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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. |