tibia with 5 fixation screws. Fracture fragments are in anatomic alignment. IMPRESSION: Intraoperative images from open reduction internal fixation of the left ankle. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p MVC and splenectomy, ORIF, now with fever // Acute process TECHNIQUE: Portable chest ___. FINDINGS: The ET tube and NG tube have been removed. Lung volumes are slightly low. Difficult to completely assess the retrocardiac region secondary to the low lung volume otherwise the lungs are clear IMPRESSION: Low lung volumes with retrocardiac opacity. Cannot exclude infiltrate in this region. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ man status post motorcycle crash, status post splenectomy and ORIF of left ankle, presenting with fever. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, 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 bilateral slow flow seen in the common femoral 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 bilateral lower extremity veins. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old man s/p ex-lap, splenectomy. Now ABD distension, pain, N/V // Evidence of obstruction, ileus TECHNIQUE: Portable abdomen COMPARISON: None. FINDINGS: Supine portable view of the abdomen demonstrates skin staples and multiple dilated loops of small bowel measuring up to 4.2 cm. This is a supine view only and therefore I cannot assess for free air or air-fluid levels. There is paucity of colonic gas IMPRESSION: Ileus versus SBO. The time of dictating this report the patient had already had a CT Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with acute tachypnea/hypoxia refractory to high flow O2 // Acute process TECHNIQUE: Portable chest ___. FINDINGS: There is a new dense left lower lobe opacity time palpable with pneumonia lung volumes are low cardiac and mediastinal silhouettes are similar compared to prior IMPRESSION: New left lower lobe pneumonia Radiology Report INDICATION: ___ year old man s/p splenectomy on ___ w/ acute onset tachycardia, hypoxia, please perform CTA to evaluate for PE. Patient also with bilious emesis, evaluate for bowel obstruction.. TECHNIQUE: MDCT images were obtained from the lung bases to the lesser trochanters after the administration of intravenous contrast. Coronal and sagittal reformations were prepared. DLP: 1027 mGy-cm. COMPARISON: CT torso on ___. FINDINGS: CT CHEST: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. The pulmonary arteries are also 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. The heart and pericardium are unremarkable, with no evidence of pericardial effusion. There is a small left pleural effusion. There are bilateral lower lobe consolidations as well as scattered low-density ground-glass and solid opacities in the left upper lobe, lingula, right middle and right lower lobe. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland and esophagus are unremarkable. CT ABDOMEN: The liver enhances homogeneously and there is no focal liver lesion. The hepatic and portal veins are patent. The spleen is surgically absent. There is moderate free fluid. The gallbladder, pancreas, and adrenals are normal. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or mass. The stomach is normal. There is dilation of the small bowel. Without a definite transition point, there is also diffuse bowel wall thickening. Colon is unremarkable. There is no portacaval, mesenteric and retroperitoneal lymphadenopathy. There is no free air or free fluid. CT PELVIS: The appendix is normal. The colon, rectum, urinary bladder and prostate and seminal vesicles are normal. There is no pelvic lymphadenopathy. OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for malignancy. IMPRESSION: No pulmonary embolism. New bilateral lower lung consolidations, most consistent with aspiration or pneumonia with adjacent atelectasis. Diffusely dilated small bowel without a transition point, this may represent ileus given recent surgery. Also mild diffuse small bowel wall thickening, mainly ileum, likely enteritis. These findings were discussed with Dr. ___ by Dr. ___ at 05:30 on ___ in person at time discovery. Radiology Report EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i INDICATION: ___ s/p MVC with Gr 5 splenic lac and low-grade L renal lac now s/p exlap and splenectomy, s/p ORIF of left ankle, with respiratory distress felt to be aspiration pneumonia and ilius // interval changes? COMPARISON: Chest radiographs ___ through ___ one. IMPRESSION: Bibasilar consolidation, but moderate on the left small on the right, improved since ___ one consistent with resolving pneumonia. There may be a small left pleural effusion, not previously recognized. Upper lungs are clear. Heart size is normal. Radiology Report EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i INDICATION: ___ year old man s/p NGT placement. // Please confirm location of NGT COMPARISON: Chest radiographs ___ through ___ one IMPRESSION: Left lower lobe consolidation which developed between ___ and ___, worsened on ___ one, at 04:00, may have improved minimally since. Right lower lobe consolidation is less extensive, but follows the same time line. Findings suggest acute pneumonia, perhaps due to substantial aspiration. Heart size is normal. Pulmonary vasculature is unremarkable. Mediastinal veins are appropriate caliber for the supine position. . Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with acute respiratory status on the floor, transferred to ICU. Did not req intubation, stable. Back on the floor, resp status stable. // Evaluation of pneumonia TECHNIQUE: CHEST (PA AND LAT) COMPARISON: ___ IMPRESSION: Interval substantial improvement in bibasal consolidations demonstrated. The findings might represent multifocal pneumonia, improving versus improving aspiration. Upper lungs are clear. Small amount of pleural effusion is noted bilaterally. There is no pneumothorax. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: Motorcycle accident Diagnosed with SPLEEN INJURY NOS-CLOSED, MV COLLIS NOS-MOTORCYCL temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0
Patient was admitted to the trauma service on ___ due to multi-trauma. CT Cspine wet read showed no evidence of acute cervical spine injury or acute intracranial abnormality. There was also a high-grade splenic injury, with extensive hematoma and multiple sites of active arterial hemorrhage raising concern for hilar avulsion, making it a grade 5 injury. Low grade left renal laceration. He also has at least a bimalleolar and possible tri malleolar acute left ankle fractures. On ___, he underwent exploratory laparotomy, splenectomy, EBL approximately 2L. He tolerated the procedure well and was transferred back to the ___ for recovery. On ___, he underwent open reduction, internal fixation distal tibia intra-articular fracture with medial plating. He again tolerated the procedure well and was moved to the floor in stable condition. ___ No acute events, pain control, pulmonary toilet, ___ eval ___ Acute desaturation event requiring rebreathing facemask. Admitted to ___. Brought to CT for CTA PE and CT abdomen, which showed no PE, ileius without transition point, and chest with bilateral consolidations most consistent with aspiration pneumonia. Started on Vanc/Zosyn. NGT placed with bilious output. Foley out. Pan-cultured. He was transferred back on to the floor on ___ in stable respiratory condition with aggressive chest ___ and physical therapy. He progressed well on the floor
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / Codeine / Penicillins Attending: ___. Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o woman with history of AFib on NOAC, HLD, hypothyroid presents for near-syncope. She was sitting on her couch when she had a sudden onset of dizziness, flushing, diaphoresis, and palpitations. This sensation came and went numerous times during the course of about 90 minutes, resolved en route to ED. Denies any preceding symptoms. Now resting comfortably. No change in medications. No recent travel, non-smoker. Describes her life style as sedentary. Past Medical History: MIGRAINE HEADACHES ASTHMA HYPERLIPIDEMIA HYPOTHYROIDISM BLADDER SPASMS OSTEOPENIA ALLERGIC RHINITIS LARYNGEAL REFLUX SENSORINEURAL HEARING LOSS ATRIAL FIBRILLATION ON NOAC ATRIAL FLUTTER MACROCYTOSIS HTN Social History: ___ Family History: Mother ___ MYOCARDIAL INFARCTION Father ___ CHRONIC OBSTRUCTIVE PULMONARY DISEASE PNEUMONIA Sister ___ BREAST CANCER Brother Living 3 DIABETES ___ CONGESTIVE HEART FAILURE Sister BREAST CANCER Brother Living DIABETES ___ Physical Exam: ADMISSION EXAM: VITALS: T 98.0, BP 167 / 92, P66, RR18, PO2 96 Ra HEENT: MMM; no conjunctival pallor or scleral icterus CV: irregularly irregular; normal S1 and S2 ; no m,r,g PULM: minimal bibasilar crackles ABD: +BS; soft NTND EXT: 2+ DP; warm; 1+ pitting edema up to shins bilaterally NEURO: ___ strength b/l; CN2-12 grossly intact DISCHARGE EXAM: VITALS: T 98.0, BP 120/78, HR 70, RR 18, O2 93% RA GENERAL: Well-appearing, elderly woman, eating her breakfast in NAD HEENT: MMM; no conjunctival pallor or scleral icterus CV: Irregularly irregular; normal S1/S2, no m/r/g PULM: CTAB ABD: Soft, non-tender to palpation, non-distended, active bowel sounds EXT: No cyanosis or clubbing, 2+ DP; 1+ pitting edema up to shins bilaterally SKIN: Warm and well perfused NEURO: Alert and oriented, moving all four extremities with purpose, no facial asymmetry Pertinent Results: ADMISSION LABS: ___ 09:35PM cTropnT-<0.01 ___ 03:45PM URINE HOURS-RANDOM ___ 03:45PM URINE UHOLD-HOLD ___ 03:45PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG* ___ 03:45PM URINE RBC-2 WBC-10* BACTERIA-FEW* YEAST-NONE EPI-<1 ___ 03:45PM URINE MUCOUS-RARE* ___ 01:31PM GLUCOSE-133* UREA N-13 CREAT-0.9 SODIUM-143 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 ___ 01:31PM estGFR-Using this ___ 01:31PM cTropnT-<0.01 ___ 01:31PM MAGNESIUM-2.0 ___ 01:31PM WBC-5.0 RBC-3.69* HGB-13.0 HCT-39.0 MCV-106* MCH-35.2* MCHC-33.3 RDW-13.2 RDWSD-51.0* ___ 01:31PM NEUTS-59.4 ___ MONOS-10.8 EOS-3.6 BASOS-0.6 IM ___ AbsNeut-2.97 AbsLymp-1.25 AbsMono-0.54 AbsEos-0.18 AbsBaso-0.03 ___ 01:31PM PLT COUNT-142* ___ 01:31PM ___ PTT-31.3 ___ DISCHARGE LABS: ___ 08:30AM BLOOD WBC-6.5 RBC-4.08 Hgb-14.1 Hct-42.7 MCV-105* MCH-34.6* MCHC-33.0 RDW-13.2 RDWSD-51.3* Plt ___ ___ 08:30AM BLOOD Plt ___ ___ 08:30AM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-143 K-4.3 Cl-102 HCO3-29 AnGap-12 ___ 08:30AM BLOOD ALT-14 AST-19 LD(LDH)-223 AlkPhos-63 TotBili-0.9 ___ 08:30AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0 MICROBIOLOGY: ___ 3:45 pm URINE URINE CULTURE (Pending): IMAGING: ___ CXR: IMPRESSION: No radiographic evidence of acute cardiopulmonary disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Metoprolol Succinate XL 25 mg PO 2 TAB AM, 1 TAB ___ 5. Oxybutynin 20 mg PO DAILY 6. Rivaroxaban 20 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. Calcium Carbonate 500 mg PO Frequency is Unknown 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Calcium Carbonate 500 mg PO DAILY 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Metoprolol Succinate XL 25 mg PO 2 TAB AM, 1 TAB ___ 6. Multivitamins 1 TAB PO DAILY 7. Oxybutynin 20 mg PO DAILY 8. Rivaroxaban 20 mg PO DAILY 9. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS - Pre-syncope SECONDARY DIAGNOSIS - HTN - HLD - Atrial fibrillation - Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with near syncope// cardiopulmonary etiology of syncope TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: The size of the cardiac silhouette is enlarged but unchanged. There is no focal consolidation, pleural effusion or pneumothorax identified. Incompletely evaluated lower thoracic/upper lumbar spinal hardware. Rounded radiodensities in the anterior upper abdomen seen on the lateral view may reflect calcified gallstones. IMPRESSION: No radiographic evidence of acute cardiopulmonary disease. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Lightheaded Diagnosed with Syncope and collapse temperature: 97.6 heartrate: 72.0 resprate: 16.0 o2sat: 98.0 sbp: 147.0 dbp: 103.0 level of pain: 0 level of acuity: 3.0
Ms. ___ is a ___ with a past medical history of atrial fibrillation on NOAC, hypertension, hyperlipidemia, and hypothyroidism who presented with near-syncope. # Near-syncopal event Patient presented with lightheadedness while at rest, without any loss of consciousness. She has a history of atrial fibrillation. Orthostatics were negative. There was no history of a trigger for a vasovagal episode. An ECG showed no evidence of ischemia and troponins were negative. Etiology remained unclear and is possibly secondary to transient arrhythmia, structural heart disease, or transient ischemia. Recommend the patient receives an outpatient transthoracic echocardiogram with consideration of stress echocardiogram and ___ of Hearts monitoring. # Bacteriuria Patient had urinalysis which showed w10 WBC, few bacteria, and large leuks. She remained afebrile and asymptomatic and was not treated with antibiotics. Urine culture was pending on day of discharge. # Afib/flutter on NOAC: Patient was switched to metoprolol tartrate 37.5mg BID while in the hospital. She can continue her home metoprolol succinate on discharge. She was continued on her home rivaraxoaban.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Falls, Unstable Gait Major Surgical or Invasive Procedure: ___ ___ w/ L2-4 stenosis s/p L2-4 laminectomy (Dr. ___, ___, admitted secondary to falls at home History of Present Illness: ___ ___ w/ L2-4 stenosis s/p L2-4 laminectomy (Dr. ___, ___, admitted secondary to falls at home, re-screened for rehab Past Medical History: Hypertension Hyperlipidemia Remote history of atrial fibrillation- on apixaban at home BPH Obesity Osteoarthritis including spine Prior history of ETOH abuse - quit ___ years ago Social History: ___ Family History: father died of MI age ___. mother died of lung cancer age ___. brother is age ___ and also has new onset atrial fibrillation. Physical Exam: dressing cdi Pertinent Results: none Medications on Admission: 1. Acetaminophen 650 mg PO 5 TIMES DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5 TIMES DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Lumbar Stenosis Discharge Condition: stable Followup Instructions: ___ Radiology Report INDICATION: ___ with weakness and recurrent falls// cxr- pna; CT head- ICH TECHNIQUE: Frontal lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Again seen is relative elevation of the right hemidiaphragm, unchanged. There is mild right basilar atelectasis. The lungs are otherwise clear. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities, hypertrophic changes noted in the spine. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ man with weakness and recurrent falls. Evaluate for hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: CTA head dated ___. FINDINGS: No evidence of acute infarction,hemorrhage,edema, or mass effect. Coarse calcifications the pons on the right is unchanged. The ventricles and sulci are normal in size and configuration for the patient's age. Bilateral carotid siphon calcifications are mild. No evidence of fracture. The nasal septum is mildly deviated to the right. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable other than right lens replacement. IMPRESSION: No intracranial hemorrhage. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness Diagnosed with Weakness temperature: 98.0 heartrate: 66.0 resprate: nan o2sat: 99.0 sbp: 131.0 dbp: 84.0 level of pain: 0 level of acuity: 3.0
Patient was admitted to the ___ Spine Surgery Service secondary to recent falls after his L2-4 stenosis s/p L2-4 laminectomy (Dr. ___, ___ He was admitted for ___ and rehab placement.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ PMH HCV, cirrhosis, HCC s/p RFA ___ who presented to the ED with abdominal pain and nausea/vomiting. He had an RFA for HCC done ___ and said he had been having sever RUQ pain since then. The pain was located in his RUQ with some radiation to his back and was so severe that it was difficult to take a deep breath. For the pain he was prescribed oxycodone, and as a result of taking the oxycodone he developed constipation. He then took lactulose, senna, and miralax for the constipation and developed diarrhea. The pain was improving slightly and then the morning of ___ he developed a new pain in his epigastric area in addition to the RUQ pain. He had nausea and vomiting associated with the pain and says that ___ is the first time after his RFA that he experienced this. He took Zofran at home with minimal relief so he presented to the ED. On arrival to the ED his initial VS were 98.3 71 130/73 15 99% RA. CBC, chem panel, LFTs were obtained and were notable for lipase 11k. RUQUS, CXR, and CT A/P were obtained and were notable for pancreatic inflammation seen on CT A/P. Hepatology was consulted. He was given PO hydromorphone 2mg x1, PO ondansetron 4mg x1. Hepatology consult in ED dash - "ED ___ and OMR reviewed, discussed with attending Dr. ___, patient not seen: ___ y/o man with HCV (s/p treatment and SVR ___ and CP class A/B cirrhosis complicated by previous variceal bleed requiring TIPS in ___ and HCC which was treated with RFA on ___, with ongoing pain since then. Presents to the ED for severe pain, found to have pancreatitis with lipase 11k. Significant bilirubin jump from baseline ~3 to ~15 today. Creatinine remains at baseline. Recommendations: - D5W can start with 150/hr - NPO - pan culture/infectious work up - agree with plan for CT with contrast (discussed with attending) - if stable for the floor, please admit to hepatology under Dr. ___ - most likely post-procedure given timing, but please send calcium/albumin and follow up biliary tree on CT (evidence of stones/obx; biliary tree not described on US) If any Q's please page again. ___, ___ GI/Liver fellow" Transfer VS were 97.6PO 125 / 72 73 18 94 Ra. On arrival to the floor, patient reports that his symptoms are still present but much improved. He describes two types of pain, one in the epigastric region and one in the RUQ. He has radiation of the pain to his back. His nausea and pain improved significantly with the hydromorphone and ondansetron that he received in the ED. He denies any fevers, chills, N/V/D, CP, SOB, cough. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: HCV Cirrhosis ___ RFA of ___ ___ Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 97.6PO 125 / 72 73 18 94 Ra GENERAL: NAD, appears stated age HEENT: atruamatic, normocephalic, EOMI, PERRL HEART: RRR, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, crackles, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: NABS, tenderness to palpation in RUQ and epigastric regions, no rebound or guarding, negative ___ sign EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose, CN II-XII grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGHE PHYSICAL EXAM ======================== VS: 98.0 116/67 65 18 96 Ra GENERAL: NAD, appears stated age HEENT: atraumatic, normocephalic, EOMI, PERRL HEART: RRR, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, crackles, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: NABS, negative ___ sign, +BS, resolved tenderness compared to admission EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose, CN II-XII grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes, not icteric Pertinent Results: ADMISSION LABS ============== ___ 10:30PM BLOOD WBC-10.2*# RBC-5.65 Hgb-15.9 Hct-45.5 MCV-81* MCH-28.1 MCHC-34.9 RDW-16.8* RDWSD-44.5 Plt Ct-65*# ___ 10:30PM BLOOD Neuts-90.1* Lymphs-4.4* Monos-4.4* Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.17*# AbsLymp-0.45* AbsMono-0.45 AbsEos-0.03* AbsBaso-0.03 ___ 10:30PM BLOOD Glucose-161* UreaN-11 Creat-0.9 Na-135 K-4.0 Cl-99 HCO3-21* AnGap-19 ___ 10:30PM BLOOD ALT-53* AST-200* AlkPhos-215* TotBili-14.9* ___ 10:30PM BLOOD ___ DISCHARGE LABS ============== ___ 04:34AM BLOOD WBC-4.3 RBC-4.62 Hgb-13.0* Hct-37.3* MCV-81* MCH-28.1 MCHC-34.9 RDW-15.4 RDWSD-43.8 Plt Ct-54* ___ 04:34AM BLOOD Glucose-125* UreaN-10 Creat-0.7 Na-135 K-3.8 Cl-102 HCO3-21* AnGap-12 ___ 04:34AM BLOOD ALT-21 AST-36 AlkPhos-159* TotBili-6.2* ___ 04:34AM BLOOD Lipase-99* ___ 04:34AM BLOOD Calcium-8.2* Phos-1.7* Mg-2.0 MICROBIOLOGY ============ ___ 6:30 pm URINE CULTURE (Final ___: NO GROWTH. ___ 10:00 pm BLOOD CULTURE: NO GROWTH. IMAGING ======= CT abdomen with contrast ___ 1. Significant peripancreatic fatty stranding and mild peripancreatic fluid without evidence of necrosis or peripancreatic fluid collection. These findings are compatible with acute interstitial pancreatitis. There is associated reactive retroperitoneal and mesenteric lymphadenopathy. 2. Nonocclusive thrombus in the splenic vein just proximal to the portal confluence is unchanged as compared to MRI abdomen ___. 3. Post RFA ablation changes in segment VI of the liver. Chest Xray ___ 1. There is blunting of the right costophrenic angle which may be compatible with a trace right pleural effusion, decreased in size as compared to chest CT ___. 2. Right basilar atelectasis. KUB ___ Nonspecific bowel gas pattern without evidence of obstruction. Abdominal US ___ 1. The portal splenic confluence cannot be evaluated due to overlying bowel gas. Of note, there was nonocclusive thrombus noted in the porta splenic confluence seen on abdominal ultrasound ___. 2. The pancreas is not well visualized. 3. Patent TIPS stent with wall-to-wall flow normal velocity measurements. 4. Nodular appearing liver with a hyperechoic mass in the right lobe measuring 3.1 x 3.9 x 2.5 cm, likely corresponding to post ablation changes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Lactulose 30 mL PO TID 3. Zolpidem Tartrate 5 mg PO QHS 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 8.6 mg PO BID:PRN constipation 6. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 7. Levemir 15 Units Breakfast Insulin SC Sliding Scale using Novolog Insulin 8. Rifaximin 550 mg PO BID 9. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 2. Levemir 15 Units Breakfast Insulin SC Sliding Scale using Novolog Insulin 3. Lactulose 30 mL PO TID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. Pantoprazole 40 mg PO Q24H 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Rifaximin 550 mg PO BID 8. Senna 8.6 mg PO BID:PRN constipation 9. Zolpidem Tartrate 5 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis ================= Acute Pancreatitis Hyperbilirubinemia Coagulopathy Thrombocytopenia Leukocytosis Secondary diagnosis =================== Cirrhosis ___ Diabetes GERD Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis with intravenous contrast. INDICATION: ___ male with hepatitis-C and cirrhosis complicated by bursal bleeding status post TIPS in ___ and ___ status post RF ablation on ___ with ongoing abdominal pain. Elevated lipase 11,000. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 956 mGy-cm. COMPARISON: CT abdomen ___ FINDINGS: LOWER CHEST: There is dependent and subsegmental atelectasis in the right lower lobe. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is a poorly delineated hyperattenuating lesion centered in segment VI measuring 3.7 x 1.4 cm (series 2:20) with a rim of hypoattenuation likely representing the ablation zone. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. TIPS is noted. There is a nonocclusive thrombosis in the splenic vein, just proximal to the portal confluence, unchanged as compared to MRI abdomen ___. PANCREAS: There is significant peripancreatic fatty stranding and mild peripancreatic fluid which is most prominent adjacent to the uncinate process. The fatty stranding tracks along the bilateral Gerota's fascia. There is no evidence of necrosis or peripancreatic fluid collection. There is no ductal dilatation. SPLEEN: The spleen is enlarged measuring 19.3 cm in length in craniocaudal dimension, unchanged as compared to CT ___. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is an exophytic simple cyst in the lower pole of the left kidney measuring up to 3.8 cm (series 2:61). There is no hydronephrosis or perinephric abnormality. abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is sigmoid colonic diverticulosis without evidence of diverticulitis. 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 is not enlarged LYMPH NODES: There are scattered peripancreatic lymph nodes measuring up to 0.7 cm (02:45). There also scattered retroperitoneal lymph nodes measuring up to 0.8 cm (series 2:48). VASCULAR: There is a nonocclusive thrombosis in the splenic vein, just proximal to the portal confluence, unchanged as compared to MRI abdomen ___. There is mild atherosclerotic disease. 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. Significant peripancreatic fatty stranding and mild peripancreatic fluid without evidence of necrosis or peripancreatic fluid collection. These findings are compatible with acute interstitial pancreatitis. There is associated reactive retroperitoneal and mesenteric lymphadenopathy. 2. Nonocclusive thrombus in the splenic vein just proximal to the portal confluence is unchanged as compared to MRI abdomen ___. 3. Post RFA ablation changes in segment VI of the liver. Gender: M Race: WHITE - BRAZILIAN Arrive by WALK IN Chief complaint: Abd pain, Dyspnea Diagnosed with Right upper quadrant pain, Pleural effusion, not elsewhere classified temperature: 98.3 heartrate: 71.0 resprate: 15.0 o2sat: 99.0 sbp: 130.0 dbp: 73.0 level of pain: 7 level of acuity: 3.0
___ year old gentleman with HCV cirrhosis and ___ s/p RFA ablation in ___ who presented with abdominal pain and nausea, lipase 11k and CT abdomen showing significant peripancreatic fatty stranding consistent with acute pancreatitis. Patient was initially made NPO, and pain was controlled. As the lipase started to downtrend, his diet was advanced to clear liquids, and then to regular diet with good tolerance. By the time of discharge the lipase was down to 99 and all the presenting symptoms were resolved. ACUTE PROBLEMS ============== # Acute pancreatitis: Patient with PMH of HCV, cirrhosis, ___ had an RFA for ___ done ___ and said he had been having severe RUQ pain since then. The pain was located in his RUQ with some radiation to his back and was so severe that it was difficult to take a deep breath The pain was improving slightly and then the morning of ___ he developed a new pain in his epigastric area in addition to the RUQ pain. He had nausea and vomiting associated with the pain and decided to come to the ED. Patient denies any use of alcohol or any toxic ingestion. He has a history of SMV thrombosis. CT A/P was obtained and was notable for pancreatic inflammation. At presentation lipase was 11k. An abdominal US showed no gallstones. The running diagnosis was pancreatitis secondary to the RFA procedure in the setting of an existing thrombus in the SMV. Gallstone pancreatitis is less likely given that the patient did not have gallstones on US. Pancreatitis due to alcohol or drug use is also less likely given that the patient has not had any exposure. On arrival lipase was 11k. The patient was made NPO, received pain medication and D5W. Infectious workup, including CXR and Ucx was negative. With bowel rest the lipase lowered to 3k with bowel rest. The patient was advanced first to clear liquids and then to a regular diet with good tolerance and improvement of abdominal pain, nausea and vomiting. Lactulose was held initially in the setting of being NPO/ clear liquids and replaced with miralax. Once the patient was advanced he was put back on his home lactulose 30 PO TID. The pain and nausea was initially controlled with PO hydromorphone 2mg x1, PO ondansetron 4mg x1, but by the time of discharge the patient did not require medication for either pain or nausea. # Hyperbilirubinemia: Similar etiology as explained above, T Bili at arrival was 15, and went down to 6.2 at the time of departure. # Coagulopathy: # Thrombocytopenia: Likely related to his cirrhosis. There was no evidence of active bleeding during this hospitalization. Was monitored with daily CBCs. # Leukocytosis: WBC checked was 2.9 on ___ and 7.8 on arrival to ED. This was a significant elevation, but considered to be a reactive leukocytosis following his recent RFA or due to his acute pancreatitis. WBC at discharge was 4.3. The infectious workup was negative. CHRONIC PROBLEMS ================ # Cirrhosis: # ___ s/p RFA ___: MELD 21 on arrival. No evidence of HE on exam. Continued rifaximin. Lactulose was initially held while patient was NPO/ on clear liquids to prevent abdominal distention/ discomfort. He was restarted on lactulose by the time of discharge. MELD Na at discharge was 20. # Diabetes: Kept on lantus with HISS # GERD: Continued home Pantoprazole 40 mg PO Q24H # Insomnia: Continued home Zolpidem TRANSITIONAL ISSUES =================== - Lipase at discharge 99 - MELD score at discharge 20 - Patient will need to have repeat LFTs and lipase within a week, and have those sent over to his transplant coordinator ___ (fax number: ___ - An MRI from ___ showed a 2.9 x 1.7 cm nonocclusive thrombus within the splenic vein, just proximal to the portal confluence, which appears more bulky compared to the prior MRI from ___. The patient needs to follow-up on this with his PCP, regarding surveillance imaging and possible need for future anticoagulation if increasing in size. - Patient will follow-up with his PCP: ___ on ___ at 1pm. Please have the lab results faxed as explained above. =========== #CODE: Full #CONTACT: ___ (wife) ___
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Codeine / Neurontin / ibuprofen / naproxen / vancomycin / Erythromycin Base Attending: ___. Chief Complaint: Left knee pain Major Surgical or Invasive Procedure: L prosthestic knee washout (___) History of Present Illness: ___ PMHx bullous pemphigoid on prednisone, AVN s/p bilateral hip replacement ___, L knee arthroplasty and palletectomy ___, bipolar disorder presenting with LLE pain and swelling x 1 week. Pt noted pain, swelling and redness of left leg which has progressively worsened over the last week and now extends above his knee. + subjective fevers. He presented to an OSH yesterday where lower extremity ultrasound was reportedly negative for DVT and he was sent home on bactrim. He presents today after being referred by his physician at the ___. Of note, patient is s/p L TKA (___) complicated by septic arthritis s/p explant, abx spacer ___ at NEB), patellectomy, and staph osteomyelitis ___ ___ who underwent short course of IV abx with poor compliance and refusal of PICC line. ___ the ED, initial vs were: 98.2 109 110/67 18 94%. Labs were remarkable for Cr 0.9, CRP 66.3, WBC 12.6 with 78.4% neutrophils, HCT 44.6, ESR 58, lactate 1.8. Lower extremity doppler showed no evidence of LLE DVT. Plain film of the L knee showed lateral subluxation at the knee with widening of the lateral joint space and unchanged appearance of antibiotic spacers and wires. Orthopedics was consulted and felt that there was no evidence of septic joint, admission for treatment of cellulitis. The patient was given cefepime and admitted to medicine for further management. Past Medical History: - Bipolar - Hepatitis C - HLD - Diabetes - Bullous pemphigoid - Asthma - Cholelithiasis - GERD - Aortic aneurysm - Osteoporosis Past Surgical History - s/p left knee replacement ___ ___ at ___, - s/p Left total knee arthroplasty explant and placement of antibiotic spacer ___ due to sepsis - s/p 2 hip replacements - Compression fractures of spine - Inguinal hernia - psoriasis Social History: ___ Family History: Maternal grandmother with bullous pemphigoid, uncle with psoriasis Mother with ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.8 111/66 90 16 100% RA General: Awake and alert, NAD HEENT: dry MM, edentulous Lungs: CTAB CV: RRR, ___ systolic murmur best heard RUSB, no radiation to carotids Abdomen: soft, NABS, soft, NTND Ext: hips nontender to palpation, 2+ dp pulses bilaterally, LLE with 2+ edema to knee, healing blisters anterior shin, erythema and +warmth extending above knee, no effusion. Unable to flex L knee ___ pain Skin: scattered small healing blisters on torso and lower extremities Psych: alert, + loose associations but redirectable, mildly agitated affect . DISCHARGE PHYSICAL EXAM: VS: 98.6 107/65 91 18 97% RA GEN: Lying ___ bed, pleasant and cooperative, ___ no acute distress. HEENT: PERRL. Moist mucous membranes. CARDIO: RRR, S1 and S2 heard. ___ systolic murmur. LUNGS: CTA b/l ABD: Soft, nontender, nondistended. normoactive bowel sounds. EXT: Left knee incision clean and dry, no drainage/erythema. ___ strength on left leg (unclear if pt not participating ___ exam), ___ strength on right. 2+ DP pulses NEURO: A&Ox3, cranial nerves grossly intact PSYCH: mildly agitated but re-directable. Fixated on having bullous pemphigoid Pertinent Results: LABS ON ADMISSION: ___ 05:00PM BLOOD WBC-12.6*# RBC-4.94 Hgb-14.8 Hct-44.6 MCV-90 MCH-30.1 MCHC-33.3 RDW-13.6 Plt ___ ___ 05:00PM BLOOD Neuts-78.4* Lymphs-14.7* Monos-5.8 Eos-0.7 Baso-0.4 ___ 05:00PM BLOOD ESR-58* ___ 05:00PM BLOOD Glucose-134* UreaN-14 Creat-0.9 Na-138 K-3.9 Cl-96 HCO3-33* AnGap-13 ___ 06:25AM BLOOD ALT-26 AST-12 CK(CPK)-16* AlkPhos-62 TotBili-0.6 ___ 05:00PM BLOOD CRP-66.3* ___ 05:00PM BLOOD Lactate-1.8 . PERTINENT MICROBIOLOGY: ___ 3:40 pm JOINT FLUID Site: KNEE LEFT KNEE. GRAM STAIN (Final ___: Reported to and read back by ___. ___ @ 5:30PM ___. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. FLUID CULTURE (Final ___: STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. . ___ 1:15 pm SWAB LEFT KNEE JOINT. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. . ___ 1:19 pm TISSUE LEFT KNEE SYNAVIUM. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. Reported to and read back by ___ ON ___ @ 512 ___. TISSUE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. . ___ 4:40 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. . . LABS ON DISCHARGE: ___ 05:45AM BLOOD WBC-8.1 RBC-4.01* Hgb-12.1* Hct-35.1* MCV-88 MCH-30.2 MCHC-34.5 RDW-14.4 Plt ___ ___ 05:45AM BLOOD Glucose-109* UreaN-13 Creat-0.8 Na-140 K-4.0 Cl-102 HCO3-28 AnGap-14 ___ 05:45AM BLOOD CK(CPK)-41* . PERTINENT IMAGING: Xray L knee (___): "IMPRESSION: Likely lateral subluxation at the knee. Antibiotic spacers and wires appear unchanged. If concerned for osteomyelitis, consider bone scan or MRI." . Left lower extremity US (___): "IMPRESSION: No evidence of left lower extremity DVT." . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 30 mg PO DAILY 2. ClonazePAM 2 mg PO Q6H 3. OxycoDONE (Immediate Release) 30 mg PO Q8H:PRN pain 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Aspirin 325 mg PO DAILY 6. Amitriptyline 50 mg PO HS 7. albuterol sulfate *NF* 90 mcg Inhalation Q4-6hrs PRN SOB 8. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet Oral daily 9. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 10. Senna 3 tabs PO DAILY 11. Morphine SR (MS ___ 60 mg PO Q12H Discharge Medications: 1. Amitriptyline 50 mg PO HS 2. ClonazePAM 2 mg PO Q6H 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Morphine SR (MS ___ 90 mg PO Q12H RX *morphine 30 mg 3 tablet(s) by mouth q12 hr Disp #*42 Tablet Refills:*0 5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain RX *oxycodone 15 mg 1 tablet(s) by mouth q4hr prn pain Disp #*42 Tablet Refills:*0 6. PredniSONE 20 mg PO DAILY 7. Senna 1 TAB PO BID:PRN constipation 8. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet Oral daily 9. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 10. Nafcillin 2 g IV Q4H 11. albuterol sulfate *NF* 90 mcg INHALATION Q4-6HRS PRN SOB 12. Outpatient Lab Work Please draw weekly CBC and Chem 7 labs (ICD ___), and fax results to ___ at ___ 13. Aspirin 81 mg PO DAILY 14. Heparin 5000 UNIT SC TID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left prosthetic knee joint infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report HISTORY: Status post left knee arthroplasty resections for spacer placement. Unable to bend or straighten the left knee. COMPARISON: ___ FINDINGS: 2 views were obtained of the left knee. The patient was unable to straighten or bend the knee for the films. Within this limitation, there is subluxation of the left knee with lateral displacement of the tibia and fibula with respect to the femur such that the intercondylar notch of the femur projects over the medial tibial plateau. Calcific densities on the lateral view along the distal femur may reflect periosteal reaction. Antibiotic spacers and K-wires appear intact. Small joint effusion and prepatellar soft tissue thickening are also noted. IMPRESSION: Likely lateral subluxation at the knee. Antibiotic spacers and wires appear unchanged. If concerned for osteomyelitis, consider bone scan or MRI. Radiology Report HISTORY: Bullous pemphigoid and diabetes with pain and swelling in the left lower extremity. Assess for DVT. COMPARISON: None. FINDINGS: Gray scale and color Doppler sonographic evaluation was performed of the left lower extremity. Normal compressibility, color flow and response to augmentation is seen left common femoral, superficial femoral and popliteal veins. Normal color flow is seen in the posterior tibial and peroneal veins. IMPRESSION: No evidence of left lower extremity DVT. Radiology Report ULTRASOUND-GUIDED LEFT KNEE ASPIRATION PROCEDURE CLINICAL INDICATION: ___ male with history of bullous pemphigoid, on prednisone, status post bilateral hip replacement and left knee arthroplasty and patellectomy in ___. Patient now reports left lower extremity pain and swelling for one week. Evaluate for septic arthritis for aspiration. COMPARISON: Knee radiography dated ___. TECHNIQUE: Written informed consent was obtained after explanation of the procedure to be performed to the patient including the risks, benefits, and alternatives. A preprocedure timeout confirmed the procedure to be performed and the identity of the patient using three patient identifiers. The skin entry site at the lateral aspect of the left knee was chosen, and skin was prepped and draped in standard sterile fashion. Care was made to avoid erythematous skin. The normal joint anatomy is markedly distorted. A 2.8 x 1.3 cm complex mixed echogenicity fluid collection is noted in the anterior soft tissues. A small amount of 1% lidocaine was infiltrated into the subcutaneous soft tissues overlying the region of interest. Under ultrasound guidance, an 18-gauge needle was advanced into the collection. Approximately 3 mL of turbid fluid was aspirated. The needle was removed and hemostasis achieved. A dry dressing was applied. There were no immediate complications. The patient tolerated the procedure well. Dr. ___ attending radiologist, was present throughout the entire procedure and provided direct supervision. IMPRESSION: 1. Successful ultrasound-guided left knee joint aspiration of approximately 3 mL of turbid fluid. The fluid was sent to the laboratory for microbiologic analysis. 2. Distortion of knee joint anatomy. Ultrasonography demonstrated a complex mixed echogenicity fluid collection anterior to the left knee. Radiology Report REASON FOR EXAMINATION: PICC line placement. AP radiograph of the chest was reviewed. The right PICC line tip terminates in the right atrium and should be pulled back for 3 cm. The heart size and mediastinum appear to be unremarkable. Bibasal linear opacities might reflect atelectasis, but infectious process in the left lower lobe cannot be excluded. The upper lungs are clear. Findings were discussed with IV nurse, ___, over the phone by Dr. ___ at 09:30 a.m. on ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LEFT LEG EDEMA Diagnosed with CELLULITIS OF LEG temperature: 98.2 heartrate: 109.0 resprate: 18.0 o2sat: 94.0 sbp: 110.0 dbp: 67.0 level of pain: 0 level of acuity: 3.0
PRIMARY REASON FOR HOSPITALIZATION: ___ y/o male with a history of L knee replacement and subsequent infected hardware removal with incomplete ABx therapy ___ the past. He presents with a hot, swollen knee, inability to move the joint, and elevated CRP/ESR. .
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: Neosporin (neo-bac-polym) Attending: ___. Chief Complaint: Fevers and pelvic pain after radical prostatectomy Major Surgical or Invasive Procedure: CT-guided drain exchange and drainage of pelvic fluid collection History of Present Illness: ___ s/p RRP ___ c/b R pelvic lymphocele and RLE swelling s/p ___ pigtail drain placement ___ now with fever to 102 at home, 102.4 in ED, and increased tenderness RLQ. Past Medical History: Hyperlipidemia h/o radical prostatectomy Social History: ___ Family History: NC Physical Exam: No acute distress, alert & oriented x3 Warm and well-perfused Non-labored breathing Abdomen soft, non-tender, non-distended Incisions clean, dry and intact ___ drain with serous drainage Foley draining clear yellow urine RLE edema resolved Pertinent Results: ___ 4:14 pm FLUID,OTHER Site: PELVIS PELVIC COLLECTION. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Bacitracin Ointment 1 Appl TP QID 4. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Atorvastatin 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Bacitracin Ointment 1 Appl TP QID apply to the tip of the penis for Foley discomfort 4. cefaDROXil 1 gram oral BID Duration: 14 Days RX *cefadroxil 1 gram 1 tablet(s) by mouth twice a day Disp #*28 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pelvic fluid collection after radical prostatectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Post-operative fever. COMPARISON: CT chest ___. FRONTAL AND LATERAL CHEST: The lungs are clear without focal consolidation, pleural effusion or pneumothorax. Heart size is normal. Mediastinal silhouette and hilar contours are normal. IMPRESSION: No pneumonia, edema or pleural effusion. Radiology Report INDICATION: Right lower quadrant tenderness to palpation with recent drain. Evaluate for abscess. COMPARISON: CT pelvis ___ and CT interventional procedure ___. TECHNIQUE: MDCT axial images from the lung bases to the pubic symphysis were displayed with 5 mm slice thickness with intravenous contrast. Coronal and sagittal reformations were displayed with 5 mm slice thickness. DLP: 781.45 mGy-cm. CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar atelectasis. There is no pleural or pericardial effusion. The liver is unremarkable without focal liver lesion identified. There is no intra- or extra-hepatic bile duct dilation. The gallbladder, spleen, pancreas and bilateral adrenal glands are normal. The kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis. Bilateral hypodensities in the kidneys bilaterally, compatible with simple cysts, measure up to 2.6 cm in the left renal interpolar region. The small and large bowel are normal in course and caliber without obstruction. The appendix is visualized and is normal (2:51-52). There is no free fluid and no free air. The abdominal aorta is of normal caliber throughout. The main portal vein, splenic vein and SMV are patent. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are identified. CT PELVIS: The rectum and sigmoid colon are normal. The bladder is decompressed with a Foley catheter in place. The patient is status post radical prostatectomy. At the right pelvic side wall, there is a 7.5 x 3.5 cm fluid collection, previously 8.1 x 3.5 cm on ___, unchanged or slightly smaller. A drainage catheter is within it. Superinfection cannot be excluded. The right iliac artery is patent. The right iliac vein is compressed, but patency cannot be evaluated due to contrast bolus timing. A smaller fluid collection along the left pelvic side wall without a drainage catheter is approximately 3.5 x 1.8 cm, previously 3.7 x 2.0 cm, unchanged. The left external iliac artery and vein are patent. Stranding in the pelvis and anterior abdominal soft tissues is similar to the prior study. There is no pelvic or inguinal lymphadenopathy. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. There is mild dextroconvex scoliosis of the lumbar ___ at L3 with multilevel degenerative change. IMPRESSION: 1. Right pelvic side wall fluid collection with a drainage catheter is unchanged or slightly smaller from ___. Superinfection of the collection cannot be excluded on this study. Please correlate with drain output. The collection compresses the external iliac vein. 2. Left pelvic side wall fluid collection is also unchanged. Radiology Report CLINICAL INDICATION: Status post prostatectomy complicated by pelvic fluid collections. Now with asymmetrical swelling of the right lower extremity. Evaluation for deep venous thrombosis. TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound examination of the bilateral lower extremity veins. COMPARISON: Right lower extremity venous ultrasound, ___. CT abdomen and pelvis performed ___. FINDINGS: There is decreased respiratory variation in the right common femoral vein with minimal response to Valsalva. There is slow flow in the right greater saphenous vein; however, the vein is compressible with transducer pressure. There is normal compressibility in the right common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins; however, there is slow flow within these vessels. There is normal compressibility and flow in the left common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. Normal flow and compressibility is demonstrated in the bilateral posterior tibial and peroneal veins. There is normal respiratory variation in the left common femoral vein. IMPRESSION: 1. Slow flow predominantly within the right greater saphenous vein as well as decreased respiratory variation in the right common femoral vein likely due to upstream compression from the known pelvic fluid collection. 2. Slow flow throughout the deep right lower extremity veins; however, no thrombus is identified. Radiology Report HISTORY: Pelvic fluid collections after radical prostatectomy for better drainage, to send for Gram stain and culture. PHYSICIANS: Dr. ___, (abdominal radiology attending) and Dr. ___ (abdominal radiology fellow). DLP: 254.6 mGy-cm. PROCEDURE: The procedure including risks, benefits and alternatives were explained to the patient and after a detailed discussion, informed written consent was obtained from the patient. A preprocedure timeout using three patient identifiers was performed as per ___ protocol. The patient was placed in supine position on CT scan table. The patient was prepped and draped in the usual sterile fashion. 5 cc of 1% lidocaine were administered to the subcutaneous tissues for local anesthetic effect. The existing 6 ___ pigtail catheter was cut and under CT guidance, a 0.35 ___ wire was introduced through the 6 ___ pigtail catheter, which was removed after which serial dilations of the tracts were performed. Exchange was made for an 8 ___ pigtail ___ catheter. The satisfactory position of the new pigtail catheter within the right pelvic collection was confirmed with the aid of CT guidance. The pigtail was formed connected to a JP suction bulb. A total of 25 cc of clear yellow-pink fluid were withdrawn and sent for culture and Gram stain. The patient tolerated the procedure well and there were no immediate post-procedural complications. A post-procedure non-contrast CT of the pelvis demonstrated the new pigtail catheter in satisfactory position within the right pelvis, with complete collapse of the previous fluid collection around the catheter. Mild amount of fat stranding seen within the pelvis. Stable small left pelvic collection. Multiple clips seen within the pelvis from recent prostatectomy. Contrast seen within the bladder, likely from recent contrast examination and Foley catheter also within the bladder. Moderate sedation was provided by administering divided doses of Versed and fentanyl throughout the total intraservice time of 20 minutes by an independent, trained radiology nurse during which the ___ hemodynamic parameters were continuously monitored. A total of 150 mcg of fentanyl and 2 mg of Versed were administered to the patient. The attending radiologist, Dr. ___, was present throughout the entire duration of the procedure. IMPRESSION: Technically successful CT-guided exchange of 6 ___ pigtail catheter with upsize to 8 ___ pigtail ___ catheter. 25 cc of clear yellow-pink fluid were withdrawn and a sample was sent for culture and Gram stain. No immediate post-procedure complications. The findings were discussed with Dr. ___ at 4:25 p.m. on ___, 10 minutes after completion of the procedure. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with POSTPROCEDURAL FEVER temperature: 102.4 heartrate: 109.0 resprate: nan o2sat: 96.0 sbp: 155.0 dbp: 72.0 level of pain: 15 level of acuity: 3.0
Dr. ___ was admitted to the urology service for Dr. ___ ___ the emergency room. He was given vancomycin and ceftriaxone empirically. Interventional radiology was consulted on hospital day two, who proceeded with CT-guided drain exchange for a larger pigtail catheter. He was NPO for the procedure, and his diet advanced post-procedure. His fever curve was trended and on day of discharge he was afebrile > 24 hours. His cultures were notable for Staphylococcus and his antibiotics were narrowed according to sensitivities. On day of discharge he was ambulating independently with pain well-controlled and tolerating a regular diet with no nausea or vomiting. His bowel function had returned. He was given appropriate prescriptions and instructed to complete a 14 day course of cefadroxil. He is instructed to follow up with interventional radiology and urology.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: HMED Admission Note ___ cc: dyspnea Major ___ or Invasive Procedure: none History of Present Illness: ___ yo M with CAD w/ prior MI, hyponatremia, DM, asthma/COPD, recent admission for suspected type 2 second degree heart block who presents with dyspnea. Pt woke up feeling dyspneic this morning after subacute shortness of breath to a lesser degree over the past few days. Reports associated cough productive of yellow sputum. He says he typically takes his nebulizer treatments twice per day. He tried this morning with minimal relief, so he was brought to the ER for evaluation by his family. Pt denies chest pain, diaphoresis. No dizziness or lightheadedness. In the ED, pt with stable vitals and sats though exam was notable for diffuse wheezing with poor air movement. CXR showed small bilateral effusions but no infiltrate or frank edema. Labs showed hyponatremia to 122. Pt received 125 of solumedrol and multiple duonembs with improvement in his exam and pt admitted for further management. On arrival to floor, pt reports some improvement in his dyspnea. No headache or confusion. ROS: otherwise negative Past Medical History: NIDDM HTN Asthma/COPD Dyslipidemia CAD, s/p reported MI ___ Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; father with asthma. Physical Exam: Vitals: T 98.1 118/57 78 16 99%RA Gen: NAD HEENT: no JVD CV: rrr, no r/m/g Pulm: diffuse wheezing with poor air movement Abd: soft, nt/nd, +bs Ext: trace to 1+ bilateral edema at ankles Neuro: alert and oriented x 3 Pertinent Results: ___ 01:44PM WBC-8.3 RBC-4.89 HGB-14.9 HCT-42.1 MCV-86 MCH-30.5 MCHC-35.5* RDW-14.1 ___ 01:44PM PLT COUNT-340 ___ 01:44PM proBNP-136 ___ 01:44PM CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-1.9 ___ 01:44PM GLUCOSE-92 UREA N-16 CREAT-0.9 SODIUM-122* POTASSIUM-4.2 CHLORIDE-85* TOTAL CO2-30 ANION GAP-11 ___ 01:44PM OSMOLAL-256* ___ 04:25PM URINE HOURS-RANDOM UREA N-465 CREAT-95 SODIUM-22 POTASSIUM-50 CHLORIDE-12 ___ 04:25PM URINE OSMOLAL-309 CXR: Small bilateral pleural effusions and bibasilar atelectasis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Furosemide 40 mg PO DAILY 5. Losartan Potassium 100 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Pravastatin 10 mg PO QPM 8. Tamsulosin 0.4 mg PO QHS 9. Acetaminophen 500 mg PO Q4H:PRN pain 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 11. MetFORMIN (Glucophage) 500 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q4H:PRN pain 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Losartan Potassium 100 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Pravastatin 10 mg PO QPM 8. Tamsulosin 0.4 mg PO QHS 9. PredniSONE 60 mg PO DAILY 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. MetFORMIN (Glucophage) 500 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: COPD exacerbation Hyponatremia Chronic diastolic heart failure HTN DM2 Gout CAD 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 shortness of breath TECHNIQUE: PA and lateral views of the chest COMPARISON: ___ FINDINGS: Mild enlargement of the cardiac silhouette is unchanged. The aorta is diffusely calcified. No pulmonary edema is present, and the hilar contours are normal. Small bilateral pleural effusions are likely unchanged with persistent patchy atelectasis at the lung bases, more so on the left. No pneumothorax is present. No acute osseous abnormality is detected. IMPRESSION: Small bilateral pleural effusions and bibasilar atelectasis. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Dyspnea, Palpitations Diagnosed with WHEEZING, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: 97.8 heartrate: 63.0 resprate: 22.0 o2sat: 94.0 sbp: 146.0 dbp: 80.0 level of pain: 5 level of acuity: 3.0
___ yo M with CAD w/ prior MI, hyponatremia, DM, asthma/COPD, recent admission for suspected type 2 second degree heart block who presents with dyspnea due to COPD/Asthma exacerbation. We treated Mr ___ for COPD exacerbation with oral prednisone and nebulizer treatments. He should follow up with his primary care doctor for ___ and optimization of his outpatient COPD management. He also had hyponatremia which we felt was secondary to SIADH. He was free-water restricted and his sodium improved to 130. He will get labs done ___ and fax to PCP.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with history of chronic left leg lymphedema and no past cardiac history, presents s/p syncopal episode. Around midnight, she describes becoming diaphoretic, nauseated and feeling like she needed to have a bowel movement with significant stomach cramping. She was bearing down to try to prevent vomiting. She tried to ride it out in bed for 2 hours. She then got up to walk to the bathroom, became light-headed, and experienced a syncopal episode. She denies any chest pain, dyspnea or palpitations prior to the episode. Nothing like this has happended before. No fevers, chills. Family members are sick with colds but no GI illness. On arrival in ED, she continued to have mild nausea but denies any other symptoms. In the ED, initial VS were: 97.8 74 101/69 20 98%. Her EKG showed NSR, NA/NI, and <1mm ST depressions in the lateral leads, without any prior for comparison. She received a full dose ASA and initial labs were completely unremarkable. CXR was normal. Given 2L NS and admitted to medicine for syncope. On transfer, VS 98.3 76 108/56 13 98 RA. On arrival to the floor, patient felt fine. No specific complaints. Nausea now gone. She wants to go home. 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: - chronic left leg/foot lymphedema - Meniere's disease - right hand surgery for Dupytren's - osteopenia - last bone density ___ T score spine -1.0, hip -1.6 - T&A age ___ Social History: ___ Family History: Mother died at age ___ - uterine and ovarian ca, melanoma, colon ca, brain tumor, degenerative brain disease, bipolar. Father died at age ___ - bladder Ca, h/o carotid endarterctomy, NIDDM. Sisters - dx age ___ with breast Ca, BRCA neg, also with NIDDM, OCD. Physical Exam: Admission: VS - Temp 98.1F, BP 122/74, HR 72, R 18, O2-sat 97% RA GENERAL - well-appearing female in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored 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 LAD NEURO - awake, A&Ox3, CNII-XII WNL, muscle strength ___ throughout, sensation grossly intact throughout, steady gait Discharge: Unchanged Pertinent Results: Labs on admission: ___ 03:05AM WBC-8.7 RBC-4.61 HGB-14.1 HCT-42.6 MCV-93 MCH-30.7 MCHC-33.1 RDW-13.0 ___ 03:05AM NEUTS-61.3 ___ MONOS-3.5 EOS-2.7 BASOS-0.3 ___ 03:05AM PLT COUNT-252 ___ 03:05AM ALBUMIN-3.9 ___ 03:05AM cTropnT-<0.01 ___ 03:05AM LIPASE-31 ___ 03:05AM ALT(SGPT)-33 AST(SGOT)-32 ALK PHOS-89 TOT BILI-0.2 ___ 03:05AM GLUCOSE-163* UREA N-19 CREAT-0.8 SODIUM-142 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12 ___ 04:08AM ___ PTT-25.5 ___ ___ 04:30AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 04:30AM URINE RBC-1 WBC-22* BACTERIA-NONE YEAST-NONE EPI-<1 ___ 04:30AM URINE HYALINE-3* ___ 04:30AM URINE MUCOUS-RARE Other labs: ___ 10:30AM cTropnT-<0.01 ECG ___: Normal sinus rhythm. Poor R wave progression in leads V1-V3 of uncertain significance. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. CXR ___: FINDINGS: PA and lateral chest radiographs were obtained. The lungs are well expanded and clear. There is no focal consolidation, effusion or pneumothorax. Cardiac and mediastinal contours are normal. IMPRESSION: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D Dose is Unknown PO DAILY 2. Calcium Carbonate Dose is Unknown PO Frequency is Unknown 3. Multivitamins 1 TAB PO DAILY 4. traZODONE 50 mg PO HS:PRN insomnia Discharge Medications: 1. traZODONE 50 mg PO HS:PRN insomnia 2. Calcium Carbonate 0 mg PO Frequency is Unknown 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D 0 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - Syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Syncope. COMPARISON: ___. FINDINGS: PA and lateral chest radiographs were obtained. The lungs are well expanded and clear. There is no focal consolidation, effusion or pneumothorax. Cardiac and mediastinal contours are normal. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: PRESYNCOPE Diagnosed with SYNCOPE AND COLLAPSE temperature: 97.8 heartrate: 74.0 resprate: 20.0 o2sat: 98.0 sbp: 101.0 dbp: 69.0 level of pain: 0 level of acuity: 3.0
HOSPITAL SUMMARY: Ms. ___ is a generally healthy ___ who presented following a syncopal episode. She was admitted to the medicine service for monitoring and experienced no recurrence of symptoms.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old female with type 2 DM and alcohol cirrhosis who was doing well until this morning. She reports having acute onset of epigastric and substernal chest pain radiating to her jaw this morning while at detox meeting. It was associated with n/v, headache, sweats, palpitations. It was not associated shortness of breath. She took an aspirin today. She received nitroglycerin spray x3 by EMS with minimal improvement in symptoms. She has never had these symptoms before. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. In the ED, initial vitals were 7 99.3 101 136/79 18 97%. Labs notable for Trop <0.01. CXR no acute cardiopulmonary process. EKG without ischemic changes. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: 1. Diabetes complicated by peripheral neuropathy, A1c 9.4, h/o DKA 2. Depression 3. Recurrent Alcohol Abuse with multiple admissions for detox, no h/o DT or w/d seizures 4. Alcoholic hepatitis 5. Pancreatitis 6. Cirrhosis/varices by MRI 7. Prior suicidal ideation ___ Social History: ___ Family History: mother - died of ___ brother - died of ___ brother - DM Physical ___: Admission: VS: 98.4, 133/88, 91, 18, 100% RA GENERAL: WDWNF 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 6 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: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+ Discharge: Tele: no events PHYSICAL EXAMINATION: VS: 97.1, 103-130/66-88, 87, 18, 97% RA GENERAL: WDWNF in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP of 6 cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. Pertinent Results: Admission: ___ 12:35PM ___ PTT-29.1 ___ ___ 12:35PM PLT COUNT-190# ___ 12:35PM NEUTS-64.2 ___ MONOS-7.4 EOS-2.6 BASOS-0.6 ___ 12:35PM WBC-6.2# RBC-5.07 HGB-13.3 HCT-40.5 MCV-80* MCH-26.2* MCHC-32.8 RDW-20.1* ___ 12:35PM ALBUMIN-4.6 ___ 12:35PM LIPASE-64* ___ 12:35PM ALT(SGPT)-25 AST(SGOT)-24 ALK PHOS-93 TOT BILI-0.3 ___ 12:35PM estGFR-Using this ___ 12:35PM GLUCOSE-249* UREA N-13 CREAT-0.7 SODIUM-137 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18 ___ 09:30PM PTT-44.3* Troponins: ___ 06:15PM cTropnT-<0.01 ___ 12:35PM cTropnT-<0.01 ___ 06:59AM BLOOD CK-MB-2 cTropnT-<0.01 Dicharge: ___ 06:59AM BLOOD WBC-5.7 RBC-5.09 Hgb-13.8 Hct-41.9 MCV-82 MCH-27.1 MCHC-32.9 RDW-20.2* Plt ___ ___ 06:59AM BLOOD Glucose-168* UreaN-11 Creat-0.7 Na-141 K-4.2 Cl-101 HCO3-28 AnGap-16 ___ 04:26PM BLOOD D-Dimer-<150 Imaging: ___ Cardiovascular STRESS INTERPRETATION: This ___ yo woman with h/o IDDM with peripheral neuropathy, alcohol abuse, and family h/o premature CAD was referred to the lab from the floor following negative serial cardiac enzymes for evaluation of chest discomfort. The patient exercised for 7.5 minutes of ___ protocol and was stopped for fatigue. The peak estimated MET capacity was 8.7, which represents an average exercise tolerance for her age. During late exercise, the patient reported a ___ central and left-sided chest "heaviness." At peak exercise, this sensation increased to ___ and radiated to the right side of the chest. During recovery, the sensation, which was mildly tender to palpation, waxed and waned and radiated to the right jaw in late recovery. There were no significant ST segment changes noted during exercise or recovery. Rhythm was sinus with two isolated APBs. The heart rate response was blunted in the presence of beta blockade. IMPRESSION: Atypical anginal symptoms in the absence of ischemic EKG changes at a low cardiac demand and average functional capacity. Blunted hemodynamic response. ___ Cardiovascular ECHO The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>70%). 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. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild diastolic dysfunction. ___ Radiology CHEST (PA & LAT) FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. Aorta is tortuous. The mediastinum is not widened. The hilar contours are stable. Evidence of prior posterior right 7th rib fracture is seen. IMPRESSION: No acute cardiopulmonary process. The mediastinum is not widened. ECG Study Date of ___ 8:58:00 ___ Sinus rhythm. Wandering baseline. Non-specific inferolateral ST-T wave changes without diagnostic interim change. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 30 mg PO BID 2. Duloxetine 30 mg PO DAILY 3. Creon 12 2 CAP PO TID W/MEALS 4. Gabapentin 800 mg PO TID 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous QAM 8. Docusate Sodium 100 mg PO BID 9. Ibuprofen 600 mg PO Q8H 10. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous QACHS 11. traZODONE 50 mg PO HS:PRN insomnia Discharge Medications: 1. BusPIRone 30 mg PO BID 2. Creon 12 2 CAP PO TID W/MEALS 3. Docusate Sodium 100 mg PO BID 4. Duloxetine 30 mg PO DAILY 5. Gabapentin 800 mg PO TID 6. Multivitamins 1 TAB PO DAILY 7. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous QACHS 8. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous QAM 9. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN pain RX *aluminum-magnesium hydroxide [Mylanta] 500 mg-500 mg/5 mL ___ mL by mouth four times a day Disp #*1 Bottle Refills:*0 10. traZODONE 50 mg PO HS:PRN insomnia 11. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: atypical chest pain Secondary: diabetes, depression, alcoholism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Chest pain, evaluate for mediastinal widening. TECHNIQUE: Chest: Frontal and lateral views. COMPARISON: ___. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. Aorta is tortuous. The mediastinum is not widened. The hilar contours are stable. Evidence of prior posterior right 7th rib fracture is seen. IMPRESSION: No acute cardiopulmonary process. The mediastinum is not widened. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CP Diagnosed with INTERMED CORONARY SYND temperature: 99.3 heartrate: 101.0 resprate: 18.0 o2sat: 97.0 sbp: 136.0 dbp: 79.0 level of pain: 7 level of acuity: 2.0
___ year old female with type 2 DM and alcohol cirrhosis admitted with chest pain unlikely to be cardiac in nature. #. Atypical chest pain- Patient presented with acute onset of chest pain radiating to bilateral jaws associated with nausea, vomiting and diaphoresis. This was initially very concerning for an acute coronary syndrome. EKG was without any ischemic changes. Patient was placed on a nitroglycerin and heparin drip in the emergency department and admitted. Aspirin, metoprolol and atorvastatin was started. Troponins <0.01 x3. TIMI risk score of two. Nitroglycerin and heparin drip discontinued. The patient continued to have episodes of atypical chest pain that lasted for 2 minutes and subsided. An ETT was performed with no ischemic changes. An ECHO was done and showed normal biventricular systolic function with mild LVH and no significant valvular disese. A d-dimer was checked because the patient later described a pleuritic nature to the pain, this was negative. The differential includes musckuleskeletal, gastrointestinal disease and anxiety. The patient reports a recent endoscopy showing gastritis. Peptic ulcer disease is also possible as the patient has a history significant for ibuprofen use and alcohol abuse. Ibuprofen was discontinued and omeprazole was increased to BID. She also reports a lot of stress recently related to her social situation. #. Diabetes: Poorly controlled 9.4% and complicated by peripheral neuropathy. Patient placed on insulin sliding scale. Gabapentin continued. #. Depression- Continued on home buspirone and duloxetine. #. Recurrent Alcohol Abuse with multiple admissions for detox, denies history of delirium tremens or seizure. Last drink two months ago and enrolled in an alcohol abuse residential program.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending: ___ Chief Complaint: Unsteady gait Major Surgical or Invasive Procedure: ___: R crani for recurrent SDH ___: Middle Meningeal Artery embolization History of Present Illness: ___ not on anticoagulation and known to the Neurosurgery service presents with unsteady gait and increased dizziness for approx. 3 days. Patient was previously admitted for a R SDH following a fall off his bicycle in ___ - at that time he underwent a right mini craniotomy for ___ evacuation with Dr. ___. Patient did well and was discharged home in stable condition. He was last seen in follow-up on ___ and NCHCT at that time showed persistent R SDH with 7mm MLS. He denies any other neurologic symptoms or changes - no headache or visual changes. No recent falls. ___ in the ___ ED reveals interval increase of his acute-on-chronic R SDH with 12mm MLS. Neurosurgery was consulted to dictate further management. Past Medical History: ___ - right craniotomy for chronic ___ evacuation Traumatic ___ ___ s/p multiple burr holes CAD s/p DES to LAD Hypercholesterolemia Social History: ___ Family History: Noncontributory Physical Exam: ON ADMISSION ============ PHYSICAL EXAM: 1430 - HR 55; 146/73; RR 16; 100% RA Gen: No acute distress HEENT: PERRL 4-3mm, EOMI Extremities: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam. 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: PERRL 4-3mm. Visual fields are full to confrontation. III, IV, VI: EOMs intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. XI: Trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. LLE ___, otherwise ___ throughout. No drift. Sensation: Intact to light touch Handedness - Right ============= ON DISCHARGE ============= Pertinent Results: Please see OMR for pertinent lab/imaging studies. Medications on Admission: Atorvastatin 80mg daily qhs Finasteride 5mg daily Keppra 500mg BID Metoprolol 25mg qd Zolpidem 5mg prn qhs Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild/Fever 2. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID rash Duration: 7 Days 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 4. Docusate Sodium 100 mg PO BID 5. LevETIRAcetam 500 mg PO BID 6. Senna 17.2 mg PO HS 7. TraMADol 25 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 8. Atorvastatin 80 mg PO QPM 9. Finasteride 5 mg PO DAILY 10. Metoprolol Tartrate 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subdural hematoma with cerebral compression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CR - CHEST PA LATERAL INDICATION: History: ___ with R hip pain, s/p fall 1 month ago, now with dizziness, unsteady gait. hx of SDH s/p craniotomy in ___// r/o worsening SDH, r/ o PNA, r/o hip fracture TECHNIQUE: Frontal and lateral view radiographs of the chest. COMPARISON: None. FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities are identified. IMPRESSION: No pneumonia or acute cardiopulmonary process. Radiology Report EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT INDICATION: History: ___ with R hip pain, s/p fall 1 month ago, now with dizziness, unsteady gait. hx of ___ s/p craniotomy in ___// r/o worsening ___ r/o PNA r/o hip fracture TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and frog-leg lateral views of right hip. COMPARISON: None. FINDINGS: Patient is status post left hip arthroplasty. The acetabular cup has a horizontal orientation. There is no acute fracture or dislocation. Mild to moderate degenerative changes are seen in the right hip. There is no suspicious lytic or sclerotic lesion. There is a surgical clip adjacent to the pubic symphysis. IMPRESSION: 1. No evidence of acute fracture. 2. Horizontal orientation of the acetabular cup, which can represent normal postsurgical changes. Correlation with prior imaging is recommended. Radiology Report EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT INDICATION: History: ___ with L hip pain// eval prosthetic TECHNIQUE: Frontal and frog-leg lateral views of the left hip. COMPARISON: None. FINDINGS: Patient is status post total left hip arthroplasty. There is a horizontal orientation of the acetabular cup which can represent normal postsurgical changes. There is no acute fracture or dislocation. There is no suspicious lytic or sclerotic lesion. IMPRESSION: 1. Horizontal orientation of the left acetabular cup which can represent normal postsurgical changes. Correlation with prior imaging is recommended. 2. No evidence of acute fracture. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with dizziness sp craniotomy this past ___// r/o ___ TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: Head CTs dated ___ and ___. FINDINGS: Again seen are postsurgical changes related to right parietal craniotomy. Left frontal/parietal burr holes are again noted. There has been interval increase in size in the right cerebral convexity subdural hematoma, which now measures up to 2.2 cm in thickness, previously 1.4 cm. There are peripheral and linear reticular areas of hyperdensity, which likely represent evolving blood products/fibrin. No definite acute blood products are identified. There is increased mass effect and sulcal effacement of the right frontal lobe with increasing leftward midline shift now measuring up to 1.2 cm, previously 7 mm. There is also slight interval increase in effacement of the frontal horn of the right lateral ventricle and third ventricle. However, the basal cisterns remain patent. The remaining ventricles are unchanged in size. There is no evidence of acute territorial infarction. No acute fractures are seen. Re-demonstrated is a mucous retention cyst in the right sphenoid sinus. Otherwise, the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Interval increase in size in the subacute to chronic right cerebral convexity subdural hematoma with increasing mass effect on the subjacent brain parenchyma and sulcal/ventricular effacement. 2. Interval increase in leftward midline shift, now measuring up to 1.2 cm, previously 7 mm. 3. Redemonstration of postsurgical changes related to prior right parietal craniotomy. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:37 pm, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ year old man s/p R crani for evacuation of recurrent SDH// Postop eval- ___ perform 0500 ___. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.7 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: CT head from ___. FINDINGS: The patient is status post right frontal craniotomy for evacuation of a right hemispheric acute on subacute/chronic subdural hematoma. A drainage catheter has been placed which terminates along the anteromedial right frontal lobe. There is an extra-axial collection of fluid and air measuring up to 1.9 cm in thickness, previously 2.2 cm. Similar to prior, areas of hyperdensity within this collection are concerning for acute hemorrhage, similar in volume compared to prior. There is persistent mass effect on the right lateral ventricle as well as right frontal and parietal lobe sulcal effacement. There is 8 mm of leftward midline shift, previously 1.2 cm. The basal cisterns are patent. There is no evidence of acute infarction. Submucosal retention cysts are seen in the bilateral maxillary sinuses and in the right sphenoid sinus. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits show bilateral lens replacement. IMPRESSION: Status post right craniotomy and placement of a drainage catheter for acute on subacute/chronic subdural hematoma evacuation with expected postsurgical changes, interval decrease in size of the subdural collection, and improved leftward midline shift. Radiology Report EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK. INDICATION: ___ year old man with chronic SDH, s/p two craniotomies (POD1, POD53)// please evaluate for patency of neck arteries as pre-procedural study for planning of middle mengigeal artery embolization. TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the skull base during infusion of 55 mL of Omnipaque350 intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.0 s, 31.6 cm; CTDIvol = 13.1 mGy (Body) DLP = 412.0 mGy-cm. 2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.4 mGy-cm. 3) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 24.4 mGy (Body) DLP = 12.2 mGy-cm. Total DLP (Body) = 426 mGy-cm. COMPARISON: Head CT dated ___, and ___. FINDINGS: The carotidandvertebral arteries and their major branches are patent with no evidence of stenoses NASCET criteria. No evidence for dissection is seen. There is a dominant left vertebral artery. Multilevel degenerative changes are visualized throughout the cervical spine consistent with anterior and posterior spondylosis, more significant from C4-C5 through C6-C7 levels. Pleural scarring is noted in the lung apices, more pronounced on the right, the thyroid gland appears unremarkable. Mucous retention cysts are visualized in both maxillary sinuses. IMPRESSION: 1. Patent carotid and vertebral arteries with no evidence of stenosis, dissection, or aneurysm formation. 2. Multilevel degenerative changes throughout the cervical spine as above. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with recurrent right chronic SDH, now POD2 repeat right craniotomy (first crani ___// please evaluate subdural TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 843 MGy-cm COMPARISON: CT head dated ___. FINDINGS: The patient is status post right frontal craniotomy and evacuation of right hemispheric subdural hematoma. A drainage catheter is unchanged in position, terminating anterior to the right frontal lobe. There is no significant change in the extra-axial collection of mixed density fluid and air, measuring up to 1.8 cm in thickness. There is a similar amount of hyperdense component consistent with acute hemorrhage. There is persistent leftward shift of midline structures measuring 6 mm, not significantly changed from prior, as well as similar mild effacement of the right lateral ventricle. There is no evidence of acute large territorial infarction. A mucous retention cyst is again noted in the right sphenoid sinus. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There are bilateral lens replacements. The visualized portion of the orbits are otherwise unremarkable. IMPRESSION: 1. Unchanged appearance status post right craniotomy and drainage catheter placement, with no substantial change in mixed density right subdural collection and pneumocephalus. 2. Similar mass effect, with leftward midline shift and mild effacement of the right lateral ventricle. Radiology Report EXAMINATION: Right middle meningeal artery embolization for chronic subdural hematoma During the procedure the following vessels were selectively catheterized angiograms were performed: Right internal carotid artery Right external carotid artery Right middle meningeal artery micro injection Right common carotid artery after embolization Right common femoral artery INDICATION: This is an ___ gentleman who has undergone craniotomy twice for chronic subdural hematoma. He was felt to be candidate for middle meningeal artery embolization to prevent reaccumulation. 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 and middle meningeal artery embolization of the right 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 8 ___ sheath was partially introduced and connected to continuous heparinized saline flush. Next a ___ diagnostic catheter was introduced over the Glidewire into the midthoracic portion. The Glidewire was removed in favor of an Amplatz wire in order to straighten out the tortuosity of the lower aorta. The long sheath was completely advanced over the Amplatz wire using fluoroscopic guidance. The Amplatz wire was removed. The ___ catheter had been 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. Multiple attempts were made to access the right carotid artery without success. The catheter was positioned in the left subclavian artery. Exchange length Glidewire was advanced into the left subclavian artery. The diagnostic ___ catheter was removed and a flushed and prepared V-tach intermediate catheter was exchanged into the aortic arch. Glidewire was removed. The new diagnostic catheter was connected to continuous heparinized saline flush as well as the power injector. It was advanced into the right innominate artery. A roadmap was performed. The catheter was advanced into the right internal 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 catheter was withdrawn into the right common carotid artery. A roadmap was performed. The catheter was advanced over the wire to into the right external carotid artery 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 the supply the retina as well as any abnormal anastomosis between the internal and external carotid artery branches that would preclude safe 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 performed. An SL 10 microcatheter loaded with a synchro 2 standard wire was advanced in the left middle meningeal artery. The microwire was removed and microcatheter was connected to continuous heparinized saline flush. Micro injection was performed that confirmed positioning within the MMA. Embosphere was injected however there was reflux below the suspected position of the catheter. The position of the catheter was checked and found to have withdrawn slightly. Microcatheter was removed and discarded. A fresh SL 10 was prepared with a synchro 2 standard wire. It was introduced using a new roadmap and position within the middle meningeal artery on the right. Micro injection was performed in order to confirm positioning. Embosphere was injected under continuous fluoroscopic guidance. Once there is evidence of stasis of the contrast a single 2 mm x 8 cm coil was placed within the origin of the middle meningeal artery. The microcatheter was withdrawn it was noted that the coil was stuck at the tip of the microcatheter. The SL 10 wire was loaded into the microcatheter to push out the coil. The microcatheter was then removed. The diagnostic catheter was withdrawn into the common carotid artery. Final AP and lateral view was obtained in order to rule out thromboembolic complications and confirm successful embolization. Next the diagnostic catheter was removed over ___ stiff wire. 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. Device Inventory Guidant ___ Rotating Valve Cook ___ Connecting Tubing Baxter ___ 3-way Stopcock Terumo ___ .___" 150cm Angled Glidewire x2 ___ ___ x 150cm ___ Wire Terumo RSS805 ___ x 25cm Terumo Sheath Set ___ 45-754 ___ Micropuncture Set ___ ___ Injector tubing 72" ___ Scient. ___ .035 ___ cm Amplatz Super Stiff Wire Cook ___ ___ VTK .038/100cm Cath. ___ 2641 Synchro2 Standard 14 200cm Wire ___ ___ Excelsior SL-10 150cm Microcatheter ___ Medical S220EG 100-300 Embosphere Gold Particles ___ ___ InZone Detachment System ___ ___ Target HelicalUltra 2mm/8cm Coil Perclose FINDINGS: Right internal carotid artery: There is opacification of the anterior and middle cerebral arteries and their distal territories. There is a fetal configuration the PC OM. There is no evidence of aneurysm or AVM. The retinal blush is supplied via the ophthalmic artery. There is some compression from residual subdural hematoma. Vessel caliber smooth and regular. Right external carotid artery: There is no evidence of carotid stenosis in the cervical region based on roadmap images and NASCET criteria. There is filling of the distal external carotid artery branches. There is a robust middle meningeal artery that appears to supply membranes beneath the craniotomy site. There is no anastomosis was ring the middle meningeal artery and the internal carotid artery. Right middle meningeal artery: There is filling of the middle meningeal artery. There is no anastomosis the intracranial circulation. Right common carotid artery after embolization: Vessel caliber smooth and regular. There is opacification of the anterior middle cerebral arteries and their distal territories. There is coil artifact within the middle meningeal artery. There is no evidence of embolization to the internal carotid artery circulation. There is no filling of the middle meningeal artery indicating successful embolization. There is decreased filling of the external carotid artery distal to the facial artery. 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: Uncomplicated embolization of the right middle meningeal artery with embospheres and the coil for chronic subdural hematoma that is re-accumulated and undergone craniotomy twice RECOMMENDATION(S): 1. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dizziness, Unsteady gait Diagnosed with Nontraumatic acute subdural hemorrhage, Dizziness and giddiness temperature: 97.3 heartrate: 58.0 resprate: 16.0 o2sat: 100.0 sbp: 152.0 dbp: 76.0 level of pain: 0 level of acuity: 3.0
On ___, Mr. ___ presented to the ED with complaint of unsteady gait and "dragging his left foot." CT scan revealed an interval increase in the size of his known subacute on chronic right cerebral convexity subdural hematoma, with increased mass effect and midline shift of 1.2cm (previously 7mm). #Subacute on chronic subdural hematoma He was admitted to the ___ for close monitoring and planning of surgical intervention. On ___, surgical procedure was discussed and with consent, the patient was brought to the OR for right craniotomy for evacuation of subdural hematoma. The case was uncomplicated, please see OMR for detailed operative report. He was extubated in the operating room and transferred to PACU for post-anesthesia monitoring. He was somewhat agitated coming out of anesthesia, however this was controlled with Haldol. He remained hemodynamically and neurologically stable and was transferred back to the ___ for continued neurologic monitoring. Head CT on ___ showed expected post-operative changes with significant improvement in mass effect and midline shift. Out of concern for recurrence, neurointerventional radiology was consulted for possible middle meningeal artery embolization. CTA neck was performed as pre-angio planning, which revealed patent carotid and vertebral arteries. On ___, ___ showed stable postop changes. JP drain was removed ___. On ___, he was taken to angio for embolization of MMA; his operative course was uncomplicated, please see OMR for full details of procedure. Postoperatively, he was monitored in ___ where he remained neurologically and hemodynamically stable. Aline and foley were removed. He was evaluated by physical therapy, who recommended rehab at discharge. #Rash He developed diffuse itchy red popular rash on his back on ___. He had newly received oxycodone the night prior and this was discontinued. He was started on Betamethasone lotion and rash was monitored.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / Cymbalta / hydrochlorothiazide / Prozac Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a past medical history significant for hypertension, diabetes, severe osteoarthritis, vascular dementia, TIA and depression who presented to the ED on ___ with confusion. Per daughter, who is her primary caretaker, Ms. ___ was left alone briefly at home and became confused around 7:30am, at which point she called an ambulance and was brought to ___ ED. The patient was unable to explain why she called ambulance, saying that she was "scared" and "in pain." She denied fever/chills, urinary urgency, frequency, dysuria, hematuria, foul or dark urine, N/V/D, CP/SOB. Her only localizing symptom was a non-productive cough of 2 days in duration. She has longstanding history of R shoulder osteoarthritis, which she says is severe but at about her baseline. She has a history of chronic shoulder pain and knee pain w/joint effusions, is followed by Dr ___ at ___. ___ daughter, her mental status seemed completely at her baseline today and in the preceding few days. The pt does report decreased PO intake at home over the past few days. In the ED, initial VS were 98.2 79 161/69 16 98%. Repeat rectal temperature was 101.0. Labs were significant for normal chem 7, negative tox screen, CXR w/o acute finding, head CT w/o acute findings, bland UA, new mild leukopenia (WBC 3.3) Received tylenol. Ortho saw pt in ED and did not feel the shoulder or knee were concerning for infection. On arrival to the floor, vitals are 98.0 68 143/73 16 99%. Patient reports feeling about the same as when she came to the ED. Past Medical History: PAST MEDICAL HISTORY Hyperlipidemia Hypertension Osteoarthritis (R knee) Anxiety Back pain Cataract Colonic adenoma Constipation Dementia (cant remember daily activities) Depression Diabetes mellitus (insulin) Diverticulosis Glaucoma Fibroids PAST SURGICAL HISTORY Discectomy Hysterectomy d/t fibroids Shoulder surgery Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM VS - 98.2 79 161/69 16 98% RA General: NAD, lying in bed, feeling cold HEENT: MMM, OP clear, no e/o thrush, very good dentition Neck: Supple, no LAD CV: RRR, S1 S2 auscultated, no m/g/r Lungs: CTAB, no wheeze or crackles Abdomen: Soft, NT, ND, very mild suprapubic tenderness, +BS GU: Deferred Ext: R knee with moderate effusion and soft-tissue swelling superior to knee joint. Decreased ROM, but no pain on passive ROM. R shoulder with markedly decreased ROM (unable to abduct appreciably at all). No ___ edema Neuro: Gait not assessed, CN II - XI intact Skin: No rash DISCHARGE PHYSICAL EXAM VS - 98 132/74 76 20 98% RA General: NAD, patient is ambulating around room, very friendly HEENT: MMM, OP clear Neck: Supple, no LAD CV: RRR, clear S1 S2, no m/g/r Lungs: Normal respiratory rate and effort, CTAB Abdomen: Soft, non-distended, non-tender, bowel sounds present GU: Deferred Ext: R knee with moderate effusion and soft-tissue swelling with decreased ROM, R shoulder with markedly decreased ROM. ___ warm and well-perfused, no edema. Pertinent Results: IMAGING: R SHOULDER XR ___: Degenerative changes of the AC and glenohumeral joint are not significantly changed from ___. KNEE AP/LAT/OBLIQUE ___: Tricompartmental degenerative changes without definite acute fracture. Joint effusion appears smaller when compared to previous exam. CXR ___: No evidence of acute cardiopulmonary process. HEAD CT ___: No evidence of acute intracranial process. ADMISSION LABS: ___ 09:55AM BLOOD WBC-3.3* RBC-3.85* Hgb-11.3* Hct-34.1* MCV-89 MCH-29.3 MCHC-33.1 RDW-16.4* Plt ___ ___ 09:55AM BLOOD Neuts-39.1* Lymphs-50.9* Monos-6.3 Eos-2.6 Baso-1.0 ___ 09:55AM BLOOD ___ PTT-35.7 ___ ___ 09:55AM BLOOD Plt ___ ___ 09:55AM BLOOD Glucose-154* UreaN-8 Creat-0.7 Na-143 K-3.7 Cl-106 HCO3-25 AnGap-16 ___ 09:55AM BLOOD Calcium-10.2 Phos-2.6* Mg-1.7 ___ 09:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:51AM BLOOD Lactate-1.5 URINALYSIS ___: Blood-neg, Nitrite-neg, Protein-neg, Glucose-neg, Ketone-neg, Bilirub-neg, Urobiln-neg, pH-7.0, Leuks-neg MICROBIOLOGY: Blood cultures x2 ___-- pending Urine cultures ___-- pending DISCHARGE LABS: ___ 07:45AM BLOOD WBC-4.0 RBC-3.62* Hgb-10.8* Hct-31.8* MCV-88 MCH-29.8 MCHC-33.9 RDW-16.5* Plt ___ ___ 07:45AM BLOOD Neuts-34.9* Lymphs-54.0* Monos-8.4 Eos-2.3 Baso-0.4 ___ 07:45AM BLOOD Plt ___ ___ 07:45AM BLOOD Glucose-162* UreaN-7 Creat-0.6 Na-141 K-3.6 Cl-106 HCO3-27 AnGap-12 ___ 07:45AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 5 mg PO BID 2. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral BID;PRN Headache 3. Citalopram 20 mg PO DAILY 4. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous QD 7 units Q AM 5. Losartan Potassium 75 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Metoprolol Succinate XL 200 mg PO DAILY Hold if SBP < 100 or HR < 60 8. NIFEdipine CR 90 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Atorvastatin 80 mg PO HS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO HS 3. BusPIRone 5 mg PO BID 4. Citalopram 20 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Losartan Potassium 75 mg PO DAILY 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. NIFEdipine CR 90 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. butalbital-acetaminophen-caff *NF* 50-325-40 mg ORAL BID;PRN Headache 13. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous QD per home dose 14. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Dementia 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: ___ female with right shoulder pain and altered mental status. COMPARISON: ___. TECHNIQUE: Frontal upright and lateral chest radiograph. FINDINGS: The lungs are well expanded and clear. Cardiomediastinal and hilar contours are unremarkable. There is no pleural effusion or pneumothorax. Changes of the right shoulder are identified and not significantly changed from ___, better characterized on dedicated films. IMPRESSION: No evidence of acute cardiopulmonary process. Radiology Report HISTORY: Confusion. COMPARISON: Head CT ___. TECHNIQUE: Contiguous axial MDCT images were taken through the brain without the administration of IV contrast. Coronal and sagittal reformats were also examined. DLP: 897.50 mGy-cm. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or infarction. Bilateral periventricular and subcortical white matter hypodensities are consistent small vessel ischemic disease. The ventricles and sulci are normal in size and configuration for age. The basal cisterns appear patent, and there is preservation of gray-white matter differentiation. No fractures are identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: No evidence of acute intracranial process. Radiology Report HISTORY: ___ female with knee joint pain, effusion. COMPARISON: ___. FINDINGS: Severe tricompartmental degenerative changes are again seen with osteophyte formation. Chondrocalcinosis is again noted at the tibial femoral compartments. The suprapatellar effusion is slightly smaller when compared to prior exam. Severe degenerative changes also seen in the patellofemoral joint. There is diffuse osteopenia. No visualized fracture. Soft tissues are unremarkable. IMPRESSION: Tricompartmental degenerative changes without definite acute fracture. Joint effusion appears smaller when compared to previous exam. Radiology Report INDICATION: ___ female with fever and severe right shoulder pain. Evaluate. COMPARISON: ___ and ___. TECHNIQUE: Right shoulder, three views. FINDINGS: There is unchanged appearance of the AC joint with mild widening and spurring. Moderate-to-severe degenerative changes of the glenohumeral joint are reidentified, with prominent acetabular osteophytes as well as subchondral cyst in the humeral head. No definite fracture or dislocation is seen. IMPRESSION: Degenerative changes of the AC and glenohumeral joint are not significantly changed from ___. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: CONFUSION Diagnosed with FEVER, UNSPECIFIED, HYPERTENSION NOS temperature: 98.2 heartrate: 79.0 resprate: 16.0 o2sat: 98.0 sbp: 161.0 dbp: 69.0 level of pain: 13 level of acuity: 3.0
Ms. ___ is a ___ yo F with h/o hypertension, diabetes, severe osteoarthritis, vascular dementia, history of TIA and depression who presented with confusion and was found to be febrile x1 in the ED. # Fever: On initial evaluation in the ED, patient was afebrile (t= 98.2), however rectal temp was then performed with t= 101.0. The patient was completely asymptomatic, and reported no localizing symptoms with the possible exception of 2 days of non-productive cough. On arrival to the floor, she was again afebrile (t= 98.0). CXR was clear, and urinalysis was without signs of infection. Blood and urine cultures were collected and the results are still pending though prelim negative. Further evaluation included consulting the Orthopedic Surgery Service to evaluate the patient's baseline knee/shoulder effusions, which were unchanged from baseline, and they felt that septic knee or shoulder was unlikely. Although no clear etiology was found for her transient fever, the patient remained asymptomatic and afebrile for the remainder of her stay. # Dementia: The patient seemed to have altered mental status/confusion from the time she called the ambulance to presentation in the ED, where she had difficulty verbalizing her complaints. It remains unclear as to why the patient initially called the ambulance, however there is no suspician for unsafe home situation. She has remained alert and oriented x ___ throughout her stay. According to her daughter, however, this represents the patient's cognitive baseline in the setting of her vascular dementia rather than a change in mental status. On day of discharge she was oriented to place (___) but not time (could state season but not month, date, or day of week) or person (confused about PCT and writer). # DM2: Her DM is managed with metformin, which was held while in house, and lantus 7u which she received in the morning. She was put on an insulin sliding scale with meals. # Peptic ulcer disease: Non-active during this admission, however patient was continued on her home dose of PPI. # HTN: Patient was continued on her home antihypertensives, losartan, metoprolol, and nifedipine. Her BP remained well-controlled during the stay. # Hyperlipidemia: Patient was continued on her home dose of statin while admitted. # Anxiety: The patient was continued on her home doses of Busparone and Citalopram during this stay. # Constipation: Patient has a history of constipation and is on standing colace at home, which was continued during her hospitalization. Transitional Issues: The patient has two sets of blood cultures and a urine culture which remain outstanding. The primary team was in communication with the patient's daughter ___ during her stay, specifically with respect the patient's cognitive status and discharge planning. As per her daughter, Ms. ___ had visiting nurse services in the past when she lived alone but now lives with daughter who is her primary caregiver and no longer needs ___. As such, she is being discharged to home without services. In the setting of her dementia, the patient has a moderate risk for representation to the ED although readmission is less likely.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Encephalopathy Major Surgical or Invasive Procedure: Intermittent hemodialysis (___) History of Present Illness: Pre-stroke mRS ___ social history for description): ___ ___ Stroke Scale - Total [20] 1a. Level of Consciousness - 2 1b. LOC Questions - 2 1c. LOC Commands - 2 2. Best Gaze - 0 3. Visual Fields - 0 4. Facial Palsy - 1 5a. Motor arm, left - 2 5b. Motor arm, right - 2 6a. Motor leg, left - 2 6b. Motor leg, right - 2 7. Limb Ataxia - 0 8. Sensory - 0 9. Language - 3 10. Dysarthria - 2 11. Extinction and Neglect - 0 HPI: The patient is an ___ with h/o multiple myeloma, ESRD on HD ___ (Right SC catheter, has LUE fistula but doesn't function), HTN, HLD, incomplete RBBB, CAD, TIA, DMII, b/l carotid artery stenosis, restless leg syndrome, essential tremor, left heel pressure ulcer, and recent prolonged hospitalization presenting as transfer from OSH with altered mental status. Recent hospitalization was initially for evaluation of neck and arm pain, found to have upper extremity thrombophlebitis, new onset AFib vs alternative SVT, and new cardioembolic punctate strokes now on Eliquis (Plavix stopped). His hospitalization was complicated by sepsis and hypoxic respiratory failure in the setting of presumed aspiration pneumonia on ___. He is still on augmentin. Chronic neck pain thought to be related to degenerative disc changes from osteoarthritis. He has been at ___ the past week. At baseline he is very conversant, highly educated and moves all of his extremities. He occasionally becomes confused after pain medications (valium and oxycodone for chronic neck pain) but is not confused at baseline. He can walk 300 ft with a walker. On ___ he was very fatigued and had some myoclonic twitching. He was transfused for low hemoglobin. He seemed to do well on ___ and he was discharged home with ___ support on ___. He received dialysis on ___ and after was very weak which sometimes happens. He also seemed to be more confused. Then he developed frequent jerky movements of his arms and legs that worsened throughout the evening. Movements were greater in the arms than the legs and R> L. For example when he tried to pick up a cup of water his arm would jerk and the water would slosh. His wife describes that since around 4pm on ___ he has been unresponsive and not talking. He tried walking and his knees buckled. Throughout the night ___ to ___ he seemed to be constantly grabbing/picking at his blankets and moving. Given worsening symptoms, family called EMS. No recent fever. No prior history of seizure. He was brought to ___ where a CT scan of the head was obtained that did not demonstrate acute hemorrhage. Because he was outside the window, he was not a TPA candidate. He had a chest x-ray and UA that were unremarkable and he was afebrile. His other labs were notable for a white blood cell count of 8.5. H&H of 10 and 31.2. Troponin 0 0.04. Creatinine 4.32. BUN 29. Potassium 3.3. Patient was transferred to ___ for further evaluation. On neurologic review of systems, patient is not able to report but Wife denies that he has had headache. There is confusion. He has not been speaking or clearly understanding or following directions since yesterday. No clear focal weakness. Denies bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Past Medical History: 1. Gout. 2. History of tonsillectomy/adenoidectomy. 3. depression and anxiety 4. History of confusional episode for which Plavix was started, now on eliquis in the setting of atrial fibrilliation . 5. Hypertension 6. Spinal stenosis 7. Restless legs syndrome 8. Carotid artery stenosis and occlusion 9. Insomnia 10. History of basal cell carcinoma 11. Erectile Dysfunction-Dr. ___, ___ 12. ___ disease 13. Secondary hyperparathyroidism 14. ESRD on HD ___ to Diabetic nephropathy 15. Hyperlipidemia 16. TIA ___ + carotid stenosis ___ US 17. CAD (coronary artery disease) 18. Essential tremor 19. History of Lyme disease 20. Anemia in chronic kidney disease 21. Type 2 diabetes mellitus with stage 3 chronic kidney disease, without long-term current use of insulin 22. Multiple myeloma not having achieved remission Social History: ___ Family History: No history of seizure. Physical Exam: ON ADMISSION: Time TempHRBPRRPox Today ___ RA General: laying in bed, NAD HEENT: NC/AT, no scleral icterus noted, dry mucous membranes Neck: soft collar in place, Supple, pain with movement of head from side to side Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, quiet bowel sounds Extremities: No ___ edema. Left knee flexed at baseline, able to straighten Skin: bilateral surgical knee scars, abrasion on right knee, pressure ulcer left heel Neurologic: -Mental Status: Eyes open, staring ahead, raises eyebrows to voice, No verbal output, localizes and withdraws to pain in all four extremities, does not follow simple directions -Cranial Nerves: II, III, IV, VI: PERRL 2-->1.5 2mm and brisk. No spontaneous EO movements, ED reports bidirectional nystagmus however not able to elicit. V: Facial sensation intact to light touch. VII: Mouth open at baseline, slightly asymmetric with ? right facial droop but difficult to tell VIII: No response to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: Moves deltoids antigravity intermittently XII: Does not protrude tongue -Motor: Normal bulk, tone throughout. Moves fingers and moves arms at shoulders. Arms in restraints. Withdraws both lower extremities to pain. Intermittent non rhythmic thumb flexion on the left. No tremor, noted. No asterixis noted. -Sensory: Withdraws to nail bed pressure, some facial movements with light touch -DTRs: Bi ___ Pat Ach L 2 2 0 0 R 2 2 0 0 Plantar response was flexor on the left, mute on the right -Coordination: unable to assess -Gait: currently not able to ambulate ON DISCHARGE: Vitals: T 97.6 BP 162/56 HR 57 RR 20 SpO2 97% Ra Gen: Alert; NAD. Skin: Pressure ulcers, both heels, dressed. HEENT: NC/AT. MMM. CV: Well-perfused throughout. Chest: Nonlabored breathing. GI: ND/NT. Extr: Near-full RoM, some limitation due to increased tone. Neurologic: Mental status: Awake and alert. Some generalized psychomotor slowing. Oriented to ___ and ___ but unable to say date, month or season. When told that it is fall, he is unable to recall it a few minutes later. Names body parts including elbow, knee, and knuckles. Repeats short phrases with mild dysarthria. Follows one step commands but has difficulty with multistep commands. Motor: Normal bulk. Slightly increased tone in extremities. Able to lift arms against gravity for several seconds. Wiggles toes to command. ___: Intact to light touch throughout. Reflex, coordination, gait: Deferred. Pertinent Results: ADMISSION LABS: ___ 07:02AM BLOOD WBC-8.3 RBC-3.33* Hgb-11.0* Hct-34.3* MCV-103* MCH-33.0* MCHC-32.1 RDW-18.6* RDWSD-64.2* Plt ___ ___ 12:59AM BLOOD ___ PTT-28.1 ___ ___ 07:02AM BLOOD Glucose-112* UreaN-30* Creat-4.5* Na-145 K-4.2 Cl-99 HCO3-27 AnGap-19* ___ 07:02AM BLOOD ALT-34 AST-36 AlkPhos-259* TotBili-0.3 ___ 07:02AM BLOOD Albumin-3.7 Calcium-9.0 Phos-4.2 Mg-2.2 ___ 06:18PM BLOOD Type-ART pO2-460* pCO2-50* pH-7.40 calTCO2-32* Base XS-5 ___ 06:54AM BLOOD Lactate-1.5 ___ 07:02AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 07:41AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 07:41AM URINE Blood-SM* Nitrite-NEG Protein-300* Glucose-NEG Ketone-TR* Bilirub-SM* Urobiln-4* pH-6.0 Leuks-TR* ___ 07:41AM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-1 ___ 07:41AM URINE bnzodzp-POS* barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS* oxycodn-POS* mthdone-NEG PERTINENT LABS: ___ 12:59AM BLOOD TSH-1.4 ___ 11:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 02:45PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-825* Polys-0 ___ Monos-0 (TUBE 1) ___ 02:45PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-33* Polys-0 ___ Monos-0 (TUBE 4) ___ 02:45PM CEREBROSPINAL FLUID (CSF) TotProt-38 Glucose-___BNORMAL BAND IN GAMMA REGION BASED ON IFE (SEE SEPARATE REPORT), MONOCLONAL IGG KAPPA OF NOTE ___ NOTES STATE IGA (VS. IGG) MONOCLONAL PROTEIN Immunofixation MONOCLONAL IGG KAPPA DETECTED INTERPRETED BY ___, MD DISCHARGE LABS: ___ 04:35AM BLOOD WBC-4.9 RBC-2.86* Hgb-9.6* Hct-30.5* MCV-107* MCH-33.6* MCHC-31.5* RDW-21.6* RDWSD-80.1* Plt ___ ___ 04:35AM BLOOD ___ PTT-31.4 ___ ___ 04:35AM BLOOD Glucose-96 UreaN-11 Creat-2.6*# Na-145 K-4.4 Cl-103 HCO3-27 AnGap-15 ___ 04:35AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0 IMAGING: EXAMINATION: MRI AND MRA BRAIN AND MRA NECK ___ INDICATION: ___ year old man with AMS// e/o infection ischemia or lesions TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility and diffusion axial images of the brain were acquired. Following gadolinium administration, T1 axial and MPRAGE sagittal images were acquired with axial and coronal reformats. 3D time-of-flight MRA of the circle of ___ was obtained. Gadolinium enhanced MRA of the neck was acquired. COMPARISON: MRI ___. FINDINGS: There is no definite acute infarct identified. The previously seen areas of restricted diffusion are no longer visible likely secondary to evolution. A small focus of increased signal in the right centrum semiovale with central low signal (08:23) is likely due to a chronic infarct with T2 shine through. Diffuse hyperintensities in the white matter indicate moderate-to-severe changes of small vessel disease as before. There are no micro hemorrhages. Following contrast administration no abnormal enhancement is identified. The subtle enhancement along the temporal lobes described on the pretty ___ is likely artifactual. MRA of the head shows normal signal in the arteries of the anterior and posterior circulation. Mild atherosclerotic disease is identified in the intracranial arteries in particular involving the posterior cerebral artery. No evidence of vascular occlusion stenosis or an aneurysm greater than 3 mm in size seen. MRA of the neck is limited by delayed in acquisition. No vascular occlusion is seen. No evidence of high-grade stenosis. IMPRESSION: 1. No evidence of acute infarct. Previously seen acute infarcts have evolved. 2. Moderate-to-severe small vessel disease and brain atrophy. 3. No abnormal enhancement. 4. Normal MRA of the head except for atherosclerotic disease involving the posterior cerebral arteries. 5. Somewhat limited MRA of the neck demonstrates no evidence of occlusion or high-grade stenosis. MRI L SPINE ___ 1. Spinal fusion at L4-5 level with laminectomy. 2. Severe spinal stenosis above the level of spinal fusion at L3-4 level. Moderate spinal stenosis at L2-3 and mild spinal stenosis at L1-2 level. 3. Multilevel foraminal changes CT HEAD ___: No acute intracranial abnormality. NEUROPHYSIOLOGY: EEG ___: This telemetry captured no pushbutton activations. It showed a slow and disorganized background throughout, along with bursts of generalized slowing and some suppressive bursts with voltage attenuation of background in all areas for a few seconds. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. While there were no overtly epileptiform features, the blunted sharp waves indicate a risk for seizures. Nevertheless, there were no clearly epileptiform discharges or electrographic seizures in this recording. EEG ___: This telemetry captured no pushbutton activations. It showed a disorganized and slow background throughout, with frequent bursts of generalized slowing, many including bursts with sharp and "triphasic" appearance. These findings indicate a moderately severe encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no definitely epileptiform features or any electrographic seizures. EEG ___: The telemetry captured no pushbutton activations. It showed a slow and disorganized background throughout, indicating a moderately severe encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. The widespread faster activity suggests medication effect. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features or electrographic seizures. MICROBIOLOGY: HSV ___ PCR, CSF: NEGATIVE URINE CULTURE (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. MRSA SCREEN (Final ___: No MRSA isolated. CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. SPUTUM Source: Endotracheal. GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. YEAST. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 3. ProSource (amino ac-protein hydr-whey pro;<br>calcium caseinate-whey;<br>protein) ___ gram-kcal/30 mL oral with dialysis 4. Atorvastatin 80 mg PO QPM 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 6. Baclofen 5 mg PO BID 7. Gabapentin 300 mg PO QPM 8. Diazepam 2 mg PO Q6H:PRN neck pain, muscle spasms 9. Apixaban 2.5 mg PO BID 10. Mirtazapine 45 mg PO QHS 11. Escitalopram Oxalate 5 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 13. Donepezil 5 mg PO QHS 14. Ranitidine 150 mg PO DAILY 15. Losartan Potassium 25 mg PO DAILY 16. amLODIPine 5 mg PO DAILY 17. sevelamer CARBONATE 1600 mg PO TID W/MEALS 18. Amoxicillin-Clavulanic Acid ___ mg PO Q12H aspiration pneumonia Discharge Medications: 1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 2. Senna 8.6 mg PO BID:PRN Constipation - First Line 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. amLODIPine 5 mg PO DAILY 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H aspiration pneumonia 6. Apixaban 2.5 mg PO BID 7. Atorvastatin 80 mg PO QPM 8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 9. Donepezil 5 mg PO QHS 10. Escitalopram Oxalate 5 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 12. ProSource (amino ac-protein hydr-whey pro;<br>calcium caseinate-whey;<br>protein) ___ gram-kcal/30 mL oral with dialysis 13. Ranitidine 150 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Toxic-metabolic encephalopathy ___ ___ acquired pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with AMS// PNA TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Right-sided hickmancatheter is unchanged. Cardiomediastinal silhouette is stable. There is subsegmental atelectasis in the lingula. No pneumothorax is seen. There are no pleural effusions. There is stable elevation of the right hemidiaphragm. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK INDICATION: ___ year old man with AMS// e/o infection ischemia or lesions TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility and diffusion axial images of the brain were acquired. Following gadolinium administration, T1 axial and MPRAGE sagittal images were acquired with axial and coronal reformats. 3D time-of-flight MRA of the circle of ___ was obtained. Gadolinium enhanced MRA of the neck was acquired. COMPARISON: MRI ___. FINDINGS: There is no definite acute infarct identified. The previously seen areas of restricted diffusion are no longer visible likely secondary to evolution. A small focus of increased signal in the right centrum semiovale with central low signal (08:23) is likely due to a chronic infarct with T2 shine through. Diffuse hyperintensities in the white matter indicate moderate-to-severe changes of small vessel disease as before. There are no micro hemorrhages. Following contrast administration no abnormal enhancement is identified. The subtle enhancement along the temporal lobes described on the pretty ___ is likely artifactual. MRA of the head shows normal signal in the arteries of the anterior and posterior circulation. Mild atherosclerotic disease is identified in the intracranial arteries in particular involving the posterior cerebral artery. No evidence of vascular occlusion stenosis or an aneurysm greater than 3 mm in size seen. MRA of the neck is limited by delayed in acquisition. No vascular occlusion is seen. No evidence of high-grade stenosis. IMPRESSION: 1. No evidence of acute infarct. Previously seen acute infarcts have evolved. 2. Moderate-to-severe small vessel disease and brain atrophy. 3. No abnormal enhancement. 4. Normal MRA of the head except for atherosclerotic disease involving the posterior cerebral arteries. 5. Somewhat limited MRA of the neck demonstrates no evidence of occlusion or high-grade stenosis. Radiology Report EXAMINATION: CR - CHEST PORTABLE AP INDICATION: History: ___ with intubation// eval for tube position TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___ at 11:09 FINDINGS: There has been interval placement of an endotracheal tube which terminates 6.2 cm above the carina. Otherwise, no significant interval change. IMPRESSION: 1. The endotracheal tube terminates 6.2 cm above the carina. Advancement by 3 cm is recommended for optimal positioning. 2. Otherwise, no significant interval change. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with seizures possible meningitis// Assess ETT position and OGT position. Assess ETT position and OGT position. IMPRESSION: Comparison to ___. The tip of the feeding tube continues to project over the gastroesophageal junction. The other monitoring and support devices are in stable position. The tip of the endotracheal tube projects approximately 6 cm above the carina, unchanged to yesterday. Minimal atelectasis at the left lung bases. No pulmonary edema. No pleural effusion. Normal size and shape of the cardiac silhouette. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with seizures, intubated// eval ETT and OGT, advanced overnight eval ETT and OGT, advanced overnight IMPRESSION: Comparison to ___. Mild left basilar atelectasis. No pneumonia, no pulmonary edema, no pleural effusions. No pneumothorax. The tip of the endotracheal tube projects approximately 6 cm above the carinal. The feeding tube has been advanced. The 2 is coiled in the stomach, the tip projects over the proximal parts of the stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old ESRD on HD (MWF), h/o TIA, bl carotid stenosis, recent prolonged hospitalization for upper extremity thrombophlebitis, afib (now on Eliquis) p/w altered mental status.// interval change, infection interval change, infection IMPRESSION: Compared to chest radiographs ___. Left perihilar consolidation has worsened and right infrahilar consolidation is new. Findings are concerning for bilateral pneumonia, but it should be noted that the patient was extubated in the interim and that would contribute to increasing basal atelectasis that might be responsible for some the abnormalities. Heart is normal size, but bigger today than it was on ___ one. Nevertheless there is no pulmonary edema. Pleural effusion is small if any. No pneumothorax. Dual channel right jugular line ends close to the superior cavoatrial junction. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old man with seizure// dobhoff TECHNIQUE: Single AP radiograph of the chest. COMPARISON: Chest radiograph dated ___. FINDINGS: Right double-lumen central venous catheter terminates in the upper SVC. Multiple exposures are obtained during enteric tube placement. The final image shows the tip of the tube curling in the left upper hemiabdomen, likely within the stomach. Linear atelectasis at the left lung base. No focal consolidations. No pulmonary edema. Unchanged appearance of the cardiomediastinal silhouette. No pleural effusion. No pneumothorax. Osseous structures are unremarkable. Patient is status post cholecystectomy. IMPRESSION: 1. Enteric tube appears appropriate, likely terminating within the stomach. 2. Linear atelectasis at the left lung base. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old ESRD on HD (MWF), h/o TIA, bl carotid stenosis, recent prolonged hospitalization for upper ext thrombophlebitis, afib (now on Eliquis) p/w altered mental status.// interval change IMPRESSION: In comparison with the study of ___, the Dobhoff tube coils in the mid to upper stomach with the tip pointing upward in the fundal region. Hemodialysis catheter is stable. The cardiac silhouette remains within normal limits and there is no evidence pulmonary vascular congestion. A opacification at the left base could merely reflect atelectasis, though in the appropriate clinical setting superimposed aspiration/pneumonia would have to be seriously considered. Mild streaks of atelectasis at the right base above the elevated hemidiaphragmatic contour. Radiology Report EXAMINATION: MRI OF THE LUMBAR SPINE INDICATION: ___ year old man with AMS, r/o meningitis, getting ___ guided LP// ___ guided LP TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were obtained. COMPARISON: No prior similar examinations. FINDINGS: At T11-12 and T12-L1 levels disc degenerative changes seen without spinal stenosis. At L1-2 disc bulging is seen with mild spinal canal narrowing and mild-to-moderate bilateral foraminal narrowing. At L2-3 level, diffuse disc bulging results in moderate spinal stenosis and crowding of the nerve roots with moderate bilateral foraminal narrowing. At L3-4 level, diffuse disc bulge and facet degenerative changes result in severe spinal stenosis and compression of the thecal sac. There is moderate to severe left and moderate right foraminal narrowing. At L4-5 level, the patient has undergone spinal fusion. Mild anterolisthesis is seen. Laminectomy is identified. There is mild-to-moderate bilateral foraminal narrowing. At L5-S1 level, disc bulging is seen with moderate-to-severe bilateral foraminal narrowing right greater than left side. There is no spinal stenosis. The distal spinal cord shows normal signal intensities. The conus is at the upper margin of L1 level. IMPRESSION: 1. Spinal fusion at L4-5 level with laminectomy. 2. Severe spinal stenosis above the level of spinal fusion at L3-4 level. Moderate spinal stenosis at L2-3 and mild spinal stenosis at L1-2 level. 3. Multilevel foraminal changes Radiology Report INDICATION: Pain TECHNIQUE: Two views lumbar spine COMPARISON: ___ FINDINGS: There are 5 non-rib-bearing lumbar type vertebral bodies. There are pedicle screws and spinal rods transfixing L4-L5. Multilevel loss of disc height is noted with anterior osteophytes. There is a left total hip arthroplasty with heterotopic ossification about the lateral capsule. IMPRESSION: Status post posterior fusion with overall good alignment and moderately severe degenerative change. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with DOBHOFF PLACEMENT PROTOCOL// DOBHOFF PROTOCOL Contact name: ___: ___ TECHNIQUE: 4 AP portable chest radiographs were obtained COMPARISON: ___ FINDINGS: 4 sequential images demonstrate advancement of a Dobhoff into the stomach. The tip of a right internal jugular hemodialysis catheter projects over the upper right atrium, unchanged. There is left basilar atelectasis/consolidation and small volume pleural fluid, increased since prior. No pneumothorax or right pleural effusion. The size the cardiomediastinal silhouette is within normal limits. Degenerative changes are seen around both glenohumeral joints. IMPRESSION: Four sequential images demonstrate advancement of a Dobhoff which ultimately terminates in the stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with dobhoff, concern he may have pulled it// eval placement TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: The Dobhoff tube appears to have been pulled back and projects at the level of the GE junction, needs to be further advanced. Right-sided central line is unchanged. Lungs are low volume with mild pulmonary vascular congestion and subsegmental atelectasis in the lingula. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. Radiology Report EXAMINATION: Video Swallo Examination INDICATION: ___ year old man with dysphagia// 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: 2 minutes 26 seconds. COMPARISON: Video oropharyngeal swallow dated ___ FINDINGS: There was penetration with thin liquids without aspiration. No penetration or aspiration with nectar consistency. IMPRESSION: Penetration with thin consistency. No aspiration. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with acute encephalopathy and aspiration PNA. Decreased MS today.// Acute change accounting for decreased language. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.4 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: Brain MRI ___. FINDINGS: There is no evidence of acute large territorial infarction,hemorrhage,edema, or mass. Periventricular and subcortical white matter hypodensities are nonspecific, but likely reflect sequelae of chronic small vessel ischemic disease and correspond to T2/FLAIR hyperintensity on recent MRI. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, Transfer Diagnosed with Altered mental status, unspecified, Chronic kidney disease, unspecified temperature: 97.2 heartrate: 65.0 resprate: 22.0 o2sat: 97.0 sbp: nan dbp: nan level of pain: unable level of acuity: 2.0
SUMMARY: ___ y/o M with past medical history of multiple myeloma, ESRD on HD ___ (Right SC catheter, has LUE fistula but doesn't function), HTN, HLD, incomplete RBBB, CAD, TIA, DMII, b/l carotid artery stenosis, restless leg syndrome, essential tremor, left heel pressure ulcer, and recent prolonged hospitalization for thrombophlebitis who presented from as transfer from OSH with altered mental status. Etiology felt to be medication-induced encephalopathy ( gabapentin, baclofen, valium, mirtazapine) and pseudomonal HAP, improved with dialysis, treatment of PNA and supportive care. By time of discharge, had waxing-waning alertness but trending toward improvement. #Encephalopathy #Multifocal myoclonus: Presented with multifocal myoclonus (left>right), increasing confusion. Placed on cvEEG, no EEG correlate to his myoclonus, no seizures, myoclonus resolved in approximately one day. MRI brain with brain atrophy, posterior circulation atherosclerosis, otherwise unremarkable. Initially placed on broad empiric coverage for bacterial and HSV meningitis with vancomycin, ceftriaxone, ampicillin, and acyclovir. He was not placed on antiepileptic agents. Held home gabapentin, baclofen, valium, mirtazapine. Continued home citalopram, donepezil. LP unable to be performed at bedside due to large burden of fibrous tissue, to be performed with ___ tentatively ___. Overall suspect etiology of presentation medication toxicity from multiple insulting home medications. At time of transfer from ICU, myoclonus resolved, a bit hypertonic in extremities, mental status slowly improved (able to voice some minimal speech output, followed simple commands). Was transferred to floor on ___. To complete the workup for encephalopathy, on ___, pt underwent LP by Anesthesiology, which was unrevealing. CSF obtained for microbial studies; culture and HSV PCR negative; empiric CNS infection antimicrobials discontinued and he remained clinically stable. He seemed to be more confused on ___, less verbal and minimally interactive, and underwent repeat head CT which was unrevealing. He also had a routine EEG done on ___ to complete the workup which showed no seizure activity or epileptiform discharges. By the afternoon on ___ and into ___ AM, his mental status had improved. By time of discharge, his exam was awake, oriented to the correct hospital and year, and able to follow some simple commands, repeat phrases, and name objects in the room. #Dysphagia: He failed multiple speech/swallow evaluations in setting of a slowly resolving encephalopathy and requiring NG tube during prior hospitalization. NG tube was placed to allow him to receive medications as he was recovering. The topic of considering PEG had been discussed with wife, patient and palliative care. Patient and family felt strongly that a PEG was not within goals of care. On ___, pt underwent Ba swallow study; cleared for pureed foods and nectar-thick liquids. Decision made to proceed with this diet, and family is aware of significant aspiration risks. #Acute respiratory insufficiency (resolved): Intubated on presentation given altered mental status and concern for poor airway protection. Extubated ___ with no issues, remained on room air. No further respiratory issues. #Pneumonia: Left hilar PNA, history of LUL consolidation, pleural effusion s/p thoracentesis by IP 1 month ago. Sputum gram stain with pseudomonas, treated for HAP with ceftazidime to complete ___ompleted on ___. Notable was on home augmentin started during last hospitalization, to continue until ___ mg Q12H for 32 days. #ESRD: Followed by nephrology team. Received HD at bedside with no issues. #HTN: Remained normotensive. Held home losartan, amlodipine. #Paroxysmal Atrial fibrillation: Some episodes of RVR to 150s, improved with IV metoprolol. Otherwise remained in sinus with rates below 100. Held home apixaban per interventional radiology recs for 72 hours prior to ___ LP. Not on home rate controlling agents. #HLD: Continued home atorvastatin. #Bilateral carotid stenosis: MRA this admission with patency of vessels. #Multiple Myeloma: Followed by Dr. ___ at ___. Low grade disease with IgG Kapppa subtype 20% marrow involvement from BMA obtained ___, <5% with B-cell clonal population. Last SPEP ___ with IgG Kappa of 721. Repeat SPEP pending. His lenalidomide was discontinued around ___ because of new DVT, which is known side effect. #Left heel pressure ulcer: Not actively infected, followed by wound consult team, provided supportive care ========================
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Aspirin / Ibuprofen / Ciprofloxacin / Prograf / ceftriaxone Attending: ___. Chief Complaint: Abdominal Pain C. Diff Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of ETOH cirrhosis s/p OLT ___ (on MMF, prednisone), cervical stenosis s/p cervical surgery, severe malnutrition s/p G, CKD, osteoporosis, chronic diarrhea, congenital QTc prolongation requiring cardioversion in the past, colon cancer s/p resection in ___, who presents with 3 days of n/v/d and abdominal pain. Patient was in his USOH until 3 days ago, he developed sudden periumbilical abdominal pain, non-radiating, burning in nature. He also reports severe nausea with ~20 episodes of nbnb vomitting over the same period of time. He reports having chronic diarrhea ___ times a day), but states recently they have been more watery. Denies melena/hematochezia. States he has been having chills, but denies actual fever. States he has been drinking lots of liquid and overall has good nutrition. Denies chest pain, dyspnea, cough, dysuria. At baseline, he lives with his sister and has an RN, who is there 8 hours a day, who manages his medications, nutrition. He has a G tube secondary dysphagia from previous cervical surgery, which he rarely uses, about twice a week, in which he takes instruction from his nurse on when to use tube feeds. He has chronic diarrhea from prior colonic resection which is managed with opium tincture and loperamide. He ambulates well, occasionally uses cane. In the ED initial vitals: 98.1 91 118/94 16 100% RA - Exam notable for: mild abdominal tenderness periumbilically, without guarding or rebound. G tube in place just to left of midline without visible erythema or purulence, site ___ Labs notable for: - WBC 13.1 - Cr 1.5 (around recent baseline) - Bicarb 16, Cl 95 (AG 25) Imaging notable for: - CT abdomen/pelvis, which showed "percutaneous GJ tube coils back on itself within the duodenum and terminates in the gastric fundus, representing malpositioning compared to the prior CT A/P. Multiple gas air filled loops of distended small bowel without ___ dilatation or abrupt transition point to indicate SBO. The small-large bowel surgical anastomosis appears intact in LLQ." - Patient was given: dilaudid 1mg IV x5 in 16 hour period, NS, Zofran, home meds On arrival to the floor, he reports history as above. He continues to have abdominal pain and N/V. Past Medical History: # Alcoholic cirrhosis (status post orthotopic liver transplant on ___ on immunosuppression # CKD (baseline creatinine 1.5-1.6): unclear etiology # Chronic diarrhea # Congenital prolonged QT with history of torsades with a cardioversion in the past # Failure to thrive s/p G-tube # Anemia of chronic disease # Pancytopenia on darbepoetin injections # Colon cancer (status post colectomy in ___ # C. difficile colitis # SP right valgus hip fracture, status post pinning # CMV colitis ___ complication) # Osteoporosis # Dermatomal VZV (SP valacyclovir, T3/4). # Cervical stenosis (status post cervical surgery with possible erosion into the esophagus) # Recurrent UTIs - Pseudomonas, MDR. # SP tracheostomy in ___ and ___. # BPH Social History: ___ Family History: Father - living at age ___, hx of MIs Mother - alive, taking care of pts father He denies family history of liver disease, stroke. Physical Exam: ADMISSION PHYSICAL EXAM: 24 HR Data (last updated ___ @ 1801) Temp: 98.1 (Tm 98.1), BP: 148/90, HR: 78, RR: 16, O2 sat: 100%, O2 delivery: RA, Wt: 121.8 lb/55.25 kg GENERAL: pleasant, in no acute distress HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: TTP over posterior cervical spine HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Surgical scar. +BS. Soft, TTP periumbilically. GJ tube c/d/i. EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ___ ___ Temp: 98.4 PO BP: 106/76 HR: 99 RR: 18 O2 sat: 98% O2 delivery: RA GENERAL: pleasant, chronically ill appearing in no acute distress HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: TTP over posterior cervical spine HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Surgical scar. +BS. Soft, mildly TTP LLQ. GJ tube c/d/I, non-tender at site. EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ___ 08:50PM BLOOD WBC-13.1* RBC-4.99 Hgb-14.6 Hct-42.9 MCV-86 MCH-29.3 MCHC-34.0 RDW-13.3 RDWSD-41.4 Plt ___ ___ 08:00PM BLOOD ___ PTT-28.7 ___ ___ 08:50PM BLOOD Glucose-89 UreaN-35* Creat-1.5* Na-136 K-5.4 Cl-95* HCO3-16* AnGap-25* ___ 08:50PM BLOOD ALT-6 AST-21 AlkPhos-58 TotBili-0.9 ___ 08:00PM BLOOD Albumin-4.0 Calcium-7.3* Phos-1.9* Mg-2.0 ___ 01:15PM BLOOD 25VitD-27* ___ 08:50PM BLOOD Lipase-31 ___ 08:50PM BLOOD cTropnT-<0.01 DISCHARGE LABS: ___ 06:06AM BLOOD WBC-6.8 RBC-3.93* Hgb-11.5* Hct-35.4* MCV-90 MCH-29.3 MCHC-32.5 RDW-13.2 RDWSD-43.8 Plt ___ ___ 06:06AM BLOOD ___ PTT-26.7 ___ ___ 12:45PM BLOOD Glucose-148* UreaN-19 Creat-1.7* Na-138 K-4.9 Cl-102 HCO3-26 AnGap-10 ___ 06:06AM BLOOD ALT-10 AST-16 LD(LDH)-177 AlkPhos-52 TotBili-0.4 ___ 06:06AM BLOOD Albumin-3.6 Calcium-8.0* Phos-2.9 Mg-1.6 MICROBIOLOGY: **FINAL REPORT ___ C. difficile PCR (Final ___: Reported to and read back by ___ @ 0539 ON ___ - ___. POSITIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. Therefore, positive C. diff PCR tests trigger reflex C. difficile toxin testing, which is highly specific for CDI. C. difficile Toxin antigen assay (Final ___: POSITIVE. (Reference Range-Negative). PERFORMED BY EIA. This result indicates a high likelihood of C. difficile infection (CDI). ___ 6:44 pm STOOL CONSISTENCY: FORMED Source: Stool. OVA + PARASITES (Pending): __________________________________________________________ ___ 1:55 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. __________________________________________________________ ___ 1:26 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT ___ VIRAL CULTURE (Final ___: UNABLE TO RECOVER VIRUS DUE TO PRESENCE OF C. DIFFICILE TOXIN IN THE SAMPLE. __________________________________________________________ ___ 1:26 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT ___ MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FEW POLYMORPHONUCLEAR LEUKOCYTES. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. __________________________________________________________ ___ 10:31 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 10:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. CT ABDOMEN PELVIS ___: 1. The percutaneous gastrojejunostomy tube coils back on itself within the duodenum and terminates in the gastric fundus, representing malpositioning compared to the prior CT abdomen and pelvis. 2. Multiple gas air filled loops of distended small bowel without ___ dilatation or abrupt transition point to indicate a small-bowel obstruction. The small-large bowel surgical anastomosis appears intact in the left lower quadrant. 3. Normal and stable appearing posttransplant hepatic parenchyma with a patent portal vein. Re-demonstrated moderate intrahepatic biliary ductal dilatation, similar to prior. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Mild 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Multivitamins 1 TAB PO DAILY 4. Mycophenolate Mofetil 500 mg PO BID 5. PredniSONE 5 mg PO DAILY 6. Simethicone 40 mg PO QID:PRN gas 7. Tamsulosin 0.4 mg PO QHS 8. Tiotropium Bromide 1 CAP IH DAILY 9. Vitamin B Complex 1 CAP PO DAILY Start: Upon Arrival 10. amLODIPine 5 mg PO DAILY 11. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 12. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit oral BID 13. LOPERamide 2 mg PO TID:PRN diarrhea 14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 15. Opium Tincture (morphine 10 mg/mL) 10 mg PO Q8H:PRN diarrhea 16. Oxymorphone HCl 10 mg PO BID 17. Sodium Bicarbonate 650 mg PO BID Discharge Medications: 1. Multivitamins W/minerals Chewable 1 TAB PO DAILY RX *pediatric multivit-iron-min [Multi-Vitamins with Iron] 1 tab-cap by mouth once a day Disp #*30 Tablet Refills:*0 2. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Vancomycin Oral Liquid ___ mg PO QID 4. Zinc Sulfate 220 mg PO DAILY Duration: 2 Weeks RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once a day Disp #*14 Capsule Refills:*0 5. amLODIPine 5 mg PO DAILY 6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 7. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit oral BID 8. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Mild 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Mycophenolate Mofetil 500 mg PO BID 11. Oxymorphone HCl 10 mg PO BID 12. PredniSONE 5 mg PO DAILY 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 14. Simethicone 40 mg PO QID:PRN gas 15. Sodium Bicarbonate 650 mg PO BID 16. Tamsulosin 0.4 mg PO QHS 17. Tiotropium Bromide 1 CAP IH DAILY 18. Vitamin B Complex 1 CAP PO DAILY Start: Upon Arrival 19. HELD- LOPERamide 2 mg PO TID:PRN diarrhea This medication was held. Do not restart LOPERamide until your doctor tells you to do so. 20. HELD- Opium Tincture (morphine 10 mg/mL) 10 mg PO Q8H:PRN diarrhea This medication was held. Do not restart Opium Tincture (morphine 10 mg/mL) until your doctor tells you to do so. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: ================== Cdiff colitis Secondary diagnosis: ==================== Cirrhosis s/p transplant Severe protein/calorie malnutrition Dislodged G tube Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ with nausea, vomiting, diarrhea, abd pain, sob// ?portal venous patency, eval of liver, intrabdominal infection pnx TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis ___, abdominal ultrasound ___, abdominal ultrasound ___ FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. CHD: 5 mm at the junction of the intrahepatic and extrahepatic biliary system, and 12 mm inferiorly, similar to prior measurements in ___ There is no ascites, right pleural effusion, or sub- or ___ fluid collections/hematomas. The spleen has normal echotexture. Spleen length: 10.4 cm DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 37.7 cm per second. Appropriate arterial waveforms are seen in the anterior right hepatic artery, posterior write hepatic artery, and the left hepatic artery with resistive indices of 0.61, 0.66, and 0.69, respectively. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. Patent hepatic vasculature with appropriate waveforms. 2. Mild extrahepatic biliary dilation with common hepatic duct measuring up to 1.2 cm, unchanged compared to prior ultrasound ___. Radiology Report INDICATION: ___ year old man with GJ tube p/w 3 days of N/V/Abd pain, GJ tube malpositioned based on CT scan.// please replace GJ tube COMPARISON: GJ tube exchange ___ TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 20 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: 30 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 3 minutes, 6 mGy PROCEDURE: MIC gastrojejunostomy exchange. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. The existing tube was injected with contrast and showed opacification of the gastric rugae and duodenum. A stiff Glidewire was introduced into the jejunum and the tube was removed over-the-wire. Next a stomal measuring device was advanced over the wire and the stoma was measured at 2 cm. A low profile 16 ___ 2 cm stomal length mic gastrojejunostomy catheter was advanced over the wire into position. The catheters balloon was inflated with 7 ml of contrast contrast diluted in sterile water in the proximal duodenum and locked in the stomach after confirming the position of the catheter with a contrast injection. The catheter was then flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Appropriately positioned new 16 ___ MIC 2 cm stomal length low profile gastrojejunostomy tube. IMPRESSION: Successful exchange of a gastrojejunostomy tube for a new 16 ___ MIC 2 cm stomal length low profile gastrojejunostomy tube. The tube is ready to use. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with Gastrostomy malfunction, Dyspnea, unspecified, Liver transplant status temperature: 98.1 heartrate: 91.0 resprate: 16.0 o2sat: 100.0 sbp: 118.0 dbp: 94.0 level of pain: 10 level of acuity: 3.0
SUMMARY STATEMENT: ================== ___ with history of ETOH cirrhosis s/p OLT ___ (on MMF, prednisone), cervical stenosis s/p cervical surgery, severe malnutrition s/p G, CKD, osteoporosis, colon cancer s/p resection in ___ c/b chronic diarrhea, who presents with 3 days of n/v/d and abdominal pain found to have Cdiff colitis.
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: labetalol Attending: ___. Chief Complaint: elevated transaminases Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old woman with a history of HTN and UTIs, who is presenting from clinic with elevated transaminases. She presented to outpatient clinic on ___ with dark urine for 5 days, otherwise feeling well. She was found to have an elevated urobilinogen and elevated LFTs (ALT > ___, AST 980, Tbili 1.8). Has had intermittent nausea but no vomiting. She denies fevers, chills, abdominal pain, shortness of breath, cough. LMP a few years ago, but has been going through IVF treatments. She just went through estrogen therapy to attempt to thicken lining and qualify for IVF program. Of note, patient had elevated AST/ALT in ___ to approximately 500/100. Concern was for DILI secondary to labetalol (8% risk of mild-moderate transaminase changes, some instances of acute hepatitis). Of note, she re-started labetolol in ___. She had one episode of central chest pain/pressure last week which occurred while she was getting ready for work. This lasted ___ minutes and resolved with resting. Not associated with dyspnea. arm/jaw pain, diaphoresis, nausea or other symptoms. Has never had pain like this before. Never had symptoms with eating. In the ED, initial vital signs were: 98.4 78 144/77 18 99% RA Exam notable for: RRR. CTAB. NTND abd. No c/c/e. AAOx3. Well appearing. Labs were notable for: ALT: ___ AP: 151 Tbili: 1.9 Alb: 4.3 AST: 1038 LDH: 675 Lip: 146 Serum EtOH, Acetmnphn Negative HBs-Ab: Neg HAV-Ab: Neg IgM-HBc: Neg IgM-HAV: Neg HCV-Ab: Neg Studies performed include: ___ w Doppler: 1. No cholelithiasis or sonographic evidence of acute cholecystitis. 2. Unremarkable hepatic parenchyma. 3. Patent hepatic vasculature. Patient was given: Labetalol 200 mg Zofran 4mg Consults: Hepatology was consulted and recommended: CBC, BMP, LFTs, Coag, Acetaminophen level, serum tox and UTox, Viral hepatitis serologies (anti-hepatitis A IgM, hepatitis B surface antigen, anti-hepatitis B core IgM, anti-hepatitis C virus antibodies, hepatitis C RNA, anti-herpes simplex virus antibodies, anti-varicella zoster antibodies), Autoimmune markers ___, ___, anti-LKM1, immunoglobulin levels), ABG with lactate, LDH, T&S, HIV Ab test / HIV RNA level, Ceruloplasmin level, and Abdominal Ultrasound with Doppler. Vitals on transfer: 97.9 116 / 78 63 18 99 Ra Upon arrival to the floor, the patient feels well. Had nausea in ED which resolved with Zofran. Has mild headache. Otherwise, she denies symptoms. Review of Systems: (+) per HPI Past Medical History: HYPERTENSION HEART MURMUR MIGRAINES DEPRESSION CARPAL TUNNEL SYNDROME ABNORMAL LIVER FUNCTION TESTS H/O ABNORMAL PAP SMEAR H/O BACK PAIN H/O HELICOBACTER PYLORI Social History: ___ Family History: No known history of liver problems. Mother with HTN, now in remission. Father died of AIDS in ___. She has six siblings who are all well. Son with rheumatoid arthritis. step-dad with advanced lung cancer dx in ___ Physical Exam: ADMISSION PHYSICAL EXAM Vitals 97.9 116 / 78 63 18 99 Ra HEENT: MMM, OP clear CV: RRR, no murmurs Lungs: CTAB, no wheezes/crackles Abdomen: Soft, NTND, +BS Extremities: WWP, no edema DISCHARGE PHYSICAL EXAM VS: 98.8 PO ___ 18 98 RA GEN: Pleasant, middle-aged woman, appears comfortable and in no acute distress, no asterixis HEENT: NC/AT, EOMI, mild jaundice in sclera, jaundice at the frenulum of the tongue, MMM CV: RRR, normal s1/s2, no murmurs, rubs, gallops, or thrills Lungs: CTAB, no wheezes, rales, or rhonchi Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no organomegaly, no rebound/guarding EXT: warm and well perfused, no clubbing, cyanosis, or lower extremity edema Skin: no rashes or other lesions Pertinent Results: ADMISSION LABS ___ 08:13AM BLOOD WBC-4.1 RBC-4.14 Hgb-12.8 Hct-40.6 MCV-98 MCH-30.9 MCHC-31.5* RDW-13.9 RDWSD-50.5* Plt ___ ___ 08:13AM BLOOD Neuts-34.4 ___ Monos-12.9 Eos-0.7* Baso-0.5 Im ___ AbsNeut-1.41* AbsLymp-2.11 AbsMono-0.53 AbsEos-0.03* AbsBaso-0.02 ___ 08:13AM BLOOD ___ PTT-30.9 ___ ___ 08:13AM BLOOD Glucose-91 UreaN-7 Creat-0.8 Na-142 K-4.6 Cl-105 HCO3-23 AnGap-14 ___ 08:13AM BLOOD ___ AST-1038* LD(LDH)-675* AlkPhos-151* TotBili-1.9* ___ 08:13AM BLOOD Lipase-146* ___ 08:13AM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.6 Mg-2.1 ___ 08:25AM BLOOD HBsAg-NEG HBcAb-NEG ___ 08:13AM BLOOD HBsAb-NEG HAV Ab-NEG IgM HBc-NEG IgM HAV-NEG ___ 11:55AM BLOOD Smooth-NEGATIVE ___ 11:55AM BLOOD ___ Titer-1:80* ___ 11:55AM BLOOD IgG-1378 IgA-280 IgM-67 ___ 11:55AM BLOOD HIV Ab-NEG ___ 08:13AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:13AM BLOOD HCV Ab-NEG ___ 08:25AM BLOOD CMV VL-NOT DETECT ___ 08:13AM BLOOD Lactate-1.1 PERTINENT LABS ___ 08:25AM BLOOD ALT-___* AST-1127* LD(LDH)-631* AlkPhos-154* TotBili-2.7* ___ 07:08AM BLOOD ___ AST-1118* LD(LDH)-598* AlkPhos-147* TotBili-3.4* ___ 04:23AM BLOOD ___ AST-1082* LD(LDH)-556* AlkPhos-148* TotBili-4.0* DISCHARGE LABS ___ 04:17AM BLOOD WBC-5.5 RBC-4.17 Hgb-13.2 Hct-40.2 MCV-96 MCH-31.7 MCHC-32.8 RDW-14.1 RDWSD-50.3* Plt ___ ___ 04:17AM BLOOD ___ ___ 04:17AM BLOOD Glucose-98 UreaN-9 Creat-0.8 Na-139 K-4.7 Cl-99 HCO3-25 AnGap-15 ___ 04:17AM BLOOD ALT-1878* AST-953* LD(LDH)-534* AlkPhos-144* TotBili-4.1* ___ 04:17AM BLOOD Albumin-4.2 Calcium-9.8 Phos-4.5 Mg-2.4 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Labetalol 200 mg PO TID 2. Prenatal Vitamins 1 TAB PO DAILY Discharge Medications: 1. Prenatal Vitamins 1 TAB PO DAILY 2.Outpatient Lab Work ALT, AST, Alk Phos, T.bili ___ Acute liver injury Draw labs ___ Fax labs to: Dr. ___ ___ Discharge Disposition: Home Discharge Diagnosis: Primary: Drug-induced liver injury due to labetalol 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 markedly elevated elevated transaminases.?Liver pathology, cholecystitis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Renal ultrasound ___ 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 4 mm. GALLBLADDER: No cholelithiasis. Gallbladder wall appears mildly thickened, but is likely due to underdistension. No pericholecystic fluid. 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 7.5 cm. KIDNEYS: The right kidney measures 10.1 cm. The left kidney measures 10.9 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. No cholelithiasis or sonographic evidence of acute cholecystitis. 2. Unremarkable hepatic parenchyma. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ woman with transaminitis. Evaluate vascular patency. TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Right upper quadrant abdominal ultrasound ___ at 09:19 FINDINGS: Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: Patent hepatic vasculature. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Acute kidney failure, unspecified temperature: 98.4 heartrate: 78.0 resprate: 18.0 o2sat: 99.0 sbp: 144.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0
Ms. ___ is a ___ year-old woman with a history of HTN and UTIs, who presented from clinic with elevated transaminases in the setting of likely DILI ___ labetalol. ACUTE ISSUES # Drug-induced liver injury: The patient presented from clinic with elevation in AST and ALT to >1000. Viral hepatitis serologies were negative, as was a tox screen. It was noted that the patient had a mild elevation in AST and ALT (ALT to 500s) in ___ in the setting of taking labetalol. She was recently placed back on labetalol approximately 2 months prior to admission in the setting of HTN and active invitro fertilization. The patient was monitored in house and after 4 days of hospitalization, her AST and ALT began to downtrend. She remained nontoxic appearing. She was discharged with autoimmune serologies pending, but these would appear less likely. # Hypertension: The patient remained normotensive while in-house and not on any anti-hypertensives. CHRONIC ISSUES None TRANSITIONAL ISSUES [] be sure that labetalol is listed as an allergy for this patient; significant hepatotoxicity was thought to be secondary to labetolol. [] discharge AST/ALT: ___ [] f/u scheduled with PCP and hepatology (Dr. ___ will call you back) [] autoimmune serologies still pending at the time of discharge ___ titer, anti-LKM1) [] hepatitis E IgM pending at time of discharge; will need to be followed up [] hepatitis B vaccination series started, first dose on ___, will need to be completed as an outpatient [] f/u blood pressure as labetalol was discontinued this hospitalization #CODE: FULL CODE (confirmed) #CONTACT: ___ (sister), ___
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: abdominal distension, shortness of breath, melena Major Surgical or Invasive Procedure: EGD ___ Paracentesis ___ History of Present Illness: Mr. ___ is a ___ man with history of HTN, GERD, and EtOH cirrhosis, who presented with worsening shortness of breath and abdominal distention, as well as finding of melena at OSH for which he was transferred for further management. Per ED dashboard: "Patient last had paracentesis performed 10 days ago. At that time, approximately 8 L of fluid was removed. Since that paracentesis, the patient has had progressive abdominal distention as well as shortness of breath. He also reports dark stool as well as some bright red blood per rectum. He does have a history of a GI bleed. Patient presented to an outside hospital where he was noted to have a hemoglobin of 6.8. For this he was transfused 2 units of packed red cells and was transferred for higher level of care. Patient was given octreotide as well as pantoprazole. Patient otherwise without complaints of nausea, vomiting, fever, or chills." In the ED initial vitals: 98.7, 90, 152/75, 16, 98% RA - Exam notable for: HDS, non-toxic appearing, +distended but NT abdomen, evidence of melanotic stool - Labs notable for: CBC: WBC 5.1, Hgb 8.0, Plts 127 Chem7: Na 139, K 7.1 -> 3.3 (recheck), HCO3 17, BUN 25, Cr 1.9 LFTs: ALT 17, AST 48, TB 1.2, Alb 2.3, Lipase 63 Coags: INR 1.4, PTT 24.7 Trop: <0.01 Lactate: 4.9 -> 2.7 Serum Tox ASA/EtOH/APAP/TCA: Negative Peritoneal fluid studies: WBC 67, RBC 1370, Protein 0.4, Glc 136 - Imaging notable for: CXR: No acute intrathoracic process. RUQUS: 1. Cirrhotic liver, without evidence of focal lesion or splenomegaly. There is large volume ascites. 2. Patent portal vein. 3. Circular structure in the midline pelvis is likely related to a prior procedure. Recommend correlation with surgical history. - Consults: Hepatology: Recommended adding CTX given concern for GIB - Patient was given: IV Morphine 2mg, Ceftriaxone 1gm x1, IV Pantoprazole 40mg x1, IV Octreotide gtt @ 50 mcg/hr, 1L LR, Insulin + Dextrose, Calcium Gluconate 1g x1 - ED Course: Pt remained hemodynamically stable and as such was transferred to the floor for further management. Currently, Mr. ___ notes that his major issue is his breathing and distended abdomen. He states that he got a paracentesis about ___ days ago, but the fluid is coming back very quickly. He also notes having dark stools, which is new. He has had a GI bleed about ___ year ago, but none since. Otherwise, does not report fevers, chills, chest pain, nausea, vomiting, abdominal pain, and changes in bowel or bladder habits. Past Medical History: Cirrhosis GERD HTN Social History: ___ Family History: Father with a history of alcohol use disorder. No family history of other liver diseases. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 97.5 PO, BP 156 / 72, HR 88, RR 18, O2 sat 97 Ra GENERAL: NAD, pleasant, cachectic elderly man, in no acute distress HEENT: AT/NC, EOMI, anicteric sclera, pale conjunctiva, MMM NECK: supple, no LAD HEART: RRR, accentuated S1, normal S2, ___ systolic murmur heard best at the LUSB, no gallops or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, slightly increased work of breathing ABDOMEN: firm, significantly distended abdomen, non-tender, normal bowel sounds EXTREMITIES: warm and well perfused, ___ pitting edema to the knees bilaterally, chronic venous stasis changes, no cyanosis or clubbing NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis SKIN: warm and well perfused, spider angiomata on the abdomen, chest and face DISCHARGE PHYSICAL EXAM VITALS: 24 HR Data (last updated ___ @ 835) Temp: 98.0 (Tm 98.7), BP: 127/63 (124-139/62-68), HR: 63 (63-75), RR: 18 (___), O2 sat: 97% (95-100), O2 delivery: Ra, Wt: 160.6 lb/72.85 kg GENERAL: NAD, pleasant, cachectic elderly man HEENT: AT/NC, anicteric sclera, pale conjunctiva, MMM NECK: supple, no LAD HEART: RRR, accentuated S1, normal S2, ___ systolic murmur heard best at the LUSB, no gallops or rubs LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: soft, mildly distended abdomen, dull to percussion, non-tender, normal bowel sounds EXTREMITIES: warm and well perfused, trace pitting edema to the knees bilaterally, chronic venous stasis changes, no cyanosis or clubbing NEURO: A&Ox3, no asterixis, normal strength throughout SKIN: warm and well perfused, spider angiomata on the abdomen, chest and face Pertinent Results: ADMISSION LABS ___ 06:59AM WBC-5.1 RBC-2.81* HGB-8.0* HCT-26.8* MCV-95 MCH-28.5 MCHC-29.9* RDW-17.8* RDWSD-60.6* ___ 06:59AM NEUTS-62.9 ___ MONOS-11.9 EOS-1.8 BASOS-0.4 IM ___ AbsNeut-3.24 AbsLymp-1.16* AbsMono-0.61 AbsEos-0.09 AbsBaso-0.02 ___ 06:59AM ___ PTT-24.7* ___ ___ 06:59AM GLUCOSE-234* UREA N-25* CREAT-1.9* SODIUM-139 POTASSIUM-7.1* CHLORIDE-108 TOTAL CO2-17* ANION GAP-14 ___ 06:59AM ALBUMIN-2.3* CALCIUM-8.0* PHOSPHATE-4.8* MAGNESIUM-1.9 ___ 06:59AM ALT(SGPT)-17 AST(SGOT)-48* ALK PHOS-90 TOT BILI-1.2 ___ 06:59AM LIPASE-63* ___ 06:59AM cTropnT-<0.01 ___ 07:22AM LACTATE-4.9* ___ 07:45AM ASCITES TOT PROT-0.4 GLUCOSE-136 ___ 07:45AM ASCITES TNC-67* RBC-1370* POLYS-18* LYMPHS-42* MONOS-40* PROMYELO-0 OTHER-0 PERTINENT/DISCHARGE LABS ___ 06:47AM BLOOD WBC-3.9* RBC-2.84* Hgb-8.2* Hct-26.7* MCV-94 MCH-28.9 MCHC-30.7* RDW-17.2* RDWSD-59.0* Plt Ct-63* ___ 06:47AM BLOOD ___ PTT-43.3* ___ ___ 06:47AM BLOOD Glucose-89 UreaN-17 Creat-1.5* Na-142 K-3.9 Cl-108 HCO3-23 AnGap-11 ___ 06:47AM BLOOD ALT-9 AST-24 LD(LDH)-167 AlkPhos-61 TotBili-1.5 ___ 06:47AM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.6* Mg-1.7 ___ 05:58AM BLOOD CRP-24.4* ___ 05:58AM BLOOD 25VitD-10* ZINC (SPIN NVY/EDTA) Test Result Reference Range/Units ZINC 32 L 60-130 mcg/dL IMAGING/STUDIES RUQUS ___- 1. Cirrhotic liver, without evidence of focal lesion or splenomegaly. There is large volume ascites. 2. Patent portal vein. 3. Circular structure in the midline pelvis is likely related to a prior procedure. Recommend correlation with surgical history. CXR ___- No acute intrathoracic process. EGD ___- 1. Two cords of small esophageal varices with overlying erythema. 2. Congestion, petechiae and mosaic mucosal pattern in the stomach fundus and stomach body compatible with portal hypertensive gastropathy. 3. Nodularity, erythema, friability and petechiae in the stomach antrum compatible with nodular GAVE. 4. Portal hypertensive enteropathy. 5. Diverticulum in the area adjacent to the papilla. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 50 mg PO BID 2. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 tab-cap by mouth once a day Disp #*30 Tablet Refills:*0 2. Sucralfate 1 gm PO QID Duration: 10 Days RX *sucralfate 1 gram/10 mL 1 g by mouth four times per day Disp #*280 Milliliter Refills:*0 3. Vitamin D ___ UNIT PO 1X/WEEK (WE) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth one time per week Disp #*7 Capsule Refills:*0 4. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once a day Disp #*12 Capsule Refills:*0 5. Metoprolol Tartrate 50 mg PO BID 6. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Alcoholic cirrhosis Secondary: Esophageal varices GAVE Portal hypertensive gastropathy Ascites Anemia Acute kidney injury Moderate malnutrition Coagulopathy 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 shortness of breath// Pulmonary Edema, Pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated earlier same day from outside institution. FINDINGS: Lung volumes are low. There is no focal consolidation. The cardiomediastinal and hilar silhouettes are within normal limits. There is no pulmonary edema. No pleural effusions. No pneumothorax. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with cirrhosis and ascites resenting with shortness of breath// Assess for portal venous thrombosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is coarsened and nodular in echotexture consistent with known cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is large volume ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 2 mm GALLBLADDER: There is no evidence of stones. The gallbladder wall is diffusely thickened, likely secondary to third spacing in the setting of chronic liver disease. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 12.2 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 11.0 cm Left kidney: 8.9 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. There is a circular, well-circumscribed structure in the midline pelvis, which may be related to a prior procedure. IMPRESSION: 1. Cirrhotic liver, without evidence of focal lesion or splenomegaly. There is large volume ascites. 2. Patent portal vein. 3. Circular structure in the midline pelvis is likely related to a prior procedure. Recommend correlation with surgical history. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: GI bleed, Transfer Diagnosed with Gastrointestinal hemorrhage, unspecified, Other ascites, Dyspnea, unspecified temperature: 98.7 heartrate: 90.0 resprate: 16.0 o2sat: 98.0 sbp: 152.0 dbp: 75.0 level of pain: 8 level of acuity: 2.0
Mr. ___ is a ___ man with history of HTN, GERD, and alcoholic cirrhosis complicated by varices and ascites, who presented with worsening shortness of breath and abdominal distention, developed melena at OSH, and was admitted for further management.
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 thigh pain and abdominal pain Major Surgical or Invasive Procedure: MRCP ERCP x 2 History of Present Illness: Mr. ___ is a ___ male with recent surgery for hip fracture at ___, discharged to rehab at ___ of ___, and then discharged back to ___ for persistent hip pain. At ___ was found to have transaminitis and imaging concerning for choledocholithiasis. Transferred to ___ for consideration of ERCP. Patient describes falling on ___ and presenting to ___ the next day, where he was diagnosed with a hip fracture. He underwent surgery and during that admission developed shortness of breath. PE was diagnosed and he was started on lovenox as a bridge to Coumadin. He was ultimately discharged to rehab on ___ but over the past three days developed exercise intolerance, cold sweats, nausea and dizziness. While working with ___ he felt like he was about to pass out. BP per patient was 90/60. He thus returned to ___ ED and was found to have a stone within his distal CBD on CT A/P along with transaminitis. This prompted his trip to ___ for ERCP. He also presented with increasing thigh pain and swelling and was noted to have evidence of hematoma on imaging. ROS also notable for occasional chills and constipation (last BM one day ___ but no objective fevers or diarrhea. ED Course: AFVSS with NTND abdomen and firm left thigh with TTP. Labs s/f ALP 205, AST 55, ALT 99, WBC 13.2. CT at ___: 6 mm calcified stone within the distal common bile duct, with associated intra and extrahepatic biliary ductal dilatation. Interventions: levaquin at 3 am on ___, flagyl at 5 am, Seen by ortho, no c/f compartment syndrome. More likely an intramuscular hematoma in the left thigh, likely secondary to recent femoral fracture and surgical repair. Past Medical History: Hip fracture surgery DM HTN HLD Anxiety/ OCD TIA Volume overload Social History: ___ Family History: sister with gallbladder issues Physical Exam: Discharge Exam VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Thigh compartments are soft and compressible but somewhat firm. Very mildly tender to palpation. No pain with passive stretch of thigh flexors or any muscle groups in the leg. No overlying skinchanges. SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ___. Lukes labs significant for AlkP 205 AST 55 ALT 99 WBC 13.2 Blood and urine cultures drawn and pending St. Lukes imaging CT a/p w/ contrast: 6 mm calcified stone within the distal common bile duct, with associated intra and extrahepatic biliary ductal dilatation. Cholelithiasis. Partially visualized intramuscular hematoma in the left thigh, likely secondary to recent femoral fracture and surgical repair. NCHCT negative No acute intracranial abnormality. RUQUS Prominence of the common bile duct, measuring up to 11 mm in diameter. EKG reviewed and notable for NSR, rate 83, normal axis, IVCD, q waves in inferior leads MRCP: 1. Choledocholithiasis with obstruction at the distal CBD, near the ampulla. There is associated intra and extrahepatic biliary ductal dilatation. 2. Gallstone at the neck of the gallbladder measuring up to 2.5 cm in diameter. There is no wall thickening or other inflammatory findings to suggest cholecystitis. ERCP aborted twice due to food in the esophagus and stomach. Discharge Labs: ___ 04:10PM BLOOD WBC-15.2* RBC-2.63* Hgb-8.1* Hct-26.7* MCV-102* MCH-30.8 MCHC-30.3* RDW-16.1* RDWSD-59.2* Plt ___ ___ 04:10PM BLOOD Plt ___ ___ 05:55AM BLOOD Glucose-155* UreaN-23* Creat-1.1 Na-137 K-4.2 Cl-103 HCO3-24 AnGap-10 ___ 05:55AM BLOOD ALT-70* AST-30 AlkPhos-164* TotBili-1.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Fluvoxamine Maleate 50 mg PO DAILY ocd, anxiety 7. Furosemide 20 mg PO DAILY ___ MD to order daily dose PO DAILY16 Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN indigestion RX *alum-mag hydroxide-simeth [Advanced Antacid-Antigas] 200 mg-200 mg-20 mg/5 mL 5 ml by mouth four times a day Disp #*1 Bottle Refills:*0 2. Enoxaparin Sodium 90 mg SC Q12H RX *enoxaparin 100 mg/mL 100 MG IM every twelve (12) hours Disp #*20 Syringe Refills:*1 3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*20 Capsule Refills:*0 4. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 1 dose by mouth once a day Refills:*0 5. Ranitidine 150 mg PO Q12H:PRN gerd RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 8.6 mg by mouth twice a day Disp #*60 Tablet Refills:*0 7. Aspirin EC 81 mg PO DAILY 8. Atorvastatin 10 mg PO QPM 9. Fluvoxamine Maleate 50 mg PO DAILY ocd, anxiety 10. Furosemide 20 mg PO DAILY 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until you follow up with your PCP 13. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do not restart Lisinopril until until you follow up with your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: Thigh hematoma Choledocholithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with LLE swelling and pain.// Please 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, color flow, and spectral doppler of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: MRCP INDICATION: ___ year old man with choledocholithiasis// rule out obstruction TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: Gadolinium contrast was not administered. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. Evaluation is limited as the patient was claustrophobic and unable to complete the exam. Coronal SSFSE and axial SSFSE sequences were obtained. COMPARISON: CT abdomen ___ FINDINGS: Lower Thorax: The lung bases are clear. There is no pleural effusion. Liver: Liver has uniform attenuation. No evidence of focal masses or lesions. Biliary: There is suspicion of obstructing stones within the CBD at the ampulla (series 5, image 27). There is associated extrahepatic biliary ductal dilatation with the common bile duct measuring up to 1.2 cm in diameter. There is moderate intrahepatic biliary ductal dilatation. The gallbladder is moderately distended. There is no wall thickening. There is a stone within the neck of the gallbladder measuring up to 2.5 cm in diameter Pancreas: Pancreas has uniform attenuation. There is no pancreatic ductal dilatation. Spleen: The spleen is uniform attenuation. Adrenal Glands: The adrenal glands are normal in size and shape. Kidneys: There are multiple cysts within the kidneys, many of which are simple. There is a slightly complex cyst measuring 1.8 cm in diameter at the midpole of left kidney with layering contents, likely representing a hemorrhagic cyst. Gastrointestinal Tract: The visualized bowel is nonobstructed. The appendix is normal. Lymph Nodes: No adenopathy within the field of view. Vasculature: The thoracic aorta has a slightly tortuous contour. No abdominal aortic aneurysm Osseous and Soft Tissue Structures: No suspicious osseous or soft tissue lesions. IMPRESSION: Evaluation is limited as study was aborted prior to completion. There are no contrast-enhanced images. 1. Choledocholithiasis with obstruction at the distal CBD, near the ampulla. There is associated intra and extrahepatic biliary ductal dilatation. 2. Gallstone at the neck of the gallbladder measuring up to 2.5 cm in diameter. There is no wall thickening or other inflammatory findings to suggest cholecystitis. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with Unspecified abdominal pain temperature: 98.2 heartrate: 88.0 resprate: 18.0 o2sat: 96.0 sbp: 130.0 dbp: 78.0 level of pain: 3 level of acuity: 3.0
Mr. ___ is a ___ male with recent surgery for hip fracture at ___, discharged to rehab at ___ of ___, and then discharged back to ___ for persistent hip pain. At ___ was found to have transaminitis and imaging concerning for choledocholithiasis. Transferred to ___ for consideration of ERCP. Course was also complicated by a thigh hematoma in the setting of anticoagulation for a provoked PE after his surgery.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: left flank and pelvic pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman who p/w L flank pain and pelvic pain. The pain began suddenly at 4AM on ___, starting in the L flank, wrapping down the front of her hip, and down across her pelvic floor and into both of her legs. The pain was ___ at 8am on ___. On ___, she had an episode of increased urinary frequency and flank pain, nearly identical to the pain today. It was ___ and she presented to ___ ED, where she was diagnosed with a UTI (UA: large leuks) and treated with cefpodoxime. She reports that her urine has been clear, w/o cloudiness, odor, blood, or stones. No burning or itching with urination. She does complain of some nausea, chills, headache, dry cough, arthralgia. She drinks 1.5 -2 L water a day + 5 cups of coffee + tea. No hx of gout, Crohn's, hyperparathyroid, UTIs. Family hx of one stone (father). Past Medical History: -IBS ('for a long time') -Heartburn Social History: ___ Family History: Father - ___ bypass, kidney stone, prostate ca, neck and throat ca Mother - T1DM, vascular dementia, rheumatic fever as child Uncle - MI (age ___ Paternal grandfather - MI (age ___ Grandmother - ? aortic stenosis Physical Exam: Admission Exam VS: T: 98.2 BP: 123/75 P: 78 R: 18 O2: 98/RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Tender to palpation in LUQ and LLQ. Otherwise soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. No CVA tenderness bilaterally. EXT: Warm, well perfused, no clubbing, cyanosis or edema NEURO: AAOx3. CN ___ grossly intact. Strength and sensation intact in UE and ___. Discharge Exam VS: T: 97.8 BP: 108/72 P: 57 R: 18 O2: 99/RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. No CVA tenderness bilaterally. EXT: Warm, well perfused, no clubbing, cyanosis or edema NEURO: AAOx3. CN ___ grossly intact. Strength and sensation intact in UE and ___. Pertinent Results: ADMISSION LABS: ___ 09:17AM BLOOD WBC-7.4 RBC-4.76 Hgb-14.6 Hct-43.8 MCV-92 MCH-30.7 MCHC-33.3 RDW-12.1 RDWSD-40.5 Plt ___ ___ 09:17AM BLOOD Glucose-131* UreaN-14 Creat-0.8 Na-138 K-3.8 Cl-101 HCO3-19* AnGap-22* ___ 09:17AM BLOOD Albumin-4.6 Calcium-9.6 Phos-2.8 Mg-2.0 ___ 09:17AM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:17AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 09:17AM URINE RBC-13* WBC-1 Bacteri-NONE Yeast-NONE Epi-3 TransE-<1 DISCHARGE LABS: ___ 07:05AM BLOOD WBC-5.2 RBC-4.22 Hgb-13.4 Hct-39.8 MCV-94 MCH-31.8 MCHC-33.7 RDW-12.0 RDWSD-41.6 Plt ___ ___ 07:05AM BLOOD Glucose-137* UreaN-5* Creat-0.7 Na-140 K-3.6 Cl-99 HCO3-31 AnGap-14 MICROBIOLGY: ___ BLOOD CULTURE. PND. NEGATIVE AS OF ___ STUDIES: FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The left kidney is mildly enlarged and demonstrates asymmetric perinephric stranding which extends along the course of the proximal ureter. A 5 mm calculus in the region of the left ureterovesical junction is noted (2:82). There is no evidence of hydronephrosis or hydroureter. The right kidney is normal in appearance and without evidence of nephrolithiasis. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: An IUD is noted within the uterus. There is a small focus of fat attenuation in the region of the left ovary, measuring 1 cm. 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. Some degenerative sclerosis at the inferior right sacrum at the sacroiliac joint is noted. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Probable calculus at the left ureterovesical junction, but without hydronephrosis or hydroureter. 2. Left-sided perinephric fat stranding. This may be due to recent obstruction, or pyelonephritis. 3. Left adnexal fat attenuation lesion, could represent ovarian dermoid. Recommend nonemergent follow-up ultrasound. RECOMMENDATION(S): 1. Recommend correlation with urinalysis. 2. Recommend nonemergent pelvic ultrasound to assess for left ovarian dermoid. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine 75 mg PO TID 2. Multivitamins 1 TAB PO DAILY 3. ClonazePAM 0.5 mg PO DAILY:PRN anxiety Discharge Medications: 1. Tamsulosin 0.4 mg PO DAILY stone passage Take once daily RX *tamsulosin 0.4 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 2. Venlafaxine 75 mg PO TID 3. ClonazePAM 0.5 mg PO DAILY:PRN anxiety 4. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Nephrolithiathis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis. INDICATION: History: ___ with ++ suprapubic and L flank pain, UA w/ +blood // eval ? nephrolithiasis. Marked intraabdominal ttp so please run CTAP w/ contrast if CTU neg TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 5.0 s, 54.5 cm; CTDIvol = 14.2 mGy (Body) DLP = 772.8 mGy-cm. Total DLP (Body) = 773 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The left kidney is mildly enlarged and demonstrates asymmetric perinephric stranding which extends along the course of the proximal ureter. A 5 mm calculus in the region of the left ureterovesical junction is noted (2:82). There is no evidence of hydronephrosis or hydroureter. The right kidney is normal in appearance and without evidence of nephrolithiasis. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: An IUD is noted within the uterus. There is a small focus of fat attenuation in the region of the left ovary, measuring 1 cm. 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. Some degenerative sclerosis at the inferior right sacrum at the sacroiliac joint is noted. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Probable calculus at the left ureterovesical junction, but without hydronephrosis or hydroureter. 2. Left-sided perinephric fat stranding. This may be due to recent obstruction, or pyelonephritis. 3. Left adnexal fat attenuation lesion, could represent ovarian dermoid. Recommend nonemergent follow-up ultrasound. RECOMMENDATION(S): 1. Recommend correlation with urinalysis. 2. Recommend nonemergent pelvic ultrasound to assess for left ovarian dermoid. NOTIFICATION: Recommendation above were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 4:07 ___, 5 minutes after discovery of the findings. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Flank pain, Pelvic pain Diagnosed with Calculus of ureter temperature: 96.4 heartrate: 63.0 resprate: 18.0 o2sat: 99.0 sbp: 147.0 dbp: 87.0 level of pain: 9 level of acuity: 3.0
Mrs. ___ is a ___ yo woman with no significant PMH who presented with left flank and pelvic pain and was found to have a left UVJ stone on CT. # Nephrolithiasis: Pt was recently treated for UTI following a similar episode on ___, at which time she was worked up and treated for a UTI. On day of presentation she had ___ flank pain, which prompted her to present to ED. A CT scan was performed in ED, which showed a 5mm left UVJ stone without hydronephrosis. Urology evaluated her in the ED and recommended conservative management with fluids and symptomatic management. They were formally consulted on day 3, at which point the patient's pain had suddenly ceased and it was suspected that the stone had passed into the bladder. She was discharged with instruction to strain her urine and follow up with outpatient urology to determine stone type and for prevention. If severe pain or other symptoms return, she was instructed to seek medical advice. # Dermoid cyst: Found incidentally on CT. Pt was aware of this previously. Next step for evaluation would be US, if clinically indicated.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache, slurred speech, and right-sided weakness. Major Surgical or Invasive Procedure: None. History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 5 minutes Time (and date) the patient was last known well: 07:45 ___ Stroke Scale Score: 8 t-PA given: No Reason t-PA was not given or considered: hemorrhage I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. ___ Stroke Scale score was 8: 1a. Level of Consciousness: 0 1b. LOC Question: 1 1c. LOC Commands: 0 2. Best gaze: 1 3. Visual fields: 0 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 1 7. Limb Ataxia: 1 8. Sensory: 0 9. Language: 0 10. Dysarthria: 2 11. Extinction and Neglect: 0 HPI: The pt is a ___ man with a history of HTN, HL, a fib on coumadin, BPH, s/p R hip replacement ___ who presents with HA, slurred speech, and R sided weakness. Per his brother he awoke initially feeling well this am. He ate breakfast and took all of his medications around 7:45am, and was speaking normally and walking without difficulty at that time. His brother then went upstairs and did not see him again until around 9:15, when he heard a noise downstairs and came down to find him on the ground having fallen out of his recliner while reaching for some papers. His brother noticed that his speech was slurred and he appeared to have a right facial droop and some weakness in his right arm. He was also complaining of a headache. EMS was called and he was brought to the ___ ED. Upon arrival at 10:05am a code stroke was called. Initial NIHSS was 8, with points for disorientation to month, L gaze deviation, R facial droop, mild R arm and leg weakness, R arm ataxia, and dysarthria. Noncontrast head CT showed a hemorrhage in the L putamen measuring approximately 18cc in volume. His BP was elevated in the 200/100's and he received 10mg of hydralazine x 2 with improvement to 160-170 systolic. He was then started on a nicardipine drip. INR was 2.4. He was given Profilnine, Vitamin K, and FFP. Per his brother he saw his PCP ___ ___ due to dry heaving. His SBP at that visit was noted to be elevated at 202 and his INR was 3.1. He was advised to recheck his BP at home, and as it came down to 150/90 no medication changes were made. His brother helps him with his medications and says he is compliant with no missed doses. Past Medical History: Hypertension Dyslipidemia Atrial fibrillation, on Coumadin Prostatic hypertrophy Hip replacement ___ Social History: ___ Family History: Not known. Physical Exam: Physical Exam: Vitals: T: not recorded P: 65 BP: 210/134 SaO2: 100% 2L NC General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake and alert, oriented to self and hospital. Says month is ___. Speech very dysarthric and difficult to understand. Naming intact for common objects (watch, pen) but has difficulty with stroke card and with reading. Comprehension intact, follows midline and appendicular commands well except for some neglect of the R side. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Decreased blink to threat on R. III, IV, VI: Eyes deviated to L at rest but able to cross midline toward R with encouragement. V: Facial sensation intact to light touch. VII: R lower facial droop VIII: Hearing intact to voice bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes slightly toward the R. -Motor: Full strength throughout in L upper and lower extremity. He is able to lift his R arm anti-gravity although it is quite clumsy and tends to drift back down. Able to lift R leg anti-gravity and hold for 5 seconds. -Sensory: Withdraws to noxious stimulation throughout -DTRs: Bi Tri ___ Pat Ach L 1 1 1 2 0 R 1 1 1 2 0 Plantar response was flexor on L, extensor on R. -Coordination: +Ataxia on raising R arm, difficult to test formally ___ poor cooperation -Gait: Deferred Discharge exam : He is awake alert and oriented to person, place, time and context. He seems mildly beligerent at times and is impulsive with eating. Language is intact, with normal comprehension, spontaneous speech, naming, repitition. He is mildly hypophonic and dysarthric. His muscle strenght improved to ___ in right deltoid, triceps. but 4 in finger extensors with a very mild lower facial droop on the right. Other aspects of exam did not change Pertinent Results: ___ Glucose-120* Na-142 K-3.7 Cl-97 calHCO3-28 ___ Triglyc-87 HDL-61 CHOL/HD-3.6 LDLcalc-144* ___ UreaN-47* ___ Creat-3.0* ___ Glucose-117* UreaN-40* Creat-2.3* Na-146* K-3.2* Cl-103 HCO3-30 AnGap-16 ___ Glucose-145* UreaN-36* Creat-2.1* Na-147* K-3.2* Cl-104 HCO3-29 AnGap-17 ___ 06:50AM BLOOD Glucose-92 UreaN-21* Creat-1.4* Na-142 K-4.4 Cl-104 HCO3-27 AnGap-15 ___ ___ PTT-36.1 ___ ___ BLOOD ___ PTT-25.3 ___ ___ ___ PTT-29.9 ___ ___ WBC-8.5 RBC-4.71 Hgb-12.8* Hct-37.7* MCV-80* MCH-27.2 MCHC-33.9 RDW-15.7* Plt ___ ___ WBC-7.0 RBC-4.39* Hgb-11.8* Hct-34.9* MCV-80* MCH-26.9* MCHC-33.8 RDW-15.6* Plt ___ ___ WBC-7.5 RBC-4.07* Hgb-11.0* Hct-34.1* MCV-84 MCH-26.9* MCHC-32.1 RDW-15.5 Plt ___ ____________________________________________________________ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S _ _ _ _ _ _ _ _ ________________________________________________________________ CT of head: ___ Left basal ganglia hemorrhage. Mild rightward shift of midline structures including brainstem. CT of the ___ In comparison to ___ exam, there is an interval decrease in size in intraparenchymal hemorrhage centered in the left lentiform nucleus. No new intracranial hemorrhage. (His examination was stable and further imaging was not performed) Medications on Admission: (per brother's report, need to verify doses): Warfarin Tamsulosin Finasteride Verapamil Lisinopril Metoprolol Fluoxetine Zetia Levothyroxine Doxycycline Zantac Discharge Medications: 1. CefePIME 1 g IV Q24H for 7 days end date will be on ___ 2. CloniDINE 0.1 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Fluoxetine 10 mg PO DAILY 5. Heparin 5000 UNIT SC TID 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Metoprolol Tartrate 37.5 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Tamsulosin 0.4 mg PO HS 10. Verapamil 90 mg PO QID (11. On ___. Coumadin should be restarted) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Left basal gangelia hemorrhage in the setting of hypertension and coagulopathy 2. urinary track infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report HISTORY: Seizure, facial droop. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal and sagittal and thin-section bone algorithm reconstructed images were acquired. DLP: 1025.72 mGy-cm. COMPARISON: None. FINDINGS: There is a left basal ganglia intraparenchymal hemorrhage measuring 4.3 x 1.4 x 1.4 cm with some surrounding hypodensity suggesting edema. There is mild rightward shift of midline structures and slight shift of the brainstem to the right including effacement of much of the right perimesencephalic cistern. The basal cisterns otherwise appear patent, and there is preservation of gray-white matter differentiation. No fractures are identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: Left basal ganglia hemorrhage. Mild rightward shift of midline structures including brainstem. Radiology Report INDICATION: Patient with history of atrial fibrillation, on Coumadin and hypertension, with right facial droop and aphasia, and known left basal ganglia hemorrhage. COMPARISONS: CT head dated ___ (under MRN ___ at the time of dictation). TECHNIQUE: MDCT-acquired contiguous images through the head were obtained without intravenous contrast at 5-mm slice thickness. FINDINGS: There is intraparenchymal hemorrhage centered in left lentiform nucleus measuring 3.1 x 1.2 cm, previously 4.3 x 1.4 cm (2:13). There is surrounding vasogenic edema leading to minimal effacement of the body of the left lateral ventricle, as before. There is no shift of normally midline structures or compression of basal cisterns. No new focus of intracranial hemorrhage is detected. The sulci and ventricles are normal in size for age. Confluent hypodensities in the periventricular white matter likely reflect mild chronic small vessel ischemic disease. Vascular calcifications are noted. Imaged paranasal sinuses and mastoid air cells are well aerated. No acute fracture is detected. IMPRESSION: In comparison to ___ exam, there is an interval decrease in size in intraparenchymal hemorrhage centered in the left lentiform nucleus. No new intracranial hemorrhage. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: STROKE Diagnosed with INTRACEREBRAL HEMORRHAGE, ATRIAL FIBRILLATION temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan
1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No ______________________________________________________________ ___ man with a history of HTN, HL, a fib on coumadin,BPH, s/p R hip replacement ___ who presents with HA, slurred speech, and R sided weakness. Intraparenchymal Hemorrhage He was brought to the ED shortly after symptom onset (although last seen normal at 7:45am) and a code stroke was called. Initial NIHSS was 8, with points for disorientation to month, L gaze deviation, R facial droop, mild R arm and leg weakness, R arm ataxia, and dysarthria. Noncontrast head CT showed a hemorrhage in the L putamen measuring approximately 18cc in volume. His BP was elevated in the 200/100's and he received 10mg of hydralazine x 2 with improvement to 160-170 systolic. He was then started on a nicardipine drip. INR was 2.4. He was given Profilnine, Vitamin K, and FFP and INR was improved to 1.4 He was transferred to the ICU from the ED for close monitoring and BP control. Coumadin and aspirin were held and follow up CT of the head did not show any progression of Bleeding. After being 1 day in ICU he was transferred to the floor, he was evaluated by physical therapy service and they recommended inpatient physical therapy. He was evaluated regarding his swallowing and was cleared for regular diet. Urinary Tract Infection He was found to have urinary tract infection and started on cefepime as the culture came back pseudomona species. Acute Renal Failure He also came with Cr of 3, Cr went down with hydration and at the day of discharge it went down to 1.4, nephrology service suggested prerenal insufficiency. He wasted electrolytes briefly while rapidly recovering from this prerenal acute renal insufficiency. Atrial Fibrillation For atrial fibrilation we comtinue metoprolol for him.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___ ___ Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy with stent of right bronchus intermedius and tracheobronchial wash ___ History of Present Illness: ___ with a PMH of breast CA s/p mastectomy in ___- recurrence in ___ s/p right axillary lymph node dissection, on arimidex- recently found to have mediastinal lymphadenopathy on dyspnea work up by PCP so she was sent to interventional pulm for EBUS on ___. ___: EBUS showed: mucosal abnormalities in the distal trachea, RMS, TI, and LMS. Marked extrinsic compression of the bronchus intermidius with some RMS and LMS compression. Multiple enlarged lymph nodes which were biopsied. ___: presented to the ED with cough and shortness of breath since the procedure the day prior. The SOB was severe, it was worsening, it was associated with cough. The severe SOB was going on for 1 day. Another chest CT was done which showed significant narrowing/occlusion of the right main stem and bronchus intermidius. She was taken on ___ for bronchoscopy and a stent was deployed in the BI, patency restored. The biopsy on ___ has resulted in adenocarcinoma (primary site pending, ? breast vs. lung)." Past Medical History: Breast cancer, S/P mastectomy ___, recurrence in ___ S/P right axillary lymph node dissection, currently on Arimidex Social History: ___ Family History: A paternal aunt had breast cancer at age ___. Her father had prostate cancer at age ___. Her paternal grandfather had colon cancer at age ___. A maternal uncle had colon cancer in his ___. Physical Exam: ON ADMISSION: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: diffuse rhonchi. GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect ===================== ON DISCHARGE: VITALS: 24 HR Data (last updated ___ @ 1313) Temp: 98.6 (Tm 99.5), BP: 121/76 (108-131/64-78), HR: 86 (81-90), RR: 20 (___), O2 sat: 96% (95-96%-96), O2 delivery: RA, Wt: 128 lb/58.06 kg GENERAL: Alert and in no apparent distress, appears comfortable, conversant EYES: Anicteric ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Moist mucus membranes. CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses bilaterally. RESP: Lungs with coarse breath sounds throughout, but no distinct wheezes or crackles. Breathing is non-labored on room air. GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No GU catheter present MSK: Moves all extremities, no edema or swelling SKIN: No rashes or ulcerations noted NEURO: Alert, oriented x3, face symmetric, speech fluent, moves all limbs PSYCH: Pleasant, appropriate affect, calm, cooperative Pertinent Results: ON ADMISSION: ___ 10:30AM BLOOD WBC-11.1* RBC-4.75 Hgb-13.3 Hct-41.1 MCV-87 MCH-28.0 MCHC-32.4 RDW-12.5 RDWSD-39.6 Plt ___ ___ 10:30AM BLOOD Neuts-74.9* Lymphs-16.2* Monos-5.7 Eos-2.0 Baso-0.9 Im ___ AbsNeut-8.28* AbsLymp-1.79 AbsMono-0.63 AbsEos-0.22 AbsBaso-0.10* ___ 11:37AM BLOOD ___ PTT-32.0 ___ ___ 10:30AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-142 K-4.3 Cl-107 HCO3-22 AnGap-13 ___ 10:30AM BLOOD cTropnT-<0.01 ___ 10:30AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.0 ___ 02:20PM BLOOD Lactate-1.5 =============== ON DISCHARGE: ___ 05:16AM BLOOD WBC-9.1 RBC-4.48 Hgb-12.3 Hct-38.0 MCV-85 MCH-27.5 MCHC-32.4 RDW-12.1 RDWSD-37.4 Plt ___ ___ 05:16AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-141 K-4.5 Cl-103 HCO3-25 AnGap-13 =============== MICROBIOLOGY: Blood cultures x2 from ___: PENDING Bronchial washing culture ___: GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): ACID FAST SMEAR (Preliminary): ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). =============== CXR ___: No focal consolidation to suggest pneumonia. Unchanged mediastinal lymphadenopathy. CTA CHEST WITH CONTRAST ___: 1. No evidence for pulmonary embolism or acute thoracic aorta pathology. 2. New ground-glass opacity of the right upper lobe may be due to infection versus aspiration, however hemorrhage cannot be excluded considering recent biopsy. 3. New intraluminal obstructing material within the right mainstem bronchus with extension to the right upper lobe bronchus and intermediate bronchus suggestive of mucus plugging. 4. Re-demonstrated right hilar and mediastinal lymphadenopathy, some of which is necrotic, with encasement and narrowing of the right mainstem bronchus by the lymphadenopathy. 5. Post radiation changes within the right apex and anterior right upper lobe. CXR ___: Interval placement of a stent in the right mainstem bronchus. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mirtazapine 15 mg PO QHS 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 3. Anastrozole 1 mg PO DAILY Discharge Medications: 1. Acetylcysteine 20% ___ mL NEB BID RX *acetylcysteine 100 mg/mL (10 %) 4 mL twice a day Disp #*100 Milliliter Refills:*0 2. Albuterol 0.083% Neb Soln 1 NEB IH BID RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb twice a day Disp ___ Milliliter Refills:*0 3. GuaiFENesin ER 1200 mg PO Q12H RX *guaifenesin [Mucinex] 1,200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills:*0 4. nebulizers 1 machine miscellaneous BID 1 nebulizer machine RX *nebulizers 1 nebulizer machine twice a day Disp #*1 Each Refills:*0 5. TraZODone 25 mg PO QHS:PRN Insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 6. Anastrozole 1 mg PO DAILY 7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 8. Mirtazapine 15 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Dyspnea Mediastinal lymphadenopathy with compression of right bronchus intermedius Metastatic breast adenocarcinoma History of breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with presumed pulmonary malignancy, bronchomalacia s/p stent to RLL// stent location TECHNIQUE: AP portable chest radiograph COMPARISON: ___ CT chest FINDINGS: The lungs are hyperexpanded. A stent has been placed in the right mainstem bronchus. There is no focal consolidation, pleural effusion or pneumothorax. The size of the cardiac silhouette is within normal limits. Prominence of the mediastinum and medial right upper hemithorax is compatible with known mediastinal lymphadenopathy and post radiation changes in the right upper lung. IMPRESSION: Interval placement of a stent in the right mainstem bronchus. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Pneumonia, unspecified organism temperature: 98.3 heartrate: 107.0 resprate: 24.0 o2sat: 95.0 sbp: 138.0 dbp: 76.0 level of pain: 0 level of acuity: 2.0
Ms. ___ is a ___ yo lady with history of breast cancer s/p mastectomy in ___ with recurrent in ___ with right axillary node dissection on Arimidex who was found to have new mediastinal lymphadenopathy by her PCP after presenting for dyspnea. She had EBUS with nodal biopsies on ___ and presented to ED on ___ with increasing dyspnea. She was not hypoxic, but was found to have narrowing/occlusion of the right main stem and bronchus intermedius on CTA chest, so she underwent bronchoscopy with stent placement on ___. Her node biopsies from ___ are consistent with metastatic adenocarcinoma of breast origin. #Mediastinal lymphadenopathy with compression of right bronchus intermedius s/p airway stenting #Shortness of Breath: She had CT done by PCP ___ ___ for shortness of breath and was found to have mediastinal lymphadenopathy (some of which is necrotic) with compression of right mainstem bronchus and bronchus intermedius. She had ___ EBUS with biopsies and these showed metastatic breast adenocarcinoma. She re-presented on ___ with SOB and found to have compression of right bronchus intermedius. She underwent bronchoscopy with stent with restored patency. She will follow up with Dr. ___ on ___ in ___. IP recommended: -Mucomyst (N-Acetylcysteine) (100 mg/mL, 10 %) solution, 4 ml nebulized BID -Albuterol Sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization BID x 10 days -Nebulizer Machine -Guafenesin (Mucinex®) 1200mg BID -Flutter valve (Acapella) BID and PRN congestion #Metastatic breast adenocarcinoma: Mediastinal node biopsies showed breast origin. She will follow up with her primary oncologist Dr. ___ - I have emailed to ask for her to have follow up scheduled early this week. I discussed the results with the patient and her daughter. #Question of pneumonia: ___ was 11 on admission with GGO in RUL (?aspiration vs. infection), so she was empirically started on vancomycin/cefepime/flagyl on ___. She has no evidence of pneumonia on CTA chest and had no fever and leukocytosis resolved. Discussed with IP who did not recommend continuing antibiotics, which I agree with based on CT and clinical presentation. #Insomnia: She has been on Mirtazapine in the past, without improvement in insomnia and requested short course of another medication to help with sleeping especially in acute setting of new cancer diagnosis. I prescribed short course of Trazodone.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Upper gastrointestinal bleeding, hemorrhagic shock Major Surgical or Invasive Procedure: Upper gastrointestinal endoscopy ___ Upper gastrointestinal endoscopy ___ Interventional Radiology Embolization of gastroduodenal artery and superior pancreaticoduodenal artery branches History of Present Illness: Mr. ___ is a ___ y/o man w/ likely EtOH liver disease and HCC (s/p R hepatectomy ___ who presented to our hospital on ___ with melena and hypotension. Past Medical History: Past Medical History -Diabetes Mellitus II diagnosed ___ c/b neuropathy -Hypertension -TIA vs ?CVA ___ per NP note, patient does not recall. -erectile dysfunction -scalp dermatitis -HCV diagnosed ___ -blood transfusions: does not endorse -Colonoscopy: first one performed ___ yr ago, for which he was told it was "normal" and to repeat in ___ ___. Past Surgical History: appendectomy ___ Social History: ___ Family History: does not endorse a family history of Hepatitis or malignancies amongst his parents or siblings. father passed at advanced ages, and his mother died from a possible reaction to a medication. Physical Exam: Awake, oriented x3 In no acute distress T=98.1 F HR= 78 x' BP= 100/60mmHg RR= 18 x' SatO2= 98% RA Normal S1 and S2, no murmurs or gallop Lung fields clear to auscultation bilaterally Abdomen soft and nontender Surgical wound with adequate healing, clean, dry, and intact. Pertinent Results: ___ 06:11AM BLOOD WBC-7.8 RBC-2.83* Hgb-8.4* Hct-25.8* MCV-91 MCH-29.7 MCHC-32.6 RDW-17.0* RDWSD-50.3* Plt ___ ___ 12:30PM BLOOD WBC-11.1* RBC-1.00*# Hgb-2.8*# Hct-9.9*# MCV-99*# MCH-28.0 MCHC-28.3*# RDW-14.6 RDWSD-51.7* Plt ___ ___ 06:11AM BLOOD Plt ___ ___ 06:11AM BLOOD ___ PTT-29.7 ___ ___ 01:56AM BLOOD ___ 06:11AM BLOOD Glucose-127* UreaN-9 Creat-0.7 Na-135 K-3.1* Cl-102 HCO3-25 AnGap-11 ___ 06:11AM BLOOD ALT-91* AST-47* AlkPhos-103 TotBili-1.2 ___ 01:30AM BLOOD ALT-497* AST-1253* AlkPhos-88 TotBili-1.5 DirBili-0.7* IndBili-0.8 ___ 06:11AM BLOOD Albumin-2.5* Calcium-7.4* Phos-1.9* Mg-1.7 EGD (___): Grade B esophagitis Blood in the stomach Ulcer in the duodenal bulb Otherwise normal EGD to third part of the duodenum EGD (___): single oozing 4x2cm ulcer was found in the duodenal bulb with overlying adherent clot. 12 cc.Epinephrine ___ hemostasis with partial success. A gold probe was applied for hemostasis unsuccessfully. Despite multiple attempts, overlying clot was unable to be removed and could not achieve underlying hemostasis. ___ Embolization: FINDINGS: 1. Duodenal hemorrhage supplied by arteries from a presumed superior pancreaticoduodenal artery or accessory duodenal artery arising from the aorta. 2. Duodenal hemorrhage supplied by a branch of the gastroduodenal artery. 3. Altered hepatic and gastroduodenal arterial anatomy described above likely secondary to postsurgical changes of hepatectomy. 4. Successful coil and Gel-Foam embolization of the gastroduodenal artery. 5. Successful coil embolization of the SPDA branches to the hemorrhage. 6. No evidence of active extravasation at the end of the study. 7. Normal right common femoral artery anatomy. 8. Successful Angio-Seal closure of right common femoral arteriotomy. IMPRESSION: Successful coil and Gel-Foam embolization of a gastroduodenal artery which occluded a branch feeding an active duodenal hemorrhage. Successful coil embolization of third order branches of a SPDA off of the aorta which also demonstrated active hemorrhage. No active hemorrhage was identified at the end of the study. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. atenolol-chlorthalidone 100-25 mg oral DAILY 4. Atorvastatin 10 mg PO QPM 5. GlipiZIDE 5 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Loratadine 10 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 10. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Amoxicillin 1000 mg PO Q12H RX *amoxicillin 500 mg 2 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. Clarithromycin 500 mg PO Q12H 3. Pantoprazole 40 mg PO Q12H 4. Sucralfate 1 gm PO QID 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 6. atenolol-chlorthalidone 100-25 mg oral DAILY 7. Atorvastatin 10 mg PO QPM 8. GlipiZIDE 5 mg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. Loratadine 10 mg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: -Upper gastrointestinal bleeding -Duodenal ulcer -H.pylori infection -Hemorrhagic shock -DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS INDICATION: History: ___ with lightheadedness, melena // hematobilia? 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, 53.0 cm; CTDIvol = 3.9 mGy (Body) DLP = 205.7 mGy-cm. 2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 4.1 mGy (Body) DLP = 2.0 mGy-cm. 3) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 8.0 mGy (Body) DLP = 407.4 mGy-cm. 4) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 8.0 mGy (Body) DLP = 407.2 mGy-cm. Total DLP (Body) = 1,022 mGy-cm. COMPARISON: MR liver ___ FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. The left hepatic artery is visualized and appears widely patent. The left portal vein and its branches appear patent. There is mild narrowing of the origin of left hepatic vein which is patent. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: There is patchy, hypoenhancement of the left lobe of the liver. A sub diaphragmatic, 4.0 x 2.5 cm intermediate density fluid collection is noted at the site of prior right hepatic resection, presumably postsurgical. 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: Sub cm hypodensities in the kidneys are too small to characterize but likely represent simple renal cysts. There is no hydronephrosis. The nephrogram is symmetric. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. There is diverticulosis noted. Mild stranding and wall thickening is noted at the hepatic flexure. Appendix is not visualized. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: A Foley catheter is noted in the urinary bladder. 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. SOFT TISSUES: Postsurgical changes are noted in the midline and right upper quadrant abdominal wall, including a small fluid collection in the right rectus abdominis. IMPRESSION: 1. No evidence of active extravasation within the colon or small bowel. 2. Patchy hypoattenuation throughout the left lobe of the liver is concerning for hepatic necrosis. 3. Small fluid collection adjacent to the resection bed may be postoperative in nature. An infected fluid collection would be difficult to exclude. 4. Pericolonic stranding in the hepatic flexure is concerning for colitis, which may be reactive although an ischemic or infectious etiology can't be excluded. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:39 ___, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with GIB acute blood loss anemia. S/p Rt IJ CVL placement. Assess position of CVL // CVL position Contact name: ___: ___ TECHNIQUE: Chest single view COMPARISON: ___ FINDINGS: New right internal jugular vein introducer sheath in place, which is kinked at its upper end, which may be external to the patient. No pneumothorax. Surgical clips lower chest. Shallow inspiration. Enteric tube tip in the distal stomach. Minimal right basilar atelectasis, similar. Remainder normal. IMPRESSION: New right IJ introducer sheath, which is kinked at its upper end. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p multp transfusions for acute GI bleed. // acute process vs pulm edema acute process vs pulm edema IMPRESSION: Comparison to ___. Stable appearance of the heart and the lung parenchyma. No fluid overload. No pulmonary edema. No pleural effusions. No pneumonia. Borderline size of the cardiac silhouette. The monitoring and support devices are stable, with the known kinked. Right venous introduction sheet. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ man with elevated LFTs status-post right hepatic lobectomy ___ now presents with UGIB; evaluate for possible etiologies of elevated transaminases. Per OMR, lobectomy was for multifocal HCC in the right hepatic lobe. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Limited reference is made with the CTA abdomen and pelvis dated ___. FINDINGS: LIVER: The patient has had prior right hepatic lobectomy. The remaining hepatic parenchyma appears coarsened and hypertrophied. The contour of the liver is smooth. No focal liver mass. The main portal vein is patent with hepatopetal flow. There is a small volume of ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well imaged due to overlying bowel gas. Imaged portions of the pancreas appear within normal limits, without masses or pancreatic ductal dilation. SPLEEN: The spleen could not be imaged due to patient positioning and inability to reposition the patient given his recent procedure. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: S/P right hepatic lobectomy. Coarsened arcitecture left hepatic lobe. No focal hepatic mass. Small volume ascites. Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ man with hepatectomy, with a new nasoenteric tube, evaluate position. TECHNIQUE: Subsequent portable views of the chest during nasoenteric tube placement. COMPARISON: Chest radiograph ___ and ___. FINDINGS: The sequential images show repositioning of the esophageal drainage tube healed he initially looped in the mid esophagus, then in the upper stomach finally at or just beyond the pylorus. Partially imaged right IJ central venous catheter with tip projecting in the high SVC. Lung apices not included on this radiograph. Lungs are grossly clear. Surgical staples project just left of midline in the abdomen. Chain sutures and surgical clips are seen in the right upper quadrant. IMPRESSION: Nasoenteric tube appropriately positioned in the stomach. Radiology Report INDICATION: ___ year old man with actively bleeding duodenal ulcer s/p GI scope unable to control bleed. COMPARISON: Abdominopelvic CTA dated ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. ANESTHESIA: General anesthesia was administered by the anesthesiology department. Please refer to anesthesiology notes for details. CONTRAST: 195 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 51.5 min, 2206 mGy PROCEDURE: 1. Right common femoral artery access. 2. Celiac arteriogram. 3. Superior mesenteric arteriogram. 4. Superior pancreaticoduodenal (SPDA) accessory duodenal arteriogram 5. Coil embolization of SPDA branches. 6. Coil and Gel-Foam embolization of the gastroduodenal artery. 7. Right common femoral arteriogram. 8. Right common femoral arteriotomy Angio-Seal closure. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. Both groins were prepped and draped in the usual sterile fashion. Using palpatory and fluoroscopic guidance, the right common femoral artery was punctured using a micropuncture set at the level of the mid-femoral head. A 0.018 wire was passed easily into the vessel lumen. A small skin incision was made over the needle. Then the needle was exchanged for a microsheath. The 0.018 wire was exchanged for ___ wire which was advanced into the abdominal aorta under fluoroscopy. The microsheath was exchanged for a ___ sheath. The inner dilator and wire were removed and ___ wire was advanced under fluoroscopy into the aorta. The 5 ___ sheath was flushed and attached to a continuous heparinized saline side arm flush. A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire was removed and the superior pancreaticoduodenal (SPDA) or accessory duodenal artery was selected. This artery arose from the abdominal aorta just right and inferior to the celiac artery takeoff. A small hand contrast injection was made to confirm position within the ostium. A SPDA arteriogram was then performed which showed branches feeding an active bleed within the duodenum. Next, distal SPDA branches were individually selected using a STC microcatheter and a combination of Transcend and double angled microwires. Once the microcatheter was in the appropriate ___ order branch, the microwire was removed. Coil embolization was then performed using a 2 cm x 2 mm Hilal coil and one 2 cm x 1 mm Hilal coil. Afterwards, hand injection digital subtraction angiography showed no evidence of active hemorrhage. The microcatheter was removed and the base catheter was retracted into the abdominal aorta. The celiac artery was selectively cannulated by the C2 catheter and a small contrast injection was made to confirm position. A celiac arteriogram was performed which showed active hemorrhage in the duodenum from a brand of the gastroduodenal artery just distal to the middle hepatic artery. Additionally, the arterial anatomy was altered due to prior hepatectomy. The gastroduodenal artery maintained a lateral course with the left and middle hepatic arteries arising off the proper hepatic/proximal gastroduodenal arteries. Next, the STC microcatheter was negotiated into the gastroduodenal artery using combination of headliner, Transcend and double angle microwires. Hand contrast injection confirmed placement of the microcatheter in the distal GDA. Two 6 mm x 20 mm Concerto coils and Gel-Foam were carefully deployed just distal to the middle hepatic artery which sealed off the GDA feeding branch to the duodenal bleed. Hand injection digital subtraction angiography in the proximal GDA showed no evidence of active hemorrhage in the duodenum. Next, the microcatheter was removed. The C2 catheter was retracted from the celiac artery into the abdominal aorta and used to cannulate the superior mesenteric artery. A small hand contrast injection confirmed position. A superior mesenteric arteriogram was then performed which showed no evidence of hemorrhage. Next, the C2 catheter was retracted from the superior mesenteric artery and used to reselect the celiac artery. A repeat celiac arteriogram showed no evidence of duodenal hemorrhage. Next, the C2 catheter was retracted from the celiac artery an used to reselect the SPDA. A repeat SPDA arteriogram was performed which showed no evidence of hemorrhage. A ___ wire was then advanced through the C2 catheter into the abdominal aorta. The C2 catheter was removed. A right common femoral arteriogram was then performed which showed normal arterial anatomy and mid femoral head access. At this point, an Angio-Seal closure device was used to seal the right common femoral arteriotomy. Manual pressure was held over the right groin for 5 minutes to ensure hemostasis. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: 1. Duodenal hemorrhage supplied by arteries from a presumed superior pancreaticoduodenal artery or accessory duodenal artery arising from the aorta. 2. Duodenal hemorrhage supplied by a branch of the gastroduodenal artery. 3. Altered hepatic and gastroduodenal arterial anatomy described above likely secondary to postsurgical changes of hepatectomy. 4. Successful coil and Gel-Foam embolization of the gastroduodenal artery. 5. Successful coil embolization of the SPDA branches to the hemorrhage. 6. No evidence of active extravasation at the end of the study. 7. Normal right common femoral artery anatomy. 8. Successful Angio-Seal closure of right common femoral arteriotomy. IMPRESSION: Successful coil and Gel-Foam embolization of a gastroduodenal artery which occluded a branch feeding an active duodenal hemorrhage. Successful coil embolization of third order branches of a SPDA off of the aorta which also demonstrated active hemorrhage. No active hemorrhage was identified at the end of the study. Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ man with hepatectomy, with a new nasoenteric tube, evaluate position. TECHNIQUE: Subsequent portable views of the chest during nasoenteric tube placement. COMPARISON: Chest radiograph ___ and ___. FINDINGS: The sequential images show repositioning of the esophageal drainage tube healed he initially looped in the mid esophagus, then in the upper stomach finally at or just beyond the pylorus. Partially imaged right IJ central venous catheter with tip projecting in the high SVC. Lung apices not included on this radiograph. Lungs are grossly clear. Surgical staples project just left of midline in the abdomen. Chain sutures and surgical clips are seen in the right upper quadrant. IMPRESSION: Nasoenteric tube appropriately positioned in the stomach. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Altered mental status, Weakness Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 97.1 heartrate: 110.0 resprate: 20.0 o2sat: 94.0 sbp: 72.0 dbp: 33.0 level of pain: unable level of acuity: 1.0
Upon arrival to the emergency department he was found hypotensive and tachycardic for which he was volume resuscited and given emergent transfusions. CT scan at that revealed a large volume of blood in stomach. He was transferred to ICU for acute upper GI bleed and hemodynamic monitoring. Upper GI endoscopy revealed grade B esophagitis and a single oozing 2 cm ulcer was found in the duodenal bulb without significant active bleeding. He was started on IV proton pump inhibitors, sucralfate and kept in observation. However, he had new upper GI bleed on ___. Endoscopy at that time demonstrated a single oozing 4x2cm ulcer in the duodenal bulb with overlying adherent clot. Partial hemostasis was attempted with epinephrine ___, but it was not successful. Despite multiple attempts, overlying clot was unable to be removed and hemostais was not achieved. Therefore, he was treated by interventional radiology, by coil and Gel-Foam embolization of a gastroduodenal artery which occluded a branch feeding an active duodenal hemorrhage, and embolization of third order branches of a SPDA off of the aorta which also demonstrated active hemorrhage. The bleeding was controlled and the patient was extubated on post-procedure day 1 and transferred to the floor. His post-procedural recovery was uneventful. During his hospital course he had a (+) H.pylori antigen in stool, so treatment was started with amoxicillin, clarithromycin, pantoprazole, and sucralfate. Diet was resumed and tolerated. He was restarted on some of his home medications except ASA/Plavix. He was told not to resume these. His SBP was on the low side (80-80s with HR in ___ on ___ after home anti-htn meds were resumed. Repeat Hct was stable, therefore the Lisinopril dose was decreased. SBP increased to 110/56. WT was 65.5kg. He did have 1+bilateral leg edema. He was discharged in stable condition to f/u with hepatology, ___ and Dr. ___.
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, N/V Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ year old gentleman who was seen on ___ in the ED after an assault which resulted in a SDH and skull fracture. He was admitted to the ICU and intubated secondary to agitation. He was extubated in the ICU and cleared for discharge on ___ per the patients request. He returns today with an increased headache and two episodes of vomiting. Past Medical History: none Social History: ___ Family History: non-contributory Physical Exam: On Admission: O: T: 97.8 BP: 145/93 HR: 87 R 16 O2Sats 100% Neuro: Gen: laying on stretcher with head covered by blanket HEENT: Pupils: PERRL EOMs intact Neck: hard collar in place Lungs: no adventicious sounds Cardiac: RRR. Abd: Soft, NT 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 Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Handedness Right PHYSICAL EXAM UPON DISCHARGE: Her has some ___ ecchymosis. There is no CN or motor deficit. Pertinent Results: ___ CT/CTA IMPRESSION: 1. Decrease in size of right frontal subdural hematoma, now small. Stable appearance of right temporal hemorrhagic contusion, probable left supratentorial subdural hematoma, and nondepressed left occipital bone fracture. 2. Normal head CTA without evidence of stenosis or aneurysm. Medications on Admission: keppra, percocet, colace Discharge Disposition: Home Discharge Diagnosis: headache nausea post concussive syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with recent subdural hematoma and occipital skull fracture. Presenting with worsening headache and vomiting. Evaluate for intracranial hemorrhage. COMPARISONS: CT head without contrast of ___. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, rapid axial imaging was performed from the skull base through the brain during infusion of 70 cc of Omnipaque IV contrast material. Images were processed on a separate workstation with display of curved reformats, 3D volume-rendered images, and maximum intensity projection images. FINDINGS: HEAD CT: Right frontal subdural hematoma has decreased in size compared with ___, and is now small. Mild asymmetric hyperdensity at the left tentorium is similar to prior, suggestive of a small supratentorial subdural hematoma. Right temporal hemorrhagic contusion is unchanged. There is no evidence of new hemorrhage, edema, mass effect, or infarction. Left subgaleal hematoma is similar to prior. The basal cisterns appear patent, and there is preservation of the gray-white matter differentiation. Nondepressed left occipital fracture is unchanged since the prior exam. Mucosal thickening is seen within the left ethmoidal air cells. The visualized paranasal sinuses are otherwise clear. The mastoid air cells and middle ear cavities are clear. Globes and orbits are intact. HEAD CTA: The carotid and vertebral arteries and their major branches are patent without evidence of stenosis. The distal cervical internal carotid arteries measure 4.5 mm in diameter on the left and 4.0 mm in diameter on the right. The vessels of the circle of ___ are patent. There is no evidence of aneurysm formation or other vascular abnormality. The principal dural venous sinuses and major deep cerebral veins opacify normally without evidence of thrombosis. IMPRESSION: 1. Decrease in size of right frontal subdural hematoma, now small. Stable appearance of right temporal hemorrhagic contusion, probable left supratentorial subdural hematoma, and nondepressed left occipital bone fracture. 2. Normal head CTA without evidence of stenosis or aneurysm. Findings were communicated via phone call by ___ to ___ on ___ at 17:01. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: HEADACHE,BACK PAIN Diagnosed with TRAUMATIC SUBDURAL HEM, ASSAULT NOS temperature: 97.8 heartrate: 87.0 resprate: 16.0 o2sat: 100.0 sbp: 145.0 dbp: 93.0 level of pain: 11 level of acuity: 2.0
Mr. ___ was admitted to the neurosurgery service on ___ for pain and nausea control with IV antiemetics. He remained neurologically stable.He had headaches and pain control was a problem on this day. Fioricet was added to his regimen. He had emesis at night but none in the am of ___. He tolerated his diet. Ambulation was increased. ___ saw the patient and cleared him for home. He was discharged on ___.
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Bacitracin / Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___. Chief Complaint: nausea, malaise Major Surgical or Invasive Procedure: None History of Present Illness: . ___ year old female with history of RA (on Remicade and MTX) presenting with nausea/vomiting x 2 days. . Patient had root canal on five days prior to admission for dental abscess, and received Vicodin and penicillin post-procedure. After taking Vicodin and penicillin, she became ill with ___ episodes of non-bloody, bilious vomitng past 2 days, inability to tolerate PO. She was able to keep up with PO intake over the weekend, but symptoms persisted. Associated symptoms include +bloating, lower abd. discomfort diffusely but no pain. No fever, chills, diarrhea, or melena. . Given persistent symtpoms, patient saw her PCP, ___ recommended that the patient present to the ED for IVF, labs, IV abx. . ED Course: VS: 97.3 66 118/77 18 100% 2L Nasal Cannula PE: HEENT: no fluctuant masses, jaw/sinuses non-tender, full ROM on open/close mouth. no exudates/bleeding Abd: soft, minimally TTP diffusely across lower abd. No rebound/guarding. +BS. - sent labs, started IVF, WBC 7.1. labs unremarkable. - CT non contrast head negative - gave IV clindamycin 300mg x1 for root canal, tylenol for HA - Neuro consult (? concern for cerebellar pathology): possibly BPPV but no intracranial process . Disposition/Pending: patient unable to tolerate PO trial in ED, and was admitted for symptom control . Upon arrival to floor, patient complained of ___ nausea, no other pain. She had no appetite. No recent sick contacts, no other family members sick. . 12 ROS as noted above and otherwise negative. . Past Medical History: History of breast cancer on anastrazole rheumatoid arthritis on Remicaid and MTC osteopenia depression Social History: ___ Family History: Her daughter was diagnosed with ovarian at ___ and succumbed to the disease shortly after. She has a sister who was diagnosed with breast cancer at ___ and a niece who also had breast cancer. The family has been tested for BRCA and has tested negative. No other new breast cancers have developed. No family history of pancreatic, biliary, or gastric cancer. Physical Exam: VS: 98.4 116/69 HR 72 RR 18 97% RA General: fatigued appearing, nauseated HEENT: anicteric sclerae; left upper molar (recent root canal) without erythema or pus Neck: supple CV: RRR, normal S1, S2, no m,r,g Pulm: clear bilaterally Abdomen: soft, minimally tender in epigastrium, no rebound or guarding Ext: 2+ radial and DP pulses bilaterally, no c/c/e Neuro: CNs II-XII intact. cerebellar function intact, no truncal ataxia Pertinent Results: LACTATE-1.3 GLUCOSE-91 UREA N-13 CREAT-0.5 SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16 ALT(SGPT)-20 AST(SGOT)-25 ALK PHOS-70 TOT BILI-0.4 LIPASE-39 WBC-7.9 RBC-4.29 HGB-13.3 HCT-40.2 MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 NEUTS-69.1 ___ MONOS-4.8 EOS-1.4 BASOS-0.7 PLT COUNT-348 CT head: No evidence of acute process. Although there is no evidence for mass effect, hemorrhage or edema, subtle metastases may escape detection with non-contrast CT. If there is continuing clinical concern for subtle metastatic disease, then CT or preferably MR performed with contrast administration could be considered in follow-up. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - ___ puffs(s) IH Every ___ hours as needed for cough, shortness of breath ANASTROZOLE - 1 mg tablet - 1 Tablet(s) by mouth daily FOLIC ACID - 1 mg tablet - 1 Tablet(s) by mouth once a day HYDROQUINONE - 4 % Cream - apply to affected area once a day INFLIXIMAB [REMICADE] - (Prescribed by Other Provider) - 100 mg Recon Soln - 3 vials (total 300 mg) q 8 weeks METHOTREXATE SODIUM [METHOTREXATE (ANTI-RHEUMATIC)] - 2.5 mg tablets,dose pack - 5 Tablets(s) by mouth once weekly PAROXETINE HCL - 30 mg tablet - 1 (One) tablet(s) by mouth once a day SELENIUM SULFIDE - 2.5 % Suspension - apply topically to scalp twice a day as directed TRETINOIN - 0.05 % Cream - apply to affected area daily for pigmentation ZOLPIDEM - 5 mg tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ACETAMINOPHEN - (OTC) - Dosage uncertain CALCIUM CARBONATE-VIT D3-MIN - 600 mg-400 unit tablet - 1 Tablet(s) by mouth twice a day MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - tablet - 1 Tablet(s) by mouth QDay Discharge Medications: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - ___ puffs(s) IH Every ___ hours as needed for cough, shortness of breath ANASTROZOLE - 1 mg tablet - 1 Tablet(s) by mouth daily FOLIC ACID - 1 mg tablet - 1 Tablet(s) by mouth once a day HYDROQUINONE - 4 % Cream - apply to affected area once a day INFLIXIMAB [REMICADE] - (Prescribed by Other Provider) - 100 mg Recon Soln - 3 vials (total 300 mg) q 8 weeks METHOTREXATE SODIUM [METHOTREXATE (ANTI-RHEUMATIC)] - 2.5 mg tablets,dose pack - 5 Tablets(s) by mouth once weekly PAROXETINE HCL - 30 mg tablet - 1 (One) tablet(s) by mouth once a day SELENIUM SULFIDE - 2.5 % Suspension - apply topically to scalp twice a day as directed TRETINOIN - 0.05 % Cream - apply to affected area daily for pigmentation ZOLPIDEM - 5 mg tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ACETAMINOPHEN - (OTC) - Dosage uncertain CALCIUM CARBONATE-VIT D3-MIN - 600 mg-400 unit tablet - 1 Tablet(s) by mouth twice a day MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - tablet - 1 Tablet(s) by mouth QDay 1. Acetaminophen 1000 mg PO Q8H:PRN headache RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed Disp #*60 Tablet Refills:*0 2. Clindamycin 150 mg PO Q6H Duration: 2 Days RX *clindamycin HCl 150 mg 1 capsule(s) by mouth every 6 hours Disp #*8 Capsule Refills:*0 3. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: nausea and vomiting, likely due to penicillin and vicodin prescribed subsequent to root canal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HEAD CT HISTORY: Nausea and headache; history of breast cancer. COMPARISONS: None. TECHNIQUE: Non-contrast head CT. FINDINGS: There is no evidence for intra- or extra-axial hemorrhage. There is no mass effect, hydrocephalus or shift of the normally midline structures. The globes appear elongated suggesting myopia. Surrounding soft tissue structures are otherwise unremarkable. The visualized paranasal sinuses and mastoid air cells appear clear. Bony structures are unremarkable. IMPRESSION: No evidence of acute process. Although there is no evidence for mass effect, hemorrhage or edema, subtle metastases may escape detection with non-contrast CT. If there is continuing clinical concern for subtle metastatic disease, then CT or preferably MR performed with contrast administration could be considered in follow-up. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: DIZZINESS/N/V Diagnosed with HEADACHE, RHEUMATOID ARTHRITIS, VERTIGO/DIZZINESS, HX OF BREAST MALIGNANCY temperature: 97.3 heartrate: 66.0 resprate: 18.0 o2sat: 100.0 sbp: 118.0 dbp: 77.0 level of pain: 6 level of acuity: 3.0
___ year old female with history of breast cancer in remission (on anastrazole), rheumatoid arthritis on MTX and Remicaid, and recent root canal presents with nausea and malaise for five days associated with the use of vicodin and penicillin as prescribed subsequent to a root canal 5 days ago. . # Nausea/malaise- symptoms resolved in 24 hours with cessation of pcn and vicodin. Pt. was able to tolerate po intake of foods as well as clindamycin as precribed as an alternative (see below). # Recent root canal- patient was scheduled to finish penicillin on ___. Received dose of clindamycin 300 mg IV in ED. - continued clindamycin 150 mg PO TID for 2 days ** see note from ___ by me in omr about ECG that was performed in the ED on ___, result reported ___, via cardiologist read **
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness, Nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ ___ only gentleman with hypertension, paroxysmal Afib, CKD stage III, renal cell carcinoma status post partial nephrectomy, and longstanding history of brief episodes of dizziness who presents with a prolonged presyncopal episode of nausea and lightheadedness. ___ has had episodes of dizziness in the past that last up to 10 minutes, for many years, but this afternoon ___ was walking around, began feeling very nauseous and weak and generally lightheaded. The episode lasted much longer than prior episodes (several hours), so ___ called an ambulance. ___ denies any infectious systems, ___ never had chest pain or difficulty breathing or abdominal pain. Has normal nonbloody bowel movements. ___ is on aspirin but no other blood thinners for atrial fibrillation. In the ED initial vitals were:97.1 61 166/66 16 98%, at one point, SBP >200, which provoked his symptoms. His neuro exam was otherwise unremarkable. ___ was seen by neurology who felt his symptoms may be consistent with hypertensive urgency, recommended MRA head as well as carotid US, with admission to medicine for hypertensive urgency. - Labs were significant for creatinine 1.8 (unknown baseline), K5.4 with no EKG changes, Neg UA, - Patient was given 1L NS and not other meds. Vitals prior to transfer were: 97.9 48 119/55 17 97% RA On the floor,patient is in good spirits, not dizzy, without complaints. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, sore throat, cough, shortness of breath, chest pain, abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena, dysuria, hematuria. Past Medical History: #Chronic kidney disease (stage III) #Hypertension (labile BPs) #Erectile dysfunction #Renal cell carcinoma status post partial nephrectomy in ___ #Hypertriglyceridemia #History of dizzy/presyncopal episodes for many years #Paroxysmal Afib (seen by ___ in ___, recommended anticoag) #"risk for MDS" started on hydroxyurea by hematologist #Esophagitis (EGD ___- esophagitis, ___, esophageal strictures, gastritis, duodenal polyp. Patient decliens follow up EGD. Social History: ___ Family History: Non-contributory Physical Exam: On Admission: Vitals - T:98.2 BP:151/74 HR:85 RR:20 02 sat:95% GENERAL: NAD, very pleasant, hard of hearing HEENT: AT/NC, EOMI, PERRL, anicteric sclera but conjunctivae injected, MMM, OP clear NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, ___ systolic murmur, no gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema NEURO: CN II-XII intact with exception of mild L ptosis, strength intact throughout SKIN: warm and well perfused, no excoriations or lesions, no rashes On Discharge: Vitals- Tm 98.2, Tc 97.5, BP 101-139/54-77, P 55-76, RR 18, O2 94-96%RA General: elderly, ___ speaking gentleman, cooperative with exam, NAD Neck: Supple. No LAD. Cardiac: RRR, S1/S2, ___ systolic murmur best heard at upper sternal borders, no gallops, or rubs Lung: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles Abdomen: nondistended, nontender in all quadrants, no hepatosplenomegaly Extremities: no cyanosis, clubbing or edema Neuro: CN II-XII intact; EOMI w/o nystagmus. More extensive neuro exam performed late ___ ___: During Romberg felt slightly unsteady after a few seconds. No pronator drift. Able to ambulate reasonably well. Cerebellar function intact with normal FNF and HTS. Visual fields intact. No nystagmus with head movements. EOMI and no saccades noted. SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ___ 07:55AM GLUCOSE-87 UREA N-40* CREAT-1.6* SODIUM-139 POTASSIUM-5.3* CHLORIDE-106 TOTAL CO2-25 ANION GAP-13 ___ 07:55AM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-2.1 ___ 03:45PM K+-4.6 ___ 02:20PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 02:20PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 02:00PM GLUCOSE-96 UREA N-45* CREAT-1.8* SODIUM-139 POTASSIUM-5.4* CHLORIDE-106 TOTAL CO2-27 ANION GAP-11 ___ 02:00PM CALCIUM-9.5 MAGNESIUM-2.1 ___ 02:00PM WBC-6.7 RBC-5.19 HGB-15.5 HCT-48.5 MCV-94 MCH-29.9 MCHC-32.0 RDW-15.8* ___ 02:00PM NEUTS-72.7* LYMPHS-17.7* MONOS-6.9 EOS-1.4 BASOS-1.3 ___ 02:00PM PLT COUNT-509* ___ 02:00PM ___ PTT-40.5* ___ MRI Head: 1. Apparent faint high signal on diffusion-weighted images at the site of chronic hemorrhage in the right putamin and caudate is almost certainly artifactual. However, if neurologic exam suggests an acute infarction in this location, then a short-term followup MRI would be helpful for clarification. Otherwise, no acute infarction is seen. 2. No evidence for a major intracranial arterial occlusion or hemodynamically significant stenosis on motion-limited MRA of the head. Diminished signal intensity in bilateral intracranial vertebral arteries, without diminished caliber, is likely related to motion artifact. However, if there is high clinical suspicion for vertebrobasilar insufficiency, then CTA of the head and neck would be helpful for further evaluation. 3. Complete opacification of the right frontal sinus Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydroxyurea 500 mg PO 5X/WEEK (___) 2. Sodium Polystyrene Sulfonate 15 gm PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Vitamin D 800 UNIT PO DAILY 6. Solaraze (diclofenac sodium) 3 % topical BID:PRN 7. Viagra (sildenafil) 100 mg oral PRN 8. Meclizine 12.5 mg PO Q12H:PRN dizziness 9. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Hydroxyurea 500 mg PO 5X/WEEK (___) 3. Meclizine 12.5 mg PO Q12H:PRN dizziness 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Vitamin D 800 UNIT PO DAILY 7. Sodium Polystyrene Sulfonate 15 gm PO EVERY OTHER DAY 8. Solaraze (diclofenac sodium) 3 % topical BID:PRN 9. Viagra (sildenafil) 100 mg oral PRN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Active Diagnoses: #Orthostatic Hypertension #Dizziness #Old right basal ganglion infarct Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CAROTID DOPPLER ULTRASOUND INDICATION: ___ year old man with dizzy spells, hypertension // eval for stenosis TECHNIQUE: Real-time grayscale and color and spectral Doppler ultrasound imaging of carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has mild atherosclerotic plaque. The right common carotid artery had peak systolic/diastolic velocities of 36/7 cm/sec. The right internal carotid artery had peak systolic/diastolic velocities of ___ cm/sec in its proximal portion, 40/14 cm/sec in its mid portion and 38/11 cm/sec in its distal portion. The external carotid artery has peak systolic velocity of 47cm/sec. The vertebral artery has peak systolic velocity of 48 cm/sec with normal antegrade flow. The right ICA/CCA ratio is 1.1. LEFT: The left carotid vasculature has no atherosclerotic plaque. The left common carotid artery had peak systolic/diastolic velocities of 51/8 cm/sec. The left internal carotid artery had peaks ystolic/diastolic velocities of 33/9 cm/sec in its proximal portion, 34/9 cm/sec in its mid portion and 35/7 cm/sec in its distal portion. The external carotid artery has peak systolic velocity of 32cm/sec. The vertebral artery has peak systolic velocity of 36 cm/sec with normal antegrade flow. The left ICA/CCA ratio is 0.7. IMPRESSION: Mild, less than 40%, stenosis in bilateral internal carotid arteries. Radiology Report EXAMINATION: MRI AND MRA BRAIN INDICATION: ___ year old man with hypertension with systolic blood pressure >200 and associated presyncopal episodes. Also history of long-standing dizziness when standing up. Evaluate for stenosis or signs of stroke. TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained. 3D time-of-flight MRA of the brain was obtained with multiplanar maximum intensity projection angiographic reformatted images. COMPARISON: Noncontrast CT head ___. FINDINGS: MRI BRAIN: There is increased susceptibility artifact within the right putamen and caudate, indicating hemosiderin deposition from prior hemorrhage. There are small foci of high T2 signal and volume loss in the same distribution, less extensive than the area of prior hemorrhage. There is apparent faint high signal in the distribution of increased susceptibility artifact on diffusion tracer images (images 4:20, 4:21), without corresponding signal abnormality on the ADC map, which is almost certainly an artifact related to the chronic blood products. Otherwise, no acute infarction is seen. Mild high T2 signal in the periventricular white matter of the cerebral hemisphere is is likely related to sequela of mild chronic small vessel ischemic disease, given the patient's age. There is moderate generalized cerebral volume loss with commensurate enlargement of the ventricles and sulci. There is no mass effect or edema. Right frontal sinus is completely opacified, as seen on the preceding CT scan. There is a tiny mucous retention cyst and minimal mucosal thickening in the right maxillary sinus and minimal mucosal thickening in bilateral ethmoidal air cells. MRA BRAIN: The study is limited by motion artifact. Diminished signal intensity in bilateral intracranial vertebral arteries, without diminished caliber, is likely artifactual. Right posterior inferior cerebellar artery and left anterior inferior cerebellar artery are visualized. Basilar artery appears widely patent. Bilateral superior cerebellar and posterior cerebral arteries appear patent. There is no evidence for flow-limiting stenosis in the anterior circulation, although atherosclerosis of the carotid siphons is not excluded. There is no evidence for an intracranial aneurysm. IMPRESSION: 1. Apparent faint high signal on diffusion-weighted images at the site of chronic hemorrhage in the right putamin and caudate is almost certainly artifactual. However, if neurologic exam suggests an acute infarction in this location, then a short-term followup MRI would be helpful for clarification. Otherwise, no acute infarction is seen. 2. No evidence for a major intracranial arterial occlusion or hemodynamically significant stenosis on motion-limited MRA of the head. Diminished signal intensity in bilateral intracranial vertebral arteries, without diminished caliber, is likely related to motion artifact. However, if there is high clinical suspicion for vertebrobasilar insufficiency, then CTA of the head and neck would be helpful for further evaluation. 3. Complete opacification of the right frontal sinus. NOTIFICATION: Results and recommendations were discussed by Dr. ___ Dr. ___ the telephone on ___ at 10:38 Radiology Report EXAMINATION: MRA NECK W/O CONTRAST INDICATION: ___ with HTN and labile pressures, CKD, h/o RCC s/p partial nephrectomy, ?MDS, paroxysmal afib and long history of brief dizzy spells presenting with presyncopal episode, found to have labile BP with position changes but no clear orthostatic hypotension. // Assess vertebral circulation. WITHOUT contrast. TECHNIQUE: 2D time-of-flight MRA of the neck without contrast. COMPARISON: MRI and MRA of the brain dated ___. FINDINGS: Limited imaging of intracranial contents is unremarkable. Limited imaging of paraspinal and prevertebral soft tissues demonstrates no clear evidence of abnormal mass, fluid collection, or lymphadenopathy. There is diminutive signal and artifact at the origins of the great vessels, the appearance of which may be artifactual although stenosis is not excluded. The vertebral arteries are codominant and the carotid arteries bifurcate in the mid neck without evidence of hemodynamically significant stenosis or pathologic large vessel occlusion. IMPRESSION: 1. Limited noncontrast neck MRA. No evidence of large pathologic vessel occlusion within the neck. 2. The origins of the great vessels are obscured predominantly on an artifactual basis although stenosis cannot be excluded. Gender: M Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: Dizziness, Nausea Diagnosed with VERTIGO/DIZZINESS temperature: 97.1 heartrate: 61.0 resprate: 16.0 o2sat: 98.0 sbp: 166.0 dbp: 66.0 level of pain: 0 level of acuity: 2.0
___ year-old gentleman with hypertension and labile pressures, chronic kidney disease, history of renal cell carcinoma s/p partial nephrectomy, ?myelodysplastic syndrome, paroxysmal atrial fibrillation and a long history of brief dizzy spells who presented with a presyncopal episode. ACTIVE ISSUES # Presyncopal episode: ___ has had episodes of dizziness in the past that lasted up to 10 minutes, for many years, but on the afternoon ___ presented ___ was walking around, began feeling very nauseous and weak and generally lightheaded. The episode lasted much longer than prior episodes (several hours). In the ED ___ did not have EKG changes though ___ did have an episode of SBP >200 which correlated with onset of his symptoms. Orthostatics revealed that ___ had orthostatic hypertension (see below). MRI reported old basal ganglia infarcts/hemorrhages. MRA was negative for posterior circulation stenosis/dissection though there were artifactual changes in the vertebral circulation leaving open the possibility of vertebral insufficiency. Carotid ultrasound showed no significant stenosis. Overall, neurology was unable to identify a definitive diagnosis for his presyncopal episodes but felt that it may be related to his blood pressures/orthostatic hypertension. They could not definitively rule out vertebral insufficiency (though unlikely to be complete hypoperfusion since ___ has never passed out) but recommended a repeat MRA neck w/o contrast to better characterize if there is any stenosis that could cause cerebral autoregulatory mechanisms to be overactive to keep cerebral perfusion high causing hypertension during position change. THe read of this test is pending at time of discharge. During admission Mr. ___ worked with ___ and vestibular therapy was attempted to help with the symptoms but this was unsuccessful. ___ was started on amlodipine 2.5mg QD to help better control his blood pressures but when his symtpoms worsened with lower blood pressures, this was discontinued. It is recommended that ___ receive close outpatient PCP ___ and should make an appointment with the ___ neurology clinic for further ___ as well. # Orthostatic hypertension/hypertension: Orthostatics revealed the following BPs: Lying down - 144/6, P 51, Sitting up - 151/65, P 54, Standing up - 173/76, P 53. This supports a diagnosis of orthostatic hypertension. In addition ___ had systolic pressure of >200 and was symptomatic while in the Emergency Departmtment indicating hypertensive urgency. ___ will need further blood pressure management as an outpatient to bring his labile blood pressures under better control but while ___ was on amlodipine 2.5mg PO Daily his symptoms worsened and this was discontinued. Of note for future anti-hypertensive therapy, ___ appears to have baseline heart rates in the ___, sometimes dropping into the ___. # Hyperkalemia: During the admission his K was initially 5.3 and was later 4.7 after receiving kayexylate (a home medication for him). Per discussion with his PCP it appears that his K typically runs >5 secondary to his CKD. ___ was continued on his QoD home kayexylate. CHRONIC ISSUES # ?Myelodysplastic syndrome: ___ was continued on his home dose of hydroxyurea # CKD: ___ is s/p partial nephrectomy for ___ in ___ and was followed up with renal U/S's for many years subsequently until continued surveillance was felt to be no longer necessary. His K remained at baseline and his Cr was mildly elevated (2.1, his baseline is ~2 or just under). # Healthcare management: Continue aspirin and vitamin D. # GERD/gastritis: The patient had previously stopped taking his home omeprazole but this was resumed during this admission and should be continued upon discharge. TRANSITIONAL ISSUES #Outpatient ___ with PCP: ___ should make a ___ appointment with his PCP when leaving rehab. #Outpatient ___ with Neurology: Neurology will call to arrange for a ___ appointment. # Thrombocytosis: Unclear etiology. Will make transitional issue for PCP. Could be JAK2+ ET. No signs of inflammation or infection. Not iron deficient given absent anemia.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Procardia / Metoprolol Attending: ___. Chief Complaint: Afib Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ M PMHx significant for AFib, sCHF (LVEF 45%) due to ischemic CM w/ ICD and CAD s/p CAB who presents to ED with dyspnea and palpitations. Patient reports worsening shortness of breath with exertion and laying flat for the past one week. He has also noted intermittent chest pressure and palpitations. He denies weight gain, fevers, chills, lower extremity swelling, dizziness, nausea, or abdominal pain. When EMS arrived at patient's home, he was noted to be in atrial fibrillation with RVR at a rate of 150. His systolic blood pressures remained in the 110-120s. In the ED intial vitals were: 0 97.2 150 ___ 100% However, patient's heart rate varied from 120-150 in a fib with systolic blood pressures of ___. Asymptomatic. Mentating well. Labs were notable for proBNP: 2614, Trop-T: 0.90, INR: 2.6 CXR showed pulmonary edema and a small pleural effusion Patient was given: 1L NS, Calcium and PO and IV dilt, but remained in atrial fibrillation with RVR after PO and IV dilt, and so was started on dilt gtt with HR improvement to ___, but remains in afib. Repeat ECG with ST depressions. Elevated trop concern for NSTEMI. Heparin gtt started, asa and plavix given. Heme occult neg. Vitals on transfer: 0 98.6 100 111/46 14 99% RA On the floor patient reports that he has been having SOB for the past 1 week which has been mild. However today his SOB acutely worsened such that he was unable to climb stairs. He also reported he had some chest tightness before he came in. He has also noticed some swelling in his legs but has not had any weight gain and reports a stable weight of 179-180 lbs. He states that currently he is chest pain free, denies any SOB at rest. Denies any orthopnea, PND, or palpitations at this time. No recent fevers, chills, or night sweats. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes + Hypertension + Hyperlipidemia Prior tobacco Peripheral vascular disease 2. CARDIAC HISTORY: extensive: 1. CAD s.p. 5-vessel CABG ___: LIMA-D1, SVG-OM, SVG-pRDA, SVG-rPL, SVG-D (angina = R/LUE radiating to neck). Two occluded SVGs (SVG-OM, SVG-rPL). 3.01: SVG-OM BMS c/b acute graft thrombus s/p thrombectomy, SVG-rPDA: BMS. Last PCI ___ with mid LCX--> OM1 BMS. 2. Mild ischemic cardiomyopathy, EF 40-45%. 3. VT arrest in ___, ICD (Intrinsic 7288 ___ ___, atrial/RV lead extraction ___ (lead fracture), MDT Protecta generator replacement. Episodes of asymptomatic NSVT. 4. PVD s.p R. popliteal/VT PCI, b/l fem-pop bypass (___). 5. Hypertension/mild LVH (carvedilol, enalapril, HCTZ) 6. Dyslipidemia 7.12: TC82/TG110/H35/L31 (rosuva 10 mg QOD, gemfibrizol) mg QOD, gemfibrizol, fish oil. 7. PAF, asymptomatic, detected on ICD interrogation. Coumadin. CHADS2=4 3. OTHER PAST MEDICAL HISTORY: DM-2, c/b retinopathy and neuropathy Basal Cell CA BPH Social History: ___ Family History: Father had a heart murmur; he died at ___. Brother with brain cancer Brother with prostate cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=97.9 BP=127/86 HR=105 RR=16 O2 sat=98%RA GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7-8 cm. CARDIAC: irregularly irregular, S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness EXTREMITIES: trace ___ edema L>R. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ radial, DP DISCHARGE PHYSICAL EXAM: VS: 98.5, 92-109/45-63, 52-72, 18, 96RA wt 81.3 (81.5) I: 1100 O:1050 GENERAL: WDWN male in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, mild JVD CARDIAC: regular, S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness EXTREMITIES: Trace lower extremity edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ radial, DP Pertinent Results: ADMISSION LABS: ___ 06:45PM BLOOD WBC-7.0 RBC-3.94* Hgb-11.6* Hct-34.8* MCV-88 MCH-29.4 MCHC-33.4 RDW-13.0 Plt ___ ___ 06:45PM BLOOD Neuts-67.6 ___ Monos-7.2 Eos-1.5 Baso-0.5 ___ 06:45PM BLOOD ___ PTT-43.8* ___ ___ 06:45PM BLOOD Glucose-159* UreaN-29* Creat-1.0 Na-134 K-3.7 Cl-100 HCO3-23 AnGap-15 ___ 06:45PM BLOOD proBNP-2614* ___ 06:45PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7 ___ 05:45AM BLOOD TSH-1.5 TREND: ___ 06:45PM BLOOD proBNP-2614* ___ 06:45PM BLOOD cTropnT-0.90* ___ 01:49AM BLOOD cTropnT-1.74* ___ 05:45AM BLOOD CK-MB-13* MB Indx-9.4* cTropnT-1.88* ___ 09:00AM BLOOD cTropnT-1.78* ___ 05:50AM BLOOD CK-MB-5 DISCHARGE LABS: ___ 06:18AM BLOOD ___ PTT-55.1* ___ ___ 01:20PM BLOOD Glucose-255* UreaN-24* Creat-1.0 Na-133 K-4.5 Cl-95* HCO3-24 AnGap-19 IMAGING: ___ CXR IMPRESSION: No pneumonia or overt edema. Stable mild cardiomegaly ___ ECHO The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with inferior and inferolateral akinesis. The septum and anterior wall have relatively normal function with other segments being moderately hypokinetic. Right ventricular chamber size is normal with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: mild symetric LVH with moderate dilation. Severe left ventricular systolic dysfunction as described above. Moderate to severe mitral regurgitation. At least moderate tricuspid regurgitation. Moderate to severe pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the left ventricle is more dilated with more severe reduction in ejection fraction. The degree of mitral regurgitation is similar (underestimated on prior). Degree of tricuspid regurgitation and pulmonary hypertension have worsened ___ STRESS INTERPRETATION: This ___ year old IDDM man s/p NSTEMI, CABG ___, LVEF 20%, ICD, recent AF was referred to the lab for evaluation. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no significant ST segment changes during the infusion or in recovery. The rhythm was sinus with occasional isolated apbs, frequent vpbs and several ventricular couplets. In late recovery, he had a 3 second run of PAF. Appropriate hemodynamic response to the infusion and recovery. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or significant ST segment changes. Nuclear report sent separately. ___ NUCLEAR STRESS STRESS NUCLEAR The image quality is adequate Left ventricular cavity size is dilated, and has significantly increased in size compared to most recent prior examination from ___. Rest and stress perfusion images reveal large severe fixed defects in the inferior wall, inferolateral wall, and basilar segment of the lateral wall. The Gated images reveal akinesis of the inferolateral wall and entire infrior wall. Akinesis of the septum is consistent with the prior history of cardiac surgery. The calculated left ventricular ejection fraction has decreased and is now 25% with an EDV of 179 ml. Compared with prior study of ___, the ejection fraction has decreased and the ventricular cavity size has increased. The severe perfusion defects and wall motion abnormalities are unchanged. IMPRESSION: 1. Decreased ejection fraction (25%) and increased ventricular cavity size as compared to recent prior. 2. Severe fixed inferior and inferolateral perfusion defects and wall motion abnormalities are unchanged. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. Finasteride 5 mg PO QHS 4. Gemfibrozil 600 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY 7. Warfarin 4 mg PO 4X/WEEK (___) 8. Warfarin 6 mg PO 3X/WEEK (___) 9. Glumetza (metFORMIN) 1,000 mg oral BID 10. Nitroglycerin SL 0.4 mg SL PRN chest pain 11. Furosemide 20 mg PO DAILY 12. Enalapril Maleate 10 mg PO DAILY 13. NPH 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. Finasteride 5 mg PO QHS 4. Multivitamins 1 TAB PO DAILY 5. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY 6. Warfarin 4 mg PO 4X/WEEK (___) 7. Warfarin 6 mg PO 3X/WEEK (___) 8. Spironolactone 25 mg PO DAILY RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Gemfibrozil 600 mg PO BID 10. Glumetza (metFORMIN) 1,000 mg oral BID 11. Nitroglycerin SL 0.4 mg SL PRN chest pain 12. Enalapril Maleate 10 mg PO DAILY 13. Outpatient Lab Work 42___.31 -Please check CHEM 10 (Na, K, Cl, HCO3, BUN, Cr, glucose) and ___ -Please, fax results to Dr. ___ at ___ 14. Dofetilide 375 mcg PO Q12H 15. NPH 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 16. Furosemide 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation with rapid ventricular response NSTEMI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Shortness of breath, assess for pneumonia. FINDINGS: AP upright view of the chest was provided. Midline sternotomy wires, mediastinal clips, and AICD appear unchanged in position. The heart remains mildly enlarged. There is no focal consolidation, effusion or pneumothorax. There are no overt signs of edema. Bony structures are intact. Mediastinal contour is stable. IMPRESSION: No pneumonia or overt edema. Stable mild cardiomegaly. Gender: M Race: WHITE - EASTERN EUROPEAN Arrive by AMBULANCE Chief complaint: , Dyspnea Diagnosed with ATRIAL FIBRILLATION, CONGESTIVE HEART FAILURE, UNSPEC, AICD STATUS temperature: 97.2 heartrate: 150.0 resprate: 20.0 o2sat: 100.0 sbp: 111.0 dbp: 77.0 level of pain: 0 level of acuity: 2.0
Mr. ___ is a ___ M with PMH of Atrial Fibrillation, sCHF LVEF 45% due to ischemic CM w/ ICD and CAD s/p CABG who presents to ED with dyspnea and palpitations in the setting of atrial fibrillation with RVR who remained in NSR after dofetilide. # Atrial Fibrillation with RVR: Patient with history of paryoxysmal AFib with CHADS2 score of 4. Patient normally does not notice when he has atrial fibrillaton or even RVR. He was hypotensive in setting atrial fibrillation in ED and was initially not responsive to oral or IV dilt responded to dilt gtt. ACS was thought ot be a possible precipitant, as patient had akinesis of previously hypokinetic portions of left ventricular inferior and inferiolateral walls on echo during this admission. TSH normal. Dofetilide was reccommended by EP given patient had adverse reaction to amioderone with dizziness and weakness. He was loaded with dofetilide and serial EKGs were checked with stable QTc. He was anticoagulated with heparin as bridge until he was therapeutic on coumadin (initally held for possibility of cath) # NSTEMI: Pt with CAD s/p 5-vessel CABG ___: LIMA-D1, SVG-OM, SVG-pRDA, SVG-rPL, SVG-D (Two occluded SVGs (SVG-OM, SVG-rPL). 3.01: SVG-OM BMS c/b acute graft thrombus s/p thrombectomy, SVG-rPDA: BMS. PCI ___ with mid LCX--> OM1 BMS. His ECG had ST depressions on admission in setting of atrial fibrillation with RVR and with elevated troponin concern for NSTEMI. Troponins peaked at 1.88 ( 0.9->1.74->1.88->1.78), patient was continually asymptomatic. However, some concern on TTE of reduced EF from 40->25% and now akinesis of previously hypokinetic left ventricular inferior and inferiolateral wall. Stress nuclear studies indicated unchanged, fixed ischemic deficits, but a significant decrease in EF as compared with early ___. He was continued on aspirin, coumadin, statin and carvedilol. # Chronic CHF w/ ICD, systolic ___ ischemic cardiomyopathy, EF 40-45% in early ___. Current presentation not consistent with acute exacerbation. BNP 2614 on admission. Patient had episode of shortness of breath in the setting of decreased EF to ___, however, this resolved and has not recurred. On exam, some JVD but weight stable with only trace edema in bilateral lower extremities. He was given IV lasix x1 with good result and maintained on his home dose PO lasix. He was continued on carvedilol and enalapril. He was initiated on spironolactone 25mg PO daily given his now low EF of ___. # Diabetes Mellitus type II: This is complicated by retinopathy and neuropathy. On metformin and NPH insulin therapy at home. In-house, metformin was held and he was maintained on his home NPH as well as a humalog sliding scale. # Hypertension: Normotensive during admission. Was continued on carvedilol and enalapril. # Dyslipidemia: Some confusion as to whether he was supposed to receive statin. Per last clinic note in ___ with Dr. ___ was on rosuvastatin 5mg QOD not to lower cholesterol, but rather, for other properties of the statin. Was continued on home rosuvastatin 5mg QOD. Gemfibrozil was held in-house, but restarted at discharge.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o female college student with DM1 who presents with three days of elevated blood sugars at home and one episode of vomiting. She reports that three days PTA she noticed that her blood sugars were elevated to 200s-low 300s, and she continued to take her regular insulin regimen of nightly lantus and Novalog sliding scale. She also developed some nausea and loss of apetite over the course of the next several days. On the day PTA her sugar was significantly elevated (>600) and she had one episode of vomiting, prompting her to present to the ___ ED. She took 15units of Novolog approximately 1.5 hrs before presenting to the ED. She reports having minimal rhinorrhea and a slight headache in the context of sinus pressure from seasonal allergies over the past few days, but denies fevers/chills, cough, sore throat, SOB, or dysuria. She has not missed any of her lantus doses or sliding scale insulin, and she has been following her usual carb counting regimen. She does report that it is finals week at her school and she has been under increased stress over the past week. Her last episode of DKA was during high school, and she is followed by a pediatric endocrinologist in her home town of ___. In the ED, her initial vitals were T 97.0 HR 91 BP 145/75 RR 16 SpO2 100%. Initial labs were notable for glucose of 568, an anion gap of 20 and WBC count of 10.8 with 85% polys. UA demonstrated glucose and ketones. VBG was within normal limits and CXR was negative. She was observed overnight and was treated with 1 L IVF as well as IV zofran for nausea, but was not given insulin as repeat labs were notable for glucose 68 and AG 11. This morning she received 18 units Humalog for ___ 489. She was given her basal Lantus 45 units at breakfast as well as started on a sliding scale. She was seen by the ___ Diabetes team, who recommended admission for monitoring. Her vitals prior to transfer to the floor were Tc 97.9 HR 67 BP 115/75 SpO2 100% RA. Currently, she reports that her nausea has mostly resolved and she is feeling hungry. ROS: per HPI, denies night sweats, vision changes, chest pain, abdominal pain, diarrhea. Past Medical History: DM1, diagnosed age ___ Epilepsy, last seizure in ___ grade ADHD Deviated septum repair, age ___ Overbite correction surgery as a child Social History: ___ Family History: Father- DM2, HTN; Maternal grandparents both with DM2; maternal grandmother CAD Several first cousins with DM1. Older brother and sister are both healthy. Physical Exam: ADMISSION PHYSICAL EXAM: VS - T 97.9 HR 74 BP 128/86 RR 24 SpO2 100%RA FSBG 132 GENERAL - NAD, well-developed, well-nourished, lying in bed HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no w/r/rh, good air movement, resp unlabored 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 NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact DISCHARGE PHYSICAL EXAM: VS - Tm 97.9 Tc 97.6 HR 53 BP 126/89 RR 18 SpO2 100%RA FSBG ___: 248 (___), 76, ___ FSBG ___: 133 (0000), 79 (0420), 106, 144 (0725) GENERAL - NAD, well-developed, well-nourished woman, lying in bed HEENT - NC/AT, PERRLA, mucus mebranes moist HEART - RRR, nl S1-S2, no m/r/g LUNGS - CTAB, no w/r/rh ABDOMEN - +BS, soft/NT/ND EXTREMITIES - WWP, no c/c/e NEURO - A&Ox3, strength grossly intact Pertinent Results: Hematology: ___ 04:33AM BLOOD WBC-6.3 RBC-3.69* Hgb-11.5* Hct-36.8 MCV-100* MCH-31.1 MCHC-31.2 RDW-12.3 Plt ___ ___ 05:45PM BLOOD WBC-6.3 RBC-3.71* Hgb-11.4* Hct-36.5 MCV-98 MCH-30.7 MCHC-31.3 RDW-12.0 Plt ___ ___ 04:21PM BLOOD WBC-10.8 RBC-4.10* Hgb-12.9 Hct-41.7 MCV-102*# MCH-31.4 MCHC-30.8* RDW-12.2 Plt ___ Chemistries: ___ 04:33AM BLOOD Glucose-77 UreaN-10 Creat-0.5 Na-140 K-3.8 Cl-105 HCO3-27 AnGap-12 ___ 05:45PM BLOOD Glucose-229* UreaN-10 Creat-0.7 Na-139 K-4.6 Cl-102 HCO3-27 AnGap-15 ___ 11:20AM BLOOD Glucose-436* UreaN-13 Creat-0.7 Na-136 K-4.0 Cl-99 HCO3-21* AnGap-20 ___ 07:00PM BLOOD Glucose-63* UreaN-12 Creat-0.7 Na-142 K-4.2 Cl-103 HCO3-28 AnGap-15 ___ 04:21PM BLOOD Glucose-568* UreaN-15 Creat-1.0 Na-135 K-4.0 Cl-96 HCO3-19* AnGap-24* HbA1c ___: 9.0% Blood gases: ___ 11:22AM BLOOD ___ Temp-36.6 pO2-125* pCO2-37 pH-7.36 calTCO2-22 Base XS--3 ___ 07:06PM BLOOD ___ pO2-50* pCO2-48* pH-7.39 calTCO2-30 Base XS-2 UA: Glucose 1000, Ketones 10, neg leuk esterase, neg nitrites UCx: Mixed bacterial flora c/w skin or genital contamination IMAGING: CXR ___ FINDINGS: The lungs are clear. Cardiomediastinal silhouette is unremarkable. Hilar contours are normal. No pleural effusion. No pneumothorax. IMPRESSION: No evidence of acute intrathoracic process. Medications on Admission: Lantus 45 mg QHS Novalog sliding scale, 1u starting at 120 mg/dL, increasing by 1u Metformin 1000 mg qAM, 500 mg qPM Concerta 18 mg QD before attending classes Discharge Medications: 1. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal BID (2 times a day) as needed for allergies. Disp:*1 bottle* Refills:*0* 2. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty Five (45) units Subcutaneous at bedtime. Disp:*15 pens* Refills:*2* 3. insulin aspart 100 unit/mL Insulin Pen Sig: see sliding scale Subcutaneous four times a day. Disp:*15 pens* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: DKA, precipitant etiology unknown Secondary diagnoses: seasonal allergies Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL HISTORY: ___ female with hyperglycemia and vomiting. Question pneumonia. COMPARISON: ___. TECHNIQUE: PA and lateral views of the chest. FINDINGS: The lungs are clear. Cardiomediastinal silhouette is unremarkable. Hilar contours are normal. No pleural effusion. No pneumothorax. IMPRESSION: No evidence of acute intrathoracic process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: HYPERGLYCEMIA Diagnosed with DIABETES UNCOMPL JUVEN, OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY temperature: 97.0 heartrate: 91.0 resprate: 16.0 o2sat: 100.0 sbp: 145.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0
___ y/o woman with DM1 who presented with elevated blood sugar, nausea and vomiting and lab findings c/w DKA. 1. DKA: Her presenting symptoms of nausea and vomiting in the context of hyperglycemia as well as the findings of ketonuria and an anion gap were consistent with DKA, although her venous blood gases did not demonstrate an overt metabolic acidosis. The precipitant was unclear, as she did not report systemic symptoms of acute illness, her CXR was negative for a pneumonia or other lung infection, her UA did not suggest UTI, and she reports that she has been compliant with her insulin regimen at home. She was seen by the ___ diabetes team, who recommended an increased humalog sliding scale. She was given basal insulin coverage with 45 units glargine on the morning of admission; on the day of discharge she was covered with 15 units glargine in the morning and was instructed to switch back to her home dose of 45 units before bedtime on discharge. Her home Metformin was held on admission and at discharge per ___ recommendations. Clinically she improved with IVF and Mg repletion; her FSBG normalized and her anion gap closed. She will follow up with the ___ physicians next week. 2. Seasonal allergies: On admission she had some mild sinus pressure and rhinorrhea, which she reported was at her baseline. She was treated with fluticasone nasal spray PRN.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ceclor Attending: ___. Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: HPI(4): ___ with hx of longstanding eating disorder (multiple prior medical and psych admissions, last medical in ___ self-presenting after worsening dizziness, SOB and leg cramps and weakness. She describes most prominent symptoms are weakness and dizziness x 2 months, with progressive lightheadedness, "out of it," blurry vision, with tingling and cramping in her legs over the preceding week. She describes bilateral ___ cramping and tingling as intermittent, worse when waking up in the morning, ___. She did go to work the day of presentation, but weakness prompted her to speak with her mother, who advised her to go to the ED. Pt reports losing 30 lbs since ___ (currently at lowest weight ever) through calorie restriction (600/day), exercise (runs ___ miles 6 days per week)and purging (self-induced vomiting multiple times approx. 3 days per week). Reports that SOB is worse when lying supine, non-exertional. Denies palpitations, swelling in hands and feet. Denies SI. She reports continuing to try to run until 3 days prior to presentation. The day prior to presentation, she did run 2 miles ("maybe more than that"), but notes that that is less and slower than usual. She also has noted intermittent SOB which occurs typically when lying down and when driving to work. She thinks her chest pain - which is substernal, aching, ___ - is precipitated by self induced emesis. She reports approximately 15 lifetime psychiatric hospitalizations relating to her eating disorder, and ___ medical hospitalizations for stabilization. Most recently, she was at ___ until ___, and reports that, although she had improved, she insisted on discharge "to return to work" before providers felt that she was stable. During that hospitalization, her weight increased from 79 lbs on admission to 105 lbs at time of discharge. She describes weight loss since that time as both intentional and unintentional, explaining that behaviors the produce weight loss are now embedded habits. She endorses intermittent constipation and diarrhea, for which she intermittently takes Colace, "but I don't abuse it." She denies using other laxatives. Of note, she reports that she had a therapist for her eating disorder, but that her therapist declined to see her after her last discharge from ___ because, by her description, she left before providers there felt that she was ready. She currently has no therapist or psychiatrist, and reports that her new PCP "does not know anything about eating disorders." She is amenorrheic. ___ MD spoke directly with ___ mother on evening of admission, with patient's express permission. ___ mother reports that pt has struggled with eating disorder since middle school, "on and off - mostly on." She reports that in the past ___ years, she has had a sort of acceleration of disease, with repeated hospitalizations. She describes hospitalization ___. Her mother believes that her weight is at an all time low, and believes the patient is now frightened by her symptoms. Her mother reports that she has been encouraging the patient to present to the ED for weeks. ___ mother believes that pt left AMA from ___ in ___ because she often reaches a point where the weight gain is not tolerable to her, and also that she cares about returning to her work. Her mother is worried that, although psychiatric hospitalization helps some people, it has never produced sustained benefit for pt. She apparently has tried the ___ ___ program but has never been inpatient there. Typically she has been at ___ (at ___). ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Eating disorder as per HPI Social History: ___ Family History: Older sister (___) had short lived eating disorder in high school that responded well to treatment, no longer active. Father is a "high functioning" alcoholic. Physical Exam: ADMISSION EXAM: VITALS: 97.5 PO 146 / 99 60 16 Weight 71.21 lbs GENERAL: Cachetic, alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, scaphoid, non-distended, non-tender to palpation. Bowel sounds present. No HSM appreciated GU: No suprapubic fullness or tenderness to palpation, no foley MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout, no ophthalmoplegia or nystagmus PSYCH: pleasant, appropriate, slightly flattened affect DISCHARGE EXAM: 24 HR Data (last updated ___ @ 915) Temp: 97.7 (Tm 98.0), BP: 111/81 (89-121/52-81), HR: 89 (57-89), RR: 20 (___), O2 sat: 99% (97-100), O2 delivery: Ra, Wt: 82.89 lb/37.6 kg Wt: 83.55 lb/37.9 kg Orthostatics: asymptomatic, BP unchanged, HR from 64->78->102 Gen: thin young woman in NAD Eyes: anicteric, non-injected CV: RRR Pulm: CTAB Abd: S NT ND Neuro: grossly intact Skin: no visible lesions Pertinent Results: ============================== ADMISSION LABS: ___ 11:29AM BLOOD WBC-3.6* RBC-3.66* Hgb-13.3 Hct-36.9 MCV-101* MCH-36.3* MCHC-36.0 RDW-12.6 RDWSD-46.5* Plt ___ ___ 11:29AM BLOOD Plt ___ ___ 11:29AM BLOOD Glucose-38* UreaN-21* Creat-0.8 Na-132* K-3.9 Cl-90* HCO3-28 AnGap-14 ___ 11:29AM BLOOD ALT-28 AST-46* AlkPhos-115* TotBili-0.6 ___ 11:29AM BLOOD Albumin-4.6 Calcium-8.6 Phos-3.5 Mg-2.4 ___ 06:40AM BLOOD calTIBC-207* VitB12-695 Folate-6 Ferritn-384* TRF-159* ___ 06:55AM BLOOD %HbA1c-4.6 eAG-85 ___ 11:29AM BLOOD TSH-1.9 ___ 07:00AM BLOOD Cortsol-27.8* ___ 11:29AM BLOOD ASA-NEG Acetmnp-17 Tricycl-NEG OTHER PERTINENT LABS: Utox: negative UA: negative UCG: negative Leukopenia: 2.7-4.2 Anemia: 13 ----> ___ range (stable for ~2 weeks) Thrombocytopenia (resolved) Hypoglycemia ___ (resolved) Beta hydroxybutyrate: 0.1 x2 (nl <0.4) ___ 06:40AM BLOOD calTIBC-207* VitB12-695 Folate-6 Ferritn-384* TRF-159* ___ 06:55AM BLOOD %HbA1c-4.6 eAG-85 ___ 11:29AM BLOOD TSH-1.9 ___ 07:00AM BLOOD Cortsol-27.8* ___ 11:29AM BLOOD ASA-NEG Acetmnp-17 Tricycl-NEG ___ 12:02PM URINE UCG-NEGATIVE ___ 12:02PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Sent ___ AM: ------------- Insulin Ab: negative C-peptide: 0.65 (reference 0.80-3.85) B-OH: 0.1 Proinsulin: <7.5 Insulin: <1.0 Sent while serum glucose 45 on ___: Insulin Ab: negative C-peptide: 1.3 (WNL) B-OH: 0.1 (WNL) Proinsulin: <7.5 Insulin: <1.0 UCx ___ Grp B strep IMAGING: - CXR (___): No acute cardiopulmonary abnormality. - EKG (___): Sinus bradycardia at 51 bpm, nl axis, PR 196, QRS 92, QTC 455, no ischemic changes - EKG (___): Sinus bradycardia at 52 bpm, normal axis, normal intervals (QTC 418), TWI in aVL, flattening in V2, no ST segment changes, no Q waves, no priors for comparison - EKG ___: QTc 431. DISCHARGE LABS: ___ 06:50AM BLOOD Glucose-71 UreaN-12 Creat-0.5 Na-135 K-4.9 Cl-96 HCO3-22 AnGap-17 ___ 07:05AM BLOOD WBC-3.1* RBC-2.71* Hgb-9.9* Hct-28.6* MCV-106* MCH-36.5* MCHC-34.6 RDW-11.8 RDWSD-45.4 Plt ___ ============================== Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN Pain 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line 3. Cyanocobalamin 100 mcg PO DAILY 4. DULoxetine 30 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. LORazepam 0.5 mg PO TID Please give 20 minutes before mealtime RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth three times daily 20 minutes before meals Disp #*90 Tablet Refills:*0 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Omeprazole 20 mg PO DAILY 9. QUEtiapine Fumarate 37.5 mg PO QHS insomnia 10. Senna 8.6 mg PO BID:PRN Constipation 11. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Severe anoxeria nervosa, hypoglycemia, anemia, orthostatic hypotension SECONDARY: Depression 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 anorexia p/w medically unstable eating disorder.// Please evaluate for pulm edema as part of eating disorder protocol. TECHNIQUE: AP portable chest radiograph COMPARISON: None FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax identified. No evidence of pulmonary edema. The size of the cardiomediastinal silhouette is within normal limits. IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dizziness, Lightheaded, Weakness Diagnosed with Other fatigue temperature: 97.6 heartrate: 64.0 resprate: 18.0 o2sat: 99.0 sbp: 114.0 dbp: 98.0 level of pain: 0 level of acuity: 2.0
Ms ___ is a ___ year old woman with history of depression and anorexia nervosa (multiple prior medical and psych admissions, last medical in ___ admitted with medically unstable eating disorder. # Anorexia nervosa: # Severe protein-calorie malnutrition Pt met criteria for medical instability on admission based on % IBW (58% IBW on admission) and by glucose <60, with multiple other apparent sequelae of eating disorder (including bradycardia, leukopenia, thrombocytopenia). Psychiatry consulted, and patient started on eating disorder nurse-driven protocol. Reviewed protocol with patient, who was in agreement with treatment. Multidisciplinary team meetings were held weekly, with medicine, psychiatry, nutrition, nursing, social work, and case management. Her electrolytes remained largely stable, with no evidence of refeeding syndrome, and her hypoglycemia gradually improved. Endocrinology was consulted and recommended testing for hyperinsulinemia, which was negative. B12/folate and iron studies WNL. She also received thiamine 100 mg PO TID x3 days, followed by thiamine 100 mg PO daily (___), and a daily multivitamin. She was started on lorazepamn 0.5 mg prior to each meal for meal-related anxiety. She gained ___ kg during the admission, although stabilized prior to discharge, and so nutrition team continuing to increase daily calorie intake at this time. On discharge, her %IBW was 66% (37.6 kg). She was discharged to an inpatient eating disorder facility at ___. # Postural tachycardia/hyponatremia: She continued to have postural tachycardia (heart rate with significant wide swings, but blood pressures without drop). She was asymptomatic. A trial of increasing water intake reduced the postural tachycardia but was then discontinued due to mild hyponatremia (nadir 132; back to 135 by discharge). Since she was asymptomatic and the tachycardia was mild, this was not pursued further. She is currently drinking 8 oz water at night and none between meals. # Anemia: Throughout her hospitalization, patient was noted to have worsening macrocytic anemia. She had a medical work up for this, which revealed no hemolysis, no iron deficiency, and was consistent with underproduction likely in the setting of nutritional deficiencies. She was set up with a follow up appointment in the ___ clinic for further workup of her anemia. Her most recent hemoglobin prior to discharge was 9.9. # Depression. The patient was restarted on her duloxetine 20 mg daily, increased to 30 mg during this hospitalization. #Constipation. Infrequent bowel movements. Titrated constipation regimen ==========================================
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PLASTIC Allergies: lisinopril Attending: ___. Chief Complaint: dehisced left index finger wound Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo, RHD male, PMH sig for ESRD on dialysis now s/p L-IF DIPJ amputation for nonhealing wound due to steal syndrome, presents to ED after fingertip wound dehisced yesterday. Pt last seen in clinic on ___ at which time sutures were taken out. Within the past week, small amt of pus from wound cultured in clinic positive for E. coli and started on augmentin earlier this week. C/o swelling and pain at the distal tip of his partial amputated L-IF. Possible small amount of pus expressed at home. Denies F/C/N or N/V. Past Medical History: Significant for type 2 diabetes, diabetic neuropathy, cad, hyperlipidemia, hypertension, peripheral vascular disease, and kidney transplant. Social History: ___ Family History: Mother, Father, ___ GM, and about ___ siblings have DM. Parents and multiple siblings with HTN. Mother died of breast cancer. Father died of CHF. PGM and Aunt with ESRD. Many family members with gout. Physical Exam: Discharge Physical Examination: VITALS:T 98.3 HR 74, BP 108/80, RR 18 99%RA, FSBG 128-342 GEN: He is a well-appearing male in no apparent distress. EXT: L-Hand - radial pulse 1+, cap refill <2sec. Sensation in median, radial and ulnar nerve distributions are grossly intact. L-IF with mild dehisced wound without active drainage of blood or pus or expressable. TTP at remaining middle phalanx and tip along with fusiform swelling of that phalanx. motor/sensory to that digit intact. Pertinent Results: ___ 07:19AM BLOOD WBC-5.3 RBC-3.88* Hgb-11.3* Hct-33.7* MCV-87 MCH-29.2 MCHC-33.6 RDW-13.7 Plt ___ ___ 07:19AM BLOOD Neuts-77.4* Lymphs-13.5* Monos-7.5 Eos-1.0 Baso-0.5 ___ 07:19AM BLOOD Glucose-218* UreaN-28* Creat-1.2 Na-134 K-4.2 Cl-100 HCO3-23 AnGap-15 ___ FINGER(S),2+VIEWS LEFT Three views of the left fifth finger. Since exam of left hand ___ the distal phalanx of this finger has been resected. There is no bone destruction or other osseous abnormality in the remaining bones. Extensive peripheral vascular calcifications. Minimal soft tissue irregularity/bandaging at the site of resection. IMPRESSION: Post resection with no evidence of osteomyelitis. Medications on Admission: 1. Doxazosin 8 mg PO HS 2. Famotidine 20 mg PO DAILY 3. Losartan Potassium 100 mg PO HS 4. NIFEdipine 300 mg PO QAM 5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 6. Pravastatin 10 mg PO DAILY 7. PredniSONE 3 mg PO QAM 8. Spironolactone 50 mg PO BID 9. Tacrolimus 5 mg PO Q12H 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Aspirin 81 mg PO DAILY 12. Acetaminophen 1000 mg PO Q8H:PRN pain 13. Metoprolol Succinate XL 350 mg PO DAILY Discharge Medications: 1. Tacrolimus 5 mg PO Q12H 2. Spironolactone 50 mg PO BID 3. PredniSONE 3 mg PO QAM 4. Pravastatin 10 mg PO DAILY 5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 6. NIFEdipine 300 mg PO QAM 7. Losartan Potassium 100 mg PO HS 8. Aspirin 81 mg PO DAILY 9. Doxazosin 8 mg PO HS 10. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Duration: 7 Days RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 12. Famotidine 20 mg PO DAILY 13. Acetaminophen 1000 mg PO Q8H:PRN pain 14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Do not take while taking the Bactrim DS for your wound. 15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 16. Metoprolol Succinate XL 350 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Nonhealing left index finger wound Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Recent amputation. ?osteomyelitis. Three views of the left fifth finger. Since exam of left hand ___ the distal phalanx of this finger has been resected. There is no bone destruction or other osseous abnormality in the remaining bones. Extensive peripheral vascular calcifications. Minimal soft tissue irregularity/bandaging at the site of resection. IMPRESSION: Post resection with no evidence of osteomyelitis. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: WOUND EVAL Diagnosed with OTHER POST-OP INFECTION, ABN REACT-PROCEDURE NOS temperature: 97.1 heartrate: 99.0 resprate: 16.0 o2sat: 100.0 sbp: 119.0 dbp: 62.0 level of pain: 4 level of acuity: 3.0
Mr. ___ was admitted ___ for dehisced left index finger wound. IV Zosyn and PO bactrim (DS) were started. Pain was controlled with Oxycodone-Acetaminophen. He did daily betadine soaks and hand elevation. He will be discharged on PO Bactrim DS and Ciprofloxacin for 7 days. He will return to Hand Clinic on ___. While he was in the hospital, ___ Diabetes was consulted for further management of his diabetes. His fixed and sliding scale were adjusted daily by ___, however, his FSBGs were elevated during this stay in 200-300s. He will follow-up with Dr. ___ as an outpatient for better control. He was maintained on all of his home medications. At the time of discharge on ___, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bilateral mandibular fracture Major Surgical or Invasive Procedure: ___: 1) Open reduction internal fixation of left mandibular angle fracture 2} Closed reduction maxilla-mandibular fixation right subcondylar fracture 3) Extraction teeth 5 and 12 History of Present Illness: ___ with no significant past medical history presenting as a transfer from ___ for evaluation of bilateral mandibular fractures after an assault that occurred last night. Patient was assaulted by a male acquaintance but per her report could not find any health and so this morning went to ___ ___ where she felt "most safe". She received a CT scan where she was found to have bilateral mandibular fractures. No other injuries. Patient reports that she will not be in contact with this person and does not feel unsafe. She declines social work consultation. She is otherwise feeling well. ROS: (+) per HPI (-) Denies fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: PAST PSYCHIATRIC HISTORY: Prior Diagnoses: "Anger and Depression" Hospitalizations: reports two: first at ___ x 3 months in ___, then at ___ 2 months during same year; both for depression Current treaters and treatment: Psychiatrist: Dr. ___ at ___ in ___ - last saw months ago, supposed to see every month, does not know why she stopped going. Therapist: ___ at same facility, also last saw ___ months ago, does not know why stopped going. Medication and ECT trials: Zoloft, Ritalin, Wellbutrin, Neurontin, Thorazine, Lithium, Risperdal, Lamictal, Ativan; reports only ativan was helpful. Self-injury: denies history of cutting Suicide Attempts: reports overdosing on tylenol when she was ___ after an assault Harm to others: most violent thing she did was "beat the shit of a person in high school," - person ended up with a broken nose. PAST MEDICAL HISTORY: denies any medical problems; denies hx of seizure. Social History: SUBSTANCE ABUSE HISTORY: - Tobacco: ___ PPD - Alcohol: inconsistent reports: Per ED resident, she told one person her last EtOH use was 5 days ago; another one week ago and another one month ago. To neurology resident (while I was present in room), she reported she is not a daily drinker, can go weeks without a drink, last drink was last evening, but doesn't remember quantity. To myself (15 min later), she reports she has been drinking from morning until evening since ___ while staying at a friends ___. Drinks Twisted Tea, Vodka, Beer. - ETOH TREATMENT HX: reports ___ detoxes, last in ___ (does not know where). Reports longest period of sobriety was for ___ years approx ___ years ago. At this time, was going to AA meetings and in ___ clinic. Denies hx of ETOH withdrawal seizures. Reports being at ___ in ___ once. - Other Illicts: "done all of them." To Neurology resident, last used months ago. To me, she smokes MJ daily, and sniffs coke ___ times/week. Both of these were last used yesterday. Reports Drug Of Choice is Marijuana. Last used heroin years ago. FORENSIC HISTORY: Jail: for not paying ___ SOCIAL HISTORY: ___ Family History: FAMILY PSYCHIATRIC HISTORY: Denies family hx of mental illness, denies family hx of seizures Physical Exam: Physical Exam at Admission: Vitals: 98.7 88 123/88 18 98%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist, tenderness on bilateral mandibular rami, inability to bite down. CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Physical Exam at Discharge: ___: General: Patient watching television, no eye contact on exam, patient refusing lung, abd. ext. assessment VS:97.9, hr=74, bp125/88, rr=18, 95% CV: ns1, s2, no murmurs PULM: patient refusing pulmonary assessment ABD: patient refusing abdominal examination EXT: patient refusing ext. assessment Pertinent Results: ___ 05:20PM BLOOD WBC-9.0 RBC-4.05 Hgb-13.3 Hct-37.3 MCV-92 MCH-32.8* MCHC-35.7 RDW-12.5 RDWSD-42.2 Plt ___ ___ 05:20PM BLOOD Neuts-66.5 ___ Monos-5.5 Eos-1.1 Baso-0.6 Im ___ AbsNeut-6.00 AbsLymp-2.35 AbsMono-0.50 AbsEos-0.10 AbsBaso-0.05 ___ 05:20PM BLOOD ___ PTT-25.7 ___ ___ 05:20PM BLOOD Glucose-67* UreaN-14 Creat-0.7 Na-138 K-3.9 Cl-101 HCO3-21* AnGap-16 ___ 05:20PM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9 ___ Mandible x-ray: Mildly displaced bilateral mandibular rami fractures, more completely demonstrated on the preceding CT. ___: Panorex: Compared to the prior study there has been interval open reduction internal fixation of the left mandibular angle fracture with placement of a fracture plate and screw fixation device. In addition there has been stabilization of the mandible with apparent wiring of the dentition. Alignment is grossly unchanged. No evidence of a hardware complication. Medications on Admission: patient denies taking any medications Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate RX *acetaminophen 650 mg/20.3 mL 20.3 cc by mouth every six (6) hours Disp #*1 Bottle Refills:*0 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % 15 mL twice a day Disp #*420 Milliliter Refills:*0 RX *chlorhexidine gluconate 0.12 % 15cc twice a day Disp #*400 Milliliter Refills:*0 3. Docusate Sodium 100 mg PO BID please hold for loose stool, dispense in liquid form RX *docusate sodium 50 mg/5 mL 10 mL(s) by mouth twice a day Disp #*200 Milliliter Refills:*0 4. Nicotine Patch 14 mg TD DAILY 5. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate do NOT drink alcohol or drive while taking this medication RX *oxycodone 5 mg/5 mL ___ mL(s) by mouth every four (4) hours Disp #*420 Milliliter Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily Disp #*14 Packet Refills:*0 7. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Right subcondylar and left angle mandible fractures 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 mandibular fractures// please evaluate for fracture COMPARISON: CT of the facial bones performed on ___. FINDINGS: AP and lateral views of skull provided. Paranasal sinuses appear well aerated. In this patient with known mandibular fractures, fracture lines seen on the lateral view, involving the left and right mandibular ramus, appearing mildly displaced. Findings better appreciated on CT. IMPRESSION: As above.da Radiology Report EXAMINATION: MANDIBLE (PANOREX ONLY) INDICATION: ___ year old woman with facial injury s/p assult. Evaluate for fracture. TECHNIQUE: Panorex of the mandible COMPARISON: ___ facial bone CT FINDINGS: There is a mildly displaced oblique fracture through the ramus of the left mandible and a minimally displaced fracture through the ramus of the right mandible, better evaluated on the preceding CT. The temporomandibular joints are congruent on this view. The visualized maxillary sinuses are aerated. IMPRESSION: Mildly displaced bilateral mandibular rami fractures, more completely demonstrated on the preceding CT. Radiology Report EXAMINATION: MANDIBLE (PANOREX ONLY) INDICATION: ___ year old woman with b/l mandible fractures// Post-op reduction of b/l mandible fractures TECHNIQUE: Panorex view of the mandible COMPARISON: Panorex view of the mandible ___ FINDINGS: Compared to the prior study there has been interval open reduction internal fixation of the left mandibular angle fracture with placement of a fracture plate and screw fixation device. In addition there has been stabilization of the mandible with apparent wiring of the dentition. Alignment is grossly unchanged. No evidence of a hardware complication. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Assault, Transfer Diagnosed with Fracture of subcondylar process of right mandible, init, Assault by other specified means, initial encounter temperature: 98.7 heartrate: 88.0 resprate: 18.0 o2sat: 98.0 sbp: 123.0 dbp: 88.0 level of pain: 10 level of acuity: 2.0
Ms. ___ is a ___ year old female who presented to ___ with bilateral mandibular fracture as a result of an assault. The patient was admitted to the Trauma Surgery service and ___ was consulted. OMFS planned for OR for operative management and the patient was made NPO and IVF were started for hydration. The patient received IV cefazolin to prevent infection. A tertiary survey was performed which was negative for further acute traumatic findings. On HD2, the patient was taken to the operating room with OMFS and she underwent ORIF of the left mandibular angle fracture with ___ arch bar placement, closed reduction maxilla-mandibular fixation of the right subcondylar fracture and extraction teeth 5 and 12. The patient tolerated this procedure well (reader, please refer to operative note for further details). After remaining hemodynamically stable in the PACU, the patient was transferred to the surgical floor. The patient was started on a clear to full liquid diet which she tolerated. She received IV hydromorphone prn for pain control and, when tolerating a diet, she was switched to oral acetaminophen and oxycodone. The patient was alert and oriented throughout hospitalization. She remained stable from a cardiovascular and pulmonary standpoint; vital signs were stable. Early ambulation and pulmonary toilet were encouraged throughout hospitalization. The patient's intake and output were closely monitored. The patient's fever curves were closely watched for signs of infection, of which there were none. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged to the ___ ___ in stable condition. A follow-up appointment was made with the ___ service. Patient refused discharge examination
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea, Vomiting, Diarrhea, Dehydration Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old female with a history of alcohol abuse, hypertension, pancreatitis and bulimia who presented from ___ with dizziness and lightheadedness. She has been admitted at ___ for alcohol detox and for the past week has had nausea, vomiting, diarrhea and anorexia. She says that she has been unable to tolerate po intake for the past week and has had decreased appetite, also complaining of a burning abdominal pain after she vomits that moves up into her throat. She has been having ___ bowel movements per day, and sometimes the diarrhea will wake her up at night but she has been drinking coffee, water and gingerale during this time. She denies any fever/chills, dysuria, hematuria, urinary frequency/urgency. She is currently two weeks out from her last drink. She says that this nausea/vomiting/diarrhea is significantly different than her prior episodes of bulimia, now she is nauseous with even the thought of food. At ___ she had been recieving her usual medications of lisinopril and atenolol daily, along with tigan for nausea. Today the event that prompted the staff at ___ to send to the ER was that she fell becuase she was lightheaded and then vomited on a staff member. . In the ED inital vitals were 98, 80, 90/51, 78/56 sitting up, 16, 100% on RA. She triggered on arrival to the ER for hypotension. Her initial exam was notable for evidence of dehydration, bedside ultrasound showed an IVC that collapsed with respiration. Labs were notable for a Cr of 2.3 (unknown baseline), Ca of 11.1, white count of 13.6 with 79% neutrophils, no bands and urinalysis with small leuk, few bacteria and 4 WBC's. EKG was NSR at 79bpm, with TWI in III. Chest x-ray with no infiltrates. She was given 5L NS and her blood pressures remained in the 90's systolic, zofran for nausea and calcium gluconate for question of over beta blockade. VS on transfer: 92/48, 86, 21, 96% on RA. . On arrival to the ICU her initial VS were: 97.5, 86, 107/60, 10, 99% on RA. She currently says that she feels much better, but that her abdomen is sore from the vomiting but otherwise feels well. Past Medical History: Alcohol Abuse Hypertension Pancreatitis Bulimia Social History: ___ Family History: History of hypertension on her father's side, mother was an alcoholic Physical Exam: On admission: Vitals: 98, 80, 90/51, 78/56 sitting up, 16, 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Prior to discharge: 98.3 138/88 82 16 95% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: =============== ___ 07:38PM BLOOD WBC-13.6* RBC-4.36 Hgb-13.1 Hct-38.7 MCV-89 MCH-30.0 MCHC-33.8 RDW-13.5 Plt ___ ___ 07:38PM BLOOD Neuts-78.8* Lymphs-14.3* Monos-4.9 Eos-1.5 Baso-0.6 ___ 07:38PM BLOOD Glucose-126* UreaN-36* Creat-2.3* Na-135 K-3.9 Cl-99 HCO3-20* AnGap-20 ___ 07:38PM BLOOD ALT-33 AST-30 AlkPhos-82 TotBili-0.7 ___ 07:38PM BLOOD Albumin-5.0 Calcium-11.1* Phos-5.3* Mg-1.5* ___ 07:38PM BLOOD Osmolal-291 ___ 07:38PM BLOOD TSH-1.9 ___ 07:38PM BLOOD Cortsol-22.3* ___ 07:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Discharge Labs: =============== ___ 07:00AM BLOOD WBC-4.7 RBC-3.51* Hgb-10.5* Hct-31.0* MCV-89 MCH-30.0 MCHC-33.9 RDW-13.2 Plt ___ ___ 07:00AM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-142 K-3.5 Cl-109* HCO3-26 AnGap-11 . Other studies: =============== Chest X-ray: no focal infiltrates . EKG: NSR @ ___ with TWI in III . Studies Pending at time of discharge: ===================================== Stool cultures Medications on Admission: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. quetiapine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day. 5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 6. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Medications: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. quetiapine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day. 5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 6. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - Hypovolemic Shock - Acute Renal Failure - Viral Gastroenteritis Secondary: - Hypertension - Depression - Seizure Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL INFORMATION: ___ female with nausea, vomiting, and epigastric pain, evaluate for pneumonia or perforation. COMPARISON: None. FINDINGS: Frontal portable chest radiograph demonstrates no intraperitoneal free air. The lungs are clear. There is no pleural effusion or pneumothorax. The heart size is normal, the mediastinal contours are normal. The pulmonary vasculature is normal in appearance. IMPRESSION: No intraperitoneal free air, or acute chest pathology. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: HYPOTENSION Diagnosed with HYPOTENSION NOS, DEHYDRATION, VOMITING, DIARRHEA temperature: 98.0 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 90.0 dbp: 51.0 level of pain: 2 level of acuity: 1.0
Primary Reason for Hospitalization: ===================================== Ms. ___ is a ___ y/o F with a h/o alcohol abuse who presents from detox with one week of nausea/vomiting/diarrhea resulting in dehydration and symptomatic hypotension. .
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ciprofloxacin / cefepime / vancomycin / levofloxacin Attending: ___. Chief Complaint: Fever, rash Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with h/o non-Hodgkin's lymphoma s/p allogenic stem cell transplant, breast cancer s/p bilateral mastectomy on ___ c/b post-operative wound infection with MSSA abscess s/p I&D on ___ who presents with fever and diffuse rash. The patient was started on vanc/cefepime/flagyl ___ and then discharged ___ on vanc/levofloxacin (levo to end ___. The patient developed intermittent fevers (max 102) and a rash a few days after starting antibiotics (on ___, which were discontinued yesterday with PICC removed. The rash began on the bilateral hips, spreading across the abdomen, then to arms/legs/back. Two days ago the rash spread to neck, face and scalp. The rash is pruritic, nonpainful. Yesterday the patient's fever was 101.9, but no fevers noted on day of presentation to the ED. The patient began vomiting yesterday as well, 3 times, nonbloody, no abdominal pain. The patient denies recent travel although does spend time in ___. Denies new foods or other new exposures and has no history of rashes like this in the past. She reports she has had no fevers since yesterday and is overall feeling improved and operative site has shown improvement, however her rash has worsened today. She was evaluated by ID and was referred to the ED. In the ED, initial VS were: 99.2 79 114/48 16 100% Labs were notable for a WBC of 12.1 with 70% eos, 10% PMNs, AST 48 ALT 22 K 5.4 Cr 1.4 (baseline 0.8) CXR showed : resolution of prior right pleural effusion and minor associated atelectasis, Improvement in retrocardiac opacity, the latter possibly due to pneumonia versus atelectasis or lower airway inflammation. Received 25 mg PO diphenhydramine and 5 mg PO oxycodone. In the ED, surgery saw the patient and thought breast wound did not appear to be infected, granulating well, obvious left breast seroma with no obvious evidence of infection. Decision was made to admit to medicine for further management. On arrival to the floor, VS were: T 98.4 BP 122/45 HR 81 SpO2 100%RA. Patient reports itchy rash, denies CP, SOB, HA, abdominal pain, N/V/D, dysuria, pain with defectation. REVIEW OF SYSTEMS: + Per HPI and otherwise negative Past Medical History: --Breast cancer s/p resection and chemotherapy/XRT: R breast IDC,s/p partial mastectomy, L mixed IDC/lobular Ca, s/p partial mastectomy, R breast lymphoma w/lung metastasis, s/p CTX, now R breast invasive lobular carcinoma, ER+/PR+/Her2 --NHL --alpha thalassemia trait --idiopathic cholestasis syndrome without associated cirrhosis --BOOP/COP, quiescent --anxiety --Seasonal dry eye syndrome --Idiopathic hypereosinophilia s/p allo-SCT --Eosinophilic folliculitis --Essential tremor PSH: R breast partial mastectomy, L breast partial mastectomy, cholecystectomy (___), Bilateral total mastectomies ___ - ___ Social History: ___ Family History: Mother and father with CAD. Father was a smoker and had lung and esophageal cancer. Uncle with unknown cancer. Siblings are healthy, no biologic children. Physical Exam: ADMISSION EXAM: ============== VS - T 98.4 BP 122/45 HR 81 SpO2 100%RA GENERAL: Elderly woman sitting in bed in NAD, AAOx3, pleasant HEENT: PERRL, no scleral icterus, MM dry, no oral ulcerations, some palatal erythema. Periorbital edema present. NECK: Supple, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs CHEST: evidence of prior b/l mastectomy scars. R abscess site with clean packing, no purulent drainage, no tenderness. Pocket of fluctuance lateral to left breast incision site, nontender. LUNG: CTAB, no wheezes, rales, rhonchi, diminished breath sounds at the bases bilaterally. ABDOMEN: Obese, soft, nontender, nondistended, no HSM EXTREMITIES: No ___ edema, distal pulses intact, warm and well-perfused NEURO: CN II-XII grossly intact SKIN: Bright red blanching confluent macules over abdomen, back, b/l hips, thighs, arms, legs and face with scale over lower back. DISCHARGE EXAM: ============== VS - 99.2 Tc98.2 107-147/36-69 ___ 18 98%RA GENERAL: Elderly woman sitting in bed in NAD, AAOx3, pleasant HEENT: PERRL, no scleral icterus, MM dry, no oral ulcerations, some palatal erythema. Periorbital edema present. NECK: Supple, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs CHEST: evidence of prior b/l mastectomy scars. R abscess site with clean packing, no purulent drainage, no tenderness. Pocket of fluctuance lateral to left breast incision site, nontender. LUNG: CTAB, no wheezes, rales, rhonchi, diminished breath sounds at the bases bilaterally. ABDOMEN: Obese, soft, nontender, nondistended, no HSM EXTREMITIES: No ___ edema, distal pulses intact, warm and well-perfused NEURO: CN II-XII grossly intact SKIN: Bright red blanching confluent macules over abdomen, back, b/l hips, thighs, arms, legs and face with scale over lower back. Rash less erythematous today. Pertinent Results: ADMISSION LABS: ============== ___ 08:55PM GLUCOSE-108* UREA N-18 CREAT-1.5* SODIUM-134 POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-26 ANION GAP-16 ___ 08:55PM ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-371* ALK PHOS-215* TOT BILI-0.4 ___ 08:55PM ALBUMIN-3.5 CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-2.2 ___ 08:55PM I-HOS-DONE ___ 06:15PM URINE HOURS-RANDOM ___ 06:15PM URINE UHOLD-HOLD ___ 06:15PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM ___ 06:15PM URINE RBC-1 WBC-7* BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 06:15PM URINE HYALINE-3* ___ 06:15PM URINE MUCOUS-RARE ___ 02:56PM LACTATE-3.0* ___ 02:50PM GLUCOSE-98 UREA N-18 CREAT-1.4* SODIUM-133 POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-21* ANION GAP-13 ___ 02:50PM ALT(SGPT)-22 AST(SGOT)-48* ALK PHOS-232* TOT BILI-0.3 ___ 02:50PM LIPASE-58 ___ 02:50PM ALBUMIN-3.5 ___ 02:50PM WBC-12.1* RBC-4.61 HGB-12.0 HCT-37.4 MCV-81* MCH-26.0* MCHC-32.1 RDW-19.1* ___ 02:50PM NEUTS-10* ___ MONOS-2 EOS-70* BASOS-0 ___ 02:50PM PLT COUNT-147* ___ 02:15PM UREA N-17 CREAT-1.6* ___ 02:15PM estGFR-Using this ___ 02:15PM ALT(SGPT)-21 AST(SGOT)-42* ALK PHOS-275* TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 ___ 02:15PM TOT PROT-6.2* ALBUMIN-3.3* GLOBULIN-2.9 ___ 02:15PM WBC-17.4* RBC-4.11* HGB-10.4* HCT-32.6* MCV-79* MCH-25.3* MCHC-31.8 RDW-18.9* ___ 02:15PM NEUTS-79* BANDS-4 LYMPHS-9* MONOS-3 EOS-5* BASOS-0 ___ MYELOS-0 NUC RBCS-1* ___ 02:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL STIPPLED-OCCASIONAL HOW-JOL-OCCASIONAL PAPPENHEI-OCCASIONAL ___ 02:15PM PLT SMR-LOW PLT COUNT-138* PERTINENT LABS: ============== ___ 05:30AM BLOOD ALT-16 AST-26 LD(LDH)-391* AlkPhos-194* TotBili-0.3 ___ 05:30AM BLOOD cTropnT-0.03* ___ 02:56PM BLOOD Lactate-3.0* IMAGING/STUDIES: =============== ___ Imaging CHEST (PA & LAT) IMPRESSION: Resolution of right pleural effusion and minor associated atelectasis. Improvement in retrocardiac opacity, the latter possibly due to pneumonia versus atelectasis or lower airway inflammation. MICRO: ===== ___ 05:30AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND ___ STAIN-FINAL; FLUID CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARYINPATIENT ___ 9:30 am ABSCESS LEFT BREAST. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ CULTURE-FINALEMERGENCY WARD URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ CULTUREBlood Culture, Routine-PENDINGEMERGENCY WARD DISCHARGE LABS: ============== ___ 01:50PM BLOOD WBC-14.4* RBC-4.28 Hgb-11.0* Hct-33.3* MCV-78* MCH-25.7* MCHC-33.1 RDW-19.2* Plt ___ ___ 01:50PM BLOOD Neuts-21.2* ___ Monos-3.8 Eos-42.3* Baso-0.5 ___ 01:50PM BLOOD Glucose-115* UreaN-17 Creat-1.5* Na-136 K-4.6 Cl-98 HCO3-24 AnGap-19 ___ 01:50PM BLOOD ALT-16 AST-26 LD(LDH)-408* AlkPhos-181* TotBili-0.3 ___ 01:50PM BLOOD Calcium-9.4 Phos-3.7 Mg-2.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO TID 2. Acyclovir 400 mg PO Q8H 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 4. Docusate Sodium 100 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 8. Senna 17.2 mg PO HS 9. Sertraline 100 mg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Propranolol 10 mg PO QAM 13. Propranolol 10 mg PO TID Discharge Medications: 1. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID Duration: 7 Days Do not apply to face. RX *clobetasol 0.05 % 1 Appl twice a day Disp #*60 Gram Gram Refills:*0 2. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP BID rash Duration: 7 Days Do not apply to face. RX *triamcinolone acetonide 0.025 % 1 Appl twice a day Refills:*0 3. Acetaminophen 650 mg PO TID 4. Acyclovir 400 mg PO Q8H 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 6. Docusate Sodium 100 mg PO BID 7. Ferrous Sulfate 325 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY 11. Propranolol 10 mg PO QAM 12. Propranolol 10 mg PO TID 13. Senna 17.2 mg PO HS 14. Sertraline 100 mg PO DAILY 15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: DRESS syndrome vs drug eruption Secondary diagnoses: NHL s/p allogeneic stem cell transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: Fever. TECHNIQUE: Chest, PA and lateral. COMPARISON: ___. FINDINGS: The heart is at the upper limits of normal size. The mediastinal and hilar contours appear stable. Incidental note is made of an azygos fissure, which is a normal variant. Right basilar opacity suggesting atelectasis has cleared. Vague retrocardiac opacity probably referring the left lower lobe persists but has improved. The lungs appear otherwise clear. A right-sided pleural effusion has resolved. A PICC line is been removed. Surgical clips again project over each axilla. IMPRESSION: Resolution of right pleural effusion and minor associated atelectasis. Improvement in retrocardiac opacity, the latter possibly due to pneumonia versus atelectasis or lower airway inflammation. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Rash, Fever Diagnosed with LYMPHOMA NEC UNSPEC SITE temperature: 99.2 heartrate: 79.0 resprate: 16.0 o2sat: 100.0 sbp: 114.0 dbp: 48.0 level of pain: 0 level of acuity: 3.0
Ms. ___ is a ___ with h/o non-Hodgkin's lymphoma s/p allogenic stem cell transplant, breast cancer s/p bilateral mastectomy on ___ c/b post-operative wound infection with MSSA abscess s/p I&D on ___ who presents with fever and diffuse rash. # Rash: The rash is associated with the onset of several antibiotics s/p I&D of MSSA abscess, along with eosinophilia, increased from 5% to 70% in 24 hours, concerning for DRESS vs drug-eruption; however patient has known diagnosis of idiopathic hypereosinophilia syndrome s/p allo SCT. DRESS is supported by the extent of the rash, periorbital edema, LFT abnormalities, elevated Cr. Vanc/levo were stopped day prior to admission. She remained afebrile for the duration of hospitalization. Her rash showed improvement morning after admission. She was evaluated by dermatology who recommended topical steroids for possible DRESS. Given her known allergy to ciprofloxacin, it is possible that her rash was associated with initiation of levofloxacin, vs from vancomycin or cefepime (as she may have been previously sensitized to these antibiotics given that she is a transplant patient). She was closely monitored. Her eosinophilia decreased and remained stable at 42%. She was discharged on a one-week course of clobetasol ointment with then transition to triamcinolone (not to be used on the face). Strongyloides IgG was tested and pending by time of discharge. # Fever: The patient reported intermittent fevers up to 102 several days after starting antibiotics. The patient denied a fever on day of admission after stopping vanc/levo the day prior. The patient is s/p allogeneic SCT, ANC 1200 on admission. Lactate elevated at 3.0, improved with PO intake to 1.9. Blood and urine cultures showed no pathogenic organisms. Seroma culture from her left breast by surgery showed no growth to date. She remained afebrile throughout hospitalization. # ___: Cr on admission 1.4 (baseline 0.8), however Cr has been slightly elevated for several weeks. Given elevated lactate, prerenal etiology ___ is likely; however AIN from DRESS also on the differential. Her creatinine remained stable at 1.5, not higher than recent creatinine (1.8 on ___. # Breast cancer s/p resection and chemotherapy/XRT c/b MSSA abscess: breast cancer s/p bilateral mastectomy on ___ c/b post-operative wound infection with MSSA abscess s/p I&D on ___. Patient was started on vancomycin instead of PCN due to concern for allergy (pt allergic to cefepime) in past; also started on levofloxacin prior to admission by surgery, both stopped day prior to admission. ___ breast surgery aspirated 180 ccs of fluid from L breast, sent for culture. Culture showed no growth to date, as above. Wound care was provided by surgery. # S/p allogeneic SCT (___): Complicated by idiopathic hypereosinophilia, as above. LDH in 300s so not concerning for acute lymphoma. She was continued on home acyclovir prophylaxis. # Idiopathic cholestasis syndrome without associated cirrhosis: The patient did not demonstrate a transaminitis during hospital stay and alk phos remained within her previous baseline. # Anxiety: Continued sertraline 100 mg daily. # Essential Tremor: Continued home propranolol.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Pro___ Attending: ___ Chief Complaint: Fever, RUQ pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of ___'s disease, PCKD s/p renal transplant in ___, and recurrent cholangitis with his last hospitalization for cholangitis in ___ now presenting with fevers and RUQ abdominal pain. He is on suppressive ciprofloxacin 500mg po daily due to developing frequent flares of RUQ pain and feeling unwell which tend to pass without need for hospitalization, though his ciprofloxacin dose was recently decreased from BID to daily. Over the past couple of days he has experienced similar RUQ pain which he initially attributed to MSK since he has been painting his boat recently. However, the severity of the pain increased significantly the day of his admission and he also developed low-grade fevers to 100.1 despite taking acetaminophen along with feeling cold and nauseous. He and his wife therefore presented to the ___ in ___ where his labs were essentially at his baseline save for an alk phos of 225, and it was recommended that he go to ___ given his complicated history. He was discharged from the hospital and flew commercially to ___ and presented to the ED. He denies any other localizing symptoms including HA, neck stiffness, sore throat, cough, sputum production, dysuria, diarrhea, skin lesions, or any other complaints. In the ED, initial vitals were 10 97.5 103 132/89 15 95% - He was given a dose of IV pip-tazo in the ED. - RUQ u/s and CXR performed - Admitted to ET. On arrival to the floor, initial VS: 98.5 152/95 100 20 100%RA He was lying comfortably in bed in NAD. ROS: per HPI, denies headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -- ___ Cadaveric kidney transplant to right iliac fossa -- Polycystic kidney disease -- ___'s Disease: cystic disease within his liver and significant dilatation of the intrahepatic biliary tree -- Pancreas Divism -- HTN -- Hyperlipidemia -- Gout -- Kidney stone -- Tacrolimus induced thrombotic microangiopathic hemolytic anemia -- Osteoporosis ___ secondary hyperparathyroidism: followed by Dr. ___ -- ___ malformation: followed by Dr. ___ intervention necessary -- Torn L knee MCL -- L5/L4 disc herniation -- recurrent cholangitis -- recurrent cholelithiasis Social History: ___ Family History: Father: hyperlipidemia, kidney stones, gallstones, Mom: healthy Brother: gallstones Brother: alcoholic; ear and eye problems Uncler prostate CA Physical Exam: ADMISSION EXAM: ================ VS: 98.5 152/95 100 20 100%RA General: well-developed, well-nourished adult male lying comfortably in bed in NAD HEENT: NC/AT, sclera anicteric. conjunctiva pink. PERRL, EOMI. MMM, no erythema or exudates. No LAD. CV: normal rate, regular rhythm, II-III/VI SEM heard at apex. Lungs: CTAB Abdomen: soft, non-distended. + tenderness in RUQ. no rebound or guarding. renal transplant palpable, no surrounding tenderness Ext: wwp, no edema Neuro: CN II-XII grossly intact. strength full throughout. Skin: no rashes or other lesions noted. DISCHARGE EXAM: ================ VS: 97.7 100/66 61 18 97% RA General: comfortable in NAD HEENT: sclera anicteric. MMM CV: RRR, ___ systolic murmur Lungs: CTAB Abdomen: soft, NT/ND. +BS. renal transplant palpable, no surrounding tenderness Ext: no edema Neuro: A&Ox3. moving all extremities. strength full throughout. Skin: no rashes Pertinent Results: ADMISSION LABS: =============== ___ 11:20PM BLOOD WBC-8.1 RBC-5.11 Hgb-14.9 Hct-44.5 MCV-87 MCH-29.2 MCHC-33.5 RDW-13.7 Plt ___ ___ 11:20PM BLOOD Neuts-72.8* ___ Monos-6.3 Eos-0.8 Baso-0.7 ___ 11:20PM BLOOD ___ PTT-33.5 ___ ___ 11:20PM BLOOD Glucose-86 UreaN-11 Creat-1.0 Na-142 K-3.8 Cl-103 HCO3-24 AnGap-19 ___ 11:20PM BLOOD ALT-55* AST-68* AlkPhos-162* TotBili-0.6 ___ 11:20PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.5 Mg-1.7 ___ 11:46PM BLOOD Lactate-1.1 DISCHARGE LABS: ================ ___ 06:40AM BLOOD WBC-5.7 RBC-4.79 Hgb-13.8* Hct-40.8 MCV-85 MCH-28.9 MCHC-33.9 RDW-13.5 Plt ___ ___ 06:40AM BLOOD ___ PTT-31.6 ___ ___ 06:40AM BLOOD Glucose-90 UreaN-14 Creat-0.9 Na-141 K-4.4 Cl-102 HCO3-26 AnGap-17 ___ 06:40AM BLOOD ALT-76* AST-69* AlkPhos-137* TotBili-0.3 ___ 06:40AM BLOOD Calcium-10.0 Phos-3.4 Mg-1.6 URINE: ========= ___ 11:35PM URINE Color-Straw Appear-Clear Sp ___ ___ 11:35PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 11:35PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 11:35PM URINE CastGr-1* MICRO: ========== ___ 8:16 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 1:20 pm Immunology (CMV) CMV Viral Load (Pending): ___ 2:55 pm BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 11:35 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. STUDIES: ========== Chest X-Ray PA and Lateral ___ IMPRESSION: No acute cardiopulmonary process. RUQ Ultrasound ___ IMPRESSION: Markedly dilated intrahepatic bile ducts consistent with ___'s disease. The common bile duct is not dilated. The gallbladder appears normal. Ultrasound is insensitive for cholangitis, which is a clinical diagnosis. MRCP ___ IMPRESSION: 1. Multiple areas of mild biliary duct arterial hyperenhancement and minimal wall thickening, particularly in segment ___, which is most suggestive of cholangitis. Perfusional anomaly in segment ___ due to underlying cholangitis. 2. Cirrhotic liver. Intrahepatic biliary duct sacculations in keeping with known ___'s disease with several intrahepatic bile duct stones, similar to previous. 3. Hypoenhancing region in the uncinate process of the pancreas, which is indeterminate, and probably stable since ___ and might represent a small area of focal fat. Advise attention on followup. 4. Kidneys are atrophic and contain multiple cysts compatible with end-stage renal disease, similar to previous. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Ciprofloxacin HCl 500 mg PO Q24H 3. Metoprolol Tartrate 12.5 mg PO BID 4. Mycophenolate Mofetil 500 mg PO BID 5. Omeprazole 20 mg PO DAILY 6. Pravastatin 40 mg PO DAILY 7. Sirolimus 0.5 mg PO DAILY 8. Ursodiol 500 mg PO BID 9. Cetirizine 5 mg oral daily itching 10. Multivitamins 1 TAB PO DAILY 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Metoprolol Tartrate 12.5 mg PO BID 3. Mycophenolate Mofetil 500 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. Pravastatin 40 mg PO DAILY 6. Sirolimus 0.5 mg PO DAILY Daily dose to be administered at 6am 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Ursodiol 500 mg PO BID 9. Cetirizine 5 mg oral daily itching 10. Multivitamins 1 TAB PO DAILY 11. Cefpodoxime Proxetil 400 mg PO Q12H last day ___ RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*34 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS # Cholangitis SECONDARY DIAGNOSES # Caroli's disease # PCKD s/p renal transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Fever in a patient with a history of recurrent cholangitis. Evaluate for pneumonia. COMPARISON: Chest radiograph from ___. FINDINGS: PA and lateral radiographs of the chest are provided. Lung volumes are low. There is linear atelectasis in the left lower lobe. The lungs are otherwise clear. The hilar and cardiomediastinal contours are normal. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: Abdominal pain in a patient with a history of recurrent cholangitis. COMPARISON: MRI from ___. FINDINGS: The liver is normal in size and echotexture. The intrahepatic bile ducts are markedly dilated, consistent with Caroli's disease. There are no focal liver lesions. The gallbladder wall appears normal and there are no stones. There is no extrahepatic bile duct dilation. The common bile duct is 6 mm in diameter. The visualized portion of the pancreas appears normal. The spleen is without focal lesion and measures 10.9 cm in length. The imaged portion of the abdominal aorta and inferior vena cava is normal. The portal vein is patent with hepatopetal flow. There is no ascites. IMPRESSION: Markedly dilated intrahepatic bile ducts consistent with Caroli's disease. The common bile duct is not dilated. The gallbladder appears normal. Ultrasound is insensitive for cholangitis, which is a clinical diagnosis. Radiology Report EXAMINATION: MRI abdomen with and without contrast INDICATION: ___'s disease and known intrahepatic biliary duct dilatation presenting with cholangitis. Please assess for cholangiocarcinoma or other biliary pathology. TECHNIQUE: Multiplanar, multisequential MRI of the abdomen was performed pre and post the uneventful administration of 7 mL of Gadavist intravenous contrast. In addition, 1 mL of Gadavist mixed with 50 mL of water were administered as patient P.O. COMPARISON: Compared to prior MRI abdomen from ___. FINDINGS: There is a shrunken and nodular appearance of the liver consistent with the patient's known cirrhosis. There is severe intrahepatic saccular bile duct dilatation consistent with the patient's known history of ___'s disease. There are several foci of T1 hyperintense, T2 hypointense signal within the dilated intrahepatic bile ducts which are most consistent with biliary stones, overall similar to previous. The common bile duct measures 6 mm which is similar overall when compared to the prior examination. There are a few scattered T2 hyperintense foci noted within the liver which may represent biliary hamartomas, unchanged from previous. There is a small area of arterial hyperenhancement in segment 2 of the liver without correlate on other sequences, likely represents a small transient hepatic intensity difference (THIDs) (___). The gallbladder appears unremarkable. There is no extrahepatic biliary duct dilatation. There is unchanged mild narrowing of the proximal common hepatic duct, likely due to the hepatic artery impression, overall unchanged when compared to the prior examination. In addition, there are multiple areas of mild biliary duct arterial hyperenhancement and minimal wall thickening, particularly in segment ___, which is most suggestive of cholangitis. There is an area of arterial hyperenhancement in segment ___ of the liver which is likely related to perfusional anomaly due to underlying cholangitis. The kidneys are atrophic and contain multiple cysts compatible with end-stage renal disease, similar to previous. There is a hypoenhancing region in the uncinate process of the pancreas, which is indeterminate, and stable since ___ and may represent a small area of focal fat ___: 22). The spleen, gallbladder, adrenal glands appear unremarkable. There is no upper intra-abdominal or retroperitoneal lymphadenopathy. There is no ascites. There is compression of the celiac artery origin with dilatation of the proximal celiac artery, which may be due to end-expiration technique of the examination. The visualized portions of the small bowel and colon appear unremarkable. There is a transplant kidney within the right lower quadrant, which is partially imaged. The lung bases appear grossly unremarkable. There is a probable hemangioma within the L1 vertebral body. IMPRESSION: 1. Multiple areas of mild biliary duct arterial hyperenhancement and minimal wall thickening, particularly in segment ___, which is most suggestive of cholangitis. Perfusional anomaly in segment ___ due to underlying cholangitis. 2. Cirrhotic liver. Intrahepatic biliary duct sacculations in keeping with known ___'s disease with several intrahepatic bile duct stones, similar to previous. 3. Hypoenhancing region in the uncinate process of the pancreas, which is indeterminate, and probably stable since ___ and might represent a small area of focal fat. Advise attention on followup. 4. Kidneys are atrophic and contain multiple cysts compatible with end-stage renal disease, similar to previous. NOTIFICATION: Findings discussed with Dr. ___ at 9:35AM on ___, 1 hour after discovery of the findings. Gender: M Race: PORTUGUESE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with CHOLANGITIS temperature: 97.5 heartrate: 103.0 resprate: 15.0 o2sat: 95.0 sbp: 132.0 dbp: 89.0 level of pain: 10 level of acuity: 3.0
___ with hx of ___'s disease, PCKD s/p renal transplant in ___, and recurrent cholangitis who presented with fevers and recurrent RUQ abdominal pain.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: ___ Attending: ___. Chief Complaint: Right hip infection s/p intraarticular injection Major Surgical or Invasive Procedure: Right hip irrigation and debridement History of Present Illness: Mr. ___ is a ___ with h/o HTN who presents s/p ___ aspiration right hip at OSH and transferred for septic right hip. Of note, on ___ patient had injection of methylprednisone and bupivacaine. This was injection (#3) in his right hip for treatment of arthritis. Patient reports 2 days after procedure noted pin in right hip. Reports intermittent fevers up to 100.7. He was initially treated with a burst pack of prednisone. On ___, he was given tramadol for pain. On ___ aspiration was performed at ___. When the results returned today positive for septic arthritis, the patient was advised to present to our ED. Currently, the patient complains of 7 out of 10 pain in his right hip, he is been ambulating with a crutch. No fevers at the moment. Past Medical History: Right hip osteoarthritis HTN Social History: ___ Family History: N/C Physical Exam: Exam: Vitals: VSS and within normal limits General: Well-appearing, breathing comfortably MSK: dressing c/d/I on R anterior thigh, drain present with output of 150cc since surgery Firing ___, FDL, TA, GSC SILT in all nerve distributions including lateral thigh Foot WWP Pertinent Results: ___ hip aspirate - reported alpha hemolytic strep ___ aspirate ___ 12:05 pm FLUID,OTHER Site: HIP RIGHT HIP FLUID. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: Reported to and read back by ___ (___) AT 9:21 AM ___. STREPTOCOCCUS SPECIES. SPARSE GROWTH. IDENTIFIED AS STREPTOCOCCUS ___. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ___ 06:00AM BLOOD WBC-12.5* RBC-3.88* Hgb-13.0* Hct-37.6* MCV-97 MCH-33.5* MCHC-34.6 RDW-11.8 RDWSD-41.6 Plt ___ ___ 03:45AM BLOOD Glucose-154* UreaN-16 Creat-0.7 Na-141 K-4.5 Cl-102 HCO3-31 AnGap-8* Medications on Admission: atenolol 50 mg tablet oral Once Daily lisinopril 40 mg tablet oral Once Daily hydrochlorothiazide 25 mg tablet oral Once Daily Cialis 10 mg tablet oral 1 tablet(s) amlodipine 5 mg tablet oral 1 tablet(s) Once Daily meloxicam 15 mg tablet oral Once Daily tramadol 50 mg tablet oral Every ___ hrs, as needed Discharge Medications: <<<>>> Resume all home medications per prescribing provider 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 2. CefTRIAXone 2 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g iv daily Disp #*21 Intravenous Bag Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous daily Disp #*28 Syringe Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Other order is a PACU only order RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr PRN Disp #*25 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. amLODIPine 5 mg PO DAILY 8. Atenolol 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right hip 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 INDICATION: ___ with right septic hip// effusion? COMPARISON: None FINDINGS: AP pelvis and AP and lateral views of the right hip provided. The bony pelvic ring appears intact. SI joints appear symmetric and normal. No fracture or dislocation is present. There is severe osteoarthritis at the right hip with complete loss of femoroacetabular joint space along the superior margin with a bone-on-bone configuration. There is associated subchondral sclerosis and marginal osteophytosis. Evaluation for joint effusion is limited on radiograph. The left hip articulates normally without significant arthritis. IMPRESSION: Severe right hip osteoarthritis. No fracture or dislocation. There is concern for septic hip MRI is advised. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever, R Hip pain Diagnosed with Pyogenic arthritis, unspecified temperature: 96.5 heartrate: 70.0 resprate: 18.0 o2sat: 96.0 sbp: 131.0 dbp: 76.0 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 right hip infection (aspiration at OSH will cell count of ___ and eventually growing alpha hemolytic strep) and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for irrigation and debridement R hip (anterior approach), which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. Cultures taken intraoperatively. 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 followed by infectious disease services and maintained on IV antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine as well as Infectious Disease per OPAT note. He will be discharged on IV antibiotics (ceftriaxone). 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: CARDIOTHORACIC Allergies: Diovan / Lipitor Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: ___ Over the wire exchange of a left internal jugular approach tunneled dialysis catheter . ___ Insertion of inferior vena cava filter History of Present Illness: ___ s/p Coronary artery bypass grafting x 3 (LIMA-LAD, SVG-PDA and OM) and Tricuspid valve repair with 32 mm ___ Contour 3D annuloplasty ring on ___. His post-operative course was complicated by a prolonged intubation with an Enterobacter pneumonia treated with Vancomycin / Cefipime, and acute on chronic renal failure requiring CVVH tranitioned to HD MWF via a tunneled line. He was discharged to rehab on ___. He now presents to the ___ ED with chest pain. Past Medical History: Coronary artery disease NSTEMI COPD (never smoked) CKD (1.5-2) AFib Hypertension Hypercholesterolemia Iron deficiency anemia Orthostatic hypotension Seizure disorder Gout Depression BPH GERD Actinic keratosis ___ esophagus Bell's Palsy Basal cell carcinoma Colonic adenoma Complete heart block CHF ED Right knee TKR back surgery PPM Social History: ___ Family History: Mother died of an MI at ___ years old. Father died of COPD and had hypertension. Sister had hypertension and died in her ___ of breast cancer. Sister with "mental disorder" and hypertension. Has six children. Physical Exam: Temp 96.2, HR 85, BP 120/85, RR 18, 97% RA Height: Weight: General: Nods head appropriately, follows commands, minimally conversant Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x], Tunneled HD line on left chest/neck Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [] _____ Pertinent Results: ___ Chest CTA Final Report EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS INDICATION: ___ with c/o AMS, CP, SOB, recent cardiac surgery, poor historian, ESRD on Dialy MWF // eval for aortic injury, intraabdominal pathology TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 130 cc of Omnipaque 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 3.5 s, 0.5 cm; CTDIvol = 10.6 mGy (Body) DLP = 5.3 mGy-cm. 2) Spiral Acquisition 3.8 s, 29.6 cm; CTDIvol = 13.9 mGy (Body) DLP = 411.2 mGy-cm. 3) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 15.0 mGy (Body) DLP = 826.9 mGy-cm. Total DLP (Body) = 1,243 mGy-cm. COMPARISON: CT abdomen and pelvis ___. FINDINGS: CHEST: Imaged portion of thyroid gland is grossly unremarkable. No supraclavicular, axillary, mediastinal or hilar lymphadenopathy by CT size criteria. The largest mediastinal lymph node measures up to 7 mm in short axis in the left lower paratracheal station (3:74). Heart size is moderately enlarged. Coronary artery calcifications are diffuse. No aortic valvular calcifications noted. Thoracic aorta is normal in course and caliber, containing moderate atherosclerotic calcifications throughout. Main pulmonary trunk is normal in caliber. There is pulmonary embolism in the proximal apical and anterior segmental branches of the right upper lobe pulmonary artery (3:83, 84), which may be chronic. No other pulmonary emboli are detected. Along the left posterior lateral aspect of the upper trachea, near the inlet, there is a hypodense focus that spans a craniocaudal dimension of 2 cm (601b:35, 03:35). This could represent dependent secretions, although it is somewhat unusual to layer only along the left lateral aspect of the trachea. Further evaluation or follow-up is recommended to exclude an underlying tracheal lesion. There is diffuse bronchial wall thickening along with mild areas of air trapping, which can be seen in inflammatory small airways disease. Evaluation of the parenchyma reveals a 9 mm wide ground-glass opacity in the anterior right upper lobe (03:44), which may represent residual pulmonary edema or infection. Bibasilar dependent atelectasis. No pleural effusion or pneumothorax. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is a 2.0 cm simple cyst along the inferior margin of the liver (2b:128). Innumerable additional hepatic hypodensities are too small to characterize, but likely represent cysts or biliary hamartomas. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. Portal venous system is patent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Multiple bilateral renal hypodensities are noted, many of which represent cysts. Multiple hyperdense lesions date back to ___, and likely represent hemorrhagic or proteinaceous cysts. The largest is a 4.2 x 3.5 cm hyperdense cyst in the lower pole of the right kidney (2b:147). There is a 1 mm renal stone in the right upper pole (___:39), and a 3 mm stone in the interpolar region of the right kidney (___:31), unchanged from ___. No hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Moderately-sized hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Suture material is noted at the cecal base. Status post appendectomy. Colon and rectum are otherwise unremarkable. No pneumoperitoneum or ascites. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate gland is enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or acute fracture. Status post median sternotomy. Multilevel degenerative changes are noted, most pronounced in the spine. The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Pulmonary emboli in the right upper lobe subsegmental branches, which may be subacute or chronic. 2. 2 cm long hypodensity along the left posterior lateral aspect of the upper trachea, which may represent secretions. However, further evaluation with bronchoscopy or follow-up imaging is recommended to exclude the possibility of a tracheal lesion. 3. Diffuse coronary artery calcifications. 4. Bronchial wall thickening with mild air trapping, may reflect inflammatory small airways disease. 5. No acute intra-abdominal process identified. 6. Moderately-sized hiatal hernia. 7. Non-obstructing right renal stones, measuring up to 3 mm. 8. Multiple bilateral renal cysts, some are hemorrhagic/proteinaceous. NOTIFICATION: The presence of a pulmonary embolism was first discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 12:15AM, 1 minute after discovery of the findings. 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. ___, MD ___, MD electronically signed on ___ ___ 1:03 AM Imaging Lab Report History SAT ___ 9:36 AM by INFORMATION,SYSTEMS View Close ___ 1:03 AM by INFORMATION,SYSTEMS . ___ Final Report EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT) INDICATION: ___ man found to have for pulmonary embolism. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: CTA chest ___ 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. Echogenic thrombus is noted within the greater saphenous vein on the left. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Thrombus within the left greater saphenous vein. 2. No evidence of deep venous thrombosis in the right or left lower extremity veins. 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. ___, MD ___, MD electronically signed on SAT ___ 8:47 AM Imaging Lab Report History SAT ___ 8:38 AM by INFORMATION,SYSTEMS View Close SAT ___ 8:47 AM by INFORMATION,SYSTEMS . Final Report EXAMINATION: BILAT UP EXT VEINS US INDICATION: ___ year old man readmitted with PE // eval for UE DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. A very small nonocclusive thrombus is visualized on grayscale imaging within the right internal jugular vein. The right IJ compresses and demonstrates the venous vascular flow on Doppler imaging. The right axillary and brachial veins are patent, show normal color flow and compressibility. The right basilic, and cephalic veins demonstrate normal compressibility. Note is made that the patient refused the remainder of the examination. IMPRESSION: 1. Very small nonocclusive thrombus of indeterminate chronicity visualized within the right internal jugular vein. 2. The left arm was not examined as the patient refused the remainder of the examination. NOTIFICATION: Findings of right IJ nonocclusive thrombus were discovered at 15:50 on ___ and were conveyed by telephone by ___ ___ to Dr. ___ at 16:08 on the same day, 18 min after discovery. 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. ___ ___, MD electronically signed on ___ 4:17 ___ Imaging Lab Report History MON ___ 4:17 ___ by INFORMATION,SYSTEMS . ___ Final Report INDICATION: ___ year old man with tunneled line malpositioned // please exchange line COMPARISON: ___ TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: 25 mcg intravenous fentanyl was administered. Vital signs were monitored by a trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl CONTRAST: None. FLUOROSCOPY TIME AND DOSE: 1.3 min, 12 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 left neck was prepped and draped in the usual sterile fashion. Stiff glide wires were advanced through each lumen of the left internal jugular approach tunneled dialysis catheter. The cuff was loosened. The line was removed over the wires. A new tunneled dialysis catheter was advanced over both wires. The tip was guided into the right atrium under fluoroscopy. Both 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: Catheter tip in the right atrium. IMPRESSION: Over the wire exchange of a left internal jugular approach tunneled dialysis catheter. 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. ___, MD ___, MD electronically signed on ___ 1:02 ___ Imaging Lab Report History ___ ___ 12:32 ___ by INFORMATION,SYSTEMS View Close ___ ___ 1:02 ___ by INFORMATION,SYSTEMS . ___ 07:06AM BLOOD WBC-8.0 RBC-3.59* Hgb-11.0* Hct-35.3* MCV-98 MCH-30.6 MCHC-31.2* RDW-18.8* RDWSD-67.6* Plt ___ ___ 07:00AM BLOOD WBC-8.7 RBC-3.54* Hgb-10.5* Hct-34.5* MCV-98 MCH-29.7 MCHC-30.4* RDW-19.7* RDWSD-69.1* Plt ___ ___ 07:06AM BLOOD ___ ___ 07:45AM BLOOD ___ PTT-34.0 ___ ___ 07:00AM BLOOD ___ ___ 04:57AM BLOOD ___ PTT-73.3* ___ ___ 06:10AM BLOOD ___ PTT-71.6* ___ ___ 10:15PM BLOOD ___ PTT-31.8 ___ ___ 07:06AM BLOOD Glucose-83 UreaN-46* Creat-7.7*# Na-134 K-4.8 Cl-94* HCO3-21* AnGap-24* ___ 07:00AM BLOOD Glucose-118* UreaN-54* Creat-8.6* Na-133 K-4.7 Cl-93* HCO3-20* AnGap-25* ___ 10:15PM BLOOD Glucose-113* UreaN-29* Creat-5.3* Na-137 K-4.4 Cl-97 HCO3-22 AnGap-22* ___ 04:57AM BLOOD ALT-25 AST-21 LD(LDH)-265* AlkPhos-83 Amylase-113* TotBili-0.2 ___ 10:15PM BLOOD CK(CPK)-29* ___ 07:06AM BLOOD Calcium-9.0 Phos-6.3* Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. Fluticasone Propionate 110mcg ___ PUFF IH BID 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. OXcarbazepine 300 mg PO BID 7. Rosuvastatin Calcium 40 mg PO QPM 8. Acetaminophen 1000 mg PO Q6H:PRN pain 9. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob/wheezing 10. Calcium Acetate 1334 mg PO TID W/MEALS 11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 13. Glucose Gel 15 g PO PRN hypoglycemia protocol 14. Heparin Flush (1000 units/mL) 4000-11,000 UNIT DWELL PRN line flush 15. Midodrine 10 mg PO TID 16. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all dressing changes 17. Sarna Lotion 1 Appl TP QID 18. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 19. TraZODone 50 mg PO QHS:PRN insomnia 20. Ferrous Sulfate 325 mg PO DAILY 21. Metamucil (psyllium;<br>psyllium husk;<br>psyllium seed (sugar)) 1 tbsp oral DAILY 22. Omeprazole 20 mg PO BID 23. Protopic (tacrolimus) 0.1 % topical DAILY:PRN skin lesions 24. Tiotropium Bromide 1 CAP IH DAILY 25. Triglide (fenofibrate nanocrystallized) 160 mg oral DAILY 26. Tylenol Arthritis Pain (acetaminophen) 650 mg oral Q6H:PRN pain 27. Nephrocaps 1 CAP PO DAILY 28. ___ MD to order daily dose PO DAILY16 afib 29. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 30. Aspirin EC 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 3. Allopurinol ___ mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Calcium Acetate 1334 mg PO TID W/MEALS 6. Citalopram 20 mg PO DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. Fluticasone Propionate 110mcg ___ PUFF IH BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. Glucose Gel 15 g PO PRN hypoglycemia protocol 12. Heparin Flush (1000 units/mL) 4000-11,000 UNIT DWELL PRN line flush 13. Metamucil (psyllium;<br>psyllium husk;<br>psyllium seed (sugar)) 1 tbsp oral DAILY 14. Midodrine 10 mg PO TID **Give prior to HD on HD days** 15. Nephrocaps 1 CAP PO DAILY 16. Omeprazole 20 mg PO BID 17. OXcarbazepine 300 mg PO BID 18. Protopic (tacrolimus) 0.1 % topical DAILY:PRN skin lesions 19. Rosuvastatin Calcium 40 mg PO QPM 20. Sarna Lotion 1 Appl TP QID 21. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 22. Tiotropium Bromide 1 CAP IH DAILY 23. TraZODone 50 mg PO QHS:PRN insomnia 24. Triglide (fenofibrate nanocrystallized) 160 mg oral DAILY 25. ___ MD to order daily dose PO DAILY16 afib, PE **dose to change daily for goal INR ___ 26. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 27. TraMADol 50 mg PO Q12H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pulmonary Embolism PMH: Coronary artery disease s/p coronary artery bypass graft x 3 Tricuspid regurgitation s/p tricuspid valve repair Acute on chronic renal insufficiency, now on HD MWF NSTEMI COPD (never smoked) CKD (1.5-2) AFib PPM, ___ Hypertension Hypercholesterolemia Iron deficiency anemia Orthostatic hypotension Seizure disorder Gout Depression BPH GERD Actinic keratosis ___ esophagus Bell's Palsy Basal cell carcinoma Colonic adenoma Complete heart block CHF ED Right knee TKR back surgery Discharge Condition: Alert and oriented x3 non-focal deconditioned Incisional pain managed with APAP and Tramadol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage Edema - none Followup Instructions: ___ Radiology Report EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT) INDICATION: ___ man found to have for pulmonary embolism. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: CTA chest ___ 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. Echogenic thrombus is noted within the greater saphenous vein on the left. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Thrombus within the left greater saphenous vein. 2. No evidence of deep venous thrombosis in the right or left lower extremity veins. Radiology Report EXAMINATION: BILAT UP EXT VEINS US INDICATION: ___ year old man readmitted with PE // eval for UE DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. A very small nonocclusive thrombus is visualized on grayscale imaging within the right internal jugular vein. The right IJ compresses and demonstrates the venous vascular flow on Doppler imaging. The right axillary and brachial veins are patent, show normal color flow and compressibility. The right basilic, and cephalic veins demonstrate normal compressibility. Note is made that the patient refused the remainder of the examination. IMPRESSION: 1. Very small nonocclusive thrombus of indeterminate chronicity visualized within the right internal jugular vein. 2. The left arm was not examined as the patient refused the remainder of the examination. NOTIFICATION: Findings of right IJ nonocclusive thrombus were discovered at 15:50 on ___ and were conveyed by telephone by ___ to Dr. ___ at 16:08 on the same day, 18 min after discovery. Radiology Report INDICATION: ___ year old man with tunneled line malpositioned // please exchange line COMPARISON: ___ TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: 25 mcg intravenous fentanyl was administered. Vital signs were monitored by a trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl CONTRAST: None. FLUOROSCOPY TIME AND DOSE: 1.3 min, 12 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 left neck was prepped and draped in the usual sterile fashion. Stiff glide wires were advanced through each lumen of the left internal jugular approach tunneled dialysis catheter. The cuff was loosened. The line was removed over the wires. A new tunneled dialysis catheter was advanced over both wires. The tip was guided into the right atrium under fluoroscopy. Both 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: Catheter tip in the right atrium. IMPRESSION: Over the wire exchange of a left internal jugular approach tunneled dialysis catheter. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain, Abd pain, Abd pain, Dyspnea Diagnosed with Chest pain, unspecified, Unspecified atrial fibrillation, Abnormal coagulation profile, Adverse effect of anticoagulants, initial encounter, Exposure to other specified factors, initial encounter temperature: 96.0 heartrate: 82.0 resprate: 16.0 o2sat: 99.0 sbp: 160.0 dbp: 80.0 level of pain: 9 level of acuity: 2.0
Mr. ___ was admitted for further management of PE and malposition of tunneled line. IVC filter was placed. ___ re-wired existing tunneled line. He had a successful run of HD following new line. He is discharged to the ___ on ___ Day 5. He will remain on Warfarin for goal INR ___ for AFib and PE. Hemodynamics remained stable.
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: ================ ___ 01:08PM NEUTS-74.4* LYMPHS-12.8* MONOS-5.3 EOS-4.8 BASOS-0.6 IM ___ AbsNeut-9.22* AbsLymp-1.58 AbsMono-0.66 AbsEos-0.59* AbsBaso-0.07 ___ 01:08PM PLT COUNT-173 ___ 01:08PM WBC-12.4* RBC-4.28* HGB-12.8* HCT-39.8* MCV-93 MCH-29.9 MCHC-32.2 RDW-16.7* RDWSD-57.0* ___ 01:08PM ___ ___ 01:08PM estGFR-Using this ___ 01:08PM GLUCOSE-139* UREA N-32* CREAT-1.2 SODIUM-143 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17 ___ 01:13PM ___ PO2-44* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-0 RELEVANT IMAGING ================== ___ HUMERUS (AP & LAT) LEFT: Anterior inferior dislocation of the left humeral head with likely chronic ___ deformity of the humeral head. No acute fracture. ___ GLENO-HUMERAL SHOULDER: Successful reduction of the left glenohumeral joint. ___ TTE: Severe right ventricular dysfunction with severe pulmonary hypertension and likely elevated pulmonary vascular resistance. Moderate-sevevere tricuspid regurgitation. No right to left shunt seen on resting bubble study. DISCHARGE LABS: ================= None as pt on hospice Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 2 mg PO QPM 2. Morphine SR (MS ___ 15 mg PO Q12H 3. Nicotine Lozenge 2 mg PO Q4H:PRN cravings 4. Nicotine Patch 14 mg/day TD DAILY 5. PredniSONE 20 mg PO DAILY 6. RisperiDONE 1 mg PO QHS 7. Sertraline 200 mg PO DAILY 8. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. Acetaminophen 1000 mg PO Q8H 11. Midodrine 10 mg PO TID 12. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg PO Q4: PRN SOB 13. ClonazePAM 1 mg PO DAILY:PRN anxiety Discharge Medications: 1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 2. Acetaminophen 1000 mg PO Q8H 3. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 4. ClonazePAM 2 mg PO QPM RX *clonazepam 2 mg 1 tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 5. ClonazePAM 1 mg PO DAILY:PRN anxiety RX *clonazepam 1 mg 1 tablet(s) by mouth PRN Disp #*7 Tablet Refills:*0 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Midodrine 10 mg PO TID 8. Morphine SR (MS ___ 15 mg PO Q12H RX *morphine 15 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 9. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg PO Q4: PRN SOB RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.5 (One half) ml by mouth every four (4) hours Refills:*0 10. Nicotine Lozenge 2 mg PO Q4H:PRN cravings 11. Nicotine Patch 14 mg/day TD DAILY 12. PredniSONE 20 mg PO DAILY 13. RisperiDONE 1 mg PO QHS 14. Sertraline 200 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: ACUTE ISSUES: ================ #Acute on chronic hypoxemic respiratory failure #Left shoulder dislocation Chronic Issues: ================== #Interstitial lung disease #Pulmonary hypertension #Right heart failure #Chronic kidney disease #Type II diabetes #Anxiety #Depression 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: HUMERUS (AP AND LAT) LEFT INDICATION: ___ with L shouloder pain.?L shoulder dislocation TECHNIQUE: AP and transthoracic view of the left humerus is provided. COMPARISON: Multiple prior left shoulder radiographs, most recently ___. FINDINGS: Anterior inferior dislocation of the left humeral head with likely chronic appearing ___ deformity. No acute fracture is identified. Chest findings will be separately reported on this same day chest radiograph. IMPRESSION: Anterior inferior dislocation of the left humeral head with likely chronic ___ deformity of the humeral head. No acute fracture. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:29 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with hypoxia // ?ptx TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph performed ___. FINDINGS: Redemonstration of diffuse bilateral pulmonary interstitial opacities, compatible with chronic interstitial lung disease. No focal consolidation is seen. No large pleural effusion or pneumothorax. The cardiomediastinal silhouette is mildly enlarged, but unchanged. Anterior inferior dislocation left glenohumeral joint, as seen on same day dedicated left humerus radiographs. IMPRESSION: 1. No evidence of pneumothorax. 2. Stable chronic interstitial lung disease. 3. Left anterior-inferior glenohumeral joint dislocation. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:29 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT INDICATION: ___ with reduced shoulder // dilocation reduction TECHNIQUE: AP internal rotation, external rotation, and scapular Y-views of the left shoulder are provided. COMPARISON: Left humerus radiograph performed 1 hour prior. FINDINGS: There has been interval reduction of the left shoulder, now in appropriate alignment. The previously seen ___ deformity is not appreciably changed. No acute fractures identified. Chronic interstitial lung disease was better assessed on same day chest radiograph. IMPRESSION: Successful reduction of the left glenohumeral joint. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hypoxia, L Shoulder pain Diagnosed with Hypoxemia temperature: nan heartrate: 89.0 resprate: 22.0 o2sat: 83.0 sbp: 128.0 dbp: 89.0 level of pain: 8 level of acuity: 1.0
SUMMARY: ================= Mr. ___ is a ___ M with hx end-stage COPD, smoking-related ILD, with ___ O2 requirement at home, CKD, DM2, and urinary retention who presents with left shoulder dislocation, found to have hypoxemic respiratory failure, subsequently transferred to the ___ for HFNC. Patient recently transitioned to hospice at ___ and would like to return to hospice at ___ ___ now that his shoulder has been fixed. ACUTE ISSUES ============ # ACUTE ON CHRONIC HYPOXEMIC RESPIRATORY FAILURE Patient has known severe COPD and RB-ILD requiring ___ at baseline. On admission to the FICU he was requiring HFNC but was weaned down on oximizer. He states that his dyspnea symptoms have worsened over the past few weeks. Repeat echo (___) showed worsening of his RV failure, tricuspid regurgitation and pulmonary hypertension. CXR on admission with no evidence of consolidation and he remained without infectious symptoms. His recent decompensation is likely due to progression of his chronic lung disease leading to right-sided heart failure and his current symptoms represent contributions from both of these etiologies. Discussed with patient that he would like to return to ___ on Hospice. He was continued on his home Spiriva, salmeterol, duonebs, and prednisone (20 mg) and started on Bactrim for PJP prophylaxis given his high dose steroids. # LEFT SHOULDER DISLOCATION Successful reduction of shoulder in the ED. Has had frequent prior presentations for this reason and is why he came to the hospital this admission. Of note, no fractures seen on X-ray. CHRONIC ISSUES ============== # CHRONIC KIDNEY DISEASE Cr 1.2 (bl Cr ___. # TYPE II DIABETES Held home metformin and started on SSI. Can resume metformin at discharge. # ANXIETY Continued on home clonazepam # DEPRESSION Continued on home risperidone and sertraline CORE MEASURES ============= #NUTRITION: regular, carb controlled #PROPHYLAXIS: - DVT: heparin SC - Pain: tylenol #CODE STATUS: DNR/DNI #CONTACT: HCP ___ ___
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfur / Banana Attending: ___. Chief Complaint: Hyperkalemia and ___ Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ with PMH of Hep-C and NASH-cirrhosis, recent decompensation in ___ (new onset ascites per CT in ___, started on lasix and Aldactone on ___, now presenting with hyperkalemia and ___. Pt's abnormal labs were noted on ___, and she was instructed to stop the lasix and aldactone. Repeat blood work from ___ showed K 6.3, and she was instructed to come the ED for admission. She is a patient of Dr. ___. In the ED, initial vs were: 97.7 98 101/55 18 100%. Labs were remarkable for K of 6.3, Na of 132, Cr of 1.3, bicarb of 17, lactate of 2.5, and Hct of 34.7. LFTs had risen from ___ to ALT 139, AST 189, AP 126, T bili 3.5, and D bili 2.4. EKG with peaked T waves in V2 and V3. Patient was given calcium gluconate, dextrose and insulin, and kayexalate for hyperkalemia, which improved to 5.1 on recheck. She was given 3L NS, and 25g of 25% albumin. During her ED stay, her BP dipped to SBP of 81 while sleeping. She remained asymptomatic. After resuscitation with albumin, her BP was improved to 117/76. She was also given a dose of vanc and cefepime for empiric treatment of sepsis given elevated lactate and hypotension. She had an ultrasound done for her elevated liver enzymes, which showed no intrahepatic biliary ductal dilation, cirrosis with small amount of ascities, no focal liver lesion, hepatofugal flow within patent main portal vein. She was admitted to medicine for further management of ___, hyperkalemia, and decompensating cirrhosis. On the floor, vs were 98.1, 110/51, 90, 20, 100% on RA. Pt denied any symptoms, including dizziness, lightheaded, abdominal pain, shortness of breath, chest pain, or palpitations. She endorses constipation and denies and dark tarry stools or BRBPR. She reports taking her medications as instructed. She notes that she has not been eating due to abdominal distension. Her distension is currently much improved since initial presentation in ___, per pt. She has had a cough, nonproductive, over the last month. Denies fever, chills, sweats. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: GERD Anxiety Obesity Allergic sinusitis HTN Hep C Thyroid nodule Osteoporosis Vertigo Colonic adenoma Social History: ___ Family History: Father died @ ___ - "old age", mother is ___ - a&w, 3 children - 2 sons, 1 daughter. Physical Exam: ON ADMISSION: PHYSICAL EXAM: Vitals: 98.1, 110/51, 90, 20, 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear. EOMI. No tongue asterixis. Neck: supple, 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, distended, bowel sounds present, no rebound tenderness or guarding. positive fluid wave. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Neuro: No asterixis. AAOx2.5 (reported year as ___. MAEE. CNs grossly intact. No focal sensorimotor deficits. ON DISCHARGE: Vitals: 2400 T 98.1 BP 97/50 P ___ RR 22 O2: 98% RA 0400 T: 98.1 BP 103/52 P: 93 RR: 22 O2: 98% RA General: Alert, oriented, no acute distress, fluids at bedside table HEENT: Sclera anicteric, MM slightly tacky, oropharynx clear. EOMI. No tongue fasciculations Neck: supple, no LAD Lungs: lungs are clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no fluid wave present on my exam Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Neuro: No asterixis. A&Ox3. CNs grossly intact. No focal sensorimotor deficits. Pertinent Results: Labs on Admission: ___ 08:42PM ___ COMMENTS-GREEN ___ 08:42PM K+-6.1* ___ 08:35PM GLUCOSE-81 UREA N-50* CREAT-1.3* SODIUM-130* POTASSIUM-6.1* CHLORIDE-104 TOTAL CO2-17* ANION GAP-15 ___ 08:35PM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.9* ___ 08:35PM WBC-8.7 RBC-3.69* HGB-11.6* HCT-34.7* MCV-94 MCH-31.4 MCHC-33.4 RDW-15.1 ___ 08:35PM NEUTS-66.1 ___ MONOS-7.2 EOS-1.8 BASOS-0.9 ___ 08:35PM PLT COUNT-221 ___ 10:09AM UREA N-49* CREAT-1.3* SODIUM-132* POTASSIUM-6.3* CHLORIDE-105 TOTAL CO2-17* ANION GAP-16 ___ 10:09AM ALT(SGPT)-139* AST(SGOT)-189* ALK PHOS-126* TOT BILI-3.5* DIR BILI-2.4* INDIR BIL-1.1 ___ 10:09AM TOT PROT-7.5 ALBUMIN-3.8 GLOBULIN-3.7 Relevant Interval Labs: ___ 12:50PM BLOOD WBC-7.7 RBC-3.68* Hgb-11.7* Hct-35.4* MCV-96 MCH-31.7 MCHC-32.9 RDW-15.2 Plt ___ ___ 12:16AM BLOOD Na-131* K-5.1 Cl-105 ___ 12:50PM BLOOD Glucose-91 UreaN-30* Creat-0.9 Na-135 K-5.1 Cl-110* HCO3-15* AnGap-15 ___ 12:50PM BLOOD ALT-103* AST-143* AlkPhos-100 TotBili-3.4* ___ 12:50PM BLOOD Calcium-8.3* Phos-2.9 Mg-2.4 ___ 12:50PM BLOOD AFP-134.2* ___ 12:35AM BLOOD Lactate-2.5* Labs on Discharge: ___ 11:10AM BLOOD WBC-7.9 RBC-3.66* Hgb-11.5* Hct-35.5* MCV-97 MCH-31.3 MCHC-32.2 RDW-15.1 Plt ___ ___ 11:10AM BLOOD Glucose-107* UreaN-30* Creat-0.8 Na-133 K-4.6 Cl-108 HCO3-15* AnGap-15 ___ 11:10AM BLOOD ALT-114* AST-171* AlkPhos-95 TotBili-3.8* Pertinent Micro: Blood cx x2 pending on discharge Pertinent Imaging: CXR: Left lung base opacities are likely atelectasis, although, Preliminary Reportpneumonia should be considered. RUQ US: no intrahepatic biliary ductal dilation, cirrosis with small amount of ascities, no focal liver lesion, hepatofugal flow within patent main portal vein. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Spironolactone 100 mg PO DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Alendronate Sodium 70 mg PO 1X/WEEK (___) 4. Vitamin D 400 UNIT PO DAILY 5. Citalopram 20 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Furosemide 20 mg PO DAILY 8. Ibuprofen 600 mg PO Q8H:PRN pain 9. Lactulose 15 mL PO BID 10. Lorazepam 0.5 mg PO BID:PRN anxiety 11. Losartan Potassium 25 mg PO DAILY 12. Meclizine 12.5 mg PO DAILY:PRN dizziness 13. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Lactulose 15 mL PO BID 5. Lorazepam 0.5 mg PO BID:PRN anxiety 6. Pantoprazole 40 mg PO Q24H 7. Vitamin D 400 UNIT PO DAILY 8. Tucks Hemorrhoidal Oint 1% 1 Appl PR PRN hemorrhoid please apply as needed to affected area up to 5x daily. RX *pramoxine-mineral oil-zinc [Tucks] 1 %-12.5 % small amount Ointment(s) rectally up to 5 times a day Disp #*1 Tube Refills:*0 9. Alendronate Sodium 70 mg PO 1X/WEEK (___) 10. Losartan Potassium 25 mg PO DAILY 11. Meclizine 12.5 mg PO DAILY:PRN dizziness 12. Ibuprofen 600 mg PO Q8H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: hyperkalemia secondary diagnosis: decompensation of HCV cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Cough and hypotension. Evaluate for pneumonia. COMPARISON: Chest radiograph, ___ and ___. FINDINGS: Frontal and lateral views of the chest were performed. There is atelectasis of the left lung base. There is no pleural effusion or pneumothorax. The heart size is normal. Calcifications are seen within the aorta. IMPRESSION: Left lung base opacities are likely atelectasis, although, pneumonia should be considered. Radiology Report HISTORY: Hyperbilirubinemia and cirrhosis. Evaluate for common bile duct dilation or obstructive process. TECHNIQUE: Ultrasound was performed in the upper abdomen. COMPARISON: CT abdomen pelvis ___. FINDINGS: The liver is nodular in contour, consistent with cirrhosis. There are no focal liver lesions identified. There is a small amount of ascites, similar to prior. The spleen is normal in size. There is hepatofugal flow within the main portal vein. Normal direction of flow is seen within the right and left portal venous system, which are patent. This may be secondary to significant arterioportal shunting related to cirrhosis. The hepatic veins are patent. To the extent visualized, the pancreas is unremarkable. The gallbladder is surgically absent. There is no intra or extrahepatic biliary ductal dilation. Limited views of the kidneys show simple cysts, unchanged from prior. IMPRESSION: 1. No intrahepatic biliary ductal dilation. 2. Cirrhosis with a small amount of ascites. No focal liver lesions. 3. Hepatofugal flow within a patent main portal vein. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: HYPERKALEMIA Diagnosed with HYPERKALEMIA temperature: 97.7 heartrate: 98.0 resprate: 18.0 o2sat: 100.0 sbp: 101.0 dbp: 55.0 level of pain: 0 level of acuity: 2.0
Ms. ___ is a ___ with history of Hepatitis C and NASH cirrosis being diuresed with aldactone and lasix x1 month presents to liver clinic with hyperkalemia and ___. Active Issues: # Hyperkalemia: Likely due to medication side effect - aldactone and losartan - plus ___. Peaked T waves noted on EKG in ED. Given calcium, insulin, dextrose, kayexalate in ED with improvement in K to 5.1. She was rehydrated which continued to improve K+ as well as ___ (see below). Her Aldactone and Losartan were held throughout admission and she was placed on telemetry for Day 1 with no issues. # Acute kidney injury: Likely prerenal due to poor po intake and diuresis. Pt fluid resuscitated in ED with 3L NS and 25g of 25% albumin. UOP had been normal per pt and continued to be normal throughout admission. Her creatinine trended down from 1.3-->0.9 after rehydration. She tolerated PO intake and IV fluids were discontinued. Diuretics and ___ were held for above reasons. # Decompensating cirrhosis: History of Hepatitis C and NASH. Pt noted to be decompensating in ___/P revealed ascites. Last HCV VL over 9 million in ___. No recent alcohol use or bleed. Only medication changes include diuretics listed above. RUQ US shows small ascites and patent portal vein. No s/s of active bleeding. DF of 12 and MELD of 41 at present. LFTs and T.Bili trended down over course of admission and AFP was 134.2 which has also downtrended from previous studies. Patient to follow up with outpatient MRI and clinic appt with Dr. ___ week of ___.
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nitroimidazole Derivatives / Levofloxacin / Meperidine / Bactrim / Flagyl / morphine Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP with stent removal History of Present Illness: This is a ___ y/o female with a PMH notable for intermittent RUQ pain, s/p recent ERCP 10 days ago with biliary sludge extraction and stent placement; celiac artery compression syndrome s/p aorto-celiac bypass, prior LOA procedures, HTN, hypothyroidism, who presents here today with recurrent epigastric/RUQ pain radiating to the back for the last 1 week. She underwent an ERCP 10 days ago, which was uneventful, and for 2 days noted improvement and resolution of her symptoms. For the last 1 week however, she has had the same recurrent epigastric->RUQ pain that radiates to the back and is predominantly post-prandial in nature. It has been associated with nausea and non-bloody/non-bilious vomiting. She has also noted looser and lighter colored stools (though not acholic) for the last 1 week. Notes decreased po intake due to n/v, but no changes in weight. +lightheadedness due to dehydration today. Was taking oxycodone at home, but that made her nausea worse and was not relieving the pain. No urinary symptoms or changes in urine color. . In the ED, VSS. Pt given zofran, morphine x 3 after which she immediately developed local hives (following the 3rd dose of morphine). She was given benadryl with resolution of symptoms. She was given dilaudid instead for pain, without any adverse symptoms. Labs and CT abd with IV contrast were all normal. GI/ERCP was notified of her admission. . Currently patient is resting comfortably and tolerated a ___ sandwich in the ED. Pain is ___ currently. Denies f/c/s, CP/SOB, ___ edema. . 12-pt ROS otherwise negative in detail except for as noted above. Past Medical History: Hyperparathyroidism s/p parathyroidectomy History of multiple kidney stones. TAH BSO Bowel resection for adhesions. Status post cholecystectomy. Status post appendectomy. Esophageal stricture status post dilatation. Celiac artery compression syndrome s/p aorto-celiac bypass Hypertension ___'s thyoiditis GERD Leiomyosarcoma/fibroid tumors Social History: ___ Family History: Mother died of lung cancer; one brother died of CAD; another brother died from a brain tumor. Father alive and relatively healthy at age ___. Physical Exam: Admission PE VS: Tc 97.9, BP 127/77, HR 70, RR 16, SaO2 99/RA General: Well-appearing female in NAD, slightly fatigued, AO x 3 HEENT: NC/AT, PERRL, EOMI. Anicteric sclerae. MM slightly dry, OP clear Neck: supple, no LAD Chest: CTA-B, no w/r/r CV: RRR s1 s2 normal, no m/g/r Abd: soft, ND/NABS. +tenderness to deep palpation over the RUQ and epigastric area, no peritoneal signs. Negative ___. No abd bruit. Ext: no c/c/e, wwp Skin: warm, dry. No hives Neuro: AO X 3, non-focal exam . Discharge PE VSS Abdomen: active BS X4 quadrants, mild TTP in the epigastric region and TTP on the inferior costal margin, improved from prior examinations CV: RRR, no rmg Lungs: CTAB, no WRR Pertinent Results: ___ 10:40AM WBC-5.2 RBC-4.58 HGB-14.4 HCT-43.5 MCV-95 MCH-31.4 MCHC-33.0 RDW-12.9 ___ 10:40AM NEUTS-68.6 ___ MONOS-3.5 EOS-2.3 BASOS-1.0 ___ 10:40AM PLT COUNT-209 . ___ 10:40AM GLUCOSE-87 UREA N-11 CREAT-0.9 SODIUM-141 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13 ___ 10:40AM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-91 TOT BILI-0.3 ___ 10:40AM LIPASE-39 ___ 10:40AM ALBUMIN-4.5 . ___ 02:52PM URINE UCG-NEGATIVE ___ 11:00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . ___ CT abd with IV contrast: 1. No acute intra-abdominal process. 2. Satisfactory position of the common bile duct stent with expectedtpneumobilia. . ___ ERCP: Satisfactory post sphincterotomy appearance. The major papilla was open with spontanous bile draining Cannulation of the biliary duct was successful and deep after a guidewire was placed A dilation was seen at the proximal main bile duct to 15 mm with smooth distal narrowing but no clear stricture was noted. No filling defects or strictures noted. Normal intrahepatic duct Small amount of sludge was extracted successfully using a balloon. A 12mm balloon was pulled through the papilla with mild resistance. Given patient's symptoms, A 6cm by ___ Cotton ___ biliary stent was placed successfully as a therapeutic trial to see if symptoms improve with drainage. If symptoms clearly improve, consider surgical bypass. If no improvement is noted, explore other causes of abdominal pain. . Rib films ___ IMPRESSION: 1) No acute pulmonary process. 2) No rib fracture detected. Note is made that the configuration of the right lowermost rib is different on the ___ CT compared with the ___ CT, and is now extending toward the edge of the liver. Clinical correlation is requested. . ERCP ___ Previously placed stent was noted at the major papilla. Previous sphincterotomy was also noted. The stent was removed using a snare. Excellent drainage of bile was noted after the biliary stent was removed. Cannulation of the pancreatic duct was successful and deep with a ___ tapered catheter using a free-hand technique The pancreatogram revealed normal appearance of the pancreatic duct with no filling defects or narrowing. Excellent drainage of contrast was noted from the pancreatic duct orifice after the catheter was withdrawn. Otherwise normal ercp to third part of the duodenum . Medications on Admission: Nexium 40 mg twice daily Norvasc 2.5 mg daily Labetalol 50 mg daily Levoxyl 100 mcg daily Discharge Medications: 1. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:*QS for 1 month Powder in Packet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp:*14 Tablet(s)* Refills:*0* 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 5. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. labetalol 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. butalbital-aspirin-caffeine 50-325-40 mg Capsule Sig: One (1) Cap PO Q4H (every 4 hours) as needed for headache. 9. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 10. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp:*QS for 1 month Tablet, Rapid Dissolve(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: RUQ pain likely due to gastroparesis costochondritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ERCP with common bile stent ___ days prior, now with one week of epigastric and right upper quadrant pain. COMPARISONS: CT abdomen and pelvis, ___. TECHNIQUE: MDCT axial images were obtained from the dome of the liver to the pubic symphysis after the administration of IV contrast. Coronal and sagittal reformations were provided and reviewed. DLP: 355.21 mGy-cm. ABDOMEN: The visualized lung bases are unremarkable. There is no pleural effusion or pneumothorax. The visualized heart is normal, and there is no pericardial effusion. The liver enhances homogeneously. The gallbladder is surgically absent. A common bile duct stent is in place and pneumobilia is present as expected. The spleen, adrenal glands, and pancreas are unremarkable. The kidneys enhance symmetrically and excrete contrast without hydronephrosis. The abdominal aorta and its major branches are unremarkable. The portal vein, splenic vein, and superior mesenteric vein are patent. There is no retroperitoneal or mesenteric lymphadenopathy. There is no free air or free fluid. Surgical clips are seen to the left of the celiac artery. The stomach, large and small bowel are normal. There is no evidence of obstruction. PELVIS: The bladder, rectum, and sigmoid are normal. The uterus and ovaries are surgically absent. The appendix is not visualized, but there are no secondary signs of appendicitis. There is no pelvic or inguinal lymphadenopathy. Surgical material is seen in the left hemipelvis, from prior colonic anastomosis. BONES: There are no suspicious osseous lesions. There has been partial resection of the right twelfth rib. An injection granuloma is seen overlying the left sacroiliac joint. IMPRESSION: 1. No acute intra-abdominal process. 2. Satisfactory position of the common bile duct stent with expected pneumobilia. Radiology Report HISTORY: Rib pain, costochondritis, now exacerbation of right upper quadrant pain and rib pain, fracture or acute process. AP VIEW OF THE CHEST. TWO VIEWS EACH RIGHT AND LEFT RIBS, FIVE VIEWS IN ALL. CHEST: There is borderline cardiomegaly. No CHF, focal infiltrate, effusion, or pneumothorax is detected. Mild right convex curvature of the thoracic spine is noted. Rupper quadrant surgical clips are noted. Additional small clips are noted near the GE junction with a punctate BB-like density overlying the upper abdomen to the right of the spine -- based on the ___ CT, this apparently lies outside the abdomen. RIBS: No rib fracture or focal lytic or sclerotic rib lesion is identified. On the ___ CT scan, incidental note is made of a curved appearance to the tip of the lowermost right rib (___) on that study, slightly different in configuration from a CT dated ___. Has there been interval surgery in this location? IMPRESSION: 1) No acute pulmonary process. 2) No rib fracture detected. Note is made that the configuration of the right lowermost rib is different on the ___ CT compared with the ___ CT, and is now extending toward the edge of the liver. Clinical correlation is requested. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: N/V/RUQ PAIN S/P CBD STENT Diagnosed with ABDOMINAL PAIN RUQ, NAUSEA WITH VOMITING temperature: 98.8 heartrate: 81.0 resprate: 18.0 o2sat: 100.0 sbp: 137.0 dbp: 75.0 level of pain: 8 level of acuity: 3.0
___ y/o female with history of RUQ pain, s/p multiple ERCPs, most recently being 10 days ago, h/o celiac compression syndrome s/p bypass, and multiple abdominal surgeries now presenting with recurrent epigastric/RUQ pain. . # Acute on chronic RUQ pain The patient has had an extensive work up in the past and has seen multiple GI physicians both at ___ and at ___. Her initial work up included a negative CT of her abdomen and pelvis and normal labs. The current episode is likely caused by a multitude of etiologies, including possible gastroparesis, biliary colic and neuropathic pain (intercostal neuralgia) from prior costochondritis and surgery. The ERCP was involved and they took her for an ERCP during which her stent was removed and a pancreatogram was done which showed no abnormalities. They felt as though this was not biliary or pancreatic related. Rib films were negative for a fracture. The pain service was also consulted for a right costochondral joint injection, which was done in house. These interventions resulted in improvement in the patients pain. The medical team strongly advised the patient to slowly advance her diet. The patient refused and ate meat loaf, mashed potatoes and carrot cake. She then vomited. Her diet was changed back to BRAT diet as originally recommended and she tolerated this without problems. Dr. ___ was contacted and make aware of what occurred during this hospitalization. The tentative plan is to pursue a gastroparesis work up further as an outpatient. The patient was insistent that we find a unifying diagnosis for her symptoms during the current admission. I repeatedly explained that we would try and investigate urgent and life threatening issues and she would complete any additional work up that her GI team felt was necessary as an outpatient. She ultimately agreed to that plan and was discharged with anti-emetics and pain control. She was advised to continue a BRAT diet until follow up with Dr. ___. . # Transitional Issues: -Follow up with GI-Dr. ___ PCP ___ ___ weeks . # Transitional Issues
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Zestril Attending: ___. Chief Complaint: fever and abdominal pain Major Surgical or Invasive Procedure: Ultrasound-guided percutaneous cholecystostomy ___ History of Present Illness: ___ DM2, obesity, GERD p/w midepigastric pain migrating to right side x6 days, nausea, NBNB emesis x1 and subjective fevers. He was in good state of health until ___ when he had burgers/fries at ___ and noted severe midepigastric pain, nausea and emesis at that time that he attributed to indigestion. Since then he has had subjective fevers, chills and night sweats. Over the past few days, the pain has migrated to the right abdomen. He was seen at his PCPs office today with those complaints and a KUB was obtained that was concerning for ileus vs SBO and was sent into the ___ for evaluation. Last episode of emesis was ___. He passed flatus this evening. Last BM was 3 days ago. Denies jaundice, pruritis, urinary symptoms, diaphoresis, chest pain, shortness of breath, hematochizea, melena. Past Medical History: PMH: Severe reflux, moderate hiatal hernia, asthma (last PFT showing mild obstructive disease), DM2 (diet controlled per PCPs note ___enies), roseacea, HTN, HLD, acne PSH: Left kneesurgery Social History: ___ Family History: NC Pertinent Results: Admission labs: WBC 18.1 Hct 47 Plt 221 132 95 20 -----------------< 3.8 22 0.9 ALT 26 AST 20 ALP 69 Bili T 1.72 Bili D 0.59 Lipase 23 UA: negative Admission imaging: CT Abd/Pel from ___ ___: 1. Distended gallbladder, with hyperenhancing wall, pericholecystic fluid, surrounding fat strainding and continaing gallstones, concerning for acute cholecystitis. Fat stranding and inflammatory changes also seen surrounding the hepatic flexure. 2. Mild bibasilar atelectasis. 3. Hypodensities in the liver, some are too small to characterize, statistically cysts. 4. Mild splenomegaly. 5. Small amount of pelvic free fluid. Chemistry: ___ 10:40AM BLOOD Glucose-147* UreaN-18 Creat-0.8 Na-134 K-3.8 Cl-98 HCO3-23 AnGap-17 ___ 10:40AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9 CBC and Coags: ___ 10:40AM BLOOD WBC-14.6*# RBC-4.73 Hgb-15.2 Hct-44.1 MCV-93 MCH-32.1* MCHC-34.4 RDW-13.8 Plt ___ ___ 06:45AM BLOOD ___ PTT-28.1 ___ ___ 10:40AM BLOOD ___ LFTs: ___ 10:40AM BLOOD ALT-41* AST-33 AlkPhos-77 TotBili-1.5 ___ 07:47AM BLOOD ALT-65* AST-52* LD(LDH)-206 AlkPhos-72 Amylase-77 TotBili-0.7 ___ 07:47AM BLOOD calTIBC-200* Ferritn-1131* TRF-154* ___ KUB: Moderately dilated loops of small and large bowel along with air-fluid levels in the small bowel, suggesting ileus or early small bowel obstruction. Recommend close follow-up with an upright abdominal radiograph. Ultrasound-guided percutaneous cholecystostomy ___: Mildly edematous gallbladder was demonstrated. Successful placement of 8 ___ Exodus pigtail catheter into the gallbladder lumen, with aspiration of 100 cc dark brown, blood tinged fluid. Medications on Admission: Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheezing Allopurinol ___ mg PO DAILY Aspirin EC 81 mg PO DAILY Fluticasone Propionate NASAL 2 SPRY NU DAILY Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID Valsartan 320 mg PO DAILY Verapamil SR 240 mg PO Q24H Omeprazole 20 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheezing 2. Allopurinol ___ mg PO DAILY 3. Aspirin EC 81 mg PO DAILY 4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 1 Week 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Valsartan 320 mg PO DAILY 8. Verapamil SR 240 mg PO Q24H 9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 10. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Chronic cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: GB DRAINAGE,INTRO PERC TRANHEP BIL US INDICATION: ___ year old man with acute cholecystitis x 6days. Please place percutaneous cholecystostomy tube. // Percutaneous Cholecystostomy tube placement COMPARISON: CT ___ PROCEDURE: Ultrasound-guided percutaneous cholecystostomy. OPERATORS: Dr. ___ trainee and Dr. ___ radiologist, who was present and supervising throughout the total procedure time. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the ultrasound table. Limited preprocedure imaging was performed to localize the gallbladder. An appropriate skin entry site was chosen and the site marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, an ___ Exodus drainage catheter was advanced via trocar technique into the gallbladder. A sample of fluid was aspirated, confirming catheter position within the collection. The plastic stiffener was removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via ultrasound. Ultrasound images were stored on PACS. Approximately 100 cc of dark brown, blood tinged fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 15 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Mildly edematous gallbladder was demonstrated. Successful placement of 8 ___ Exodus pigtail catheter into the gallbladder lumen, with aspiration of 100 cc dark brown, blood tinged fluid. IMPRESSION: Successful ultrasound-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 1:25 ___, approximately 20 min after the procedure. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with CHOLELITH W AC CHOLECYST, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.6 heartrate: 91.0 resprate: 18.0 o2sat: 99.0 sbp: 168.0 dbp: 90.0 level of pain: 0 level of acuity: 3.0
Mr. ___ is a ___ M with h/o GERD, hiatal hernia, and asthma who was transferred from ___ ___ with abdominal pain, nausea and fever and CT scan with evidence of acute cholecystitis, likely with some chronic componenet. On admission, he underwent ultrasound-guided percutaneous cholecystostomy placement with interventional radiology and this was uneventful. He treated with appropriate empiric antibiotic therapy (first zosyn, then ceftriaxone IV and flagyl IV, and then augmentin when tolerating PO intake ___. His diet was slowly advanced and he tolerated this without nausea or vomiting. His LFTs remained stable and leukocytosis resolved. His drain put out an appropriate amount of bilious, blood-tinged fluid. Prior to discharge, his pain was well controlled with medications by mouth and he was tolerating a regular low fat diet. He was continued on his home medications during his hospital stay. He received drain care teaching and will be going home with visiting nursing services to assist with drain care. He will complete a 1 week course of augmentin by mouth and will then follow up with Dr. ___ in clinic.
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: None History of Present Illness: ___ yo male with a history of metastatic lung cancer who is admitted with shortness of breath and constipation. The patient stats overall he has not been feeling well. He has been having more trouble breathing. He has a nonproductive cough. He also has been having nausea which is ongoing but worse the last few days. He has been taking Zofran but it doesn't always help. His abdominal pain is also worse the last few days. He thinks the increased dose of oxycontin is helping some. He is constipated and has not have a bowel movement in three days. He denies any fevers. He denies any dysuria or rashes. In the ED a CT was done which showed a possible pneumonia in the setting of known lung masses. He was given ceftriaxone and azithromycin as well as Zofran, oxycodone, Compazine, and IV fluids. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ patient noted a submandibular area swelling. - ___: Underwent CT neck which demonstrated a 2 cm mass in the left submandibular region which was initially concerning for primary hea ___ and ___ and neck cancer. ¬ ___: Was seen by Dr. ___ FNA was performed on ___. Initial path results were indeterminate. - ___: Repeat biopsy of the submandibular mass returned as malignancy with squamous and glandular features identified, Including Signet Ring Features. - ___: Chest x-ray was performed for cough which showed left lower lobe lung mass. CT chest the following day confirmed a 12 cm left lower lobe perihilar mass abutting the IPV and the aorta. Given the new findings on CT chest definitive therapy on the salivary gland was held off, and initial diagnosis was question. - ___: PET scan obtained which showed asymmetric enlargement of the left submandibular gland, 7.7 left hilar mass, lymph node enlargement along the left inferior parasternal and epicardial region, a separate 6 mm groundglass nodule in the left upper lobe, as well as a 3.6 cm soft tissue mass overlying the sacrum with possible bony destruction. MRI of the head was also obtained which showed a 9 x 13 mm left occipital lesion as well as subtle 3 mm focus in the right parietal-occiptal lobe. - ___: Biopsy of the sacral lesion revealed metastatic lung adenocarcinoma, positive for CK 7, TTF-1, Napsin-A and p40. Slides from the submandibular thought to be identical to the sacral lesion consistent with adenocarcinoma - ___ to ___: Admission for sacral pain and SOB. Found to have left malignant pleural effusion {cytology positive) requiring chest tube. Completed 3000 cGy XRT to the sacrum. Started ___ as mutation panel WT and PD-L1 <1%. C1D1 ___. - ___ to ___: Patient admitted for failure to thrive and worsening jaw pain. Repeat imaging submandibular mass appeared to have grown, and he started radiation as an inpatient. CT of torso showed worsening metastatic disease, specifically with a new metastatic lesion in the pancreas 2 ill-defined lesions in the liver, as well as apparent worsening of the L5/sacral mass. - ___: Cycle 1 day 1 Nivolumab - ___: Cycle 1 day 15 Nivolumab - ___: Cycle 2 day 1 Nivolumab - ___: Cycle 2 day 15 Nivolumab PAST MEDICAL HISTORY: - Metastatic Lung Cancer, as above Social History: ___ Family History: Sister was diagnosed with metastatic HER-2 positive breast cancer ___ years ago and was found to be BRCA negative. His grandmother died of colon cancer in old age. No other history of malignancy or hematologic diseases in the family. Physical Exam: ADMISSION EXAM =========================== General: NAD, cachectic VITAL SIGNS: T 97.3 BP 95/70 HR 84 RR 18 O2 98%RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: Decreased breath sounds. ABD: Soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficits. DISCHARGE EXAM =========================== VS: 98.8 PO 110 / 63 105 16 94 RA GEN: cachexic, lying in bed, alert and interactive HEENT: temporal wasting, EOMI, sclera anicteric, MMM Cards: RRR, no murmurs, rubs, or gallops Pulm: decreased breath sounds at L base, otherwise CTAB without wheezing Abd: normoactive bowel sounds, no tenderness to palpation, no rebound or guarding Extremities: warm, well-perfused, no lower extremity edema Skin: no rashes or bruising Neuro: A/Ox3, CN II-XII grossly intact, moving all extremities with purpose Pertinent Results: ADMISSION LABS ============================= ___ 09:00PM BLOOD WBC-7.3 RBC-4.24* Hgb-11.3* Hct-34.7* MCV-82 MCH-26.7 MCHC-32.6 RDW-14.3 RDWSD-41.8 Plt ___ ___ 09:00PM BLOOD Neuts-88.2* Lymphs-9.2* Monos-1.9* Eos-0.3* Baso-0.1 Im ___ AbsNeut-6.43* AbsLymp-0.67* AbsMono-0.14* AbsEos-0.02* AbsBaso-0.01 ___ 09:00PM BLOOD ___ PTT-31.4 ___ ___ 09:00PM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-133* K-4.1 Cl-91* HCO3-22 AnGap-20* ___ 09:00PM BLOOD ALT-26 AST-32 AlkPhos-135* TotBili-0.4 ___ 09:00PM BLOOD Lipase-17 ___ 09:00PM BLOOD Albumin-3.9 RELEVANT STUDIES ============================ ___ CXR PA/LATERAL: Similar appearance of the chest in this patient with known left perihilar mass. There may be slight increase in opacity in the left upper to mid lung, which could relate to aspiration or possibly underlying infection versus disease spread. Volume loss in the left lung is re-demonstrated with elevation of left hemidiaphragm. A 1.5 cm rounded opacity projecting over the lateral right lower hemithorax may represent nipple shadow which can be confirmed with nipple marker. Cardiac and mediastinal silhouettes are stable. ___ CTA CHEST AND ABDOMEN: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Similar appearance of the large left lower lobe perihilar mass invading the mediastinum, obliterating the left lower lobe bronchi, and attenuating the left lower lobe segmental pulmonary arteries. Circumferential left pleural thickening compatible with disease involvement. 3. Right middle lobe consolidation has improved from ___ with mild residual. 1.4 cm right lower lobe nodular opacity has grown and 6 mm left upper lobe nodular opacity is new which may be infectious/inflammatory or represent neoplastic involvement. 4. Debris seen in the right main bronchus. Air-fluid fluid level in the esophagus within the patient at risk for aspiration. 5. Large rectal stool loading and moderate to large colonic stool burden. 6. Lytic lesions in the L3 and L4 vertebral bodies with moderate compression deformities, pathologic fractures, and 3 mm of retropulsion of the posterior aspect L3 vertebral body are new from ___. Grown presacral soft tissue nodule concerning metastatic deposit. ___ MR HEAD W/ & W/O CONTRAST: 1. Numerous scattered linear and serpentine, nodular punctate cortically based areas of enhancement many of which are new and demonstrate associated slow diffusion, and likely represent enhancing subacute infarcts.. Metastatic deposits within some of these areas cannot be excluded. 2. Few nodular foci of enhancement are consistent with metastases, including lesion in the anterior right frontal lobe, superior cerebellar vermis, and inferior left occipital lobe. 3. Left cerebellar small lesion may represent late subacute infarct. 4. Serpiginous linear area of enhancement overlying superior left occipital lobe is likely leptomeningeal, is also present on prior, and may represent leptomeningeal metastatic disease; inflammatory or infectious process could have similar appearance. Subtle enhancement within left internal auditory canal is likely part of the same process. 5. Follow-up brain MRI without and with contrast in ___ weeks would be helpful to clarify above picture. RECOMMENDATION(S): Consider MRI brain without and with contrast in ___ weeks prior to radiation treatment, if appropriate MICROBIOLOGY ============================ ___ 8:30 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 9:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): DISCHARGE LABS ============================ ___ 08:12AM BLOOD WBC-2.5* RBC-3.77* Hgb-10.3* Hct-31.5* MCV-84 MCH-27.3 MCHC-32.7 RDW-14.0 RDWSD-42.0 Plt ___ ___ 08:12AM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-136 K-4.5 Cl-95* HCO3-25 AnGap-16 ___ 08:12AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath/wheezing 2. Docusate Sodium 100 mg PO BID 3. Multivitamins W/minerals 1 TAB PO DAILY 4. OxyCODONE (Immediate Release) 20 mg PO Q3H:PRN Pain - Moderate 5. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 6. Polyethylene Glycol 17 g PO DAILY 7. Prochlorperazine 10 mg PO Q8H:PRN Nausea 8. Senna 8.6 mg PO BID 9. Dexamethasone 4 mg PO DAILY 10. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 11. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting 12. FoLIC Acid 1 mg PO DAILY 13. Lactulose 15 mL PO DAILY:PRN Constipation 14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX *bisacodyl 5 mg Two tablet(s) by mouth Once a day Disp #*60 Tablet Refills:*0 2. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN SOB RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL IH every four hours as needed Disp #*30 Ampule Refills:*0 3. LORazepam 0.5 mg PO Q4H:PRN Nausea RX *lorazepam 0.5 mg One tablet by mouth Once every 4 hours Disp #*60 Tablet Refills:*0 4. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS RX *olanzapine 5 mg 0.5 (One half) tablet(s) by mouth Once in the evening Disp #*15 Tablet Refills:*0 5. Lactulose 15 mL PO BID:PRN Constipation RX *lactulose 10 gram/15 mL (15 mL) 15 mL by mouth Twice a day Disp #*300 Milliliter Refills:*0 6. Polyethylene Glycol 17 g PO BID Constipation RX *polyethylene glycol 3350 17 gram One packet(s) by mouth Twice a day Disp #*30 Packet Refills:*0 7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 8. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath/wheezing 9. Dexamethasone 4 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Omeprazole 20 mg PO DAILY 12. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting 13. OxyCODONE (Immediate Release) 20 mg PO Q3H:PRN Pain - Moderate RX *oxycodone 20 mg One tablet(s) by mouth Once every 3 hours Disp #*56 Tablet Refills:*0 14. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H RX *oxycodone 80 mg One tablet(s) by mouth Once every 8 hours Disp #*21 Tablet Refills:*0 15. Senna 8.6 mg PO BID 16.Nebulizer ICD-10 C34.90- Malignant neoplasm of unspecified part of unspecified bronchus or lung. Please provide patient with home nebulizer. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Metastatic non-small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with metastatic lung adenocarcinoma being evaluated for XRT.// Progression of brain mets? Please do with Cyberknife protocol sequence TECHNIQUE: After administration of 6 mL of Gadavist intravenous contrast, axial imaging was performed with diffusion. Axial MPRAGE imaging was performed. COMPARISON: MRI head ___. FINDINGS: There are numerous scattered linear and serpentine mostly cortically based areas of enhancement, the majority of which are new with areas of corresponding slow diffusion in the bilateral frontal, parietal and occipital lobes. 5 the ease are strongly suggestive of subacute infarcts. Early metastatic deposits on the cortex could have this appearance if there is vascular component to tumor spread. FLAIR T2 weighted images were not obtained, on images there provided there is no evidence of any local mass effect. Many of the foci of decreased diffusion do not demonstrate associated postcontrast enhancement (e.g. series 402, image 22). One of the lesions identified on the previous study (right occipital lobe) is no longer seen. There is a new small 3 mm enhancing lesion within the left cerebellum has suggestion of barely perceptible increased signal on diffusion images, may represent late subacute infarct. The similar 0.4 cm lesion in the superior cerebellar vermis. Mild increase in size of the 5 mm rim enhancing lesion within the right frontal lobe (series 5, image 59) demonstrating an increase in central hypodensity which may be from posttreatment change or growth, it measured 0.3 cm on prior ___. There is focus of enhancement involving superior left occipital lobe surface, probably within subarachnoid space and not confined to the cortex, similar to prior, is worrisome for left meningeal tumor spread,, inflammatory or infectious process could have similar appearance; enhancing late subacute infarct is less likely as this appears superficial to the cortex. Just inferior to this there is separate focus of cortical enhancement, which may represent metastatic lesion versus enhancing infarct measuring 0.5 cm. Suggestion of asymmetric linear enhancement in the left internal auditory canal. No significant change in the small meningocele related to a left temporal burr hole (series 5, image 50). No change in findings compatible with an 8 mm intraosseous hemangioma within the left parietal bone (series 5, image 76). The ventricles and sulci are normal in caliber and configuration. IMPRESSION: 1. Numerous scattered linear and serpentine, nodular punctate cortically based areas of enhancement many of which are new and demonstrate associated slow diffusion, and likely represent enhancing subacute infarcts.. Metastatic deposits within some of these areas cannot be excluded. 2. Few nodular foci of enhancement are consistent with metastases, including lesion in the anterior right frontal lobe, superior cerebellar vermis, and inferior left occipital lobe. 3. Left cerebellar small lesion may represent late subacute infarct. 4. Serpiginous linear area of enhancement overlying superior left occipital lobe is likely leptomeningeal, is also present on prior, and may represent leptomeningeal metastatic disease; inflammatory or infectious process could have similar appearance. Subtle enhancement within left internal auditory canal is likely part of the same process. 5. Follow-up brain MRI without and with contrast in ___ weeks would be helpful to clarify above picture. RECOMMENDATION(S): Consider MRI brain without and with contrast in ___ weeks prior to radiation treatment, if appropriate NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 18:37, 10 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, N/V, RLQ abdominal pain Diagnosed with Shortness of breath, Unspecified abdominal pain temperature: 99.0 heartrate: 107.0 resprate: 22.0 o2sat: 99.0 sbp: 108.0 dbp: 60.0 level of pain: 5 level of acuity: 2.0
Mr. ___ is a ___ gentleman with history of metastatic lung adenocarcinoma s/p ___ and palliative XRT to the sacrum/jaw who presented with constipation, SOB, nausea, and overall weakness. #METASTATIC LUNG ADENOCARCINOMA: Stage IV NSCLC. Was on carboplatin/premetrexed but had disease progression on this regimen; per primary team ___ and ___, will not offer any further treatment. He has, in the past, received palliative XRT to the sacrum/jaw and been treated with nivolumab. ___ MRI Head w/ & w/o contrast showed stability of cerebellar lesion. Rad Onc will not do palliative XRT to this lesion given stability and limited life expectancy. Pt was seen by palliative care and social work; a family meeting was held with mother, sister, uncles, friend, medical/social work/palliative care/case management teams on ___, in which transfer to home hospice care was discussed and agreed upon. Please see attached medication list for discharge meds. #CONSTIPATION: reporting significant constipation on admission. ___ CT Abdomen showed significant stool burden in rectum and large bowel. Had been concurrently taking ondansetron for nausea, possibly exacerbating constipation. Bowel regimen was titrated and patient had BM on ___ with improvement in symptoms (including nausea). Patient now having regular bowel movements. Please see attached medication list for discharge meds. #SHORTNESS OF BREATH: This is likely due to worsening of his lung cancer. CT chest from ___ shows known disease involvement as well as new lytic lesions in the L-spine, which could be increasing SOB due to increased pain with respirations. CT chest showed questionable consolidation, which was initially worrisome for pneumonia. However, in the absence of fever, leukocytosis, and change in cough, antibiotics were stopped (was given ___ doses each of ceftriaxone and azithromycin). Pt remained stable off antibiotics. TRANSITIONAL ISSUES =================== [] Discharged home with hospice [] If any questions or concerns, can call Dr ___ ___ office at ___.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ibuprofen / Neurontin / Depo-Medrol / Topamax / Elidel / Lipitor / Norvasc / Doxazosin / Protonix / Prilosec Attending: ___. Chief Complaint: Left lower extremity cellulitis. Major Surgical or Invasive Procedure: None. History of Present Illness: This is a ___ year-old female with ___, chronic diastolic heart failure, and hypertension admitted ___ for ___ cellulitis (d/c'd on cipro/keflex) who is admitted this presentation for persistent ___ cellulitis and ?pneumonia. . She was discharged home 3 days ago. Felt that the ___ redness and swelling was getting better. Took Bactrim and Keflex as directed. But then woke up this AM with worsened pain in her left leg. She tried calling Healthcare Associates but could not get through. Says that more than swelling or redness, it is pain that brought her in this time. Also, during her last hospitalization she had a persistent cough with negative CXR's, and the cough has not gone away. She cannot walk up a flight of stairs before feeling short of breath. . In the ED, initial VS were: 8 98.0 68 104/68 16 98%. Labs were notable for WBC 17.3 (78%N, 2% bands) compared to 16.2 prior to discharge. Cr 1.4 (baseline 1.0; on last admission had been up to 1.5 but was 1.0 on discharge). ___ was negative for DVT. CXR showed "a focal right perihilar opacity most suggestive of pneumonia." She received blood cultures x2 then Vancomycin and IV Cipro. For pain control received MS ___ 60mg (home med), MS ___ 15mg x2, and Oxycodone 5mg. She was admitted to Medicine for cellulitis and PNA. . On arrival to the floor, patient is comfortable but requests more morphine. . ROS is negative for chest pain, palpitations, numbness/tingling, weakness, abdominal pain, N/V/D, constipation. No dysuria. Past Medical History: -DM c/b peripheral neuropathy, diabetic amyotrophy of the left lower leg and Charcot ankle, last A1C in ___ is 8.2, followed at ___ -Recurrent cellulitis -Diastolic heart failure EF >60% -HTN -Hyperlipidemia -Depression -Chronic low back pain -Chronic hepatitis C: Never treated. -Probable early osteoarthritis in bilateral knees -s/p Breast reduction surgery bilaterally -s/p Bilateral carpal tunnel repair -s/p left knee surgery -s/p Liposuction ___ -s/p hysterectomy ___ Social History: ___ Family History: Daughter has h/o PE, sinus headaches. Mother: DM, HTN,CVA. Father: DM, HTN, emphysema. Brother: MI in his ___. Sister with ___. Physical Exam: ON ADMISSION: Vitals - 98.3, 132/60, 66, 18, 97%RA, ___ glucose 331 GENERAL: Pleasant, NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or ___. JVP flat LUNGS: CTAB, good air movement biaterally. No wheezing, rales, rhonchi. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Chronic changes on bilateral shins. Erythema from left foot to just the level of the knee, warm to the touch SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3 though falling asleep during exam . ON DISCHARGE: Vitals - 98.5-98.6, 122-129/50-82, 53-67, 18, 98-100%RA Glucose: 101-301 BM: (+) GENERAL: Pleasant, NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Supple, No LAD, No masses. CARDIAC: RRR. Normal S1, S2. JVP flat, No mrg LUNGS: CTAB, good air movement biaterally. No w/r/r ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Chronic changes on b/l shins. Erythema/warmth improved SKIN: No lesions, ecchymoses scattered. NEURO: A&Ox3, grossly intact Pertinent Results: LABS ON ADMISSION: ___ 03:30PM BLOOD WBC-17.3* RBC-3.60* Hgb-10.3* Hct-31.0* MCV-86 MCH-28.6 MCHC-33.2 RDW-15.3 Plt ___ ___ 03:30PM BLOOD Neuts-78* Bands-2 Lymphs-16* Monos-1* Eos-1 Baso-0 ___ Metas-1* Myelos-1* ___ 03:30PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL Tear Dr-OCCASIONAL ___ 06:15AM BLOOD ___ ___ 03:30PM BLOOD Glucose-267* UreaN-19 Creat-1.4* Na-134 K-4.9 Cl-98 HCO3-27 AnGap-14 ___ 03:30PM BLOOD cTropnT-<0.01 ___ 03:40PM BLOOD Lactate-1.2 . LABS ON DISCHARGE: ___ 09:20AM BLOOD Creat-1.0 ___ 08:10PM BLOOD Vanco-13.4 . IMAGING & STUDIES: ___ EKG: Sinus rhythm. Borderline P-R interval prolongation. Somewhat late R wave progression. Since the previous tracing of ___ the Q-T interval is longer. Rate PR QRS QT/QTc P QRS T 67 204 80 ___ 33 . ___ LEFT ___: IMPRESSION: No evidence of left lower extremity deep vein thrombosis. . ___ CXR: IMPRESSION: Although there is new diffuse mild haziness of pulmonary vascularity, suggestive of slight congestion or fluid overload, or perhaps a diffuse inflammatory process, a focal right perihilar opacity is most suggestive of pneumonia. . ___ LEFT FOOT X-RAY: IMPRESSION: Little change from ___ study. Medications on Admission: Keflex ___ mg TID (planned ___ Ciprofloxacin 500 mg BID (planned ___ aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily) atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). moexipril 7.5 mg Tablet Sig: One (1) Tablet PO once a day. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. glipizide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. Levemir Flexpen 100 unit/mL (3 mL) Insulin Pen Sig: Forty (40) units Subcutaneous at bedtime. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) injection Subcutaneous twice a day. morphine 15 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: do not drive or operate machinery while on this medication. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. clotrimazole 1 % Cream Sig: One (1) Appl Topical DAILY (Daily): to feet once a day. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). fluocinonide 0.05 % Cream Sig: One (1) Appl Topical DAILY (Daily): to hands and legs once a day. AmLactin XL Lotion Sig: One (1) application to affected areas Topical BID (2 times a day). calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO twice a day. urea 40 % Cream Sig: One (1) application to affected area colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Every other day. allopurinol ___ mg Tablet Sig: Two (2) Tablet PO DAILY nystatin 100,000 unit/mL Suspension Sig: One (1) swish and swallow PO three times a day as needed for mouth pain. Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Moexipril 7.5 mg PO DAILY 4. Torsemide 60 mg PO DAILY 5. Spironolactone 25 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. GlipiZIDE 10 mg PO BID 8. Levemir Flexpen *NF* (insulin detemir) 40 units Subcutaneous at bedtime 9. Byetta *NF* (exenatide) 10 mcg/0.04 mL Subcutaneous twice a day 10. Morphine Sulfate ___ 30 mg PO Q6H:PRN pain 11. Benzonatate 100 mg PO TID 12. Clotrimazole Cream 1 Appl TP DAILY to feet 13. Duloxetine 60 mg PO DAILY 14. Fluocinonide 0.05% Cream 1 Appl TP DAILY to hands and legs 15. AmLactin XL *NF* (ammonium,pot.& sodium lactates) 1 application Topical BID to affected areas * Patient Taking Own Meds * 16. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit Oral twice a day 17. urea *NF* 40 % Topical DAILY to affected area * Patient Taking Own Meds * 18. Colchicine 0.6 mg PO EOD Start: In am 19. Allopurinol ___ mg PO DAILY 20. Acetaminophen 1000 mg PO Q6H:PRN fever/pain Do not exceed more than 4grams in 24 hours. 21. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days until ___ (which will complete a 14-day course of antibiotics) RX *Cipro 500 mg twice a day Disp #*7 Tablet Refills:*0 22. Clindamycin 300 mg PO Q8H RX *Cleocin 300 mg three times a day Disp #*15 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: cellulitis acute kidney injury hyponatremia . SECONDARY: diabetes mellitus chronic diastolic 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: Chest pain. COMPARISONS: Recent prior study from ___. TECHNIQUE: Chest, PA and lateral. FINDINGS: The heart is at the upper limits of normal size. The aorta is mild to moderately tortuous, as before, with calcification along the arch. There is new haziness of pulmonary vascularity suggesting mild vascular congestion, although diffuse inflammation could also be considered. In addition a focal right perihilar opacification has developed, worrisome for pneumonia. Less likely, a relatively focal appearance of pulmonary edema could be considered. There is no pleural effusion or pneumothorax. IMPRESSION: Although there is new diffuse mild haziness of pulmonary vascularity, suggestive of slight congestion or fluid overload, or perhaps a diffuse inflammatory process, a focal right perihilar opacity is most suggestive of pneumonia. Radiology Report INDICATION: ___ F with LLE pain, swelling, erythema. Evaluate for DVT. TECHNIQUE: Left Lower Extremity color Doppler and spectral analysis of the venous system. FINDINGS: There is normal compression and augmentation of the common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal veins. There is normal phasicity of the common femoral veins bilaterally. IMPRESSION: No evidence of left lower extremity deep vein thrombosis. Radiology Report HISTORY: Left lower extremity cellulitis with red left toe. FINDINGS: In comparison with the study of ___, there is little overall change. The resection of the distal phalanx of the second digit is again appreciated. Large region of lucency with sclerotic rim is again seen in the lower half of the proximal phalanx of the first digit. The poorly healing fracture of the proximal second metatarsal is again seen and worrisome for neuropathy. IMPRESSION: Little change. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: LLE SWELLING Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF LEG, PNEUMONIA,ORGANISM UNSPECIFIED, LEUKOCYTOSIS, UNSPECIFIED temperature: 98.0 heartrate: 68.0 resprate: 16.0 o2sat: 98.0 sbp: 104.0 dbp: 68.0 level of pain: 8 level of acuity: 3.0
This is the brief hospital course for a ___ year-old female w/ ___, chronic diastolic heart failure, and hypertension admitted ___ for ___ cellulitis (d/c'd on oral cipro/keflex) who was readmitted this time for concern of persistent ___ cellulitis. . # ___ pain/redness: c/w resolving cellulitis, as erythematous/warmth resolved. Negative ___ and ___ foot x-ray. - Continued home Morphine for pain - Continued PO Cipro and PO Clinda for total ___ach . # Cough: URI as PNA ruled out on exam and CXR. Respiratory status improved. . # Bandemia: Resolved. No more diarrhea. -treat cellulitis as above -___ final Blood Cx: NGTD . # ARF: Cr 1.1 at baseline, now 1.0, likely was elevated on admission from dehydration from infection/fever, decreased PO intake, insensible losses, and home diuretic use. - continued home diuretics, ACEI, gout meds - CR RECHECK AT PCP ___ appointment . # ___: hyperglycemia improving w/ ___ recs, appreciate greatly. Levemir, Byetta, Metformin, and Glipizide at home. Held oral agents while admitted, but resumed on discharge with new ___ recs. - Continue Glargine 40 units at bedtime and other home oral agents . # Chronic diastolic heart failure: Stable. Gentle hydration only in house. - continued home diuretics, ACEI - TORSEMIDE dose decreased, needs VOLUME STATUS EXAM AT PCP ___ visit. . # Gout: on colchicine and allopurinol at home - continued home gout meds
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Malaise, left lower extremity swelling and pain Major Surgical or Invasive Procedure: Wound debridement History of Present Illness: ___ with CAD s/p CABG in ___, Type II diabetes controlled with metformin (last HbA1c reportedly 6.5%) who presents with headache, malaise and warmth/swelling on the dorsal surface of his left first cuneiform bone. His symptoms began during a recent trip to ___, where he walked along the beach in salt water barefoot every day. A few days into the trip, a day or two before he returned on ___, he began to experience malaise, headache and chills. He noticed that his left foot became more swollen and painful to ___ pain. He does not recall stepping on any objects, or noticing any open skin breaks. Denies any previous history of soft tissue infection or any significant bacterial infection requiring antibiotics. He feels as though the swelling in his foot is relatively stable, and has not noticed significant redness associated with the area. On ___, he saw his podiatrist, Dr. ___, in ___, who prescribed percocet for the pain and antibiotics (patient does not know the name), of which he took 3 doses. His pain improved, but the swelling persisted and he continued to feel unwell, prompting him to seek care at ___. In the ED, initial VS were Temp 97.1, HR 55, BP 150/68, RR 14, SaO2 99% (RA). Radiographs of the left foot revealed no osteomyelitis or fracture. Received IV vancomycin 1g, and Unasyn. On arrival to the floor, patient reports he has ___ left foot pain, a headache, malaise, and occasional lightheadedness with standing. He does not currently feel fevers, chills, or rigors. He has stable peripheral neuropathy in his feet bilaterally. Past Medical History: CAD s/p CABG ___ DMII c/b neuropathy on metformin HLD Crohn's B12 deficiency BPH Depression PVD Social History: ___ Family History: Mother and 3 brothers with history of CAD. No family history of DM. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: Temp 97.3, HR 62, BP 123/64, RR 16, O2sat 99%(RA), FSG 167 General: Well-appearing, NAD HEENT: EOMI, MMM, no oropharyngeal lesions. Neck: No cervical lymphadenopathy. CV: RRR, normal S1 & S2. No murmurs, rubs, or gallops. Lungs: No increased respiratory effort. CTAB. No rales, wheezes, or rhonchi. Abdomen: Soft, non-tender, non-distended with normal bowel sounds. Ext: Right foot is cool. Left foot has a boggy swelling on the dorsal aspect near the MTP joints with warmth and erythema. An ~5 mm ulcer is noted on the left first metatarsal head with surrounding erythema. It is mildly tender. No clubbing or cyanosis. No pretibial edema. Neuro: Awake and alert. Oriented to situation. Moving all extremities. Skin: Severe xerosis on the legs and feet bilaterally. DISCHARGE PHYSCIAL EXAM ======================= VS: Temp 97.3-98.4, HR 62-66, BP 123-134/64-79, RR ___, O2sat 99-100% (RA) I/O: NR General: Well-appearing, NAD HEENT: EOMI, MMM, no oropharyngeal lesions. Neck: No cervical lymphadenopathy. CV: RRR with occasional extra beat, normal S1 & S2. No murmurs, rubs, or gallops. Lungs: No increased respiratory effort. CTAB. No rales, wheezes, or rhonchi. Abdomen: Soft, non-tender, non-distended with normal bowel sounds. Ext: Left foot has a boggy swelling on the dorsal aspect near the MTP joints with warmth and erythema. A tender ~5 mm ulcer is noted on the left first metatarsal head without surrounding erythema. No clubbing or cyanosis. No pretibial edema. 2+ DP pulses bilaterally. Neuro: Awake and alert. Oriented to situation. Moving all extremities. Skin: Severe xerosis on the legs and feet bilaterally Pertinent Results: ADMISSION LABS ============== ___ 04:16PM BLOOD WBC-6.3 RBC-3.94* Hgb-11.8* Hct-37.2* MCV-94 MCH-30.0 MCHC-31.8 RDW-14.9 Plt ___ ___ 04:16PM BLOOD Neuts-68.7 ___ Monos-6.1 Eos-3.7 Baso-1.8 ___ 04:16PM BLOOD Glucose-119* UreaN-22* Creat-1.2 Na-137 K-5.7* Cl-102 HCO3-23 AnGap-18 ___ 04:27PM BLOOD Lactate-1.7 K-5.4* PERTINENT IMAGING RESULTS ========================= FOOT AP,LAT & OBL LEFT (___): FINDINGS: AP, lateral and oblique views of the left foot. There is no acute fracture. There is no focal osseous abnormality. Small posterior calcaneal spurs identified. Ossification seen adjacent to the base of the fifth metatarsal. Degenerative spurring seen in multiple tarsal bones as well, which all appears chronic. Soft tissues are unremarkable without subcutaneous gas or radiopaque foreign body. IMPRESSION: No radiographic evidence of osteomyelitis, no fracture. DISCHARGE LABS ============== ___ 07:10AM BLOOD WBC-5.9 RBC-3.72* Hgb-11.5* Hct-34.0* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.5 Plt ___ ___ 07:10AM BLOOD Glucose-136* UreaN-18 Creat-1.1 Na-142 K-5.1 Cl-106 HCO3-30 AnGap-11 MICROBIOLOGY =========== ___ 11:47 am SWAB Source: Left foot wound. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): Blood cultures x 2 and urine culture from ___ pending at time of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mesalamine ___ 400 mg PO BID 2. Atorvastatin 40 mg PO DAILY 3. Tamsulosin 0.4 mg PO HS 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. BuPROPion 200 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 10. Levofloxacin 750 mg PO Q24H Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. BuPROPion 200 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Mesalamine ___ 400 mg PO BID 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Tamsulosin 0.4 mg PO HS 8. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #*28 Capsule Refills:*0 9. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: left first metatarsal head cellulitis and abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent - non weight bearing on ball of left foot Followup Instructions: ___ Radiology Report LEFT FOOT, THREE VIEWS: ___ HISTORY: ___ with foot swelling. Question fracture or osteomyelitis. COMPARISON: None. FINDINGS: AP, lateral and oblique views of the left foot. There is no acute fracture. There is no focal osseous abnormality. Small posterior calcaneal spurs identified. Ossification seen adjacent to the base of the fifth metatarsal. Degenerative spurring seen in multiple tarsal bones as well, which all appears chronic. Soft tissues are unremarkable without subcutaneous gas or radiopaque foreign body. IMPRESSION: No radiographic evidence of osteomyelitis, no fracture. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L Foot swelling Diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS OF FOOT temperature: 97.1 heartrate: 55.0 resprate: 14.0 o2sat: 99.0 sbp: 150.0 dbp: 68.0 level of pain: 2 level of acuity: 3.0
___ year-old man with a history of DM, CAD s/p CABG, and PVD admitted with cellulitis and abscess of the left first metatarsal head. ACTIVE DIAGNOSES ================ # Cellulitis and abscess: Based on symptoms and signs of swelling, fluctuance, tenderness, warmth, and erythema, he was diagnosed with cellulitis and adjacent abscess of the left foot. There was no ulceration that probed to bone or any evidence of osteomyelitis on plain films. He has reportedly failed three days of oral antibiotic therapy as an outpatient. He was initially treated with IV vancomycin and was subsequently transitioned to clindamycin for a total course of 7 days (last dose on ___. His pain was controlled with percocet and tylenol as needed. He was evaluated by podiatry, and the abscess was drained of 2 cc of purulent fluid and debrided. He was advised to use adaptic covered by sterile dry dressing (change daily) and be non-weight bearing. A post-op shoe was provided. Microbiology from the adjacent fluid collection is so far remarkable for no cells seen on gram stain. Wound culture is pending. # Hyperkalemia: His potassium was slightly elevated at 5.7 on admission, with no clear precipitant in terms of new medications or renal failure. He was monitored clinically and his potassium level normalized to 5.1 the day after admission. No intervention was required. CHRONIC DIAGNOSES ================= # Type II DM: He has a history of type II DM on metformin at home. His metformin was held while inpatient, and he was placed on an insulin sliding scale, with fingerstick glucose monitoring. His glucose levels were well controlled without hypoglycemic episodes. He should restart his home metformin on discharge. # CAD s/p CABG: His home aspirin and metoprolol succinate were continued. He did not show any evidence of myocardial ischemia during his hospitalization. # Depression: His home Wellbutrin was continued. # BPH: His home tamsulosin was continued. TRANSITIONAL ISSUES =================== # Continue clindamycin for a 7 day course, with the last dose on ___. ___ on final wound culture. # Wound care as instructed. # Schedule an appointment with outpatient podiatrist, Dr. ___ ___, within a few days after discharge for ___. # Close PCP ___. Per patient he already has an appointment scheduled either this week or the next with Dr. ___.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: ACE Inhibitors / Ambien / fiorcet / Xanax / alendronate sodium Attending: ___. Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: ___: Right hip hemiarthroplasty History of Present Illness: Ms. ___ is a ___ female with history of dementia, otherwise healthy, who presents to the ___ ED with right hip pain after a fall in the nursing home yesterday. Her right foot got caught on the couch, and she fell onto her right side. No headstrike, no pain elsewhere. Past Medical History: PMH: Dementia Hypertension Hyperlipidemia Glaucoma Migraines Osteoporosis Allergic rhinitis Colon cancer s/p R colectomy Deep vein thrombosis ___ PSH: Right colectomy ___ Hysterectomy Left hip hemi-arthroplasty ___ Social History: ___ Family History: Noncontributory Physical Exam: On admission: Vitals: T 98.2, HR 96, BP 103/65, RR 18, O2 97% RA Gen: NAD CAM: Normal Acute onset/Fluctuating Course: No Inattention: No Disorganized Speech: No Altered level of conciousness: No MiniCog: Fail 3 object recall: ___ Clock: Abnormal Right lower extremity: Skin clean and intact No gross deformity, erythema, edema, induration or ecchymosis. Thighs and legs are soft SILT SP/DP/T/S/S Firing ___ 2+ DP pulses Pertinent Results: ___ 03:50PM WBC-8.5 RBC-4.42 HGB-12.8 HCT-38.8 MCV-88 MCH-29.0 MCHC-33.0 RDW-14.6 RDWSD-46.8* ___ 03:50PM NEUTS-71.9* LYMPHS-17.7* MONOS-7.7 EOS-1.8 BASOS-0.4 IM ___ AbsNeut-6.12* AbsLymp-1.50 AbsMono-0.65 AbsEos-0.15 AbsBaso-0.03 ___ 03:50PM PLT COUNT-194 ___ 03:50PM ___ PTT-26.2 ___ ___ 03:50PM GLUCOSE-109* UREA N-22* CREAT-1.0 SODIUM-134 POTASSIUM-7.2* CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 500 mcg PO DAILY 2. Senna 8.6 mg PO QHS 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. travoprost 0.004 % ophthalmic QHS 5. Acetaminophen 1000 mg PO Q8H 6. Milk of Magnesia 30 mL PO Q12H:PRN constipation Discharge Medications: 1. Cyanocobalamin 500 mcg PO DAILY 2. Milk of Magnesia 30 mL PO Q12H:PRN constipation 3. Senna 8.6 mg PO QHS 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Enoxaparin Sodium 40 mg SC QHS Duration: 30 Days Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous at bedtime Disp #*30 Syringe Refills:*0 6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 7. travoprost 0.004 % ophthalmic QHS 8. Bisacodyl 10 mg PR QHS:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right femoral neck fracture 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: ___ with report of right hip fx, needs pre-op x-ray // acute process? TECHNIQUE: Single portable view of the chest. COMPARISON: None. FINDINGS: Lungs are grossly clear given patient's positioning. Relative elevation of the right hemidiaphragm is noted. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ with report of right hip fx without x-rays sent, please also eval full length femur for operative planning // right hip fx? TECHNIQUE: AP view of the pelvis. AP and lateral views of the right femur. COMPARISON: None. FINDINGS: There is an acute fracture through the right femoral neck with impaction. Distally the right femur is intact. Atherosclerotic calcifications are noted. Bipolar left hip hemiarthroplasty changes are partially visualized. There is diffuse osteopenia. Pubic symphysis and SI joints are preserved. Degenerative changes noted in the lower lumbar spine. IMPRESSION: Impacted right femoral neck fracture. Radiology Report EXAMINATION: HIP 1 VIEW INDICATION: RT HIP FX, HEMI IMPRESSION: In comparison with the study ___, there has been placement of a right hip hemi arthroplasty that appears to be well seated without evidence of acute complication. Standard postsurgical changes in soft tissues. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with FX NECK OF FEMUR NOS-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING temperature: 98.2 heartrate: 96.0 resprate: 18.0 o2sat: 97.0 sbp: 103.0 dbp: 65.0 level of pain: 0 level of acuity: 3.0
The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right hip hemiarthroplasty, 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 with supplements and oral medications by POD#1. The patient was able to void on her own prior to discharge. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to nursing home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hallucinations and psychosis Major Surgical or Invasive Procedure: NON History of Present Illness: ___ is a ___ man with a past medical history notable for ___ disease who presents to the emergency department with hallucinations and psychosis; neurology is consulted for concern for toxicity related to his ___ medications. History is primarily obtained from ___ as wife is not available (via telephone or in person). Of note, pt has been followed by Dr. ___ at ___ for the past ___ years. Symptoms started with LUE tremor in ___ and pt was started on Sinemet in ___. Rasagiline was added in ___ and then ropinirole. His last neurology office visit was ___ and he has had multiple cancellations since. In ___, for his PD, office note states he was on carbidopa-levadopa ___ 9 times daily, amantadine 100 BID, ropinirole 16 daily, and Rasagiline 1mg daily. Of note, on ___ pt had an increase in his Sinemet to 10x/day per a telephone communication in the OMR. Over the past 2 weeks, pt has had new hallucinations, psychosis, and insomnia. Pt tells me he called the police after he felt a camera was attached to a tree outside his room. Per neurologist evaluation at ___: "Over the past 24 hours he has become more agitated at home. He is not sleeping. He is having frequent formed visual hallucinations. Last night and in the early hours of the morning he reported that he was seeing individuals looking in the window at him. At one point at about 3 AM his wife took him outside the home to convince him that his car was not set on fire. [...] He was not particularly alarmed by the hallucinations but did call the police several times. I believe it was one of these calls to the police that eventually prompted that he come to the emergency department." On ___, pt called Atrius (spoke with ___ regarding his hallucinations; Dr. ___ decreasing ropinirole to 12mg daily. On ___ (day of admission), pt again called At___ (spoke with Dr. ___ and reported taking Sinemet up to 20x/day. He also stated he had stopped his ropinirole entirely. He was then referred to the ED. At ___, neurology was consulted (Dr. ___. There was concern for symptoms consistent with dopamine dysregulation. Per Dr. ___ spoke with Dr. ___ "the patient is out of control in regard to using his medications. Dr. ___ he needs to be hospitalized for a controlled adjustment of his antiparkinsonian medication and to closely monitor his medical/neurological/psychiatric response to this necessary changes. Dr. ___ not feel that this can be done on an outpatient basis". Pt was then placed on a ___ and tx to ___ for further management. Of note, pt denies suicidal or homicidal ideation. ROS unable to be reliably obtained but pt denies unilateral weakness or numbness, diplopia, nausea, vomiting, chest pain or shortness of breath. Past Medical History: - ___ Disease - HTN - Sciatica Social History: ___ Family History: could not obtained Physical Exam: Physical Examination on Admission : Vitals: 98.0 86 135/84 16 95% RA General: Awake, sitting in a chair, fidgets frequently HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: Soft, NT/ND Extremities: No C/C/E bilaterally Skin: No rashes or lesions noted Neurologic: -Mental Status: Alert, oriented to person, place and time. Able to name ___ backwards briskly and follow 3-step commands. Exhibits pressured speech and is tangential with history telling. +psychomotor agitation. Poor insight into medical condition. Language is fluent with intact repetition and comprehension. No paraphasic errors. Naming intact to both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. No neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk and power throughout. Increased tone in LUE>RUE>LLE>RLE. +cogwheeling and rigidity LUE > RUE. No pronator drift bilaterally. No dyskinesia or tremor observed. No asterixis noted. -Sensory: No deficits to light touch throughout. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No dysmetria on FNF or HKS bilaterally. -Gait: +stooped shuffling gait but able to ambulate independently. Physical Examination on discharge : General: Awake, sitting in a chair, fidgets frequently HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: Soft, NT/ND Extremities: No C/C/E bilaterally Skin: No rashes or lesions noted Neurologic: -Mental Status: Alert, oriented to person, place and time. Able to name ___ backwards briskly and follow 3-step commands. Exhibits pressured speech. Language is fluent with intact repetition and comprehension. No paraphasic errors. Naming intact to both high and low frequency objects. Able to follow No neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk and power throughout. Increased tone in ___ >UE but much improved . Mild cogwheeling and rigidity Rt > L, ___ > UE. No pronator drift bilaterally. No dyskinesia or tremor observed. No asterixis noted. -Sensory: No deficits to light touch throughout. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No dysmetria on FNF or HKS bilaterally. -Gait:____ Pertinent Results: EKG from ___ Clinical indication for EKG: ___.___ - QT interval for medication monitoring Sinus tachycardia. Indeterminate axis. Probable inferior wall myocardial infarction, age indeterminate. Markedly delayed R wave progression. Cannot exclude anterior wall myocardial infarction, age indeterminate versus left anterior hemiblock. Compared to the previous tracing of ___ sinus rate is slower. Evidence for right bundle-branch block is less pronounced. Latest CXR from ___ IMPRESSION: Comparison to ___. The nasogastric tube has been advanced. The tip is no securely positioned in the middle parts of the stomach. No complications, notably no pneumothorax. Otherwise unchanged radiograph. ___ 10:30AM BLOOD WBC-8.0 RBC-4.35* Hgb-12.9* Hct-38.5* MCV-89 MCH-29.7 MCHC-33.5 RDW-12.1 RDWSD-38.9 Plt ___ ___ 12:30PM BLOOD WBC-8.3 RBC-4.14* Hgb-12.3* Hct-37.5* MCV-91 MCH-29.7 MCHC-32.8 RDW-12.1 RDWSD-39.9 Plt ___ ___ 05:30AM BLOOD WBC-10.0 RBC-4.73 Hgb-13.9 Hct-42.3 MCV-89 MCH-29.4 MCHC-32.9 RDW-12.4 RDWSD-40.3 Plt ___ ___ 05:20AM BLOOD WBC-7.0 RBC-4.49* Hgb-13.3* Hct-40.2 MCV-90 MCH-29.6 MCHC-33.1 RDW-12.5 RDWSD-41.1 Plt ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carbidopa-Levodopa (___) 1 TAB PO 10X/DAY 2. Amantadine 100 mg PO DAILY 3. rOPINIRole 2 mg PO BID 4. rOPINIRole 8 mg PO BID 5. Atenolol 25 mg PO BID 6. Zonisamide 25 mg PO BID 7. Rasagiline 1 mg PO DAILY 8. Isradipine 5 mg oral BID Discharge Medications: 1. Carbidopa-Levodopa (___) 1.5 TAB PO Q3H 2. amLODIPine 10 mg PO DAILY 3. Clozapine 25 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. ENTAcapone 200 mg PO BID 6. Heparin 5000 UNIT SC BID 7. Polyethylene Glycol 17 g PO DAILY constipation 8. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ___ disease Psychosis 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: Portable chest radiograph INDICATION: ___ year old man with question of aspiration PNA // infiltrate? TECHNIQUE: Portable AP chest COMPARISON: None FINDINGS: Minimal elevation of the left hemidiaphragm. Left greater than right bibasilar atelectasis. No additional focal opacities are identified. Heart size is top-normal. Cardiomediastinal and hilar silhouettes are normal. No pleural abnormalities. IMPRESSION: Left greater than right bibasilar atelectasis, less likely developing left lower lobe pneumonia. Recommend follow-up conventional radiographs when feasible. RECOMMENDATION(S): Left greater than right bibasilar atelectasis, less likely developing left lower lobe pneumonia. Recommend follow-up conventional radiographs when feasible. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: ___ year old man with parkinsons // NG placement TECHNIQUE: Portable AP chest COMPARISON: ___ portable chest radiograph FINDINGS: Nearly resolved bibasilar atelectasis. No new focal opacity. No pleural abnormality. Heart size is top-normal. Cardiomediastinal hilar silhouettes are normal. Interval placement of an NG tube which terminates just distal to the GE junction with a side port in the distal esophagus. IMPRESSION: An NG tube terminates just distal to the GE junction with a side-port in the distal esophagus. Recommend advancement by 5 cm. RECOMMENDATION(S): An NG tube terminates just distal to the GE junction with a side-port in the distal esophagus. Recommend advancement by 5 cm. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:46 ___, less than 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hx of Parkinsons disease // NG tube placement NG tube placement IMPRESSION: Comparison to ___. The nasogastric tube has been advanced. The tip is no securely positioned in the middle parts of the stomach. No complications, notably no pneumothorax. Otherwise unchanged radiograph. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, Hallucinations Diagnosed with Auditory hallucinations temperature: 98.0 heartrate: 86.0 resprate: 16.0 o2sat: 95.0 sbp: 135.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0
Mr. ___ is a ___ year-old-male with a past medical history of ___ transferred from an OSH for visual hallucinations, paranoia, psychosis, and insomnia in the setting of intentional excessive dosing of his ___ medications. Mr. ___ has been followed for ___ disease by Dr. ___ at ___ for ___ years, began Sinemet in ___ and has subsequently been prescribed a number of different dopaminergic medications. It is likely that he was purchasing additional dopaminergic medications other than those prescribed to him and there is a possibility that he had two prescribers for Ropinorole. He has missed multiple outpatient appointments with Dr. ___ his last visit was on ___. However, Mr. ___ had contacted his outpatient providers for changes in dosing of his medications. On ___, he called complaining of hallucinations and was advised to decrease his Ropinorole. He called again on ___ reporting taking Sinemet up to 20x daily and stopping his Ropinorole entirely. At this time the patient was referred to the ED and was placed on Section XII. #Neuro: On admission to the neurology floor, the patient was agitated and very insistent on going home. On physical examination, hypomimia, cogwheeling that increased with distraction, mild rigidity greater in the left than right, and an overconfident gait were noted. His speech was rapid, difficult to interrupt and hard to follow. From ___ of his hospitalization he endorsed various delusions including paranoia about his neighbors trying to kill him by throwing bombs into the room, various legal matters regarding his house having to be sold immediately, and the government placing thoughts into his head. The patient also had visual hallucinations, believing that there were rainstorms overnight, various other people in the room, and saying that his urine would change colors. On various occasions, the patient was also overheard self-dialoging. However, Mr. ___ began to demonstrate increased insight into his current condition stating that "I took too much of my ___ medication which has made me hallucinate" and agreed to stay after his Section XII expired for management of his medications. During his admission, his Rasagiline and Zonisamide were discontinued, and his Amantadine and Ropinorole were tapered off. His Sinemet ___ dose was adjusted to 1.5 tabs every Q3 hours and Entacapone 200mg BID was added . Seroquel 12.5mg BID was started to address his irritability, paranoid delusions, and visual hallucinations. The reasons for initiating this medication were explained to the patient, and he understood the role it played in his medical care. His TSH was noted to be normal and work-up did not suggest any possible infectious causes. As the medications were gradually discontinued, there were various incidents in which Mr. ___ became acutely agitated. The patient triggered twice during his hospital course. During the first event, Mr. ___ began yelling and became aggressive towards staff. At this point, restraints were required and Mr. ___ was given additional Ativan and Seroquel with little effect. As a result, the patient was placed on 1:1 monitoring and his Seroquel was increased to 25mg QAM + 50mg QHS + 12.5mg-25mg Q6HRS. The increased Seroquel led to increased sedation limiting intake PO medications and his usual antihypertensives and BP elevated to 180/120 and HR to 120-130. An NG tube was placed , his home isradipine was replaced by Amlodipine 10 mg daily. He had an elevated WBC count and a + UA for which he was started on empiric ABX for UTI which were d/c after a negative urine culture 2 days later. He improved significantly after treating his dehydration and restarting his PO medications but was still actively hallucination and starting to get agitated again and was till rigid. Increasing Sinemet to treat rigidity would mean worsening his agitation and psychosis so instead we started Entacapone 200 mg BID . Given persistent psychosis and agitation the decision was made to start him on Clozaril 12.5 mg QHs with a slow uptitration , psych was involved. He continued to improve everyday on Clozaril which he tolerated well. We monitored his cell count and ANC which remainedd stable. He was evaluated by T/OT who recommended an acute rehab . Dr. ___ primary neurologist has been involved in his care while he was admitted and will follow him up after discharge
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ history of depression, hypertension, and remote alcohol abuse who presents to the ED from his PCP's office for frequent falls, disorientation, and possible atrial fibrillation identified at PCP ___. He states that he has progressive symptoms of weakness, frequent falls without headstrike or LOC, slight confusion for the last 4 weeks. It has gotten worse over the last few days. He has also been complaining of nauseated, fatigued, with poor appetite. He also complains some mild shortness of breath that has been going on "for some time". He also complains of recent 10 lb weight loss over last 5 months, and occasional night sweats as well. ___ also reports recent malignant melanoma which was surgically removed. At his primary care office today he was found to be in afib so sent to the emergency department. The ___ has no history of afib but has documented atrial tachycardia and "arrhythmia" in his records. In the ED, initial vitals: 97.4 98 124/65 18 99% RA - Exam notable for: guaiac negative stool - Labs notable for: Plt 61 (newly low), H/H 10.8/31.2, WBC 7.2 (57.6N, 25.3L, ___, no blasts, no atypicals), INR 1.3, fibrinogen 643, trop negative x1, creatinine 1.6 (up from 1.2 in ___, AST 43, ALT 39, LDH 497, LFT's otherwise wnl, sodium 130, heme/onc smear ordered and pending. - Imaging notable for: CT head with no acute intracranial abnormality. CXR No acute intrathoracic abnormality. - ___ given: 1L NS - Vitals prior to transfer: 97 118/44 20 97% RA On arrival to the floor, pt reports persistently feeling slightly confused and weak. He is otherwise comfortable lying in bed and is not complaining of any chest pain, shortness of breath, other pain. Past Medical History: -depression-pt followed by Dr ___- prescribed effexor for depression -colonoscopy- ___ adenoma- ___- int hemorrhoids- f/up in ___ no polyps - ___ - ruptured 2 lumbar discs while lifting. he had surgical excision of discs and his pain has improved. -h/o hyperlipidemia- has had significant rxn to statins- visual hallucinations- no response to zetia and niacin, so on high dose omega 3 fatty acids. Has been seen at ___ center- ___- most recent ___ - mild gout- has rare great toe pain- takes colchicine <1/day Social History: ___ Family History: FATHER DIED AGE ___ AFTER HAVING SEVERAL MI'S- ___ at age ___ MOST MEN ON FATHER'S SIDE DIED OF MI'S MOTHER- ___ d- 2 brothers- 1 died, living brother- ___ Physical Exam: ADMISSION EXAM: General: NAD, oriented X 3 though slow to answer questions/recall Noted pallor Eyes: PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus. Neck: No cervical or clavicular LAD Lungs: CTAB no w/r/r Heart: Regular rhythm mostly with skipped beats. Abdomen: s/nt, slightly distended normal bowel sounds; no hepatosplenomegaly no ventral, umbilical hernias or masses noted. Neurologic: no focal deficits, cranial nerves II-XII grossly intact (rhomberg noted to be positive at ___ ___ DISCHARGE EXAM: Vitals: 97.5 117 / 70 81 20 95 RA General: NAD, oriented X 3. Some psychomotor slowing Neck: No cervical or clavicular LAD Lungs: CTAB Heart: Regular rhythm mostly with skipped beats. No m/r/g Abdomen: soft, nontender, moderate distention. No rebound tenderness or guarding. Extremities: No stigmata of liver disease Neurologic: no focal deficits, CN II-XII intact Pertinent Results: ====================== ADMISSION LABS ====================== ___ 05:45PM BLOOD WBC-7.4 RBC-3.44*# Hgb-10.8*# Hct-31.2*# MCV-91 MCH-31.4 MCHC-34.6 RDW-14.5 RDWSD-47.7* Plt Ct-61*# ___ 05:45PM BLOOD Neuts-57.6 ___ Monos-15.2* Eos-0.4* Baso-0.4 Im ___ AbsNeut-4.29 AbsLymp-1.88 AbsMono-1.13* AbsEos-0.03* AbsBaso-0.03 ___ 05:45PM BLOOD Plt Ct-61*# ___ 11:48PM BLOOD ___ PTT-27.3 ___ ___ 11:48PM BLOOD Plt Ct-53* ___ 05:45PM BLOOD ALT-39 AST-43* LD(LDH)-497* AlkPhos-59 TotBili-1.0 ___ 05:45PM BLOOD proBNP-75 ___ 11:48PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:45PM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.5 Mg-2.3 Iron-44* ___ 07:06AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.1 UricAcd-6.6 ___ 05:45PM BLOOD TSH-1.6 ___ 05:45PM BLOOD calTIBC-268 Hapto-<10* Ferritn-1287* TRF-206 ====================== DISCHARGE LABS ====================== ___ 07:32AM BLOOD WBC-5.1 RBC-2.75* Hgb-8.6* Hct-25.6* MCV-93 MCH-31.3 MCHC-33.6 RDW-15.2 RDWSD-51.7* Plt Ct-49* ___ 07:32AM BLOOD Glucose-156* UreaN-23* Creat-1.0 Na-139 K-4.6 Cl-104 HCO3-26 AnGap-14 ___ 07:32AM BLOOD Glucose-156* UreaN-23* Creat-1.0 Na-139 K-4.6 Cl-104 HCO3-26 AnGap-14 ====================== KEY INTERIM LABS ====================== ___ 07:32AM BLOOD ___ PTT-29.0 ___ ___ 07:32AM BLOOD Plt Ct-49* ___ 05:45PM BLOOD Glucose-156* UreaN-34* Creat-1.6* Na-130* K-4.6 Cl-95* HCO3-22 AnGap-18 ___ 07:06AM BLOOD Glucose-168* UreaN-31* Creat-1.1 Na-134 K-4.2 Cl-96 HCO3-24 AnGap-18 ___ 11:00AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* ___ 07:06AM BLOOD PSA-1.8 ___ 11:00AM BLOOD HIV Ab-Negative ___ 06:10PM BLOOD Lactate-1.4 ___ 04:21PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG ___ 04:21PM URINE RBC-97* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 ====================== MICROBIOLOGY ====================== ___ Blood PARASITE SMEAR POSITIVE FOR BABESIOSIS 1.9% parasitemia ___ BLOOD CULTURE: No growth to date ___ BLOOD CULTURE: No growth to date ___ URINE CULTURE: No growth. ___ Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING ___ URINE URINE CULTURE: No growth. ___ BLOOD CULTURE: No growth to date. ___ BLOOD CULTURE: No growth to date. ====================== IMAGING ====================== RUQ Ultrasound ___: Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. Given the presence of splenomegaly, the possibility of more advanced fibrosis/cirrhosis should be considered. Radiology Report INDICATION: ___ with frequent falls // eval for pna cxr TECHNIQUE: Chest PA and lateral COMPARISON: None available FINDINGS: PA and lateral chest radiograph demonstrate clear lungs bilaterally. Cardiomediastinal contours are within normal limits. Pulmonary vasculature is unremarkable. There is no pneumothorax or pleural effusion. No evidence of pulmonary edema. There is no air under the right hemidiaphragm. IMPRESSION: No acute intrathoracic abnormality. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with frequent falls // eval for ich TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 903 mGy-cm. COMPARISON: None. FINDINGS: There is no acute hemorrhage, edema, or mass effect. Prominent ventricles and sulci likely reflect age related volume loss, mild moderate. Minimal periventricular and subcortical white matter hypodensities are nonspecific, likely reflective of small vessel ischemic changes. Basal cisterns are patent. There is no shift of normally midline structures. Gray-white matter differentiation is preserved. Imaged paranasal sinuses demonstrates a small mucous retention cysts in the right maxillary sinus. Bilateral mastoid air cells and middle ear cavities are clear. Vertebral artery and carotid siphon vascular calcifications are mild. Orbits bilaterally are unremarkable. IMPRESSION: No acute intracranial abnormality. Mild small vessel disease. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with h/o EtOH abuse, slightly elevated AST/ALT, new thrombocytopenia, anemia, and elevated INR, concern for possible new liver disease // evidence of cirrhosis 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 5 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, enlarged measuring 16.5 cm. KIDNEYS: The right kidney measures 11.0 cm. The left kidney measures 11.5 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. RETROPERITONEUM: The visualized portions of aorta shows some atherosclerosis. Visualized portions of the IVC are within normal limits. IMPRESSION: Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. Given the presence of splenomegaly, the possibility of more advanced fibrosis/cirrhosis should be considered. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: s/p Fall, Fatigue, Confusion Diagnosed with Weakness temperature: 97.4 heartrate: 98.0 resprate: 18.0 o2sat: 99.0 sbp: 124.0 dbp: 65.0 level of pain: 0 level of acuity: 2.0
SUMMARY: ___ M h/o depression and hypertension who presents with weakness, fevers, found to have hemolytic anemia and thrombocytopenia. An extensive initial workup was performed; a parasite smear returned positive for babesiosis. He was discharged on a 14-day course of doxycycline, azithromycin, and atovaquone with plan to follow up with PCP and infectious disease.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / ceftriaxone / omeprazole Attending: ___. Chief Complaint: Chest pain, abdominal pain, nausea/vomiting Major Surgical or Invasive Procedure: Transesophageal Echocardiogram Toenail removal History of Present Illness: Mr. ___ is a ___ year old ___ player with past medical history of CAD s/p 2v CABG (___), cardiac arrest (___) c/b ESRD on HD (MWF), T2DM, HTN, HLD; presenting with chest pain, nausea, and vomiting. Starting ___ night (___), patient developed constant substernal nonradiating, nonpleuritic, non-exertional chest heaviness with associated nausea and dry heaving. This pain has persisted since then. It has not gotten better or worse. It was bad enough that the patient missed dialysis yesterday, but was able to to complete it today. He has had associated anorexia, occasional episodes of diarrhea which was nonbloody/nonmelanotic. There is moderate abdominal pain which is nonradiating, cramping, and difficult to localize. Is still making urine at his baseline. He does have a dry cough, no sore throat, no HA, no visual change, no arthralgias, no rash. In the ED, initial vitals: 98.3| 90| 164/77| 17 | 96% RA Interval vitals: 100.1 |93 | 172/64| 16 | 95% 3L NC - Exam notable for: Obese Benign cardiac exam Quiet end-exp wheeze RLE pitting edema and ttp over the calf - Labs notable for: ___ 06:05PM BLOOD WBC: 6.1 RBC: 3.12* Hgb: 9.1* Hct: 29.8* MCV: 96 MCH: 29.2 MCHC: 30.5* RDW: 17.8* RDWSD: 62.1* Plt Ct: 191 ___ 06:05PM BLOOD Neuts: 77.3* Lymphs: 8.5* Monos: 10.6 Eos: 2.0 Baso: 0.5 Im ___: 1.1* AbsNeut: 4.74 AbsLymp: 0.52* AbsMono: 0.65 AbsEos: 0.12 AbsBaso: 0.03 ___ 06:05PM BLOOD ___: 13.3* PTT: 33.9 ___: 1.2* ___ 06:05PM BLOOD Glucose: 92 UreaN: 24* Creat: 4.3* Na: 138 K: 3.7 Cl: 94* HCO3: 30 AnGap: 14 ___ 06:05PM BLOOD ALT: 11 AST: 17 AlkPhos: 142* TotBili: 0.4 ___ 11:45PM BLOOD CK(CPK): 147 ___ 06:05PM BLOOD cTropnT: 0.07* ___ 11:45PM BLOOD CK-MB: 1 cTropnT: 0.04* ___ 06:05PM BLOOD ___: ___* ___ 06:08PM BLOOD Lactate: 1.2 ___ 06:05PM BLOOD Albumin: 3.8 Calcium: 8.9 Phos: 3.8 Mg: 1.8 - Imaging notable for: CT ABD/PELVIS W/ CON: No acute abdominopelvic findings to explain patient's symptoms. ___ VEIN RIGHT: Calf veins not visualized. Within this limitation, no evidence of deep venous thrombosis in the right lower extremity veins. CXR: 1. Small residual left pleural effusion, improved compared to ___. 2. No focal consolidation. - Pt given: ___ 17:47 PO Aspirin 243 mg ___ ___ 19:33 IV LORazepam .5 mg ___ ___ 19:33 PO/NG Torsemide 20 mg ___ ___ 23:47 IV Morphine Sulfate 4 mg ___ ___ 02:25 IV Furosemide 80 mg - Vitals prior to transfer: 99.0 |82| 144/65| 24| 97% RA Upon arrival to the floor, the patient reports history as above. He is acutely bleeding from trauma to left hallux with onycholysis of that nail which is saturating dressing nurse applied. Unclear how this wound occurred, perhaps during transfer to bed. He has no sensation in lower extremities and was not aware of the injury. On discussion of presenting symptoms, he reports he has had two days of chest pressure with associated nausea, SOB, orthopnea. He has had some pain with "catching his breath." No fevers or chills. REVIEW OF SYSTEMS: A 10-point ROS was taken and is negative except otherwise stated in the HPI. Past Medical History: - Coronary Artery Disease s/p revascularization ___ - Diabetes mellitus type II c/b gastroparesis, retinopathy, neuropathy, and nephropathy - ESRD on HD with RUE AV fistula. (___) - Charcot feet - CHF - Hypertension - Hyperlipidemia - Peripheral neuropathy - ETOH abuse- last drink ___ - Obesity - Diverticulitis - Osteomyelitis left foot - GERD Past Surgical History: - LEFT GREAT TOE PARTIAL AMPUTATION - COLONIC RESECTION ___ for diverticulitis per patient - Cataracts and prior laser surgery both eyes Past Cardiac Procedures: s/p CORONARY ARTERY BYPASS GRAFT x 2 USING LEFT INTERNAL MAMMARY ARTERY AND RIGHT LEG SAPHENOUS VEIN ___. Social History: ___ Family History: Uncle: died of an MI at age ___. Father: ___ abuse, ?cirrhosis Brother: ___ at age ___ Alcohol abuse, ?cirrhosis Brother: ___ at age ___ Heroin overdose Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: ___ 0403 Temp: 98.2 PO BP: 136/71 R Lying HR: 92 RR: 16 O2 sat: 95% O2 delivery: Ra FSBG: 122 General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, difficult to appreciate JVP due to habitus, no LAD CV: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs, gallops. Lungs: Diminished breath sounds. No rhonchi, rales. Abdomen: Normoactive bowel sounds. Soft, non-tender, non-distended, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, there is mild erythema and 2+ edema of RLE, 1+ edema of LLE. L hallux with onycholysis and sanguinous exudate. Skin: Skin type II. RLE with mild pink erythema, edema as above. L hallux with traumatic onycholysis, sanguinous exudate. Neuro: CNII-XII intact, ___ strength upper/lower extremities, diminished sensation to light touch in b/l ___, 2+ reflexes bilaterally. DISCHARGE PHYSICAL EXAM: ======================= PHYSICAL EXAM: VS: Temp: 97.5 PO BP: 153/76 L Sitting HR: 62 RR: 17 O2 sat: 99% O2 delivery: Ra FSBG: 236 General: Alert, oriented, no acute distress , appears tired CV: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs, gallops. Lungs: Diminished breath sounds bilateral bases, no crackles/wheezing/rhonchi. Abdomen: Normoactive bowel sounds. Soft, non-tender, non-distended. Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CN2-12 intact, no focal neuro deficits Pertinent Results: ADMISSION LABS: ====================== ___ 06:05PM BLOOD WBC-6.1 RBC-3.12* Hgb-9.1* Hct-29.8* MCV-96 MCH-29.2 MCHC-30.5* RDW-17.8* RDWSD-62.1* Plt ___ ___ 06:05PM BLOOD Neuts-77.3* Lymphs-8.5* Monos-10.6 Eos-2.0 Baso-0.5 Im ___ AbsNeut-4.74 AbsLymp-0.52* AbsMono-0.65 AbsEos-0.12 AbsBaso-0.03 ___ 06:05PM BLOOD ___ PTT-33.9 ___ ___ 06:05PM BLOOD Plt ___ ___ 06:05PM BLOOD Glucose-92 UreaN-24* Creat-4.3* Na-138 K-3.7 Cl-94* HCO3-30 AnGap-14 ___ 06:05PM BLOOD ALT-11 AST-17 AlkPhos-142* TotBili-0.4 ___ 06:05PM BLOOD Lipase-23 ___ 06:05PM BLOOD ___ ___ 06:05PM BLOOD cTropnT-0.07* ___ 11:45PM BLOOD CK-MB-1 cTropnT-0.04* ___ 06:05PM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.8 Mg-1.8 ___ 12:26PM BLOOD CRP-34.9* ___ 06:08PM BLOOD Lactate-1.2 MICROBIOLOGY: ============= ___ Blood Culture: Blood Culture, Routine (Final ___: NO GROWTH. ___ Urine Culture: URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ Blood Culture: No growth (x4) ___ Blood Culture: No growth (x1) KEY IMAGING/PROCEDURES: ====================== ___ Right Lower Extremity Venous Ultrasound: Calf veins not visualized. Within this limitation, no evidence of deep venous thrombosis in the right lower extremity veins. ___ CXR: 1. Small residual left pleural effusion, improved compared to ___. 2. No focal consolidation. ___ CT Abdomen and Pelvis with Contrast: FINDINGS: LOWER CHEST: Small left pleural effusion has improved since ___, mild thickening of the pleura raises the concern for loculation. Associated left basilar atelectasis is noted. Punctate granuloma in the left lower lobe. Coronary and aortic and mitral valve calcifications. 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. Punctate calcifications in the pancreas likely reflect chronic pancreatitis. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout. Large multilobulated hypodense lesion with rim calcifications measuring 7.2 x 5.6 cm is unchanged since ___. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Bilateral atrophic kidneys without cystic lesions in keeping with history of end-stage renal disease. No renal calculi are noted. 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. Patient is status post partial sigmoidectomy, with unremarkable appearance of the remaining colon and rectum. 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: No abdominopelvic lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease in the peripheral vasculature. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Small fat containing infraumbilical and umbilical hernias are stable. IMPRESSION: No acute abdominopelvic findings to explain patient's symptoms. ___ Left Foot AP, Lateral, Oblique: In comparison with the study of ___, a extensive chronic changes of neuropathy are again seen along with prior resection of the head of the fifth metatarsal. Specifically, there again are see significant degenerative changes at the first MTP joint. However, no evidence of acute fracture or dislocation of the first digit. ___ TTE: CONCLUSION: The left atrial volume index is mildly increased. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy with a normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior wall (see schematic). Overall left ventricular systolic function is low normal. Quantitative biplane left ventricular ejection fraction is 53 %. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. There is a normal descending aorta diameter. The aortic valve leaflets (3) are mildly thickened. There is a highly reflective, LARGE, highly mobile 1.1 x 0.6 cm echodensity seen on the LVOT side of the aortic valve, attached to the intervalvular fibrosa, most c/w a vegetation in the appropriate clinical context. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. There is moderate mitral annular calcification. There is minimal functional mitral stenosis from the prominent mitral annular calcification. There is trivial mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are not well seen. No mass/ vegetations seen, but cannot fully exclude due to suboptimal image quality. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a trivial pericardial effusion. IMPRESSION: Large mobile mass in the left ventricular outflow tract c/w a vegetation in the appropriate clinical context. Moderate symmetric left ventricular hypertrophy with normal cavity size and mild regional systolic dysfunction. Trivial mitral stenosis due to mitral annular calcification. Compared with the prior TTE ___ , a vegetation is now identified. ___ TEE: CONCLUSION: There is no spontaneous echo contrast or thrombus in the body of the left atrium/left atrial appendage. The left atrial appendage ejection velocity is normal. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. The right atrial appendage ejection velocity is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. . A large (1.6cmx0.5cm), elongated mobile left ventricular MASS is seen attached to the base of the mitral valve with motion into the LVOT during systole. This may represent organized thrombus. A vegetation is less likely given the location and appearance. A papillary fibroelastoma is unlikely given that this mass was not present on prior TEE from ___. Overall left ventricular systolic function is normal. The right ventricle has normal free wall motion. There are no aortic arch atheroma with no atheroma in the descending aorta to 35 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is mild [1+] mitral regurgitation. The tricuspid EMR ___-P-IP-OP (___) Name: ___ MRN: ___ Study Date: ___ 15:34:00 p. ___ 195/55 mmHg valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is physiologic tricuspid regurgitation. IMPRESSION: Large mobile mass attached to the mitral annulus and extending into the LVOT, which likely represents an organized thrombus given it was not present on the prior TEE of ___ or the prior TTE of ___. Otherwise no discrete vegetation or abscess. Mild mitral regurgitation. Compared with the prior TEE ___, the mass described above is new. ___ TTE: CONCLUSION: The right atrium is moderately enlarged. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 63 %. There is no resting left ventricular outflow tract gradient. Mildly dilated right ventricular cavity with normal free wall motion. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. A LARGE (1.2 cm, mobile) echodensity is seen on the left ventricular side of the anteiror mitral leaflet along the aorto-mitral continuity. There is moderate mitral annular calcification. There is trivial mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mobile, echobright mass attached to base of the anterior mitral leaflet extending into the LVOT. STRESS CONCLUSION: Poor functional exercise capacity for age and gender. Indication: This ___ year-old male with no major coronary artery disease risk factors was referred for a stress test for evaluation of Type of stress/symptoms: The patient exercised on a protocol for ( METS) representing a poor exercise capacity for age and gender. Compared with the prior TTE (images reviewed) of ___ , the appearance and size of the mass is not changed. DISCHARGE LABS: =============== ___ 07:51AM BLOOD WBC-10.8* RBC-3.07* Hgb-9.2* Hct-30.8* MCV-100* MCH-30.0 MCHC-29.9* RDW-20.9* RDWSD-70.4* Plt ___ ___ 07:44AM BLOOD ___ PTT-74.1* ___ ___ 07:51AM BLOOD Glucose-151* UreaN-33* Creat-5.4*# Na-137 K-5.4 Cl-94* HCO3-24 AnGap-19* ___ 07:51AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.1 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin EC 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. CARVedilol 12.5 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 6. Gabapentin 300 mg PO BID 7. Nephrocaps 1 CAP PO DAILY 8. Pravastatin 80 mg PO QPM 9. Ranitidine 150 mg PO BID 10. Sertraline 50 mg PO DAILY 11. sevelamer CARBONATE 800 mg PO TID W/MEALS 12. Torsemide 20 mg PO 4X/WEEK (___) 13. LORazepam 0.5 mg PO DAILY:PRN anxiety 14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 15. Glargine 44 Units Breakfast 16. amLODIPine 5 mg PO DAILY 17. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Gabapentin 300 mg PO DAILY 4. Glargine 40 Units Breakfast 5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 6. Aspirin EC 81 mg PO DAILY 7. Calcitriol 0.25 mcg PO DAILY 8. CARVedilol 12.5 mg PO BID 9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 10. LORazepam 0.5 mg PO DAILY:PRN anxiety 11. Nephrocaps 1 CAP PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 13. Pravastatin 80 mg PO QPM 14. Ranitidine 150 mg PO BID 15. Sertraline 50 mg PO DAILY 16. sevelamer CARBONATE 800 mg PO TID W/MEALS 17. Torsemide 20 mg PO 4X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== LVOT mass Acute on chronic congestive heart failure exacerbation NSTEMI SECONDARY DIAGNOSIS =========================== Atraumatic onycholysis ESRD on HD Anemia of Chronic Disease Type 2 Diabetes Mellitus c/b nephropathy, neuropathy 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 LEFT INDICATION: ___ year old man with DM with neuropathy with trauma to L hallux.// Evaluate for evidence of fracture IMPRESSION: In comparison with the study of ___, a extensive chronic changes of neuropathy are again seen along with prior resection of the head of the fifth metatarsal. Specifically, there again are see significant degenerative changes at the first MTP joint. However, no evidence of acute fracture or dislocation of the first digit. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Chest pain Diagnosed with Chest pain, unspecified, Unspecified abdominal pain temperature: 98.3 heartrate: 90.0 resprate: 17.0 o2sat: 96.0 sbp: 164.0 dbp: 77.0 level of pain: uncomfortable level of acuity: 2.0
=========================== TRANSITIONAL ISSUES =========================== [] It is not completely clear whether LVOT mass is thrombus, tumor, or calcification. Started on Apixiban 2.5 BID for AC in case of thrombus. [] will need repeat TEE in ___ weeks to re-evaluate LVOT pedunculated thrombous vs mass (to be arranged by outpatient cardiologist Dr. ___ and then re-consideration for cardiac surgery based on the results. [] Noted to desat to high ___ several times o/n while on tele --> may benefit from outpatient sleep study to eval for OSA. [] Patient hypertensive, increased Amlodipine to 10mg po daily. Uptitrate BP meds as needed. [] Patient on Pravastatin, which is more renal cleared than other statins. Consider transitioning to Atorvastatin. =========================== BRIEF SUMMARY =========================== Mr. ___ is a ___ year old ___ player with past medical history of CAD s/p 2v CABG (___), cardiac arrest (___) c/b ESRD on HD (MWF), T2DM, HTN, HLD; presenting with chest pain, nausea, and vomiting. He was found to have an intra-cardiac mass on ECHO, which was treated as a presumed thrombus as a cardiac MRI (which would be the definitive test) could not be obtained given his ESRD. He was evaluated by cardiac surgery for consideration of surgical excision, but the risks of a re-do sternotomy were felt to be even greater than his risk of embolization, and as such he was turned down for the operation. We discharged him to home without service on low dose apixaban (okayed by the renal team after patient preferred to avoid the monitoring issues with warfarin) and plan to repeat a TEE in ___ weeks to see how the mass progresses and re-involve cardiac surgery based on the results. =========================== PROBLEM-BASED SUMMARY =========================== #LVOT Mass Found to have vegetative, calcified, mobile mass concerning for aortic valve endocarditis, though did not display infectious signs of symptoms. Low grade temp on initial arrival. No hx IVDU, recent dental work, skin breakdown (though recent L hallux trauma in ED), no history of structural heart disease. Did not satisfy Duke's criteria, so antibiotics not started and blood cultures with no growth. TEE demonstrating mass that seems more consistent with thrombus than vegetation. Less likely papillary fibroelastoma given that wasot present on echo last year prior to CABG. Patient started on heparin get bridge to ___. Evaluated by cardiac surgery who recommended ongoing medical management. Repeat TTE ___ with stable size of LVOT mass. It was ultimately decided that patient would not undergo cardiac MRI due to concern over gadolinium toxicity, even with aggressive HD (since not emergent reason). At this point patient was re-evaluated by cardiac surgery who again explained the extremely high risk of repeat operation. The decision was made to repeat TTE in ___ weeks and to follow with Dr. ___ outpatient at ___ for further management. # NSTEMI, resolved Patient presents with two days of chest pressure and nausea with RLE edema. Cardiac biomarkers elevated with Troponin 0.07-->0.04 with BNP 20737, likely Type 2 NSTEMI. Presentation most concerning for heart failure exacerbation, given orthopnea though patient seems to be at stable weight since last discharge. Chest pain has been stable and appears atypical in nature. #Acute on Chronic HFpEF Exacerbation TTE stable from prior aside from new vegetation. BNP elevated. Volume status difficult to appreciate. Patient initially diursed with IV Lasix before transitioned to home Torsemide. RA pressure ___ on TTE with collapsible IVC indicating not significantly volume overloaded # Multifactorial anemia HgB 7.6 from 8.7, 7.5. Iron studies ___ consistent with mixed AOCD/iron deficiency anemia. Stopped home iron supplementation given minimal benefit for anemia of chronic disease. #Gastroparesis #Nausea/vomiting CT abodmen/pelvis negative. Unclear etiology, may be secondary to chest pain vs gastroparesis vs. gastroenteritis. Treated initially with Zofran before transitioned to Reglan given clearer benefit in patient with gastroparesis. #L hallux traumatic onycholysis Patient does not remember stubbing toe but on arrival to floor with bleeding from L hallux with onycholysis. Podiatry consulted and removed toe nail. LLE XR without fracture or dislocation. Dressings were changed per podiatry recommendations. #Coronary Artery Disease s/p revascularization ___ Continue home carvedilol, ASA, statin, amlodipine #Diabetes mellitus type II c/b gastroparesis, retinopathy, neuropathy, and nephropathy. Follows with ___. Discharged on ##. #ESRD on HD with RUE AV fistula (___) Listed for renal transplant. Continued MWF dialysis. Home Sevelamer, Nephrocaps. #Hypertension Home Carvedilol. Given hypertension, increased Amlodipine to 10mg po daily. #Hyperlipidemia Home Pravastatin. #Peripheral neuropathy Home gabapentin #GERD Home ranitidine
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tramadol Hcl / Lisinopril / Salmon Attending: ___. Chief Complaint: SOB, smoke inhalation Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ with history of Type 2 Diabetes, CKD, HTN/HLD, asthma, afib on coumadin, provoked PE (leg fracture), pulmonary HTN, and anemia who presents with SOB after a recent fire in a neighboring apartment caused her to inhale smoke. Patient states that at ~9PM ___ she received help leaving her building after the fire alarm went off. While there was no smoke or fire in her apartment, she did see smoke in the hallway and could taste 'soot' in her mouth. Patient says that several other residents from her building were also taken to the hospital. Patient endorses ongoing dry cough, SOB, and some tightness in the chest. She also appears to be quite shaken by the experience, clearly anxious. Patient denies any swelling in her mouth/throat, chest pain, palpitations, or burns on her skin. No fevers chills. Of note, patient was recently admitted to ___ in ___ for dyspnea/cough/hypoxemia. In the ED, initial vital signs were: 96.8, 78, 139/61, 20, 98% RA - Exam notable for: clear lungs - Labs were notable for VBG (7.42, 42, 46, 31), Cr 1.2, Hb 8.5, INR 1.8 - Patient had a CXR, which was normal - Patient was given albuterol/ipratropium nebs and prednisone 60mg - Vitals on transfer: 98.2, 159/69, 81, 24, 100 RA Upon arrival to the floor, the patient spoke to the team with an in person translator. She recounted the story as above. She continues to endorse a dry cough and some tightness in her chest. SOB seems minimal. She is visibly distraught over the exposure to smoke and evacuation of her apartment. Her caretaker later arrived and states that while he provides her with her medications daily, he is not sure of the names/doses. He plans to bring in a list from home ASAP. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PMHx: #Atrial fibrillation/flutter on warfarin #History of provoked pulmonary embolism (after leg fracture) in ___ -- s/p 6mths of warfarin #Partial anomalous pulmonary venous return with right sided dysfunction #Sinus arrhythmia and bradycardia with multiple PACs and occ PVCs, asymptomatic, declined pacer #Pulmonary HTN -- ___ TTE w/PASP 44mmHg, w/RA mod dilated, hypertrophied RV w/depressed free wall contractility and abnormal septal motion/position consistent with RV pressure/volume overload, with mod TR #RBBB #Hypertension #Hyperlipidemia #Likely dementia -- wasn't on PMHx #Chronic kidney injury (stage 3) - baseline Cr 1.1 #Noninsulin dependent diabetes mellitus type 2 #MSSA bacteremia in ___ #History of H. Pylori infection ___ s/p tx #Purported h/o C. difficile infection (no positive PCR in WebOMR) #History of pneumonia #Depression, h/o admission ___ -- Followed by Dr. ___ at ___ #Memory loss #History of angioedema after fish #History of labyrinthitis #H/o L tibial fracture ___ -- pedestrian MVA. S/P ORIF at ___ #Multinodular goiter #Osteoporosis #H/o shoulder pain PSHx: As above Social History: ___ Family History: Denies family history of cardiac or respiratory disease. Physical Exam: ADMISSION PHYSICAL ================= Vitals- 98.5, 143/71, 84, 22, 98RA GENERAL: Pleasant elderly female, anxious, taking deep breaths HEENT: Sclerae anicteric, no conjunctival pallor. No erythema/swelling in oropharynx. Black residue over tongue. MMM. NECK: No JVD, no thyromegaly. CARDIAC: s1 s2, regular rate, irregular rhythm, ___ systolic murmur LUNGS: Patient taking onerous breaths using accessory muscles. No stridor. Lungs clear to auscultation b/l, no inspiratory crackles or wheezes. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: NABS, soft, NTND, no HSM. EXTREMITIES: WWP. No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions. NEUROLOGIC: AOx3, grossly non focal. DISCHARGE PHYSICAL ================= Vitals- 98.5, 126-159/48-71, ___ (110s while ambulating), ___, 97-100 RA (90 while ambulating) GENERAL: Pleasant elderly female, anxious, taking deep breaths HEENT: Sclerae anicteric, no conjunctival pallor. No erythema/swelling in oropharynx. Black papules on tongue. MMM. NECK: No JVD, no thyromegaly. CARDIAC: s1 s2, regular rate, irregular rhythm, ___ systolic murmur LUNGS: Patient intermittently taking onerous breaths using accessory muscles. No stridor. CTABL. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: NABS, soft, NTND, no HSM. EXTREMITIES: WWP. No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions. NEUROLOGIC: AOx3, grossly non focal. Pertinent Results: ADMISSION LABS ============= ___ 03:30AM BLOOD WBC-8.8 RBC-3.46* Hgb-8.5* Hct-28.9* MCV-84 MCH-24.6* MCHC-29.4* RDW-18.1* RDWSD-54.5* Plt ___ ___ 03:30AM BLOOD Neuts-54.6 ___ Monos-8.5 Eos-1.0 Baso-0.3 Im ___ AbsNeut-4.79 AbsLymp-3.08 AbsMono-0.75 AbsEos-0.09 AbsBaso-0.03 ___ 03:30AM BLOOD ___ PTT-36.1 ___ ___ 03:30AM BLOOD Plt ___ ___ 03:30AM BLOOD Glucose-130* UreaN-24* Creat-1.2* Na-138 K-4.4 Cl-99 HCO3-24 AnGap-19 ___ 04:15AM BLOOD ___ pO2-46* pCO2-46* pH-7.42 calTCO2-31* Base XS-4 Intubat-NOT INTUBA ___ 04:15AM BLOOD O2 Sat-76 COHgb-1 DISCHARGE LABS ============== ___ 07:20AM BLOOD WBC-7.7 RBC-3.95 Hgb-9.7* Hct-33.2* MCV-84 MCH-24.6* MCHC-29.2* RDW-18.0* RDWSD-55.2* Plt ___ ___ 07:20AM BLOOD Plt ___ ___ 07:20AM BLOOD ___ ___ 07:20AM BLOOD Glucose-170* UreaN-28* Creat-1.3* Na-140 K-4.7 Cl-98 HCO3-26 AnGap-21* ___ 07:20AM BLOOD Calcium-9.7 Phos-5.0* Mg-1.9 STUDIES/IMAGING ============== ECG ___ Sinus rhythm with premature atrial complexes. A-V conduction delay. Right bundle-branch block. Non-specific ST segment changes in inferolateral leads. Compared to the previous tracing of ___, the Q-T interval is shorter. CXR ___ FINDINGS: The lungs are clear without focal consolidation on the frontal view. However, there is increased retrocardiac opacity on the lateral view, likely related to expiratory phase and atelectasis. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are enlarged, unchanged. IMPRESSION: 1. No acute cardiopulmonary abnormalities. 2. Stable moderate to severe cardiomegaly. CXR ___ IMPRESSION: Compared to chest radiographs since ___ most recently ___. Severe cardiomegaly has worsened. Lungs are clear. No pulmonary edema or pleural abnormality. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO PRN anxiety 2. Fluticasone Propionate 110mcg 1 PUFF IH BID 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. linagliptin 5 mg oral DAILY 5. Omeprazole 20 mg PO BID 6. PARoxetine 40 mg PO QHS 7. Simvastatin 10 mg PO QPM 8. Valsartan 80 mg PO DAILY 9. Warfarin 4 mg PO 5X/WEEK (___) 10. Warfarin 2 mg PO 2X/WEEK (___) 11. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN wheezing, shortness of breath, cough 12. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 13. MetFORMIN (Glucophage) 850 mg PO BID 14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 15. Acetaminophen 500 mg PO BID:PRN Pain - Mild 16. Docusate Sodium 100 mg PO BID 17. Montelukast 10 mg PO DAILY:PRN allergies Discharge Medications: 1. Acetaminophen 500 mg PO BID:PRN Pain - Mild 2. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN wheezing, shortness of breath, cough 3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 4. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate 110mcg 1 PUFF IH BID 7. Hydrochlorothiazide 12.5 mg PO DAILY 8. linagliptin 5 mg oral DAILY 9. MetFORMIN (Glucophage) 850 mg PO BID 10. Montelukast 10 mg PO DAILY:PRN allergies 11. Omeprazole 20 mg PO BID 12. PARoxetine 40 mg PO QHS 13. Simvastatin 10 mg PO QPM 14. Valsartan 80 mg PO DAILY 15. Warfarin 4 mg PO 5X/WEEK (___) 16. Warfarin 2 mg PO 2X/WEEK (___) 17. HELD- ALPRAZolam 0.5 mg PO PRN anxiety This medication was held. Do not restart ALPRAZolam until speaking with your primary care physician 18.Outpatient Lab Work I48.91 INR on ___ Please send results to Dr. ___. ___: ___ Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY - Asthma SECONDARY - Diabetes type 2 - Chronic kidney disease - Hypertension - Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with smoke inhalation, SOB // pneumonitis? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation on the frontal view. However, there is increased retrocardiac opacity on the lateral view, likely related to expiratory phase and atelectasis. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are enlarged, unchanged. IMPRESSION: 1. No acute cardiopulmonary abnormalities. 2. Stable moderate to severe cardiomegaly. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with hx of asthma , afib on Coumadin, DVT/PE admitted for smoke inhalation, now with chills and RLL inspiratory crackles? // RLL consolidation? RLL consolidation? IMPRESSION: Compared to chest radiographs since ___ most recently ___. Severe cardiomegaly has worsened. Lungs are clear. No pulmonary edema or pleural abnormality. Gender: F Race: BLACK/CAPE VERDEAN Arrive by UNKNOWN Chief complaint: Cough, Anxiety Diagnosed with Cough temperature: 96.8 heartrate: 78.0 resprate: 20.0 o2sat: 98.0 sbp: 139.0 dbp: 61.0 level of pain: 0 level of acuity: 3.0
___ with history of Type 2 Diabetes, CKD Stage 3, HTN/HLD, asthma, atrial fibrillation on coumadin, provoked PE (leg fracture), pulmonary HTN, and anemia who presents with shortness of breath after a recent fire. Initially with concern for smoke inhalation injury but further collateral information suggests fire was in neighboring building and patient without evidence of inhalation injury on exam. CXR was reassuring and patient remained stable on room air. She was treated with nebulizer treatments with improvement in her breathing. Ambulatory saturations >92%, O2 sats > 95% on room air. # Smoke inhalation - Exposure appeared to have been nonexistent, no risk of heat/smoke related airway damage low. Black in mouth was likely not soot but melanosis as it did not resolved with eating/drinking. No stridor. She remained with good O2 saturation without supplemental O2, largely not tachycardic (though patient tachy to 110s/sats to 90% on ambulation ___. No suspicion for CO toxicity given no exposure, patient never complained of headaches/dizziness/seems confused. Patient was taking large breaths and using accessory muscles, complaining of intermittent chills, CXR clear with cardiomegaly ___. Patient afebrile and without leukocytosis. Cardiac etiology considered, cardiomegaly on CXR, BNP 1227, (last TTE ___ showed ventricular hypertrophy, EF 60%, moderate pul HTN), can consider outpatient work-up. Some component of anxiety also considered, patient had been taking alprazolam as outpatient. # Atrial Fibrillation - INR currently subtherapeutic, gave increased dose 5mg ___. - Continued Warfarin, close follow-up with outpatient PCP # ___ - Continued valsartan, HCTZ # Hyperlipidemia - Continued simvastatin # Gastroesophageal Reflux Disease - Continued omeprazole # Depression - Continued paroxetine TRANSITIONAL ISSUES ================= - CXR with cardiomegaly, prior TTE with diastolic dysfunction. BNP elevated to 1200, but no evidence of CHF exacerbation on exam. ___ consider repeat TTE as outpatient. - Subtherapeutic INR of 1.7 on discharge. Given 5 mg on day of discharge and discharged on home regimen. Should have repeat INR on ___ and likely adjustment of warfarin dosing to 4mg daily
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: face pain Major Surgical or Invasive Procedure: Bedside incision and drainage of dental ___ History of Present Illness: Mr. ___ is a ___ male PMH lung adenocarcinoma with metastasis to rib on chemotherapy who presents with right-sided facial swelling. Patient reports that early this morning he noticed some right-sided swelling of his cheek, associated with erythema and pain. Later in the morning when he woke up, he felt like this was getting worse. This is in the setting of some poor dentition, and a fractured tooth around a year ago. He otherwise had been feeling himself, with no fevers or chills, no chest pain or shortness of breath, and no abdominal issues. He was not having any trouble swallowing or breathing. Given his facial swelling, he presented to the emergency department at ___ ___. On presentation to ___ ED, he was noted to be tachycardic to the 150s, with blood pressures in the 140s to 150s. There was concern that patient's elevated heart rate represented an SVT or atrial flutter. He was given adenosine, with rhythm strips then showing P waves with no flutter waves. Strips were reviewed with on-call cardiologist, who felt this is more likely sinus tachycardia. Labs were significant for a lactate of 3.4 and a white count of 11.1. He had a CT scan of his face, showing right first maxillary molar caries with root extension and periapical lucencies, suggesting periapical abscesses. Dehiscence of buccal cortex identified with extension of infection to the right buccal space. Significant enlargement of the right buccinators muscle, suggesting myositis. No soft tissue drainable fluid collection. Since floor of maxillary sinus at site of infection with significant opacification of right maxillary sinus, consistent with odontogenic sinusitis. He was given IV Unasyn around noon. Repeat lactate was 2.1. He was transferred to ___ ___ for ___. Regarding his cancer, on review of records this was diagnosed last year, after being found incidentally on CT scan. He has since been receiving his care at ___ with Dr. ___. He notes that he is due for his next dose of chemo this ___. In the ED: Initial vital signs were notable for: T 37.1, HR 130, BP 151/47, RR 18, 96% RA Exam notable for: HEENT- PERRL, EOMI, for dental caries on RS mandible, right-sided pupil mucosa swelling with obvious abscess, no sublingual edema Labs were notable for: - CBC: WBC 14.8 (81%n), hgb 14.7, plt 277 - Lytes: 132 / 94 / 5 AGap=20 ------------- 142 6.0 \ 18 \ 0.7 - repeat K 5.1 - trop <0.01 - lactate 3.2 -> 1.5 Studies performed include: - CTA chest with no evidence of pulmonary embolism or aortic dissection. Again seen right upper lobe masslike opacity, grossly similar in size, possibly less wide, compared to prior CT and PET-CT from ___, now with increased spiculation/adjacent architectural distortion/scarring. Consults: ___ was consulted and patient underwent intraoral I&D of R buccal vestibule abscess associated with teeth #1,3 with wick placement. Wick to be removed in 2 days or sooner prior to his discharge. Recommend IV Unasyn, Peridex mouth rinse, 15cc swish and spit BID. Extraction of offending teeth will be arranged as outpatient after his discharge. Patient was given: 3L LR, Tylenol, and oxycodone Vitals on transfer: T 97.4, HR 128, BP 172/80, RR 18, 97% RA Upon arrival to the floor, patient recounts history as above. He continues to have pain in the right side of his face. His wife expressed that she was upset at the delay in receiving antibiotics-she notes that he last received antibiotics while at ___, and received none in our emergency department, despite being admitted for an infection. Discussed with her that we would get antibiotics started right away, and offer number to patient relations. We also discussed his tachycardia, as she had questions around whether a cardiology floor would be more appropriate. Discussed but given that this seemed most likely sinus tachycardia, there may not be a role for cardiology, that we would further monitor on telemetry. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - lung adenocarcinoma - Hypertension - Hyperlipidemia - Anterior cervical discectomy C7-T1/spinal fusion - Ankle surgery Social History: ___ Family History: - Father: ___ cancer - Sister: ___ cancer Physical Exam: VITALS: T 98.4, HR 126, BP 146/80, RR 18, 95% RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Significant swelling of the right side of face, as well as buccal mucosa. CV: Heart tachycardic and 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, moderately distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Exam in discharge: 98.4 BP 142/ 58 HR:88 18 96 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Swelling of the right side of face, as well as buccal mucosa. CV: RRR, 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, moderately distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: Labs on admission: ___ 06:55PM BLOOD WBC-14.8* RBC-4.48* Hgb-14.7 Hct-40.9 MCV-91 MCH-32.8* MCHC-35.9 RDW-13.7 RDWSD-45.0 Plt ___ ___ 06:55PM BLOOD Glucose-142* UreaN-5* Creat-0.7 Na-132* K-6.0* Cl-94* HCO3-18* AnGap-20* ___ 07:00AM BLOOD ALT-37 AST-19 AlkPhos-49 TotBili-1.0 ___ 07:05PM BLOOD Lactate-3.2* K-5.1 Labs on discharge; ___ 06:18AM BLOOD Glucose-127* UreaN-5* Creat-0.7 Na-139 K-4.0 Cl-99 HCO3-23 AnGap-17 ___ 06:18AM BLOOD WBC-8.6 RBC-4.17* Hgb-13.4* Hct-39.2* MCV-94 MCH-32.1* MCHC-34.2 RDW-13.3 RDWSD-45.4 Plt ___ ___ 11:17PM BLOOD Lactate-1.5 Imaging: ___ Facial bones with contrast: IMPRESSION: Right first maxillary molar caries with root extension and periapical lucencies, suggesting periapical abscesses. Dehiscence of buccal cortex identified with extension of infection to the right buccal space. Significant enlargement of the right buccinators muscle, suggesting myositis. No soft tissue drainable fluid collection. Since floor of maxillary sinus at site of infection with significant opacification of right maxillary sinus, consistent with odontogenic sinusitis. ___ CTA chest: IMPRESSION: 1. No evidence of pulmonary embolism or aortic dissection. 2. Again seen right upper lobe masslike opacity, grossly similar in size, possibly less wide, compared to prior CT and PET-CT from ___, now with increased spiculation/adjacent architectural distortion/scarring. Recommend comparison with any more recent priors. 3. Re-demonstrated right pleural thickening. 4. A 1.4 cm right middle lobe nodule is unchanged in size. 5. Increase in mottling of the posterolateral right tenth rib ___ CT scan: Neck: IMPRESSION: 1. Interval increase in the size of the right submandibular gland with surrounding fat stranding and evidence of possible early abscess. 2. Likely chronic infection ___ 3 with decayed roots. Extensive right facial swelling and induration related to local infection. 3. Partially visualized area of fat stranding the level of the right axilla, likely related to inflammatory process. 4. No evidence of large vessel occlusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Terazosin 2 mg PO DAILY 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. FoLIC Acid 1 mg PO DAILY 6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 8. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth Q12hrs Disp #*10 Tablet Refills:*0 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % 15 ml swish and spit twice a day Refills:*0 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 4. amLODIPine 10 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Lisinopril 40 mg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 9. Terazosin 2 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Dental abscess Sinus tachycardia Lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with PMH lung cancer on chemotherapy stenting with tachycardia and facial plethora, right-sided facial abscess diagnosed at outside hospital // Rule out PE, large mass in the right upper lobe. Patient received 80 cc of Omnipaque at outside hospital for CT head and neck. Patient has good renal function. 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 = 15.2 mGy (Body) DLP = 7.6 mGy-cm. 2) Spiral Acquisition 4.7 s, 37.1 cm; CTDIvol = 17.3 mGy (Body) DLP = 640.1 mGy-cm. Total DLP (Body) = 648 mGy-cm. COMPARISON: CT chest ___, PET-CT ___ FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. 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: Re-demonstrated right-sided pleural thickening is seen. LUNGS/AIRWAYS: Respiratory motion limits evaluation for small nodules. Several previously seen subcentimeter nodules are difficult to appreciate on the current study. There are moderate centrilobular and paraseptal emphysematous changes. Right middle lobe 2 mm granuloma is unchanged (2:68). Right middle lobe spiculated nodule measuring 1.4 cm is unchanged (02:59). Right upper lobe spiculated mass measuring roughly 4.5 cm is grossly similar in size, possibly less wide, but with now increased peripheral architectural distortion/scarring, query radiation to this site. (02:49). The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: There is a 1.1 cm right thyroid nodule, not significantly changed from ___. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: There is been interval increase in mottling of the posterolateral right tenth rib at level where a pathologic fracture was seen previously.. Upper thoracic hardware is noted. IMPRESSION: 1. No evidence of pulmonary embolism or aortic dissection. 2. Again seen right upper lobe masslike opacity, grossly similar in size, possibly less wide, compared to prior CT and PET-CT from ___, now with increased spiculation/adjacent architectural distortion/scarring. Recommend comparison with any more recent priors. 3. Re-demonstrated right pleural thickening. 4. A 1.4 cm right middle lobe nodule is unchanged in size. 5. Increase in mottling of the posterolateral right tenth rib Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT INDICATION: ___ year old male with HTN, HLD, lung adenocarcinoma (in active chemotherapy) here with acute odontogenic infection (localized, buccal vestibule abscess associated with teeth #1,3) now with right arm swelling. Please asses for extension of infection or DVT. // ? clot, extension of infection TECHNIQUE: Imaging was performed after administration of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 30.1 cm; CTDIvol = 16.1 mGy (Body) DLP = 474.7 mGy-cm. Total DLP (Body) = 475 mGy-cm. COMPARISON: None. FINDINGS: Aero digestive tract: There is no mass. Neck lymph nodes: Prominent, clustered lymph nodes at level 3, though no lymphadenopathy per CT criteria. Extra nodal tumor spread: There are no findings suggestive of extra nodal extension. Deep neck muscles, masticator space: There is no muscle invasion. There is fat stranding of the masticator and parotid spaces at the right, likely related to inflammatory response. Interval increase in the size of the right submandibular gland in comparison to the study of ___. There is a possible hypodense, rim enhancing lesion within the right submandibular gland that may represent early abscess (02:44). Partially imaged additional inflammation noted at the level of the right axilla (02:59). Incidental note of left sided tonsillith (06:30). Bones, skull base: Suspect chronic infection ___ 3, with likely decay of the root (02:22). Mild multilevel degenerate changes of visualized spine. Surgical fusion hardware noted between C7-T1. Vessels: There is no vascular invasion. Atherosclerotic vascular calcifications are noted at the level of the carotid bifurcations, left greater than right. No evidence of large vessel occlusion. The jugular and subclavian vessels appear patent. Brachial Plexus: There is no brachial plexus contact or invasion. Thyroid, salivary glands: There is no mass. Other findings: There are no lung nodules. Mild emphysematous changes, most predominantly in the left lung. Bilateral facet hypertrophy noted between C3-C6. No evidence of high grade spinal canal or neural foraminal narrowing. IMPRESSION: 1. Interval increase in the size of the right submandibular gland with surrounding fat stranding and evidence of possible early abscess. 2. Likely chronic infection ___ 3 with decayed roots. Extensive right facial swelling and induration related to local infection. 3. Partially visualized area of fat stranding the level of the right axilla, likely related to inflammatory process. 4. No evidence of large vessel occlusion. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 1:10 pm, 3 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Facial swelling, Tachycardia, Transfer Diagnosed with Periapical abscess without sinus temperature: 37.1 heartrate: 130.0 resprate: 18.0 o2sat: 96.0 sbp: 151.0 dbp: 47.0 level of pain: 6 level of acuity: 2.0
Mr. ___ is a ___ male ___ lung adenocarcinoma with metastasis to rib on chemotherapy who presents with signs of sepsis and a dental abscess
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: EGD lymph node biopsy History of Present Illness: The patient is a ___ year old community dwelling female with a history of multinodular goiter who first presented with abdominal pain and constipation to the ED. Since then she had low level chronic LLQ and epigastric pain. She started eating less but she has not lost weight. She has not had fevers or chills. She followed up with her PCP on ___ was started on zantac. An US then demonstrated lymphadenopathy. Last night she developed severe pain that she could not sleep. She had dry heaves and could not tolerate water. Her dtr then called Dr. ___ saw her in clinic and recommended that she go to the ED. In the ED she had a CT scan which demonstrated mesenteric stranding and innumerable lymph nodes concerning for lymphoma. + post dry heaves cough. Last BM yesterday pm. No blood in it. + clear foamy emesis. Non bilious and non-bilious In ER: (Triage Vitals:10 98.7 81 149/63 18 100% RA ) Meds Given: morphine 5mg IV x 2, zofran 4 mg IV Fluids given: 2L Radiology Studies: abdominal CT Consults called: none PAIN SCALE: ___ Epigastric and LLQ ________________________________________________________________ REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative" CONSTITUTIONAL: [] All Normal [- ] Fever [ -] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [+ ]Anorexia [ ]Night sweats [- ] _____ lbs. weight loss/gain over _____ months Eyes [X] All Normal [ ] Blurred vision [ ] Loss of vision [] Diplopia [ ] Photophobia ENT [X]WNL [ -] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [] Sore throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ] Other: RESPIRATORY: [X] All Normal [ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [X] All Normal [ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ] Chest Pain [ ] Dyspnea on exertion [ ] Other: GI: [+] per HPI [ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [ ] Diarrhea [ ] Constipation [ ] Hematemesis [ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Incontinence or retention [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [X] All Normal [ ] Rash [ ] Pruritus MS: [] All Normal [ ] Joint pain [ ] Jt swelling [ +] Back pain- chronic x years [ ] Bony pain NEURO: [X] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [] All Normal [ ] Skin changes [ ] Hair changes [ ] Heat or cold intolerance [- ] loss of energy HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy ALLERGY: [+ ]Medication allergies-> compazine - mouth swelling [ ] Seasonal allergies [X]all other systems negative except as noted above Past Medical History: Multinodular goiter DJD of the spine HTN PSHx s/p appendectomy Social History: ___ Family History: Her father died of prostate cancer at age ___. Her mother died when she was ___ years old thought to be from childbrith. Physical Exam: ADMISSION EXAM 1. VS: T = 98.6 P 73 BP = 157/80 RR = 18 O2Sat on __99% on RA GENERAL: Very well appearing pleasant female laying in bed. She looks younger than her stated age. Nourishment: good Mentation: alert, conversant. 2. Eyes: [x] WNL PERRL, EOMI without nystagmus, Conjunctiva: clear 3. ENT [] WNL [x] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate 4. Cardiovascular [] WNL [x] Regular [] Tachy [x] S1 [x] S2 [-] Systolic Murmur /6, Location: [] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6, Location: [x] Edema RLE None [x] Edema LLE None [] Vascular access [x] Peripheral [] Central site: 2+ dpp B/l 5. Respiratory [x] WNL [x] CTA bilaterally [ ] Rales [ ] Diminshed [] Comfortable [ ] Rhonchi [ ] Dullness [ ] Percussion WNL [ ] Wheeze [] Egophony 6. Gastrointestinal [ ] WNL NABS, soft, + epigastric and LLQ pain. No rebound or guarding. 7. Musculoskeletal-Extremities [x] WNL [ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [ ]Other: [ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica [ ] Other: 8. Neurological [] WNL [X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ] CN II-XII intact [X] Normal attention [ ] FNF/HTS WNL [] Sensation WNL [-] Delirious/confused [ ] Asterixis Present/Absent [ ] Position sense WNL [ ] Demented [ ] No pronator drift [X] Fluent speech 9. Integument [X] WNL [X] Warm [X] Dry [] Cyanotic [] Rash: none/diffuse/face/trunk/back/limbs [ ] Cool [] Moist [] Mottled [] Ulcer: None/decubitus/sacral/heel: Right/Left 10. Psychiatric [X] WNL [X] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated [X] Pleasant [] Depressed [] Agitated [] Psychotic DISCHARGE EXAM: Vital Signs: 98.5 104/67 59 16 99% RA GEN: NAD well-appearing HEENT: conjunctiva clear, anicteric, MMM CV: RRR, Nl S1/S2, no MRG PULM: CTA, no w/r/r GI: +BS, NT/ND EXT: WWP, no CCE SKIN: no rashes PSYCH: appropriate, normal affect, not depressed Pertinent Results: Admission Labs: ___ 03:30PM BLOOD WBC-12.1* RBC-5.03 Hgb-15.1 Hct-44.2 MCV-88 MCH-30.0 MCHC-34.1 RDW-13.3 Plt ___ ___ 03:30PM BLOOD Neuts-76.5* ___ Monos-4.7 Eos-0.4 Baso-0.2 ___ 03:43PM BLOOD ___ PTT-29.3 ___ ___ 03:30PM BLOOD Plt ___ ___ 03:30PM BLOOD Glucose-81 UreaN-12 Creat-0.9 Na-137 K-4.1 Cl-99 HCO3-26 AnGap-16 ___ 03:30PM BLOOD ALT-28 AST-25 LD(LDH)-297* AlkPhos-94 TotBili-0.7 ___ 03:30PM BLOOD Albumin-4.7 Calcium-9.9 Phos-3.2 Mg-2.2 UricAcd-4.4 ___ 12:45PM BLOOD CEA-<1.0 CA125-10 ___ 12:45PM BLOOD PEP-NO SPECIFI IgG-985 IgA-398 IgM-89 ___ 12:45PM BLOOD HIV Ab-NEGATIVE ___ 03:42PM BLOOD Lactate-1.8 ___ 05:40AM BLOOD CA ___ -Test ___ 12:45PM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN BLOT-Test H pylori negative Ultrasound: IMPRESSION: 1. Numerous pathologically enlarged abdominal and retroperitoneal lymph nodes. The spleen is normal. 2. Further evaluation with CT of the abdomen and pelvis with contrast is advised. CT abdomen/pelvis: IMPRESSION: 1. Significant abdominal lymphadenopathy and mesenteric stranding, as described above. This is concerning for lymphoma. 2. Left adnexal cystic lesion. A nonemergent pelvic ultrasound is recommended for further characterization. CT Chest: IMPRESSION: No evidence of mediastinal or hilar lymphadenopathy Lung nodules, followup in 3 months is recommended Irregular opacities in the right upper lobe and ground-glass nodule in the right lower lobe are likely infectious in etiology can be re-evaluated after treatment in the followup study Heterogeneous thyroid upper lobe ultrasound is recommend Gastric biopsy: - Oxyntic and antral mucosa, within normal limits. EGD Normal mucosa in the esophagus Mild erythema throughout stomach. One 5 mm erosion in gastric antrum. Compatible with likely gastritis. (biopsy) Normal mucosa in the duodenum No evidence of mass lesions appreciated. Otherwise normal EGD to third part of the duodenum Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN pain 3. Ranitidine 300 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Ranitidine 300 mg PO DAILY 3. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*2 4. Acetaminophen 650 mg PO Q8H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary: lymphadenopathy Secondary: abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: One month of abdominal pain and retroperitoneal lymphadenopathy seen on recent ultrasound. Evaluate lymph nodes. TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was not administered. DOSE: DLP: 604.48 mGy-cm. IV Contrast: 130 mL Omnipaque. COMPARISON: Abdominal ultrasound from ___. CT of the abdomen and pelvis from ___. FINDINGS: LOWER CHEST: There is minimal bibasilar atelectasis. The bases of the lungs are otherwise clear. There is no nodule, consolidation, or pleural effusion. The base of the heart is normal in size. There is no pericardial effusion. ABDOMEN: The liver is normal in shape and contour. No focal hepatic lesions are identified. The portal veins are patent. The gallbladder, spleen, pancreas, and adrenal glands are normal. Two tiny sub 5 mm hypodensities in the left kidney are too small fully characterize, though statistically represent cysts. No worrisome renal lesions are identified. There is no hydronephrosis. The kidneys enhance and excrete contrast symmetrically. The stomach and small bowel are normal in caliber without evidence of obstruction. There is no free air. The abdominal vasculature is normal in caliber without significant atherosclerotic calcifications. There are numerous enlarged lymph nodes in the upper abdomen, around the celiac axis, in the mesentery, and in the retroperitoneum. For example, in the lower mesentery, the largest lymph node measures 34 x 23 mm (2, 53). A left gastric lymph node measures 22 x 16 mm. In the left retroperitoneum, there is a 23 x 11 mm lymph node. There is associated stranding in the mesentery. These lymph nodes surround and abuts the mesenteric vessels, particularly the SMV and branches of the SMA. There is no evidence of compression or thrombus. Given these findings, this is worrisome for lymphoma. There is no ascites. PELVIS: There is diverticulosis without diverticulitis. The large bowel is otherwise normal. The bladder, uterus, and right adnexa are unremarkable. In the left adnexa, there is a 45 x 27 mm cystic lesion with some apparent mild wall thickening. There is no pelvic or inguinal lymphadenopathy. No free fluid is identified in the pelvis. OSSEOUS STRUCTURES AND SOFT TISSUES: There are no concerning lytic or sclerotic osseous lesions. Hemangioma identified in the L3 vertebral body. No fracture is identified. Mild degenerative changes are noted in the thoracic spine. The soft tissues are unremarkable. There is no hernia. IMPRESSION: 1. Significant abdominal lymphadenopathy and mesenteric stranding, as described above. This is concerning for lymphoma. 2. Left adnexal cystic lesion. A nonemergent pelvic ultrasound is recommended for further characterization. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with U/S and CT evidence of lymphoma in the abdomen // Evaluate for lymphoma- to complete staging TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agent reconstructed as axial, coronal , parasagittal, and ,MIPs axial images. DOSE: DLP: 202 mGy COMPARISON: None FINDINGS: The thyroid is enlarged and heterogeneous. Supraclavicular, axillary, mediastinal and hilar lymph nodes are not enlarged. Aorta and pulmonary arteries are normal size. Cardiac configuration is normal and there is no appreciable coronary calcification. There is no pleural or pericardial effusion. Irregular faint peribronchial opacities in the right upper upper lobe are likely infectious in etiology Ground-glass nodule in the right lower lobe measures 9 mm (5:156) Other several lung nodules measure less than 3 mm (5:53, 76, 88, 99, 122, 176) Please refer to the complete description of the intra-abdominal findings on prior CT abdomen of ___ There are no bone findings of malignancy IMPRESSION: No evidence of mediastinal or hilar lymphadenopathy Lung nodules, followup in 3 months is recommended Irregular opacities in the right upper lobe and ground-glass nodule in the right lower lobe are likely infectious in etiology can be re-evaluated after treatment in the followup study Heterogeneous thyroid upper lobe ultrasound is recommend Radiology Report EXAMINATION: CT INTERVENTIONAL PROCEDURE INDICATION: ___ year old woman with newly found lymphoma involving the abdomen, needs core biopsy for diagnosis // core CT guided biopsy for presumed lymphoma involving abdomen. GI will first perform EGD on ___ to see if there is anything to biopsy, if not, requesting ___ biopsy, per ___, would need to be CT guided. Could this be performed ___ pm if EGD is negative? COMPARISON: ___. PROCEDURE: CT-guided mesenteric nodal biopsy. OPERATORS: Dr. ___ trainee and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CTscan of the intended biopsy area in the left mid abdomen was performed. Based on the CT findings an appropriate position for the biopsy was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the lesion. An 18 gauge core biopsy device with a 11 mm throw was used to obtain two core biopsy specimens, one placed in formalin and the other in RPMI, which were sent for pathology. The specimen was evaluated by onsite cytologist and deemed adequate. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: DLP: 1236 mGy-cm SEDATION: Moderate sedation was provided by administering divided doses of 1 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 30 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited pre-procedure and intra-procedural CT demonstrates retroperitoneal and mesenteric adenopathy, as demonstrated on recent CT scan. A left anterior mesenteric node was targeted for biopsy. IMPRESSION: Successful 18 gauge core biopsies of an enlarged mesenteric lymph node. Gender: F Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Abd pain, N/V Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ENLARGEMENT LYMPH NODES temperature: 98.7 heartrate: 81.0 resprate: 18.0 o2sat: 100.0 sbp: 149.0 dbp: 63.0 level of pain: 10 level of acuity: 3.0
___ year old female with HTN and multinodular goiter who presented with constipation and approximately 1 month of abdominal pain found to have retroperitoneal lymphadenopathy concerning for lymphoma. # Likely LYMPHOMA CT imaging of abd/pelvis concerning for lymphoma. Chest CT without findings for malignancy, however did show irregular opacities in the right upper lobe and ground-glass nodule in the right lower lobe concerning for infection. Given no clinical evidence of infection, she was not treated with antibiotics but will require repeat chest CT in 3 months. Heme onc was consulted and diagnostic lab testing including SPEP/UPEP, HIV, HTLV, CEA, ___, CA125, and immunoglobulins were unremarkable. EGD was performed and was notable only for gastritis. The pt underwent lymph node biopsy and results were pending on discharge. She was scheduled to follow up in ___ clinic. # Constipation and abd pain: Symptomatically managed with a bowel regimen and pain control with oxycodone-acetaminophen. After EGD revealed gastritis, she was started on omeprazole with significant improvement in her symptoms. H pylori was sent and was negative. She was advised to take tylenol instead of ibuprofen as needed for pain. # HTN: she was continued on her home norvasc # TRANSITIONAL: -- F/u Lung nodules, followup in 3 months -- Heterogeneous thyroid upper lobe ultrasound is recommend -- Left adnexal cystic lesion, pelvic US recommended
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sevoflurane / Orange Juice / Reglan / Bactrim Attending: ___ Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ M w/ hx IDDM1 with ESRD s/p renal transplant (___) c/b fungal peritonitis (c. krusei s/p micafungin from ___ with a recent admission ___ for fevers and malaise concerning for transplant pyelo discharged on micafungin/ertapenem x4 week course with recent ___ ureteral stents removal via flex cystoscopy who now presents to ED after developing hyperglycemia to ___ yesterday. He has daily ___ care and has been compliant with his medications including insulin, and he received 8 units humalog at home. BG 279 two days ago, also above his normal baseline. He reports drinking a small amount of peach nectar yesterday but otherwise reports having slightly decreased appetite the past 2 days. ___ called PCP who referred to ED. In the ED, initial vitals were: 99.3 87 140/68 20 96% RA - Labs notable for leukopenia to 1.7k (ANC 1040) compared to 3.4k on ___, creatinine 1.3 (baseline 1.1-1.3) - CXR with stable cardiomegaly. No acute process. - Seen by Renal Txplant in ED, recommended broad spectrum abx, AM tacro trough, CMV viral load, ID consultation in the AM. - He did not receive any meds in the ED. This AM, pt's VS are 97.7 85 121/58 20 100% on RA. Pt denies f/c, n/v/d, abdominal pain, sob, cough. Pt reports he feels well this AM. Past Medical History: ___ MSSA bacteremia, L arm fistula - s/p surgical debridement of left arm fistula (___) and ruptured aneurysm repair (___), s/p MSSA bacteremia and surgical debridment of fistula ___ - History of PEA arrest ___ AV fistula repair ___ MSSA bacteremia -Pacemaker: During hospitalization for MSSA AV graft infection on ___, pt developed bradycardia to ___ and arrhythmias felt to be due to pericardial effusion. He underwent pericardial drainage and placement of epicardial pacemaker in abdomen. - Diabetes mellitus, type I, c/b retinopathy (legally blind on left), neuropathy and nephropathy, gastroparesis - CAD, NSTEMI ___ - CHF: Echo in ___ with EF of 40% and evidence of diastolic heart failure. Cath on ___ with evidence of hypertensive heart disease but no clear CAD. - Pulmonary hypertension - Hypertension - Glaucoma - History of positive PPD, s/p one year of treatment although no documentation here - hx seizure d/o - Hypothyroidism - CARPAL TUNNEL SYNDROME AND LEFT ___ CANAL COMPRESSION Social History: ___ Family History: Multiple siblings with hypertension and diabetes. Two sisters with a "heart problem." No known early coronary disease or kidney disease. Physical Exam: ADMISSION EXAM: ============= VS: 97.7 121/58 85 20 100%RA General: cachectic-appearing adult male lying comfortably in bed in NAD. HEENT: MM moist and pink, no erythema or exudates. no JVD. Neck: supple CV: normal rate, regular rhythm, no m/r/g appreciated Lungs: CTAB Abdomen: soft, NT, ND, NABS, graft in right pelvis, non-tender GU: no foley in place Ext: LUE PICC line in place, no surrounding erythema, induration, or tenderness. scattered hyperpigmentated lesions across skin. no obvious ulceration or source of infection. Neuro: CN II-XII intact. DISCHARGE EXAM: ============== VS: 98.7 128/48 75 18 97%RA General: cachectic-appearing adult male lying comfortably in bed in NAD. HEENT: MM moist and pink, no erythema or exudates. no JVD. Neck: supple CV: normal rate, regular rhythm, no m/r/g appreciated Lungs: CTAB Abdomen: soft, NT, ND, NABS, graft in right pelvis, non-tender GU: no foley in place Ext: LUE PICC line in place, no surrounding erythema, induration, or tenderness. scattered hyperpigmentated lesions across skin. no obvious ulceration or source of infection. Neuro: CN II-XII intact. Pertinent Results: ADMISSION LABS: ============== ___ 09:40PM BLOOD WBC-1.7* RBC-3.13* Hgb-9.4* Hct-30.6* MCV-98 MCH-30.0 MCHC-30.7* RDW-15.9* Plt ___ ___ 09:40PM BLOOD Neuts-60.9 ___ Monos-2.0 Eos-4.0 Baso-2.3* ___ 09:40PM BLOOD Plt ___ ___ 09:40PM BLOOD Glucose-81 UreaN-22* Creat-1.3* Na-136 K-4.4 Cl-104 HCO3-24 AnGap-12 ___ 09:40PM BLOOD ALT-10 AST-23 LD(LDH)-273* AlkPhos-101 TotBili-0.6 ___ 09:40PM BLOOD Albumin-3.8 Calcium-10.5* Phos-2.0* Mg-2.1 ___ 05:45AM BLOOD tacroFK-9.3 ___ 04:59AM BLOOD tacroFK-11.3 ___ 09:42PM BLOOD ___ pO2-39* pCO2-43 pH-7.36 calTCO2-25 Base XS--1 ___ 09:42PM BLOOD Lactate-1.4 DISCHARGE LABS: =============== ___ 04:59AM BLOOD WBC-2.0* RBC-3.29* Hgb-9.9* Hct-32.1* MCV-98 MCH-30.1 MCHC-30.9* RDW-15.8* Plt ___ ___ 04:59AM BLOOD Plt ___ ___ 04:59AM BLOOD ___ PTT-35.8 ___ ___ 04:59AM BLOOD Glucose-270* UreaN-23* Creat-1.1 Na-134 K-5.2* Cl-102 HCO3-26 AnGap-11 ___ 04:59AM BLOOD ALT-9 AST-14 AlkPhos-92 TotBili-0.6 ___ 04:59AM BLOOD Calcium-10.7* Phos-2.3* Mg-2.0 ___ 04:59AM BLOOD tacroFK-11.3 MICRO: ======= ___ 8:16 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 11:25 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 5:45 am Immunology (CMV) CMV Viral Load (Pending): ___ 5:45 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 5:45 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Pending): BLOOD/AFB CULTURE (Pending): ___ 2:04 am SWAB Source: Rectal swab. R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Preliminary): ENTEROCOCCUS SP.. ___ 10:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 9:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): STUDIES: ======== Chest X-Ray PA and Lateral ___ IMPRESSION: Stable cardiomegaly. No acute process. RUQ Ultrasound ___ FINDINGS: LIVER: The hepatic architecture is nodular consistent with the patient's known cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 0.3 cm. GALLBLADDER: The gallbladder is partially contracted. No gallstones are visualized. PANCREAS: The pancreas is unremarkable but is only minimally visualized due to overlying bowel gas. SPLEEN: The spleen is normal measuring 11.4 cm. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN fevers or pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Calcium Carbonate 500 mg PO BID 5. Carvedilol 25 mg PO BID 6. CloniDINE 0.1 mg PO DAILY 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Furosemide 20 mg PO DAILY 10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 11. LaMIVudine 100 mg PO DAILY 12. Mycophenolate Mofetil 500 mg PO BID 13. Omeprazole 20 mg PO BID 14. Senna 8.6 mg PO BID:PRN constipation 15. ValGANCIclovir 450 mg PO Q24H 16. Vitamin D 800 UNIT PO DAILY 17. Tretinoin 0.1% Cream 1 Appl TP QHS 18. Sodium Polystyrene Sulfonate 30 gm PO ASDIR 19. DiphenhydrAMINE 25 mg PO Q6H:PRN itch 20. Levothyroxine Sodium 25 mcg PO DAILY 21. Micafungin 100 mg IV Q24H 22. ertapenem 1 gram injection once 23. Tacrolimus 2 mg PO Q12H 24. Glargine 4 Units Breakfast Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fevers or pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Calcium Carbonate 500 mg PO BID 5. Carvedilol 25 mg PO BID 6. CloniDINE 0.1 mg PO DAILY 7. Dapsone 100 mg PO DAILY 8. DiphenhydrAMINE 25 mg PO Q6H:PRN itch 9. Docusate Sodium 100 mg PO BID 10. Furosemide 20 mg PO DAILY 11. Glargine 4 Units Breakfast 12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 13. LaMIVudine 100 mg PO DAILY 14. Levothyroxine Sodium 25 mcg PO DAILY 15. Micafungin 100 mg IV Q24H 16. Mycophenolate Mofetil 500 mg PO BID 17. Omeprazole 20 mg PO BID 18. Senna 8.6 mg PO BID:PRN constipation 19. Tacrolimus 2 mg PO Q12H 20. Sodium Polystyrene Sulfonate 30 gm PO ASDIR 21. Tretinoin 0.1% Cream 1 Appl TP QHS 22. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: primary diagnosis: type 1 diabetes, ESRD s/p renal transplant secondary diagnosis: coronary artery disease, hypertension, hypothyroid Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Hyperglycemia, renal transplant, assess for infection. COMPARISON: Comparison is made to chest radiograph performed ___. FINDINGS: Frontal and lateral chest radiographs demonstrate stable cardiomegaly. Lungs are clear. No pleural effusion or pneumothorax present. Pacing wires are stable in position. Left-sided PICC line likely terminates within the right atrium. IMPRESSION: Stable cardiomegaly. No acute process. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with cirrhosis and s/p renal transplant // eval for ascites, obstruction, intrahepatic process TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained. COMPARISON: Abdomen CT ___, liver ultrasound ___ FINDINGS: LIVER: The hepatic architecture is nodular consistent with the patient's known cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 0.3 cm. GALLBLADDER: The gallbladder is partially contracted. No gallstones are visualized. PANCREAS: The pancreas is unremarkable but is only minimally visualized due to overlying bowel gas. SPLEEN: The spleen is normal measuring 11.4 cm. KIDNEYS: No hydronephrosis is seen on limited views of the transplant kidneys in the right lower quadrant. IMPRESSION: 1. No ascites 2. No biliary dilatation. Nodular hepatic architecture however no focal hepatic abnormality is identified. . Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Hyperglycemia, POST TRANSPLANT Diagnosed with LEUKOCYTOSIS, UNSPECIFIED , NEUTROPENIA, UNSPECIFIED temperature: 99.3 heartrate: 87.0 resprate: 20.0 o2sat: 96.0 sbp: 140.0 dbp: 68.0 level of pain: 0 level of acuity: 2.0
___ M w/ hx IDDM1 with ESRD s/p renal transplant (___) c/b fungal peritonitis and recent admission for transplant pyelonephritis d/c'd on micafungin/ertapenem now presents with 2 days of worsening hyperglycemia and leukopenia, along with vague malaise.
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, weight loss Major Surgical or Invasive Procedure: None History of Present Illness: As per HPI by Dr. ___ ___: "This is a ___ with history of recently diagnosed lung cancer (SCLC, limited stage, per patient and his family) that was diagnosed in ___, s/p chemotherapy and radiation, who now presents to ___ with weakness and weight loss. History is taken from the patient and his family, who report that he was diagnosed with lung cancer because of a low sodium level (114) that led to his workup back in ___. He subsequently had chemotherapy which he finished in ___ and radiation which he finished in ___, and the family believes he also had prophylactic whole brain radiation. He had routine staging scans which showed he was disease free at the end of the ___ (___). In the last few weeks he has had 16lb weight loss and he started to develop abdominal pain and weakness. He had a set of labwork which showed a potassium of 3.1 and was referred to the ED, ___ of last week. He was scheduled for outpatient CT scan this week which was done last week while in the ED because of his symptoms and this scan showed spread of his lung cancer to the liver and the spine. The following day (___) he went to see his oncologist (Dr ___ who informed the patient that his disease had spread and that they could consider chemotherapy but that it would be a longshot. The ___ daughter reports they were not informed of a stage or prognosis at this visit and they went home feeling unsettled on ___, with plans to get chemotherapy ___ (tomorrow) as an outpatient. Over the weekend however, the patient began to decline, and became significantly weak which led to presentation at the ___ ED for another opinion. Of note, when initially diagnosed, the patient and his family sought an opinion from ___ who had agreed with ___ oncology. Currently Mr ___ reports significant fatigue, malaise, diarrhea x few days, weakness. No nausea, vomiting, CP, SOB. +Some abdominal discomfort. Has not been taking his medications ___ feeling like there was no point and feeling unwell. He tripped and fell yesterday over his work boots but did not sustain any injuries. Also complains of some numbness/tingling of his left toes but this has been present for several weeks. Denies bowel/bladder incontinence. In the ED he was found to have worsening liver function and guiac positive stool in addition to significant weakness and was admitted to the medical service. Remainder of ROS negative unless stated above. ED Course: Oxycodone 5mg PO x1 Zofran 4mg iv x1 NS 1L bolus x 2 Insulin 14 units subq x1 Insulin 6 units subq x1 " Past Medical History: History of lung cancer, per family SCLC limited stage dx ___ History of hyponatremia which preceded diagnosis of lung ca Diabetes CAD s/p MI ___ y/a) and DESx2 ___ y/a) HLD Htn R hip replacement Social History: ___ Family History: Father - MI No ___ of lung cancer Physical Exam: Admission Exam: T98.0, BP 134/83, HR 54, O2 93 RA, RR 18 Gen - no distress, fatigued appearing, resting comfortably in bed HEENT - nc/at, dry oral mucosa, no OP lesion or exudate, perrl Neck - supple, no JVD ___ - RRR, s1/2, no murmurs Lungs - scattered faint rhonchi b/l lungs, no wheezes, breathing symmetric and unlabored Abd - firm, non distended, diffuse tenderness to deep palpation worst in RUQ, +hepatomegaly, +bowel sounds Ext - no peripheral edema or cyanosis Skin - warm, dry, no rashes Psych - calm, appropriate Neuro - motor ___ all extremities, +tingling of left ___ toe with palpation Discharge Exam: No vitals being checked Gen: Patient is somnolent but rousable, breathing comfortably Pulm: normal effort, no distress Abd: slightly distended Ext: No edema or cyanosis Psych: somnolent Pertinent Results: Admission Labs: Wbc 5.7, Hg 11.3, Hct 32.9, Plt 29 Na 142, K 3.4, Cl 99, Co2 26, BUN 36, Cr 0.9, Gluc 324 ALT 246, AST 231, ALP 501, T bili 3.3, Direct bili 1.8 LDH 2424, BNP 3691, Albumin 3.0, Lipase 38 Lactate 3.7 -> 2.9 Discharge Labs: ___ 04:05AM BLOOD WBC-5.1 RBC-3.40* Hgb-10.5* Hct-31.2* MCV-92 MCH-30.9 MCHC-33.7 RDW-18.5* RDWSD-61.3* Plt Ct-22* ___ 03:00PM BLOOD Glucose-133* UreaN-31* Creat-0.7 Na-148* K-3.8 Cl-105 HCO3-29 AnGap-14 ___ 04:05AM BLOOD ALT-212* AST-215* ___ AlkPhos-419* TotBili-4.0* ___ 03:00PM BLOOD Calcium-8.5 Phos-1.9* Mg-1.9 Imaging: CT abd/pelvis W contrast, ___: IMPRESSION: 1. Multiple hypoattenuating hepatic lesions measuring up to 5.1 cm are highly suspicious for metastatic disease. 2. Enlarged 1.4 cm porta hepatis lymph node. Prominent retroperitoneal and gastrohepatic lymph nodes are not enlarged by CT size criteria, but are suspicious for metastatic disease. 3. Heterogeneity of the bilateral ilia and a 1.7 cm lucency in the inferior left ilium are indeterminate. Recommend correlation with bone scan. CT chest W contrast, ___: IMPRESSION: 1. Multiple pulmonary nodules in all lobes of the right lung and left upper lobe as described in the body of the report in keeping with history of metastatic small cell lung cancer. Assessment of known osseous metastases is limited. 2. Mediastinal lymphadenopathy. 3. Trace left pleural effusion. 4. Please see separate report performed on the same day for detailed evaluation of the abdomen or pelvis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. Aspirin 81 mg PO DAILY 4. glimepiride 2 mg oral BID 5. Rosuvastatin Calcium 10 mg PO QPM 6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY:PRN 7. FLUoxetine 40 mg PO DAILY 8. Lisinopril 40 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Ondansetron 8 mg PO Q8H:PRN nausea 12. OxyCODONE (Immediate Release) 10 mg PO Frequency is Unknown 13. TraZODone 50 mg PO QHS:PRN sleep 14. amLODIPine 10 mg PO DAILY 15. Lantus Solostar (insulin glargine) 18 u subcutaneous QHS 16. Gabapentin 600 mg PO TID 17. Potassium Chloride 20 mEq PO DAILY 18. Tizanidine 2 mg PO TID:PRN back spasm Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 500 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Fentanyl Patch 12 mcg/h TD Q72H RX *fentanyl 12 mcg/hour Apply patch Every 72 hours Disp #*10 Patch Refills:*0 3. LORazepam Oral Solution 0.5 mg PO Q8H:PRN anxiety RX *lorazepam 2 mg/mL 0.25 mL by mouth Every 6 hours Refills:*0 4. MethylPHENIDATE (Ritalin) 5 mg PO BID:PRN for sleepiness to use as needed RX *methylphenidate HCl 5 mg/5 mL 5 mL by mouth Twice daily Refills:*0 5. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO RX *oxycodone 20 mg/mL ___ mL by mouth every four (4) hours Refills:*0 6. FLUoxetine 40 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. Lantus Solostar (insulin glargine) 18 u subcutaneous QHS 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Ondansetron 8 mg PO Q8H:PRN nausea 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY:PRN 12. Tizanidine 2 mg PO TID:PRN back spasm 13. TraZODone 50 mg PO QHS:PRN sleep Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Metastatic small cell lung cancer Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with failure to thrive// ? pna TECHNIQUE: Chest PA and lateral COMPARISON: None available FINDINGS: The lungs are fully expanded. There is mild bibasilar atelectasis. No evidence of focal consolidation. Cardiomediastinal and hilar silhouettes are normal. Pleural surfaces are normal. Degenerative changes are noted of the visualized thoracic spine. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with small cell lung cancer and thrombocytopenia with mild encephalopathy// R/o bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP = 855.5 mGy-cm. Total DLP (Head) = 856 mGy-cm. COMPARISON: None. FINDINGS: This examination is mildly motion limited. There is no evidence of infarction,hemorrhage,edema, or mass. There is mild prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical white matter hypodensity is nonspecific but likely reflect sequelae of chronic small vessel ischemic disease. Who atherosclerotic vascular calcification of the right greater than left cavernous internal carotid artery is noted. 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 abnormality. Radiology Report EXAMINATION: CT ABDOMEN PELVIS WITH AND WITHOUT CONTRAST INDICATION: ___ year old man with metastatic SCLC//evaluate extent of metastatic disease TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was done as part of CT torso with IV contrast. A single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by 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 3.2 s, 35.1 cm; CTDIvol = 14.2 mGy (Body) DLP = 487.7 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 3) Stationary Acquisition 11.5 s, 0.2 cm; CTDIvol = 195.3 mGy (Body) DLP = 39.1 mGy-cm. 4) Spiral Acquisition 11.0 s, 71.4 cm; CTDIvol = 13.2 mGy (Body) DLP = 933.6 mGy-cm. 5) Spiral Acquisition 5.1 s, 33.4 cm; CTDIvol = 14.2 mGy (Body) DLP = 466.4 mGy-cm. Total DLP (Body) = 1,929 mGy-cm. COMPARISON: Same day CT chest. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: Multiple hypoattenuating lesions are seen scattered throughout the entire liver, measuring up to 5.1 cm (5:62). The remainder of the liver demonstrates appropriate, mostly homogeneous enhancement. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or surrounding inflammation. The portal veins are patent. There is small perihepatic ascites. PANCREAS: The pancreas is atrophic in appearance, without evidence of focal lesions. There is no main pancreatic ductal dilatation or peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right adrenal gland is normal. There is thickening of the medial leaflet of the left adrenal gland, of indeterminate significance. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Subcentimeter bilateral cortical hypoattenuating lesions are too small to characterize. There is no hydronephrosis or perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. The appendix is not visualized. PELVIS: Relation the pelvis is limited due to streak artifact from right hip prosthesis. The bladder is grossly unremarkable. There is no large free fluid in the pelvis. The prostate is mildly enlarged. The seminal vesicles appear within normal limits. LYMPH NODES: An enlarged 1.4 cm porta hepatis node is seen (5:67). Prominent gastrohepatic ligament lymph nodes measure up to 0.9 cm (5:53). Multiple prominent retroperitoneal lymph nodes measure up to 0.8 cm (5:63, 72, 75). There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: Heterogeneity of the bilateral ilia and a 1.7 cm lucency in the inferior left ilium (5:97) are indeterminate. Patient is post right hip total arthroplasty, without evidence of hardware-related complication. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Multiple hypoattenuating hepatic lesions measuring up to 5.1 cm are highly suspicious for metastatic disease. 2. Enlarged 1.4 cm porta hepatis lymph node. Prominent retroperitoneal and gastrohepatic lymph nodes are not enlarged by CT size criteria, but are suspicious for metastatic disease. 3. Heterogeneity of the bilateral ilia and a 1.7 cm lucency in the inferior left ilium are indeterminate. Recommend correlation with bone scan. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ male with metstatic small-cell lung cancer to the lumbar spine status post chemotherapy here for re-staging. TECHNIQUE: Multidetector helical scanning of the chest was and reconstructed as contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.2 s, 35.1 cm; CTDIvol = 14.2 mGy (Body) DLP = 487.7 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 3) Stationary Acquisition 11.5 s, 0.2 cm; CTDIvol = 195.3 mGy (Body) DLP = 39.1 mGy-cm. 4) Spiral Acquisition 11.0 s, 71.4 cm; CTDIvol = 13.2 mGy (Body) DLP = 933.6 mGy-cm. 5) Spiral Acquisition 5.1 s, 33.4 cm; CTDIvol = 14.2 mGy (Body) DLP = 466.4 mGy-cm. Total DLP (Body) = 1,929 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: None available. FINDINGS: NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal. Supraclavicular and axillary lymph nodes are not enlarged. MEDIASTINUM: Multiple prominent mediastinal lymph nodes measuring up to 19 mm in the right paratracheal station (series 5, image 10) and 13 mm left paratracheal node (series 5, image 14) are noted. HILA: Hilar lymph nodes are not enlarged. HEART: The heart is not enlarged and there is moderate coronary arterial calcification. There is no pericardial effusion. VESSELS: Vascular configuration is conventional. Aortic caliber is normal. The main, right, and left pulmonary arteries are normal caliber. PULMONARY PARENCHYMA: Evaluation of the pulmonary parenchyma is more limited by respiratory motion. There is a 8 mm subpleural solid nodule in the left upper lobe (series 6, image 87). A part solid 5 mm pulmonary nodule is located in the right upper lobe (series 6, image 85). Additional pulmonary nodules in the right middle lobe (series 6, image 155 and 157), right lower lobe (6, image 165, and left upper lobe (series 6, image 124) are no larger than 3 mm. These are most likely metastatic disease. There is bilateral dependent atelectasis. AIRWAYS: The airways are patent to the subsegmental level bilaterally. PLEURA: There is trace left pleural effusion. No right pleural effusion. No pneumothorax. CHEST WALL AND BONES: Assessment of marrow is limited. Known metastatic disease to the bone is difficult to evaluate. Multilevel degenerative changes are mild. UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report for subdiaphragmatic findings. IMPRESSION: 1. Multiple pulmonary nodules in all lobes of the right lung and left upper lobe as described in the body of the report in keeping with history of metastatic small cell lung cancer. Assessment of known osseous metastases is limited. 2. Mediastinal lymphadenopathy. 3. Trace left pleural effusion. 4. Please see separate report performed on the same day for detailed evaluation of the abdomen or pelvis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Failure to thrive Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 96.0 heartrate: 95.0 resprate: 20.0 o2sat: 94.0 sbp: 137.0 dbp: 90.0 level of pain: 10 level of acuity: 2.0
Mr. ___ is a ___ history of SCLC dx ___ s/p chemo/rads and WBR, DM, CAD s/p MI and DES, HLD now presents with worsening weakness and fatigue, also with new metastasis of lung ca, elevated liver enzymes and guaiac+ stool. # Fatigue, weakness, failure to thrive, weight loss # Metastatic SCLC Failure to thrive is likely ___ progression of his metastatic lung cancer. Per extensive discussion with patient and family, he was diagnosed with SCLC (Limited stage) in ___ after being found to have hyponatremia (114), likely paraneoplastic syndrome. Was on tolvaptan, since discontinued. S/p chemo and chest radiation as well as prophylactic whole brain radiation. He had initially gone to ___ for a second opinion which was similar to that of ___ oncology team and subsequently stayed at ___ for cancer care. Reportedly his staging CT scans after chemo/rads indicated no recurrence of disease. The ___ wife has a copy of MRI L spine from ___ which indicates osseous metastatic disease, patient and his family report they were not informed of spread of cancer until this past week when he had CT in ED at ___. They visited Dr. ___ on ___ who told the family that it was a "long shot" but that they could start chemotherapy on ___. Over the weekend, he became weaker and his wife brought him in for weakness as well as a second opinion. Outpatient oncology records indicate that he was known to have osseous metastases since ___. In notes, his SCLC was always referred to as "extensive stage." CT torso was completed which demonstrated widespread metastatic disease (see report under imaging). BICMD oncology was consulted. They recommended against cancer-directed therapy and recommended Hospice care. Dr. ___ ___ outpatient oncologist) is in agreement with this plan. A family meeting was held on ___ and they agreed with transition to hospice. Palliative care was consulted for hospice planning, which was arranged prior to discharge. His pain was controlled with fentanyl 12 mcg patch and liquid oxycodone ___ mg PO q4h prn pain. His anxiety was treated with liquid lorazepam 0.25-0.5 mg PO q6h prn. Due to somnolence, the family was also provided with a prescription for Ritalin to use as needed so that he could be alert and present with visiting family. Other home medications which would not contribute to the ___ comfort were discontinued. # Elevated liver enzymes Liver enzymes elevated including AST/ALT/ALP and Tbili. ALP could be elevated from bony disease, but all abnormalities could be explained by liver mets. Has some diffuse abdominal discomfort but on exam is non tender. On CT torso he did not have external compression with intra/extrahepatic biliary ductal dilation that would be amenable to a palliative biliary stent. # Thrombocytopenia -Plt 29, with INR 1.4 on admit. Platelets were 50 last week. Oncology was contacted by ED for concern of TTP who recommended smear in AM as well as hemolysis labs (as above) and that this was not likely TTP, may be related to marrow infiltration/liver disease. -No active or overt signs of bleeding however prophylactic heparin was held given low platelets. # Guaiac positive stool # Diarrhea - He had diarrhea for a few days, no sick contacts, no fevers. WBC not elevated. ___ be related to food intake vs viral gastroenteritis. Had colonoscopy (screening) a few years ago and was told repeat in ___ years. -Guiac+: is hemodynamically stable, and unclear of baseline hemoglobin. No history of visible blood in his stool. -As vitals are stable and patient had no overt signs of bleeding. #Anemia -Not clear of baseline. Is hemodynamically stable as above and is not below the threshold for transfusion. #Diabetes -Continued lantus 18 units qhs. ___ consider decrease if PO intake remains poor. PO diabetic meds held given poor intake. # CAD s/p MI, DES x2 # HTN - Discontinued aspirin, Crestor, Plavix, metoprolol, amlodipine and lisinopril. #Back spasms - unclear if this is related to metastatic dz. Continued gabapentin; other pain control as above. #Mood - continued Prozac, trazodone as needed
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left sphenoid wing lesion. Major Surgical or Invasive Procedure: ___ L craniotomy for tumor resection History of Present Illness: Ms. ___ is a ___ right-handed woman with history of migraines who tonight around 8pm was found by her husband. They had been watching the ___ Bowl at home and she had gone to the bedroom around half time and had been gone around ___ minutes when he found her on the floor. He did not witness any convulsive activity and there was no incontinence. He states that at first she opened her eyes and spoke a few words but was not giving any clear answers. She then closed her eyes and was breathing deeply but not responding to him verbally. He called ___ and when EMS arrived she tried to stand up and was verbally responsive but confused. She remained disoriented for awhile. She was brought to ___ where a CT scan showed an intracranial mass, for which she was transferred to ___. She did receive 1G dilantin IV and 10mg decadron IV prior to transfer. Outside hospital labs reportedly showed wbc 7.7, Hg 13.2, Hct 40.1, Plt 297, normal electrolytes, LFTs, troponins. The patient states that over the past month she has been experiencing "dissociative" episodes. These at first consisted of auditory hallucinations - voices that she would hear and be confused. They would last around one minute or less and were at first every ___ days. She now is no longer hearing the voices but instead she has episodes were she feels that she is outside her body watching herself. The episodes last 1 minute or less and she has them about once a day now. She also states she was having intermittent double vision which would occur when she was looking at something in the distance that was moving. When asked, she states that she has had some word-finding difficulty over the past month as well, at first subtly. Recently her husband has noticed this as well. She does have migraines about once a month, and takes excedrin when she feels this is coming on (last took excedrin migraine one pill 2 days ago). She frequently has headaches for which she takes tylenol or ibuprofen. She last took ibuprofen 500 mg this morning, and maybe took it one other time this week. She has not noticed any change in the timing or frequency of headaches. She has been waking up the past couple of days with neck stiffness which she attributed to positioning/pillow. She has not noted any numbness or weakness or paresthesias. She does have nausea chronically and has not noted any difference in this symptom. No vomiting. Past Medical History: PMHx: migraines seasonal allergies Social History: ___ Family History: Family Hx: Mother - hypertension ___ grandmother - breast cancer in her ___ Paternal aunt - MS ___ - may have had ___ disease Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: T:97.9 BP: 122/71 HR: 80 RR 16 O2Sats 99% on RA 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. Adequate fund of knowledge. Serial 7s- made a few errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally. Coordination: normal on finger-nose-finger, rapid alternating movements. PHYSICAL EXAMINATION ON DISCHARGE: alert & oriented Cranial nerve ___ palsy PERRL No pronator drift Incision c/d/i MAE ___ strength Pertinent Results: CTA Head ___ Mass lesion centered in the left middle cranial fossa with mass effect and vasogenic edema as previously described. There is superior displacement of the left MCA M1 and M2 branches which remain patent. The mass lesion abuts these branches without evidence of encasement. MRI Head with and without ___ Avidly extra-axial enhancing lesion identified in the area of the left sphenoid wing, associated with significant vasogenic edema, and mass effect towards the right, likely consistent with meningioma. Chest X-Ray ___ No acute intrathoracic process. Chest CT Abdomen and Pelvis with and without Contrast ___ No evidence of malignancy in the abdomen or pelvis. CT Chest with Contrast ___ 1. No evidence of intrathoracic malignancy. MRI Brain with and without Contrast and Functional Brain MRI ___ 1. Unchanged extra axial avidly enhancing mass lesion in the left sphenoid wing region, associated with mass effect and vasogenic edema as described in detail above, likely consistent with a meningioma. 2. The functional MRI demonstrates the expected BOLD activation areas in the primary motor cortex, with no evidence of activation areas adjacent to the mass lesion. The language paradigm demonstrates the majority of the BOLD activation in the left cerebral hemisphere, consistent with left hemispheric dominance with activation areas (Broca's area) anterior and superior to the mass lesion. MRI WAND ___: Left sphenoid wing meningioma identified for surgical planning ___ ___ Expected postoperative changes after a left sphenoid wing meningioma resection. There is a small amount of hemorrhage in the resection bed and along the left frontal craniotomy site, as described above. Edema and mass effect are similar to the pre-operative MRI. ___ brain MRI w/&w/o contrast Post- surgical changes including blood products in left temporal region. No obvious acute infarct. Persistent vasogenic edema and mass effect and rightward shift of midline structures, with some distortion of the midbrain, as before. Allowing for the T1 pre-contrast hyperintense blood products, only a small nodular focus of enhancement noted- se 13, im 7 that can relate to residual tumor or post-surgical changes. Consider close followup to assess for interval change. Medications on Admission: zyrtec 1 pill daily excedrin migraine PRN, last dose 2 days ago, 1 pill tylenol PRN ibuprofen 500 mg PRN, last dose morning of ___, may have taken another dose in the past week Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN headache 2. Bisacodyl 10 mg PO/PR DAILY 3. Cetirizine 10 mg PO DAILY 4. Dexamethasone 4 mg PO Q6H 4mgQ6H x 5d, 4mg Q8 x2d, 4mg Q12 x 2d, 3mg Q12 x 2 d, 2mg Q12 x2 d, 2mg daily x1 then stop RX *dexamethasone 2 mg ___ tablet(s) by mouth taper per instructions Disp #*108 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID 6. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H PRN pain Disp #*60 Tablet Refills:*0 8. Phenytoin Sodium Extended 200 mg PO TID RX *phenytoin sodium extended 200 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*3 Discharge Disposition: Home With Service Facility: ___ ___: Left sphenoid wing lesion. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS INDICATION: ___ with seizure, intracranial mass // Eval for aneurysm, vascular supply to ?intracranial mass TECHNIQUE: Contiguous axial images were obtained through the brain after the administration of intravenous contrast. Subsequently, repeat exam was performed after the administration of intravenous contrast. Images were processed on a separate workstation with curved reformats, 3D volume rendered images, and maximum intensity projection images. DOSE: DLP: 676 mGy-cm COMPARISON: Head CT from ___. MRI from ___, performed shortly after this exam. FINDINGS: Avidly enhancing mass lesion centered in the left middle cranial fossa extending superiorly is as detailed on prior MRI. Degree of mass effect with midline shift and vasogenic edema is as described on concurrent MRI. CTA HEAD: There is superior displacement of the distal M1 and M2 branches of the left MCA secondary to adjacent mass lesion. The lesion is seen in close proximity to the proximal M2 branches without encasement. The ICAs, MCAs and ACAS are all patent without significant stenosis, aneurysm or occlusion. The vertebral arteries appear codominant. Basilar artery and PCAs appear normal. IMPRESSION: Mass lesion centered in the left middle cranial fossa with mass effect and vasogenic edema as previously described. There is superior displacement of the left MCA M1 and M2 branches which remain patent. The mass lesion abuts these branches without evidence of encasement. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old woman with seizure, ICH // Please further characterize intracranial mass TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T-weighted, axial fast spin echo T2-weighted, axial FLAIR, axial diffusion weighted and axial gradient echo images. Axial T1 weighted images were repeated after the administration of intravenous gadolinium contrast. Sagittal MP-RAGE and multiplanar reformations were provided and reviewed. COMPARISON: Head CT from an outside institution ___) dated ___, and CTA of the head dated ___. FINDINGS: Unchanged avid extra-axial enhancing lesion identified in the area of the left sphenoidal wing, associated with vasogenic edema and mass effect, causing approximately 7 mm of shifting of the normally midline structures towards the right and also causing effacement of the left perimesencephalic cisterns. This lesion measures approximately 32 by 34 mm in transverse dimension and approximately 37 x 34 mm in coronal projection, in the coronal view is evident how this lesion is extending in the left temporal fossa and superiorly causes displacement of the M2 and M3 segments of the left middle cerebral artery. No other areas with abnormal enhancement are seen. No diffusion abnormalities are detected to indicate acute to subacute ischemic changes, the mass lesion demonstrates slow diffusion, likely related with hypercellularity. The orbits are unremarkable, the paranasal sinuses and mastoid air cells are clear. IMPRESSION: Avidly extra-axial enhancing lesion identified in the area of the left sphenoid wing, associated with significant vasogenic edema, and mass effect towards the right, likely consistent with meningioma. Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old woman with brain lesion // pre-op cxr COMPARISON: None FINDINGS: PA and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal, allowing for the patient's pectus deformity. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: MR FUNCTIONAL BRAIN BY PHYS/PSYCH INDICATION: ___ year old woman with a L temporal lesion. // operative planning. TECHNIQUE: Functional MRI was obtained on a 3 Tesla magnet with Echo Planar/BOLD technique. The functional paradigms include analysis of the motor areas during the alternating movement of the hands, feet and tongue. Language paradigm during the mental process of generating words with different letters. Additionally axial MP-RAGE sequence was obtained as a reference anatomical image. Arterial spin label (ASL), diffusion tensor images (DTI) in axial projections and tractography with 36 directions were obtained and reviewed. COMPARISON: Prior MRI of the brain dated ___. FINDINGS: Unchanged extra-axial avidly enhancing mass lesion is again seen in the left sphenoid wing region, measuring approximately 33 x 36 mm in transverse dimension, causing significant mass effect and associated vasogenic edema, however unchanged the prior study. There is increased profusion on the ASL sequence indicating hypervascularity within this mass. The vasogenic edema is also producing displacement of the major adjacent tracts as visualized on the image 74, series 35. The functional MRI demonstrates the expected activation areas during the movement of the hands, feet and tongue. There language paradigms demonstrate the majority of the BOLD activation on the left cerebral hemisphere, which is consistent with left hemispheric dominance for the language, with the major activation areas (Broca's area) anterior and superior to the mass lesion. IMPRESSION: 1. Unchanged extra axial avidly enhancing mass lesion in the left sphenoid wing region, associated with mass effect and vasogenic edema as described in detail above, likely consistent with a meningioma. 2. The functional MRI demonstrates the expected BOLD activation areas in the primary motor cortex, with no evidence of activation areas adjacent to the mass lesion. The language paradigm demonstrates the majority of the BOLD activation in the left cerebral hemisphere, consistent with left hemispheric dominance with activation areas (Broca's area) anterior and superior to the mass lesion. Radiology Report INDICATION: ___ year old woman with a new intracranial lesion // evaluation for primary or metastatic disease . TECHNIQUE: MDCT images were obtained through the abdomen and pelvis in conjunction with imaging of the chest. Noncontrast, portal venous, and ___ Min delayed phases were obtained. Coronal and sagittal reformations were prepared. DLP: 1183 mGy-cm. COMPARISON: None. FINDINGS: CT ABDOMEN: The lung bases are clear. The visualized portions of the heart pericardium are normal. The liver enhances homogeneously and there is no focal liver lesion. The hepatic and portal veins are patent. The gallbladder, pancreas, spleen, and adrenals are normal. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or mass. The stomach and small bowel are unremarkable. There are prominent mesenteric lymph nodes that are not enlarged by size criteria (6:63,67,68). There is no free air or free fluid. CT PELVIS: The appendix is normal. The colon, rectum, urinary bladder uterus, and adnexae are unremarkable. There is no pelvic lymphadenopathy or free fluid. OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for malignancy. IMPRESSION: No evidence of malignancy in the abdomen or pelvis. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: Newly diagnosed intracranial mass. Evaluation for metastatic disease. TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agentand 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: 1183 mGy-cmfor the entire examination of the torso. COMPARISON: The study is read in conjunction with concurrently obtained CT of the abdomen and pelvis, and MRI of the brain obtained on ___. Comparison is also made to chest radiograph from ___. FINDINGS: MEDIASTINUM: The thyroid is normal. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The aorta and pulmonary arteries are normal in size. The heart size is normal and there is no pericardial effusion. PLEURA: There is no pneumothorax. There is no pleural effusion. Mild biapical scarring is noted, greater on the right (12:18). LUNGS: The airways are patent. There is no airspace consolidation. There is no diffuse interstitial abnormality. There are no concerning pulmonary nodules. BONES: There are no destructive focal osseous lesions concerning for malignancy within the imaged thoracic skeleton. UPPER ABDOMEN: Findings within the abdomen and pelvis will be reported separately by the Abdominal Radiology division. IMPRESSION: 1. No evidence of intrathoracic malignancy. Radiology Report EXAMINATION: MR HEAD W/ CONTRAST INDICATION: ___ year old woman with a left brain lesion. MRI with and without contrast with fiducials placed for operative planning. Please perform MRI WAND on ___ prior to 0600AM in anticipation for early AM surgery. // Please perform MRI WAND on ___ prior to 0600AM for operative planning in anticipation for early AM surgery. TECHNIQUE: Axial T1 and MPRAGE post gadolinium images were obtained with surface markers for surgical planning. COMPARISON: ___. FINDINGS: Again a left sphenoid wing extra-axial enhancing mass consistent with meningioma identified. There is extensive left temporal parietal and frontal edema identified. There is mass effect on the left lateral ventricle. There is no significant interval change since the previous MRI. IMPRESSION: Left sphenoid wing meningioma identified for surgical planning. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: Status post left midbrain mass resection. Evaluate for postop changes. TECHNIQUE: Contiguous axial images of the brain were obtained without the administration of IV contrast. DOSE: DLP: 897.12 mGy-cm; CTDIvol: 54.74 mGy. COMPARISON: MRI of the head from ___. CT of the head from ___. FINDINGS: The patient is status post a left sphenoid wing meningioma resection. There are expected postoperative changes in the resection bed with a thin rim of hyperdensity, likely reflecting hemorrhage, some low-density fluid, and a few locules of air. There is also pneumocephalus layering anterior to the left frontal lobe. A thin rim of high density material along the lateral aspect of the left frontal lobe (3, 16), below the craniotomy site, likely represents an additional focus of hemorrhage. There may be a small amount of intraparenchymal hemorrhage in this region as well (3, 17). Edema in the left temporal lobe is similar in extent to the preoperative MRI. This results in approximately 8 mm of rightward shift of normal midline structures. Again, this is similar to the preoperative MRI. There is mild compression of the left lateral ventricle. There is no hydrocephalus. The basal cisterns are patent. No large vascular territory infarction is identified. Osseous changes from a left frontal and temporal craniotomy are noted with expected changes in the overlying subcutaneous tissue. No other acute osseous finding is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Expected postoperative changes after a left sphenoid wing meningioma resection. There is a small amount of hemorrhage in the resection bed and along the left frontal craniotomy site, as described above. Edema and mass effect are similar to the pre-operative MRI. Radiology Report EXAMINATION: MR ___ W AND W/O CONTRAST INDICATION: ___ year old woman with L sided brain lesion s/p resection // Evaluate for post-op change TECHNIQUE: MRI of the ___ without an with IV contrast COMPARISON: MR ___ ___ and ___ FINDINGS: Post- surgical changes including blood products. No obvious acute infarct. Persistent vasogenic edema and mass effect and rightward shift of midline structures, with some distortion of the midbrain, as before. Allowing for the T1 pre-contrast hyperintense blood products, only a small nodular focus of enhancement noted- se 13, im 7 that can relate to residual tumor or post-surgical changes. Minimal fluid in mastoids. IMPRESSION: Post- surgical changes including blood products in left temporal region. No obvious acute infarct. Persistent vasogenic edema and mass effect and rightward shift of midline structures, with some distortion of the midbrain, as before. Allowing for the T1 pre-contrast hyperintense blood products, only a small nodular focus of enhancement noted- se 13, im 7 that can relate to residual tumor or post-surgical changes. Consider close followup to assess for interval change. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Transfer, s/p Fall Diagnosed with BRAIN CONDITION NOS, CEREBRAL EDEMA temperature: 97.9 heartrate: 80.0 resprate: 16.0 o2sat: 99.0 sbp: 122.0 dbp: 71.0 level of pain: 0 level of acuity: 2.0
The patient was admitted to the Neurosurgery service from an OSH on ___ after experiencing seizure-like activity the prior day. She underwent a MRI of the brain which showed a left sphenoid wing tumor and a CT torso which was negative for intrathoracic malignancy. On ___, the patient's neurologic examination remained stable. She underwent a Functional MRI of the Brain for operative planning. The pre-operative evaluation was started today. Her corrected Dilantin level was 11.1. On ___, the patient's examination remained neurologically stable. Her corrected Dilantin level was 9.8 and she received a one-time additional PO dose. She signed the consent form for surgery scheduled for ___. She was made NPO after midnight in anticipation for resection of the brain lesion. On ___ her Dilantin level was therapeutic at 14.3 and she was taken to the OR for a left sided craniotomy for tumor resection. She toelrated the proceudre well, was extubated in the operating room, and transferred to the PACU post-operatively for continued management and care. She underwent a Post-operative Head CT was WNL. On ___, the patient was stable from a neurologic standpoint. She was transferred to the floor after having spent the night in the PACU. On ___ A MRI of the brain was ordered which showed Post- surgical changes including blood products in left temporal region. No obvious acute infarct. Persistent vasogenic edema and mass effect and rightward shift of midline structures, with some distortion of the midbrain, as before. She continued on Dex 4mg Q6 On ___ Patient was evaluated by ___ and was cleared for discharge home with home ___. Dilantin level came back as 5.9. Dilantin dose was increased accordingly. Her pain was well controlled. She was tolerating a diet. She was discharged home on a Dex taper with instructions for follow up. She was given an eye patch for comfort given post op cranial nerve ___ palsy.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bactrim / Flonase / latex / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: abdominal pain, vomiting Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ F who has been experiencing abdominal pain, daily vomiting, diarrhea since ___ presents with worsening RUQ pain and vomiting over the past day. She has known GB polyps seen on u/s in ___ and is scheduled for elective CCY with Dr. ___ on ___. On the night prior to presentation, her RUQ became sharp and worsened to ___ on pain scale. This morning, she was nauseous with ___ episodes of vomiting after eating a small meal. Vomit was bilious and had small amounts of blood (she reports her vomit often has small amounts blood.) Says she was vomiting so hard she had a nose bleed, but this stopped after several mintues. She also complains of muscular pain throughout her abdomen ___ repeated vomiting. Denies fevers/chills. Had normal BM today, not black/tarry or bloody. Is passing flatus. She did not take anything for pain at home (was told not to take NSAIDs or tylenol), but took zofran and promethazine. In terms of her chronic GI issues, she reports she has constant RUQ pain which intermittently worsens. Pain is worsened with food intake but does not seem associated with fatty goods. She vomits once per day and often has ___ episodes of diarrhea. Even if she doesn't eat, at times she vomits what she ate the night before. Prior work-up has included an endoscopy in ___, which showed mild gastritis with stains negative for H. pylori. U/s in ___ showed small gallbladder polyps measuring up to 4 mm with no other abnormalities. Given severe pain and repeated vomiting, she called the ___ clinic who referred her to the ED. In the ED, she received morphine, ondansetron and metoclopramide. Her pain is now ___ on the pain scale. ROS: Positive per HPI. Negative for fevers, chills, CP, SOB, dysuria. Past Medical History: PMH: asthma PSH: breast reduction Social History: ___ Family History: FH: Aunt had same issues with chronic RUQ pain and normal u/s; resolved after CCY. Otherwise negative for liver, biliary, other GI disease. Positive for DM, breast cancer, cervical cancer. Physical Exam: #ADMISSION PHYSICAL EXAM: PE: 98.5 85 116/66 16 100%on RA Gen: No acute distress. HEENT: Sclera anicteric. MMM, OP clear Cor: RRR, nl S1, S2, no m/r/g Res: CTAB Abd: TTP in RUQ with voluntary guarding. No peritoneal signs. Mildly TTP throughout epigastrium and RLQ. Ext: WWP, no c/c/e, 2+ DP pulses Neuro: A Ox3 . #DISCHARGE PHYSICAL EXAM: T 98, HR 71, BP 105/61, RR 16, O2 sat 97% RA GEN: WD/WN, NAD HEENT: sclera anicteric, MMM, PERRL, NC/AT, OP clear CV: RRR, no m/g/r PULM: CTAB ABD: minimally TTP in RUQ, normoactive BS, no HSM, no guarding or peritoneal signs. EXT: WWP, no c/c/e, 2+ DP and ___ pulses Neuro: A&O x 3, grossly non focal, gait normal Pertinent Results: #ADMISSION LABS: ___ 08:17PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 05:15PM GLUCOSE-93 UREA N-8 CREAT-0.8 SODIUM-142 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11 ___ 05:15PM estGFR-Using this ___ 05:15PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-58 TOT BILI-0.1 ___ 05:15PM LIPASE-36 ___ 05:15PM ALBUMIN-4.1 ___ 05:15PM WBC-3.7* RBC-4.29 HGB-12.6 HCT-38.0 MCV-89 MCH-29.4 MCHC-33.1 RDW-12.3 ___ 05:15PM NEUTS-38.2* LYMPHS-50.2* MONOS-7.4 EOS-3.0 BASOS-1.3 ___ 05:15PM PLT COUNT-279 . #PERTINENT HOSPITAL COURSE LABS: ___ 08:10AM BLOOD WBC-3.9* RBC-4.03* Hgb-11.7* Hct-35.1* MCV-87 MCH-29.0 MCHC-33.3 RDW-12.3 Plt ___ ___ 08:10AM BLOOD Glucose-100 UreaN-7 Creat-0.7 Na-139 K-4.1 Cl-107 HCO3-25 AnGap-11 ___ 08:10AM BLOOD ALT-18 AST-22 AlkPhos-52 TotBili-0.1 ___ 08:10AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8 . #IMAGING: [] RUQ U/S (___) IMPRESSION: Two 2 mm gallbladder polyps without findings to suggest cholecystitis or other explanation for the patient's symptoms. Medications on Admission: Maxair inhaler Ondansetron Promethazine 25 mg tablet Q6H PRN nausea Compazine Omeprazole 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. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: abdominal pain and vomiting Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Known gallbladder polyps with right upper quadrant pain, assess for cholecystitis. COMPARISON: ___. FINDINGS: The liver is normal in echotexture without intra or extrahepatic biliary ductal dilatation. The common bile duct measures 3 mm. A tiny right hepatic cyst is seen measuring 1 cm. The gallbladder is without gallstones or findings to suggest cholecystitis with two, 2 mm gallbladder polyps noted. The portal vein is patent with hepatopetal flow. The pancreas is obscured due to overlying bowel gas as is the aorta. IMPRESSION: Two 2 mm gallbladder polyps without findings to suggest cholecystitis or other explanation for the patient's symptoms. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with ABDOMINAL PAIN RUQ, VOMITING, GB CHOLESTEROLOSIS temperature: 98.5 heartrate: 85.0 resprate: 16.0 o2sat: 100.0 sbp: 116.0 dbp: 66.0 level of pain: 10 level of acuity: 3.0
___ F who has been experiencing abdominal pain, daily vomiting, diarrhea since ___ presents with worsening RUQ pain and vomiting over the past day prior to admission. PAtient underwent RUQ u/s in ___ ED which revealed Two 2 mm gallbladder polyps without findings to suggest cholecystitis or other explanation for the patient's symptoms. She was admitted to the ___ surgical service fo IVF resuscitation, nausea and pain control. Her laboratory studies including LFTs and CBC were not concerning for infectious or biliary etiology. The patient was placed on IVF, given zofran for nausea, and received dilaudid for pain control. All the aforementioned interventions were well tolerated and by the AM of HD 2, the patient had no episodes of emesis, improved nausea, and good pain control. The patient was advised to maintain previously scheduled surgical procedure (lap chole) on ___. At the time of discharge she was ambulatory, pain and nausea free.
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Dilaudid / Percocet / codeine Attending: ___ Chief Complaint: difficulty with math and dates Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a pleasant ___ yo woman with medical history of lung cancer, hypothyroidism, and RT Pcomm aneurysm s/p stent assisted coiling in ___, pipeline embolization in ___, and more recently diagnostic angio on ___. She presents for neurological evaluation of difficulty with dates and math, referred from an OSH after she was found to have subacute RT parieto-occipital infarcts on MRI. She reports was in her usual state of health after her diagnostic angiography until ___ days ago , when she started noticing had some trouble with simple math, as well as orienting herself to the days of the week, and telling time. She endorsed mild bifrontal retro-orbital headache which has not obstructed her activities of daily living. Otherwise denies blurry/double vision, visual scotoma. Denies language difficulty, focal weakness, sensory symptoms, or gait disturbance. Of note, she was diagnosed with lung cancer and Pcomm aneurysm in ___ while being worked up for vertigo. She was then treated for her lung cancer with chemotherapy and radiation prior to her neurovascular interventions. These include: RT pcomm aneurysm stent assisted coiling in ___, pipeline embolization in ___, and more recently diagnostic angio on ___, which was negative per report. She also reports had been taking full dose ASA and Plavix until ___, when she believes discontinued both. She has since resumed the full dose ASA after her angio on ___. On neurologic review of systems, other than the above mentioned symptoms the patient denies lightheadedness. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient notes intermittent palpitations. Otherwise denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: Lung ca, s/p chemo + radiation Osteoarthritis - knees Positional vertigo IBS Urinary retention w/stricture, s/p dilation (requires small Foley) PSH: Right rotator cuff surgery Hysterectomy Lap chole Social History: ___ Family History: NC Physical Exam: Admission Exam: PHYSICAL EXAMINATION Vitals: 97.3 77 173/97 18 100% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: Unlabored breathing on RA Abdomen: Soft Extremities: Warm, no edema Neurologic Examination: MS: Awake, alert, oriented x 3 (slow to recall date but able). Able to relate history without difficulty. Mildly inattentive, able to name ___ backward slowly. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming from stroke card intact. No paraphasias. No dysarthria. Reading intact. Normal prosody. Able to register 3 objects and recall ___ at 5 minutes. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. Cranial Nerves: PERRL 2.5->2mm brisk. VF full to confrontation. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Tongue midline. Motor: Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 *LT upper effort dependent Sensory: No deficits to light touch, decreased sensation to pin over distal lower extremities. No exinction to DSS. DTRs: Bi Tri ___ Pat Ach L 2+ 2+ 2+ 2+ 2+ R 2+ 2+ 2+ 2+ 2+ Plantar response flexor bilaterally. Coordination: No dysmetria with finger to nose testing bilaterally. ******** Discharge exam: Vitals:98, 152/84, 78, 98%RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: Unlabored breathing on RA Abdomen: Soft Extremities: Warm, no edema Neurologic Examination: MS: Awake, alert, oriented x 3 (slow to recall date but able to do so correctly). Able to relate history without difficulty. Unable to name ___ backward stops at ___ Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming from stroke card intact. No paraphasias. No dysarthria. Reading intact. Normal prosody. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. Some difficulty with basic math. Cranial Nerves: PERRL 2.5->2mm brisk. VF full to confrontation. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Tongue midline. Motor: Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 *LT upper effort dependent Sensory: No deficits to light touch, decreased sensation to pin over distal lower extremities. No exinction to DSS. DTRs: Bi Tri ___ Pat Ach L 2+ 2+ 2+ 2+ 2+ R 2+ 2+ 2+ 2+ 2+ Plantar response flexor bilaterally. Coordination: No dysmetria with finger to nose testing bilaterally. Pertinent Results: ___ 10:14AM CK-MB-1 cTropnT-<0.01 ___ 10:14AM %HbA1c-5.1 eAG-100 ___ 10:14AM WBC-5.3 RBC-4.03 HGB-12.5 HCT-37.6 MCV-93 MCH-31.0 MCHC-33.2 RDW-12.3 RDWSD-42.4 ___ 10:14AM PLT COUNT-216 ___ 12:12AM GLUCOSE-90 UREA N-20 CREAT-0.8 SODIUM-141 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17 ___ 12:12AM estGFR-Using this ___ 12:12AM ALT(SGPT)-11 AST(SGOT)-17 ALK PHOS-65 TOT BILI-0.5 ___ 12:12AM LIPASE-19 ___ 12:12AM cTropnT-<0.01 ___ 12:12AM ALBUMIN-4.0 ___ 12:12AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:12AM WBC-5.2 RBC-3.44* HGB-11.0* HCT-32.9* MCV-96 MCH-32.0 MCHC-33.4 RDW-12.4 RDWSD-43.2 ___ 12:12AM NEUTS-60.1 ___ MONOS-8.1 EOS-6.0 BASOS-0.6 IM ___ AbsNeut-3.11 AbsLymp-1.29 AbsMono-0.42 AbsEos-0.31 AbsBaso-0.03 ___ 12:12AM PLT COUNT-172 ___ 12:12AM ___ PTT-32.2 ___ ___ 11:05PM URINE HOURS-RANDOM ___ 11:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 11:05PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM ___ 11:05PM URINE RBC-1 WBC-10* BACTERIA-NONE YEAST-NONE EPI-0 ___ 11:05PM URINE MUCOUS-RARE CTA head and neck ___ IMPRESSION: 1. Area of right frontal hyperdensity corresponding to acute to subacute infarct on recent MR, may represent laminar necrosis or hemorrhagic transformation of infarct. 2. Bilateral cerebellar and right posterior temporal/occipital/parietal hypodensities corresponding to acute to subacute infarct as seen on recent prior MR. ___ is somewhat decreased vascularity in the areas of infarct. 3. Additional smaller infarcts as seen on the prior MR are not well visualized on CT. 4. Pipeline embolization of a right posterior communicating artery aneurysm with residual 3 x 3 mm filling of the aneurysm, unchanged from the recent prior MRA examination. 5. Otherwise patent intracranial arterial vasculature without significant stenosis, occlusion, aneurysm formation. 6. Patent cervical arterial vasculature without significant stenosis, occlusion, or dissection. 7. Right-sided paramediastinal radiation fibrosis. CT head w/o con ___ IMPRESSION: 1. No new intracranial bleeding or large territorial acute infarction detected. 2. Bilateral cerebellar hypodensities and right posterior temporal/occipital/parietal hypodensities, which correspond to areas of acute/subacute infarcts seen on prior MRI head from ___. 3. Area of increased density in the right lateral frontal lobe (series 4, image 19), corresponding to an area of infarct seen on the recent MR study, which may represent hemorrhagic conversion or laminar necrosis. This is not significantly changed in appearance compared to the prior CTA study from ___. Echo ___ The left atrial volume index is normal. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (3D LVEF = 57 %). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No structural heart disease or pathologic flow identified. No definite structural cardiac source of embolism identified. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. ClonazePAM 0.5 mg PO QHS 3. Gabapentin 400 mg PO QHS 4. Doxepin HCl 75 mg PO HS 5. Levothyroxine Sodium 50 mcg PO QHS Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Rosuvastatin Calcium 40 mg PO QPM RX *rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth qpm Disp #*60 Tablet Refills:*0 3. Aspirin 325 mg PO DAILY 4. ClonazePAM 0.5 mg PO QHS 5. Doxepin HCl 75 mg PO HS 6. Gabapentin 400 mg PO QHS 7. Levothyroxine Sodium 50 mcg PO QHS 8.Outpatient Occupational Therapy Discharge Disposition: Home Discharge Diagnosis: ischemic stroke and SAH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: Recent strokes. Evaluate for dissection. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 1,009.3 mGy-cm. 2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP = 24.5 mGy-cm. 3) Spiral Acquisition 5.2 s, 40.7 cm; CTDIvol = 31.9 mGy (Head) DLP = 1,299.5 mGy-cm. Total DLP (Head) = 2,333 mGy-cm. COMPARISON: Outside hospital head CT examinations dating from ___ through ___. Noncontrast head CTs dating from ___ through ___. Outside hospital MR head examinations dating from ___ through ___. FINDINGS: CT HEAD WITHOUT CONTRAST: Bilateral inferior cerebellar hypodensities as well as right posterior temporal/occipital/parietal hypodensities correspond to acute to subacute infarcts as seen on the prior MR examination. There is an area of increased density in the right middle frontal lobe (03:23) in in area of infarct as seen on the recent prior MR examination, and may represent an area of LAMINAR laminar necrosis or early hemorrhagic transformation. Scattered tiny infarcts seen elsewhere on prior MR are not well seen on the CT examination. The ventricles and sulci are normal in size and configuration. Areas of scattered periventricular hypodensities are in a configuration most suggestive of chronic small vessel ischemic disease. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There are mild type like atherosclerotic calcifications of the bilateral intracranial internal carotid arteries without significant narrowing. There has been pipeline embolization of a right posterior communicating artery aneurysm with residual 3 x 3 mm filling of aneurysm, unchanged from the recent prior MRA examination (5: 251). There is somewhat decreased vascularity in the areas infarct. The vessels of the circle of ___ and their principal intracranial branches otherwise appear patent without significant stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There are mild atherosclerotic calcifications of the aortic arch. There are trace atherosclerotic calcifications of the carotid bifurcations without significant narrowing. The carotid and vertebral arteries and their major branches appear patent with no evidence of dissection, significant stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: There is right-sided paramediastinal fibrosis with traction bronchiectasis and volume loss, suggestive of prior radiation. The imaged lung apices are otherwise clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Area of right frontal hyperdensity corresponding to acute to subacute infarct on recent MR, may represent laminar necrosis or hemorrhagic transformation of infarct. 2. Bilateral cerebellar and right posterior temporal/occipital/parietal hypodensities corresponding to acute to subacute infarct as seen on recent prior MR. ___ is somewhat decreased vascularity in the areas of infarct. 3. Additional smaller infarcts as seen on the prior MR are not well visualized on CT. 4. Pipeline embolization of a right posterior communicating artery aneurysm with residual 3 x 3 mm filling of the aneurysm, unchanged from the recent prior MRA examination. 5. Otherwise patent intracranial arterial vasculature without significant stenosis, occlusion, aneurysm formation. 6. Patent cervical arterial vasculature without significant stenosis, occlusion, or dissection. 7. Right-sided paramediastinal radiation fibrosis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:51 AM, less than 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with recent ischemic stroke and SAH now with worsening HA and elevated BP // TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.4 cm; CTDIvol = 51.8 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: CTA head from ___ at 02:05. Outside reference MR head from ___. FINDINGS: Again seen are bilateral cerebellar hypodensities and right posterior temporal/occipital/parietal hypodensities, which correspond to areas of acute/subacute infarcts seen on prior MRI from ___. An area of increased density is again seen in the right lateral frontal lobe (04:19), corresponding to an area of infarct seen on the recent MR study, not significantly changed in appearance compared to the prior CTA study. Periventricular white matter hypodensities are nonspecific, but are suggestive of chronic microangiopathic disease. The ventricles and sulci are normal in size and configuration. Right internal carotid artery flow diverting stent is unchanged from prior exam. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No new intracranial bleeding or large territorial acute infarction detected. 2. Bilateral cerebellar hypodensities and right posterior temporal/occipital/parietal hypodensities, which correspond to areas of acute/subacute infarcts seen on prior MRI head from ___. 3. Area of increased density in the right lateral frontal lobe (series 4, image 19), corresponding to an area of infarct seen on the recent MR study, which may represent hemorrhagic conversion or laminar necrosis. This is not significantly changed in appearance compared to the prior CTA study from ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal MRI, Transfer Diagnosed with Cerebral infarction, unspecified temperature: 97.3 heartrate: 77.0 resprate: 18.0 o2sat: 100.0 sbp: 173.0 dbp: 97.0 level of pain: 0 level of acuity: 2.0
Mrs. ___ is a pleasant ___ yo woman with medical history of lung cancer, hypothyroidism, and RT Pcomm aneurysm s/p stent assisted coiling in ___, pipeline embolization in ___, and more recently diagnostic angio on ___. She presented for neurological evaluation of difficulty with dates and math, referred from an OSH after she was found to have subacute RT parieto-occipital, and b/l cerebellar infarcts as well as right frontal hyperdensity c/f hemorrhagic transformation of infarct vs convexal SAH on MRI from OSH. CTA head and neck at ___ confirmed these findings. Although the recent diagnostic angio with ___ could have certainly caused her stroke, it is unusual to cause stroke in areas so distant from the R. PCOMM. She underwent an Echo to rule out other possibilities for stroke, which showed no abnormality. She was stated on amlodipine 5mg daily for blood pressure control.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / lisinopril / Sulfa (Sulfonamide Antibiotics) / Tetracycline Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old male with a PMH siginificant for CLL, on leukeran, rituximab (first dose rituximab ___, multiple CVA (hemiparetic in ___, hypertension and hyperlipidemia who presents with chills and fever. His fever is not associated with worsening cough, shortness of breath, chest pain, rhinorrhea, congestion, sore throat, abdominal pain, constipation, diarrhea, dysuria, frequency or urgency. He had his first dose of rituximab on ___ and otherwise has been in a good state of health. He has not had any worsening of symptoms. He has a chronic cough, related to PO intake likely secondary to aspiration from dysphagia from his CVA. His predominant symptom was chills at home that started today. ED Course (labs, imaging, interventions, consults): Initial vitals: Pain 0 T 102 HR 120 BP 162/98 RR 22 Sat 94% Vitals on transfer: HR 91 BP 107/49 RR 22 Sat 97% NC Meds given: Cefepime 2g, Vancomycin 1g, acetaminophen 1300mg Fluids: 2L NS Access: 18g PIV Labs notable for cbc 7.8/12.2/37.9/135 with 26%N and 1 band, lactate 2.7, chem7 wnl except glu 130 Studies: CXR - RLL PNA On the floor, he is in good spirits, oriented, and feels much improved from when he came in. He has no complaints currently. Review of Systems: (+) Per HPI (-) Denies night sweats. Denies blurry vision. Denies headache, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria. Denies arthralgias or myalgias. Denies rashes. No numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: Per Atrius records Chronic lymphocytic lymphoma, with 17p deletion stroke (left MCA, residual right hemiparesis, ___, who was admitted to ___ ___ on ___ for further evaluation a complaint of dizziness. Neurology consultation recommended CT scanning of the head. CT angiography revealed complete occlusion of the intradural right vertebral artery, and findings consistent with a new punctate stroke in the right posterior cerebellum. Neurology recommended medical management with aspirin and Plavix. While in the hospital, his admission white blood cell count was noted to be 20,000 and increased to 34,000 before discharge. There was lymphocyte predominance. Further evaluation by hematology/oncology was advised, with peripheral blood flow cytometry. The patient went to ___ where he was cared for by ___ peripheral blood flow cytometry to a commercial vendor. The peripheral blood flow cytometry demonstrated a monoclonal B cell population of CD19 and CD20 positive, and negative for CD5, negative for CD10, negative for CD23, CD38, and CD103. The pathologist thought that it may represent marginal zone lymphoma or perhaps lymphoplasmacytic lymphoma. A CBC was collected on ___. His white blood cell count remained 34,000; his hematocrit was 38%; and his platelet count was 221,000. Again, he had a predominance of lymphocytes, some deemed atypical. ___ Initial consult, lesion on arm ___ PB flow at ___: poss MCL or atypical CLL ___ Follow up plan for bone marrow biopsy, skin lesion resolved; CT scan: splenomegaly 19 cm, no other concerning lymphadenopathy ___ Seen at ___ ED for abd pain, scan ___ except for 19 cm spleen ___ Bone marrow biopsy cytogenetics cyclin D1 negative, karyotype complex cytogenetics, 17p- ___ Start chlorambucil, with rituximab to be added cycle #2 PAST MEDICAL HISTORY: Stroke that left the patient with right hemiparesis in ___. Hypertension Hyperlipidemia GERD BPH, status post TURP He has a history of a nasal papilloma. Social History: ___ Family History: Apparently, his father had some sort of a rare blood condition, but the patient and his wife are not sure which one. He died of an MI. Mother lived to ___. He has a twin brother who had a stroke. Physical Exam: DISCHARGE PHYSICAL EXAM: Vitals: 98.4 124/50 50 18 94%RA GENERAL: Elderly male NAD, awake and alert HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD CARDIAC: Normal rate, nl S1 S2, ___ SEM throughout the precordium LUNG: Bibasilar crackles, moderate effort, no wheezes, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, or clubbing. ___ peripheral edema PULSES: 2+ DP pulses bilaterally NEURO: Left ptosis, right sided hemiparesis, some difficulty phonating, otherwise strength full on left SKIN: breakdown on buttocks on admission Pertinent Results: ___ 12:20AM BLOOD WBC-7.8 RBC-4.76 Hgb-12.2* Hct-37.9* MCV-80* MCH-25.7* MCHC-32.3 RDW-15.2 Plt ___ ___ 09:05AM BLOOD WBC-13.0*# RBC-4.39* Hgb-11.3* Hct-34.6* MCV-79* MCH-25.8* MCHC-32.7 RDW-14.8 Plt ___ ___ 06:10AM BLOOD WBC-11.1* RBC-3.86* Hgb-10.3* Hct-30.2* MCV-78* MCH-26.6* MCHC-34.0 RDW-14.7 Plt ___ ___ 12:20AM BLOOD ___ PTT-27.7 ___ ___ 12:20AM BLOOD Glucose-130* UreaN-16 Creat-1.0 Na-141 K-4.0 Cl-103 HCO3-24 AnGap-18 ___ 09:05AM BLOOD Glucose-117* UreaN-16 Creat-0.9 Na-139 K-3.5 Cl-104 HCO3-26 AnGap-13 ___ 06:10AM BLOOD Glucose-102* UreaN-16 Creat-0.9 Na-138 K-3.7 Cl-104 HCO3-25 AnGap-13 ___ 09:05AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7 ___ 12:44AM BLOOD Lactate-2.7* ___ 09:51AM BLOOD Lactate-1.9 CXR ___ FINDINGS: There is mild cardiomegaly. The aorta is mildly tortuous. Lung volumes are low, however there is no focal consolidation concerning for pneumonia. There is no evidence of a pneumothorax. The visualized osseous structures are unremarkable. IMPRESSION: No evidence of pneumonia. Head CT, head/neck CTA FINDINGS: Head CT: Within the left thalamus there is a 1.4 x 1.1 cm hypodense lesion with a peripheral rim of hyperdensity likely representing calcification. There is associated volume loss in this region. There are nonspecific periventricular and subcortical white matter hypodensities likely related to chronic small vessel ischemic disease. There is a ex vacuo dilatation of the left lateral ventricle. The remainder of the ventricles and cisterns are unremarkable. There is no midline shift. There is extensive left maxillary sinus opacification with hyperostosis. There is left ethmoidal mucosal thickening. Head and Neck CTA: There is calcified plaque in the carotid siphons without significant stenosis. The anterior and middle cerebral arteries are unremarkable. There is extensive calcified plaque of the intracranial vertebral arteries. There is focal occlusion of the right V4 segment with reconstitution from the vertebrobasilar junction. There is also mild soft plaque within the right V3 segment. The common carotid and internal carotid arteries are patent without significant stenosis based on NASCET criteria. There is mild calcified plaque at the carotid bifurcations bilaterally. The right vertebral artery is hypoplastic. There is mild calcified plaque at the origin of both vertebral arteries. There is a 6 mm nodule within the right upper lobe on image 16 series 3. IMPRESSION: 1.4 cm hypodensity within the left thalamus with a peripheral rim calcification and associated volume loss. Findings likely relate to a prior infarct. Periventricular and subcortical white matter hypodensities likely relate to chronic small vessel ischemic disease. Extensive calcified plaque of the intracranial vertebral arteries. There is a focal occlusion of the right V4 segment. 6 mm right upper lobe nodule and recommend a followup chest CT in 3 months. Head MRI ___ FINDINGS: There is no evidence of acute infarctions. There is redemonstration of a left thalamic lesion which demonstrates susceptibility artifact and is most compatible with an old hemorrhage. Susceptibility artifact is also noted in the right external capsule, most compatible with an old hemorrhage. Note is made of wallerian degeneration in the left cerebral peduncle. Area of FLAIR hypointensity and T2 hyperintensity with increased signal on ADC map in the right cerebellar hemisphere is consistent with chronic infarction. There is redemonstration of focal occlusion of the right vertebral artery. Left vertebral artery and intracranial flow voids are maintained. Prominence of ventricles and sulci is consistent with age-related involutional changes. Confluent T2/FLAIR hyperintensities in the periventricular white matter, are likely the sequelae of chronic small vessel ischemic disease. There is complete opacification of the left maxillary sinus. Fluid /mucosal thickening is seen within the left frontal sinus and extending to the anterior ethmoidal air cells, predominantly on the left. IMPRESSION: 1. No evidence of acute infarction. 2. Susceptibility artifact within the left thalamus and right external capsule, compatible with old hemorrhage. Wallerian degeneration of the left cerebral peduncle. 3. Chronic infarction of the right cerebellar hemisphere. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. cilostazol 100 mg Oral BID 3. FoLIC Acid 1 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Ranitidine 150 mg PO BID 8. Chlorambucil 14 mg PO MONTHLY 9. Rituximab 0 mg IV Frequency is Unknown Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. cilostazol 100 mg Oral BID 4. Docusate Sodium 100 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Ranitidine 150 mg PO BID 8. Levofloxacin 750 mg PO Q24H RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: fever ?pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ man with new expressive aphasia, known right hemiparesis. COMPARISON: No prior studies available comparison. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, rapid axial imaging was performed from aortic arch through the brain during infusion of 70 cc of Omnipaque intravenous contrast material. Images were processed on a separate workstation with display of curved reformats, 3D volume rendered images and maximum intensity projection images. FINDINGS: Head CT: Within the left thalamus there is a 1.4 x 1.1 cm hypodense lesion with a peripheral rim of hyperdensity likely representing calcification. There is associated volume loss in this region. There are nonspecific periventricular and subcortical white matter hypodensities likely related to chronic small vessel ischemic disease. There is a ex vacuo dilatation of the left lateral ventricle. The remainder of the ventricles and cisterns are unremarkable. There is no midline shift. There is extensive left maxillary sinus opacification with hyperostosis. There is left ethmoidal mucosal thickening. Head and Neck CTA: There is calcified plaque in the carotid siphons without significant stenosis. The anterior and middle cerebral arteries are unremarkable. There is extensive calcified plaque of the intracranial vertebral arteries. There is focal occlusion of the right V4 segment with reconstitution from the vertebrobasilar junction. There is also mild soft plaque within the right V3 segment. The common carotid and internal carotid arteries are patent without significant stenosis based on NASCET criteria. There is mild calcified plaque at the carotid bifurcations bilaterally. The right vertebral artery is hypoplastic. There is mild calcified plaque at the origin of both vertebral arteries. There is a 6 mm nodule within the right upper lobe on image 16 series 3. IMPRESSION: 1.4 cm hypodensity within the left thalamus with a peripheral rim calcification and associated volume loss. Findings likely relate to a prior infarct. Periventricular and subcortical white matter hypodensities likely relate to chronic small vessel ischemic disease. Extensive calcified plaque of the intracranial vertebral arteries. There is a focal occlusion of the right V4 segment. 6 mm right upper lobe nodule and recommend a followup chest CT in 3 months. Radiology Report HISTORY: ___ man with new word finding difficulties. COMPARISON: Prior head/neck CTA from ___. TECHNIQUE: Sagittal T1, axial MPRAGE as well as axial T1 FLAIR, gradient echo, FLAIR and T2 weighted images were obtained through the brain. Diffusion-weighted imaging was also obtained for further evaluation. Axial and coronal reformats as well as axial T1 weighted imaging was obtained after the administration of 9 mL of Gadavist. FINDINGS: There is no evidence of acute infarctions. There is redemonstration of a left thalamic lesion which demonstrates susceptibility artifact and is most compatible with an old hemorrhage. Susceptibility artifact is also noted in the right external capsule, most compatible with an old hemorrhage. Note is made of wallerian degeneration in the left cerebral peduncle. Area of FLAIR hypointensity and T2 hyperintensity with increased signal on ADC map in the right cerebellar hemisphere is consistent with chronic infarction. There is redemonstration of focal occlusion of the right vertebral artery. Left vertebral artery and intracranial flow voids are maintained. Prominence of ventricles and sulci is consistent with age-related involutional changes. Confluent T2/FLAIR hyperintensities in the periventricular white matter, are likely the sequelae of chronic small vessel ischemic disease. There is complete opacification of the left maxillary sinus. Fluid /mucosal thickening is seen within the left frontal sinus and extending to the anterior ethmoidal air cells, predominantly on the left. IMPRESSION: 1. No evidence of acute infarction. 2. Susceptibility artifact within the left thalamus and right external capsule, compatible with old hemorrhage. Wallerian degeneration of the left cerebral peduncle. 3. Chronic infarction of the right cerebellar hemisphere. Findings discussed with Dr. ___ by ___ via telephone on ___ at 16:10. Radiology Report INDICATION: History of shortness of breath, fever on chemotherapy. Please evaluate for pneumonia. COMPARISON: Chest radiograph from ___. TECHNIQUE: AP and lateral views of the chest. FINDINGS: There is mild cardiomegaly. The aorta is mildly tortuous. Lung volumes are low, however there is no focal consolidation concerning for pneumonia. There is no evidence of a pneumothorax. The visualized osseous structures are unremarkable. IMPRESSION: No evidence of pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: CHILLS Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 102.0 heartrate: 120.0 resprate: 22.0 o2sat: 94.0 sbp: 162.0 dbp: 98.0 level of pain: 0 level of acuity: 2.0
the patient was admitted to the hospital for treatment of his fever and chills. He was initially thought to have a pneumonia given his history of aspiration. He was given vancomycin and cefepime in the emergency room and started on Levaquin and Flagyl after arrival to the floor. He quickly defervesced. A chest x-ray did not clearly show a pneumonia, but given that no other source of his fevers was found, he will be continued on Levaquin for one week post discharge. his wife had noted an increase in neurological symptoms, namely that he was substituting numbers for words. The patient was seen by the neurology service. He had imaging including CT angiogram of the head and neck as well as an MRI of the brain. This imaging did not reveal any new stroke. It was thought that he may have recrudescence of old stroke symptoms or maybe having a seizure activity. The patient did not want to stay in house for EEG. Given that he is not having any further symptoms or overt seizure like activity, he will have the EEG done as an outpatient with his neurologist at ___. he will follow-up with Dr. ___ treatment of his CLL.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: Nausea, vomiting, falls Major Surgical or Invasive Procedure: None History of Present Illness: This is an ___ gentleman with a pmhx. significant for HTN, BPH, CKD (baseline creatinine ~2), Gait Disorder NOS who presents with nausea, vomiting and recent falls. Three weeks prior to admission, Mr. ___ was ambulating with a cane/walker without difficulty and going to the gym ___ days a week. During the last week patient was noted to have "a couple of falls" where he describes loosing his balance. . During a visit with Dr. ___ primary care physician last week he was diagnosed with shingles and started on valacyclovir and bactrim (for a left forearm wound). Patient reports that since being seen for the shingles he has had nausea, vomiting and decreased appetite. Patient denies fevers, chills, sweats, HA, dizziness. Patient reports that currently he is thirsty and a little lightheaded. Multiple abrasions noted to his left leg, left arm from falls. . In the ED, initial VS: 98 96 142/90 16 95%. Labs revelaed creatinine of 2.4 up from baseline of ~2.0, sodium found to be 129. Blood counts revealed a normocytic anemia with a hematocrit of 33 which is down slightly from baseline of ~37. He was given 2 liters of IVF, odansetron 4 mg IV x 1, CT head was performed without acute intracranial process, wounds cleaned and dressed, patient tolerated PO diet, and was evaluated by ___ who noted decreased balance, decreased functional mobility with need for rehab placement. Vitals prior to transfer 98.1 66 16 108/54. . Currently, patient feels better after hydration. However, he continues to have nausea and vomited once (weakly gastrooccult positive emesis) upon arrival to the floor. He also says that he has not moved his bowels in ___ days and relates this to poor PO intake. He is passing gas. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - HTN - BPH - Osteoarthritis, sp right knee fusion - CKD (baseline cr 2.0) - Gait Disturbance, evaluated by neurology ___ who felt that there was likely a mechanical component given right knee fusion however peripheral neuropathy also found on exam. Now walks with cane/walker. - Cataracts, right eye - Herpes Zoster, right axilla, diagnosed on ___ - Peroneal neuropathy (shrapnel wound ___- tx by 6 mo electrical stim therapy w/ improved motor fxn Social History: ___ Family History: NC Physical Exam: Physical Exam on Day of Admission: VS: 98.1 66 16 108/54 GENERAL: Elderly gentleman lying in bed, no acute distress HEENT: EOMI, mucous membranes slightly dry CHEST: CTA bilaterally, no wheezes, rales, or rhonchi CARDIAC: RRR, no MRG ABDOMEN: +BS, soft, non-tender, non-distended EXTREMITIES: No edema bilaterally, right knee with deformity and evidence of prior injury SKIN: Pinkish vesicular lesions under right arm (not completely scaled over), abrasions over left arm (healing), abrasions over left knee. NEURO: Alert and oriented x3, CNII-XII intact bilaterally, ___ motor strength intact in upper and lower extremities, gait not assessed Physical Exam on Day of Discharge: VS: 96.5 70 100/65 18 97 RA GENERAL: Elderly male in NAD HEENT: EOMI, MMM, oropharynx clear LUNGS: CTAB, w/o wheeze, rales, or rhonchi HEART: RRR, no murmurs, rubs, or gallops ABDOMEN: soft, nontender, nondistended, + hypoactive BS EXT: 2+ pulses x4 limbs, no cyanosis, clubbing, or edema. R knee deformity with no ROM, consistent with known prior injury. DERM: Confluent macular rash, nontender, no excoriations, extending to face (malar distribution), anterior and posterior torso, and proximal limbs. Multiple abrasions to LLE and LUE, cl/d/int, bandaged. Laceration, 4cm in length, on volar surface of L wrist, cl/d/int, bandaged. NEURO: Alert and oriented x3, MS intact. CNII-XII intact bilaterally. ___ motor strength x4 limbs. Sensation to light touch mildly decreased in R foot c/w known prior injury. Coordination intact by FNF, HS (LLE only), RAM. No micrographia. Gait notable for slow, shuffling, small steps, tendency to fall to L and backwards; Romberg (+). Pertinent Results: ___ 10:10AM BLOOD WBC-4.8 RBC-3.56* Hgb-11.1* Hct-33.3* MCV-94 MCH-31.3 MCHC-33.4 RDW-12.9 Plt ___ ___ 10:10AM BLOOD Neuts-87.9* Lymphs-5.0* Monos-5.1 Eos-1.2 Baso-0.8 ___ 10:10AM BLOOD Glucose-121* UreaN-32* Creat-2.4* Na-129* K-4.3 Cl-93* HCO3-28 AnGap-12 ___ 10:10AM BLOOD ALT-17 AST-23 LD(LDH)-172 AlkPhos-71 TotBili-0.2 ___ 10:10AM BLOOD Albumin-3.8 ___ 10:10AM BLOOD VitB12-368 Folate-6.9 ___ 10:10AM BLOOD Lipase-49 ___ 05:50PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 05:50PM URINE Eos-NEGATIVE ___ 11:42PM URINE Osmolal-551 ___ 11:42PM URINE Hours-RANDOM UreaN-675 Creat-102 Na-84 K-46 Cl-92 Phos-69.9 ___ 06:00AM BLOOD ___ PTT-25.2 ___ ___ 07:10AM BLOOD WBC-5.4 RBC-3.67* Hgb-12.1* Hct-35.3* MCV-96 MCH-32.9* MCHC-34.2 RDW-13.1 Plt ___ ___ 07:10AM BLOOD Glucose-91 UreaN-32* Creat-2.2* Na-133 K-4.3 Cl-97 HCO3-24 AnGap-16 ___ 06:00 BLOOD GLUCOSE-107 BUN-41* CRE-2.3* NA-136 K-4.2 CL-98 HCO3-31 AnGap-11 EKG ___ Sinus rhythm with first degree atrio-ventricular conduction delay. Non-diagnostic repolarization abnormalities. Compared to the previous tracing of ___ there is non-diagnostic repolarization abnormalities. Otherwise, no major change. IntervalsAxes ___ ___ CT head w/o contrast ___ There is no acute intracranial hemorrhage, edema, mass effect, or acute territorial infarction. There are moderate subinsular confluent hypodensities bilaterally consistent with sequela of chronic small vessel disease. There is no large acute territorial infarction. The ___ matter differentiation is well preserved. The paranasal sinuses and mastoids are clear. There is no acute fracture. IMPRESSION: No acute intracranial process. KUB ___ Supine and upright views of the abdomen reveal a large amount of stool extending to the cecum. There is no evidence for ileus or obstruction. No free intraperitoneal air is seen. There is a 4.5 mm granuloma seen in the left upper lung. Otherwise, the imaged lungs are clear. The bones are osteopenic and there are no suspicious osseous lesions. IMPRESSION: 1. Constipation. 2. Small granuloma in the left upper lung. Wrist X-ray ___ (Wet read) no acute fracture or dislocation. Medications on Admission: HCTZ 25 mg qday Valacyclovir 1,000 mg tid (started ___ Bactrim 800 mg/160 mg bid (started ___ Aspirin 81 mg qday Acetaminophen 500 mg qday Vitamin D Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO once a day as needed for arthritis pain. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for pruritis. 5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis. 6. Metamucil 3.4 gram/12 gram Powder Sig: ___ packets PO twice a day as needed for constipation. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day. 10. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 6 weeks. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Hyponatremia Acute on Chronic kidney disease Delayed drug reaction Falls Secondary diagnoses: Herpes zoster Gait disorder Discharge Condition: On discharge, patient was active and talkative. His rash consisted of mostly confluent 0.5-2 cm macular lesions across the face (malar distribution), chest, abdomen, back, arms, and buttocks, and was mildly pruritic on fexofenadine and sarna. He had a bandaged laceration on the volar surface of the left wrist and multiple bandaged abrasions on the left arm and leg. 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 gait disturbance. TECHNIQUE: Axial images of the head were obtained. Coronal and sagittal reformats were acquired. COMPARISON: There are no comparison studies available. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or acute territorial infarction. There are moderate subinsular confluent hypodensities bilaterally consistent with sequela of chronic small vessel disease. There is no large acute territorial infarction. The gray-white matter differentiation is well preserved. The paranasal sinuses and mastoids are clear. There is no acute fracture. IMPRESSION: No acute intracranial process. Radiology Report INDICATION: Constipation x10 days, nausea and vomiting, evaluate for obstruction. COMPARISONS: None. FINDINGS: Supine and upright views of the abdomen reveal a large amount of stool extending to the cecum. There is no evidence for ileus or obstruction. No free intraperitoneal air is seen. There is a 4.5 mm granuloma seen in the left upper lung. Otherwise, the imaged lungs are clear. The bones are osteopenic and there are no suspicious osseous lesions. IMPRESSION: 1. Constipation. 2. Small granuloma in the left upper lung. Radiology Report INDICATION: Status post fall with deep laceration to the wrist. COMPARISON: None. THREE VIEWS LEFT WRIST: There is a bandage overlying the left wrist. There is no acute fracture or dislocation. An overlying IV and vascular calcifications are noted. There are severe degenerative changes of the first carpometacarpal joint with joint space narrowing, subchondral sclerosis, and osteophyte formation. Proximal carpal rows are aligned. No definite radiopaque foreign bodies. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: N&V Diagnosed with RENAL & URETERAL DIS NOS, ABNORMALITY OF GAIT, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED temperature: 98.0 heartrate: 96.0 resprate: 16.0 o2sat: 95.0 sbp: 142.0 dbp: 90.0 level of pain: 0 level of acuity: 3.0
This is an ___ yo M with CKD (baseline Crt ~ 1.8- 2.0), HTN, peroneal neuropathy s/p shrapnel injury ___, BPH, and gait disturbance NOS presents with 1 week of poor po intake, constipation, N/V, new onset rash, and fall # Fall ___ mild orthostatic hypotension from nausea, vomiting, po intake, underlying peroneal neuropathy with right knee fusion and gait disturbance. He did not have respiratory symptoms to suggest pneumonia. UA was bland without evidence of UTI. CT head did not show any intracranial bleeding, however, suggested small vessel disease. Neurological exam revealed mild decrease sensation in the ___ but no obvious deficit in proprioception and no cerebellar signs. He does have wider based gait with mild outward swinging of the right leg (most likely due to right knee fusion) on observation. Patient was subsequently hydrated. Nausea and vomiting improved with discontinuation of the recent antibiotics/antiviral agents. Neurology recommended outpatient follow up for further evaluation of underlying gait disturbance. Physical therapy assessed the patient and felt that he would benefit from rehabilitation. He was encouraged to use a walker. # Adverse drug reaction: nausea, vomiting, rash. Based on patient's account of recent eventa, it appears that his nausea, vomiting, and decreased po intake correlated with initiation of his Bactrim (for possible cellulitis of the left arm) and valacyclovir. His KUB did not show signs of obstruction or ileus. Bactrim and valacyclovir were discontinued upon his arrival to the floor. Nausea and vomiting resolved upon discontinuation of these antimicrobial agents. On exam, he was noted to have macular erythematous rash on the posterior torso that gradually spread to his face, anterior torso, and proximal extremities. This was thought to be consistent with a drug reaction, most likely to Bactrim. It is expected that he will have the rash for about ___ weeks. He was given antihistamine and sarna lotion for pruritis. # Lacerations and ecchymosis in the left extremities. ___ fall as mentioned above. Patient was evaluated by hand surgeon for the laceration on his left ventral wrist and it was felt that suturing the wound would not be helpful. Wound care was provided. A splint was applied to the left wrist to avoid excessive extension given the location of the laceration in order to facilitate healing. These sites were without signs of infection at the time of discharge. # Acute renal failure on chronic kidney disease (baseline creatinine ~ 1.8 to 2.0). Likely result of Bactrim use (which affect the creatinine secretion) and mild hypovolemia. Patient was given IVF in the ED. Bactrim was discontinued. Hydrochlorothiazide was discontinued. It is unclear what his true recent baseline is as there was no recent labs drawn. However, the most recent Crt was back in ___, during which his creatinine fluctuated between 1.8 and 2.0. His creatinine improved to 2.2 on ___. # UGIB, most likely ___ ___ tear or esophagitis/gastritis. Noted to have weakly + gastro-occult emesis on initial presentation. Patient did not have any further emesis. His Hct remained stable. The bleeding was mostly result of forceful retching leading to ___ tear or inflammation of the esophagus/stomach. He was placed on pantoprazole. This was switched to omeprazole upon discharge. He should continue for about ___ weeks before stopping the omeprazole. # Hyponatremia. Thought to be ___ SIADH based on initial urine lytes and FeNa did not suggest pre-renal picture. However, it is unclear about the timing of the urine lytes, chemistry, in relation to the initial IVF while he was in the ED. He could have been dehydrated prior to the IVF received in the ED. His hyponatremia resolved over the course of his hospital course. # History of HTN. HCTZ was held given ARF and orthostatic hypotension. His systolic BP was not > 140. Therefore, HCTZ was not restarted upon discharge. # Recent herpes zosters. Given improvement of the right axillary lesions as well as the symptoms that prompted the hospitalization, valacyclovir was discontinued. He completed a total of ~ 7 days.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: syncope, dysarthria Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ yo. RH HF with PMH of HTN and Roux-en-Y gastric bypass ___, also with episodes of room-spinning vertigo for last few weeks, who presents as transfer from ___ for workup of syncope, dysarthria and abnormal head CT. Pt watched her boyfriend run a race today, and was standing for about ___ hours before the syncopal event. She could feel it coming on as a lightheadedness and vision closing in (not clearly a vertigo sensation like she has been having), and alerted her boyfriend to the fact that she was not feeling well. She then collapsed and was unconscious for a few seconds. There was no convulsive activity, eye deviation, tongue biting or incontinence with this. After waking up, she was immediately alert and recalls this, with no postictal confusion but was nauseous and diaphoretic. Pt was then brought to ___ ED, where a CT head was obtained, which showed R temporal hypodensity and swelling. Whilst in the ED, Ms. ___ also developed dysarthria, which gradually improved. Per family, her speech was slurred but she has also developed a strange "tingly" sensation on the right side of her face and the last 3 digits of her right hand, and feels like her balance is off. The pt has never had a seizure or intracranial injury, stroke or CNS infection before this. She is the product of a normal pregnancy and delivery, and had normal milestones in childhood. She did not have febrile seizures as a child. There is no family history of epilepsy. ROS is also negative for unexplained syncope or LOC as well as strange sensory or extrasensory phenomena (such as strange body sensations ___. Past Medical History: - HTN - S/p Roux-en-Y gastric bypass in ___. It appears that her micronutrient levels have been checked, and she has been found to have low B12. She is inconsistent about taking the supplements for this. - S/p cosmetic surgeries (breast implants and tummy tuck) Social History: ___ Family History: Parents: father w/stroke at ___ yo.; both parents with DM, HTN; cousin w/breast CA There is no history of early strokes or heart attacks, bleeding or clotting disorders, seizures, developmental disability, learning disorders, migraine headaches, movement disorders, neuromuscular disorders, dementia. Physical Exam: VS T:98.8 HR:78 BP:134/89 RR:24 SaO2:99%RA. Orthostatics were checked and were negative. General: NAD, lying in bed comfortably. - Head: NC/AT, no conjunctival pallor or icterus, no oropharyngeal lesions - Neck: Supple, no nuchal rigidity, no meningismus. No lymphadenopathy or thyromegaly. - Cardiovascular: carotids with normal volume & upstroke; jugular veins nondistended, venous waveform normal with a > v; no RV heave; RRR, no M/R/G - Respiratory: Nonlabored, clear to auscultation with good air movement bilaterally - Abdomen: nondistended, no tenderness/rigidity/guarding, no hepatosplenomegaly to palpation and percussion - Extremities: Warm, no cyanosis/clubbing/edema, palpable radial/dorsalis pedis pulses. - Back: no tenderness to percussion of spine or CV angles - Skin was without rash, induration or neurocutaneous stigmata. Intact hair, nails and nail folds. Neurologic Examination: Mental Status: Awake, alert, oriented x 3. Attention: Recalls a coherent history; thought process coherent and linear without circumstantiality and tangentiality. Concentration maintained when recalling months backwards. Affect: euthymic Language: fluent without dysarthria and with intact repetition and verbal comprehension. No paraphasic errors. Follows two-step commands, midline and appendicular and crossing the midline. High- and low-frequency naming intact. Normal reading. Normal prosody. I could not appreciate dysarthria Memory: Registration ___ and recall ___ at 3 and 15 minutes Praxis: No ideomotor apraxia or neglect w/o bodypart-as-object or spacing errors. Executive function tests: She had some difficulty with Luria hand sequencing, especially in the R hand Cranial Nerves: [II] Pupils: equal in size and briskly reactive to light and accommodation. VF full to finger counting and motion Fundoscopy: Right disc was tilted but flat with crisp disc margins (no papilledema), normal color. Cup-to-disc ratio normal. I was unable to visualize the left disc as pt had a hard time with the exam. On limited exam, no other retinal or optic disc lesions seen. [III, IV, VI] There is mild esotropia in primary gaze, and especially with cover-uncover. EOM intact, no nystagmus. Saccades symmetric without evidence of INO. Head thrust maneuver w/o corrective saccade. [V] V1-V3 with symmetrical sensation to light touch. Pterygoids contract normally. There is no sensory loss corresponding to the area that the pt claims feels different. [VII] No facial asymmetry at rest and with voluntary activation. [VIII] Hearing grossly intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI] SCM strength ___. Trapezii ___. [XII] Tongue shows no atrophy, emerges in midline and moves easily. Motor: Normal bulk and tone. No pronation or drift. No tremor or asterixis. [ Direct Confrontational Strength Testing ] Arm Deltoids [R 5] [L 5] Biceps [R 5] [L 5] Triceps [R 5] [L 5] Extensor Carpi Radialis [R 5] [L 5] Finger Extensors [R 5] [L 5] Finger Flexors [R 5] [L 5] Interossei [R 5] [L 5] Abductor Digiti Minimi [R 4+] [L 5] Abductor Pollicis Brevis [R 5] [L 5] Leg Iliopsoas [R 5] [L 5] Quadriceps [R 5] [L 5] Hamstrings [R 5] [L 5] Tibialis Anterior [R 5] [L 5] Gastrocnemius [R 5] [L 5] Extensor Hallucis Longus [R 5] [L 5] Sensory: Intact proprioception at halluces bilaterally. No deficits to pinprick testing on extremities and trunk. Cortical sensation: No extinction to double simultaneous stimulation. Graphesthesia intact. Reflexes [Bic] [Tri] [___] [Quad] [Ankle] L ___ 2 2 R ___ 2 2 Plantar response flexor bilaterally. Negative ___ and Troemner's. Coordination: No rebound. When touching own nose with finger, with eyes closed, she past-points to the right with the right hand. Right hand seems mildly clumsy on RAM and finger taps, and mildly dysmetric as well. No dysmetria on heel-knee-shin testing. No dysdiadochokinesia. Gait& station: No Romberg. She has a wide-based and unsteady gait. She can stand on heels and toes. Discharge exam is notable for right lower facial weakness, mild impairment on right FNF and finger tapping, markedly improved from admission. Gait is normal upon discharge. Pertinent Results: CT/CTA head and neck: TECHNIQUE: CTA head and neck is obtained after the intravenous administration of 70 cc of Omnipaque contrast. Images were processed on a separate workstation with display of curved reformats, 3D volume rendered images, and maximum intensity projection images. FINDINGS: Head CT: There is no evidence of hemorrhage, edema, mass effect or infarct. Hypodensity in the right lobe is artifactual. The ventricles and sulci are normal. The orbits, and paranasal sinuses are unremarkable. Head neck CTA: Right A1 segment is hypoplastic. The anterior and middle cerebral arteries are otherwise unremarkable. There are bilateral fetal type PCAs. The left vertebral artery is hypoplastic and the V4 segment is not identified and likely relates to an occlusion. The basilar artery is hypoplastic with possible multiple focal areas of narrowing. The common carotid and internal carotid arteries are patent without evidence of significant stenosis based on NASCET criteria. There is no dissection. IMPRESSION: No intracranial hemorrhage or evidence of acute infarct. Hypoplastic basilary with questionable areas of narrowing. The left vertebral artery is hypoplstic. The left V4 segment is not identified and likely relates to a distal vertebral occlusion. An MRI and MRA maybe helpful for further evaluation. There is no aneurysm or dissection. MRI head: TECHNIQUE: Sagittal T1, MP-RAGE imaging, as well as axial T1, T2 gradient echo, and FLAIR imaging was obtained through the head. Axial T1 imaging was obtained after the administration of intravenous Gadovist contrast. Diffusion-weighted imaging was also performed. FINDINGS: There are T2 and FLAIR hyperintense nonenhancing signal abnormalities in the pons (8:8, 7:7). There is no evidence of a right temporal mass. There is no evidence of hemorrhage. Ventricles and sulci are normal in size and configuration. Visualized paranasal sinuses are clear. IMPRESSION: T2 and FLAIR nonenhancing hyperintense signal abnormalities within the pons, for which the differential diagnosis includes inflammatory, ischemic and/or demyelinating disorders. No evidence of a right temporal lobe mass. EEG: FINDINGS: BACKGROUND: The background, during the awake portion of the record, shows a fairly well-developed posterior 10.0-10.5 Hz alpha that attenuates with eye opening. HYPERVENTILATION: Was not performed. INTERMITTENT PHOTIC STIMULATION: Intermittent photic stimulation, done at the end of the study using multiple stimulating frequencies, did not lead to significant occipital driving. SLEEP: The patient was extremely drowsy throughout this record. When left alone, she progressed rapidly into late stage N2 sleep and also spent some time in stage N3 sleep. Excessive snoring was noted during some of the deeper phases of sleep but no apnea occurred. CARDIAC MONITOR: Cardiac rhythm is sinus-based with a rate between 60 and 65 bpm. IMPRESSION: This prolonged study shows brief normal awake EEG with normal progression through drowsiness, stage N2 and stage N3 sleep. No focal or epileptiform features were identified. MRA neck (with fat sat) TECHNIQUE: MRA of the neck is obtained pre- and post intravenous administration of 12 cc of gadolinium. The following sequences were utilized: Axial T1 fat sat, coronal 3D vibe pre, and coronal 3D vibe post. FINDINGS: The common carotid, and internal carotid arteries are patent without significant stenosis based on NASCET criteria. The right vertebral artery is unremarkable. There is no flow signal seen within the distal left vertebral artery predominantly involving the V3 and V4 segments. There is no hyperintensity on the T1 fat sat axial images in the expected course of the left vertebral artery to definitively indicate a dissection. IMPRESSION: No flow signal within the distal left vertebral artery that is unchanged from recent CTA. There is no hyperintensity on the axial T1 fat sat images to definitely indicate dissection. Usually an MR done 2 days a after the dissection occurred is sufficient to see a T1 hyperintense signal. However, its absence doesn't exclude a dissection, and a short term follow MRA in several more days may be helpful for further evaluation. Echo: The left atrium is normal in size. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The 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 leaflets are structurally normal. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No intracardiac source of embolism identified. Normal biventricular cavity size and regional/global systolic function. No pathologic valvular abnormalities. Medications on Admission: - lisinopril 20 mg daily - B12 and MVI when she remembers Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth Daily Disp #*30 Tablet Refills:*5 2. Cyanocobalamin 50 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*5 3. Multivitamins 1 TAB PO DAILY 4. Simvastatin 10 mg PO DAILY RX *simvastatin 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*5 5. Lisinopril 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: bilateral pontine ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge exam: mild ataxia on right FNF, finger tapping. Right lower facial droop. Followup Instructions: ___ Radiology Report INDICATION: ___ woman with hemiparetic ataxia. Stroke workup and question of right temporal mass. COMPARISON: Prior head and neck CTA from ___. TECHNIQUE: Sagittal T1, MP-RAGE imaging, as well as axial T1, T2 gradient echo, and FLAIR imaging was obtained through the head. Axial T1 imaging was obtained after the administration of intravenous Gadovist contrast. Diffusion-weighted imaging was also performed. FINDINGS: There are T2 and FLAIR hyperintense nonenhancing signal abnormalities in the pons (8:8, 7:7). There is no evidence of a right temporal mass. There is no evidence of hemorrhage. Ventricles and sulci are normal in size and configuration. Visualized paranasal sinuses are clear. IMPRESSION: T2 and FLAIR nonenhancing hyperintense signal abnormalities within the pons, for which the differential diagnosis includes inflammatory, ischemic and/or demyelinating disorders. No evidence of a right temporal lobe mass. Radiology Report HISTORY: ___ woman with absent left V4 on CTA, acute pontine ischemia bilaterally. Evaluate for vertebral dissection. COMPARISON: Compared to head and neck CTA dated ___. TECHNIQUE: MRA of the neck is obtained pre- and post intravenous administration of 12 cc of gadolinium. The following sequences were utilized: Axial T1 fat sat, coronal 3D vibe pre, and coronal 3D vibe post. FINDINGS: The common carotid, and internal carotid arteries are patent without significant stenosis based on NASCET criteria. The right vertebral artery is unremarkable. There is no flow signal seen within the distal left vertebral artery predominantly involving the V3 and V4 segments. There is no hyperintensity on the T1 fat sat axial images in the expected course of the left vertebral artery to definitively indicate a dissection. IMPRESSION: No flow signal within the distal left vertebral artery that is unchanged from recent CTA. There is no hyperintensity on the axial T1 fat sat images to definitely indicate dissection. Usually an MR done 2 days a after the dissection occurred is sufficient to see a T1 hyperintense signal. However, its absence doesn't exclude a dissection, and a short term follow MRA in several more days may be helpful for further evaluation. Radiology Report ___ with dizziness, aphasia, CT at OSH with ?aneursysm. COMPARISON: Non con head CT dated ___. TECHNIQUE: CTA head and neck is obtained after the intravenous administration of 70 cc of Omnipaque contrast. Images were processed on a separate workstation with display of curved reformats, 3D volume rendered images, and maximum intensity projection images. FINDINGS: Head CT: There is no evidence of hemorrhage, edema, mass effect or infarct. Hypodensity in the right lobe is artifactual. The ventricles and sulci are normal. The orbits, and paranasal sinuses are unremarkable. Head neck CTA: Right A1 segment is hypoplastic. The anterior and middle cerebral arteries are otherwise unremarkable. There are bilateral fetal type PCAs. The left vertebral artery is hypoplastic and the V4 segment is not identified and likely relates to an occlusion. The basilar artery is hypoplastic with possible multiple focal areas of narrowing. The common carotid and internal carotid arteries are patent without evidence of significant stenosis based on NASCET criteria. There is no dissection. IMPRESSION: No intracranial hemorrhage or evidence of acute infarct. Hypoplastic basilary with questionable areas of narrowing. The left vertebral artery is hypoplstic. The left V4 segment is not identified and likely relates to a distal vertebral occlusion. An MRI and MRA maybe helpful for further evaluation. There is no aneurysm or dissection. Case discussed with Dr. ___ phone by Dr. ___ at 1:25pm on ___, at the time the findings were made. Radiology Report HISTORY: Female with possible seizures. Assess for pneumonia. COMPARISON: None. TECHNIQUE: Frontal and lateral chest radiographs. FINDINGS: Clear lungs bilaterally without pleural effusion or pneumothorax. Heart size, mediastinal contour and hila are normal. No bony abnormality. IMPRESSION: Normal chest radiograph. No pneumonia. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: DIZZINESS Diagnosed with VERTIGO/DIZZINESS, HYPERTENSION NOS temperature: 98.8 heartrate: 78.0 resprate: 24.0 o2sat: 99.0 sbp: 134.0 dbp: 89.0 level of pain: 0 level of acuity: 2.0
Ms. ___ was admitted to the general neurology service. Head imaging was negative for mass, but did show bilateral pontine ischemic stroke. Vascular imaging displayed a markedly hypoplastic posterior circulation with absence of a large segment of the intracranial left vertebral artery concerning for dissection. MRA with fat sat was obtained that did not demonstrate evidence of obstruction, but repeating this study should be considered in the future as the suspicion for vertebral dissection remains high. The patient was started on daily aspirin as well as a low dose statin. Her symptoms improved markedly and at the time of discharge she was able to walk normally. Minimal ataxia remained on the right side, as well as a right facial droop. She will follow up closely in neurology clinic.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Gadolinium-Containing Agents / Demerol / Morphine / Haldol / Cardizem / Protonix / epinephrine Attending: ___ Chief Complaint: Chest, abdominal pain, itching Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old woman with mast cell degranulation syndrome with frequent mast cell attacks (history of intubation), CAD/CABG ___, who presents with chest and abdominal pain. Chest pain described as left sided tightness, radiating to her back, constant, no alleviating factors. Chest pain is reportedly similar to her previous epidosed that occur with mast cell flairs. Pain typically improves with IV narcotics, benadryl and ativan. She has associated SOB and wheezing. Abdominal pain is located in epigastrim and is associated with nausea and vomiting x2. She states she is unable to take her benadryl secondary to nausea. She also has diarrhea that started today, denies melena/hematochezia. She has generalized pruritis on the top half of her body. Notably, discharge summary from ___ reads, "There have been recurrent concerns raised in the medical record regarding the validity of this diagnosis [mast cell degranulation syndrome] in this patient. She has been seen by allergy at ___ in the past that have recommended against the use of IV narcotics as it can actually exacerbate her symptoms. Additionally per the medical record the physician who has made the diagnosis has stated the IV protocol should be used in cases of true anaphylaxis. Of note the patient has never truly had an anaphylactic reaction." In the ED, initial VS were: 97.5 108 132/85 30 98% RA. Labs including CBC, chem 10, LFTs, trop all within normal limits. ECG without ST/T changes. She received 2mg IV dilaudid, IV benadryl 50mg x2, IV lorazepam 2mg, IV ondansetron 4mg, and aspirin. VS prior to transfer were: 97, RR: 20, BP: 121/68, Rhythm: sr, O2Sat: 97, O2Flow: 2l (nc). On arrival to the floor, she states she is SOB, and itchy. She has ongoing chest pain and nausea. REVIEW OF SYSTEMS: Denies fever. + night sweats. No vision changes, rhinorrhea, congestion, sore throat, cough. No abdominal pain, dysuria, hematuria. Past Medical History: -CABG ___ - Mast Cell Degranulation Syndrome (Not mastocytosis) - Primary allergist: ___ (___; ___ ___ - Also seen by Dr. ___ (___ Allergy Asthma and Immunology; ___ - Portacath ___ - removed for MRSA infection, re-placed ___ - syncope attributed to orthostatic hypotension with positive tilt table testing ___ - Hypothyroidism - Histrionic personality disorder - ADHD/depression/anxiety - Erosive rheumatoid arthritis - GERD, gastritis and esophagitis on EGD ___ - Paradoxical Vocal Cord Dysfunction on fiberoptic laryngoscopy - s/p hysterectomy and oophorectomy - left wrist cellulitis concerning for necrotizing fasciitis s/p fasciotomy - s/p cholecystectomy - s/p tonsillectomy Social History: ___ Family History: Mother died of MI at ___. Sister with breast cancer and bilateral mastectomy and thyroid cancer. Brother with ___ and hyperlipidemia. Physical Exam: ADMISSION EXAM: VITALS: 98.7, 105/66 84 20 98% 1L NC GENERAL: well appearing, anxious, initially breathing rapidly but slows during interview HEENT: PERRL, EOMI, MM dry NECK: no carotid bruits, JVD LUNGS: CTAB no W/R/R HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3, normal mentation DISCHARGE EXAM PHYSICAL EXAMINATION: VITALS: 97.9 BP102/61 P74 R18 O2 95 RA GENERAL: well appearing, anxious, initially breathing rapidly but slows during interview HEENT: NCAT, no scleral icterus, mild shoddy LAD, oropharynx clear, MM dry LUNGS: CTAB no W/R/R, poor inspiratory effort HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3, normal mentation Pertinent Results: ADMISSION LABS ___ 04:25PM PLT COUNT-280 ___ 04:25PM WBC-4.3 RBC-4.29 HGB-12.8 HCT-38.4 MCV-90 MCH-29.7 MCHC-33.2 RDW-15.1 ___ 04:25PM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-2.1 ___ 04:25PM CK-MB-2 ___ 04:25PM cTropnT-<0.01 ___ 04:25PM LIPASE-24 ___ 04:25PM ALT(SGPT)-22 AST(SGOT)-26 CK(CPK)-72 ALK PHOS-94 TOT BILI-0.3 ___ 04:25PM estGFR-Using this ___ 04:25PM GLUCOSE-111* UREA N-15 CREAT-0.9 SODIUM-142 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15 DISCHARGE LABS ___ 02:30PM BLOOD WBC-4.1# RBC-3.98* Hgb-11.8* Hct-35.5* MCV-89 MCH-29.6 MCHC-33.2 RDW-14.8 Plt ___ ___ 02:30PM BLOOD Glucose-143* UreaN-12 Creat-0.8 Na-143 K-3.5 Cl-108 HCO3-28 AnGap-11 ___ 05:52AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 04:25PM BLOOD cTropnT-<0.01 ___ 02:30PM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0 MICROBIOLOGY ___ 10:49 am URINE Source: Kidney. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Lorazepam 1 mg PO DAILY PRN nausea 2. Zolpidem Tartrate 10 mg PO HS 3. Vitamin D 1000 UNIT PO DAILY 4. Rosuvastatin Calcium 40 mg PO DAILY 5. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache 6. Aripiprazole 1 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Carvedilol 3.125 mg PO DAILY hold for SBP <90 or HR <60 9. Duloxetine 60 mg PO DAILY 10. Clopidogrel 75 mg PO DAILY 11. Ferrous Sulfate 650 mg PO DAILY 12. Fexofenadine 180 mg PO BID 13. FoLIC Acid 1 mg PO DAILY 14. Furosemide 40 mg PO DAILY 15. Gabapentin 600 mg PO TID 16. Levothyroxine Sodium 25 mcg PO DAILY 17. Methadone 5 mg PO TID 18. Multivitamins 1 TAB PO DAILY 19. Omeprazole 40 mg PO DAILY 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation 21. Promethazine 25 mg PO Q8H:PRN nausea 22. Ranitidine 300 mg PO HS 23. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 24. Methotrexate 22.5 mg PO 1X/WEEK (FR) ___ 25. Montelukast Sodium 10 mg PO DAILY 26. etanercept *NF* 50 mg/mL (0.98 mL) Subcutaneous qweek 27. cromolyn *NF* 100 mg/5 mL Oral QID please give 30mL Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache 2. Aripiprazole 1 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Carvedilol 3.125 mg PO DAILY hold for SBP <90 or HR <60 5. Clopidogrel 75 mg PO DAILY 6. cromolyn *NF* 100 mg/5 mL Oral QID please give 30mL 7. Duloxetine 60 mg PO DAILY 8. Ferrous Sulfate 650 mg PO DAILY 9. Fexofenadine 180 mg PO BID 10. FoLIC Acid 1 mg PO DAILY 11. Furosemide 40 mg PO DAILY 12. Gabapentin 600 mg PO TID 13. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 14. Levothyroxine Sodium 25 mcg PO DAILY 15. Lorazepam 1 mg PO DAILY PRN nausea 16. Methadone 5 mg PO TID 17. Methotrexate 22.5 mg PO 1X/WEEK (FR) ___ 18. Montelukast Sodium 10 mg PO DAILY 19. Multivitamins 1 TAB PO DAILY 20. Omeprazole 40 mg PO DAILY 21. Polyethylene Glycol 17 g PO DAILY:PRN constipation 22. Promethazine 25 mg PO Q8H:PRN nausea 23. Ranitidine 300 mg PO HS 24. Rosuvastatin Calcium 40 mg PO DAILY 25. Vitamin D 1000 UNIT PO DAILY 26. Zolpidem Tartrate 10 mg PO HS 27. etanercept *NF* 50 mg/mL (0.98 mL) Subcutaneous qweek Discharge Disposition: Home Discharge Diagnosis: Mast Cell degranulation syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Shortness of breath. Patient with history of mast cell degranulation syndrome. Assess for pulmonary edema or pneumonia. Comparison is made with prior study, ___. There are low lung volumes. Bibasilar atelectases are larger on the left side. Cardiac size is top normal. Right central catheter tip is at the cavoatrial junction. There is no pneumothorax. Left lower lobe subpleural triangular opacity is again noted. Sternal wires are aligned. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: CP/MAST CELL FLARE Diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC, NODULAR LYMPHOMA HEAD, CAD UNSPEC VESSEL, NATIVE OR GRAFT, AORTOCORONARY BYPASS temperature: 97.5 heartrate: 108.0 resprate: 30.0 o2sat: 98.0 sbp: 132.0 dbp: 85.0 level of pain: 9 level of acuity: 2.0
___ year old woman with mast cell degranulation syndrome with frequent mast cell attacks (history of intubation), CAD/CABG ___, who presents with chest and abdominal pain. # Chest pain: Patient was recently discharged on ___ with similar presentation of symptoms. Her chest pain typically improves with IV narcotics, benadryl and ativan. ACS is not suspected give her story, reassuring ECG and normal trop. However, she has a significant cardiac history. Patient did not receive IV narcotics on the floor (was on her home dose of methadone and hydromorphone PO. Complained of significant itching and nausea, which she initially received lorazepam and diphenhydramine IV, however she was transitioned to PO on day 2 of admission. At that time patient would writhe in bed and stated that PO did not work. She was told that no IV medications would be given. At that time she complained of difficulty breathing, and MD evaluated patient. O2 sat monitor showed mid ___ on room air, however patient attempted to take off O2 sat or to dislodge O2 sat from her fingers during exam. She was told again that no IV medications are indicated. Patient then stated that she felt she was able to go home. # Epigastric pain: Note abdominal pain can cause mast cell release and may have caused a flair of her pruritis. Her liver function tests are all within normal limits. She had similar pain during her last admission. Note, see below for further discussion of mast cell disease. # Mast cell degranulation syndrome: Note several notes in ___ have raised question of the validity of this diagnosis. Allergy consultation on ___ states that there is no role for IV narcotics in the treatment of mast cell degranulation and may make symptoms worse. She is on oral pain medications at home that were continued along with anti-emetics. She currently is not seeing an allergist. She needs an established protocol for when she presents to the ED which should be formulated by allergy. She has an appointment scheduled with Dr. ___ at ___, however his office will contact her regarding who she should see in the future. # RA: chronic condition without acute flare while in hospital. No medication changes were made. # Psych: Histrionic traits, needs ongoing care. No acute exacerbation in hospital, no medication changes were made. # Hypothyroidism: No acute exacerbation in hospital, no medication changes were made. TRANSITIONAL ISSUES Allergy appointment needed, and allergist needs to develop plan for future ED presentations and what medications to give.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: simvastatin / Codeine Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o female with moderate to severe AS w/ likely underlying dCHF, HTN, HLD, and CKD who presents with worsening DOE. Pt was underoging outpt work-up for TAVR which included a TAVR CTA w/ pre (150cc/hr x2hr) and post hydration today. After CTA, pt with DOE to bathroom and a result, post hydration did not occur. She was discharged home after the scan with plans to initiate Lasix 20mg PO starting tomorrow. While picking up the Lasix at the ___ phamarcay, pt experienced worsening SOB, unable to ambulate, stopping with a few steps, reporting feeling lightheaded, ?LOC. No head strike, fell on buttocks. Did not have chest pain. She was brought up to urgent care where she was found to have crackles and an EKG showing LBBB with new afib and referred to ED. Pt reports DOE, about ___ steps after her recent cath with stenting, to about 6 steps starting 2 weeks ago. Denies syncope previously. In terms of DOE, she states that she felt her self after the CT (despite OMR note not suggesting this) and developed the change in DOE at the pharmacy. No hemoptysis. No pleuriitic CP. No visual changes. She does endorse leg swelling as well. No orthopnea or PNA, never had been on Lasix. Recently admittd in ___ for CHF and consideration for TAVR versus AVR. Deemed to not be a candidate for surgery, as a result, began the work-up for a TAVR. Cath during that admission did show 2 vessel disease, no intervention at that time. She was discharged and brought back 10 days later for a planned cardiac cath with subsequent ___ in the RCA x2; mLAD x 1 stent. Discharged at that time on ASA and Plavix. In the ED intial vitals were: 98.6 80 123/37 17 96% 2L Nasal Cannula Patient was given: 20 mg PO Lasix. Labs notable for: Hct 30 (baseline 32-33), WBC 17 (baseline ___, cr 1.7 (baseline ~1.5), and a positive d dimer. Given the + d-dimer, new afib, and ?syncope, pt was started on heparin gtt in ED without bolus. Vitals on transfer: 89 ___ 96% RA? ROS: Per HPI Past Medical History: CAD (DES x2 to RCA, DES to mLAD x1, ___ Hypertension Hyperlipidemia Moderate to severe AS w/ underlying ___ Graves disease Severe glaucoma Lymphoproliferative disorder/CLL CKD stage III Social History: ___ Family History: Father and mother with CAD. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 97.8 125/62 82 18 96%RA GENERAL: NAD, comfortable in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with no JVD. CARDIAC: Loud crescendo decrescendo murmur radiating thoughout all areas but most pronounce in the AV area and into carotids, irregularly irregular, S1S2. LUNGS: Mild crackles at bases ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c, mild trace pitting edema on LLE. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ pulses peripherally. DISCHARGE PHYSICAL EXAMINATION: VS: Tm 98.5, 120/42, 64-73, 20, 92-100%RA GENERAL: NAD, comfortable in bed. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with no discernible JVD at 90 degrees. CARDIAC: Crescendo-decrescendo murmur diffusely but most pronounced at the upper right sternal border and into carotids, regular rhythm, normal S1S2. LUNGS: Improved scattered rales throughout lung fields. Not base predominant. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Trace edema in lower extremities. SKIN: No stasis dermatitis, ulcers. PULSES: 2+ radial and DP pulses bilaterally Pertinent Results: ==== ADMISSION LABS ==== ___ 07:20PM BLOOD WBC-17.8* RBC-3.51* Hgb-9.9* Hct-30.2* MCV-86 MCH-28.3 MCHC-32.9 RDW-17.8* Plt ___ ___ 07:20PM BLOOD Neuts-38* Bands-0 Lymphs-55* Monos-5 Eos-1 Baso-1 ___ Myelos-0 ___ 05:41AM BLOOD ___ PTT-64.8* ___ ___ 07:20PM BLOOD Glucose-94 UreaN-34* Creat-1.7* Na-143 K-4.2 Cl-110* HCO3-21* AnGap-16 ___ 05:41AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.1 ___ 07:20PM BLOOD CK-MB-3 cTropnT-0.03* ___ ___ 05:41AM BLOOD CK-MB-3 cTropnT-0.05* ==== IMAGING ==== CXR (___): Small pleural effusions and thickened fissures suggesting mild fluid overload although no frank pulmonary edema. BILATERAL LOWER EXTREMITY DOPPLER (___): No evidence of deep venous thrombosis in the bilateral lower extremity veins. Radiology Report EXAMINATION: CTA TORSO CARDIOTHORACIC SECTION INDICATION: ___ year old woman with severe aortic stenosis // Evaluation of aorta, vascular access TECHNIQUE: 320-slice multi-detector CT angiogram of the heart and aorta was obtained in 3 phases, including a noncontrast chest CT, CTA of the heart using retrospective ECG gating, and CTA Torso, with 160cc Omnipaque contrast administered intravenously. 3D reconstructions, including multiplanar, curved and volume rendered reformatted images were created on a separate workstation and reviewed. The patient's heart rate was continuously monitored by a nurse. Prior to this study, the heart rate was 76 beats per min and the blood pressure was 133/67 mm Hg. Upon discharge, the heart rate was 69 beats per min and the blood pressure was 132/58 mm Hg. Medications: Metoprolol 5 mg IV Procedure complications/allergic reactions: none DOSE: Total body DLP: 1231.30 mGy-cm COMPARISON: Chest CT dated ___. FINDINGS: EXTRACARDIAC FINDINGS: CT CHEST WITH CONTRAST: The thyroid gland is enlarged and contains multiple hypodense nodules measuring up to 11 mm on the right. A heterogeneously enhancing complex nodule in the left lobe measures 20 x 24 mm (11, 40). Prominent mediastinal lymph nodes have grown since ___. For reference, a a right upper paratracheal lymph node measures 9 mm in short axis, previously 5 mm (11, 67). A subcarinal lymph node measures 18 mm in short axis, previously 8 mm (11, 89). Diffuse bilateral ground-glass opacities and interlobular septal thickening are most likely due to new pulmonary edema. Small layering nonhemorrhagic pleural effusions are also new. Airways are patent to the subsegmental level. A 4 mm left lower lobe solid nodule is stable (11, 109). A punctate calcified left upper lobe granuloma is incidentally noted. CT ABDOMEN/PELVIS WITH CONTRAST: The liver is enlarged in the craniocaudad dimension measuring 20 cm. The spleen is also mildly enlarged measuring 15.5 cm in the craniocaudad dimension. A small splenule is incidentally noted (11, 174). A subcentimeter hypodense right renal lesion is too small to characterize. Both kidneys enhance symmetrically without evidence of hydronephrosis. There are a few layering gallstones in the gallbladder. The pancreas and adrenal glands are unremarkable. There is no bowel obstruction or inflammation. There is colonic diverticulosis without evidence for diverticulitis. The appendix is identified, but there are no secondary signs of inflammation. No ascites, pneumatosis or pneumoperitoneum is present. Beam hardening artifact from bilateral hip replacements limits visualization of the pelvis, including the urinary bladder and reproductive organs. There is mild dextroscoliosis of the lumbar spine with extensive multilevel spinal degenerative changes. There is grade 1 anterolisthesis of L4 on L5 and L5 on S1. Moderate degenerative changes involve both glenohumeral joints. No lytic or sclerotic bone lesions are identified. CTA: CARDIAC: The right atrium is normal. The right ventricle is normal. The left atrium is enlarged. The left ventricle is normal. The pericardium is normal and there is no pericardial effusion. The aortic valve is is tricuspid with calcified leaflets. There is also mild calcification of the mitral valve. Dominance of the coronary artery system is right with normal origins and course. Coronary artery calcification is extensive and involves all 3 vascular territories.. PULMONARY ARTERIES: The main pulmonary artery is normal caliber, however the right and left pulmonary arteries appear mildly dilated measuring 2.9 cm on the right and 2.7 cm on the left. There is no evidence of pulmonary embolus. AORTA: The thoracic and abdominal aorta is normal caliber. Moderate to severe atherosclerosis diffusely involves the aorta and its branches. Extensive noncalcified ulcerated plaque involves the descending thoracic aorta starting at the level of the SMA origin, and extending distally to approximately the level of the ___ (series 11, images 167 through 196). The celiac trunk, SMA, ___, and both renal arteries are patent, although there is marked luminal narrowing of the ostium of the left renal artery by atherosclerotic plaque (11, 176). MEASUREMENTS: (3D imaging lab) Major aortic annulus diameter: 25.0mm Minor aortic annulus diameter: 21.3mm Aortic valve area: 402.4mm 2 Aortic annulus perimeter: 73.4mm Sinus of Valsalva height: 22.2mm Sinus of Valsalva width: 32.4mm Height of origin of coronary arteries from aortic valve: 14.4mm Ascending aortic diameter approximately 4.5 cm from aortic valve: 30.0x45.0mm ILIOFEMORAL ARTERIES: The right side is patent at the common iliac, external iliac and common femoral levels, calcifications are mild, tortuosity is moderate to severe. Right common iliac minimal diameter: 8.6X11.9mm Right external iliac minimal diameter: 7.8x9.8mm Right common femoral minimal diameter: 6.0x6.5mm The left side is patentat the common iliac, external iliac and common femoral levels, calcifications are mild , tortuosity is moderate to severe. Left common iliac minimal diameter: 5.8x10.1mm Left external iliac minimal diameter: 6.7x8.4mm Left common femoral minimal diameter: 5.2x6.5mm SUBCLAVIAN ARTERIES: The right subclavian artery is patent. The left subclavian artery is patent. Calcifications are moderate on the right, but mild on the left. Tortuosity is mild. Right subclavian minimal diameter: 6.1x10.9mm Left subclavian minimal diameter: 8.5x11.2mm IMPRESSION: Aortic valve stenosis without evidence of aortic aneurysm. Patent subclavian and common femoral arteries bilaterally with lumen diameters provided above. Enlarged heterogeneous thyroid gland containing multiple nodules measuring up to 20 x 24 mm on the left. A dedicated thyroid ultrasound is recommended for further evaluation. New CHF marked by pulmonary edema small bilateral nonhemorrhagic pleural effusions. Interval increase in size of mildly enlarged mediastinal lymph nodes since ___, which may be due to edema or reactive to cardiac disease. Extensive coronary artery calcifications. Cholelithiasis. Diverticulosis without evidence for diverticulitis. Mild hepatosplenomegaly. Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: Aortic stenosis and stents presenting with fluid overload versus pneumonia. COMPARISON: ___. TECHNIQUE: Chest, PA and lateral. FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged including mild cardiomegaly. There are small new pleural effusions bilaterally since the prior radiographs. Streaky opacities at the lung bases are probably due to associated atelectasis but there is no definite parenchymal edema. Fissures appear slightly more thickened, however. IMPRESSION: Small pleural effusions and thickened fissures suggesting mild fluid overload although no frank pulmonary edema. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with new afib, DOE, ?PE // ?DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None available. FINDINGS: There is normal compressibility, 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. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower extremity veins. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with SYNCOPE AND COLLAPSE temperature: 98.6 heartrate: 80.0 resprate: 17.0 o2sat: 96.0 sbp: 123.0 dbp: 37.0 level of pain: 0 level of acuity: 2.0
___ y/o with severe to moderate AS and CKD who presents with DOE after a CT requiring IVF pre-hydration and development of new-onset atrial fibrillation. # Dyspnea on exertion: Initially thought that patient had become volume overloaded in the setting of pre-hydration for CT. She did, indeed, have a CXR with mild fluid in the fissure. An EKG showed new atrial fibrillation but no ischemic changes. She was given 20mg lasix PO in the ED and started on a heparin gtt for her new-onset atrial fibrillation. The patient's exam on the morning of ___ was not consistent with volume overload, making her overall presentation more consistent with SOB secondary to new atrial fibrillation. LENIs negative for DVT. She was scheduled for cardioversion for her symptomatic AFib, however on the day of cardioversion she spontaneously converted to sinus rhythm with improvement in her respiratory status back to her baseline. She was discharged home with ___ services and PCP/cardiology follow up. She will follow up with the TAVR team for ongoing workup as previously scheduled. # Atrial fibrillation: New onset in the s/o severe AS. CHADS2 score of 2. TSH, T3/FT4 within normal limits. Heparin gtt discontinued on ___ after patient became therapeutic on coumadin. She was also started on metoprolol succinate 25mg qday for rate control. # Severe AS w/ underlying dCHF: Had been undergoing workup and TAVR evaluation as an outpatient. She will follow up with her outpatient cardiologist to continue her workup for TAVR. ==== TRANSITIONAL ==== # AORTIC STENOSIS - Ongoing TAVR workup per outpatient cardiologist # ATRIAL FIBRILLATION - Started on coumadin while inpatient - Started on metoprolol succinate while inpatient - INR check on ___ # Dry Weight: 60.0 kg # CODE: Full (confirmed) # CONTACT: Patient, Sister ___ ___
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing / simvastatin / pravastatin / atorvastatin Attending: ___. Chief Complaint: Nausea, vomiting, dizziness Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is an ___ with history of vertigo, ocular migraines, and tinnitus who presents with nausea and vomiting. The patient reports that she woke up yesterday morning and felt nauseous in the setting of distorted vision. She reports that the objects she saw were "broken and moving". This was worse while lying back than sitting forward. It gradually improved throughout the day with increased fluid intake though she eventually vomited which prompted her presentation to the ED. The patient reports that it was similar to an episode a week ago during which time she was hospitalized. She denies headache, abdominal pain, fevers, chills, night sweats, weight loss, cough, or SOB but did have two episodes of watery stools which she states is normal for her. She endorses some intermittent tinnitus but denies vertiginous symptoms. The patient reports that her current symptoms are similar to those she experienced during her recent admission from ___. During that admission, she was on the Neurology service. The the time, the patient reported visual disturbance, head motion intolerance, nausea, and inability to ambulate and had a reported inconclusive workup for stroke versus peripheral vertigo which included CT head on ___ which showed no acute intracranial process, MRI/A on ___ which showed mild atrophy but was otherwise a normal study, and telemetry which was negative for atrial fibrillation. At the time of her discharge her neurological symptoms improved but it was not clear if she had a stroke, peripheral vertigo, or vestibular neuritis. The Neurology team started the patient on aspirin 81mg daily and atorvastatin 30mg daily to reduce her stroke risk factors, though she did not continue the statin since she had a prior adverse reaction. In the ED, initial vital signs were 96.69 70 114/66 18 98% RA. Labs demonstrated an unremarkable CBC, sodium 129, unremarkable UA. Neurology consult was initiated though completed on the floor given significant symptoms. Upon arrival to the floor, initial vital signs were 98.3 112/46 66 16 98RA. Patient was asymptomatic on arrival, requesting to eat breakfast. Past Medical History: PAST MEDICAL HISTORY: 1. Osteoporosis. 2. Hypercholesterolemia. 3. History of bunions. 4. Ocular migraines. 5. Umbilical hernia. 6. Osteoarthritis. 7. Cataracts. 8. Tinnitus. 9. Vertigo, 1 previous episode PAST SURGICAL HISTORY: 1. Repair of right rotator cuff tear. 2. Mesh repair of recurrent umbilical hernia, ___. 3. Appendectomy. 4. Tonsillectomy and adenoidectomy. Social History: ___ Family History: Siblings: sister w/breast CA in ___ Parents: father died at ___. of heart disease Grandparents: grandfather died at ___. of heart disease Physical Exam: ADMISSION: Vitals-98.3 112/46 66 16 98RA, not orthostatic General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, SEM radiating to LCA Abdomen- soft, NT/ND 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, fleeting left-going nystagmus, cerebellar exam intact DISCHARGE: 98.1 92/38 70 20 94RA Upright in bed, eating breakfast, well-appearing NCAT, MMM Supple RRR (+)S1/S2 no m/r/g Generally CTA b/l Soft, non-tender, NABS Warm, well-perfused No foley Erythema of right foot with minimal tenderness Pertinent Results: ADMISSION: ___ 11:50PM BLOOD WBC-7.8 RBC-4.08* Hgb-12.9 Hct-37.3 MCV-91 MCH-31.7 MCHC-34.7 RDW-12.6 Plt ___ ___ 11:50PM BLOOD Neuts-77.7* Lymphs-14.9* Monos-6.4 Eos-0.6 Baso-0.5 ___ 11:50PM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-129* K-3.6 Cl-97 HCO3-21* AnGap-15 ___ 06:00AM URINE Color-Straw Appear-Clear Sp ___ ___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 06:00AM URINE Hours-RANDOM UreaN-376 Creat-34 Na-71 K-40 Cl-53 RADIOLOGY: ___ FOOT XR Soft tissue swelling over the distal forefoot and chronic severe hallux valgus but no bony erosions, fracture or subcutaneous emphysema seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral QD Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Meclizine 12.5 mg PO Q8H:PRN dizziness RX *meclizine 12.5 mg ___ tablet(s) by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 3. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral QD 4. Outpatient Physical Therapy Rolling walker for gait instability and peripheral vestibulopathy. 5. Naproxen 500 mg PO BID Duration: 5 Days RX *naproxen 500 mg 1 tablet(s) by mouth twice daily Disp #*8 Tablet Refills:*0 6. Omeprazole 20 mg PO DAILY Duration: 5 Days RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*5 Capsule Refills:*0 7. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8) hours Disp #*18 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Vestibular neuritis Hyponatremia 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: ___ year old woman with new-onset swelling of right foot // evaluate for pseudogout TECHNIQUE: Plain film COMPARISON: NONE. FINDINGS: Three views of the right foot show severe hallux valgus deformity (90 degrees) with resultant uncovered the head of the first metatarsal. Abutting subchondral sclerosis at the first MTP joint and osteophytosis at the head of the first metatarsal indicates this is not acute. Soft tissue fullness over the distal forefoot is seen without a subjacent fracture or focal bone erosion. Some minor cortical thickening is seen at the medial shaft of the second metatarsal but this does not have an aggressive appearance. Patchy osteopenia is noted in the midfoot. No gouty tophi are seen and no air is seen in the soft tissues appear IMPRESSION: Soft tissue swelling over the distal forefoot and chronic severe hallux valgus but no bony erosions, fracture or subcutaneous emphysema seen in Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dizziness Diagnosed with VERTIGO/DIZZINESS temperature: 96.69 heartrate: 70.0 resprate: 18.0 o2sat: 98.0 sbp: 114.0 dbp: 66.0 level of pain: 5 level of acuity: 2.0
Ms. ___ is an ___ with history of vertigo, ocular migraines, and tinnitus who presents with dizziness, nausea, and vomiting likely secondary to vestibular neuritis. #Vestibular neuritis Patient with recent admission for similar symptoms complex, unclear etiology, thought by Neurology to be vestibular (peripheral) vs. TIA. On this presentation, no evidence of other neurologic deficits consistent with TIA, and appears to be intermittent/waxing-and-waning which is less consistent with TIA. Patient found not to be orthostatic. It was thought that her presentation was most consistent with a vestibular neuritis. She was given meclizine and ondansetron as needed. Her aspirin was held given risk of vestibular toxicity. The patient was recommended to follow-up with Neurology and ENT as an outpatient for ongoing vestibular neuritis as well as ___ for vestibular therapy. #Right foot erythema Patient developed erythema and tenderness of her right foot. There was concern for pseudogout, though there was no suggestion of foot x-ray. The x-ray was without other findings, as well. The patient was started on a five-day course of naproxen and omeprazole. Follow-up is recommended as an outpatient. #Hyponatremia Patient with Na 129 in setting of increased water intake and nausea/vomiting on admission. Most likely related to SIADH secondary to nausea/vomiting. Patient was given IVF in ED with normalization of her sodium. #Hyperlipidemia Found to have LDL of 160 on prior admission but patient unable to tolerate statins. A low cholesterol diet was recommended. # Caregiver ___ Significant anxiety and stress secondary to caring for husband with dementia. She has experienced sleep deprived and physical exaustion from this responsibility. The patient was seen by Social Work during her hospital stay.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Flomax / Hydrochlorothiazide / Biaxin / Atenolol / Lisinopril / Levaquin / Ativan Attending: ___. Chief Complaint: Lower GI bleeding, ascites. Major Surgical or Invasive Procedure: Red blood cell transfusion 2 units ___, 1 unit ___. Paracentesis ___ (3L), ___ IVC filter placement. ___ Colonoscopy. ___ EGD. ___: 1. Ultrasound-guided puncture of right popliteal vein. 2. Right lower extremity venogram including inferior vena cava. 3. Catheterization of right iliac vein extending into inferior vena cava. 4. AngioJet thrombolysis with tissue plasminogen activator of the right lower extremity venous system as well as the inferior vena cava. 5. Balloon angioplasty and stenting of right iliac vein. 6. Inferior vena cava catheterization for infusion of tissue plasminogen activator overnight. ___: 1. Right lower extremity venogram including the inferior vena cava. 2. Removal of right popliteal sheath with manual compression. ___ Pleurex catheter placement. History of Present Illness: Patient is a ___ Y M with Stage IV colon cancer and portal vein thrombosis who presents from the ER with anemia, vomiting, and BRBPR. He was admitted to the hospital from ___ initially for nausea, vomiting, ascites, and abdominal pain. His hospital course was complicated by aspiration RLL pneumonia and hypoxemic respiratory distress requiring transfer to the ICU. He was also given a course of ABX which lasted for greater than 10 days. His ascites was progressing and secondary to peritoneal carcinomatosis. He received 3 therapeutic paracentesis, each of which drained ___ liters, the last of which was on ___. He was discharged to rehab. t was also diagnosed with a small PE during this past admission. . He states that 2 days after he was admitted to rehab, he began having increasing abdominal distention and discomfort. Although his MS ___ 15mg q12 was discontinued at rehab, his pain has been well controlled with MSIR ___ PRN. He also notes that the last 4 bowel movements have been, "all red" with gross blood and loose stools but no melena. His Hct on ___ was 31.3, on ___ it was 28.6, on ___ it was 29.5 and day of admission to ___ it is 32. He states that he has felt lightheaded upon standing yesterday but no chest pain, syncope, or shortness of breath. He also felt nauseous and vomited non-bloody or coffee grounds. In the ER he had a therapeutic paracentesis which was negative for infection. Currently he has lower abdominal discomfort but otherwise feels well. . Review of Systems: (+) Per HPI + ___ edema (-) Denies fever, chills, night sweats, recent weight loss. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, Denies cough, shortness of breath, or wheezes. Denies constipation, melena, hematemesis, 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: ONCOLOGIC HISTORY: He presented in ___ with abdominal pain. He had a cecal cancer with no evidence of metastatic disease by CT. At the time of open colectomy, there was evidence of miliary studding and he underwent resection of at least one metastatic macroscopically visible omental nodule. FOLFOX chemotherapy was begun in ___ because of symptomatic left lower quadrant pain related to disease progression. We switched to an every three-week basis in ___ because of myelosuppression, especially thrombocytopenia. A repeat CT after four courses showed slight progression. He had restless legs that was felt to represent oxaliplatin toxicity and he was subsequently switched to short-term infusional ___ and leucovorin according to the DeGramont schedule in ___. CTs since then have shown gradually progressive disease. His last CT scan two weeks ago showed increasing ascites and the decision was made to discontinue ___ and leucovorin and proceed with FOLFIRI. He received C1 D1 of modified folfiri on ___. . Other Past Medical/Oncologic History: 1) Hypertension 2) Hyperlipidemia 3) Osteoarthritis 4) Extensive portal vein thrombosis extending up the right hepatic vein on Lovenox since ___ 5) BPH 6) s/p tonsillectomy 7) s/p traumatic finger amputation of left hand at age ___ 8) Nephrolithiasis 9) Peritoneal Carcinomatosis with recurrent ascites and intermittant urinary retention 10) RLL aspiration pneumonia 11) Hiccups likely due to diaphragmatic irritation from peritoneal mets 12) Small PE found during admission ___ (occured on Lovenox) 13) Port clot s/p Angio study and stripping of fibrin sheath done ___. 14) aspiration RLL pneumonia Social History: ___ Family History: Mother had lung cancer. No other family history of malignancy. Physical Exam: ADMISSION EXAM: VS: T 98.1 bp 114/76 HR 85 RR 20 ___ GEN: Elderly man in NAD, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP slightly dry and without lesion NECK: Supple, no JVD appreciated CV: Reg rate and rhythm, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: very firm and distended but no rebound or guarging, minimal tenderness, bowel sounds present, + fluid wave MSK: normal muscle tone and bulk EXT: 1+ bilateral ___ edema with normal distal perfusion SKIN: No rash, warm skin NEURO: oriented x 3, normal attention, no focal deficits PSYCH: appropriate Pertinent Results: ADMISSION LABS: ___ 09:30PM ASCITES WBC-250* RBC-3700* POLYS-25* LYMPHS-54* MONOS-6* MACROPHAG-15* ___ 07:11PM LACTATE-1.0 ___ 06:30PM GLUCOSE-111* UREA N-10 CREAT-0.6 SODIUM-136 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-12 ___ 06:30PM ALT(SGPT)-25 AST(SGOT)-29 ALK PHOS-114 TOT BILI-0.4 ___ 06:30PM LIPASE-57 ___ 06:30PM ALBUMIN-2.7* ___ 06:30PM WBC-15.3* RBC-3.67* HGB-10.6* HCT-32.6* MCV-89 MCH-28.8 MCHC-32.4 RDW-19.3* ___ 06:30PM NEUTS-86.4* LYMPHS-10.3* MONOS-2.4 EOS-0.2 BASOS-0.6 ___ 06:30PM PLT COUNT-473* . ___ ECG: Sinus tachycardia. There is an early transition that is non-specific. Non-specific ST-T wave changes. Compared to the previous tracing of ___ is no significant change. . ___ IVC Placement: FINDINGS: 1. Normal IVC anatomy without duplication or megacava. 2. No filling defect. IMPRESSION: 1. Patent IVC without evidence of thrombosis. 2. Venatech IVC filter placement, infrarenally. . ___ Colonoscopy: Diverticulosis of the whole examined colon, internal hemorrhoids. Mass in the colon (biopsy). Otherwise normal colonoscopy to right colon; unclear surgical history and luminal mass limited interpretation of anatomy. . ___ EGD: Friability, erythema with exudate in the middle third of the esophagus and lower third of the esophagus; most prominent at 25-30cm compatible with esophagitis (biopsy). Normal mucosa in the stomach. Normal mucosa in the duodenum. Otherwise normal EGD to third part of the duodenum. . ___ ___ DOPPLER U/S: IMPRESSION: No evidence of DVT. . ___ CTA AORTA/LEs: IMPRESSION: 1. Acute deep venous thrombosis involving the entire right leg from the calf veins to the right common iliac vein. While the thrombus in the right common iliac vein and external iliac vein is nonocclusive, the remainder of the vessels are filled by occlusive thrombus. Small amount of clot in the IVC filter. Extensive soft tissue edema involving the right leg and right hemipelvis. 2. Nonocclusive thrombosis of the left portal vein is similar in extent than on ___. 3. Moderate amount of ascites. This is somewhat improved. 4. Stable nodularity of the omentum as well as enhancement along the peritoneum are concerning for metastatic disease. 5. Increase in bilateral pleural effusions and dependent atelectasis. . DISCHARGE LABS: ___ 06:03AM BLOOD WBC-6.6 RBC-3.27* Hgb-9.2* Hct-29.0* MCV-89 MCH-28.1 MCHC-31.7 RDW-18.9* Plt ___ ___ 06:29AM BLOOD Neuts-85* Bands-1 Lymphs-7* Monos-6 Eos-0 Baso-1 ___ Myelos-0 NRBC-1* ___ 02:52AM BLOOD ___ ___ 12:27PM BLOOD LMWH-0.33 ___ 06:03AM BLOOD Glucose-96 UreaN-13 Creat-1.0 Na-135 K-3.7 Cl-101 HCO3-27 AnGap-11 ___ 08:15AM BLOOD CK(CPK)-7408* ___ 05:11AM BLOOD ALT-41* AST-41* CK(CPK)-349* AlkPhos-107 TotBili-0.6 ___ 06:10PM BLOOD CK-MB-17* MB Indx-0.5 cTropnT-<0.01 ___ 06:03AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.4 ___ 06:29AM BLOOD Albumin-2.2* ___ 11:18AM BLOOD freeCa-1.08* Medications on Admission: 1. alfuzosin 10 mg Extended Release 24 hr PO daily. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 2. fluticasone 50 mcg/Actuation, SIG: One (1) Spray Nasal DAILY PRN congestion. 3. potassium & sodium phosphates ___ mg Powder in Packet PO TID. 4. morphine ___ mg PO Q4H PRN pain. 5. omeprazole 20 mg PO DAILY. 6. prochlorperazine maleate 10 mg PO Q6H PRN nausea. 7. aspirin 81 mg PO DAILY. 8. enoxaparin 100 mg/mL SC Q12H. 9. ZOFRAN ODT ___issolve PO q8HR PRN nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 10. Imodium A-D 2 mg PO q6HR PRN diarrhea x5 days. 11. ___ 200-25-400-40mg/30mL Mouthwash Sig: 30mL Mucous membrane QID PRN pain. 12. zolpidem 6.25-12.5mg PO qHS PRN insomnia. 13. acetaminophen 325-650mg PO Q6H PRN Pain. 14. loperamide 2 mg PO QID PRN Diarrhea. 15. baclofen 10 mg PO Q8H PRN Hiccups. 16. pantoprazole 40 mg PO Q24H. Discharge Medications: 1. Augmentin 875-125 mg PO BID x3 days. 2. alfuzosin 10 mg Tablet Extended Release 24 hr PO daily. 3. fluticasone 50 mcg/Actuation 1 Spray Nasal DAILY PRN congestion. 4. morphine ___ PO Q4H PRN pain. 5. omeprazole 20 mg PO DAILY. 6. prochlorperazine maleate 10 mg PO Q6H PRN nausea. 7. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Syringe Subcutaneous Q12H. 8. ondansetron ___ Rapid Dissolve PO q8HR PRN nausea. 9. docusate sodium 100 mg PO BID. 10. senna 8.6 mg PO BID. 11. ___ 200-25-400-40mg/30mL Mouthwash Sig: 30mL Mucous membrane QID PRN pain. 12. zolpidem 5 mg PO HS PRN insomnia. 13. baclofen 10 mg PO TID PRN hiccups. 14. fluconazole 400 mg PO Q24H x5 days. 15. calcium carbonate 200 mg calcium (500 mg) PO QID PRN heartburn. 16. metoprolol tartrate 25 mg PO BID. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bleeding per rectum. Metastatic colon cancer. Hemorrhoids. Recurrent malignant ascites (fluid in abdomen). Pulmonary embolism (blood clot in lung). Right leg deep vein thrombosis (DVT, blood clot) with arterial compromise. Elevated white blood count. Portal vein thrombosis (blood clot in abdomenal vein). Candidal esophagitis (yeast infection of esophagus). Hiccups. Low oxygen level, due to ascites (fluid in abdomen). Hypertension (high blood pressure). Sinus tachycardia (fast heart rate). Swelling (edema) of the scrotum. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ year old male with metastatic colon cancer, portal vein thrombosis, and pulmonary emboli with new GI bleed. IVC filter placement in order to safely stop anticoagulation. PROCEDURES: 1. Right common femoral venous access. 2. Preprocedure cavogram 3. Placement of infrarenal Venatech IVC filter. 4. Post-procedure IVC venogram. MEDICATIONS: Moderate sedation was provided by administering divided doses of 25 mcg of fentanyl throughout the total intraservice time during which the patient's hemodynamic parameters were continuously monitored. 1% lidocaine was used for local pain control. OPERATORS: Dr ___ (resident), Dr. ___ (fellow) and Dr. ___ (attending interventional radiologist) who supervised the procedure. TECHNIQUE: After discussion of the risks, benefits and alternatives to the procedure with the patient, written informed consent was obtained. The patient was brought to the angiography suite and placed supine on the imaging table. A preprocedure huddle and timeout were performed. The right groin was prepped and draped in the usual sterile fashion. Following local anesthesia, the right common femoral vein was accessed under ultrasound guidance near the femoral head. A 0.018 guide wire was advanced under fluoroscopic guidance into the right common iliac vein. The needle was exchanged for a 4.5 ___ micropuncture sheath. The inner dilator and 0.018 wire were removed and exchanged for a 0.035 ___ wire. A 5 ___ Omni Flush catheter was placed in the lower IVC near the bifurcation. Digital subtraction venogram was then performed confirming normal venous anatomy, patent IVC, no evidence of thrombosis and no megacava. The level of appropriate placement was then established. The flush catheter and 5 ___ sheath were exchanged for a long 6 ___ sheath over the ___ wire. The Venatech IVC filter was loaded into the sheath and carefully deployed under continuous fluoroscopy with the filter apex at the level of the left renal ostium. A Venatech filter was placed. Post-placement venogram via hand injection was satisfactory and the sheath was subsequently removed. Manual pressure achieved hemostasis. Sterile dressing was applied. The patient tolerated the procedure well without immediate complication. FINDINGS: 1. Normal IVC anatomy without duplication or megacava. 2. No filling defect. IMPRESSION: 1. Patent IVC without evidence of thrombosis. 2. Venatech IVC filter placement, infrarenally. Radiology Report PROCEDURE: Ultrasound-guided paracentesis. INDICATION: A ___ male with metastatic colon carcinoma and ascites. Request therapeutic and diagnostic paracentesis prior to colonoscopy. OPERATORS: Dr. ___ Dr. ___. Dr. ___ was present for the entire duration of the procedure. PROCEDURE: After explaining the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was brought to the ultrasound suite and was laid supine on the ultrasound table. A preprocedure timeout was performed using three unique patient identifiers as per standard ___ protocol. Limited preprocedure sonographic images of the abdomen demonstrated large ascites fluid pocket in the left lower quadrant of the abdomen. This region was targeted for paracentesis. The overlying skin was prepped and draped in usual sterile fashion. Buffered 1% lidocaine was used to anesthetize the skin, subcutaneous soft tissues, abdominal wall musculature, and parietal peritoneum. Following this, a 5 ___ ___ centesis needle was advanced into the peritoneal cavity. There was immediate return of straw-colored ascitic fluid. A sample of the specimen was collected for microbiological analysis. Following this, the ___ centesis needle was connected to vacutainer bottle. 1.6 liters of ascitic fluid was drained from the abdomen. The patient tolerated the procedure well without any immediate periprocedural complications. IMPRESSION: Successful ultrasound-guided diagnostic and therapeutic paracentesis. Laboratory results pending at this time. Radiology Report INDICATION: History of pulmonary embolism with worsening lower extremity edema, off enoxaparin due to GI bleed. Evaluate for DVT. COMPARISON: Bilateral lower extremity ultrasound from ___. FINDINGS: Grayscale and color sonograms were acquired of the bilateral common femoral, superficial femoral, popliteal, posterior tibial, and peroneal veins. There is normal compressibility, flow, and augmentation throughout. IMPRESSION: No evidence of DVT. Radiology Report CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST INDICATION: Right lower extremity swelling, paralysis, paraesthesia. Evaluate for extent of thrombus with CT venogram. CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST TECHNIQUE: Multidetector scanning is performed from the diaphragm through the foot during dynamic injection of 130 cc of Optiray. Comparison is made to prior examination of ___. There are small-to-moderate bilateral pleural effusions. These have slightly increased in size. There is atelectasis in the lower lobes bilaterally. There is thrombosis in the left portal vein which terminates at the bifurcation of the main portal vein and this is similar in extent. No focal liver lesions are seen. The gallbladder is contracted and contains several stones. The spleen is normal in size and without focal lesions. There is a moderate amount of ascites which is decreased. There is persistent nodularity in the omentum consistent with metastatic disease. There is enhancement of the peritoneum in several areas along the right flank and the inferior tip of the liver with some suggestion of nodularity. These may represent peritoneal implants. The splenic vein and SMV are patent. The pancreas is unremarkable. The adrenal glands are normal. There is mild hydronephrosis of the right kidney to an area of narrowing in the proximal ureter. This is unchanged in extent. An infrarenal IVC filter is identified, and clot is seen within the filter. CT OF THE PELVIS WITH IV CONTRAST: There is a nonocclusive thrombus in the right common femoral vein extending into the external iliac vein. There is no pelvic lymphadenopathy. There are multiple diverticula in the sigmoid colon. There is ascites, loculated anterior to the sigmoid colon. There are several areas of enhancement within the peritoneum, most prominently along the left anterior abdominal wall, and again these are concerning for peritoneal implants. There is massive edema around the right hip in the soft tissues. CT OF THE LOWER EXTREMITIES: There is a bilateral hydrocele. Within the right leg, the superficial femoral vein, deep femoral vein, popliteal vein, and the calf veins are completely occluded. There is distention of the vessels consistent with acute thrombus. There are superficial veins which are opacified. There is extensive soft tissue edema of the right leg. There is also edema of the musculature. On bone windows, there are extensive degenerative changes involving the lumbar spine and the sacroiliac joints bilaterally as well as moderate osteoarthritis in the hip joints. No concerning osteolytic or osteosclerotic lesions are seen. IMPRESSION: 1. Acute deep venous thrombosis involving the entire right leg from the calf veins to the right common iliac vein. While the thrombus in the right common iliac vein and external iliac vein is nonocclusive, the remainder of the vessels are filled by occlusive thrombus. Small amount of clot in the IVC filter. Extensive soft tissue edema involving the right leg and right hemipelvis. 2. Nonocclusive thrombosis of the left portal vein is similar in extent than on ___. 3. Moderate amount of ascites. This is somewhat improved. 4. Stable nodularity of the omentum as well as enhancement along the peritoneum are concerning for metastatic disease. 5. Increase in bilateral pleural effusions and dependent atelectasis. Findings were discussed with Dr. ___ by Dr. ___ in person on ___ at 9:00 a.m. Radiology Report INDICATION: ___ year old man with metastatic colon cancer and PE on lovenox. Assess for brain mets prior to surgery. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. COMPARISON: None available. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified and there is no destructive bone lesion suggesting metastatic process. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. No facial or cranial soft tissue abnormalities are present. IMPRESSION: Normal head CT. Radiology Report AP CHEST 10:35 A.M. ___: HISTORY: Elevated white count, assess for pneumonia. IMPRESSION: AP chest compared to ___ through ___: Right lower lobe consolidation persists, possibly improved. Opacification projecting over the left hilus could be posteriorly collected pleural effusion. Heart size is normal. Left subclavian infusion pump ends low in the SVC. No pneumothorax. Radiology Report INDICATION: ___ man with ascites and metastatic colon cancer. Please place Pleurx catheter for ascites drainage. RADIOLOGISTS: Dr. ___ (fellow) and Dr. ___ (attending) performed the procedure. The attending physician was present and supervised throughout the procedure. ANESTHESIA: Moderate sedation was provided by administering divided doses of 50 mcg of fentanyl and 1 mg of Versed throughout the total intra-service time of 25 minutes during which the patient's hemodynamic parameters were continuously monitored. PROCEDURE: Written informed consent was obtained from the patient after explaining the risks, benefits and alternatives to the procedure. The patient was brought to the angiographic table and laid supine on the table. The abdomen was prepped and draped in a sterile fashion. A pre-procedural huddle and timeout were performed per ___ protocol. On initial ultrasound, there was hardly any ascitic fluid present in the right lower, right upper and central/umbilical quadrant of the abdomen. There was ascites noticed in the left lower quadrant of the abdomen. Under ultrasound and fluoroscopic guidance, ___ catheter was inserted into the ascitic pocket through the left-sided abdominal wall. A ___ wire was then inserted and coiled in the pelvis. Attention was now shifted to a spot four fingerbreadths superior and posterior to the insertion site to begin tunneling of the Pleurx catheter. The skin was anesthetized utilizing 1% lidocaine at the insertion site and through the tunnel. A skin ___ was made and the tunneler was utilized to tunnel the Pleurx catheter through the abdominal wall. The insertion site was dilated utilizing multiple dilators and a peel-away sheath was placed over the ___. The inner dilator and ___ wire were removed and the Pleurx catheter was fed into the ascitic fluid. The positioning was confirmed by contrast injection. The venotomy site was closed utilizing ___ Vicryl sutures. The catheter was secured to the skin utilizing 0 silk. Sterile dressings were applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Successful uncomplicated placement of Pleurx catheter into the abdomen. One liter of ascites was drained on the table. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABD DISTENTION Diagnosed with OTHER ASCITES, NAUSEA WITH VOMITING, HYPERTENSION NOS, HX OF COLONIC MALIGNANCY temperature: 97.4 heartrate: 116.0 resprate: 18.0 o2sat: 97.0 sbp: 143.0 dbp: 85.0 level of pain: 4 level of acuity: 2.0
___ man with stage IV colon cancer with peritoneal carcinomatosis, portal vein thrombosis and PE admitted for hematochezia and worsening ascites. IVC filter placed and anticoagulation stopped, but he then rapidly developed a massive RLE DVT, was restarted on heparin gtt and taken for thrombolysis, angioplaty, and stenting by Vascular Surgery. Restarted enoxaparin BID. . # RLE DVT causing arterial compromise (phlegmasia cerulea dolens): Thrombolysis, angioplasty, and stenting of right common iliac ___. Follow-up venography ___ revealed patent right femoral vein, non-occlusive thrombus in common femoral vein, widely patent right iliac wall stents, residual thrombus in IVC filter extending into IVC. CK improving. BLE ACE wraps from toes to groins. Elevated RLE when supine. Restarted enoxaparin post-Pleurex placement. Analgesia as needed. . # Leukocytosis: Present on admission then resolved. A second episode in setting of severe DVT without fever or clear infectious source. Started vancomycin, cipro, and metronidazole ___, changed to pip/tazo and vancomycin with resolution of leukocytosis. Vancomycin stopped given negative cultures. Changed pip/tazo to amoxicillin/clavulanate to complete 10d course. . # Metastatic colon cancer with peritoneal carcinomatosis: s/p modified FOLFIRI x1 cycle ___. Paracentesis ___ (3L), ___ (4.2L), ___ (3L), ___ (3L), ___ (1.6L). Colonoscopy biopsy positive for malignancy with semi-circumferential partially obstructing mass in right colon. Pleurex placed ___. Drained ascites prior to discharge. . # Lower GI bleed while anticoagulated for DVT/PE: Colonscopy ___ showed tumor with partially obstructing mass and internal hemorrhoids. EGD showed esophagitis with ulceration and ___. Aspirin and enoxaparin initially held and IVC filter placed, but restarted anti-coagulation for new severe RLE DVT. Hemodynamically and H/H stable after reinstitution of anticoagulation. . # Portal vein thrombosis: Enoxaparin initially stopped and IVC filter placed for GI bleed, but restarted anticoagulation for severe RLE DVT. . # PE: Incidental finding last admission, but unclear age of PE and very small. IVC filter placed ___ and anti-coagulation discontinued for GI bleed. Restarted enoxaparin for severe RLE DVT. . # Candidal esophagitis: EGD positive for ___. Continued fluconazole. . # Nausea/vomiting: Anti-emetics PRN. Avoid FOSAPREPITANT AND APREPITANT DUE TO HICCUPS. . # Hypoxemia/dyspnea: Due to hypoventilation from ascites and pleural effusion. Resolved with paracentesis. Weaned off O2. . # Hiccups: Improved since last admission. Likely due to diaphragmatic irritation from peritoneal mets + fosaprepitant. Avoided metoclopramide due to recent diarrhea. Continued PRN baclofen. . # BPH with history urethral obstruction: Possibly exacerbated by tumor/ascites. Continued outpatient alfuzosin (Uroxatral), allergy to tamsulosin. . # Scrotal edema: Due to massive IVC clot +/- ascites. On enoxaparin. . # Pain (abdomen): Continued PRN morphine. . # HTN: Normotensive off meds, but metoprolol started for sinus tachycardia. . # GI PPx: Continued PPI. Bowel regimen on hold with recent diarrhea. . # FEN: Regular diet. . # DVT PPx: Enoxaparin and ACE wraps. . # Precautions: Fall. . # Lines: Port. . # CODE: DNI (yes for ACLS).
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: none History of Present Illness: ___ history of intermittent asthma, tobacco abuse presents with asthma exacerbation. Patient states that he started developing a cold last night at work with rhinorrhea, dry cough, and headache. He started to also having wheezing, but did not have his inhaler present while at work. When he came home, he utilized his inhaler; however, this did not relieve his symptoms of shortness of breath and wheezing. He states that he has significant significant shortness of breath with wheezing. He denies fever, cough, myalgias, chest pain, or other symptoms except as above. He also denies sick contacts. He denies receiving flu vaccination this year. He states that tobacco abuse has been weaned down in past few months but actively smoking. He denies any occupational exposures, changes in household (carpet cleaning, new pets/animals, etc). At baseline, he states that his asthma has been present since childhood. He has required ER visits ___ times over the past ___ years. He has never been hospitalized or required PO prednisone. . In the ED inital vitals were, 00:35 5 98.5 118 165/97 18 95% ra A CXR was performed that showed no acute cardiopulmonary process. He was given multiple nebulizer treatments and prednisone 60 mg PO x 1. His initial peak flow was 150. Repeat after 3 nebs was 200. Initial exam showed poor air movement and diffuse wheezing. He was able to speak in complete sentences and was not in respiratory distress with no accessory muscle usage. He was intially placed in observation for nebulizer treatments every two hours. However while he was in observation, he triggered for pulse oximetry reading of 88 % on room air. On repeat exam, his lungs were very tight with poor air movement. He was given magnesium 2 mg. He received continuous nebulized albuterol for an hour and on repeat exam, he still have poor air movement. He was subsequently admitted to the MICU for continued asthma exacerbation and poor peak flow measurements. Labs on transfer were significant for WBC 13.4, Hgb 16.6, Plt 340 with neutrophilia and lymphopenia. Chem panel was within normal limits except hyperglycemia. VS on transfer: 110 19 152/101 94% on neb, peak flow 200. . On arrival to the ICU, patient was able to relate above history. He was in no acute respiratory distress. He was given continuous albuterol nebs, 3 L of LR given tachycardia and hypovolemia. ABG on 5 L NC and 50 % FM showed pH 7.42, pCO2 35, pO2 70, HCO3 23, lactate 4.6. RRV screen was performed, and he was placed on influenza precautions. A sputum culture was also obtained. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Asthma Onset after birth. Triggers are cold and exercise. He uses his albuterol inhaler excluding exercise about 1x/week. He does not see a pulmonary doctor. He has never been intubated or hospitalized for asthma attack before. - Tobacco abuse He currently smokes ___ cigs/day Social History: ___ Family History: Mother has asthma Physical Exam: ADMISSION PHYSICAL EXAM General Appearance: No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Mallampati ___, difficult to assess oropharynx Lymphatic: Cervical WNL Cardiovascular: Heart sounds distant. No murmur. Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: , speaking in complete sentences, good air movement , mild inspiratory squeks, no expiratory wheeze Abdominal: Soft, Non-tender, No(t) Distended, Obese Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace Skin: Warm Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: Labs: ___ 02:25PM BLOOD WBC-13.4* RBC-5.96 Hgb-16.6 Hct-49.6 MCV-83 MCH-27.9 MCHC-33.5 RDW-13.5 Plt ___ ___ 02:25PM BLOOD Neuts-87.8* Lymphs-10.0* Monos-1.7* Eos-0.3 Baso-0.2 ___ 03:29AM BLOOD WBC-16.4* RBC-5.59 Hgb-15.5 Hct-46.0 MCV-82 MCH-27.8 MCHC-33.7 RDW-13.6 Plt ___ ___ 01:30AM BLOOD WBC-20.8* RBC-5.56 Hgb-15.9 Hct-46.4 MCV-83 MCH-28.6 MCHC-34.4 RDW-13.6 Plt ___ ___ 02:25PM BLOOD Glucose-167* UreaN-13 Creat-1.0 Na-136 K-4.3 Cl-102 HCO3-22 AnGap-16 ___ 05:00AM BLOOD Glucose-157* UreaN-11 Creat-0.9 Na-137 K-4.3 Cl-104 HCO3-22 AnGap-15 ___ 01:30AM BLOOD Glucose-138* UreaN-15 Creat-0.9 Na-137 K-4.3 Cl-102 HCO3-22 AnGap-17 ___ 05:00AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 10:01AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 04:55PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 10:39PM BLOOD Calcium-9.4 Phos-2.9 Mg-1.9 ___ 10:01AM BLOOD Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:51PM BLOOD Type-ART pO2-70* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 Comment-NEBULIZER ___ 10:58PM BLOOD ___ pO2-34* pCO2-42 pH-7.39 calTCO2-26 Base XS-0 ___ 03:47AM BLOOD ___ Temp-36.3 Rates-/18 pO2-61* pCO2-37 pH-7.43 calTCO2-25 Base XS-0 Intubat-NOT INTUBA Comment-HIGH FLOW ___ 04:51PM BLOOD Lactate-4.6* ___ 03:47AM BLOOD Lactate-2.6* ___ 04:18PM URINE bnzodzp-NEG barbitr-NEG cocaine-NEG amphetm-NEG MICRO: ___ 3:38 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. ___ 7:06 pm 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. ___: STUDY: PA and lateral chest radiograph. COMPARISON: None. FINDINGS: The cardiomediastinal and hilar contours are normal. The lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. ___: AP radiograph of the chest was reviewed in comparison to ___. Heart size and mediastinum are stable. Lungs are essentially clear. There is no evidence of pneumothorax or pneumomediastinum demonstrated on the current examination. Bibasal opacities are noted and might reflect small areas of atelectasis, new since the prior study that might also reflect compromised aeration through compromised airways or fatigue of inspiration musculature, please correlate clinically. CTA w/ and w/out contrast (___): IMPRESSION: 1. No evidence of acute aortic syndrome or pulmonary embolus. 2. Areas of atelectasis in the lingula, and right lower lobe. Medications on Admission: - albuterol prn wheezing/SOB Discharge Medications: 1. prednisone 10 mg Tablet Sig: ___ Tablets PO once a day: as follows: 4 pills (40mg) ___ pills (20mg) ___ 1 pill (10mg) ___ STOP. Disp:*12 Tablet(s)* Refills:*0* 2. codeine-guaifenesin ___ mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6 hours) as needed for cough: do use with alcohol or driving. Disp:*100 ML(s)* Refills:*0* 3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every ___ hours: until symptoms improved. then as needed after that. Disp:*1 inhaler* Refills:*1* 4. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day: wash mouth off with water afterwards. Disp:*1 inhaler* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation Leukocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ male with shortness of breath. STUDY: PA and lateral chest radiograph. COMPARISON: None. FINDINGS: The cardiomediastinal and hilar contours are normal. The lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Radiology Report REASON FOR EXAMINATION: Asthma with central chest discomfort and difficulty breathing. AP radiograph of the chest was reviewed in comparison to ___. Heart size and mediastinum are stable. Lungs are essentially clear. There is no evidence of pneumothorax or pneumomediastinum demonstrated on the current examination. Bibasal opacities are noted and might reflect small areas of atelectasis, new since the prior study that might also reflect compromised aeration through compromised airways or fatigue of inspiration musculature, please correlate clinically. Radiology Report INDICATION: Patient with pleuritic chest pain and hypoxemia. Assess for pulmonary embolus. COMPARISONS: None available. TECHNIQUE: MDCT-acquired contiguous images through the chest were obtained with intravenous contrast at 1.25 mm slice thickness. Coronally and sagittally reformatted images were displayed. FINDINGS: CT OF THE CHEST: Evaluation for pulmonary embolus is suboptimal due to poor timing of contrast bolus. Within this limitation, the pulmonary artery appears well opacified without perfusion defect to suggest acute pulmonary embolus. The aorta is normal in caliber without evidence of dissection. The heart is normal in size without pericardial effusion. Great vessels appear unremarkable. There are no pathologically enlarged mediastinal lymph nodes. The hilar nodes measure up to 7 mm (2:26, 2:34). Linear consolidation predominantly involving superior segment of the right upper lobe most likely represents atelectasis (2:33). Additional small focus of consolidation in the lingula is also compatible with atelectasis (2:55). Area of atelectasis at the right lung base is also present.No suspicious pulmonary mass or nodule is identified. There is no pleural effusion or pneumothorax. This study is not tailored for subdiaphragmatic evaluation, however partially imaged upper abdominal organs are unremarkable. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen. IMPRESSION: 1. No evidence of acute aortic syndrome or pulmonary embolus. 2. Areas of atelectasis in the lingula, and right lower lobe. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: ASTHMA EXACERBATION Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION temperature: 98.5 heartrate: 118.0 resprate: 18.0 o2sat: 95.0 sbp: 165.0 dbp: 97.0 level of pain: 5 level of acuity: 3.0
===================== Brief Hospital Summary ===================== ___ history of intermittent asthma, tobacco abuse presents with asthma exacerbation, likely secondary to a respiratory viral illness. # Asthma exacerbation with Hypoxemia: Respiratory distress most likely secondary to asthma exacerbation likely in the setting of a viral upper respiratory infection especially given inspiratory squeaks. Pt has no hx of sickle cell, no anemia and no family members w/ sickle cell. Patient moving air, without wheeze. No evidence for pneumonia. Peak flow in the ED was <150 but is now up to 300. Still requiring nasal cannula 6L. Looks comfortable. WBC increasing, likely ___ steroids. Patient's oxygenation improves with large breaths (inspiratory effort), so encouraging peak flows and inspiratory spirometry. Continuing albuterol q ___ hr and ipratropium q 6 hr. Initially gave MethylPREDNISolone Sodium Succ 60 mg IV Q8H with GI prophylaxis and SSI, and now are transitioning to PO prednisone 40mg. Guaifenasen with codine for cough provided. Start ibuprofen PRN and standing tylenol for chest pain. Pt will need pulmonary follow-up at discharge. Would recommend flu and PNA vaccinations before d/c. Lactic acidosis likely secondary to respiratory muscle use and albuterol. Upon call-out to medical floor, patient saturating 91% on 6L nasal cannula, improving with deep breaths and cough. Patient continued to improve to 93% RA with ambulation. Patient was feeling better on prednisone. - Discharged to complete steroid taper of Prednisone - Initiated on Flovent and continued on Albuterol - PCP and ___ follow up arranged # Tobacco abuse: Patient in pre-contemplative state of tobacco cessation. Advised to quit smoking and provided counseling. continued to encourage smoking cessation throughout hospitalization. # Tachycardia: Etiology likely secondary to albuterol and hypovolemia. ECG showing non-specific ST-T changes. Pt w/ some chest pain, likely secondary to pleurisy. Troponin negative x3. CTA neg for PE # Leukocytosis: Etiolology likely secondary to steroid administration given neutrophilia and lymphopenia. Do not suspect superimposed bacterial infection
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillin G / Codeine / Protonix / Cefaclor Attending: ___. Chief Complaint: left lower quadrant abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ presenting with left lower quadrant abdominal pain. He was admitted with diverticulitis and treated with cipro/flagyl IV inpatient for 3 days. He was discharged after he tolerated a normal diet and was pain free, and not tender. He returns today with similar left lower quadrant abdominal pain. He reports increased frequency in his bowel habits, and that he continues to tolerate PO, and no nausea or vomiting. He reports subjective fevers. Past Medical History: Past Medical History: hemachromatosis, gerd, ibs, OA knees and back, asthma Past Surgical History: b/l knee surgery Medications: loratadine 10', lactobacillus acidophilus fluticasone 2 sprays per nostril daily Allergies: Cefaclor Codeine Penicillin G Protonix Social History: ___ Family History: cva, htn, diverticulitis, AAA Physical Exam: GEN: A&O, NAD CV: tachycardic ABD: Soft, nondistended, moderately ttp suprapubic area Ext: No ___ edema, ___ warm and well perfused VS: GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, (-) cyanosis. ABDOMEN: +BS x 4 quadrants, soft, mildly tender to palpation in LLQ, non-distended. EXTREMITIES: Warm, well perfused, pulses palpable, (+/-) edema. Pertinent Results: ___ 05:05AM BLOOD WBC-6.2 RBC-4.48* Hgb-12.8* Hct-40.3 MCV-90 MCH-28.5 MCHC-31.7 RDW-13.2 Plt ___ ___ 06:15AM BLOOD WBC-7.0 RBC-4.42* Hgb-12.7* Hct-39.6* MCV-90 MCH-28.6 MCHC-32.0 RDW-13.3 Plt ___ ___ 05:40AM BLOOD WBC-7.6 RBC-4.46* Hgb-12.8* Hct-40.4 MCV-91 MCH-28.8 MCHC-31.8 RDW-13.4 Plt ___ ___ 06:10AM BLOOD WBC-12.6* RBC-4.36* Hgb-12.5* Hct-38.8* MCV-89 MCH-28.7 MCHC-32.3 RDW-13.2 Plt ___ ___ 05:00PM BLOOD WBC-14.6* RBC-4.75 Hgb-13.4* Hct-41.7 MCV-88 MCH-28.2 MCHC-32.0 RDW-13.0 Plt ___ ___ 06:15AM BLOOD Glucose-100 UreaN-5* Creat-0.7 Na-140 K-3.8 Cl-104 HCO3-25 AnGap-15 ___ 05:40AM BLOOD Glucose-90 UreaN-5* Creat-0.8 Na-139 K-3.5 Cl-103 HCO3-28 AnGap-12 ___ 06:10AM BLOOD Glucose-94 UreaN-6 Creat-0.9 Na-142 K-4.0 Cl-108 HCO3-24 AnGap-14 ___ 05:00PM BLOOD Glucose-82 UreaN-8 Creat-0.9 Na-134 K-3.3 Cl-99 HCO3-24 AnGap-14 IMAGING: ___ CHEST (PA & LAT): No acute intrathoracic process ___ CT ABD & PELVIS WITH CONTRAST: 1. No interval change in thickening of distal sigmoid colonic wall since ___, consistent with diverticulitis. No interval change in 5.3 cm perisigmoid bi-lobed fluid collection. No new fluid collection. 2. 0.7 cm pancreatic tail hypodensity is statistically likely to represent side branch IPMN. Recommend non-urgent dedicated MR for further evaluation. Medications on Admission: Current Medications: loratadine 10', lactobacillus acidophilus fluticasone 2 sprays per nostril daily Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q8H 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. Loratadine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: Prior exam from ___. CLINICAL HISTORY: Nonproductive cough, question pneumonia. FINDINGS: PA and lateral views of the chest were provided demonstrating clear well-expanded lungs without focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Bony structures are intact. No free air is seen below the right hemidiaphragm. IMPRESSION: No acute intrathoracic process. Radiology Report HISTORY: Recent discharge after treatment for diverticulitis complicated with abscess. Returning now with worsening abdominal pain. Assess abscess size. COMPARISON: CT abdomen/pelvis ___. TECHNIQUE: Axial helical MDCT images were obtained from the bases of the lungs to the pubic symphysis after the administration of 130 cc IV Omnipaque 350. Multiplanar reformatted images in coronal and sagittal axes were generated. DLP: 487.6 mGy-cm FINDINGS: Lungs and heart: Limited assessment of the lung bases are clear. The visualized heart and pericardium are unremarkable. Liver: Homogeneous enhancement, without focal lesions. No intrahepatic or extrahepatic biliary duct dilatation. The gallbladder is thin walled without gallstones. The main portal vein and splenic vein are patent. Mixing artifact is seen within the patent SMV. Pancreas: No peripancreatic stranding or fluid collection. A 0.7 cm pancreatic tail hypodensity is noted. Spleen: The spleen is homogeneous and normal in size. Adrenals: Adrenal glands are unremarkable. Kidneys: No interval change in a 0.8 cm hypodense lesion within the upper pole of left kidney which is too small to characterize however is likely cystic in nature. No additional solid or cystic lesions. Present symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation, perinephric fat stranding, or perinephric abnormalities seen. GI tract: The distal esophagus is without hiatal hernia. The stomach is decompressed. The duodenum and small bowel are within normal limits, without focal wall thickening, adjacent fat stranding, or obstruction. Again noted is a thickened distal sigmoid colon with a bi-lobed rim enhancing fluid collection with locules of air in the perisigmoid region measuring approximately 5.3 cm in long axis with each lobe measuring 3.3 cm and 3.0 cm (2: 70, 68), similar to ___ study. Scattered diverticula are seen throughout the colon without additional areas of diverticulitis. Interval passage of stool contents in the rectum with residual fluid. The remaining colon is normal without focal wall thickening or adjacent fat stranding. The appendix is not visualized but there is no evidence of acute appendicitis. Vascular: The descending aorta and its major branches are patent without aneurysmal dilatation. Retroperitoneum, abdomen, soft tissue: No retroperitoneal or mesenteric lymph node enlargement. No free air, ascites, or abdominal wall hernia. The soft tissue is unremarkable. Pelvic CT: The urinary bladder and terminal ureters are normal. No pelvic wall or inguinal lymph node enlargement. No free pelvic fluid. Osseous structures: No blastic or lytic lesions suspicious for malignancy. IMPRESSION: 1. No interval change in thickening of distal sigmoid colonic wall since ___, consistent with diverticulitis. No interval change in 5.3 cm perisigmoid bi-lobed fluid collection. No new fluid collection. 2. 0.7 cm pancreatic tail hypodensity is statistically likely to represent side branch IPMN. Recommend non-urgent dedicated MR for further evaluation. Updated read conveyed via telephone by ___ to Dr. ___ on ___ at 10:41pm. Radiology Report INDICATION: ___ year old man with diverticulitis, abscesses // please assess abscess collection and place drain COMPARISON: Prior CT abdomen and pelvis from ___ and ___. PROCEDURE: CT-guided drainage of pelvic collection. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. The patient was placed in a supine position on the CT scan table. Limited preprocedure CTscan was performed to localize the collection. Previously identified pelvic fluid collection demonstrates significant interval decrease in size with small residual non drainable collection now seen adjacent to the sigmoid colon. The residual collection now measures 3.4 x 3.2 x 1 cm (4B:56). In the small residual collection, it was decided to not proceed with the CT-guided drainage. DOSE: DLP: 330 mGy-cm SEDATION: No IV moderate sedation was administered as the procedure was not performed. FINDINGS: As mentioned above, previously identified perisigmoid bilobed fluid collection demonstrates significant interval decrease in size, now measuring 3.4 cm. This collection is now too small to be drained. In consultation with the patient, it was decided not to proceed with the procedure. Small bilateral inguinal hernias are identified, right side greater than left. Partially distended urinary bladder is unremarkable. No inguinal or pelvic lymphadenopathy. No focal soft tissue abnormality. No osteolytic or osteoblastic lesion identified. IMPRESSION: Marked interval improvement of the perisigmoid fluid collection with now a small 3.4 cm residual collection identified. No CT guided drainage was performed given the much smaller size of the collection. Patient's nurse ___ was paged the result at 14:25 hr on ___ by Radiology Nurse ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Diarrhea Diagnosed with DIVERTICULITIS OF COLON, INTESTINAL ABSCESS temperature: 100.4 heartrate: 98.0 resprate: 18.0 o2sat: 94.0 sbp: 147.0 dbp: 90.0 level of pain: 6 level of acuity: 3.0
This is a ___ presenting with left lower quadrant abdominal pain who had failed initial treatment with course of cipro/flagyl. In the ED, the patient was hemodynamically stable and tender on exam; WBC 11.9 and repeat CT positive for acute sigmoid diverticulitis complicated by microperforation and two abscesses. He was admitted to ___ service for IV meropenem, bowel rest, IV fluids, monitoring WBC trend and serial Abdominal exams. On HD2 the patient's WBC was trending up and ___ attempted to drain the abscess but they were unsuccessful, as the collection was too small. By HD3 the patient's abdominal exam was improving and his WBC had normalized. He was started on a clear liquid diet and advanced to regular. On HD5 the patient was switched to oral antibiotics. He tolerated this well and continued to tolerate a regular diet without any increased abdominal pain. He was moving his bowels and voiding without difficulty. The patient was discharged home on HD6. He remained afebrile hemodynamically stable, with minimal tenderness to abdominal palpation, tolerating a regular diet and having bowel function. He was to complete a course of augmentin and follow up in the ___ clinic. Discharge instructions and prescriptions were reviewed with the patient with positive agreement. The patient had follow up appointments made in the ___ clinic as well as with his PCP.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Status epilepticus Major Surgical or Invasive Procedure: - Endotracheal intubation (___) History of Present Illness: ___ is a ___ right-handed woman with metastatic renal cancer to the brain currently treated with Avastin who presents with status epilepticus. Briefly, per patient's sister the patient was in her usual state of health until this morning when she complained of stomach pain and diarrhea. Sister is not sure if patient took her medications today because of her stomach issues. Then later in the evening sister heard a loud noise in patient's room and when she went in to check on the patient she found her down with generalized tonic-clonic movements eyes deviated although unclear to which side. She called EMS who found her to be febrile to 102, with heart rate of 140s, blood pressure 181/153, gave her 4 mg of Ativan, and intubated her for airway protection. Seizures continued despite 4 mg of Ativan so another 2 mg of Ativan was given and patient was transported to ___ emergency room. In the ED her blood pressure was noted to be 166/119 and heart rate 90. CT head showed moderate vasogenic edema in the left frontal and parietal lobes likely secondary to known brain tumor. Patient was loaded with Keppra 1500 mg ×1 and maintained on Keppra 1500 twice daily. cvEEG was ordered. And patient admitted to neuro ICU. Of note, per ___ records: Began with a fall on ___. She did not lose consciousness and was taken to ___. A head MRI revealed two lesions, a large left frontal and a smaller left parietal. Staging was done after the craniotomy results and a left kidney mass was found. There are also some nodules in the lungs and adrenal gland. She is s/p resection to left frontal mass and SRS treatment to resected cavity and left parietal lesion. Her next MRI will be in ___. Most recent MRI showed radiation Necrosis vs. Progression. She is being treated with of avstatin. Persistent patient is on dexamethasone 4 mg daily which was decreased to 1 mg daily today. She is also on Keppra 500 twice daily. She is on prophylactic treatment of valacyclovir for shingles. She recently completed treatment for UTI On neuro ROS, unable to obtain On general review of systems, unable to obtain Past Medical History: PMH: - Stage IV Renal cell cancer (diag. ___ - Hypertension - Sleep apnea with CPAP - Osteopenia - Gout - Fatty Liver PSH: - Open hysterectomy with oophorectomy for benign fibroids (___) - Laparoscopic cholecystectomy (___) - Appendectomy - Right ORIF and coccydynia (___) - Craniotomy and resection of left frontal met ___ by Dr. ___ at ___ - CyberKnife SRS to left frontal cavity, 2400 cGy (___) - SRS to left parietal met, ___ cGy (___) - Laparoscopic left radical nephrectomy for 10cm mass with left adrenalectomy (___) Social History: ___ Family History: Mother deceased, had coronary artery disease and TB. Father deceased with hypertension and CHF. She has two sisters and one brother. Physical Exam: ============== ADMISSION EXAM ============== General: Intubated HEENT: NC/AT ET tube in place neck: Supple Pulmonary: Mechanical breath sounds bilaterally cardiac: RRR, nl. Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: Off sedation Patient intubated, no eye opening to verbal stimuli or sternal rub, moves bilateral upper extremity to sternal rub, pupils equally round and reactive, positive corneals, positive cough, unable to assess gag, withdraws in all 4 extremities to noxious stimuli ============== DISCHARGE EXAM ============== Vitals: Tm 98.1, HR 56-67, RR 18, BP 118-157/65-87, >95% RA Gen: sitting up in chair, NAD HEENT: NCAT, no conjunctival injection, thin gray hair, MMM CV: RRR, well perfused Resp: normal WOB Abd: soft, NT, ND Ext: well perfused throughout Neuro: - MS: awake and alert, oriented, language intact with no paraphasic errors, appropriate naming and repetition, follows 2 step commands - CN: PERRL (4to3mm), EOMI, face symmetric, moderate dysarthria, tongue midline Motor: Normal Bulk and Tone. Mild tremor without asterixis [Delt] [Bi] [Tri] [WrE] [FEx] [IO] [IP] [Quad] [Ham] [TA] [Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 4+ 4+ 4+ 4+ 4- 4- 4+ 4+ 4+ 4+ 5- Sensory: Intact to light touch and pinprick DTRs: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 toes downgoing Gait: requires two-person assistance to transfer Pertinent Results: ======= IMAGING ======= - ___ CT Head Patient is status post left frontal craniotomy. There is moderate vasogenic edema in the left frontal and parietal lobes likely secondary to known brain tumor. Recommend MRI for further evaluation of tumor. MRI Brain ___: FINDINGS: Markedly limited evaluation given severe motion artifact on post-contrast sequences. Within the limitations described above: Stable postsurgical changes status-post left frontal craniotomy. The previously seen peripherally enhancing lesion in the left frontal lobe previously identified only on postcontrast sequences, is not definitively identified. Increased T2 and FLAIR signal hyperintensity in the adjacent white matter. An adjacent resection cavity measuring 1.4 x 1.2 cm is unchanged. Comparing FLAIR and diffusion weighted sequences, a 2.0 x 2.0 cm periventricular left posterior parietal lesion with associated predominantly peripheral susceptibility artifact reflecting prior hemorrhage and hemosiderin deposition probably not significantly changed. Adjacent white matter T2 and FLAIR signal hyperintensity is decreased since the prior examination. No new hemorrhage, new mass, infarction, or significant mass-effect. The ventricles and sulci are normal in caliber and configuration. IMPRESSION: 1. Markedly limited evaluation given substantial motion artifact on post-contrast sequences. If evaluation for intracranial lesion size stability is desired, recommend repeat postcontrast sequences. 2. No new focus of restricted diffusion or T2/FLAIR hyperintensity 2 suggesting new lesion. 3. Slightly decreased FLAIR hyperintensities in the left parietal region and slightly increased FLAIR hyperintensities in the left frontal region. 4. No evidence of infarction or new hemorrhage. Renal US ___: FINDINGS: The patient is status post left nephrectomy. The right kidney measures 13.6 cm. There is no hydronephrosis, stones, or mass in the right kidney. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Bladder is decompressed with Foley catheter in situ. IMPRESSION: 1. Left nephrectomy. 2. No hydronephrosis in the right kidney. ================= ELECTROPHYSIOLOGY ================= - ___ EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of (1) five focal electrographic seizures arising from the left frontal region, without clinical correlate; (2) abundant left frontal epileptiform discharges, occurring periodically every ___ seconds at the onset of the study, and which become less frequent by the end of the recording; (3) discontinuous and low voltage background, indicative of a severe etiologically-nonspecific encephalopathy, which can be seen with sedative effects. There is one pushbutton activation as above but without scalp EEG correlate. - ___ EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of (1) abundant left frontal epileptiform discharges, at times occurring periodically every ___ seconds, indicative of a potential epileptogenic focus in this region; (2) nearly continuous focal slowing in the left frontal region, indicative of focal cerebral dysfunction; (3) slow and disorganized background, indicative of a moderate encephalopathy, which is nonspecific as to etiology. Higher voltage activity in the left frontal region is likely a breach rhythm due to underlying skull defect. There is one pushbutton activation as above but without scalp EEG correlate. Compared to the prior day's study, there are no electrographic seizures, but the abundant left frontal epileptiform discharges, the slow and disorganized background remains unchanged. - ___ EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of (1) abundant left frontal epileptiform discharges, at times occurring pseudoperiodically every ___ seconds, indicative of a potential epileptogenic focus in this region; (2) nearly continuous focal slowing in the left frontal region, indicative of focal cerebral dysfunction; (3) mild background slowing consistent with a mild encephalopathy, which is nonspecific as to etiology. Higher voltage activity in the left frontal region is likely a breach rhythm due to underlying skull defect. There is one pushbutton activation for left arm tremoring without scalp EEG correlate. Compared to the prior day's study, the left frontal epileptiform discharges are essentially unchanged, but the background is improved. ___ 04:40AM BLOOD WBC-8.3 RBC-2.72* Hgb-8.5* Hct-26.4* MCV-97 MCH-31.3 MCHC-32.2 RDW-17.9* RDWSD-63.3* Plt ___ ___ 05:46AM BLOOD Neuts-72* Bands-0 Lymphs-15* Monos-6 Eos-1 Baso-4* ___ Metas-2* Myelos-0 AbsNeut-5.33 AbsLymp-1.11* AbsMono-0.44 AbsEos-0.07 AbsBaso-0.30* ___ 05:46AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 04:51AM BLOOD ___ PTT-32.8 ___ ___ 05:30AM BLOOD Ret Aut-3.1* Abs Ret-0.06 ___ 04:40AM BLOOD Glucose-107* UreaN-47* Creat-2.7* Na-141 K-4.8 Cl-103 HCO3-25 AnGap-18 ___ 04:21AM BLOOD Glucose-132* UreaN-40* Creat-2.8* Na-137 K-5.0 Cl-100 HCO3-25 AnGap-17 ___ 05:46AM BLOOD Glucose-107* UreaN-39* Creat-2.8* Na-139 K-4.7 Cl-102 HCO3-25 AnGap-17 ___ 05:21AM BLOOD Glucose-119* UreaN-37* Creat-2.6* Na-140 K-4.9 Cl-103 HCO3-26 AnGap-16 ___ 05:06AM BLOOD Glucose-123* UreaN-37* Creat-2.5* Na-141 K-4.6 Cl-102 HCO3-27 AnGap-17 ___ 06:22AM BLOOD Glucose-117* UreaN-37* Creat-2.6* Na-143 K-4.6 Cl-103 HCO3-29 AnGap-16 ___ 12:00AM BLOOD Glucose-130* UreaN-29* Creat-1.0 Na-134 K-5.1 Cl-96 HCO3-21* AnGap-22* ___ 06:55AM BLOOD ALT-13 AST-9 LD(LDH)-158 AlkPhos-82 TotBili-0.2 ___ 02:46AM BLOOD CK-MB-<1 cTropnT-0.05* ___ 05:51AM BLOOD CK-MB-<1 cTropnT-0.03* ___:32AM BLOOD Lipase-37 ___ 04:40AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.8 ___ 05:30AM BLOOD Hapto-178 ___ 04:56PM BLOOD calTIBC-133* Ferritn-959* TRF-102* ___ 02:46AM BLOOD VitB12-307 ___ 02:46AM BLOOD TSH-1.3 ___ 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Dexamethasone 1 mg PO DAILY 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. Labetalol 100 mg PO BID 5. LevETIRAcetam 500 mg PO BID 6. ValACYclovir 1000 mg PO ASDIR 7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 9. Polyethylene Glycol 17 g PO DAILY 10. Senna 8.6 mg PO PRN Constipation Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY 2. LACOSamide 200 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Ranitidine 150 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. amLODIPine 10 mg PO DAILY 7. Dexamethasone 3 mg PO Q12H 8. Labetalol 200 mg PO TID 9. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 11. LevETIRAcetam 500 mg PO BID 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 8.6 mg PO PRN Constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Status Epilepticus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with intubated confirm placement*** WARNING *** Multiple patients with same last name!// confirm ET placment TECHNIQUE: Single frontal view of the chest COMPARISON: None. FINDINGS: Right subclavian line terminates in the right atrium. Endotracheal tube projects 2.4 cm above the carina. The enteric tube side port is seen projecting over the left upper quadrant with tip out of view. Surgical clips are seen in the right upper quadrant likely secondary to cholecystectomy. The lung volumes are low. There is mild pulmonary edema. Cardiac size is normal. The lungs are clear. There is no pneumothorax or large pleural effusion. IMPRESSION: Endotracheal tube projects 2.4 cm above the carina. Low lung volumes with mild pulmonary edema. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with brain cancer, status seizures tonight- WILL CALL WHEN ___ READY FOR SCANNER, ___ ETA to ED// ?increased ICP, shift, herniation? 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 18.0 s, 18.6 cm; CTDIvol = 48.6 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: None. FINDINGS: Patient is status post left frontal craniotomy. There is moderate vasogenic edema in the left frontal and parietal lobes likely secondary to known brain tumor. There is no intra-axial or extra-axial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: Patient is status post left frontal craniotomy. There is moderate vasogenic edema in the left frontal and parietal lobes likely secondary to known brain tumor. Recommend MRI for further evaluation of tumor. RECOMMENDATION(S): Brain MRI or correlation with prior studies. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:07am, 10minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with status epilepticus s/p intubation ? aspiration// assess for interval change assess for interval change IMPRESSION: In comparison with the earlier study of this date, the endotracheal tube has been pulled back so that the tip now measures approximately 3.2 cm above the carina. Other monitoring and support devices are unchanged. There are improved lung volumes with continued prominence of the cardiac silhouette but no evidence of vascular congestion. Retrocardiac opacification silhouetting hemidiaphragm could represent merely atelectatic changes. However, in the appropriate clinical setting, superimposed pneumonia would have to be seriously considered. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old woman with n/v, elevated LFTs// cholecystitis? 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 a very minimal amount of ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: No gallbladder is seen in the gallbladder fossa. 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 12 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. Right kidney measures 11.0 cm. Left kidney is not identified, may be due to overlying gas shadowing. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: No gallbladder can be identified, query surgically absent. There is a minimal amount of ascites. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with intubated// PNA PNA IMPRESSION: Comparison to ___. Stable mild elevation of the left hemidiaphragm, with atelectasis at the left lung bases. Moderate cardiomegaly persists. Stable position of the monitoring and support devices. Normal appearance of the right lung. Radiology Report INDICATION: ___ year old woman with intubated// PNA TECHNIQUE: AP portable chest radiograph COMPARISON: Chest radiograph dated ___ FINDINGS: AP portable chest radiograph demonstrates interval removal of an endotracheal tube and enteric tube. A right chest port terminates at or just below the superior cavoatrial junction. Lung volumes are low with associated bibasilar atelectasis. Heart size is mildly enlarged, stable, with mild pulmonary edema unchanged. There is no new focal consolidation. Blunting of the left costophrenic angle suggest a small pleural effusion. IMPRESSION: Mild pulmonary edema. Interval removal of endotracheal tube and enteric tube. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with renal cell cancer with brain mets, spiking fever// ? eval for any consolidations/ signs of pneumonia ? eval for any consolidations/ signs of pneumonia IMPRESSION: In comparison with the study of ___, there is obliquity of the patient, but no evidence of acute pneumonia or pleural effusion. Cardiac silhouette is probably unchanged and there again is evidence of elevated pulmonary venous pressure. Central catheter is unchanged. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ year old woman with hx of renal cell CA w/ mets to brain, presented w/ status epilepticus. Now seen to be tachycardic with dysarthria and febrile// Evaluate for pulmonary infecton or volume overload TECHNIQUE: Chest single view COMPARISON: ___ 13:52 FINDINGS: Right Port-A-Cath in place. Better inspiration compared to prior. Increased heart size, mild pulmonary vascular congestion, stable since prior. Minimal interstitial prominence, may represent developing edema. Small right pleural effusion is more apparent. Mild predominantly linear opacities at the right base, likely atelectasis, with probable small volume fluid along the fissure. No consolidations. No pneumothorax. IMPRESSION: Increased heart size, pulmonary vascular congestion. Minimal interstitial prominence, may represent developing edema. Right basilar linear opacities, likely atelectasis. Small right pleural effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with hx of renal cell CA w/ mets to brain who previously presented with status epilepticus// Evaluate for new hemorrhage or other intracerebral 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 18.0 s, 18.3 cm; CTDIvol = 49.3 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: CT head without contrast from ___. MRI head with and without contrast from ___ FINDINGS: Patient is status post left frontal craniotomy. There is stable low-attenuation changes in the left frontal, parietal lobes there is probable 1.0 cm cystic lesion in the posterior left centrum semiovale, slightly hyperdense along the posterior margin, similar compared with ___. No new lesions. There is no evidence of new intracranial hemorrhage, midline shift, or acute major vascular territory infarction. The ventricles and sulci are normal in size and configuration. Atherosclerotic calcifications are seen in the bilateral carotid siphons. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No new intracranial hemorrhage. 2. Unchanged pattern of edema in the left frontal, parietal lobes with known metastasis and posttreatment changes, similar compared with ___, improved since ___. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with renal cell mets, now with increased RR// eval for aspiration, pulm edema eval for aspiration, pulm edema IMPRESSION: In comparison with study of ___, there is little change. Cardiac silhouette remains enlarged with some vascular congestion and minimal atelectatic changes at the bases. Blunting of the costophrenic angle on the right is again seen. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old woman with c.diff, altered mental status, seizure, cns metastasis from kidney cancer// ? toxic ___ colon TECHNIQUE: Abdomen single view COMPARISON: Chest x-ray ___, CT abdomen ___ FINDINGS: Suggestion of mild thickening left colon, consistent with known C diff colitis. No bowel dilatation. Surgical clips right upper quadrant. Degenerative changes lower lumbar spine. IMPRESSION: No bowel dilatation. Suggestion of wall thickening left colon, consistent with known colitis. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ year old woman with recent ngt placement// confirm NGT TECHNIQUE: Lower chest, abdomen single view COMPARISON: ___ FINDINGS: Enteric tube tip is in the distal stomach. Right upper quadrant surgical clips. No bowel dilatation. Central line tip is in the upper right atrium, similar. IMPRESSION: Enteric tube tip in the distal stomach. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with renal cell mets to brain and now severe c.diff and sepsis// ? eval hemorrhage of mets, patient unresponsive TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 936 mGy cm COMPARISON: Head CT on ___ FINDINGS: The patient is status post left frontal craniotomy with stable low-attenuation changes involving the left frontal, and parietal lobes, consistent with known metastasis, posttreatment change. There is no evidence of acute intracranial hemorrhage. There is no shift of normally midline structures. No new masses or mass effect is identified. The ventricles and sulci are within normal limits for size and stable. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: No new intracranial hemorrhage. No significant change from ___. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ is a ___ woman with PMHx significant for HTN and metastatic renal cell carcimona to the brain, lungs and adrenal glands Dx ___, currently treated with Avastin who presented to an OSH ED from home with seizures after some stomach pain and diarrhea earlier in the day. She was found to be febrile to 102 with heart rate of 140s blood pressure 181/153 in status epilepticus. She was intubated for airway protection, transferred to ___ and admitted to the neuro ICU. Now with unexplained fevers and rising lactate// Eval for Pulm edema/PNAEval for Pulm edema/PNA IMPRESSION: Comparison to ___. No relevant change. The feeding tube and the right pectoral Port-A-Cath are in stable correct position. No pleural effusions. No pulmonary edema. Moderate cardiomegaly persists. No pneumothorax. No pleural effusions. Radiology Report EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE INDICATION: History of metastatic RCC to the brain presenting with fevers, seizures and unresponsiveness. Failed bedside lumbar puncture. TECHNIQUE: After informed consent was obtained from the patient's healthcare proxy via phone explaining the risks, benefits, and alternatives to the procedure, the patient was laid in prone position on the fluoroscopic table. A pre-procedure time-out was performed confirming the patient's identity, relevant history, procedure to be performed and labs. Puncture was performed at L4-5. Approximately 5 cc of 1% lidocaine was administered for local anesthesia. Under fluoroscopic guidance, a 22 gauge, 13 cm spinal needle was inserted into the thecal sac. There was good return of clear CSF. 26 mls of CSF were collected in 5 tubes (10 cc separated into CytoLyt) and sent for requested analysis. Fluoroscopy time: 0.1 minute Air kerma: 0.6 mGy Dose area product: 7.68 uGym 2 COMPARISON: None. FINDINGS: 26 mls of CSF were collected in 5 tubes (10 cc separated into CytoLyt). Opening pressure was measured at 19 cm CSF. IMPRESSION: 1. Lumbar puncture at L4-5 without complication. 2. Opening pressure of 19 cm CSF. I, Dr. ___ supervised the trainee during the key components of the above procedure and I reviewed and agree with the trainee's findings and dictation. Radiology Report EXAMINATION: Chest single view INDICATION: ___ year old woman with ICU// interval changes TECHNIQUE: Chest portable AP COMPARISON: ___ FINDINGS: The lungs are clear. Port-A-Cath with tip projecting over the SVC-RA juncture no pleural effusion or pneumothorax. NG tube in the stomach. IMPRESSION: No interval change. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old woman with known intracranial renal cell carcinoma metastases now with AMS, seizure. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: ___ brain MRI FINDINGS: Markedly limited evaluation given severe motion artifact on post-contrast sequences. Within the limitations described above: Stable postsurgical changes status-post left frontal craniotomy. The previously seen peripherally enhancing lesion in the left frontal lobe previously identified only on postcontrast sequences, is not definitively identified. Increased T2 and FLAIR signal hyperintensity in the adjacent white matter. An adjacent resection cavity measuring 1.4 x 1.2 cm is unchanged. Comparing FLAIR and diffusion weighted sequences, a 2.0 x 2.0 cm periventricular left posterior parietal lesion with associated predominantly peripheral susceptibility artifact reflecting prior hemorrhage and hemosiderin deposition probably not significantly changed. Adjacent white matter T2 and FLAIR signal hyperintensity is decreased since the prior examination. No new hemorrhage, new mass, infarction, or significant mass-effect. The ventricles and sulci are normal in caliber and configuration. IMPRESSION: 1. Markedly limited evaluation given substantial motion artifact on post-contrast sequences. If evaluation for intracranial lesion size stability is desired, recommend repeat postcontrast sequences. 2. No new focus of restricted diffusion or T2/FLAIR hyperintensity 2 suggesting new lesion. 3. Slightly decreased FLAIR hyperintensities in the left parietal region and slightly increased FLAIR hyperintensities in the left frontal region. 4. No evidence of infarction or new hemorrhage. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with h/o metastatic RCC presents with status epilepticus, waxing/waning mental status.// please assess for PNA please assess for PNA IMPRESSION: Right internal jugular line tip is at the level of the right atrium. Patient had is projecting over the chest. Bibasal opacities have progressed in the interim. The might potentially represent infectious process. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with new L PICC R SL Port// 43 cm L basilic DL PICC ___ ___ Contact name: ___: ___ TECHNIQUE: Portable AP frontal view of the chest COMPARISON: Chest radiograph ___ FINDINGS: There has been interval placement of a left-sided PICC which terminates overlying the cavoatrial junction. Right subclavian Port-A-Cath terminates overlying the right atrium, unchanged. Enteric tube terminates below the left hemidiaphragm and out of view. Lung volumes are improved from comparison study. There is mild to moderate pulmonary interstitial edema, unchanged. Prominent cardiomediastinal silhouette is unchanged. Linear opacities overlying the right lung bases compatible with subsegmental atelectasis. Right basilar opacity is unchanged and may represent an infectious process. IMPRESSION: 1. Left-sided PICC terminates overlying the cavoatrial junction. 2. Moderate pulmonary edema is unchanged from chest radiograph ___ 10:38. 3. Right basilar atelectasis. 4. Right basilar opacity is unchanged and may represent an infectious process. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with metastatic renal cell ca, with worsening cough, ? fluid overload// eval for PNA, pulm edema eval for PNA, pulm edema IMPRESSION: Comparison to ___. The feeding tube has been pulled back, the tip now projects over the lower part of the esophagus, the tube has to be advanced and positioned into the stomach. The patient is rotated. Borderline size of the cardiac silhouette. Bilateral areas of basilar atelectasis. No relevant change in appearance of the lung parenchyma. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with metastatic RCC, altered mental status// please eval NGT adjustment TECHNIQUE: Chest single view COMPARISON: ___ 16:25 FINDINGS: Enteric tube tip is near gastroduodenal junction. Shallower inspiration compared to prior. Otherwise no change IMPRESSION: Enteric tube tip is at gastroduodenal junction. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: ___ year old woman with metastatic renal cell ca, s/p NG tube placement// NGT placement TECHNIQUE: Chest AP COMPARISON: Chest radiographs from ___ FINDINGS: Tip of the nasogastric tube is in unchanged position near the distal antrum. Right-sided Port-A-Cath terminates at the level the right atrium. A left PICC line terminates in unchanged position likely in the distal left brachiocephalic vein. Lung volumes are low. There is bibasilar atelectasis. A small left-sided pleural effusion is noted. Cardiac silhouette is unchanged. No pneumothorax. IMPRESSION: Nasogastric tube terminates near the distal antrum. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: ___ year old woman with NGT placement// NGT placement TECHNIQUE: Chest AP COMPARISON: ___ at 12:09 FINDINGS: Compared to ___ at 12:09, lung volumes are increased. Cardiomediastinal silhouette is stable. There is a small left pleural effusion. No pneumothorax. Right subclavian Port-A-Cath and left PICC line are in unchanged position. The nasogastric tube extends to the body of the stomach where it crosses the lower margin of the image. IMPRESSION: The nasogastric tube extends to the body of the stomach where it crosses the lower margin of the image. No significant change from ___ at 12:09. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with renal cell carcinoma, brain mets, seizures, concern for new ATN// obstructive uropathy TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The patient is status post left nephrectomy. The right kidney measures 13.6 cm. There is no hydronephrosis, stones, or mass in the right kidney. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Bladder is decompressed with Foley catheter in situ. IMPRESSION: 1. Left nephrectomy. 2. No hydronephrosis in the right kidney. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Seizure Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus, Acute respiratory failure, unsp w hypoxia or hypercapnia temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: c level of acuity: 1.0
Brief Hospital Course: Ms. ___ is a ___ woman with metastatic renal cancer to the brain who presented with status epilepticus. She had been experiencing stomach pain and diarrhea earlier during the day on ___, then late in the evening had a witnessed generalized tonic-clonic seizure for she was given 6mg of Ativan and intubated by EMS. Upon arrival to the ED she was loaded with Keppra 1,500mg IV, admitted to the neuro ICU and placed on continuous EEG. In the first 90 minutes of recording, 5 left frontal electrographic seizures were recorded, so she was given an additional 2mg of Ativan and loaded with fosphenytoin 20mg/kg IV, which resolved her seizures. Her home Keppra dose was increased from 500mg BID to ___ BID and she was continued on fosphenytoin 100mg Q8H. Her initial labs were notable for pre-renal azotemia, and urine positive for E.coli. She was given IV hydration, and started on ceftriaxone. She was extubated the following afternoon on ___. Her exam was significant for very mild right hemiparesis and delayed response times. For her cancer she is ___ months status-post surgery and radiotherapy to her left frontal and parietal mets, treated with Avastin. She also Decadron daily, but this had been reduced from 4mg to 1mg starting on the morning of her seizure. She continued to slowly improve, but her course was complicated by a C. diff infection with fevers and required transfer back to the ICU. She received PO vancomycin for 2 weeks (___). She also had prolonged altered mental status for which she received a 7-day course of broad spectrum antibiotics (___). She was then continued on her Bactrim prophylaxis. She had renal dysfunction in the setting of prolonged diarrhea. She also had elevated phenytoin levels with asterixis and evidence of toxicity, so this medication was held and she to be seizure free. By the time of discharge she was able to take PO and was alert, oriented, and able to follow commands. Her ___ team was also notified of her hospitalization.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: peanut / iodine Attending: ___. Chief Complaint: SOB and back pain Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms ___ is a ___ year old woman with PMHx notable for melanoma, Leiomyosarcoma of uterus s/p TAH and LSO ___, sciatica and a recent prolonged hosptialization at ___ for complicated abdominal abscess. She presents to ___ with abdominal pain, back pain and dyspnea. She reports that this all stated on ___ when she presented to ___ with chest pain and went to ER ___. She reports that her heart was ruled out and she was noted to have sciatica taht was treated with a steroid injection. She subsequently had a very elevated WBC led them to note 3 abscesses in abdomen. She had an ___ drain placed and wnet to rehab. After several days she represented to ___ with lower abdmonal pain. She was readmitted to the ___ Surgical Service for her re-accumulation of abscesses. She was brought to the operating room and underwent ex-lap, extensive LOA, drainage of massive pelvic abscess, biopsy of multiple mesenteric nodules, and finally ileocectomy for likely perforated appendicitis. She was initially started on Unasyn perioperatively then was put on Zosyn as a prior culture of enterobacter was resistant to unasyn. After her surgery she was weaned off her PCA and managed her pain with IV tylenol initially. Dr. ___ planned a 10 day course of zosyn and a PICC line was placed. Her foley was removed successfully as well as a NGT. An ID consult was requested after cultures grew enterococcus. They recommended a course of linezolid and and flagyl. After her NGT was taken out POD3, she was started on sips and advanced as tolerated. She had some small episodes of nausea and emesis and was my NPO. She was started on TPN for 4 days until she was able to tolerate enough PO intake and her diet was advanced. Her bowel function returned. She did have a mildly swollen left arm for which a UE ultrasound and doppler were negative for venous clot. Her course of linezolid and flagyl were continued through a total of a ___nd she was sent home with ultram and lidoderm patch for her sciatica. She was discharged from ___ on ___. She reports that since that time she has had abdominal pain and now presnts to ___ ED with abdominal pain, back pain and dyspnea. She states she has had back pain since approximately ___, she previously had sciatica in right leg but this has resolved. She denies any bowel or bladder issues, no weakness in extremities. Her dyspnea has been increasing, yesterday she felt very short of breath even when lying down at night. She denies any fevers or cough. no chest pain. She underwent CT abdomen 2 days ago at ___ (report below) which showed L1 and L2 compression fractures, mild hepatomegaly, small pericardial and pleural effusions. Also a renal mass. She does have a remote history of melanoma and leiomyosarcoma status post total abdominal hysterectomy. She has had anaphylaxis to IV contrast dye in the past. Past Medical History: Melanoma Anaphylaxis Osteoporosis Osteoarthitis s/p left knee partial replacement Leiomyosarcoma of uterus s/p TAH and LSO ___ BASAL CELL CARCINOMA, Left Mid Forehead Social History: ___ Family History: Daughter ___ Father ___ - Type II; Heart Dz-Congenital Mother ___ Sister ___ Physical Exam: ADMISSION PHYSICAL EXAM: ========================== Vitals - T:97.8 BP:151/107 HR:89 RR:16 02 sat:96%RA GENERAL: NAD, sitting upright in the bed, ___. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, JVD ___ CM above the clavical at 90 degrees CARDIAC: RRR, S1/S2, no murmurs LUNG: Bibasilar crackles, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mildly tender in left flank/LUQ, no r/g EXTREMITIES: moving all extremities well, 2+ pitting edema on the right (baseline ___ to melanoma surgery), trace edema on the right lower extemity up to the knee PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused DISCHARGE PHYSICAL EXAM: ========================= VS: T 97.8 HR 77- 95 BP 125/81; ___ RR 02 sat 98% on RA GENERAL: NAD, breathing comfortabley HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, No appreciable JVD. Large lipoma on right shoulder, non-tender. CARDIAC: tachy, regular, S1/S2, no murmurs LUNG: Mild bibasilar crackles, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mildly tender in RLQ, no rebound tenderness, no gaurding EXTREMITIES: moving all extremities well, 2+ pitting edema on the left (baseline ___ to melanoma surgery/lymph dissection), trace edema on the right lower extemity up to ankle PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused Pertinent Results: ADMISSION LABS =============== ___ 06:20PM BLOOD WBC-8.2 RBC-4.53 Hgb-12.8 Hct-40.7 MCV-90 MCH-28.2 MCHC-31.4 RDW-14.8 Plt ___ ___ 06:20PM BLOOD Neuts-60.2 ___ Monos-5.4 Eos-4.7* Baso-0.5 ___ 06:20PM BLOOD ___ PTT-28.4 ___ ___ 06:20PM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-137 K-4.4 Cl-98 HCO3-29 AnGap-14 ___ 06:20PM BLOOD ALT-46* AST-32 AlkPhos-77 TotBili-0.3 ___ 06:20PM BLOOD TSH-3.0 DISCHARGE LABS =============== ___ 06:23AM BLOOD WBC-5.8 RBC-4.61 Hgb-13.1 Hct-40.6 MCV-88 MCH-28.5 MCHC-32.4 RDW-14.9 Plt ___ ___ 06:23AM BLOOD Plt ___ ___ 06:23AM BLOOD Glucose-90 UreaN-15 Creat-0.7 Na-138 K-5.0 Cl-99 HCO3-32 AnGap-12 ___ 06:23AM BLOOD Albumin-3.8 Calcium-9.9 Phos-4.8* Mg-2.1 RELEVANT LABS ============== ___ BLOOD cTropnT-<0.01 proBNP-3242* ___ BLOOD TSH-3.0 IMAGING: ========= CHEST (PA & LAT) Study Date of ___ IMPRESSION: Hyperinflation. Increased interstitial markings throughout the lungs could be due to chronic interstitial changes although a component of interstitial edema is possible especially in the setting of small bilateral effusions and moderate cardiomegaly. Age-indeterminate upper lumbar compression deformity. ECHO Portable TTE (Complete) Done ___ Conclusions The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the abdominal aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The posterior mitral leaflet appears tetheredThe tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. L-SPINE (AP & LAT) Study Date of ___ IMPRESSION: There is a scoliosis convex left centered at L1-2 where there are compression fractures. there is diffuse osteopenia. The compression fractures have sclerotic superior margin of the vertebral body and are age indeterminate. There is minimal anterolisthesis of L2 on L3 and minimal anterolisthesis of T12 on L1 EKG ==== ECG Study Date of ___ 8:47:24 ___ Baseline artifact. Sinus tachycardia. Late R wave progression. Small R waves versus Q waves. Consider anterior wall myocardial infarction. No previous tracing available for comparison. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 2. Aspirin 162 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Acetaminophen 500 mg PO Q6H:PRN pain 6. Ibuprofen 400 mg PO Q4H:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 162 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 6. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 7. Furosemide 10 mg PO DAILY RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 8. OxycoDONE (Immediate Release) 2.5 mg PO ONCE MR1 back pain Duration: 1 Dose RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*5 Tablet Refills:*0 9. Metoprolol Succinate XL 25 mg PO BID RX *metoprolol succinate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 10. Lidocaine 5% Patch 1 PTCH TD QPM RX *lidocaine [Lidoderm] 5 % (700 mg/patch) once a day Disp #*5 Patch Refills:*3 11. Lidocaine 5% Patch 1 PTCH TD QAM Discharge Disposition: Home Discharge Diagnosis: Primary: # New Onset Congestive Heart Failure Secondary: # L1-L2 compression fracture # abdominal pain s/p recent abdominal surgery # new renal mass on CT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with dyspnea // infiltrate? TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: None. FINDINGS: The lungs are hyperinflated. There are small bilateral effusions. Increased interstitial markings are seen throughout the lungs. The cardiac silhouette is moderately enlarged. Compression deformity in the upper lumbar spine is age indeterminate. IMPRESSION: Hyperinflation. Increased interstitial markings throughout the lungs could be due to chronic interstitial changes although a component of interstitial edema is possible especially in the setting of small bilateral effusions and moderate cardiomegaly. Age-indeterminate upper lumbar compression deformity. Radiology Report EXAMINATION: L-SPINE (AP AND LAT) INDICATION: ___ w hx of PMH of melanoma, osteoporosis, recent abdominal abscesses whoe presented with new CHF and back pain x months p/w L1 and L2 compression fractures. // ? stability recently identified L1 and L2 compression fractures; no red flags; ortho consulted in ED TECHNIQUE: Frontal and lateral views of the lumbar spine. COMPARISON: Chest x-ray from 2 days prior. IMPRESSION: There is a scoliosis convex left centered at L1-2 where there are compression fractures. there is diffuse osteopenia. The compression fractures have sclerotic superior margin of the vertebral body and are age indeterminate. There is minimal anterolisthesis of L2 on L3 and minimal anterolisthesis of T12 on L1 Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with LUMBAGO, ABDOMINAL PAIN OTHER SPECIED, RESPIRATORY ABNORM NEC temperature: 98.6 heartrate: 116.0 resprate: 20.0 o2sat: 100.0 sbp: 160.0 dbp: 99.0 level of pain: 7 level of acuity: 3.0
___ year old woman with PMHx notable for melanoma, leiomyosarcoma of uterus s/p TAH and LSO ___, and a recent prolonged hosptialization at ___ for complicated abdominal abscess, who was admitted for abdominal pain, back pain and dyspnea. # Dyspnea: Several months of worsening dyspnea on ambulation and while lying flat. Cardiomegaly on CXR, small pericardial effusion on CT scan, elevated BNP, and ECHO on ___ all consistent with CHF. Normal admission EKG, negative troponins, normal TSH. Daughter reports she's had several months of HRs in 120s, so perhaps has tachycardia-induced HF. She was started on metoprolol and lisinopril with good response, and Cardiology was consulted. She was discharged on Metop Succ 25 BID, Lisinopril 2.5 mg daily, and Lasix 10 mg daily with outpatient cardiology appointments in place. # sCHF: Acute systolic CHF with new LVEF of 30% dilated diffuse hypokinesis without coronary distribution. ___ cardiology was consulted in house. She was diuresed and started on Metoprolol and Lisinopril with improvements in HRs and resolution of symptoms. # Back Pain: Patient has back pain with age-undetermined with L1 and L2 compression fractures. Ortho spine was consulted, and felt no intervention needed during admission as fractures appeared stable on repeat imaging. Pain was moderately-well controlled with Tylenol, tramadol and lidocaine patches, with PO oxycodone for breakthrough pain. She has follow up scheduled at the ___ in ___ weeks. # Abdominal Pain: Patient has a extensive history of recent abdominal abscess of unknown etiology and is s/p drainage and antibiotic course with no recurance on CT scan from ___. # Renal Mass: Patient with a 2.3cm left renal mass concerning for renal cell carcincoma. Has nephrology appointment scheduled as an outpatient. # Pericardial Effusion: Too small to tap for diagnostic purposes, may need additional follow up imaging
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Struck by car Major Surgical or Invasive Procedure: None History of Present Illness: ___ with no ___ transferred from ___ s/p being struck by vehicle. Walking his dog this morning when he was struck by a vehicle. Thrown into the air and landed on the ground. Unclear if a LOC. At OSH had CT head, neck, torso that were negative. He endorses severe leg pain and parasthesias and were transferred for further evaluation. On arrival continues to complain of numbness in the left face, arm, and leg and severe pain with any movement. Also endorses back pain. No episodes of loss of control of bladder or bowel. Past Medical History: None Social History: ___ Family History: Noncontributory Physical Exam: GEN: AVSS HEENT: atraumatic, normocephalic Neck: supple, trachea midline, no c-spine tenderness Chest: atraumatic, CTAB, equal CV: RRR, S1 and S2 without m/r/g ABD: NTND, soft, (+) bowel sounds Right upper extremity: Skin intact Soft, non-tender arm and forearm ___ strength of UE and fist strength Full, painless AROM/PROM of shoulder, elbow, wrist, and digits +EPL/FPL/DIO (index) fire +SILT axillary/radial/median/ulnar nerve distributions +Radial pulse Left upper extremity: Skin intact Soft, non-tender arm and forearm ___ strength of UE and fist strength Full, painless AROM/PROM of shoulder, elbow, wrist, and digits +EPL/FPL/DIO (index) fire +SILT axillary/radial/median/ulnar nerve distributions but cannot discriminate two point sensation +Radial pulse Right lower extremity: Skin intact Soft, non-tender thigh and leg ___ quad, ___ full leg strength positive straight leg raise AROM/PROM of hip, knee, and ankle limited ___ low back pain +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Left lower extremity: Skin intact Soft, non-tender thigh and leg ___ quad, 435 full leg strength positive straight leg raise AROM/PROM of hip, knee, and ankle limited ___ low back pain +SILT SPN/DPN/TN/saphenous/sural distributions but cannot discriminate two point sensation ___ pulses, foot warm and well-perfused CN III-XII intact, decreased two point discrimination on left face Babinski: downgoing Clonus: none Perianal sensation: intact Rectal tone: intact Pertinent Results: ___ 01:10PM BLOOD WBC-9.8 RBC-4.94 Hgb-15.8 Hct-46.1 MCV-93 MCH-32.0 MCHC-34.3 RDW-13.7 Plt ___ ___ 06:00AM BLOOD WBC-6.6 RBC-5.01 Hgb-15.9 Hct-46.6 MCV-93 MCH-31.8 MCHC-34.1 RDW-13.5 Plt ___ ___ 01:10PM BLOOD ___ PTT-32.3 ___ ___ 06:00AM BLOOD Plt ___ ___ 01:10PM BLOOD Glucose-93 UreaN-18 Creat-0.8 Na-138 K-4.0 Cl-104 HCO3-26 AnGap-12 ___ 06:00AM BLOOD Glucose-87 UreaN-18 Creat-0.9 Na-140 K-4.0 Cl-100 HCO3-26 AnGap-18 ___ MRI C-spine, T-spine, L-spine Vertebral body heights and disc spaces are maintained. There is no cord signal abnormality to suggest edema or myelomalacia. No epidural hematoma, spinal canal narrowing, cord compression, or ligamentous injury is identified. The conus terminates at the L1-2 level. Mild multilevel degenerative changes are noted, with a mild disk bulge at the C4-5 level without canal stenosis or neural foraminal narrowing. The visualized paraspinal soft tissues are unremarkable. IMPRESSION: No evidence of epidural hematoma, spinal canal narrowing, cord compression, or ligamentous injury. Mild multilevel degenerative changes. ___ MRI Left Hip Pending at time of discharge Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID Take this while taking your prescription pain medicine. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Leg/groin pain, awaiting final MRI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Left leg and arm weakness after being struck by motor vehicle. Evaluate for cord compression. TECHNIQUE: Multiplanar, multisequence MR imaging was performed from the base of the skull through the sacrum without the administration of IV contrast. COMPARISON: None available. FINDINGS: Vertebral body heights and disc spaces are maintained. There is no cord signal abnormality to suggest edema or myelomalacia. No epidural hematoma, spinal canal narrowing, cord compression, or ligamentous injury is identified. The conus terminates at the L1-2 level. Mild multilevel degenerative changes are noted, with a mild disk bulge at the C4-5 level without canal stenosis or neural foraminal narrowing. The visualized paraspinal soft tissues are unremarkable. IMPRESSION: No evidence of epidural hematoma, spinal canal narrowing, cord compression, or ligamentous injury. Mild multilevel degenerative changes. Radiology Report INDICATION: Left lower extremity distal numbness and weakness after being struck by a car. Evaluate for soft tissue injury. TECHNIQUE: Multiplanar and multisequence T1 and T2 weighted images were acquired through the left hip without the administration of IV contrast 1.5 Tesla magnet. Sequences include bilateral coronal STIR and T1 weighted images, and left-sided coronal proton density images, axial oblique proton density images, and sagittal proton density images. COMPARISON: CT of the torso from ___. MRI of the total spine from ___. FINDINGS: On the coronal STIR images, there is mild asymmetric high signal on the STIR images in the left adductor longus muscle (3, 8), consistent with mild diffuse edema. It extends laterally to the femoral vessels. It extends inferiorly to the mid muscle, at which point the inferior portion of the muscle extends beyond the field of view. There is no suggestion of a frank focal fluid collection or high T1 signal suggestive of a hematoma. The musculature is otherwise within normal limits. It is symmetric in bulk. There is no evidence of a focal atrophy. No axial images through this finding are available. There is trace asymmetric bone marrow edema in the left ilium (3, 11). There is no underlying fracture. While this edema is near the insertion site of the rectus femoris, the rectus femoris tendon is intact. There is no edema in the rectus femoris muscle. There is also focal marrow edema in the proximal diaphysis of the right femur, nonspecific in appearance. This does not extend to the cortex and is not suggestive of fracture. (03:15). The tendons and ligaments about the left hip are intact. Specifically, evaluation of the iliopsoas tendon, semimembranosus tendon, semitendinosis tendon, and biceps femoris tendon are all within normal limits. There is no evidence of an avulsion injury. The imaged portions of the femoral and sciatic nerves are normal. There is no soft tissue mass or edema along their courses. There is no hip joint effusion on either side. The cartilage is preserved. Within the limitations of this non-arthrographic study, the labrum is grossly unremarkable. Small rounded high T2 focus posterior to the right hip joint (03:20) could represent either fluid in a recess of the joint or possibly a paralabral cyst . Incidentally noted is transitional anatomy with a pseudoarthrosis of L5 and S1, on the left only. There is trace edema at the pseudoarthrosis, which is likely chronic and degenerative. The imaged portions of the lower lumbar spine are otherwise normal, and better characterized on the recent spine MRI. The sacroiliac joints are normal without degenerative changes. Please note that no targeted sacral plexus imaging was performed as part of this study. The bone marrow signal is otherwise within normal limits. Limited assessment of the intrapelvic soft tissue structures is grossly unremarkable. There is no free fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy. IMPRESSION: 1. Diffuse edema in the left adductor longus muscle. No focal fluid collection or hematoma is identified. Of note, the entire muscle is not included in the field of view and there are no axial images through the area. If clinically indicated, an MRI of the thigh, including axial images, could help to better characterize this finding. 2. Mild focal marrow edema in the left iliac bony anteriorly. No fracture line identified. Marrow edema is a nonspecific finding, but, with the appropriate history of local trauma, the most likely etiology would be a bone contusion. No fracture line identified. 3. Focal asymmetric marrow edema in the proximal shaft of the right femur. This is a nonspecific finding, but doubt fracture. ? intraosseous vessel or, less likely, a bone contusion. 4. Small focus of fluid posterior right hip joint --? small focus of joint fluid or possibly a small paralabral cyst. There is no significant joint effusion . s Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Ped struck Diagnosed with MUSCSKEL SYMPT LIMB NEC, MV COLL W PEDEST-PEDEST temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 2.0
The patient presented to pre-op/Emergency Department on ___. Pt was evaluated by ED, trauma surgery, and ortho/spine staff, without clear evidence of orthopedic or neurologic injury, however pain and parasthesias continued. Given findings, the patient was admitted for observation. Subsequently parasthesias resolved but left groin pain remained, with limited active and passive range of motion and ability to bear weight. Due to ongoing pain a musculoskeletal MRI of the left hip was performed, and the patient opted to await final read at home with crutches and WBAT status. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was given a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating with crutches, 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, which included a pending MRI read.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / penicillin G Attending: ___. Chief Complaint: Abdominal pain, nausea, pruritis Major Surgical or Invasive Procedure: Percutaneous liver biopsy (___) History of Present Illness: Dr. ___ is a ___ yo podiatrist with hypothyroidism and thyroid nodule c/f follicular neoplasm, now presenting with ___ weeks abdominal pain found in urgent care to have elevated LFTs and innumerable liver masses concerning for malignancy, with additional compression on porta hepatis and intrahepatic biliary dilation. He reports 6 weeks of constant cramping/aching abdominal pain, worse in LUQ but also RUQ, with associated nausea but no vomiting. He is not aware of any aggravating or alleviating factors (such as position or food) though it may be less bothersome at night. He tried tums w/o benefit. For approximately 3 weeks he has also had generalized pruritis. His appetite has been the same and he is not aware of any weight loss or heartburn. He denies any diarrhea, change in the color or caliber of his stools, or jaundice. He has had no fevers/chills, myalgias, ___ edema. He has no recent travel or diarrheal illnesses. He presented to ___ urgent care, where it was revealed that he had elevated AST/ALT/Alk P, and a CT abdomen/pelvis shows numerous hepatic masses. He was transferred to ___ for expedited workup. He received Zofran IV 4mg. Past Medical History: -Hypothyroidism attributed to ___'s thyroiditis -Thyroid nodule: cytology suspicious for a follicular neoplasm; atypia of undetermined significance; Afirma test was suspicious; scheduled for hemithyroidectomy ___ -BPH -Colonic polyps -Pyloric stenosis s/p surgery as an infant Social History: ___ Family History: -Father: ___ cancer, died of other causes at ___ -Mother: died of breast cancer at ___ -3 brothers and 1 sister in generally good health without cancer, other liver disease Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 | 117/71 | 57 | 17 | 96%Ra GENERAL: NAD, resting in bed, appearing slightly anxious HEENT: pupils equal and reactive to light, anicteric sclera, pink conjunctiva, MMM NECK: supple, no cervical/supraclavicular/axillary lymphadenopathy, no JVD. HEART: RRR, S1/S2, no murmurs appreciated LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: well-healed RUQ scar (per pt from pyloric stenosis surgery). Abd minimally distended, tender to medium palpation in RUQ and LUQ. No rebound/guarding. Liver edge palpated & percussed approx. 5cm below rib. Dullness to percussion in the anterior axillary line 2cm below the last intercostal space on the left suggestive of possible splenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: Face grossly symmetric, no dysarthria, moving all 4 extremities with purpose against gravity. SKIN: warm and well perfused, left lower leg excoriations DISCHARGE PHYSICAL EXAM: VS: T 98.2F | BP 110/70 | HR 53 | RR 18 | 95% RA GENERAL: NAD, resting in bed, lying comfortably in bed HEENT: Sclera anicteric HEART: normal S1, S2 without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally ABDOMEN: Hepatomegaly appreciated with liver edge palpable 4cm below right costal angle. Otherwise, abdomen is soft, non-distended, no-tender; bowel sounds present. EXTREMITIES: no edema noted in bilateral lower extremities NEURO: Patient is responding to questions appropriately and moving all four extremities SKIN: no lesions noted Pertinent Results: ADMISSION LABS: ___ 05:30PM BLOOD WBC-10.3* RBC-4.47* Hgb-14.0 Hct-41.8 MCV-94 MCH-31.3 MCHC-33.5 RDW-14.5 RDWSD-49.8* Plt ___ ___ 05:30PM BLOOD Neuts-73.3* Lymphs-15.5* Monos-8.6 Eos-1.3 Baso-0.6 Im ___ AbsNeut-7.54* AbsLymp-1.59 AbsMono-0.88* AbsEos-0.13 AbsBaso-0.06 ___ 06:05AM BLOOD ___ PTT-29.7 ___ ___ 05:30PM BLOOD Glucose-95 UreaN-20 Creat-0.9 Na-136 K-3.8 Cl-99 HCO3-24 AnGap-17 ___ 05:30PM BLOOD ALT-122* AST-99* AlkPhos-451* TotBili-0.9 ___ 05:30PM BLOOD Lipase-55 ___ 05:30PM BLOOD Albumin-4.2 ___ 05:44PM BLOOD Lactate-0.8 DISCHARGE LABS: ___ 05:55AM BLOOD WBC-8.5 RBC-4.43* Hgb-13.7 Hct-41.9 MCV-95 MCH-30.9 MCHC-32.7 RDW-14.6 RDWSD-50.8* Plt Ct-80* ___ 05:55AM BLOOD ___ PTT-30.4 ___ ___ 05:55AM BLOOD Glucose-98 UreaN-19 Creat-0.8 Na-140 K-4.5 Cl-104 HCO3-23 AnGap-18 ___ 05:55AM BLOOD ALT-149* AST-107* LD(LDH)-212 AlkPhos-416* TotBili-0.8 ___ 05:___ BLOOD Calcium-9.4 Phos-3.8 Mg-2.0 IMAGING/STUDIES: CT A/P (___)- 1. Central ill-defined hypodensity in the liver with numerous additional intrahepatic lesions and intrahepatic biliary ductal dilatation, most severe in the left lobe of the liver, highly worrisome for metastatic disease due to a liver primary, with concern most for cholangiocarcinoma. The left portal vein and branches are not seen, likely attenuated by liver mass/tumor thrombus. Focal severe attenuation of the main portal vein. Severe attenuation of the mid to distal intrahepatic IVC, IVC thrombus not excluded. 2. Associated porta hepatis lymphadenopathy. 3. Heterogeneous material within the urinary bladder most likely related to early contrast mixing; correlate with hematuria. 4. Splenomegaly to 14.5 cm. Liver U/S (___)- 1. Nonvisualization of the left portal veins, presumably occluded. 2. Multiple hepatic masses previously described on prior CT. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO 2X/WEEK (MO,WE) 2. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 3. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth Every 8hrs PRN Disp #*24 Tablet Refills:*0 2. Cetirizine 10 mg PO DAILY 3. Levothyroxine Sodium 125 mcg PO 2X/WEEK (MO,WE) 4. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 5.Outpatient Lab Work CBC on ___, please fax result to Dr. ___ ___ ICD-10: ___ Discharge Disposition: Home Discharge Diagnosis: Primary: Metastatic cancer with unknown primary tumor Secondary: Thyroid cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: ULTRASOUND GUIDED TARGET NEEDLE LIVER BIOPSY BY RADIOLOGIST INDICATION: ___ year old man with questionable liver metastasis on CT. Request biopsy of liver lesions. COMPARISON: Fixed or CT abdomen/pelvis ___ and ultrasound liver ___. PROCEDURE: Ultrasound-guided targeted liver biopsy. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. FINDINGS: Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was performed. Hypoechoic mass was identified in the right hepatic lobe. A suitable approach for targeted liver biopsy was determined. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. Based on the preprocedure imaging, an appropriate skin entry site for the biopsy was chosen. The site was marked. The skin was then prepped and draped in the usual sterile fashion. The superficial soft tissues to the liver capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound guidance, 2 x 18-gauge core biopsy samples were obtained. The skin was then cleaned and a dry sterile dressing was applied. There were no immediate complications. SEDATION: Moderate sedation was provided by administering divided doses of 1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 60 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. IMPRESSION: Uncomplicated 18-gauge targeted liver biopsy x 2, with specimen sent to pathology. RECOMMENDATION(S): Pathology pending. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT INDICATION: History: ___ with Liver lesions// On Ct The left portal vein and branches are not seen, likely attenuated by liver mass/tumor thrombus TECHNIQUE: Grey scale and color Doppler ultrasound images of the liver were obtained. COMPARISON: CT of the abdomen pelvis performed ___ at 18:29 FINDINGS: LIVER: The hepatic parenchyma is distorted and heterogeneous consistent with multiple mass lesions as previously described on prior CT. The main portal vein is patent with normal direction of flow. No venous flow is demonstrated in the left portal veins, which are presumably occluded. The left hepatic artery is patent with normal vascular waveform. IMPRESSION: 1. Nonvisualization of the left portal veins, presumably occluded. 2. Multiple hepatic masses previously described on prior CT. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Abnormal CT Diagnosed with Unspecified abdominal pain temperature: 97.5 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 146.0 dbp: 73.0 level of pain: 6 level of acuity: 3.0
___ man with hypothyroidism and thyroid nodule s/p FNAx2 that were inconclusive, though suggestive of Hurthle cell neoplasm, who presented with sub-acute abdominal pain, nausea, and pruritis, and was found to have elevated transaminases and innumerable liver lesions concerning for malignancy. ===================
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Hemoptysis, N/V Major Surgical or Invasive Procedure: Endoscopy with Celiac Nerve Plexus Block History of Present Illness: Pt is a ___ y/o M with PMHx of metastatic adenocarcinoma of unknown primary with mets to the lungs and liver (last chemo 2 weeks ago) who presents with hemoptysis. The patient describes several days of nausea and vomiting. He reports intermittent episodes of this ever since he started chemotherapy. However, on the evening of presentation, he also started to cough up thick phelgm tinged with dark red sputum. While he does frequently cough up a lot of thick sputum, the blood was new. In addition to the above symptoms, the patient also reports persistent shortness of breath since his recent admission for pneumonia. He also reports abdominal pain related to his underlying malignancy, as well as constipation from pain medications. He endorses lightheadedness, as well as tachycardia / shortness of breath with exertion. He states that he feels that he has continued to decline ever since his initial diagnosis last fall. ED Course: Initial VS: 97 ___ 20 95% RA Pain ___ Labs significant for stable anemia, AST 79. INR 1.5. Imaging: see below Meds given: ___ 02:06 IV Ondansetron 4 mg ___ 02:06 IVF 1000 mL NS 1000 mL ___ 02:28 IV HYDROmorphone (Dilaudid) .5 mg ___ 03:04 IV HYDROmorphone (Dilaudid) 1 mg ___ 06:05 IV HYDROmorphone (Dilaudid) 1 mg ___ 08:06 PO OxyCODONE SR (OxyconTIN) 40 mg VS prior to transfer: 98.2 112 138/99 19 He was satting 93-95% on RA in the ED, improved with 2LNC. On arrival to the floor, the patient reports ongoing diffuse abdominal pain radiating to the bilateral flanks and paraspinal regions. Currently ___. ROS: As above. Denies chest pressure, diarrhea, urinary symptoms, muscle or joint pains, focal numbness or tingling, skin rash. The remainder of the ROS was negative. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ - hematemesis, admission, endoscopy with ___ esophagitis and H. pylori; both treated - ___ - right neck and shoulder pain; XRay with pulm nodules, new since ___ - ___ - CT Torso with b/l pulm nodules c/w metastatic disease, mediastinal LAD, metastatic lesions in the liver; diffuse LAD; Brain MRI w/o e/o mets - ___ - Biopsy of liver lesion with adenocarcinoma, moderately differentiated; positive for CK7, CK19, and ___, and negative for CK20, TTF-1, napsin, and CDX; immunotype raises the possibility of a pancreatic, biliary or upper GI primary - ___ - Start FOLFIRINOX, irinotecan stopped after 3 cycles due to allergic reaction - ___ - CT Torso with disease progression in lungs and liver - ___ - Tx changed to Gemcitabine/Abraxane - ___ - Cycle 2 of Gemcitabine/Abraxane held due to thrombocytopenia - ___ - Received Gem/Abrax PAST MEDICAL HISTORY: HTN Back Pain Fatty Liver Positive PPD s/p INH Social History: ___ Family History: Has 2 brother, 2 sisters, several ___ siblings. Mother died from complications of AIDS in the ___. Father alive, currently in prison. Maternal uncle diagnosed with lung cancer age ___. Never smoked. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.8 143/96 112 20 98%2lNC (91%RA) GEN - Alert, NAD HEENT - NC/AT, face symmetric, dry MM NECK - Supple, no cervical or supraclavicular LAD appreciated CV - Tachycardic, no m/r/g appreciated RESP - Diminished BS on the right; otherwise CTA; mildly labored BACK - No spinal tenderness ABD - Significant hepatomegaly with palpable nodules; soft; diffusely tender without rebound or guarding; reducible midline hernia; BS present EXT - 1+ BLE edema, no calf tenderness, pboots in place SKIN - No apparent rashes NEURO - Face symmetric; ___ strength in all 4 extremities PSYCH - Calm, appropriate DISCHARGE PHYSICAL EXAM: Vital Signs: 98.9 98.6 130/88 106 16 92%RA Ambulatory O2 Sat 87-88% on RA GEN: Alert, NAD, cachectic HEENT: NC/AT, temporal wasting CV: tachy, no m/r/g PULM: continued diminished BS on the right, otherwise CTA GI: soft, TTP in the upper abdomen, + hepatomegaly, no r/g, BS present EXT: 2+ pitting edema in the LEs, no calf tenderness NEURO: Non-focal Pertinent Results: Admission Labs: ___ 01:54AM BLOOD WBC-7.2 RBC-3.64* Hgb-10.7* Hct-33.7* MCV-93 MCH-29.4 MCHC-31.8* RDW-16.7* RDWSD-56.2* Plt ___ ___ 01:54AM BLOOD Neuts-74.9* Lymphs-12.9* Monos-10.3 Eos-0.6* Baso-0.7 Im ___ AbsNeut-5.41# AbsLymp-0.93* AbsMono-0.74 AbsEos-0.04 AbsBaso-0.05 ___ 01:54AM BLOOD ___ PTT-29.8 ___ ___ 01:54AM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-138 K-3.7 Cl-99 HCO3-27 AnGap-16 ___ 01:54AM BLOOD ALT-8 AST-79* AlkPhos-114 TotBili-0.9 ___ 01:54AM BLOOD Lipase-21 ___ 01:54AM BLOOD Albumin-3.6 Discharge Labs: ___ 06:00AM BLOOD WBC-11.4* RBC-3.58* Hgb-10.3* Hct-32.4* MCV-91 MCH-28.8 MCHC-31.8* RDW-16.7* RDWSD-55.0* Plt ___ ___ 06:00AM BLOOD Glucose-98 UreaN-11 Creat-0.4* Na-133 K-4.0 Cl-96 HCO3-29 AnGap-12 ___ 06:00AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.7 ECG - Baseline artifact. Sinus tachycardia. RSR' pattern in lead V1, likely a normal variant. Diffuse non-specific ST segment and T wave changes which may be rate-related, though cannot exclude myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of ___ the rate has decreased by about 30 beats per minute with no other diagnostic change. CXR - IMPRESSION: 1. Diffuse rounded opacities throughout the bilateral lungs again seen, some increased in size compared to the most recent chest radiograph. It would be difficult to detect a focal consolidation given these underlying opacities. 2. Right pleural effusion, similar to slightly decreased in size. CT A/P - IMPRESSION: 1. No evidence of acute pulmonary embolism. 2. Progression of metastatic disease, with slight increase in size of some pulmonary and hepatic metastatic lesions, as well as osseous lesions. 3. Unchanged mediastinal, hilar, mesenteric, and retroperitoneal lymphadenopathy. 4. No evidence of hernia or small bowel obstruction. MRI Head - IMPRESSION: 1. Limited study due to patient discomfort with only precontrast T1 and diffusion-weighted sequences performed. Interpretation is based on these limitations. 2. Punctate mild slow diffusion in the anterior left centrum semiovale, likely representing a small subacute infarct. 3. No mass effect or midline shift, however consider completion study including postcontrast imaging to evaluate for metastatic disease. CXR - IMPRESSION: Compared to prior chest radiographs, since ___, most recently ___. Large right pleural effusion has increased substantially, shifting the mediastinum to the left, responsible for more collapse in the right middle and lower lobes. Numerous lung nodules have increased in size and number since ___. Right central venous infusion catheter ends in the SVC. It is shifted more medially than the remainder the mediastinum suggesting that the cava is either thrombosed or severely narrowed. B LENIs - 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. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 2. Lactulose 15 mL PO Q8H:PRN constipation 3. Lorazepam 0.5 mg PO Q6H:PRN anxiety, nausea, insomnia 4. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 5. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Home Oxygen Ambulatory O2 Sat: 88% on RA Oxygen As Needed 2L via nasal cannula Concentrated plus portable Diagnosis: C80.1, C78.00 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 NEB IH every 6 hours as needed Disp #*15 Ampule Refills:*0 4. Lactulose 15 mL PO Q8H:PRN constipation 5. Lorazepam 0.5 mg PO Q6H:PRN anxiety, nausea, insomnia 6. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H RX *oxycodone [OxyContin] 60 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 8.6 mg PO BID:PRN constipation 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Dexamethasone 4 mg PO BID RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 11. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 12. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tablet by mouth before meals and at night Disp #*120 Tablet Refills:*0 13. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 14. OxycoDONE (Immediate Release) 20 mg PO Q2H:PRN pain RX *oxycodone 10 mg 2 tablet(s) by mouth every 2 - 4 hours as needed Disp #*100 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Metastatic Adenocarcinoma of Unknown Primary Pulmonary Metastases Liver Metastases Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Evaluate for pneumonia in a patient with hemoptysis. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs from ___. FINDINGS: Frontal lateral chest radiographs demonstrate a right chest wall port terminating in the low SVC and an unchanged cardiomediastinal silhouette. Diffuse rounded opacities throughout the bilateral lungs are again seen, some increase in size compared to the most recent chest radiograph. It would be difficult to detect a focal consolidation given these underlying opacities. A right pleural effusion is similar to slightly decreased in size. There may be a trace left pleural effusion. No pneumothorax is appreciated. The visualized upper abdomen is unremarkable. IMPRESSION: 1. Diffuse rounded opacities throughout the bilateral lungs again seen, some increased in size compared to the most recent chest radiograph. It would be difficult to detect a focal consolidation given these underlying opacities. 2. Right pleural effusion, similar to slightly decreased in size. Radiology Report INDICATION: Evaluate for pulmonary embolism and incarcerated ventral wall hernia/SBO at in a a patient with active malignancy, hemoptysis, and abdominal pain. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast in the arterial phase. Then, imaging was obtained through the abdomen and pelvis in the portal venous phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 6.1 mGy (Body) DLP = 3.0 mGy-cm. 2) Spiral Acquisition 3.8 s, 29.9 cm; CTDIvol = 14.0 mGy (Body) DLP = 417.2 mGy-cm. 3) Spiral Acquisition 5.7 s, 62.5 cm; CTDIvol = 16.0 mGy (Body) DLP = 998.4 mGy-cm. Total DLP (Body) = 1,419 mGy-cm. COMPARISON: CTA chest and CT abdomen/pelvis from ___. FINDINGS: CHEST: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There is no axillary or supraclavicular lymphadenopathy. Bulky mediastinal and hilar lymphadenopathy is similar in appearance compared to prior exam. PLEURAL SPACES: A small to moderate simple right pleural effusion is slightly increased compared to ___. There is no pneumothorax. LUNGS/AIRWAYS: Again seen are innumerable pulmonary masses bilaterally. These are difficult compared to prior exam, but nodules subjectively appear slightly larger. There is no focal consolidation to suggest pneumonia. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous background attenuation. There are again innumerable hypodense lesions throughout the liver, more confluent centrally, compatible with metastatic disease. Some lesions measure slightly bigger compared to ___ (for example, in the left lobe measuring 2.9 x 5.1 cm, 2b: 122, compared to 2.1 x 4.2 cm previously) There is no evidence of intrahepatic or extrahepatic biliary dilatation. There is a moderate amount of perihepatic simple free fluid which extends down the right pericolic gutter and into the pelvis. 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 remains enlarged, measuring 19.3 cm. There is no focal lesion. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are symmetric and normal in size, demonstrating normal nephrograms and excreting contrast promptly. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is decompressed, without obvious wall thickening or focal mass. Small bowel loops are normal in caliber, without wall thickening or evidence of obstruction. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: Diffuse bladder wall thickening may be in part due to underdistention. There is a moderate to large amount of simple pelvic free fluid, as described above. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable. LYMPH NODES: Periaortic retroperitoneal lymphadenopathy and nodal mass at the mesenteric root is unchanged. There is no significant pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES AND SOFT TISSUES: There are again erosive changes of the manubrium, with increased size of the soft tissue component, measuring 1.8 x 2.4 cm (03:44, previously 1.1 x 1.5 cm). Erosive changes of the fourth and sixth right lateral ribs with soft tissue masses are also increased in size, now measuring 1.8 x 3.2 cm and 1.5 x 2.6 cm (03:58, 110, previously 1.1 x 2.2 cm and 1.2 x 2.0 cm, respectively). A lytic lesion of the posterior left fifth rib is also increased in size, now measuring 1.0 x 2.6 cm (3:74, previously 1.0 x 1.6 cm. No new osseous lesion is identified. The abdominal and pelvic walls within normal limits. No hernia is identified. IMPRESSION: 1. No evidence of acute pulmonary embolism. 2. Progression of metastatic disease, with slight increase in size of some pulmonary and hepatic metastatic lesions, as well as osseous lesions. 3. Unchanged mediastinal, hilar, mesenteric, and retroperitoneal lymphadenopathy. 4. No evidence of hernia or small bowel obstruction. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ male with metastatic adenocarcinoma of unknown primary experiencing persistent nausea vomiting. Evaluate for metastatic disease. TECHNIQUE: Sagittal T1, axial T1, and diffusion sequences were acquired. Patient could not tolerate further imaging due to nausea. Of note, study was initially protocol for postcontrast imaging however this could not be performed. COMPARISON None. FINDINGS: Interpretation is based on precontrast T1 and diffusion-weighted imaging. There is punctate diffusion hyperintensity on the isotropic sequence with correlate mild ADC hypointensity within the left anterior centrum semiovale (5 02:21), likely representing a subacute infarct. The remainder of the parenchyma demonstrates normal morphology and T1 signal. The ventricles and cortical sulci are normal in caliber and configuration. The extra-axial spaces are unremarkable. The orbits, calvarium, and soft tissues are unremarkable. IMPRESSION: 1. Limited study due to patient discomfort with only precontrast T1 and diffusion-weighted sequences performed. Interpretation is based on these limitations. 2. Punctate mild slow diffusion in the anterior left centrum semiovale, likely representing a small subacute infarct. 3. No mass effect or midline shift, however consider completion study including postcontrast imaging to evaluate for metastatic disease. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with metastatic adenocarcinoma of unknown primary with new wheezing // Please evaluate for infiltrate, effusion, edema Please evaluate for infiltrate, effusion, edema IMPRESSION: Compared to prior chest radiographs, since ___, most recently ___. Large right pleural effusion has increased substantially, shifting the mediastinum to the left, responsible for more collapse in the right middle and lower lobes. Numerous lung nodules have increased in size and number since ___. Right central venous infusion catheter ends in the SVC. It is shifted more medially than the remainder the mediastinum suggesting that the cava is either thrombosed or severely narrowed. NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on ___ at 3:56 ___, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with metastatic adenoca with BLE edema // please assess 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, 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. Mild subcutaneous edema is noted in the bilateral upper and lower legs. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Abd pain, Hemoptysis Diagnosed with Hemoptysis, Unspecified abdominal pain temperature: 97.0 heartrate: 130.0 resprate: 20.0 o2sat: 95.0 sbp: 137.0 dbp: 100.0 level of pain: 8 level of acuity: 2.0
___ y/o M with PMHx of metastatic adenocarcinoma of unknown primary with mets to the lungs and liver (last chemo 2 weeks ago) who presents with hemoptysis and abdominal pain N/V. # Abdominal Pain / Nausea / Vomiting: Likely related to progression of his known liver mets, as seen on CT scan. No obstructive process seen on LFT's or imaging. Chemo-induced N/V also a possibility; however, his last chemo was 2 weeks ago making this less likely. Nausea improved with Reglan. Palliative care involved, helped with titration of pain medications for optimal pain control. Also underwent celiac nerve plexus block by GI. He was intermittently on IV dilaudid as well as dilaudid PCA. Ultimatley, he was discharged on a regimen of oxycontin as well as PRN oxycodone. Constipation have played a significant role in patient's symptoms as well. He was maintained on an aggressive bowel regimen. # Hemoptysis / Shortness of Breath: Most likely etiology of hemoptysis is progression of his known malignancy with pulmonary mets. MW tear also a possibility given frequent nausea / vomiting. No further episodes during admission. H/H remained stable. Repeat CXR during admission did show increase in size of right sided pleural effusion compared to prior admission. IP evaluated and did not feel amenable to thoracentesis. He was weaned to room air at rest prior to discharge; however, he did still require O2 with ambulation. Of note, CXR also reported the following: "Right central venous infusion catheter ends in the SVC. It is shifted more medially than the remainder the mediastinum suggesting that the cava is either thrombosed or severely narrowed." However, thrombosis was felt unlikely given CTA report on admission that the great vessels were within normal limits. # Metastatic Adenocarcinoma: Unknown primary. Followed by Dr. ___ as an outpatient. Last chemo dose 2 prior to presentation. Imaging showing progression of disease. He was started on steroids during admission for symptom control as well as ___ concern for stridor on exam. Symptoms improved with this.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall, ___ swelling, dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male with CAD s/p CABG, AFib, CKD (baseline Cr 1.4-1.7), right renal mass (?RCC), and total right hip replacement who presents with fall. Patient reports he had been having an exacerbation of chronic right hip pain for several weeks. The pain was responsive to two tabs of Tylenol, after which attempted to ambulate to the bathroom and stumbled and fell this morning. He denies LOC but struck his head. Pt denies any preceding chest pain, palpitations, lightheadedness/dizziness, visual changes. Pt is normally ambulatory with a walker at baseline. Pt also reports having used ibuprofen for the past two weeks for the hip pain (about 400mg bid). Also of note, he reports increased leg swelling and he reports his weight has gone up significantly. He usually ranges between 197-205 lbs, but it has been up as high as 212 pounds this past week. Pt denies any recent illnesses or dietary changes. He denies F/C, cough, diarrhea, cold/flu symptoms. Pt is usually able to sleep at night on the bed and denies any orthopnea or PNDs. For these reasons, pt visited his PCP 4 days ago where labs were drawn and a renal U/S showed stable findings. In the ED initial vitals were: 96.8 60 156/72 20 98% RA. Labs were significant for: WBC 5.1, H/H 10.9/30.7 (baseline), INR 1.4, Na 128, Cr 1.4, BNP 1675, UA bland. He had a normal CT c-spine, head CT, chest x-ray. Patient was given: Tylenol 1g, oxycodone 2.5mg, lasix 20mg IV, and morphine IV 4mg. Vitals on transfer: 96.0 71 181/72 14 98% RA. On the floor, pt is stable on RA. Review of sytems: (+) Per HPI Past Medical History: - CAD s/p MI in ___ and CABG in ___ at ___ - Atrial Fibrillation - Right Renal mass, 2.2 cm (incidentally discovered ___ - Hypertension - Type II Diabetes, diet-controlled, last A1c 6.3% in ___ - Chronic Kidney Disease (baseline Cr 1.4-1.7) - Severe osteoarthritis s/p recent right hip replacement in ___ - AAA (5.6 cm) s/p stent - Hyperlipidemia - BPH - Urinary incontinence - Hx 7mm pulm nodule (may need CT f/u) Social History: ___ Family History: Father w CVA @ ___, MI @ ___ Physical Exam: ADMISSION EXAM ============== VS: 97.5 70 168/73 18 97% RA GENERAL: 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 8cm. CARDIAC: Irregularly irregular, normal rate, normal S1, S2. No murmurs/rubs/gallops. LUNGS: Mild basilar rales bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: 3+ pitting edema in bilateral ___ up to above knees. DISCHARGE EXAM ============== VS: 97.7 97.5 62-64 135-143/64-71 18 97% RA Wt (kg): **<-82.6<-85.0<-86.5<-88.9<-89.3<-90.9<-94.1<-100<-97.9 I/O/Net: ___, ___ since MN GENERAL: NAD. AAOx3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with mildly elevated JVP CARDIAC: Regular rhythm, normal rate, normal S1, S2. No murmurs/rubs/gallops. LUNGS: CTAB ABDOMEN: Soft, bowel sounds normal, nttp. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Trace edema in thighs Pertinent Results: ADMISSION LABS ============== ___ 08:50AM BLOOD WBC-5.1 RBC-3.31* Hgb-10.9* Hct-30.7* MCV-93 MCH-32.9* MCHC-35.5* RDW-14.6 Plt ___ ___ 08:50AM BLOOD Neuts-52.3 ___ Monos-7.3 Eos-3.0 Baso-0.5 ___ 08:50AM BLOOD ___ PTT-34.6 ___ ___ 08:50AM BLOOD Glucose-197* UreaN-19 Creat-1.4* Na-128* K-4.5 Cl-93* HCO3-22 AnGap-18 ___ 08:50AM BLOOD ALT-17 AST-30 AlkPhos-98 TotBili-0.5 ___ 08:50AM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-1675* ___ 08:50AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.6 Mg-1.7 ___ 08:50AM BLOOD Osmolal-270* ___ 01:15PM BLOOD Lactate-1.7 DISCHARGE LABS ============== ___ 05:18AM BLOOD WBC-5.4 RBC-3.40* Hgb-10.8* Hct-31.5* MCV-93 MCH-31.7 MCHC-34.2 RDW-14.7 Plt ___ ___ 05:18AM BLOOD Glucose-137* UreaN-44* Creat-1.7* Na-134 K-4.1 Cl-92* HCO3-31 AnGap-15 ___ 05:18AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.1 STUDIES ======= ___ CXR: No acute cardiopulmonary process. No acute osseous injury identified, however if concern for rib fracture, dedicated rib fracture series should be obtained. ___ ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF = 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular free wall thickness is normal. The right ventricular cavity is moderately dilated with borderline normal free wall function. The ascending aorta is mildly dilated. There are three aortic valve leaflets. 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. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, the findings are similar. ___ CT HEAD W/O CONTRAST: No acute intracranial hemorrhage or mass effect. No acute fractures are identified. Left frontal scalp swelling ___. Other details as above. ___ CT SPINE W/O CONTRAST: No evidence of fracture or traumatic malalignment in the cervical spine. Multilevel, multifactorial degenerative changes, similar to the prior study from ___ with mild canal and moderate to severe foraminal narrowing and subchondral cystic changes. Correlate clinically to decide on the need for further workup. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Furosemide 20 mg PO 6X/WEEK (___) 3. HydrALAzine 10 mg PO BID 4. Potassium Chloride 20 mEq PO DAILY 5. Labetalol 100 mg PO TID 6. Omeprazole 40 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Calcium Carbonate 500 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Ferrous Sulfate 65 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. HydrALAzine 10 mg PO BID 4. Omeprazole 40 mg PO DAILY 5. Acetaminophen 1000 mg PO TID 6. Bisacodyl 10 mg PR QHS:PRN constipation 7. Docusate Sodium 100 mg PO BID 8. Guaifenesin ___ mL PO Q6H:PRN cough 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Senna 8.6 mg PO BID 13. Torsemide 20 mg PO DAILY 14. TraMADOL (Ultram) 25 mg PO Q4H:PRN pain 15. Calcium Carbonate 500 mg PO DAILY 16. Ferrous Sulfate 65 mg PO DAILY 17. Multivitamins 1 TAB PO DAILY 18. Potassium Chloride 20 mEq PO DAILY 19. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: - Acute on Chronic Diastolic Heart Failure - Hyponatremia - Ileus Secondary Diagnosis: - Atrial Fibrillation - Hypertension - Type II Diabetes - Chronic Kidney 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: PELVIC AND FEMUR RADIOGRAPHS INDICATION: Fall, right hip pain. TECHNIQUE: Frontal view of the pelvis. Two views of the right hip and right femur each. COMPARISON: Abdominal/pelvic CTA from ___ and pelvic radiographs from ___. FINDINGS: Patient is status post total right hip replacement. Surgical hardware appears in good alignment, with no evidence of fracture or perihardware lucency to suggest loosening. There is redemonstration of mild amount of heterotopic ossification adjacent to the acetabulum. No fracture identified within the distal femur. Visualized portions of the lower lumbar spine show mild to moderate degenerative changes. Moderate degenerate changes are noted at the left hip. Visualized portions of the knee show moderate osteoarthritic changes of the medial compartment. There is chondrocalcinosis. There may be a small suprapatellar joint effusion. Note is made of vascular calcifications. IMPRESSION: 1. Post right total hip arthroplasty. No hardware failure or acute fracture. 2. Right knee chondrocalcinosis. Radiology Report EXAMINATION: CHEST RADIOGRAPH INDICATION: History: ___ with fall // ?rib fx ?rib fx TECHNIQUE: Frontal supine chest radiograph. COMPARISON: Prior chest radiograph from ___. FINDINGS: The patient is status post CABG. Median sternotomy wires and multiple surgical clips remain in unchanged position. The cardiomediastinal and hilar contours are stable. Lungs are well expanded and clear. There is no focal consolidation, pleural effusion or pneumothorax. No acute osseous injury identified. IMPRESSION: No acute cardiopulmonary process. No acute osseous injury identified, however if concern for rib fracture, dedicated rib fracture series should be obtained. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with fall, right hip pain, hx of total right hip replacement // ?bleed, fracture TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 1337.1 mGy-cm CTDI: 53.5 mGy COMPARISON: ___. FINDINGS: There is no evidence of acute infarction, hemorrhage, edema, or mass effect. The ventricles and sulci are prominent, compatible with age related global atrophy. Periventricular white matter hypodensities are likely results of chronic small vessel ischemic disease. An unchanged focal hypodensity in the right putamen is evidence of a prior lacunar infarct (2a:17). No acute fractures are identified. Left frontal scalp swelling ___. There is mild mucosal thickening in the ethmoid air cells. Otherwise, the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No acute intracranial hemorrhage or mass effect. No acute fractures are identified. Left frontal scalp swelling ___. Other details as above. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with fall, right hip pain, hx of total right hip replacement // ?bleed, fracture ?bleed, fracture TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 37.1 mGy DLP: 916.5 mGy-cm COMPARISON: ___. FINDINGS: Alignment is unchanged with exaggerated cervical lordosis. No acute fractures are identified. There is no evidence of critical spinal canal or neural foraminal narrowing. There is no evidence of infection or neoplasm. Multilevel, multifactorial degenerative changes are again noted, including endplate sclerosis and intervertebral disc space narrowing, as well as multilevel bilateral facet and uncovertebral arthropathy resulting in mild canal and moderate to severe foraminal narrowing from C2-C7 levels with some deformity on the nerves, assessment of the foraminal narrowing is somewhat limited due to the exaggerated lordosis and rotated positioning. Vascular calcifications are noted on both sides. Punctate calcification is noted in the right submandibular gland . IMPRESSION: No evidence of fracture or traumatic malalignment in the cervical spine. Multilevel, multifactorial degenerative changes, similar to the prior study from ___ with mild canal and moderate to severe foraminal narrowing and subchondral cystic changes. Correlate clinically to decide on the need for further workup. Radiology Report INDICATION: ___ male with atrial fibrillation not on coumadin, coronary artery disease status post CABG, who presented yesterday after fall at home in setting of acute CHF exacerbation. ED CT-head was negative but the patient is having acute onset nausea/vomiting, interval drop in hemoglobin/hematocrit and confusion and concern for intracranial bleeding. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. DOSE: DLP: 897 mGy-cm. CTDIvol: ___ MGy. COMPARISON: CT from ___ and ___. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or loss of gray/ white matter differentiation. Prominent ventricles and sulci are likely secondary to age-related parenchymal involutional change, as before. Periventricular white matter hypodensities are likely sequela of chronic small vessel ischemic disease. A focal hypodensity within the right putamen, better seen on the prior CT due to slice selection, likely represents a chronic lacunar infarct or prominent perivascular space (3:16). The bones are unremarkable. Mild mucosal thickening in the ethmoid air cells was better seen on the prior CT due to differences in technique. IMPRESSION: No evidence for acute intracranial abnormalities. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ presenting in acute on chronic CHF exacerbation. Developed abdominal distension overnight. // assess abdominal distention COMPARISON: MRI abdomen dated ___. FINDINGS: Supine portable views of the abdomen demonstrate multiple air-filled prominent small and large bowel loops. There is no evidence of small bowel obstruction. There is no pneumatosis or free air. Degenerative changes of the lower lumbar spine are demonstrated. Right hip prosthesis is in place. Osseous structures appear intact. IMPRESSION: Multiple prominent air-filled small and large bowel loops, may reflect ileus. No evidence of small bowel obstruction. Radiology Report INDICATION: NG tube placement. COMPARISON: Radiograph from ___. TECHNIQUE: Frontal abdominal radiograph. IMPRESSION: An NG tube terminates within the stomach. The patient is post CABG. There is no pneumothorax. A normal bowel gas pattern is demonstrated. FINDINGS: A normal bowel gas pattern is demonstrated here. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, R Hip pain Diagnosed with JOINT PAIN-PELVIS, UNSPECIFIED FALL, OPEN WOUND OF SCALP, HYPOSMOLALITY/HYPONATREMIA, CONGESTIVE HEART FAILURE, UNSPEC temperature: 96.8 heartrate: 60.0 resprate: 20.0 o2sat: 98.0 sbp: 156.0 dbp: 72.0 level of pain: 5 level of acuity: 3.0
___ with hx of diastolic CHF, CAD s/p CABG, AFib not on coumadin (due to recurrent falls), CKD (baseline Cr 1.4-1.7), right renal mass (concerning for RCC), and total right hip replacement who presented with a mechanical fall at home in the setting of increased ___ edema and pulmonary edema concerning for acute on chronic CHF exacerbation. CT-head on admission showed no acute intracranial abnormalities and hip xrays showed no fracturs. Pt was diuresed with IV lasix with removal of a significant amount of excess fluid and discharged to rehab on a maintenance dose of oral torsemide. #Acute on chronic diastolic CHF Pt presented in volume overload and was diuresed with IV lasix during the course of his admission. The aggressiveness with which he was diuresed was limited by his elevated Cr in the setting of CKD. His Cr level was maintained within the upper range of his known baseline. Pt was discharged on 20mg oral torsemide daily as a maintenance diuretic to be titrated per outpatient follow-up. #Ileus Pt experienced acute onset nausea and emesis upon admission. A KUB showed bowel gas patterns consistent with ileus. He was treated with Zofran prn and a nasogastric tube was placed for decompression. His symptoms improved overnight and a repeat KUB showed resolution of his ileus. NGT was removed and he did not have a recurrence of ileus. #Hyponatremia Pt presented with a Na of 125 likely secondary to hypervolemia and free water excess. He may have been symptomatic with some word-finding difficulty that was noticed. With ongoing diuresis during his admission, his Na level increased in response to diuresis. His mental status and speech improved to baseline per daughter's assessment. His Na on discharge had improved to 134. TRANSITIONAL ISSUES =================== -Pt's dry weight on discharge is 82.8kg (182lbs). Please continue to monitor his weight daily and adjust torsemide dose as necessary. -Pt's previous maintenance oral lasix 20mg 6x/week was discontinued and pt was discharged on torsemide 20mg qd as a new maintenance diuretic. -Pt presented with hyponatremia at Na 125 that subsequently improved with diuresis. His Na on discharge was 134. Please continue to monitor his chem panel on a regular basis. -Pt's home labetolol 100mg tid was discontinued during this admission in the setting of bradycardia to HR ___ while he was nauseated and vomiting from ileus. After resolution of ileus, he was started on Metoprolol XL 25mg daily for afib rate control.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Abacavir / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Hematuria, clot retention Major Surgical or Invasive Procedure: none History of Present Illness: ___ h/o low grade bladder cancer, BPH, urethral stricture, CAD on ASA81, Afib on Eliquis, and HIV who presents with hematuria, clot retention since last night. The patient last underwent bladder resection ___ years ago for low grade disease (@ ___ and surveillance cystoscopy 1 month ago was reportedly negative. He self caths for the urethral stricture, but voids without issues. This is his first episode of gross hematuria. He awoke from sleep last night with abdominal pain and urge to urinate, was able to urinate a small amount of bloody urine but was unable to empty completely. His pain increased so he presented to the ER. He has had multiple symptomatic UTIs in the past, but denies recent symptoms of dysuria, frequency, has baseline urgency. Denies f/c/n/v. He has been having constipation and has been straining to defecate. UA >182 RBC, >182 WBC, bacteria, + nitrites started on ceftriaxone-->zosyn. 3-way placed by ER and started on CBI but they have been unable to clear him. Past Medical History: - Hypertension - Dyslipidemia - Pulm htn - CAD ___ CABG (___) - EF 55% - RHD/AS/MS ___ bioAVR/MVR in ___, repeat bioAVR ___ (for stenosis) - Afib ___ ablation ___ and ___ on xarelto - HIV last cd4 392 ___ - Squamous cell carcinoma Social History: ___ Family History: Father: throat cancer Physical Exam: Admission Physical Exam: VITALS: T: 97.9, HR 60, BP 134/66, RR 14, 97% RA GEN: appears uncomfortable, AAO HEENT: NCAT, EOMI, anicteric sclera PULM: nonlabored breathing, normal chest rise ABD: soft, tender lower abdomen, bladder palpably distended GU: uncircumcised penis, orthotopic meatus, penile shaft without masses or lesions, no urethral discharge, 3-way foley in place, secured, CBI off, urine red opaque EXT: WWP Discharge Physical Exam: Pertinent Results: Admission Labs: ___ 04:46AM BLOOD WBC-11.1* RBC-4.96 Hgb-14.7 Hct-44.1 MCV-89 MCH-29.6 MCHC-33.3 RDW-16.9* RDWSD-54.7* Plt ___ ___ 04:46AM BLOOD Glucose-109* UreaN-25* Creat-1.4* Na-136 K-4.8 Cl-96 HCO3-25 AnGap-15 ___ 06:40AM BLOOD Iron-20* ___ 06:40AM BLOOD calTIBC-276 Ferritn-90 TRF-212 ___ 06:40AM BLOOD TSH-5.5* Imaging: CT Chest: Diffuse ground-glass opacification bilaterally right greater than left most likely represents pulmonary edema. The appearance is uncharacteristic for bacterial or fungal pneumonia however superimposed PCP pneumonia cannot be excluded. Small bilateral pleural effusions. Borderline enlarged mediastinal bilateral hilar lymph nodes could be related to HIV status. Or the could be reactive. Status post cardiac surgery. Moderate to severe cardiomegaly. CXR: Heterogeneous pulmonary opacification was initially a asymmetric, severe in the right lung and mild in the left. Over the past 4 days, right lung has barely improved, but heterogeneous opacification in the left lung has worsened. Character the abnormality on the left looks like pulmonary edema, attributable to severe cardiomegaly and reflected also in distension of mediastinal veins. Right pleural effusion is moderate, left pleural effusion is small if any. No pneumothorax. Overall the findings suggest initial aspiration episode accompanied by progressive cardiac decompensation. Bilateral ___ U/S: No evidence of deep venous thrombosis in the right or left lower extremity veins. Bladder Ultrasound: 1. An intraluminal bladder clot measures approximately 5.6 x 4.3 x 4.2 cm. Discharge Labs: Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Apixaban 2.5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Baclofen 10 mg PO TID:PRN Muscle Spasms 6. Carvedilol 12.5 mg PO BID 7. Darunavir 800 mg PO BID 8. Dolutegravir 50 mg PO DAILY 9. LaMIVudine 150 mg PO DAILY 10. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 11. Amiodarone 400 mg PO TID 12. Amiodarone 200 mg PO DAILY 13. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) ___ mg-mcg oral DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Amiodarone 200 mg PO DAILY 3. Apixaban 2.5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Baclofen 10 mg PO TID:PRN Muscle Spasms 7. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) ___ mg-mcg oral DAILY 8. Darunavir 800 mg PO BID 9. Dolutegravir 50 mg PO DAILY 10. LaMIVudine 150 mg PO DAILY 11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 12.Rolling walker Diagnosis: Orthostasis, CHF Prognosis: Good ___ 13 months 13.Rolling Walker Diagnosis: Orthostasis Prognosis: Good ___: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hematuria Volume overload Hospital acquired pneumonia Hyponatremia ___ HIV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: BLADDER US INDICATION: ___ year old man with hematuria.// Clot burden in bladder. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: Dedicated ultrasound of the urinary bladder demonstrates an inflated Foley catheter bulb and an intraluminal echogenic soft tissue mass measuring approximately 5.6 x 4.3 x 4.2 cm. There is no internal vascularity on color Doppler. Findings compatible with intraluminal clot. According to clinic notes, recent cystoscopy was negative for tumor recurrence. Limited evaluation of the kidneys demonstrate no hydronephrosis. The right kidney measures 13.4 cm in length. The left kidney measures 13.3 cm in length. IMPRESSION: 1. An intraluminal bladder clot measures approximately 5.6 x 4.3 x 4.2 cm. Radiology Report EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL) INDICATION: ___ year old man with hematuria clot retention. Assess for bladder clot burden. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and bladder were obtained. COMPARISON: Comparison is made to ultrasound from ___ and CT abdomen and pelvis from ___. FINDINGS: The right kidney measures 11.6 cm. The left kidney measures 11.3 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Again demonstrated is an inflated Foley catheter bulb within the bladder with an intraluminal echogenic soft tissue mass measuring 1.7 x 3.4 x 3.0 cm without internal vascularity on color Doppler, consistent with intraluminal clot. This appears decreased in size compared to prior performed ___. Limited evaluation of the gallbladder demonstrates a hypoechoic mass on a nondependent portion of the gallbladder wall with irregular margins and without evidence of internal vascularity. The mass measures 1.0 x 1.2 x 1.1 cm without associated gallbladder wall thickening or edema. A calcified gallstone is also demonstrated. There is a small right pleural effusion. IMPRESSION: 1. Decreased size of an intraluminal bladder clot measuring 1.7 x 3.4 x 3.0 cm. 2. A 1.2 cm hypoechoic gallbladder wall mass with irregular margins is incompletely characterized and may represent a gallbladder wall polyp or tumefactive biliary sludge. Recommend further evaluation with dedicated MR imaging. 3. Small right pleural effusion. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:57 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with AFib on AC currently held for severe gross hematuria, c/o LLE pain and desat to 86% with ambulation, evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, 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. Radiology Report INDICATION: ___ year old man with cardiac hx, hematuria now desaturating.// r/o pulm edema, atalectasis TECHNIQUE: AP and lateral chest radiographs COMPARISON: ___ FINDINGS: There are diffuse bilateral airspace opacities, right greater than left which may reflect asymmetric pulmonary edema. The size of the cardiac silhouette is enlarged and there is prominence of the vascular pedicle. There is no pneumothorax or large pleural effusion. A left chest wall dual lead pacemaker is present IMPRESSION: Diffuse bilateral right greater than left airspace opacities are thought to reflect asymmetric pulmonary edema given the enlarged cardiac silhouette and prominent vascular pedicle. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with vascular congestion on CXR s/p Lasix admin, reassess// assess pulmonary edema assess pulmonary edema IMPRESSION: Compared to chest radiographs since ___, most recently ___ and ___. Asymmetric opacification of the lungs, severe on the right, less extensive on the left has improved on the right and worsened on the left. The pattern suggests redistribution of pulmonary edema but pneumonia pulmonary hemorrhage are certainly not excluded. A moderate to severe enlargement of cardiac silhouette is stable. There is no pleural effusion. Transvenous right atrial and right ventricular pacer leads are on course from the left pectoral generator. Radiology Report INDICATION: ___ year old man with acute on chronic heart failure, acute hypoxic respiratory failure// Assess for pulmonary edema, pleural effusions TECHNIQUE: AP portable COMPARISON: ___ IMPRESSION: Right-sided pacemaker with the tips in correct position. Surgical clips along the right side of the cardiac border likely from prior CABG. Median sternotomy wires are unchanged. There has been an interval improvement of the pulmonary edema better seen in the left upper lobe. Nonetheless, the opacities in the right lung appear more coalescent, in addition to an increase of right pleural effusion. This is concerning for a superimposed pneumonia in the right upper lung. Stable severe cardiomegaly. There is no pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hematuria, acute on chronic heart failure, possible pneumonia with worsening shortness of breath// Assess for change in edema, consolidations, pneumothorax Assess for change in edema, consolidations, pneumothorax IMPRESSION: Compared to chest radiographs since ___, most recently ___ through ___. Heterogeneous pulmonary opacification was initially a asymmetric, severe in the right lung and mild in the left. Over the past 4 days, right lung has barely improved, but heterogeneous opacification in the left lung has worsened. Character the abnormality on the left looks like pulmonary edema, attributable to severe cardiomegaly and reflected also in distension of mediastinal veins. Right pleural effusion is moderate, left pleural effusion is small if any. No pneumothorax. Overall the findings suggest initial aspiration episode accompanied by progressive cardiac decompensation. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with hypoxia and CXR that is read as pulmonary edema despite being clinically dry. Now with SIADH with sodium down to 126. Patient had HIV with CD4 count of 380 in ___// Please evaluate for infiltrate, mass given SIADH. Given HIV status please eval for atypical infection vs fungal as well. If atypical findings may target ___ with BAL for further evaluation. TECHNIQUE: Multi detector CT of the chest was performed after the administration of intravenous contrast. Axial coronal and sagittal reconstructions were acquired. Maximum intensity projections were also acquired DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 37.9 cm; CTDIvol = 8.5 mGy (Body) DLP = 315.6 mGy-cm. Total DLP (Body) = 316 mGy-cm. COMPARISON: Comparison is done to prior radiographs done on ___ FINDINGS: THORACIC INLET: The thyroid is unremarkable. There are small left supraclavicular lymph nodes largest measuring 6 mm. There is a left-sided pacemaker with leads projecting to the right atrium and right ventricle. BREAST AND AXILLA : There are no enlarged axillary lymph nodes MEDIASTINUM: The multiple small mediastinal lymph nodes the right paratracheal node measures 16 mm. The subcarinal lymph node measures 22 mm. There are small bilateral hilar lymph nodes measuring up to a cm. There is moderate cardiomegaly. Prosthetic aortic and mitral valve are in place. There is also evidence of prior coronary artery bypass graft surgery. There is no pericardial effusion PLEURA: There are small bilateral pleural effusions right greater than left. LUNG: There is diffuse ground-glass opacification bilaterally right greater than left associated with mild septal thickening the appearance of the lungs is unchanged since the prior study. No consolidations or nodules are seen. BONES AND CHEST WALL : Review of bones shows degenerative changes involving the thoracic spine. Sternal sutures are intact UPPER ABDOMEN: Limited sections through the upper abdomen shows no focal liver lesions. There is trace perihepatic ascites. The spleen is top-normal in size. No adrenal masses are seen. IMPRESSION: Diffuse ground-glass opacification bilaterally right greater than left most likely represents pulmonary edema. The appearance is uncharacteristic for bacterial or fungal pneumonia however superimposed PCP pneumonia cannot be excluded. Small bilateral pleural effusions. Borderline enlarged mediastinal bilateral hilar lymph nodes could be related to HIV status. Or the could be reactive. Status post cardiac surgery. Moderate to severe cardiomegaly. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hematuria Diagnosed with Gross hematuria temperature: 98.3 heartrate: 60.0 resprate: 16.0 o2sat: 97.0 sbp: 128.0 dbp: 59.0 level of pain: 8 level of acuity: 3.0
___ with a history of low grade bladder cancer, HIV (CD4 ___, BPH, urethral stricture CAD ___ CABG ___. SVG-PDA, SVG-OM), AS and MS from rheumatic heart disease ___ bioAVR/bioMVR in ___ with repeat bioAVR in ___ (for recurrent stenosis of valve), dysfunction of the mitral valve prosthesis that required ___ on ___, several PCIs, and AFib/Flutter ___ ablation (on apixaban), tachy brady syndrome ___ PPM presenting with hematuria likely secondary to prostatatic trauma I/s/o self catheterization and UTI. Course complicated by volume overload with pulmonary edema, acute hypoxic respiratory failure, PNA and hyponatremia. #Hematuria, clot retention: Resolved. Likely prostatic origin from self catheterization he does given that he has a known urethral stricture. He had hematuria developed after this self catheterization/dilation and straining to have a bowel movement. Also found to have a UTI, which may have contributed. Cystoscopy 1 month ago negative for tumor recurrence. Hgb stable, catheter removed, voiding spontaneously. His urologist is Dr ___ at ___ and he was encouraged to make a ___ with him. # Acute blood loss anemia due to hematuria: Hemoglobin stabilized near 8; he did not meet criteria for transfusion, and was encouraged to consume iron rich foods. # Hyponatremia, both SIADH and Hypovolemic hypoNa: New to 126 at worst. Urine osoms 300 his urine sodium was in the ___. Given this pattern was difficult to determine the underlying etiology. He was given a 500 cc bolus of LR as a trial. His sodium following the 500 cc of LR fell 126. This most likely confirms SIADH as the underlying etiology. He was then fluid restricted to 1.5 L and his sodium is improved to 129 and then fell again. On the repeat fall his urine lytes were now consistent with salt avid (Urine sodium <20) and likely represented hypovoemia hypoNa. He was given some IVF and his sodium improved. Discharge Na was 132, and should be rechecked by PCP at ___. He was told to continue following a 2 liter fluid restriction and to consume solute rich fluids. # Acute hypoxic respiratory failure # Hospital Acquired PNA: Patient with cough with sputum production, persistent O2 requirement, mild leukocytosis and CXR concerning for a right sided PNA. He was initially started on p.o. levofloxacin on ___ but he continued to feel unwell and had no improvement in his oxygenation. He underwent a chest CT on ___ due to his SIADH and no improvement. CT scan is consistent with a multilobular right-sided pneumonia. Started vancomycin/cefepime/azithromycin on ___ as D1 of antibiotics. Vancomycin stopped when MRSA nasal swab was negative. Completed a 7 day course of cefepime. # Acute on chronic diastolic CHF # Valvular disease: AS and MS from rheumatic heart disease, ___ bioprosthetic AVR and MVR in ___, worsening aortic valve gradient in ___ with repeat bio-AVR at that time during second CABG, severe MR in ___ ___ on ___. His BNP is the lowest it has been at 860 making problem with the valve not likely. ___ diuresis with now euvolemia/dry and resolved O2 requirement. # Fatigue, poor appetite: Patient states that he has had poor appetite for some time preceding hospitalization, and that his appetite remained "not great" during hospital stay. He endorsed significant fatigue 2 days prior to discharge, improved by discharge. Likely reasons for fatigue likely include hospitalization, anemia, infection, deconditioning. He will have ___ at home and was sent home with a walker. PCP should ___ with discussion of mood, query of dysthymia. ___: Likely combination of prerenal and obstructive. Peak 1.8. Trended down to 1.2 on day of discharge. #Orthostatic hypotension: Resolved. Baseline SBP 110-130. Initial blood loss was resuscitated with fluids. This had been an issue as an outpatient as well. Discussed with cardiology and reduced coreg to 3.125mg BID, but he felt very fatigued after receiving low dose coreg, so it was held on discharge. # Incidental finding: Gallbladder wall polyp/mass: A 1.2 cm hypoechoic gallbladder wall mass with irregular margins was incompletely characterized and may represent a gallbladder wall polyp or tumefactive biliary sludge. Radiology recommends further evaluation with dedicated MR imaging. I discussed this with the patient and he is aware. I have also sent a letter to his PCP to notify him of this finding. - Outpatient follow-up # CAD: The patient has an extensive history of coronary artery disease ___ CABG x 2 in ___ and ___, and PCI in ___. -- Continued Atorvastatin 20 mg PO/NG QPM - Continued ASA 81mg PO - Coreg held #Atrial arrhythmias: Pt with a long history of multiple atrial arrhythmias, ___ multiple cardioversions, PVI, CTI ablation and atrial tach ablation, recently found to have long conversion pauses ___ dual chamber PPM. Apixaban was held on admission in the setting of acute bleed and has now been resumed. Of note, his device was interrogated today, and his last episode of afib was on ___. He has not had afib during this admission. - Continued apixaban at home dose - Continued Amiodarone 200 mg PO/NG DAILY #HIV: (CD4 ___ - Continued home ART. Patient was concerned that his dolutegravir was supposed to be 150 mg and not 50 mg. However, review of outpatient medications shows a 50 mg dose. Advised to d/w Dr ___ any concerns. Greater than ___ hour spent on care on day of discharge.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Gold Salts / minocycline / Penicillins / Sulfa (Sulfonamide Antibiotics) / sulindac Attending: ___. Chief Complaint: Diarrhea, anxiety, depression Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with h/o COPD, depression, rheumatoid arthritis, hep C and CML on Dasatanib who presented with diarrhea and SI iso running out of ___ medication. In ED patient reported feeling very uncomfortable with a knot in his stomach and diffuse ___. He also endorses only being able to eat a yogurt today. He had chills, nausea, and diarrhea ___ per day). Denies fevers, vomiting, chest ___, cough, sick contact. Denies bloody stools or melena. Recently discharged from nursing home and now lives alone with assistance from home health aide who comes daily, dresses him, cooks for him and drives him to appointment. He reports being out of his home ___ medications (methadone and oxycodone) for a week. He was seen by heme/onc (Dr. ___ today for CML who refered him to the ED for his complaints. At this visit he complained of diffuse ___, ___ loose stools a day, and unable to eat. His medical aid confirmed that the patient had decreased po intake d/t decreased appetite. Per Dr. ___ is in remission and he has no active onc needs at this time. In review of records he also went to ___ ED (___) with non-specific complaints of ___ and requesting ___ medications. He was not given any ___ meds and was discharged. PMP Review ___ LORAZEPAM 0.5 MG TABLET 60.0 15 ___ METHADONE HCL 10 MG TABLET 42.0 ___ OXYCODONE HCL 15 MG TABLET 120.0 ___ METHADONE HCL 10 MG TABLET 42.0 While in the ED he expressed suicidal ideation and increased depression. He denied HI, AH, or VH. He was placed on section and seclusion orders. In the ED, initial VS were:98.6, 73, 175/95, 18, 96% RA Exam notable for:Extensive joint deformities due to RA, no HI, AH, or VH. Labs showed: CBC: 6.9/14.4/44.9/213 BMP: ___ Lactate 1.0 Serum tox: negative for asa, etoh, acet, benzo, barb, tricyc Urine tox: + oxycodone, negative for benzos, barbs, opiates, cocaine, amph, methadone UA: SM blood, neg leuk, neg nite, 30 protein, neg glu, 40ketones, 3rbcs, <1 WBC, few bacteria Imaging showed: CXR: Small bilateral pleural effusions. Bibasilar opacities could be due to atelectasis but pneumonia is not excluded in the appropriate clinical setting. In addition, patchy left mid lung opacity raises concern for pneumonia. Received: ___ 18:18 IH Albuterol 0.083% Neb Soln 1 NEB ___ 18:18 IH Ipratropium Bromide Neb 1 NEB ___ 18:31 IV MethylPREDNISolone Sodium Succ 125 mg ___ 19:52 IV Azithromycin (500 mg ordered) ___ 19:52 IVF NS 1 mL ___ 20:24 IV LORazepam .25 mg ___ 20:55 IV Azithromycin 500 mg ___ 20:55 IV Levofloxacin 750 mg ___ 21:12 PO/NG Gabapentin 600 mg ___ 21:12 PO/NG OxyCODONE (Immediate Release) 10 mg Transfer VS were: 98.1, 75, 173/89, 22, 95% RA On arrival to the floor, patient reports diarrhea, nausea, chills, increased ___, feeling like his skin in crawling, and runny nose for about a week now. He also endorses feeling more short of breath with decreased sputum production. He usually uses 1.5L at home and has been trying to taper it off. He walks around with Pulse ox and O2 sat stays around 94% without oxygen. Over the past week thought he has started to wear it most times again. He denies o2 sat dropping lower than 94%. He also endorses frequent episodes of anxiety and chest pressure. He denies chest pressure at rest other than when having a "panic" or when walking. He has a pill rolling resting tremor bilaterally that patient said has gotten worse recently. He had a tremor prior in just his left hand but since being in the nursing home tremor has increased and become bilateral. He denies any increased stiffness and thinks difficulty walking is d/t ___. He also endorses having a migraine headache currently. He says that he gets them about once a week and doesn't take any medication for them. He denies every being on any preventative or abortive therapy. He endorses depression and feeling lonely most of the time. He said that he recently moved into an apartment by himself from nursing home and doesn't see anyone most of the day. He has frequent panic attracts and persistent anxiety. He said that in the ED he was feeling so bad that "he would have done something to stop feeling that way". He denies having a plan, but says that "he's in ___ all the time and it would be nice to have it all go away". He said that currently he feels like it's manageable and says "I wouldn't do anything because I've got my kids". I asked that if he started to feel like he did in the ED would he be safe. He assured me he would call someone for help and would not hurt himself. He would like to see a psychiatrist and thinks that it would help. Currently, he feels better with no nausea, decreased ___, and feels calmer. He does endorse a headache. He currently denies any cp, sob, or abdominal ___. Past Medical History: Depressive disorder Asthma Low back ___ Hepatitis C, chronic ARTHRITIS - RHEUMATOID TRIGGER FINGER-R ___ TENOSYNOVITIS - HAND / WRIST-R EDQ Esophageal reflux ___ syndrome, chronic Neuropathy LIPOMA, UNSPEC SITE Headache, migraine Erectile dysfunction Obesity COPD (chronic obstructive pulmonary disease) CML (chronic myelocytic leukemia) Spondylosis of cervical region without myelopathy or radiculopathy Immunosuppression BPH Lung reduction surgery in ___ for a "fungal infection" Recent surgery on L flank for "scar tissue removal at ___. Patient says he has a history of CHF but no record or CHF and no ECHO in Atrius and BI records Social History: ___ Family History: Brother: alcoholism, drug additions Brother: ___ Daughter: asthma family history includes Tuberculosis in his mother; copd in his father; lung cancer in his mother; scleroderma in his brother. Physical Exam: ADMISSION EXAM ======================= VS: 97.9, 170/82, 70, 18, 94%RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, unable to asses JVD d/t body habitus HEART: Distant heart sounds, but RRR, no murmurs appreciated LUNGS: Barrel chested, breathing comfortably on 2L, wheezes throughout, course rhonchi throughout that cleared some with cough ABDOMEN: Normoactive bowel sounds, soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, two well healed abdominal incisions. EXTREMITIES: no cyanosis, clubbing, or edema. Deformity of PIP and MCP joints bilaterally, ulnar deviation bilaterally, joints are cold. PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, pill rolling resting tremor bilaterally, no rigidity in upper extremities, couldn't appreciate any cogwheeling, SKIN: warm and well perfused, no excoriations or lesions, no rashes Psych: depressed mood and affect, speaks openly about feeling depressed and lonely. DISCHARGE EXAM ======================== Vitals: 98.4, HR 65, BP 143/74, RR 18, 95% 2L NC (though on room air when I examined him) General: Alert, oriented, more comfortable and pleasant appearing today, NAD Lungs: Coarse breath sounds bilaterally with scattered wheezes, stable since yesterday CV: RRR, no m/r/g Ext: warm, no edema Neuro: A+OX3, moving all extremities Pertinent Results: IMAGING/REPORTS ======================= CXR ___ Small bilateral pleural effusions. Bibasilar opacities could be due to atelectasis but pneumonia is not excluded in the appropriate clinical setting. In addition, patchy left mid lung opacity raises concern for pneumonia. MICROBIOLOGY ======================= Urine culture - Coag Negative Staph (contaminant) Blood cultures - NGTD LABS ======================= ___ 06:00PM BLOOD WBC-6.9 RBC-5.32 Hgb-14.4 Hct-44.9 MCV-84 MCH-27.1 MCHC-32.1 RDW-13.8 RDWSD-42.1 Plt ___ ___ 06:00PM BLOOD Neuts-67.6 Lymphs-18.4* Monos-5.8 Eos-7.2* Baso-0.7 Im ___ AbsNeut-4.67 AbsLymp-1.27 AbsMono-0.40 AbsEos-0.50 AbsBaso-0.05 ___ 06:00PM BLOOD Glucose-93 UreaN-9 Creat-0.7 Na-140 K-4.2 Cl-100 HCO3-26 AnGap-14 ___ 06:00PM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 ___ 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:34PM BLOOD Lactate-1.0 ___ 07:55PM URINE RBC-3* WBC-<1 Bacteri-FEW* Yeast-NONE Epi-<1 ___ 07:55PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG ___ 07:55PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 40 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. LamoTRIgine 200 mg PO DAILY 4. Loratadine 10 mg PO DAILY 5. Methadone 10 mg PO TID 6. OxyCODONE (Immediate Release) 15 mg PO TID:PRN ___ 7. Pantoprazole 40 mg PO Q12H 8. Ranitidine 300 mg PO DAILY 9. tamsuLOSIN 0.4 mg oral QHS 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION Q4H:PRN sob 11. TraZODone 100 mg PO QHS insomnia 12. DASatinib 100 mg PO DAILY 13. Lidocaine 5% Patch 1 PTCH TD QAM 14. LORazepam 0.5 mg PO Q4H:PRN anxiety 15. GuaiFENesin 400 mg PO BID 16. Gabapentin 600 mg PO TID 17. Baclofen 10 mg PO TID 18. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation Daily 19. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob, wheeze Discharge Medications: 1. Mirtazapine 7.5 mg PO QHS RX *mirtazapine 7.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob, wheeze 3. Baclofen 10 mg PO TID 4. DASatinib 100 mg PO DAILY 5. FLUoxetine 40 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. GuaiFENesin 400 mg PO BID 9. LamoTRIgine 200 mg PO DAILY 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. Loratadine 10 mg PO DAILY 12. LORazepam 0.5 mg PO Q4H:PRN anxiety 13. Methadone 10 mg PO TID RX *methadone 10 mg 1 tablet by mouth three times per day Disp #*30 Tablet Refills:*0 14. OxyCODONE (Immediate Release) 15 mg PO TID:PRN ___ RX *oxycodone 15 mg 1 tablet(s) by mouth three times per day Disp #*30 Tablet Refills:*0 15. Pantoprazole 40 mg PO Q12H 16. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION Q4H:PRN sob 17. Ranitidine 300 mg PO DAILY 18. tamsuLOSIN 0.4 mg oral QHS 19. TraZODone 100 mg PO QHS insomnia 20. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation Daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Opioid withdrawal Chronic ___ Depression Suicidal Ideation 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 sob// pna? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: There is persistent elevation of the right hemidiaphragm. Right base atelectasis is seen. Blunting of the costophrenic angles suggests small bilateral pleural effusions. Bibasilar opacities could be due to atelectasis, but pneumonia is not excluded in the appropriate clinical setting. In addition, patchy left mid lung opacity raises concern for pneumonia. Cardiac silhouette is mildly enlarged. IMPRESSION: Small bilateral pleural effusions. Bibasilar opacities could be due to atelectasis but pneumonia is not excluded in the appropriate clinical setting. In addition, patchy left mid lung opacity raises concern for pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Body pain, Med refill Diagnosed with Pneumonia, unspecified organism, Myalgia, Suicidal ideations temperature: 98.6 heartrate: 73.0 resprate: 18.0 o2sat: 96.0 sbp: 175.0 dbp: 95.0 level of pain: 9 level of acuity: 3.0
___ male with h/o COPD, depression, rheumatoid arthritis and Rheumatic lung disease, chronic ___ on chronic narcotics, CML on Dasatanib, who presented with opioid withdrawal and worsened depression in the setting of running out of his home narcotic medications. # Opioid Withdrawal # Chronic ___ His presenting symptoms (diarrhea, anxiety, gooseflesh, tremor) were consistent with opioid withdrawal. They had developed as there was confusion among his outpatient providers as to who would be prescribing his chronic narcotics. He was restarted on his home narcotic regimen, and his symptoms promptly resolved. He will be provided with a 10 day supply of his Methadone 10mg TID and Oxycodone 15mg TID on discharge. He will need close follow up as an outpatient with his PCP, ___ Physicians (Dr. ___ at ___, as well as ___ Chronic ___. Also, for chronic ___, he will continue on home Gabapentin and Lidocaine patch. # Suicidal Ideation # Depression In the setting of worsening loneliness and opioid withdrawal, he developed worsening symptoms of depression as well as passive suicidal ideation. He was seen by Psychiatry who found him to be depressed, but psychiatrically overall stable, with no need for sitter, ___, or inpatient Psych hospitalization. Mirtazapine was added to help with depression and sleep. Otherwise, his home Psych regimen was left unchanged (see below), though recommendations were made for outpatient changes (see transitional issues). He will need close follow up with a Psychiatrist as well as a therapist, which his case manager will help arrange.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Morphine Sulfate / Lovenox / Lipitor / Penicillins / Codeine / Erythromycin Base / Acetazolamide Attending: ___ Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: None History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: <2> minutes Time/Date the patient was last known well: ___ Stroke Scale Score: t-PA Administration [] Yes - Time given: [x] No - Reason t-PA was not given/considered: INR>1.7 I was present during the CT scanning and reviewed the images within 20 minutes of their completion. I reviewed the benefits, risks, and contraindications to IV tPA with the patient and/or family who consented to this treatment. ___ Stroke Scale - Total [10] 1a. Level of Consciousness - 0 1b. LOC Questions - 2 (just answered "ok") 1c. LOC Commands - 0 2. Best Gaze - didn't follow but moving in all directions 3. Visual Fields - 0 (BTT) 4. Facial Palsy - 2 (right) 5a. Motor arm, left - 0 5b. Motor arm, right - 3 6a. Motor leg, left - 0 6b. Motor leg, right - 0 7. Limb Ataxia - unable to test 8. Sensory - 1 (withdrawal to noxious in RUE) 9. Language - 2 10. Dysarthria - unable to test 11. Extinction and Neglect - unable to test Pre-stroke mRS - Modified ___ Scale: [] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [x] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead HPI: ___ is a ___ female with a PMHx of AF, arachnoid cyst, possible partial seizures (followed by Dr. ___, prior strokes (___), expressive aphasia, HTN, and HL who presents with a seizure characterized by low amplitude right arm shaking, right eye closed/left open, and head version to right followed by right face/arm/leg weakness. The family notes that she has been more lethargic and sleeping more often for the last 3 weeks, including the day of presentation. Today (___), at 4:00pm, she had a witnessed event concerning for seizure that lasted five minutes as described above. Afterward, she developed a right facial droop and was unable to move her right arm or leg. Her family feels the patient's language is "almost" at baseline, although the patient can typically answer yes/no questions which she was unable to do today. Of note, she had previously been diagnosed with possible partial seizures versus TIAs characterized by right facial droop, decreased word output, and confusion lasting 5 minutes with fatigue afterward. Per family, she was on an AED (they did not recall name) that made her very lethargic, and her possible seizures have not been treated since then. Family, together with their PCP, decided not to treat or hospitalize her for these events because of the fatigue to the patient of going to the ED. However, this is the first time that she has had limb shaking or arm/leg weakness, and this prompted the family to bring Ms. ___ to ___. There, a Code Stroke was called, and a ___ identified a new zone of hypoattentuation involving the left periatrial white matter extending into the posterior left putamen, internal capsule, temporal lobe which could represent a subacute infarct. Chronic infarcts and a stable left arachnoid cyst were also noted. She was not given tPA due to an INR of 3.1. She was given 1g Keppra and transferred here for possible endovascular intervention. Patient unable to complete ROS but family note that she has been having urinary incontinence which is new and she has been lethargic/sleepy for 3 weeks. They also noted that she could not get a spoon to her mouth for the last ___ days (because she would hold the spoon in the wrong direction). Past Medical History: Includes the following as documented in the previous notes and confirmed by the patient and family: 1. Atrial fibrillation, longstanding on a beta-blocker and anticoagulated with warfarin since prior strokes, the most recent of which was in ___. 2. Hypertension, on an ACE inhibitor medication and a beta-blocker. 3. Hypercholesterolemia, on a statin medication. 4. Hyperhomocysteinemia 5. History of a traumatic C1 and C2 fracture status post immobilization and a halo vest and healing and back to baseline neuromuscular function. 6. Previous history of two strokes, one in the late ___, possibly ___ with some transient left visual field deficit that has since resolved involving the right occipital cortex and another in ___, which caused an expressive aphasia that was also transient. This ___ infarct involved a small region near the left angular gyrus. She has also been documented to have two prior TIA episodes consisting of word finding difficulties in the past. 7. History of basal cell carcinoma. 8. History of appendectomy, TAH/BSO procedures in the past, remote. 9. Aortic Stenosis +/- mild MR with aortic valve leaflet thickening (followed by Cardiology): Last echo in ___ showed " The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The 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. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Social History: ___ Family History: Negative for neurologic illness. Two sisters has type 1 diabetes. Breast cancer in siblings. Physical Exam: ADMISSION Physical Exam: Vitals: ___ P: 90-101 R: 18 BP: 144/71-->182/75 SaO2: 93%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: no work of breathing Cardiac: irregularly irregular Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally Neurologic: Please see top of note for NIHSS. -Mental Status: Alert, regards examiner, repeats "okay." Answered one yes/no question ("Are you in pain?" "Yes.") but not others. Unable to answer orientation questions or participate in attention or memory testing. Able to follow some commands (squeeze/let go fingers, open/close yes; showed thumbs up after delay) but not others ("show two fingers"). Does not participate in naming or repetition tasks. Does not read from stroke card or describe picture. Scooted to edge of bed and attempted to get up a few times and then started taking off her pants (to indicate need to use the restroom). -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. Did not cooperate with EOM testing but looking in all directions. +BTT bilaterally. VII: Right facial droop. IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. -Motor: Decreased bulk and normal tone. No adventitious movements, such as tremor, noted. ___ dropped to bed upon being lifted, initially, but on repeat testing, she was able to hold it ___ distal to the elbow. Was able to hold RLE ___ for 5 seconds. Left UE and ___. Unable to cooperate with formal manual motor testing. -Sensory: No movement to noxious in RUE, withdraws brisly in other extremities. -DTRs: 1+ diffusely. Plantar response was flexor bilaterally. -Coordination and Gait: deferred ===================================================== DISCHARGE Physical Exam: Vitals: Tm/c: 98.0/98.0 BP: 100-144/60-80 HR: ___ RR: 18 SaO2: 93-97% RA General: Awake, cooperative, lying in bed in NAD. HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: skin warm, well-perfused, no pallor nor diaphoresis. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic: -Mental Status: Alert, attends to examiner. Answers simple yes/no questions. Gives full name. Not oriented to year, even with choices. Comprehension intact to simple appendicular commands, but not complex appendicular commands. Names 'glasses' but not lower frequency words. Answers yes/no questions with the correct word and corresponding head shake/nod and facial expression. Mimics appendicular commands. -Cranial Nerves: Gaze crosses midline to each side. Facial activation symmetric. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. Briskly moves LUE, LLE ___ and intermittently provides some full resistance in scattered muscle groups. RUE, RLE sluggishly ___, and provides some resistance intermittently. -Sensory: Reacts to tickle throughout. -Coordination: UTA due to comprehension deficits. Pertinent Results: ___ 08:04PM BLOOD WBC-8.6 RBC-4.54 Hgb-12.5 Hct-39.4 MCV-87 MCH-27.5 MCHC-31.7* RDW-16.1* RDWSD-51.4* Plt ___ ___ 05:40AM BLOOD WBC-9.0 RBC-4.38 Hgb-12.1 Hct-38.0 MCV-87 MCH-27.6 MCHC-31.8* RDW-16.5* RDWSD-52.5* Plt ___ ___ 08:04PM BLOOD ___ PTT-43.7* ___ ___ 06:10AM BLOOD ___ PTT-43.7* ___ ___ 07:55AM BLOOD ___ PTT-44.3* ___ ___ 06:10AM BLOOD ___ PTT-40.5* ___ ___ 10:16AM BLOOD ___ ___ 06:10AM BLOOD Glucose-109* UreaN-11 Creat-0.6 Na-137 K-3.3 Cl-101 HCO3-22 AnGap-17 ___ 05:40AM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-138 K-3.8 Cl-101 HCO3-25 AnGap-16 ___ 06:10AM BLOOD %HbA1c-6.9* eAG-151* ___ 06:10AM BLOOD Triglyc-94 HDL-34 CHOL/HD-3.3 LDLcalc-59 ___ 06:10AM BLOOD TSH-1.8 ___ 08:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:40PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 08:40PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 08:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Imaging: ___ MRI brain w/wo: 1. No acute infarct. Findings on prior CT examination were likely artifactual. 2. No hemorrhage, or enhancing mass. 3. Unchanged large left convexal arachnoid cyst with prominent associated mass effect and 6 mm rightward midline shift. 4. Chronic left parieto-occipital, right occipital and right cerebellar infarcts. 5. Background mild global atrophy and mild areas of white matter signal abnormality most suggestive of chronic small vessel ischemic disease. ___ CTA head/neck: 1. No evidence for an acute intracranial abnormality. 2. Unchanged 97 x 48 mm left convexity arachnoid cyst with stable associated mass effect. 3. Unchanged chronic left inferior parietal/occipital and right occipital infarcts. Unchanged small chronic infarcts versus prominent perivascular spaces in the right basal ganglia, deep white matter, and thalamus. 4. Unchanged chronic occlusion of the right posterior cerebral artery distal P1. 5. Unchanged severe focal stenosis of the inferior M2 division of the left middle cerebral artery poststenotic dilatation, and unchanged severe short-segment stenosis of the right A2 segment of the anterior cerebral artery. Unchanged mild short-segment stenosis of the proximal P2 segment of the left posterior cerebral artery. 6. Unchanged mild narrowing of the right vertebral artery origin. Unchanged atherosclerosis of proximal internal carotid arteries without evidence for stenosis by NASCET criteria. 7. Centrilobular micronodularity and ground-glass attenuation in the visualized upper lungs, which may be related to small airways disease or infection. Mild mediastinal lymphadenopathy. 8. Periapical lucency of the left maxillary lateral incisor. Please correlate clinically whether there may be active dental inflammation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 1.25 mg PO 2X/WEEK (MO,FR) 2. Warfarin 2.5 mg PO 5X/WEEK (___) 3. Lisinopril 20 mg PO QAM 4. Lisinopril 10 mg PO QPM 5. Metoprolol Tartrate 50 mg PO BID 6. Simvastatin 20 mg PO QPM 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. LevETIRAcetam 250 mg PO Q12H 2. Metoprolol Succinate XL 75 mg PO DAILY 3. Warfarin 2.5 mg PO 4X/WEEK (___) 4. Warfarin 1.25 mg PO 3X/WEEK (___) 5. Aspirin 81 mg PO DAILY 6. Lisinopril 20 mg PO QAM 7. Lisinopril 10 mg PO QPM 8. Simvastatin 20 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Post-stroke Epilepsy Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: Seizure and right-sided weakness. Evaluate for large vessel occlusion. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. 2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP = 27.2 mGy-cm. 3) Spiral Acquisition 4.5 s, 35.5 cm; CTDIvol = 30.9 mGy (Head) DLP = 1,098.5 mGy-cm. Total DLP (Head) = 2,029 mGy-cm. COMPARISON: Noncontrast head CTs from ___. CTA head and neck from ___. MR head ___ and ___. FINDINGS: CT HEAD WITHOUT CONTRAST: A large left convexity arachnoid cyst measuring up to 97 x 48 mm is unchanged as compared to numerous prior examinations, with unchanged mass effect upon the left cerebral hemisphere, effacement of the left lateral ventricle, and up to 5 mm of rightward shift of midline structures. There are unchanged chronic left inferior parietal/occipital and right occipital infarcts. Small foci of low density involving the right globus pallidus, posterior limb of the internal capsule and right thalamus is unchanged, compatible with chronic infarcts or prominent perivascular spaces. There is no acute hemorrhage and no CT evidence for an acute major vascular territorial infarction. The paranasal sinuses and mastoid air cells are well aerated. The orbits are unremarkable. CTA NECK: There is extensive atherosclerotic calcification of a 3 vessel aortic arch. There is atherosclerotic calcification at the origins of the great vessels without significant narrowing. There is mild narrowing of the right vertebral artery origin by calcified plaque, and a focus of calcified plaque adjacent to the left vertebral artery origin without definite luminal narrowing, unchanged. Right greater than left, calcified and noncalcified atherosclerotic plaque is noted at the bilateral carotid bifurcations, though without stenosis by NASCET criteria, similar to prior. Proximal common carotid arteries at medialized. CTA HEAD: Right calcification is noted at the V4 segment of the left vertebral artery without significant narrowing. There are mild scattered atherosclerotic calcifications of the bilateral intracranial internal carotid arteries without significant narrowing. There is chronic occlusion of the distal P1 segment of the right posterior cerebral artery, as seen previously. Re-identified is severe focal stenosis of the proximal inferior M2 division of the left middle cerebral artery with poststenotic dilatation (3:206). Mild areas of irregularity are noted in the distal M2/M3 branches on the left, compatible with atherosclerotic disease. There is additional severe narrowing of the right A2 segment of the anterior cerebral artery (3:230, 457:22), unchanged. There is also unchanged mild narrowing of the proximal P 2 segment of the left posterior cerebral artery. There is no evidence for a saccular aneurysm. The dural venous sinuses are patent. OTHER: There is nonspecific diffuse centrilobular micronodularity and ground-glass attenuation in the visualized upper lungs. There is also mild mediastinal lymphadenopathy with the largest mediastinal lymph node measuring up to 16 x 14 mm (03:10). The thyroid gland is unremarkable. There is no cervical lymphadenopathy by CT size criteria. There is periapical lucency of the left maxillary lateral incisor. IMPRESSION: 1. No evidence for an acute intracranial abnormality. 2. Unchanged 97 x 48 mm left convexity arachnoid cyst with stable associated mass effect. 3. Unchanged chronic left inferior parietal/occipital and right occipital infarcts. Unchanged small chronic infarcts versus prominent perivascular spaces in the right basal ganglia, deep white matter, and thalamus. 4. Unchanged chronic occlusion of the right posterior cerebral artery distal P1. 5. Unchanged severe focal stenosis of the inferior M2 division of the left middle cerebral artery poststenotic dilatation, and unchanged severe short-segment stenosis of the right A2 segment of the anterior cerebral artery. Unchanged mild short-segment stenosis of the proximal P2 segment of the left posterior cerebral artery. 6. Unchanged mild narrowing of the right vertebral artery origin. Unchanged atherosclerosis of proximal internal carotid arteries without evidence for stenosis by NASCET criteria. 7. Centrilobular micronodularity and ground-glass attenuation in the visualized upper lungs, which may be related to small airways disease or infection. Mild mediastinal lymphadenopathy. 8. Periapical lucency of the left maxillary lateral incisor. Please correlate clinically whether there may be active dental inflammation. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: History of arachnoid cyst with seizure followed by right-sided weakness. Evaluate for infarct. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 6 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Multiple prior CT and MR head examinations dating from ___ through ___. FINDINGS: There is unchanged large left convexal arachnoid cyst measuring up to 92 x 51 mm, with prominent associated mass effect upon the adjacent left hemispheric brain parenchyma, effacement of the left lateral ventricle, and up to 6 mm rightward midline shift. There are unchanged areas of left parieto-occipital, and right occipital encephalomalacia compatible with chronic infarcts. There is additional tiny right cerebellar infarct. A prominent perivascular spaces noted in the right frontal lobe. There is no evidence of hemorrhage, edema, or infarction. The apparent hypodensity centered within the thalamus/posterior limb of the internal capsule on the right as well as of the right midbrain demonstrates no correlate, and was likely artifactual. There is mild background prominence of the ventricles and sulci suggestive of involutional change. Background areas of periventricular and pontine white matter T2/FLAIR hyperintensity most likely reflect the sequela of chronic small vessel ischemic disease. There is no abnormal enhancement after contrast administration. The principal intracranial vascular flow voids are preserved. The dural venous sinuses are patent on MP-RAGE images. The visualized paranasal sinuses are grossly clear. The orbits are grossly unremarkable. The mastoid air cells are clear. IMPRESSION: 1. No acute infarct. Findings on prior CT examination were likely artifactual. 2. No hemorrhage, or enhancing mass. 3. Unchanged large left convexal arachnoid cyst with prominent associated mass effect and 6 mm rightward midline shift. 4. Chronic left parieto-occipital, right occipital and right cerebellar infarcts. 5. Background mild global atrophy and mild areas of white matter signal abnormality most suggestive of chronic small vessel ischemic disease. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: R Weakness, Seizure Diagnosed with Cerebral infarction, unspecified, Unspecified atrial fibrillation temperature: 98.0 heartrate: 90.0 resprate: 18.0 o2sat: 93.0 sbp: 144.0 dbp: 71.0 level of pain: 0 level of acuity: 2.0
Ms. ___ was admitted with a seizure characterized by right arm shaking, right eye closed/left open, and head version to right. She was started on Keppra at 500mg bid, but this was associated with sleepiness. After discussions with her outpatient neurologist, PCP and family, decision was made to decrease the Keppra to 250 mg bid, which she tolerated without somnolence. No clear precipitating factors were found. Her neurologic deficits were unchanged from baseline. She had an episode of afib with RVR early in her admission, and her home metoprolol 50 mg bid was fractionated to 25 mg tid, which she tolerated without event. She was switched to metoprolol succinate 75 mg daily. She remained in rate-controlled afib the remainder of her admission. INR was supratherapeutic on admission, peaking at 4.7. Coumadin was held x2 days, until INR was 3.2, then it was restarted. Her prior home dose was 1.25 mg M/F, 2.5 mg all other days. Plan to decrease to 1.25 mg ___, and 2.5 mg ___ She was evaluated by ___, who recommended discharge to rehab. =============================================================== Transitional Issues: [ ] Rehab: Continue to titrate Coumadin as needed. [ ] Rehab: titrate metoprolol as needed.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Norvasc / Zestril Attending: ___. Chief Complaint: Nausea/vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: HPI(4): Ms. ___ is a ___ female with PMH HTN, hyperlipidemia, atypical chest pain admitted with 1-day history of nausea, vomiting, diarrhea, and diffuse abdominal pain. Patient describes symptom onset on ___ after eating at restaurant where she had seafood casserole but denies any raw/undercooked shellfish/seafood or meats. Soon after that meal had multiple episodes non-bloody, non-bilious vomiting as well as watery diarrhea and diffuse crampy abdominal discomfort. Denies fever/chills. Patient seen in ED on ___ with ILI symptoms that have improved since that time. Also endorses episodic, non-exertional anterior chest discomfort similar to longstanding symptoms for which she has had prior extensive evaluation with ___ Cardiology (felt to be non-ischemic in etiology). Since arrival to ED, nausea/vomiting, diarrhea, and abdominal discomfort have largely subsided. Patient currently without any specific complaints. Denies fever/chills, headache, dysuria, rash, joint pains/muscle aches, focal numbness or weakness. Feels that she is easily winded recently, and suspects that she may have lost a few pounds with this illness. Past Medical History: 1. HTN 2. Hyperlipidemia 3. History of stage 1A grade 1 endometrioid endometrial adenocarcinoma, s/p total laparascopi hysterectomy/BSO and bilateral pelvic lymph node dissection in ___. Atypical chest pain, s/p nuclear stress ___ without reversible defects, mild-mod fixed inferior defect however subsequent echo with ___ Cardiology without FWMA. 5. LBBB 6. Glaucoma 7. History of DCIS R breast Social History: ___ Family History: Brother with CAD/PVD, sister with CAD/PVD and T2DM. Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress HEENT: Anicteric sclerae. OP clear with dry MMs. JVP: Not elevated COR: S1 S2 RRR with soft systolic murmur at base LUNGS: CTAB without rales or wheeze. GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No palpable organomegaly. GU: No suprapubic fullness or tenderness to palpation EXTREM: No clubbing, cyanosis, or edema. SKIN: No rashes or ulcerations noted NEURO: Alert and interactive, detailed and fluent historian. Face symmetric, moving all limbs without apparent limitation. No pronator drift. No asterixis. PSYCH: pleasant, appropriate affect Pertinent Results: ___ 02:30AM BLOOD WBC: 13.9* Neuts: 90.4* ___ 02:30AM BLOOD Creat: 0.8 ___ 02:30AM BLOOD ALT: 14 AST: 28 AlkPhos: 81 TotBili: 0.3 cTropnT: <0.01 CRP: 6.1* ___ 02:45AM BLOOD Lactate: 1.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 75 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Simvastatin 40 mg PO QPM 5. Potassium Chloride 10 mEq PO DAILY 6. Aspirin 81 mg PO DAILY 7. Loratadine Dose is Unknown PO Frequency is Unknown 8. Multivitamins 1 TAB PO DAILY 9. Fluticasone Propionate NASAL Dose is Unknown NU Frequency is Unknown 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*18 Tablet Refills:*0 2. Senna 8.6 mg PO BID:PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*10 Capsule Refills:*0 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Loratadine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atenolol 75 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Losartan Potassium 50 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Potassium Chloride 10 mEq PO DAILY Hold for K > 12. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Gastroenteritis Terminal ileitis with partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with chief complaint of epigastric abdominal pain and chest pain or shortness of breath // Chest path? COMPARISON: None FINDINGS: PA and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. No evidence of displaced fracture. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with chief complaint of epigastric abdominal pain, and vomiting and diarrheaNO_PO contrast // Cholecystitis? Pancreatitis? Colitis? Diverticulitis abdominal pathology patient 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 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP = 14.4 mGy-cm. 2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 25.2 mGy (Body) DLP = 1,235.4 mGy-cm. Total DLP (Body) = 1,250 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 suspicious focal lesion. Segment 4 a simple cyst measuring 1.1 cm. 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. 8mm splenic hemangioma is 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 solid renal lesions. There is no perinephric abnormality. There is no hydronephrosis or hydroureter. Multiple bilateral hypodensities consistent with cysts, the largest measuring 6.4 cm in the right lower pole. The urinary bladder is unremarkable. GASTROINTESTINAL: The stomach is unremarkable. There are loops of ileum that demonstrate wall thickening with stranding, hyperenhancement and luminal narrowing consistent with ileitis. There is fluid-filled distension of loops of small bowel measuring up to 2.7 cm demonstrating intraluminal feces sign in the left lower quadrant, with a smooth transition point into narrowed inflamed ileum, likely representing partial small bowel obstruction. The colon demonstrates sigmoid diverticulosis without evidence of diverticulitis. The appendix is fluid-filled measuring up to 7 mm with hyperenhancement. PELVIS: Small volume pelvic free fluid. REPRODUCTIVE ORGANS: The uterus is not visualized. 3.4 cm simple cyst in the right adnexa.. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Mild atherosclerotic disease is present. There is no abdominal aortic aneurysm. 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. Wall thickening with stranding, hyperenhancement and intraluminal stenosis consistent with terminal ileitis. Differential includes inflammatory and infectious etiology, with bowel ischemia less likely. 2. Segmental partial small bowel obstruction with smooth transition into the inflamed narrowed ileum. 3. Mild inflammatory changes of the appendix likely due to secondary inflammation in the setting of adjacent ileitis. 4. Small volume pelvic free fluid. 5. 3.4 cm simple cyst in the right adnexa. Follow-up ultrasound is recommended in a year. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, n/v/d Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Chest pain, unspecified, Right lower quadrant pain temperature: 97.7 heartrate: 66.0 resprate: 18.0 o2sat: 100.0 sbp: 155.0 dbp: 80.0 level of pain: 4 level of acuity: 3.0
Ms ___ is a ___ year-old female with past medical history of hypertension, endometrial CA s/p prior laparoscopic TAH/BSO, admitted with 1-day history of profuse nausea/vomiting and diarrhea s/p recent restaurant meal. Her CT scan was notable for terminal ileitis and segmental partial small bowel obstruction. Symptoms resolved spontaneously with bowel rest and brief supportive care in our Emergency Department, and did not recur over ensuing 48hrs in the hospital. Her diet was advanced without complication. She had no further bowel movement during her stay, and thus no stool specimen was available for further testing. Given abrupt onset and self-limited nature of this episode, we suspect that it may have been caused by an infectious/toxin-mediated process, though we recommend an outpatient colonoscopy to verify that the abnormalities on her CT scan do not represent a more chronic process.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Ultram / Dilaudid / Amoxicillin / Zithromax / Bactrim / Doxycycline / Keflex / Erythromycin Base / Penicillins Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of mitochondrial disorder, gastroparesis, autonomic dysfunction, chronic abdominal pain, and GERD who presents with right sided abdominal pain. Of note, she was recently on Medicine service for similar symptoms. During that admission, she became constipated while on a trip to ___ to visit family. As is common for her whilst traveling, she began to develop constipation and did not have a BM for 5 days. During that time, she complained of colicky R sided abdominal pain sometimes radiating to the RLQ. CT of the abdomen/pelvis with contrast did not demonstrate any appendicitis or acute abdominal pathology, although a corpus luteum was noted on the R ovary. The pain was worse after PO intake and also worse with movement and has been associated with abdominal distension. during that admission, she refused a pelvic exam, She was initially kept NPO except for meds and was started on IV fluids. Pain control with toradol and heating pack initially and with tylenol when LFTs returned normal. Narcotics were avoided given constipation. Patient was started on aggressive bowel regimen including oral senna and colase, bisacodyl suppositories, and fleets enema with resolution of constipation and improvement in abdominal cramps and distension. Dr. ___ gastroenterologist was contacted and would like outpatient follow up which was scheduled. Patient was discharged on Pantoprazole 40 mg PO for GERD symptoms and should discuss with outpatient GI MD. She came back this time, with worsening RUQ and suprapubic pain for 5 days. She has had similar pain before but this is worse. Has associated nausea but no vomiting. She also tells me that she has a lot of new symptoms, including urinary frequency, decreased volume, as well as significant dysuria at initiation and completion of urination. Overall, her pain has been getting progressively worse, and she has been feeling worn down, and unable to walk around, due to pain. The location of the pain, she also feels has shifted. "This is not typical mitochondrial pain". She relates that her pain is now mostly in the upper quadrant of her right side, as well as lower quadrant on her left side. Furthermore, she wanted to let us know that she is actively moving her bowels, with loose bowel movements that she described as copious diarrhea, but really soft stools. In the ED, initial VS were: 7 98.6 70 111/68 15 100% -[x] pelvic exam w/ cultures - mucopurulent discharge, R adnexal tenderness although difficult to interpret, since patient says being in position for pelvic exam was so painful that she could not focus on the exam itself, no frank CMT [x] pelvic ultrasound -CT done ___ without clear source of pain, although corpus luteal cyst visualized. Abdominal ultrasound ___ with no cause of pain identified. Possibly GYN in origin - ___, given pelvic & RUQ pain? -Diagnosis: abdominal / pelvic pain -Vitals prior to transfer: 97.9, 80, 102/63, 18, 96%RA On arrival to the floor, patient was writhing in pain, but with stable vitals. She has had no other complaints, other than the pain described above. Past Medical History: -GERD -Gastroparesis-GI emptying study T1/2 of 89 minutes (slightly delayed) -pelvic dyssynergia per Dr. ___ -Chronic Constipation -Mitochondrial disorder. Symptoms have included muscle fatigue, migraines with hemiplegia or hemibody sensory changes and question of seizures. Per neurology notes, initial testing showed alteration in the DNA sequence for notch 3, but it was not one of the known alterations associated with CADASIL. Also she has had low carnitine levels and slight increase in lactate with exercise. Diagnosis was confirmed by muscle biopsy at ___ ___ in ___. Muscle biopsy showed decreased OXPHOS activity of complexes ___ and all fatty acid oxidation substrates in freshly isolated mitochondria, decreased complex 2 ETC enzyme activity in freshly isolated muscle mitochondria and normal ETC, histopathology and electron microscopy in intact muscle. -Migraines with hemibody sensory changes (Episodes of periodic hemiparesis in the past, last in ___, each lasting 30 min to hours in duration. Per patient and her husband, many years ago there was a question of a stroke on imaging, but in the end it was thought to be a ___ space. No definite strokes. Prior neurology notes describe hemiplegic migraines. ) -Hashimotos thyroiditis -s/p ovarian cyst resections -interstitial cystitis - complex partial sezures Social History: ___ Family History: Mother with possibly ___ disorder (migraines, seizures, strokes) Physical Exam: PHYSICAL EXAMINATION: Vitals:97.6 Hr 70 113/74 100%RA GENERAL: talkative, conversant and pleasant, occassional discomfort ___ abdominal pain HEENT: PERRL, EOMI NECK: no carotid bruits, JVD LUNGS: CTAB HEART: RR, normal S1 S2, no MRG ABDOMEN: Soft, slightly distended, TTP in R side of abdomen, no rebound/guarding, NABS, no organomegaly EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3 Skin: minimal diffuse erythema, no hives or maculopapular rash DISCHARGE Vitals: 98.1 100/62 67 18 99%RA GENERAL: talkative, conversant and pleasant except when speaking about her pain, then winces. HEENT: PERRL, EOMI NECK: no carotid bruits, JVD LUNGS: CTAB HEART: RR, normal S1 S2, no MRG ABDOMEN: Soft, slightly distended, TTP in R side of abdomen but quite soft and without ___ sign, no rebound/guarding, NABS, no organomegaly EXTREMITIES: No c/c/e MSK: Unable to stand up straight due to RUQ pain. NEUROLOGIC: A+OX3 Pertinent Results: ___ 08:00PM BLOOD WBC-6.3 RBC-4.16* Hgb-13.2 Hct-39.4 MCV-95 MCH-31.7 MCHC-33.5 RDW-13.1 Plt ___ ___ 07:30AM BLOOD WBC-4.6 RBC-3.82* Hgb-12.2 Hct-36.6 MCV-96 MCH-31.9 MCHC-33.3 RDW-13.4 Plt ___ ___ 07:05AM BLOOD WBC-3.8* RBC-3.83* Hgb-12.3 Hct-36.8 MCV-96 MCH-32.2* MCHC-33.4 RDW-13.0 Plt ___ ___ 07:30AM BLOOD ___ PTT-32.4 ___ ___ 07:05AM BLOOD ___ PTT-30.5 ___ ___ 08:00PM BLOOD Glucose-92 UreaN-7 Creat-0.6 Na-140 K-3.2* Cl-101 HCO3-32 AnGap-10 ___ 07:30AM BLOOD Glucose-77 UreaN-5* Creat-0.6 Na-142 K-3.7 Cl-108 HCO3-28 AnGap-10 ___ 07:05AM BLOOD Glucose-92 UreaN-3* Creat-0.7 Na-141 K-4.2 Cl-109* HCO3-26 AnGap-10 ___ 08:00PM BLOOD ALT-15 AST-18 AlkPhos-31* TotBili-0.2 ___ 07:05AM BLOOD ALT-18 AST-17 LD(LDH)-118 AlkPhos-26* TotBili-0.3 ___ 07:05AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.6 Mg-2.2 Iron-166* ___ 07:05AM BLOOD calTIBC-209* Ferritn-56 TRF-161* ___ 07:05AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.6 Mg-2.2 Iron-166* ___ 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 2:23 am SWAB Source: Cervical. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR. Pelvic Ultrasound IMPRESSION: 1. No evidence of tubo-ovarian abscess. 2. Normal appearing uterus and ovaries. 3. Small simple 1.1 cm probable right paraovarian cyst. MRCP IMPRESSION: 1. Iron deposition pattern dominantly in the liver, without significant deposition in the spleen or bone marrow; this is a deposition pattern suggesting primary hemochromatosis. 2. Multiple liver cysts. 3. 3-mm pancreatic cyst. Consider follow-up MR in ___ year. 4. Status post cholecystectomy, without current evidence of complications. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache 2. coenzyme Q10 *NF* 1000 mg Oral daily 3. Diazepam 2 mg PO QID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Levocarnitine 2310 mg PO BID 6. Levothyroxine Sodium 75 mcg PO DAILY 7. metaxalone *NF* 800 mg Oral TID 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Oxcarbazepine 150 mg PO BID 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 1 TAB PO BID:PRN constipation 12. Sertraline 37.5 mg PO DAILY 13. Simethicone 40-80 mg PO QID:PRN bloating 14. Topiramate (Topamax) 300 mg PO BID 15. Xopenex Neb *NF* 0.31 mg/3 mL Inhalation q4h PRN SOB 16. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. coenzyme Q10 *NF* 1000 mg Oral daily 2. Diazepam 2 mg PO QID 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Levocarnitine 2310 mg PO BID 5. Levothyroxine Sodium 75 mcg PO DAILY 6. metaxalone *NF* 800 mg Oral TID 7. Oxcarbazepine 150 mg PO BID 8. Pantoprazole 40 mg PO Q24H 9. Senna 1 TAB PO BID:PRN constipation 10. Sertraline 37.5 mg PO DAILY 11. Topiramate (Topamax) 300 mg PO BID 12. Xopenex Neb *NF* 0.31 mg/3 mL Inhalation q4h PRN SOB 13. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache 14. Ondansetron 4 mg PO Q8H:PRN nausea 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Simethicone 40-80 mg PO QID:PRN bloating Discharge Disposition: Home Discharge Diagnosis: Abdominal pain of unknown source Bladder pain of unknown source Chronic: Mitochondrial disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with pelvic and right upper quadrant pain, status post recent prior normal abdominal ultrasound. Question ovarian cyst or tubo-ovarian abscess. COMPARISON: Abdominal ultrasound dated ___. CT dated ___. LMP: ___. FINDINGS: Transabdominal and transvaginal sonograms were performed, the latter of which for further assessment of endometrium and adnexa. The uterus is anteflexed, measuring 8.9 x 6.6 x 5.7 cm without focal lesion. The endometrium appears unremarkable, measuring 10 mm. Bilateral ovaries are normal in size and morphology, with demonstrable arterial and venous waveforms. A small anechoic thin walled 1.1 cm right paraovarian cyst is seen. Trace free fluid is seen in the cul-de-sac. IMPRESSION: 1. No evidence of tubo-ovarian abscess. 2. Normal appearing uterus and ovaries. 3. Small simple 1.1 cm probable right paraovarian cyst. Radiology Report INDICATION: ___ female with mitochondrial disorder complicated by gastroparesis, gastroesophageal reflux, and chronic constipation. History of ovarian cystectomy in ___ and ___, laparoscopic cholecystectomy complicated by bile leak. Now presents with right upper quadrant pain. COMPARISON: MR enterography from ___, CT abdomen/pelvis from ___, abdominal ultrasound from ___, and pelvic ultrasound from ___. TECHNIQUE: Axial in- and opposed-phase, coronal HASTE, axial HASTE, coronal thick slab MRCP, axial diffusion-weighted, axial 3D LAVA pre- and triphasic post-contrast images with subtraction were acquired through the biliary system. 6 mL of intravenous Gadavist was administered without complications. FINDINGS: Examination is suboptimal due to patient's inability to breath-hold. There is abnormal increased iron deposition in the liver with drop of signal on the longer echo gradient-echo images, but without significant changes in the spleen and bone marrow. Multiple T2-hyperintense, T1-hypointense nonenhancing lesions are present, most compatible with cysts and/or biliary hamartomas. Cholecystectomy changes are present, with residual cystic duct stump and clip (5:21). Note is made of an aberrant right anterior bile duct draining into the left hepatic duct (7:2). The common bile duct is ectatic at 7 mm, but tapers smoothly to the ampulla. There is a 3-mm cyst in the pancreatic body (7:3), likely side-branch IPMN. No significant susceptibility in the pancreas. The main pancreatic duct is normal. No parenchymal signal changes, abnormal enhancement, fat stranding, or fluid collections to suggest acute inflammation. The adrenals are normal. Kidneys enhance and excrete contrast promptly and symmetrically, without masses or hydronephrosis. The stomach and visualized portions of small and large bowel are unremarkable. There are no pathologically enlarged retroperitoneal or mesenteric lymph nodes. There is apparent mild narrowing of the proximal celiac artery with post-stenotic dilation, a finding which may be accentuated by phase of patient respiration. IMPRESSION: 1. Iron deposition pattern dominantly in the liver, without significant deposition in the spleen or bone marrow; this is a deposition pattern suggesting primary hemochromatosis. 2. Multiple liver cysts. 3. 3-mm pancreatic cyst. Consider follow-up MR in ___ year. 4. Status post cholecystectomy, without current evidence of complications. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: RUQ PAIN Diagnosed with ABDOMINAL PAIN RUQ temperature: 98.6 heartrate: 70.0 resprate: 15.0 o2sat: 100.0 sbp: 111.0 dbp: 68.0 level of pain: 7 level of acuity: 3.0
Ms. ___ is a ___ year old woman with a PMHx of migraines, gastroparesis, and pelvic dyssynergia who presents with R sided abdominal pain x 5 days, with recent admission for same. # Abdominal Pain: Patient has a history of chronic abdominal pain secondary to constipation and gastroparesis (which was not an issue on this admission). Also with interstitial cystitis dx in the past as well as IBS. All labwork and imaging to date normal or negative. Was recently admitted and then discharged with the same pain, felt secondary to musculoskeletal injury as her pain is exacerbated by extension of her torso. She returns with the same symptoms requesting ERCP and narcotics (she was discharged previously with a short script for oxycodone). Pt also complains of nausea with the abdominal pain but yet is quite hungry and requests full diet, which was provided and tolerated well without vomiting. GI was consulted who recommended MRCP. MRCP was negative for any acute cause for her pain. The patient requested ERCP be performed to test for sphincter of oddi dysfunction; ERCP was consulted, who felt that this was not an indication for inpatient ERCP with manometry and recommended follow-up in ___ clinic, which was scheduled. She was discharged without further narcotics, and was encouraged to use tylenol and NSAIDS prn. # Suprapubic pain: likely secondary to interstitial cystitis. Tried on nortriptyline which per the patient provided no symptom relief over a few days, and which she refused to continue to take. Asked her to follow-up with her outpatient uro-gyn at ___ for further evaluation. # Mitochondrial disorder: Continued on her home medications. # Complex partial seizures: Continued topiramate and oxcarbazepine # Depression: Continue sertraline # Asthma: Continue advair, xopenex
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hyponatremia, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ M with hx SIADH and chronic abdominal pain since cholecystectomy ___, presenting with hyponatremia to 123, associated with new-onset confusion, unsteady gait, and worsening abdominal pain. The pt was seen and examined with daughter, ___, present and serving as translator due to pt's hearing impairment and inability to use translator phone effectively (in-person translator unavailable at time of admission). She states she saw her father on ___ and he was "not himself." He was repeating questions, complaining of weakness in his legs, and was unable to get around the house like usual. She returned to visit her father on ___ and found him drastically changed. He was bedridden, unable to walk or even stand. She called his PCP who recommended bloodwork which was done ___. It showed ___ 118. The PCP left ___ message with the daughter to bring pt to ___ for evaluation. She got the message this morning and called ambulance for her father. At baseline, the pt is very indepedent. He drives and lives with wife in a private home. He often goes to coffee shops to socialize and enjoys grocery shopping. The daughter is currently taking care of her parent's finances, but other IADLs are done by pt. The pt has h/o hypoNa, first noticed in ___ during a hospitalization for PNA at ___. He was discharged without a fluid restriction or salt tabs. The pt's ___ (as well as overall health) has been stable since that time, up until his hospitalization at ___ for cholecystectomy ___. The surgery was complicated by hematoma and wound infection, resulting in a prolonged recovery. It took 2 months for the incision to heal, per daughter's report. The pt and his family were very upset with the care they received at ___, noting a lack of home services upon discharge as one frustration. Since then, the pt has had very significant difficulty with abd pain, needing hospitalization nearly every 2 weeks at ___ for severe abdominal pain. Each time, he has been treated with normal saline (for hypoNa) and morphine. The pain resolves for about a week, but then starts building again, resulting in another hospitalization. The pt and his family are very discouraged and want definitive answers regarding the cause of the pain and the etiology of hypoNa. In terms of the hypoNa, previous w/u has included negative head CT at ___ ___. Pt also had a CT chest ___ which was normal. Recent lab work by PCP shows SIADH picture ___ serum osm 274, urine osm 525, urine ___ 94). Prior evaluations of abdominal pain at ___ thought pain ___ constipation. (A CT abd/pelvis at ___ on ___ was negative). The pt is now on aggressive bowel regimen, but pain persists. It is not related to eating. It is characterized as a sharp pain around umbilicus, as well as dull pain in b/l lower quadrants. Severity up to ___ at times. He has very diminished appetite since ___ surgery, really has to force himself to eat. He has lost about 25 lbs since the surgery per daughter. Dinner last night was a few bites of chicken and some carrots. Only had cereal for bfast this AM. He drinks ___ cup of Gatorade every few hours. He is not on strict fluid restriction. He has been taking salt tabs (prescribed for 1 tab daily, although pt took ___ tab daily all of last week). Notably, the pt was started on duloxetine 20mg daily for abdominal pain and took for about 1 week, but stopped taking ___. He was prescribed oxycodone after his surgery but did not take due to constipation side effect. He has been trying to manage pain with only 1 dose of Tylenol on one day, then 1 dose of ibuprofen the next day. The pt feels depressed ___ poor health since surgery. In the ___, initial vs were: T97.8 P94 BP120/58 R16 O2 sat 95% RA. Labs were remarkable for nml CBC, VBG, ___ 123. Patient was given 1 L NS and 1 dose albuterol and 4mg IV Zofran. CXR was obtained. Vitals on Transfer: 97.6, 70, 19, 91/76, 97% RA, pain ___. On the floor, vs were: T98.0 P67 BP160/64 R18 O2 sat 97% RA Review of sytems: (+) Per HPI. In addition, pt's daughter notes pt increasingly chilled lately. Occas night sweats. He has had a cough for ___ yr productive of phlegm. (-) Denies fever, recent weight gain. Denies sinus tenderness, rhinorrhea or congestion. Denies shortness of breath. Denies chest pain or tightness, palpitations. Denies vomiting, diarrhea. No recent change in bladder habits. No dysuria. Ten point review of systems is otherwise negative. Past Medical History: - SIADH - Diabetes mellitus type 2 - COPD - GERD - HTN - HLD - Thalassemia minor - Hemorrhoids - Constipation - PVD with claudication - Bell palsy - BPH - Insomnia - L eye cateract - Allergic rhinitis - Anemia - Anal/rectal region abscess - Irritable bowel syndrome - Cholecystectomy ___ for chronic cholecystitis complicated by hematoma and wound infection, successfully treated cephalexin. Social History: ___ Family History: Non contributory Physical Exam: ADMISSION EXAM: Vitals: T98.0 P67 BP160/64 R18 O2 sat 97% RA General: Elderly male supine in bed, labile emotions, frustrated easily. HEENT: PERRL, MMM Neck: No LAD, No JVD Lungs: CTAB CV: RRR, nl S1/S2, no m/r/g Abdomen: Soft, +BS, Mild TTP throughout but most in lower quadrants and periumbilical, no rebounding or guarding. No HSM. Ext: WWP, 2+ DP pulses b/l. No ___ edema. Skin: No rashes or lesions Neuro: R facial droop, otherwise CN ___ intact. ___ strength in UE and ___ b/l. Normal reflexes. Intact finger-nose-finger (slow). rapid alternating movements slowed, but good. Unable to do heel-shin as he doesn't understand directions. Mental Status: Alert and oriented to self, place, month, yr. Knows President. Can name ___ ___ backwards. Names pen and phone. DISCHARGE EXAM: VSS and WNL. Resting comfortably in bed. Slightly anxious with continued emotional lability. Abdominal exam notable for mild tenderness in RUQ, no rebound or guarding, +BS. Mental status is good- A+Ox3, answering questions appropriately. Pertinent Results: ADMISSION LABS: ___ 10:45AM PLT COUNT-205 ___ 10:45AM NEUTS-67.1 ___ MONOS-7.8 EOS-1.9 BASOS-0.7 ___ 10:45AM WBC-4.6# RBC-5.77 HGB-12.2* HCT-35.9* MCV-62* MCH-21.1* MCHC-34.0 RDW-15.3 ___ 10:45AM TSH-1.3 ___ 10:45AM ALBUMIN-4.3 ___ 10:45AM LIPASE-25 ___ 10:45AM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-74 TOT BILI-0.8 ___ 10:45AM GLUCOSE-146* UREA N-11 CREAT-0.8 SODIUM-123* POTASSIUM-4.0 CHLORIDE-87* TOTAL CO2-23 ANION GAP-17 ___ 10:54AM LACTATE-2.6* ___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 01:00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:00PM URINE OSMOLAL-310 ___ 01:00PM URINE HOURS-RANDOM UREA N-382 CREAT-45 SODIUM-55 POTASSIUM-23 CHLORIDE-39 ___ 01:17PM ___ PO2-34* PCO2-44 PH-7.40 TOTAL CO2-28 BASE XS-1 INTUBATED-NOT INTUBA ___ 04:50PM SODIUM-126* POTASSIUM-4.3 CHLORIDE-92* ___ 05:23PM LACTATE-1.0 PERTINENT LABS: ___ 06:00AM BLOOD Glucose-90 UreaN-14 Creat-0.9 ___ K-4.4 Cl-93* HCO3-24 AnGap-13 DISCHARGE LABS: ___ 05:50AM BLOOD ___ K-4.5 Cl-95* IMAGING: CXR ___: No acute intrathoracic process KUB ___: Normal bowel gas pattern without evidence of ileus or obstruction. No definite stool seen in the colon. HEAD MRI ___: Age-related involutional and chronic microvascular angiopathic changes. No evidence of abnormal enhancement or mass. EKG ___: Sinus rhythm. T wave flattening in leads I and aVL. RSR' pattern in lead V1. Since the previous tracing of ___ T wave amplitude is less prominent. Otherwise, no change. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing/sob 2. Docusate Sodium 100 mg PO BID 3. Ondansetron 4 mg PO Q12H:PRN nausea 4. Psyllium 1 PKT PO BID 5. Omeprazole 20 mg PO BID 6. Sodium Chloride 1 gm PO DAILY 7. Lorazepam 0.5 mg PO HS:PRN anxiety 8. Gabapentin 100 mg PO DAILY:PRN restless legs 9. Polyethylene Glycol 17 g PO BID 10. Lisinopril 5 mg PO DAILY 11. Simvastatin 20 mg PO DAILY 12. Temazepam 15 mg PO HS:PRN insomnia 13. Acetaminophen 325-650 mg PO Q6H:PRN pain 14. Ibuprofen 400 mg PO Q8H:PRN pain 15. Lidocaine Viscous 2% 20 mL PO TID:PRN tooth/gum pain Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing/sob 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 100 mg PO DAILY:PRN restless legs 5. Lidocaine Viscous 2% 20 mL PO TID:PRN tooth/gum pain 6. Lisinopril 5 mg PO DAILY 7. Omeprazole 20 mg PO BID 8. Ondansetron 4 mg PO Q12H:PRN nausea 9. Polyethylene Glycol 17 g PO BID 10. Simvastatin 20 mg PO DAILY 11. Sodium Chloride 1 gm PO DAILY 12. Ibuprofen 400 mg PO Q8H:PRN pain 13. Lorazepam 0.5 mg PO HS:PRN anxiety 14. Psyllium 1 PKT PO BID Discharge Disposition: Home Discharge Diagnosis: Primary: - Metabolic encephalopathy secondary to hyponatremia - Syndrome of Inappropriate Anti-Diuretic Hormone - Abdominal pain, not otherwise specified Secondary: - Gastroesophageal reflux disease - Chronic Obstructive Pulmonary Disease - Hyperlipidemia - Hypertension - Thalassemia minor - Hemorrhoids - Bell's palsy - Benign prostatic hypertrophy - Status-post cholecystectomy ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Nonproductive cough, altered mental status, question acute intrathoracic process. COMPARISON: None. FINDINGS: AP upright and lateral views of the chest were provided. Multiple linear densities project over the chest most notable on the lateral projection, likely external. Minimal linear density on the frontal projection in the left midlung and right lower lung could represent focal areas of platelike atelectasis. There is no definite consolidation, effusion, or pneumothorax. The aorta is tortuous and atherosclerotic calcifications are present. The heart size appears within normal limits. No bony abnormalities are detected. IMPRESSION: No acute intrathoracic process. Radiology Report HISTORY: ___ male with history of chronic abdominal pain and constipation status post cholecystectomy. Evaluate for constipation. COMPARISON: Plain films abdomen dated ___. FINDINGS: This single frontal view of the abdomen demonstrates a normal bowel gas pattern without evidence of ileus or obstruction. There is no definite stool seen within the colon. There are multiple metallic density surgical clips projecting over the right upper quadrant. Visualized osseous structures demonstrate mild degenerative changes. IMPRESSION: Normal bowel gas pattern without evidence of ileus or obstruction. No definite stool seen in the colon. Radiology Report HISTORY: ___ year old man with hx SIADH of unknown etiology, presenting with hypoNa, gait disturbance, weakness. TECHNIQUE: Multi planar multi sequence MR images are obtained through the head before and after the intravenous administration of 8 cc of Gadavist. COMPARISON: No pertinent prior examinations for comparison at this institution. FINDINGS: There is a moderate degree of bihemispheric white matter T2 FLAIR signal abnormality, predominately involving the periventricular and deep white matter ; in light of patient's age, these are likely a function of small-vessel ischemic changes. Gray-white matter differentiation is otherwise preserved. There is no evidence of acute intracranial hemorrhage or infarct. Ventricular, cisternal, and sulcal prominence may be a function of age-related parenchymal volume loss. The major intracranial vessels and dural sinuses exhibit the expected signal void related to vascular flow without evidence of obstruction or post-contrast images. Con no abnormal parenchymal, leptomeningeal, or pachymeningeal enhancement is noted. There is fluid within the left mastoid air cells. The remainder of the paranasal sinuses and right mastoid air cells demonstrate normal signal. The sella is CSF filled. Bilateral lens replacement changes are noted. The craniocervical junction is grossly unremarkable. IMPRESSION: Age-related involutional and chronic microvascular angiopathic changes. No evidence of abnormal enhancement or mass. Findings discussed with Dr. ___ at 11:26 a.m. via phone ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: HYPONATREMIA Diagnosed with HYPOSMOLALITY/HYPONATREMIA temperature: 97.8 heartrate: 94.0 resprate: 16.0 o2sat: 95.0 sbp: 120.0 dbp: 58.0 level of pain: 0 level of acuity: 2.0
___ M with hx SIADH and chronic abdominal pain worsened since cholecystectomy ___, presenting with hyponatremia to 123, associated with new-onset confusion, unsteady gait, and worsening abdominal pain. Etiology for the hyponatremia determined to be multifactorial: a side effect of recently prescribed duloxetine, a recent decrease in salt tab intake by pt, as well as abdominal pain worsening his underlying SIADH. No etiology found for chronic abdominal pain. # Hyponatremia: The pt presented after labs ordered by his PCP showed ___ 118. In the ___ at ___, ___ was 123. He was given 1L NS in ___, then transferred to medicine service where a 1.5L fluid restriction was placed. His ___ rose to 126 the following day. Urine 'lytes were consistent with SIADH. Daily salt tabs were re-started. The following day ___ was up to 128. A head MRI was negative for intracranial mass. AM cortisol was normal, ruling out adrenal insufficiency. TSH was normal. CXR did not show a lung mass. SIADH is likely secondary to pain, med non-compliance with salt tabs (pt was taking ___ tab daily rather than full tab the week prior), as well as side effect from duloxetine. Pt was instructed to NOT continue taking duloxetine, adhere to fluid restriction, and take 1 salt tab daily. # Toxic metabolic encephalopathy: Felt to be secondary to hyponatremia as discussed above, causing his symptoms of confusion and unsteady gait. After his ___ night in the hospital, the pt was ambulating around the ward without difficulty. # Functional abdominal pain: Records were reviewed from ___. The pt has had multiple normal abdominal CT scans, including one from ___, ruling out post-op complications such as seroma or hematoma. Mesenteric ischemia was considered, but I spoke with a radiologist at ___ regarding an abdominal CT with IV contrast in ___. Aside from calcifications in his aorta, his blood vessels looked great. SMA and ___ were widely patent and bowel wall was not thickened or ischemic in appearance. The pt has records of a normal EGD in the recent past. He has previously been constipated, but KUB during this admission was negative for constipation. The pt was continued on a scheduled bowel regimen and simethicone was added for gas pain and belching. Pain was well controlled with Tylenol. He was set up with GI follow-up.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___ Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: Femoral Central Line Placement Internal jugular central line Tunneled catheter Dialysis History of Present Illness: ___ with hypercholesterolemia, mood disorder and chronic headaches transferred from ___ in respiratory failure and presumed septic shock. According to her husband, she was in her usual state of health until the couple went to bed on ___ night. He kissed her goodbye when he left for work and said she stirred minimally, which was not unusual. When he returned home, she was still in the same spot and he found her unresponsive. She was brought to ___ There, she was intubated, sedated and started on pressors. She received several liters of fluid. She had a CT head that was negative for acute process. Labs were notable for UTox positive for opiates, coagulopathy, ___ with Cr 4.52, AST 8000, ALT ___, CK 7000. Smear negative for babesia and anaplasma. She received acyclovir, ceftriaxone, ampicillin, vancomycin and meropenem. They planned to perform an LP, but were unable to reverse his coagulopathy. The decision was made to transfer the patient to ___. In the ___ ER, vital signs and labs were similarly deranged. Blood pressure was maintained with norepinephrine. She had a CT C/A/P. She was hypoxic and had to be bagged for a period, paralyzed and returned to the vent on low tidal volume ventilation. She was admitted to the MICU for further workup and management. VS prior to transfer: .15 levophed. 99% sao2. 123/64. 103. 30 x ___. 18 PEEP. 100% FiO2. 36 deg. On arrival to the MICU, she is intubated on pressors. Her family came to the bedside. Husband described the patient's longstanding headache issues. For the last ___ yeas, she has had approximately daily left frontal headaches. She has had multiple procedures including resection of a meningeal lesion in ___. She has had multiple other procedures, including injections recently. Her husband does not believe that she had bad headaches leading up to her presentation and did not believe that she would have taken any narcotics on ___ night. Past Medical History: Depression Alcohol Abuse Hypercholesterolemia Headaches IBS Social History: Patient lives with her husband. She has three children. She drinks alcohol. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= GENERAL: inubated, sedated HEENT: Sclera anicteric, MMM LUNGS: Clear to auscultation anteriorly, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: ecchymoses on medial aspects of bilateral knees and ankles NEURO: PERRL DISCHARGE PHYSICAL EXAM: ======================= VITALS: Afebrile, 124-166/82, 77, 18, 94% on room air GENERAL: Well-appearing woman in no acute distress EYES anicteric ENT: Moist mucous membranes CV: Regular rate and rhythm, S1, S2, no murmurs rubs or gallops RESP: Decreased breath sounds at the bases with crackles bilaterally, otherwise clear to auscultation GI: Soft and nontender, nondistended, bowel sounds present, no rebound tenderness or guarding MSK: 1+ pitting edema to the knee bilaterally, left side greater than right. Left thigh tender and warm to palpation. Extremities are warm SKIN: Pressure necrosis present over the medial aspect of the knees bilaterally NEURO: Awake alert and oriented ×3 Pertinent Results: ADMISSION LABS: ================ ___ 09:22PM ___ 09:22PM ___ PTT-30.2 ___ ___ 09:22PM PLT COUNT-126* ___ 09:22PM NEUTS-86.8* LYMPHS-9.8* MONOS-2.9* EOS-0.0* BASOS-0.1 NUC RBCS-0.5* IM ___ AbsNeut-6.67* AbsLymp-0.75* AbsMono-0.22 AbsEos-0.00* AbsBaso-0.01 ___ 09:22PM WBC-7.7 RBC-3.21* HGB-10.6* HCT-34.4 MCV-107* MCH-33.0* MCHC-30.8* RDW-14.0 RDWSD-55.6* ___ 09:22PM O2 SAT-56 ___ 09:22PM LACTATE-3.0* ___ 09:22PM TYPE-CENTRAL VE PO2-40* PCO2-64* PH-6.96* TOTAL CO2-16* BASE XS--20 INTUBATED-INTUBATED ___ 09:22PM ALBUMIN-2.9* CALCIUM-5.1* PHOSPHATE-7.4* MAGNESIUM-1.4* ___ 09:22PM HAPTOGLOB-90 ___ 09:22PM CK-MB-141* MB INDX-1.2 ___ 09:22PM cTropnT-1.26* ___ 09:22PM ALT(SGPT)-1662* AST(SGOT)-8245* LD(LDH)-3390* ___ ALK PHOS-51 TOT BILI-0.3 ___ 09:22PM LIPASE-55 ___ 09:22PM GLUCOSE-213* UREA N-17 CREAT-3.9* SODIUM-135 POTASSIUM-5.4* CHLORIDE-106 TOTAL CO2-11* ANION GAP-23* ___ 09:30PM LACTATE-3.1* PERTINENT RESULTS: ================== Blood cultures (___): No growth CSF fluid culture (___): No growth Urine culture (___): No growth Sputum (___): No growth ___ 04:02PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-1+* Macrocy-1+* Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Burr-OCCASIONAL Stipple-OCCASIONAL ___ 04:02PM BLOOD Ret Aut-1.6 Abs Ret-0.04 ___ 05:56AM BLOOD ___ 10:37PM BLOOD Glucose-99 UreaN-26* Creat-5.8* Na-118* K-4.2 Cl-87* HCO3-21* AnGap-14 ___ 02:11AM BLOOD ALT-___* ___ LD(LDH)-4299* ___ AlkPhos-55 TotBili-0.3 ___ 03:16AM BLOOD %HbA1c-5.9 eAG-123 ___ 02:58AM BLOOD HDL-40* CHOL/HD-2.9 ___ 05:56AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative DISCHARGE LABS: =============== ___ 07:50AM BLOOD WBC-5.4 RBC-2.26* Hgb-7.2* Hct-22.0* MCV-97 MCH-31.9 MCHC-32.7 RDW-13.5 RDWSD-48.2* Plt ___ ___ 01:15PM BLOOD ___ PTT-30.3 ___ ___ 07:50AM BLOOD Glucose-103* UreaN-11 Creat-4.8* Na-139 K-3.8 Cl-96 HCO3-28 AnGap-15 ___ 07:50AM BLOOD ALT-22 AST-19 AlkPhos-65 TotBili-0.5 ___ 07:50AM BLOOD Albumin-3.2* Calcium-8.6 Phos-5.0* Mg-1.6 IMAGING: ========= ECHO (___): IMPRESSION: There is early appearance of agitated saline/microbubbles in the left atrium/ventricle at rest most consistent with an atrial septal defect or stretched patent foramen ovale (though a very proximal intrapulmonary shunt cannot be fully excluded). Compared with the prior study (images reviewed) of ___, a likely patent foramen ovale or atrial septal defect is identified. If clinically indicated, a TEE would be better able to define the interatrial septum. CT Chest/Abd/Pelvis (___): 1. Multifocal pneumonia. 2. Mild pulmonary edema. 3. Small volume ascites. 4. Colonic diverticulosis without evidence of diverticulitis. 5. ETT and endogastric tubes appear well positioned. MRI Head (___): 1. Scattered right frontal, left putaminal, bilateral parietal and bilateral perirolandic late acute to early subacute infarcts. Given history and perirolandic involvement, hypoxic ischemic injury is a consideration, though some of these may be embolic. 2. No hemorrhage or suggestion of mass. 3. Nonspecific bilateral mastoid air cell opacification which can be seen in the setting of mastoiditis. Carotid series (___): 1. Less than 40% stenosis in the right internal carotid artery is small heterogeneous plaque in the carotid bulb. 2. Normal left carotid system. MRA Brain (___): 1. Unremarkable MRA brain. 2. Within confines of 2D time-of-flight MRA neck technique, no evidence of internal carotid artery stenosis by NASCET criteria. Unremarkable MRA neck. 3. Mild to moderate bilateral pleural effusions. MRV Pelvis w/o contrast (___): 1. No MR evidence of venous thrombus. Right femoral venous catheter extends to the level of the common iliac vein. 2. Diffuse anasarca. DVT US ___ & ___: Negative. Right-sided ___ cyst. CT LLE (___): 1. Extensive diffuse soft tissue edema involving the subcutaneous and deep tissues of the left hemipelvis and imaged portion of the left lower extremity, without evidence of hematoma. 2. Sigmoid diverticulosis. 3. Trace free fluid within the pelvis. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Zolpidem Tartrate 10 mg PO QHS 2. Estradiol .5 mg PO DAILY 3. QUEtiapine Fumarate 25 mg PO BID 4. Pantoprazole 40 mg PO Q12H 5. Ranitidine 150 mg PO BID 6. Topiramate (Topamax) 100 mg PO QID 7. Ibuprofen 800 mg PO Q8H:PRN Headache 8. Fentanyl Patch 25 mcg/h TD Q72H breakthrough pain 9. BusPIRone 10 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 2. Metoprolol Succinate XL 75 mg PO DAILY RX *metoprolol succinate 25 mg Three tablet(s) by mouth Once a day Disp #*90 Tablet Refills:*0 3. Ramelteon 8 mg PO QHS RX *ramelteon [Rozerem] 8 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 4. Sertraline 50 mg PO DAILY RX *sertraline 50 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 5. QUEtiapine Fumarate 12.5 mg PO QHS RX *quetiapine 25 mg One-half tablet(s) by mouth At night Disp #*15 Tablet Refills:*0 6. Ranitidine 75 mg PO QHS RX *ranitidine HCl 150 mg One-half capsule(s) by mouth At night Disp #*15 Capsule Refills:*0 7. Atorvastatin 80 mg PO QPM 8. Multivitamins 1 TAB PO DAILY 9. Pantoprazole 40 mg PO Q12H 10. HELD- Estradiol .5 mg PO DAILY This medication was held. Do not restart Estradiol until your doctor tells you it is safe to do so 11. HELD- Ibuprofen 800 mg PO Q8H:PRN Headache This medication was held. Do not restart Ibuprofen until your kidney function improves and your doctor tells you it is safe to take 12.Outpatient Physical Therapy ICD-10: ___ Responsible provider: (PCP) ___. ___ Please evaluate and treat 13.Outpatient Occupational Therapy ICD-10: ___ Responsible provider: (PCP) ___. ___ Please evaluate and treat Discharge Disposition: Home Discharge Diagnosis: Encephalopathy Acute kidney injury requiring hemodialysis Acute liver injury Rhabdomyolysis Hyponatremia Anemia Thrombocytopenia Multifocal pneumonia with sepsis Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman found down, now intubated// Please assess for pulm edema and PNA COMPARISON: Chest radiographs ___ Chest CT ___ FINDINGS: Semiupright portable AP view of the chest was provided. A right internal jugular line terminates in the mid SVC. An endotracheal tube terminates 2.8 cm above the level the carina. Enteric tube passes into the stomach beyond the field of view of this image. Left lower lobe consolidation appears slightly improved compared to yesterday's exam, and substantially improved compared to exam from ___. Right lower lobe consolidation is stable. There is no significant pulmonary edema. There is no pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits.. IMPRESSION: Interval improvement of left lower consolidation. Stable right lower lobe consolidation. Radiology Report INDICATION: ___ year old woman with resp failure,// Please confirm the OG tube placement TECHNIQUE: Frontal chest COMPARISON: ___ FINDINGS: Portions of the upper thorax and left hemithorax were excluded. A right IJ central line again ends in the distal SVC. The enteric tube ends in the distal stomach/proximal duodenum. Suggestion of a right femoral central catheter. IMPRESSION: Enteric tube ending in the distal stomach/proximal duodenum. Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old woman with new strokes// embolic source? TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has small heterogeneous atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 93 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 49, 108, and 72 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 42 cm/sec. The ICA/CCA ratio is 1.1. The external carotid artery has peak systolic velocity of 207 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has no atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 59 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 61, 69, and 100 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 37 cm/sec. The ICA/CCA ratio is 1.6. The external carotid artery has peak systolic velocity of 80 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: 1. Less than 40% stenosis in the right internal carotid artery is small heterogeneous plaque in the carotid bulb. 2. Normal left carotid system. Radiology Report INDICATION: ___ year old woman with NG// dobhoff placement TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: Enteric tube is seen, with tip projecting over the stomach. There are no abnormally dilated loops of large or small bowel. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. Bilateral lower lobe opacities are consistent with known history of multifocal pneumonia, better evaluated on CT chest dated ___. IMPRESSION: Status post Dobhoff placement, with tip projecting over the stomach. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with PFO, strokes// please assess for DVTs 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 left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial veins. The left peroneal veins were not well visualized. There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. The proximal right femoral vein was not well visualized due to an overlying dressing. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. There is a right-sided ___ cyst that measures 3.0 x 0.8 x 1.6 cm. IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. Limited visualization of the proximal right femoral and left peroneal veins. 2. Right-sided ___ cyst. Radiology Report EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT INDICATION: ___ year old woman with stroke, pfo, LUE swelling// DVT? TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Radiology Report EXAMINATION: MRA BRAIN AND NECK PT97 MR ___ INDICATION: ___ year old woman with strokes// embolic source TECHNIQUE: Three dimensional time of flight MR arteriography was performed through the brain with maximum intensity projection reconstructions. 2D time of flight MR angiography of the neck was performed. 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: Carotid ultrasound of ___, MRI head without contrast of ___. FINDINGS: MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of high-grade stenosis, occlusion, or aneurysm formation. MRA neck: The visualized portions of the bilateral common carotid, subclavian and vertebral arteries are unremarkable. Within confines of 2 dimensional time-of-flight MRA technique, there is no evidence stenosis of the internal carotid arteries by NASCET criteria. Mild to moderate bilateral pleural effusions are incidentally noted. IMPRESSION: 1. Unremarkable MRA brain. 2. Within confines of 2D time-of-flight MRA neck technique, no evidence of internal carotid artery stenosis by NASCET criteria. Unremarkable MRA neck. 3. Mild to moderate bilateral pleural effusions. Radiology Report EXAMINATION: MRV PELVIS INDICATION: ___ year old woman with strokes and PFO, evaluate for thrombus TECHNIQUE: Routine MR of the pelvis without intravenous contrast performed on a 1.5 Tesla magnet. COMPARISON: Venous Ultrasound ___ FINDINGS: There is a rounded low intensity structure in the right common femoral vein extending to the common iliac seen on Fiesta imaging, consistent with the known femoral catheter. No thrombus is seen. Views of the small bowel are unremarkable. Views of the large bowel are notable for sigmoid diverticulosis. There is no pelvic free fluid. There is no pelvic sidewall adenopathy. Superficial soft tissues are notable for diffuse anasarca. There are no suspicious bony lesions. IMPRESSION: 1. No MR evidence of venous thrombus. Right femoral venous catheter extends to the level of the common iliac vein. 2. Diffuse anasarca. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with recently treated pneumonia, now with new fever// Evidence of new pneumonia TECHNIQUE: Chest single view COMPARISON: ___ FINDINGS: Feeding tube tip in mid stomach. Right IJ central line tip in mid to low SVC. Accentuated heart size, pulmonary vascularity from shallow inspiration. Bibasilar opacities have mildly improved since prior. Small pleural effusions have improved. Interstitial prominence has nearly resolved. For no pneumothorax. IMPRESSION: Improved cardiopulmonary findings. Feeding tube tip in mid stomach. Radiology Report INDICATION: ___ year old woman found down with renal failure now on HD. COMPARISON: Chest x-ray dated ___ TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was not provided. 1 mg of midazolam was given. The patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine with and without epinephrine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: As above. CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1 minutes 21 seconds, 2.0 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 and upper chest were prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 23 cm tip-to-cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. ___ Vicryl suture and Steri-Strips wereused to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing tunneled hemodialysis catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 23 cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ year old woman presented with ___ requiring HD, rhabdomyolysis and acute liver injury, now with worsening LLE pain and swelling, specifically over thigh.// Concern for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. There is left leg edema. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with bleeding at IJ site// confirm IJ placement TECHNIQUE: Chest, single AP portable view COMPARISON: Chest x-ray from ___ at 18:52 FINDINGS: A new dual lumen type catheter is present, with tip at SVC/RA junction. Again seen is a right IJ central line, with tip over distal SVC. Dobbhoff tube no longer visualized. No pneumothorax is identified.. Curvilinear lucency at the right lung apex likely represents ___ artifact. Cardiomediastinal silhouette and increased retrocardiac density are similar to the prior study.. Patchy opacity in the right infrahilar region and minimal blunting of the right costophrenic angle suggestive of small effusion are also similar to prior study. Atelectasis or other faint opacity at the right base may be very slightly worse. There is upper zone redistribution, but doubt overt CHF. IMPRESSION: Right IJ line tip overlies mid SVC, similar to prior. New right-sided catheter tip lies at the cavoatrial junction. No evidence for interval enlargement of the mediastinum or for apical capping. Possible minimal worsening of opacity right lung base. Otherwise, doubt significant interval change. Radiology Report INDICATION: ___ year old woman found down, admitted with ___ ___ rhabdo now on HD with worsening L thigh swelling, downtrending H/H requiring transfusion.// any evidence of bleeding? Please include buttocks in this study. TECHNIQUE: Multidetector CT scanning was performed of the left lower extremity without the administration of intravenous contrast. Multiplanar reformatted images in coronal and sagittal planes are provided. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.5 s, 70.7 cm; CTDIvol = 10.5 mGy (Body) DLP = 740.6 mGy-cm. Total DLP (Body) = 741 mGy-cm. COMPARISON: MR pelvis dated ___. FINDINGS: SOFT TISSUES: There is extensive diffuse soft tissue edema involving the subcutaneous tissues of the left gluteal region, and extending to involve the subcutaneous tissues of the entire imaged portion of the left lower extremity. Soft tissue edema is additionally seen surrounding the muscles of the anterior compartment of the left thigh, and note is made of adjacent fascial thickening. No evidence of hematoma. No subcutaneous gas. PELVIS: Intrapelvic loops of large and small bowel are normal in course and caliber. Note is made of extensive sigmoid diverticulosis, without evidence of wall thickening or fat stranding. The bladder is decompressed by a Foley catheter. No left pelvic sidewall or inguinal lymphadenopathy by CT size criteria. There is presacral edema, and trace simple free fluid seen within the pelvis. BONES: No fracture. No concerning lytic or sclerotic lesion. Note is made of a small left knee joint effusion. Degenerative changes are seen at L4-5 IMPRESSION: 1. Extensive diffuse soft tissue edema involving the subcutaneous and deep tissues of the left hemipelvis and imaged portion of the left lower extremity, without evidence of hematoma. 2. Sigmoid diverticulosis. 3. Trace free fluid within the pelvis. NOTIFICATION: The findings were discussed with ___, by ___, M.D. on the telephone on ___ at 4:18 pm, 2 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with headaches, depression, organ failure now with temp 100.3// PNA r/o TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The right internal jugular central venous catheter has been removed. The right subclavian catheter tip again projects over the right atrium. There are layering bilateral pleural effusions, increased on the left, as well as subjacent atelectasis and/or pneumonia. New mild pulmonary interstitial edema. The size of the cardiac silhouette is within normal limits. IMPRESSION: Increased bilateral pleural effusions, particularly on the left with subjacent atelectasis and/or pneumonia. New pulmonary edema. Radiology Report INDICATION: ___ year old woman with encephalopathy complicated by multi organ failure, kidneys improving and no longer needing dialysis. plan is for discharge today if line can be removed// please remove tunneled catheter, no longer needs dialysis COMPARISON: Chest x-ray ___ TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1% lidocaine CONTRAST: None FLUOROSCOPY TIME AND DOSE: None PROCEDURE: 1. Right chest tunneled IJ catheter removal. PROCEDURE DETAILS: The patient was positioned with her head upright. The right chest tunneled line site was cleaned and draped in standard sterile fashion. 1% lidocaine was administered around the tube track. The cuff was loosened with a bent forceps. The catheter was removed with gentle traction while manual pressure was held at the venotomy site. Hemostasis was achieved after 5 min of manual pressure. A clean sterile dressing was applied. The patient tolerated the procedure well. There were no immediate postprocedural complications. FINDINGS: Expected appearance after tunneled line removal. IMPRESSION: Successful removal of a right chest tunneled line. Radiology Report INDICATION: Altered mental status, sepsis. COMPARISON: None FINDINGS: Portable supine AP view the chest provided. An endotracheal tube is in place with its tip located there is 3.2 cm above the carina. A right IJ central venous catheter terminates in the region of the mid SVC. An NG tube courses into the left upper abdomen. Lower lung consolidations concerning for pneumonia and/or aspiration.Mild edema is suspected. Cardiomediastinal silhouette appears normal. No large effusion or pneumothorax. Bony structures are intact. IMPRESSION: As above. Please refer to subsequent CT for further details. Radiology Report EXAMINATION: CT Torso with IV contrast INDICATION: ___ with ams, septic// acute process TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen and pelvis without intravenous contrast. Coronal and sagittal reformats were performed. DOSE: Total DLP (Body) = 858 mGy-cm. COMPARISON: None. FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury based on an unenhanced scan. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There is scattered mediastinal lymph nodes none of which are pathologically enlarged by CT size criteria and likely reactive. No axillary or mediastinal lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There are dense consolidations in the left lower lobe, right lower lobe, and left upper lobe. There are also ill-defined ground-glass and nodular opacities in the same distribution. There is interlobular septal thickening compatible with mild pulmonary edema. The airways are patent to the level of the segmental bronchi bilaterally. Endotracheal tube terminates in the mid thoracic trachea BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesion or laceration within the limitation of an unenhanced scan. There is a small amount of perihepatic free fluid.. There is no evidence of intrahepatic or extrahepatic biliary dilatation. There is gallbladder wall edema. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesion or laceration within the limitation of an unenhanced scan. There is a splenule. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Enteric tube terminates in the distal body of the stomach. The stomach is unremarkable. Small bowel loops demonstrate normal caliber. There is colonic diverticulosis without evidence of diverticulitis. The appendix is normal. There is no evidence of mesenteric injury. There is a moderate amount of pelvic free fluid. There is no free air in the abdomen. PELVIS: A Foley catheter is in the bladder. There is a moderate amount of pelvic free fluid REPRODUCTIVE ORGANS: The uterus is not enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Mild atherosclerotic disease is noted. BONES: There is no acute fracture. No focal suspicious osseous abnormality. There is moderate degenerative changes at L3-L4. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Multifocal pneumonia. 2. Mild pulmonary edema. 3. Small volume ascites. 4. Colonic diverticulosis without evidence of diverticulitis. 5. ETT and endogastric tubes appear well positioned. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with shock after being found down// Please assess for evidence of cirrhosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT of the abdomen and pelvis from ___. FINDINGS: LIVER: The liver is diffusely mildly echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace ascites and trace right pleural effusion. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 8.9 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. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Trace ascites and right pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old found down, in shock, s/p attempted L IJ// eval for pneumothorax eval for pneumothorax IMPRESSION: Right internal jugular line tip is at the level of mid SVC. Heart size and mediastinum are similar in appearance. Bilateral extensive consolidations, left more than right are unchanged. There is no evidence of pneumothorax or appreciable pleural effusion NG tube tip is in the stomach. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Intubated, Transfer Diagnosed with Acute respiratory distress syndrome temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: UTA level of acuity: 1.0
___ with history of chronic headaches and depression, found unresponsive in bed at home, now with multi-organ failure and c/f ingestion v. underlying neurological event. #Altered Mental Status/Encephalopathy/Shock: Ms. ___ was admitted to the MICU, intubated and sedated requiring pressors for shock of unclear etiology. Given her renal failure and anuria as well as concern for a toxin ingestion, she was started on dialysis on the morning after admission. She responded well to hemodialysis and both pressor requirements and mental status began to improve. Work-up included EEG, which showed encephalopathy. Tox screen was only positive for fentanyl- she was known to be using a fentanyl patch. Infectious work-up notable for pneumonia, presumed aspiration, which was treated with broad-spectrum antibiotics given the concern for a septic etiology of her shock. She underwent MRI of the brain given persistent altered mental status which showed multiple new, small strokes. Subsequent work-up of these strokes revealed a likely PFO/ASD on TTE but lower extremity dopplers were negative. With supportive care, her hemodynamics, shock and mental status improved and she was successfully extubated. She required precedex for several days after extubation due to agitation but this also improved and she was then transferred to the floor. On the floor she required seroquel TID for several days before being weaned to 12.5mg qhs at discharge. Etiology of the encephalopathy/shock unknown but there remains high concern for toxic ingestion (likely unknowingly) vs a neurologic event. Psychiatry was consulted to help clarify whether or not there was any intention behind this event; they could make no definitive statements but felt as though the patient was not acutely at risk of harm to self. There was no evidence per family and patient report to suggest that there was any evidence of this being intentional. ___: Patient presented in renal renal failure, believed to be multifactorial in the setting of rhabdomyolsis (CK peaked at ___, ischemic injury, and possible toxin exposure. She was started on hemodialysis, initially through a femoral line but then had a tunneled line placed ___. Throughout the hospitalization, she went from being anuric to oliguric with urine output up to 1 liter. PPD (___) was negative. The patient's creatinine plateaued in the two days prior to discharge. The tunneled line was removed on the day of discharge and the patient was sent home off of dialysis. She will follow-up with renal at ___ shortly after discharge. #Rhabdomyolysis: On admission, creatinine kinase was elevated and peaked at ~17,000. CK eventually came down with fluids and supportive care. #Acute Liver Injury: AST/ALT elevated to several thousand on admission, then slowly down-trended. Believed to be due to shock liver vs possible toxic insult. #ELEVATE BP: BPs were elevated (SBP in 160s) prior to discharge. This was felt to be due to her persisting hypervolemia, which we anticipate will improve with improving renal function. #LLE Edema/Pain: Began developing left thigh pain and swelling on ___, that worsened until ___ when it began moving into her left lower abdomen, flank, and back. DVT US was negative and CT non-con showed diffuse soft-tissue swelling. CK was still downtrending. Ortho was consulted and had a low suspicion for compartment syndrome. It was believed to be ___ fluid overload and improved slowly after dialysis. Pain was treated with tramadol and dilaudid given inability to give NSAIDs or acetaminophen because ___ and acute liver injury. #Hyponatremia: Na dropped to 118 on ___, believed to be due to fluid overload in setting of minimal urine output and 4 days between dialysis sessions. Osmolarity studies were consistent with acute renal failure and volume overload. Asymptomatic. Na improved to 130 following dialysis that same day. Na on discharge was 139. #Depression: Patient began having anxiety and depressive symptoms on ___. She reported previously being on buspar 10 mg BID, duloxetine 60 mg BID, and seroquel 25 mg BID at home; however both buspar and duloxetine could not be restarted given her renal failure. She was started on sertraline 25 mg on ___. Seroquel was slowed weaned prior to discharge and she was discharged on 12.5mg qhs. #Anemia/thrombocytopenia: Hgb trended down from ~12 to 6.9 over 9 days. Fibrinogen, ferritin, and coags were normal. Retic was 1.6%, low given the significance of her anemia. Iron was also slightly low. Hemolysis labs were unremkarable. It was believed her anemia was due to acute illness. She required 1 unit pRBC on ___.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: syncope, altered mental status Major Surgical or Invasive Procedure: thoracentesis ___ History of Present Illness: Pt is a ___ y/o woman with history of anemia, depression, frontal dementia, polymyalgia rheumatic, recent diagnosis of cardiac and pleural effusions, HFrEF, who presents following an episode this morning of unresponsiveness. Her daughter reports patient woke up at 9am, and vomited. She then had bowel incontinence in bed, which is unusual for her. She sat on the commode and vomited some more. At 12:30, her daughter was helping her onto the commode again, when her arms became rigid, she was staring forward, groaned and then started drooling. During this time pt was shaking, unresponsive to voice for 1 minute and lost bowel function. Afterwards, she was a bit slower to move for around 5 minutes. EMS arrived 15 minutes later, and by then she was back to herself. First time this event has happened and family reports patient has started Lasix 3 weeks ago. Pt has dementia, slow gait and hearing difficulty at baseline. She denies headache, loss of vision, diplopia, dysarthria, dysphagia. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesia. Pt also a cough in the past month associated with white sputum production. Finally pt has 1 day of n/v/d. However no BBRBR, melena, bloody vomit or fevers. Of note no sick contacts. Neurology consult saw her in the ED and noted she is back to baseline. No further neurological workup for now. Will contact her outpatient neurologist Dr. ___ follow up. In the ED, initial vital signs were: T:98.3 P:111 BP:137/80 R:24 94% O2 sat. Exam notable for inability to hold LLE off the bed - unclear etiology of this although rapidly reassessed several minutes later and now able to bring her leg off the bed + hold for 10 seconds. Labs were notable for HNH 9.4 and 32.2 neutrophils 86%, Mg 1.5, BUN 32 Lactate 1.5 Patient was given 1L IV NS On Transfer Vitals were: 99.3 143/89 HR 88 RR 16 96%RA At the floor patient family reports she is not back to baseline. She is usually more responsive and less lethargic, however family notes this could be because she is tired and has not eaten for the day. Finally family reports a month of bilateral lower back pain lasts for a brief period and was worse today occurring every 30 minutes. Past Medical History: 1. POLYMYALGIA RHEUMATICA- diagnosed ___ yrs ago 2. Frontal Dementia- with gait disturbance 3. REFLUX ESOPHAGITIS 4. DEPRESSION 5. COLONIC POLYPS 6. Anemia, currently on iron supplementation 7. Recent finding of cardiac and pleural effusions- pt went for follow up apt 3 weeks ago and found to have effusions. Social History: ___ Family History: Grandson w/ seizures, parents passed from enlarged heart. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== Vitals: 99.3 143/89 HR 88 RR 16 96%RA General: tired appearing woman in NAD HEENT: NCAT, MMM, EOMI, PERRLA, Lymph: no LAD, no thyromegaly CV: irregular rate and rhythm no M/R/G Lungs: crackles bilaterally Abdomen: nt/nd/ normal bowel sounds. Ext: no clubbing, ___ edema Neuro: AOx2- able to say her name and name her location. Knew it was ___ but not the year or date. CN ___ intact. Mental status exam- pt was able to say days of the week forward. Name the president. Unable to do calculations, or repetitions. Strength- pt able to lift upper and lower extremities against gravity but not against force. Sensation intact DISCHARGE PHYSICAL EXAM: ====================== Weight: 63.5kg standing Vitals: 98.2 BP 155/69 HR 70 RR 16 97%RA I/O: 8 hr ___ 24hrs 660/500+ Incontinence General: well appearing woman in NAD HEENT: NCAT, MMM, EOMI Lymph: no LAD, no thyromegaly CV: irregular rate and rhythm no M/R/G Lungs: CTAB, trace crackles in the base (improved) Abdomen: nt/nd/ normal bowel sounds. Ext: no clubbing, no edema, stable tremor. Neuro: AOx2- able to say her name and name her location although today thought she was in ___. Today she was able to name the month and year. CN ___ intact, although pt has very poor hearing. Mental status exam- pt able to say the days of the week forward and backward. Named the president. Also could do calculations. Today pt could respond to commands and could name her children and where she lives. Unable to remember when she ate, short term memory poor. Strength- pt able to lift upper and lower extremities against gravity but not against force. Sensation intact in upper and lower extremities Pertinent Results: ADMISSION LABS: ============== ___ 01:20PM BLOOD WBC-7.8 RBC-3.60* Hgb-9.4* Hct-32.3* MCV-90 MCH-26.1 MCHC-29.1* RDW-17.7* RDWSD-57.9* Plt ___ ___ 01:20PM BLOOD Neuts-85.6* Lymphs-7.2* Monos-5.9 Eos-0.4* Baso-0.1 Im ___ AbsNeut-6.68* AbsLymp-0.56* AbsMono-0.46 AbsEos-0.03* AbsBaso-0.01 ___ 05:20AM BLOOD ___ PTT-30.8 ___ ___ 01:20PM BLOOD Glucose-135* UreaN-32* Creat-0.6 Na-137 K-3.8 Cl-101 HCO3-25 AnGap-15 ___ 01:20PM BLOOD ALT-18 AST-19 AlkPhos-91 TotBili-0.3 ___ 01:20PM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.9 Mg-1.5* ___ 01:20PM BLOOD CRP-19.0* ___ 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:29PM BLOOD Lactate-1.5 ___ 03:15PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03:15PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 03:15PM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 ___ 03:15PM URINE Mucous-MANY ___ 11:19PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE OTHER PERTINENT/DISCHARGE LABS: ============================ ___ 09:52PM BLOOD SED RATE-PND ___ 04:20PM PLEURAL WBC-775* RBC-4* Polys-66* Lymphs-4* Monos-4* Eos-1* Macro-25* ___ 04:20PM PLEURAL TotProt-4.7 Glucose-134 LD(LDH)-228 Albumin-2.4 Cholest-PND Misc-PND ___ 04:35PM BLOOD pH-7.39 Comment-FLUID ___ 06:00AM BLOOD WBC-3.5* RBC-3.03* Hgb-7.9* Hct-27.3* MCV-90 MCH-26.1 MCHC-28.9* RDW-17.4* RDWSD-57.1* Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-89 UreaN-24* Creat-0.5 Na-138 K-3.6 Cl-103 HCO3-29 AnGap-10 ___ 06:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1 IMAGING/STUDIES: ============== CT head non-contrast ___ 1. No acute intracranial abnormalities identified. 2. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described. Chest PA/LAT ___ Pulmonary congestion and edema with left greater than right pleural effusions and left basal consolidation likely atelectasis though difficult to exclude pneumonia. Chest AP portable ___ Heart size is enlarged but stable. There has been improvement of the left-sided pleural effusion and improved aeration at the lung bases. There has also been improvement of the mild pulmonary edema since prior. No pneumothoraces are seen. Chest AP portable ___ Interval appearance of mild to moderate pulmonary and interstitial edema. Increasing more focal consolidation at the left lung base may be related to the pulmonary edema, although underlying pneumonia or aspiration cannot be excluded. This can be better assessed on followup imaging. The cardiac mediastinal contours remain stably enlarged. No pneumothorax. MICROBIOLOGY: ============== ___ 4:20 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): ___- blood culture x1 - pending Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with syncope // eval for infection COMPARISON: Prior exam from ___. FINDINGS: AP upright and lateral views of the chest provided. Pulmonary vascular congestion and edema is new from prior. There is persistent moderate left pleural effusion with probable compressive lower lobe atelectasis. A tiny right effusion is also likely present, unchanged from prior. Heart size cannot be assessed. Mediastinal contour appears prominent likely due to technique and an unfolded thoracic aorta. No acute osseous abnormality is seen. IMPRESSION: Pulmonary congestion and edema with left greater than right pleural effusions and left basal consolidation likely atelectasis though difficult to exclude pneumonia. Radiology Report INDICATION: ___ year old woman with left ___. // ? ptx COMPARISON: Radiographs from ___ IMPRESSION: Heart size is enlarged but stable. There has been improvement of the left-sided pleural effusion and improved aeration at the lung bases. There has also been improvement of the mild pulmonary edema since prior. No pneumothoraces are seen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with pleural effusion s/p drainage // please evaluate effusion please evaluate effusion COMPARISON: Comparison to ___ at 16:40 FINDINGS: Portable semi-erect chest radiograph ___ at 08:29 is submitted. IMPRESSION: Interval appearance of mild to moderate pulmonary and interstitial edema. Increasing more focal consolidation at the left lung base may be related to the pulmonary edema, although underlying pneumonia or aspiration cannot be excluded. This can be better assessed on followup imaging. The cardiac mediastinal contours remain stably enlarged. No pneumothorax. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with AMS // 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) = 803 mGy-cm. COMPARISON: MRI of the brain from ___. FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass effect or large territorial infarction. Prominence of the ventricles and sulci is likely related to age related involutional changes. Periventricular and subcortical deep white matter hypodensities, are likely related to small vessel ischemic disease. The basilar cisterns are patent, and there is preservation of gray-white matter differentiation. No acute fractures identified. Aside from mild ethmoid sinus and left sphenoid sinus mucosal thickening, the remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. Calcifications are seen within the carotid siphons. IMPRESSION: 1. No acute intracranial abnormalities identified. 2. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Syncope, Altered mental status Diagnosed with Syncope and collapse, Altered mental status, unspecified temperature: 98.3 heartrate: 111.0 resprate: 24.0 o2sat: 94.0 sbp: 137.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0
Pt is a ___ y/o woman with history of frontal dementia, polymyalgia rheumatic, HFrEF (LVEF = 43% ___, recent diagnosis of cardiac and pleural effusions (3 weeks ago), anemia, and depression presenting with a new onset 1 minute syncope episode preceded by nausea/emesis complicated by 5 minutes altered mental status. #Syncope- multifactorial with several possible etiologies. Most likely hypovolemia (newly on Lasix, recent nausea/emesis). Negative flu swab. Evaluated by neurology in ED who felt unlikely primary seizure disorder. Possible arrhythmia given significant ectopy while monitored on telemetry. No orthostats checked in ED prior to fluid resuscitation. She was evaluated by physical therapy who recommended short term rehabilitation. #Pleural and pericardial Effusion- Underwent previously planned thoracentesis. Preliminary studies consistent with exudate given pleural protein and cholesterol. Cytology pending at discharge. Suspected etiology is inflammatory from known Polymyalgia Rheumatica vs malignancy. She was restarted on home furosemide 20mg daily and may need additional titration as an outpatient. #Supraventricular tachycardia- atrial ectopy vs multifocal atrial tachycardia. Increased home metoprolol from 12.mg BID to 25mg BID. #Nausea/ Vomiting/diarrhea - no evidence of recurrence in hospital. Consistent with viral gastroenteritis. # HFrEF- TTE ___ 43% ejection fraction. Continued on metoprolol as per above. Held furosemide in setting of concern for infection. Will need repeat TTE as outpatient. # Anemia- chronic. Low iron, continued home ferrous sulfate liquid after initially holding for preceding GI illness. # Gastritis - EGD ___ with gastritis, oozing in atrum, continued on BID 20mg omeprazole/lansoprazole for difficulty swallowing and sucralfate #Depression- chronic - continued Sertraline 50 mg PO DAILY #PMR- chronic - continued PredniSONE 15 mg PO DAILY
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue Major Surgical or Invasive Procedure: Bone Marrow Biopsy Core Breast Biopsy History of Present Illness: ___ w/o regular medical care in many years, no diagnosed chronic medical problems p/w 3 weeks of constant blurry vision in left (?bilateral) eye, and LLE swelling w/exertion. She presented to ___ with worsening shortness of breath and generalized weakness. H&H was 3 and 11 on presentation, noted to have HR to 140s with minimal effort, but was guaiac negative on exam. Initial WBC read as <1, covered with vanc/zosyn. Final read 13 with 11% bands. Patient got 2 units PRBCs during her time at ___. Transferred for management of severe anemia/pancytopenia of likely hematologic origin. Of note, patient also has also has a left breast lump > ___ year, no mammogram or workup for this. Patient denies fevers or chills, chest pain or localized weakness, hematochezia or melena. In the ED, initial vitals were 99.6 114 144/81 16 100% RA. Exam was significant for a large mass in the left breast that has been present for the last year. Labs were significant for hematocrit of 20.3, with platelet count of 21K. White blood cell count was 9.8K with 70% neutrophils and 2% bands. Liver function tests showed and AST of 209, LDH of 433, total bilirubin of 2.8, with direct bilirubin of 0.5 and albumin of 3.4. Chest X-ray was performed at the OSH and was reportedly normal. ECG showed sinus tachycardia to 103, with no evidence of STE. CT head showed no acute intracranial process. Heme/onc was consulted and recommended CT torso, no evidence of leukemia on blood smear. Vital signs on transfer were 125/53, HR 91, RR 19, O2 sat 99 2L NC, temp 99.2. On the floor, patient reports continued fatigue, but improved after transfusion. There is no current dyspnea at rest, no abdominal pain, no headache, no dizziness, no diarrhea or constipation, and no weight loss. She does endorse decreased appetite that she attributes to fatigue while eating. Her vision remains blurry. Past Medical History: None Social History: ___ Family History: - Mother: Healthy - Father: Healthy - P uncle: ___ anemia - Sister: Died young of a brain tumor - Brother: Died young of an MI - Son: Died ___ years ago of CF Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 98.8 BP: 150/80 P: 106 R: 20 O2: 100%3L O2 Gen: NAD, AOx3, thin woman HEENT: MMM, no OP lesions, no cervical or supraclavicular LAD, no thyromegaly, left axillary LN 2 cm but mobile CV: RR, tachycardic, S1/S2, +II/VI systolic murmur PULM: CTAB, no adventitious sounds BREAST: left breast has a 3 x 4 cm firm lesion in the upper inner quadrant ABD: +BS, soft, liver palpable 2 cm below the costaphrenic margin EXT: No c/c/e SKIN: No rashes or skin breakdown or bruises DISCHARGE PHYSICAL EXAM Vitals - 99.6 (Tm/Tc) 124/64 95 18 99%RA Gen: NAD, AOx3, thin woman HEENT: MMM, no OP lesions, no cervical or supraclavicular LAD, no thyromegaly, left axillary LN 2 cm but mobile CV: RRR, S1/S2, +II/VI systolic murmur PULM: CTAB, no adventitious sounds BREAST: left breast has a 3 x 4 cm firm lesion in the upper inner quadrant. area of biopsy has no surrounding erythema and overlying dressing is c/d/i. ABD: +BS, soft, liver palpable 2 cm below the costaphrenic margin EXT: No c/c/e SKIN: No rashes or skin breakdown or bruises Pertinent Results: ADMISSION LABS ___ 03:20PM BLOOD WBC-9.8 RBC-1.95* Hgb-6.8* Hct-20.3* MCV-104* MCH-34.7* MCHC-33.4 RDW-28.1* Plt Ct-21* ___ 03:20PM BLOOD Neuts-70 Bands-2 ___ Monos-0 Eos-0 Baso-0 ___ Metas-2* Myelos-2* NRBC-16* ___ 10:10AM BLOOD ___ PTT-33.7 ___ ___ 03:20PM BLOOD Ret Man-8.8* ___ 03:20PM BLOOD Glucose-85 UreaN-13 Creat-0.7 Na-143 K-3.4 Cl-108 HCO3-24 AnGap-14 ___ 03:20PM BLOOD ALT-38 AST-209* LD(LDH)-433* AlkPhos-58 TotBili-2.8* DirBili-0.5* IndBili-2.3 ___ 03:20PM BLOOD Albumin-3.4* Calcium-7.9* Phos-4.4 Mg-2.4 ___ 10:10AM BLOOD calTIBC-304 VitB12-660 Folate-15.2 ___ TRF-234 ___ 03:20PM BLOOD Hapto-119 ___ 08:00AM BLOOD Triglyc-103 ___ 10:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 10:10AM BLOOD HCV Ab-NEGATIVE DISCHARGE LABS ___ 07:22AM BLOOD WBC-7.4 RBC-2.33* Hgb-7.9* Hct-25.0* MCV-107* MCH-34.0* MCHC-31.6 RDW-26.6* Plt Ct-43*# ___ 07:22AM BLOOD Glucose-106* UreaN-13 Creat-0.6 Na-139 K-3.8 Cl-104 HCO3-26 AnGap-13 ___ 06:45AM BLOOD ALT-51* AST-188* LD(LDH)-414* AlkPhos-83 TotBili-2.0* ___ 07:22AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1 MICROBIOLOGY ___ URINE CULTURE (Final ___: NO GROWTH. ___ CMV IgG ANTIBODY (Final ___: NEGATIVE FOR CMV IgG ANTIBODY CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY ___ ___ VIRUS VCA-IgG AB (Final ___: POSITIVE ___ VIRUS EBNA IgG AB (Final ___: POSITIVE ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10 ___ TOXOPLASMA IgG ANTIBODY (Final ___: NEGATIVE TOXOPLASMA IgM ANTIBODY (Final ___: NEGATIVE ___ Blood Culture, Routine (Pending): ___ Blood Culture, Routine (Pending): ___ Blood Culture, Routine (Pending): ___ Blood Culture, Routine (Pending): IMAGING ___ ECG: Sinus tachycardia. Non-specific ST-T wave changes. No previous tracing available for comparison. ___ CT HEAD W/O CONTRAST: No evidence of acute intracranial process. No CT evidence of mass or mass effect. ___ MR HEAD W & W/O CONTRAST: Normal MRI of the head, with no finding to suggest intracranial metastasis. NOTE ADDED IN ATTENDING REVIEW: The calvarial, clival and limited included upper cervical vertebral bone marrow is relatively uniformly T1-hypointense; while this may represent red marrow reconversion in response to the anemia mentioned in the given history, a diffuse infiltrative marrow-replacing process is another consideration. ___ CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS, CT CHEST W/CONTRAST: Heterogenous liver with areas of hypodensity on pre-contrast CT. It is not possible to reliably distinguish between hepatic steatosis versus metastases on this study and an MRI is recommended to further evaluate. Splenomegaly, gallbladder wall edema, and ascites raising the possibility of underlying liver dysfunction. Unusual appearance to air filled structure adjacent to the sigmoid colon in the setting of extensive sigmoid diverticulosis. Assuming no localizing signs or symptoms, this probably represents a sigmoid diverticulum. Clinical correlation is recommended. Subcentimeter (2mm) pulmonary nodules. Follow up on routine surveillance imaging is recommended. ___ MRV HEAD W/O CONTRAST: Essentially normal MRV of the head with no evidence of venous dural sinus thrombosis. ___ LIVER OR GALLBLADDER US (SINGLE ORGAN): Echogenic and coarsened liver, likely denoting hepatic steatosis. More advanced disease such as cirrhosis or fibrosis cannot be excluded. Lesions seen on the CT examination are not appreciated on this ultrasound examination, likely secondary to their small size. MRI is recommended for more sensitive evaluation. Trace perihepatic ascites. Cholelithiasis. Unchanged thickened gallbladder wall. ___ DIG DIAGNOSTIC ___ BILATERAL; CAD DIAGNOSTIC: Large highly suspicious left breast mass on mammogram and ultrasound in the upper central left breast corresponding to the palpable finding. The dominant component on ultrasound measures 4.5 cm, although both ultrasound and mammographic findings (the later including suspicious microcalcifications extending 3-4 cm posterior to the dominant mass) suggest the extent of tumor may be as large as 7 cm. Abnormal-appearing axillary lymph nodes, suspicious for tumor involvement. Indeterminate clustered microcalcifications upper and slightly inner right breast. Right breast BI-RADS 4B -- indeterminate -- biopsy should be considered. Left breast BI-RADS 5 -- highly suspicious -- appropriate action should be taken. ___ UNILAT BREAST US LEFT: BI-RADS 5 - suspicious - appropriate action should be taken. ___ CHEST (PA & LAT): Heart size top normal. Aside from linear atelectasis or scarring at the bases, lungs are clear, though volume is submaximal. There is no pleural abnormality or evidence of central adenopathy. ___ UNILAT LOWER EXT VEINS: No left lower extremity DVT. ___ BREAST CORE BX WITH US GUIDANCE LEFT; CLIP PLACMENT FOLLOWING BREAST BX LEFT: Technically successful ultrasound guided core biopsy of highly suspicious mass in the left breast. Pathology is pending. PATHOLOGY ___ BONE MARROW CORE BIOPSY: - DIAGNOSIS: INVOLVEMENT BY METASTATIC CARCINOMA, Additional morphological evaluation on the core biopsy will be done by the surgical pathology team and this work-up will be reported in an addendum. - MICROSCOPIC DESCRIPTION: # Peripheral Blood Smear - The smear is adequate for evaluation and shows mild leukoerythroblastic changes. Red blood cells are normochromic and macrocytic with anisopoikilocytosis including tear drops, spherocytes, target cells, and numerous polychromatophils seen. The white blood cell count appears normal. Rare immature forms are seen. Platelet count appears decreased; large forms are seen. Differential shows: 60% neutrophils, 2% bands, 7% monocytes, 26% lymphocytes, 1% eosinophils, 0% basophils, 4% nucleated RBCs. # Aspirate Smear - The aspirate material is inadequate for evaluation due to lack of spicules and hemodilution. A 100 cell differential shows: 0% Blasts, 0% Promyelocytes, 0% Myelocytes, 0% Metamyelocytes, 60% Plasma Cells, 30% Lymphocytes, 10% Erythroid. Rare atypical cells are noted, singly and in small clusters. # Clot section and biopsy slides: The core biopsy material is adequate for evaluation. It consists of a 1.7 cm core biopsy of trabecular marrow with a cellularity of 90%. Almost the entire marrow (~70%) is replaced by sheets of monotonous large epithelioid cells (consistent with metastatic tumor) with large round nuclei with a very prominent centrally located eosinophilic nucleoli and abundant of amphophilic cytoplasm. residual normal marrow shows maturing trilineage hematopoiesis without overt dysplasia. ___ immunophenotyping - PB: Red blood cells and granulocytes were examined for phosphatidylinositol linked antigens. RBCs and granulocytes express expected levels of DAF (CD55) and MIRL (CD59). These findings do not support a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). ___ BONE MARROW - CYTOGENETICS: Report pending. ___ RUSH...LEFT BREAST CORE: Report pending. Medications on Admission: Senna Discharge Medications: 1. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*28 Tablet(s)* Refills:*0* 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Adenocarcinoma of unknown primary Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Blurry vision. Pancytopenia. TECHNIQUE: Multidetector CT scan of the head was obtained without the administration of contrast. Coronal and sagittal reformations were prepared. COMPARISON: None available. FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or recent infarction. The ventricles and sulci are age appropriate in size and appearance. No concerning osseous lesion is seen. The visualized paranasal sinuses and mastoid air cells are grossly clear. IMPRESSION: No evidence of acute intracranial process. No CT evidence of mass or mass effect. Radiology Report HISTORY: ___ year old woman with left breast mass, abnormal LFTs, anemia and thrombocytopenia. COMPARISON: CT head dated ___. TECHNIQUE: Sagittal T1, and axial T1, T2, FLAIR, GRE and diffusion with ADC map images of the brain were obtained without contrast. Following IV administration of Gadolinium, axial T1 and sagittal 3D TFE T1 with axial and coronal MPR reformatted images were obtained. FINDINGS: The cerebral sulci, ventricles and extra-axial CSF containing spaces are normal in size and configuration; asymmetric prominence of all components of the right lateral ventricle is likely congenital/developmental. There is no shift of the midline structures. The brain parenchyma has normal gray-white matter differentiation. There is no evidence of acute infarction, intracranial hemorrhage, space-occupying lesion, mass effect or shift of midline structures. No abnormality is noted with regard to basal ganglia, brain stem, cerebellum and craniocervical junction. There is no abnormal parenchymal or leptomeningeal focus of enhancement. The flow-voids of the major intracranial vessels, including those of the principal dural venous sinuses are preserved, and these structures enhance normally. The visualized paranasal sinuses and mastoid air cells are clear. The orbits and osseous structures are unremarkable. IMPRESSION: Normal MRI of the head, with no finding to suggest intracranial metastasis. NOTE ADDED IN ATTENDING REVIEW: The calvarial, clival and limited included upper cervical vertebral bone marrow is relatively uniformly T1-hypointense; while this may represent red marrow reconversion in response to the anemia mentioned in the given history, a diffuse infiltrative marrow-replacing process is another consideration. Radiology Report CT DATED ___ INDICATION: ___ woman with left breast mass, hepatomegaly, abnormal LFTs. Please evaluate for malignancy, liver architecture, breast architecture, infiltrates and effusion. COMPARISON: No previous studies available for comparison. TECHNIQUE: Axial MDCT images acquired from the thoracic inlet to the pubic symphysis, non-contrast images of the abdomen along with portal venous phase images of the torso along with delayed images of the abdomen were performed. Coronal and sagittal reformats were obtained. DLP: 713.04 mGy-cm. FINDINGS: CT CHEST WITH IV CONTRAST: The visualized thyroid gland is normal in appearance. There is no significant axillary, supraclavicular, hilar or mediastinal adenopathy. The airways and bronchi are patent to subsegmental levels. The esophagus is normal in appearance. The central pulmonary vessels opacify normally with no evidence of pulmonary embolus. There is a 1 mm pulmonary nodule within the right upper lobe (3:9). There is a 1 mm pulmonary nodule within the left lower lobe (3:33). There is a 2 mm calcified granuloma within the left lower lobe (3:27) and a calcified granuloma within the left upper lobe (3:20). There is bibasal pleural thickening. There is bibasal atelectasis. The heart is normal in size. No pericardial effusion. There is no pleural effusion. CT ABDOMEN WITH ORAL AND IV CONTRAST: The liver is diffusely heterogenous in appearance on portal venous phase imaging with some portions of the liver demonstrating low density on pre-contrast CT. The liver appears more homogenous in appearance on delayed phase imaging. There are multiple innumberable subcentimeter (<5mm) hypodensities on portal venous phase imaging which do not persist on more delayed phases of imaging. There is no intra- or extra-hepatic duct dilation. The portal vein, SMV, splenic vein are patent. Assymetric gallbladder edema without pericholecystic fluid or fat stranding. There is splenomegaly measuring 14 cm. Accessory spleen is noted (3:55). The adrenal glands are normal in appearance bilaterally. Both kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or renal lesion. There is no significant mesenteric adenopathy. Subcentimeter left paraaortic lymph nodes, none of which meet size criteria for pathology (3:61). The visualized portions of the small and large bowel appear normal. There is a small-to-moderate amount of intra-abdominal ascites. CT PELVIS: There is a 4.5 x 4.3 cm homogenous fibroid within the uterus. There is evidence of sigmoid diverticulosis with a possible large diverticulum noted along the anterior wall of the sigmoid colon (3:95). There is a small-to-moderate amount of free pelvic fluid. There are no pathologically enlarged lymph nodes. OSSEOUS STRUCTURES: No suspicious osseous sclerotic or lucent lesions identified. IMPRESSION: 1. Heterogenous liver with areas of hypodensity on pre-contrast CT. It is not possible to reliably distinguish between hepatic steatosis versus metastases on this study and an MRI is recommended to further evaluate. 2. Splenomegaly, gallbladder wall edema, and ascites raising the possibility of underlying liver dysfunction. 3. Unusual appearance to air filled structure adjacent to the sigmoid colon in the setting of extensive sigmoid diverticulosis. Assuming no localizing signs or symptoms, this probably represents a sigmoid diverticulum. Clinical correlation is recommended. 4. Subcentimeter (2mm) pulmonary nodules. Follow up on routine surveillance imaging is recomended. Findings were discussed at 20:38 with Dr. ___ by phone with Dr. ___. Radiology Report STUDY: MRV of the head. CLINICAL INDICATION: ___ woman with blurry vision, evaluate for cerebral venous thrombosis. COMPARISON: Prior MRI of the head dated ___ and head CT dated ___. TECHNIQUE: 2D time-of-flight venography of the head was obtained, multiple rotational images and oblique source images were reviewed. FINDINGS: The major dural venous sinuses are patent, there is no evidence of venous sinus thrombosis. The right transverse sinus is dominant with the main drainage pattern throughout the right sigmoid sinus. The superior longitudinal sinus, straight sinus are patent. The oblique projections demonstrate patency of the major venous structures. IMPRESSION: Essentially normal MRV of the head with no evidence of venous dural sinus thrombosis. Radiology Report INDICATION: Multiple hepatic hypodensities on CT scan concerning for metastatic breast cancer. COMPARISON: CT available from ___. TECHNIQUE: Ultrasonography of the liver and gallbladder. FINDINGS: The liver is slightly echogenic and coarsened, likely denoting steatosis. The main portal vein is patent, demonstrating proper hepatopetal flow. There is no intrahepatic bile duct dilation. The CBD is not dilated, measuring 2 mm. The gallbladder is collapsed, containing multiple small stones. The gallbladder wall is thickened and edematous, as seen on the CT examination from ___. The spleen is enlarged measuring up to 15.6 cm. The pancreas is normal. There is trace perihepatic ascites, as seen on the CT examination. IMPRESSION: 1. Echogenic and coarsened liver, likely denoting hepatic steatosis. More advanced disease such as cirrhosis or fibrosis cannot be excluded. 2. Lesions seen on the CT examination are not appreciated on this ultrasound examination, likely secondary to their small size. MRI is recommended for more sensitive evaluation. 3. Trace perihepatic ascites. 4. Cholelithiasis. Unchanged thickened gallbladder wall. Radiology Report INDICATION: Lump upper inner left breast. COMPARISONS: None; this is the patient's baseline study. BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM WITH COMPUTER-AIDED DETECTION: A BB was placed in the upper and slightly inner left breast in the region of palpable concern indicated by the patient. The breasts are heterogeneously dense, limiting mammographic sensitivity. There is subtle increased density in the region of the BB marker, without a discrete border-forming mass. On the CC view, there is an 2 cm ill-defined asymmetry medial to the region of the palpable finding, considered suspicious in this setting. There are innumerable pleomorphic microcalcifications, including linear forms, extending in a linear array posteriorly for 3 to 4 cm from the area of palpable concern. This is highly suspicious for malignancy. An approximately 3.5 X 1.5 multilobulated asymmetry in the medial right breast on the CC view becomes much less conspicuous on a spot CC view and has no suspicious correlate on the right MLO or true lateral views. There are numerous indeterminate clustered microcalcifications spanning approximately 1 cm in the right upper and slightly inner posterior breast. UNILATERAL LEFT BREAST ULTRASOUND: Targeted ultrasound of the lump indicated by the patient demonstrates extensive abnormality predominantly in the upper central breast, but extending to the upper inner quadrant as well. At ___ o'clock, 5 cm from the nipple, there is a dominant irregular, heterogeneously hypoechoic solid mass measuring 3.3 x 1.6 x 4.5 cm. Dense posterior acoustic shadowing is noted at the inferior periphery of this dominant mass. Associated increased vascularity is noted both within the mass, as well as at its periphery. A 7 mm satellite lesion is noted at 1 o'clock, 3 cm from the nipple. At 10 o'clock, medial to the dominant mass, there appears to be some subtle disruption of normal parenchymal planes, suggesting some additional tumor infiltration medially. Exact ___ of the lesion are difficult to ascertain from ultrasound, but the abnormality may be as large as 7 cm. Ultrasound of the left axilla demonstrates several lymph nodes with eccentric cortical thickening, with the largest focus of thickening measuring 7 mm. IMPRESSION: 1. Large highly suspicious left breast mass on mammogram and ultrasound in the upper central left breast corresponding to the palpable finding. The dominant component on ultrasound measures 4.5 cm, although both ultrasound and mammographic findings (the later including suspicious microcalcifications extending 3-4 cm posterior to the dominant mass) suggest the extent of tumor may be as large as 7 cm. 2. Abnormal-appearing axillary lymph nodes, suspicious for tumor involvement. 3. Indeterminate clustered microcalcifications upper and slightly inner right breast. Findings were communicated to Dr. ___. Percutaneous core biopsy was deferred today due to the patient's low platelet count. Right breast BI-RADS 4B -- indeterminate -- biopsy should be considered. Left breast BI-RADS 5 -- highly suspicious -- appropriate action should be taken. Radiology Report Please see mammogram report (___) for findings and recommendations. BI-RADS 5 - suspicious - appropriate action should be taken. Radiology Report PA AND LATERAL CHEST ON ___ HISTORY: Breast cancer and fever, question infiltrate. IMPRESSION: PA and lateral chest reviewed in the absence of prior chest radiographs: Heart size top normal. Aside from linear atelectasis or scarring at the bases, lungs are clear, though volume is submaximal. There is no pleural abnormality or evidence of central adenopathy. Radiology Report LEFT LOWER EXTREMITY ULTRASOUND DATE: ___. There are no priors available for comparison. CLINICAL INDICATION: ___ woman with newly diagnosed adenocarcinoma (likely a primary is breast) has fever overnight of unclear etiology. Please evaluate for DVT. Left foot swelling. TECHNIQUE: Multiple sonographic grayscale images of the left lower extremity vessels were obtained with select images supplemented with color Doppler, spectral waveform analysis, compression and augmentation where appropriate. FINDINGS: The right and left common femoral veins are patent and demonstrate symmetric spectral waveform analysis. The left common femoral, superficial femoral and popliteal veins demonstrate normal grayscale appearance, compressibility, flow, spectral waveform analysis and response to augmentation. The left posterior tibial and peroneal veins demonstrate normal grayscale appearance, compression and color flow. IMPRESSION: No left lower extremity DVT. Radiology Report INDICATION: ___ woman with metastatic adenocarcinoma to the bone probably from a primary breast mass, presents for ultrasound guided core biopsy of a highly suspicious left breast mass. COMPARISON: Comparison is made to mammogram and ultrasound performed ___. ULTRASOUND GUIDED CORE BIOPSY LEFT BREAST WITH CLIP PLACEMENT: Following discussion of the procedure, risks, benefits, and alternatives, written, informed consent was obtained. A pre-procedure time out was performed using three patient identifiers. Using standard aseptic technique, and 1 % lidocaine for local anesthesia, under ultrasound guidance, five core biopsies were obtained of the irregular hypoechoic mass in the left breast located at the 11 o'clock position, 5 cm from the nipple, using a 14 gauge coaxial spring loaded biopsy device. A percutaneous clip was subsequently placed at the site of biopsy under ultrasound guidance. The needle was removed and hemostasis was achieved. Specimens were sent to Pathology. No post procedure mammogram was performed as the patient is an inpatient and the procedure was performed on the ___ without a nearby mammography unit. Confirmation of clip placement was performed under ultrasound. The patient tolerated the procedure well with no immediate complications. The patient was discharged back to the floor with standard post-biopsy instructions. IMPRESSION: Technically successful ultrasound guided core biopsy of highly suspicious mass in the left breast. Pathology is pending. The patient expects to hear the results from Dr. ___ Dr. ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ABNORMAL LABS Diagnosed with ANEMIA NOS, THROMBOCYTOPENIA NOS temperature: 99.6 heartrate: 114.0 resprate: 16.0 o2sat: 100.0 sbp: 144.0 dbp: 81.0 level of pain: 0 level of acuity: 2.0
___ yo female with no known past medical history presenting with fatigue, noted to have left breast mass, anemia and thrombocytopenia, as well as abnormal LFTs concerning for metastatic breast cancer. # Likely breast cancer: Pt reports having a breast lesion for the past ___ year, though did not seek medical attention for it. Breast exam was performed at the bedside. Oblong, firm breast mass palpated on the upper, medial quadrant of the left breast. No dippling of the nipple but appeared pale and did not seem to have the texture as the right nipple. There is a strong suspicion for malignancy given mammogram findings. Bone marrow biopsy was performed (because of anemia and thrombocytopenia), which demonstrated infiltration of poorly differentiated adenocarcinoma, that is likely from a primary breast cancer. This is not ___ certain because ER, PR, and Her2Neu staining was unable to be performed on the bone marrow sample, and so a core breast biopsy was performed on ___, on which this staining will done. Given the marrow infiltration and pt's lab values during her hospitalization, pt was transfusion dependent, and received 4 units pRBC and 3 packs platelets prior to discharge. She was transfused 1 pack platelets on the day of discharge with follow-up on ___ for lab check and possible platelet transfusion and follow-up with hematology-oncology on ___ for biopsy results. # Abnormal liver function tests: Abnormalities likely due to metastatic disease, though pattern suggests possible mixed hepatocellular and obstructive picture, and no stigmata of chronic liver disease on exam. Hepatitis B testing was negative and pt had no immunity. Hepatitis C negative was also negative. Pt's EBV indicated past infection though no current infection, CMV and toxoplasmosis were both negative. LFTs remained elevated, but were stable during the hospitalization. An MRI should be considered in the near future to further characterize ultrasound findings. # Macrocytic anemia, unknown chronicity: HCT was 11 on initial presentation to OSH, which responded to transfusions. B12, folate were normal, but pt was initiated on folate supplement to help the anemia. Bone marrow was evaluated for paroxysmal nocturnal hemoglobinuria, but this was negative. It is most likely that pt has decreased bone marrow production given infiltration seen on biopsy. # Thrombocytopenia: Platelet count was 21K upon admission with an unknown baseline. Pt had no episodes of bleeding throughout the hospitalization was transfused a total of 3 packs of platelets with appropriate response. This is likely due to decreased production secondary to the infiltrative process in the bone marrow, and the pt is currently transfusion dependent. Pt has follow-up on ___ for lab check and possible transfusion. # Fever - Pt spiked once, to 101.4, during her hospitalization. Infectious work-up was unrevealing. Given her malignancy and therefore hypercoagulable state, ___ was performed of her LLE (as it appeared slightly more swollen than the right), and this was negative for clot. Could be caused by her malignancy alone. She remained afebrile throughout the rest of her hospitalization. # Fatigue: Likely due to pt's severe anemia upon presentation and this improved with transfusions. She was transfused as above and worked up for malignancy as above. Could consider checking ___ as an outpatient. # Visual changes - Pt reports blurry vision, without double vision. Unclear in etiology - but concerning for possible oncologic involvement given the likely metastatic nature of the cancer. MRI of the head was normal, without evidence of intracranial metastases. MRV of the head was normal, with no evidence of venous dural sinus thrombosis. Outpatient appointment with ophthalmologist was made for the patient on ___ for further investigation into potential abnormalities. TRANSITIONAL ISSUES # Subcentimeter (2mm) pulmonary nodules found on CT chest and should be followed-up with routine surveillance # Pt will need breast biopsy results followed-up on # Can consider checking TSH as outpatient # Would consider MRI of the torso to further evaluate liver abnormalities # Recommend checking LFTs in the near future to ensure their stability
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Vicodin Attending: ___. Chief Complaint: Lethargy, cough Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old male with metastatic clear cell renal carcinoma (brain mets) and history of prostate CA who is admitted with cough and lethargy at home. Patient recently completed seven cycles of cyberknife treatment and also had avastin last week. Soon after receiving the avastin, wife notes that he "slept much of the day". Then patient started to cough and produced "greenish" phlegm. No nausea, vomiting, chest pain, headaches, shortness of breath. Has been unable to walk secondary to weakness. Has h/o seizure d/o. On dexamethasone and valproic acid. Is fully PEG tube dependent for feeds. Past Medical History: # Mestatastic clear cell renal CA s/p R nephrectomy ___ yrs ago # Prostate CA s/p prostatectomy # HTN # DM # HL # Anxiety # GERD # Gout Summary of Past Oncologic Treatment: 1. ___ - A renal ultrasound obtained as part of an investigation into the etiology of his elevated creatinine showed a right renal mass for which the patient underwent a nephrectomy. 2. ___ - Prostatectomy for prostate carcinoma. 3. ___ - The patient developed confusion and was found to have a left frontal lobe metastasis. A stereotactic biopsy was done that showed metastatic renal cell carcinoma. 4. ___ - CyberKnife treatment to the brain metastasis. 5. Brief admission for recent onset seizures. 6. ___ - Avastin treatment begun because of persistent symptomatic vasogenic edema surrounding the treated brain metastasis and because of steroid myopathy. This allowed Mr. ___ to be weaned from decadron. Social History: ___ Family History: He has two daughtres and one son, all healthy. His father died at age ___ after returning from ___, cause unclear. His mother died at age ___. He has no siblings. Physical Exam: Exam: AF 102/60 80 pox 98% on RA Gen: Well developed male, but chronically ill appearing. Speaks in soft tones, and answers questions appropriately Skin: Multiple ecchymoses Lung: + rales bilateral bases, but greater on the right CV: RRR with frequent ectopy Abd: +PEG in place, no drainage. Nabs, soft, nt/nd Ext: +2 edema B feet, right greater than left (wife says this is chronic, and improved from baseline) Neuro: AO x 3. Patient unwilling to participate in full strength exam. Pertinent Results: ___ 12:25PM BLOOD WBC-15.0*# RBC-3.95* Hgb-11.7* Hct-33.7* MCV-85 MCH-29.6 MCHC-34.7 RDW-17.1* Plt Ct-ERROR ___ 12:25PM BLOOD Glucose-309* UreaN-35* Creat-1.3* Na-131* K-3.5 Cl-88* HCO3-29 AnGap-18 ___ 12:40PM BLOOD Lactate-3.6* CXR: RML/RLL pneumonia Abd CT ___: 1. Mild diffuse wall thickening of the large bowel consistent with pan-colitis, predominantly involving the sigmoid colon, descending colon, and cecal tip with relative sparing of the transverse colon to the splenix flexure. 2. New osseous metastases involving the left iliac crest and left posterior acetabulum as well as multiple vertebrae including the vertebral bodies of T9, L2, and L3. 3. Slight increase in size of right middle lobe pulmonary nodule with stable size of two satellite pulmonary nodules from ___. 4. Small non-hemorrhagic right-sided pleural effusion with compressive atelectasis is new from ___. 5. Perihepatic and perisplenic ascites, new from ___. 6. Cholelithiasis without evidence of cholecystitis. Pericholecystic fluid is likely due to systemic process in the setting of ascites. 7. Splenomegaly. 8. Status post right nephrectomy without evidence of local recurrence. Video Swallow Study ___: IMPRESSION: Aspiration with thin and nectar liquids. Penetration with puree. Cervical osteophytes causing narrowing of the hypopharynx. ___ 07:54AM BLOOD WBC-6.0 RBC-3.38* Hgb-10.3* Hct-30.8* MCV-91 MCH-30.6 MCHC-33.6 RDW-17.1* Plt Ct-UNABLE TO ___ 07:35PM BLOOD Plt Smr-LOW Plt Ct-99* ___ 06:49AM BLOOD Glucose-144* UreaN-11 Creat-0.8 Na-139 K-4.0 Cl-103 HCO3-29 AnGap-11 ___ 07:50AM BLOOD TSH-7.1* Medications on Admission: Allopurinol ___ mg PEG ___ Alprazolam .5 mg ___ bid Dexamethasone 2 mg ___ Lantus 40 units sc qam Sliding scale regular insluin Lansoprazole 30 mg ___ Loperamide 2 mg ___ bid for prevention of tube feed diarrhea Zoloft 50 mg PEG ___ Temazepam 15 mg PEG QHS for insomnia prn Valproic acid ___ mg/5ml syrup 15 ml PEG bid. Discharge Medications: 1. allopurinol ___ mg Tablet Sig: One (1) Tablet ___ (___). 2. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1) Tablet,Rapid Dissolve, ___ ___. 3. sertraline 50 mg Tablet Sig: One (1) Tablet ___. 4. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig: 15 ml ___ Q12H (every 12 hours). 5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet ___ twice a day. 6. dexamethasone 4 mg Tablet Sig: One (1) Tablet ___ (___). 7. Lantus 100 unit/mL Solution Sig: 28 units Subcutaneous at bedtime. 8. vancomycin oral liquid Sig: 500 mg every six (6) hours for 6 days: Please administer until ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Clostridium difficile colitis -Pneumonia -Diarrhea -Diabetes mellitus type 2, controlled, without complications -Renal cell carcinoma, metastatic 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: Cough and weakness. COMPARISON: Radiograph available from ___. FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart is moderately enlarged. The hilar and mediastinal contours are unchanged since ___. There has been increase in central vascular congestion with mild interstitial edema. There are right lower and middle lobe densities, increased since the ___ examination, concerning for consolidations. There is no pneumothorax. IMPRESSION: 1. Increase in density of a right lower and middle lobe opacities, concerning for pneumonia. 2. Cardiomegaly with central vascular congestion and mild interstitial edema. Radiology Report INDICATION: ___ man with C. diff and abdominal pain. Evaluate for megacolon. COMPARISONS: None. FINDINGS: Supine view of the abdomen demonstrates a normal bowel gas pattern. No obstruction, ileus, or megacolon. No free air or pneumatosis. A PEG tube overlies the left abdomen and inserts into the stomach. Multiple clips overlie the mid and right abdomen. Osseous structures are unremarkable. IMPRESSION: Normal bowel gas pattern without megacolon. Radiology Report INDICATION: ___ male with history of metastatic renal cell carcinoma, now with Clostridium difficile colitis and persistent diarrhea on antibiotic therapy, here to assess extent of colitis. COMPARISON: Non-contrast CT of the chest performed ___ and CT of the torso with contrast performed on ___. TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to the pubic symphysis after the uneventful administration of 100 cc Omnipaque intravenous contrast and oral contrast. Coronally and sagittally reformatted images were generated and reviewed. DLP: 811 mGy-cm FINDINGS: CT OF THE ABDOMEN: Limited supradiaphragmatic evaluation shows a small non-hemorrhagic right-sided pleural effusion with associated compressive atelectasis which is new from ___. There is a trace left-sided pleural effusion with minimal associated atelectasis. There is a nodule in the right middle lobe (2:12) that now measures 19 x 16 mm (previously 16 x 16 mm), which is slightly increased in size from ___ with two 4-5 mm satellite pulmonary nodules (2:4, 10), which are unchanged in size. No new pulmonary nodules are present in the lung bases. No focal consolidations or pneumothoraces. Limited evaluation of the heart shows calcifications of the coronary arteries. No pericardial effusion. The liver enhances homogeneously without focal liver lesions. No thrombosis is identified in the portal venous system. There is perihepatic ascites which is new from ___. No intra- or extra-hepatic biliary dilation is seen. The gallbladder is contracted and contains a 9-mm calcified gallstone, which is unchanged in size from the prior study. There is new pericholecystic fluid or, less likely, an edematous gallbladder wall, which is likely due to a systemic process in the setting of ascites and third spacing. The pancreas and bilateral adrenal glands are unremarkable. The spleen is enlarged, measuring 16 cm. There is a small amount of perisplenic ascites. The patient is status post right nephrectomy with multiple surgical clips in the surgical bed. There is no evidence of locally recurrent mass. Two small portacaval lymph nodes are noted (2:30, 26), which measure up to 8 mm in short axis, which is not pathologically enlarged by CT size criteria. The left kidney enhances and excretes contrast normally without evidence of hydronephrosis or solid renal mass. A 9-mm hypodensity in the lower pole of the left kidney is incompletely characterized by CT, but unchanged from ___. A percutaneous gastrostomy tube is in appropriate position within the distal stomach. There is a calcification in the anterior upper abdomen abutting the abdominal wall (2:23), which measures 2.4 x 1.9 cm and is unchanged from the prior study, likely posttraumatic changes at the xyphoid tip. The intra-abdominal loops of small bowel are unremarkable without evidence of wall thickening or obstruction. No free air or significant abdominal ascites is noted. There are scattered colonic diverticula without inflammatory changes. There are small periaortic lymph nodes, but none are pathologically enlarged by CT size criteria. CT OF THE PELVIS: There is diffuse mild wall thickening involving the entire large bowel with predominance in the cecal tip and descending colon and relative sparing of the transverse colon to the splenic flexure. There are scattered diverticula in the sigmoid colon without focal inflammatory changes but mild generalized pericolonic fat stranding involving the sigmoid colon. The urinary bladder is unremarkable. There is no free pelvic fluid, pelvic or inguinal lymphadenopathy. Surgical clips are noted in the right pelvis anterior to the right psoas muscle. OSSEOUS STRUCTURES: There is evidence of new bony metastasis involving the left iliac crest (2:61) measuring 4.3 x 2.9 cm. There is also a new bony metastasis to the left posterior acetabulum measuring 1.7 x 1.3 cm. There are lucent lesions involving the vertebral bodies of T9, L2, and L3 and multiple additional small lucent lesions with peripheral rims in the vertebrae not seen on ___ which are concerning for metastases. Osseous lesions in the right ninth posterior rib and left seventh lateral rib are unchanged from ___. There is extensive multilevel degenerative disc disease throughout the lumbar and thoracic spine with multilevel bridging osteophytes. IMPRESSION: 1. Mild diffuse wall thickening of the large bowel consistent with pan-colitis, predominantly involving the sigmoid colon, descending colon, and cecal tip with relative sparing of the transverse colon to the splenix flexure. 2. New osseous metastases involving the left iliac crest and left posterior acetabulum as well as multiple vertebrae including the vertebral bodies of T9, L2, and L3. 3. Slight increase in size of right middle lobe pulmonary nodule with stable size of two satellite pulmonary nodules from ___. 4. Small non-hemorrhagic right-sided pleural effusion with compressive atelectasis is new from ___. 5. Perihepatic and perisplenic ascites, new from ___. 6. Cholelithiasis without evidence of cholecystitis. Pericholecystic fluid is likely due to systemic process in the setting of ascites. 7. Splenomegaly. 8. Status post right nephrectomy without evidence of local recurrence. Radiology Report INDICATION: Recent difficulty with swallowing and managing secretions. SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with speech and swallow division. Multiple consistencies of barium were administered. Barium passed freely through the oropharynx without evidence of obstruction. There was aspiration with thin and nectar liquids, and laryngeal penetration with puree. Note is also made of prominent cervical osteophytes causing narrowing of the hypopharynx. IMPRESSION: Aspiration with thin and nectar liquids. Penetration with puree. Cervical osteophytes causing narrowing of the hypopharynx. For details and recommendations, please refer to speech and swallow note in OMR. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: LETHARGY Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, ACIDOSIS, SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS temperature: 97.9 heartrate: 102.0 resprate: 18.0 o2sat: 95.0 sbp: 99.0 dbp: 59.0 level of pain: 0 level of acuity: 2.0
___ year old male with complex oncologic history, on dexamethasone, admitted with cough and lethargy and found to have RML/RLL pneumonia. # Pneumonia, bacterial - treated with high-dose levofloxacin for 5 days ___ through ___. Respiratory symptoms resolved. # Clostridium diffcile colitis: no evidence of megacolon on KUB. Initially treated with metronidazole ___, then iv). However, his symptoms persisted, so he was evaluated by the GI service who advised treatment with vancomycin orally. CT scan showed colitis but no evidence of megacolon. After treatment with oral vancomycin, his diarrhea largely improved. He should finish his oral vancomycin dose on ___. # Lethargy/ generalized weakness: Cortisol level in am was less than 10, suggestive of some adrenal insufficiency despite being on dexamethasone 2 mg at home. However, his diarrhea at home may have caused some malabsorption of the dexamethasone that he was taking. Advise slow taper of dexamethasone. This should be done by his outpatient providers. His lethargy resolved during his hospitalization as his C diff was treated and his pneumonia was treated. # h/o Gout: no active flare. Continued allopurinol # Nutrition: Patient had video swallow study done that showed aspiration so he needs to be kept NPO. He was seen by the nutrition service who advised Peptamen tube feeds in the hope that his diarrhea associated with tube feeds would improve. He did have more solid stools once started on this formulation. # Diabetes Mellitus type 2, controlled, without complications. Patient was taking lantus 40 units sc at home, but his sugars were lower here in the hospital. Will dicharge patient on lantus 28 units at night. Please titrate as needed. # Anxiety: When patient was lethargic, we attempted to wean off the xanax, but he became very anxious. His anxiety was well controlled on xanax .25 mg ___ bid. # History of seizure disorder: Continued home valproic acid. # Depression: continued Zoloft. Patient upset by prolonged hospitalization, but not demonstrating severe neurovegetative signs of depression. # Metastatic Clear Cell carcinoma: Patient seen by primary hematologist oncologist. THey discussed the option of possibly starting sunitinib in the future once he has fully recovered from this hospitalization. # ? Hypothyroidism. TSH is 7.1 PLEASE RECHECK THIS AT REHAB. This may be secondary to his acute illness or due to subclinical hypothyroidism. Please recheck TSH and if it remains elevated, please discuss with PCP start of low dose synthroid. # THrombocytopenia: Chronic. CBC often had platelet clumping. Patient has diffuse ecchymoses. Heparin SC held. Platelets are 99K on discharge. Would advise one recheck at rehab to ensure that their are stable. If they continue to drop further, can discuss with his oncologist Dr ___ at ___. Patient is a full code. Plan was discussed at length with patient and his wife ___ ___, RN.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / iodine / Darvon / Demerol / Percocet Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female bicuspid valve c/b AS/AI now s/p MVR ___ (___ 25mm Regent valve) and newly diagnosed with cardiomyopathy ED 20% in ___ who is admitted for chest pains without EKG changes or cardiac biomarker elevation. Past Medical History: Aortic Insufficiency Aortic Stenosis Atrophic Vaginitis Colon Polyps Depression/Post-Partum Depression Diabetes Mellitus Difficult intubation Fibromyalgia Glaucoma Hyperlipidemia Hypertension Hyperlipidemia Mechanical Fall, ___ Migraine Vertigo Social History: ___ Family History: Father - myocardial infarction at age ___. Uncle - died suddenly of myocardial infarction in his late ___. Physical Exam: PHYSICAL EXAM AT ADMISSION: Vitals: 98.1 128-168/71 ___ Wt: 79.4kg I/O: O/N: 286/200 General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM Neck: No JVD CV: RRR, nl S1, mechanical S2 II/VI systolic murmur heard best at LUSB, no extra heart sounds Lungs: CTABL, no wheezes/rhonci/crackles Ext: Warm, well perfused, 2+ pulses, no ___ edema PHYSICAL EXAM AT DISCHARGE Vitals: 0445 97.8 125/70 62 18 98% RA I/O: 24H: 1020/1750 O/N: NPO/0 General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM CV: RRR, nl S1, mechanical S2 II/VI systolic murmur heard best at LUSB, no extra heart sounds Lungs: CTABL, no wheezes/rhonci/crackles Ext: Warm, well perfused, no ___ edema Pertinent Results: LABS AT ADMISSION ================== ___ 02:50PM BLOOD WBC-7.2 RBC-4.09 Hgb-12.3 Hct-36.7 MCV-90 MCH-30.1 MCHC-33.5 RDW-12.0 RDWSD-37.7 Plt ___ ___ 02:50PM BLOOD ___ PTT-48.9* ___ ___ 02:50PM BLOOD Glucose-117* UreaN-25* Creat-0.8 Na-136 K-8.6* Cl-105 HCO3-19* AnGap-21* ___ 02:50PM BLOOD proBNP-1782* ___ 02:50PM BLOOD cTropnT-<0.01 INTERVAL LABS ___ 02:50PM BLOOD cTropnT-<0.01 ___ 11:20PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:58AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:58AM BLOOD ___ PTT-89.6* ___ ___ 05:45AM BLOOD ___ PTT-42.4* ___ ___ 06:58AM BLOOD Glucose-132* UreaN-20 Creat-0.8 Na-139 K-3.8 Cl-101 HCO3-24 AnGap-18 ___ 05:45AM BLOOD Glucose-176* UreaN-24* Creat-1.0 Na-140 K-3.8 Cl-104 HCO3-24 AnGap-16 ___ 06:58AM BLOOD WBC-6.1 RBC-3.72* Hgb-11.4 Hct-33.4* MCV-90 MCH-30.6 MCHC-34.1 RDW-11.8 RDWSD-38.1 Plt ___ ___ 05:45AM BLOOD WBC-5.4 RBC-3.81* Hgb-11.3 Hct-34.6 MCV-91 MCH-29.7 MCHC-32.7 RDW-11.8 RDWSD-38.9 Plt ___ PERTINENT IMAGING CXR ___ IMPRESSION: Status post sternotomy, with prosthetic aortic valve. Mild cardiomegaly is unchanged compared with ___. Equivocal minimal upper zone redistribution, without overt CHF. No focal infiltrate to suggest pneumonia. Stress Test ___ INTERPRETATION: This ___ year old NIDDM woman with a h/o HTN, HFrEF (LVEF 20%) s/p AVR in ___ was referred to the lab for evaluation of atypical chest discomfort and shortness of breath. The patient was adminstered 0.142 mg/kg/min of dipyridamole over four minutes. There were no chest, neck, arm or back discomforts reported by the patient throughout the study. In the setting of a baseline LBBB, the ST segments are uninterpretable for ischemia. The rhythm was sinus with rare isolated APBs during the infusion. Baseline systolic hypertension with appropriate blood pressure and heart rate responses to the infusion and in recovery. Post-MIBI, the dipyridamole was reversed with 125 mg aminophylline IV. IMPRESSION: No anginal type symptoms with uninterpretable ST segments in the setting of baseline LBBB. Appropriate hemodynamic response to vasodilator stress. Nuclear report sent separately. MICROBIOLOGY ============== none Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 8 mg PO DAILY16 2. Azithromycin 500 mg PO AS DIRECTED 3. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY 4. LORazepam 0.5 mg PO QHS 5. Simvastatin 20 mg PO QPM 6. Eplerenone 25 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. GlipiZIDE XL 2.5 mg PO DAILY 10. estradiol 0.01 % (0.1 mg/gram) vaginal ___ per week 11. clotrimazole-betamethasone ___ % topical BID 12. Aspirin 81 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO DAILY 15. Calcium Carbonate 500 mg PO BID 16. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. Azithromycin 500 mg PO AS DIRECTED BY PCP 4. Calcium Carbonate 500 mg PO BID 5. clotrimazole-betamethasone ___ % topical BID 6. Eplerenone 25 mg PO DAILY 7. estradiol 0.01 % (0.1 mg/gram) vaginal ___ per week 8. GlipiZIDE XL 2.5 mg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. LORazepam 0.5 mg PO QHS 11. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY 12. Metoprolol Succinate XL 100 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO DAILY 15. Simvastatin 20 mg PO QPM 16. Warfarin 8 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Chest Pain Secondary Diagnoses Cardiomyopathy Bicuspid Valve s/p Aortic Valve Replacement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with chest pain, eval for ptx or edema// chest pain, eval for ptx or edema COMPARISON: Chest x-ray dated ___ FINDINGS: The patient is status post sternotomy, with prosthetic aortic valve.. The cardiomediastinal silhouette is unchanged compared with ___. Again seen is mild cardiomegaly. Equivocal minimal upper zone redistribution, but no other evidence of CHF. Minimal subsegmental atelectasis and/or scarring at the lung bases, similar to prior. No focal infiltrate, consolidation, gross pleural effusion, or pneumothorax is detected. IMPRESSION: Status post sternotomy, with prosthetic aortic valve. Mild cardiomegaly is unchanged compared with ___. Equivocal minimal upper zone redistribution, without overt CHF. No focal infiltrate to suggest pneumonia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Unstable angina temperature: 96.5 heartrate: 83.0 resprate: 16.0 o2sat: 99.0 sbp: 172.0 dbp: 84.0 level of pain: 4 level of acuity: 3.0
Mrs ___ is a ___ year old woman with a history of a bicuspid aortic valve c/b AS/AI now s/p AVR ___ (___ 25mm Regent valve) and newly diagnosed with cardiomyopathy ED 20% admitted with chest pains. EKG and troponins were negative for ischemic changes. She underwent a nuclear stress test which demonstrated known cardiomyopathy, but without any reversible perfusion defects. She was continued to be managed medically and discharged home for further cardiac evaluation. TRANSITIONAL ISSUES # Medication Changes: None # Discharge Weight: 79.7 kg # Discharge Creatinine: 1.0 # Code: Full # HCP: None Identified.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: HPI: ___ w/ dCHF, Mobitz II w/ pacemaker (___) s/p unwitnessed fall out of bed at assisted living facility this AM who presents with craniofacial trauma. She states she fell this AM but has no recollection of the event, +LOC. She just remembers waking up on the floor. She has subjective decrease in vision and pain on the right eye. She also has pain over the right temporal bone. She is blind in the left eye at baseline. Denies pain elsewhere. ROS otherwise negative. In ED, head CT showed small subdural hematoma, for which neurosurgery is following. CT C-spine negative. CT sinus/mandible/maxillofacial + for mildly displaced fx of frontal process of right maxillary bone & periorbital edema. Globes intact bilaterally. PRS consulted for facial fx. Major Surgical or Invasive Procedure: none History of Present Illness: PI: ___ w/ dCHF, Mobitz II w/ pacemaker (___) s/p unwitnessed fall out of bed at assisted living facility this AM who presents with craniofacial trauma. She states she fell this AM but has no recollection of the event, +LOC. She just remembers waking up on the floor. She has subjective decrease in vision and pain on the right eye. She also has pain over the right temporal bone. She is blind in the left eye at baseline. Denies pain elsewhere. ROS otherwise negative. In ED, head CT showed small subdural hematoma, for which neurosurgery is following. CT C-spine negative. CT sinus/mandible/maxillofacial + for mildly displaced fx of frontal process of right maxillary bone & periorbital edema. Globes intact bilaterally. PRS consulted for facial fx. Past Medical History: PAST MEDICAL HISTORY: - Anxiety/depression - Cataracts - macular degeneration - Urinary frequency - Status post uterine fibroid removal ___ years ago - Back pain - BCC forehead ___ s/p Mohs - Frontal Process/Maxiallary Bone Fracture - Sub Dural Hematoma (___) Social History: ___ Family History: Mother died of cancer; father of lung disease NOS; sister died of colon cancer; sister died of heart disease. Physical Exam: ADMISSION PE: Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils Left irregular, right 4mm minimally reactive Blind in left eye. 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: NA XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Sensation: Intact to light touch, DISCHARGE PE: Vitals: T:98.6 P: 87 BP: 148/54 RR: 18 O2: 96RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, moist mucous membranes, oropharynx clear. L pupil asymetric, dialated (pt states baseline). R pupil round, reactive to light. Echymosis around R eye. Neck: Supple, JVP not elevated, no tonsillar or cervical lymphadenopathy 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 Neuro: (except blind L eye, but appears able to track, so unlikely complete blindness), Sensations, strength grossly in tact. Pertinent Results: ADMISSION LABS: ___ 09:00AM BLOOD WBC-6.9 RBC-3.49* Hgb-11.7* Hct-36.4 MCV-104* MCH-33.5* MCHC-32.1 RDW-14.5 Plt ___ ___ 09:00AM BLOOD Neuts-78.6* Lymphs-13.6* Monos-5.2 Eos-2.3 Baso-0.3 ___ 09:00AM BLOOD Glucose-91 UreaN-19 Creat-0.7 Na-135 K-4.1 Cl-99 HCO3-26 AnGap-14 ___ 05:55AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0 ___ 09:00AM BLOOD CK(CPK)-63 ___ 01:56PM BLOOD Lactate-1.8 ___ 09:11AM URINE Color-Straw Appear-Hazy Sp ___ ___ 09:11AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG ___ 09:11AM URINE RBC-3* WBC-49* Bacteri-NONE Yeast-NONE Epi-3 DISCHARGE LABS: ___ 06:30AM BLOOD WBC-5.9 RBC-3.22* Hgb-10.9* Hct-33.1* MCV-103* MCH-33.9* MCHC-33.0 RDW-15.1 Plt ___ ___ 06:30AM BLOOD Glucose-91 UreaN-18 Creat-0.6 Na-133 K-3.8 Cl-100 HCO3-22 AnGap-15 ___ 06:30AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 MICRO: Blood Cx/Urine Cx pending at time of discharge STUDIES/IMAGING: CXR ___: Vitals: T:98.6 P: 87 BP: 148/54 RR: 18 O2: 96RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, moist mucous membranes, oropharynx clear. L pupil asymetric, dialated (pt states baseline). R pupil round, reactive to light. Echymosis around R eye. Neck: Supple, JVP not elevated, no tonsillar or cervical lymphadenopathy 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 Neuro: (except blind L eye, but appears able to track, so unlikely complete blindness), Sensations, strength grossly in tact. CT Head ___: There is a small subdural hematoma which tracks along the right cerebral convexity and also tracks along the falx. It measures 8 mm at its widest dimension. There is mild mass effect on the right frontal lobe, however, there is no shift of normally midline structures. There is no evidence of acute territorial infarction. There is no evidence of mass or cerebral edema. The ventricles and sulci are normal in size and configuration for age. Periventricular, subcortical, and deep white matter hypodensities likely reflect the sequela of chronic small vessel ischemia. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. There is irregularity of the frontal process of the right maxillary sinus concerning for fracture. Additionally, there is high density fluid in the right maxillary sinus compatible with leg, with an air-fluid level. There is mild to moderate mucosal thickening of the paranasal sinuses diffusely with small amount of opacification of the inferior left mastoid air cells. The right mastoid air cells appear clear. There is right periorbital soft tissue swelling. The globes are unremarkable. IMPRESSION: 1. Small subdural hematoma which tracks along the right cerebral convexity and along the falx with mild mass effect upon the right frontal lobe but no evidence of midline shift. 2. Irregularity of the frontal process of the right maxillary sinus concerning for fracture. 3. Blood within the right maxillary sinus, though no right maxillary sinus fracture is seen on these images. Recommend facial bone CT for further evaluation. CT Abd/Pel ___: Lungs and Heart: There is minimal bibasilar atelectasis. A pacemaker lead is seen within the right ventricle. The heart is mildly enlarged. The pericardium is normal. Liver, Gallbladder: The liver is normal in size and attenuation. Few subcentimeter hypodensities in the left lobe are too small to characterize. The gallbladder is distended but is otherwise normal appearing. The portal and hepatic veins are patent. There is no intra or extrahepatic biliary ductal dilatation. Spleen: The spleen is normal in size and attenuation. Pancreas: The pancreas shows normal enhancement. There is no pancreatic duct dilatation or peripancreatic fat stranding. Kidneys, Adrenals: In the lower pole of the left kidney there is a 4.8 x 4.8 cm simple cyst. The right kidney is normal appearing. There is no evidence of hydronephrosis in either kidney. Bowel: The small bowel is normal appearing. There is diverticulosis throughout the large bowel with no evidence of diverticulitis. No free air or free fluid is identified in the abdomen or pelvis. Vessels: There is diffuse atherosclerosis of the abdominal aorta. There is no aneurysmal dilatation of the aorta and its major branches appear patent. Lymph Nodes: There are no pathologically enlarged retroperitoneal or mesenteric lymph nodes by CT size criteria. Pelvis: The bladder is unremarkable. The sigmoid colon and rectum are normal appearing. There is no pelvic sidewall lymphadenopathy. A pessary is seen in place. Osseous Structures: There is moderate degenerative change seen in the thoracolumbar spine. There are no suspicious lytic or sclerotic lesions identified. No fracture is identified. There is a small ventral hernia which contains fat. IMPRESSION: No evidence of acute intra-abdominal process. CT Spine ___: No evidence of acute fracture. There is mild anterolisthesis of C3 on C4, C4 on C5, and C7 on T1. There are severe degenerative changes seen throughout the cervical spine with intervertebral disc space narrowing, vacuum disc phenomena, endplate sclerosis and cystic change, and anterior and posterior osteophyte formation. While there is mild multilevel central canal narrowing, worst at C5/6 and C6/7, no critical central canal stenosis is seen. There is no prevertebral soft tissue swelling. There is multilevel bilateral facet joint and uncovertebral joint hypertrophy causing moderate to severe bilateral neural foraminal narrowing at multiple levels. Dense atherosclerotic calcifications are seen at the carotid bifurcations bilaterally. Air-fluid level within the right maxillary sinus with hyperdense components suggestive of blood is noted. IMPRESSION: No evidence of fracture. Severe cervical spondylosis with multilevel mild anterolisthesis. CT Sinus ___: There is some irregularity of the frontal process of the right maxillary bone compatible with a mildly displaced fracture. There are no other acute fractures identified. The lamina papyracea is intact. An air-fluid level is seen within the right maxillary sinus and the fluid within the sinus is hyperdense, which could represent blood. Moderate mucosal thickening is seen involving the ethmoid air cells, both frontal sinuses, both sphenoid sinuses, and mild mucosal thickening within the left maxillary sinus. There is right periorbital soft tissue swelling. The globes are intact. Partially imaged is a right subdural hematoma. IMPRESSION: 1. Mildly displaced fracture of the frontal process of the right maxillary bone. 2. Pansinus disease with high density fluid in the right maxillary sinus, possibly suggestive of blood. No fracture of the right maxillary sinus is identified. 3. Right periorbital soft tissue swelling. Globes intact. CT Chest ___: Axillary, supraclavicular, mediastinal, and hilar lymph nodes are not pathologically enlarged. The great vessels are normal caliber. There is calcification of the aortic valve and mitral valve annulus. The heart size is normal. Pacing leads are seen within the right atrium right ventricle. Dense coronary artery calcifications are noted. Heart is mildly enlarged. The trivial pericardial effusion is present. There is diffuse calcification of the walls of the segmental airways which are mildly dilated compatible with mild bronchiectasis. There is a small bleb in the left lower lobe. There are a few small nodules in left upper lobe measuring up to 5 mm (04:50). No focal consolidation, pleural effusion, or pneumothorax. There is mild centrilobular emphysema within the apices. The esophagus and visualized upper abdominal organs are unremarkable. OSSEOUS STRUCTURES: Irregularity of the ribs of the right fifth and sixth ribs laterally may represent acute nondisplaced fractures. Severe degenerative changes are seen throughout the visualized thoracic spine with ossification of the anterior longitudinal ligament and osseous fusion of multiple vertebral bodies. IMPRESSION: 1. Irregularity of the ribs of the right fifth and sixth ribs laterally which may represent acute nondisplaced fractures. 2. No mediastinal hematoma. No focal consolidation in the lungs. No evidence of pneumothorax. C CT Head 8.12 Small mixed density, predominantly hyperdense subdural hematoma is again seen along the right convexity, falx, and right tentorium. There has been posterior redistribution of blood along the convexity and falx secondary to supine positioning, but no evidence for enlargement of the subcu or hematoma. New blood is seen layering in the occipital horns of lateral ventricles. The ventricles are stable in size. Small hypodense subdural collection along the left convexity is unchanged, compatible with a chronic subdural hematoma or subdural hygroma. The basal cisterns are not compressed. There is no evidence for an acute major vascular territorial infarction. The minimally displaced comminuted fracture at the base of the right nasal bone is again see. Soft tissue swelling overlying the right orbit is again seen. Blood in the right maxillary sinus has slightly decreased. Mucosal thickening is again seen in bilateral ethmoid air cells, bilateral frontoethmoidal recesses, left frontal sinus, and bilateral sphenoid sinuses. Mastoid air cells are clear. IMPRESSION: 1. Small right subdural hematoma along the convexity, falx, and tentorium is stable in size with posterior redistribution. 2. New small amount of blood in the occipital horns of the lateral ventricles. Ventricles are stable in size. 3. Stable small hypodense subdural collection along the left convexity, compatible with a chronic hematoma or hygroma. 4. Fracture at the base of the right nasal bone is again noted. Knee X-ray ___: Images of the knee demonstrates no signs for acute fractures or dislocations. There is no knee joint effusion. There is minimal spurring seen of the superior pole of the patella. There is mild medial compartmental joint space narrowing. There are vascular calcifications. Focused imaging of the tibia and fibula demonstrates no signs for acute fractures or dislocations. Soft tissues are within normal limits. Mineralization is slightly decreased. Focused imaging the ankles demonstrates no acute fractures. Ankle mortise is relatively preserved but is slightly narrowed. There is slight cortical thickening involving the posterior aspect of the distal tibial metaphysis which may be due to prior old trauma. Tib/Fib/Ankle X-ray 8.12 Images of the knee demonstrates no signs for acute fractures or dislocations. There is no knee joint effusion. There is minimal spurring seen of the superior pole of the patella. There is mild medial compartmental joint space narrowing. There are vascular calcifications. Focused imaging of the tibia and fibula demonstrates no signs for acute fractures or dislocations. Soft tissues are within normal limits. Mineralization is slightly decreased. Focused imaging the ankles demonstrates no acute fractures. Ankle mortise is relatively preserved but is slightly narrowed. There is slight cortical thickening involving the posterior aspect of the distal tibial metaphysis which may be due to prior old trauma. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Glycerin Supps ___AILY:PRN constipation 2. Multivitamins 1 TAB PO DAILY 3. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID Discharge Medications: 1. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID 2. Glycerin Supps ___AILY:PRN constipation 3. Multivitamins 1 TAB PO DAILY 4. Acetaminophen 650 mg PO TID 5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 6. Docusate Sodium 100 mg PO BID 7. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: - Syncope - Right Frontal Subdural Hematoma - Right Frontal Process Fracture of Maxillary Bone - Uncomplicated Cystitis - Right rib fracture Secondary Diagnosis: - Left eye blindness - Cataracts - Permanent pacermaker for second degree heart block 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: History: ___ with fall now with rib rib pain // r/o right rib fractures, pna TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: A left-sided pacemaker and leads are in appropriate position. Heart size is mildly enlarged. The mediastinal and hilar contours are unremarkable. The pulmonary vasculature is normal. Lungs are hyperinflated without focal consolidation. Streaky opacities at both lung bases likely reflect atelectasis. The bronchial tree is calcified and there is mild dilatation of the bronchi particularly in the lung bases suggestive of bronchiectasis. No pleural effusion or pneumothorax is seen. Deformity of the right-sided ribs likely reflect remote rib fractures. No acutely displaced fractures seen. IMPRESSION: Mild bibasilar atelectasis. No acutely displaced fractures identified. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with fall and periorbital hematoma // r/o ICH TECHNIQUE: Contiguous axial CT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: DLP: 891 mGy-cm CTDI: 54 COMPARISON: None. FINDINGS: There is a small subdural hematoma which tracks along the right cerebral convexity and also tracks along the falx. It measures 8 mm at its widest dimension. There is mild mass effect on the right frontal lobe, however, there is no shift of normally midline structures. There is no evidence of acute territorial infarction. There is no evidence of mass or cerebral edema. The ventricles and sulci are normal in size and configuration for age. Periventricular, subcortical, and deep white matter hypodensities likely reflect the sequela of chronic small vessel ischemia. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. There is irregularity of the frontal process of the right maxillary sinus concerning for fracture. Additionally, there is high density fluid in the right maxillary sinus compatible with leg, with an air-fluid level. There is mild to moderate mucosal thickening of the paranasal sinuses diffusely with small amount of opacification of the inferior left mastoid air cells. The right mastoid air cells appear clear. There is right periorbital soft tissue swelling. The globes are unremarkable. IMPRESSION: 1. Small subdural hematoma which tracks along the right cerebral convexity and along the falx with mild mass effect upon the right frontal lobe but no evidence of midline shift. 2. Irregularity of the frontal process of the right maxillary sinus concerning for fracture. 3. Blood within the right maxillary sinus, though no right maxillary sinus fracture is seen on these images. Recommend facial bone CT for further evaluation. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with fall, head injury TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 36 mGy DLP: 621 mGy-cm COMPARISON: None. FINDINGS: No evidence of acute fracture. There is mild anterolisthesis of C3 on C4, C4 on C5, and C7 on T1. There are severe degenerative changes seen throughout the cervical spine with intervertebral disc space narrowing, vacuum disc phenomena, endplate sclerosis and cystic change, and anterior and posterior osteophyte formation. While there is mild multilevel central canal narrowing, worst at C5/6 and C6/7, no critical central canal stenosis is seen. There is no prevertebral soft tissue swelling. There is multilevel bilateral facet joint and uncovertebral joint hypertrophy causing moderate to severe bilateral neural foraminal narrowing at multiple levels. Dense atherosclerotic calcifications are seen at the carotid bifurcations bilaterally. Air-fluid level within the right maxillary sinus with hyperdense components suggestive of blood is noted. IMPRESSION: No evidence of fracture. Severe cervical spondylosis with multilevel mild anterolisthesis. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: History: ___ with right rib pain after fall TECHNIQUE: MDCT images were obtained from the lung bases to the lesser trochanters after administration intravenous contrast. Coronal and sagittal reformations were prepared. DOSE: DLP: 476 mGy-cm COMPARISON: None FINDINGS: Lungs and Heart: There is minimal bibasilar atelectasis. A pacemaker lead is seen within the right ventricle. The heart is mildly enlarged. The pericardium is normal. Liver, Gallbladder: The liver is normal in size and attenuation. Few subcentimeter hypodensities in the left lobe are too small to characterize. The gallbladder is distended but is otherwise normal appearing. The portal and hepatic veins are patent. There is no intra or extrahepatic biliary ductal dilatation. Spleen: The spleen is normal in size and attenuation. Pancreas: The pancreas shows normal enhancement. There is no pancreatic duct dilatation or peripancreatic fat stranding. Kidneys, Adrenals: In the lower pole of the left kidney there is a 4.8 x 4.8 cm simple cyst. The right kidney is normal appearing. There is no evidence of hydronephrosis in either kidney. Bowel: The small bowel is normal appearing. There is diverticulosis throughout the large bowel with no evidence of diverticulitis. No free air or free fluid is identified in the abdomen or pelvis. Vessels: There is diffuse atherosclerosis of the abdominal aorta. There is no aneurysmal dilatation of the aorta and its major branches appear patent. Lymph Nodes: There are no pathologically enlarged retroperitoneal or mesenteric lymph nodes by CT size criteria. Pelvis: The bladder is unremarkable. The sigmoid colon and rectum are normal appearing. There is no pelvic sidewall lymphadenopathy. A pessary is seen in place. Osseous Structures: There is moderate degenerative change seen in the thoracolumbar spine. There are no suspicious lytic or sclerotic lesions identified. No fracture is identified. There is a small ventral hernia which contains fat. IMPRESSION: No evidence of acute intra-abdominal process. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST INDICATION: History: ___ with irregularity of the frontal process of the right maxillary sinus concerning for fracture after fall // r/o fracture TECHNIQUE: Helical axial images were acquired through the facial bones. Coronal reformatted images were also obtained DOSE: DLP: 527 mGy-cm; CTDI: 25 mGy COMPARISON: None. FINDINGS: There is some irregularity of the frontal process of the right maxillary bone compatible with a mildly displaced fracture. There are no other acute fractures identified. The lamina papyracea is intact. An air-fluid level is seen within the right maxillary sinus and the fluid within the sinus is hyperdense, which could represent blood. Moderate mucosal thickening is seen involving the ethmoid air cells, both frontal sinuses, both sphenoid sinuses, and mild mucosal thickening within the left maxillary sinus. There is right periorbital soft tissue swelling. The globes are intact. Partially imaged is a right subdural hematoma. IMPRESSION: 1. Mildly displaced fracture of the frontal process of the right maxillary bone. 2. Pansinus disease with high density fluid in the right maxillary sinus, possibly suggestive of blood. No fracture of the right maxillary sinus is identified. 3. Right periorbital soft tissue swelling. Globes intact. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: History: ___ with right rib ternderness after fall // r/o rib fractures TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper abdomen. IV contrast was administered previously for a CT of the abdomen and pelvis and no repeat administration of IV contrast was given. Axial images were interpreted in conjunction with sagittal and coronal reformats. DLP: 328 mGy-cm COMPARISON: None. FINDINGS: Axillary, supraclavicular, mediastinal, and hilar lymph nodes are not pathologically enlarged. The great vessels are normal caliber. There is calcification of the aortic valve and mitral valve annulus. The heart size is normal. Pacing leads are seen within the right atrium right ventricle. Dense coronary artery calcifications are noted. Heart is mildly enlarged. The trivial pericardial effusion is present. There is diffuse calcification of the walls of the segmental airways which are mildly dilated compatible with mild bronchiectasis. There is a small bleb in the left lower lobe. There are a few small nodules in left upper lobe measuring up to 5 mm (04:50). No focal consolidation, pleural effusion, or pneumothorax. There is mild centrilobular emphysema within the apices. The esophagus and visualized upper abdominal organs are unremarkable. OSSEOUS STRUCTURES: Irregularity of the ribs of the right fifth and sixth ribs laterally may represent acute nondisplaced fractures. Severe degenerative changes are seen throughout the visualized thoracic spine with ossification of the anterior longitudinal ligament and osseous fusion of multiple vertebral bodies. IMPRESSION: 1. Irregularity of the ribs of the right fifth and sixth ribs laterally which may represent acute nondisplaced fractures. 2. No mediastinal hematoma. No focal consolidation in the lungs. No evidence of pneumothorax. NOTIFICATION: Updated findings were communicated to Dr. ___ at 13:30 on ___ by Dr. ___. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman s/p fall with right subdural hematoma. Evaluate for interval change/progression. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: CTDIvol: 25 mGy DLP: 527 mGy-cm COMPARISON: CT head without contrast ___ FINDINGS: Small mixed density, predominantly hyperdense subdural hematoma is again seen along the right convexity, falx, and right tentorium. There has been posterior redistribution of blood along the convexity and falx secondary to supine positioning, but no evidence for enlargement of the subcu or hematoma. New blood is seen layering in the occipital horns of lateral ventricles. The ventricles are stable in size. Small hypodense subdural collection along the left convexity is unchanged, compatible with a chronic subdural hematoma or subdural hygroma. The basal cisterns are not compressed. There is no evidence for an acute major vascular territorial infarction. The minimally displaced comminuted fracture at the base of the right nasal bone is again see. Soft tissue swelling overlying the right orbit is again seen. Blood in the right maxillary sinus has slightly decreased. Mucosal thickening is again seen in bilateral ethmoid air cells, bilateral frontoethmoidal recesses, left frontal sinus, and bilateral sphenoid sinuses. Mastoid air cells are clear. IMPRESSION: 1. Small right subdural hematoma along the convexity, falx, and tentorium is stable in size with posterior redistribution. 2. New small amount of blood in the occipital horns of the lateral ventricles. Ventricles are stable in size. 3. Stable small hypodense subdural collection along the left convexity, compatible with a chronic hematoma or hygroma. 4. Fracture at the base of the right nasal bone is again noted. Radiology Report INDICATION: ___ s/p fall with left knee, anterior tibial and medial ankle tenderness // r/o fracture IMPRESSION: Images of the knee demonstrates no signs for acute fractures or dislocations. There is no knee joint effusion. There is minimal spurring seen of the superior pole of the patella. There is mild medial compartmental joint space narrowing. There are vascular calcifications. Focused imaging of the tibia and fibula demonstrates no signs for acute fractures or dislocations. Soft tissues are within normal limits. Mineralization is slightly decreased. Focused imaging the ankles demonstrates no acute fractures. Ankle mortise is relatively preserved but is slightly narrowed. There is slight cortical thickening involving the posterior aspect of the distal tibial metaphysis which may be due to prior old trauma. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with FRACTURE ONE RIB-CLOSED, OTHER FALL temperature: 98.3 heartrate: 91.0 resprate: 16.0 o2sat: 97.0 sbp: 181.0 dbp: 66.0 level of pain: 13 level of acuity: 2.0
___ with hx dCHF, hx Mobitz II s/p BS PPM ___ in DDD who presents after unwitnessed fall at her independent living home. Currently non-surgical management of facial fracture, rib fracture and sub-dural. On medicine service for ___.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pressure; weakness Major Surgical or Invasive Procedure: Cardiac catheterization, ___ History of Present Illness: ___ female with HTN, HL, prior TIA per her report presents with two distinct episodes of chest pressure over the weekend. Occurred at rest, lasted for a few hours each time, resolved spontaneously. Associated with left facial tingling and left arm tingling. Yesterday evening, the left facial tingling and left arm tingling recurred, and she presented to ___ ___ concerned about possible stroke symptoms. At ___ ___, found to have mildly elevated troponin and diffuse T wave inversions, and she was transferred here for eval. No chest pressure since ___. Still with very mild left facial paresthesia. ECG sinus tach with diffuse T wave inversions. CTA chest without PE, CTA head/neck with no stroke, but with suggestion of right > left carotid disease. TTE with hypokinesis of distal third of LV, suggestive of Takotsubo's cardiomyopathy vs. LAD disease. In the ED initial vitals were: 0 97.4 120 122/75 18 98% RA. EKG showed >3mm T wave inversions in anterolateral leads with 1-2mm T wave inversions in limb leads. Labs/studies notable for elevated BNP >4000, decreasing troponin, and hyponatremia. Patient was seen by neurology in the ED for weakness and tingling in Left arm and face. Neurology exam at this time does not reveal any focal deficit except for decrease LT (95% compared to normal) on a small patch over the left cheek. Non - contrast CT and CTA showed No acute intracranial abnormality. No evidence for vertebral artery dissection. Significant amount of mixed plaque at the right carotid bulb, with mild soft plaque noted on the left. No flow limiting stenosis. No aneurysm greater than 3 mm. Patient was given: ___ 07:58 IV LORazepam 0.5 mg ___ 18:43 IVF 1000 mL NS 500 mL ___ 18:43 IV Heparin 3400 UNIT ___ 18:43 IV Heparin Started 700 The patient was transferred to the floor. VS were 98.1 128/96 141 19 98RA. On arrival the patient was found to have tachycardia to 160s on arrival to the floor with stable vital signs in active atrial fibrillation. The patient was given 5mg of IV metoprolol, in addition to 12.5mg of metoprolol. She was noted to be in atrial fibrillation on telemetry. The patient was asymptomatic. [Addendum ___: Attending reviewed telemetry from night of admission and found no clear evidence of atrial fibrillation.] Past Medical History: - Cardiomyopathy, ?Takotsubo - Transient Ischemic Event - Hypertension - Hyperlipidemia - GERD - ___ cyst left leg - Arthritis - Lumbar spine arthritis 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: 98.1 128/96 141 19 98RA. GENERAL: NAD however noted to be anxious when the plan of MRI and possible Cath was brought up. 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 6 cm while sitting up in bed CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: Tm/Tc 98.3 | HR ___ | BP 98/65-104/68 | RR 18 | 02 93% RA Telemetry: Sinus tachycardia 80 with peaks to 130s with movement, multiple PVCs Admission Wt=57.2 kg Wt= n.r. <-- 57.3 kg General: Well appearing, NAD. Somewhat anxious but A+Ox3 and pleasantly interactive. HEENT: MMM, EOMI. PERRL. Neck: No JVD at 45 degrees. CV: Regular rhythm. +S1/S2. No M/R/G. Lungs: CTAB with no crackles or wheezes. Breathing comfortably on room air. Abdomen: Soft, nontender, nondistended. Ext: Warm and well perfused. Right radial access site with dressing, clean and dry. 2+ Radial pulses above and below dressing, right hand warm and well perfused. 2+ DP pulses b/L. No edema b/L Neuro: Grossly normal. Face symmetric. No dysarthria. Facial sensation intact and equal bilaterally. Pertinent Results: ================ ADMISSION LABS: ================ ___ 11:59PM BLOOD WBC-8.5 RBC-3.51* Hgb-11.6 Hct-34.4 MCV-98 MCH-33.0* MCHC-33.7 RDW-13.4 RDWSD-47.8* Plt ___ ___ 05:10AM BLOOD Glucose-94 UreaN-7 Creat-0.6 Na-128* K-3.8 Cl-90* HCO3-22 AnGap-20 ___ 05:10AM BLOOD CK(CPK)-186 ___ 05:10AM BLOOD CK-MB-4 cTropnT-0.04* proBNP-4684* ========= KEY LABS: ========= ___ 05:10AM BLOOD CK-MB-4 cTropnT-0.04* proBNP-4684* ___ 05:47PM BLOOD cTropnT-0.04* ___ 06:40AM BLOOD CK-MB-6 cTropnT-0.03* =============== DISCHARGE LABS: =============== ___ 06:15AM BLOOD WBC-5.8 RBC-3.42* Hgb-11.2 Hct-33.8* MCV-99* MCH-32.7* MCHC-33.1 RDW-13.9 RDWSD-49.7* Plt ___ ___ 06:15AM BLOOD Glucose-91 UreaN-5* Creat-0.5 Na-137 K-3.8 Cl-102 HCO3-25 AnGap-14 ___ 06:15AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.2 ============= KEY IMAGING: ============= ___ ECG: Clinical indication for EKG - Chest pain, unspecified Artifact is present. Sinus tachycardia. Ventricular ectopy. The Q-T interval is prolonged. ST-T wave changes concerning for ischemia or infarction. ___ ECG #2: Clinical indication for EKG - Supraventricular tachycardia Sinus tachycardia. Frequent premature ventricular contractions. Compared to the previous tracing of ___ no change. ___ ECHOCARDIOGRAM: The left atrial volume index is normal. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the distal third of the ventricle and mild apical dyskinesis. The remaining segments contract normally (LVEF = 40 %). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with apical dysfunction c/w Takotsubo cardiomyopathy (vs. mid-LAD lesion). Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. ___ CTA CHEST: 1. No evidence of pulmonary embolism or aortic abnormality. 2. 8 mm hypodense lesion in the right hepatic lobe too small to characterize, but likely a simple cyst or biliary hamartoma. 3. Moderate-sized hiatal hernia. 4. Hepatic steatosis. ___ CTA HEAD & NECK: 1. No acute intracranial abnormality on noncontrast head CT. 2. Unremarkable intracranial circulation with fetal type origin of the right PCA. 3. Moderate atherosclerotic disease of the cervical vasculature with less than 25% stenosis of the proximal right internal carotid artery by NASCET criteria. 4. Unremarkable vertebral arteries. ___ CARDIAC CATH: Coronary Anatomy Dominance: Right * Left Main Coronary Artery: The LMCA is normal * Left Anterior Descending: The LAD is normal. * Circumflex: The Circumflex is normal. * Right Coronary Artery: The RCA is normal. Intra-procedural Complications: None *Impressions: Normal coronary arteries. LV apical ballooning typical for stress (Takotsubo) cardiomyopathy. *Recommendations: Medical therapy *Pressures: Site Systolic | Diastolic | EDP | HR LV 110 5 86 AO 110 59 71 105 ___ MR HEAD W/ W/O CONTRAST: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is no abnormal enhancement after contrast administration. There are scattered foci of T2/FLAIR hyperintensity in the subcortical and periventricular white matter, nonspecific, likely secondary to small vessel ischemic disease. There is mild mucosal thickening in bilateral anterior ethmoid air cells. The remaining visualized paranasal sinuses are clear. The mastoid air cells are clear. The orbits are unremarkable. Intracranial flow voids are maintained. IMPRESSION: 1. There is no evidence of acute or subacute intracranial process. 2. Findings of small vessel ischemic disease as described above. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex) oral Frequency is Unknown 3. Vitamin D 1000 UNIT PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 10 mg PO DAILY 7. Simvastatin 40 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. Omeprazole 10 mg PO DAILY 4. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet Refills:*0 5. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex) 1000 mcg ORAL ASDIR Dose unknown. 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: - NSTEMI - Takotsubo Cardiomyopathy - Concern for Transient Ischemic Event SECONDARY DIAGNOSES: - Tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: History: ___ with hx HTN, HLD who presented with chest pressure, left cheek/arm numbness, LLE weakness. // dissection TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 38.1 mGy (Head) DLP = 19.1 mGy-cm. 3) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 32.0 mGy (Head) DLP = 1,262.6 mGy-cm. Total DLP (Head) = 2,179 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of large territory infarction, hemorrhage, edema, or mass/mass effect. The ventricles and sulci are normal in size and configuration. Small amount of mucosal fluid is layering in the left posterior ethmoidal air cells. Otherwise, the remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. There is fetal type origin of the right PCA. CTA NECK: There is moderate amount of mixed plaque in the right carotid bulb with some calcifications extending to the proximal right internal carotid artery. There is minimal amount of calcified plaque noted in the left carotid bulb. The carotid and vertebral arteries and their major branches otherwise appear normal. There is less than 25% stenosis of the proximal right internal carotid artery by NASCET criteria (14 percent). There is no evidence of left internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the lungs are clear. The thyroid gland is mildly heterogeneous demonstrating sub cm nodules, for which no further follow-up is recommended by current ACR guidelines for incidentally noted thyroid nodules. There is no lymphadenopathy by CT size criteria. Multilevel degenerative changes are noted along the cervical spine, which appears to be most prominent at C5-C6 and C6-C7 where there is likely at least mild to moderate spinal canal narrowing. IMPRESSION: 1. No acute intracranial abnormality on noncontrast head CT. 2. Unremarkable intracranial circulation with fetal type origin of the right PCA. 3. Moderate atherosclerotic disease of the cervical vasculature with less than 25% stenosis of the proximal right internal carotid artery by NASCET criteria. 4. Unremarkable vertebral arteries. Radiology Report EXAMINATION: Chest CTA INDICATION: History: ___ with chest tightness, left arm/cheek numbness 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 = 1.5 mGy (Body) DLP = 0.8 mGy-cm. 2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP = 6.1 mGy-cm. 3) Spiral Acquisition 3.6 s, 28.4 cm; CTDIvol = 8.8 mGy (Body) DLP = 249.0 mGy-cm. Total DLP (Body) = 256 mGy-cm. COMPARISON: CTA head and neck ___ FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable except for a 3 mm hypodensity in the left lobe. There is no evidence of pericardial effusion. There is no pleural effusion. There is no evidence of pulmonary parenchymal abnormality. The airways are patent to the subsegmental level. Calcified granuloma is seen in right middle lobe. There is a moderate sized hiatal hernia. An 8 mm hypodense lesion is seen in the right hepatic lobe which is too small to characterize. There is hepatic steatosis. Multilevel degenerative changes with disc space narrowing an osteophyte formation is noted. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. 8 mm hypodense lesion in the right hepatic lobe too small to characterize, but likely a simple cyst or biliary hamartoma. 3. Moderate-sized hiatal hernia. 4. Hepatic steatosis. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD. INDICATION: ___ year old woman presents with episodes of chest pain and associated left face/arm numbness at rest concerning for unstable angina. Neurologic exam at this time does not reveal any focal deficit except for decrease LT (95% compared to normal) on a small patch over the left cheek. CTA negative. Neuro team recommending MRI. // evidence of ischemic stroke or lesion. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 5 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CTA head and neck from ___. FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is no abnormal enhancement after contrast administration. There are scattered foci of T2/FLAIR hyperintensity in the subcortical and periventricular white matter, nonspecific, likely secondary to small vessel ischemic disease. There is mild mucosal thickening in bilateral anterior ethmoid air cells. The remaining visualized paranasal sinuses are clear. The mastoid air cells are clear. The orbits are unremarkable. Intracranial flow voids are maintained. IMPRESSION: 1. There is no evidence of acute or subacute intracranial process. 2. Findings of small vessel ischemic disease as described above. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain, Transfer Diagnosed with Chest pain, unspecified, Weakness, Abnormal electrocardiogram [ECG] [EKG] temperature: 97.4 heartrate: 120.0 resprate: 18.0 o2sat: 98.0 sbp: 122.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0
___ female with hypertension, hyperlipidemia, prior TIA presented with two distinct episodes of chest pressure over the preceding weekend, found to have diffuse T-wave inversions and troponin elevation. Also complained of left arm weakness and tingling as well as difficulty speaking concerning for TIA. Echocardiography demonstrated depressed EF to 40% and apical hypokinesis and akinesis. CTA of head neck revealed no clear stroke/bleed but atherosclerosis of carotid arteries up to 25% stenosis. Troponins peaked at 0.06 at ___ and then downtrended after admission to ___. Patient had no chest pain after admission. Received full-dose aspirin, clopidrogrel load, and atorvastatin 80 mg. Underwent cardiac catheterization which revealed clean coronary arteries, but also apical ballooning consistent with Takotsubo cardiomyopathy. Patient will need follow up with cardiology at ___ for repeat echocardiography in ___ months. Neurological deficits were not apparent during hospitalization. Neurology team was consulted. MRI of the brain showed NO evidence of stroke. There were signs of small vessel ischemic disease on MRI. Hospital course complicated by tachycardia, which patient stated was baseline for her; however, on telemetry she had sinus tachycardia in 100s-150s with multiple PVCs. This was responsive to metoprolol, which was uptitrated from home dose. ==============
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: shortness of breath, leg swelling Major Surgical or Invasive Procedure: ___ Thoracentesis History of Present Illness: ___ yo M w/ PMH of Afib on coumadin and metoprolol, diastolic CHF, moderate AS, chronic bronchitis, HTN, and past TIAs presents with RLE swelling/erythema and worsening shortness of breath x 3days. Has presented to the ED 3 times this week due to the leg swelling as well as anemia. He has had 2 negative LENIs and 1 negative CTA LEs as part of the work up for his leg, and he was started initially on bactrim for presumed early cellulitis on ___. When he re-presented for anemia and had continued leg swelling and erythema, he was started on cipro (___), however he was given one dose of this in the ED and was not able to start it at home. Starting that day, his son notes that he seemed more short of breath, and he was complaining to him about not being able to sleep at night because he felt so short of breath. He is unsure, but he thinks his weight was decreasing at that time. The following AM on ___, he was eating breakfast and then had significant non-bloody emesis without significant nausea. This occured again at lunchtime. He initially did not want to come into the hospital, but on the AM of ___ (day of admission), his son insisted given his continued shortness of breath, vomiting, and leg swelling. In the ED, initial vitals: 102 138/76 21 98%. CXR showed possible opacity in R lung base and pulmonary congestion, and BNP elevated >4000, so given 20mg IV lasix with 450cc urine output. Given albuterol and ipratropium nebs. He was given IV levofloxacin and admitted to medicine Currently, the patient says his shortness of breath is somewhat improved, but he thinks the nebs temporarily made it worse while in the ED. He has mild epigastric pain and complains of a sour taste in his mouth, mild nausea. Denies fever, chills. Cough is at baseline (has chronic cough from post-nasal drip and chronic bronchitits), not productive. Still somewhat orthopneic. Thinks his leg is getting a little bit better. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - a-fib with RVR (dx ___, rate controlled, on coumadin - diastolic CHF (EF 55% in ___ - moderate aortic stenosis (area 1.2cm ___ echo) - Hypertension - TIA - Chronic bronchitis - History of anemia - PUD - Hyponatremia attributed to SIADH ___ Na 125-131) - s/p septic joint ___ - Chronic bilateral rotator cuff tears - Zoster and postherpetic neuralgia (___) Social History: ___ Family History: His grandparents died of strokes. His GF had complicated foot ulcer. Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 98.3F, BP 131/74, HR 69, R 20, O2-sat 90% 3L NC GENERAL - elderly man, very hard of hearing, comfortable, somewhat demanding but in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, loud ___ crescendo-decrescendo murmur heard throughout the precordium radiating to carotids LUNGS - resp unlabored, no accessory muscle use. Decreased breath sounds in bilateral bases with inspiratory crackles, rare wheeze, no rhonchi ABDOMEN - NABS, soft, ND, mildly tender to palp in epigastrium. no masses or HSM, no rebound/guarding EXTREMITIES - RLE with erythema to mid-shin as well as some healing breaks in skin, soft 3+ pitting edema past knee. LLE also with soft pitting edema, 2+. SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: LABS: On admission: ___ 09:00AM BLOOD WBC-11.2* RBC-3.31* Hgb-9.8* Hct-29.3* MCV-88 MCH-29.5 MCHC-33.4 RDW-15.2 Plt ___ ___ 09:00AM BLOOD ___ PTT-37.7* ___ ___ 09:00AM BLOOD Glucose-103* UreaN-26* Creat-1.2 Na-133 K-4.8 Cl-99 HCO3-23 AnGap-16 ___ 09:00AM BLOOD proBNP-4213* ___ 07:55AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1 ___ 09:19AM BLOOD Lactate-1.9 On discharge: ___ 06:20AM BLOOD WBC-7.5 RBC-3.36* Hgb-10.0* Hct-30.6* MCV-91 MCH-29.9 MCHC-32.7 RDW-14.9 Plt ___ ___ 06:40AM BLOOD Glucose-80 UreaN-32* Creat-0.9 Na-132* K-5.2* Cl-96 HCO3-23 AnGap-18 ___ 06:40AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 INRs: ___ 09:00AM BLOOD ___ PTT-37.7* ___ ___ 09:00AM BLOOD Plt ___ ___ 07:55AM BLOOD ___ PTT-38.1* ___ ___ 06:30AM BLOOD ___ PTT-37.1* ___ ___ 12:45PM BLOOD ___ PTT-32.4 ___ ___ 06:20AM BLOOD ___ PTT-32.9 ___ ___ 06:41AM BLOOD ___ PTT-32.1 ___ ___ 06:40AM BLOOD ___ PTT-27.3 ___ MICRO: ___ blood cultures negative ___ MRSA screen negative Pleural fluid: ___ 03:15PM PLEURAL WBC-545* RBC-110* Polys-11* Lymphs-80* ___ Macro-9* ___ 03:15PM PLEURAL TotProt-2.5 Glucose-111 LD(LDH)-73 Cholest-23 Triglyc-9 Cytology NEGATIVE IMAGING: ___ CXR: FINDINGS: A frontal upright view of the chest was obtained portably with a lateral performed 1 hour later. New bibasilar opacities with indistinctness of the pulmonary vasculature is likely due to pulmonary edema with increased pleural effusions. Underlying infection cannot be excluded. The heart cannot be assessed. The aortic knob appearance is unchanged. There is no pneumothorax. Degenerative changes are seen in the shoulder girdles bilaterally. IMPRESSION: Findings suggest congestive heart failure. Underlying infection cannot be excluded. Recommend repeat radiograph after treatment. ___ R ___: IMPRESSION: No right lower extremity deep venous thrombosis. ___ Video swallow study: FINDINGS: There was no aspiration or penetration with any consistency of barium. The patient swallowed the barium pill without difficulty and without any holdup at any esophageal level. For further details, please refer to Speech and Swallow division note in OMR. IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy. ___ Echo: The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 5mmHg) 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Biatrial enlargement. Severe symmetric left ventricular hypertrophy, small left ventricular cavity size and preserved global and regional left ventricular systolic function. Mildly dilated aortic root. Severe aortic stenosis with mild to moderate aortic regurgitation. Functional mitral stenosis secondary to severe mitral annular calcification. At least mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, the severity of aortic stenosis as calculated by the continuity equation appears to have increased, but the increased transvalvular gradients may be, in part, secondary to an increase in aortic regurgitation severity and near-hyperdynamic left ventricular systolic function. The severity of pulmonary artery systolic hypertension has increased (previously borderline). ___ CXR: IMPRESSION: Regression of right-sided pleural effusion, indicating successful performance of thoracotomy on that side. No pneumothorax. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/CaregiverwebOMR. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Aspirin 81 mg PO DAILY 3. Bisacodyl 20 mg PO HS 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 5. Digoxin 0.125 mg PO DAILY hold for HR below 60 6. Diltiazem Extended-Release 120 mg PO DAILY hold for SBP < 90, HR < 50 7. Docusate Sodium 100 mg PO BID 8. Ferrous Sulfate 325 mg PO BID 9. Fluticasone Propionate NASAL 1 SPRY NU BID 10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 11. Furosemide 20 mg PO DAILY 12. Gabapentin 300 mg PO HS 13. Ipratropium Bromide MDI 2 PUFF IH HS 14. Lidocaine 5% Patch 1 PTCH TD DAILY apply to lower back for 12 hours, off for 12 hours. 15. Meclizine 12.5 mg PO TID 16. Metoprolol Succinate XL 100 mg PO QAM hold for SBP < 90 or HR < 50 17. Metoprolol Succinate XL 50 mg PO HS hold for SBP < 90 or HR < 50 18. Ranitidine 300 mg PO BID 19. Rosuvastatin Calcium 10 mg PO HS 20. Vitamin A 25,000 UNIT PO DAILY 21. Warfarin 2.5 mg PO DAILY16 22. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN mild-mod pain 23. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 24. PreserVision *NF* (vit C-vit E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) 226-200-5 mg-unit-mg Oral DAILY 25. Senna 2 TAB PO HS 26. polyvinyl alcohol *NF* 1.4 % ___ BID 27. coenzyme Q10 *NF* 200 mg Oral daily Discharge Medications: 1. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN mild-mod pain 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 3. Aspirin 81 mg PO DAILY 4. Bisacodyl 20 mg PO HS 5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 6. Digoxin 0.125 mg PO DAILY hold for HR below 60 7. Diltiazem Extended-Release 120 mg PO DAILY hold for SBP < 90, HR < 50 8. Docusate Sodium 100 mg PO BID 9. Ferrous Sulfate 325 mg PO BID 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 12. Furosemide 20 mg PO DAILY 13. Gabapentin 300 mg PO HS 14. Ipratropium Bromide MDI 2 PUFF IH HS 15. Lidocaine 5% Patch 1 PTCH TD DAILY apply to lower back for 12 hours, off for 12 hours. 16. Meclizine 12.5 mg PO TID 17. Metoprolol Succinate XL 100 mg PO QAM hold for SBP < 90 or HR < 50 18. Metoprolol Succinate XL 50 mg PO HS hold for SBP < 90 or HR < 50 19. Rosuvastatin Calcium 10 mg PO HS 20. Senna 2 TAB PO HS 21. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 22. Vitamin A 25,000 UNIT PO DAILY 23. Warfarin 2.5 mg PO DAILY16 24. diclofenac sodium *NF* 3 % TOPICAL BID Apply to bilateral shoulders. 25. PreserVision *NF* (vit C-vit E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) 226-200-5 mg-unit-mg Oral DAILY 26. Ranitidine 300 mg PO BID 27. polyvinyl alcohol *NF* 1.4 % ___ BID 28. coenzyme Q10 *NF* 200 mg ORAL DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Acute on chronic diastolic heart failure Pleural effusions Cellulitis Acute kidney injury Aortic stenosis Secondary diagnoses: Atrial fibrillation Hyponatremia 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: ___ man with dyspnea for two days. Evaluate for acute process. ___. FINDINGS: A frontal upright view of the chest was obtained portably with a lateral performed 1 hour later. New bibasilar opacities with indistinctness of the pulmonary vasculature is likely due to pulmonary edema with increased pleural effusions. Underlying infection cannot be excluded. The heart cannot be assessed. The aortic knob appearance is unchanged. There is no pneumothorax. Degenerative changes are seen in the shoulder girdles bilaterally. IMPRESSION: Findings suggest congestive heart failure. Underlying infection cannot be excluded. Recommend repeat radiograph after treatment. Please refer to clip ___ for the lateral view. Radiology Report INDICATION: ___ man with dyspnea for two days. Evaluate for acute process. ___. FINDINGS: A frontal upright view of the chest was obtained portably with a lateral performed 1 hour later. New bibasilar opacities with indistinctness of the pulmonary vasculature is likely due to pulmonary edema with increased pleural effusions. Underlying infection cannot be excluded. The heart cannot be assessed. The aortic knob appearance is unchanged. There is no pneumothorax. Degenerative changes are seen in the shoulder girdles bilaterally. IMPRESSION: Findings suggest congestive heart failure. Underlying infection cannot be excluded. Recommend repeat radiograph after treatment. Please refer to clip ___ for the frontal view. Radiology Report HISTORY: Right lower extremity swelling. COMPARISON: ___. FINDINGS: Gray scale and color Doppler sonograms with spectral analysis of the bilateral common femoral and the right superficial femoral, popliteal, peroneal and posterior tibial veins were performed. There is normal compressibility, flow, and augmentation. Normal phasicity is seen in the common femoral veins bilaterally. IMPRESSION: No right lower extremity deep venous thrombosis. Radiology Report INDICATION: ___ male with possible silent aspiration. Evaluate. COMPARISON: None available. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium as well as a 13-mm barium pill were administered. FINDINGS: There was no aspiration or penetration with any consistency of barium. The patient swallowed the barium pill without difficulty and without any holdup at any esophageal level. For further details, please refer to Speech and Swallow division note in OMR. IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy. Radiology Report TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: ___ male patient with pleural effusion, underwent right pleural fluid thoracocentesis, checking for reduction of pleural fluid and absence of pneumothorax. FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made with the next preceding similar study of ___. The degree of cardiomegaly appears unchanged. Pulmonary congestive pattern with some perivascular haze as before. Comparison of the frontal views demonstrates marked reduction of the right-sided pleural effusion that obliterated the lateral pleural sinus. The left-sided pleural density blunting the pleural sinus and obliterating the diaphragmatic contour appears unchanged. Apical area does not reveal any pneumothorax on the right side. IMPRESSION: Regression of right-sided pleural effusion, indicating successful performance of thoracotomy on that side. No pneumothorax. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: SHORTNESS OF BREATH Diagnosed with HEART FAILURE NOS, LONG TERM USE ANTIGOAGULANT temperature: 98.0 heartrate: 100.0 resprate: 24.0 o2sat: 96.0 sbp: nan dbp: nan level of pain: 6 level of acuity: 3.0
___ yo M w/ PMH of Afib on coumadin and metoprolol, diastolic CHF, moderate AS, chronic bronchitis, HTN, and past TIAs presents with RLE swelling/erythema and worsening shortness of breath x 3days.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / fentanyl Attending: ___. Chief Complaint: Bloody Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female with a PMH significant for HTN who presents with abdominal pain, intermittent nausea, vomiting, and bloody stools. Symptoms began suddenly at 5:00 AM on ___ when patient vomited 3 times, and noted that vomit had pink tinge. She continued to be nauseous without further vomiting. On ___ she had three unremarkable bowel movements, and was still unable to eat due to nausea. She also noted fevers and chills. On ___ between 5:00 AM and 11:00 AM, she had 2 bloody bowel movements that she described as being purely blood/clots, at which point she called her PCP and was advised to come to the ED. - In the ED, initial vitals @ 1334 on ___ were: T: 98.2, P: 83, BP: 111/61, R: 18, O2 Sat: 99% RA - Exam was notable for: Abdominal tenderness, LLQ > LUQ/RLQ, no rebound tenderness. - Labs were notable for: Leukocytosis, Mild Anemia - Studies were notable for: Left sided colitis - The patient was given: Ciprofloxacin, Metronidazole, 1L LR On arrival to the floor, patient noted continued left sided abdominal pain, and she had one small bowel movement that consisted of only a blood clot. She denies shortness of breath, recent illness, chest pain, nausea, vomiting, pain with urination, and vaginal bleeding. Last colonoscopy was ___ years ago and was unremarkable per patient. Past Medical History: HTN Dysphonia Nephrolithiasis (age ___ Right Ovarian Cystectomy, Appendectomy (both age ___ G3 ___, all NSVD without complications Social History: ___ Family History: Mother: ___ Cancer, ___ AVM Sister: ___ Type 2 Sister: ___ Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T: 99.2, BP: 136 / 73, P: 86, R: 18, O2 Sat: 98% on RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: +LLQ>LUQ/RLQ tenderness, no rebound tenderness. Otherwise non-tender, abdomen non-distended. Normal bowels sounds. EXTREMITIES: No ___ edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM ======================== PHYSICAL EXAM: VS: 24 HR Data (last updated ___ @ 829) Temp: 98.0 (Tm 98.8), BP: 126/76 (108-126/67-78), HR: 74 (71-81), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: Ra GENERAL: Sitting up in bed, eating breakfast, NAD PULM: Breathing comfortably. Clear to auscultation in posterior and anterior fields. CARDIAC: RRR. Audible S1/S2. ABD: Soft, tenderness to palpation in epigastrium/LLQ/LUQ, no rebound, active bowel sounds. NEURO: A&Ox3 Pertinent Results: ADMISSION LABS ================= ___ 02:09PM BLOOD WBC-12.3* RBC-4.72 Hgb-12.0 Hct-36.7 MCV-78* MCH-25.4* MCHC-32.7 RDW-13.0 RDWSD-36.8 Plt ___ ___ 02:09PM BLOOD Neuts-81.4* Lymphs-11.0* Monos-6.6 Eos-0.1* Baso-0.4 Im ___ AbsNeut-10.04* AbsLymp-1.36 AbsMono-0.81* AbsEos-0.01* AbsBaso-0.05 ___ 02:09PM BLOOD ___ PTT-27.4 ___ ___ 02:09PM BLOOD Glucose-109* UreaN-16 Creat-0.8 Na-140 K-3.9 Cl-103 HCO3-22 AnGap-15 ___ 06:55AM BLOOD ALT-7 AST-11 AlkPhos-50 TotBili-1.3 ___ 06:55AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1 Iron-27* ___ 06:55AM BLOOD calTIBC-294 Ferritn-620* TRF-226 ___ 06:41PM BLOOD Lactate-1.3 DISCHARGE LABS ============= ___ 06:42AM BLOOD WBC-8.1 RBC-3.82* Hgb-9.8* Hct-30.5* MCV-80* MCH-25.7* MCHC-32.1 RDW-13.0 RDWSD-37.1 Plt ___ ___ 06:42AM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-142 K-3.8 Cl-106 HCO3-25 AnGap-11 MICROBIOLOGY ============= ___ 9:51 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: No E. coli O157:H7 found. C DIFF - NEGATIVE PCR IMAGING ======= 1. Acute colitis involving the descending ___. Given preserved enhancement of the mucosa along this segment, findings likely reflect a colitis of infectious or inflammatory nature. 2. No evidence of active GI bleeding. 3. Diverticulosis without evidence of acute diverticulitis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*12 Tablet Refills:*0 3. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Colitis Secondary Diagnosis: HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP upright AND LAT) INDICATION: ___ with lower abdominal pain, pink tinged emesis and brbpr/clots since yesterday am.// r/o diverticulitis, boerhaaves or other acute cardiopulmonary or abdominal abnormalties COMPARISON: None FINDINGS: AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ with abdominal pain, blood clots in her stool and BRBPR for the past 36 hours// Rule out mesenteric ischemia, diverticulitis or other acute abdominal abnormality 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: Total DLP (Body) = 1,089 mGy-cm. COMPARISON: None. FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium burden in the abdominal aorta and great abdominal arteries. No evidence of active extravasation. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There are multiple subcentimeter hypodensities throughout the liver , too small to fully characterize on CT but likely may represent hamartomas or hepatic cysts. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of stones, focal renal lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. There is mural thickening involving the splenic flexure and descending colon with submucosal edema and pericolonic fat stranding. There is preservation of mucosal enhancement along this segment. No pneumatosis. No signs of perforation. Diverticulosis without diverticulitis. The sigmoid colon appears grossly unremarkable. No pooling of contrast within the colon to suggest active extravasation. 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 uterus and bilateral adnexae are grossly within normal limits. There is dilation of the left gonadal plexus of veins which may represent pelvic congestion syndrome in the appropriate clinical setting. BONES: Severe degenerative disease at L5-S1 is seen. Marked facet arthropathy is noted in the lower lumbar spine. Grade 1 anterolisthesis of L4 on L5 is seen. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Acute colitis involving the descending colon. Given preserved enhancement of the mucosa along this segment, findings likely reflect a colitis of infectious or inflammatory nature. 2. No evidence of active GI bleeding. 3. Diverticulosis without evidence of acute diverticulitis. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, BRBPR, Hypotension Diagnosed with Other specified noninfective gastroenteritis and colitis, Left lower quadrant pain, Diarrhea, unspecified, Nausea with vomiting, unspecified temperature: 98.2 heartrate: 83.0 resprate: 18.0 o2sat: 99.0 sbp: 111.0 dbp: 61.0 level of pain: 5 level of acuity: 2.0
___ year old female with a PMH significant for HTN who presents with abdominal pain, intermittent nausea, vomiting, and bloody stools with CT notable for colitis, treated with ciprofloxacin and metronidazole. ACUTE ISSUES ============= #Abdominal Pain #Nausea, Vomiting #Bloody Diarrhea Based on history and CT findings, most likely infectious vs. inflammatory colitis. C. diff negative, other stool studies pending at time of discharge. She improved clinically with ciprofloxacin and metronidazole and is being discharged with a prescription to complete a 7 day course (D1= ___. Colonoscopy was deferred to the outpatient setting. CHRONIC ISSUES ============== #HTN We held her home HCTZ due to soft BPs on arrival, it was restarted on discharge. TRANSITIONAL ISSUES =================== [] Recommend screening colonoscopy after resolution of symptoms
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / Naproxen / Vicodin / Tylenol-Codeine #3 Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p DM2, HTN, mitral valve replacement in ___ for MR ___ rheumatic heart disease (25-mm ___ mechanical valve, ref ___ p/w recurrent chest pain x 1 month. Describes intermittent nonradiating, nonexertional chest pressure and palpitations for past 1 month, typically occurring soon after chronic headaches with L-sided neck pain x ___ years that are getting worse (does have known pituitary microadenoma, but per endocrinologist Dr. ___ at ___ in ___, was stable at 3-4mm on MRI with normal prolactin level next month). Also reports visual episodes over the past month where she saw "lights" then her vision went completely black, then came back after a short period, which she attributes to glaucoma. Pt reports that cardiologist Dr. ___ her for outpatient stress test on ___, but came to OSH ED since pain persisted, where CT head was reportedly unremarkable and transferred to ___ for further evaluation. Per Dr. ___ scheduled her for the stress test due to her diabetes and recurrent atypical chest pain, though his clinical suspicion for cardiac etiology is very low. In ___ ED, initial vitals were 5 96.5 50 ___ 98%. EKG showed NSR 51 NA NI TWI V1-V3 c/w EKG at OSH. A posterior EKG showed no STEMI, prolonged QTc. Labs showed CBC, chem 7 wnl, Trop < 0.01, and D-dimer < 150. Bedside US - bradycardic, good squeeze, no pericardial effusion. She was given ASA 325mg, morphine 5mg IV x2, and zofran 4mg IV x1. She was admitted for her multiple complaints. On transfer, vitals were: 97 49 110/60 19 100%. On the floor, she developed ___ chest pain while being interviewed with the ___ interpreter over the phone. EKG was unchanged, vitals stable. Pain completely dissipated 20 minutes after 1 nitro SL. Repeat labs including troponin were sent. Patient had a BM which she described as bloody with bright red blood. She also complained to the nurse of left ankle pain stemming from a fracture she had in ___. This AM, continued to have headaches and reproducible chest pain at times. Past Medical History: 1. Hypertension 2. Diabetes mellitus, non-insulin dependent 3. Asthma 4. h/o blood transfusion 5. h/o stomach ulcers 6. Depression and anxiety 7. Poor circulation in her legs 8. Sleep apnea 9. s/p right femoral rodding, pelvic fracture, fx skull 10. s/p cyst excision right breast Social History: ___ Family History: There is a significant family history for CAD, diabetes, stroke, and hypertension. Her mother is alive at age ___ with HTN. Her father died at age ___ of a cardiac arrest. She has one sister who has diabetes. States had a brother with a heart attack at age ___. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 37.9 144/67 50 18 100%RA General: NAD, ___ hispanic woman HEENT: EOMI, clear OP Neck: supple, no LAD CV: RRR, +s1, s2, no m/r/g Lungs: CTA bilaterally Abdomen: soft, NT/ND, +BS, small tear above rectum with mild bleeding, rectal exam with brown stool - guaiac positive on one side of sample (may have been from skin tear above anus) GU: no foley Ext: w/wp, no edema, 2+ distal pulses Neuro: CNII-XII intact, able to walk to bathroom and back without difficulty DISCHARGE PHYSICAL EXAM: VS: 98.0, 103-122/49-75, 61-69, 97-100% RA, fs 111-139 General: more comfortable this AM HEENT: EOMI, clear OP Neck: supple, no LAD CV: RRR, S1/S2, no m/r/g, reproducible chest pain over mid-sternum Lungs: CTA bilaterally Abdomen: soft, ND, anticipatory wincing on palpation but no clear tenderness, +BS Ext: w/wp, no edema, 2+ distal pulses Neuro: CNII-XII intact, able to walk to bathroom and back without difficulty Pertinent Results: ADMISSION LABS: ___ 10:26PM BLOOD WBC-8.2 RBC-4.03* Hgb-12.7 Hct-37.7 MCV-94# MCH-31.5# MCHC-33.6 RDW-13.9 Plt ___ ___ 10:26PM BLOOD Neuts-45.4* Lymphs-43.7* Monos-7.9 Eos-2.1 Baso-0.9 ___ 10:26PM BLOOD ___ PTT-49.0* ___ ___ 10:26PM BLOOD Glucose-116* UreaN-11 Creat-0.8 Na-142 K-3.8 Cl-109* HCO3-24 AnGap-13 ___ 11:48PM BLOOD D-Dimer-<150 ___ 10:26PM BLOOD cTropnT-<0.01 ___ 03:55AM BLOOD cTropnT-<0.01 ___ 10:50AM BLOOD cTropnT-<0.01 ___ 03:55AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.1 Cholest-183 ___ 03:55AM BLOOD Triglyc-184* HDL-35 CHOL/HD-5.2 LDLcalc-111 LDLmeas-129 ___ 03:55AM BLOOD %HbA1c-6.0* eAG-126* ___ 03:55AM BLOOD TSH-3.8 DISCHARGE LABS: ___ 07:50AM BLOOD WBC-8.4 RBC-4.17* Hgb-13.0 Hct-39.3 MCV-94 MCH-31.1 MCHC-33.0 RDW-13.9 Plt ___ ___ 07:50AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 ___ 07:50AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2 IMAGING: CT chest without contrast ___: 1. The sternotomy is completely fused without significant lesion. 2. Small lung nodules, unchanged since ___, do not require any further followup. 3. Increase in small left breast nodule should be evaluated by dedicated mammogram. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pioglitazone 30 mg PO DAILY 2. Albuterol 0.083% Neb Soln 1 NEB IH BID 3. Aspirin 81 mg PO DAILY 4. Furosemide 40 mg PO DAILY hold for SBP < 90 5. ClonazePAM 2 mg PO DAILY:PRN anxiety 6. Omeprazole 20 mg PO DAILY 7. Potassium Chloride 20 mEq PO DAILY Hold for K > 8. Montelukast Sodium 10 mg PO DAILY 9. TraZODone 100 mg PO HS:PRN insomnia 10. Warfarin 3 mg PO 4X/WEEK (___) 11. Warfarin 2 mg PO 3X/WEEK (___) Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH BID 2. Aspirin 81 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Montelukast Sodium 10 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Potassium Chloride 20 mEq PO DAILY 7. TraZODone 100 mg PO HS:PRN insomnia 8. Warfarin 3 mg PO 4X/WEEK (___) 9. Warfarin 2 mg PO 3X/WEEK (___) 10. ClonazePAM 2 mg PO DAILY:PRN anxiety 11. Pioglitazone 30 mg PO DAILY 12. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 13. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills:*0 14. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine RX *sumatriptan succinate 50 mg 1 tablet(s) by mouth daily Disp #*9 Tablet Refills:*0 15. Lidocaine 5% Patch 1 PTCH TD DAILY RX *lidocaine [Lidoderm] 5 % (700 mg/patch) 1 patch daily Disp #*30 Each Refills:*0 16. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN very severe pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*6 Tablet Refills:*0 17. 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:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: atypical chest pain SECONDARY: mitral valve replacement diabetes mellitus hypertension Migraine Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST CT WITHOUT CONTRAST INDICATION: Patient with cardiac surgery in ___ with history of sternal dehiscence now with sternal chest pain at palpation, rule out for sternal dehiscence. COMPARISON: ___. TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal notch to the upper abdomen without administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axis were generated. LUNGS AND AIRWAYS: A few tiny nodules are scattered throughout lungs, the dominant ones are unchanged since ___ for example along the left major fissure, series 4, image 104 measuring 3 mm. The airways are patent to the subsegmental level. MEDIASTINUM: Thyroid is unremarkable. There is no pathologic supraclavicular, mediastinal, or axillary lymph node enlargement by CT size criteria. Prior sternotomy was done for MVR. There is no pericardial effusion. The epicardial wires are still in place. Left small pleural effusion of ___ has completely resolved. There is now minimal pleural thickening. A nodule in the left breast has increased from 4.5 mm to 8.4 mm (2;26) and should be investigated with dedicated mammogram. UPPER ABDOMEN: This study is not tailored for assessment for intra-abdominal organs. The upper abdomen appears unremarkable. OSSEOUS STRUCTURES: The sternum is completely fused. There is no sign of dehiscence. There is no sternal lesion. CONCLUSION: 1. The sternotomy is completely fused without significant lesion. 2. Small lung nodules, unchanged since ___, do not require any further followup. 3. Increase in small left breast nodule should be evaluated by dedicated mammogram. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with CHEST PAIN NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT temperature: 96.5 heartrate: 50.0 resprate: 14.0 o2sat: 98.0 sbp: 104.0 dbp: 76.0 level of pain: 5 level of acuity: 3.0
Ms. ___ is a ___ woman with DM2, HTN, mitral valve replacement in ___ for MR ___ rheumatic heart disease (25-mm ___ mechanical valve, ref ___ who presented with reproducible sternal chest pain. ACTIVE ISSUES 1. Chest pain: Unlikely unstable angina given atypical history (associated with headaches), reproducible pain, negative troponins x3 and unchanged EKG's. D-dimer negative and therapeutically anticoagulated making PE unlikely. Clean cath in ___. Normal TTE within past 1 month as outpatient. Patient's history of sternal wound dehissance was concerning for recurrent dehissance, but this was ruled out by CT scan. Exercise stress test was deferred to her outpatient cardiologist (already scheduled for ___. Aspirin was continued at 81mg daily. 2. Headache w/ Vision Changes: Has been chronic for the past ___ years. Per endocrinologist Dr. ___ at ___ ___ in ___, pituitary microadenoma (found in setting of risperdal, which has since been discontinued) was stable at 3-4mm on MRI with normal prolactin level. Due for another prolactin level next month. CT Head at OSH was unremarkable, and exam non-focal. She was placed on standing tylenol and oxycodone prn for now with ice and heat packs, as well as small doses of ativan given high levels of anxiety. Given description of photophobia, symptoms were concerning for migraine. Patient was given a trial of Imitrex that appeared to be helpful. 3. BRBPR: Most likely from skin tear above rectum. Her hemoglobin/hematocrit remained stable during hospitalization. CHRONIC ISSUES 1. S/p MVR: She was continued on warfarin for MVR, 3mg 4x/week and 2mg 3x/week, with goal 2.5-3.5. 2. Possible dCHF: Euvolemic. Recent TTE last month at OSH with LVEF >55%. Not on beta-blocker but heart rates in ___, and so a beta blocker was not started. She was continued on lasix 40mg daily. 3. Diabetes mellitus: Actos was held and patient maintained on sliding scale insulin while in-house. Actos was resumed upon discharge. HbA1C was 6.0%. 4. Hyperlipidemia: LDL was 129, HDL was 35, and triglycerides were 184. Atorvastatin was added. 5. Asthma: She was continued on home regimen of albuterol and singulair. 6. GERD: She was continued on home omeprazole. TRANSITIONAL ISSUES # CODE: Full # CONTACT: Patient, ___ (daughter) ___ # Will need continued outpatient follow-up of chronic headaches, neck pain, abdominal pain, and nausea, as well as poorly controlled anxiety that may be contributing significantly to the above symptoms (appointments for PCP, ___, and gynecology; consider psychiatry as well as reportedly was on risperdal but is no longer on any antipsychotic) # Monitor INR # Consider outpatient pain consult for management of sternal pain, which is likely related to post-surgical changes and may be expected to last years after sternotomy
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 lower extremity swelling Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENTING ILLNESS: ___ M with history of HFpEF, CAD, COPD, HTN, PVD with right AKA, pAF and hx of CVA on warfarin, CKD III and type II diabetes (on insulin) presenting with left lower extremity edema. His main presenting symptom today is a superficial skin break with weaping fluid of his left foot. He has baseline left lower extremity swelling (and R AKA) today he noticed a small area of skin breakdown on the dorsal aspect of his left foot that is mildy tender. He also has some increased shortness of breath but not as severe as during past admissions when he has been admitted for heart failure and/or COPD. He at baseline sleeps with an elevated head of the bed but no worse than usual. He reports that he takes his torsemide 80 mg daily but takes one 20 mg pill 4 times daily rather than all at once. He has several admission at ___ for heart failure and COPD with most recent heart failure exacerbation in ___ of this year at which time was noted to have poorly controlled hypertension and was started on hydralazine. He was diuresed with IV Lasix boluses of 120 mg. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD - Pump: LVEF 67% ___ - SR, hx of paroxysmal AF 3. OTHER PAST MEDICAL HISTORY ___ GERD Gout GCA (___) GI bleed CAD COPD EOTH abuse CVA PVD CKD Stage 3 Afib on warfarin Social History: ___ Family History: Uncles with alcoholism. Mother with a heart attack after ___ y/o. Daughter passed away of complications due to diabetes. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ======================= VS: ___ ___ Temp: 97.5 PO BP: 133/69 L Lying HR: 63 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: Obese male, lying in bed HEENT: Corneal arcus. PERRL. EOMI. NECK: JVP of 12 cm. CARDIAC: Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: Diminished breath sounds throughout but no wheezing or crackles. ABDOMEN: Soft, distended abdomen with an umbilical hernia, non-tender to palpation. EXTREMITIES: R AKA. Left lower extremity with 2+ edema to the knee with dorsal aspect of the foot with superficial area of skin breakdown (2x2cm) with weeping fluid and small fluid filled collections. There is mild TTP but no warmth, redness, or purulence. PULSES: Peripheral pulse not palpable on the LLE (DP or DP). DISCHARGE PHYSICAL EXAMINATION: ======================= Pertinent Results: ADMISSION LABS ======================= ___ 10:00AM BLOOD WBC-10.1* RBC-4.28* Hgb-10.0* Hct-33.7* MCV-79* MCH-23.4* MCHC-29.7* RDW-17.2* RDWSD-48.7* Plt ___ ___ 10:00AM BLOOD Neuts-74.4* Lymphs-9.9* Monos-13.5* Eos-1.4 Baso-0.4 Im ___ AbsNeut-7.55* AbsLymp-1.00* AbsMono-1.37* AbsEos-0.14 AbsBaso-0.04 ___ 10:00AM BLOOD ___ PTT-54.8* ___ ___ 10:00AM BLOOD Glucose-153* UreaN-87* Creat-2.5* Na-139 K-5.9* Cl-104 HCO3-22 AnGap-13 ___ 10:13PM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9 ___ 11:24AM BLOOD K-4.2 DISCHARGE LABS and INRs prior to D/C ======================= ___ 06:35AM BLOOD WBC-11.5* RBC-3.87* Hgb-9.0* Hct-31.3* MCV-81* MCH-23.3* MCHC-28.8* RDW-17.6* RDWSD-51.5* Plt ___ ___ 06:32AM BLOOD Neuts-77.3* Lymphs-8.5* Monos-12.2 Eos-1.2 Baso-0.1 AbsNeut-10.41* AbsLymp-1.14* AbsMono-1.64* AbsEos-0.16 AbsBaso-0.02 ___ 06:35AM BLOOD Plt ___ ___ 06:35AM BLOOD ___ PTT-55.8* ___ ___ 06:35AM BLOOD Glucose-94 UreaN-51* Creat-2.3* Na-138 K-5.3 Cl-98 HCO3-29 AnGap-11 ___ 06:35AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9 ___ 07:19AM BLOOD %HbA1c-10.5* eAG-255* ___ 01:00PM BLOOD ___ PTT-150* ___ ___ 02:53PM BLOOD ___ PTT-85.0* ___ PERTINENT STUDIES ======================= ___ PORTABLE CHEST XR Comparison to ___. The lung volumes have decreased. The current image shows evidence of mild pulmonary edema. In addition, there is a new parenchymal opacity at the level of the left hilus, with ill-defined margins and air bronchograms. Overall, the findings are highly suggestive of pulmonary edema, complicated by left perihilar pneumonia. New blunting of the right costophrenic sinus, likely caused by a small right pleural effusion. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with copd, here w/ worsening sob and ___ swelling// PNA? CHF? COMPARISON: Chest radiograph from ___. FINDINGS: AP upright and lateral views of the chest provided. In the setting of low lung volumes, the cardiac silhouette is enlarged, unchanged from prior. New interstitial edema. There is no focal consolidation, effusion, or pneumothorax. The mediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. There is a small right-sided pleural effusion, stable IMPRESSION: Stable cardiomegaly with new interstitial edema. Small right effusion stable. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with asymmetric left lower extremity swelling that is increasing from prior// DVT? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: Limited examination given body habitus and significant superficial soft tissue edema. 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 limited examination of the deep peroneal vein. 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. Limited examination of the deep peroneal vein. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with HFpEF p/w mild diastolic heart failure exacerbation, now with new O2 requirement and 1x temp 100.7// pulmonary edema, pneumonia, new O2 requirement pulmonary edema, pneumonia, new O2 requirement IMPRESSION: Comparison to ___. The lung volumes have decreased. The current image shows evidence of mild pulmonary edema. In addition, there is a new parenchymal opacity at the level of the left hilus, with ill-defined margins and air bronchograms. Overall, the findings are highly suggestive of pulmonary edema, complicated by left perihilar pneumonia. New blunting of the right costophrenic sinus, likely caused by a small right pleural effusion. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with HFpEF exacerbation and COPD/PNA, presented with ___, initially peaked and downtrending, now increasing// Evidence of hydronephrosis? TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Renal artery ultrasound ___ FINDINGS: There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. A small simple exophytic cyst is seen in the interpolar region of the right kidney measuring 1.0 cm. Right kidney: 10.0 cm Left kidney: 10.7 cm The bladder is moderately well distended and normal in appearance. IMPRESSION: No hydronephrosis in either kidney. Simple 1 cm right renal cyst. Radiology Report INDICATION: ___ year old man with HFpEF, COPD, ___, distended abdomen/nausea// Evidence of obstruction TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: None prior. FINDINGS: The upper abdomen and right hemiabdomen are incompletely imaged in this radiograph. There are no abnormally dilated loops of large or small bowel. There is no evidence of ileus or obstruction. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are notable for age-related degenerative changes within the lower lumbar spine. There are calcifications seen within pelvis and imaged extremities that likely represents atherosclerosis of the iliac and femoral vessels. Multiple EKG leads project over the abdomen. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: 1. No evidence of bowel obstruction or ileus on this limited radiograph. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Heart failure, unspecified, Acute kidney failure, unspecified, Dyspnea, unspecified temperature: 97.7 heartrate: 55.0 resprate: 20.0 o2sat: 96.0 sbp: 95.0 dbp: 43.0 level of pain: 0 level of acuity: 2.0
===================== BRIEF HOSPITAL COURSE ===================== ___ with HFpEF (63% ___, CAD, COPD, HTN, prior CVA, PVD, paroxysmal atrial fibrillation (on warfarin), CKD IV and type II diabetes (on insulin) presenting with left lower extremity edema thought due to mild acute diastolic heart failure, course complicated by COPD exacerbation and concern for pneumonia, status post steroid course, antibiotic course, admitted to the floor found to have no need for urgent dialysis. On the floor, the patient's creatinine and BUN gradually improved without medical intervention, and with auto diuresis post kidney injury. Patient was sent home in stable condition, with appropriate follow-up for heart failure, and notably was not discharged on home dose torsemide given urine output above baseline, placed on 40mg daily. Additionally, patient's hydralazine was uptitrated, 100 mg 3 times daily. Discharge Weight: Inaccurate without prosthesis, can obtain home weights with standardized scale Discharge Creatinine: 2.3 Discharge Diuretic: Torsemide 40 mg daily ===================== TRANSITIONAL ISSUES ===================== [ ]f/u with ___ for INR check on ___ [ ]f/u with outpatient cardiology ___ at 3pm) to re-establish care and monitor BP on new anti-hypertensive regimen [ ]f/u with PCP for goals of care and patient education regarding low salt diet, continued monitoring of insulin and blood glucoses, and continued family education about the management of the patient's complex medical issues. [ ]F/u with PCP about potential for starting a DOAC, in light of significant issues with managing warfarin =============== ACTIVE ISSUES: =============== # Acute on chronic diastolic heart failure # LLE edema Patient presented with increased left lower extremity swelling and mild increase above baseline dyspnea with chest film showing new mild interstitial edema. proBNP < 450 and he has mounted a BNP > 1000 in prior decompensations. Likely precipitant includes reported dietary noncompliance of heavy take-out and fast food, inaccurate dosing of home torsemide 80 daily (son reports taking 20 mg 4x/day although blister pack verified by pharmacy has 4 tablets in morning dose), hypertension. He was admitted to the cardiology service. He was noted to have superficial skin breakdown of the left lower extremity that appears to be related to edema/weeping. No evidence of infection/cellulitis. Wound care was consulted. Recent echo showed preserved EF 63%. Patient was diuresed with increasing doses of furosemide 100-160mg IV and, while the patient was on the floor, patient was not immediately placed on torsemide in the setting of increasing urine output from baseline. He developed a significant ___ on CKD4 while on the cardiology and was then transferred to the medicine service, where diuretics were held for almost a week. Nephrology was consulted and agreed with plan. He was transitioned to Torsemide 40 mg PO daily, decreased from home 80mg dose, on the day of discharge. He was notably not placed on torsemide while on the floor because of consistent auto diuresis and recovery from his ___. Patient's hydralazine was also increased to 100 mg p.o. 3 times daily. Of note, patient has not tolerated spironolactone in past due to hyperkalemia. - f/u with outpatient Cardiology for diuretic titration [] Likely need to go back to 80 mg torsemide once autodiuresis drops off from ___. He had a negative duplex of his LLE on ___. He had a trop leak that peaked at 0.13 attributed to type II NSTEMI. # CKD stage IV (baseline Cr ~2.3 eGFR 27) Most recent discharge in ___ with Cr of 2.3, 2.5 this admission, stable. As above, patient was diuresed to the point that his BUN/Cr was 161/4.9. Nephrology was consulted for possible initiation of hemodialysis, although given steadily improving creatinine, stable urine output, this was deferred. Of note, patient was making about ___ cc of urine daily in the days before discharge. On the day of discharge the patient's urine output was also significantly elevated above baseline, and both the patient and family have been alerted to the fact that the patient needs to be on home torsemide given eventual drop in urine output. He had a normal renal US on on ___. His ACR was 355. His BUN/Cr on discharge was 51/2.3. #Dyspnea and Fever #COPD exacerbation Last fever T100.7 on ___ without respiratory symptoms although with intermittently increased oxygen requirement. CXR suggestive of increased pulmonary congestion and potential left perihilar infiltrate. Patient denies history of aspiration but prior admission noting dysphagia with patient and family education, but appears non-adherent to dietary changes. Initiated on prednisone burst x5days, stacked duonebs, and started on ceftazidime for increased risk factor COPD exacerbation with transition to levofloxacin, completed the course and was not on any antibiotics on discharge. When the patient was transitioned to the floor, he denied any respiratory symptoms, had no focal findings on his respiratory exam, he was not given any further antibiotics or steroids. # DM II Home insulin regimen is levemir 4 units at night and sliding scale, continued. Continued home gabapentin for peripheral neuropathy. While as inpatient, ___ diabetes service was consulted to assist with glucose management, and his new insulin regimen was reviewed with the patient and the patient's son to ensure that it was reasonable and easy to manage. He on an outpatient should be on 15 units of Lantus, 7 units Humalog, and 5 mg linagliptin. His regimen was simplified to injection medication given at night when son is home from work as patient does not have the ability to administer daytime or mealtime medication/insulin. If the patient eats a full meal there should also be a blood glucose check. The ongoing concern is that the patient sometimes does not eat a full meal at dinnertime, and becomes hypoglycemic, as noted one evening during his hospitalization. This should continue to be closely monitored as an outpatient. #Goals of Care Patient with multiple hospitalizations. Confirmed full code. Pursued goals of care conversation with patient and son's expressing inclination for full code. Repeat hospitalizations seem to stem significantly from dietary indiscretion, as patient reports he is continuing to eat ___ food, fast food, and ___. Education received during admission with unclear benefit; suspicion for patient to exhibit vascular dementia. As patient receives much care under son and daughter, family would greatly benefit from increased education to maximize preventable hospitalizations in the future. - f/u with PCP for patient and family education on preventing hospitalizations #Supratherapeutic INR #pAFib Previously on apixaban but switched to warfarin given renal function. Sinus rhythm on admission. INR 4.7 with warfarin held. Receives ___ services with INR checks. Discharge INR 2.1 and plan for ___ re-check tomorrow. - f/u with ___ for INR monitoring #Hypertension: Patient with hypertension to 140's, increased home hydralazine dose to 100 mg TID. Continued home Isosorbide dinitrate 10 mg TID, Carvedilol 25 BID, and amlodipine 10. - f/u with cardiology for titration of increased hydralazine; of note the patient may have a difficult time taking medications that require three times a day at home. #Troponinemia Differential diagnosis included type II demand NSTEMI vs troponinemia in the setting of CKD. No chest pain or concerning EKG changes. Downtrended. #) Leukocytosis ___ steroids #) Chronic anemia ___ CKD #) Abdominal distension Had KUB on ___ which did not show obstruction/ileus. Discharged on bowel regimen. ================ CHRONIC ISSUES: ================ # PVD: s/p R right AKA (___) and left fem to ATA bypass with reversed greater saphenous ___. Continued on home clopidogrel 75 mg QDay #GERD: Continued home pantoprazole 40 mg daily #Gout: Continued home allopurinol ___ mg daily #BPH: Continued home Tamsulosin 0.4 mg QD Code status: Full code (confirmed) Name of health care proxy: ___ ___: son Phone number: ___
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: increasing weight, shortness of breath and fatigue Major Surgical or Invasive Procedure: ___: ___ notable for multivessel disease: 50% mid-LAD stenosis after high D1, 75% stenosis just before + 70% stenosis after large branching S1. ___ Cx calcified 85% stenosis. SA nodal branch RCA 70% origin stenosis. ___ Left heart catheterization: DES placed in LCx History of Present Illness: Mr. ___ is a ___ with history of iCMP (LVEF 13% ___ s/p ICD, CAD - STEMI ___ with BMS LAD ___ + POBA D1 ___, DM2, HTN, CKD (baseline Cr 1.5), HLD, resident on ___ with care at ___ and ___, who presents with increasing weight, shortness of breath and fatigue, concerning for heart failure exacerbation. He reports that he has had multiple presentations to ___ for worsening shortness of breath and fatigue over the last month, and has had progressive shortness of breath, weight gain, abdominal swelling, and fatigue over the last month. He denies chest pain, palpitations, lightheadedness. He has shortness of breath at baseline can walk for 35 seconds before stopping, now walking only 15 seconds. He has baseline orthopnea and has slept in a chair for years, so he has not noticed a difference. Describes occasional PND though this is at baseline. He has mild ___ edema, but notes that his weight gain usually is predominantly in his abdomen. His dry weight s around 256 lbs, though he has not been there for several weeks. He reports that he has a cardiologist at ___ and apparently is not being workup up for transplant due to multiple comorbidities. Records from ___ and ___ were reviewed. He had the following admissions: ___ Admitted to ___ with heart failure exacerbation. He had hypotension which limited diuresis. His discharge weight at that time was apparently 275 lb and he was discharged on 40mg torsemide. Cr at discharge 1.5. Admitted to ___ ___ with progressive SOB/DOE. He was diuresed with IV Lasix 80 then switched to IV Lasix 60 BID, and ultimately put back on his home torsemide 40mg daily.He was also noted to have a leukocytosis and possible PNA on Xray and was treated for CAP. His weight was 269 lb on discharge. His Cr at discharge was 1.6. Presented to ___ ___ with SOB at rest. Noted to have Cr 2.0 (baseline 1.5), Na 129, AST 161, ALT 146. Weight 275lb. BNP 809. Per note he was felt to be volume depleted and not given Lasix. Discharged. Presented to ___ ___ with cough, worsening SOB. Weight was 273 lbs. Troponin was negative. Cr 2.0, Na 130. LFTs not checked. He was given Lasix 20mg and discharged. In the ED initial vitals were afeb, 87 ___ 100% 4L NC. His exam was notable for crackles and ability to speak full sentences. EKG without acute ischemia. His labs were notable for Cr 2.0, Na 130, Bicarb 30. ALT 61, SAT 146, tbili 1.7, alk phos 126. ProBNP 2409, trop 0.02. VBG 7.32/63, lactate 3.0. On the floor he endorses the history above and denies any present discomfort. A 10 point ROS is negative except per the HPI above. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes on insulin c/b neuropathy, CKD - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD, STEMI ___ s/p BMS to ___ LAD + balloon angioplasty D1 - dilated iCMP LVEf 13% ___, s/p ___ ICD; ___ class III - sinus rhythm, hx NSVT 3. OTHER PAST MEDICAL HISTORY CKD (chronic kidney disease) stage 3, GFR ___ ml/min Primary insomnia Social History: ___ Family History: Family history of cardiomyopathy and coronary disease. His brother had a heart transplant. Physical Exam: ADMISSION EXAM =============== 98.4 PO 107 / 74 R Sitting 88 20 100 3L Weight 124.8 kg (275.13 lb) GENERAL: Obese man, not in distress, Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP seen at 11 though difficult habitus. CARDIAC: distant heart sounds, no murmurs auscultated. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. +bibasilar crackles, good air movements. no wheezing. ABDOMEN: obese, firm but not rigid, mod distended. EXTREMITIES: Extremities cool below the knee. 2+ edema on the shins pretibially bilaterally with chronic venous stasis changes. DISCHARGE EXAM =============== 24 HR Data (last updated ___ @ 517) Temp: 98.4 (Tm 98.4), BP: 90/71 (86-115/54-76), HR: 98 (94-107), RR: 20 (___), O2 sat: 98% (96-100), O2 delivery: RA, Wt: 249.56 lb/113.2 kg Fluid Balance (last updated ___ @ 520) Last 24 hours Total cumulative -1570ml IN: Total 1180ml, PO Amt 1180ml OUT: Total 2750ml, Urine Amt 2750ml GENERAL: NAD. NECK: Supple. CARDIAC: Distant heart sounds, no m/r/g appreciated. LUNGS: LCTAB. ABDOMEN: Obese, firm but not rigid, distended. EXTREMITIES: No ___ edema b/l, venous stasis changes b/l. Pertinent Results: ADMISSION LABS ============== ___ 11:00PM BLOOD WBC-8.1 RBC-5.59 Hgb-16.0 Hct-50.5 MCV-90 MCH-28.6 MCHC-31.7* RDW-17.7* RDWSD-53.9* Plt ___ ___ 11:00PM BLOOD Neuts-52.5 ___ Monos-10.3 Eos-1.0 Baso-0.4 Im ___ AbsNeut-4.27 AbsLymp-2.90 AbsMono-0.84* AbsEos-0.08 AbsBaso-0.03 ___ 11:30PM BLOOD ___ PTT-29.8 ___ ___ 11:00PM BLOOD Glucose-141* UreaN-27* Creat-2.0* Na-130* K-5.4 Cl-90* HCO3-30 AnGap-10 ___ 11:00PM BLOOD ALT-61* AST-146* CK(CPK)-2233* AlkPhos-126 TotBili-1.7* DirBili-0.6* IndBili-1.1 ___ 11:00PM BLOOD CK-MB-12* MB Indx-0.5 cTropnT-0.02* proBNP-2409* ___ 11:00PM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.3 Mg-2.7* DISCHARGE LABS =============== ___ 07:47AM BLOOD WBC-6.3 RBC-5.69 Hgb-16.2 Hct-50.9 MCV-90 MCH-28.5 MCHC-31.8* RDW-15.9* RDWSD-51.8* Plt ___ ___ 07:47AM BLOOD ___ ___ 07:47AM BLOOD Glucose-167* UreaN-28* Creat-1.2 Na-133* K-5.0 Cl-99 HCO3-23 AnGap-11 ___ 07:47AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1 MICROBIOLOGY =============== ___ UCX: MIXED BACTERIAL FLORA ___ MUMPS: IgG+ ___ RUBEOLA: IgG+ ___ RUBELLA: IgG+ ___ RPR: Non-reactive ___ Varicella Zoster: IgG+ ___ CMV: IgG+ ___ ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE BY EIA. ___ TOXOPLASMA: IgG neg. REPORTS =============== ___ CXR: Moderate pulmonary edema. ___ TTE: LVEF 15%. Biatrial enlargement. Severely depressed left ventricular systolic function with possible apical adherent thrombus (non-mobile; clips 72 and 73). Mildly dilated, mildly EMR 2853-P-IP-OP (O7/17) Name: ___ MRN: ___ Study Date: ___ 10:00:00 p. ___ hypokinetic right ventricle. Mild to moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. ___ PATHOLOGY REPORT: Mr. ___ has a confirmed diagnosis of an anti-K antibody. The ___ is a member of the Kell blood group system. Anti-K antibodies are clinically significant and capable of causing hemolytic transfusion reactions. In the future, Mr. ___ should receive ___ negative products for all red cell transfusions. Approximately 91% of compatible ABO blood will be ___ negative. ___ CARDIAC CATH REPORT: 1. Three vessel calcific coronry artery disease. 2. Severe left ventricular diastolic heart failure. 3. Mild-moderate right ventricular diastolic heart failure. 4. Mild pulmonary hypertension. Name: ___ MRN: ___ Study Date: ___ 12:51:00 p. ___. Slightly depressed calculated cardiac index. 6. No oxymetric evidence of significant left-to-right shunting. ___ ABDOMINAL U/S: 1. Evaluation limited by poor sonographic penetration due to patient body habitus. 2. Grossly unremarkable appearance of the liver and gallbladder. No ascites. 3. The visualized portion of the proximal and mid abdominal aorta appear within normal limits in AP dimension, and is not well evaluated in the transverse dimension due to poor sonographic delineation. However, there does not appear to be an abdominal aortic aneurysm. If there is further specific concern, cross-sectional imaging should be considered. ___ PMIBI: 1. Severe apical and moderate anterior and anterior septal fixed perfusion defect. 2. Severe enlargement of the left ventricular cavity. Left ventricular ejection fraction is 19%. ___ EP STUDY (FLUOROSCOPY OF RV RIATTA LEAD): fluoro of rv riatta lead no evidence of the coil outside the lead ___ CAROTID: < 40% stenosis of the right internal carotid artery. < 40% stenosis of the left internal carotid artery. ___ ABI: Indeterminate ABIs bilaterally due to noncompressible distal vessels consistent with likely arterial calcification artifact; however, with normal toe pressures there is unlikely to be significant arterial obstructive disease. ___ CT CHEST W/O CONTRAST: Ectasia of the main pulmonary artery, suggestive of pulmonary hypertension. Correlation with echocardiogram findings is recommended. Severe coronary atherosclerotic disease. Small hiatal hernia. Otherwise unremarkable chest CT ___ LEFT HEART CATH: Findings • Two vessel coronary artery disease. • Successful PCI with drug-eluting stent of the circumflex coronary artery. Recommendations • ASA 81mg per day. • Plavix 75mg/day for minimum 6 months. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ with history of iCMP (LVEF 13% ___ s/p ICD, CAD- STEMI ___ with BMS LAD ___ + POBA D1 ___, DM2,HTN, CKD (baseline Cr 1.5), HLD, resident on ___ with ___ and ___, who presents with increasingweight, shortness of breath and fatigue and was admitted on ___ decompensated HFrEF, now starting w/u for advanced therapies (e.g. LVAD vs. heart transplant).// R/O gallbladder pathology, ascites, AAA for LVAD/heart transplant w/u. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: Evaluation limited by poor sonographic penetration due to patient body habitus. LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 2 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 8.4 cm KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. Right kidney: 10.3 cm Left kidney: 9.3 cm RETROPERITONEUM: The visualized portion of the proximal and mid abdominal aorta appear within normal limits in AP dimension, and is not well evaluated in the transverse dimension due to poor sonographic delineation, however the dense not appear to be an abdominal aortic aneurysm. The visualized portions of the IVC are within normal limits. IMPRESSION: 1. Evaluation limited by poor sonographic penetration due to patient body habitus. 2. Grossly unremarkable appearance of the liver and gallbladder. No ascites. 3. The visualized portion of the proximal and mid abdominal aorta appear within normal limits in AP dimension, and is not well evaluated in the transverse dimension due to poor sonographic delineation. However, there does not appear to be an abdominal aortic aneurysm. If there is further specific concern, cross-sectional imaging should be considered. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ w/ history of ischemic cardiomyopathy (LVEF 15%), CAD s/p BMS to LAD/ POBA to D1, diabetes, HTN, CKD admitted for CHF exacerbation with course notable for newly discovered possible LV thrombus. Currently diuresing and undergoing transplant evaluation.// LVAD/OHT work-up TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Contrast agent was not administered. All images were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.4 s, 38.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 788.9 mGy-cm. Total DLP (Body) = 789 mGy-cm. COMPARISON: None available. FINDINGS: NECK, THORACIC INLET, AXILLAE AND CHEST WALL: The thyroid is unremarkable. No enlarged lymph nodes in either axilla or thoracic inlet. Left anterior pacemaker with leads in the right atrium and right ventricle. Mild bilateral gynecomastia. No atherosclerotic calcifications in the head and neck arteries. HEART AND VASCULATURE: The heart is normal size and shape. No pericardial effusions. Severe atherosclerotic calcifications in the coronary arteries, mild in the aorta and none in the cardiac valves. The pulmonary artery is dilated measuring 3.5 cm. The aorta is normal in caliber throughout. MEDIASTINUM AND HILA: Small hiatal hernia. The esophagus is otherwise unremarkable. Small mediastinal lymph nodes, none pathologically enlarged by CT size criteria. No apparent hilar lymphadenopathy. PLEURA: No pleural effusions. No apical scarring bilaterally. LUNGS: The airways are patent to the subsegmental levels. No bronchial wall thickening, bronchiectasis or mucus plugging. No suspicious lung nodules or masses. No consolidations or atelectasis. CHEST CAGE: Mild dorsal spondylosis. No acute fractures. No suspicious lytic or sclerotic lesions. UPPER ABDOMEN: The limited sections of the upper abdomen show no significant abnormal findings. IMPRESSION: Ectasia of the main pulmonary artery, suggestive of pulmonary hypertension. Correlation with echocardiogram findings is recommended. Severe coronary atherosclerotic disease. Small hiatal hernia. Otherwise unremarkable chest CT Radiology Report EXAMINATION: ART EXT (REST ONLY) INDICATION: ___ with history of iCMP (LVEF 13% ___ s/p ICD, CAD- STEMI ___ with ___ LAD ___ + POBA D1 ___, DM2,HTN, CKD (baseline Cr 1.5), HLD, resident on ___ with ___ and ___, who presents with increasingweight, shortness of breath and fatigue and was admitted on ___ decompensated HFrEF, now starting w/u for advanced therapies (e.g. LVAD vs. heart transplant).// LVAD/heart transplant work-up 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: None FINDINGS: On the right-side, triphasic Doppler waveforms were seen at the right femoral, popliteal, posterior tibial, and dorsalis pedis arteries. The right ABI was indeterminate due to noncompressible vessels, with toe pressure of 93 mm Hg. Pulse volume recordings demonstrate mildly abnormal waveforms in the low thigh, calf, ankle, metatarsal, normal at the digit. On the left-side, triphasic Doppler waveforms were seen at the left femoral, popliteal, posterior tibial, and dorsalis pedis arteries. The left ABI was indeterminate due to noncompressible vessels, with a toe pressure of 94 mm Hg. Pulse volume recordings demonstrate mildly abnormal waveforms in the low thigh, calf, ankle, metatarsal, normal at the digit. IMPRESSION: Indeterminate ABIs bilaterally due to noncompressible distal vessels consistent with likely arterial calcification artifact; however, with normal toe pressures there is unlikely to be significant arterial obstructive disease. Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ with history of iCMP (LVEF 13% ___ s/p ICD, CAD- STEMI ___ with BMS LAD ___ + POBA D1 ___, DM2,HTN, CKD (baseline Cr 1.5), HLD, resident on ___ with ___ and ___, who presents with increasingweight, shortness of breath and fatigue and was admitted on ___ decompensated HFrEF, now starting w/u for advanced therapies (e.g. LVAD vs. heart transplant).// LVAD/heart transplant w/u TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has mild heterogeneous atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 70 cm/s. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 35 cm/s, 62 cm/s, and 63 cm/s respectively. The peak end diastolic velocity in the right internal carotid artery is 22 cm/sec. The ICA/CCA ratio is 0.9. The external carotid artery has peak systolic velocity of89 cm/s. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild heterogeneous atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 83 cm/s. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 24 cm/s, 50 cm/s, and 47 cm/s respectively. The peak end diastolic velocity in the left internal carotid artery is 20 cm/sec. The ICA/CCA ratio is 0.6. The external carotid artery has peak systolic velocity of 74 cm/s. The vertebral artery is patent with antegrade flow. IMPRESSION: < 40% stenosis of the right internal carotid artery. < 40% stenosis of the left internal carotid artery. Gender: M Race: OTHER Arrive by HELICOPTER Chief complaint: Dyspnea Diagnosed with Heart failure, unspecified, Ischemic cardiomyopathy, Acute respiratory failure with hypoxia, Dyspnea, unspecified, Type 2 diabetes mellitus without complications temperature: nan heartrate: 87.0 resprate: 20.0 o2sat: 100.0 sbp: 107.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0
Mr. ___ is a ___ with history of iCMP (LVEF 13% ___ s/p ICD, CAD - STEMI ___ with ___ LAD ___ + POBA D1 ___, insulin-dependent DM2, HTN, CKD (baseline Cr 1.5), HLD, resident on ___ with prior care at ___ and ___, who presented with increasing weight, shortness of breath and fatigue and was admitted on ___ for decompensated HFrEF. He is s/p active diuresis + DES in LCx on ___ and was initiated on heart transplant work-up during this hospitalization after discussion with prior ___ cardiologist Dr ___ decided to switch care from ___ > ___ during this hospitalization). =============== ACTIVE ISSUES: =============== # Acute Decompensated HFrEF # Mixed ischemic/nonischemic dilated cardiomyopathy, LVEF 13% ___, s/p ICD placement Presented with dyspnea, orthopnea, lower extremity swelling and weight gain c/w acute decompensated HFrEF. Review of ___ ___ + ___ records suggests chronic low EF felt to be at least partly ischemic but possibly also with nonischemic component. Notably, he mentioned his brother had a heart transplant as well. He has biventricular systolic dysfunction. He has had recurrent exacerbations in the past year which seem to be due to inadequate diuresis while hospitalized - he has not achieved his dry weight for several months, and inadequate torsemide dosing at home. Although he endorsed compliance at admission, his PCP's nurse reported pt was ___ with medications. Per the last ___ cardiology note in ___ he as on torsemide 40 BID, but on repeated discharges from ___ ___ he was on 40mg daily. From diuresis perspective, he received IV Lasix 80-120mg boluses during this hospitalization. Course was as follows: -___ TTE was obtained and notable for LVEF 15%. Severely depressed with possible apical adherent thrombus. Mildly dilated, mildly hypokinetic RV. Mild-mod MR. ___ TR. ___. - ___: St ___ ___ interrogated, no issues. - ___ LHC: Multi-vessel disease. 50% mid-LAD stenosis after high D1, 75% stenosis just before + 70% stenosis after large branching S1. ___ Cx calcified 85% stenosis. SA nodal branch RCA 70% origin stenosis. *NB: Compared to ___ cath ___: LM patent, LAD occluded, LCx patent, RCA not imaged but previously patent. - ___ pMIBI: Severe apical and moderate anterior and anterior septal fixed perfusion defect. - ___ LHC: DES in LCx Upon ___ cath findings of multi-vessel disease, Cardiac Surgery was consulted but felt he was too high risk for surgery. pMIBI showed moderate defect and attending reviewing this study suggested he may have some myocardial viability and reversibility with PCI. Subsequently, he underwent ___ LHC for DES in LCx. He was initiated for heart transplant work-up. All recommended serologies per ID were ordered and completed. BMI: 39.4 on ___. #Apical thrombus. Seen on ___ TTE notable for POSSIBLE apical adherent thrombus. He was initially started on a hep gtt prior to Left heart cath and eventually transitioned to warfarin. #Hx CAD, STEMI ___ s/p BMS LAD and balloon angioplasty D1 Continued home ASA 81mg, Crestor. B-blocker was held initially iso decompensated heart failure. He underwent a ___ left heart catheterization during which DES was placed in LCx. Additional information as above. #CK elevation: CK elevated to 2233 at admission. On OSH labs his AST has been elevated out of proportion to ALT suggesting possibly some low grade myopathy. Home fenofibrate was discontinued and Crestor was continued. After this, AST downtrended though LFTs overall remained mildly elevated. Notably, CK downtrended to normal limits after fenofibrate was discontinued. #Transaminitis Presented with ALT 61, AST 146. Likely ___ congestive hepatopathy vs. statin+fenofibrate use at admission. Pt denied etoh use. #Hyperbilirubinemia Presented with Tbili 1.7, Dbili 0.6, indirect 1.1 with unclear etiology. Appeared to have resolved during hospitalization. Repeat Tbili 1.2. #Testosterone Levels As part of heart transplant work-up, HDL was noted to be low at 12, then 15 with fasting lipid panel. Endocrine was consulted. Pt reported using exogenous steroids in his ___, but not using anything since. Testosterone levels (fasting 0800AM) were as follows: Test. 305, SHBG 113, calc FT 25. Per Endocrine, they recommended a repeat panel (total testosterone, SHBG, free testosterone, FSH/LH, Prolactin) as an outpatient in ___, as these measurements will more accurately reflect patient's true values. ___ warrant further evaluation of low HDL (___, ___) given family history (brother with heart transplant) suggests low HDL not fully accounted by abnormal testosterone levels. ================== CHRONIC ISSUES ================== #Hyperlipidemia: CK elevated to 2233 at admission. He was on both rosuvastatin and fenofibrate at home. Given elevation in CK, his fenofibrate was discontinued and CK levels returned to normal limits. ___
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Amoxicillin / Erythromycin Base / Cleocin / Motrin / Biaxin / Avelox / Abreva / Lipitor / Savella / wheat sprout / vira extract / Sulindac / Levofloxacin / Motrin IB / morphine / Vioxx / gluten Attending: ___. Chief Complaint: SOB in setting of NASH cirrhosis c/b hepaopulmonary syndrome and chronic portal venous thrombosis with a MELD of 35 (HPS exception points) Major Surgical or Invasive Procedure: ___: Liver transplant ___: PICC placement ___: ERCP with stent placement History of Present Illness: ___ ___ cirrhosis c/b hepaopulmonary syndrome and chronic portal venous thrombosis with a MELD of 35 (HPS exception points) who presented to ED this ___ with subjective increase in shortness of breath as well as a guaic positive stool. She was evaluated in ED and workup was notable for a slight decrease in hematocrit decrease from 25 to 23.8. Patient also had a CTA which did not demonstrate a PE or pneumonia. Patient has been stable on her home O2 of 6L. She does also report that she had a guaic positive stool at rehab but denies any gross melena or bright red blood per rectum. Additionally she denies any cough, congestion, headache, fever, diarrhea, dysuria, hematuia, or rash. She does report some vague abdominal pain when being examined in the ED. She also reports that she still has some residual pain around the healing mastectomy incision. Past Medical History: Child B NASH cirrhosis c/b hepatopulmonary syndrome and chronic portal vein thrombosis (on Coumadin), portal hypertension (has been on the liver transplant list for ___ years), hx of hepatic encephalopathy, known esophageal varices, type 2 diabetes, migraines, fibromyalgia, L5 radiculopathy, gastroesophageal reflux disease, chronic sinusitis, hypothyroidism and a right vocal cord mobility issue with vocal cord injection with carboxymethylcellulose in ___. PSH: Tubal ligation in ___, appendectomy in childhood, laparoscopic cholecystectomy in ___ for chronic cholecystitis, hemorrhoidectomy, carpal tunnel disease and left knee arthroscopy, ___: left total, simple mastectomy and left axillary sentinel node biopsy. Social History: ___ Family History: Significant Hx of liver disease: two siblings with varices, both of whom are alcoholics, and a sister w/ hep C who died of a variceal bleed. Physical Exam: ROS: GEN: denies fever/chills/fatigue/malaise HEENT: denies changes in vision/hearing CV: denies angina/palpitations PULM: +subjective shortness of breath GI: denies pain/nausea/vomiting/diarrhea/constipation GU: denies dysuria DERM: denies rash/lesions/pruritis NEURO: denies headache, denies numbness/tingling HEME: denies easy bruising/bleeding P/E: VS: T:97.9 P:77 BP:107/55 RR:18 O2sat:95% 6L GEN: WD, WN in NAD HEENT: NCAT, EOMI, anicteric CV: RRR, PULM: CTA B/L w no W/R/R, normal excursion, no respiratory distress ABD: soft, NT, ND, no mass, no hernia DRE: normal tone, no mass, hemeoccult negative EXT: WWP, no CCE, NEURO: A&Ox3, no focal neurologic deficits PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: Labs on Admission ___ WBC-3.1* RBC-3.41* Hgb-6.8* Hct-23.8* MCV-70* MCH-19.9* MCHC-28.6* RDW-19.1* RDWSD-47.8* Plt ___ PTT-41.7* ___ Glucose-100 UreaN-11 Creat-0.6 Na-136 K-4.1 Cl-109* HCO3-22 AnGap-9 ALT-27 AST-45* AlkPhos-134* TotBili-1.2 Albumin-3.0* Calcium-8.6 Phos-3.0 Mg-2.0 HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE HCV Ab-NEGATIVE ___ TSH-3.7 . Labs at Discharge: ******************* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cetirizine 10 mg PO DAILY 2. Lactulose 30 mL PO QID 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Nadolol 20 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Paroxetine 30 mg PO DAILY 7. Rifaximin 550 mg PO BID 8. Spironolactone 150 mg PO DAILY 9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 10. TraZODone 25 mg PO QHS:PRN insomnia 11. Warfarin 7 mg PO DAILY16 12. Glargine 35 Units Bedtime Humalog 20 Units Breakfast Humalog 20 Units Lunch Humalog 20 Units Dinner Insulin SC Sliding Scale using HUM Insulin 13. Furosemide 40 mg PO DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*6 3. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*2 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 6. Mycophenolate Mofetil 1000 mg PO BID RX *mycophenolate mofetil 500 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*5 RX *mycophenolate mofetil 500 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*5 7. Pantoprazole 40 mg PO DAILY RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 8. Pravastatin 20 mg PO QPM RX *pravastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*6 10. Enoxaparin Sodium 40 mg SC QD 11. ValGANCIclovir 450 mg PO Q24H RX *valganciclovir 450 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*2 12. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium take when instructed to by Transplant coordinator RX *sodium polystyrene sulfonate 1 powder(s) by mouth once a day Refills:*2 13. TraZODone 25 mg PO QHS:PRN insomnia 14. Acetaminophen 650 mg PO Q8H:PRN pain maximum 6 of the 325 mg tablets daily RX *acetaminophen 325 mg 1 tablet(s) by mouth daily Disp #*50 Tablet Refills:*0 15. Amlodipine 5 mg PO DAILY 5 RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 16. Cyclobenzaprine 2.5 mg PO TID:PRN back spasm Dose lowered due to medication interactions RX *cyclobenzaprine 5 mg 0.5 (One half) tablet(s) by mouth three times a day Disp #*45 Tablet Refills:*1 17. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*5 18. Lidocaine 5% Patch 2 PTCH TD QPM Remove in morning 19. Lorazepam 0.5 mg PO BID:PRN anxiety 20. Glargine 35 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 21. PredniSONE 15 mg PO DAILY Follow transplant taper Tapered dose - DOWN 22. Paroxetine 30 mg PO DAILY 23. Tacrolimus 2 mg PO ONCE Duration: 1 Dose Please take at 6pm ___ and 6am ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hepatopulmonary syndrome ___ cirrhosis s/p liver transplant 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: ___ NASH cirrhosis c/b hepatopulmonary syndrome s/p liver transplantation. // S/p re-intubation COMPARISON: Compared to prior radiographs from ___ at 05:00. IMPRESSION: Swan-Ganz catheter has been removed. There is a right IJ central line with the distal lead tip in the proximal right atrium. Nasogastric tube has been removed. Endotracheal tube tip is 4.7 cm above the carina. Heart size is upper limits of normal. There is prominence of the pulmonary interstitial markings suggestive of mild pulmonary edema. Radiology Report INDICATION: ___ year old woman s/p liver transplant and reintubation. // S/p NGT placement COMPARISON: Compared to radiographs from ___ IMPRESSION: There has been placement of a nasogastric tube whose tip and side port are below the GE junction. The right IJ central line and endotracheal tube are unchanged in position and appropriately sited. Heart size is upper limits of normal. The opacities throughout both lung fields continue to worsened and are most prominent in the right lung base. Superimposed pulmonary edema is possible. There are no pleural effusions. There are no pneumothoraces. Radiology Report INDICATION: ___ year old woman with intubated // new lung pathology COMPARISON: Radiographs from ___ IMPRESSION: Support lines and tubes are unchanged in position. Heart size is upper limits of normal and stable. Diffuse airspace opacities bilaterally are again seen, slightly improved since prior. There are no pleural effusions. There are no pneumothoraces. Radiology Report INDICATION: ___ year old woman with liver transplant // high 02 requirement, look for lung pathology COMPARISON: Radiographs from ___ IMPRESSION: Endotracheal tube and nasogastric tube have been removed. There remains a right IJ central line with the distal lead tip in the proximal right atrium. Heart size is enlarged but stable. There is mild improvement of the diffuse airspace opacities bilaterally. No pneumothoraces are seen. Several old healed right-sided rib fractures are again visualized. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ NASH cirrhosis c/b hepatopulmonary syndrome presents for liver transplantation and portal vein thrombosis (on coumadin). Admitted to SICU for post-op management. // serial exam serial exam IMPRESSION: In comparison with the study of ___, the patient has taken a better inspiration. Cardiac silhouette remains at the upper limits of normal in size or mildly enlarged. The pulmonary vascular congestion has decreased. Bilateral opacifications persist, most likely reflecting atelectatic changes more prominent on the right. However, in the appropriate clinical setting, superimposed pneumonia would have to be considered. Right IJ catheter again extends into the right atrium. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with liver transplant right IJ // position of IJ IMPRESSION: As compared to ___ radiograph, a right internal jugular central venous catheter is again demonstrated, with tip terminating just below the expected location of the cavoatrial junction. A questionable new small right apical pneumothorax is noted, for which short-term followup radiographs may be helpful. Exam is otherwise remarkable for worsening atelectasis at the right lung base. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ woman status post right PICC placement. TECHNIQUE: Portable AP chest radiograph COMPARISON: Multiple prior chest radiographs, most recent from ___. FINDINGS: Right PICC either kinked in the SVC or extending posteriorly into the azygos vein. Right IJ central venous catheter is again demonstrated. Old right rib fracture deformities are visualized. No cardiomegaly. Improved pulmonary edema. No appreciable right pneumothorax. IMPRESSION: Right PICC either kinked in the SVC or extending posteriorly into the azygos vein. Improvement in pulmonary edema. RECOMMENDATION(S): Reposition right PICC. The exact location of the right PICC tip is unclear, consider obtaining a lateral chest radiograph for further elucidation. NOTIFICATION: Findings were communicated to the PICC nurse at 13:24. Findings were also discussed with the transplant team at 15:50. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ hx of hepatopulmonary syndrome, NASH cirrhosis s/p DCD liver transplant // Correct placement of R LUE PICC Contact name: ___, ___: ___ Correct placement of R LUE PICC IMPRESSION: In comparison with the earlier study of this date, the tip of the PICC line is difficult to see, though it appears to be in the mid to lower SVC. Later study showed the tip in the region of the cavoatrial junction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with poorly visualized PICC // please do oblique view to see R PICC aslo has RIJ please do oblique view to see R PICC aslo has RIJ IMPRESSION: In comparison with the earlier study of this date, the tip of the PICC line extends to the cavoatrial junction. Otherwise little change. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman s/p CVL removal, assess that PICC not dislodged during line removal // Assess PICC line placement after removal of the Central line today Assess PICC line placement after removal of the Central line IMPRESSION: In comparison with the study of ___, the right IJ catheter is been removed. The subclavian PICC line again extends to the lower SVC. There again is some asymmetric opacification at the right base, consistent with lower lung pneumonia. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ hx of hepatopulmonary syndrome, NASH cirrhosis s/p DBD liver transplant // new desats to ___ off ___ mask TECHNIQUE: Portable chest COMPARISON: ___. FINDINGS: A right PICC in stable position within the SVC. There continues to be right lung base opacification which may represent pneumonia. The cardiac silhouette is stable in size. No new focal consolidation, pleural effusion or pneumothorax is seen. IMPRESSION: No change. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ hx of hepatopulmonary syndrome, NASH cirrhosis s/p DBD liver transplant with elevated wbc // Assess for pneumonia IMPRESSION: As compared to ___ chest radiograph, there has been little change in the appearance of the chest except for worsening bibasilar atelectasis. No definite pneumonia. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT INDICATION: ___ woman with transplant and portal vein thrombosis, with thrombectomy at transplant, complaints of vague abdominal pain and also now has bilious appearance to JP drain output. Please evaluate portal vein by doppler U/S TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen was performed. COMPARISON: ___ FINDINGS: Liver: The transplant hepatic parenchyma is within normal limits. Nofocal liver lesions are identified. There is mild ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct measures 6 mm. Gallbladder: The gallbladder is surgically absent. Pancreas: The pancreas is obscured by overlying bowel gas. Spleen: The spleen demonstrates normal echotexture, and measures 13.8 cm. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. There is focal narrowing of the portal vein at the hepatic hilum where there is aliasing and increased flow of the main portal vein up to 181 centimeter/second. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic artery and vein are patent, with antegrade flow. IMPRESSION: 1. Patent hepatic vasculature with improved waveforms of the hepatic arteries compared to the prior ultrasound from ___. 2. Patent portal veins, however notable area of narrowing in the main portal vein at the hepatic hilum with elevated velocities and aliasing. 3. Mild ascites and mild splenomegaly. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with increased o2 requirement // edema, pna edema, pna COMPARISON: Prior chest radiographs ___ through ___. IMPRESSION: Mild pulmonary edema persists. Cardiomediastinal and hilar silhouettes are unremarkable. Moderate right basal atelectasis is unchanged. Pleural effusions are presumed, but not substantial. There is no pneumothorax. Radiology Report INDICATION: ___ year old woman s/p liver transplant. // Assess position of pancreatic duct stent prior to removal TECHNIQUE: Frontal supine abdominal radiographs were obtained. COMPARISON: None. FINDINGS: There are surgical staples overlying the right abdomen due to the patient's recent liver transplantation. There is common bile duct stent seen in the right upper quadrant which appears to be in normal position. There is a pancreatic stent seen in the right lower quadrant which does not appear to be in appropriate position. The bowel gas pattern is unremarkable with gas seen in nondistended loops of large and small bowel. There is no evidence of ileus or obstruction. There is no evidence of intraperitoneal free air, although exam limited by supine technique. The bony structures are unremarkable. There is a calcified fibroid seen in the left lower pelvis. The smaller calcifications in the pelvis likely represent phleboliths. IMPRESSION: 1. Pancreatic stent seen in the right lower quadrant, which does not appear to be in appropriate position. 2. Non-obstructive bowel gas pattern. 3. Calcified fibroid in the left lower pelvis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ hx of hepatopulmonary syndrome, NASH cirrhosis s/p liver transplant // Chest pain/Dyspnea, r/o PTX Chest pain/Dyspnea, r/o PTX IMPRESSION: In comparison with the study of ___, the basilar atelectatic changes are less prominent. Specifically, there is no evidence of pneumothorax. PICC line extends to the mid portion of the SVC. Radiology Report INDICATION: History: ___ with PMH of hepatorenal synd inc dyspnea // Concern for PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 336 mGy-cm COMPARISON: CT on ___. FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is enlarged left axillary lymph node measuring up to 1 cm with adjacent fat stranding. The patient is status post recent left mastectomy. There is no evidence of pericardial effusion. There is no pleural effusion. There is a 6 mm right upper lobe ground-glass nodule (series 2, image 31). Additionally there is a 4 mm right upper lobe solid nodule (series 2, image 45). There is bibasilar atelectasis which is minimal. The airways are patent to the subsegmental level. Limited images of the upper abdomen show cirrhotic liver with sequela of portal hypertension including splenomegaly and abdominal and paraesophageal varices. Persistent thrombosis of the portal vein with cavernous transformation is unchanged. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Enlarged left axillary lymph nodes with left axillary fat stranding suggesting infection. With the recent left mastectomy, correlation and clinical work up is recommended. Solid and ground-glass nodules as described above. Recommend followup CT in 3 months for further evaluation. Radiology Report INDICATION: ___ year old woman intra op for liver transplant // intra-op liver transplant ultrasound, vascular patency TECHNIQUE: INTRAOPERATIVE ULTRASOUND, ABDOMEN, LIVER FINDINGS: The portal vein anastomosis, main portal vein distal and proximal to the anastomosis, left portal vein, right portal vein, right anterior and right posterior portal vein branches are all widely patent without evidence of thrombus. There is mild thickening of the wall of the extrahepatic portal vein poor just proximal to the anastomosis. Visualized hepatic veins are patent. Visualized portions of the hepatic arteries are patent and had normal-appearing waveforms. IMPRESSION: Patent portal veins without evidence of thrombus. Mild thickening of the portal venous wall at and just proximal to the anastomosis. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with liver transplant // eval lines/tubes Contact name: ___, ___: ___ TECHNIQUE: Portable semi upright chest radiograph COMPARISON: ___ FINDINGS: Endotracheal tube terminates at the level of the clavicular heads, just at the thoracic inlet. Enteric tube terminates beyond the diaphragm. A right subdiaphragmatic drain is noted. Swan-Ganz catheter likely terminates in the region of the pulmonary outflow tract. Heart size is normal and lungs are clear. No pleural effusion or pneumothorax. IMPRESSION: 1. Endotracheal tube terminates at the level of the clavicular heads and should be advanced for better positioning. 2. Swan-Ganz catheter is likely in the region of the pulmonary outflow tract. 3. No pulmonary edema or pleural effusions. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old woman with liver transplant w/ portal vein thrombectomy // ***TO BE DONE AT 7 AM ___ (POD #0) liver duplex (transplant) TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. There is minimal ___ ascites. The spleen measures 17.7 cm and has normal echotexture. DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow, except for the right hepatic artery which shows diminished diastolic flow. Peak systolic velocity in the main hepatic artery is 67 cm per second. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.81, and 0.78, respectively. The main portal vein, right and left portal veins are patent with hepatopetal flow with normal waveform. There is in increased in portal vein velocities at the region of the portal vein anastomosis, with peak velocity of 152 centimeters/second, compared to velocities of approximately 60 cm/sec proximal and distal to the anastomosis. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: Patent hepatic vasculature with focal increased velocities at the portal vein anastomosis, which could indicate an anastomotic stenosis. Doppler waveforms are otherwise normal. RECOMMENDATION(S): Repeat Doppler ultrasound in 1 or 2 days to re-evaluate portal vein velocities. Radiology Report INDICATION: ___ year old woman with evaluation post-op s/p liver transplant // evaluation COMPARISON: Radiographs from ___ IMPRESSION: Support lines and tubes are unchanged in position. Heart size is enlarged. There are new hazy opacities at the lung bases which are likely atelectasis; however, developing infiltrate particularly at the right base is not excluded. There are no pneumothoraces. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: evaluate vasculature post transplantation TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Doppler ultrasound ___ FINDINGS: This study is limited by significant overlying bowel gas. Liver: The hepatic parenchyma is within normal limits. Nofocal liver lesions are identified. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. The common bile duct measures 4 mm. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Peak main portal vein velocity near the anastomosis measures 130 cm/sec, previously up to 152 cm/sec on ___. Right and left portal veins are patent, with antegrade flow. Assessment of the main hepatic artery and right hepatic arteries are limited, but overall similar in appearance compared to the prior study performed one day earlier. Diminished or absent diastolic flow in the main hepatic artery noted. Left hepatic artery is normal, with an appropriate resistive index of 0.76. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic and superior mesenteric veins were not evaluated on the current study. IMPRESSION: 1. Limited study due to extensive overlying bowel gas. 2. Patent hepatic vasculature. 3. Diminished or absent diastolic flow in main hepatic artery may be a reversible finding in early postoperative phase, recommend attention on followup exam. RECOMMENDATION(S): Continue close follow-up as clinically appropriate. NOTIFICATION: D/w transplant team at 10:07am. Gender: F Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with RESPIRATORY ABNORM NEC, ANEMIA NOS, CHRONIC LIVER DIS NEC, HEPATOPULMONARY SYNDROME temperature: 99.3 heartrate: 74.0 resprate: 24.0 o2sat: 100.0 sbp: 105.0 dbp: 51.0 level of pain: 0 level of acuity: 2.0
___ y/o female with NASH cirrhosis, hepatopulmonary syndrome and known portal vein thrombosis who was admitted through the emergency department with shortness of breath, and during that admission phase received an offer for a liver transplant. After evaluation by the transplant team, she was deemed suitable for transplant. She accepted a donor offer and underwent liver transplant using piggyback technique and portal vein thrombectomy. Surgeons were Drs ___ and ___. Per Dr ___ note, the procedure was 50% more difficult than usual given the extensive portal vein cavernous transformation and thrombosis. Dr ___ performed the impantation of the liver, it was noted an intraoperative ultrasound was performed on the portal vein. At the end of the surgery, there was excellent flow and no visible clot in the portal vein. Two ___ ___ drains were placed with the lateral drain in the bare area of the liver and the medial drain behind the porta. Postop, she was transferred intubated to the SICU in stable condition. Routine induction immunosuppression was given (Solu medrol, Cellcept). Cellcept was continued postop and Tacrolimus was started on POD 1. Dosages were adjusted per trough levels. She was hemodynamically stable. On POD 1 she was started on heparin drip with low dose heparin secondary to the pre-op portal vein thrombus. Ultrasound showed patent hepatic vasculature with focal increased velocities at the portal vein anastomosis. Doppler waveforms are otherwise normal. On POD 2, during a CVL removal, she experienced an air emboli and became hypoxic. Neuro exam was intact. She was reintubated. An echo was performed showing mildly depressed left ventricular systolic function and Air bubbles in the left atrium and ventricle. On POD 3, repeat liver ultrasound showed a limited study due to extensive overlying bowel gas with patent hepatic vasculature. There was a report of diminished or absent diastolic flow in main hepatic artery, attributed to possible reversible finding in early postoperative phase. Another ultrasound was done on POD 12 showing patent main portal vein, with flow in the appropriate direction. Focal narrowing of the portal vein at the hepatic hilum and increased flow of the main portal vein up to 181 were noted. Right and left portal veins were patent, with antegrade flow. The main hepatic artery was patent, with appropriate waveform. LFTs, peaked on POD 1, (AST 922, ALT 397, Alk phos 124, T bili 4.1,) then decreased. Heparin drip was transitioned to Lovenox on POD 4. She received 3 days of higher dose lovenox, and then was discharged on 40 mcgs daily. Following the reintubation on POD 2, the patient was able again to be extubated on POD 3. She remained on a high flow mask secondary to the hepatopulmonary syndrome with goal to keep O2 sats greater than 90%. It was anticipated that she would require O2 for a long period following transplant. A repeat echo showed there was no more PFO. O2 sats were stable with some desats into the 80's with movement. She transferred out of the SICU surgical on POD 5. LFTs were monitored daily and were decreasing, (AST, ALT and T Bili were WNL by time of discharge. The alk phos took a mild increase around POD 12, but was again decreasing although not within normal range by time of discharge. An insulin drip was started in the SICU when blood sugars were elevated. A ___ consult was obtained, and insulin regimen adjusted with improved control. The plan was to follow up as an outpatient with the ___ team. Patient was seen by podiatry for complaint of red nailbed on ___ toe of left foot.Redness was felt to be due to irritation from a long toenail. There was low suspicion for infection. All toe nails were trimmed. Psychiatry was also consulted per patient request regarding management of her anxiety. Some medication adjustments were made, but there were some modifications required due to drug interactions. Patient requested to continue with psychiatry follow up when she transferred to ___ as part of her outpatient care planning. Just prior to discharge she was again seen with final medication recommendations noted in the discharge med list. Prophylactic antibiotics were continued (fluconazole, valganciclovir and Bactrim). Of note, she had a VRE UTI on POD 4 which was treated with Linezolid. About one week later she was agian having UTI symptoms and a culture showed greater then 100,000 E coli. Cefepime was started then changed to Augmentin at time of discharge. The medial JP drain was removed on POD 10. On POD 12, the lateral JP drain output was noted to appear increasingly bilious. A drain bili was sent and returned at 16.9 (serum 0.8 that day) She was scheduled for ERCP the following day. There was difficulty cannulating the duct, and a pancreatic drain was placed in addition to a common bile duct stent. JP drainage decreased in volume and was non-bilious. This drain was removed just prior to discharge. She did have post ERCP pancreatitis with an increase in the amylase and lipase to 307/417 and some mild epigastric discomfort. Diet was kept at clears for an additional 24 hours with good resolution of symptoms as well as decrease in the amylase and lipase. She was accepted at ___ for continued rehab for pulmonary needs. Liver function was great. Mobility was limited due to pulmonary status and deconditioning. At time of discharge, she was tolerating a regular diet, voiding without difficulty and had return of bowel function.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R frontal contusion Major Surgical or Invasive Procedure: none. History of Present Illness: ___ w/ h/o dementia, presents s/p unwitnessed fall. Last evening, pt found down at ___. Noted to have L periorbital echymosis, abrasions. Confused at baseline. On IV Imipenem/cilastatin for UTI, PICC line placed today. pt. is a transfer from ___ for a right frontal lobe hemmorage, s/p a fall. pt. at baseline MS. ___ dementia. on daily ASA. arrives with a foley, a ___ line Past Medical History: Severe dementia Social History: ___ Family History: NC Physical Exam: Admission PE: AVSS Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Awake, severely confused, oriented x self only follows simple commands throughout PERRL, EOMI, FSTM No drift MAE ___ sensation intact throughout Discharge PE: A+O to self, profoundly confused, aphasic, PERRLA, slight left and no L forehead wrinkles, tongue midline, follows simple commands x4. Pertinent Results: ___ 03:15AM WBC-5.8 RBC-3.72* HGB-10.4* HCT-31.0* MCV-84 MCH-28.0 MCHC-33.5 RDW-13.1 Medications on Admission: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. Docusate Sodium 100 mg PO BID 3. Fluoxetine 20 mg PO DAILY 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 4. Levothyroxine Sodium 75 mcg PO DAILY 5. OLANZapine 15 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Senna 17.2 mg PO HS 8. imipenem-cilastatin 500 mg intravenous q6h Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Docusate Sodium 100 mg PO BID 4. Fluoxetine 20 mg PO DAILY 5. LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 6. Levothyroxine Sodium 75 mcg PO DAILY 7. OLANZapine 15 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Senna 17.2 mg PO HS 10. imipenem-cilastatin 500 mg intravenous q6h Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: R frontal contusion, left inferior frontal mass Discharge Condition: Baseline dementia. WBAT BLE. Ambulate BID as able. Followup Instructions: ___ Radiology Report EXAMINATION: Trauma series radiographs INDICATION: Unwitnessed fall with intracranial hemorrhage. TECHNIQUE: Frontal and a repeat frontal views of the chest, frontal view of the pelvis. COMPARISON: None. FINDINGS: Chest: Heart size is normal with mild tortuosity of the thoracic aorta. The mediastinal and hilar contours are normal. Lungs are clear. The pleural surfaces are clear without effusion or pneumothorax. No overt traumatic findings. Right-sided PICC terminates at the cavoatrial junction. Pelvis: Pelvic ring is intact without fracture or dislocation. Mild bilateral hip degenerative change. Mild degenerative changes of the imaged lumbar spine. Pubic symphysis and SI joints are preserved. IMPRESSION: 1. No acute intrathoracic abnormality. 2. No overt traumatic findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with intracranial hemorrhage TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: DLP: 2230 mGy-cm COMPARISON: Noncontrast head CT study from ___ at 1:00. FINDINGS: There is re- demonstration of a small acute intraparenchymal hemorrhage in the right frontal lobe, stable in size and configuration compared to prior study from earlier today. In addition, there is a linear hyperdensity in the dependent portion of the right lateral ventricle occipital horn, concerning for a small intraventricular bleed, which was also previously seen. A predominantly hypodense mass in the left frontal lobe is again seen, which appears to cross midline through the head of the corpus callosum into the contralateral hemisphere and measuring approximately 3.6 x 2.1 cm. There is a small hyperdense internal component which could reflect internal bleed. Overall, this mass appears unchanged compared to prior study. There appears to be unchanged associated vasogenic edema and local mass effect. The ventricles and sulci are moderately prominent due to age-related cerebral atrophy. The basal cisterns appear patent. There is subcortical and periventricular white matter hypodensities, which are most likely sequela of chronic small vessel ischemic disease. Small hypodensity in the left basal ganglia likely represents an old lacunar infarct. The visualized bony structures are grossly unremarkable. There is mild mucosal thickening in the anterior ethmoidal air cells. The frontal and maxillary sinuses, mastoid air cells, and middle ear cavities are clear. Atherosclerotic mural calcification of the bilateral internal carotid arteries is noted. The globes are unremarkable. IMPRESSION: 1. Compared to earlier study, there is stable small intraparenchymal hemorrhage in the right frontal lobe and tiny amount of blood within the occipital horn of the right lateral ventricle. 2. Redemonstration of a large left frontal mass which appears to extend to the contralateral hemisphere through the corpus callosum head. MRI is recommended for further characterization. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with PICC, please evaluate for placement // ___ year old man with PICC, please evaluate for placement Contact name: ___ ___: ___ year old man with PICC, please evaluate for placement COMPARISON: Chest radiograph ___, 3:47. IMPRESSION: Right PIC line ends at the superior cavoatrial junction. Lungs clear. Normal cardiomediastinal silhouette and pleural surfaces. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with traumatic SAH s/p fall // ___ year old man with traumatic SAH s/p fall TECHNIQUE: Routine MDCT axial imaging was obtained of the brain without the administration intravenous contrast material. Coronal and sagittal reformats were obtained. DOSE: DLP: 2229 point mGy-cm; CTDI: 55.7 mGy COMPARISON: CT head without contrast from ___. FINDINGS: Again seen is a small focus of intraparenchymal hemorrhage in the right frontal lobe measuring 6 mm unchanged since the previous exam. A small linear hyperdensity within the occipital horn of the right lateral ventricle persists possibly representing a small amount of intraventricular hemorrhage (series 3, image 21). The hypodense left frontal mass extending into the rostrum of the corpus callosum with a small central focus of hyperdensity is unchanged. There is no evidence of new hemorrhage or of infarction. The ventricles and sulci remain enlarged, although unchanged in size and configuration compared to the prior study. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. There is no acute fracture. IMPRESSION: 1. Stable right frontal lobe intraparenchymal hemorrhage and stable possible right intraventricular hemorrhage. 2. Unchanged left frontal lobe mass for which further evaluation with MRI is recommended. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, ICH Diagnosed with SUBARACHNOID HEM-NO COMA, OTHER FALL temperature: 98.0 heartrate: 70.0 resprate: 16.0 o2sat: 99.0 sbp: 166.0 dbp: 93.0 level of pain: 13 level of acuity: 2.0
Patient was brought to ED with profound dementia at baseline, stable repeat head CT w/ R frontal contusion and large left frontal mass. Keppra x7d, hold asa tx initiated. No MRI or work up for mass indicated. indicated given age and mental status. Pt presenteed with UTI tx w/IV abx via ___. SW consulted. Pt retutned to nursing home HD2.