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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / aspirin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo ___ man with COPD,
hypertension, and pre-diabetes presenting for evaluation of
chest pain.
He was previously seen in the ED on ___ and was discharged 2
hrs prior to presentation with a diagnosis of GERD. He had left
sided chest pain that started at 10AM. A single troponin was
negative and pain subsided prior to discharge. Pain described as
constant in L side of chest, radiating to left upper shoulder.
He had pain with inspiration as well. He describes very minor
difficulty breathing. No fever/chills, n/v/d, abd pain, dysuria,
or any other concerns.
Of note, he had a clean catheterization and admission in ___.
Vitals in the ED: 97.8 73 159/65 16 100%. Labs notable for: Hct
37.7 (baseline 41), Cr 1.3 (baseline ___, Na 146. Initial
trop <0.01 but second trop 0.15. On physical exam, he was very
uncomfortable and was clutching his chest/back. CTA showed no PE
or evidence of aortic dissection. EKG showed bradycardia at 57.
TWI ii, iii, avf, v4-v6. Guaiac was negative. In the ED, he
received 1L NS for SBP in the ___, IV morphine, po ASA 324, 80
mg atorvastatin, IV dilaudid, and was placed on a heparin drip.
Cardiology was consulted and he was admitted to ___ for further
managment. Vitals prior to transfer: 97.4 62 120/74 16 100% RA.
On the floor, the patient denied any chest pain and stated that
he was thirsty. Otherwise, no complaints.
Past Medical History:
- COPD, Gold stage II
- BPH s/p TURP
- HTN
- GERD
- Tobacco abuse
- Hydrocele
- Pre-DM (A1C 6.0% ___
Social History:
___
Family History:
No history of early MI, SCD, CHF
Physical Exam:
Admission Physical Exam:
========================
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=============================
Discharge Physical Exam:
Vitals - 98.6 ((Tmax 98.8) 154/75 (90/68-162/66) 60 (52-115) 20
99% RA (99-100% RA)
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
===============
___ 05:00PM BLOOD WBC-6.5# RBC-4.46* Hgb-13.7* Hct-39.5*
MCV-88 MCH-30.8 MCHC-34.8 RDW-13.9 Plt ___
___ 05:00PM BLOOD Neuts-68.7 ___ Monos-5.6 Eos-4.3*
Baso-0.5
___ 05:00PM BLOOD Glucose-105* UreaN-23* Creat-1.3* Na-139
K-5.0 Cl-105 HCO3-24 AnGap-15
Pertinent Results:
===================
___ 05:00PM BLOOD cTropnT-<0.01
___ 02:20AM BLOOD cTropnT-0.15*
___ 09:20AM BLOOD CK-MB-10 MB Indx-6.7* cTropnT-0.12*
Imaging:
=========
___ CXR:
Frontal and lateral radiographs demonstrate hyperexpanded, clear
lungs. The
cardiomediastinal and hilar contours are unchanged. There is no
pneumothorax,
pleural effusion, or consolidation.
___ CTA:
No evidence of pulmonary embolism or aortic abnormality.
___ Echo:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. 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.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Discharge Labs:
================
___ 05:15AM BLOOD WBC-5.3 RBC-4.02* Hgb-12.4* Hct-35.2*
MCV-88 MCH-30.8 MCHC-35.2* RDW-14.1 Plt ___
___ 05:15AM BLOOD ___ PTT-49.0* ___
___ 05:15AM BLOOD Glucose-93 UreaN-15 Creat-1.2 Na-141
K-4.2 Cl-105 HCO3-29 AnGap-11
___ 05:15AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob, wheeze
2. Citalopram 10 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Ranitidine 150 mg PO BID dyspepsia
6. Tiotropium Bromide 1 CAP IH DAILY
7. TraZODone 25 mg PO HS:PRN insomnia
8. Atorvastatin 10 mg PO DAILY
9. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
0 unknown ORAL DAILY
10. Aspirin 81 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob, wheeze
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Citalopram 10 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. Ranitidine 150 mg PO BID dyspepsia
10. Tiotropium Bromide 1 CAP IH DAILY
11. TraZODone 25 mg PO HS:PRN insomnia
12. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
13. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B
complex) 0 unknown ORAL DAILY
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six hours as
needed for Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Chest pain, tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: Chest pain radiating to the back. Evaluate for dissection.
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: 271.0 mGy-cm
COMPARISON: None available.
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. Mild calcification is noted.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
Severe centrilobular emphysema is predominantly within the upper lobes. No
focal consolidation, pleural effusion, or pneumothorax is identified.
Dependent atelectasis is minimal bilaterally.
Except for a hiatal hernia, limited images of the upper abdomen are
unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS
temperature: 97.8
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 159.0
dbp: 65.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ with COPD, hypertension, and
pre-diabetes who presented for evaluation of chest pain, with
positive troponin concerning for NSTEMI.
# NSTEMI: Presented to the ED with chest pain. EKG notable for T
wave inversions, unchanged from prior EKG. Initial troponin was
negative, but second set returned elevated at 0.15. He received
ASA 324, atorvastatin 80, and was started on a heparin drip. His
third troponin was 0.12. He was started on low dose metoprolol
XL 12.5mg. He had a CTA that ruled out PE. There was no evidence
of pericarditis/myocarditis clinically or on EKG. ACS was
thought to be unlikely given ___ cath that revealed
clean coronaries. He had a repeat echo that was negative for any
new wall motion abnormalities. His pain was thought to be most
likely secondary to costochondritis vs. GERD. Pain was
intermittenly reproducible with palpation. He was discharged
with tramadol and was instructed to continue taking omeprazole
and ranitidine to control symptoms of GERD. In addition, he was
noted to have several brief episodes of SVT on telemetry, and
was discharged with ___ of Hearts for further monitoring and
potential correlation with symptoms.
#Depression: continued citalopram
#HTN: continued HCTZ, lisinopril
#GERD: continued omeprazole/ranitidine
#COPD: continued albuterol and tiotropium. |
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, left facial droop, L sided tingling, L enlarged pupil
Major Surgical or Invasive Procedure:
trigger point injections
History of Present Illness:
Mrs. ___ is a -___ right-handed woman presenting with
purported left facial weakness on a background of an undiagnosed
paroxysmal disorder, undergoing work-up for seizures, along with
unlateral pulsatile headaches.
She awoke with a severe headache this morning. Her daughter
came
down stairs, from where she lives, at about 10 AM, the patient
guesses. Her daughter noted that the patient was unable to
speak
- the patient does not know exactly what her daughter noted, but
she endorses slow, slurred speech with word-finding
difficulties.
Her daughter noted a left facial droop. At the same time, her
husband arrived home. He took her to the emergency department
immediately (___). It seems that they may have also
contacted her neurologist at ___ in the
meantime. He has been working her up for seizures, and she was
due to get her first EEG today.
The patient recalls waking with a bifrontal pulsatile headache,
nausea, lightheadedness, feel 'tunnelly', without tunnel vision
that she could not further explain. Her hearing also seemed
off.
She did not note weakness or numbness. She felt chest pressure
and got up to splash water on her face shortly before her
daughter arrived. She was in the middle of taking her
medications, does not think that she finished taking them this
AM.
No recent illness. Husband has cold and sleeping in another
room
(not present to witness patient's sleep last night). Review of
systems negative except as above.
Past Medical History:
Past Medical History:
- ___ years ago, a friend with a child with a seizure disorder,
noted that she had a seizure while sleeping and woke her up.
She
has sometimes felt spacey in the morning and has frequently had
a
headache on waking. She also, about two months ago, saw a flash
of light as a train went by. The next thing she knew, she was
on
the ground and her friend told her that she had a convulsion.
Hence, work-up with a neurologist at ___ Neuro___.
EEG
was planned for today and she thinks that she now takes Topamax
(not on the list she brought).
- Hypercholesterolemia
- Hypertension
- Arthiritis
- Denies depression, says her family need venlafaxine
Social History:
___
Family History:
Mother DM
Father ___ Cancer
Siblings Brother (___)- Brain tumor, Sister - ___
Other ___ Grandmother, aunts, cousins - ___ Cancer
Physical Exam:
Vitals: 90 BPM 147/95 mmHg, 12 breaths, 97% RA
General Appearance: Overweight. Comfortable, no apparent
distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Neurologic:
Mental status:
Mildly somnolent, bradyphrenic. Speaks slowly, but fluent,
normal comprehension, repetition, naming. No paraphasic errors.
Oriented to self, month, year, eventually offered the date
correctly, context. Inattentive ___ ... ___ ... lost
train), therefore memory not tested. Vague memory for this AM
as
above, but good memory for events prior (yesterday).
Cranial Nerves:
I: Not tested.
II: Left pupil large and sluggish. Both react. Visual fields
are
full to confrontation. Normal fundi.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength mildly down on left and sensation intact
and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Tone normal throughout. Normal bulk.
Drift with wavering and no pronation of both arms.
Power
D B T WE WF FF FAb | IP Q H AT G/S ___ TF
R ___ ___ 5 | ___ ___ 5
L ___ ___ 5 | ___ ___ 5
Reflexes: B T Br Pa Ac
Right ___ 2 1
Left ___ 2 1
Toes downgoing bilaterally
Sensation diminished to light touch and pain on left leg,
symmetrical in arms (but on arrival withdrew on right, not on
left arm).
Normal finger nose, RAM's bilaterally.
Gait:
Not tested.
Discharge:
Improved giveaway weakness and functional tremor on R side. No
droop.
Pertinent Results:
___ 01:15PM BLOOD ___ PTT-31.6 ___
___ 01:21PM BLOOD Creat-0.8
___ 01:15PM BLOOD UreaN-12
___ 01:20PM BLOOD Glucose-110* Na-144 K-4.1 Cl-106
calHCO3-21
CT/CTA:
Noncontrast head CT: There is no hemorrhage, edema, mass effect
or acute
large territory infarct. The ventricles and sulci are normal in
size and
configuration for age. The basal cisterns are patent and there
is
preservation of gray-white matter differentiation. No fracture
is identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. The globes are
unremarkable.
CTA head and neck: The vertebral arteries are widely patent
without evidence of flow-limiting stenosis or dissection. The
internal carotid arteries are widely patent without evidence of
flow-limiting stenosis or dissection. The distal internal
carotid arteries measure 4.1 mm in diameter on the right and 3.9
mm on the left. The thyroid is unremarkable in appearance the
trachea is midline. The visualized lung apices are clear. A
right dominant vertebrobasilar system with mildly hypoplastic
left vertebral artery is identified with normal takeoff of the
superior cerebellar and posterior cerebral arteries without
evidence of flow-limiting stenosis or aneurysm greater than 3
mm. The supraclinoid internal carotid arteries are widely
patent with normal takeoff of the middle cerebral and anterior
cerebral arteries without evidence of flow-limiting stenosis or
aneurysm greater than 3 mm. There is normal, symmetric distal
embolization of vessels. No other vascular abnormality is
identified.
IMPRESSION:
No cervical vessel flow-limiting stenosis or dissection. No
intracranial
vessel flow-limiting stenosis or aneurysm.
MRI: IMPRESSION: Signal abnormalities in the left superior
cerebellar hemisphere adjacent vermis may be due to focal
cerebellar dysplasia. A focal cerebellar diaschisis is also
considered but appears less likely. No enhancing lesions are
seen. No focal abnormalities in frontal or temporal lobes. No
signs of mesial temporal sclerosis.
EEG:
Medications on Admission:
- ASA 81 mg QD
- Venlafaxine 75 mg QD
- Gabapentin 200 mg BID (joint pain)
- Fenofibrate 134 mg QD
- Simvastatin 40 mg HS
- Quetiapine 200 mg HS (pain and sleep)
- Clonidine 0.1 mg BID
- Meloxicam 15 mg QD
- Metoprolol 25 mg BID
- Vitamin D 50k units ___
- Clonazepam 0.5 - 1 mg PRN (not taking)
- Possibly taking Topamax
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. CloniDINE 0.1 mg PO BID
3. fenofibrate *NF* 145 mg ORAL DAILY Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
4. Gabapentin 200 mg PO BID
5. Ibuprofen 400-600 mg PO Q8H:PRN headache
Please do not take more than twice per week on a regular basis
6. Metoprolol Tartrate 25 mg PO BID
7. Venlafaxine XR 75 mg PO DAILY
8. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
9. Topiramate (Topamax) 50 mg PO BID
10. Simvastatin 40 mg PO HS
11. Quetiapine Fumarate 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
acute migraine attack with aura
chronic tension type headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Left facial droop and left-sided weakness.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Subsequently, rapid axial imaging was performed from the aortic
arch to the head during the administration of IV contrast. Multiplanar
maximum intensity projection images were generated in the axial, coronal and
sagittal planes. Additional 3D reformats were generated on a separate
workstation for review.
DLP: 2386.26 mGy-cm..
COMPARISON: MR head ___.
FINDINGS:
Noncontrast head CT: There is no hemorrhage, edema, mass effect or acute
large territory infarct. The ventricles and sulci are normal in size and
configuration for age. The basal cisterns are patent and there is
preservation of gray-white matter differentiation. No fracture is identified.
The visualized paranasal sinuses, mastoid air cells and middle ear cavities
are clear. The globes are unremarkable.
CTA head and neck: The vertebral arteries are widely patent without evidence
of flow-limiting stenosis or dissection. The internal carotid arteries are
widely patent without evidence of flow-limiting stenosis or dissection. The
distal internal carotid arteries measure 4.1 mm in diameter on the right and
3.9 mm on the left.
The thyroid is unremarkable in appearance the trachea is midline. The
visualized lung apices are clear.
A right dominant vertebrobasilar system with mildly hypoplastic left vertebral
artery is identified with normal takeoff of the superior cerebellar and
posterior cerebral arteries without evidence of flow-limiting stenosis or
aneurysm greater than 3 mm. The supraclinoid internal carotid arteries are
widely patent with normal takeoff of the middle cerebral and anterior cerebral
arteries without evidence of flow-limiting stenosis or aneurysm greater than 3
mm. There is normal, symmetric distal embolization of vessels. No other
vascular abnormality is identified.
IMPRESSION:
No cervical vessel flow-limiting stenosis or dissection. No intracranial
vessel flow-limiting stenosis or aneurysm.
A wet read was entered into this system by Dr. ___ on ___ at
13:55.
Radiology Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with symptomatic epilepsy for further
evaluation. The frontal areas of interest.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion
axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal
images acquired following gadolinium. There are no prior similar examinations
for comparison.
FINDINGS: There is no acute infarct seen, mass effect, or hydrocephalus
identified.
In the left superior cerebellar hemisphere and adjacent vermis, the linear
signal abnormalities are seen, which could be due to focal cerebellar
dysplasia or atrophy. There is no abnormal enhancement seen in this region.
There are no other focal abnormalities within the brain. In particular, no
focal abnormalities are seen or cortical abnormalities noted in the frontal
lobes. No hippocampal abnormalities are seen or atrophy noted. There is no
evidence of blood products. No abnormal parenchymal, vascular, or meningeal
enhancement seen.
IMPRESSION: Signal abnormalities in the left superior cerebellar hemisphere
adjacent vermis may be due to focal cerebellar dysplasia. A focal cerebellar
diaschisis is also considered but appears less likely. No enhancing lesions
are seen. No focal abnormalities in frontal or temporal lobes. No signs of
mesial temporal sclerosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: STROKE
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mrs. ___ was admitted for severe holocephalic headache with
nausea, photo- and phonophobia, that was accompanied by
transient L sided tingling, a left facial droop, and a left
enlarged pupil.
Her symptoms were consistent with a migraine attack and improved
upon treatment with toradol and iv fluids. Her CT and CTA were
normal, her MRI showed a small cerebellar signal abnormality,
consistent with a focal dysplasia, which had been present on her
prior MRIs as well.
In addition, she has daily chronic tension type headaches with
tense neck muscles. Hot packs helped with her symptoms. She can
be started on tizanidine if needed.
She was seen by our pain service, who recommended outpatient
follow up in our pain clinic for botox injections.
Her EEG monitoring over 48hrs did not capture any of her falling
events, but was completely normal, making a seizure as the cause
of her falls very unlikely.
Since OSA could be contributing to her headache, we told her to
follow up in our sleep clinic as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with a history of apical
variant hypertrophic cardiomyopathy, paroxysmal atrial
fibrillation, pancreatic neuroendocrine tumor, prostate cancer,
who presents with syncope. He was standing in ___ after a
long day when he had a syncopal episode. He had a prodrome of
lightheadedness. Prior to going to ___ he had one vodka drink
and smoked some marijuana. One day prior he experienced
palpitations which he is known to have with his a-fib. Initially
his ECG was concerning for STE in the anterior leads but repeat
ECG reviewed by cardiology was more consistent with his baseline
hypertrophic cardiomyopathy and repolarization abnormalities. He
received a full dose aspirin from EMS.
Past Medical History:
- Apical variant hypertrophic cardiomyopathy
- GERD
- Paroxysmal atrial fibrillation (follows with ___
- Prostate cancer (s/p prostatectomy in ___ follows with GU
oncology at ___
- Pancreatic neuroendocrine tumor (s/p robotic distal
pancreatectomy and splenectomy ___, follows with ML ___,
no
evidence of disease recurrence)
- Vasovagal syncope
Social History:
___
Family History:
His family history is negative for gastrointestinal malignancy.
His father had prostate cancer. A brother and his mother had
coronary artery disease, and his mother and uncle also have type
II diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM
dry
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Weight: 79.6 kg
VS: Afebrile, 125/75, 58, 18, 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM
dry
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EKG: Repolarization changes in V1-V6, II, III, aVF, similar to
prior ECGs
Telemetry: No events, SR/SB HR 58-60's, rare PAC's
Pertinent Results:
ADMISSION RESULTS:
___ 09:10PM BLOOD WBC-12.8* RBC-5.44 Hgb-16.8 Hct-49.9
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.4 RDWSD-48.0* Plt ___
___ 09:10PM BLOOD Neuts-59.3 ___ Monos-8.9 Eos-0.5*
Baso-0.6 Im ___ AbsNeut-7.58* AbsLymp-3.89* AbsMono-1.14*
AbsEos-0.07 AbsBaso-0.08
___ 09:10PM BLOOD Glucose-141* UreaN-25* Creat-0.9 Na-142
K-6.1* Cl-104 HCO3-20* AnGap-18
___ 09:10PM BLOOD ALT-25 AST-53* CK(CPK)-237 AlkPhos-35*
TotBili-0.6
___ 09:10PM BLOOD cTropnT-<0.01
___ 09:10PM BLOOD CK-MB-4
___ 09:10PM BLOOD Lipase-37
___ 09:10PM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.9 Mg-2.1
___ 09:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE RESULTS:
___ 02:45AM BLOOD WBC-11.1* RBC-4.60 Hgb-14.2 Hct-42.2
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.4 RDWSD-48.2* Plt ___
___ 02:45AM BLOOD Glucose-168* UreaN-24* Creat-1.0 Na-142
K-4.6 Cl-108 HCO3-24 AnGap-10
___ 02:45AM BLOOD CK(CPK)-114
___ 02:45AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:45AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.0
TTE ___:
The left atrial volume index is normal. The right atrium is
moderately enlarged. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. Global left ventricular
systolic function is hyperdynamic. Quantitative biplane left
ventricular ejection fraction is 87 %. The visually estimated
left ventricular ejection fraction is 80%. There is no left
ventricular outflow tract gradient at rest or with Valsalva.
Mildly dilated right ventricular cavity with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal
ascending aorta diameter for gender. The aortic arch diameter is
normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is trace aortic
regurgitation. The mitral leaflets are mildly thickened. No
valvular systolic anterior motion (___) is present. There is no
mitral valve stenosis. There is trivial mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is trivial tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. IMPRESSION: Adequate image
quality. Hypertrophic, hyperdynamic left ventricle without
demonstrable outflow tract obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Rivaroxaban 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Lisinopril 2.5 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Physical Exam:
VS: Afebrile, 125/75, 58, 18, 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM
dry
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EKG: Repolarization changes in V1-V6, II, III, aVF, similar to
prior ECGs
Telemetry: No events, SR/SB HR 58-60's, rare PAC's
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with syncope, leukocytosis// Pneumonia?
COMPARISON: Chest radiograph ___
FINDINGS:
Portable upright AP view of the chest provided.
No focal consolidation. No pleural effusion or pneumothorax. Heart size is
mildly enlarged, unchanged from prior. Aorta is tortuous. Cardiomediastinal
silhouette is otherwise within normal limits.
IMPRESSION:
Unchanged mild cardiomegaly. No focal consolidation.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: STEMI
Diagnosed with Syncope and collapse
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | ASSESSMENT & PLAN: ___ with a history of apical variant
hypertrophic cardiomyopathy, paroxysmal atrial fibrillation,
pancreatic neuroendocrine tumor, prostate cancer, who presents
with syncope.
#SYNCOPE: Prodromal symptoms of lightheadedness and dizziness
are classic for vasovagal syncope, possibly brought on by
marijuana/ETOH use earlier in the day and/or dehydration. Denies
any palpitations leading up to syncopal episode. He has a
history of vasovagal syncope as well. No chest pain or cardiac
enzyme elevations. No arrhythmias noted on telemetry,
orthostatic VS normal. TTE shows hyperdynamic LV with no
demonstrable outflow tract obstruction.
- Reduce lisinopril from 5 mg daily to 2.5 mg daily
- Increase metoprolol from 12.5 mg daily to 12.5 mg BID
- Follow up with cardiologist, Dr. ___, in 1 month
#HYPERTENSION: BP today 120-130's/70's.
- Reduce lisinopril and increase metoprolol as noted above
#PAROXYSMAL ATRIAL FIBRILLIATON: Recent Ziopatch revealed no
frequent episodes of a-fib.
- Continue rivaroxaban
- Continue metoprolol as noted above
#GERD:
- Continue omeprazole
#DISPO: Discharge home today, above plan discussed with ___
attending Dr. ___. Follow up with PCP ___ ___ weeks for
routine post hospital care and follow up with cardiologist, Dr.
___, in 1 month. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Tylenol / sulfur dioxide
Attending: ___.
Chief Complaint:
Right leg pain and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old right handed man with past history
of a motorcycle accident in ___ which required two surgeries to
his cervical spine (___ in ___ and lumbar spine
(L1-L3
laminectomy and fusion also in ___ ___ who presented as a
transfer from ___ with concern for traumatic cord
compression. Per the patient's report, he had been in his usual
state of health prior to the evening of ___ at 0000hrs at
which time he was walking down his stairs and fell over his dog
resulting in impact to the sacral bone multiple times "like a
child riding down steps on his bottom." He noted immediate pain
which felt like a shock in a sciatic pattern down the right leg,
which caused him to hop a number of times. He was able to
ambulate without trouble, just persistent pain to the lower back
which was mild-moderate.
On waking up in the morning through the early afternoon, he
noted
the sensation of "pins and needles" in the right leg and some
weakness, but could ambulate. In the early afternoon he noted
the paresthesia had worsened and while watching TV had an
episode
of urinary incontinence which he felt no urge, or sensation of
voiding. This prompted presentation to the ED at ___
___
where a second episode of urinary incontinence only with a hint
of urge prior to void was experienced. A CT of the lumbar spine
was suggestive of disk disease which combined with his
presentation was concerning for cord compression for which
transfer to ___ was initiated and a code cord was called on
arrival.
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 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. Denies rash.
Past Medical History:
- Motorcycle accident in ___ with anterior cervical fusion C5-7
and L4-S1 Laminectomy and fusion with some residual pain
- Type I Diabetes (diagnosed approx ___ years PTA)
Social History:
___
Family History:
- Negative for any history of neurologic illness
Physical Exam:
Admission exam:
___ in ___ back, T=98.0F, HR=95, BP=108/53, RR=16,
SaO2=97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, obese
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Attentive, with good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-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 *4+ ___ 5 5 5
R ___ ___ 5 ___ 2 2 1 1
* possibly confounded by lower back pain
- Rectal tone intact with good sensation
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 1 1
- Plantar response was flexor on left, equivocal on right.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: Marked deficits to light touch, pinprick, cold
sensation, vibratory sense, proprioception in right lower
extremity from hip joint downward. No extinction to DSS. All
modalities were intact in the remainder of the body.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Did not assess ___ pain and weakness in RLE.
.
Discharge Exam:
99.1 98.3 ___ 18 94-97% RA
General: Comfortable in bed, NAD, ND NT.
HEENT: NC/AT, OP clear
Pulmonary: CTAB no rales rhonchi or wheeze
Cardiac: RRR, no murmurs rubs or gallops
Abdomen: soft, nontender, obese
Extremities: no edema, cyanosis, or clubbing. warm and well
perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Speech was not dysarthric. Able to follow both midline
andappendicular
commands. Attentive, with good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. Fundoscopy deferred.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, temperature in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically, no dysphonia.
XI: ___ strength in trapezii 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
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor on left and right.
-Sensory: The majority of the right leg distal to the inguinal
fold is approximately 85% to touch and temperature as compared
to the left with the exception of the ___ and ___ toes, which
are approximately 20% of their counterparts on the left.
Proprioception is mildly affected and vibratory sense moderately
affected.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Able to ambulate self with crutches.
Pertinent Results:
Admission results:
___ 10:50PM BLOOD WBC-10.1 RBC-5.36 Hgb-16.1 Hct-44.2
MCV-83 MCH-30.0 MCHC-36.3* RDW-13.1 Plt ___
___ 10:50PM BLOOD Neuts-60.0 ___ Monos-4.5 Eos-3.7
Baso-1.3
___ 10:50PM BLOOD Plt ___
___ 06:41AM BLOOD ___ PTT-33.6 ___
___ 10:50PM BLOOD Glucose-266* UreaN-11 Creat-0.6 Na-138
K-4.6 Cl-103 HCO3-24 AnGap-16
___ 06:41AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8
.
Reports
MRI C/T/L Spine ___
The study limited by motion artifact.
There are postsurgical changes from anterior fusion of C5-C7.
There are mild disc osteophyte complexes in the cervical spine
without significant canal stenosis.
.
The thoracic spine is unremarkable.
.
There are postsurgical changes from posterior fusion of L4-S1.
There is no
significant canal stenosis. There are degenerate changes of the
lower lumbar
spine.
.
The coccyx is not imaged.
.
IMPRESSION:
The study limited by motion artifact. No evidence of cord
compression.
.
MRI ___
FINDINGS:
The study is somewhatlimited by motion artifact. Alignment of
the lumbar spine is normal. The conus medullaris ends at L1.
The patient is status post laminectomy and fusion from L4-S1.
There are postoperative changes at these levels. Otherwise,
vertebral body and intervertebral disc signal intensity appears
normal. There is no evidence of significant encroachment on the
thecal sac.
.
Artifacts from the fusion hardware compromise images of the
neural foramina at L4-5 and L5-S1. However, there is no
evidence of nerve root compression, foraminal narrowing, or
thecal sac compromise. There is expected postoperative
enhancement, with no evidence of infection.
.
IMPRESSION:
Technically limited study due to motion artifact. Status post
laminectomy and fusion L4-S1. No evidence of conus medullaris
or thecal sac compression.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Glargine 20 Units Bedtime
3. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous
unknown
sliding scale but details unknown
Discharge Medications:
1. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous
unknown
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Glargine 25 Units Bedtime
4. Gabapentin 1200 mg PO Q8H
RX *gabapentin 600 mg 2 tablet(s) by mouth every 8 hours Disp
#*45 Capsule Refills:*1
5. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth every four hours
Disp #*30 Tablet Refills:*0
6. OxyCODONE SR (OxyconTIN) 80 mg PO Q12H
RX *oxycodone [OxyContin] 80 mg 1 tablet extended release 12
hr(s) by mouth every 12 hours Disp #*30 Tablet Refills:*0
7. Outpatient Physical Therapy
Outpatient physical therapy for right leg strength and balance
exercises.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Conus medullaris contusion
Secondary diagnosis: Diabetes mellitus, type 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Urinary incontinence.
TECHNIQUE: Sagittal imaging was performed with T2-T1, and ___ technique.
Axial T2 weighted imaging was performed through the lower lumbar spine. After
administration of intravenous contrast, axial and sagittal T1 weighted imaging
were performed.
COMPARISON: Spine MR ___.
FINDINGS:
The study is somewhatlimited by motion artifact. Alignment of the lumbar spine
is normal. The conus medullaris ends at L1. The patient is status post
laminectomy and fusion from L4-S1. There are postoperative changes at these
levels. Otherwise, vertebral body and intervertebral disc signal intensity
appears normal. There is no evidence of significant encroachment on the
thecal sac.
Artifacts from the fusion hardware compromise images of the neural foramina at
L4-5 and L5-S1. However, there is no evidence of nerve root compression,
foraminal narrowing, or thecal sac compromise. There is expected
postoperative enhancement, with no evidence of infection.
IMPRESSION:
Technically limited study due to motion artifact. Status post laminectomy and
fusion L4-S1. No evidence of conus medullaris or thecal sac compression.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Numbness
Diagnosed with BACKACHE NOS, OTHER MALAISE AND FATIGUE
temperature: 96.2
heartrate: 82.0
resprate: 20.0
o2sat: 95.0
sbp: 106.0
dbp: 63.0
level of pain: 8
level of acuity: 2.0 | ___ h/o cervical + lumbar lami-fusion presenting s/p
sacral/lumbar trauma with right leg weakness/numbness and
urinary incontinence concerning for conus medullaris syndrome
but with MRI L-spine negative x2 for conus/cauda/cord
compression. He was diagnosed with a CONUS MEDULLARIS CONTUSION,
the pain and weakness from which resolved during his
hospitalization. The day after admission, his urinary symptoms
normalized and did not recur.
.
ACTIVE ISSUES
# CONUS MEDULLARIS CONTUSION: The patient had severe pain and
weakness of the right leg along with urinary incontinence after
sliding down a flight of stairs on his buttocks. There was
concern for conus medullaris syndrome but MRI was negative x2
for conus/cauda pathology. The day after admission, his urinary
symptoms normalized and did not recur. His pain and weakness
improved slowly. He was eventually able to mobilize himself with
crutches. His pain requirements were substantial and he required
standing gabapentin (3600mg total daily dose) and oxycontin
(80mg BID) with hydromorphone PO 4mg q4:PRN breakthrough pain.
While in house, he also received frequent IV Dilaudid, reaching
doses as high as 2.125mg q3h. He was given a prescription for
outpatient physical therapy.
.
# DM1: Asymptomatic, sugars above goal on admission. His
metformin was held while in house. Lantus was increased from 20
to 22 and then to 25. His sugars remained high, often in the
200s and 300s. He was sent home on his metformin with Lantus 25
HS and his pre-admission Humalog sliding scale.
.
INACTIVE ISSUES
NONE
.
TRANSITIONAL ISSUES
# CONUS MEDULLARIS CONTUSION: Followed for increased mobility,
continued absence of bowel/bladder symptoms. Wean analgesics as
possible.
.
# DM1: Please follow for euglycemia; adjust insulin/metformin as
needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Sulfamide / Amoxicillin / gabapentin / Lipitor / Lipitor /
lisinopril / Tetracycline
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ - Right EVD placement
___ - Angiogram
___ - IVC filter placement
___ R VP shunt placement
History of Present Illness:
___ is a ___ year old male who presented to ___
___ for altered mental status. Per the ED staff, patient was
last seen normal on ___ per ___ services, was found the
morning of ___ by ___ services incontinent of urine with
altered mental status. He was brought through the ED where CT
Head w/o contrast revealed diffuse SAH with IVH. Neurosurgery
was consulted for management. Per limited information, patient
on Coumadin for afib.
Past Medical History:
- Afib on Coumadin
- HIV
- prostate cancer
Social History:
___
Family History:
Unknown
Physical Exam:
ON ADMISSION
============
PHYSICAL EXAM:
___ and ___:
[ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[ ]Grade II: Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy.
[x]Grade III: Drowsiness/Confusion, mild focal neurological
deficit.
[ ]Grade IV: Stupor, moderate-severe hemiparesis.
[ ]Grade V: Coma, decerebrate posturing.
Fisher Grade:
[ ]1 No hemorrhage evident
[ ]2 Subarachnoid hemorrhage less than 1mm thick
[x]3 Subarachnoid hemorrhage more than 1mm thick
[ ]4 Subarachnoid hemorrhage of any thickness with IVH or
parenchymal extension
___ SAH Grading Scale:
[ ]Grade I: GCS 15, no motor deficit
[ ]Grade II: GCS ___, no motor deficit
[ ]Grade III: GCS ___, with motor deficit
[x]Grade IV: GCS ___, with or without motor deficit
[ ]Grade V: GCS ___, with or without motor deficit
___ Coma Scale:
[ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[x]2 Opens eyes to painful stimuli (briefly)
[ ]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[x]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[x]5 Localizes to painful stimuli
[ ]6 Obeys commands
10 Total
O:
T: 99.4 BP: 146/72 HR: R: O2Sats:
Gen: lethargic, catechetic
HEENT: L pupil opacified, R pupil opacified, 2mm NR
Neck: Supple.
Lungs: rhonchus
Cardiac: afib
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: lethargic,
Orientation: Oriented to person only, stated ___ to year.
stated "friend" for month.
Recall: UTA
Language: incomprehensible speech.
Cranial Nerves: UTA due to patient uncooperative/lethargic.
Motor: antigravity with bilateral ___ lift off bed and
wiggle toes. bilateral UE antigravity, R>L. will localize to
pain. did not follow commands on UE expect for mildly lift off
bed.
Sensation: UTA
Coordination: UTA
ON DISCHARGE
============
Awake, alert, oriented to self and "hospital." Intermittently
only oriented to self (mainly in the evenings). PERRL, Follows
commands. MAE full except LUE -___, slight R upward drift.
Pertinent Results:
Please see OMR for pertinent imaging & labs
___ 05:25AM BLOOD WBC-5.2 RBC-4.16* Hgb-11.6* Hct-36.6*
MCV-88 MCH-27.9 MCHC-31.7* RDW-17.2* RDWSD-54.3* Plt ___
___ 05:25AM BLOOD Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD ___ PTT-30.8 ___
___ 07:05AM BLOOD Plt ___
___ 05:25AM BLOOD Glucose-92 UreaN-8 Creat-0.5 Na-142 K-4.7
Cl-100 HCO3-32 AnGap-10
___ 07:30PM BLOOD Glucose-108* UreaN-8 Creat-0.5 Na-143
K-4.4 Cl-100 HCO3-28 AnGap-15
___ 05:30AM BLOOD Glucose-80 UreaN-7 Creat-0.4* Na-141
K-3.2* Cl-102 HCO3-30 AnGap-9
___ 05:25AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
___ 07:30PM BLOOD Albumin-3.4* Calcium-9.2 Mg-1.9
___ 05:30AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.9
Medications on Admission:
- Coumadin 6.25 ___
- Coumadin 7.5mg ___
- Intelence 200mg tablet
- Nifedilul XL 60mg tablet
- Flomax 0.4mg daily
- Truvada 200/300mg
- Advair 500mcq/50mcq
- Albuterol sulfate
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Ascorbic Acid ___ mg PO BID Duration: 10 Days
3. Enoxaparin Sodium 60 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Famotidine 20 mg IV Q12H
5. HydrALAZINE ___ mg IV Q6H:PRN SBP>160
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
9. Polyethylene Glycol 17 g PO DAILY
10. Simethicone 40 mg PO QID:PRN abd discomfort
11. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
12. Warfarin 5 mg PO DAILY16
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
14. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
15. Etravirine 400 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
17. NIFEdipine CR 60 mg PO DAILY
18. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
IVH
Hydrocephalus
Cerebellar AVM
Pneumonia
MRSA
Deep venous thrombosis
Urinary tract infection
Hypokalemia
Hypocalcemia
Cardiac arrhythmia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with altered mental status// ?pneumonia (cxr), ?bleed (CT
head)
COMPARISON: PET-CT exam dated ___
FINDINGS:
AP upright and lateral views of the chest provided. Band like opacity
projecting over the heart on the lateral view is reflective of chronic
atelectasis seen on prior PET-CT. Hyperinflated and lucent lungs reflect
known COPD. No focal consolidation concerning for pneumonia. No large
effusion or pneumothorax. Prominence of retrosternal clear space noted.
Cardiomediastinal silhouette appears normal. No acute bony abnormalities.
IMPRESSION:
No signs of pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111
INDICATION: ___ male with altered mental status//evaluate for bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: PET-CT dated ___.
FINDINGS:
Subarachnoid hemorrhage is noted pooling in the suprasellar cistern and
tracking along the right sylvian fissure into the sulci of the right posterior
frontal lobe. There is a small parafalcine anterior component also noted.
Blood layers within the occipital horns of the lateral ventricles with
interval increase in ventriculomegaly when compared with the prior PET-CT exam
suggesting possible obstructive hydrocephalus. Periventricular white matter
hypodensity most likely reflects small vessel disease though difficult to
exclude transependymal CSF migration in the setting of acute hydrocephalus.
Ventriculostomy should be considered.
There is no fracture. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. Patient is status of
bilateral lens replacement.
IMPRESSION:
1. Subarachnoid hemorrhage.
2. Intraventricular hemorrhage with increased hydrocephalus, difficult to
exclude obstructive hydrocephalus and clinical correlation is advised,
consider ventriculostomy.
RECOMMENDATION(S): Given hydrocephalus and intraventricular hemorrhage,
ventriculostomy should be considered given concern for obstructive
hydrocephalus.
NOTIFICATION: Recommendations were discussed with Dr. ___
Radiology Report
INDICATION: ___ male status post intubation here for evaluation of
endotracheal tube placement.
TECHNIQUE: Supine AP chest radiograph.
COMPARISON: Chest radiograph performed earlier on the same day.
FINDINGS:
The endotracheal tube terminates 6 cm above the carina. The enteric tube
extends below the diaphragm and out of view. Again seen is inflation of the
lungs consistent with COPD. No focal consolidation to suggest pneumonia.
There is bibasilar atelectasis. The pulmonary vasculature is unremarkable.
No pleural effusion or pneumothorax. No acute osseous abnormalities.
IMPRESSION:
1. The endotracheal tube terminates 6 cm above the carina. The enteric tube
extends below diaphragm and out of view.
2. No acute cardiopulmonary process.
RECOMMENDATION(S): Consider slight advancement of the endotracheal tube for
more optimal positioning.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT ___ ___
INDICATION: ___ with Subarachnoid hemorrhage. Evaluate for aneurysm or
steno-occlusive disease.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 8.5 s, 0.5 cm; CTDIvol = 92.6 mGy (Head) DLP =
46.3 mGy-cm.
3) Spiral Acquisition 5.7 s, 44.7 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,392.1 mGy-cm.
Total DLP (Head) = 2,341 mGy-cm.
COMPARISON: CT head performed ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
The patient is status post interval placement of a right frontal approach VP
shunt catheter which terminates at the foramina of ___. Redemonstrated is
extensive subarachnoid hemorrhage, more notable within the right-sided
cerebral sulci and within the basal cisterns. Additional sites of layering
intraventricular hemorrhage are noted. Overall, the extent of hemorrhage
appears similar to the previous examination.
The lateral and third ventricles remain enlarged, with a decompressed fourth
ventricle which is similar in appearance to the previous examination.
Incidentally noted is a cavum septum pellucidum et vergae.
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 mucous retention cyst is noted in the left maxillary sinus. There is
partial opacification of scattered bilateral anterior and posterior ethmoid
air cells. Secretions are seen in the left sphenoid sinus. The bilateral
middle ear cavities and mastoid air cells are grossly clear.
CTA HEAD:
There is a tangle of small irregular but prominent vessels located between the
posterior horns of the lateral ventricles and posterior to the third ventricle
with extension into the posterior fossa. Hypertrophy of the distal vein of
___ and the superior vermian vein are noted. Question communication of
bilateral superior cerebellar arteries with AVM mass.
Calcifications are noted in the bilateral cavernous and supraclinoid internal
carotid arteries without severe stenosis. Left supraclinoid internal carotid
artery probable infundibulum versus small aneurysm is noted see 456:5.
Otherwise, the vessels of the circle of ___ and their principal
intracranial branches appear patent without stenosis, occlusion, or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
Moderate atherosclerotic calcifications are seen at the bilateral carotid
bifurcations. Otherwise, the remainder of the carotid and vertebral arteries
and their major branches appear normal with no evidence of stenosis or
occlusion. There is no evidence of internal carotid stenosis by NASCET
criteria.
OTHER:
The visualized portion of the lungs demonstrates severe centrilobular and
paraseptal emphysematous changes. An endotracheal tube terminates within the
mid thoracic trachea. Nonspecific nasopharyngeal may be related to intubation
status. The visualized portion of the thyroid gland is within normal limits.
Scattered subcentimeter nonspecific lymph nodes are noted throughout the neck
bilaterally, without definite enlargement by CT size criteria. Limited
imaging of cervical spine demonstrates extensive multilevel degenerative
changes.
IMPRESSION:
1. Interval placement of a right frontal approach external ventricular drain,
with a stable appearance to the ventricular system.
2. Grossly stable subarachnoid and intraventricular hemorrhage, as described.
3. Posterior fossa arteriovenous malformation with prominent distal vein of
___, superior and inferior vermian veins and question communication with
bilateral superior cerebellar communicating arteries. Consider cerebral
angiogram for further evaluation.
4. Mild-to-moderate atherosclerotic calcifications seen at the bilateral
carotid bifurcations, bilateral cavernous, and bilateral supraclinoid portions
of the internal carotid arteries. Otherwise patent intracranial and neck
vasculature without high-grade stenosis, dissection, or aneurysm greater than
3 mm.
5. Severe paraseptal and centrilobular emphysema within the visualized
bilateral lung apices are again noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH, EVD in place. Intubated with OGT in
place, concern for PNA via report from EMS// r/o PNA, confirm ETT placement
and OGT placement r/o PNA, confirm ETT placement and OGT placement
IMPRESSION:
ET tube tip is 6 cm above the carina. Heart size and mediastinum are stable.
NG tube tip is in the stomach. Left basal opacity has progressed there is no
appreciable pleural effusion. There is no pneumothorax. Emphysema is
predominantly basal, unchanged.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram for evaluation of subarachnoid
hemorrhage
During the procedure the following vessels were selectively catheterized
angiograms were performed: Left vertebral artery
Right common carotid artery
Left common carotid artery
Right common femoral artery
Three-dimensional rotational angiography of the left vertebral artery
requiring post processing on an independent workstation concurrent
interpretation by the attending physician
___: This ___ man who presented the hospital with altered
mental status. Was found have hydrocephalus and subarachnoid hemorrhage. CTA
showed some fullness in the posterior fossa but no clear aneurysm or AVM.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl throughout the intra service time of 58 minutes during which the
patient's hemodynamic parameters were continuously monitored.
TECHNIQUE: Diagnostic cerebral angiogram
COMPARISON: CTA
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. He was transferred to the fluoroscopic table supine. Moderate
sedation was administered. Bilateral groins were prepped and draped in
standard sterile fashion. A time-out was performed. The right common femoral
artery was identified using anatomic local radiographic landmarks. The right
common femoral artery was accessed using standard micropuncture technique
after infiltration of local anesthetic. A long 5 ___ sheath was
introduced, connected to continuous heparinized saline flush, and secured.
A ___ 2 diagnostic catheter was introduced, connected to continuous
heparinized saline flush and the power injector. It was advanced over a 038
glidewire. The left vertebral artery was selected under road map guidance.
Vessel injection was confirmed via hand injection. AP lateral high
magnification oblique as well as 3 dimensional rotational angiography were
obtained of the posterior circulation.
Next the ___ 2 catheter was reconstituted and the right common carotid
artery was selected under road map guidance using is 0 3 8 glidewire. Vessel
confirmation was achieved with hand injection. AP, lateral, and high
magnification oblique views were obtained via power injector.
Next the ___ 2 was reconstituted the left common carotid artery was
selected. Was advanced over 038 glidewire under roadmap guidance. Vessel
confirmation was achieved via hand injection. AP lateral and high
magnification oblique views were obtained.
Next the diagnostic catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Angio-Seal. The patient was
removed from the fluoroscopy table remained at his neurologic baseline without
any evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___,, attending physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Left vertebral artery: Vessel caliber is normal. There is filling in of the
basilar artery, bilateral superior cerebellar arteries which is also
duplicated on the right, there is no clear opacification the posterior
cerebral arteries. There is no retrograde filling of the right vertebral
artery. There is an arteriovenous malformation supplied by the bilateral
superior cerebellar arteries within nidus measuring 4.7 x 4.2 centimeters
located in the midline vermis below the tentorium. Large draining vein
appears to terminate at the torcula. Another draining vein appears to
terminate in the straight sinus. There are no feeding vessel aneurysms
identified. Three-dimensional angiography supports the same.
Right common carotid artery: Vessel caliber is regular and normal. There is
filling of the anterior and middle cerebral arteries and their distal
territories. There is a fetal PCOM configuration. There is delayed filling
of the AVM likely the related to the fetal PCOM. There did not appear to be
any direct feeders from the anterior circulation. There is no aneurysm. The
venous phase is unremarkable.
Left common carotid artery: Vessel caliber is regular and normal. There is
filling of the anterior and middle cerebral arteries and their distal
territories. There is a fetal PCOM configuration. There is delayed filling of
the AVM likely related to the fetal PCOM. There did not appear to be any
direct feeders from the anterior circulation. There is no aneurysm. The
venous phase is unremarkable.
Right common femoral artery arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection.
IMPRESSION:
___ grade 3 (3-6cm:2, non eloquent:0, deep drainage:1) Posterior
fossa AVM supplied by the bilateral superior cerebellar arteries.
RECOMMENDATION(S):
1. Plan for treatment of the AVM likely involving surgical resection the next
several weeks in delayed fashion after the patient is able to recover from his
current subarachnoid hemorrhage.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old man with SAH, IVH and hydrocephalus s/p EVD and
diagnostic angio w/ cerebellar angio. No intervention. following commands,
some agitation.// **must be performed by 12:30P**bleed, mass?.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 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 ___.
FINDINGS:
Study is motion degraded.
There are several foci of restricted diffusion in the right frontal lobe along
the precentral gyrus and in the right parietal lobe along the postcentral
gyrus as well as in the right occipital and temporal lobes, left occipital
lobe, and left cerebellum. Right temporal subarachnoid hemorrhage is again
noted and grossly stable. There is also small amount of hemorrhage layering
in the occipital horns of bilateral lateral ventricles. Right frontal EVD
device appears in stable position, terminating in the third ventricle. There
is no abnormal enhancement after contrast administration. The ventricles are
prominent consistent with hydrocephalus, though this is improved compared to
prior exam. The FLAIR images are notable for scattered foci of high signal
intensity distributed in the subcortical periventricular white matter, which
are nonspecific and may reflect changes due to small vessel disease.
Major intracranial flow voids are patent. Posterior fossa AVM is again noted
and and better evaluated on recent cerebral angiogram. Dural venous sinuses
are pain on MP rage images.
IMPRESSION:
1. Numerous infra and supratentorial foci of slow diffusion suggesting acute
to subacute infarcts in multiple vascular territories, concerning for embolic
etiology.
2. Grossly stable right temporal subarachnoid hemorrhage with small amount of
layering intraventricular hemorrhage.
3. Stable posterior fossa AVM better evaluated on recent cerebral angiogram.
4. Chronic microvascular ischemic changes as described above.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:20 pm, 120 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH, IVH intubated// tube placement**please
do by 1400**
COMPARISON: Chest radiographs from ___ and from earlier today and ___
FINDINGS:
AP portable view of the chest provided.
ET tube tip is 6 cm above the carina. The heart and mediastinum are stable.
NG tube tip is in the stomach. There has been mild improvement in the left
basilar opacity since the study performed earlier today, which likely
represents atelectasis. There is no appreciable pleural effusion. There is
no pneumothorax. Emphysema, primarily basilar is unchanged.
IMPRESSION:
1. ETT tip is 6 cm above the carina.
2. Persistent left lower lobe atelectasis, improved from prior study.
3. Emphysema, predominantly basal, unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH, extubated ___ with concern for
pneumonia// concern for pneumonia concern for pneumonia
IMPRESSION:
Interval progression as compared to ___ 13:36 of right basal
consolidation and to lesser extent left basal consolidation is highly
concerning for aspiration or potentially rapidly progressing infectious
process. Otherwise, hyperinflated lungs, relatively stable cardiomediastinal
silhouette, lack of pleural effusion or pneumothorax and bullous disease in
the right lung base are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH, extubated, hypoxia, productive cough//
r/o pna r/o pna
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lungs are hyperexpanded due to emphysema. Bibasilar opacification has
improved. Whether this is pneumonia or atelectasis is indeterminate but
aspiration is probably responsible in either case. Left skin fold should not
be mistaken for pneumothorax. Heart size is normal.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD.
INDICATION: ___ year old man with SAH// assess for hydrocephalus and assess
SAH.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: ___ MGy-cm.
COMPARISON: MR head with and without contrast ___. CTA head and
neck ___.
FINDINGS:
The patient is status post placement of right frontal approach VP shunt
catheter which terminates at the third ventricle. Again seen is right
temporal subarachnoid hemorrhage with sulcal effacement, that appears
minimally improved from CT head performed ___. Again demonstrated is
a small amount of hemorrhage layering in the occipital horns of the bilateral
lateral ventricle in appears grossly unchanged from prior exam. The
ventricles are prominent, consistent with hydrocephalus, however this is
unchanged from prior MR exam. Persistent areas of low density in the
periventricular white matter likely secondary small-vessel disease or sequelae
of hydrocephalus. There is no significant shift of midline structures. There
is no evidence for new hemorrhage, or large vascular territory infarct.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Bilateral lens replacements are noted. The remaining
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Right temporal subarachnoid hemorrhages sulcal effacement that appears
minimally improved from prior CT study performed ___.
Re-demonstration of intraventricular hemorrhage in the occipital horns of the
lateral ventricles, appear grossly unchanged from prior exam.
2. There is no evidence for new hemorrhage or large vascular territory
infarct. No significant shift of midline structures.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ year old man with SAH, new fever// eval for PNA
TECHNIQUE: Chest x-ray
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lungs are hyperaerated. There are developing bibasilar opacities worrisome
for pneumonia. The heart is normal in size. The trachea is midline.
IMPRESSION:
Progressive bibasilar opacities, possibly pneumonia. Hyperaeration
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man HD5 with SAH, EVD, fever.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is occlusive thrombus in the left deep femoral vein extending proximally
into the left common femoral vein for a short, less than 2 cm, nonocclusive
segment of left common femoral vein thrombosis.
There is otherwise normal compressibility, flow, and augmentation of the right
common femoral, bilateral superficial femoral, and bilateral popliteal veins.
Normal color flow and compressibility are demonstrated in the tibial and
peroneal veins.
There is severe calcified atherosclerosis.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
1. Occlusive left deep femoral vein thrombus extends proximally for a short
segment of nonocclusive left common femoral deep vein thrombosis.
2. No evidence of right deep vein thrombosis.
3. Severe calcified atherosclerosis.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:54 pm.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old man with subarachnoid and intraventricular
hemorrhage, cerebellar AVM s/p EVD placement. Now lethargic and not following
commands or speaking. Evaluate hemorrhage and vessels.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 8.0 s, 0.5 cm; CTDIvol = 87.1 mGy (Head) DLP =
43.6 mGy-cm.
3) Spiral Acquisition 2.9 s, 22.4 cm; CTDIvol = 30.2 mGy (Head) DLP = 678.0
mGy-cm.
Total DLP (Head) = 1,524 mGy-cm.
COMPARISON: CT head ___.
MRI head ___.
Cerebral angiogram ___.
CTA head ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Slight decrease in bilateral convexity subarachnoid hemorrhage. Right frontal
approach ventriculostomy catheter terminates in the third ventricle,
unchanged. Blood products in the occipital horns of the lateral ventricle are
unchanged. No significant change in size of the prominent lateral and third
ventricles. No new hemorrhage or large territorial infarct identified.
Moderate patchy periventricular, deep, and subcortical white matter
hypoattenuation is grossly unchanged, nonspecific likely secondary to chronic
small vessel disease in this age group.
There is a 9 mm retention cyst and mild mucosal thickening within the left
maxillary sinus. The mastoid air cells and middle ear cavities are clear.
There is evidence of bilateral cataract surgery.
CTA HEAD:
Redemonstrated is a arteriovenous malformation with the nidus in the midline
superior cerebellar vermis (approximately 2.6 cm AP x 1.6 cm TV x 2.2 cm CC).
Bilateral superior cerebellar arteries are enlarged and are confirmed to
supply the arteriovenous malformation on the prior conventional cerebral
angiogram. Apparent draining veins appear to communicate with the straight
sinus and torcula as demonstrated on the prior conventional cerebral
angiogram. The circle of ___ and their principal intracranial branches
appear patent without evidence for dissection, flow-limiting stenosis, or
aneurysm. There is mild calcified plaque in bilateral carotid siphons without
flow-limiting stenosis. The dural venous sinuses are patent.
IMPRESSION:
1. Stable intraventricular hemorrhage. Stable prominence of the lateral and
third ventricles. Stable position of the right frontal approach
ventriculostomy catheter terminating in the third ventricle.
2. Slightly decreased subarachnoid hemorrhage. No new hemorrhage.
3. Unchanged appearance of the arteriovenous malformation with the nidus in
the midline superior cerebellar vermis compared to the ___ CTA.
4. No evidence for dissection or flow-limiting stenosis in the major
intracranial arteries.
Radiology Report
INDICATION: ___ year old man with DVT, SAH/IVH unable to anticoagulate// IVC
filter placement
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: 25 mcg of fentanyl 1% lidocaine was injected in the skin and
subcutaneous tissues overlying the access site.
MEDICATIONS: As above
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2.0 min, 12 mGy
PROCEDURE:
1. Left iliac vein and IVC venogram.
2. Infrarenal Denali IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. the right neck was prepped and draped in the usual sterile fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible Right
common femoral vein was punctured using a 21G micropuncture needle. Ultrasound
images of the access was stored on PACS. A ___ wire was advanced through
the micropuncture sheath into the inferior vena cava. Then, the IVC filter
sheath was placed and the left iliac vein.
A left common iliac and inferior vena cava venogram was performed. Based on
the results of the venogram, detailed below, a decision was made to place a
filter. An Denali vena cava filter was advanced over the wire until the
cranial tip was at the level of the inferior margin of the lower renal vein.
The sheath was then withdrawn until the filter was deployed. The wire and
loading device were then removed through the sheath and a repeat contrast
injection was performed, confirming appropriate filter positioning. The final
image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes,at which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal Denali IVC filter approximately 1
cm below the lowest renal vein.
IMPRESSION:
Successful deployment of retrievable IVC filter.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with EVD elevated ICPs.// ___ year old man with
EVD elevated ICPs.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head with and without contrast performed ___.
FINDINGS:
There is re-demonstration of bilateral convexity subarachnoid hemorrhages,
unchanged from prior CTA performed ___. Right frontal approach
ventriculostomy catheter terminates in the third ventricle. Blood products in
the occipital horns of the lateral ventricles are unchanged. There is no
significant change in size of the enlarged lateral and third ventricles. No
new hemorrhage or large territory infarctions are identified. Moderate patchy
periventricular, deep, and subcortical white matter hyperdense attenuation is
grossly unchanged and nonspecific, likely secondary to chronic vessel disease.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Patient is
status post bilateral cataract surgery. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
1. Redemonstration of bilateral convexity subarachnoid hemorrhages, unchanged
from prior CT performed ___.
2. Blood products and a subtle horns of the lateral ventricles are unchanged.
There is no new hemorrhage or large territory infarction.
3. Right frontal approach ventriculostomy catheter terminates in the third
ventricle.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old man with LUE swelling// concern for LEFT UE 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 brachial and, basilic veins are patent,
compressible and show normal color flow and augmentation.
The left cephalic vein is distended with echogenic contents, not compressible
with transducer pressure and no flow is detected on Color and Spectral
Doppler.
IMPRESSION:
1. There is thrombus in the left upper extremity involving the left cephalic
vein in the antecubital fossa.
2. The left internal jugular, axillary, brachial, and basilic veins are
patent and show normal color flow and compressibility.
NOTIFICATION: The left cephalic vein is distended with echogenic contents,
not compressible with transducer pressure and no flow is detected on Color and
Spectral Doppler. Findings represent acute thrombosis of the left cephalic
vein.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with subarachnoid hemorrhage, cerebellar AVM.
For interval change, vasospasm.
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 Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 4.7 s, 37.4 cm; CTDIvol = 11.4 mGy (Body) DLP = 424.4
mGy-cm.
3) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 22.9 mGy (Body) DLP =
11.4 mGy-cm.
Total DLP (Body) = 436 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Prior CT brain done ___, prior CT angio head neck done
___ and prior MRI head done ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Subarachnoid hemorrhage is slightly decreased in volume and density (expected
evolution). Interventricular hemorrhage in the occipital horns of the lateral
ventricles are similar to slightly decreased in volume. Right frontal
approach EVD tube in situ terminating in the third ventricle, unchanged. The
lateral and third ventricular dilatation appears stable allowing for
differences in patient head position.
No new hemorrhage. Multiple suspected embolic infarcts are better visualized
on prior MRI done ___. Bilateral periventricular and deep white
matter hypodensities are most likely secondary to microangiopathy. There
could also be an element of transependymal CSF flow in the periventricular
white matter.
Small left maxillary sinus mucous retention cyst. Mastoid air cells appear
grossly well-aerated. There is evidence of bilateral cataract surgery.
CTA HEAD:
Posterior fossa AVM with the nidus in the superior cerebellar vermis measuring
approximately 31 x 22 mm in the sagittal plane and appears to be supplied by
the bilateral enlarged superior cerebellar arteries, with superficial and deep
drainage to the straight sinus and torcula, as seen on the prior conventional
cerebral angiogram.
No evidence for aneurysms involving the circle of ___. Mild
atherosclerotic changes of the carotid siphons. Unchanged mild narrowing of
the distal M1 segment of the right middle cerebral artery. Fetal type
configuration of bilateral posterior cerebral arteries. No evidence for
significant vasospasm.
CTA NECK:
There is a 3 vessel aortic arch. The vertebral arteries appear widely patent.
There is mild atherosclerosis of bilateral proximal internal carotid arteries
without stenosis by NASCET criteria.
OTHER:
Moderate to severe centrilobular and paraseptal emphysematous changes with
associated mild bronchial wall thickening suggesting bronchial wall
inflammation. There are multiple thyroid nodules which is difficult to
measure due to poorly defined margins but do not appear to exceed 15 mm.
Therefore, no further thyroid imaging is needed according to the ___
guidelines. There is no lymphadenopathy by CT size criteria. Marked cervical
spondylosis is again seen.
IMPRESSION:
1. Slight improvement (expected evolution) of subarachnoid hemorrhage. Stable
mild intraventricular hemorrhage. Lateral and third ventricular dilatation is
not significantly changed. Stable position of the right frontal approach
ventriculostomy catheter terminating in the third ventricle.
2. Unchanged appearance of the posterior fossa arteriovenous malformation with
the nidus in the midline superior cerebellar vermis with supply from the
superior cerebellar arteries bilateral which are enlarged in caliber.
3. No evidence for significant vasospasm.
4. Mild atherosclerosis of bilateral proximal internal carotid arteries
without stenosis by NASCET criteria.
5. Moderate to severe emphysema is again seen in the included upper lungs.
6. Multiple thyroid nodules do not appear to exceed 15 mm and do not require
further imaging according to the ACR guidelines.
Radiology Report
INDICATION: ___ year old man who completed course of ABX for pneumonia, wet
cough// eval for interval change, ?pneumonia
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The lungs are again noted to be hyperexpanded. Opacities at both lung bases
are not significantly changed when compared to prior given differences in
technique. There is no pneumothorax or large pleural effusion. The size of
the cardiac silhouette is within normal limits.
IMPRESSION:
Persisting bibasilar opacities, not significantly changed since prior given
differences in technique.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with SAH and EVD now s/p VPS placement// eval of
VPS placement
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 47.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CTA head and neck dated ___.
FINDINGS:
A right transfrontal ventriculostomy catheter terminates adjacent to the right
septal leaflet, in the region of the foramen of ___. The size and
configuration of the ventricular system is unchanged compared to prior.
Expected pneumocephalus is seen within the anterior horns of the lateral
ventricles bilaterally. There is a small amount of acute blood products
layering within the occipital horns bilaterally unchanged compared to prior.
Note is made of a persistent cavum septum pellucidum.
There is a small amount of subarachnoid hemorrhage within the bilateral
parietal sulci, unchanged compared to prior. There is no evidence of new
hemorrhage. There is no evidence of acute territorial infarction,edema,or
mass.
There is expected swelling and subcutaneous air overlying the right calvarium.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Patient is
status post bilateral lens resections.
IMPRESSION:
1. The right transfrontal ventriculostomy catheter terminates in the region
the foramen of ___. Ventricular size and configuration is unchanged.
2. Unchanged bilateral subarachnoid hemorrhage, as well as layering within the
dependent portion of the bilateral occipital horns. No evidence of new
hemorrhage.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with SAH w/ IVH now with persistent tachypnea and
tachycardia. CTA chest to rule out PE.// CTA chest to rule out PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 6.4 mGy (Body) DLP = 222.1
mGy-cm.
2) Stationary Acquisition 5.1 s, 0.5 cm; CTDIvol = 8.8 mGy (Body) DLP = 4.4
mGy-cm.
Total DLP (Body) = 226 mGy-cm.
COMPARISON: Abdominal radiograph ___
FINDINGS:
Imaged thyroid gland enhances homogeneously. There is no evidence of axillary
or mediastinal adenopathy. A subcarinal lymph node measures up to 0.8 cm, may
be reactive (series 301, image 114).
Heart is normal in size, with trace pericardial fluid. Multifocal coronary
calcifications. Mild aortic valve calcifications. Thoracic aorta is normal
in caliber. Main pulmonary artery is slightly prominent, measuring up to 3.0
cm, which may reflect pulmonary artery hypertension. There is no evidence of
pulmonary embolism to the subsegmental levels.
There is diffuse bronchial wall thickening with scattered areas of mucous
plugging that are most pronounced in the lower lobes. Severe centrilobular
and paraseptal emphysema is upper lobe predominant. Heterogeneously enhancing
consolidation at the dependent portion of the bilateral lung bases is
suspicious for aspiration. No pleural effusion.
Evaluation of the included images of the upper abdomen is notable for multiple
dilated loops of proximal bowel, better assessed on the same day abdominal
radiograph.
No suspicious lytic or sclerotic lesion is identified. There is no acute
fracture. There is diffuse body wall edema.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Heterogeneously enhancing bibasilar consolidation with associated bronchial
wall thickening and mucous plugging, suspicious for aspiration pneumonia.
3. Severe upper lobe predominant centrilobular and paraseptal emphysema.
4. Multiple dilated loops of bowel, partially imaged in the upper abdomen.
Dedicated CT abdomen and pelvis is recommended to exclude underlying
obstruction.
RECOMMENDATION(S): CT abdomen and pelvis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man s/p VPS placement on ___ now with vomiting.
CT head without contrast to evaluate size of ventricles and evaluate for
potential etiology of vomiting.// CT head without contrast to eval for
potential etiology of vomiting.
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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.7 mGy-cm.
Total DLP (Head) = 1,121 mGy-cm.
COMPARISON: CT head from ___ at 21:39; CTA head and neck from ___ at 17:52; CT head without contrast from ___ CT head from
___
FINDINGS:
Again seen is a right transfrontal ventriculostomy catheter which terminates
adjacent to the right septal leaflet, in the region of the foramina ___.
The size and configuration of ventricular system is unchanged compared to
prior. Expected postsurgical pneumocephalus has decreased in the interim.
Expected evolution of blood products layering within the occipital horns of
the lateral ventricles bilaterally. Unchanged cavum septum pellucidum. There
is a small amount of subarachnoid hemorrhage within the bilateral parietal
sulci, slightly improved compared to prior. There is no evidence of new
hemorrhage. There is no evidence of acute large territorial infarction,
edema, or mass effect. Unchanged subcortical and periventricular areas of low
attenuation, suggesting a combination of chronic microvascular ischemic
disease, and residual transependymal migration of CSF.
There is expected swelling and subcutaneous air overlying the right calvarium.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Patient is status post bilateral lens replacements.
IMPRESSION:
1. Right transfrontal ventriculostomy catheter is unchanged, terminating in
the region of the foramina ___. Ventricular size and configuration is
unchanged.
2. Interval improvement of bilateral subarachnoid hemorrhage with expected
evolution of blood products layering within the occipital horns of the lateral
ventricles bilaterally. No evidence of new hemorrhage.
Radiology Report
INDICATION: ___ M POD#2 status post laparoscopic VPS placement now with
hematemesis, abdominal distension. STAT KUB to eval for ileus or obstruction.
TECHNIQUE: Supine and right lateral decubitus abdominal radiographs were
obtained.
COMPARISON: Abdominal radiograph from ___
FINDINGS:
There is significant dilatation of the bowel with nonspecific air-fluid
levels.
There is no free intraperitoneal air, however right lateral decubitus view
limits detection of free intraperitoneal air. Osseous structures are notable
for lumbosacral degenerative changes. There is an IVC filter seen overlying
the mid lower abdomen. VP shunt catheter is seen overlying the right upper
quadrant. There is contrast seen within bilateral kidneys and within the
bladder.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Significant dilatation of the bowel concerning for obstruction, recommend
cross-sectional imaging for better characterization. VP shunt is seen
overlying the right upper quadrant.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with ileus// ?NGT placement Contact name: ___
___: ___
IMPRESSION:
In comparison with the study of ___, there is an placement of a
nasogastric tube that extends to the upper to mid stomach. The side-port is
close to the esophagogastric junction and, if possible, the tube should be
advanced at least 5-8 cm.
Bibasilar opacifications are again seen, which were described as worrisome for
aspiration pneumonia in the contemporaneously CT scan. The emphysematous
changes in the upper lobe were better seen on the CT examination.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NGT to wall suction// Evaluate for NGT
placement Evaluate for NGT placement
IMPRESSION:
Compared to chest radiographs ___ through ___ at 14:04.
Frontal radiograph centered at the diaphragm.
Nasogastric drainage tube still ends in the stomach. Severe generalized
intestinal distention, not fully evaluated by this study, persists. No
definite pneumo peritoneum. Opacification of both lung bases could be
atelectasis or pneumonia. Pulmonary vasculature is engorged but there is no
edema as yet. Heart size normal. Pleural effusions are small if any.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with previous AVM and SAH with worsening mental
status// eval for new hemorrhage or worsening hydro
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.
2) Sequenced Acquisition 8.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: CT head on ___ and ___
FINDINGS:
Compared with ___, a right frontal approach ventriculostomy is
stable in position, terminating in the region of the foramen of ___. The
ventricles are stable in size. A small amount of pneumocephalus is again seen
in the frontal horn of the right lateral ventricle. Small amount of
subarachnoid hemorrhage and intraventricular blood layering in the occipital
horns of the lateral ventricles is stable. No new intracranial hemorrhage.
Subcortical and periventricular hypodensities are not significantly changed,
likely representing a combination of chronic small vessel disease and
transependymal migration of CSF.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Patient is
status post bilateral lens replacement. The visualized portion of the orbits
are otherwise unremarkable.
IMPRESSION:
1. Stable positioning of a right frontal approach ventriculostomy, with stable
ventricular size.
2. No significant change in degree of subarachnoid and intraventricular
hemorrhage. No new intracranial hemorrhage.
Radiology Report
INDICATION: ___ year old man s/p placement of VPS now with ilieus versus
obstruction. CT Abdomen and Pelvis WITH both IV and PO contrast.// CT Abdomen
and Pelvis WITH both IV and PO contrast to evaluate for ileus versus
obstruction.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 50.7 cm; CTDIvol = 9.9 mGy (Body) DLP = 502.5
mGy-cm.
2) Stationary Acquisition 5.1 s, 0.5 cm; CTDIvol = 27.8 mGy (Body) DLP =
13.9 mGy-cm.
Total DLP (Body) = 516 mGy-cm.
COMPARISON: Abdominal radiograph dated ___, CTA chest dated ___, and PET-CT dated ___.
FINDINGS:
LOWER CHEST: Again seen are heterogeneously enhancing consolidation, similar
to ___. Bronchial wall thickening with mucous plugging in the
bilateral lower lobes are unchanged. Unchanged centrilobular and paraseptal
emphysematous changes. No pleural effusion or pericardial effusion.
ABDOMEN:
VP shunt is noted terminating in the right perihepatic area.
HEPATOBILIARY: The liver demonstrate normal morphology and attenuation
throughout without focal lesions. No biliary ductal dilatation.
The gallbladder is distended without wall thickening. Hyperdense material in
the dependent portion of the gallbladder consistent with biliary sludge.
PANCREAS: The pancreas demonstrate normal morphology and enhancement without
focal lesion or pancreatic ductal dilatation.
SPLEEN: The spleen is normal in size enhancement without focal lesions.
ADRENALS: The right adrenal gland is difficult to visualize due to compression
by the large simple right renal cyst. Given the limitation, the right adrenal
gland appears grossly rim unremarkable. The left adrenal gland is
unremarkable.
URINARY: The kidneys are symmetric in size with normal nephrogram. There are
2 exophytic simple cysts in the right kidney with largest measuring 9.2 x 6.9
cm in the upper pole of the right kidney. Additional subcentimeter
hypoattenuating lesions throughout the bilateral kidneys are too small to
characterize but most likely representing cysts. There is no hydronephrosis
on the left. Extrarenal pelvis on the right. No suspicious mass. No
perinephric abnormalities.
GASTROINTESTINAL: The stomach is unremarkable. The small bowel demonstrate
normal caliber. The colon contains fluid and fecal material throughout with
air-fluid level. Dilatation is most severe at the cecum and ascending colon.
Contrast material is seen in the proximal ascending colon. The colon smoothly
tapers distally without an abrupt transition point. Constellation of findings
is most consistent with severe ileus. No pneumatosis or free air.
PELVIS: The bladder is decompressed. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Moderate prostatomegaly.
LYMPH NODES: There is no retroperitoneal, mesenteric, pelvic, or inguinal
lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. Moderate atherosclerotic disease is
noted. IVC filter is noted.
BONES: No suspicious osseous lesions or acute fracture.
SOFT TISSUES: There is in right inguinal hernia. Diffuse soft tissue edema is
most likely due to third spacing.
IMPRESSION:
1. Fecal material/fluid filled dilated large bowel with air-fluid level tapers
smoothly to the rectum without abrupt transition point, consistent with
colonic pseudo-obstruction ___ syndrome).
2. Stable bibasilar heterogeneously enhancing consolidation with mucous
plugging concerning for aspiration.
3. Cholelithiasis without cholecystitis.
NOTIFICATION: Impression point 1 discussed with Dr. ___ by ___
___, M.D. in person on ___ at 3:41 pm.
Radiology Report
INDICATION: ___ s/p placement of NG Tube. Portable CXR to evaluate for
placement of tube.// Portable CXR to evaluate for placement of tube.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ and CT scan of the abdomen and pelvis from earlier
today
FINDINGS:
The tip of the nasogastric tube projects over the mid thoracic esophagus.
Advancement by approximately 20 cm is recommended. The tip of the
endotracheal tube projects over the mid thoracic trachea. The lung apices are
not included on these radiographs.
Re-demonstrated are increased opacities in the medial lung bases bilaterally,
better evaluated on the CT abdomen from earlier today. No pleural effusion.
The size of the cardiac silhouette is unchanged.
Limited evaluation of the upper abdomen demonstrates a dilated and prominent
opacified right collecting system. Dilated bowel loops are re-visualized. An
IVC filter is present.
IMPRESSION:
The tip of the nasogastric tube projects over the mid thoracic esophagus and
advancement by approximately 20 cm is recommended.
Otherwise persisting bibasilar consolidations and dilated loops of bowel over
the upper abdomen.
Radiology Report
INDICATION: ___ s/p NGT advancement. Repeat CXR to evaluate for placement of
NGT.// Repeat CXR to evaluate for placement of NGT s/p advancement.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The tip of the feeding tube still projects over the mid the thorax, presumed
to be within the mid thoracic esophagus. Mildly increased atelectasis at both
lung bases. Otherwise no significant interval change since prior.
IMPRESSION:
The tip of the feeding tube projects over the expected location of the mid
thoracic esophagus.
Radiology Report
INDICATION: ___ year old man with new NG tube placed// confirm NG tube
placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The tip of the nasogastric tube projects over the stomach. Dilated loops of
small bowel are seen over the upper abdomen as well as retained contrast
material within the right renal collecting system.
Mild bibasilar atelectasis. No pneumothorax or large pleural effusion. The
size of the cardiac silhouette is unchanged.
IMPRESSION:
The tip of the nasogastric tube now projects over the stomach. Unchanged
dilated loops of bowel over the upper abdomen.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Other nontraumatic subarachnoid hemorrhage
temperature: 98.7
heartrate: 95.0
resprate: 16.0
o2sat: 96.0
sbp: 172.0
dbp: 56.0
level of pain: unable
level of acuity: 2.0 | Mr. ___ is a ___ with history of afib on Coumadin who
presented with diffuse SAH with IVH and obstructive
hydrocephalus.
#SAH/IVH/Hydrocephalus
The patient was transferred to ___ after being found down with
altered mental status. ___ revealed diffuse SAH with
intraventricular blood in the bilateral lateral ventricles and
obstructive hydrocephalus. INR of 2.8 was reversed with KCentra
and Vitamin K. CTA head & neck was performed which again
revealed extensive SAH and IVH with a question of posterior
fossa AVM. EVD was placed emergently. The patient was taken to
angio on ___ which confirmed cerebellar AVM; there was no
further neurovascular intervention at this time. Pressure was
held on the groin site postprocedure; please see operative note
for full details of procedure. MRI w/wo contrast was performed
which was consistent with acute and subacute infarcts that
appeared embolic in origin. Neuro-stroke was consulted, nothing
to do for now, except possibly a repeat diagnostic angiogram. In
the evening of ___, the patient was lethargic and not following
commands. STAT NCHCT/CTA was stable. On ___ the patient was
transferred to the ___. On ___, EVD was raised to 10 and the
patient tolerated that well. On ___, EVD was raised to 15. The
patient tolerated this well with ICPs ___. He denied headache,
nausea, or vomiting. On ___, EVD was raised to 20. Attempted to
clamp on ___ but, ICPs increased to 25 and sustained, opened
back up at 15. EVD dropped to 10 on ___. Repeat CTA on ___
revealed expected evolution of SAH. He remained stable and was
brought to the OR ___ for VPS placement. Post-op CT showed
good placement and VPS was confirmed @ 1.0.
#Hyponatremia
The patient was started on salt tabs, 1g TID on ___. His serum
Na remained stable and the salt tabs were decreased to 1g BID on
___.
#CV
The patient was treated for hypertension with SBP goal < 140; he
was treated with nicardipine drip and PRN IV labetalol. The
patient has a known history of atrial fibrillation for which he
on Coumadin at home; anticoagulation has been held since his
admission. Prior to transfer to the ___ he was started on
Labetalol, home dose anti-hypertensive on hold for now. On ___,
nifedipine was started at half dose and labetalol was weaned as
tolerated. ___ Nifedipine was increased to home dosing and
labetalol was stopped. On ___, the patient was noted to be
tachycardic and tachypnic; a CTA chest was ordered and negative
for PE but noted bilateral effusions and concern for PNA.
#DVT
The patient was noted to have a left common femoral DVT. He is
unable to start anticoagulation so an IVC filter was placed on
___. On ___ the patient was also noted to have a superficial
thrombosis in the Left cephalic vein. He remained on BID SQH. On
___ he started a Lovenox bridge to Coumadin.
#GI
On ___, the patient passed a bedside swallow evaluation and was
started on a regular diet. On ___ he was made NPO and a NGT was
placed in the setting of his ileus. He resumed a regular diet
___. On ___, a swallow eval confirmed a regular diet, thin
liquids, and whole pills.
#Ileus
The patient began vomiting on ___ and underwent a KUB which
showed an ileus. He was made NPO and a NGT was placed. ACS was
consulted. On ___, the patient underwent a CT of the abdomen and
pelvis which confirmed a ileus. The patient removed his NGT
which was replaced at the bedside. He remained NPO. On ___ his
NGT was clamped and on ___ discontinued per ACS. A diet was
resumed without issue and noted bowel movements.
#GU
The patient has a history of prostate cancer followed at At___.
Foley was placed and discontinued on ___. He had urinary
retention to coude catheter was placed. Urine culture grew
enterococcus so he was started on ampicillin. He completed his
course and a void trial failed on ___. His foley remained in.
Plan was to try another void trial ___ but patient discharged to
rehab.
#UTI
On ___, the patient was started on Ampicillin for enterococcus
UTI. On ___, he was febrile to 101.7 and pan-cultured. Chest
xray showed progressive opacities concerning for pneumonia. He
was started on empiric vancomycin and cefepime, which was then
changed to ceftazidime.
#Infectious Disease
The patient has a history of HIV infection on HAART. He was
continued on his home antiviral regimen. However
#PNA
The patient was started on a 7-day course of Vancomycin and
Cefepime for PNA. On ___ he was swapped to Ceftriaxone with a
completion date of ___.
#Discharge Planning/Transitional Issues
The patient's HCP was identified by social work as the patients
neighbor, ___. Patient was screened for rehab and pending bed
placement. He received a rehab bed on ___ at the ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of PKD (s/p
LURT in ___, chronic allograft nephropathy, CKD, and recent
admission for C. dif, diastolic dysfunction, and gastritis. He
presented with 24 hours of nausea, vomiting, and abdominal pain.
Mr. ___ was recently admitted from ___ with
abdominal pain and diarrhea and was diagnosed with C. Dif. He
met criteria for severe C. dif infection given his
immunosuppression and was started on PO vancomycin on ___ with
plans for a 14 day course (to finish ___. His epigastric
pain was thought to be secondary to gastroesophageal reflux, and
he was started on PPI and Maalox. H. pylori was negative. During
the same admission, he also underwent ECHO because of a recent
history of orthopnea/SOB. ECHO was consistent with dCHF and
patient was diuresed with furosemide (discharge dose 80 mg PO
BID from pre-admit dose of 40 mg daily).
Patient reports he had been feeling better since discharge, with
significant improvement in diarrhea. He had his first formed
bowel movement this morning. Over the weekend, he ate and drank
normally, though notes he may have "over-eaten" yesterday while
watching the game. Yesterday evening around 6pm, he developed
n/v and abdominal pain and vomited (NB/NB) x 1. On morning of
presentation, he tried to drink water and later a glass of milk
but vomited on both occasions. He notes ongoing paroxysms of
abdominal pain that are located in the epigastric region but
extend down to the umbilicus and are burning and not currently
related to eating. He has not had any chest pain and feels
breathing is "better than ever" with no SOB over past few days.
No fevers, chills, night sweats. Last bowel movement was formed
this morning. Not sure if he's passing gas. Urinating normally.
Patient was seen in the ED, where initial vitals were 6 98.4 89
165/89 18 97%. He received 2L NS, IV PPI, IV morphine, and IV
ondansetron. Initial labs were notable for lactate of 2.6, WBC
9.1, and Cr 4.3 from recent value of 3.9 on ___. He was seen
by the renal transplant team, who advised admission to their
service.
On arrival to the floor, vitals are 98.5 119/73 85 18 99 RA.
Patient reports his pain is much improved after getting morphine
in the ED. He is hungry and wants to try water/crackers.
Past Medical History:
- ESRD ___ PKD, s/p LURT ___, ___ and re-exploration of
transplant with revision of ureteral anastomosis ___,
___
- CKD (baseline Cr 2.1-2.5 in ___, around 3.5 in ___
- S/p bilateral UE AV fistula
- OSA
- HTN
- T2DM
- HL
Social History:
___
Family History:
Father - DM.
Mother - ___ lymphoma.
Sister - PKD s/p transplant.
Physical Exam:
Admission:
Vitals- 98.5 119/73 85 18 99 RA
General- Alert, oriented, no acute distress, though breathing
somewhat heavily
HEENT- Sclera anicteric, MM are dry, oropharynx clear
Neck- supple, JVP not elevated (but difficult to assess due to
habitus), no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- Obese, soft, minimally tender in epigastric and
periumbilical regions, bowel sounds present but high pitched, no
rebound tenderness or guarding, no tenderness overlying
transplanted kidney, no organomegaly appreciated
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace peripheral edema or edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge:
Vitals- 98 139/83 80 18 O2 sat 100%RA prior to discharge
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, dry MM, oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- Obese, soft, nontender, normoactive bowel sounds, no
rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace ___ edema
Pertinent Results:
================
Labs:
================
___ 05:20PM BLOOD WBC-9.1# RBC-4.01* Hgb-12.1* Hct-39.7*
MCV-99* MCH-30.1 MCHC-30.4* RDW-13.0 Plt ___
___ 06:00AM BLOOD WBC-4.8 RBC-3.27* Hgb-9.9* Hct-31.8*
MCV-97 MCH-30.3 MCHC-31.1 RDW-12.8 Plt ___
___ 05:20PM BLOOD Neuts-90.4* Lymphs-4.8* Monos-3.7 Eos-0.8
Baso-0.2
___ 05:20PM BLOOD Glucose-105* UreaN-47* Creat-4.3* Na-137
K-4.9 Cl-102 HCO3-20* AnGap-20
___ 06:00AM BLOOD Glucose-97 UreaN-48* Creat-4.1* Na-135
K-4.3 Cl-100 HCO3-23 AnGap-16
___ 05:20PM BLOOD ALT-9 AST-13 AlkPhos-40 TotBili-0.2
___ 09:20AM BLOOD ALT-13 AST-18 AlkPhos-34* TotBili-0.2
___ 05:20PM BLOOD Lipase-43
___ 09:20AM BLOOD proBNP-8023*
___ 09:20AM BLOOD Albumin-3.4* Calcium-8.9 Phos-5.5* Mg-2.5
___ 06:00AM BLOOD Cyclspr-194
___ 05:31PM BLOOD Lactate-2.6*
___ 06:32AM BLOOD Lactate-0.5
___ 04:07PM URINE Color-Straw Appear-Clear Sp ___
___ 04:07PM URINE Blood-TR Nitrite-NEG Protein-600
Glucose-150 Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:07PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 04:07PM URINE CastHy-1*
================
Micro:
================
___ blood culture pending
___ 4:07 pm URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
================
Imaging:
================
ABDOMEN (SUPINE & ERECT)Study Date of ___ 12:35 AM
FINDINGS:
Supine and upright views of the abdomen shows multiple dilated
loops of small bowel measuring up to 6.5 cm. On upright view,
there are multiple air-fluid levels. These findings are
concerning for a small bowel obstruction. There is no evidence
of pneumatosis or free air. There are surgical clips noted in
the right lower abdomen. Visualized osseous structures are
unremarkable.
IMPRESSION:
Multiple dilated loops of small bowel with air-fluid levels on
upright view. Findings are concerning for a small bowel
obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Mycophenolate Mofetil 1000 mg PO BID
3. NIFEdipine CR 120 mg PO DAILY
4. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
epigastric pain
5. Pantoprazole 40 mg PO Q12H
6. Vancomycin Oral Liquid ___ mg PO Q6H
7. Fenoglide (fenofibrate) 54 oral daily
8. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN difficulty
breathing
9. Furosemide 80 mg PO BID
10. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
11. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
12. Metoprolol Succinate XL 200 mg PO DAILY
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
epigastric pain
2. Atorvastatin 20 mg PO DAILY
3. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
4. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
5. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN difficulty
breathing
6. Mycophenolate Mofetil 1000 mg PO BID
7. NIFEdipine CR 120 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Vancomycin Oral Liquid ___ mg PO Q6H
10. Metoprolol Succinate XL 200 mg PO DAILY
11. Fenoglide (fenofibrate) 54 oral daily
12. Furosemide 80 mg PO BID
START ___
Discharge Disposition:
Home
Discharge Diagnosis:
C diff infection
Ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: C. diff colitis with abdominal pain, nausea and vomiting, assess for
ileus or obstruction.
COMPARISON: CT abdomen and pelvis ___, Abdominal Radiograph ___.
FINDINGS:
Supine and upright views of the abdomen shows multiple dilated loops of small
bowel measuring up to 6.5 cm. On upright view, there are multiple air-fluid
levels. These findings are concerning for a small bowel obstruction. There
is no evidence of pneumatosis or free air. There are surgical clips noted in
the right lower abdomen. Visualized osseous structures are unremarkable.
IMPRESSION:
Multiple dilated loops of small bowel with air-fluid levels on upright view.
Findings are concerning for a small bowel obstruction.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RLQ
temperature: 98.4
heartrate: 89.0
resprate: 18.0
o2sat: 97.0
sbp: 165.0
dbp: 89.0
level of pain: 6
level of acuity: 3.0 | ___ y/o man with a history of PKD s/p LURT in ___ and recent
hospitalization for C. dif infection. He presented with one day
of abdominal pain, nausea, and vomiting, and with evidence of
ileus on KUB.
# Severe C. Diff Infection, abdominal pain, ileus: Patient meets
criteria for severe C. dif based upon immunosuppression. He
began treatment on ___ with plans for a 2-week course,
ending ___. His diarrhea has improved. Given that pain on
this admission was identical to prior presentation with c diff,
continued c diff was felt most likely etiology. C diff infection
could have also caused ileus shown on KUB. Pt was continued on
po vanc and also started on IV flagyl. During admission,
abdominal pain resolved, and pt began having regular BMs.
Abdominal exam was benign, and urine culture was negative. Diet
was advanced from npo to regular, which was well tolerated prior
to discharge. Pt to remain on po vanc following discharge.
# ___ on CKD: Most likely due to volume depletion in the setting
of vomiting, poor PO, and recent uptitration of furosemide. Pt
received IV fluids while npo. Furosemide was held during
admission and restarted at discharge. Cr improved from 4.3 on
admission to 4.1 at discharge, near his recent baseline.
# dCHF: Patient reports SOB is significantly improved on higher
dose of furosemide. BNP was elevated at ~8000. Pt received IV
fluids with furosemide held as noted above. O2 sat decline
slightly to 93%, but pt continued to breath comfortably and have
clear lung exam. Prior to discharge, pt had O2 sat of 100% on
room air. Restarted on furosemide at discharge.
# PKD s/p LURT: Continued on cyclosporine and MMF.
# Hyperglycemia: Prior med lists include sulfonylureas but
patient no longer on any anti hyperglycemic meds at home. Was
presribed insulin sliding scale during admission.
# Hyperlipidemia: Continued on atorvastatin.
# HTN: Continued on metoprolol and nifedipine.
# SOB: Continued on fluticasone. Pt planned for stress test as
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, hematuria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo M with hx of C7/T1 spinous process fractures s/p recent
major crush trauma presenting with abdominal pain and concern
for clots in his foley. Pt reports waking up this morning with a
dry foley bag, which is unusual for him. He proceeded to flush
it and noticed some "red clots and mucus." He also notes having
a ___ F fever last night and abdominal pain with decreased
appetite and inability to tolerate PO since yesterday, with
episode of non bloody vomiting, which is new. He also mentioned
he fell in the shower yesterday without his neck collar on- it
was an accidental fall, he slipped on the soap in the shower. He
now complains of increased neck pain, but no numbness or
tingling, or loss of strength.
In the ED, initial vitals were: 98.3 78 135/70 19 100% RA
Exam notable for:RLQ tenderness
Labs notable for: WBC 11.8, UA large leuks, mod blood, few
bacteria, neg nitrites
Imaging notable for:
CT abd/pelvis: No acute intra-abdominal process. Normal
appendix. No nephrolithiasis. Unchanged mild splenomegaly.
Unchanged multilevel wedge configuration of thoracic spine
consistent with Scheuermann's disease.
CT C spine: No cervical spine fracture or malalignment.
EKG SR @ 73 bpm. NANA. No ischemia. QTc 424
Patient was given:
___ 16:02 IV HYDROmorphone (Dilaudid) 1 mg
___ 17:11 IV HYDROmorphone (Dilaudid) 1 mg
___ 19:27 IV HYDROmorphone (Dilaudid) 1 mg
___ 19:34 IV CeftriaXONE 1 gm
___ 20:55 IV Ondansetron 4 mg
___ 23:09 PO OxycoDONE (Immediate Release) 10 mg
___ 23:17 IV Ondansetron 4 mg
Vitals prior to transfer: 98.3 51 116/68 14 99% RA
On the floor, the patient endorses above HPI, but as well as
the following multiple complaints when doing ROS.
#Neck pain: Since the accident. Aggravated by recent fall.
Oxycodone recently changed to PO dilaudid.
#Abdominal pain: Since yesterday. Also reports no BM x5 days
and cannot recall when last passed gas.
#Nausea/emesis: >10 episodes today. Has had multiple episodes
of emesis for several days now with poor PO intake.
#Chest pain: Started on ___. Pressure-like, "like someone is
sitting on chest." It is intermittent, lasting ___ to several
minutes. Unclear aggravating factors. Occasionally associated
shortness of breath. No radiation to jaw, but sometimes to arm.
Episodes occurring ___ times per day.
#Dyspnea: New since last hospitalization. He feels like he
cannot get enough air and endorses pleuritic chest pain. No
cough, orthopnea.
#Vertigo, acute on chronic: He describes at least 15 episodes
per day of room spinning associated with emesis (>10 today) for
the last 3 weeks (normal flares of vertigo last 3 days on
average). No aggravating factors, and it is not associated with
head movements.
#Numbness/tingling: In R legs since the accident. No stool
incontinence or new weeks. Constipation (BM 1 week ago). Cannot
recall when he last passes gas.
#BLE edema: Noticed by mother.
Past Medical History:
Asthma
Vertigo
Major crush injury resulting in thoracic C7/T1 spinous process
(discharged ___
Urinary retention (discharged with foley ___
OSA on CPAP
MDD with history of prior suicide attempts
Cyclical vomiting syndrome (significant workup at ___,
improvement with erythromycin)
Social History:
___
Family History:
No family history of cardiac issues (adopted, however).
Physical Exam:
ADMISSION:
T 98.5 60 16 116/75 99RA
General: Alert, oriented, uncomfortable appearing. Lying flat
in bed with C-collar.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
Chest: Very tender to palpation of anterior chest
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding. TTP of epigastrium/RUQ
GU: Foley in place with yellow urine.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. R foot in boot.
MSK: Exquisite tenderness to light touch of entire spine.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred. Bilateral nystagmus
with lateral gaze. Finger-to-nose intact bilaterally.
DISCHARGE:
Vitals: Tm 98.3 HR 60-100 BP (116-153)/(58-95) RR 20 O2 sat
98-100% on RA
I: ___, O: 1600
Exam:
General: Alert. Sitting in a chair.
HEENT: Sclerae anicteric. Conjunctiva non-injected.
Abdomen: Soft, non-distended, tender to palpation over LUQ.
GU/Back: Foley in place with yellow, non-dark, nonbloody urine.
No clots.
Neuro: Generally nonfocal. Alert and interactive.
Pertinent Results:
ADMISSION LABS:
___ 03:45PM BLOOD WBC-11.8* RBC-4.90 Hgb-14.4 Hct-42.5
MCV-87 MCH-29.4 MCHC-33.9 RDW-12.8 RDWSD-40.1 Plt ___
___ 03:45PM BLOOD Neuts-82.0* Lymphs-11.1* Monos-5.2
Eos-0.9* Baso-0.5 Im ___ AbsNeut-9.64* AbsLymp-1.31
AbsMono-0.61 AbsEos-0.11 AbsBaso-0.06
___ 03:45PM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-142
K-3.8 Cl-106 HCO3-23 AnGap-17
___ 03:45PM BLOOD ALT-18 AST-19 AlkPhos-51 TotBili-0.3
___ 05:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 05:00PM URINE RBC-58* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
___ 05:00PM URINE Mucous-RARE
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-5.7 RBC-5.16 Hgb-15.2 Hct-45.4 MCV-88
MCH-29.5 MCHC-33.5 RDW-12.8 RDWSD-41.5 Plt ___
___ 06:35AM BLOOD Glucose-84 UreaN-8 Creat-0.8 Na-141 K-3.8
Cl-104 HCO3-21* AnGap-20
___ 06:35AM BLOOD Calcium-9.5 Phos-4.9* Mg-1.9
MICROBIOLOGY:
___ 5:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. ___ CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
___ CT A/P:
1. No acute intra-abdominal pathology. No renal calculus.
Normal appendix.
2. Unchanged mild splenomegaly.
___ CT C-spine:
No cervical spine fracture or malalignment.
___ Chest X ray:
In comparison to ___ chest radiograph, lung volumes are
slightly low, accentuating the cardiac silhouette and resulting
in crowding of
bronchovascular structures at the lung bases. There are no
areas of
consolidation within the lungs to suggest the presence of
pneumonia. No
pneumothorax or acute, displaced rib fracture is identified on
this portable chest exam.
___ CT C and T spine:
In comparison to ___ chest radiograph, lung volumes are
slightly low, accentuating the cardiac silhouette and resulting
in crowding of
bronchovascular structures at the lung bases. There are no
areas of
consolidation within the lungs to suggest the presence of
pneumonia. No
pneumothorax or acute, displaced rib fracture is identified on
this portable chest exam.
___ Chest X ray:
Comparison to ___. No evidence of pneumothorax. Mild
cardiomegaly. No pleural effusions. No pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
3. Docusate Sodium 100 mg PO BID
4. Meclizine 25 mg PO QID vertigo
5. Senna 8.6 mg PO BID:PRN constipation
6. Tamsulosin 0.4 mg PO QHS
7. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN
8. TraZODone 150 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 10 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*15 Tablet Refills:*0
3. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
4. Docusate Sodium 100 mg PO BID
5. Erythromycin 250 mg PO Q6H
RX *erythromycin 250 mg 1 tablet(s) by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
6. Metoclopramide 10 mg PO TID nausea
RX *metoclopramide HCl 10 mg 1 tablet by mouth every eight (8)
hours Disp #*24 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Tamsulosin 0.4 mg PO QHS
9. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN
10. Meclizine 25 mg PO QID vertigo
11. TraZODone 150 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY: Pyelonephritis; Chronic pain; Cyclical vomiting
syndrome
SECONDARY: Chronic C7 fracture; Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with neck pain and abdominal pain, recently had a trauma with
Cspine fx, now with worsening neck pain - fell in shower yesterday without
collar on. Has RLQ pain on exam // r/o appy, r/o kidney stone, r/o new
c-spine fx or worsening fx
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 600 mGy-cm.
COMPARISON: MRI cervical spine from ___.
FINDINGS:
Alignment is normal. No fractures are identified.Small osseous fragments
posterior to the C7 and T1 spinous processes may be from prior trauma or
accessory ossification centers. There is no significant canal or foraminal
narrowing.There is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No cervical spine fracture or malalignment.
Radiology Report
INDICATION: ___ with neck pain and abdominal pain, recently had a trauma with
Cspine fx, now with worsening neck pain - fell in shower yesterday without
collar on. Has RLQ pain on examNO_PO contrast // r/o appy, r/o kidney stone,
r/o new c-spine fx or worsening fx
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis both before and following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,931 mGy-cm.
COMPARISON: ___ CT torso with contrast.
FINDINGS:
LOWER CHEST: Mild atelectasis is noted in bilateral lung bases posteriorly.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Enlarged spleen measures 15.4 cm.
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 renal or ureteral calculus. There is no evidence of focal renal
lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. Foley
catheter is noted within the bladder which also has intraluminal air. There
is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Anterior wedge-shaped deformities of multiple thoracic spine are unchanged.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal pathology. No renal calculus. Normal appendix.
2. Unchanged mild splenomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest pain/dyspnea. Recent major crush
injury with C7/T1 fracture // eval for PNA/effusion/rib fx
IMPRESSION:
In comparison to ___ chest radiograph, lung volumes are slightly low,
accentuating the cardiac silhouette and resulting in crowding of
bronchovascular structures at the lung bases. There are no areas of
consolidation within the lungs to suggest the presence of pneumonia. No
pneumothorax or acute, displaced rib fracture is identified on this portable
chest exam.
Radiology Report
EXAMINATION: DX CERVICAL AND THORACIC SPINES
INDICATION: ___ year old man with C7/T1 spinous process fractures //
AP/Lateral Views
TECHNIQUE: AP and lateral views of the cervical spine, AP and lateral views
of the thoracic spine.
COMPARISON: CT cervical spine ___, MRI whole spine ___
FINDINGS:
Cervical spine:
C1-C7 visualized with the aid of a swimmer's view. A fracture of the spinous
process at C7 is visualized only on the swimmer's view. No additional
fractures are seen. There is straightening of the normal cervical lordosis,
presumed to be were due to the patient's collar. No prevertebral soft tissue
swelling. Visualized portions of the lung apices are grossly clear.
Thoracic spine: Mild anterior wedging of multiple lower thoracic vertebrae is
unchanged compared to the prior studies. No new fracture seen. No
destructive lytic or sclerotic bone lesion. The known T1 spinous process
fracture is not clearly visualized on this study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recent C7/T1 fracture after crush injury
presenting with pyelonephritis now with worsening SOB and CP // eval for PNA,
pneumothorax, rib fractures eval for PNA, pneumothorax, rib fractures
IMPRESSION:
Comparison to ___. No evidence of pneumothorax. Mild cardiomegaly.
No pleural effusions. No pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematuria, Abd pain, Epigastric pain
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 98.3
heartrate: 78.0
resprate: 19.0
o2sat: 100.0
sbp: 135.0
dbp: 70.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ yo M with hx of MDD with multiple suicide
attempts, multiple pain complaints, chronic C7/T1 spinous
process fractures, spontaneous urinary incontinence, and a
recent crush injury who presented with bloody clots in his
foley, N/V, mechanical fall, and abdominal pain.
# Pyelonephritis: He was afebrile on admission, with WBC of 11.8
and positive UA. There was moderate blood on UA, but no gross
hematuria was observed throughout hospitalization. He was
started on IV Ceftriaxone (completed 6 days and was transitioned
to Cefpodoxime upon discharge to complete ___nding
___.
# Nausea and vomiting: Mr. ___ developed severe nausea and
multiple daily episodes of vomiting. This was initially felt to
be a combination of his chronic vertigo as well as constipation
from chronic opiate use. Records from ___ were obtained, and
indicated prior extensive workup (MRI, gastric emptying study,
EGD, ENT eval, multiple CT Abd/Pelv, multiple KUBs), all of
which were unrevealing. He was diagnosed at that point with
cyclical vomiting syndrome. He had responded in the past to
erythromycin so this was started on ___. He was also placed on
an aggressive bowel regimen and felt marginally better as he had
bowel movements. Despite maximum ___ medical therapy, he
continued to have nausea and severe emesis. Opiate-induced
gastroparesis was considered, so his opiates were discontinued.
His symptoms resolved overnight after stopping the opiates and
with addition of Reglan, and he was able to tolerate POs without
nausea or vomiting.
# Mechanical fall: He described a fall while in the shower. He
slipped on the wet floor and fell out of the shower, twisting
his neck. Imaging showed his chronic fractures but no new
fractures. Ortho spine planned to follow up with him as an
outpatient as originally scheduled.
# Multiple pain complaints: During hospitalization, he
complained of multiple areas of severe pain including in his
neck, RUQ, back, spine, R ankle, groin, and R thigh. Repeat C-
and T-spine xrays of his neck were obtained which showed chronic
C7/T1 fracture. MRI from ___ (prior admission for crush injury)
was reviewed, and again felt to be chronic indicating old
fractures from an unknown injury. No ankle films given benign
exam. Abdominal pain was felt to be ___ constipation and opiate
use as above and resolved. For his multiple pain complaints, he
was initially started on Tylenol and ibuprofen, as well as IV
Dilaudid. Based on review of ___, he had been given 2
recent short prescriptions for oxycodone and dilaudid (4 and 3
days respectively) but was not otherwise on chronic narcotics.
He felt that his pain was not controlled on Dilaudid and
requested PCA but given his constipation and cyclical vomiting
syndrome with active, difficult to treat vomiting, he was weaned
off Dilaudid on ___ as above. Of note, the plan to discontinue
opiates elicited a hostile reaction by the patient in which he
threatened to leave AMA or else he might "hurt someone." He
later said that his uncle, who was a ___, was coming to the
hospital to advocate for him with his doctors but this ___
occurred. After discontinuation of opiates, his pain was well
controlled with acetaminophen alone and he expressed readiness
for discharge with improvement in his pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin base
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ y/o woman with
history of ___, AS, HTN, HLD, TIA, presenting with weakness,
shortness of breath, decreased mental status.
Per daughter, the patient was hospitalized after a fall 3 weeks
prior where she was down for greater than 24 hours, hospitalized
for 1 week at ___ with course notable for
rhabdomyolysis, ___, demand ischemia, urinary tract infection.
During that stay she had kidney injury and therefore her
diuretics including Lasix were stopped as well as her
lisinopril.
She was discharged to rehab at baseline 2 weeks prior, and then
discharged from rehab 1 week prior. She was doing well until 3
days prior, at which point she developed increasing intermittent
shortness of breath, worse in the morning, exacerbated by
exertion, as well as generalized weakness and decreasing mental
function. The patient is still oriented, but is not responding
as
quickly as usual per her daughter. She denies any fevers,
chills,
changes in her cough (patient has chronic intermittent
nonproductive cough), chest pain, changes in urination,
vomiting,
diarrhea, sick contacts, travel, other changes in medications.
She went to her follow-up PCP appointment today, at which point
she was noted to be hypoxic to 86% on room air, and was put on 2
L nasal cannula and transferred here.
In the ED, initial VS were: 98.5 77 153/85 16 97% Nasal Cannula
Exam notable for: Mild wheezing bilaterally, with crackles at
bases bilaterally. No increased work of breathing, retractions
___ systolic murmur, greatest R parasternal, JVD to mandible. 2+
pitting edema to upper shin.
ECG: NSR at 71 bpm, 1st degree AVB, no acute ST-T wave changes
Labs showed: WBC 12.6 H/H ___ BNP 4161, trop-T 0.01; lactate
1.2; BUN/Cr ___ flu swab negative; UA negative
Imaging showed:
- CXR: Moderate to large bilateral pleural effusions. Moderate
to
severe pulmonary edema. Bibasilar opacities may be due to
combination of pleural effusion atelectasis, but focal
consolidation, particularly at the right lung base, is not
excluded. Underlying infection is difficult to exclude.
Consults: None
Patient received:
___ 16:40 IH Albuterol 0.083% Neb Soln 1 NEB
___ 16:40 IH Ipratropium Bromide Neb 1 NEB
___ 17:50 IV Furosemide 20 mg
Transfer VS were: 98.2 68 141/61 16 98% 3L NC
On arrival to the floor, patient reports that she feels well.
She
denies any chest pain, palpitations, shortness of breath, cough.
She has noticed that her legs have become increasingly swollen
over the past days to weeks. She has noted some shortness of
breath with exertion but not at rest. No orthopnea. No fevers,
chills, cough. No other complaints at this time.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- Diastolic CHF (LVEF 55-60%)
- Moderate aortic stenosis
- TIA
- HTN
- HLD
- PVD
- Asymptomatic mild carotid stenosis (minor < 50% ___ dz)
- Glaucoma
- DCIS breast
- S/p bilateral cataract surgery
- S/p left ORIF ___
Social History:
___
Family History:
Son with ___. No known family history of cardiac
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.4 156/70 67 18 94 2L
GENERAL: Lying in bed, in NAD
HEENT: Surgical pupils, anicteric sclerae, MMM
NECK: HVD to angle of mandible
HEART: RRR, III/VI systolic murmur at RUSB
LUNGS: Bilateral crackles midway up lung fields
ABDOMEN: Soft, NTND
EXTREMITIES: 1+ bilateral peripheral edema to knees
PULSES: 2+ DP pulses bilaterally
NEURO: AOx3, CN II-XII tested and intact, moving all 4
extremities with purpose
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: ___ ___ Temp: 97.4 PO BP: 123/60 R Lying HR: 63 RR: 18
O2 sat: 97% O2 delivery: 2L NC I/O: inaccurate due to
incontinence, Tele: no events
GENERAL: Thin Caucasian woman, laying in bed. NAD
HEENT: Sclerae anicteric, mucous members moist.
HEART: JVP 7cm at 45 degrees. RRR, loud III/VI wheezing systolic
murmur best auscultated RUSB, no gallops or rubs.
LUNGS: Crackles at base and decreased breath sounds
ABDOMEN: Soft, NTND
EXTREMITIES: trace bilateral peripheral edema to just below the
ankles bilaterally.
NEURO: AOx3, CNs grossly intact, moving all 4 extremities with
purpose.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABORATORY STUDIES
====================================
___ 04:00PM BLOOD WBC-12.6* RBC-3.36* Hgb-10.1* Hct-31.0*
MCV-92 MCH-30.1 MCHC-32.6 RDW-14.1 RDWSD-47.8* Plt ___
___ 04:00PM BLOOD Neuts-80.6* Lymphs-5.1* Monos-13.5*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-10.19* AbsLymp-0.65*
AbsMono-1.70* AbsEos-0.02* AbsBaso-0.02
___ 04:00PM BLOOD Glucose-105* UreaN-22* Creat-0.7 Na-136
K-4.2 Cl-98 HCO3-25 AnGap-13
___ 04:00PM BLOOD ALT-14 AST-23 AlkPhos-137* TotBili-0.6
___ 04:00PM BLOOD proBNP-4161*
___ 04:00PM BLOOD cTropnT-<0.01
___ 12:25AM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:25AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.6
___ 04:00PM BLOOD Albumin-3.2*
___ 04:05PM BLOOD Lactate-1.2
DISCHARGE LABORATORY STUDIES
====================================
___ 06:10AM BLOOD WBC-8.0 RBC-3.13* Hgb-9.2* Hct-29.6*
MCV-95 MCH-29.4 MCHC-31.1* RDW-13.8 RDWSD-47.6* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-94 UreaN-58* Creat-1.1 Na-141
K-4.7 Cl-94* HCO3-36* AnGap-11
___ 06:10AM BLOOD Calcium-10.0 Phos-4.4 Mg-2.1
IMAGING/REPORTS
====================================
CXR:
IMPRESSION:
Patient is rotated and obliqued to the left, slightly limiting
evaluation.
Moderate to large bilateral pleural effusions.
Moderate to severe pulmonary edema.
Bibasilar opacities may be due to combination of pleural
effusion atelectasis,
but focal consolidation, particularly at the right lung base, is
not excluded.
Underlying infection is difficult to exclude.
___ TTE: The left atrial volume index is severely increased.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Diastolic function could not be assessed. The right ventricular
cavity is mildly dilated with normal free wall contractility.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area <1.0cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
severe mitral annular calcification. There is mild functional
mitral stenosis (mean gradient XXmmHg) due to mitral annular
calcification. Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe
calcific/degenerative aortic stenosis. Diastolic dysfunction.
Moderate mitral and tricuspid regurgitation and mild functional
mitral stenosis from annular calcification. Pulmonary artery
systolic hypertension.
MICROBIOLOGY
====================================
___: negative blood and urine cultures
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Caltrate + D3 Plus Minerals (Ca carb-D3-mag ___
300 mg-800 unit -25 mg-0.5 mg oral DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
per day Disp #*60 Capsule Refills:*0
2. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Pravastatin 80 mg PO QPM
RX *pravastatin [Pravachol] 80 mg 1 tablet(s) by mouth at
bedtime Disp #*30 Tablet Refills:*0
4. Torsemide 60 mg PO DAILY
RX *torsemide [Demadex] 20 mg 3 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Caltrate + D3 Plus Minerals (Ca carb-D3-mag ___
300 mg-800 unit -25 mg-0.5 mg oral DAILY
7. Citalopram 10 mg PO DAILY
8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended ___
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Acute on chronic heart failure with preserved
ejection fraction
SECONDARY DIAGNOSES: Severe aortic stenosis, hypertension,
hyperlipidemia, glaucoma,
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with elevated WBC, SOB but also edema b/l// Edema
greater than baseline, pna?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
Patient is rotated and obliqued to the left, slightly limiting it evaluation.
There are moderate to large bilateral pleural effusions. Moderate to severe
pulmonary edema is seen. Bibasilar opacities, may be due to pleural effusion
and atelectasis, but focal consolidation, particularly on the right, is not
excluded. Cardiac silhouette is difficult echo early assessed due to
bilateral lower hemithorax opacities. Mediastinal contours are grossly
unremarkable.
IMPRESSION:
Patient is rotated and obliqued to the left, slightly limiting evaluation.
Moderate to large bilateral pleural effusions.
Moderate to severe pulmonary edema.
Bibasilar opacities may be due to combination of pleural effusion atelectasis,
but focal consolidation, particularly at the right lung base, is not excluded.
Underlying infection is difficult to exclude.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Dyspnea, unspecified
temperature: 98.5
heartrate: 77.0
resprate: 16.0
o2sat: 97.0
sbp: 153.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY
=============
___ w/ HFpEF, AS, HTN, HLD, CKD, possible TIA and recent
admission for a fall complicated by rhabdomyolisis and ___,
discharged home without diuretics and now presenting with a
heart failure exacerbation. She was diuresed with intravenous
Lasix, transitioned to PO torsemide. She was determined not to
be a SAVR candidate and ___ was not within goals of ___.
TRANSITIONAL ISSUES
=========================
Discharge weight 44.3 kg or 97.66 lbs. Discharge creatinine 1.1
Discharge diuretic regimen: Torsemide 60qd until she is 95lbs at
which point she can be transitioned to torsemide 20mg daily.
[] Ask daughter whether she would be amenable to Palliative ___
involvement given severe AS, no SAVR or ___. Should be
considered for hospice options. Will need referral from PCP for
___.
[] Will be discharged on torsemide 60mg. When her weight is
95kg, transition to 20mg qd
ACTIVE ISSUES
============
#Acute on chronic HFpEF exacerbation:
Patient has a history of diastolic heart failure with a LVEF 55%
with aortic stenosis. Dry weight reportedly ~105 lbs.
Presented with dyspnea on exertion in the setting of
discontinuing diuretics. Workup notable for volume overload on
exam, elevated proBNP, and pulmonary edema on imaging that was
consistent with heart failure exacerbation. Received lasix 20mg
IV BID with improvement. She was transitioned to torsemide 60mg
on discharge with goal to get her to 95kg, at which point she
should be switched to 20mg torsemide daily.
# Aortic stenosis: Area 0.75 cm2, mean gradient 35 mmHg, peak
gradient 56, concerning for severe low grade AS with normal
LVEF. Recent fall, unclear if syncopal event related to severe
AS. Determined to be high risk candidate with CSurg. ___ team
consulted, who recommended a discussion with patient and family
re: risks/benefits of ___, however per discussion with
daughter, ___ not within ___. Per Dr. ___, unlikely to be a
candidate for ___.
#GOC: As above, interventions for her severe AS will not be
pursued. Called daughter to discuss this as transitional issue,
however, could not reach her as this was day of discharge. A
conversation should be initiated about whether or not to
consider hospice based on life expectancy of 6 months with
severe AS. She will be ___ connected with palliative ___ but
this needs to be discussed further with daughter who is HCP.
# Toxic-metabolic encephalopathy: Patient reportedly with
altered mental status per daughter on admission. Likely hospital
acquired delirium and volume overload from heart failure. No
localizing infectious etiology was identified. She remained
afebrile, without localizing symptoms. Her encephalopathy
improved with treatment of heart failure as above.
# Concern for aspiration: was evlaueted by speech and swallow
who suspected oropharyngeal dysphagia and recommended ground
solids with thin liquids.
CHRONIC ISSUES
==============
# HTN: She was continued on home Lisinopril as above.
# HLD: continued on pravastatin.
# Possible prior TIA: Continued ASA and statin.
# Depression/Grief: Recent unexpected death of patient's son.
Continued citalopram.
# Gait instability: Patient with recent fall complicated by
rhabdomyolysis. She was evaluated in house by ___. She was
recommended for rehab.
# Glaucoma: Continue eye gtts.
# Anemia: Baseline Hb ___, at baseline on admission. This
remained stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness, jaundice
Major Surgical or Invasive Procedure:
CVL
History of Present Illness:
Primary Oncologist: Dr. ___
Primary ___ Physician: ___
.
CC: ___
.
HPI:
Ms. ___ is ___ with history of HTN, Gallbladder cancer s/p
cholecysectomy and liver resection in ___, s/p ___ - C2D1
___ and stent placement in early ___ for nausea and
vomiting, who is being referred in by oncologist for painless
jaundice. The patient reports that for the last ___ days she has
been having worsening weakness and lethargy at home along with
some falls without loss of consciousness. She reports having
increased ___ swelling, progressing over the last few days.
Denies any SOB, no chest pain. The patient does endorse having
decreased appetite over the last few months.
.
In ED, initial vitals were: ___ pain, 97.8 99 99/54 18 100%
Labs were significant for a WBC 25, TBili 21, AST 148, ALT 68,
Albumin 2.3, Na 131, BUN 45, INR 1.7
Consulting services were ERCP who recomended unasyn, NPO and
ERCP tomorrow.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain, chest pressure. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain. Denies
dysuria, frequency, or urgency. All other ROS negative
.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ is a ___ yrs. woman with PMHX of HTN who was
diagnosed with gallbladder cancer in ___ after a laparoscopic
cholecystectomy and subsequently underwent segment 4a and
segment 5 resection of the liver wit portal node dissection for
additional margins which was negative for tumor. She reports
today she remained well until the past six months when she was
noted to have nausea and vomiting. She started on PPI with some
improvement in her symptoms although her family reports she has
had significant weight loss (50 pounds over the past four
months). CT scan of the abdomen in ___ confirmed and lesion
in the liver adjoining the margin of the resection in the liver.
A colonoscopy did not demonstrate any malignancy but a EGD
demonstrated external compression of the duodenum distal to the
pylorus and biopsy confirmed adenocarcinoma.
.
A PET scan performed at ___ on ___ demonstrated increased
uptake on the ___ part of duodenum, liver corresponding to
CT findings and 2 small spots in left lung concerning for
primary malignancy of lung. While she is still not feeling well
(having abdominal cramping, decreased appetite), she is able to
tolerate a soft diet. She is drinking one ensure a day - does
not like the taste of it ("too milky"). She does not complain of
pain. She reports she has had friends who underwent chemotherapy
and were "miserable". She presents to this consultation with son
___, daughter ___ (who is undergone kidney transplant), and
daughter in law ___ (who is a ___ ___ for ___
___).
.
CHEMO HX
___ C1D1 - gem only, consent signed
___ C1D8 - ___
___ C2D1 gem only
___ C2 D8 plts 51K gem ___ to 400mg/m2 and hold ___
___ C3D1 plts 400s, gem ___ to 400 mg/m2 and dose reduced
___ given
___ D3D8 gem ___ given
___ CT response to chemo noted
___ opted for more chemo over surgery, C4D1 ___ with
dose reductions
___ C4D8
___ C5D1
___ C6D1
CT ___ - SD
___ - PD on CT and by symptoms clinically, restart chemo
C1D1 ___
___ C1D8 gem only
___- C2D1 ___
___ - chemo hold - rising ___ - CT demonstrates pneumobilia
.
PAST MEDICAL HISTORY:
GENERALIZED ANXIETY DISORDER
HYPERTENSION - ESSENTIAL, BENIGN
HYPERCHOLESTEROLEMIA
OSTEOARTHRITIS, GENERALIZED - MULTIPLE JOINTS
FRACTURE - CLAVICLE, UNSPEC PART
Cancer of gallbladder
URINARY TRACT INFECTION
Obesity
IBS (irritable bowel syndrome)
Gastritis
S/P cholecystectomy
Colon polyps
Duodenal mass
Lung nodule
.
Social History:
___
Family History:
No Hx of malignancy
Physical Exam:
Vitals: T97.7 bp 123/88 HR 98 RR 18 SaO2 96 RA Wt 123.8 lbs
GEN: NAD, awake, alert, cachectic
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, NT, slightly sidtended, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry, jaundiced
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
DISCHARGE EXAM:
PHYSICAL EXAM
Vitals: 97.3 136/64 79 16 98RA
GEN: NAD, awake, alert,
HEENT: supple neck, MMM, no oropharyngeal lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, NT, slightly sidtended, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry, jaundiced
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
___ 08:13PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:13PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-5.5 LEUK-LG
___ 08:13PM URINE RBC-2 WBC-21* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 06:31PM LACTATE-2.7*
___ 03:30PM GLUCOSE-112* UREA N-45* CREAT-1.9*#
SODIUM-131* POTASSIUM-4.1 CHLORIDE-90* TOTAL CO2-28 ANION GAP-17
___ 03:30PM ALT(SGPT)-68* AST(SGOT)-148* ALK PHOS-386*
TOT BILI-21.3*
___ 03:30PM LIPASE-7
___ 03:30PM ALBUMIN-2.3*
___ 03:30PM WBC-24.9*# RBC-3.48* HGB-10.1* HCT-30.8*
MCV-88 MCH-29.1 MCHC-33.0 RDW-18.6*
___ 03:30PM NEUTS-85.9* LYMPHS-9.3* MONOS-4.1 EOS-0.4
BASOS-0.4
___ 03:30PM PLT COUNT-311#
___ 03:30PM ___ PTT-28.9 ___
MICROBIOLOGY:
Bcx - ___ - GNRs
Ucx - ___ - NEGATIVE
Bcx - ___ - PENDING
IMAGING:
RUQ U/S ___
1. Moderate intra-hepatic bile duct dilation with 9mm CBD are
increased from ___.
2. 2.1cm intrahepatic lesion may have been present on ___
single phase study, concerning for recurrence vs metastasis.
DISCHARGE LABS>:
___ 06:00AM BLOOD WBC-11.1* RBC-3.14* Hgb-9.0* Hct-27.8*
MCV-89 MCH-28.7 MCHC-32.4 RDW-20.0* Plt Ct-71*
___ 06:00AM BLOOD Glucose-104* UreaN-36* Creat-1.3* Na-136
K-3.0* Cl-106 HCO3-21* AnGap-12
___ 06:00AM BLOOD ALT-22 AST-51* LD(LDH)-182 AlkPhos-299*
TotBili-8.8*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
2. Docusate Sodium 100-200 mg PO HS:PRN constipation
3. Fentanyl Patch 12 mcg/h TP Q72H
4. Pantoprazole 40 mg PO Q12H
5. Tenex *NF* (guanFACINE) 1 mg Oral daily
Discharge Medications:
1. Docusate Sodium 100-200 mg PO HS:PRN constipation
2. Fentanyl Patch 12 mcg/h TP Q72H
3. Pantoprazole 40 mg PO Q12H
4. Cholestyramine 4 gm PO BID
5. Ciprofloxacin HCl 750 mg PO Q24H Duration: 7 Days
last day = ___
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
7. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
8. Tenex *NF* (guanFACINE) 1 mg Oral daily
9. Miconazole Powder 2% 1 Appl TP BID:PRN Groin irritation
Discharge Disposition:
Extended ___
Facility:
___
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Gallbladder cancer with known duodenal mass, presenting with
painless jaundice.
___ CT and PET CT ___.
FINDINGS: A 2.1 x 1.6 x 2.3 cm lesion intra-hepatic lesion may have been
present on CT ___. Doppler assessment of the main portal vein shows
patency and hepatopetal flow. Moderate intrahepatic bile duct dilation has
increased from ___. The CBD is dilated measuring 9 mm. The gallbladder
is absent. The pancreas is not seen. The right kidney is 10.3cm. A single
view shows no hydronephrosis. There is no ascites in the upper abdomen. The
imaged portions of the IVC are normal.
IMPRESSION:
1. Moderate intra-hepatic bile duct dilation with 9mm CBD are increased from
___.
2. 2.1cm intrahepatic lesion may have been present on ___ single phase
study, concerning for recurrence vs metastasis.
Radiology Report
HISTORY: ___ woman status postcholecystectomy and liver resection for
gallbladder cancer. Now with painless jaundice, failed ERCP.
PHYSICIANS: ___ (radiology fellow) and Dr. ___
___ (radiology attending) who was present throughout and supervised the
procedure.
CONTRAST: Optiray 320 85 cc.
MEDICATION: The procedure was performed under general anesthesia please see
the dedicated anesthesia notes for further detail. The patient received 1g
Ceftriaxone and 1 unit FFP during the procedure.
FINDINGS:
Following discussion of the risks, benefits and alternatives to the procedure
with the patient and the patient's son, informed written consent was obtained.
The patient was brought to the angiographic suite and placed supine on the
table. A preprocedure time out was performed using 3 patient identifiers.
General anesthesia was induced on the table. The skin of the anterior
abdominal wall was prepped and draped in usual sterile fashion. An initial
limited ultrasound demonstrated gross intrahepatic duct dilatation involving
both the right and left lobes. The left lobe ducts were deemed to be more
accessible and these were targeted for access. Using ultrasound visualization
a Cook 21G needle was advanced into a large left hepatic duct. Injection of
contrast opacified very large, tortuous intrahepatic ducts. The access point
was too central, therefore a ___ Cook needle was used to access a slightly
more peripheral ducts, again using ultrasound guidance. However, when we
tried to advance a nitinol wire through the needle, this would only pass
peripherally within the liver parenchyma rather than passing centrally. In
the end it was neccessary to acquire an additional access into a peripheral
left lobe ducts with appropriate directionality towards the porta hepatis. A
Nitinol wire was advanced through the needle without difficulty, this passed
centrally into the central intrahepatic ducts and reached at the level of the
stenosis at the common hepatic duct. A small skin incision was made on the
Cook needle was exchanged for an Accustick sheath. This was positioned at the
level of the obstruction in the common hepatic duct and with minimal
difficulty common Nitinol wire passed through the stricture into distal common
bile duct but did not reach this duodenal stent. The Accustick sheath was
advanced over the wire into the distal common bile duct and contrast was
injected via the sheath. This demonstrated a mildly dilated distal common
bile duct but also reflux of contrast more proximally in the common bile duct
with a ___ communication between the common bile duct and duodenum seen very
close to the liver margin. The appearances suggested a surgically created
choledochoduodenostomy. Review of the prior CT abdomen confirmed this
finding.
Therefore we felt it was most appropriate to stent open the choledochal
duodenonostomy to allow optimal drainage of the biliary tree. A ___ wire
was readvanced through the Accustick sheath which was immediately exchanged
for a ___ bright tip sheath. This was positioned above the level of the
choledochoduodenostomy. An Amplatz wire was positioned initially via the
bright tip sheath, down the common bile duct and through the ampulla to
maintain access. A Glidewire was then advanced using a C2 catheter through
the choledochoduodenostomy and passed into the through the ___ the
duodenal stent. The catheter was advanced over the wire which is in exchange
for the Amplatz wire. A 10 mm x 60 mm luminexx stent was selected and
deployed over the narrowing at the choledochoduodenostomy. Balloon dilatation
performed with a 10 ___ balloon. Following completion of this maneuver,
contrast was injected via the bright tip sheath which showed ready flow of
contrast from the intrahepatic bile ducts into the stent, through the duodenal
stent and into the distal duodenum. The biliary stent had been placed through
the lumen of the duodenal stent as planned. The bright tip sheath was removed
and exchanged for an ___ destrung internal-external biliary drain. This
was positioned through the biliary stent, through the duodenal stent and into
the distal duodenum. The Amplatz wire was removed and injection of contrast
confirmed the opacification of the intrahepatic ducts as well as the distal
duodenum. The catheter was secured to the skin with a silk suture and a Stat
Lock device. The catheter has been capped to maximize internal drainage.
There were no immediate postprocedure complications.
IMPRESSION:
1. Percutaneous transhepatic cholangiogram performed via left duct access
demonstrating a tight stenosis at the level of the common hepatic duct.
2. Evidence of a choledochoduodenostomy from prior surgery.
3. Successful stenting of the choledochoduodenostomy with placement of a 10mm
Luminexx stent.
4. Placement of ___ destroying the internal-external biliary drain.
Radiology Report
TYPE OF EXAMINATION: Chest AP single view.
INDICATION: ___ female patient with sepsis and hypotension, requiring
chest examination to evaluate central venous line placement. Contact ___,
___ ___.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Comparison can be made with the next preceding similar
study of ___. There is cardiac enlargement and a pulmonary
pattern suggestive of left-sided heart failure. Bilateral basal densities
blunt the diaphragmatic contours and the lateral pleural sinuses suggestive of
bilateral pleural effusions. Acute parenchymal infiltrates cannot be seen.
Thoracic aorta generally widened and elongated. A right-sided internal
jugular approach central venous line has been placed, seen to terminate
overlying the right-sided mediastinal structures at a level 5 cm below the
carina. Withdrawal by 3 cm is recommended to avoid unintentional contact with
intracardiac structures. No pneumothorax is present. Page was placed to
___ at 4:30 p.m.
Radiology Report
HISTORY:
Gallbladder cancer with a drain in the left-sided biliary system. Please
perform a cholangiogram and drain removal.
COMPARISON: ___ from ___.
PHYSICIANS: Dr. ___ and Dr ___ (attending) performed
the procedure. Dr. ___ was present and supervising during the entire
procedure.
Contrast: Optiray 15 cc.
ANESTHESIA: Moderate sedation was provided by administered in divided doses
of 25 mcg of fentanyl and 0.5 mg of Versed, throughout the intra-service time
of 10 minutes during which the patient's hemodynamic parameters were
continuously monitored. Lidocaine jelly and 1% lidocaine subcutaneous
injections were used for local anesthesia.
FINDINGS:
Following discussion 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 table. A preprocedure time out
was performed using 3 patient identifiers. The drain site was prepped and
draped in the usual sterile fashion.
Initial scout images showed a left-sided percutaneous transhepatic biliary
drain passing through a choledochal-duodenal stent into the proximal duodenum.
Contrast injection showed a freely draining system with no leaks or
obstruction. No dilated bile ducts were noted. The stay sutures were then
removed and ___ wire was advanced into the jejunum. The drainage
catheter was removed over the wire and replaced with an ___ sheath. The
sheath was pulled back to until it was just proximal to the liver entry site.
A small pledget of Gelfoam was then inserted into the sheath and pushed using
a dilator to obstruct the drainage site. The sheath was then removed. A
sterile dressing was applied.
IMPRESSION:
1. Successful removal of a left-sided percutaneous biliary drain.
2. No intra or extrahepatic biliary dilatation.
3. Rapid drainage through the stent into the duodenum
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LOWER EXTREMITY EDEMA
Diagnosed with JAUNDICE NOS
temperature: 97.8
heartrate: 99.0
resprate: 18.0
o2sat: 100.0
sbp: 99.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ y/o F with PMHx Gallbladder cancer s/p
cholecystectomy, duodenal stenting, multiple cycles of chemo p/w
cholangitis and gram negative rod bacteremia.
# Cholangitis and GNR Bacteremia: Pt presented with an elevated
bili, RUQ pain, and jaundice in setting of Septic Shock. She was
found to have GNR bacteremia and imaging was consistent with
cholangitis. She is now s/p percutaneous internal-external drain
placement. She was treated with zosyn (D1: ___ for coverage
of anaerobes and GNRs and was transitioned to PO ciprofloxacin.
We continued cholestyramine. Antibiotics should be continued
until ___.
# Acute Kidney Injury: Pt presented with a Cr of 1.9 up from a
baseline 0.9, to 1.7 with fluid resuscitation. This was
consistent with a pre-renal etiolpgy in setting of insufficient
volume resuscitation. Remained elevated and is likely in setting
of volume depletion. It is slowly going back down to baseline.
#Gallbladder cancer: Pt progressing through multiple cycles of
___. No current plans for further chemotherapy.
# Psych: chlordiazepoxide and guanificine were held on admisson
and restarted upon discharge.
# Chronic Pain: We continued home fentanyl patch and gave prn
tramadol.
# HTN: Pt was hypotensive while in th ICU so home dose of
indapamide was held. She can continue to hold anti-hypertensives
until she is seen by her PCP.
# GERD: Stable so we continued pantoprazole. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iodine / povidone / erythromycin base / ciprofloxacin /
azithromycin / sildenafil
Attending: ___.
Chief Complaint:
dyspnea, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ former surgical ICU nurse with ___ history
of
recovered dilated cardiomyopathy, severe pulmonary hypertension
with RV dysfunction, OSA requiring BiPAP, COPD on 2 L home O2,
paroxysmal A. fib on apixaban, type 2 diabetes, CKD stage III
who
presents for evaluation of dyspnea.
Per referral from the nursing home at which she resides, her
oxygen saturation was measured when she was not on her home O2,
and noted to be 49%. She is noted not to be adherent to her home
oxygen.
The patient states she has had difficulty breathing for the last
24 hours or so. She describes a tightness in her chest,
worsening
exertional dyspnea. She is also had increasing leg swelling and
has gained about 10 pounds from her dry weight over the past 10
days.
She denies any frank chest pain. No fevers, chills, cough. No
abdominal pain, nausea, vomiting. No dysuria. States she has
been
adherent to her diuretics and oxygen, and has not eaten any
unusual or especially salty foods.
On arrival to the ED, her vital signs are notable for stable
blood pressure, and oxygen saturation 92% on room air.
Labs notable for CBC with hemoglobin of 10.0, BNP 4726, troponin
0 0.03-0.04, creatinine 1.4.
Chest x-ray notable for mild pulmonary vascular congestion,
hyperinflation of the chest, sharp costophrenic angles, per my
read.
EKG: Sinus rhythm 89. First-degree AV block. Right axis
deviation. Inverted T waves in V1 through V6, stable from
previous EKG.
The patient was given 1000mg of acetaminophen, 5 mg oxycodone,
120 mg IV Lasix.
She was admitted to cardiology for acute on chronic heart
failure
exacerbation.
On the floor, the patient is very somnolent. She verifies that
she takes her medications daily, and has adhere to a low-salt
diet. She denies any systemic symptoms. Reports "nerve pain"
that started on her anterior shins in the emergency department.
Reports that nursing at the home that she lives helps with her
medications.
Past Medical History:
DM c/b peripheral neuropathy, no longer on insulin
HFpEF
Severe pulmonary hypertension with RV dysfunction
pAF s/p DCCV (___)
HLD
COPD on ___ O2
OSA on CPAP
Crohn's disease
DVT, remote history
Gout
Chronic low back pain
Iron deficiency anemia
DJD (degenerative joint disease)
Lumbar spinal stenosis
CKD3
Social History:
___
Family History:
PE, prostate cancer, Crohn's disease. No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 98.7PO 91 / 54L Lying 80 18 90 5L Nc
GENERAL: Very somnolent, arousable to voice. Intermittently
opens eyes on command.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: Bilateral crackles one third of the way up the posterior
chest
GI: Mild tenderness to palpation diffusely
EXTREMITIES: Bilateral venous stasis changes and excoriations on
the anterior shins.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
VS: Temp: 99.4 PO BP: 107/69 L Sitting HR: 70 RR: 20 O2 sat: 92%
O2 delivery: 2 L
GENERAL: awake, NAD, AOx 3
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, JVP not elevated
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: Clear to auscultation bilaterally, no crackles, wheezes or
rhonchi
GI: NT/ND
EXTREMITIES: Warm, bilateral venous stasis changes and
excoriations on the anterior shins, no lower extremity edema
bilaterally. Left bicipital groove point tenderness to
palpation. Right shoulder with limited active range of motion
and diffuse tenderness to palpation or with passive motion.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 07:28PM BLOOD WBC-8.0 RBC-4.35 Hgb-10.0* Hct-35.3
MCV-81* MCH-23.0* MCHC-28.3* RDW-25.6* RDWSD-73.3* Plt ___
___ 07:28PM BLOOD Neuts-69.6 Lymphs-17.0* Monos-8.0 Eos-4.5
Baso-0.6 Im ___ AbsNeut-5.55 AbsLymp-1.36 AbsMono-0.64
AbsEos-0.36 AbsBaso-0.05
___ 07:28PM BLOOD Glucose-128* UreaN-43* Creat-1.4* Na-142
K-4.0 Cl-102 HCO3-27 AnGap-13
___ 07:30AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 Iron-38
___ 07:28PM BLOOD CK-MB-5 cTropnT-0.03* proBNP-4726*
___ 07:30AM BLOOD calTIBC-395 Ferritn-57 TRF-304
___ 07:30AM BLOOD TSH-1.2
DISCHARGE LABS:
___ 08:14AM BLOOD WBC-10.3* RBC-4.95 Hgb-11.4 Hct-40.1
MCV-81* MCH-23.0* MCHC-28.4* RDW-24.9* RDWSD-71.6* Plt ___
___ 08:14AM BLOOD Glucose-175* UreaN-36* Creat-1.1 Na-138
K-5.2 Cl-95* HCO3-33* AnGap-10
___ 08:14AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.3
___ CXR:
No acute intrathoracic process.
Known pulmonary nodules from the recent chest CT of ___ are not
discerned on the current exam.
___ TTE:
IMPRESSION: Marked right ventricular cavity dilation with severe
free wall hypokinesis. Severe
pulmonary artery systolic hypertension. Mild-moderate tricuspid
regurgitation. Normal left
ventricular wall thicknesses, cavity size, and regional/global
systolic function.
Compared with the prior TTE (images reviewed) of ___ ,
the findings are similar (the left
ventricular systolic function is less vigorous, but remains
normal).
___ Left Shoulder XR:
No evidence for fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Apixaban 5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Colchicine 0.6 mg PO DAILY
5. Fentanyl Patch 25 mcg/h TD Q72H
6. Gabapentin 300 mg PO BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
10. Artificial Tears ___ DROP BOTH EYES BID
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
13. Sarna Lotion 1 Appl TP QID
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Loratadine 10 mg PO DAILY
16. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
17. Miconazole Powder 2% 1 Appl TP TID
18. Torsemide 100 mg PO DAILY
19. Ipratropium-Albuterol Neb 1 NEB NEB Q8H
20. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
21. Hydrocerin 1 Appl TP QID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1
inhalation inhaled twice daily Disp #*1 Disk Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % 1 patch applied to each shoulder daily Disp
#*60 Patch Refills:*0
4. LORazepam 0.5 mg PO Q4H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 4 hours
Disp #*5 Tablet Refills:*0
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
7. Allopurinol ___ mg PO DAILY
8. Apixaban 5 mg PO BID
9. Artificial Tears ___ DROP BOTH EYES BID
10. Atorvastatin 40 mg PO QPM
11. Colchicine 0.6 mg PO DAILY
12. Fentanyl Patch 25 mcg/h TD Q72H
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Gabapentin 300 mg PO BID
15. Hydrocerin 1 Appl TP QID
16. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY
17. Loratadine 10 mg PO DAILY
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Miconazole Powder 2% 1 Appl TP TID
20. Omeprazole 20 mg PO DAILY
21. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Severe
22. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
23. Sarna Lotion 1 Appl TP QID
24. Senna 8.6 mg PO BID:PRN Constipation - First Line
25. Torsemide 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
# HEART FAILURE WITH PRESERVED EJECTION FRACTION ACUTE ON
CHRONIC
# HYPOXEMIC RESPIRATORY FAILURE
# Acute Kidney Injury on Chronic Kidney Injury
# SEVERE PULMONARY HYPERTENSION
# COPD
# OSA
# ANXIETY
Secondary diagnoses
=================
# MICROCYTIC ANEMIA
# ALLERGIES
# ABRASIONS ON FEET
# RECURRENT FALLS
# PAROXYSMAL ATRIAL FIBRILLATION
# SHOULDER PAIN
# CHRONIC LOW BACK PAIN
# GOUT
# HYPERLIPIDEMIA
# TYPE II DIABETES C/B NEUROPATHY
# DEPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Left shoulder radiographs, three views.
INDICATION: Felt pop in left shoulder.
COMPARISON: Prior study from ___.
FINDINGS:
Acromioclavicular and glenohumeral joints are preserved. There is no evidence
of fracture, dislocation or lysis.
IMPRESSION:
No evidence for fracture or dislocation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 97.6
heartrate: 83.0
resprate: 17.0
o2sat: 92.0
sbp: 98.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | P - Patient summary statement for admission
============================================
Ms. ___ is a ___ female with recovered dilated
cardiomyopathy
and severe pulmonary hypertension secondary to COPD (on 2L O2 at
home), OSA (BiPAP at night), and severe asthma, type II
diabetes,
paroxysmal atrial fibrillation (on apixaban), and CKD stage III
who presents with asymptomatic hypoxia, admitted for heart
failure exacerbation likely secondary to increased salt intake.
A - Acute medical/surgical issues addressed
============================================
# HFpEF ACUTE ON CHRONIC
Most likely due to saltier diet (new ___ at assisted living
___). Patient reported compliance with home torsemide 100
mg
daily. She presented with symptoms of volume overload, crackles,
lower extremity edema, elevated BNP to 4000. No significant
change on TTE this admission. TSH 1.2. Of note, during prior
admission spironolactone was started then discontinued in
setting of worsening kidney function. On this admission she was
diuresed with IV Lasix 120mg boluses, then transitioned to PO
torsemide. She was discharged on regimen of 100mg PO torsemide
QD for preload, discharge weight 100.1kg.
# ANXIETY
Patient had a difficult time coping with health challenges and
recurrent admissions, was tearful and shared anxiety. Pt may be
a good candidate for CardioMEMS to reduce frequency of heart
failure admissions. Diazepam then lorazepam given during this
admission with limited effect. Palliative Care was consulted.
They spoke with her CCA provider with hopes of continuing
palliative care at home or in clinic as well as with managing
her anxiety.
# ___ ON CKD III
Baseline Cr approximately 1.0. Elevated Cr on admission likely
secondary to cardiorenal syndrome. After diuretic holiday, Cr at
1.1 on discharge.
# SHOULDER PAIN
History of left rotator cuff injury and right shoulder
arthritis, with recurrent pain this admission. Pt heard "pop"
with mechanical stress to left shoulder when getting up from the
toilet, XR without evidence of fracture or dislocation.
Lidocaine patch with good effect. Home fentanyl patch, oxycodone
prn, and gabapentin for chronic back pain continued, as below.
# HYPOXEMIC RESPIRATORY FAIURE
# SEVERE PULMONARY HYPERTENSION GROUP II/III
# COPD ON 2L O2
# OSA ON BiPAP
On 2L home O2. Brought in by assisted living facility because
she was hypoxic. Of note, last admission, the team considered
starting tadalafil (she had previously failed two trials of
sildenafil with severe headaches) but given her complicated
hospitalization course, deferred this decision to an outpatient
setting. Continued supplemental ___ NC for oxygen goal
between 88% and 92%. Continued BiPAP at night.
C - Chronic issues pertinent to admission
============================================
# MICROCYTIC ANEMIA
Iron studies on last admission consistent with iron deficiency
anemia. Likely secondary to her chronic kidney disease. She was
administered IV iron last admission. Iron studies this admission
wnl.
# PAROXYSMAL ATRIAL FIBRILLATION
Continued home apixaban and fractionated metoprolol.
# CHRONIC LOW BACK PAIN
Continue on her home fentanyl patch, oxycodone and gabapentin
# GOUT:
Continued home allopurinol and colchicine per most recent
Rheumatology recommendations from ___ appointment
# HYPERLIPIDEMIA:
Continued home atorvastatin.
# TYPE II DIABETES C/B NEUROPATHY
Not recently on treatment for diabetes and did not require
insulin sliding scale previous admissions.
# ABRASIONS/ULCERS ON FEET
# LOWER EXTREMITY PAIN
The patient reported multiple abrasions from repeated falls
secondary to a history of neuropathy. Her wounds appear well
healing.
T - Transitional Issues
============================================
[] Follow up anxiety management. Pt discharged with 5 tablets of
lorazepam which she received during this admission, please
continue to assess need for benzodiazepines as well as more long
term treatment of her anxiety
[] wean fentanyl patch as tolerated to 12mcg TD x72 hrs and then
discontinue
[] continue to assess need for social work at home
[] continue discussions with palliative care at home
[] Consider CardioMEMS placement to help reduce frequency of
exacerbations and hospitalizations in the future.
[] Follow up weights, electrolytes at NP CDAC visit- will likely
need titration of home torsemide with saltier diet at SNF.
[] Follow up tophaceous gout management - continued home
allopurinol and colchicine per most recent Rheumatology
recommendations ___ clinic visit), no current flare,
consider discontinuing colchicine in outpatient setting.
[] Consider initiating ACE inhibitor after ___ resolves.
- ___ started Advair 500/50 BID per most recent Pulmonary note
recommendations (was not on home med list)
- Discharge weight: 100.1kg
- Discharge diuretic regimen: 100mg torsemide po qd
- Discharge Cr: 1.1
# CODE: Full (presumed)
# CONTACT: HCP: ___, (Daughter) Phone: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary Angiography with PCI: s/p DES to RCA.
History of Present Illness:
Mr. ___ is a very pleasant ___ year old ___
patient with a history of CAD c/b NSTEMI (___) s/p DES to
pLAD, HTN, HLD, recent GI bleed on DAPT who presents with 5 days
of crescendoing chest pain concerning for unstable angina.
Mr. ___ was last seen by ___ Cardioveon ___ where he
was complaining of daily exertional angina. At that time he
reported taht he could walk approximately ___ meters until he
needed to stop secondary to chest pain. The pain resolves with
rest. He was instructed to increase his imdur which he did and
followup in the next month. Since that time he has had
progressive anginal symptoms which are now occurring at rest.
This AM he awoke with chest pain at rest. It was not relieved
with sitting up or leaning forward. It continued to persist so
he called his PCP who advised his to call EMS and report to the
ED. He was given ASA 324mg by EMS, and SL NTG with improvement
in pain.
In the ED intial vitals were: 09:40 3 98 80 130/80 20 100%
Labs notable for: Troponin-T less than <0.01 x2 with BNP of 411.
Imaging notable for CXR with new R pleural effusion with
associated possible consolidation.
EKG showed NSR at 62 bpm, NA/NI. Incomplete RBBB, TWI in III.
TWF in anterolateral leads.
Patient was given: SL Nitroglycerin SL .4 mg x2 and Morphine
Sulfate 2 mg with resolution of his chest pain.
Vitals on transfer: 17:02 0 98.2 59 120/53 16 94% RA
On the floor patient reports that his chest pain has resolved
and is better with nitroglycerin. He denies shortness of breath,
nausea, fever, or cough, and denies back pain. He denies weight
loss, night sweats. He denies cough or hemoptysis. He reports
that his chest pain is localized and sharp over his chest wall.
It is worth with exertion. It has been present since his last
admission but worse recently. It usually does not radiate but
has gone to his left back.
Of note, patient was recently admitted with GI bleeding in
___. He had colonoscopy and polypectomy. His lowest hemoglobin
was 6 with HCT 23. During the admission, his plavix was held for
several days. He takes iron supplements and eats iron rich food.
He is back on dual antiplatelet therapy with no signs of
bleeding. He reports good medication compliance.
REVIEW OF SYSTEMS:
(+) per HPI
On review of systems, denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
- CAD c/b NSTEMI (___) s/p DES to pLAD
- Hypertension (since ___
- Hyperlipidemia.
- Glaucoma
- Cataracts
- Prostatic hypertrophy.
- Esophageal papilloma.
PAST SURGICAL HISTORY:
- Prostate surgery
- Eye surgery, unspecified.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Family
history notable for hypertension. Denies family history of GI
malignancy or GI illnesses.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
VS: 98.2 180/80 72 18 100RA
WT: 72.9 kg
GENERAL: WDWN elderly gentleman 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 murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: unlabored. R sided dullness to percussion with decreased
breath sounds at base. otherwise clear.
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: 97.7 109-146/50-68 ___ 16 >95RA
WT: 72.9 kg
GENERAL: WDWN elderly gentleman 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 murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: unlabored. R sided dullness to percussion with decreased
breath sounds at base. otherwise clear.
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
Pertinent Results:
ADMISSION LABS:
==================
GROSSLY HEMOLYZED SPECIMEN
123 89 11
-------------< 110 AGap=17
5.8 23 1.0
Repeat K 3.8
Ca: 9.4 Mg: 1.8 P: 3.5
ALT: 25 AP: 59 Tbili: 0.4 Alb: 4.3
AST: 97 Lip: 56
Trop-T: <0.01 (x2)
proBNP: 411
77
4.8 \ 9.4 / 464
/28.2 \
N:74.3 L:18.2 M:6.1 E:0.9 Bas:0.4
UA: bland
GI STUDIES:
==================
# Colonoscopy (___): A 2 cm sessile [flat] polyp in the
ascending colon (polypectomy, thermal therapy, injection).
Diverticulosis of the sigmoid colon. Otherwise normal
colonoscopy to cecum
# EGD (___): Mass in the middle third of the esophagus
(squamous papilloma) Polyp in the second part of the duodenum
(biopsy wnl). Otherwise normal EGD to third part of the duodenum
CARDIOVASCULAR STUDIES:
==================
+ Echo (___) ___: nl RV/LV, nl valves.
+ ETT ___: ___ METs, no ST changes or anginal sx.
+ LHC ___: 90% pLAD s/p Promus DES, 30% mLAD, 80% ostial D1
stenosis, LCx with MLA, 40% OMB1 and totally occluded OMB2
filling via L-L and R-L collaterals. RCA with ___ proximal
and mid vessel stenosis, dRCA with ___ stenosis, 60-70% mid
RPDA with small PLB.
+ ECG (___): SR rate 60, ___, LVH, nl intervals, no ischemic
changes, Crista pattern V1
+ ECG (___): NSR 68/min, TWI on III, early precordial R
wave ___.
STUDIES THIS ADMISSION:
==================
+ CXR ___:
1. New large right pleural effusion.
2. Superimposed opacity may represent compressive atelectasis or
infectious process in the proper clinical setting.
3. Mild pulmonary vascular congestion without overt pulmonary
edema.
+ EKG: NSR at 62 bpm, NA/NI. LA, Incomplete RBBB, TWI in III
(CWP). TWF in anterolateral leads.
+ Coronary Angiography (___):
Dominance Right:
LMCA: normal
LAD: proximal stent patent, first diag with 80% proximal
(unchanged)
Lcx: promixal normal, first marginal large with proximal 40%
(unchanged)
RCA: proximal 70% lesion followed by a mid 90% lesion, beyond
this there is a ___ diffuse disease. Right PDA focal mid 70%
lesion unchanged.
INTERVENTIONS: Successful DES to covering proximal and mid RCA
lesions.
RECOMMENDATIONS: Aspirin indefinitely, clopidogrel x ___ year.
CT CHEST (___):
1. Large nonhemorrhagic right pleural effusion with associated
atelectasis. Bronchial wall thickening and mucus plugging is
most severe in the right Lower lobe. On this noncontrast
enhanced study there is no obvious large mass or lymphadenopathy
to account for the pleural effusion. Thoracentesis with
cytology should be considered for further evaluation.
2. Followup for multiple tiny pulmonary nodules, the largest 4
mm in the left upper ___ depend on the outcome of the
workup of the right pleural effusion. If no malignancy is
detected, the nodules may be followed up in ___ year.
3. Hyperattenuation of myocardium relative to blood pool
suggesting anemia.
4. Multiple calcified right axillary foci likely sequela of
prior granulomatous infection.
5. Atherosclerosis of the thoracic aorta and coronary arteries.
6. Cholelithiasis
DISCHARGE LABS:
==================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. brimonidine-timolol 0.2-0.5 % ophthalmic BID
4. Clopidogrel 75 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
6. Lorazepam 0.5 mg PO BID anxiety, insomnia
7. Tamsulosin 0.4 mg PO QHS
8. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Iron Polysaccharides Complex ___ mg PO DAILY
12. NIFEdipine CR 60 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Iron Polysaccharides Complex ___ mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
6. Lorazepam 0.5 mg PO BID anxiety, insomnia
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Tamsulosin 0.4 mg PO QHS
9. brimonidine-timolol 0.2-0.5 % ophthalmic BID
10. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. NIFEdipine CR 60 mg PO DAILY
13. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Unstable angina
- Coronary Artery Disease s/p drug eluting stent to right
coronary artery.
SECONDARY:
- Pleural effusion
- Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with chest pain, hx CAD with stent, for acute process
Eval for acute process
TECHNIQUE: PA and lateral view radiographs of the chest.
COMPARISON: Prior chest radiographs from ___.
FINDINGS:
A large right pleural effusion is new from the prior study. Superimposed
opacity likely represents compressive atelectasis, however infectious process
could be considered the proper clinical setting. There is no left pleural
effusion. There is mild pulmonary vascular congestion without overt pulmonary
edema.
IMPRESSION:
1. New large right pleural effusion.
2. Superimposed opacity may represent compressive atelectasis or infectious
process in the proper clinical setting.
3. Mild pulmonary vascular congestion without overt pulmonary edema.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with new right sided pleural effusion, no
infectious signs. No overt heart failure. Has "hypnatremia." Evaluate for
mass, consolidation
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images
DOSE: DLP: 643
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
CT CHEST WITHOUT IV CONTRAST: Thyroid is unremarkable. There is no
supraclavicular or axillary lymphadenopathy. There are numerous calcified
right subdermal and right axillary foci with central lucencies, likely
calcified lymph nodes. There is no mediastinal lymphadenopathy and within the
limitations of the study obtained without IV contrast no appreciable hilar
lymphadenopathy.
Heart and pericardium are within normal limits. Hyperattenuation of
myocardium relative to blood pool suggests anemia. The thoracic aorta and
great vessels are normal in caliber with scattered atherosclerosis
particularly of the aortic arch. There is calcification of aortic valve and
coronary arteries.
Nonhemorrhagic right pleural effusion is large with associated atelectasis in
the right lower lobe and to a lesser extent the superior segment of the right
upper lobe. The etiology of the effusion is not clear on this noncontrast
enhanced study. Specifically, there is no evidence of large mass.
The central airways are patent. There is bronchial wall thickening and
segmental and subsegmental branches particularly in the lower lobes with
multiple sites of mucus plugging, for example series 4, image 67 in the left
upper lobe and image 144 in the right lower lobe.
4 mm left upper lobe nodule (4:118)
1 mm left upper lobe nodule (4:63)
1 mm left upper lobe nodule (4:85)
2 mm calcified granuloma in the lingula (4:149)
2 mm nodule in the lingula (4:165)
OSSEOUS STRUCTURES: There is no worrisome blastic or lytic lesion
UPPER ABDOMEN: Tiny calcified granuloma in the liver. Cholelithiasis without
evidence of cholecystitis in the partially imaged gallbladder. There is small
hiatal hernia. Remainder the partially included upper abdomen is grossly
normal although the study is not designed for evaluation of the abdomen.
IMPRESSION:
1. Large nonhemorrhagic right pleural effusion with associated atelectasis.
Bronchial wall thickening and mucus plugging is most severe in the right Lower
lobe. On this noncontrast enhanced study there is no obvious large mass or
lymphadenopathy to account for the pleural effusion. Thoracentesis with
cytology should be considered for further evaluation.
2. Followup for multiple tiny pulmonary nodules, the largest 4 mm in the left
upper ___ depend on the outcome of the workup of the right pleural
effusion. If no malignancy is detected, the nodules may be followed up in ___
year.
3. Hyperattenuation of myocardium relative to blood pool suggesting anemia.
4. Multiple calcified right axillary foci likely sequela of prior
granulomatous infection.
5. Atherosclerosis of the thoracic aorta and coronary arteries.
6. Cholelithiasis
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS
temperature: 98.0
heartrate: 80.0
resprate: 20.0
o2sat: 100.0
sbp: 130.0
dbp: 80.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a very pleasant ___ year old ___
patient with a history of CAD c/b NSTEMI (___) s/p DES to
pLAD, HTN, HLD, recent GI bleed on DAPT who presents with 5 days
of crescendoing chest pain concerning for unstable angina. He
was found to have a new RLL effusion and a right coronary artery
stenosis now s/p DES.
#CORONARIES (as of ___: 90% pLAD s/p Promus DES, 30% mLAD,
80% ostial D1 stenosis, LCx with MLA, 40% OMB1 and totally
occluded OMB2 filling via L-L and R-L collaterals. RCA with
___ proximal and mid vessel stenosis, dRCA with ___
stenosis, 60-70% mid RPDA with small PLB.
#PUMP: nl RV/LV, nl valves
#RHYTHM: NSR
ACTIVE ISSUES:
================
# Unstable angina: Patient with history of CAD c/b NSTEMI
(___) s/p DES to pLAD with stable exertional angina x 2 month
now with symptoms at rest that are relieved with nitroglycerin.
Symptoms are highly concerning for cardiac chest pain. However
cardiac biomarkers are negative x2 and EKG with new t-wave
flattening, though new TWI in lead III since last cardiac
catheterization. Plan was made for cardiac catheterization which
showed a new blockage in proximal and mid RCA which were opened
with a drug eluting stent. There was also significant disease of
the PDA, distal Lcx and D1 all of which were small vessel and
not amenable to stenting. He will need to continue Aspirin 81mg
indefinitely, clopidogrel 75mg daily x ___ year. He will continue
Atorvastatin 80 mg PO QPM and Isosorbide Mononitrate (Extended
Release) 90 mg PO DAILY and Nifedipine.
He will followup with Dr. ___ as an outpatient.
# RLL effusion with possible consolidation: Unclear etiology.
Newly seen on admission CXR. No leukocytosis, fevers, or
hypotension to suggest pneumonia. Assymetric presentation and
BNP of 411 without gross evidence of volume overload. Combined
with hyponatremia on admssion, concern for possible malignancy
though patient is a never smoker without family history. CT
Chest without mass or consolidation. The CT did show some small
pulmonary nodules throughout the lungs. No further diagnostic
testing was recommended but radiology does recommend a repeat CT
chest in ___ year to re-evaluate these nodules.
- He was seen by interventional pulmonology who recommended
pleural tap but patient refused. He was provided with the ___
clinic phone number should he reconsider the tap or require
further evaluation. He will follow up with IP as an outpatient
as needed.
# Hyponatremia: Seen incidentally on admission labs. Patient
appears euvolemic on admission. Given CXR evidence of new
pleural effusion, concern initially for SIADH, but hyponatremia
improved with IV hydration suggesting hypovolemic in etiology.
Urine electrolytes and osms pending at discharge. 2L fluid
restriction initiated the day of discharge. Will have repeat
sodium checked on ___ to be follow up by his PCP.
CHRONIC ISSUES:
===================
# Hypertension: Currently well controlled. Continued lisinopril
20mg daily / hydrochlorothiazide 12.5 mg daily / Metoprolol
Succinate XL 100 mg PO DAILY / NIFEdipine CR 60 mg PO DAILY
# Hyperglycemia: No documented hx of DM. HbA1c 6.3%. No need to
ISS.
# HL: Continued Atorvastatin
# BPH: Continued Tamsulosin 0.4 mg PO QHS
# Anxiety: Continued Lorazepam 0.5 mg PO BID PRN anxiety,
insomnia
# Glaucoma: brimonidine-timolol 0.2-0.5 % ophthalmic BID
CORE:
===================
# CODE: full
# CONTACT
- Daughter: ___
- Wife ___ speaking only): ___ |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atorvastatin
Attending: ___.
Chief Complaint:
Abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
Left ureteral stent placement ___
History of Present Illness:
___ with h/o colon cancer (in remission), lipomatosis, HTN,
asthma presents with N/V/abd pain - found to have UTI. She was
recently admitted to ___ 4 days ago for similar complaints and
was found to have a UTI. She was prescribed an oral
antibiotic(not sure of the name) of which she took 2 doses.
However, over the past ___ days, she has been too nauseous to
eat or to take the pain medication and so represented to ___
ER today.
In the ER, initial VS 98.6--> 100.0 ___ 20 99% on RA.
Urine showed large leuks, 48 WBC, mod bacteria. Labs with ___ Cr
1.8, WBC to 12.4 w/ 84% PMNs. AlkP elevated to 158. She was
given 1L NS, 1g Cftx, tylenol, zofran, and albuterol.
Currently, the patient's nausea is under better control. She
still c/o slight periumbilical pain but is mildly tender
diffusely on exam. She recently was in the ER for back pain on
___ and recently had a lipoma removed from her groin on ___.
Past Medical History:
- Stage I (pT1 pN0 cM0) sigmoid colon adenocarcinoma in ___
- Stage IIA (pT3 pN0 cM0) rectosigmoid colon adenoCA ___
intact IHC for MLH1, MSH2, MSH6, and PMS2; microsatellite stable
(MSS) by PCR; KRAS wild-type, BRAF wild-type
-obesity
-asthma
- HTN
- lipomatosis
- depression
SurgHx:
___ surgical history, in addition to the two colectomies, by
her report includes a cesarean section and possible bilateral
salpingo-oophorectomies. She also states that she underwent a
benign breast biopsy in the 1980s. I could find no record of the
pelvic surgery or any breast surgery by operative note or
pathology.
Social History:
___
Family History:
___ family history is significant for her father who had a
laryngeal cancer, but was a heavy smoker. She has two children
who are well. There are no other family members with colon
cancer, sarcoma or any other malignancy that she was aware of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.6 98 127/98 16 100% on RA
General: Alert, oriented, appears uncomfortable/restless
HEENT: Sclera anicteric, MMM, oropharynx clear, large tongue
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, diffusely tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Back: No CVAT
DISCHARGE PHYSICAL EXAM:
Vitals: 98.8, BP 132/88, HR 93, RR 16, 98%RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, large tongue,
edontulous
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 / S2, no murmurs, rubs,
___
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Back: negative for CVAT
Pertinent Results:
ADMISSION LABS:
___ 12:40AM BLOOD WBC-12.4*# RBC-4.17* Hgb-11.9* Hct-36.0
MCV-86 MCH-28.6 MCHC-33.1 RDW-13.4 Plt ___
___ 12:40AM BLOOD Neuts-83.6* Lymphs-12.5* Monos-3.4
Eos-0.1 Baso-0.4
___ 12:40AM BLOOD Glucose-165* UreaN-15 Creat-1.8* Na-137
K-3.7 Cl-99 HCO3-27 AnGap-15
___ 12:40AM BLOOD ALT-39 AST-29 AlkPhos-158* TotBili-0.5
___ 07:25AM BLOOD GGT-59*
___ 12:40AM BLOOD Lipase-17
___ 12:40AM BLOOD Albumin-3.2*
___ 02:02AM BLOOD Lactate-1.7
___ 01:45AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:45AM URINE RBC-2 WBC-48* Bacteri-MOD Yeast-NONE
Epi-6
RELEVANT LABS:
___ 08:25AM BLOOD CEA-3.4
___ 08:25AM BLOOD WBC-9.2 RBC-3.60* Hgb-10.3* Hct-31.5*
MCV-88 MCH-28.6 MCHC-32.7 RDW-13.5 Plt ___
___ 09:14AM URINE Hours-RANDOM UreaN-388 Creat-135 Na-71
K-21 Cl-66
PERTINENT MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
___ 07:10AM BLOOD Glucose-107* UreaN-9 Creat-1.7* Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
___ 07:10AM BLOOD Calcium-9.3 Phos-4.9* Mg-1.6
IMAGING:
Renal U/S (___):
FINDINGS:
The right kidney measures 10 cm. The left kidney measures 11.8
cm.
Incidental left renal cyst measuring 1.1 cm, simple in
appearance. There is left-sided hydronephrosis. The proximal
left ureter is seen, but the mid and distal ureters are not
visualized. Bilaterally, the renal morphology is normal. The
cortical thickness and echogenicity appear normal. The renal
sinus fat appears normal.
DOPPLERS:
On the right, the resistive index of the intrarenal arteries
ranges from 0.5 to 0.6, within the normal range. The
acceleration times and peak systolic velocities of the main
renal arteries are normal. The renal vein is patent and shows
normal waveforms.
On the left, the resistive index of the intrarenal arteries
ranges from 0.6 to 0.7, within the normal range. The
acceleration times and peak systolic velocities of the main
renal arteries are normal. The renal vein is patent and shows
normal waveforms. There are elevated venous velocities within
the lower pole of right kidney.
IMPRESSION:
1. Left-sided hydronephrosis without identifiable cause.
2. There are normal resistive indices, acceleration times and
peak systolic velocities of the intrarenal arteries. There is
no evidence of renal artery stenosis.
3. Within the left lower renal pole, there is elevated velocity
intrarenal venous flow. This can be seen in the setting of an
arteriovenous fistula. The patient denies a biopsy or
intervention. Further imaging can be performed with multi-phase
CT scan to look for vascular etiology of this elevated venous
flow, as well as to assess the site and cause of the left
hydronephrosis.
CT OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST
(___):
The liver, gallbladder, spleen, adrenal glands, stomach, and
intra-abdominal loops of small bowel appear normal. There is a
small hiatal hernia (4:28). A tubular, low-density right
retrocrural structure measures up to 1.7 x 2.1 cm (4:42,
500B:34), minimally enlarged since the earliest available
comparison CT from ___, likely representing a small
lymphangioma.
Tiny ventral hernias are present (4:101, 60), likely along prior
surgical port sites.
Prominent left para-aortic lymph nodes measure up to 8 mm
(4:61), and have increased in size since the ___
examination.
There is new moderate left hydronephrosis and left hydroureter
with mild perinephric stranding. A distal transition point is
seen at the level of an oval 2.3 x 1.3 cm left pelvic side wall
mass with components which appear both intrinsic and extrinsic
to the ureter (4:121).
The abdominal aorta, celiac trunk, SMA, and ___ are patent and
normal in caliber.
The patient is post distal colectomy. There is moderate colonic
diverticulosis, with no evidence of diverticulitis. A rectal
anastomosis appears intact (4:139).
The bladder is normal. There is mild stranding throughout the
left perinephric fat.
IMPRESSION:
1. Moderate left hydronephrosis and proximal hydroureter
secondary to an obstructing left pelvic side wall mass, with an
apparent intrinsic component. This may represent a new
metastasis versus a ureteral mass. A urological evaluation could
be considered for further evaluation with ureteroscopy.
2. Prominent left paraaortic lymph nodes may be reactive,
however, continued attention to this region is recommended.
3. Post partial colectomy. Intact rectal anastomosis.
MRU (___):
FINDINGS:
UROGRAM:
There is moderate left hydronephrosis and moderate left
hydroureter. The left ureter is dilated down to the level of
the pelvic brim at which point there is an abrupt cut-off with
the ureter distal to this point being normal in caliber. There
is a 2.1 x 0.9 cm enhancing lesion adjacent to the distal left
ureter at this point (1203:49) - on review of previous multiple
previous CTs, this lesion was very small but appears to have
been slowly increasing in size since ___ and is highly
concerning for recurrent disease. There is enhancement of the
urothelium within the left renal pelvis and ureter likely
related to obstruction. There is fat stranding surrounding the
left renal
pelvis and ureter. There are multiple mildly enlarged left
para-aortic lymph nodes (___:41) - these are non-specific but
are likely reactive.
The right kidney and ureter are unremarkable. There is normal
excretion of contrast by the right renal collecting system and
ureter into the bladder. No excretion of contrast is
demonstrated from the left kidney.
ABDOMEN:
The liver is unremarkable. The portal vein is patent. No intra
or
extrahepatic duct dilatation. The gallbladder is unremarkable.
The adrenals and spleen are within normal limits. The pancreas
is unremarkable. Normal caliber pancreatic duct. Note is made
of sigmoid diverticulosis. The visualized small and large bowel
is otherwise unremarkable. No mesenteric adenopathy. The lung
bases are clear. Bone marrow signal is normal. No destructive
osseous lesions.
PELVIS:
The patient is status post hysterectomy. The vagina is
unremarkable. The ovaries are not clearly identified. No
pelvic adenopathy. Bone marrow signal is normal. No
destructive osseous lesions.
IMPRESSION:
2.1 x 0.9 cm enhancing lesion adjacent to and apparently
compressing the
distal left ureter with resultant moderate left hydronephrosis
and
hydroureter. The lesion has been increasing in size since
___ on
multiple prior CTs. The findings are highly concerning for
recurrent colon cancer. There is not an obvious intrinsic
ureteral intraluminal mass or circumferential thickening.
RENAL SCAN (___):
IMPRESSION: Obstructed left kidney with loss of function. 2.
Normal right renal function. Differential function is 18% on
the left and 82% on the right, although visually the left kidney
seems to be functioning even less.
Radiology Report
HISTORY: ___ year old woman with elevated creatinine.
COMPARISON: ___.
TECHNIQUE: Gray scale and Doppler ultrasound images of the renal transplant
were obtained.
FINDINGS:
The right kidney measures 10 cm. The left kidney measures 11.8 cm.
Incidental left renal cyst measuring 1.1 cm, simple in appearance. There is
left-sided hydronephrosis. The proximal left ureter is seen, but the mid and
distal ureters are not visualized. Bilaterally, the renal morphology is
normal. The cortical thickness and echogenicity appear normal. The renal
sinus fat appears normal.
DOPPLERS:
On the right, the resistive index of the intrarenal arteries ranges from 0.5
to 0.6, within the normal range. The acceleration times and peak systolic
velocities of the main renal arteries are normal. The renal vein is patent
and shows normal waveforms.
On the left, the resistive index of the intrarenal arteries ranges from 0.6 to
0.7, within the normal range. The acceleration times and peak systolic
velocities of the main renal arteries are normal. The renal vein is patent
and shows normal waveforms. There are elevated venous velocities within the
lower pole of right kidney.
IMPRESSION:
1. Left-sided hydronephrosis without identifiable cause.
2. There are normal resistive indices, acceleration times and peak systolic
velocities of the intrarenal arteries. There is no evidence of renal artery
stenosis.
3. Within the left lower renal pole, there is elevated velocity intrarenal
venous flow. This can be seen in the setting of an arteriovenous fistula.
The patient denies a biopsy or intervention. Further imaging can be performed
with multi-phase CT scan to look for vascular etiology of this elevated venous
flow, as well as to assess the site and cause of the left hydronephrosis.
The findings were discussed with ___. At 11:56am by Dr. ___
telephone, at the time of reporting.
Radiology Report
INDICATION: History of UTI and abdominal pain with elevated creatinine.
Prior history of colon cancer.
COMPARISON: CTs available from ___ through ___.
TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained
prior to and following the uneventful administration of intravenous contrast.
Coronal and sagittal reformations were performed.
EXAMINATION DLP: 1192 mGy-cm.
CT OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST:
Included views of the lung bases demonstrate mild bibasilar scarring and
minimal dependent atelectasis. There is no pericardial or pleural effusion.
The heart size is normal.
The liver, gallbladder, spleen, adrenal glands, stomach, and intra-abdominal
loops of small bowel appear normal. There is a small hiatal hernia (4:28). A
tubular, low-density right retrocrural structure measures up to 1.7 x 2.1 cm
(4:42, 500B:34), minimally enlarged since the earliest available comparison CT
from ___, likely representing a small lymphangioma.
Tiny ventral hernias are present (4:101, 60), likely along prior surgical port
sites.
Prominent left para-aortic lymph nodes measure up to 8 mm (4:61), and have
increased in size since the ___ examination.
There is new moderate left hydronephrosis and left hydroureter with mild
perinephric stranding. A distal transition point is seen at the level of an
oval 2.3 x 1.3 cm left pelvic side wall mass with components which appear both
intrinsic and extrinsic to the ureter (4:121).
The abdominal aorta, celiac trunk, SMA, and ___ are patent and normal in
caliber.
The patient is post distal colectomy. There is moderate colonic
diverticulosis, with no evidence of diverticulitis. A rectal anastomosis
appears intact (4:139).
The bladder and prostate are normal. There is mild stranding throughout the
left perinephric fat.
OSSEOUS STRUCTURES: There is no acute fracture. There are no bony lesions
concerning for malignancy or infection.
IMPRESSION:
1. Moderate left hydronephrosis and proximal hydroureter secondary to an
obstructing left pelvic side wall mass, with a suggestion of an intrinsic
component. This may represent a new metastasis adjacent to the ureter versus a
ureteral mass. A urological evaluation could be considered for further
evaluation with ureteroscopy with consideration for stenting vs percutaneous
decompression of the kidney.
2. Prominent left paraaortic lymph nodes may be reactive, however, continued
attention to this region is recommended.
3. Post partial colectomy. Intact rectal anastomosis.
The findings and recommendations were discussed by Dr. ___ with Dr ___
___ telephone at 12:02pm ___.
Radiology Report
HISTORY: Stricture of left ureter of unclear cause on CT. MRU recommended.
History of colon cancer treated with surgical resection only. No history of
radiation. ?Cause of stricture.
COMPARISON: CT dated ___.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla
magnet including dynamic 3D imaging obtained prior to, during and after the
uneventful intravenous administration of 21 mL of ProHance. The patient also
received 10 mg IV Lasix.
FINDINGS:
UROGRAM:
There is moderate left hydronephrosis and moderate left hydroureter. The left
ureter is dilated down to the level of the pelvic brim at which point there is
an abrupt cut-off with the ureter distal to this point being normal in
caliber. There is a 2.1 x 0.9 cm enhancing lesion adjacent to the distal left
ureter at this point (1203:49) - on review of previous multiple previous CTs,
this lesion was very small but appears to have been slowly increasing in size
since ___ and is highly concerning for recurrent disease. There is
enhancement of the urothelium within the left renal pelvis and ureter likely
related to obstruction. There is fat stranding surrounding the left renal
pelvis and ureter. There are multiple mildly enlarged left para-aortic lymph
nodes (1201:41) - these are non-specific but are likely reactive.
The right kidney and ureter are unremarkable. There is normal excretion of
contrast by the right renal collecting system and ureter into the bladder. No
excretion of contrast is demonstrated from the left kidney.
ABDOMEN:
The liver is unremarkable. The portal vein is patent. No intra or
extrahepatic duct dilatation. The gallbladder is unremarkable. The adrenals
and spleen are within normal limits. The pancreas is unremarkable. Normal
caliber pancreatic duct. Note is made of sigmoid diverticulosis. The
visualized small and large bowel is otherwise unremarkable. No mesenteric
adenopathy. The lung bases are clear. Bone marrow signal is normal. No
destructive osseous lesions.
PELVIS:
The patient is status post hysterectomy. The vagina is unremarkable. The
ovaries are not clearly identified. No pelvic adenopathy. Bone marrow signal
is normal. No destructive osseous lesions.
IMPRESSION:
2.1 x 0.9 cm enhancing lesion adjacent to and apparently compressing the
distal left ureter with resultant moderate left hydronephrosis and
hydroureter. The lesion has been increasing in size since ___ on
multiple prior CTs. The findings are highly concerning for recurrent colon
cancer. There is not an obvious intrinsic ureteral intraluminal mass or
circumferential thickening.
Radiology Report
INDICATION: Left ureteral obstruction.
COMPARISON: CTA abdomen and pelvis ___.
FINDINGS: Seven spot fluoroscopic images were obtained without a radiologist
present and are submitted for review. Images demonstrate cannulation of the
left ureteral orifice and contrast opacification of the left ureter
demonstrating dilation and mild tortuosity proximally above a narrowed distal
segment. A wire was then introduced to the renal pelvis over which a double
pigtail catheter was placed. The proximal pigtail resides in the renal pelvis
and the distal pigtail in the urinary bladder.
IMPRESSION: Successful placement of left ureteral double pigtail stent. Please
consult the operative note in the ___ medical record for further details.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: N/V/D
Diagnosed with NAUSEA WITH VOMITING, DIARRHEA
temperature: 98.6
heartrate: 103.0
resprate: 20.0
o2sat: 99.0
sbp: 174.0
dbp: 85.0
level of pain: 5
level of acuity: 3.0 | ___ with h/o colon cancer (in remission), lipomatosis, HTN,
asthma presents with N/V/abd pain/diarrhea and found to have a
partially treated UTI complicated left renal outflow
obstruction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / lisinopril / Losartan / amlodipine
Attending: ___.
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with PMH significant for CAD s/p DES x1 to
OM1 in ___, HTN, and HLD that presented to her cardiologist's
office today in the setting of progressive dyspnea on exertion
over the last 2 months. She states that she can normally walk
the length of a football field without getting short of breath,
but can now only walk ___ feet without having to stop and
catch her breath. She reports mild chest discomfort after
walking several steps, but this has not changed in severity for
some time now. Denies chest pain or discomfort at rest. At her
cardiologists office today she was only able to ambulate 20 feet
before becoming SOB and desatted to 85% on RA. BP was also
elevated to 192/85. In light of this, she was sent to the ED for
further evaluation.
In the ED, initial VS were: 99.5 86 220/82 18 98% ra. CBC was
unremarkable. Chem-7 unremarkable. BNP elevated to 775. CXR with
Severe cardiomegaly with mild pulmonary vascular congestion. She
was given 200mg labetalol, 20mg IV lasix, and ASA 324mg.
Cardiology was consulted in ED with recommendation to admit to
___ for diuresis and TTE.
On the medical floor, patient states no complaints. She reports
PND, but denies orthopnea. No significant weight gain or
swelling. She has a chronic cough, but no increase in sputum or
severity of cough in last few months. Denies fever, chills, N/V,
chest pain, dizziness, lightheadedness, diaphoresis, abdominal
pain, dysuria, weakness, numbness, or paresthesias. Patient does
not take any medications despite recommendations to do so.
Past Medical History:
PMHx:Cervical CA, bronchitis, HTN, TAH, left rotator cuff
repair,
appendectomy, tonsils, cardiac stent
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PE:
Vitals: 97.8 131/53 72 20 94%RA
General: NAD. A&Ox3. Obese body habitus
HEENT: EOMI. NCAT. MMM
NECK: Supple JVP difficult to ascertain given body habitus
Heart: RRR. NS1&S2. NMRG
Lungs: Decreased breath sounds throughout with diffuse
expiratory wheeze and porlonged expiratory phase
Abdomen: BS+4. S/NT/ND
Extremities: No c/c/e
DISCHARGE PE:
VS: 97.8; 125-150/50-60; 60-70; ___ 95%RA
I/Os: none recorded as from ED (unclear response to 20IV lasix)
WT: 81kg (81.6 in ED)
Tele: No events
GENERAL: A&Ox3. NAD.
HEENT: NCAT.
NECK: Unable to assess JVP given body habitus
CARDIAC: RRR, No MRG appreciated
LUNGS: No rales, ronchi. Diffuse expiratory wheezes, prolonged
expiratory phase
ABDOMEN: Soft, NTND. No hepatomegally appreciated
EXTREMITIES: WWP, no peripheral edema
Pertinent Results:
ADMISSION LABS:
___ 05:44PM BLOOD WBC-8.3 RBC-4.80 Hgb-14.1 Hct-40.7 MCV-85
MCH-29.4 MCHC-34.6 RDW-14.8 Plt ___
___ 05:44PM BLOOD Neuts-38.2* Lymphs-53.9* Monos-6.1
Eos-1.1 Baso-0.7
___ 05:44PM BLOOD ___ PTT-27.8 ___
___ 05:44PM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-140
K-3.7 Cl-105 HCO3-25 AnGap-14
___:44PM BLOOD proBNP-775*
___ 05:17AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.8
DISCHARGE LABS:
___ 05:17AM BLOOD WBC-7.3 RBC-4.51 Hgb-12.9 Hct-38.9 MCV-86
MCH-28.7 MCHC-33.2 RDW-14.6 Plt ___
___ 05:17AM BLOOD Glucose-91 UreaN-18 Creat-0.7 Na-146*
K-3.4 Cl-105 HCO3-26 AnGap-18
___ 12:38AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:17AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.8
MICRO: None
STUDIES/IMAGING:
CXR: Severe cardiomegaly is re- demonstrated. Aortic knob
calcifications are noted, with the mediastinal and hilar
contours appearing unchanged. Mild pulmonary vascular
congestion is present without focal consolidation, pleural
effusion or pneumothorax. Linear opacities in the left mid lung
field likely reflect subsegmental atelectasis. There are no
acute osseous abnormalities.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff q4H:PRN Disp
#*2 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Dyspnea ___ pulmonary edema
- Hypertensive urgency
Secondary Diagnosis:
- Hypothyroidism
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: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Severe cardiomegaly is re- demonstrated. Aortic knob calcifications are noted,
with the mediastinal and hilar contours appearing unchanged. Mild pulmonary
vascular congestion is present without focal consolidation, pleural effusion
or pneumothorax. Linear opacities in the left mid lung field likely reflect
subsegmental atelectasis. There are no acute osseous abnormalities.
IMPRESSION:
Severe cardiomegaly with mild pulmonary vascular congestion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with HEART FAILURE NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS
temperature: 99.5
heartrate: 86.0
resprate: 18.0
o2sat: 98.0
sbp: 220.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | ___ with PMH significant for CAD and HTN currently off all
medications who presented to cardiology clinic today with
subacute DOE and new hypoxia with ambulation in setting of
refusing to take medications as an outpatient.
#DOE/hypoxemia with ambulation: Initially felt to be ___ new HF
given CXR findings, elevated and untreated BP in ED and patient
at risk for diastolic HF given prolonged untreated HTN (patient
refuses to take outpatient medications and prefers juice diets
to treat her medical conditions). However also considered
primary pulmonary process such as COPD given prolonged
expiratory phase and wheeze on exam. Low suspicion for ACS, but
ruled out with tropx2 negative and no EKG changes. Patient's
weight this admission stable over previous past ___ years when
reviewed in OMR. Patient given PO labetalol with good BP
control. Patient also given duonebs and was able to ambulate
without dyspnea and ambulatory sats stable at 97% with
abmulation. Patient should obtain outpatient PFTs as well as TTE
and stress testing as may also be component of diastolic heart
failure contributing to symptoms.
#Hypertensive urgency vs. emergency: Hypertensive to 220/82 in
ED with evidence of end organ damage given hypoxia and pulmonary
edema, however this was a subacute picture so not clearly
emergency. Responded well to 200mg PO labetalol, but BPs 120s
systolic and prefer avoid over correction too fast. Continued on
100mg BID and encouraged to continue taking medication as
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Found Down / Altered Mental Status
Major Surgical or Invasive Procedure:
ORIF of Anterior Mandibular Fracture
Tracheal Intubation
Mechanical Ventilation
History of Present Illness:
Patient is a ___ year-old woman found down in the rain by EMS,
some report of whether she had visited another ER previously
today (by speaking to other medics). Altered mental status,
moaning not answering questions. Several empty bottles of
Listerine nearby.
.
Inital vitas on the ED were 120 20 110/70 99%. On arrival to
the ED, she spontaneously opened her eyes, moaning,
intermittently following commands. She was found to have
increase secretions with a GCS 13 and was not protecting her
airway, thus she was intubated for airway protection. Labs in
the ED were notable for an alcohol level 423, lactate of 4.4,
WBC 14.4 w/ 72% PMNs, anion gap 16, osm gap 106 that is
explained by EtOH level of 423, and negative UA/UTOX. CT head
did not identify acute intracranial process or crainal fracture
and CT C-spine identified possible mandibular fracture and
anterior subluxation of right mandibular condyle. The decision
made to admit the patient to the MICU. VS on transfer were
31.1C, 59, 103/70, 18, 100% ventilated.
.
On arrival to the MICU, patient is intubated and sedated. She
open eyes and follows commands.
Past Medical History:
Depression with prior suicide attempts
Anxiety
ETOH abuse
Social History:
___
Family History:
Father with likely depression, no formal treatment. No FH or
suicide or substance use disorders.
Physical Exam:
Admission Physical Exam:
General: Intubated and sedated, comfortable and following
commands
HEENT: Sclera anicteric, Pupils 4mm to 3mm ___
Neck: JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Symmetric breath sounds bilaterally, no wheezes or rales
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
Ext: Well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs
___ 06:39AM URINE UCG-NEGATIVE
___ 05:17AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:17AM BLOOD Osmolal-408*
___ 06:33AM BLOOD Type-ART Temp-30.9 Rates-/18 Tidal V-500
FiO2-100 pO2-294* pCO2-22* pH-7.47* calTCO2-16* Base XS--4
AADO2-401 REQ O2-70 -ASSIST/CON Intubat-INTUBATED
___ 05:28AM BLOOD Glucose-161* Lactate-4.4* Na-146* K-4.4
Cl-110* calHCO3-17*
___ 05:28AM BLOOD Hgb-14.3 calcHCT-43 O2 Sat-96 COHgb-2
MetHgb-0
___ 05:28AM BLOOD freeCa-0.99*
___ 05:42AM BLOOD Glucose-85 UreaN-5* Creat-0.4 Na-141
K-3.0* Cl-104 HCO3-27 AnGap-13
___ 05:17AM BLOOD WBC-14.4* RBC-4.24 Hgb-13.6 Hct-40.7
MCV-96 MCH-32.0 MCHC-33.3 RDW-13.3 Plt ___
___ 05:42AM BLOOD WBC-5.3# RBC-3.78* Hgb-12.1 Hct-36.1
MCV-95 MCH-32.1* MCHC-33.7 RDW-13.5 Plt ___
___ 05:17AM BLOOD Neuts-72.0* ___ Monos-2.4 Eos-0.5
Baso-0.8
.
Discharge Labs:
.
Imaging:
CXR [___]:
FINDINGS: The ET tube ends 6.1 cm above the level of the carina.
An NG tube ends near the level of the GE junction. A trauma
board slightly limits evaluation of this radiograph. The lungs
are clear. Lung volumes are low. The cardiac and mediastinal
contours are normal. There are no pleural effusions. No
pneumothorax is seen. The bony thorax is grossly intact.
IMPRESSION:
1. No acute cardiac or pulmonary process.
2. Appropriately positioned endotracheal tube.
3. NG tube ends near the level of the GE junction. Recommend
advancing.
.
CT CSPINE [___]:
FINDINGS: There is no acute fracture of the cervical spinal or
malalignment, although there is slight loss of the normal
cervical lordosis. Multilevel degenerative changes of the
cervical spine include small anterior osteophytes and mild
posterior disc bulging at C5-6 with minimal associated narrowing
of the spinal canal. A lucency through the right paramedian
portion of the mandible (3:29) could be a non-displaced
fracture, but is incompletely evaluated on the present study
(3:28). The right mandibular condyle is subluxed anteriorly.
There are no pathologically enlarged cervical lymph nodes. The
orogastric tube is coiled within the pharynx. An ET tube is
present. The visualized portions of the lung apices are
unremarkable aside from biapical pleuroparenchymal
thickening/scarring. There is minimal left maxillary sinus
mucosal thickening. The remainder of the visualized portions of
the paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. No acute cervical fracture or malalignment.
2. Possible fracture through the body of the mandible is
incompletely
assessed on the present study. Further evaluation with a
dedicated
maxillofacial CT could be performed.
3. Anterior subluxation of the right mandibular condyle.
4. Orogastric tube is looped within the oropharynx. Recommend
repositioning.
.
CT HEAD [___]:
FINDINGS: There is no evidence of intracranial hemorrhage,
edema, shift of normally midline structures, hydrocephalus, or
acute large vascular territorial infarction. Aside from minimal
left maxillary sinus mucosal thickening, the visualized portions
of the paranasal sinuses and mastoid air cells are well aerated.
No fractures are identified. The left mandibular condyle is
subluxed slightly anteriorly, of uncertain chronicity. Note is
made of a right parietal subgaleal hematoma.
IMPRESSION:
1. No acute intracranial process.
2. Slight anterior subluxation of the right mandibular condyle,
of uncertain chronicity.
3. Right parietal subgaleal hematoma.
.
CT SINUS [___]:
FINDINGS: There is an acute comminuted and nondisplaced fracture
of the anterior body of the right mandible. This extends to, but
does not appear to involve, the roots of the right central and
lateral incisors. The right mental foramen is spared. There is
no significant surrounding fat stranding or large fluid
collections. The submandibular and sublingual glands appear
symmetric. TMuscles of the floor of mouth appear intact.
Cervical lymph nodes are not pathologically enlarged. The right
mandibular condyle is anteriorly and inferiorly subluxed from
the right glenoid fossa. It appears irregularly enlarged and
dystrophic, suggesting prior trauma and/or degenerative changes.
Mild mucosal thickening is noted throughout the ethmoid and
maxillary sinuses. There is mild rightward deviation of the
nasal septum, with a broad-based bony spur that does not contact
the middle meatus. The ostiomeatal units are widely patent. The
lamina papyracea are intact. Note is made ___ type 2
olfactory fossae bilaterally. Imaged frontal calvarium, nasal
bones, facial bones, and maxilla appear intact. Upper cervical
spine is within normal limits. The airway is widely patent.
IMPRESSION:
1. Comminuted nondisplaced fracture of the right anterior
mandibular body.
2. Dystrophic right mandibular condyle, with anterior and
inferior
subluxation.
.
Micro:
___ 9:45 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 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.
___ BLOOD CULTURE - PENDING
___ MRSA SCREEN - FINAL [negative]
___ URINE CULTURE - FINAL [negative]
Medications on Admission:
None
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain: Do not take more than prescribed. Do not
combine with alcohol.
Disp:*30 Tablet(s)* Refills:*0*
5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 7 days.
Disp:*13 Tablet(s)* Refills:*0*
6. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Comminuted Jaw fracture
Anxiety
Depression
Alcohol Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Status post ET tube placement. Evaluate position.
COMPARISON: None.
FINDINGS: The ET tube ends 6.1 cm above the level of the carina. An NG tube
ends near the level of the GE junction. A trauma board slightly limits
evaluation of this radiograph. The lungs are clear. Lung volumes are low.
The cardiac and mediastinal contours are normal. There are no pleural
effusions. No pneumothorax is seen. The bony thorax is grossly intact.
IMPRESSION:
1. No acute cardiac or pulmonary process.
2. Appropriately positioned endotracheal tube.
3. NG tube ends near the level of the GE junction. Recommend advancing.
Radiology Report
INDICATION: Altered mental status, hypothermic, found down. Evaluate for
intracranial hemorrhage.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformations
were performed.
COMPARISON: None.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of
normally midline structures, hydrocephalus, or acute large vascular
territorial infarction. Aside from minimal left maxillary sinus mucosal
thickening, the visualized portions of the paranasal sinuses and mastoid air
cells are well aerated. No fractures are identified. The left mandibular
condyle is subluxed slightly anteriorly, of uncertain chronicity. Note is
made of a right parietal subgaleal hematoma.
IMPRESSION:
1. No acute intracranial process.
2. Slight anterior subluxation of the right mandibular condyle, of uncertain
chronicity.
3. Right parietal subgaleal hematoma.
Radiology Report
INDICATION: Altered mental status with hypothermia, found down. Evaluate for
fracture.
TECHNIQUE: MDCT axial images were acquired through the cervical spine without
administration of intravenous contrast material. Multiplanar reformations
were performed.
COMPARISON: None.
FINDINGS: There is no acute fracture of the cervical spinal or malalignment,
although there is slight loss of the normal cervical lordosis. Multilevel
degenerative changes of the cervical spine include small anterior osteophytes
and mild posterior disc bulging at C5-6 with minimal associated narrowing of
the spinal canal. A lucency through the right paramedian portion of the
mandible (3:29) could be a non-displaced fracture, but is incompletely
evaluated on the present study (3:28). The right mandibular condyle is
subluxed anteriorly.
There are no pathologically enlarged cervical lymph nodes. The orogastric
tube is coiled within the pharynx. An ET tube is present. The visualized
portions of the lung apices are unremarkable aside from biapical
pleuroparenchymal thickening/scarring. There is minimal left maxillary sinus
mucosal thickening. The remainder of the visualized portions of the paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. No acute cervical fracture or malalignment.
2. Possible fracture through the body of the mandible is incompletely
assessed on the present study. Further evaluation with a dedicated
maxillofacial CT could be performed.
3. Anterior subluxation of the right mandibular condyle.
4. Orogastric tube is looped within the oropharynx. Recommend repositioning.
Radiology Report
MANDIBLE
INDICATION: Jaw fracture, evaluation.
FINDINGS: There is a known nondisplaced fracture of the right anterior
mandible, documented by CT examination from ___. This fracture
is not visualized on the current radiographic image.
Radiology Report
INDICATION: ___ female with acute-on-chronic mandibular fractures,
partially imaged on cervical spine CT.
Correlation to cervical spine CT from ___ at 5:59.
TECHNIQUE: Helical MDCT images were acquired through the facial bones without
intravenous contrast. 1.25-mm axial images were formatted in soft tissue and
bone kernels. 1-mm coronal and sagittal multiplanar reformats were also
generated.
FINDINGS: There is an acute comminuted and nondisplaced fracture of the
anterior body of the right mandible. This extends to, but does not appear to
involve, the roots of the right central and lateral incisors. The right
mental foramen is spared. There is no significant surrounding fat stranding
or large fluid collections. The submandibular and sublingual glands appear
symmetric. TMuscles of the floor of mouth appear intact. Cervical lymph
nodes are not pathologically enlarged.
The right mandibular condyle is anteriorly and inferiorly subluxed from the
right glenoid fossa. It appears irregularly enlarged and dystrophic,
suggesting prior trauma and/or degenerative changes.
Mild mucosal thickening is noted throughout the ethmoid and maxillary sinuses.
There is mild rightward deviation of the nasal septum, with a broad-based bony
spur that does not contact the middle meatus. The ostiomeatal units are
widely patent. The lamina papyracea are intact. Note is made ___ type 2
olfactory fossae bilaterally.
Imaged frontal calvarium, nasal bones, facial bones, and maxilla appear
intact. Upper cervical spine is within normal limits. The airway is widely
patent.
IMPRESSION:
1. Comminuted nondisplaced fracture of the right anterior mandibular body.
2. Dystrophic right mandibular condyle, with anterior and inferior
subluxation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FOUND DOWN
Diagnosed with ALTERED MENTAL STATUS , ALCOHOL ABUSE-UNSPEC, HYPOTHERMIA, EXCESSIVE COLD NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ year-old woman with unknown medical history presenting with
AMS after being found down in the rain by EMS found to have a
EtOH level of 423 and intubated for airway protection admitted
for alcohol intoxication found to have comminuted jaw fracture.
. |
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 and chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ w/ hx of HTN, BPH and UTI in past who
presents to the ED for abdominal pain and nausea.
He states that he started having nausea and some vomiting about
two to three days ago. Also started having abdominal pain at
that time. The abdominal pain had been ___ that was tender
in bandlike distribution across middle of abdomen. No back
pain. No radiation. Not associated with food or worse with
eating. The vomiting was nonbloody and biliuos. Also has been
having cold sweats for past two days.
Patient states he has a history of UTIs, and had the abdominal
pain at that time as well.
Patient denies fevers, lightheadedness. He has not eaten much of
anything in past two days.
Per our records, he had a serious of UTIs enterococcus
vancomycin sensitive in ___. He does have a hx of BPH and
has been put on flomax for that.
ROS: Denies fevers, myalgias. Denies diarrhea or constipation.
Denies bloody urine. Denies changes in vision. Denies weight
loss. Denies CP or SOB.
In the ED, initial VS were 97.8 69 116/97 15 98% ra. Received
pantoprazole, zofran, azithromycin, CTX, morphine.
Labs demonstrated WBC 8.8, Hct 46, Plt 279; LFTs normal; Chem 7
nl. Lactate 1.9. UA demonstrated > 182 WBC, 17RBC, few
bacteria, mod blood, large leuk, 100 prot and 40 ketone. Blood
and urine cultures were sent. CT abd/pelvis prelim demonstrated
no acute intra-abdominal process. CXR demosntrated subtle
interstitial abnormality in the left lower lobe which could
represent infection or other non-specific process.
Transfer VS were 97.9 95 134/92 16 99% RA.
On arrival to the floor, patient reports that he still has ___
pain but has no chills. Patient is comfortable.
Past Medical History:
ABNORMAL LIVER FUNCTION TESTS
BENIGN PROSTATIC HYPERTROPHY
CHRONIC FATIGUE
DYSPEPSIA
EMPHYSEMA
HEMATOSPERMIA
HEPATITIS C
HIP PAIN
HYPERLIPIDEMIA
HYPERTENSION
KNEE PAIN
POSITIVE H. PYLORI ANTIBODY SCREEN
URINARY TRACT INFECTION
H/O INGUINAL HERNIA
H/O TESTOSTERONE DEFICIENCY
Social History:
___
Family History:
Mother died at age of ___, father died of multiple gunshot
wounds.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.5 141/82 92 18 98%RA
General - NAD, lying in bed
HEENT - PERRL, anicteric sclerae
Neck - supple, FROM
CV - RRR, no m/r/g
Lungs - CTAB
Abdomen - nondistended, tender to palpation in mid-abdomen, no
organomegaly, no suprapubic tenderness, BS+
GU - mildly enlarged prostate without prostate tenderness, no
CVA tenderness
Ext - no edema, palpable distal pulses b/l
Neuro - AOx3
Skin - no rashes
DISCHARGE PHYSICAL EXAM:
VS - 98.1 (99.5) 141/50 (SBP 110-140) 68 18 95%RA
General - NAD, lying in bed
HEENT - PERRL, MMM
CV - RRR, no m/r/g
Lungs - CTAB
Abdomen - nondistended, tender to palpation in mid-abdomen, no
organomegaly, no suprapubic tenderness, BS+
Ext - no edema, palpable distal pulses b/l
Neuro - AOx3
Skin - no rashes
Pertinent Results:
Admission Labs:
___ 04:55AM BLOOD WBC-8.8# RBC-4.97 Hgb-14.6 Hct-46.6#
MCV-94 MCH-29.3 MCHC-31.2 RDW-12.6 Plt ___
___ 04:55AM BLOOD Neuts-78.5* Lymphs-15.9* Monos-3.5
Eos-1.7 Baso-0.4
___ 04:55AM BLOOD Glucose-123* UreaN-17 Creat-1.0 Na-139
K-4.2 Cl-101 HCO3-26 AnGap-16
___ 04:55AM BLOOD ALT-15 AST-27 AlkPhos-70 TotBili-0.7
___ 04:55AM BLOOD Lipase-18
___ 09:15AM BLOOD Calcium-8.0* Phos-1.5* Mg-1.6
___ 09:50AM BLOOD Lactate-1.9
CXR ___
Subtle interstitial abnormality in the left lower lobe which
could represent infection or other non-specific process.
CT Abd/Pelvis w/ contrast ___. No acute intra-abdominal process to explain the patient's
symptoms.
Renal U/s ___
Normal-appearing kidneys. No hydronephrosis or hydroureter.
Discharge Labs:
___ 07:45AM BLOOD WBC-10.8 RBC-4.01* Hgb-12.3* Hct-37.6*
MCV-94 MCH-30.6 MCHC-32.7 RDW-12.6 Plt ___
___ 07:45AM BLOOD Glucose-107* UreaN-10 Creat-0.8 Na-132*
K-3.5 Cl-97 HCO3-29 AnGap-10
___:
___ 07:45AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.9
___ 07:35AM BLOOD Vanco-7.9*
___ 08:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:20AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:20AM URINE RBC-17* WBC->182* Bacteri-FEW Yeast-NONE
Epi-1
Micro:
___ 8:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Blood cultures x2 ___: no growth to date
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO HS
2. Vitamin D 1000 UNIT PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Tamsulosin 0.4 mg PO HS
2. Vitamin D 1000 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 325 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
4. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 500 mg 1 tablet(s) by mouth three times a day
Disp #*33 Capsule Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
6. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs PRN Disp #*20
Tablet Refills:*0
8. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*42 Tablet Refills:*0
9. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID PRN Disp
#*28 Tablet Refills:*0
10. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: enterococcus UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fever
COMPARISON: ___
FINDINGS:
PA and lateral chest radiographs were obtained. The lungs are well expanded.
There is a subtle interstitial abnormality in the left lower lobe. There is
no focal consolidation, effusion, or pneumothorax. Cardiac and mediastinal
contours are normal.
IMPRESSION:
Subtle interstitial abnormality in the left lower lobe which could represent
infection or other non-specific process.
Radiology Report
HISTORY: Nausea, vomiting, fevers, and abdominal pain. Evaluate for
obstruction, infection.
TECHNIQUE: Helical axial MDCT images were obtained from the bases of the
lungs through the pubic symphysis after the administration of IV and oral
contrast. Multiplanar reformatted images in coronal and sagittal axes were
generated.
DLP: 661.34 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
There are bibasilar linear opacities within the lungs representing mild
atelectasis. There is no pleural or pericardial effusion.
CT abdomen: Multiple hypoattenuating hepatic lesions are again seen
throughout the liver in the same distribution as the prior exam, the largest
measuring up to 1.8 cm. The spleen is homogeneous and normal in size. There
is a small anterior inferior splenule. The pancreas is without focal lesions
or peripancreatic stranding or fluid collection. The adrenal glands are
unremarkable. The kidneys appear normal without focal lesion or
hydronephrosis. The right renal stone that was seen in ___ is not well
assessed on this contrast study.
The stomach, small bowel, and colon are within normal limits without wall
thickening or obstruction. The appendix is visualized and normal. The
intra-abdominal vasculature is normal in caliber and without atherosclerotic
disease. There is no retroperitoneal or mesenteric lymph node enlargement by
CT size criteria is seen. There is no ascites, free air, or abdominal wall
hernia.
CT pelvis: The questionable anterior bladder wall thickening seen on prior CT
is not seen on this study. There are calcifications within the prostate. No
pelvic wall or inguinal lymph node enlargement by CT size criteria is seen.
No pelvic free fluid is identified.
Osseous structures: There is multilevel degenerative disease of the spine.
No blastic or lytic lesion suspicious for malignancy is present.
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's symptoms.
Radiology Report
HISTORY: ___ year old man with history of abdominal pain and UTIs. Query
pyelonephritis /hydroureter
COMPARISON: CT abdomen from the same day and prior CT abdomen from ___.
FINDINGS:
The right kidney measures 9.7 cm and the left kidney measures 9.8 cm. No
evidence of hydronephrosis. No renal calculi are identified. No focal renal
masses or perinephric fluid collections. Partially distended urinary bladder
is unremarkable. Incidental hepatic cysts are identified, largest measuring
2.0 cm with lobulated contours in segment 6 of the liver.
Non-specific pocket of fluid is identified in the right lower quadrant,
however this may be within a loop of bowel.
IMPRESSION:
Normal-appearing kidneys. No hydronephrosis or hydroureter.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with NAUSEA WITH VOMITING
temperature: 97.8
heartrate: 69.0
resprate: 15.0
o2sat: 98.0
sbp: 116.0
dbp: 97.0
level of pain: 4
level of acuity: 3.0 | BRIEF CLINICAL SUMMARY:
Mr. ___ is a ___ w/ hx of BPH and UTI in past who presented
to the ED for abdominal pain and nausea, found to be
enterococcus UTI/pyelo. We treated the patient initially with
vancomycin and ceftriaxone until urine culture returned positive
for enterococcus sensitive to vancomycin and ampicillin.
Patient transitioned to amoxicillin and discharged to home,
tolerating POs and with improved abdominal pain.
ACTIVE ISSUES:
# UTI/pyelonephritis: Found to be enterococcus UTI, sensitive to
vancomycin/ampicillin. Patient with nausea and abdominal pain,
treated symptomatically. His abdominal pain was evaluated with
CT abdomen and pelvis and renal ultrasound which showed no acute
abnormalities. Prostate exam demonstrated no evidence of
prostatitis. His abdominal pain attributed to bladder spasm. He
was treated with tylenol (~2g/day with hx of Hepatitis C) and
morphine IV/oxycodone PO, as well as pyridium. His BPH was also
treated as below. Initially his UTI was treated with
vancomycin/ceftriaxone, and was transitioned to amoxicillin
500mg TID on day of discharge. Patient should continue
antibiotics for 11 days after discharge for a total course of 14
days. Would recommend post-treatment UA/urine culture given
previous recurrent enterococcal infections requiring long-term
therapy.
# BPH: Continued patient's tamsulosin and initiated finasteride.
TRANSITIONAL ISSUES:
- amoxicillin 500mg tid for 14 day total antibiotic course for
complicated UTI/pyelonephritis. Consider post-treatment
UA/Uculture given history of recurrent enterococcal infection
previously requiring long-term antibiotic therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin / morphine / ciprofloxacin / OxyContin
Attending: ___.
Chief Complaint:
Confusion
Generalized weakness
Major Surgical or Invasive Procedure:
Peripherally inserted central catheter (___) placement
History of Present Illness:
Ms. ___ is a ___ with history of recently diagnosed Crohn's
disease complicated by pelvic abscess who presents with
progressive confusion and generalized weakness. EMS was called
by her daughter due to poor PO intake, generalized weakness, and
decline in ability to function at home. According to her
husband, since returning home from the hospital approximately
2.5 weeks ago, she has become progressively confused and
agitation, and it has been "hell." He believes that she has been
misinterpreting her physicians' instructions, allowing herself
to eat only 2 egg whites per day. She has remained in bed
despite having been advised to engage in physical therapy. She
has "gone hysterical" and screamed at multiple relatives,
perhaps in the context of having taken too many prednisone
pills. She denies fevers, chills, sweats, nausea, vomiting,
abdominal pain, diarrhea, constipation, hematochezia, melena, or
focal weakness.
In the ED, initial vital signs were as follows: 97.7 110 120/74
16 97% RA. Labs were notable for essentially unremarkable
chemistries and CBC and negative urinalysis. CT abdomen/pelvis
revealed sigmoid diverticulosis, with resolution of previously
noted pelvic abscess. Head CT was negative for acute
intracranial pathology. She received acetaminophen 650mg x1
prior to admission for further evaluation.
On the floor, she is slightly agitated and cursing at the
admitting physician. She believes that she was admitted for
removal of "fluid from her whole body," but is otherwise without
specific complaints.
Past Medical History:
Crohn's disease complicated by pelvic abscess
Hemorrhoids
Elevated PTH
Left frontal cranial resection for recurrent abscess secondary
to infected tooth implant in ___
GERD
Hyperlipidemia
Osteoporosis
Social History:
___
Family History:
No known family history of gastrointestinal disease, including
malignancy.
Physical Exam:
On admission:
Vitals - T: 97.3 BP: 142/63 HR: 93 RR: 16 02 sat: 100% RA
GENERAL: NAD, intermittently swearing, A and O x3, confused but
redirectable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: CN II-XII intact, strength in all 4 extremities somewhat
diminished, but difficult to sense if patient was cooperating
fully
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
At discharge:
Vitals: 97.6, 147/88 (110-150s/60-90s), 118 (110-150s), 20, 97%
RA
General- Comfortable, NAD, but oriented to person/place/date.
HEENT- MMM, oropharynx and tongue has white exudates, supple
neck
Lungs- Clear to auscultation bilaterally, no W/R/R
CV- Tachycardic, normal S1 + S2, no rubs, no gallops.
Abdomen- Soft, BS+, NT/ND, no guarding/organomegaly
GU- no foley
Ext- Warm, well perfused, 2+ ___ pulses, no clubbing, cyanosis,
edema.
Neuro- CN ___ grossly intact.
Pertinent Results:
On admission:
___ 03:26PM BLOOD WBC-8.2# RBC-3.21* Hgb-10.1* Hct-31.2*
MCV-97 MCH-31.4# MCHC-32.3 RDW-19.5* Plt ___
___ 03:26PM BLOOD Neuts-91.3* Lymphs-5.9* Monos-2.6 Eos-0.1
Baso-0.1
___ 03:26PM BLOOD Glucose-141* UreaN-20 Creat-0.7 Na-137
K-3.3 Cl-105 HCO3-21* AnGap-14
___ 03:26PM BLOOD ALT-19 AST-20 CK(CPK)-14* AlkPhos-55
TotBili-0.2
___ 03:26PM BLOOD Albumin-3.0* Calcium-9.1 Phos-2.2* Mg-1.9
___ 03:26PM BLOOD TSH-0.10*
___ 03:26PM BLOOD T3-64* Free T4-1.0
___ 05:45AM BLOOD Cortsol-19.1
___ 08:32PM BLOOD Lactate-1.8
___ 08:07PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:07PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 08:07PM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-1
TransE-<1
In the interim:
___ 07:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
At discharge:
___ 05:45AM BLOOD WBC-8.9 RBC-3.14* Hgb-9.9* Hct-31.4*
MCV-100* MCH-31.5 MCHC-31.5 RDW-18.5* Plt ___
___ 05:45AM BLOOD Glucose-91 UreaN-24* Creat-0.7 Na-136
K-4.0 Cl-105 HCO3-24 AnGap-11
___ 05:45AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.9*
Microbiology:
Blood Cx ___ x2): No growth
Urine Cx (___):
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Urine Cx (___): Mixed flora
RPR (___): Nonreactive
Stool studies, including C. difficile assay (___): Negative
Imaging:
Noncontrast head CT (___):
No evidence of acute intracranial hemorrhage. Status post left
frontal resection and craniectomy. Left frontal
encephalomalacia with ex
vacuo dilatation of the left frontal horn. MRI is more
sensitive in detecting acute ischemia. Atrophy, most
prominently in the bifrontal regions.
CT abdomen/pelvis with conrast (___):
1. Posterior right pelvic gas containing fistula from the right
rectum to the right gluteal region.
2. Interdeterminate liver density in the liver adjacent to the
gallbladder
for which further evaluation with MRI is recommended.
CXR PA/lateral (___):
External artifact projects over the posterior chest on the
lateral view, somewhat limiting its evaluation. Otherwise,
aside from mild
bibasilar atelectasis, no acute cardiopulmonary process seen.
Portable CXR (___):
Lungs are better expanded, clear, cardiac silhouette is normal,
pulmonary
vasculature not distended, and no pleural effusion. Aside from
mild-to-moderate scoliosis, centered in the mid thoracic spine,
this is a
normal chest radiograph.
ECG (___):
Sinus tachycardia. Wandering baseline. Compared to the previous
tracing
of ___ the rate has increased. There are non-specific ST
segment changes. Otherwise, no diagnostic interim change.
IntervalsAxes
___
___
ECG (___):
The rhythm is probably sinus tachycardia, new as compared with
previous
tracing of ___. Clinical correlation is suggested.
IntervalsAxes
___
___
ECG (___):
Sinus tachycardia. Prominent voltage in leads I and aVL for left
ventricular hypertrophy. Compared to the previous tracing of
___ the rate has slowed. Otherwise, no diagnostic interim
change.
IntervalsAxes
___
___
CTA chest (___):
1. Chronic pulmonary emboli within left upper lobe subsegmental
branches. No acute pulmonary embolus.
2. Diffuse ground-glass opacities throughout the lungs, likely
from low lung volumes. No discrete consolidation, nodule, or
mass.
3. 10 mm nonspecific hypodensity within the right hepatic lobe,
statistically likely benign, but is incompletely characterized.
A recommendation for MRI was made on the ___ CT
examination.
TTE (___):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The posterior mitral
valve leaflet is mildly elongated with mild systlic prolapse.
Mild to moderate (___) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mitral valve prolapse with
mild-moderate mitral regurgitation. Normal biventricular cavity
sizes with preserved global biventricular systolic function.
Bilateral lower extremity venous ultrasound (___):
No evidence of DVT in the right or left lower extremity.
ECG (___):
Artifact is present. Sinus tachycardia. Non-specific ST-T wave
changes.
Possible left ventricular hypertrophy. Compared to the previous
tracing
of ___ ST-T wave changes are new.
IntervalsAxes
___
___
ECG (___):
Artifact is present. Sinus tachycardia. Possible non-specific
ST-T wave
changes. Compared to the previous tracing of ___ voltage for
left
ventricular hypertrophy is no longer present.
IntervalsAxes
___
___
Portable CXR (___):
Right PICC ends in the upper right atrium.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 50 mg PO DAILY
Tapered dose - DOWN
2. Ciprofloxacin HCl 500 mg PO Q12H
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID
4. Promethazine 12.5 mg PO Q8H:PRN nausea
5. Simvastatin 20 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Alendronate Sodium 70 mg PO 1X/WEEK (___)
8. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP Frequency is
Unknown
Discharge Medications:
1. Alendronate Sodium 70 mg PO 1X/WEEK (___)
Please take on the day you were taking prior to your
hospitalization.
2. Simvastatin 20 mg PO DAILY
3. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP ASDIR
4. Ciprofloxacin 400 mg IV Q12H
5. Heparin 5000 UNIT SC TID
6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
7. Nystatin Oral Suspension 5 mL PO QID Thrush
8. PredniSONE 30 mg PO DAILY
9. Pantoprazole 40 mg IV Q12H
10. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Crohn's disease
Rectovaginal fistula
Chronic pulmonary embolus
Sinus tachycardia
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
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Altered mental status.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. On the
lateral view, external artifact projects over the posterior thorax, partially
obscuring the view. Given this, there is a left greater than right mild
bibasilar atelectasis. No definite focal consolidation is seen. There is no
pleural effusion or pneumothorax. The aortic knob is calcified. The cardiac
silhouette is not enlarged.
IMPRESSION: External artifact projects over the posterior chest on the
lateral view, somewhat limiting its evaluation. Otherwise, aside from mild
bibasilar atelectasis, no acute cardiopulmonary process seen.
Radiology Report
EXAM: Non-contrast-enhanced CT of the head.
CLINICAL INFORMATION: Altered mental status, evaluate for acute intracranial
hemorrhage.
COMPARISON: None.
TECHNIQUE: Non-contrast-enhanced MDCT images of the head were obtained.
Reformatted coronal and sagittal images were also obtained.
TOTAL DLP: 842 mGy-cm.
FINDINGS: The patient is status post previous resection in the left frontal
lobe and left frontal craniectomy with a portion of the left frontal bone
missing. There is left frontal encephalomalacia and ex vacuo dilatation of
the left frontal horn. Additional prominence of the ventricles and sulci,
most notably in the bifrontal region, most consistent with atrophy. No acute
intracranial hemorrhage is seen. There is no midline shift or evidence of
acute large vascular territorial infarct. Periventricular deep white matter
hypodensities, in addition to the left frontal encephalomalacia is most
consistent with chronic small vessel disease. Patient is status post
bilateral sinus surgery. There is mild mucosal thickening in the right
maxillary sinus. There is also mucosal thickening in the left sphenoid sinus
and remaining ethmoid air cells. In the left frontal region (series 602A,
image 34 and series 4, image 52), there is a calcified structure measuring
approximately 1.3 x 0.3 cm (series 4, image 53), nonspecific, could relate to
postoperative change or a calcified meningioma.
IMPRESSION: No evidence of acute intracranial hemorrhage. Status post left
frontal resection and craniectomy. Left frontal encephalomalacia with ex
vacuo dilatation of the left frontal horn. MRI is more sensitive in detecting
acute ischemia. Atrophy, most prominently in the bifrontal regions.
Radiology Report
INDICATION: Nausea and rectal bleeding. Evaluate for a mass.
COMPARISONS: ___.
TECHNIQUE: Axial helical MDCT images were obtained through the abdomen and
pelvis after the administration of IV contrast. Sagittal and coronal
reformatted images were obtained and reviewed.
TOTAL DLP: 496 mGy-cm.
FINDINGS:
LUNG BASES: There is linear left basilar atelectasis and scarring. The bases
of the lungs are otherwise clear. The base of the heart is normal in size.
There is no pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. There is a 10-mm
hypodensity in the right lobe which is not fully characterized but unchanged
from prior. There is no intra- or extra-hepatic biliary duct dilation. The
portal veins are patent. The gallbladder shows fundal adenomyosis but there
is no CT evidence of cholecystitis. There is focal irregularity of the liver
just adjacent to the fundus of the gallbladder(3;18, 4b;10) for which further
evaluation with MRI is recommended. Unclear whether seen on ultrasound. The
spleen, pancreas and adrenal glands are normal. Several small subcentimeter
punctate hypodensities in the bilateral kidneys are too small to fully
characterize, though likely represents a small cyst. There are no worrisome
renal lesions. There is no hydronephrosis. The kidneys enhance and excrete
contrast symmetrically.
The stomach is collapsed. Apparently wall thickening of the stomach may
relate to collapse. The small bowel is unremarkable without evidence of
obstruction. There is calcification and narrowing at the takeoff of the
celiac artery. The SMA, renal artery, and ___ takeoffs are patent without
evidence of narrowing. The abdominal aorta is normal in caliber without
evidence of aneurysm. There is mild atherosclerotic disease. There is no
periportal, retroperitoneal, or mesenteric lymphadenopathy. No abdominal free
air or fluid.
PELVIS: There is extensive sigmoid diverticulosis. At the level of prior
right perirectal fluid collection, there has been interval essential
resolution of fluid, but now a linear fistula tract of gas is seen extending
from the right side of the rectum (3;61-66) to the right gluteal region. The
uterus is atrophic and displaced by the bladder. The bladder is distended.
There is no pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There is mild anterolisthesis of L4 on L5. There is a
compression fracture of L1 with greater than 50% loss of height, stable from
___. There is mild retropulsion of the anterior fracture
fragment without significant central canal narrowing. No other fracture is
identified. No concerning lytic or sclerotic osseous lesions are identified.
IMPRESSION:
1. Posterior right pelvic gas containing fistula from the right rectum to the
right gluteal region.
2. Interdeterminate liver density in the liver adjacent to the gallbladder
for which further evaluation with MRI is recommended.
Findings under Impression discussed by Dr. ___ with Dr. ___ at
10:23 AM on ___.
Radiology Report
AP CHEST, 9:35 A.M. ON ___
HISTORY: ___ woman with Crohn's disease and altered mental status.
Witnessed aspiration.
IMPRESSION: AP chest compared to ___:
Lungs are better expanded, clear, cardiac silhouette is normal, pulmonary
vasculature not distended, and no pleural effusion. Aside from
mild-to-moderate scoliosis, centered in the mid thoracic spine, this is a
normal chest radiograph.
Radiology Report
HISTORY: Persistent sinus tachycardia.
TECHNIQUE: MDCT acquired axial images of the chest were acquired following
the administration of 100 cc of Omnipaque intravenous contrast. Coronal and
sagittal reformations were performed. Additional right and left oblique
reconstructions were obtained for further evaluation of the pulmonary
vasculature.
EXAMINATION DLP: 162 mGy-cm.
COMPARISON: None available.
CTA OF THE CHEST WITH IV CONTRAST:
An eccentric filling defect within a left segmental upper lobe pulmonary
artery (series 7 image 109) and adjacent right upper lobe subsegmental
arterial branches demonstrating distal attenuation with sharp transition
points (series 6 image 36, 39, 40), denote chronic pulmonary emboli. No acute
pulmonary embolus is detected. The main pulmonary arteries are patent and
normal in caliber.
The thoracic aorta is patent and normal in caliber.
Included views of the thyroid are normal. There is no axillary, mediastinal,
or hilar lymphadenopathy. The heart size is normal, and there is no
pericardial effusion.
There are diffuse ground-glass opacities throughout the lungs, with subpleural
sparing (series 6 image 35), likely secondary to underinflation. No discrete
pulmonary nodule or mass detected. There is mild dependent atelectasis
(series 6 image 71).
A 10 mm hypodensity arising from the right hepatic lobe is incompletely imaged
(series 6, image 80), statistically likely a benign cyst or hemangioma, but
too small for further characterization on this single phase study. Included
views of the spleen, left adrenal gland, and stomach are normal.
There are no bony lesions concerning for malignancy or infection.
IMPRESSION:
1. Chronic pulmonary emboli within left upper lobe subsegmental branches. No
acute pulmonary embolus.
2. Diffuse ground-glass opacities throughout the lungs, likely from low lung
volumes. No discrete consolidation, nodule, or mass.
3. 10 mm nonspecific hypodensity within the right hepatic lobe, statistically
likely benign, but is incompletely characterized. A recommendation for MRI
was made on the ___ CT examination.
Radiology Report
HISTORY: ___ female with Crohn's disease and chronic PE.
COMPARISON: No Prior DVT study available for comparison.
TECHNIQUE: Realtime grayscale and color Doppler imaging of the right and left
lower extremity with augmentation.
FINDINGS:
Normal phasicity in the right and left common femoral vein suggesting patent
iliac veins bilaterally.
Right-side:
Common femoral vein is compressible.
Femoral vein is compressible.
Popliteal vein is compressible.
Calf veins are patent with compression and augmentation.
Greater and lesser saphenous veins is compressible.
Left -side:
Common femoral vein is compressible.
Femoral vein is compressible.
Popliteal vein is compressible.
Calf veins are patent with compression and augmentation.
Greater and lesser saphenous veins is compressible.
IMPRESSION:
No evidence of DVT in the right or left lower extremity.
Radiology Report
INDICATION: Right PICC placement.
COMPARISON: ___.
FINDINGS: AP view of the chest. The right PICC ends in the upper atrium.
Otherwise, the lungs are clear, there is no pleural effusion or pneumothorax,
the cardiomediastinal and hilar contours are normal.
IMPRESSION: Right PICC ends in the upper right atrium.
These findings were discussed with ___, IV nurse by Dr. ___ at
1:30 p.m. on ___ by telephone.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS , SEMICOMA/STUPOR, REGIONAL ENTERITIS NOS
temperature: 97.7
heartrate: 110.0
resprate: 16.0
o2sat: 97.0
sbp: 120.0
dbp: 74.0
level of pain: 13
level of acuity: 2.0 | Ms. ___ is a ___ with newly diagnosed Crohn's disease
complicated by pelvic abscess in ___ who presented with
confusion and generalized weakness. |
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:
none
History of Present Illness:
___ year old man who presented to the ED ___ with c/o chest pain,
dizziness and vision changes while at work as a ___. He states
it feels like he's looking through one eye. During his
observation stay in the ED he also experienced nausea and
headache. An exercise stress test was attempted today but was
stopped after 1 min due to patient reports of lightheadedness
and near fall. No EKG changes. He was then admitted for further
management.
Past Medical History:
"hole in my heart" s/p repair at ___ no longer
requiring follow up
Per chart IVDA, patient denies at present
"nerve pain" in bilat hands d/t using ___ hammer for years
ADHD
MRSA skin infections while living in sober house
Right hand cellulitis
lipomas
Social History:
___
Family History:
Father died of a heart attack at age ___, mom died of cancer in
her ___. 5 sisters and 3 brothers without heart disease
Physical Exam:
ADMISSION EXAM:
EKG: rate 57 SB with 1st degree AVB PR 0.23 QRS 0.10 QT 0.44
TWI aVL, V1 and V2
Tele: SR
VS: 142/83, 58, 18, 95% ra, 97.6
Physical Exam:
Gen: anxious appearing man sitting in bed
Neuro: alert and oriented w/o focal deficit
Neck/JVP: no JVD
CV: RRR, no M/R/G
Chest: exp wheezes BUL anterior no crackles or rhonchi
breathing regular and unlabored
ABD: soft NT/ND + bs + mid upper quadrant lipoma
Extr: warm and well perfused PPP bilat no edema left and right
forearm with lipoma
Skin: WD+I small scabs noted on right hand no erythema
DISCHARGE EXAM:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS: 97.8 141/84 58 16 94% on RA
tele: NSR, no events
Gen: ___ yr old man in NAD
Neuro: alert and oriented x 3. No focal deficits or asymmetries
noted
Neck/JVP: no JVD
CV: S1S2 regular, no MRG
Chest: Initial rhonchi on expiration, and then clear b/l
ABD: soft NT/ND + bs + mid upper quadrant lipoma
Extr: warm and well perfused PPP bilat no edema left and right
forearm with lipoma
Skin: WD+I small scabs noted on right hand no erythema
Pertinent Results:
___ 01:30AM BLOOD cTropnT-<0.01
___ 07:42AM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD cTropnT-<0.01
___ 01:34AM BLOOD Lactate-0.9
___ 01:30AM BLOOD Lipase-25
___ 01:30AM BLOOD ALT-36 AST-48* AlkPhos-75 TotBili-0.3
___ 01:30AM BLOOD Glucose-74 UreaN-13 Creat-0.8 Na-138
K-5.1 Cl-102 HCO3-26 AnGap-15
___ 06:25AM BLOOD UreaN-8 Creat-0.6 Na-138 K-4.1 Cl-104
HCO3-26 AnGap-12
___ 01:30AM BLOOD Neuts-43.4 ___ Monos-8.3 Eos-5.5
Baso-0.9 Im ___ AbsNeut-2.52 AbsLymp-2.42 AbsMono-0.48
AbsEos-0.32 AbsBaso-0.05
___ 01:30AM BLOOD WBC-5.8 RBC-4.26* Hgb-13.2* Hct-38.9*
MCV-91 MCH-31.0 MCHC-33.9 RDW-12.7 RDWSD-41.9 Plt ___
___ 06:25AM BLOOD WBC-4.5 RBC-4.45* Hgb-13.8 Hct-39.9*
MCV-90 MCH-31.0 MCHC-34.6 RDW-12.4 RDWSD-40.7 Plt ___
TTE: ___
Findings
LEFT ATRIUM: Normal LA volume index.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler. Normal IVC diameter (<=2.1cm) with >50% decrease
with sniff (estimated RA pressure ___ mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
regional/global systolic function (biplane LVEF>55%). Estimated
cardiac index is normal (>=2.5L/min/m2). Global longitudinal
strain is normal (nl <-20%) False LV tendon (normal variant).
TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root. Normal descending
aorta diameter. No 2D or Doppler evidence of distal arch
coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. No mass or
vegetation on mitral valve. Mild mitral annular calcification.
Mild (1+) MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. No TS. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PS. No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The patient appears to be in sinus rhythm.
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. No PFO/ASD occluder or patch is
seen. The estimated right atrial pressure is ___ mmHg. Normal
left ventricular wall thickness, cavity size, and
regional/global systolic function (biplane LVEF = 63%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with mild
[1+] mitral regurgitation. There is no mitral valve prolapse. No
mass or vegetation is seen on the mitral valve. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness, cavity size,
and regional/global systolic function. Mild mitral regurgitation
with normal valve morphology. Trace aortic regurgitation with
normal valve morphology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MethylPHENIDATE (Ritalin) 20 mg PO TID
2. Gabapentin 800 mg PO TID
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
2. Gabapentin 800 mg PO TID
3. MethylPHENIDATE (Ritalin) 20 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
Hypertension
Tobacco abuse
ADHD
Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS: 97.8 141/84 58 16 94% on RA
tele: NSR, no events
Gen: ___ yr old man in NAD
Neuro: alert and oriented x 3. No focal deficits or asymmetries
noted
Neck/JVP: no JVD
CV: S1S2 regular, no MRG
Chest: Initial rhonchi on expiration, and then clear b/l
ABD: soft NT/ND + bs + mid upper quadrant lipoma
Extr: warm and well perfused PPP bilat no edema left and right
forearm with lipoma
Skin: WD+I small scabs noted on right hand no erythema
Assessment/Plan: ___ year old man who presented to the ED ___
with c/o chest pain, dizziness and vision changes while at work
as a ___. Troponins negative for MI, with no acute EKG
changes. Experienced dizziness and near fall with exercise
stress test. Continued to have fleeting ___ chest pain. No EKG
changes with pain. Echo is normal.
# Chest pain: + Family history and active smoker. Continues with
left sided CP worse with movement or inspiration. Did not
respond to NTG.
-Echo to assess for valve disorder/malformations vegetations:
normal echo
-blood cultures for possible endocarditis pending. Based on pt's
clinical status and echo results, there is no indication to keep
the pt until these results are finalized
# Hypertenson: SBP 140's-150's
-Pt was on Lisinopril in the past, but ran out of medication
-Restarted Lisinopril
# Nicotine Dependence: Patient verbalizes desire to quit and
interest in Chantix.
-14mg Nicotine Patch while in hospital
-Has follow up in place with a new PCP ___ ___
# IVDA: Pt denies current use although there was a ER visit from
___ for right hand cellulitis thought to be d/t injection.
When questioned he denies it was due to current injection.
Additionally he has an Rx for Suboxone most recently filled
___. Patient states he weaned himself off Suboxone 3 weeks
to 1 month ago without issue and that he did not fill this Rx.
States his former girlfriend may have filled it.
-monitor for sign/symptom withdrawl
# ADHD:
-Continue Ritalin 20mg tid (confirmed on MA PAT)
# Nerve Pain:
-Continue gabapentin 800mg tid
#. Disp
-DC home
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with chest pain, nausea, evaluate for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax. There is no focal lung consolidation.
IMPRESSION:
No radiographic explanation for chest pain.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.2
heartrate: 79.0
resprate: 20.0
o2sat: 96.0
sbp: 150.0
dbp: 94.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ was admitted from the emergency department and was
ruled out by troponins x3. He underwent an exercise stress test
which was stopped after a minute and a half due to dizziness and
pre-syncope symptoms. There were no ischemic EKG changes noted.
He was monitored on telemetry and continued to have episodes of
"fleeting" chest pain that lasted seconds and resolved without
intervention. He had an echocardiogram which showed a normally
functioning heart.
Assessment/Plan: ___ year old man who presented to the ED ___
with c/o chest pain, dizziness and vision changes while at work
as a ___. Troponins negative for MI, with no acute EKG
changes. Experienced dizziness and near fall with exercise
stress test. Continued to have fleeting ___ chest pain. No EKG
changes with pain. Echo is normal.
# Chest pain: + Family history and active smoker. Continues with
left sided CP worse with movement or inspiration. Did not
respond to NTG.
-Echo to assess for valve disorder/malformations vegetations:
normal echo
-blood cultures for possible endocarditis pending. Based on pt's
clinical status and echo results, there is no indication to keep
the pt until these results are finalized
# Hypertenson: SBP 140's-150's
-Pt was on Lisinopril in the past, but ran out of medication
-Restarted Lisinopril
# Nicotine Dependence: Patient verbalizes desire to quit and
interest in Chantix.
-14mg Nicotine Patch while in hospital
-Has follow up in place with a new PCP ___ ___
# IVDA: Pt denies current use although there was a ER visit from
___ for right hand cellulitis thought to be d/t injection.
When questioned he denies it was due to current injection.
Additionally he has an Rx for Suboxone most recently filled
___. Patient states he weaned himself off Suboxone 3 weeks
to 1 month ago without issue and that he did not fill this Rx.
States his former girlfriend may have filled it.
-monitor for sign/symptom withdrawl
# ADHD:
-Continue Ritalin 20mg tid (confirmed on MA PAT)
# Nerve Pain:
-Continue gabapentin 800mg tid
#. Disp
-DC home |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug)
Attending: ___.
Chief Complaint:
Fever/chills, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with RCC s/p left nephrectomy in ___, ESRD s/p LURT in
___, CAD, hyperlipidemia, diabetes who presents to the
emergency department for evaluation of fever, cough, and chills.
Patient describes 1 day history of productive cough and chills
associated with body aches and fever of 100.7. Did not have any
headache or rashes. No chest pain or pressure. No dyspnea except
whenever he is coughing repeatedly.
Of note, patient had a routine CT scan done a few weeks ago for
monitoring of pancreatic neuroendocrine tumors (follows with
surgical oncology). At that time, he was found to have ground
glass opacity, for which he has been following with transplant
infectious disease. He went in for an induced sputum test this
on
___ but they were unable to induce any sputum. Went back on
___ and had a sputum test done. After leaving the test, he
developed the aforementioned symptoms that brought him to the
ED.
No known sick contacts. No abdominal pain. No nausea or
vomiting.
No dysuria.
In the ED:
-Initial vital signs were notable for: 98.2, 79, 134/80, 15, 96%
RA
-Exam notable for: faint crackles the left lung base
-Labs were notable for:
WBC 16.1
AST/ALT 43/58
Mg 1.2
-Studies performed include:
CXR: lingular pneumonia
-Patient was given:
___ 02:03 IV CefTRIAXone (1 g ordered)
-Consults:
Renal transplant: CXR, continue tacro, renal transplant will
follow
- Vitals on transfer: 98.4, 75, 135/79, 20, 95% RA
Upon arrival to the floor, the patient reports feeling better
than when he first arrived. Chills/feverish feeling resolved. No
longer coughing. Denies shortness of breath.
Past Medical History:
PAST MEDICAL HISTORY:
ESRD s/p LURT in ___
___ s/p left radical nephrectomy
Pancreatic neuroendocrine tumor, monitoring with surgical
oncology
Type II diabetes
CAD s/p CABG in ___
Depression
Gout
OSA (cannot tolerate CPAP)
Social History:
___
Family History:
His father died at ___ of heart disease. He has a brother with
prostate cancer, a sister with unspecified illness and two
others, who are relatively healthy. He has four children age
___, all of whom are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.4, BP 137/81, HR 71, RR 20, SpO2 94 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL. Sclera anicteric and without injection. MMM.
CARDIAC: RRR, S1+S2, no M/R/G
LUNGS: CTAB posteriorly, no W/R/C
ABDOMEN: non-distended, soft, non-tender. Renal transplant in
RLQ
without any tenderness.
EXTREMITIES: WWP, no edema
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Moving all 4 extremities with purpose.
DISCHARGE PHYSICAL EXAM:
=================================
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL. Sclera anicteric and without injection. MMM.
CARDIAC: RRR, S1+S2, no M/R/G
LUNGS: CTAB posteriorly, no W/R/C
ABDOMEN: non-distended, soft, non-tender. Renal transplant in
RLQ
without any tenderness.
EXTREMITIES: WWP, no edema
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Moving all 4 extremities with purpose.
Pertinent Results:
NOTABLE LABS:
___ 12:35AM BLOOD WBC-16.1* RBC-4.95 Hgb-13.8 Hct-42.1
MCV-85 MCH-27.9 MCHC-32.8 RDW-14.6 RDWSD-45.1 Plt ___
___ 07:50AM BLOOD WBC-11.4* RBC-4.90 Hgb-13.8 Hct-41.4
MCV-85 MCH-28.2 MCHC-33.3 RDW-14.7 RDWSD-44.9 Plt ___
___ 07:50AM BLOOD Glucose-210* UreaN-15 Creat-1.0 Na-142
K-3.6 Cl-105 HCO3-23 AnGap-14
___ 12:35AM BLOOD ALT-58* AST-43* AlkPhos-67 TotBili-0.6
___ 07:50AM BLOOD Calcium-9.6 Phos-1.7* Mg-1.3*
MICRO:
NONE POSITIVE TO DATE
Respiratory viral Panel: Pending
Urine legionella: Pending
STUDIES:
=======================
CHEST (PA & LAT)Study Date of ___ 12:06 AM
FINDINGS:
The lungs are well expanded. There is a lingular consolidation.
No pleural
effusion or pneumothorax. Heart size is top-normal. Median
sternotomy wires
and small mediastinal clips are noted.
IMPRESSION:
Lingular pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Escitalopram Oxalate 20 mg PO DAILY
3. Famotidine 20 mg PO BID
4. Hydrocortisone Oint 2.5% 1 Appl TP BID:PRN scrotal itching
5. Metoprolol Tartrate 100 mg PO BID
6. Mycophenolate Sodium ___ 360 mg PO BID
7. NIFEdipine (Extended Release) 60 mg PO DAILY
8. sAXagliptin 2.5 mg oral DAILY
9. Tacrolimus 4 mg PO Q12H
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itching
11. Aspirin 81 mg PO DAILY
12. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
DAILY
Discharge Medications:
1. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
DAILY
5. Escitalopram Oxalate 20 mg PO DAILY
6. Famotidine 20 mg PO BID
7. Hydrocortisone Oint 2.5% 1 Appl TP BID:___ scrotal itching
8. Metoprolol Tartrate 100 mg PO BID
9. Mycophenolate Sodium ___ 360 mg PO BID
10. NIFEdipine (Extended Release) 60 mg PO DAILY
11. sAXagliptin 2.5 mg oral DAILY
12. Tacrolimus 4 mg PO Q12H
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN
itching
Discharge Disposition:
Home
Discharge Diagnosis:
Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough, fevers.
TECHNIQUE: Frontal and lateral views of the chest
COMPARISON: Chest radiographs between ___ and ___
___ first ___ chest CT
FINDINGS:
The lungs are well expanded. There is a lingular consolidation. No pleural
effusion or pneumothorax. Heart size is top-normal. Median sternotomy wires
and small mediastinal clips are noted.
IMPRESSION:
Lingular pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Fever
Diagnosed with Other pneumonia, unspecified organism, Dyspnea, unspecified
temperature: 98.2
heartrate: 79.0
resprate: 15.0
o2sat: 96.0
sbp: 134.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ with RCC s/p left nephrectomy in ___, ESRD s/p LURT in
___, CAD, hyperlipidemia, diabetes who presented to the
emergency department for evaluation of fever, cough, and chills.
Found to have pneumonia on imaging. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
fever, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo w/COPD presents with fever and cough. Symptoms present for
about 5 days, subjective fever only, +SOB, malaise, fatigue.
Denies CP, wheeze, GI symptoms.
In ED pt tachycardic, found to have PNA. Given duonebs x2,
azithromycin, CTX and tamiflu with improvement in HR and SOB. VS
prior to tfr 99.0 178/74 120 24 97% (O2 requirement not
documented)
On arrival to floor pt immediately triggered for RR >30 and
HR>150 with increased O2 requirement compared to the ED. Pt
given duonebs followed by xopenex nebs, 1L ns bolus and cough
supressant with improvement in HR and shortness of breath, but
pt remained tachypneic.
ROS: otherwise negative
Past Medical History:
# HTN/HLD
# CM
- stress MIBI ___ - EF 74%, no inducible ischemia
# COPD
- PFT's ___: FEV1 1.32(71%) FVC 2.29(79%) FEV1/FVC 90% DL/VA
56%
# CRI (Cr 1.2)
# Dementia
# GERD
# Prostate Cancer (enlarged prostate on pelvic CT ___
# Gout
# Chronic Neurocysticercosis -
Social History:
___
Family History:
no early CAD
Physical Exam:
VS: 98.5 174/88 HR 154-118 RR ___ sat 94-96% on ___
Pain: 0
Gen: respiratory distress
Heent: mmm
Chest: ctab, distant breath sounds, tachypneic w/accessory
muscle use
CV: tachy, regular, no m/r/g
Abd: nabs, soft, nt/nd
Ext: no e/c/c
Neuro: alert, follows commands
Pertinent Results:
___ 05:42PM GLUCOSE-124* UREA N-11 CREAT-1.2 SODIUM-140
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-28 ANION GAP-17
___ 06:15PM LACTATE-1.5
___ 05:42PM WBC-8.8# RBC-4.42* HGB-13.3* HCT-40.6 MCV-92
MCH-30.1 MCHC-32.8 RDW-12.9
___ 05:42PM NEUTS-73* BANDS-0 LYMPHS-12* MONOS-14* EOS-1
BASOS-0 ___ MYELOS-0
CXR IMPRESSION:
Multi focal regions of consolidation at the left lung base and
right mid-upper lung compatible with pneumonia in the proper
clinical setting. Recommend repeat after treatment to document
resolution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
2. Amlodipine 2.5 mg PO DAILY
3. Fluticasone Propionate 110mcg 1 PUFF IH BID
4. Furosemide 20 mg PO DAILY
5. Hydrocortisone (Rectal) 2.5% Cream ___ID
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. rivastigmine *NF* 3 mg Oral BID
9. Sertraline 25 mg PO DAILY
10. Viagra *NF* (sildenafil) 100 mg Oral prn
11. Tiotropium Bromide 1 CAP IH DAILY
12. traZODONE 50 mg PO HS
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Amlodipine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Fluticasone Propionate 110mcg 1 PUFF IH BID
5. Furosemide 20 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Sertraline 25 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. traZODONE 50 mg PO HS
11. Benzonatate 100 mg PO TID:PRN cough
12. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
13. Cepacol (Menthol) 1 LOZ PO PRN cough
14. PredniSONE 40 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*2 Tablet
Refills:*0
15. Hydrocortisone (Rectal) 2.5% Cream ___ID
16. rivastigmine *NF* 3 mg ORAL BID
17. Viagra *NF* (sildenafil) 100 mg Oral prn
18. Azithromycin 250 mg PO Q24H Duration: 5 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Pneumonia
- Emphysema exacerbations
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with cough.
COMPARISON: ___.
FINDINGS:
Single portable view of the chest. There are new, multifocal regions of
consolidation identified in the retrocardiac region and the right mid-upper
lung. The cardiomediastinal silhouette is stable. Osseous and soft tissue
structures are unchanged noting calcific densities projecting over the left
chest wall as on prior.
IMPRESSION:
Multi focal regions of consolidation at the left lung base and right mid-upper
lung compatible with pneumonia in the proper clinical setting. Recommend
repeat after treatment to document resolution.
Gender: M
Race: HISPANIC/LATINO - HONDURAN
Arrive by WALK IN
Chief complaint: INFLUENZA LIKE ILLNESS
Diagnosed with SHORTNESS OF BREATH
temperature: 100.0
heartrate: 131.0
resprate: 18.0
o2sat: 91.0
sbp: 151.0
dbp: 86.0
level of pain: 0
level of acuity: 1.0 | ___ yo w/COPD presents with fever and cough, found to have LLL,
RML pneumonia with COPD exacerbation.
# Pulm: Mr. ___ was admitted with significant hypoxia
(requiring 5 L NC), delirium. He was initially treated with
tamiflu but influenza DFA x2 were negative. CXR revealed LLL
and RML consolidation c/w pneumonia. He was treated with iv
ceftriaxone and azithro and given iv solumedrol/nebulizers for
presumed superimposed COPD exacerbation. Over time, his
respirations improved significantly and he was able to wean off
the oxygen by HD#2. Ambulatory sats remained above 90%.
All his medications were transitioned to orals and inhalers.
He was given prednisone 40 daily for 5 days total. He was also
given cepacol, Guaifenesin/DM PRN. He should be updated on his
pneumonia vaccinations as an outpt.
# Tachycardia: ___ respiratory distress. Now resolved s/p bolus
1L
NS. Xopenex was used in place of albuterol. He was monitored on
tele with no significant arrhythmia.
# HTN/HLD: ON toprol, statin, norvasc, ASA, lasix.
# Dementia, depression: cont zoloft, rivastigmine. He was
evaluated by OT prior to discharge. Their examination revealed
that his cognitive function is significantly impaired - likely
due to delirium in the setting of the pneumonia and COPD
exacerbation. Home OT was arranged and numerous recommendations
for reducing cognitive dysfunctions were provided. He is not
safe to drive, be alone at home alone, or to work as a ___
___. Family was made aware and is able to help.
# Gait unsteadiness: Increased gait unsteadiness over the past 1
week, in the setting of pneumonia. He was placed on fall
precautions and seen by ___. He was deemed safe for discharge
but could benefit from home ___. This was arranged on discharge.
# OTHER ISSUES AS OUTLINED.
.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: []heparin sc []SCDs [X] ambulation
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: [X] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#CONTACT: ___ Relationship: daughter ___
#CONSULTS: None
#CODE STATUS:
FULL CODE, confirmed on admission |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Advil / Bactrim
Attending: ___.
Chief Complaint:
Cough, fevers
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ woman with a pmh of pulmonary
tuberculosis (s/p tx ___ years ago ___ ___,
bronchiectasis, influenza, and ___ syndrome on low dose
prednisone, who presents to the ED with fevers and productive
cough.
She presented to the ED with her ___ and states
she has had a sore throat, cough, runny nose, and headache for
the past three days. Last night she developed a worsening
productive cough with yellow sputum, no hemoptysis. This morning
had temperature ___. She went to her PCP today, who referred her
to the ED given her complicated history. Ms. ___ also reports
some abdominal pain similar to prior IBS, worse upon coughing,
no diarrhea or blood ___ stool. She does endorse mild nausea for
the past day, worsening today, limiting food/water intake. No
emesis.
Ms. ___ received a flu shot this year. Her ___ says
that both he and his wife were slightly ill with similar
symptoms (runny nose and sore throat) last week. No recent
travel, though both ___ fly frequently for work.
Of note, Ms. ___ was hospitalized at ___ ___ ___
for pneumonia (by report, she has been treated with antibiotics
on average ___ times a year for bronchitis/pneumonias for
several years). She had three low quality AFB smears at that
time, all of which were negative (also negative NAAT testing). A
CT scan from ___ demonstrated evidence of old TB
infection with broncholiths and a large calcified lesion ___ the
left upper lobe potentially disrupting her recurrent laryngeal
nerve leading to vocal cord paralysis, bronchiectasis with mucus
plugging, particularly ___ the right lower lobe, and ___
opacities, most prominent ___ the right middle lobe. After
discharge, she followed up with her pulmonologist, and a
bronchoscopy was performed ___ for AFB and NTM, which was
negative. Cultures did grow Penicillium and Pseudomonas, which
were felt to be colonizers. She was then prescribed
ciprofloxacin (did not take) to treat colonizing organisms with
the plan for outpatient pulmonary rehab.
___ the ED, initial vital signs were: 99.0 (Tm 102.2), 123,
166/87, 20 96% RA
- Exam notable for bilateral crackles at the bases and mild
abdominal tenderness to palpation.
- Labs were notable as follows
BMP: 133,3.4,95,25,6,.7,glucose 79
CMB: 7.2,11.7/36.3,286
UA: 1.010, pH 7.0, urobil NEG, bili NRG, leuks NEG, bld TRACE,
nitr NEG, prot NEG, glu NEG, ket NEG, RBC 1, WBC 0, bacteria
NONE, yeast NONE
FluAPCR: Pnd
FluBPCR: Pnd
- Studies performed include
CXR ___
IMPRESSION:
1. New patchy opacities within the right middle lobe and left
lung base concerning for multifocal pneumonia with airways
infection/ inflammation and mucous plugging. Active tuberculosis
cannot be excluded.
2. Background of multifocal bronchiectasis with endobronchial
calcifications and mucus plugging as noted on the previous CT.
Left apical scarring with superior left hilar retraction.
Spiculated opacity ___ the right apex, better characterized on
the previous CT.
ECG ___
Sinus tachycardia, RAD, LAE, RBBB
- Patient was given 1L NS, APAP, and Cefepime 2g
- Vitals on transfer: 99.2, 101, 124/64, 18, 95% RA
Upon arrival to the floor, the Ms. ___ and ___
recount the history as above. Her largest complain is the
ongoing productive cough. She denies any subjective SOB, CP, or
palpitations. No fevers/chills. She does says that she has not
eaten or drank anything all day, still with some mild nausea.
10-point ROS otherwise NEGATIVE.
Past Medical History:
1. History of tuberculosis infection status post treatment ___
___ ___ years ago.
2. Postpartum panhypopituitarism on chronic low-dose
prednisone.
3. Hypertension.
4. History of pulmonary influenza.
5. History of abdominal and thoracic gunshot wound ___ ___.
6. Chronic vocal cord dysfunction, reportedly related to
panhypopituitarism.
7. Irritable bowel syndrome.
8. Osteoporosis.
Social History:
___
Family History:
Stomach cancer
Stroke
Hypertension.
Physical Exam:
ADMISSION EXAM
==============
Vitals- 99.4, 138/85, 129, 18, 98 RA
GENERAL: AOx3, intermittently coughing
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: Thyroid is normal ___ size and texture, no nodules.
Palpable R cervical lymph node.
CARDIAC: s1 with prominent s2. Intermittently tachycardic,
regular rhythm, no murmurs/rubs/gallops. No JVD.
LUNGS: Inspiratory crackles ___ LLL with intermittent expiratory
rhonchi. Relative decreased breath sounds over R lung.
BACK: No spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mild epigastric
tenderness. No organomegaly.
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. No ataxia, dysmetria, disdiadochokinesia.
DISCHARGE EXAM
==============
98.6, 109/63, 96, 16, 94 RA
GENERAL: AOx3, intermittently coughing
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: Thyroid is normal ___ size and texture, no nodules.
Palpable R cervical lymph node.
CARDIAC: s1 with prominent s2. Regular rate, regular rhythm, no
murmurs/rubs/gallops. No JVD.
LUNGS: Relative decreased breath sounds over R lung. Otherwise
improved aeration throughout, no inspiratory crackles or
wheezes.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mild epigastric
tenderness. No organomegaly.
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. No ataxia, dysmetria, disdiadochokinesia.
Pertinent Results:
ADMISSION LABS
==============
___ 11:30AM BLOOD WBC-7.2 RBC-3.93 Hgb-11.7 Hct-36.3 MCV-92
MCH-29.8 MCHC-32.2 RDW-12.9 RDWSD-43.8 Plt ___
___ 11:30AM BLOOD Neuts-64.4 ___ Monos-9.1 Eos-1.7
Baso-0.4 Im ___ AbsNeut-4.61# AbsLymp-1.72 AbsMono-0.65
AbsEos-0.12 AbsBaso-0.03
___ 11:30AM BLOOD Plt ___
___ 11:30AM BLOOD Glucose-79 UreaN-6 Creat-0.7 Na-133 K-3.4
Cl-95* HCO3-25 AnGap-16
___ 07:50AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
___ 11:30AM URINE Color-Straw Appear-Clear Sp ___
___ 11:30AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:30AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT LABS
==============
___ 12:20PM URINE Hours-RANDOM UreaN-<6 Creat-15 Na-<20
Cl-<20
___ 12:20PM URINE Osmolal-94
___ 07:50AM BLOOD Glucose-77 UreaN-7 Creat-0.7 Na-132*
K-3.4 Cl-91* HCO3-25 AnGap-19
___ 08:17AM BLOOD Glucose-78 UreaN-4* Creat-0.7 Na-130*
K-3.4 Cl-88* HCO3-23 AnGap-22*
___ 07:55AM BLOOD Glucose-87 UreaN-5* Creat-0.7 Na-125*
K-3.7 Cl-86* HCO3-26 AnGap-17
___ 08:15AM BLOOD Glucose-76 UreaN-4* Creat-0.7 Na-132*
K-3.6 Cl-92* HCO3-27 AnGap-17
___ 04:06PM BLOOD Glucose-97 UreaN-5* Creat-0.7 Na-136
K-4.2 Cl-96 HCO3-25 AnGap-19
___ 08:10AM BLOOD Glucose-120* UreaN-3* Creat-0.7 Na-134
K-3.2* Cl-96 HCO3-29 AnGap-12
___ 08:00AM BLOOD Glucose-94 UreaN-4* Creat-0.7 Na-131*
K-3.7 Cl-91* HCO3-28 AnGap-16
___ 08:15AM BLOOD Osmolal-272*
DISCHARGE LABS
==============
___ 08:10AM BLOOD WBC-5.7 RBC-3.46* Hgb-10.3* Hct-32.6*
MCV-94 MCH-29.8 MCHC-31.6* RDW-13.4 RDWSD-45.4 Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-94 UreaN-4* Creat-0.7 Na-131*
K-3.7 Cl-91* HCO3-28 AnGap-16
___ 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.4
MICRO
=====
___ 11:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 4:58 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to respiratory viral antigen screen and respiratory
virus
identification test results for further information.
Respiratory Viral Antigen Screen (Final ___:
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
Respiratory Virus Identification (Final ___:
Reported to and read back by ___ ___ (___)
ON ___
@ 11AM.
POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV).
Viral antigen identified by immunofluorescence.
___ 4:58 pm SPUTUM Site: INDUCED Source: Induced.
GRAM STAIN (Final ___:
<10 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.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 7:59 am SPUTUM Site: INDUCED Source: Induced.
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.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 10:35 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Time Taken Not Noted ___ Date/Time: ___ 1:30 pm
SPUTUM Site: EXPECTORATED Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S).
WORK UP REQUESTED BY ___ ON ___ PAGER
___.
SPARSE GROWTH.
Time Taken Not Noted ___ Date/Time: ___ 1:31 pm
MRSA SCREEN Site: NASOPHARYNX Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 2:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 9:26 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
___ 2:13 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 1:16 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 1:28 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
STUDIES/IMAGING
===============
ECG ___
Sinus tachycardia. Right bundle-branch block. Compared to the
previous
tracing of ___, the rate has increased.
CXR ___
IMPRESSION:
1. New patchy opacities within the right middle lobe and left
lung base
concerning for multifocal pneumonia with airways infection/
inflammation and mucous plugging. Active tuberculosis cannot be
excluded.
2. Background of multifocal bronchiectasis with endobronchial
calcifications and mucus plugging as noted on the previous CT.
Left apical scarring with superior left hilar retraction.
Spiculated opacity ___ the right apex, better characterized on
the previous CT.
PELVIS XRAY ___
FINDINGS:
Radiopaque metallic densities projected over low central abdomen
and left
pelvis. Benign injection granuloma left buttock. There are no
fractures ___ the pelvis or hips. Right hip is normal.
IMPRESSION:
No fracture
CT HEAD WO CONTRAST ___
IMPRESSION:
1. There are no acute intracranial findings.
2. Degenerative changes bilateral temporomandibular joints.
Suggestion of
bilateral anterior subluxation at TMJ, similar appearance may be
from
open-mouth position, clinically correlate.
3. Suggestion of acute paranasal sinusitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Humatrope (somatropin) 0.9 mg injection QAM
5. Levothyroxine Sodium 56 mcg PO DAILY
6. Iophen C-NR (codeine-guaifenesin) ___ mg/5 mL oral EVERY 4
TO 6 HOURS AS NEEDED
7. Hydrocortisone 10 mg PO QAM
8. Hydrocortisone 2.5-5 mg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
2. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
RX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5
mg-7.5 mg 1 lozenge(s) by mouth q2h Disp #*50 Lozenge Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H
End date ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*17 Tablet Refills:*0
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
5. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Humatrope (somatropin) 0.9 mg injection QAM
8. Hydrocortisone 10 mg PO QAM
9. Hydrocortisone 2.5-5 mg PO DAILY
10. Iophen C-NR (codeine-guaifenesin) ___ mg/5 mL oral EVERY
4 TO 6 HOURS AS NEEDED
RX *codeine-guaifenesin [Cheratussin AC] 100 mg-10 mg/5 mL ___
mL by mouth every six (6) hours Refills:*0
11. Levothyroxine Sodium 56 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
RSV infection
Secondary Diagnoses
===================
Hyponatremia
Sinus tachycardia
Hypertension
Hypopituitarism
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 productive cough, fever history of
bronchiectasis // ? Pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is normal. Mediastinal contour appears unchanged with dilatation
of the ascending aorta better assessed on the previous CT. Abnormal superior
retraction of the left hilum is re- demonstrated with similar scarring with
calcification in the left apex. The left hilum remains asymmetrically
enlarged, as seen previously. Extensive bronchiectasis with areas of
endobronchial calcification and mucous plugging are re- demonstrated, better
assessed on the previous CT, with new patchy opacities noted in the right
middle lobe and left lower lobe compared to the previous chest radiograph. No
pleural effusion or pneumothorax is seen. Spiculated opacity in the right
apex is also better assessed on the prior CT. No acute osseous abnormality is
visualized.
IMPRESSION:
1. New patchy opacities within the right middle lobe and left lung base
concerning for multifocal pneumonia with airways infection/ inflammation and
mucous plugging. Active tuberculosis cannot be excluded.
2. Background of multifocal bronchiectasis with endobronchial calcifications
and mucus plugging as noted on the previous CT. Left apical scarring with
superior left hilar retraction. Spiculated opacity in the right apex, better
characterized on the previous CT.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: ___ year old woman with bronchiectasis s/p fall // s/p fall on
right hip; please eval for r hip fracture
TECHNIQUE: Pelvis single view, right hip two views.
COMPARISON: None
FINDINGS:
Radiopaque metallic densities projected over low central abdomen and left
pelvis. Benign injection granuloma left buttock. There are no fractures in
the pelvis or hips. Right hip is normal.
IMPRESSION:
No fracture
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman s/p fall with head strike; difficulty with
providing history // s/p fall with head strike; please eval for intracranial
bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.3 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. There is mild
chronic small vessel ischemic changes.
There is no evidence of fracture. There is small volume fluid in the
partially visualized left maxillary sinus. There is mild opacification of the
ethmoid sinuses. Remaining visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable. There is mild soft tissue swelling posterior parietal scalp.
There is degenerative arthritis of bilateral temporomandibular joints, with
suggestion of bilateral anterior subluxation at temporomandibular joints,
similar appearance may be from open-mouth position. Clinically correlate for
potential TMJ dysfunction.
IMPRESSION:
1. There are no acute intracranial findings.
2. Degenerative changes bilateral temporomandibular joints. Suggestion of
bilateral anterior subluxation at TMJ, similar appearance may be from
open-mouth position, clinically correlate.
3. Suggestion of acute paranasal sinusitis.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 99.0
heartrate: 123.0
resprate: 20.0
o2sat: 96.0
sbp: 166.0
dbp: 87.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ woman with a pmh of pulmonary
tuberculosis (s/p tx ___ years ago ___ ___,
bronchiectasis, hx of influenza, and hx ___ syndrome on
hydrocortisone, who presented to the ED with fevers and
productive cough.
# Cough, fevers - Flu NEG, RSV POSITIVE, given constellation of
sore throat/runny nose/cough and recent sick family members RSV
infection likely explains her presentation. Also concern for
bacterial pneumonia given productive cough, lung exam, and CXR
findings (small, multifocal consolidations), though these all
can be seen with RSV infection causing bronchiectasis flare.
Patient was initially started on Cefepime/Cipro given concern
for bacterial PNA, though broad spectrum abx were not continued
once RSV resulted. Sputum cultures showed sparse growth of GNRs
likely known Pseudomonas from BAL ___ (colonization with
pseudomonas and penicillium). Blood cultures NEG.
Legionella/Strep pneumo antigens NEG. Pulmonology was consulted
___, agreed with unifying diagnosis of RSV infection as
patient clinically improved with supportive treatment (IVF,
codeine-guaifenesin, benzonatate, ipratropium/albuterol nebs),
no indication for broad spectrum antibiotics. Also recommended
completing 2-week cipro course, which had been outlined by
outpatient pulmonologist for known pseudomonas (cipro started
inpatient, will continue through ___. Patient will have
outpatient pulm follow-up with pulmonary ___.
# Sinus Tachycardia - Most likely ___ setting of
hypovolemia/infection, improved with IVF, HR ___ ___ on day of
discharge.
# Hyponatremia - Most likely hypovolemic hyponatremia as patient
was not eating/drinking well. Legionella NEG. Considered other
etiologies as well (SIADH possible ___ setting of RSV infection
(hyponatremia has been described ___ infants with bronchiolitis
___ RSV), patient additionally with other reasons to have
hyponatremia, including adrenal insufficiency (noted to have low
AM cortisol during last admission), hypothyroidism, also s/p
recent head strike). Urine studies from ___ consistent with
resolving hypovolemia, appropriate Na avid kidneys (urine Na
<20) and dilute urine (ADH shutting off). Na 131 on day of
discharge.
# s/p fall ___ - Patient fell ___ bathroom while cleaning feet
___ sink. +Head strike, occipital. Pelvic film and NCCTH NEG
for any acute process/fracture.
# Hypertension - Continued on home Amlodipine, though d/c'd on
day of discharge as patient was not hypertensive.
# Hypoptuitarism
- Continued Humatrope (somatropin) .9 mg injection QAM
- Continued Levothyroxine Sodium 56 mcg PO DAILY
- Continued Hydrocortisone 10mg PO qAM, 2.5-5mg PO daily
TRANSITIONAL ISSUES
===================
TRANSITIONAL ISSUES
===================
- Patient will continue Cipro 500mg PO BID through ___ for
treatment of Pseudomonas discovered on ___ bronchoscopy
- Sputum culture growing GNRs, final speciation not yet
finalized
- Na 131 on day of d/c, should have repeat labs drawn at PCP
___ ___ or ___
- Pulm ___ will contact patient about setting up outpatient
appointment, order is ___ OMR
- Amlodipine 5mg qd d/c'd on day of discharge as she was not
hypertensive, should have continued BP monitoring as outpatient
- Patient with weight loss over past several years, has IBS,
will be contacted for appointment scheduling
==================================
#CODE STATUS: Full Code (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Metoprolol /
verapamil / flecainide / Remicade / sotalol / Imuran /
mercaptopurine
Attending: ___.
Chief Complaint:
Dyspnea, diarrhea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year-old female with hx of paroxysmal atrial
fibrillation/atrial tachycardia (s/p pulmonary vein isolation,
multiple cardioversions, and multiple antiarrhythmic trials),
multiple PE/DVTs on Eliquis, adrenal insufficiency, ulcerative
colitis s/p total colectomy, and chronotropic incompetence s/p
PPM who presented to the ED for worsened lightheadedness and
shortness of breath.
She reports that 3 days ago she began to have diarrhea, which
she
further describes as large-volume, yellowish stools. She denies
any hematochezia or melena, but is noticing small amounts of
bright red blood on the toilet paper today. She has chronic
abdominal pain, but reports that her pain acutely worsened with
onset of diarrhea. She is having severe pain with bowel
movements that resolves after stooling. Since onset of these
symptoms, she has had decreased appetite and decreased oral
intake. She denies any fevers, chills, or sweats. No
presyncopal or syncopal episodes at home. This feels different
to her than her previous pouchitis episodes. She reports that
she traveled to ___ recently. No history of IV drug use.
Since the onset of her diarrhea, she reports that she has
experienced progressively worsening shortness of breath as well.
The patient reports that she has chronic dyspnea on exertion.
She currently is not having dyspnea at rest, but reports that
she
becomes quite winded with minimal activity, such as taking a few
steps or getting out of bed. Denies peripheral edema,
orthopnea,
paroxysmal nocturnal dyspnea, wheezing, or abdominal distention.
No pleurisy. No cough, excessive or discolored sputum, recent
sick contacts.
She reports substernal chest pain that started 24 hours prior to
arrival. Since then, the pain has been constant. She describes
it as "sharp" and "stabbing." No radiation of pain. No
palliating or provoking factors that she can appreciate.
In the ED initial vitals were: T 97.2F, HR 82, BP 96/64, RR 17,
SpO2 96% RA
EKG: HR 94, NSR, L axis deviation. Q wave in III. No ST
elevation
or depression. T wave flattening throughout. Low QRS voltage in
V4-V6.
Labs/studies notable for:
- WBC 13.5, Hgb 15.1, Hct 45.0, plts 297
- Na 140, K 4.4, Ct ___, HCO3 24, BUN 14, Cr 1.4, glc 122
- Ca ___, Mg 2.1, PO4 2.7
- lactate 1.8
- troponin negative x2
- AST 70, ALT 33, AP 106, lipase 28, Tbili 0.6, albumin 4.3
- BNP 229
Patient was given: Tylenol 1g, Benadryl 25mg, morphine 4mg,
oxycodone 5mg, citalopram 10mg, fludrocortisone 0.1mg, midodrine
2.5mg, prednisone 4mg, LR 1L
In the ED, EP was consulted given her significant history of
atrial arrhythmias and concern that these may be playing a role
in her current symptoms. Based on their evaluation, it was felt
that her lightheadedness is more related to her underlying
autonomic dysfunction and adrenal insufficiency in the setting
of
an acute diarrheal illness.
Vitals on transfer: T 97.8F, BP 117/76, HR 63, RR 18, SpO2 95%
RA
On the floor, the patient confirms the above history. She
reports that she is still having chest pain and that is has not
changed. She also reports ongoing epigastric and infraumbilical
abdominal pain, as well as diarrhea. Denies questions or
concerns at this time.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
Past Medical History:
- Dyslipidemia
- no known history of CAD
- paroxysmal A fib/tachycardia
- hx of chronotropic incompetence s/p ___ implantation
- adrenal insufficiency
- ulcerative colitis s/p total colectomy
- hx PE/DVT
- chronic exertional dyspnea
Social History:
___
Family History:
Four siblings with early CAD with first MI at ages ___, ___, ___,
and ___. Mother with MI at age ___. Father with CAD and CABG,
age
unknown. 2 living sisters with CAD. No family history of known
arrhythmias.
Physical Exam:
ADMISSION PHYSICAL:
===================
VS: T 97.8F, BP 117/76, HR 63, RR 18, SpO2 95% RA
GENERAL: Well developed, well nourished female in NAD. Oriented
x3. Mood, affect appropriate. Appears comfortable and in NAD.
HEENT: Normocephalic/atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP visible at base of neck.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi. No conversational dyspnea.
ABDOMEN: Obese, soft, non-distended. There is tenderness on
light
palpation in the epigastric area. There is also a palpable mass
inferior to the umbilicus that is tender to palpation, possibly
diastasis.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes. There is an
ecchymosis at the right ankle.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
==============
97.9 119/74 65 18 98 RA
General: Pleasant in conversation, alert, oriented, no acute
distress at rest.
HEENT: Sclera anicteric, MMM, oropharynx clear.
Neck: No appreciable JVP elevation.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Surgical scars are well healed. Soft, non-distended,
bowel sounds present, moderate TTP over the epigastrum, no
rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: CNs2-12 intact, motor function grossly normal.
Pertinent Results:
ADMISSION LABS
==============
___ 01:42PM ___
___ 01:42PM PLT COUNT-297
___ 01:42PM NEUTS-86.9* LYMPHS-5.7* MONOS-5.4 EOS-1.0
BASOS-0.3 IM ___ AbsNeut-11.67* AbsLymp-0.77* AbsMono-0.73
AbsEos-0.14 AbsBaso-0.04
___ 01:42PM WBC-13.5* RBC-4.75 HGB-15.1 HCT-45.0 MCV-95
MCH-31.8 MCHC-33.6 RDW-13.4 RDWSD-46.7*
___ 01:42PM ALBUMIN-4.3 CALCIUM-10.5* PHOSPHATE-2.7
MAGNESIUM-2.1
___ 01:42PM proBNP-229
___ 01:42PM cTropnT-<0.01
___ 01:42PM LIPASE-28
___ 01:42PM ALT(SGPT)-33 AST(SGOT)-70* ALK PHOS-106* TOT
BILI-0.6
___ 01:42PM GLUCOSE-122* UREA N-14 CREAT-1.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
___ 01:58PM LACTATE-1.8
___ 01:58PM ___ COMMENTS-TEST REPOR
___ 08:56PM cTropnT-<0.01
___ 09:26PM cTropnT-<0.01
___ 09:36PM URINE MUCOUS-RARE*
DISCHARGE LABS
==============
___ 08:08AM BLOOD WBC-6.8 RBC-3.96 Hgb-12.3 Hct-38.8 MCV-98
MCH-31.1 MCHC-31.7* RDW-13.6 RDWSD-48.7* Plt ___
___ 08:08AM BLOOD Plt ___
___ 08:08AM BLOOD ___ PTT-26.9 ___
___ 08:08AM BLOOD Glucose-82 UreaN-10 Creat-1.0 Na-139
K-4.2 Cl-106 HCO3-25 AnGap-8*
___ 08:08AM BLOOD ALT-52* AST-21 LD(LDH)-141 AlkPhos-182*
TotBili-0.3
___ 08:08AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.9
NOTABLE LABS
============
___ 01:42PM BLOOD ALT-33 AST-70* AlkPhos-106* TotBili-0.6
___ 06:15AM BLOOD ALT-135* AST-115* AlkPhos-295*
TotBili-0.4
___ 06:00AM BLOOD ALT-91* AST-47* LD(LDH)-132 AlkPhos-241*
TotBili-0.3
___ 05:58AM BLOOD ALT-67* AST-26 AlkPhos-199* TotBili-0.2
___ 08:08AM BLOOD ALT-52* AST-21 LD(LDH)-141 AlkPhos-182*
TotBili-0.3
___ 09:26PM BLOOD cTropnT-<0.01
___ 08:56PM BLOOD cTropnT-<0.01
___ 01:42PM BLOOD cTropnT-<0.01
___ 01:42PM BLOOD proBNP-229
___ 09:26PM BLOOD IgM HAV-NEG
___ 06:00AM BLOOD IgA-309
___ 06:00AM BLOOD tTG-IgA-5
___ 09:36PM URINE Color-Straw Appear-Clear Sp ___
___ 09:36PM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 09:36PM URINE RBC-1 WBC-25* Bacteri-FEW* Yeast-NONE
Epi-0 TransE-1
___ 09:36PM URINE CastHy-1*
MICRO
=====
___ 8:13 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
___ 8:13 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
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.
___ 10:56 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
STUDIES/IMAGING
===============
CXR ___
IMPRESSION:
No acute pulmonary disease.
CTA A/P ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild intrahepatic biliary ductal dilatation and dilation of
the common
bile duct up to 1.6 cm is nonspecific and may be secondary to
prior
cholecystectomy or may represent ampullary stenosis. No
discrete obstructing mass is identified. Recommend correlation
with liver function tests for signs of obstruction. If degree
of dilation warrants intervention, ERCP can be considered.
Otherwise, further evaluation with MRCP could be considered.
RUQUS ___
IMPRESSION:
1. Redemonstration of mild extrahepatic biliary ductal
dilatation, measuring up to 1.1 cm. No filling defects are
identified.
2. Intrahepatic biliary ductal dilatation, as seen on prior CT,
is not well visualized on the current study.
MRCP ___ (WET READ)
IMPRESSION:
1. Mild dilatation of the extrahepatic common bile duct and the
central
intrahepatic bile ducts with normal tapering at the level of the
ampulla.
Findings may be normal in the setting of prior cholecystectomy,
or may
represent sphincter of Oddi dysfunction or ampullary stenosis.
An occult
obstructing ampullary lesion cannot be excluded.
2. Findings of hepatic hemosiderosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Apixaban 5 mg PO BID
3. Atorvastatin 10 mg PO QPM
4. Citalopram 10 mg PO DAILY
5. Colestid (colestipol) 5 g oral BID
6. Fludrocortisone Acetate 0.1 mg PO BID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Midodrine 2.5 mg PO TID
9. Omeprazole 40 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. PredniSONE 4 mg PO DAILY
12. propafenone ___ mg oral BID
13. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
14. Calcium Carbonate 500 mg PO BID
15. Cetirizine 10 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Pyridoxine 50 mg PO DAILY
18. FoLIC Acid 1 mg PO DAILY
19. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 14 Days
Please continue through ___.
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*27 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H Duration: 14 Days
Please continue through ___.
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*41 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*8 Tablet Refills:*0
4. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
6. Apixaban 5 mg PO BID
7. Atorvastatin 10 mg PO QPM
8. Calcium Carbonate 500 mg PO BID
9. Cetirizine 10 mg PO DAILY
10. Citalopram 10 mg PO DAILY
11. Cyanocobalamin 1000 mcg IM/SC MONTHLY
12. Fludrocortisone Acetate 0.1 mg PO BID
13. FoLIC Acid 1 mg PO DAILY
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Midodrine 2.5 mg PO TID
16. PredniSONE 4 mg PO DAILY
17. propafenone ___ mg oral BID
18. Pyridoxine 50 mg PO DAILY
19. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
20. Vitamin D 1000 UNIT PO DAILY
21. HELD- Colestid (colestipol) 5 g oral BID This medication
was held. Do not restart Colestid until you speak with your
gastroenterologist.
22. HELD- Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First
Line This medication was held. Do not restart Ondansetron until
you have finshed treatment with antibiotics.
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnoses
=================
Acute pouchitis
Abnormal liver function tests
Secondary diagnoses
===================
Ulcerative colitis with history of colectomy
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS
INDICATION: History: ___ with shortness of breath, chest pain w/ concern for
PE// eval for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
3) Spiral Acquisition 3.5 s, 27.4 cm; CTDIvol = 16.8 mGy (Body) DLP = 459.9
mGy-cm.
4) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 26.2 mGy (Body) DLP =
1,366.5 mGy-cm.
Total DLP (Body) = 1,831 mGy-cm.
COMPARISON: None.
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. There are mild atherosclerotic calcifications in the
thoracic aorta and the origins of the great vessels. There are moderate
atherosclerotic calcifications in the coronary arteries. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is a punctate granuloma in the left upper lobe. Lungs
are clear without masses or areas of parenchymal opacification. The airways
are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is mild intrahepatic biliary
ductal dilatation. The common bile duct is dilated up to 1.6 cm (601:24).
The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized. There is no
free intraperitoneal fluid or free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. The abdominal and pelvic wall is within normal limits. 4 mm
focus of sclerosis in the left iliac bone (05:55) likely represents a bone
island.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild intrahepatic biliary ductal dilatation and dilation of the common
bile duct up to 1.6 cm is nonspecific and may be secondary to prior
cholecystectomy or may represent ampullary stenosis. No discrete obstructing
mass is identified. Recommend correlation with liver function tests for signs
of obstruction. If degree of dilation warrants intervention, ERCP can be
considered. Otherwise, further evaluation with MRCP could be considered.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with biliary ductal dilatation, abdominal pain//
Further characterization of biliary ductal dilatation and possible retained
stone
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis performed the same date.
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: Mild intrahepatic biliary ductal dilatation as seen on prior CT is
not appreciated on the current study. However, the common bile duct remains
dilated without evidence of filling defects.
CHD: 11 mm
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 8.8 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Redemonstration of mild extrahepatic biliary ductal dilatation, measuring
up to 1.1 cm. No filling defects are identified.
2. Intrahepatic biliary ductal dilatation, as seen on prior CT, is not well
visualized on the current study.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ with hx paroxysmal atrial fibrillation/atrial tachycardia
(s/p pulmonary vein isolation, multiple cardioversions, and multiple
antiarrhythmic trials), multiple PE/DVTs on Eliquis, adrenal insufficiency,
ulcerative colitis s/p total colectomy, and chronotropic incompetence s/p PPM
who presented to the ED for worsened lightheadedness and shortness of breath.
Having diarrhea with painful BMs. Elevated LFTs// eval for obstruction
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 cc Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT of the chest, abdomen, and pelvis dated ___ and
liver gallbladder ultrasound dated ___.
FINDINGS:
Lower Thorax: There is no pleural or pericardial effusion.
Liver: Hepatic morphology is normal. There is drop in signal intensity on the
in phase images with respect to the out of phase images consistent with iron
deposition. There is no suspicious lesion. The portal and hepatic veins are
patent.
Biliary: There is mild dilatation of the common bile duct with mild associated
central intrahepatic biliary ductal dilatation. There is normal tapering at
the level of the ampulla. There is no choledocholithiasis or suspicious
obstructing lesion. Findings may be attributable to post cholecystectomy
change.
Pancreas: Pancreas is normal in signal intensity and morphology without ductal
dilatation. Multiple millimetric T2 hyperintensities are noted consistent
with small side-branch IPMNs, with the largest measuring up to 3 mm in the
pancreatic body (02:11). These require no further dedicated follow-up
according to current departmental guidelines.
Spleen: Normal in size without focal lesion.
Adrenal Glands: Unremarkable.
Kidneys: Simple renal cysts are present bilaterally. There is no suspicious
lesion or hydronephrosis.
Gastrointestinal Tract: Visualized loops of large and small bowel are
unremarkable.
Lymph Nodes: No suspicious lymphadenopathy.
Vasculature: Unremarkable.
Osseous and Soft Tissue Structures: An L1 vertebral body hemangioma is noted.
Multilevel degenerative changes are otherwise moderate.
IMPRESSION:
1. Mild dilatation of the extrahepatic common bile duct and the central
intrahepatic bile ducts with normal tapering at the level of the ampulla.
Findings may be normal in the setting of prior cholecystectomy (however prior
imaging is not available for comparison to evaluate for stability) or may
represent sphincter of Oddi dysfunction or ampullary stenosis. An occult
obstructing ampullary lesion cannot be excluded.
2. Findings of hepatic hemosiderosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Chest pain, Transfer
Diagnosed with Chest pain, unspecified
temperature: 97.2
heartrate: 82.0
resprate: 17.0
o2sat: 96.0
sbp: 96.0
dbp: 64.0
level of pain: 4
level of acuity: 2.0 | Patient is a ___ with history of paroxysmal atrial
fibrillation/atrial tachycardia (s/p pulmonary vein isolation,
multiple cardioversions, and multiple antiarrhythmic trials),
multiple PE/DVTs on Eliquis, adrenal insufficiency on
prednisone, ulcerative colitis s/p total colectomy, and
chronotropic incompetence s/p PPM who presented to ___ ED with
subacute worsening lightheadedness/shortness of breath
associated with increased abdominal pain and increased stool
frequency (at baseline has 15BM/day), initially on the
cardiology service with low suspicion for underlying
evolving/symptomatic CAD, subsequently transferred to the
medicine service given transaminitis and persistent abdominal
pain/diarrhea with abdominal imaging notable for biliary
dilation, GI consulted with recommendation to treat with empiric
antibiotics for pouchitis, MRCP notable for extrahepatic
CBD/central intrahepatic bile duct dilation (mild) of unknown
significance, LFTs improving nearly to normal by time of
discharge.
===============
ACTIVE ISSUES:
===============
# Diarrhea
# Abdominal pain
# Acute liver function test abnormalities
# CBD and biliary duct dilation on CT - Patient reported acute
worsening of her chronic diarrhea for the last ___, no
laboratory evidence to suggest voluminous GI losses. CT A/P
showed CBD and intrahepatic ductal dilation, also biliary
dilation on RUQUS. Unclear significance s/p CCY, though LFTs
were found to be acutely abnormal with ALT predominant
transaminitis and ALP elevation (Tbili wnl). There was some
report of Sphincter of Oddi dysfunction from ERCP performed in
___. LFTs subsequently improved without intervention
suggesting a self limited process (eg infection, brief
hypotensive episode). It is very possible that patient was
recovering from a gastrointestinal viral infection. GI was
consulted and they suspected an infectious etiology to be most
likely. Given her history of pouchitis, GI ultimately
recommended empiric treatment with ciprofloxacin/metronidazole
x14days (D1 ___, also increased omeprazole to 40mg BID.
Pouchoscopy/EGD were initially considered, though ultimately
deferred. MRCP was performed given abnormal LFTs/CT findings and
revealed mild dilatation of the extrahepatic common bile duct
and the central intrahepatic bile ducts with normal tapering at
the level of the ampulla (possibly normal in the setting of
prior CCY, or may represent sphincter of Oddi dysfunction or
ampullary stenosis; an occult obstructing ampullary lesion
cannot be excluded). Work-up was otherwise notable for NEGATIVE
HAV IgM, NEGATIVE Cdiff/stool cultures, and unremarkable celiac
studies. Antibiotics will continue through ___ and patient
will have follow-up with her outpatient gastroenterologist. Of
note, patient was given a limited prescription for oxycodone at
time of discharge to treat acute on chronic abdominal
discomfort.
# Acute worsening of chronic dyspnea on exertion - Patient has
reportedly undergoing a significant work-up as an outpatient
including TTE ___, unremarkable), RHC/CPET ___,
unrevealing for cardiac pathology), as well as stress testing.
She reportedly had normal PFTs at ___ within the past ___ years.
Patient now presented with acute on chronic exertional dyspnea
over the past two weeks PTA with associated gastrointestinal
symptoms as above. CTA performed in ED r/o PE or other acute
process, no signs of pulmonary edema/effusion. Her pacemaker was
interrogated this admission without any findings of malignant
arrhythmias, patient is A-paced ~50% of the time. No clinical
signs of significant volume overload. Patient had normal oxygen
saturation at rest and did not have any supplemental O2
requirement. Ambulatory oxygen saturations were reassuring ___
on RA. The cardiology service felt that evolving CAD seems
unlikely, troponin NEGATIVE x3 and ECG without any ischemic
findings. Overall, unclear etiology, may consider outpatient
PFTs to assess for restrictive disease, also high resolution
chest CT to assess for subtle parenchymal disease.
- Continued home albuterol PRN
- Continued home salmeterol
# Chest pain - Patient reported substernal chest pain associated
with interval worsening of chronic DOE as above. The cardiology
service felt that evolving CAD seemed very unlikely, troponin
NEGATIVE x3 and ECG without any ischemic findings. Both stress
echo and Mibi were normal within past year. No indication for
LHC this admission.
- Continue fractionated metoprolol with holding parameters
# Inflammatory UA - UA with 25WBCs and large leukocyte esterase
with few bacteria, patient denied any urinary symptoms. Urine
culture ultimately showed mixed bacterial flora. No specific
treatment was initiated, though patient was started on
ciprofloxacin for pouchitis as above.
# Acute kidney injury - Baseline Cr ~1.0, was 1.4 just prior to
admission. Suspected renal hypoperfusion related to GI losses.
Cr improved to ___ s/p IVF and improved PO intake.
# Paroxysmal atrial fibrillation/AT - Unremarkable PPM
interrogation this admission as above.
- Continued home Eliquis
- continued home propafenone
- Continued fractionated metoprolol with holding parameters
================
CHRONIC ISSUES:
================
#Hx DVT/PE
- Continued home Eliquis
#Adrenal insufficiency
- Continued home prednisone
#Chronic orthostasis
- Continued home midodrine, patient takes 2.5mg TID (sometimes
skipping the ___ dose if SBP>140)
- Continued home fludrocortisone
#Dyslipidemia
- Home atorvastatin initially held given abnormal LFTs,
restarted at time of discharge
TRANSITIONAL ISSUES
===================
[] Patient will continue ciprofloxacin/metronidazole through
___ as empiric treatment for pouchitis (QTc 460 ___
[] Patient should have repeat LFTs drawn within ___ to
ensure continued improvement
[] Omeprazole was increased to 40mg BID as per gastroenterology
[] MRCP notable for intrahepatic/CBD mild dilation with tapering
at the level of the ampulla, consider ERCP for recurrent
symptoms (Sphincter of Oddi dysfunction or an obstructing
ampullary lesion cannot be excluded)
[] MRCP was also notable for hepatic hemosiderosis, patient
should have iron studies sent to assess for evidence of iron
overload
obstructing ampullary lesion cannot be excluded)
[] Consider EGD/pouchoscopy if patient should have persistent
abdominal discomfort/diarrhea
[] Colestipol was held at discharge, unclear indication while
patient is on statin, it does not appear that patient has filled
this script since ___
[] Consider outpatient pulmonology referral for additional
work-up of dyspnea if this remains a persistent problem,
including PFTs and high resolution chest CT
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Ms. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
speech difficulty, hemiparesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ was unable to speak earlier today, according to family
and is now sedated with Olanzapine 20 mg. History obtained from
family and review of medical records.
Ms. ___ is a ___ year-old right-handed ___ woman with
PMH significant for HTN, DMII, moderate dementia and admission
in
___ for multiple rib fractures and small SAH (though no
witnessed or reported trauma) who presents with right sided
weakness and aphasia. She was brought to the ED yesterday with
chest pain and was ruled out for MI. She was discharged home
yesterday evening; her daughter-in-law noted at that time that
when she went to use her walker, she was able to use her left
hand normally to put her hand on top of the walker, but was
unable to place her right hand on top of the walker as usual,
but
was rather grabbing on to the walker lower down with her right
hand and she seemed to have difficulty controlling her right
arm.
She went home and did not sleep well overnight. This morning,
her
daughter, with whom she lives, noted that she was dragging her
right foot when walking and was not using her right arm well.
Her
daughter-in-law then came over and saw that her right arm
appeared further impaired than yesterday evening. Her family
also
noted that she was not able to say any words today; they said
words were just not coming out and they were unable to
understand
anything she was trying to say. Her daughter-in-law is unsure if
she was able to comprehend anything, but she says it did not
appear she was paying attention to her family. Her family also
notes that it appeared at times as if she was trying to catch
something in the air; it is unclear is she was having visual
hallucinations. She was brought into the ED for further
evaluation. In the ED, she was very agitated and pulling at
lines so received Zyprexa 10 mg x 2.
ROS: Unable to obtain from patient as she was previously noted
to
be aphasic by family and is now sedated.
Past Medical History:
1. Hypertension
2. Diabetes mellitus, type 2
3. Moderate dementia
4. Osteopenia
5. s/p right distal radial fracture (___)
6. h/o acute cholesystitis s/p open cholecystectomy (___)
7. recent admission ___ for multiple rib fractures and
small SAH, family unaware of a fall
8. small bowel tumor s/p resection
Social History:
___
Family History:
Per family, no known family history of strokes or
seizures.
Physical Exam:
ADMISSION
Physical Exam:
Vitals: T: 96.8 P: 90 R: 16 BP: 182/111 SaO2: 99% RA
General: somnolent, difficult to arouse (had previously received
Olanzapine 10 mg x 2).
HEENT: NC/AT, no scleral icterus noted,no lesions noted in
oropharynx
Neck: Supple
Pulmonary: anterior lung fields cta b/l
Cardiac: RRR, S1S2, II/VI systolic murmur
Abdomen: soft, nondistended, +BS
Extremities: warm, well perfused
Neurologic: no eye opening. no commands (commands were given in
her native language by her family). PERRL 2-->1 mm. Pupils in
midline. She would resist Doll's Eyes maneuver, so unable to
assess. Blinks to threat on left but not on right. Face appears
symmetric at rest. She spontaneously moves left upper extremity
more than right upper extremity, though there is spontaneous
movement on the left. Moves ___ spontaneously b/l. Withdraws all
exttremities to noxious stimuli briskly. During noxious stimuli
testing, she did say "devil" in her native language, which is
first word family says they understood her say all day. Reflexes
were 1+ and symmetric throughout. She had a withdrawal response
with plantar testing b/l.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5, 136/80, 70, 20, 100% on RA
GEN: lying in bed in NAD
HEENT: OP clear
CV: RRR
PULM: CTAB
ABD: soft, NT, ND, PEG in place with c/d/i dressing
EXT: no edema
NEURO:
MS - AAOx1 (with interpreter), unable to follow commands except
to open and close eyes with miming
CN - forced eye closure, pupils 2->1.5, tracks examiner
MOTOR - MAEE to tickle bilaterally
SENSATION - intact to tickle as above
COORDINATION - pt unable to cooperate
GAIT - deferred
Pertinent Results:
ADMISSION LABS:
___ 11:55AM BLOOD WBC-8.7 RBC-4.62 Hgb-13.9 Hct-42.5 MCV-92
MCH-30.0 MCHC-32.6 RDW-14.0 Plt ___
___ 05:05AM BLOOD WBC-5.8 RBC-3.94* Hgb-11.8* Hct-35.5*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.8 Plt ___
___ 11:55AM BLOOD Neuts-84.8* Lymphs-11.9* Monos-2.4
Eos-0.5 Baso-0.4
___ 11:55AM BLOOD Plt ___
___ 04:09PM BLOOD ___ PTT-29.0 ___
___ 11:55AM BLOOD Glucose-116* UreaN-12 Creat-0.9 Na-142
K-4.0 Cl-103 HCO3-27 AnGap-16
___ 05:01AM BLOOD Glucose-124* UreaN-12 Creat-0.8 Na-141
K-3.4 Cl-106 HCO3-24 AnGap-14
___ 02:01AM BLOOD ALT-17 AST-27 AlkPhos-91 TotBili-0.7
___ 12:08PM BLOOD CK(CPK)-343*
___ 05:01AM BLOOD CK(CPK)-250*
___ 11:55AM BLOOD proBNP-276
___ 11:55AM BLOOD cTropnT-<0.01
___ 05:01AM BLOOD CK-MB-5 cTropnT-0.01
___ 02:01AM BLOOD Albumin-4.4 Calcium-9.4 Phos-2.8# Mg-1.9
Cholest-185
___ 05:05AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.9
___ 12:13AM BLOOD %HbA1c-5.5 eAG-111
___ 02:01AM BLOOD Triglyc-48 HDL-93 CHOL/HD-2.0 LDLcalc-82
DISCHARGE LABS:
___ 04:25AM BLOOD WBC-7.8 RBC-4.06* Hgb-12.1 Hct-36.5
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.3 Plt ___
___ 04:25AM BLOOD Glucose-142* UreaN-21* Creat-0.9 Na-134
K-4.3 Cl-98 HCO3-27 AnGap-13
___ 04:25AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.8
REPORTS:
___ ___
FINDINGS: There is a large left 4.8 x 3.4 parieto-occipital
intraparenchymal hemorrhage with surrounding edema and
intraventricular extension into the left lateral ventricle and
occipital horn (2:18, 601:51). There is no shift of midline
structures or evidence of central herniation. Prominent
ventricles and sulci are consistent with age-related atrophy,
without evidence of hydrocephalus. Periventricular white matter
hypoattenuation is compatible with chronic small vessel
infarciton. The basal cisterns are patent. There is no
fracture. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear.
IMPRESSION: Large 4.8-cm left parieto-occipital acute
intraparenchymal
hemorrhage with surrounding edema and intraventricular
extension. No evidence of central herniation.
___ CXR
FINDINGS: As compared to the previous radiograph, the patient
has received a Dobbhoff catheter. The tip of the catheter
projects over the middle parts of the stomach, the course of the
catheter is unremarkable, there is no evidence of complications,
notably no pneumothorax. Borderline size of the cardiac
silhouette. Mild areas of atelectasis at the left and right
lung bases. No evidence of other parenchymal opacities, notably
no evidence of pneumonia.
___ CXR
FINDINGS: As compared to the previous radiograph, the lung
volumes have
decreased. There is mild fluid overload and a plate-like
atelectasis at the left lung bases that has minimally increased
in extent. The pre-existing minimal left pleural effusion is
unchanged. Unchanged course of the nasogastric tube. No
pneumothorax.
___ CXR FINDINGS: Comparison is made to previous study from
___. The Dobbhoff tube has been removed. There has
been placement of nasogastric tube whose tip and side port are
well below the gastroesophageal junction in the distal body of
the stomach. However, there is a loop in the distal nasogastric
tube. The cardiac silhouette and mediastinum is prominent but
stable. There is improvement of the atelectasis at the lung
bases. There remains low lung volumes. There are no
pneumothoraces.
Medications on Admission:
-Lisinopril 30 mg daily
-Calcium + D 500 mg-200 units
-Proair 2 puffs q6h prn
-Senna 8.6 mg qhs
-Docusate 100 mg bid
-Tylenol ___ mg tid
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
3. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Oral
6. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
7. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Intracerebral hemorrhage (intraparenchymal),
Amyloid Angiopathy
Secondary Diagnosis: Hypertension, Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
NEURO EXAM: AAOx1 (chronic dementia), moves all extremities
spontaneously
Followup Instructions:
___
Radiology Report
INDICATION: Unequal pupils and elevated blood pressure and blurred vision.
Evaluation for stroke or bleed.
TECHNIQUE: Contiguous axial images were obtained through the brain. Coronal
and sagittal reformations were acquired.
COMPARISON: NECT of the head ___.
FINDINGS: There is a large left 4.8 x 3.4 parieto-occipital intraparenchymal
hemorrhage with surrounding edema and intraventricular extension into the left
lateral ventricle and occipital horn (2:18, 601:51). There is no shift of
midline structures or evidence of central herniation. Prominent ventricles
and sulci are consistent with age-related atrophy, without evidence of
hydrocephalus. Periventricular white matter hypoattenuation is compatible with
chronic small vessel infarciton. The basal cisterns are patent. There is no
fracture. The visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
IMPRESSION: Large 4.8-cm left parieto-occipital acute intraparenchymal
hemorrhage with surrounding edema and intraventricular extension. No evidence
of central herniation.
Findings were identified at approximately 5:20 p.m. and relayed by Dr.
___ to Dr. ___ by phone at 6:18 p.m. on ___.
Radiology Report
INDICATION: Evaluate for evolution of parenchymal hemorrhage with
intraventricular extension. Evaluate for presence of hydrocephalus.
COMPARISONS: NECTs of the head from ___ and ___.
TECHNIQUE: Contiguous axial images from the vertex through the posterior
fossa were obtained without intravenous contrast. A bedside CT scanner was
used. The remainder of the posterior fossa could not be imaged due to
difficulty with patient cooperation.
FINDINGS: The left parieto-occipital parenchymal hemorrhage is unchanged in
size. The surrounding vasogenic edema causing local sulcal effacement is
stable. As seen previously, there has been transependymal dissection of blood
into the occipital horn of the left lateral ventricle and a small amount can
be seen layering in the occipital horn of the right lateral ventricle, as
well. There is newly-evident small focus of subarachnoid hemorrhage (2:7).
Ventricular size is unchanged from the prior study. There is no evidence of
new mass effect or acute vascular territorial infarction. The visualized
paranasal sinuses, mastoid air cells and middle ear cavities are clear, but
images are distorted by significant motion artifact. There is no fracture
identified.
IMPRESSION: Stable size and mass effect due to left parieto-occipital lobar
parenchymal hemorrhage with intraventricular and subarachnoid components.
There is no ventriculomegaly.
COMMENT: Given the lobar and multicompartmental hemorrhage, coupled with the
patient's advanced age, as well as a similar parenchymal hemorrhage on prior
admission, cerebral amyloid angiopathy should be strongly considered as the
underlying etiology of these findings.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dobbhoff tube placement.
COMPARISON: ___, 11:53 a.m.
FINDINGS: As compared to the previous radiograph, the patient has received a
Dobbhoff catheter. The tip of the catheter projects over the middle parts of
the stomach, the course of the catheter is unremarkable, there is no evidence
of complications, notably no pneumothorax. Borderline size of the cardiac
silhouette. Mild areas of atelectasis at the left and right lung bases. No
evidence of other parenchymal opacities, notably no evidence of pneumonia.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Large left parietal hemorrhage, decreased breath sounds.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
decreased. There is mild fluid overload and a plate-like atelectasis at the
left lung bases that has minimally increased in extent. The pre-existing
minimal left pleural effusion is unchanged. Unchanged course of the
nasogastric tube. No pneumothorax.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with stroke. Placement of nasogastric
tube.
FINDINGS: Comparison is made to previous study from ___.
The Dobbhoff tube has been removed. There has been placement of nasogastric
tube whose tip and side port are well below the gastroesophageal junction in
the distal body of the stomach. However, there is a loop in the distal
nasogastric tube. The cardiac silhouette and mediastinum is prominent but
stable. There is improvement of the atelectasis at the lung bases. There
remains low lung volumes. There are no pneumothoraces.
Radiology Report
INDICATION: ___ year old woman with left frontal intracerebral hemorrhage.
Placement of percutaneous gastrostomy tube for feeding.
CLINICIANS: Dr. ___, fellow and Dr ___, attending
radiologist.
ANESTHESIA: The procedure was performed under general anesthesia and patient
was cared by anesthesiologist throughiout the procedure. Local anesthesia was
provided with 1% buffered lidocaine.
PROCEDURE AND FINDINGS:
An informed written consent was obtained from patient's health care proxy
after explaining the procedure, benefits, alternatives and risks involved. The
patient was brought to the angiography suite and placed supine on the imaging
table. General anesthesia was induced. The upper abdomen was prepped and
draped in the usual sterile fashion. A preprocedure huddle and timeout was
performed as per ___ protocol.
A scout image of the abdomen was obtained and stored. The stomach was
insufflated with air through the indwelling nasogastric tube. Due to the
concern for the proximity of the transverse colon that was seen on the prior
CT study of the abdomen and DynaCT was performed. Safe window was chosen. Then
under fluoroscopic guidance, three T-fastener buttons were sequentially
deployed elevating the stomach to the anterior abdominal wall in a triangular
fashion. A small skin incision was made between the T-fastener buttons and an
18-gauge needle was introduced into the stomach under fluoroscopic guidance.
The position of the needle was confirmed with small amount of contrast
injection. The needle was removed over ___ wire and soft tissue tract
was dilated with ___ F dilator. Then a 12 ___ ___ G-tube was placed over
the wire. Guidewire was removed and the pigtail was formed and locked after
confirming the position of the catheter by contrast injection. The catheter
was secured to the skin with Flexitrack. Sterile dressings were applied. The
patient tolerated the procedure well and there were no immediate
complications.
IMPRESSION:
Uncomplicated placement of a ___ ___ G-tube under fluoroscopic
guidance. The catheter can be used after 24h.
Gender: F
Race: MULTIPLE RACE/ETHNICITY
Arrive by AMBULANCE
Chief complaint: RIGHT SIDED WEAKNESS
Diagnosed with INTRACEREBRAL HEMORRHAGE, HYPERTENSION NOS, SENILE DEMENTIA UNCOMP
temperature: 96.8
heartrate: 90.0
resprate: 16.0
o2sat: 99.0
sbp: 182.0
dbp: 111.0
level of pain: unable
level of acuity: 2.0 | ___ yo RHF with HTN, DM, moderate dementia, with acute onset R
sided weakness and facial droop and found to have large IPH on
NCHCT. Neurological exam is significant for fluctuating
agitation/drowsiness, inattention, inability to follow commands,
?facial droop, decreased spontaneous movement on the right.
Etiology most likely amyloid angiopathy. Other causes include
underlying vascular abnormalities (eg. AVM). Localization of IPH
was not typical for hypertensive bleed.
.
ICU course ___: Overnight patient was agitated with
hypertension and tachycardia and received olanzepine. She was
given standing IV tylenol for presumed pain which made her
drowsy and less agitated. She did not demonstrate clinical
seizure activity. Patient underwent repeat NCHCT which showed
stable L parieto-occipital hemorrhage and she was transfered to
the floor for further monitoring and treatment.
.
Floor ___: The patient was transferred to the Neurology
floor from the ICU in stable condition. She as kept on contact
precautions for prior Oxacillin-resistant Staphylococcus aureus
infection with one negative MRSA isolate on screening on this
admission. Her blood pressure medications were uptitrated to
maintain an SBP < 140. She was noted to have intermittent
nonsustained VT which lessened after repleting electrolytes. She
was placed on low-dose beta-blocker therapy. She was evaluated
by ___. She would not cooperate with Speech therapy.
She was continued on tube feeds via NGT. Her family agreed to
have a gastrostomy placed. ACS was consulted who recommended
___ placement due to a prior abdominal surgery. This was
placed on ___ without complication. She was discharged to rehab
once her restraints were able to be stopped for 24 hours.
.
PENDING STUDIES: None
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Wound Eval
Major Surgical or Invasive Procedure:
Partial nail resection, podiatry, ___
History of Present Illness:
This is a ___ w/ poorly controlled DM who presents from his
PCP's office with concern for right great toe infection. Seen by
Dr. ___ today, apparently has had infection of his
right great toe for over a month s/p trauma to the area. It has
been red, whole foot swollen. He has been putting an antibiotic
ointment on it. He states that he doesn't exactly remember when
he injured it, but he has reinjured it several times. Endorses
bilateral numbness in his feet, has longstadning foot drop on
the R. Denies any tenderness, denies any fevers, cough, chills,
or any other new symptoms.
Per pt and discussion with daughter he has not been taking his
meds consistently at home, though does note he takes allopurinol
and insulin.
In the ___, initial vitals were: 97.6 70 183/73 20 98%. Labs
were significant for HCT 26.1, Cr 3.7 (baseline 3.3-3.9). X-rays
of the toe showed no obvious e/o osteo. Pt was given IV unasyn,
IV cipro and his home labetalol. Dr. ___ was paged in the ___,
and was reported that he felt the pt needed to be admitted with
IV antibiotics double coverage, and consultation with either
podiatry or vascular surgery. States that he has a very tenuous
baseline, and that his mental status changes easily with
infections and that he will not be able to take care of this
wound at home even with ___ assistance.
On the floor, pt denies pain or systemic symptoms. He does not
feel more confused than baseline.
Review of systems: As above. Denies HA, N/V, diarrhea, chest
pain, SOB, HA blurry vision, orthopnea, PND.
Past Medical History:
- T2DM
- HTN
- CKD
- dCHF
- HLD
- obesity
- gout
- depression
- hypothyroidism
- h/o prostate ca s/p radiation
- h/o nephrolithiasis
- s/p cholecystectomy
Social History:
___
Family History:
Daughter with lupus and ESRD and pulmonary infarct, on
peritoneal dialysis. Father passed away from cancer, unsure of
etiology
Physical Exam:
ADMISSION:
Vitals: 97.6 189/74 73 18 97% RA
General: NAD, poorly groomed. Oriented to place, year, birthday.
Cannot do serial 7s, can do days of week backwards.
HEENT: MMM, no LAD or oral lesions
Neck: JVP at lower ___ ___t 45 deg
CV: RRR, systolic murmur heard throughout the precordium
Lungs: CTAB
Abdomen: Soft, obese, nontender
Ext: 2+ bilateral pitting edema to knees, R>L with R foot quite
edematous. R big toe with erythema, dried/crusted bloody exudate
on inner edge of nail, no fluctuance or ulceration or exposed
bone. Nontender. No crepitance. Brisk pedal pulses bilaterally
Neuro: CN II-XII intact, symmetric deficit to light touch to
bilateral mid feet
Skin: See above
DISCHARGE:
VS: 98.0 159/70 65 18 97%RA
GENERAL: NAD
HEENT: head normocephalic, atraumatic
LUNGS: CTAB
HEART: systolic murmur across the precordium, no gallops or rubs
ABD: Soft, NT/ND, large reproducible abdominal hernia
EXTREMITIES: distal UE tremor, peripheral dorsal pedis pulses +2
bilaterally; great R toe nontender and slightly erythematous,
s/p debridement; no erythema of foot; peripheral edema slightly
reduced from yesterday +2 on R, +1 on L
NEURO: A&Ox3, foot drop on right, decreased sensation to light
touch to midfeet bilaterally
Pertinent Results:
ADMISSION LABS:
___ 06:00PM PLT COUNT-244
___ 06:00PM NEUTS-68.9 ___ MONOS-5.1 EOS-4.0
BASOS-0.4
___ 06:00PM WBC-4.9 RBC-2.87* HGB-9.2* HCT-26.1* MCV-91
MCH-32.0 MCHC-35.1* RDW-14.0
___ 06:00PM estGFR-Using this
___ 06:00PM GLUCOSE-171* UREA N-56* CREAT-3.7* SODIUM-140
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16
DISCHARGE LABS:
___ 08:10AM BLOOD WBC-4.2 RBC-2.63* Hgb-8.2* Hct-23.8*
MCV-91 MCH-31.3 MCHC-34.5 RDW-14.0 Plt ___
___ 08:10AM BLOOD Glucose-103* UreaN-54* Creat-4.3* Na-138
K-4.0 Cl-106 HCO3-24 AnGap-12
___ 08:10AM BLOOD Calcium-8.6 Phos-5.1* Mg-1.9 Iron-PND
___ 08:10AM BLOOD Ferritn-PND TRF-PND
___ 08:10PM BLOOD Vanco-8.6*
___ 08:10AM BLOOD Ret Aut-1.9
MICRO:
___ 12:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
CLOSTRIDIUM PERFRINGENS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S) CONSISTENT WITH CLOSTRIDIUM OR
BACILLUS SPECIES.
Reported to and read back by ___. ___ ___ @
8:30 AM.
IMAGING:
R big toe ___: IMPRESSION: No definite evidence for acute
bony lysis. Marginal irregularities, but probably chronic,
along the medial first
metatarsophalangeal joint. Juxtarticular erosion near the first
interphalangeal joint. These are findings that could be seen
with gout, and in the case of the first metatarsophalangeal
joint, may accompany hallux valgus, for which evaluation is
limited on this study (study is performed with
non-weight-bearing).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lantus (insulin glargine) 100 unit/mL subcutaneous Daily
2. Allopurinol ___ mg PO DAILY
3. Venlafaxine XR 225 mg PO DAILY
4. Labetalol 200 mg PO BID
5. Furosemide 120 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Amlodipine 5 mg PO DAILY
8. Diltiazem Extended-Release 300 mg PO DAILY
9. Atorvastatin 80 mg PO DAILY
10. Levothyroxine Sodium 125 mcg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Labetalol 200 mg PO BID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Venlafaxine XR 225 mg PO DAILY
8. Diltiazem Extended-Release 300 mg PO DAILY
9. Lantus (insulin glargine) 24 Units SUBCUTANEOUS DAILY in the
morning
10. Ciprofloxacin HCl 500 mg PO Q24H Duration: 5 Days
Last day ___. Clindamycin 450 mg PO Q8H Duration: 5 Days
Last day ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Diabetic foot infection
Diabetes Mellitus
Peripheral neuropathy
Secondary:
Chronic kidney disease
Diastolic heart failure, chronic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
RADIOGRAPHS OF THE RIGHT FIRST TOE
COMPARISONS: None.
TECHNIQUE: Right first toe, two views, as well as AP foot view.
FINDINGS: The first tarsometatarsal joint appears mildly narrowed without
erosive changes. The first metatarsophalangeal joint is preserved with
minimal spurring and irregular, but chronic-appearing, mild medial erosive
changes on either side of the joint. There is a small juxta-articular erosion
along the medial distal part of the proximal phalanx near the interphalangeal
joint, which does not appear narrowed. There is no definite evidence for
recent or ongoing lysis, however. The entire forefoot shows swelling,
particularly prominent along the fifth digit, where the distal part of the
proximal phalanx appears laced with irregular articular margins adjacent to
the proximal interphalangeal joint, including patchy lucencies. Periarticular
demineralization is noted in the vicinity of second through fifth
metatarsophalangeal joints. Vascular calcifications are widespread.
IMPRESSION: No definite evidence for acute bony lysis. Marginal
irregularities, but probably chronic, along the medial first
metatarsophalangeal joint. Juxtarticular erosion near the first
interphalangeal joint. These are findings that could be seen with gout, and
in the case of the first metatarsophalangeal joint, may accompany hallux
valgus, for which evaluation is limited on this study (study is performed with
non-weight-bearing).
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with ALTERED MENTAL STATUS
temperature: 97.6
heartrate: 70.0
resprate: 20.0
o2sat: 98.0
sbp: 183.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | This is a ___ w/ poorly controlled DM who presents from his
PCP's office with concern for right great toe infection.
# Foot infection: Significant soft tissue swelling. No e/o
abscess, nec-fasc, ulceration to suggest osteo. Plain film neg
for obvious osteo. There likely was a component of paronychia
requiring partial nail resection by podiatry. Likely related to
underlying apparent peripheral neuropathy. No s/s of systemic
infxn. No e/o vascular compromise. Presentation was not c/w
gout. Covered with vanc/zosyn and then transitioned to PO
ciprofloxacin/clindamycin to complete a total of 8 days
(completes ___. Blood cultures grew clostridium perfringens
in ___ bottles, anaerobic. Rpt cultures NGTD at discharge, and
initial culture was felt to most likely represent a contaminant.
# DM: Previously poorly controlled. A1c 6.5 ___. Apparently
c/b symmetric distal peripheral neuropathy (seems to have not
been documented in chart previously). Kept on home lantus with
sliding scale coverage.
# dCHF: Pt appeared grossly volume overloaded. Likely
precipitated by not taking home diuretic. No stigmata of liver
dx. Less volume overloaded at discharge. Decreased lasix dose at
discharge to 60 mg daily due to elevated Cr from baseline.
# Hypothyroidism: Continued levothyroxine.
# Prolonged QTc/PR intervals: QTc 476 on admission, trended down
to 450s on discharge. PR interval initially >200 after
restarting nodal blocking agents but came back to normal at
discharge. Heart rate consistently >60.
# HTN: Poorly controlled without signs of hypertensive
emergency. Likely ___ not taking meds. Improved after restarting
home Diltiazem (with short acting dosing), amlodipine,
labetalol.
# Metabolic acidosis: Non-gap. Possibly ___ CKD. Mild. Quickly
resolved.
# CKD: Pt has stage IV CKD at baseline. Cr midly above baseline
at discharge, likely due to resumption of diuretic and very poor
renal reserve. Vancomycin felt to be less likely contributor.
Labs should be checked at rehab as below and communicated to
PCP. Pt also will f/u with renal closely as outpt.
# Anemia: Longstanding. Attributed in the past to CKD, likely
with an acute component of inflammation. Trended down during
this hospitalization, but did not meet transfusion threshold and
retic count was inappropriately nml (would likely normally be
low due to his CKD) - no e/o hemolysis or bleeding.
# HLD: Held statin while on cipro due to risk of rhabdomyolysis.
Should be restarted after this is stopped at lower dose, 40 mg
daily.
# Gout: No e/o acute gout. Pt says it has been many years since
last attack and symptoms were different. Continued home
allopurinol.
# Depression/dementia: Pt with apparent h/o ?vascular dementia,
though per daughter improved over last ___ yr. Lives alone but
seemed to be not caring for himself adequately. Pt was given
delirium precautions, home venlafaxine, and discharged to rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nitrostat / lobster
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ M with history of early CAD s/p CABGx4 and
multiple PCIs, most recently s/p re-do CABG and AVR ___, CKD,
and hypothyroidism who presented with lightheadedness. Per
patient and chart, on ___ (___), he became very dizzy
after he stood up from a sitting position and lost
consciousness. He recovered spontaneously and felt normal
afterwards.
He has felt dizzy on at least two other occasions since,
although he he did not faint or fall to the ground. Again, the
episodes resolved spontaneously within ___ minutes and
afterwards he felt normal. All of his episodes have been
immediately or soon after changes in position. He has not had
associated headache, vision changes, nausea, diaphoresis, chest
pain, shortness of breath, or palpitations. He has not noticed
any bloody or black stools.
Today, he felt dizzy after rising from the bus. He alighted the
bus and stood still for a moment feeling very dizzy, then walked
a block and his symptoms did not abate. He presented to his PCP,
who then sent him to the ED.
Past Medical History:
- Coronary artery disease:
* NSTEMI (___)
* CABG (___): LIMA-LAD, SVG-M2, SVG-OM3, SVG-RPDA,
* U/A (___): BMS to SVG-OM3, ___ to SVG-RPDA. SVG-OM2
occluded, not intervened upon, LIMA patent.
* U/A (___): DES to LMCA, 3x DES to pLCX
* U/A (___): Diagnostic angiography shows 80% ISRS of LMCA,
pLCX. Planned to do staged intervention since patient
hypervolemic.
* U/A (___): S/p DES to ramus intermedius and DES to
LCX. LAD likely jailed, but "protected" by widely patent
LIMA->LAD graft. Chest pain free following.
- Carotid stenosis (CEA x2)
- CKD stage III
- Hypertension
- Dyslipidemia
- Claudication
- Hypothyroidism
- Gout
- Foot fracture
- Bell's palsy
- History of EtOH abuse (quit 1990s)
- HIstory of tobacco abuse (quit ___
Social History:
___
Family History:
- Father: Died of an MI at age ___.
- Mother: breast cancer and liver cancer
- Sister: ___ artery disease.
Physical Exam:
ADMISSION EXAM:
VS: T 98.1 BP 157/78 HR 74 RR 20 SaO2 100 RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor.
Pupils are fixed and constricted, which pt reports is baseline.
EOMI
NECK: Supple without LAD
PULM: CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2. Audible prosthetic click at LLSB
Chest: well-healed surgical incision
ABD: Obese, soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no ___ edema. L knee moderately TTP.
NEURO: CN II-XII intact, strength ___ and symmetric in upper and
lower extremities, sensation intact throughout
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
===============
___ 12:35PM BLOOD WBC-5.7 RBC-3.97*# Hgb-11.9*# Hct-36.7*#
MCV-92 MCH-30.0 MCHC-32.4 RDW-13.6 RDWSD-46.7* Plt ___
___ 12:35PM BLOOD Neuts-74.7* Lymphs-13.3* Monos-9.6
Eos-1.6 Baso-0.5 Im ___ AbsNeut-4.28 AbsLymp-0.76*
AbsMono-0.55 AbsEos-0.09 AbsBaso-0.03
___ 12:35PM BLOOD Plt ___
___ 12:35PM BLOOD Glucose-91 UreaN-43* Creat-2.4*# Na-134
K-4.6 Cl-96 HCO3-22 AnGap-21*
MICRO:
======
UCx ___ no growth
OTHER NOTABLE VALUES:
=====================
___ 06:20AM BLOOD %HbA1c-5.6 eAG-114
___ 06:11AM BLOOD ___ PTT-35.9 ___
___ 06:20AM BLOOD ___ PTT-35.5 ___
___ 06:50AM BLOOD ___ PTT-36.8* ___
___ 06:27AM BLOOD Glucose-86 UreaN-40* Creat-1.4* Na-136
K-4.7 Cl-104 HCO3-22 AnGap-15
___ 06:25AM BLOOD Glucose-122* UreaN-36* Creat-1.2 Na-137
K-4.3 Cl-103 HCO3-23 AnGap-15
___ 12:35AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:06AM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:17AM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:35PM BLOOD cTropnT-<0.01
___ 03:20PM BLOOD cTropnT-<0.01
IMAGING:
========
CXR ___ IMPRESSION:
No acute cardiopulmonary abnormality identified.
XR L Knee ___ IMPRESSION:
Degenerative changes and small suprapatellar effusion. No
fracture.
XR L Hip ___ IMPRESSION:
No fracture.
MRI Head w/o Contrast ___ IMPRESSION:
1. No acute intracranial infarction.
2. Please note that this study was limited as FLAIR sequences
were not generated.
ECHO ___ IMPRESSION:
--------------------
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>65%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The effective orifice
area/m2 is normal (1.27; nl >0.9 cm2/m2). A paravalvular jet of
trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function. High
cardiac index without evidence of dynamic left ventricular
outflow tract obstruction. Well seated bioprosthetic aortic
valve with normal gradients and trace paravalvular leak.
PHARMACOLOGIC NUCLEAR STRESS TEST ___:
INTERPRETATION: The patient was infused with 0.142 mg/kg/min of
dipyridamole over 4 minutes. At peak infusion, the patient
noted a localized and focal ___ chest discomfort on the left
side of
his chest and left elbow discomfort as well. There were no
significant ST segment changes throughout the study. The rhythm
was sinus with one apb. Appropriate hemodynamic response to the
infusion and recovery. The dipyridamole was reversed with 125 mg
of aminophylline IV.
IMPRESSION: Atypical chest discomfort in the absence of ST
segment
changes. Nuclear report sent separately.
IMPRESSION: Mild reversible defect in the inferior wall. Septal
wall motion compatible with CABG. Normal ejection fraction at
62%.
CARDIAC CATHETERIZATION ___:
Coronary Anatomy
left main patent
LAD occluded
Ramus with 80% proximal and 90% mid
LCX mild disease
SVG-Ramnus with 80% oproximal, 70% mid, 70% distal-->all stented
with DES with 0% residual and
normal flow
LIMA-LAD patent
SVG-RCA occluded
native RCA occluded, RCA fills by collaterals
Impressions:
left main patent
LAD occluded
Ramus with 80% proximal and 90% mid
LCX mild disease
SVG-Ramnus with 80% oproximal, 70% mid, 70% distal-->all stented
with DES with 0% residual and
normal flow
LIMA-LAD patent
SVG-RCA occluded
native RCA occluded, RCA fills by collaterals
Recommendations:
ASA, Plavix
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-4.4 RBC-3.37* Hgb-10.2* Hct-31.9*
MCV-95 MCH-30.3 MCHC-32.0 RDW-15.7* RDWSD-52.7* Plt ___
___ 06:50AM BLOOD ___ PTT-36.8* ___
___ 06:50AM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-141
K-4.3 Cl-104 HCO3-26 AnGap-15
___ 06:50AM BLOOD Calcium-9.7 Phos-3.6 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO QHS
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Warfarin 5 mg PO DAILY16
4. Clopidogrel 75 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Furosemide 20 mg PO DAILY
8. fenofibrate micronized 200 mg oral DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 150 mg SC DAILY
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
You should call your anticoagulation nurse before stopping this
medication
RX *enoxaparin 150 mg/mL 150 mg SC daily Disp #*10 Syringe
Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
This medication may cause slow heart rate, if dizziness or have
slow heart rate call MD
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually if needed Disp
#*1 Package Refills:*0
6. Senna 8.6 mg PO BID
7. Triamcinolone Acetonide 0.025% Cream 1 Appl TP PRN redness
8. Atorvastatin 80 mg PO QPM
9. Clopidogrel 75 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Warfarin 5 mg PO DAILY16
14. HELD- fenofibrate micronized 200 mg oral DAILY This
medication was held. Do not restart fenofibrate micronized until
you see your cardiologist
15. HELD- Lisinopril 20 mg PO QHS This medication was held. Do
not restart Lisinopril until you have seen your cardiologist
16.Outpatient Physical Therapy
ICD 10 R42 dizziness
Outpatient physical therapy
___ rehab
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Unstable angina
Coronary artherosclerosis status-post percutaneous intervention
with deployment of drug-eluting stents
Hypovolemia due to medication side effect
Vestibular hypofunction
Acute kidney injury secondary to hypovolemia
SECONDARY DIAGNOSES:
====================
Mechanical aortic valve on chronic anti-coagulation
Seborrheic dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with CAD s/p CABGx4 and AVR who presents with
lightheadedness and ___// Is there suspicion for infection?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The right internal jugular central venous catheter has been removed. The
patient is status post prior median sternotomy and cardiac valve replacement.
The lungs appear hyperexpanded. There is no focal consolidation, pleural
effusion or pneumothorax identified. The size and appearance of the
cardiomediastinal silhouette is unchanged.
IMPRESSION:
No acute cardiopulmonary abnormality identified.
Radiology Report
INDICATION: ___ year old man with h/o fall on ___, continuing pain.// Is
there a fracture?
TECHNIQUE: AP, oblique and lateral views of the left knee.
COMPARISON: ___ left knee films.
FINDINGS:
There is no acute fracture. No focal osseous abnormality. Degenerative
changes are notable for spurring at the patellofemoral joint as seen on prior.
There is a small suprapatellar effusion. Enthesophyte formation at the
quadriceps and patellar tendon insertions on the patella. Vascular
calcifications and surgical clips are noted.
IMPRESSION:
Degenerative changes and small suprapatellar effusion. No fracture.
Radiology Report
INDICATION: ___ year old man with h/o fall on ___, continuing pain.// Is
there a fracture?
TECHNIQUE: AP and frogleg views of the left hip.
COMPARISON: None.
FINDINGS:
There is no fracture. Femoroacetabular joint is anatomically aligned with
minimal degenerative changes. Vascular calcifications are noted. Soft tissues
are otherwise unremarkable.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old man p/w with acute onset of dizziness and
lightheadedness that started weeks prior to admission. He has an metallic AVR
and is at high risk for stroke. His symptoms have not resolved with IVF and
correction of orthostatic hypotension// concern for stroke in the cerebellum
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, diffusion, and T2 technique were then obtained.
Please note that FLAIR imaging was not performed as patient could not tolerate
lesion of the exam.
COMPARISON None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, or infarction. Chronic
left cerebellar infarction is seen, series 5, image 4. Ventricles and sulci
are age appropriate.
Mild mucosal sinus thickening is seen involving the ethmoid air cells. The
remainder the visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The globes are unremarkable. The principal vascular flow
voids appear to be well preserved.
IMPRESSION:
1. No acute intracranial infarction.
2. Please note that this study was limited as FLAIR sequences were not
generated.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Lightheaded
Diagnosed with Acute kidney failure, unspecified
temperature: 97.7
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 158.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | Mr ___ is a ___ M with history of early CAD s/p CABGx4,
multiple PCIs, and most recently AVR ___, CKD, and
hypothyroidism who presented ___ to the ED with lightheadedness,
found to be in ___ with a creatinine of 2x baseline. While
admitted patient had episode of rest angina on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Codeine / Ciprofloxacin / Naproxen / Tape ___
Attending: ___.
Chief Complaint:
NG tube clogged
Major Surgical or Invasive Procedure:
___ placement ___
History of Present Illness:
Ms. ___ is a ___ with h/o Roux en Y gastric bypass with
multiple complications including Jejuno-Jejunosotmy anastomotic
stricture s/p revision in ___, chronic post-prandial abdominal
pain attributed to afferent limb syndrome, and malnutrition on
tube feeds via ___ who presents with clogged dobhoff and
worsening abdominal pain.
She was started on tube feeds via dobhoff with the goal of
improving her nutrition status prior to eventual surgery for J-J
stricture revision v. reversal. Her Dobhoff was working
yesterday; however, today she was unable to flush the tube, get
any soda down, or get any return with pulling back. She also
endorses nausea with tube feeds and has been unable to complete
tube feed cycles for the past several days. She has also had
worsening post-prandial abdominal pain since ___ with
acute
worsening since ___.
She was seen in GI clinic ___, where they noted low grade
obstructive symptoms and confirmed need for surgical revision of
J-J anastamosis. They also planned to empirically treat with
metronidazole for SIBO.
She was recently discharged from ___ on ___ for a similar
presentation with clogged NJ tube and abdominal pain. She had
EGD
on ___ with replacement of NJ tube and no other new
findings.
Tube feeds were gradually increased. She was also suspected to
have worsening obstruction of the afferent limb.
Upon arrival to the floor, patient reports ongoing abdominal
pain
which she describes as a diffuse sore/bloating feeling with
sharp
pain in LLQ radiating through to her back (baseline pattern).
She
also has intermittent radiation of pain to her R shoulder.
Having
daily bowel movements. She feels puffy in her legs and face. She
also notes she has had rhinorrea, congestion, post-nasal drip,
sore throat, and pain over left maxillary sinus NJ tube was
placed in left nostril.
She denies any chest pain/pressure, dyspnea, dysuria, vomiting,
constipation, diarrhea, BRBPR or melena.
Past Medical History:
- Roux en Y gastric bypass surgery (___) complicated by
jejuno-jejunosotmy anastomotic stricture, adhesions/SBO,
afferent limb syndrome, Hiatal hernia, Hypertensive lower
esophageal sphincter
- Vitamin B12 deficiency, iron deficiency anemia, vitamin D
deficiency
- Right breast lump (___)
- Constipation
- Severe protein calorie malnutrition
- Anxiety
- Lower extremity edema
Social History:
___
Family History:
morbid obesity
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.1PO 122 / 77 ___ 100RA
GENERAL: Well appearing, NAD
HEENT: PERRL, MMM
CARDIAC: RRR, no murmurs
LUNGS: CTAB, no wheezes, crackles
ABDOMEN: Moderately distended, ttp in all quadrants and worst in
central abdomen/LLQ, no rebound or guarding, tympanic to
percussion
EXTREMITIES: WWP, non-pitting edema
NEUROLOGIC: Alert, answering questions appropriately, moves all
extremities with purpose
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 1519)
Temp: 98.3 (Tm 98.9), BP: 96/62 (95-104/53-65), HR: 87
(71-90), RR: 20 (___), O2 sat: 98% (96-100), O2 delivery: Ra,
Wt: 130 lb/58.97 kg
GENERAL: Sitting up in bed, well appearing
HEENT: PERRL, MMM
CARDIAC: RRR, normal S1 and S2, no m/r/g
LUNGS: CTAB, no wheezes, crackles
ABDOMEN: Well-healed surgical scar over umbilicus. Tender to
palpation diffusely, greatest in LLQ, no rebound or guarding,
tympanic to percussion. Pain in LLQ when palpating RLQ.
EXTREMITIES: WWP, non-pitting edema
NEUROLOGIC: Alert, answering questions appropriately, moves all
extremities with purpose
Pertinent Results:
ADMISSION LABS
=============
___ 06:40PM BLOOD WBC-5.7 RBC-3.37* Hgb-9.8* Hct-32.3*
MCV-96 MCH-29.1 MCHC-30.3* RDW-12.5 RDWSD-42.5 Plt ___
___ 06:40PM BLOOD Neuts-57.2 ___ Monos-7.1 Eos-0.2*
Baso-0.4 Im ___ AbsNeut-3.25 AbsLymp-1.83 AbsMono-0.40
AbsEos-0.01* AbsBaso-0.02
___ 06:40PM BLOOD ___ PTT-30.0 ___
___ 06:40PM BLOOD Glucose-84 UreaN-17 Creat-0.6 Na-139
K-4.8 Cl-103 HCO3-25 AnGap-11
___ 06:40PM BLOOD ALT-19 AST-22 AlkPhos-92 TotBili-<0.2
___ 06:40PM BLOOD Albumin-3.4* Calcium-8.6 Phos-5.3* Mg-2.3
IMAGING
========
___ CXR
IMPRESSION:
Successful placement of a right 29 cm basilic approach double
lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
MICRO
======
___ 10:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
===============
___ 04:41AM BLOOD WBC-3.9* RBC-2.99* Hgb-8.7* Hct-28.3*
MCV-95 MCH-29.1 MCHC-30.7* RDW-12.7 RDWSD-43.4 Plt ___
___ 04:41AM BLOOD Glucose-84 UreaN-14 Creat-0.6 Na-142
K-4.5 Cl-107 HCO3-28 AnGap-7*
___ 04:41AM BLOOD ALT-28 AST-38 AlkPhos-78 TotBili-<0.2
___ 04:41AM BLOOD Calcium-8.5 Phos-4.7* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. copper gluconate 2 mg oral DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Abdominal pain
6. Methadone 40 mg PO BID
7. OxyCODONE (Immediate Release) 30 mg PO BID:PRN Pain - Severe
8. OxyCODONE (Immediate Release) 20 mg PO BID:PRN Pain - Severe
9. Pantoprazole 40 mg PO Q12H
10. Thiamine 100 mg PO DAILY
11. Tizanidine 4 mg PO DAILY:PRN Abdominal discomfort
12. Vitamin D ___ UNIT PO 1X/WEEK (___)
13. Cyanocobalamin 1000 mcg IM/SC MONTHLY
14. Hyoscyamine 0.125 mg SL Q8H:PRN Nausea
15. Lactobacillus acidophilus 5 billion cell oral DAILY
16. melatonin 5 mg oral DAILY
17. Multivitamins 1 TAB PO DAILY
18. MetroNIDAZOLE 250 mg PO TID
19. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Cyanocobalamin 1000 mcg IM/SC MONTHLY
4. FoLIC Acid 1 mg PO DAILY
5. Hyoscyamine 0.125 mg SL Q8H:PRN Nausea
6. Lactobacillus acidophilus 5 billion cell oral DAILY
7. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Abdominal pain
8. Loratadine 10 mg PO DAILY
9. melatonin 5 mg oral DAILY
10. Methadone 40 mg PO BID
11. MetroNIDAZOLE 250 mg PO TID
12. Multivitamins 1 TAB PO DAILY
13. OxyCODONE (Immediate Release) 30 mg PO BID:PRN Pain -
Severe
14. OxyCODONE (Immediate Release) 20 mg PO BID:PRN Pain -
Severe
15. Pantoprazole 40 mg PO Q12H
16. Thiamine 100 mg PO DAILY
17. Tizanidine 4 mg PO DAILY:PRN Abdominal discomfort
18. Vitamin D ___ UNIT PO 1X/WEEK (___)
19. HELD- copper gluconate 2 mg oral DAILY This medication was
held. Do not restart copper gluconate until your PCP tells you
to
20.Outpatient Lab Work
weekly triglycerides, CBC w/ differential, chem-10 drawn and
faxed to ___ attention Dr. ___. ICD10 ___.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Malnutrition
SECONDARY DIAGNOSES
===================
Chronic partial small bowel obstruction
Status post Roux-en-Y gastric bypass
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: ___ with dophoff and abd pain// approp dophoff placement?
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Portable AP view of the chest provided. Enteric feeding tube passes into the
stomach and then continues to project over the left mid abdomen, likely within
small bowel loops given patient's history of Roux-en-Y gastric bypass
procedure. Imaged portion the lungs are clear without pleural effusion or
pneumothorax. Imaged portion of the abdomen is unremarkable with a
nonobstructive bowel gas pattern.
IMPRESSION:
Status post gastric bypass procedure. Dobhoff tube likely terminates within
proximal efferent small-bowel loops.
Radiology Report
INDICATION: ___ year old woman with severe malnutrition s/p Roux-en-Y bypass,
chronic SBO, requires TPN. IV nurse unable to place on right, ___ placed
midline on R (unable to advance due to old injury in R shoulder from MVA),
removed due to neurologic symptoms overnight (tingling).// Please place PICC
on LEFT.
COMPARISON: No relevant comparisons available
TECHNIQUE: OPERATOR: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2 min, 5 mGy
PROCEDURE:
1. Double lumen PICC placement through the right basilic vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the right
basilic vein was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A double lumen PIC line measuring 29 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach double lumen right PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 29 cm basilic approach double lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, gtube eval
Diagnosed with Unspecified abdominal pain, Mech compl of gastrointestinal prosth dev/grft, init, Exposure to other specified factors, initial encounter
temperature: 98.6
heartrate: 108.0
resprate: 16.0
o2sat: 100.0
sbp: 126.0
dbp: 75.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ with a history of Roux en Y gastric bypass
with multiple complications including jejuno-jejunostomy
anastomotic stricture s/p revision in ___, now with afferent
limb syndrome, chronic partial SBO, and malnutrition, admitted
for initiation of TPN to maximize nutrition prior to surgical
revision.
# Acute on chronic abdominal pain
# S/p RYGB c/b afferent limb syndrome
# Chronic partial SBO
Patient presents with acute on chronic abdominal pain,
associated with stably increased abdominal distention over the
past few days. Still having BMs regularly. Culprit is likely
jejunal stricture given evidence chronic SBO on MR enterography.
She may also have SIBO, and is on empiric Flagyl. Continued home
pain regimen (on narcotics agreement), and bowel regimen.
Started Metronidazole empirically per GI recs for possible SIBO.
The surgical team decided to defer plans for J-J anastomosis
revision until the patient's nutritional status was optimized.
Surgery visited with her prior to discharge and they will
schedule earlier follow up with her, scheduled to f/u early
___.
# Malnutrition
Patient did not tolerate TF trial, given underlying partial
bowel obstruction at jejunal stricture. In order to optimize
nutrition prior to surgery, she was started on TPN via a PICC
and electrolytes were stable this admission. She already has ___
services at home.
# Normocytic anemia:
H/H at baseline, no signs/symptoms of active bleeding. Continued
PO iron supplementation.
TRANSITIONAL ISSUES
===================
# Malnutrition:
[ ] Continue TPN with weekly bloodwork, to be followed by Dr.
___. Will need weekly triglycerides, CBC w/
differential, chem-10 drawn and faxed to ___ attention
Dr. ___. Dr. ___ will also adjust TPN in addition to
monitoring labs.
[ ] Per nutrition recs, stopped copper supplements iso normal
copper levels.
[ ] Iron supplements were changed to every other day, per new
guidelines.
# Chronic Partial SBO:
[ ] Follow up with Dr. ___ as scheduled.
# CODE: full (presumed)
# CONTACT: ___ (husband) - ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levaquin in D5W / Prozac
Attending: ___.
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M w/ PMH type 1 diabetes, chronic
kidney disease, MEN 1, hyperparathyroidism, gastrinoma,
___ syndrome, who presents with hyperglycemia and
syncope.
Of note, his sugars have been poorly controlled over the last
several days. On ___, he was found unresponsive and brought to
the ER where he was found to have severe hypoglycemia. Per the
patient and his partner who are at bedside, he has not felt
particularly unwell but has been registering high sugars over
the
last several days. Apparently glucometer has been reading > 500
intermittently for several days, but they thought glucometer was
broken. He has felt progressively weak and orthostatic without
polyuria. He has had very poor oral intake due to poor appetite,
and only oral intake has been a few sips of ___ in the
last
3 days. On that background has had multiple syncopal episodes
unwitnessed over the last 2 days; unclear if loss of
consciousness. Patient states no head strike but his partner has
found him laying out flat on the ground.
In the ED, initial vitals: 96.7 ___ 16 96% RA
Exam significant for:
chronically ill appearing
cor pulm unremarkable - not tachypneic
abd s/ntnd
___ without edema
Labs were significant for Cr 3.7 which improved to 2.2, Na 122
also improved, K 6 now improved, bicarb 17 now improved, anion
gap 19 now 12.
Imaging showed CXR No acute cardiopulmonary process. NCHCT with
No acute intracranial process.
In the ED, pt received IV insulin gtt which was stopped around 6
am, 5L NS IVF, 80 mEq KCl, 45U Lantus, 150 mcg Levothyroxine,
Creon, Lamotrigine 200 mg, Pantoprazole 40 mg PO, Venlafaxine XR
225 mg PO, 1g IV Ceftriaxone, 1L LR IVF.
Vitals prior to transfer: 57 105/68 18 98% RA ___ 105.
On arrival to floor, ___ 93.
He reports that he has been feeling fatigued for the past couple
of months. He has been getting treatment for his gastrinoma
with
octreotide. He was due for a shot today. He was started on
radiation therapy before ___. He got about 3 weeks of
radiation therapy. After radiation therapy he felt a little bit
better in terms of his appetite. However, he felt that over the
past week his appetite had gone back to him he was not eating
much. He was mainly drinking water to prevent dehydration and
he
had a couple sips of regular ___. He reports feeling
somewhat lightheaded earlier today when trying to come to the
clinic for his appointment and he passed out at home without
hitting his head. His fall was witnessed by his partner ___ confirms that he did not hit his head and that he very
quickly woke up and was oriented ×3. He also passed out as he
declined getting out of the car and did hit his head. At that
time in the emergency room they scanned his head without any
signs of bleed. He has been taking his medications as
scheduled.
Couple days ago he had low blood sugars and so he had sometimes
skipping his mealtime insulin if he was not eating. He also
thinks on the day of admission he did not take his Tresiba. He
did not take the Tresiba because he was sleeping because he has
been so fatigued.
He denies nausea vomiting diarrhea constipation. Denies fevers.
He is constantly cold. He denies night sweats. He denies any
skin changes. He has lost 10 pounds over the past month. He
reports that his mood is stable. His partner is concerned that
maybe the rash could be contributing to his not eating. But he
is not sure. Denies chest pain.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-Initial diagnosis of MEN I at ___ in ___ with R
adrenalectomy for pheo in ___ and partial pancreatectomy for
gastrinoma, as well as several parathyroidectomies with L
forearm
implant.
-___ presented to ___ with abdominal pain found to have
gastrin level of ___ and gastric mass, had a completion
pancreatectomy and whipple with seg 3 partial hepatectomy for
metastatic gastrinoma ___ followed by parathyroidectomy
___
and RF ablation of met gastrinoma in the liver c/b ___
requiring ICU.
-___ ___ for eval of iron defic anemia showed
neuroendocrine tumor concerning for metastatic gastrinoma vs.
new
primary; octreotide scan concerning for nodal involvement.
Surgery favored octreotide treatment instead of total
gastrectomy.
-Initial med onc visit ___ for octreotide therapy; we felt
that the new gastric tumors were likely due to gastrin-mediated
hyperplasia rather than metastatic disease given the lack of
liver and peritoneal lesions. We discussed therapy options
including octreotide, sunitinib, and everolimus, and the patient
opted to proceed with monthly
octreotide initiated ___.
-He was diagnosed with another parathyroid adenoma, and on
___ he underwent his ___ parathyroid adenoma removal with
Dr.
___. Post-op PTH was 82 (down from 250), so no implant
was performed.
-Once he started monthly octreotide ___, CGA and gastrin
declined.
-___ admitted for thrombocytopenia, ___, hepatic abscess and
polymicrobial sepsis likely of GI source, also noted to have
pulm
nodules which were improving on his last visit with pulm.
Gastrin
and chromogranin again improved after renal function improved.
The source of his infection remained unclear, and repeat
colonoscopy ___ showed no abnormalities other than a benign
polyp. U/S abdomen ___ showed no liver abscess or focal
lesions; he did have an intrahepatic fluid collection
essentially
stable compared to prior CT.
-___ Transient elevation in tumor markers; MRI was
reassuring;
variation thought due to changes in renal function.
-___: last MRI abdomen which showed stability of a 5mm
non-specific lesion in the liver, stable gastric neuroendocrine
tumor, stable RP LAD and LUQ peritoneal implant, chronic L
hepatic vein thrombus and stable L adrenal nodularity.
-___: CT chest showed improvement in pulmonary nodules
-___: CT chest and MRI A/P stable, but worsening iron
deficiency anemia. EGD with ulcerated mass in the distal
stomach
(present, but not ulcerated in last endoscopy a couple of years
ago) as well as duodenal AVM thought to be incidental. Path
unclear if gastric hyperplasia/tumor vs. metastatic lesion.
-___ increased octreotide from 20 mg monthly to 30 mg
monthly
PAST MEDICAL HISTORY:
-DM initially diagnosed prior to pancreatectomy
-Iron deficiency
-Fatty liver disease
-CKD, presumed diabetic
-Radioactive iodine treatment for hyperthyroidism, unclear
whether any malignancy was diagnosed.
-Recent skin lesion excised, pathology showing trichodiscoma.
Derm referred patient to genetic counseling.
-Anxiety, depression
-Retinopathy
-ADHD
PAST SURGICAL HISTORY: adrenalectomy for pheochromocytoma,
partial pancreatectomy for gastrinoma followed by completion
pancreatectomy and Whipple with Seg 3 partial hepatectomy for
metastatic gastrinoma, 3+ gland parathyroidectomy for adenomas
with a left forearm partial parathyroid implantation, laser
ablation of retinal hemorrhage, bilateral lens replacement for
cataracts
Social History:
___
Family History:
Father also has MEN I s/p Whipple and colon cancer diagnosed in
his early-to-mid ___. Mother is healthy. Paternal grandmother
had
DM. Maternal grandmother had colon cancer, unclear age of
diagnosis. Maternal aunt had breast cancer, unclear age of
diagnosis. His brother and his children were tested for MEN1 and
none were positive.
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ 1131 Temp: 97.5 PO BP: 115/74 HR: 70 RR: 18 O2 sat:
98% O2 delivery: Ra FSBG: 93
GEN: Alert, lying in bed, no acute distress, fatigued, slow to
respond to questions
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended. Large scar across abdomen
from Whipple procedure.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
___ 0736 Temp: 98.6 PO BP: 121/74 R Sitting HR: 62 RR: 18
O2
sat: 95% O2 delivery: Ra FSBG: 154
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM
PULM: CTA b/l without wheeze or rhonchi
ABD: Soft, non-tender, scar noted
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 06:42PM BLOOD WBC-11.0* RBC-4.65 Hgb-15.1 Hct-44.2
MCV-95# MCH-32.5* MCHC-34.2 RDW-12.9 RDWSD-45.1 Plt ___
___ 06:42PM BLOOD Neuts-73.4* Lymphs-13.9* Monos-10.2
Eos-0.8* Baso-1.0 Im ___ AbsNeut-8.06* AbsLymp-1.53
AbsMono-1.12* AbsEos-0.09 AbsBaso-0.11*
___ 06:42PM BLOOD UreaN-37* Creat-3.7*# Na-122* K-6.0*
Cl-86* HCO3-17* AnGap-19*
___ 06:42PM BLOOD ALT-51* AST-56* AlkPhos-210* TotBili-0.6
___ 12:15AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7
___ 06:42PM BLOOD TSH-9.5*
___ 06:20AM BLOOD T3-51* Free T4-1.1
___ 08:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:18AM BLOOD ___ pO2-71* pCO2-39 pH-7.34*
calTCO2-22 Base XS--4
___ 08:24PM BLOOD Glucose-GREATER TH Na-121* K-5.5* Cl-85*
calHCO3-20*
DISCHARGE LABS:
___ 07:08AM BLOOD WBC-7.8 RBC-3.65* Hgb-11.7* Hct-36.2*
MCV-99* MCH-32.1* MCHC-32.3 RDW-14.3 RDWSD-52.3* Plt ___
___ 07:08AM BLOOD Glucose-167* UreaN-21* Creat-1.5* Na-141
K-5.6* Cl-102 HCO3-29 AnGap-10
NCHCT:
No acute intracranial process.
MRI A/P: 1. Mild interval progression of disease with enlarging
left adrenal nodules
and an increasing left mesenteric lymph node.
2. Four left lower lobe pulmonary nodules measuring up to 0.6
cm, at least one
was present previously but the other three are likely new,
recommend dedicated
chest CT for further evaluation.
3. Attention on follow-up imaging to a 0.8 cm focus of
restricted diffusion in
segment V of the liver.
4. Stable 1.3 cm right renal artery aneurysm.
TTE: The left atrial volume index is normal. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF = 70%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). 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. Mild (1+) mitral regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
PMIBI: IMPRESSION: 1. Normal left ventricular perfusion
2. Left ventricular wall motion is within normal limits. LVEF
of 57%.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit
oral 6xdaily
2. Ferrous Sulfate 325 mg PO DAILY
3. Gabapentin 300 mg PO QHS
4. LaMOTrigine 200 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___)
6. Levothyroxine Sodium 300 mcg PO 1X/WEEK (MO)
7. Lorazepam 1 mg PO QHS
8. Pantoprazole 40 mg PO Q12H
9. RisperiDONE 1.5 mg PO QHS
10. Venlafaxine XR 225 mg PO QHS
11. Vitamin D 5000 UNIT PO DAILY
12. Atorvastatin 80 mg PO QPM
13. calcium citrate-vitamin D3 315 mg-units ORAL 2 TABS TID
14. Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
15. Tresiba FlexTouch U-100 (insulin degludec) 9 units
subcutaneous QAM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *blood-glucose meter [FreeStyle Lite Meter] check blood
sugars as directed Disp #*1 Kit Refills:*0
3. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___)
4. Levothyroxine Sodium 300 mcg PO 2X/WEEK (___)
5. Atorvastatin 80 mg PO QPM
6. calcium citrate-vitamin D3 315 mg-units ORAL 2 TABS TID
7. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit
oral 6xdaily
8. Ferrous Sulfate 325 mg PO DAILY
9. Gabapentin 300 mg PO QHS
10. LaMOTrigine 200 mg PO DAILY
11. Lorazepam 1 mg PO QHS
12. Pantoprazole 40 mg PO Q12H
13. RisperiDONE 1.5 mg PO QHS
14. Tresiba FlexTouch U-100 (insulin degludec) 9 units
subcutaneous QAM
15. Venlafaxine XR 225 mg PO QHS
16. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
T-wave inversions on EKG
Decreased appetite
Diabetic ketoacidosis
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI ABDOMEN AND PELVIS
INDICATION: ___ year old man with MEN I and type I DM who presents with DKA
and decreased appetite concerning for progression of gastrinoma. ___ improved
to normal now.// eval for progression of gastrinoma
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: Abdominal and pelvic MRI ___.
FINDINGS:
Lower thorax There are four enhancing pulmonary nodules located in the left
lung base measuring up to 0.6 cm, one was present on the prior examination,
but the other three were not seen (series 1401, image 20, 31).
Liver: Postsurgical changes noted from prior left lateral hepatectomy.
Unchanged appearance of fibrotic change and focal biliary duct dilation in
segment VIII. There is a 0.8 cm focus of restricted diffusion in segment V
without definite correlate on other images, unclear if this is new from prior
given motion limitations of ___ (series 7, image 32).
Biliary: The gallbladder is surgically absent. There is no intra or
extrahepatic biliary duct dilation.
Pancreas: The pancreas is surgically absent.
Spleen: Spleen is absent. Left upper quadrant nodule measuring 1.0 x 9.2 cm
adjacent to the gastric body is unchanged is consistent with splenosis (series
5, image 14).
Adrenal Glands: The right adrenal gland is absent. There is mild increasing
nodularity adrenal gland. For example, superior nodularity now measures 3.0 x
2.7 cm, previously 2.5 x 1.4 cm. Inferior aspects of nodularity are only
minimally changed compared to prior.
Kidneys: The kidneys are symmetric in size. There are scattered sub
centimeter T2 hyperintense lesions in the bilateral renal cortices which are
consistent with cysts. No suspicious renal lesions are seen. There is no
hydronephrosis.
Gastrointestinal Tract: Patient is post partial gastrectomy. There is
diffuse thickening along the lesser curvature of the stomach with associated
enhancement. Given differential distension of the stomach direct comparison
of the degree of gastric wall thickening is limited. There is no bowel
obstruction. Views of the small and large bowel are unremarkable.
Pelvis: The bladder is distended and unremarkable. There is no pelvic
sidewall or inguinal lymphadenopathy.
Lymph Nodes: There is an enlarging left mesenteric lymph node now measuring
2.0 x 3.0 cm, previously 1.9 x 2.6 cm (series 1401, image 96).
Vasculature: There is no abdominal aortic aneurysm. Hepatic arterial anatomy
is conventional. There is a single renal artery bilaterally. Note is made of
an unchanged 1.3 x 1.4 cm aneurysm of the right distal renal artery (Series
1401, image 95). The portal vein is patent.
Osseous and Soft Tissue Structures: There are no suspicious bony lesions.
There is a lipoma in the left gluteus medius muscle measuring 6.7 x 3.1 cm.
IMPRESSION:
1. Mild interval progression of disease with enlarging left adrenal nodules
and an increasing left mesenteric lymph node.
2. Four left lower lobe pulmonary nodules measuring up to 0.6 cm, at least one
was present previously but the other three are likely new, recommend dedicated
chest CT for further evaluation.
3. Attention on follow-up imaging to a 0.8 cm focus of restricted diffusion in
segment V of the liver.
4. Stable 1.3 cm right renal artery aneurysm.
RECOMMENDATION(S): Chest CT to further characterize left
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:28 am, 5 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperglycemia, Syncope
Diagnosed with Type 1 diabetes mellitus with ketoacidosis without coma, Long term (current) use of insulin
temperature: 96.7
heartrate: 112.0
resprate: 16.0
o2sat: 96.0
sbp: 93.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old M with history of type 1 diabetes,
chronic kidney disease, MEN1, hyperparathyroidism, gastrinoma,
___ syndrome, who presented with hyperglycemia
and syncope, found to have DKA, ___, and new T wave inversions.
# Diabetic ketoacidosis: Most likely in the setting of not
taking long-acting insulin in the morning of admission. No
other trigger identified on initial history. He receives
insulin drip in the emergency room and then was transitioned to
45 units of Lantus on hospital day 1. Gap was closed at this
time. ___ was consulted and his Lantus was started at 9
units with 6 units of Humalog with every meal in addition to
sliding scale. Glucometer has been broken at home so a new one
was prescribed for him.
# Syncope: Most likely was due to dehydration and orthostatic
hypotension. TTE showed normal ejection fraction and no motion
abnormalities, and no RV strain.
#EKG changes and elevated cardiac enzymes: Patient did not have
any chest pain per his report, but did have new T-wave changes
with deeper T waves on progressive EKGs. Could be related to a
demand NSTEMI from DKA and hypotension or metabolic derangement
on admission. Could be due to intermittent LBBB with memory T
wave inversions but none were seen on telemetry. Cardiology
consulted and recommended starting aspirin 81 daily. Also
recommended echo and stress test all of which were negative.
Discussed starting aspirin with oncology team due to risk of
bleeding from gastrinoma, but oncology felt that after
radiation therapy, the risk of bleeding was much less and that
it was okay to start aspirin.
# Gastrinoma: Continued Creon, continued pantoprazole 40 mg
twice daily, continue iron daily. Progression of disease seen
on MRI A/P, will be followed up in clinic with oncology.
# Decreased appetite: Most likely this is due to progression
of his gastrinoma with only mild improvement from radiation
therapy.
# Elevated TSH: T3 low and free T4 normal, appeared consistent
with sick euthyroid in setting of acute stress/illness.
Continued levothyroxine home dose
# Transaminitis: Most likely due to fatty liver disease versus
spread of gastrinoma. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Complications s/p cholecystectomy for choledocholithiasis,
transaminitis
Major Surgical or Invasive Procedure:
No invasive procedures this admission.
History of Present Illness:
___ otherwise health who is currently admitted to the medical
service with a concern for right posterior bile duct and right
hepatic artery injury. He underwent a lap converted to open
partial cholecystectomy on ___ at ___
after undergoing a preoperative ERCP for cholangitis. His
operative report notes that his ductal and portal anatomy was
unclear. A bleeding vessel was encountered and ligated however
it
was unclear if this was the right hepatic artery. He was noted
post-op to have an elevation in his LFTs (TB 1.0, AST 145, AP
239
ALT 393) with a MRCP which demonstrated a dilated right
posterior
hepatic duct. He therefore underwent repeat ERCP on ___ with
placement of a ___ plastic stent in to the CBD. There was
reportedly no evidence of bile leak or filling defects. He
presented to the ED yesterday evening with constant worsening
RUQ
pain, after being told to come here for a PTBD and was admitted
to the medical service. Labs in the ED were notable for AST/ALT
427/213, AP 225, tbili 0.7, lipase 99. He currently has no
complaints and is without significant abdominal pain. He does
have a surgical drain in place which is draining ___ cc of bile
per day.
Past Medical History:
- gallstones
- choledocolithiasis
Social History:
___
Family History:
- no family history of heart disease, diabetes, liver disease,
positive family history of gallstone disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- 97.9 132/80 18 96RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, good dentition. Oropharynx
is clear.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
ABDOMEN: Surgical scar well healing without erythema or pus.
Biliary drain with serosanguinous fluid. Normal bowels sounds,
non distended, mild tenderness in RUQ without rebound or
guarding. EXTREMITIES: No clubbing, cyanosis, or edema
NEUROLOGIC: CNs grossly intact. Moving all four extremities.
A&Ox3.
DISCHARGE PHYSICAL EXAM
========================
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
incisions c/d/i, surgical drain in RUQ w/ bilious drainage
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
ADMISSION LABS
===============
___ 04:55PM BLOOD WBC-8.5 RBC-3.97* Hgb-12.7* Hct-37.8*
MCV-95 MCH-32.0 MCHC-33.6 RDW-12.1 RDWSD-42.4 Plt ___
___ 04:55PM BLOOD Neuts-61.3 ___ Monos-8.5 Eos-2.5
Baso-1.2* Im ___ AbsNeut-5.19 AbsLymp-2.18 AbsMono-0.72
AbsEos-0.21 AbsBaso-0.10*
___ 04:55PM BLOOD ___ PTT-30.5 ___
___ 04:55PM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-140
K-4.9 Cl-104 HCO3-22 AnGap-19
___ 04:55PM BLOOD ALT-427* AST-213* AlkPhos-225*
TotBili-0.7
___ 04:55PM BLOOD Albumin-4.2
___ 04:59PM BLOOD Lactate-1.2
___ 07:20AM BLOOD WBC-6.7 RBC-4.10* Hgb-12.9* Hct-39.7*
MCV-97 MCH-31.5 MCHC-32.5 RDW-12.3 RDWSD-43.4 Plt ___
___ 04:55PM BLOOD WBC-8.5 RBC-3.97* Hgb-12.7* Hct-37.8*
MCV-95 MCH-32.0 MCHC-33.6 RDW-12.1 RDWSD-42.4 Plt ___
___ 07:20AM BLOOD Glucose-88 UreaN-8 Creat-0.7 Na-140 K-4.6
Cl-103 HCO3-24 AnGap-18
___ 04:55PM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-140
K-4.9 Cl-104 HCO3-22 AnGap-19
___ 07:30AM BLOOD ALT-447* AST-195* AlkPhos-209*
TotBili-0.7
___ 07:20AM BLOOD ALT-433* AST-182* LD(LDH)-198
AlkPhos-207* TotBili-0.7
___ 04:55PM BLOOD ALT-427* AST-213* AlkPhos-225*
TotBili-0.7
IMAGING/STUDIES
============
___ CTA Abdomen
1. Common hepatic arising from the SMA. Surgical clip abutting
the right
hepatic artery at the hilum, vessel is mildly irregular, 1 of
its branches is attenuated, consistent with vessel injury.
2. Status post partial cholecystectomy, with a portion of the
gall bladder
neck remaining. 2.5 x 2.2 cm simple fluid collection the
gallbladder fossa.
Right lateral approach drain terminating in the porta hepatis,
in close
proximity but not passing through the fluid collection the
gallbladder fossa.
3. Mild intrahepatic biliary ductal dilatation in the right
lobe. Stent within the extrahepatic duct, and expected
pneumobilia indicating stent patency.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetroNIDAZOLE 250 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
transaminitis, possible right hepatic artery branch and right
posterior hepatic duct injuries
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD WANDW/O C AND RECONS
INDICATION: ___ year old man with one week post CCY, had an ERCP prior to CCY
(8 days ago, Dr. ___ 2 stones were removed and pus was seen. During Lap
CCY there was low visualization with intraoperative review of the MRCP showed
no common hepatic duct, low division for Rt and Lt biliary system, Lap was
converted to open CCY and there was bleeding and it seems that the Rt hepatic
artery was ligated. Catheter throw the GB remnant was not successful, had
partial cholecystectomy. MRCP showed that Rt. Hepatic duct dilated and seems
that it is occluded at the level of the bifurcation.
TECHNIQUE: Abdomen CTA: Non-contrast and multiphasic post-contrast images
were acquired through the abdomen.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 38.7 cm; CTDIvol = 3.7 mGy (Body) DLP = 141.6
mGy-cm.
2) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 19.1 mGy (Body) DLP = 720.8
mGy-cm.
3) Spiral Acquisition 2.4 s, 37.4 cm; CTDIvol = 19.1 mGy (Body) DLP = 715.6
mGy-cm.
4) Spiral Acquisition 1.4 s, 22.2 cm; CTDIvol = 19.1 mGy (Body) DLP = 424.0
mGy-cm.
5) Stationary Acquisition 4.1 s, 0.5 cm; CTDIvol = 22.3 mGy (Body) DLP =
11.2 mGy-cm.
Total DLP (Body) = 2,013 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
The common hepatic artery arises from the SMA. There is a surgical clip
abutting the right hepatic artery in the gallbladder fossa (series 601, image
60), the vessel is mildly irregular near the clip, distal branches are largely
patent, 1 branches attenuated, just posterior to common bile duct series 3A
image 46. The left hepatic artery is patent. The portal and hepatic veins
are patent. There is no contrast extravasation to indicate active bleed.
LOWER CHEST: The bilateral lung bases are clear. There is no pleural
effusion..
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in attenuation. No focal lesion is
detected. There is mild intrahepatic biliary ductal dilatation in the right
lobe. There a stent within the extrahepatic duct, and expected pneumobilia
indicating stent patency. The patient is status post partial cholecystectomy,
with a portion of the gallbladder neck remaining. Just medial to this, there
is a 2.5 x 2.2 cm simple fluid collection in the gallbladder fossa. There are
multiple surgical clips in the gallbladder fossa. There is also a small
amount of simple fluid within the gallbladder fossa.
There is a drain entering the right lower abdomen and coursing superiorly to
terminate in the porta hepatis. The drain is in close proximity but does not
pass through the fluid collection the gallbladder fossa.
PANCREAS: The pancreas is homogeneous in attenuation without focal lesion or
main ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is normal in size and attenuation, without evidence of
focal lesion.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are symmetric in size with normal bilateral nephrograms.
There is a 4 mm nonobstructing stone in the lower pole of the left kidney
(series 2, image 43). There is a 5 mm cyst in the lower pole of the left
kidney (series 3B, image 215). There is no hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Visualized upper abdominal small large bowel loops are
normal in caliber..
LYMPH NODES: There is no mesenteric lymphadenopathy in the upper abdomen.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There are transversely oriented incisional changes in the right
mid abdominal wall.
IMPRESSION:
1. Common hepatic arising from the SMA. Surgical clip abutting the right
hepatic artery at the hilum, vessel is mildly irregular, 1 of its branches is
attenuated, consistent with vessel injury.
2. Status post partial cholecystectomy, with a portion of the gall bladder
neck remaining. 2.5 x 2.2 cm simple fluid collection the gallbladder fossa.
Right lateral approach drain terminating in the porta hepatis, in close
proximity but not passing through the fluid collection the gallbladder fossa.
3. Mild intrahepatic biliary ductal dilatation in the right lobe. Stent within
the extrahepatic duct, and expected pneumobilia indicating stent patency.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Right upper quadrant pain
temperature: 98.2
heartrate: 101.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 79.0
level of pain: 5
level of acuity: 3.0 | ___ who underwent a lap converted to open partial
cholecystectomy on ___ which based on the op note likely
resulted in a right hepatic arterial injury. Post op he was
found to have bilious drainage from his JP as well as abdominal
pain and elevated LFTs with an MRCP concerning for a right
posterior hepatic duct injury consistent with a St___ B/C
injury. He underwent ERCP ___ with plastic stenting of the
CBB but no reported filling defects on cholangiogram. This
patient was presented at the multidisciplinary conference. Per
their recommendations he underwent a CTA which showed CHA
arising from the SMA, a surgical clip abutting the RHA with an
attenuated branch possibly indicating a vessel injury,
pneumobilia consistent with his recent ERCP with CBC plastic
stenting, and mild intrahepatic biliary dilation in the right
lobe possibly indicating ductal injury of the right hepatic
ductal system. He has a drain in place from the original surgery
which has been putting out small amounts of bilious output. He
had a persistent elevation of his LFTs which was stable with no
elevation of the total bilirubin (3 sets with approximately 400
ALT, 200 AST, 200 AP, and 0.7 Tb on all three sets). He was
continued on ciprofloxacin and flagyl which was started
post-operatively per report. This was discontinued on day of
discharge for an estimated 12 day course. He was afebrile with a
normal white blood cell count. Given his stability, improving
pain, and tolerance of a regular diet it was felt safe to
discharge the patient with the caveat that he return to care for
worsening pain, fevers, jaundice, or other new concerning
symptom. He was instructed to follow up with Dr. ___ ___ days
after his drain output falls to zero or in ___ weeks, whichever
comes sooner. He is in agreement with the plan. He was given
instructions on caring for the drain and felt comfortable doing
so independently at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Periods of asystole with syncopal events
Major Surgical or Invasive Procedure:
___: ___ Dual Chamber permanent pacemaker
History of Present Illness:
___ man h/o Afib on coumadin w/ CVAx2 including large R
MCA stroke resulting in severe left sided hemiparesis now
wheelchair bound, CAD s/p MI s/p CABG (ejection fraction 35
percent secondary to severe hypokinesis of the inferior and
posterior walls) who presented to ___ with vomiting
and lightheadedness with telemetry showing multiple pauses of
extended duration and syncopal events. He had total of 5
episodes w/ pauses lasting between 6 and 10 seconds and he was
asymptomatic between episodes. Of note, pt was seen in ___
___ for syncopal event.
In the ___, initial vitals were 98.2 F (36.8 C). Pulse:
89. Respiratory Rate: 18. Blood-pressure: 152/75. Oxygen
Saturation: 96% room air; normal. Patient was given atropine,
calcium, aspirin, vitamin K and FFP for INR 2.95. Temporary
pacer wire was placed in IJ and patient sent to ___ for
pacemaker placement.
In ___ labs s/f lactate of 2.7, WBC of 13.5 w/ 2% bands,
H&H of 13.5 and 39.7, Plt of 189
Chem 7 of ___
INR of 2.95
A rhythm strip is present demonstrating >6 second pause. An ECG
is done demonstrating a paced V sensed with prolonged PR
interval with no clear p wave capture.
An ECG done presumably before pacer placement demosntrates
regular rate left bundle pattern without clear pwave ?
accelerated junctional.
In ___ ___, vs pending. Telemetry and ECG revealed pacing via
his temporary pacemaker, with narrow QRS complexes indicative of
atrial pacing. CXR (reviewed with radiology in the ___ showed
the pacing wire in the lateral RA. Pt seen by EP fellow who
determined pacing threshold was 2.5mA. In the ___ pt pacing
consistently at rates from 50-100 bpm, but had only a
ventricular escape at <10bpm underlying. While there is no clear
atrial capture he conducts consistently with a narrow QRS and PR
of ~380 ms.
___ arrival to the floor, patient is comfortable and well
appearing with family. His family notes that he vomited and
felt lightheaded yesterday. Pt states he may have had diarrhea
but is unsure. He denies constitutional symptoms. He denies
recent changes in medications. Pt endorses mild shortness of
breath.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
cough, hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.
Past Medical History:
PAST MEDICAL HISTORY:
PAF on coumadin
CAD w/ MI s/p 5 vessel CABG in ___ with Lima/SVG
Mild AR
Moderate MR
___
CVA x2 (large R MCA stroke and AICA stroke)resulting in profound
left-sided hemiparesis and is essentially wheelchair bound
Dementia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP dificult to assess given presence of IJ line.
CARDIAC: RRR, nL S1 and S2, ___ systolic murmur heard best at
RUSB.
LUNGS: Unable to complete posterior exam, but decreased breath
sounds with poor air movement.
ABDOMEN: Obese, non tender, no clear organomegaly
EXTREMITIES: 1+ lower extremity edema
PULSES: Right: Dopplerable Left: Dopplerable
Discharge Exam:
Temp 97.9, HR 58-91, RR 18, BP ___ O2 sat 99% RA
General: alert, confused, cooperative, NAD
HEENT: no JVD
CV: RRR, no M/R/G
Chest: Clear ant, pt not cooperative with exam
ABD: soft, NT, pos BS
Extrememties: 1+ edema bilat with pneumoboots
Neuro: confused but easily reoriented. Long term memory intact,
speech clear, left sided weakness of upper and lower
extremeties.
Pertinent Results:
Admission Labs:
___ 04:30AM BLOOD WBC-7.9 RBC-3.70* Hgb-11.6* Hct-34.2*
MCV-92 MCH-31.3 MCHC-33.8 RDW-13.8 Plt ___
___ 04:30AM BLOOD Neuts-76.7* Lymphs-15.0* Monos-6.1
Eos-1.8 Baso-0.3
___ 04:30AM BLOOD ___ PTT-35.0 ___
___ 04:30AM BLOOD Glucose-115* UreaN-22* Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-28 AnGap-12
___ 04:30AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.0
DISCHARGE LABS
___ 06:54AM BLOOD WBC-8.1 RBC-3.79* Hgb-11.8* Hct-35.5*
MCV-94 MCH-31.1 MCHC-33.2 RDW-13.7 Plt ___
___ 06:49AM BLOOD Glucose-140* UreaN-23* Creat-1.0 Na-138
K-4.1 Cl-99 HCO3-29 AnGap-14
___ 06:49AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.0
Urine:
___ 11:23PM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:23PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 11:23PM URINE RBC-5* WBC->182* Bacteri-MOD Yeast-NONE
Epi-3
___ 11:23PM URINE CastHy-4*
___ 11:23PM URINE WBC Clm-FEW Mucous-OCC
Imaging:
CXR ___: IMPRESSION: Mild pulmonary vascular congestion and
probable trace right pleural effusion. Retrocardiac
atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine *NF* 10 mg Oral daily
2. Doxazosin 4 mg PO HS
3. Finasteride 5 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. Nortriptyline 75 mg PO HS
7. Simvastatin 20 mg PO DAILY
8. Warfarin 5 mg PO DAILY16
9. Acetaminophen 500 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Doxazosin 4 mg PO HS
4. Finasteride 5 mg PO DAILY
5. Nortriptyline 75 mg PO HS
6. Simvastatin 20 mg PO DAILY
7. Warfarin 5 mg PO DAILY16
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
9. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg one capsule(s) by mouth four times a day
Disp #*20 Capsule Refills:*0
10. Enoxaparin Sodium 120 mg SC DAILY
RX *enoxaparin 120 mg/0.8 mL one injection daily Disp #*6
Syringe Refills:*2
11. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
12. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
13. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg one tablet(s) by mouth daily
Disp #*30 Tablet Refills:*2
14. Cetirizine *NF* 10 mg Oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-asystole/ tachy brady syndrome, s/p ___ dual chamber
permanent pacemaker
-Chronic systolic heart failure with an EF of 35%
-Coronary artery disesae with a hx of conronary artery bypass
grafting
-BPH
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: Syncope.
TECHNIQUE: Semi-upright AP view of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The patient is status post median sternotomy and CABG. Mild enlargement of
cardiac silhouette is unchanged, and the mediastinal contours are stable.
There is mild pulmonary vascular congestion. Blunting of the right
costophrenic angle suggests the presence presence of a trace effusion.
Retrocardiac atelectasis is noted. There is no pneumothorax. No acute
osseous abnormalities are visualized.
IMPRESSION:
Mild pulmonary vascular congestion and probable trace right pleural effusion.
Retrocardiac atelectasis.
Radiology Report
INDICATION: Confirmation of lead position in a patient status post
percutaneous pacemaker placement.
COMPARISON: Chest radiograph ___ and ___.
FINDINGS: Upright AP and lateral views of the chest were reviewed and
compared to the prior study. A dual-chamber pacemaker is seen over the left
hemithorax with leads extending into the right atrium and right ventricle.
Median sternotomy wires and clips along the left mediastinal contour are
likely from prior cardiac surgery. The lung fields are clear. Bilateral
blunting of the costophrenic angles is unchanged since ___ and likely
represents chronic small pleural effusions or pleural thickening. There is no
pneumothorax or vascular congestion.
The bones and soft tissues are unchanged.
IMPRESSION: Dual-chamber cardiac pacemaker leads ending in the right atrium
and right ventricle. No acute cardiopulmonary process.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Subclavian pacemaker, rule out pneumothorax.
COMPARISON: ___.
FINDINGS:
Right jugular venous pacemaker has been removed. New left-sided pacemaker has
leads in right atrium and ventricle. There is no pneumothorax or pleural
effusion. Mild pulmonary edema has resolved. Moderate cardiomegaly is stable
in this patient with prior sternotomy for CABG.
CONCLUSION:
There is no complication after pacemaker placement.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SYNCOPE/BRADY
Diagnosed with CARDIAC DYSRHYTHMIAS NEC, ATRIAL FIBRILLATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ man w/ known pAfib on coumadin, CVA, CAD s/p CABG
who presented to ___ with vomiting and
lightheadedness w/ multiple pauses with syncopal events now s/p
temporary pacing wire placement complicated by migration from
ventricle to atria. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Intubation ___ - extubated ___
Re-intubated ___ - extubated ___
R. PICC ___
History of Present Illness:
This is a ___ female with a history of advanced dementia
who presents with her son after a fall at home. Patient lives at
home with her son. He states she turned around and tried to
reach out for a wall, but fell down, landing on the left hip. He
denies head strike or loss of consciousness. He helped her to
bed, and she was able to bear weight on the leg, however she
continued to complain of pain. He therefore brought her here for
evaluation. Patient is unable to provide additional history. Son
states that she has been in her usual state of health, and has
not been complaining of any headaches, dizziness, chest pain,
shortness of breath, or fevers. He states she had another fall
in the past 2 weeks. He states her balance is excellent, and she
usually uses a walker at home.
In the ED, vitals were largely unremarkable however patient
occasionally noted to have tachycardia in the low 100s, as well
as elevated SBP to the 160s. Patient received trauma evaluation
notable for several subacute rib fractures and 1 acute rib
fracture of the right ninth rib, small left psoas hematoma
without discrete fluid collection. Labs were notable for an
initial CBC with elevated white count to 13.3, slight anemia at
10.8, CBC normalized several hours later and all other lab
unremarkable. She was given about 1 L of normal saline at
maintenance fluid rate, 10 mg olanzapine.
Upon arrival to the floor, the patient unable to give further
history.
Past Medical History:
HTN
SBO ___ hernia s/p bowel resection in ___
Breast CA s/p L mastectomy in ___
Dementia
Social History:
___
Family History:
Not pertinent to current admission.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: Reviewed in POE
GENERAL: thin, younger than stated age, agitated and confused
HEENT: sclera anicteric, MM very dry
CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: CTABL in anterior fields
ABDOMEN: soft, ND, +BS, no grimacing/guarding/localizing w palp
GU: No foley
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: alert but not oriented, cannot answer any questions
sensically, moving all limbs, face symmetric
DISCHARGE PHYSICAL EXAM
=======================
VS: No vitals for CMO, nontachypneic
GENERAL: Comfortable appearing, NAD.
HEENT: Normocephalic, atraumatic. MMM
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No skin breakdown noted on extremities
NEUROLOGIC: No focal deficit
Pertinent Results:
ADMISSION LABS:
================
___ 08:47PM BLOOD WBC-13.3* RBC-3.42* Hgb-10.8* Hct-33.7*
MCV-99* MCH-31.6 MCHC-32.0 RDW-14.8 RDWSD-53.1* Plt ___
___ 08:47PM BLOOD Neuts-75.8* Lymphs-11.5* Monos-10.2
Eos-1.7 Baso-0.3 Im ___ AbsNeut-10.08* AbsLymp-1.53
AbsMono-1.35* AbsEos-0.23 AbsBaso-0.04
___ 08:47PM BLOOD Glucose-108* UreaN-34* Creat-1.0 Na-144
K-4.7 Cl-107 HCO3-24 AnGap-13
MICROBIOLOGY:
==============
___ 2:00 am URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:07 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:36 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 8:33 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 8:17 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
___ 5:09 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:03 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
IMAGING:
============
___ BILAT HIPS (AP, LAT, & PELVIS) 5 OR MORE VIEWS
No acute fracture or dislocation.
___ CXR
Bibasilar opacities, likely atelectasis on the left and
potentially
atelectasis on the right as well however infection would be
difficult to and exclude. Consider PA and lateral if patient is
amenable.
___ CT HEAD W/O CONTRAST
1. The study is severely limited by motion artifact. Within
these limits, there is severe enlargement of the lateral, third
and fourth ventricles, particularly temporal horns of the
bilateral lateral ventricles and global volume loss.
2. No definite intracranial hemorrhage.
___ CT PELVIS ORTHO W/O C
1. Old pelvic fractures. No acute displaced fractures within
the limitations of severe osteopenia.
2. Left retroperitoneal hematoma, incompletely visualized.
___ CT ABD & PELVIS WITH CONTRAST
1. Minimal change in a small left psoas hematoma with overlying
mild
stranding. No discrete fluid collection is demonstrated.
Discontinuity at the left anterior osteophytes of L3/4 is new
since ___, consistent with a fracture.
2. fractures of the right eleventh and twelfth ribs are new from
___ but with evidence of healing, indicating either a subacute
or chronic chronicity. There is a single, corticated fracture
of the right ninth rib.
3. Redemonstration of a large right Bochdalek's hernia
containing colon.
4. Interval reduction of bowel within the right inguinal canal.
___ CXR
Elevation of right hemidiaphragm likely due to paralysis or
eventration.
Interposition of dilated colon between the elevated
hemidiaphragm and liver. A remote laceration of the diaphragm
is less likely.
___ CXR
The lesion from possible profiles with a remote laceration the
diaphragm being much less likely. There is no pulmonary edema.
___ BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Large right ___ cyst.
___ CT HEAD W/O CONTRAST
1. No acute intracranial process, specifically no large
territorial
infarction, hemorrhage or mass.
2. Prominent ventricles which appear out of portion in relation
with the
sulci, in the appropriate clinical setting, the possibility of
normal pressure hydrocephalus is a consideration, please
correlate.
___ TTE
IMPRESSION: Preserved biventricular systolic function. Mild
aortic, mitral, and tricuspid regurgitation. Normal pulmonary
pressure.
___ CXR
New right-sided PICC line terminating in the lower SVC. There
is stable
elevation of the right hemidiaphragm with stable atelectasis in
the right
base. Left-sided pacemaker is stable. Otherwise stable chest
radiograph.
___ CXR
Status post endotracheal intubation. Endotracheal tube
terminating in the mid trachea. Marked increased volume loss
and opacification of the right
hemithorax.
___ CXR
Comparison to ___. Tip of the endotracheal tube
projects 2 cm
above the carinal. The previous consolidations at the right
lung base are
substantially improved, the lung volume on the right is
increased. However, a substantial portion of perihilar and
right basal consolidations persist. Normal size of the heart.
Slightly decreased but still normal left lung volumes.
___ CXR
Interval worsening of right lung consolidations and elevation of
the right
hemidiaphragm.
___ CXR
Compared to chest radiographs ___ through ___. Left
lung is clear. Left skin fold should not be mistaken for
pneumothorax. No appreciable left pleural effusion. Heart is
only mildly enlarged. Severe atelectasis and moderate pleural
effusion persist on the right. No pneumothorax. ET tube in
standard placement. Right PIC line ends in the low SVC.
Transvenous right atrial right ventricular pacer leads
continuous from the left pectoral generator are unchanged in
position. Nasogastric drainage tube ends in the midportion of a
nondilated stomach.
DISCHARGE LABS:
===============
___ 04:32AM BLOOD WBC-9.6 RBC-2.77* Hgb-8.8* Hct-28.2*
MCV-102* MCH-31.8 MCHC-31.2* RDW-15.3 RDWSD-56.7* Plt ___
___ 04:32AM BLOOD ___ PTT-47.7* ___
___ 04:32AM BLOOD Glucose-96 UreaN-26* Creat-0.9 Na-147
K-4.3 Cl-105 HCO3-32 AnGap-10
___ 04:32AM BLOOD ALT-12 AST-24 LD(LDH)-225 AlkPhos-97
TotBili-0.4
___ 04:32AM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.6 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidocaine Pain Relief] 4 % apply to painful areas
daily Disp #*10 Patch Refills:*0
2. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN
respiratory distress or pain
Please place under her tongue
RX *morphine 10 mg/5 mL 2.5 mL by mouth every four (4) hours
Refills:*0
3. OLANZapine (Disintegrating Tablet) 5 mg PO QHS:PRN
anxiety/agitation
RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Ninth left rib fracture
#Acute hypoxemic respiratory failure
#Pneumonia
#Mechanical fall
#Altered mental status
#Delirium
#Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT PELVIS ORTHO W/O C
INDICATION: ___ female with fall, and persistent L hip pain. neg
negative x-ray. Evaluate for hip fracture.
TECHNIQUE: Multidetector CT images of the pelvis were acquired without
intravenous contrast. Non-contrast scan has several limitations in detecting
vascular and parenchymal organ abnormalities, including tumor detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 28.6 cm; CTDIvol = 24.8 mGy (Body) DLP = 708.0
mGy-cm.
Total DLP (Body) = 708 mGy-cm.
COMPARISON: Comparison is made to CT abdomen pelvis performed ___.
FINDINGS:
PELVIS: No bowel obstruction in the visualized abdomen. There are right
lower quadrant bowel anastomosis, as on prior. Hysterectomy changes are
noted.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Extensive atherosclerotic disease is again noted.
BONES: Marked osteopenia limits evaluation for nondisplaced fractures. No
evidence of acute displaced fracture or dislocation. Old healed superior and
inferior bilateral pubic rami fractures are again noted. Extensive
degenerative changes of the lower thoracic spine are again seen without
evidence of acute compression deformity.
SOFT TISSUES: A small bowel containing right inguinal hernia is again seen.
Known rib deformities reaching the pelvis are again seen. There is new linear
high density soft tissue stranding anterior to the left psoas extending into
the pelvis compatible with a retroperitoneal hematoma. It appears small in
the pelvis, however it is incompletely visualized.
IMPRESSION:
1. Old pelvic fractures. No acute displaced fractures within the limitations
of severe osteopenia.
2. Left retroperitoneal hematoma, incompletely visualized.
NOTIFICATION: The updated findings were notified to ___ by Dr. ___
at 1300 hours.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with RP bleed. needs CT w./ contrast
to better eval for RPNO_PO contrast// RP bleed
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen following intravenous contrast administration with split
bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
3) Spiral Acquisition 5.2 s, 40.6 cm; CTDIvol = 14.0 mGy (Body) DLP = 568.7
mGy-cm.
4) Spiral Acquisition 0.9 s, 7.1 cm; CTDIvol = 13.3 mGy (Body) DLP = 94.2
mGy-cm.
5) Spiral Acquisition 1.1 s, 8.8 cm; CTDIvol = 13.9 mGy (Body) DLP = 122.3
mGy-cm.
6) Spiral Acquisition 0.9 s, 7.1 cm; CTDIvol = 13.4 mGy (Body) DLP = 94.9
mGy-cm.
7) Spiral Acquisition 1.0 s, 7.8 cm; CTDIvol = 13.2 mGy (Body) DLP = 102.8
mGy-cm.
8) Spiral Acquisition 1.0 s, 7.6 cm; CTDIvol = 13.2 mGy (Body) DLP = 99.8
mGy-cm.
Total DLP (Body) = 1,093 mGy-cm.
COMPARISON: Same day CT ___, CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: There is redemonstration of a previously noted Bochdalek's hernia
on the right with herniation of large bowel into the right hemithorax. There
is cardiomegaly with pacing leads partially visualized. No effusion. Likely
eventration of the left hemithorax.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The left adrenal gland is normal in size and shape. The right
adrenal gland is not visualized.
URINARY: The kidneys contain low intermediate density cysts bilaterally, the
largest in the right kidney measuring 1.9 cm. The left kidney is atrophic
compared to the right. Both kidneys demonstrate normal nephrogram. No
hydronephrosis or perinephric abnormality bilaterally. There is no evidence
of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: No bowel obstruction. Right lower quadrant bowel
anastomosis is unchanged.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Patient is status post hysterectomy.
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: There are healing rib fractures with mild displaced demonstrated at the
posterior aspect of the right eleventh rib (series 2, image 12, 19), the
posterior aspect of the tenth right rib (series 2, image 8, 16) and a single,
minimally displaced fracture of the lateral aspect of the ninth rib (series 2,
image 17). These demonstrate evidence of healing, indicating that there
likely subacute to chronic, but new from ___. Diffuse degenerative
changes throughout the lumbar spine are unchanged. There is a new
discontinuity of the anterior bridging osteophytes of L3/4, consistent with an
acute or subacute fracture.
Similar appearance of old pelvic fractures and degenerative changes.
SOFT TISSUES: Once again demonstrated is a relative expansion of the left
psoas muscle relative to the right, with high density soft tissue stranding
anterior unchanged in extent. A right inguinal hernia containing bowel
demonstrate previously has been reduced.
IMPRESSION:
1. Minimal change in a small left psoas hematoma with overlying mild
stranding. No discrete fluid collection is demonstrated. Discontinuity at
the left anterior osteophytes of L3/4 is new since ___, consistent with
a fracture.
2. fractures of the right eleventh and twelfth ribs are new from ___ but with
evidence of healing, indicating either a subacute or chronic chronicity.
There is a single, corticated fracture of the right ninth rib.
3. Redemonstration of a large right Bochdalek's hernia containing colon.
4. Interval reduction of bowel within the right inguinal canal.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ woman w dementia presenting from home after a fall. Being
treated for CAP.// Eval for worsening pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
A left-sided pacemaker with leads in appropriate placement is noted.
Elevation of the right hemidiaphragm with bowel in the right hemithorax likely
due to paralysis or eventration. Interposition of dilated colon between the
elevated hemidiaphragm and liver. There is no pulmonary edema.
IMPRESSION:
Elevation of right hemidiaphragm likely due to paralysis or eventration.
Interposition of dilated colon between the elevated hemidiaphragm and liver.
A remote laceration of the diaphragm is less likely.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dementia, brief period of tachypnea
overnight without desat at time of prior CXR, now with more substantial
desaturation. Suspect aspiration// Eval for development of interval pulm edema
or consolidation
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left-sided pacemaker with leads in appropriate placement. There is severe
scoliosis of the thoracolumbar spine. There is bowel in the right thorax
likely due to an elevated right hemidiaphragm from possible paralysis or
eventration. A remote laceration is less likely. There is no pulmonary
edema. No significant change compared to prior about 3 hours earlier.
Cardiomediastinal silhouette is mildly enlarged.
IMPRESSION:
The lesion from possible profiles with a remote laceration the diaphragm being
much less likely. There is no pulmonary edema.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ yo woman h/o aspirations, now s/p intubation for hypoxemia,
has been on vancomycin, ceftaz and flagyl for aspiration pneumonia.// ET
placement? Contact name: ___: ___
TECHNIQUE: The chest AP
COMPARISON: ___
IMPRESSION:
There is stable elevation of the right hemidiaphragm with subsegmental
atelectasis in the right lung base. Left-sided pacemaker is unchanged. The
ETT projects to the right mainstem bronchus and needs to be pulled back by at
least 2 cm.
The NG tube projects below the left hemidiaphragm and out of field-of-view.
There is dextroscoliosis. Interstitial edema has slightly improved. No
pneumothorax is seen
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with dementia, L 9th rib fx s/p fall, now intubated and on
antibiotics for presumed aspiration, AMS.// evaluate for hemorrhage, mass,
infarction.
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 =
934.5 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of large territorial infarction,intracranial hemorrhage,
mass or mass effect. There is ventriculomegaly of the lateral, third and
fourth ventricles out of proportion with prominent sulci. Calcified
atherosclerotic changes are noted in the bilateral cavernous segments of the
internal carotid arteries. Multiple hypodensities within the subcortical and
periventricular white matter are nonspecific but may represent chronic
microvascular disease.
There is no acute evidence of fracture. There is mild mucosal thickening of
the bilateral ethmoid sinuses. The visualized portion of the other paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The patient is
status post bilateral lens replacements.
IMPRESSION:
1. No acute intracranial process, specifically no large territorial
infarction, hemorrhage or mass.
2. Prominent ventricles which appear out of portion in relation with the
sulci, in the appropriate clinical setting, the possibility of normal pressure
hydrocephalus is a consideration, please correlate.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ with dementia, L 9th rib fx s/p fall, now intubated and on
antibiotics for presumed aspiration.// 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.
There is a 1.9 x 4.0 x 5.4 cm right ___ cyst with layering internal
debris, suggesting chronicity.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Large right ___ cyst.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxia// evaluate ET tube location, PNA,
effusion
TECHNIQUE: Portable chest radiograph
COMPARISON: ___
FINDINGS:
There is stable elevation of right hemidiaphragm with worsening atelectasis in
the right base. A left-sided pacemaker with unchanged leads in the right
atrium and the right ventricle. The ET tube projects about 5 mm from the
carina and could be pulled back by 2 cm. The NG tube projects below the
diaphragm and is out of the field of view. There is severe scoliosis.
Interstitial edema appears mildly worse. There is a line in the left lateral
chest wall that is likely a skin fold and not a pneumothorax.
IMPRESSION:
1. ET tube projecting close to the carina and could be pulled back by 2 cm.
2. Interval worsening of interstitial edema.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new picc// R picc 45cm Contact name:
sal, ___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ at 09:50
FINDINGS:
New right-sided PICC line terminating in the lower SVC. There is stable
elevation of the right hemidiaphragm with stable atelectasis in the right
base. Left-sided pacemaker is stable. Otherwise stable chest radiograph.
IMPRESSION:
Right-sided PICC line tip in the lower SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with aspiration pneumonia, intubated, tube
became slightly dislodged yesterday,// eval for ETT placement/movement
eval for ETT placement/movement
IMPRESSION:
Comparison to ___. The tip of the endotracheal tube is within 1
cm of the carinal. The tube should be pulled back by approximately 1-2 cm to
avoid accidental intubation of the right main bronchus. Substantial scoliosis
with subsequent asymmetry of the ribcage persists. The substantial elevation
of the right hemidiaphragm persists. Stable moderate cardiomegaly without
pulmonary edema.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Tachycardic status post extubation.
COMPARISON: Earlier on the same day.
FINDINGS:
Endotracheal tube was removed. Orogastric tube was also removed. Dual lead
pacemaker/ICD device and PICC line remain. Cardiac, mediastinal and hilar
contours appear stable. Lung volumes have decreased since extubation. There
is similar opacity at the right lung base suggesting a small layering pleural
effusion with persistent elevation of the right hemidiaphragm. Possible
persistent pleural effusion also found on the left. There is no pneumothorax.
Right mid to lower lung opacification and retrocardiac opacification are
probably unchanged allowing for some decrease in lung volumes. Bones appear
demineralized. Severe S shaped thoracolumbar curvature with rotary component
again of observed.
IMPRESSION:
Some decrease in lung volumes without other definite change. Status post
endotracheal tube removal.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Endotracheal intubation.
COMPARISON: Earlier on the same day.
FINDINGS:
Endotracheal tube has been placed. It terminates about 5 cm above the carina
at a right lateral bend in the trachea. An orogastric tube has been placed
terminates in the stomach. PICC line and dual lead pacemaker device are
unchanged. There is quite substantial new atelectasis of much of the right
lung, particularly the right middle and lower lobes, with associated rightward
shift of mediastinal structures. Right upper lobe is also partly atelectatic.
Left upper lobe shows compensatory hyperventilation. There is probably still
a pleural effusion on the right as a component of more widespread
opacification largely due to volume loss. No definite pleural effusion found
on the left. There is no pneumothorax.
IMPRESSION:
Status post endotracheal intubation. Endotracheal tube terminating in the mid
trachea. Marked increased volume loss and opacification of the right
hemithorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with dementia, L 9th rib fx s/p fall, now intubated and on
antibiotics for presumed aspiration.// evaluate for PNA, ET tube position.
evaluate for PNA, ET tube position.
IMPRESSION:
Comparison to ___. Tip of the endotracheal tube projects 2 cm
above the carinal. The previous consolidations at the right lung base are
substantially improved, the lung volume on the right is increased. However, a
substantial portion of perihilar and right basal consolidations persist.
Normal size of the heart. Slightly decreased but still normal left lung
volumes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with dementia, L 9th rib fx s/p fall, now intubated and on
antibiotics for presumed aspiration.// evaluate PNA stable right lung
base consolidations.
TECHNIQUE: Portable chest radiograph
COMPARISON: ___
FINDINGS:
Stable ET tube terminates about 2 cm above the carina. There is interval
worsening of right-sided opacification and atelectasis as well as elevation of
the right hemidiaphragm. Previous right lung base consolidations now extend
into the apex of the lung. Cardiac silhouette is stable. No left lung field
consolidations. There is severe scoliosis. There is no pneumothorax.
IMPRESSION:
Interval worsening of right lung consolidations and elevation of the right
hemidiaphragm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with complications ___ likely aspiration// Eval
acute state, potential plan to extubated today Eval acute state,
potential plan to extubated today
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left lung is clear. Left skin fold should not be mistaken for pneumothorax.
No appreciable left pleural effusion.
Heart is only mildly enlarged. Severe atelectasis and moderate pleural
effusion persist on the right. No pneumothorax.
ET tube in standard placement. Right PIC line ends in the low SVC.
Transvenous right atrial right ventricular pacer leads continuous from the
left pectoral generator are unchanged in position. Nasogastric drainage tube
ends in the midportion of a nondilated stomach.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hip pain, s/p Fall
Diagnosed with Pain in left hip, Other fall on same level, initial encounter
temperature: 98.0
heartrate: 90.0
resprate: 20.0
o2sat: 97.0
sbp: 144.0
dbp: 78.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ female w/ past medical history
most notable for dementia who was admitted due to a fall at
home. Hospital course complicated by aspiration event requiring
intubation. Failed extubation in ICU, requiring reintubation.
Subsequent family meeting with ultimate decision to pursue
comfort measures only.
# Goals of care
# Dementia with aspiration risk
After initial trigger event, family decided she would be DNR but
ok to intubate, now transitioned to DNR/DNI. This decision was
made given her overall prognosis, dementia, concern for risk of
repeat aspiration events, and poor PO intake, her prognosis is
likely less than 6 months. Patient will be discharged to home
hospice (son ___ house with 24-hours nursing care). Given
morphine, olanzapine, and lidocaine for pain and agitation.
Please continue to adjust medications based on symptoms.
#S/p mechanical fall: Symptom control with lidocaine patch and
oral morphine as needed. Family given ___ exercises for at home
# Delirium on dementia
Seroquel switched to Olanzapine qhs. Mental status at the time
of discharge was in line with baseline dementia. She was able to
express her level of comfort and desire to be home with her son
___.
#Nutrition
Unlikely to recover full swallowing function given age and
critical illness. Dysphagia diet for comfort. Family understands
risk of aspiration. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Novocain / Meprobamate / Nsaids / Latex
Attending: ___.
Chief Complaint:
nausea and vomitting
Major Surgical or Invasive Procedure:
none
Past Medical History:
Past Medical Hx:
- small bowel obstruction
- Type 2 diabetes mellitus
- Stage IIIB chronic kidney disease
- Diastolic congestive heart failure with left ventricular
hypertrophy
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Anxiety
- Pernicious anemia
- GERD
- Depression
- Osteoarthritis
- Cataracts
- Obstructive sleep apnea
- Obesity
Past Surgical Hx:
___ LSC cholecystectomy
___ cataracts surgery
___ open reduction internal fixation of right
intra-articular distal humerus fracture
___ BAL
___ Appendectomy
OB/GYN history: Stage IV endometrial cancer, as above; G4P4;
post-menopausal; history of abnormal pap smears; not currently
sexually active; no history of hormone replacement therapy.
Social History:
___
Family History:
-Mother with myocardial infarction at the age of ___.
-Father with a myocardial infarction at the age of ___.
-Sister with cancer, unclear what type, passed at age ___.
-Brother with a myocardial infarction.
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
pulm: clear to ausculatation bilaterally
abd: soft, nontender, nondistended
___: nontender, nonedematous
Pertinent Results:
___ 06:05AM BLOOD WBC-7.3 RBC-3.47* Hgb-10.6* Hct-32.2*
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.7 Plt ___
___ 06:15AM BLOOD WBC-8.2 RBC-3.72* Hgb-11.5* Hct-34.2*
MCV-92 MCH-30.8 MCHC-33.6 RDW-14.7 Plt ___
___ 08:20AM BLOOD WBC-10.6 RBC-3.95* Hgb-12.1 Hct-35.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-14.6 Plt ___
___ 06:20AM BLOOD WBC-9.5 RBC-3.62* Hgb-11.2* Hct-33.6*
MCV-93 MCH-30.9 MCHC-33.3 RDW-14.4 Plt ___
___ 07:45AM BLOOD WBC-8.9 RBC-3.58* Hgb-11.0* Hct-33.6*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.5 Plt ___
___ 08:00AM BLOOD WBC-8.7 RBC-3.30* Hgb-10.0* Hct-31.0*
MCV-94 MCH-30.2 MCHC-32.2 RDW-14.7 Plt ___
___ 06:30AM BLOOD WBC-14.4* RBC-3.84* Hgb-11.7* Hct-36.4
MCV-95 MCH-30.5 MCHC-32.3 RDW-14.6 Plt ___
___ 08:41PM BLOOD WBC-18.0*# RBC-4.55# Hgb-13.7 Hct-42.3
MCV-93 MCH-30.2 MCHC-32.4 RDW-14.5 Plt ___
___ 06:05AM BLOOD Neuts-64.4 ___ Monos-6.1 Eos-1.8
Baso-0.5
___ 06:15AM BLOOD Neuts-65.5 ___ Monos-4.5 Eos-2.4
Baso-0.3
___ 08:20AM BLOOD Neuts-73.6* ___ Monos-5.3 Eos-1.2
Baso-0.1
___ 06:20AM BLOOD Neuts-72.7* ___ Monos-5.2 Eos-1.1
Baso-0.3
___ 07:45AM BLOOD Neuts-72.9* ___ Monos-5.1 Eos-1.4
Baso-0.2
___ 08:00AM BLOOD Neuts-69.4 ___ Monos-6.1 Eos-1.4
Baso-0.1
___ 08:41PM BLOOD Neuts-86.7* Lymphs-8.6* Monos-3.4 Eos-0.6
Baso-0.7
___ 06:05AM BLOOD Glucose-126* UreaN-6 Creat-1.3* Na-143
K-3.6 Cl-111* HCO3-23 AnGap-13
___ 06:15AM BLOOD Glucose-123* UreaN-6 Creat-1.3* Na-144
K-3.7 Cl-110* HCO3-26 AnGap-12
___ 08:20AM BLOOD Glucose-134* UreaN-5* Creat-1.3* Na-144
K-4.3 Cl-110* HCO3-21* AnGap-17
___ 06:20AM BLOOD Glucose-144* UreaN-5* Creat-1.3* Na-144
K-4.1 Cl-111* HCO3-23 AnGap-14
___ 07:45AM BLOOD Glucose-150* UreaN-12 Creat-1.5* Na-146*
K-4.1 Cl-110* HCO3-25 AnGap-15
___ 08:00AM BLOOD Glucose-115* UreaN-19 Creat-1.7* Na-149*
K-4.3 Cl-110* HCO3-30 AnGap-13
___ 06:30AM BLOOD Glucose-142* UreaN-31* Creat-2.0* Na-143
K-4.6 Cl-102 HCO3-30 AnGap-16
___ 08:41PM BLOOD Glucose-185* UreaN-29* Creat-1.8* Na-141
K-5.1 Cl-98 HCO3-24 AnGap-24*
___ 06:05AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.9
___ 06:15AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.0
___ 08:20AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.2
___ 06:20AM BLOOD Calcium-9.3 Phos-2.1* Mg-1.7
___ 07:45AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.0
___ 08:00AM BLOOD Calcium-9.1 Phos-2.6*# Mg-2.0
___ 06:30AM BLOOD Calcium-9.7 Phos-4.2# Mg-1.8
___ 08:42PM BLOOD Lactate-2.4*
___ CT A/P:
IMPRESSION:
1. Small bowel obstruction with probable transition point in
the lower mid
abdomen anteriorly. Small amount of free fluid in the pelvis,
but no
nonenhancing loops of bowel are seen. Fluid-filled distended
stomach.
2. Sigmoid diverticulosis without evidence of diverticulitis.
___ Knee Xray:
IMPRESSION: Small joint effusion and degenerative changes. No
conclusive
findings for infection. However, please note that septic
arthritis or early
osteomeylitis would be difficult to exclude on the basis of
radiographs.
Medications on Admission:
Amitriptyline- 10mg at bedtime
Atorvastatin- 10mg once daily
Calcitriol- 0.25 mcg capsule, taken ___
Clonazepam- 0.5mg three times a day
Furosemide- 20mg once daily
Gabapentin- 800mg tablet three times a day
Insulin, glargine- 100 unit/mL, 16 units subcutaneous injection,
once daily at bedtime
Levothyroxine- 75mcg once daily
Pantoprazole- 40mg tablet, twice a day
Propanolol- 40mg tablet, twice a day
Colace- 100mg, twice daily
Bisacodyl- 5mg tablet, daily, as needed for constipation
Calcium
Vitamin D3
Vitamin B-12,
Miralax- 17gram/dose, twice a day as needed
Ondansetron- 8mg tablet, as needed
Discharge Medications:
1. Bengay Cream 1 Appl TP TID:PRN pain
2. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
3. ClonazePAM 0.5 mg PO TID anxiety
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day
Disp #*60 Capsule Refills:*0
5. Gabapentin 800 mg PO TID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
hold for loose stool
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 gram by mouth
daily Disp #*60 Packet Refills:*0
8. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
small bowel obstruction
serous uterine cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Small bowel obstruction with history of hysterectomy for enteric
tube positioning.
COMPARISON: Abdominal CT from ___ and chest CT from ___.
FINDINGS:
Enteric tube traverses the with the tip in the stomach. Minimal bibasilar
atelectasis is noted; otherwise, the lungs are clear. There is no pleural
effusion or pneumothorax. Atherosclerotic calcifications are noted at the
aortic arch. The heart appears borderline in size.
IMPRESSION:
Enteric tube with the tip in the stomach.
Radiology Report
HISTORY: New onset knee pain and tenderness, no trauma, question infection.
LEFT KNEE THREE VIEWS: No recent knee radiographs on PACS record for
comparison.
No discrete fracture line or displaced bony fragment is identified. There
are mild degenerative changes, with spurring and subchondral sclerosis in the
medial femorotibial compartment and spurring about the patellofemoral
compartment. No bone erosion or aggressive osteolysis is appreciated.There is
a small joint effusion.
IMPRESSION: Small joint effusion and degenerative changes. No conclusive
findings for infection. However, please note that septic arthritis or early
osteomeylitis would be difficult to exclude on the basis of radiographs.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.2
heartrate: 101.0
resprate: 18.0
o2sat: 96.0
sbp: 113.0
dbp: 73.0
level of pain: 12
level of acuity: 3.0 | Ms. ___ was admitted to the gyn oncology service for treatment
of a small bowel obstruction. An NG tube was placed on admission
with large volume output and significant improvement in her
abdominal distension and symptoms. The NG output gradually
decreased and on ___ it was discontinued when no further
bilious output was noted. No recurrent nausea or vomitting
ocurred and her diet was able to be slowly but easily advanced
to regular.
Of note, on HD#3 she developed significant left knee pain which
did not resolve with conservative management. On HD#5 an xray
was performed showing a small effusion. Orthopedics was
consulted for concern for a septic joint. Joint fluid was
consistent with a simple effusion and continued conservative
management was recommended.
Physical therapy was consulted for evaluation and treatment
given patient's prolonged immobility and ___ recommended home ___.
On HD#7 the patient was tolerating a regular diet without nausea
and vomitting and was felt to be safe to be discharged with
outpatient follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures during
hospitalization.
History of Present Illness:
Mr. ___ is a ___ year old man with a complex PMH, including
sCHF (EF 40-45%), AF (on warfarin), bradycardia, CKD-III and
DM-II who presented with acute on chronic kidney failure and
hyperkalemia.
He saw his PCP today after ___ 20 hour long episode of epistaxis.
There, he had labs checked and his Cr was elevated to 3, up from
1.9 in ___. K was also elevated at 5.8.
Repeat labs this evening Cr 2.7 and K 5.7. Labs also notable for
2 point drop in hemoglobin 12.9-10.9. Concern for significant
blood loss leading to hypovolemia and prerenal injury. Pt sent
to ED by ambulance for further management of renal failure,
anemia, and hyperkalemia. Per patient, he is feeling well
currently and denies recent epistaxis. he reports that his last
stool yesterday was tan in color.
In the ___ ED, initial vital signs: T 97.5, P 45, BP 111/87,
R 18, SpO2 97%/RA
- Exam notable for asymptomatic bradycardia, guaiac negative, no
JVD, 1+ bilateral peripheral edema, clear lungs
- Labs notable for K 5.8, HCO3 17, BUN 57/Cr 2.4
- CXR demonstrated moderate cardiomegaly with mild pulmonary
edema. Patchy left basilar opacity could reflect atelectasis,
but infection is not excluded in the correct clinical setting.
- Renal was consulted and he was given calcium gluconate,
Kayexalate, 500 cc NS, 10 u regular insulin & 1 ampoule of
dextrose.
On arrival to the MICU, he feels relatively well, with mild
dyspnea, but otherwise no significant complaints. Otherwise he
notes chronic dyspnea on exertion, after 100 steps, for the past
few months. He denies orthopnea or PND, but endorses ___ edema,
LLE > RLE.
Past Medical History:
- CAD, s/p CABG
- Diabetes mellitus, type II
- Chronic kidney disease, stage III - baseline Cr 1.9-2.3
(___)
- Atrial fibrillation, chronic
- Bradycardia
- Aortic stenosis, mild
- Systolic CHF, EF 40-45% (___)
- Obesity
- Hypertension
- ___: hospitalization for AoCKD likely secondary to heart
failure exacerbation.
Social History:
___
Family History:
mother with PVD, father with CAD, PVD and etOH use. Paternal
aunt with DM.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: afebrile, P 45, BP 100/30, R 16, SpO2 95%/2L, 90%/RA
GENERAL: Alert, oriented, no acute distress, breathing somewhat
labored
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated but EJ somewhat dilated, no LAD
LUNGS: bibasilar crackles without wheezes, somewhat increased
work of breathing
CV: bradycardic, regular, 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 or cyanosis, 2+
RLE edema to the knee, with 3+ LLE edema (chronically LLE > RLE
after CABG)
SKIN: dry
NEURO: face symmetric, CN II-XII intact, strength ___ throughout
PSYCH: appropriate
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 97.4, 146/66, 53, 16, 97% on RA.
GENERAL: laying in bed comfortably, breathing comfortably in
NAD.
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated.
RESP: Clear to auscultation bilaterally.
CV: Irregularly irregular rhythm, bradycardic, S1 and S2
present, systolic murmur appreciated.
ABD: soft abdomen, non-tender, non-distended, no rebound or
guarding.
EXT: Point tenderness to palpation of the between the plantar
surface of the first and second toes. No pain elsewhere of the
feet. No lower extremity edema. No tenderness of the first toe,
no swelling, erythema or warmth.
NEURO: grossly normal motor function.
Pertinent Results:
ADMISSION LABS
==============
___ 06:45PM BLOOD WBC-6.1 RBC-3.17* Hgb-10.0* Hct-31.2*
MCV-98 MCH-31.5 MCHC-32.1 RDW-14.8 RDWSD-53.1* Plt ___
___ 06:45PM BLOOD Neuts-72.1* Lymphs-13.1* Monos-12.7
Eos-1.0 Baso-0.8 Im ___ AbsNeut-4.36 AbsLymp-0.79*
AbsMono-0.77 AbsEos-0.06 AbsBaso-0.05
___ 02:41AM BLOOD ___ PTT-35.4 ___
___ 06:45PM BLOOD Glucose-123* UreaN-57* Creat-2.4* Na-129*
K-6.8* Cl-95* HCO3-17* AnGap-24*
___ 06:45PM BLOOD proBNP-___*
___ 02:41AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.6
DISCHARGE LABS
==============
___ 07:20AM BLOOD WBC-6.0 RBC-3.08* Hgb-9.7* Hct-30.3*
MCV-98 MCH-31.5 MCHC-32.0 RDW-14.2 RDWSD-51.6* Plt ___
___ 07:20AM BLOOD ___ PTT-37.1* ___
___ 07:20AM BLOOD Glucose-112* UreaN-24* Creat-1.5* Na-135
K-4.1 Cl-96 HCO3-23 AnGap-20
___ 07:20AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3
URINE STUDIES
=============
___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:00PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 09:00PM URINE CastHy-20*
MICROBIOLOGY
============
___ 9:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING
=======
___: CHEST X-RAY (PORTABLE AP)
IMPRESSION:
Moderate cardiomegaly with mild pulmonary edema. Patchy left
basilar opacity could reflect atelectasis, but infection is not
excluded in the correct clinical setting.
___: RENAL ULTRASOUND
IMPRESSION:
1. No evidence of hydronephrosis or abnormal renal
echogenicity.
2. Multiple bladder diverticula.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 30 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Warfarin 3.75 mg PO DAILY16
5. Lisinopril 20 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN ANGINA
7. Aspirin 81 mg PO DAILY
8. GlipiZIDE 2.5 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. PredniSONE 20 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
3. Torsemide 20 mg PO DAILY
4. Warfarin 5 mg PO DAILY16
5. Aspirin 81 mg PO DAILY
6. GlipiZIDE 2.5 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN ANGINA
10. Simvastatin 40 mg PO QPM
11.Outpatient Lab Work
Please check INR
Fax results to Dr. ___ ___
ICD10 I48.2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
-Acute on chronic kidney disease
-Acute on chronic systolic heart failure
-Anemia
-Bradycardia
-Left Foot Pain
SECONDARY DIAGNOSIS
===================
-Atrial Fibrillation
-CAD s/p CABG
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: RENAL U.S. PORT
INDICATION: ___ year old man with sCHF (EF45%), CKD-III, bradycardia.
Evaluate for medical renal disease or hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.2 cm. The left kidney measures 10.2 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally. There
is trace perinephric fluid bilaterally, a nonspecific finding.
The bladder is moderately well distended, with multiple bladder diverticula,
the largest located to the right of the bladder.
IMPRESSION:
1. No evidence of hydronephrosis or abnormal renal echogenicity.
2. Multiple bladder diverticula.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Hyperkalemia
temperature: 97.5
heartrate: 45.0
resprate: 18.0
o2sat: 97.0
sbp: 111.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with a complex PMH, including
sCHF (EF 40-45%), AF (on warfarin), bradycardia, CKD-III and
DM-II who presented with acute on chronic kidney failure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal labs/Hypotension
Rectus Sheath Hematoma
Major Surgical or Invasive Procedure:
Paracentesis x 2
History of Present Illness:
___ history of alcoholic cirrhosis on transplant list (MELD 26),
history of HCV presents that was referred to ER for hyponatremia
(Na 125) and acute renal failure (Cr 1.8). He was to go for an
outpatient paracentesis today, but when he arrived, he was told
to present to the ER due to abnormal labs. He is otherwise
without complaint. He denies constitutional symptoms,
nausea/vomiting, chest pain, abdominal pain. He does endorse a
mild feeling of abdominal bloating. In the ED, initial VS were:
97.0 62 90/56 22 97%
Of note, he has a low baseline BP. His BP in clinic was 103/65.
ECG performed showing NSR at 63, NA, NI, non-significant Q-wave
in III, TWI in V1, V2, V3 with poor R-wave progression, STD in
V2, anteroseptal T wave changes. No prior for comparison.
Serial ECG at ___ showed improvement in STD in V2,
improvement in TWF in V3. Poor R-wave progression.
Labs were performed as below:
- First specimen was hemolyzed with Na 120 (L), Cl 90, K 6.9,
HCO3 26, BUN 47, Cr 2 (no prior data, Cr 1.8 on ___
- Repeat K was 6
- CBC with WBC 8.6, Hgb 11.8 (recently 12.6 on ___, MCV
103, Platelet 100
- Coags with INR 1.8, PTT 50.3
- LFTs ALT 36, AST 88, ALP 126, Tbili 5 with direct fraction of
1.6, lipase 79, albumin 2.1
- Urine lytes
Na:<10
K:81
Cl:<10
A diagnostic paracentesis was performed:
- WBC 125, RBC 195 with poly 28, lymph 24, mono 25, meso 4,
macro 19
Various cultures were performed including
- peritoneal gram stain and fluid culture
- blood cultures
- negative toxoplasma antigen
For his hyperkalemia, he had no ECG changes. He was given D50,
calcium, and insulin 10 units IV. Repeat labs showed persistent
hyperkalemia for which he was the same therapy again but now
with insulin 5 units IV.
He was also given 1 L NS and 100 mL of 25 % albumin.
RUQ US with dopplers was performed showing shrunken cirrhotic
liver without focal masses, atent portal vein with normal flow,
large amount of ascites, and thickened gallbladder wall, likely
due to ascites. No evidence of cholecystitis or cholelithiasis.
CXR was performed that showed no acute cardiopulmonary
abnormality with low lung volumes.
Access on transfer: 22G, 18G
VS on transfer were not given.
Patient was admitted to ICU for abnormal labs and borderline SBP
although at his baseline per reports.
On arrival to the MICU, patient was pleasant, calm, NAD. His BP
was 89/56 with HR 75. VS otherwise stable.
The patient's labs quickly normalized and the patient was
transfered to the floor. On the floor, the patient had a
paracentesis complicated by a large rectus sheath hematoma.
Past Medical History:
1. Cirrhosis
- Diagnosed in the past ___ years after being admitted to
hospital for LGIB from NSAIDs (although details unclear)
- Complicated by ascites for which he has received a couple of
thoracentesis in the past, encephalopathy, no known varices
- Prior work-up significant for + Hep C, + Hep B sAb, + Hep A, +
Smooth Ab, + ___ (titer pending), CEA 21, AFP 285
- History of alcoholism
- Vitamin D deficiency based on labs dated ___ (VitD 11)
Social History:
___
Family History:
Father died in ___ from alcoholism
Physical Exam:
ADMISSION EXAM
General: AAOx3, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM, no rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, distended, + ascites, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
pitting edema to above knee in bilateral lower extremities
Neuro: CNIII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
+ asterixis
DISCHARGE EXAM
VS: T 98.4 BP 101/62 HR 89 RR 12 SpO2 94/RA
General: NAD, appears well
HEENT: Mildly icteric sclerae
CV: RRR, ___ systolic murmur at the LUSB
Resp: Mildly decreased breath sounds at bases
Abd: +BS, soft, slightly distended. Large ecchymosis of left
abdomen with extension to the axilla and inguinal ligament ___
rectus sheath hematoma, slightly firm and tender around bruise
site
Extr: 2+ edema to the mid-shin bilaterally. CLubbed fingers.
Neuro: A&Ox3, no asterixis
Pertinent Results:
ADMISSION LABS
___ 02:35PM BLOOD WBC-8.1 RBC-3.68* Hgb-12.6* Hct-38.0*
MCV-103* MCH-34.1* MCHC-33.1 RDW-16.0* Plt Ct-99*
___ 02:35PM BLOOD Neuts-74.6* Bands-0 Lymphs-12.6*
Monos-8.6 Eos-1.8 Baso-0.3
___ 02:35PM BLOOD ___ PTT-52.7* ___
___ 02:35PM BLOOD UreaN-46* Creat-1.8* Na-125* K-6.9*
Cl-90* HCO3-22 AnGap-20
___ 02:35PM BLOOD ALT-40 AST-75* AlkPhos-144* TotBili-5.6*
___ 02:35PM BLOOD Albumin-2.3* Calcium-8.8 Mg-2.4 Iron-203*
Cholest-137
___ 02:35PM BLOOD calTIBC-213 Ferritn-1709* TRF-164*
___ 02:35PM BLOOD Triglyc-46 HDL-47 CHOL/HD-2.9 LDLcalc-81
___ 02:35PM BLOOD TSH-5.1*
___ 02:35PM BLOOD Free T4-1.4
___ 02:35PM BLOOD Testost-46* SHBG-106* calcFT-3.9*
25VitD-11*
___ 02:35PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 02:35PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
___ 02:35PM BLOOD ___ * Titer-1:40
___ 02:35PM BLOOD CEA-21* PSA-<0.1 AFP-285*
___ 04:26AM BLOOD PEP-POLYCLONAL
___ 02:35PM BLOOD IgG-4810* IgM-171
___ 02:35PM BLOOD HCV Ab-POSITIVE*
Imaging:
TTE: The left atrium is mildly dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 70%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic root is mildly dilated at the sinus level. 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. There is at
least moderate pulmonary artery systolic hypertension. There is
no pericardial effusion
CXR - IMPRESSION: Low lung volumes with prominent interstitial
markings; there ___ be a component of chronic interstitial
disease underlying interstitial edema. No focal consolidation.
RUQ U/S - IMPRESSION:
1. Shrunken and nodular cirrhotic liver without focal lesions.
2. Patent portal vein.
3. Large amount of ascites.
4. Mild splenomegaly.
DISCHARGE LABS:
___ 05:35AM BLOOD WBC-7.1 RBC-2.53* Hgb-8.2* Hct-24.9*
MCV-98 MCH-32.4* MCHC-33.0 RDW-21.6* Plt Ct-53*
___ 11:45AM BLOOD Hct-26.2*
___ 05:35AM BLOOD ___ PTT-44.5* ___
___ 05:35AM BLOOD Glucose-82 UreaN-23* Creat-0.8 Na-131*
K-4.5 Cl-101 HCO3-26 AnGap-9
___ 05:35AM BLOOD ALT-26 AST-64* LD(LDH)-301* AlkPhos-100
TotBili-12.3*
___ 05:35AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.8
CT ABD:
IMPRESSION:
1. Subacute hematoma that is located between the left external
and internal
oblique muscles. No active bleeding is identified.
2. Cirrhotic liver with sequelae of portal hypertension.
3. Two small arterially hyperenhancing lesions are identified
at the dome of
the liver with questionable washout pattern in one of the
lesions.
4. Two hypoattenuating lesions are seen in segment II and VIII
of the liver,
too small to characterize. All these lesions should be further
characterized with dedicated MR
examination.
5. Degenerative changes of the left hip joint with mild
subluxation of the
femur head.
6. New fracture of the left 11th rib.
Medications on Admission:
Patient did not know full medication list. Per pharmacy
(___ (___):
- rifaximin 550 mg PO BID
- tramadol 50 mg PO TID prn pain
- fentanyl 100 mcg TD q 72 hr
Per patient, he also takes:
- lactuose
- furosemide 20 mg PO qD
- nadolol 40 mg PO qD (?)
- spironolactone 100 mg PO qD
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
Disp:*3600 ML(s)* Refills:*2*
4. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
8. Outpatient Lab Work
Please have a hematocrit drawn on ___ and results
faxed to Dr. ___ # ___.
Dx: Acute Blood Loss Anemia
Discharge Disposition:
Home
Discharge Diagnosis:
Liver Cirrhosis
Hepatitis C Virus
Rectus Sheath Hematoma
Hyponatremia
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ man with cirrhosis, had
paracentesis of his left abdomen on ___, now with continued reexpanding
hematoma with drop in hematocrit. The request is to rule out active bleeding
into expanding hematoma.
COMPARISONS: No priors are available.
TECHNIQUE: CT of the abdomen and pelvis with and without IV contrast.
Scanning was performed on arterial and venous phase. Sagittal and coronal
reformations were made.
TOTAL EXAM DLP: 1740.44 mGy-cm.
FINDINGS: Subsegmental atelectasis is seen in the lower lobes of the lungs
and in the right middle lobe.
Minimal amount of right pleural effusion is seen with secondary atelectasis.
The visualized portions of the heart are within normal limits. Few prominent
lymph nodes are seen in the cardiophrenic angle (4A, 22). Hyperdense ovoid
structure is seen between the left external and internal oblique muscles
measuring 61 x ___ mm (4A, 110). No enhancement is seen between the arterial
and venous phases.
Few blood vessels are seen coursing around this structure. No active bleeding
is detected.
Ascites is seen.
Cirrhotic liver.
Two lesions are seen at the dome of the liver. The superior one measures 9 mm
(4a, 17) and the inferior one measures 10.5 mm (4a, 19)
Both lesions demonstrate arterial hyperenhancement (4A, 19 and 4a, 17) and a
questionable washout pattern in the inferior one (4B, 201). Asymmetric
hypoattenuating lesion is seen in segment II of the liver (4B, 211) too small
to characterize.
Small hypoattenuating lesion is seen in segment VIII of the liver (4B, 219)
too small to characterize.
The gallbladder is within normal limits.
The spleen measured 13 cm.
There is no intra- or extra-hepatic biliary duct dilation.
The pancreas is mildly atrophic with mild dilation of the pancreatic duct (up
to 3.7 mm), mainly in the pancreas body. Portosystemic collaterals are seen
that includes the left gastric; short gastric, esophageal and paraesophageal
veins.
Recanalized paraumbilical vein is seen.
The right adrenal is within normal limits. Mild thickening of the left
adrenal is seen.
Both kidneys enhance and excrete adequately. The large and small bowels are
within normal limits.
PELVIS: The urinary bladder and the prostate are within normal limits. No
lymphadenopathy is seen within the pelvis. Mild atherosclerotic changes are
seen along the course of the aorta, which is otherwise of normal caliber and
patent. The portal vein and its branches, splenic vein and SMV are patent.
The vena cava and its branches are within normal limits.
OSSEOUS STRUCTURES: Degenerative changes are seen in the left.
Mild lateral subluxation of the left femur head (500B, 39).
New fracture of the left 11th rib.
No concerning lytic or osteoblastic lesions are identified.
IMPRESSION:
1. Subacute hematoma that is located between the left external and internal
oblique muscles. No active bleeding is identified.
2. Cirrhotic liver with sequelae of portal hypertension.
3. Two small arterially hyperenhancing lesions are identified at the dome of
the liver with questionable washout pattern in one of the lesions.
4. Two hypoattenuating lesions are seen in segment II and VIII of the liver,
too small to characterize.
All these lesions should be further characterized with dedicated MR
examination.
5. Degenerative changes of the left hip joint with mild subluxation of the
femur head.
6. New fracture of the left 11th rib.
Findings were discussed by Dr ___ Dr ___ by phone at 10:30,
___.
Radiology Report
REASON FOR EXAMINATION: Decreased oxygen saturation.
PA and lateral upright chest radiographs were reviewed in comparison to ___.
Heart size is mildly enlarged, unchanged since the prior study. There is
substantial enlargement of main pulmonary artery and both right and left
pulmonary arteries, most likely consistent with pulmonary hypertension.
Diffuse interstitial opacities are widespread throughout the lungs involving
both lungs as well as old lung fields. In comparison to the prior examination
they have slightly increased. The findings might reflect a combination of
chronic interstitial lung disease as well as superimposed overload of fluid.
Small amount of right pleural effusion is noted. Given the abnormalities
within the lung bases partially demonstrated on CTA from ___, further
assessment of the chest CT is required to exclude the possibility of
underlying lung disease, which potentially leads to the evident pulmonary
hypertension. Partial contribution of hilar lymphadenopathy to be enlarged
hila cannot be entirely excluded and can also be assessed on chest CT.
Radiology Report
INDICATION: ___ man with worsening liver function.
COMPARISON: None.
PA & LATERAL VIEWS CHEST: Lung volumes are low which may accentuate lung
markings, however they are still somewhat more prominent than expected.
Cardiomediastinal silhouette and hilar contours appear grossly unremarkable.
There is a trace right pleural effusion. No pneumothorax.
IMPRESSION: Low lung volumes with prominent interstitial markings; there may
be a component of chronic interstitial disease underlying interstitial edema.
No focal consolidation.
Radiology Report
INDICATION: Worsening liver function tests. Evaluate for infectious process
or portal vein thrombosis.
COMPARISONS: None.
FINDINGS: The liver is shrunken and nodular consistent with the patient's
history of cirrhosis. There are no focal hepatic lesions. The portal vein is
patent with normal hepatopetal flow. The gallbladder is collapsed with
thickened wall, likely due to the surrounding ascites. The common bile duct
is not well visualized, but the visualized portion is at the upper limits of
normal, measuring 6 mm. There is a large amount of abdominal ascites. There
is splenomegaly. The spleen measures 13.8 cm. The pancreas is not well
visualized due to overlying bowel gas. The kidneys are normal without
evidence of hydronephrosis or renal masses. The right kidney measures 11.0
cm. The left kidney measures 10.2 cm.
IMPRESSION:
1. Shrunken and nodular cirrhotic liver without focal lesions.
2. Patent portal vein.
3. Large amount of ascites.
4. Mild splenomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNL LABS/HYPOTENSIVE
Diagnosed with CHEST PAIN NEC, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA, HYPERKALEMIA
temperature: 97.0
heartrate: 62.0
resprate: 22.0
o2sat: 97.0
sbp: 90.0
dbp: 56.0
level of pain: 6
level of acuity: 1.0 | ___ history of alcoholic cirrhosis, HCV (MELD 26), who was
initially referred to ER for hyponatremia (Na 125) and acute
renal failure (Cr 1.8). ___ hospital course was complicated by
encephalopathy, ascites, and a large rectus sheath hematoma.
1. Alcoholic cirrhosis: Patient was recently diagnosed with
liver disease attributed to alcoholism and HCV. Childs Class C.
It seems as though the patient's liver disease has been managed
elsewhere. Liver disease has been complicated by encephalopathy
and ascites. No evidence of SBP on paracentesis. RUQ ultrasound
showed cirrhotic liver without lesions and evidence of ascites.
The patient had a full set of liver labs sent. The patient's
MELD on discharge was 22. He was discharged on lactulose,
rifaxamin, lasix, spironolactone, and nadolol.
Of note, the patient's AFP was elevated. A CT of the abdomen
showed two small liver lesions that were concerning for HCC. The
patient will need MRI follow-up in ___ weeks.
2. Hyponatremia: Likely hypervolemic hyponatremia in the setting
of liver disease. The patient's sodium improved with fluid
restriction and holding of his diuretics. His sodium on
discharge was stable. His diuretics were restarted prior to
discharge.
3. Acute Renal Failure: This was most consistent with a
prerenal etiology based on urine lytes. The renal function
improved with albumin challenge and holding of his diuretics. A
renal ultrasound showed normal kidneys bilaterally. He had no
signs of a UTI. The patient's Cr on discharge was 1.2. His
diuretics were restarted prior to discharge.
4. Rectus Sheath Hematoma: The patient had a paracentesis that
was complicated by a large rectus sheath hematoma of the left
abdomen. The patient was treated conservatively with twice daily
hematocrits and transfusions to keep his Hct > 21. The patient
continued to drop his blood counts, so a CTA was done to try to
localize an active bleeding vessel. While a small vessel was
identified, this was not able to be intervened on. Instead, the
patient was supported with multiple PRBC, FFP, and platelet
transfusions. His Hct on discharge was stable at 26. He will
have his Hct checked as an outpatient.
5. Vitamin D deficiency: Vitamin D level low on recent labs for
screening for transplant. Consider vitamin D treatment after
acute issues resolved
6. Tobacco abuse: Patient in pre-contemplative state of quiting
and was advised to quit |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Sinus pauses
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
___ w/ h/o CVA and recurrent syncope, presents from cardiology
clinic for sinus pauses on outpatient cardiac monitoring. He is
originally from ___. In ___ in ___ he had a couple of
syncopal episodes and was apparently evaluated by a cardiologist
but nothing was found. In the ___ he had another
syncopal episode and work-up at ___ was unrevealing. A few weeks
later he had another syncopal episode without provocation and
this time was taken to ___. He had an
MRI of his brain which was said to show a left middle cerebral
artery territory stroke. The rest of the work-up was
unremarkable. He had a couple more syncopal episodes after that.
His outpatient neurologist ordered a 30-day event monitor, which
reportedly showed occasional episodes of sinus node arrest w/
pauses up to 7 seconds, although he was not symptomatic during
these episodes. He was referred to Dr. ___ cardiology,
who recommended admission and PPM placement. The patient reports
that his last syncopal episode was 2 weeks ago, but he has had
several episodes of pre-syncope since that time.
Past Medical History:
CVA ___ w/o residual deficits
Social History:
___
Family History:
There is no heart disease in the family.
Physical Exam:
Admission Physical Exam:
Vitals - 98.5 ___ 16 100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact. Strength ___ throughout.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 06:20PM K+-3.5
___ 06:02PM GLUCOSE-85 UREA N-14 CREAT-0.8 SODIUM-142
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-30 ANION GAP-13
___ 06:02PM estGFR-Using this
___ 06:02PM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-2.1
___ 06:02PM WBC-6.3 RBC-4.90 HGB-14.6 HCT-42.8 MCV-87
MCH-29.8 MCHC-34.0 RDW-13.1
___ 06:02PM NEUTS-68.1 ___ MONOS-6.2 EOS-1.0
BASOS-0.7
___ 06:02PM ___ PTT-29.1 ___
___ 06:02PM PLT COUNT-183
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p ppm // PTX, leads Contact name: ___,
___: ___ PTX, leads
COMPARISON: There are no prior chest radiographs available.
IMPRESSION:
Transvenous right atrial right ventricular pacer leads are continuous from the
left pectoral generator. There is no pneumothorax pleural effusion or
mediastinal widening. Lungs clear. Heart size normal.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p ppm // ptx, leads
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal contours are normal. Pacer leads tips are in standard
position in the right atrium and right ventricle. The lungs are clear. There
is no pneumothorax or pleural effusion. The osseous structures are
unremarkable
IMPRESSION:
No acute cardiopulmonary abnormalities no pneumothorax.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Syncope
Diagnosed with SYNCOPE AND COLLAPSE, CARDIAC DYSRHYTHMIAS NEC
temperature: 98.0
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | # Syncope: Syncope was thought to be likely to SA node
dysfunction, as evidenced by multiple prolonged sinus pauses on
outpatient cardiac monitoring of up to 7 seconds with some
symptoms during these episodes. In addition, quick return to
consciousness after these episodes is consistent with
cardiogenic syncope. Prodrome less suggestive, however no
symptoms specific to vasovagal syncope such as nausea,
diaphoresis. No shaking during episodes or tongue biting to
suggest seizures. Therefore, plans were made to admit for
pacemaker placement. The night of admission, he had an
approximately three minute run of SVT, thought to be AVNRT,
without symptoms. During the first full hospital day, he was
noted to have tachycardia while walking to the bathroom.
Orthostatic vital signs were BP: 130/78 P: 62 lying down, BP:
125/83 P: 61 sitting down; and BP: 118/85 and P: 92 standing.
Given this, he was given 1L NS. That afternoon, he went to the
OR for dual-chamber pacemaker placement. Chest x-ray was
performed after surgery and no pneumothorax was appreciated.
The surgery was well-tolerated and patient had mild discomfort
at surgical site but no recurrent symptoms. Orthostatics were
checked on the day of discharge and the patient continued to be
orthostatic by pulse; therefore, he was encouraged to drink
plenty of fluids after discharge. He was counseled not to drive
for the next 6 months. He will also need cephalexin
prophylactic antibiotics for three days.
# H/o CVA: He was continued on ASA 81mg daily.
# B12 deficiency: He was continued on B12. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p same level mechanical fall with L ___ rib fx and small PTX
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ at concert last night, slipped, struck in L side of chest
just lateral to breast. She was feeling okay but then was awoken
from sleep with pain worse with inspiration. In the morning, it
continued, so she went to ___, then was transferred to
___ for further evaluation.
Past Medical History:
PMHx: none
PSHx: C section x3, knee surgery
Meds: none
Social History:
___
Family History:
NC
Physical Exam:
On Discharge:
VS: hr 45 bp 103/64 rr 16 temp 97.8 F
General: AAOx3, affable, NAD
Neuro: CN ___ intact, no focal deficits
CV: RRR no MRG
Pulm: CTAB no adventitious breath sounds
Abd: Soft, non tender non distended
Ext: UE and ___ strength equal b/l, warm well perfused
Pertinent Results:
Radiology Report CHEST (PA & LAT) Study Date of ___ 9:42
AM
___ ___ 9:42 AM
CHEST (PA & LAT) Clip # ___
Reason: interval change in PTX
UNDERLYING MEDICAL CONDITION:
___ year old woman with PTX and rib fractures on left
REASON FOR THIS EXAMINATION:
interval change in PTX
Final Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with PTX and rib fractures on
left // interval
change in PTX
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal contours are normal. The lungs are clear.
There is no
pleural effusion. Now small left pneumothorax has decreased.
IMPRESSION:
Decrease in size in now small left pneumothorax
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth q4hrs Disp #*40 Tablet Refills:*0
2. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*40 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hrs Disp #*40 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L ___ rib fx and small left PTX
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: History: ___ with ptx, pls assess interbval change // History:
___ with ptx, pls assess interbval change
COMPARISON: Outside hospital chest x-ray ___ at 10:14
FINDINGS:
There is a 17 mm left apical pneumothorax, previously 21 mm on the outside
hospital chest x-ray performed 3 hours earlier. No evidence of tension. Right
lung is clear. No evidence of pulmonary edema or pneumonia. Cardiomediastinal
silhouette is within normal limits. Acute fractures are re-demonstrated in the
left fourth and fifth ribs.
IMPRESSION:
1. Stable to slightly improved left apical pneumothorax without evidence of
tension.
2. Acute fractures of the left fourth and fifth ribs.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with PTX and rib fractures on left // interval
change in PTX
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal contours are normal. The lungs are clear. There is no
pleural effusion. Now small left pneumothorax has decreased.
IMPRESSION:
Decrease in size in now small left pneumothorax
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Rib pain, Transfer
Diagnosed with FRACTURE TWO RIBS-CLOSED, INTUSSUSCEPTION, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT
temperature: 98.2
heartrate: 58.0
resprate: 18.0
o2sat: 100.0
sbp: 106.0
dbp: 72.0
level of pain: 7
level of acuity: 2.0 | Hemodynamically stable patient with no respiratory distress was
admitted to ___ on ___ from ED after sustaining single
level mechanical fall. CXR ___ showed left 4 and 5 rib
fractures and a small left apical pneumothorax. Patient was
admitted to ___ surgery service floor, started on nasal canula
oxygen and provided with incentive spirometry and respiratory
exercise instruction.
On HD2, repeat CXR showed decreased size of left apical
pneumothorax. Pain was well controlled on PO pain medications.
Patient was HDS, with no respiratory distress or pain at
discharge to home. Follow up arranged in 2 weeks in clinic for
repeat CXR. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Crestor / Metformin
Attending: ___
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M well known to ACS w/ multiple comorbidities and prior
abdominal operations, most recent ex.lap for LOA in ___ because of abdominal pain and
nausea in setting of 2 days without flatus or BM. He had a fever
earlier in the week which he attributes to a
flu. Currently he complains of chills.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia,
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: No stents, 3 caths, ___,
___, now.
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Obesity
chronic lower back pain
S/P multiple abdominal surguries including cholecystectomy,
ventral hernia repair, sigmoidectomy, and prior abdominal
abscess:
sigmoid colectomy and cecectomy at OSH c/b EC fistula and abcess
-___ abdominal abcess drainage, ventral hernia repair with SIS
-___ wound exploration and EC fistula drainage
-___ ex lap, LOA, SB EC fistula take down, partial CCY, ventral
hernia repair with mesh and component separation.
-appendectomy
Social History:
___
Family History:
Father passed away with CAD at ___, first MI in ___
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Minimal distention, min tender, no rebound or
guarding, supraumbilical hernia which is reducible, rectal
diastasis at lower aspect of incision
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:55AM BLOOD WBC-8.1 RBC-4.19* Hgb-12.8* Hct-38.7*
MCV-92 MCH-30.6 MCHC-33.2 RDW-14.0 Plt ___
___ 01:25AM BLOOD Neuts-81.1* Lymphs-12.9* Monos-4.5
Eos-1.2 Baso-0.3
___ 06:55AM BLOOD Glucose-114* UreaN-8 Creat-0.8 Na-143
K-3.8 Cl-109* HCO3-27 AnGap-11
___ 01:25AM BLOOD ALT-41* AST-33 AlkPhos-77 TotBili-0.4
___ 06:55AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8
___ ___ 2:___BD & PELVIS W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip #
___
Reason: please read the CT abd/pelvis. thanks!
UNDERLYING MEDICAL CONDITION:
___ year old man with ?SBO at OSH. no official read with
patient
REASON FOR THIS EXAMINATION:
please read the CT abd/pelvis. thanks!
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: ___ ___ 3:27 AM
1. Findings suggestive of partial small bowel obstruction with
possible
transition point in the right lower abdomen adjacent to a site
of small bowel
anastomosis. This is in close proximity to the ventral abdominal
wall.
2. Ventral abdominal hernia containing small and large bowel
loops.
3. right lung nodule, similar to prior.
d/w dr. ___ at 3am on ___ in person.
Final Report
INDICATION: ___ male with question of small bowel
obstruction.
COMPARISON: CT of the abdomen and pelvis with contrast ___.
TECHNIQUE: Images of the abdomen and pelvis without the
administration of IV
or oral contrast were uploaded for second read into the BI
system.
FINDINGS: CT OF THE ABDOMEN: A right lower lobe nodule is
unchanged from the
prior examination (3:8). Persistent tree in ___ pattern in the
right lung is
unchanged from the prior exam. Visualized heart and pericardium
are
unremarkable.
Evaluation of solid organs and intra-abdominal vasculature is
limited by
non-contrast technique. Within this limitation, a subcentimeter
hypodense
lesion within the left hepatic lobe (3:24) is too small to
characterize,
likely represents a biliary hamartoma or hepatic cyst and is
unchanged from
the prior examination.
Patient is status post cholecystectomy with a 4.4 x 3.6 cm fluid
collection
within the gallbladder fossa, unchanged since ___.
Spleen,
bilateral adrenal glands, and both kidneys are unremarkable. A
subcentimeter
hypodensity within the lower pole of the left kidney (201B:100)
is also too
small to characterize but likely represents a renal cyst. There
is no
hydronephrosis.
The patient is status post extensive bowel surgery including
cecectomy,
sigmoidectomy with bowel anastomosis and multiple small bowel
surgeries with
small bowel anastomoses.
There is a ventral herniation superior to the umbilicus with
extension of
large and small bowel into the hernia, but no evidence of
obstruction.
Additionally, there is diastasis of the recti and mild
outpouching of bowel
just inferior to the level of the umbilicus possibly at a prior
surgical site.
There is dilatation of the small bowel loops in the mid abdomen
measuring up
to 4.5 cm (201B:74)with possible transition point in the right
lower abdomen
at the site of prior small bowel anastomosis. Distal to this
point, the small
bowel loops appear relatively decompressed. There is mild
mesenteric
stranding. No free air or free fluid is noted within the
abdomen.
Retroperitoneal and mesenteric lymph nodes do not meet CT size
criteria for
pathology. Atherosclerotic calcification is noted within the
abdominal aorta.
CT OF THE PELVIS: The bladder, distal ureters, rectum and
sigmoid colon are
unremarkable. There is evidence of redundant portions of
sigmoid at the sites
of anastomosis. There is no free air or free fluid within the
pelvis. The
pelvic lymph nodes do not meet CT size criteria for pathology.
Soft tissue density within the anterior central abdomen (3:82)
appears
consistent with prior surgery.
Visualized osseous structures show no focal lytic or sclerotic
lesions
suspicious for malignancy. Multilevel degenerative changes are
noted in the
lumbar spine.
IMPRESSION: Findings suggestive of partial small-bowel
obstruction with
posible transition point in the right lower abdomen adjacent to
site of small
bowel anastomosis in close proximity to the ventral abdominal
wall. Ventral
abdominal hernia and diastasis of recti containing large and
small bowel loops
with no evidence of transition point to suggest that hernia
contents are
responsible for the obstruction.
Medications on Admission:
ASA 325', amlodipine 10', furosemide 40', fish oil 1200''',
insulin 70/30 60 am and 80 pm, isosorbide mononitrate 120'',
lipitor 80', losartan 100'', metoprolol tartrate 150 q am & 200
pm, MV', ntg prn, oxycodone prn, plavix 75', ranexa 1000'',
vitamin D 50,000 units twice weekly, spironolactone 25',
metamucil daily.
Discharge Medications:
1. 70/30 60 Units Breakfast
70/30 80 Units Bedtime
2. Aspirin 325 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 120 mg PO BID
6. Atorvastatin 80 mg PO DAILY
7. Losartan Potassium 100 mg PO BID
8. Metoprolol Tartrate 150 mg PO QAM
9. Metoprolol Tartrate 200 mg PO QPM
10. Clopidogrel 75 mg PO DAILY
11. Ranexa *NF* (ranolazine) 1,000 mg Oral BID
12. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with small bowel obstruction for G-tube
placement.
COMPARISON: ___.
PORTABLE AP CHEST RADIOGRAPH: A nasogastric tube ends in the stomach looping
into the fundus. Lungs are clear. Cardiac silhouette is exaggerated by low
lung volumes. No focal consolidation, pleural effusion or pneumothorax is
noted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TX SBO
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.0
heartrate: 74.0
resprate: 20.0
o2sat: 99.0
sbp: 177.0
dbp: 85.0
level of pain: 9
level of acuity: 2.0 | Mr ___ was admitted to the acute care surgery service on
___ after being transferred from an OSH with a several day
history of abdominal pain. CT at the OSH was concerning for SBO.
CT scan on arrival revealed a partial small-bowel obstruction
with possible transition point in the right lower abdomen
adjacent to site of small bowel anastomosis in close proximity
to the ventral abdominal wall. He was admitted to the floor and
made NPO with IVF and was monitored with serial abdominal exams.
By the morning of HD 2 he was having flatus and bowel movements
and his abdominal pain was subsiding. His diet was advanced to
regular which he tolerated well. At the time of discharge his
pain was well controlled, he was ambulating and he was
instructed to follow up with his PCP and with the acute care
surgery clinic as needed. |
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, Hypotension
Major Surgical or Invasive Procedure:
CVL placement ___
History of Present Illness:
___ year old gentleman with advanced MS, chronic indwelling foley
w/ multiple UTIs in past, presents from his nursing home with
lethargy and weakness. Per EMS report, the patient was found
this morning pale, lethargic and diaphoretic. Scant other
history available and patient unable to provide more details.
Vitals at nursing facility were 106/84, P ___, sO2 91%.
On arrival to the ED, initial vitals were T 97.3, HR 130, BP
93/61 RR 16, satting 97% on 2L supplemental O2. Mr. ___ was
weak but reportedly oriented, stating that his symptoms were
similar to prior UTI/urosepsis episodes. Urine was cloudy w/
large bacteria and nitrites, 1 WBC. Labs notable for WBC 51.6
(94% neutrophils, some hypersegmented), lactate 3.9 (recovered
to ___ s/p fluids), Cr. 2.5, K 5.4, Na 135 with an anion gap of
19. Urine cloudy with large leukocytes, positive nitrites, many
bacteria and one WBC.
A CXR showed a retrocardiac linear opacity but no clear cut
infectious focus. CT abd pelvis showed no acute GI process, a
distended bladder w/ hydronephrosis, and a foley catheter with
balloon insufflated in the prostate needing repositioning. Pt
was noted to have his catheter inserted in the dorsal aspect of
the meatus, unable to pass further. Urology saw pt in ED, said
ok to insert into erosion in ventral area of penis at the base
of the scrotum; new foley was inserted with >1L Uop, w/ visible
pt relief.
Pt became febrile to 102.7 and dropped his pressures into the
___ systolic, unresponsive to 5L IVF. A central venous line was
inserted and he was initiated on levophed with pressures
recovering into the ___. He was started on vanc/zosyn and
transferred to the ICU for further evaluation and management.
On arrival to the MICU, pt's vitals were: T 98, BP 100/71, HR
126,
RR 22, satting 91% on 6L NC. Pt c/o R ankle pain, no SOB, no CP
or belly pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Multiple sclerosis
Neurogenic bladder w/ chronic foley
Osteoporosis
Pressure ulcers
S/p colectomy for bowel obstruction
Multiple urinary tract infections (Pseudomonas, E.coli,
Enterococcus, Klebsiella); followed by Dr. ___ (Urology)
Social History:
___
Family History:
- No family history of MS.
- No history of MI, CVA
- Father and mother with alcohol abuse, father with diabetes,
cousin with ___ disease.
Physical Exam:
ADMISSION EXAM:
GENERAL: Thin, contracted. Responds to commands, able to report
place and situation ("I think I have a UTI") but not month or
year.
HEENT: Sclera anicteric, dry MMM.
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, no rebound tenderness or
guarding. Colostomy in place, stoma not examinined.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Pressure ulcer on sacrum and over L trochanter; both
appear deep but not inflamed. Skin tear on L knee.
GENITALIA: Erosion at junction of penis and scrotum, some
?purulent vs. fibrinous material at base, catheter in place
through this opening.
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
___ 01:05PM BLOOD WBC-51.6*# RBC-4.64# Hgb-12.8*# Hct-42.0#
MCV-90# MCH-27.5 MCHC-30.5* RDW-14.9 Plt ___
___ 01:05PM BLOOD Neuts-94* Bands-0 Lymphs-4* Monos-2 Eos-0
Baso-0 ___ Myelos-0
___ 04:13AM BLOOD ___ PTT-43.2* ___
___ 01:05PM BLOOD Glucose-111* UreaN-62* Creat-2.5*# Na-135
K-5.4* Cl-96 HCO3-22 AnGap-22*
___ 04:13AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.8
___ 01:13PM BLOOD Lactate-3.9*
___ 01:05PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 01:05PM URINE Blood-NEG Nitrite-POS Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-8.5* Leuks-LG
___ 01:05PM URINE RBC-0 WBC-<1 Bacteri-MANY Yeast-NONE
Epi-0
OTHER RELEVANT LABS:
___ 02:10AM BLOOD ALT-36 AST-29 AlkPhos-84 TotBili-0.3
___ 02:10AM BLOOD Hapto-296*
___ 01:13PM BLOOD Lactate-3.9*
___ 06:10PM BLOOD Lactate-2.0
___ 10:19PM BLOOD Lactate-2.2*
___ 06:33PM BLOOD Lactate-0.9
___ 06:15AM BLOOD Lactate-1.0
___ 02:00PM URINE Color-Straw Appear-Clear Sp ___
___ 02:00PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD
___ 02:00PM URINE RBC-2 WBC-18* Bacteri-NONE Yeast-NONE
Epi-0
___ 02:00PM URINE Hours-RANDOM UreaN-112 Creat-18 Na-102
K-11 Cl-79
___ 02:00PM URINE Osmolal-255
___ LABS:
___:
Blood Culture, Routine (Final ___:
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Time Taken Not Noted Log-In Date/Time: ___ 1:22 pm
URINE Site: CLEAN CATCH URINE HOLD # ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
THIS IS A CORRECTED REPORT ___.
Reported to and read back by ___ ___ ___ ___
1540.
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PREVIOUSLY REPORTED AS (ON ___.
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PROVIDENCIA ___. 10,000-100,000 ORGANISMS/ML..
GENTAMICIN AND TOBRAMYCIN sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ___
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
___ 1:20 pm BLOOD CULTURE #2.
Blood Culture, Routine (Preliminary):
PROTEUS MIRABILIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0640.
GRAM NEGATIVE ROD(S).
___ 10:40 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ MRSA SCREEN POSITIVE
___: blood cultures x 3: negative
___: blood cultures negative
IMAGING:
CT AP ___:
IMPRESSION:
Distention of the bladder and secondary hydroureteronephrosis
with moderate stranding in the retroperitoneum. Foley catheter
insufflated within the prostate and repositioning is suggested.
Otherwise no evidence of acute intra-abdominal process based on
unenhanced scan.
___ RENAL US:
No hydronephrosis.
___ PICC LINE PLACEMENT:
Successful placement of a left 39 cm basilic approach double
lumen PICC with tip in the distal SVC. The line is ready to use.
Calcified granuloma in RLL.
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-10.6 RBC-3.14* Hgb-8.7* Hct-28.4*
MCV-91 MCH-27.9 MCHC-30.8* RDW-15.4 Plt ___
___ 07:30AM BLOOD Glucose-82 UreaN-15 Creat-1.5* Na-139
K-4.0 Cl-107 HCO3-25 AnGap-11
___ 07:30AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Magnesium Oxide 400 mg PO BID
3. Ezetimibe 10 mg PO DAILY
4. Milk of Magnesia 30 mL PO DAILY
5. lactobacillus acidophilus 1 billion cell oral daily
6. Zinc Sulfate 220 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Heparin 5000 UNIT SC TID
11. Oxybutynin 5 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Phosphorus 250 mg PO DAILY
14. Mirtazapine 15 mg PO HS
15. Psyllium 1 PKT PO BID
16. Polyethylene Glycol 17 g PO DAILY
17. Juven (arginine-glutamine-calcium Hmb) ___ gram oral BID
18. Docusate Sodium 100 mg PO BID
19. Baclofen 0 mcg/hr IT ASDIR
20. Mylanta 30 oral daily
21. Senna 8.6 mg PO BID:PRN constipation
22. Bisacodyl ___ID:PRN constipation
23. Acetaminophen 650 mg PO Q4H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Septic shock from Proteus bacteremia and urinary tract
infection
Secondary:
- Severe multiple sclerosis
- Neurogenic bladder
- Acute kidney injury
- Ostomy prolapse
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___
HISTORY: ___ male with new right IJ central venous line.
COMPARISON: Chest x-ray from earlier the same day at 1:06 p.m.
FINDINGS: Single portable view of the chest. Again, low lung volumes are
seen. Increased interstitial markings on the current exam suggestive of
vascular congestion. Left costophrenic angle is now more blunted potentially
due to atelectasis, although effusion is also possible. Linear retrocardiac
opacity persists. Cardiomediastinal silhouette is stable. There is a new
right IJ central venous catheter whose tip is in the right atrium and could be
withdrawn 4.5 cm to be at the lower SVC. No visualized pneumothorax. Lower
cervical fixation hardware is identified.
IMPRESSION: New right IJ central venous line with tip likely within the right
atrium and could be withdrawn to be in the lower SVC. Pulmonary vascular
congestion.
Radiology Report
HISTORY: ___ male with weakness and white blood cell the 51,000 with
no obvious source.
TECHNIQUE: Contiguous axial images obtained through the abdomen and pelvis
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DLP: 893 mGy-cm.
COMPARISON: ___.
FINDINGS:
There are trace bilateral effusions with adjacent atelectasis. Calcified
granuloma seen in the right lower lobe. Atherosclerotic calcifications are
identified in the coronary arteries. Central venous catheter tip seen in the
upper right atrium.
Based on an unenhanced study, the liver, spleen, and adrenal glands and are
unremarkable. Pancreas is not well assessed due to motion and lack of
contrast however is grossly unremarkable. The stomach is moderately
distended. Small bowel is normal in caliber without obstruction. Right lower
quadrant ostomy is identified. Stool seen within the ___ pouch and
transverse colon which is not significantly dilated.
There is significant distention of the bladder with moderate bilateral
hydroureteronephrosis. There is moderate stranding within the
retroperitoneum, right greater than left, and along the course of the right
ureter. Foley catheter is identified and appears to be within the prostate.
Nonobstructing punctate calcification seen at the lower pole the right kidney.
Multiple small dependent stones also seen within the bladder.
Atherosclerotic calcifications seen within a normal caliber aorta.
Intrathecal catheter is identified with device in the left lower quadrant
subcutaneous tissues. No acute osseous abnormality is identified.
IMPRESSION:
Distention of the bladder and secondary hydroureteronephrosis with moderate
stranding in the retroperitoneum. Foley catheter insufflated within the
prostate and repositioning is suggested.
Otherwise no evidence of acute intra-abdominal process based on unenhanced
scan.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ man with resolving sepsis. Evaluate for
pneumonia.
FINDINGS: Comparison is made to previous study from ___.
The right IJ central line has been removed. There is hardware within the
lower cervical spine. The heart size is unchanged and stable. There is some
atelectasis at the lung bases. There are no signs for overt pulmonary edema
or definite consolidation. No pneumothoraces are present.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with neurogenic bladder, chronic indwelling
foley. ___ w/ FeNa >6% suggesting post renal. // hydronephrosis?
TECHNIQUE: Grey scale ultrasound images of the kidneys were obtained.
COMPARISON: Abdomen CT ___
FINDINGS:
The right kidney measures 12.1 cm. The left kidney measures 11.5 cm. There is
no hydronephrosis. No cyst or stone or suspicious solid mass is seen in either
kidney. Normal cortical echogenicity and corticomedullary differentiation are
seen bilaterally. No perinephric fluid collection is identified.
The bladder is minimally distended and contains a Foley catheter.
IMPRESSION:
No hydronephrosis.
Radiology Report
INDICATION: ___ year old man admitted with gram negative bacteremia, will need
2 weeks IV abx. IV team requested ___ guided PICC
COMPARISON: CHEST X-RAY ___.
TECHNIQUE: OPERATORS: Dr. ___ (interventional radiology fellow) and
Dr. ___ (interventional radiology attending) performed the procedure.
The attending was present and supervising throughout the procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.4 min, 1 mGy
PROCEDURE: 1. Double lumen PICC placement through the basilic vein on the
left.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, multiple
attempts were made to access the right basilic vein, however, all were
unsuccessful due to small caliber and tortuosity. The cephalic vein and
brachial vein on the right were not adequate for PICC insertion.
At this time the left upper extremity was prepped and draped in usual sterile
fashion. The basilic vein on the left was punctured under direct ultrasound
guidance using a micropuncture set. Permanent ultrasound images were obtained
before and after intravenous access, which confirmed vein patency. A peel-away
sheath was then placed over a guidewire. The guidewire was then advanced into
the superior vena cava using fluoroscopic guidance. A double lumen PIC line
measuring 39 cm in length was then placed through the peel-away sheath with
its tip positioned in the distal SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the chest. The
peel-away sheath and guidewire were then removed. The catheter was secured to
the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach double lumen left PICC with tip in the distal SVC.
3. Failed right upper extemity venous access attempts
IMPRESSION:
Successful placement of a left 39 cm basilic approach double lumen PICC with
tip in the distal SVC. The line is ready to use.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Lethargy. Question pneumonia.
COMPARISONS: ___.
TECHNIQUE: Chest, semi-AP portable.
FINDINGS: The lung volumes are low. The cardiac, mediastinal and hilar
contours appear stable allowing for differences in technique. There is fairly
substantial retrocardiac opacification, although predominantly linear and
streaky. Elsewhere, the lungs appear clear. There is no pleural effusion or
pneumothorax.
IMPRESSION: Retrocardiac opacity at the left lung base, somewhat striking
although suggestive atelectasis; an infectious process is difficult to
exclude, however.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with SEPTICEMIA NOS, SEPSIS , ACUTE KIDNEY FAILURE, UNSPECIFIED, ACCIDENT NOS, MULTIPLE SCLEROSIS
temperature: 97.3
heartrate: 130.0
resprate: 16.0
o2sat: 97.0
sbp: 93.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ with a PMHx of advanced MS, dependent in
all ADLs, who presented with lethargy and weakness, was found to
be hypotensive in the setting of urosepsis and was admitted to
MICU. Once stable he was transferred to the medical floor.
# Septic shock. / Proteus bacteremia
Pt presented with hypotension, tachycardia, leukocytosis, +UA
(for proteus and prevotella). PNA was originally in ddx but was
felt to be less likely on chest re-imaging. He received LR,
vancomycin (___) and zosyn (day 1 = ___ briefly switched
to CTX on ___ but switched back to Zosyn until ___. Zosyn was
transitioned to CTX on ___ with plan to complete a 14d course.
He briefly required norepi, which was switched to phenylephrine
and weaned on HD1. Once called out to the floor patient remained
afebrile, hemodynamically stable. PICC was placed on ___.
# ___.
Likely due to septic shock/prerenal insult and urinary
obstruction. Baseline Cr 0.5. Pt recevied IVF and BP support
with pressors as above. Obstruction was relieved with Foley
catheter replacement. FeNa >6% so likely intrarenal +/-
post-renal etiology. Likely some component of ATN due to shock
physiology. Creatinine is slowly trending down. Cr is 1.5 upon
discharge.
# Penile erosion:
Developed in setting of long-term indwelling foley catheter.
Opening at base of scrotum was indurated, though nontender.
There was question of purulent drainage deeper in the wound.
Pt's Urologist, Dr. ___ was consulted and recommended outpatient
follow-up.
# Hypoxia.
Pt was briefly hypoxic during admission. CXR c/w vascular
congestion, likely ___ fluid resuscitation initially in setting
of urinary obstruction.
# Pressure ulcers. Chronic and healing. No concern for active
infection.
# MS. ___ dependent in all ADLs. Has been living at rehab for
almost a year, was about to move back into his house w/
extensive nursing care and ___. Pt's sister/HCP expresses hope
that this was still the pt's goal. Pt carries implanted baclofen
for spasticity intrathecal pump that will need refill on ___.
# Protrusion of bowel through ostomy:
Pt had recurrent episodes of bowel protruding through ostomy.
This was manually adjusted by surgery service. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / Reglan / vancomycin / shellfish
derived / ceftazidime
Attending: ___.
Chief Complaint:
whole body shakes, pyuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ year-old man w/ a history of
uncontrolled Type 1 Diabetes c/b by ESRD on HD ___, central
pontine myelysis in ___ with baseline quadriplegia affecting
legs more than arms, neurogenic bladder requiring intermittent
straight cath, Stage IV decubitus ulcer, colonic fistula
requiring diverting colostomy, jaundice with unknown etiology,
and a recent admission for HD-Line assoc. MRSA bacteremia
(___), who presents with 3 days of urinary
retention.
Per patient he has had "white" urine over the past few months,
and starting 3 days prior to admission began developing
increasing straining with urine. He notes that he feels
tremulous
and has "spasms" while attempting to urinate, and has been
unable
to pass urine. At baseline, he is straight-cathed every other
day. He has some lower abdominal tenderness, and notes some
occasional streaks of blood in his colostomy bag. He denies any
fever, chills, nausea, vomiting.
In the ED,
- Initial vitals: T:99.1 P:82 BP:144/91 RR:18 POx:99% RA
- Exam notable for: Comfortable in NAD, Pus at meatus and in
catheter specimen per nurse, ___, and abdomen was
soft,
non-tender, non-distended. Streaks of blood were seen in his
colostomy bag, which were less than baseline per patient.
- Labs showed:
WBC: 8.4 RBC: 4.08* Hgb: 10.7* Hct: 34.5* MCV: 85 MCH: 26.2
MCHC:
31.0* RDW: 16.1* RDWSD: 48.3* Plt Ct: 143*
Neuts: 57.4 Lymphs: ___ Monos: 5.3 Eos: 15.4* Baso: 0.9 Im
___:
0.4 AbsNeut: 4.84 AbsLymp: 1.74 AbsMono: 0.45 AbsEos: 1.30*
AbsBaso: 0.08
___: 12.3 PTT: 33.7 ___: 1.1
Glucose: 128* UreaN: 31* Creat: 5.2* Na: 140 K: 5.8* Cl: 98
HCO3:
28 AnGap: 14
ALT: 11 AST: 13 AlkPhos: 990* TotBili: 2.0*
Albumin: 3.2* Calcium: 8.5 Phos: 4.6* Mg: 2.7*
Lactate: 1.5 K: 5.5*
Urine:
Color: Yellow Appear: Cloudy* Sp ___: 1.015 Blood: SM* Nitrite:
NEG Protein: 100* Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln:
NEG pH: 7.0 Leuks: LG* RBC: 8* WBC: >182* Bacteri: NONE Yeast:
MANY* Epi: 0
WBC Clm: MANY*
- Imaging showed:
Bedside Ultrasound: no hydro bilaterally, but diffuse echogenic
material in bladder.
CT Abdomen Pelvis with contrast
IMPRESSION:
1. Diffuse wall thickening of the bladder, layering complex
fluid
and trapped locules of gas within the bladder, and perivesical
stranding. Findings are compatible with cystitis and reported
pyuria. No evidence of ascending urinary tract infection. No
renal abscess.
2. No definite colonic mass identified, noting that evaluation
is
limited by CT, especially in the setting of an unprepped colon.
Please correlate with endoscopic evaluation if there is clinical
concern for colonic mass.
3. Status post diverting colostomy in the left lower quadrant
with parastomal hernia containing nonobstructed small bowel
loops
and small amount of free fluid.
4. Moderate left pleural effusion.
5. Subcutaneous soft tissue stranding just below the level of
the
sacral tip likely corresponds to known sacral decubitus ulcer.
No osseous erosion.
Chest Xray:
IMPRESSION:
1. No evidence of pneumonia.
2. Moderate left pleural effusion with compressive atelectasis.
3. 0.9 cm nodular opacity projecting over the left upper lung
could represent a pulmonary nodule or pulmonary vessel viewed on
end. Repeat chest radiograph or nonurgent chest CT can provide
further assessment.
- Patient received: IV Fluids, Ceftriazone, and Morphine
sulfate.
- Transfer VS were: T:98.6 P:66 BP:133/80 RR:18 POx:99% RA
On arrival to the floor, the patient corroborates with the above
history. He is experiencing pain in his testicle because his
legs
are too close together, and has had one episode of "mayonnaise"
foul smelling urine. He is hungry, and is requesting bacon. He
reports that he is due for dialysis today.
REVIEW OF SYSTEMS:
Denies fevers/chills, nausea/vomiting, shortness of breath,
chest
pain/dizziness, palpitations, abdominal pain,
constipation/diarrhea, urinary symptoms, numbness/weakness.
Past Medical History:
Type I DM
ESRD on HD ___
Quadriplegia from ?HD initiation/hyponatremia/CPM
OSA on CPAP
GERD
Stage 4 presacral left buttock decubitus ulcer c/b diverting
colostomy
MRSA bacteremia ___ RIJ HD line infection
Colostomy
Tracheostomy s/p removal
PEG s/p removal with open connection between stomach and skin
Retinopathy
Pseudomonas osteomyelitis of sacral ulcer in ___
Asthma
HLD
Neurogenic bladder requiring intermittent catheterization
Gastroparesis
Oropharnygeal dysphagia s/p PEG s/p removal
Hx of ESBL in urine
Reactive thrombocytosis
Neuropathy
HTN
UTI due to enterococcus
Social History:
___
Family History:
Mother with asthma, father with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T:98.4 BP:157/117 P:70 RR:18 POx:99% on room air
General: Alert, oriented, no acute distress
HEENT: scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: RRR, S1/S2, no m/r/g
GI: soft, parastomal hernia and mild tenderness to palpation
around ostomy site in left lower quadrant, BS+, no rebound
tenderness or guarding. Ostomy bag with brown formed stool and
streaks of red blood.
MSK: warm, well perfused, 2+ pulses, lower extremities atrophic
with feet in dorsiflexion.
Neuro: CN2-12 intact, weakness bilaterally lower
extremities>upper extremities.
Skin: Jaundice. Some excoriated papules on right upper chest
near dialysis catheter dressing.
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: ___ 0805 BP: 149/88 HR: 67 RR: 18 O2 sat: 99% O2
delivery: ___ FSBG: 205
General: Alert, oriented, scratching, no acute distress
HEENT: faint scleral icterus, MMM, oropharynx clear, +anisocoria
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, or rhonchi
Chest: scant blood around HD catheter on right chest,
non-tender, non-erythematous
CV: RRR, S1/S2, no m/r/g; diffuse anasarca
GI: soft, parastomal hernia and mild tenderness to palpation
around ostomy site in left lower quadrant, BS+, no rebound
tenderness or guarding. Ostomy bag with brown formed stool and
no red blood.
MSK: warm, well perfused, 2+ pulses, lower extremities atrophic
with feet in dorsiflexion.
Neuro: CN2-12 intact, weakness bilaterally lower
extremities>upper extremities.
Skin: Rash resolved.
Pertinent Results:
Admission Labs:
----------------
___ 12:45AM BLOOD WBC-8.4 RBC-4.08*# Hgb-10.7*# Hct-34.5*#
MCV-85# MCH-26.2# MCHC-31.0* RDW-16.1* RDWSD-48.3* Plt ___
___ 12:45AM BLOOD Neuts-57.4 ___ Monos-5.3
Eos-15.4* Baso-0.9 Im ___ AbsNeut-4.84# AbsLymp-1.74
AbsMono-0.45 AbsEos-1.30* AbsBaso-0.08
___ 12:45AM BLOOD ___ PTT-33.7 ___
___ 12:45AM BLOOD Glucose-128* UreaN-31* Creat-5.2* Na-140
K-5.8* Cl-98 HCO3-28 AnGap-14
___ 12:45AM BLOOD ALT-11 AST-13 AlkPhos-990* TotBili-2.0*
___ 12:55AM BLOOD Lactate-1.5 K-5.5*
Microbiology:
--------------
URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000
CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
FOSFOMYCIN ---------- S
Imaging:
--------
CT Abdomen Pelvis with contrast ___
IMPRESSION:
1. Diffuse wall thickening of the bladder, layering complex
fluid
and trapped locules of gas within the bladder, and perivesical
stranding. Findings are compatible with cystitis and reported
pyuria. No evidence of ascending urinary tract infection. No
renal abscess.
2. No definite colonic mass identified, noting that evaluation
is
limited by CT, especially in the setting of an unprepped colon.
Please correlate with endoscopic evaluation if there is clinical
concern for colonic mass.
3. Status post diverting colostomy in the left lower quadrant
with parastomal hernia containing non-obstructed small bowel
loops
and small amount of free fluid.
4. Moderate left pleural effusion.
5. Subcutaneous soft tissue stranding just below the level of
the
sacral tip likely corresponds to known sacral decubitus ulcer.
No osseous erosion.
Chest Xray ___:
IMPRESSION:
1. No evidence of pneumonia.
2. Moderate left pleural effusion with compressive atelectasis.
3. 0.9 cm nodular opacity projecting over the left upper lung
could represent a pulmonary nodule or pulmonary vessel viewed on
end. Repeat chest radiograph or non-urgent chest CT can provide
further assessment.
Discharge Labs:
----------------
___ 11:15AM BLOOD WBC-15.0* RBC-4.39* Hgb-11.3* Hct-37.3*
MCV-85 MCH-25.7* MCHC-30.3* RDW-16.4* RDWSD-50.3* Plt ___
___ 11:15AM BLOOD ___ PTT-30.4 ___
___ 11:15AM BLOOD Glucose-341* UreaN-35* Creat-6.0* Na-139
K-5.1 Cl-98 HCO3-26 AnGap-15
___ 11:15AM BLOOD ALT-10 AST-12 AlkPhos-660* TotBili-1.5
___ 11:15AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.6 Mg-2.5
Radiology Report
INDICATION: History: ___ with Fever// PNA
TECHNIQUE: Portable AP semi rec chest radiograph.
COMPARISON: CT chest dated ___. Chest radiograph dated ___.
FINDINGS:
The right-sided dialysis catheter terminates in the atrium. The lung volume
is small, exaggerating bronchovascular markings. No focal consolidation to
suggest pneumonia. A 0.9 cm nodular opacity projecting over the left upper
lung could represent a pulmonary nodule or pulmonary vessel viewed on end. No
pulmonary edema. There is moderate left pleural effusion with compressive
atelectasis. No pneumothorax. No sign of silhouette is unremarkable. No
acute osseous abnormalities.
IMPRESSION:
1. No evidence of pneumonia.
2. Moderate left pleural effusion with compressive atelectasis.
3. 0.9 cm nodular opacity projecting over the left upper lung could represent
a pulmonary nodule or pulmonary vessel viewed on end. Repeat chest radiograph
or nonurgent chest CT can provide further assessment.
Radiology Report
EXAMINATION: CT of the abdomen and pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with frank pyruia, GI bleed,
painNO_PO contrast// abscess?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 26.3 mGy (Body) DLP =
1,370.5 mGy-cm.
Total DLP (Body) = 1,380 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___ and ___.
FINDINGS:
LOWER CHEST: There is moderate left pleural effusion with compressive
atelectasis. Otherwise the lung bases are clear. No pericardial effusion. A
right central venous catheter tip terminates at the cavoatrial junction.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: Pancreas is atrophic without evidence of focal lesion 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 hydronephrosis in either kidney. No evidence of renal abscess.
Left lower pole 2.0 cm cyst is unchanged. No suspicious renal lesions. There
is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The patient is status post
diverting colostomy with the stoma seen in the left lower quadrant. There is
a parastomal hernia containing nonobstructed small bowel loops. Small amount
of free fluid is also seen within the hernia sac. There is no bowel
obstruction. No definite colonic mass is identified, noting that evaluation
is limited by CT, especially in the setting of an unprepped colon.
Rectosigmoid stump is within normal limits and contains oral contrast. The
appendix is normal. No abnormal fluid collection is seen within the abdomen
or pelvis.
PELVIS: The bladder wall is diffusely thickened. There is layering complex
fluid and trapped locules of gas within the bladder. There is fat stranding
around the bladder. Findings are compatible with cystitis and reported
pyuria. The distal ureters unremarkable. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is a 1.2 cm porta hepatic lymph node (series 2, image 33),
smaller compared to ___. Additional retroperitoneal nodes are
not enlarged by CT criteria. No 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.
No significant degenerative changes.
SOFT TISSUES: See above regarding the parastomal hernia. There is diastasis
of the rectus abdominus with ventral protrusion of transverse colon. There is
diffuse anasarca. Subcutaneous soft tissue stranding just below the level of
the sacral tip likely corresponds to patient's known sacral decubitus ulcer.
No osseous erosion.
IMPRESSION:
1. Diffuse wall thickening of the bladder, layering complex fluid and trapped
locules of gas within the bladder, and perivesical stranding. Findings are
compatible with cystitis and reported pyuria. No evidence of ascending
urinary tract infection. No renal abscess.
2. No definite colonic mass identified, noting that evaluation is limited by
CT, especially in the setting of an unprepped colon. Please correlate with
endoscopic evaluation if there is clinical concern for colonic mass.
3. Status post diverting colostomy in the left lower quadrant with parastomal
hernia containing nonobstructed small bowel loops and small amount of free
fluid.
4. Moderate left pleural effusion.
5. Subcutaneous soft tissue stranding just below the level of the sacral tip
likely corresponds to known sacral decubitus ulcer. No osseous erosion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Urinary retention
Diagnosed with Urinary tract infection, site not specified
temperature: 99.1
heartrate: 82.0
resprate: 18.0
o2sat: 99.0
sbp: 144.0
dbp: 91.0
level of pain: 10
level of acuity: 3.0 | Summary:
============
Mr. ___ is a pleasant ___ year old man with a history of
paralysis and neurogenic bladder secondary to central pontine
myelysis who presented with 3 days of urinary retention and
chronic pyuria, found to have E. coli UTI and acute pyocystis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Mercaptopurine
Attending: ___.
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M w/COPD, chronic loculated pleural effusion, prior
pneumonia, presents with PNA. Pt was seen in PCP office on ___
due to not feeling well, cough productive of yellow sputum, poor
appetite, fever, SOB. This is similar to his prior PNA but more
severe. He was started on Levaquin. Yesterday SOB worsened and
pt weak, unsteady on feet and nauseous. 88% O2Sat on room air
for EMS. Wheezy and rhoncourous. Duoneb by EMS and Zofran. Got
Tylenol PTA.
In ED pt febrile to 102, tachycardic and hypotensive as low as
62/36. Pressors ordered but BP very volume responsive so never
given. BP improved ot baseline ~100s. Given CTX, Solumedrol,
Duonebs, 2L NS.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
PAST MEDICAL HISTORY:
- Plasmacytoma, R. kidney. Dx via needle biopsy ___, s/p
gamma knife XRT. No bone marrow involvement.
### ___: SPEP/UPEP negative, kappa/lambda ratio stable
- Idiopathic bilateral pleural effusions since ___
+ Thoracenteses c/w exudates, with low pH
+ One sample grew VRE and VSE, though unclear that this was the
etiology
+ s/p pleural biopsy in ___, which showed granulation tissue
and rare giant cells
- COPD; moderate (FEV1= 55% predicted on prior PFTs)
- Coronary artery disease s/p MI in ___
- Diabetes mellitus
+ c/b peripheral neuropathy
- Hypertension
- Hyperlipidemia
- Carotid stenosis, s/p stent in right ICA
- Autoimmune hepatitis, on chronic steroids
- Chronic kidney disease
- B12 deficiency
- Osteopenia
- Gastritis
- Peudogout
- GERD
- s/p bilateral TKR
- colon infarction, s/p partial colectomy ___
- s/p CCY
Social History:
___
Family History:
Sister had kidney or bladder cancer. Father had polyps on the
bladder.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: Tm:102 (in ED) Tc:98.1 BP:129/66 P:129 R:20 O2:95%4Lnc
PAIN: 0
General: nad
EYES: anicteric
Lungs: R lung with diffuse rhonchi
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
.
DISCHARGE PHYSICAL EXAM:
VS: AF, 98.4, 122/70, 69, 18, 90-92% on RA
BS: 24 hour range 119-196
AM ___: pending
Pain: zero out of 10
Gen: comfortable, NAD, seen ambulating with ___ under RN
supervision comfortably
HEENT: anicteric
CV: RRR, no murmur appreciated
Pulm: improved BS, minimal crackles on right base, mild wheeze
Ext: warm, no edema
Skin: multiple ecchymoses
Neuro: fluent speech
Psych: Appropriate, stable
.
Pertinent Results:
ADMISSION LABS:
___ 09:30PM BLOOD WBC-13.5*# RBC-3.91* Hgb-12.1* Hct-34.9*
MCV-89 MCH-30.9 MCHC-34.6 RDW-13.9 Plt ___
___ 09:30PM BLOOD Glucose-173* UreaN-42* Creat-2.6* Na-130*
K-4.7 Cl-94* HCO3-23 AnGap-18
___ 09:30PM BLOOD ___ PTT-45.5* ___
___ 06:05AM BLOOD ALT-15 AST-26 AlkPhos-69 TotBili-1.0
___ 06:05AM BLOOD Albumin-2.8* Calcium-7.7* Phos-4.0 Mg-2.0
___ 06:15AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.3 Iron-27*
___ 06:15AM BLOOD calTIBC-174* Ferritn-472* TRF-134*
___ 11:41AM BLOOD %HbA1c-7.1* eAG-157*
___ 06:05AM BLOOD TSH-0.91
___ 06:05AM BLOOD Cortsol-99.0*
___ 09:41PM BLOOD Lactate-2.0
___ 08:46PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:46PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 08:46PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-1
___ 05:38PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
.
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-8.3 RBC-3.71* Hgb-11.5* Hct-33.3*
MCV-90 MCH-30.9 MCHC-34.5 RDW-13.8 Plt ___
___ 06:25AM BLOOD ___ PTT-40.2* ___
___ 06:25AM BLOOD UreaN-29* Creat-1.4*
.
MICROBIOLOGY:
___ Blood Culture x 2 sets: NGTD, final PENDING
___ Respiratory viral screen/culture: NEGATIVE/NEGATIVE
___ Sputum Culture: poor sample, not processed
___ Urine Culture: < 10K CFU organisms
___ Urine Legionella: NEGATIVE
.
IMAGING:
___ PCXR
IMPRESSION:
Increased opacity projecting over the right hemi thorax likely
due to increased right pleural effusion with overlying
atelectasis, underlying infectious process not excluded.
.
___ CT CHEST
IMPRESSION:
1. Multifocal opacities within the right upper lobe consistent
with pneumonia. Given the fullness of the right hilum and
significant ___ thickening, followup with CT after
treatment is recommended to ensure resolution.
2. Chronic bilateral pleural effusions, loculated on the right
and associated with pleural thickening and calcification.
3. Bibasilar opacities most likely atelectasis, right greater
than left.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Metoprolol Tartrate 25 mg PO BID
4. Omeprazole 40 mg PO DAILY
5. PredniSONE 4 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Warfarin 2 mg PO DAILY16
8. Calcium Carbonate 500 mg PO QID:PRN osteopenia
9. Doxazosin 4 mg PO HS
10. GlipiZIDE 5 mg PO TID
11. Lisinopril 2.5 mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Levofloxacin 500 mg PO Q24H
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Doxazosin 4 mg PO HS
4. Gabapentin 300 mg PO TID
5. GlipiZIDE 5 mg PO TID
6. Metoprolol Tartrate 25 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. PredniSONE 4 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Calcium Carbonate 500 mg PO QID:PRN osteopenia
13. Warfarin 1 mg PO DAILY16
will need next INR on ___ for further adjustment
14. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze, shortness of
breath
RX *albuterol sulfate 90 mcg ___ puffs inhaled every 4 hours
Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
pneumonia, community acquired, with sepsis
anemia, iron-deficiency
hyperglycemia
acute renal failure / acute kidney injury
elevated INR level (Coumadin level) / coagulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with right sided pleural effusion, right sided
infiltrate on CXR // eval size of pleural effusion
TECHNIQUE: MDCT axial imaging was obtained of the chest without the
administration of intravenous contrast material. Coronal, sagittal and
maximum intensity projection images were completed.
DOSAGE: TOTAL DLP 263.5mGy-cm
COMPARISON: PET-CT from. ___. Chest radiographs, most recently
from ___.
FINDINGS:
The thyroid gland is unremarkable. There are no enlarged supraclavicular,
axillary, mediastinal or hilar lymph nodes. The aorta and pulmonary artery
are of normal caliber. There are moderate coronary artery calcifications but
no pericardial effusion. Secretions are noted within the right lateral wall
of the trachea (series 2, image 17).
Multifocal opacities are present within the posterior aspect of the right
upper lobe consistent with pneumonia. There is fullness of the right hilum
which is incompletely evaluated without intravenous contrast material (series
2, image 1). There is significant thickening along the major fissure.
Bibasilar opacities, right greater than left are noted which may represent
infection or atelectasis. Small bilateral pleural effusions, right greater
than left with associated pleural thickening and calcifications are unchanged
since the prior PET-CT. The left pleural effusion is loculated Peribronchial
thickening is noted particularly in the lower lobes likely due to bronchial
infection. There is no pneumothorax.
This study is not tailored for evaluation of subdiaphragmatic structures but
limited views demonstrate prior cholecystectomy but are otherwise
unremarkable.
There no osseous lesions concerning for malignancy. There are moderate
degenerative changes in the thoracic spine with vacuum phenomenon and disc
space narrowing.
IMPRESSION:
1. Multifocal opacities within the right upper lobe consistent with pneumonia.
Given the fullness of the right hilum and significant ___
thickening, followup with CT after treatment is recommended to ensure
resolution.
2. Chronic bilateral pleural effusions, loculated on the right and associated
with pleural thickening and calcification.
3. Bibasilar opacities most likely atelectasis, right greater than left.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 102.0
heartrate: 104.0
resprate: 30.0
o2sat: 88.0
sbp: 100.0
dbp: 54.0
level of pain: 5
level of acuity: 1.0 | ___ yo M with AF/Aflutter on Coumadin, COPD, DM2 withneuropathy,
CKD, AIH/cirrhosis on chronic prednisone, chronic pleural
effusion, admitted with fever, cough, right-sided infiltrate,
failed outpt PO Abx for PNA, now on IV CTX and azithro, also
with hyperglycemia and ___ on admission.
.
# Fever
# Sepsis
# Pneumonia
# Loculated pleural effusion
# Hypotension
Patient presenting with overall clinical picture c/w an acute
bacterial pneumonia. Has history of recurrent PNA, last in ___
per patient report. No RF's for HCAP. Notable for significant
hypotension on admission concerning for septic shock, although
responded to IVF and normal lactate. Flu NEGATIVE, respiratory
viral screen/culture NEGATIVE, Legionella Ag NEGATIVE. Already
started on Levaquin PO as outpatient but did not respond with 2
doses. CT scan c/w PNA, no significant effusions to tap. He was
weaned off O2 and remained afebrile. He was treated inpatient
with IV ceftriaxone and azithromycin, but is being discharged on
Levaquin to complete a total 7 day course, last day = ___.
Needs f/u chest CT after PNA treatment given fullness seen in
hilum and fissure. Blood cultures NGTD, final pending.
.
# COPD, moderate, no home O2
Moderate COPD by last PFT's (___). Received 1 dose of IV
solumedrol in ED. Minimal wheeze during hospitalization.
During hospitalization, received standing nebs but held off on
additional systemic steroids, given
hyperglycemia. Provided albuterol MDI script for PRN use on
discharge. No wheeze or O2 requirement on day of discharge.
.
# Anemia
Hct currently stable and without evidence of active bleed. Has
history of gastritis per OMR, but last EGD ___ without varices
or ulcers. ___ ___ with polyp, stable anastamosis, due
for repeat ___ ___. CKD may be contributing. Hx of
plasmocytoma is always a concern, but at last f/u in ___,
labs without evidence of marrow involvement. Iron studies c/w
at least a component of ___. CBC remained stable throughout
hospitalization. Patient was continued on his home PPI. Needs
outpatient ___ defer to PCP. Consider starting iron
supplementation, will defer to PCP.
.
# AIH / # cirrhosis
Followed by Dr. ___, maintained on 4mg Prednisone. No
encephalopathy. Albumin is low, but this is acute, likely from
poor PO intake. Plt # WNL. INR elevated from Coumadin.
Continued prednisone. f/u w/Liver Clinic per previous schedule.
.
# Afib/Aflutter
# CAD
# HLD
# ?HTN
# PVD, s/p right carotid stent, occluded left ICA
# Coagulopathy
Appears to be in NSR on telemetry, confirmed on EKG. No new EKG
changes to suggest recent cardiac event or ongoing ischemia. HR
and BP currently in good range. Per pt, his baseline BP is
100's ("I don't know why I need blood pressure meds!").
Hypotension likely ___ sepsis, unlikely from cardiogenic shock.
CHADS2 = 3. Continued ASA, BB (with holding parameters) and
statin. ACEi held during admission, but will be restarted on DC
as ___ has resolved. INR 3.2 on admission, peaked at 5.4. Was
then drifting down to 3.2 on day of discharge, will resume
Coumadin at reduced dose with ___ to recheck INR on ___.
PCP office to follow. INR goal is 2 - 3.
.
# DM2, controlled (A1C 6.8 in ___, c/b neuropathy and
nephropathy
Hyperglycemic, likely in the setting of infection, as well as IV
Solumedrol administration in ED. Mild AG on presentation, but
no ketones in urine. Due to ___, his home glipizide was held
initially. He was placed on Lantus and HISS. Repeat A1C during
this admission was 7.1, showing overall good control. With
improvement of his Cr, his glipizide was restarted and he was
weaned off insulin. 24hr prior to DC, his BS was in excellent
range. Continued his gabapentin for neuropathy, dose was
initially adjusted for ___, but resumed home dose on DC.
home. Resumed glipizide yesterday, BS in good range.
.
# ___ on CKD /# Hyponatremia
Baseline Cr 1.7, p/w Cr 2.6. Likely ___ in setting of
hypotension / volume depletion from sepsis. ACEi and anti-HTN
agents held, responded well to IVF. Cr now back to baseline at
1.4. ACEi resumed on discharge. Hypernatremia resolved prior
to discharge.
.
# BPH
Stable, denies new urinary symptoms. No e/o UTI on UA, UCx.
Continued home doxazosin.
.
# DECONDITIONING
Patient seen by ___. Recommended rolling walker, which was
provided to patient prior to discharge. Patient will also have
___ services on discharge.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Symptomatic abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
___:
1. Endovascular aneurysm repair.
2. Right external iliac to right internal iliac stent graft.
3. Left to right femoral-femoral bypass graft.
History of Present Illness:
___ with history of AAA s/p repair ___, ___ years ago for 5cm
AAA), ESRD on HD presenting with abdominal pain for 1 week,
worsening in the last 48 hours. The patient reports symptoms
worsened gradually, prompting presentation to ___
early this morning. There he was found to be hypertensive to SBP
190s, with a palpable abdominal mass. He underwent a CT scan
which demonstrated a 9cm AAA, non-ruptured, containing the stent
graft in addition to a 2cm R CIA aneurysm. The patient was
started on esmolol gtt on route to ___ for further evaluation.
He denies fevers, chills, diarrhea; denies chest pain, back pain
or shortness of breath.
His preliminary labs were notable for a hematocrit of 35,
creatinine of 4.77.
Past Medical History:
Atrial fibrillation not on coumadin, angina, CAD s/p MI, ESRD on
HD (___), HLN, HTN
Past Surgical History:
AAA stent repair ___ years ago, ___, cardiac
catheterization
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission,
VS: afebrile HR 88, 160/90 18 100%2LNC
General: in no acute distress, but appears slightly anxious
HEENT: sclera anicteric, mucus membranes dry, nares clear,
trachea at midline
CV: regular rate, rhythm. Well-healed midline sternotomy
Pulm: clear to auscultation bilaterally
Abd: palpable, pulsatile, and tender midline abdominal mass.
Well-healed low transverse incision.
MSK: Palpable pulses throughout. RUE AVF with palpable thrill.
Neuro: alert, oriented to person, place, time
On discharge,
VS: 98.3 70 118/64 21 98% RA
General: well-appearing, in no acute distress, elderly and frail
Cardiovascular: irregular heart sounds, no murmurs, rubs or
gallops. Lungs are clear to auscultation bilaterally
Abdomen: firm, mildly tender to palpation over periumbilical
area, non-distended, no rebound or guarding. Bilateral groin
incisions with Dermabond in place, appear clean, dry and intact
with minimal surrounding erythema.
Genitals: resolving penile and scrotal echymosis
Neurologic: grossly intact, alert and oriented x 3
Extremities: atraumatic without clubbing, cyanosis or edema.
Pulses as follows:
Femoral Popliteal ___ DP
Right palp palp dopp dopp
Left palp palp palp dopp
Pertinent Results:
On admission,
___ 06:37AM BLOOD WBC-6.6 RBC-4.28* Hgb-11.1* Hct-36.9*
MCV-86 MCH-25.9* MCHC-30.1* RDW-16.8* Plt ___
___ 06:37AM BLOOD Neuts-77.2* Lymphs-14.2* Monos-6.3
Eos-1.7 Baso-0.6
___ 06:37AM BLOOD ___ PTT-32.4 ___
___ 06:37AM BLOOD Glucose-123* UreaN-55* Creat-4.8* Na-141
K-3.9 Cl-91* HCO3-29 AnGap-25*
___ 06:30PM BLOOD CK(CPK)-338*
___ 11:19AM BLOOD cTropnT-0.28*
___ 06:30PM BLOOD CK-MB-18* MB Indx-5.3 cTropnT-0.42*
___ 01:00AM BLOOD CK-MB-13* MB Indx-4.4 cTropnT-0.47*
___ 05:54AM BLOOD CK-MB-15* MB Indx-4.5 cTropnT-0.51*
___ 03:30PM BLOOD CK-MB-11* MB Indx-4.3
___ 10:58PM BLOOD CK-MB-6 cTropnT-0.67*
___ 12:31PM BLOOD Calcium-8.2* Phos-5.1* Mg-1.7
On discharge,
___ 06:23AM BLOOD WBC-6.8 RBC-3.45* Hgb-8.6* Hct-30.5*
MCV-88 MCH-25.0* MCHC-28.4* RDW-16.7* Plt ___
___ 06:23AM BLOOD Glucose-132* UreaN-72* Creat-5.8* Na-134
K-3.7 Cl-92* HCO3-26 AnGap-20
___ 06:23AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
CTA Torso (___)
1. 8.9 x 8 x 8.7 cm infrarenal abdominal aortic aneurysm with
large communication between the native supra-graft aorta and
aneurysm sac and the native right common iliac artery and the
aneurysm sac. Stranding adjacent to the aneurysm is worrisome
for threatened rupture but no evidence of active hemorrhage.
2. Smaller aneurysm up to 4.5 cm above the graft and 2.2 cm
common right
iliac artery aneurysm.
3. Occlusion of the right common iliac graft by thrombus.
4. Caliber change in the coronary artery graft emanating from
the ascending aorta, although incompletely evaluated on this
non-gated study.
5. Incomplete opacification of the left atrial appendage, clot
cannot be
excluded. Echo may be obtained for further evaluation.
6. Moderate cardiomegaly. Small bilateral pleural effusions and
interstitial thickening likely reflecting pulmonary edema.
7. Mediastinal lymphadenopathy, likely reactive.
ECG (___)
Atrial fibrillation with moderate ventricular response and
ventricular ectopy. Left ventricular hypertrophy. No previous
tracing available for comparison
Echocardiogram (___)
Mild left ventricular hypertrophy wih normal cavity size and
mild regional systolic dysfunction c/w CAD. Normal right
ventricular cavity size with mild systolic dysfunction. Mild
pulmonary artery systolic hypertension. Mildly dilated thoracic
aortic root. LVEF 45%
CXR (___)
There is a right IJ central line with distal lead tip in the
proximal SVC. Heart size is enlarged but stable. There is a
persistent left retrocardiac opacity and left basilar
subsegmental atelectasis. There are no pneumothoraces
identified. There is improvement of the pulmonary interstitial
edema as well as the basilar opacity at the right base.
ECG (___)
Atrial fibrillation with a controlled ventricular response.
Slightly prolonged Q-T interval. Left ventricular hypertrophy.
Medications on Admission:
calcium acetate 667''', cardura 2'', vit B 1000', imdur 15'',
MVI 1', prilosec 20', pravachol 20', soy protein 52''', toprol
XL 12.5', ASA 81'
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Pravastatin 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Vitamin B Complex 1 CAP PO DAILY
11. Isosorbide Mononitrate (Extended Release) 15 mg PO BID
12. Calcium Acetate 667 mg PO TID W/MEALS
13. Doxazosin 2 mg PO BID
14. soy protein 52 g oral TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Symptomatic abdominal aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with RIJ, assess position.
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest CTA ___.
FINDINGS:
A portable view of the chest shows a right IJ ending in the upper SVC.
Bilateral lung opacities, most pronounced in the right lower lobe, and
cardiomegaly is consistent with pulmonary edema. Pleural effusions are small,
if any. There is no pneumothorax.
IMPRESSION:
Right IJ ends in the upper SVC. No pneumothorax.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ man with leukocytosis. Evaluate for source.
FINDINGS: Comparison is made to previous study from ___.
There is a right IJ central line with distal lead tip in the proximal SVC.
Heart size is enlarged but stable. There is a persistent left retrocardiac
opacity and left basilar subsegmental atelectasis. There are no
pneumothoraces identified. There is improvement of the pulmonary interstitial
edema as well as the basilar opacity at the right base.
Radiology Report
INDICATION: 9 cm abdominal aortic aneurysm on outside hospital imaging.
Evaluate for abdominal aortic aneurysm.
COMPARISON: Outside CT of the abdomen and pelvis without contrast ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest,
abdomen and pelvis utilizing angiographic technique after administering 130 cc
of Omnipaque IV contrast. Multiplanar axial, coronal and sagittal images were
generated.
TOTAL BODY DLP: 1424 mGy-cm
CTDI VOLUME : 16 mGy
FINDINGS:
CTA CHEST, ABDOMEN AND PELVIS: The large infrarenal abdominal aortic aneurysm
measures 8.9 x 8.7 cm (400B:76 and 401B:35). A smaller aneurysm above the
graft measures 4.5 x 4.1 cm. The proximal portion of the graft has become
unseated resulting in a large communication between the native supra-graft
aorta and the aneurysm sac. This communication exits inferiorly through the
infra-graft right common iliac artery where the distal portion of the right
common iliac graft extension is also unseated. The right common iliac graft
extension is thrombosed throughout most of its length (401B:39). The right
common iliac aneurysm measures 2.2 x 2.2 cm (3:180). The left limb looks
stretched and stenotic as the graft is displaced and pinched laterally by the
large aortic aneurysm. However, the left limb appears patent. The external
and internal iliac arteries are patent. There is stranding about the dominant
aortic aneurysm on the left (3:156), but there is no frank hemorrhage.
Additionally, there is no evidence of end-organ ischemia. The celiac axis,
SMA, renal arteries appear patent. The ___ is filled retrograde to near its
origin, but there is no evidence of type 2 endoleak.
CT CHEST WITH CONTRAST: The thyroid is unremarkable except for a small
hypodense nodule in the right lobe (3:3). There is no supraclavicular or
axillary lymphadenopathy. There are enlarged mediastinal lymph nodes,
predominantly paratracheal, for example, 1.1 cm left lower paratracheal node
(3:38). However, these show normal morphology and are likely reactive. There
is no hilar lymphadenopathy. Moderate cardiomegaly is present. The patient
is status post median sternotomy; sternotomy wires appear intact. There has
been coronary artery bypass. There is a notable change in caliber from the
graft emanating from the ascending aorta as it courses around the left aspect
of the heart (3:52-56). However, this is incompletely evaluated on this
non-gated study. The left atrial appendage appears not completely opacified,
clot cannot be excluded. There are mild emphysematous changes in the lungs.
Small bilateral pleural effusions, left greater than right and interstitial
thickening, most prominent at the lung bases suggests mild pulmonary edema.
Atelectatic lung in the left lower lobe is not enhancing well, this may be
secondary to edema in the setting of chronic atelectasis. The airways are
patent to the subsegmental level.
CT ABDOMEN WITH CONTRAST: The liver enhances normally. A 9 mm hypodensity in
segment VII (3:116) is likely a simple cyst. There is no intra- or
extra-hepatic biliary duct dilation. The gallbladder is normal. The portal
vein is patent. The spleen and adrenals are normal. The pancreas is
atrophic. The kidneys are atrophic. 2.1 cm hypodense focus in the interpolar
region of the left kidney and 3.4 x 3.2 cm exophytic hypodensity at the lower
pole of the left kidney are both compatible with simple cysts. A 4.2 x 4 cm
exophytic hypodensity at the lower pole of the right kidney is also compatible
with a simple cyst.
The stomach, small and large bowel are normal in caliber without obstruction.
There are sigmoid diverticula but no evidence of diverticulitis. There is no
mesenteric or retroperitoneal lymphadenopathy.
CT PELVIS WITH CONTRAST: The urinary bladder and rectum are normal. The
prostate and seminal vesicles are unremarkable. Trace free fluid is noted.
OSSEOUS STRUCTURES: There are degenerative changes in the thoracic spine with
bridging anterior osteophytes but no worrisome sclerotic or lytic lesions. A 7
mm sclerotic focus in the left aspect of the sacrum (3:178) is most likely
degenerative.
IMPRESSION:
1. 8.9 x 8 x 8.7 cm infrarenal abdominal aortic aneurysm with large
communication between the native supra-graft aorta and aneurysm sac and the
native right common iliac artery and the aneurysm sac. Stranding adjacent to
the aneurysm is worrisome for threatened rupture but no evidence of active
hemorrhage.
2. Smaller aneurysm up to 4.5 cm above the graft and 2.2 cm common right
iliac artery aneurysm.
3. Occlusion of the right common iliac graft by thrombus.
4. Caliber change in the coronary artery graft emanating from the ascending
aorta, although incompletely evaluated on this non-gated study.
5. Incomplete opacification of the left atrial appendage, clot cannot be
excluded. Echo may be obtained for further evaluation.
6. Moderate cardiomegaly. Small bilateral pleural effusions and interstitial
thickening likely reflecting pulmonary edema.
7. Mediastinal lymphadenopathy, likely reactive.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: AAA
Diagnosed with ABDOM AORTIC ANEURYSM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Patient was admitted to our institution transferred from outside
hospital given symptomatic abdominal aortic aneurysm. Upon
admission, he was started on an esmolol drip for blood pressure
control. A CTA of his torso was obtained and then patient was
immediately taken to the operating room for endovascular repair.
Given complexity of case, two attendings, Dr ___ Dr
___ in the procedure where he underwent
endovascular aneurysm repair, right external iliac to right
internal iliac stent graft, as well as a left to right
femoral-femoral bypass graft. Procedure went without
complications (please see Operative Note for details). Patient
was transferred from the endovascular suite to the vascular ICU
for further management and postoperative care.
A nitroglycerin drip, labetalol, and hydralazine were
administered to control elevated blood pressures. On POD#0,
patient was kept NPO and on IVF. Given favorable response,
patient was transferred to the intermediate care unit on POD#1.
Diet was slowly advanced and well-tolerated. Hemodialysis was
resumed and scheduled for ___, and ___ as
was at baseline. During the first HD session, patient became
tachycardic to the 160s and hypertensive with systolic blood
pressures to the 200s. ECG was performed and showed no acute
changes. Troponins, although slightly elevated, were trended and
remained unchanged. Patient remained asymptomatic and vital
signs normalized after giving back fluid through hemodialysis.
Foley catheter was removed on this day.
On POD#2, patient complained of abdominal pain and was found to
be tender to palpation. He was put back on sips. Labs remained
unchanged and a lactate was found to be within normal limits.
CXR showed no acute changes. Serial abdominal exams were done
and remained unchanged. By POD#3 the abdominal pain had resolved
and patient was advanced back to a regular diet, which was
well-tolerated. He was encouraged to get out of bed and central
venous line was removed. All his home medications were
restarted. On POD#4, antibiotics were discontinued. Anticipating
discharge, patient was evaluated by our physical therapists who
recommended discharge to a rehabilitation facility. Case
management was involved in the bed-search process and patient
was placed by POD#5, when he was deemed clinically ready to be
discharged.
At the time of discharge, Mr ___ was doing well, afebrile with
stable vital signs. He was tolerating a regular diet, ambulating
with assistance, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___ Coronary Angiogram via left radial arterial access, no
intervention.
History of Present Illness:
___ year-old man with ___ CAD s/p 4v CABG, DMII, HTN/HLD,
hypothyroidism, and GERD who presents w/ 2 months of DOE.
Mr. ___ noticed worsening dyspnea on exertion over the last
two months which has been relatively stable. He can only walk
about ___ yards and <1 flight of stairs before becoming severely
short of breath which he could easily due several months ago. He
denies orthopnea, PND, ___ swelling, weight gain. He further
denies fevers, chills, n/v/d, syncope, or falls. He is a prior
smoker, quit ___ yrs ago, no alcohol, or drugs.
Outpatient evaluation by PCP who per verbal report obtained
unremarkable exercise stress test (confirmed EMR on ___ 1
minute duration, predicted HR % max 79% stopped due to dyspnea,
bassline LBBB, he had no chest pain: None and bigeminy) and CXR.
Of note, he had a bad "chest cold" which was treated ___ with
azithromycin x 5days, and prednisone 10mg which he continues on.
He was treated for sinusitis starting ___ with a ten day course
of amoxicillin. These treatment courses did not change his
dypnea. He has no diagnosis of COPD. He has no occupational
exposures.
In the ED initial vitals were: T: 97.8 HR: 68 BP: 192/76 RR:
20 SO2: 94% RA Exam notable for RRR, loud S1/S2 w/ ___ early
diastolic murmur. Trace peripheral pitting edema
EKG: NSR, LAD, LVH, RBBB, STD in V4-V6, Q waves in III and aVF.
Labs/studies notable for: nl CBC, creatinine 1.0, D-Dimer: 962
proBNP: 935. trop 0.01, CK-Mb 3 x2
CXR: no acute cardiopulmonary process.
Patient was given: no medications
Vitals on transfer: HR 69 BP 143/84 RR 18 O2sat 100% RA
On the floor denies any symptoms. He feels hungry.
Of note, is metoprolol 25mg ER daily was changed to atenolol
50mg
daily in ___.
Past Medical History:
CAD s/p 4v CABG approx. ___ years ago at ___
Diabetes
Hypertension
Dyslipidemia
PAD
Hypothyroidism
GERD
Severe onycholytic nails ___ bilaterally.
Osteoarthritis.
complete rupture of his left quad tendon (___)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Physical Exam:
GENERAL: Well developed, well nourished male in NAD. Oriented
x3. Pleasant.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 5-6 cm.
CARDIAC: well healed midline scar. PMI located in ___
intercostal space, midclavicular line. Regular rate and rhythm.
Normal S1, S2. ___ early diastolic murmur
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace
edema to ankles bilaterally. Venous stasis changes to bilateral
lower extremities.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge Physical Exam: Temp: 97.7, BP: 163/75 (112-163/60-96),
HR: 54 (54-70), RR: 18 (___), O2 sat: 98% (96-98) RA
Wt: 180.7 lb/81.97 kg
General: Alert, no acute distress
Cardiovascular: Regular rate/rhythm
Respiratory: Lungs clear bilaterally, breathing non-labored
Abdomen: Soft, Non-tender, +BS
Extremities: BLE warm/well-perfused, ___ pulses, no ___ edema
Skin: Warm, dry and intact
Neuro: Alert, oriented x 3, appropriate
Access: Left radial TR band access site stable without evidence
of hematoma, radial pulse strong with normal distal CSM
Pertinent Results:
CXR ___: Midline sternotomy wires are noted as well as
mediastinal clips. Overlying EKG leads are present. No focal
consolidation, large effusion or pneumothorax is seen. There is
an eventration of the left hemidiaphragm. No signs of edema.
CTA ___: No evidence of pulmonary embolism to the segmental
level.
EKG ___: NSR, LAD, LVH, RBBB, STD in V4-V6, Q waves in III
and aVF.
ECHOCARDIOGRAM ___: Mild symmetric left ventricular
hypertrophy with mild regional systolic dysfunction most
consistent with coronary artery disease (RCA distribution).
Mildly dilated right ventricle with mild global hypokinesis.
Moderate pulmonary hypertension accounting for increased right
atrial pressure. No prior TTE available for comparison.
CARDIAC PERFUSION PHARM ___:
The patient was administered 0.4 mg of regadenoson IV over 20
seconds. There were no chest, neck, arm or back discomforts
reported by the patient throughout the study. In the setting of
a RBBB with NSSTTWs (0.5-1.0 mm STD inf/V4-6 with
biphasic/inverted T waves) there were no significant ST segment
changes seen during the infusion or in recovery. The rhythm was
sinus with rare isolated ABPs, and occasional isolated VPBs.
Appropriate blood pressure and heart rate responses to the
infusion and in recovery. Post-MIBI, the regadenoson was
reversed with 60 mg/3 mL IV caffeine.
IMPRESSION: No anginal type symptoms or significant ST segment
changes
from abnormal baseline EKG. Appropriate hemodynamic response to
vasodilator stress.
1. Moderate to severe, partially reversible perfusion defect of
the
inferolateral wall.
2. Moderate reversible perfusion defect of the distal anterior
wall.
3. Akinesis of the interventricular septum is likely secondary
to prior CABG. Calculated left ventricular ejection fraction is
45%.
Cardiac Cath ___:
LM: The left main coronary artery is with 30%.
LAD: The left anterior descending coronary artery is heavily
calcified, with 90% mid.
Circ: The circumflex coronary artery is heavily calcified, with
50% mid and 100% distal. OM1 is a small caliber vessel with
diffuse proximal 80-90%. OM2 is small-moderate caliber with
80-90% proximal.
RCA: The right coronary artery is heavily calcified, with 100%
mid. Right-to-right and left-to-right collaterals are present.
LIMA-LAD: A left internal mammary artery to the LAD is widely
patent and provides robust collaterals.
SVG-OM1-OM2: A saphenous vein graft to OM1-OM2 was 100%
occluded.
SVG-RPDA: A saphenous vein graft to the RPDA is 100% occluded.
Findings
Three vessel coronary artery disease.
LIMA-LAD was widely patent.
SVG-OM1-OM2 and SVG-RPDA are occluded.
Recommendations
Maximize medical therapy.
LABS
----
___ 10:54AM BLOOD WBC-7.7 RBC-4.92 Hgb-14.5 Hct-45.9 MCV-93
MCH-29.5 MCHC-31.6* RDW-13.6 RDWSD-45.6 Plt ___
___ 10:54AM BLOOD Neuts-76.9* Lymphs-12.3* Monos-8.0
Eos-1.3 Baso-0.5 Im ___ AbsNeut-5.93 AbsLymp-0.95*
AbsMono-0.62 AbsEos-0.10 AbsBaso-0.04
___ 07:35AM BLOOD WBC-8.5 RBC-5.36 Hgb-15.7 Hct-49.6 MCV-93
MCH-29.3 MCHC-31.7* RDW-13.7 RDWSD-46.0 Plt ___
___ 07:04AM BLOOD WBC-7.7 RBC-4.99 Hgb-14.8 Hct-46.3 MCV-93
MCH-29.7 MCHC-32.0 RDW-13.6 RDWSD-46.2 Plt ___
___ 07:04AM BLOOD ___ PTT-29.9 ___
___ 10:57AM BLOOD D-Dimer-962*
___ 10:54AM BLOOD Glucose-232* UreaN-24* Creat-1.0 Na-142
K-4.7 Cl-105 HCO3-22 AnGap-15
___ 10:54AM BLOOD Calcium-10.0 Phos-4.0 Mg-1.7
___ 07:35AM BLOOD Glucose-122* UreaN-26* Creat-1.0 Na-142
K-4.6 Cl-100 HCO3-29 AnGap-13
___ 07:35AM BLOOD Calcium-10.0 Phos-4.5 Mg-2.4
___ 07:04AM BLOOD UreaN-27* Creat-1.0 Na-139 K-4.4 Cl-102
HCO3-27 AnGap-10
___ 07:04AM BLOOD Cholest-164 Triglyc-188* HDL-60
LDLcalc-66
___ 07:04AM BLOOD %HbA1c-7.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Aspirin 81 mg PO 3X/WEEK (___)
4. Levothyroxine Sodium 100 mcg PO DAILY
5. linagliptin-metformin 2.5-1,000 mg oral BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Pantoprazole 20 mg PO Q24H
8. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Lisinopril 5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Pantoprazole 20 mg PO Q24H
8. HELD- linagliptin-metformin 2.5-1,000 mg oral BID This
medication was held. Do not restart linagliptin-metformin until
___
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Non-Insulin Dependent Diabetes, Type II
Hypertension
Hyperlipidemia
Hypothyroidism
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with DOE// Assess for cardiopulmonary abnormalities
COMPARISON: None
FINDINGS:
AP upright and lateral views of the chest provided.
Midline sternotomy wires are noted as well as mediastinal clips. Overlying
EKG leads are present. No focal consolidation, large effusion or pneumothorax
is seen. There is an eventration of the left hemidiaphragm. No signs of
edema. Bony structures are intact.
IMPRESSION:
No acute findings.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with DOE, elevated Ddimer// Assess for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 511 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Severe coronary artery calcifications. Severe
atherosclerotic calcifications of the descending thoracic aorta. Otherwise,
the heart, pericardium, and great vessels are within normal limits. No
pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Multiple mediastinal nodes are prominent, but
not pathologically enlarged by CT size criteria. There is no axillary or
hilar lymphadenopathy. No mediastinal mass. Surgical clips are seen within
the mediastinum.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Mild, biapical pleuroparenchymal scarring. Mild, bibasilar
atelectasis. Lungs are clear without masses or areas of parenchymal
opacification. Mild bronchial wall thickening of the bilateral lower lobes.
The airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: The right thyroid lobe is asymmetrically enlarged, measuring
approximately 2.5 x 2.3 cm, demonstrating a small focal calcification (03:18).
No discrete thyroid nodule is clearly identified. Otherwise, the visualized
portions of the base of the neck show no abnormality.
ABDOMEN: The esophagus is patulous. Mild circumferential wall thickening of
the distal esophagus, near the gastroesophageal junction, could be sequela of
reflux. A 1 cm right adrenal lesion, demonstrating bulk fat, is likely a
myelolipoma (3:118). Otherwise, included portion of the upper abdomen is
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Median sternotomy wires are in place.
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level.
2. Asymmetrically enlarged right thyroid lobe, demonstrating a small focal
calcification, without discrete nodule identified. Recommend clinical
correlation.
3. 1 cm right adrenal lesion, demonstrating bulk fat, likely a myelolipoma.
4. Other findings, as described above.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion
Diagnosed with Adult failure to thrive
temperature: 97.8
heartrate: 68.0
resprate: 20.0
o2sat: 94.0
sbp: 192.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | ___ with PMH CAD s/p CABG, HTN, HLD & DM2 admitted with DOE
now s/p abnormal nuclear stress and cardiac catheterization with
results as noted. Patient was seen and examined the day of
discharge and plan is below.
# Dyspnea on exertion: s/p outpatient treatment with abx and
prednisone for URI without improvement. Given 20mg IV Lasix on
admission given nocturnal diuresis and elevated BNP. Troponins
negative. P-MIBI ___ showing moderate to severe partially
reversible inf/lat wall defect, moderate reversible distal
anterior wall defect, akinesis of septum & LVEF 45%. Cath with
results as noted.
- Continue Aspirin 81mg daily
- Continue Atorvastatin 80mg daily (changed from Simvastatin)
- Atenolol held for low HR (<55) in AM, BP range 112-163/60-96,
change to Metoprolol Succinate 25mg daily
- Add Lisinopril 5mg daily and check renal labs & lytes ___
- Follow up with Dr. ___ on discharge
#CAD s/p CABG ___: Records from ___ obtained and uploaded to
___ record. Cath w/results as noted.
- Continue regimen as above
#DM2: A1C 7.2. FSBG have been stable.
-Hold Linagliptin-Metformin x48 hours post cath
#HTN: BP ___
-Not getting Atenolol at times due to bradycardia, however still
having elevated BPs. Change to Metoprolol and add Lisinopril as
above.
#HLD: ___ Chol 164 Trig 188 HDL 60 LDL 66
-Home Simvastatin (20mg) changed to Atorvastatin 80mg on admit
given CAD
#Hypothyroidism
-Continue home levothyroxine 100mcg daily
#GERD
-Continue Pantoprazole
#TRANSITIONAL:
*Labs ___ for lytes and renal function post cath & added Ace
Inhibitor
*Please f/u imaging results as noted:
- Asymmetrically enlarged right thyroid lobe, demonstrating a
small focal calcification, without discrete nodule identified.
If
not conducted previously, a non emergent thyroid ultrasound may
be obtained for further evaluation.
- 1 cm right adrenal lesion, demonstrating bulk fat, likely a
myelolipoma. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
___ Diagnostic cerebral angiogram
___ Diagnostic cerebral angiogram
History of Present Illness:
Ms. ___ is a ___ year old right-handed woman with no significant
past medical history who last night around 8pm while she was at
work began feeling dizzy and nauseous, and per a co-worker was
"walking sideways" and almost fell. She felt better when
sitting down, but every time she stood back up her
symptoms would return. She also had a severe headache. She
went to ___, and was discharged from the
ED after a head CT was done. This morning she felt worse and
went back to the ED, where the original CT was re-read as having
a posterior fossa hyperdensity along the left lateral aspect of
the midbrain. A CTA was done that reportedly showed no stenosis
or
occlusion. She was transferred to ___ for further management.
The patient states that since this morning she has felt numbness
in her right arm and leg. This morning her right face also felt
numb, although this has since resolved. She thinks her right
leg is a little weaker as well. She states she has been having
headaches for the past 2 months that are at times severe and
that she treats by taking ___ aspirin (600mg) at a time. These
occur in the evening and have been happening nearly daily
according to
her boyfriend. She has been trying to decrease her use of
aspirin, and thinks she may have had ___ over this past week.
She denies any visual symptoms, other paresthesias or weakness,
tinnitus or hearing problems. Last night she felt that sounds
were abnormally distant sounding but this has since resolved.
She hasn't been able to drink or eat over the past 2 days due to
the nausea and vomiting.
Past Medical History:
hypertension during pregnancy
s/p biopsy of cervical lesion ___ - results were negative
s/p right elbow surgery for fracture
Social History:
___
Family History:
maternal grandfather - died of MI
maternal grandmother - died of breast cancer
father - history of severe MRSA infection
paternal side - two cousins with cancer, unknown type
Physical Exam:
On admission:
PHYSICAL EXAM:
T:99.1 BP: 133/77 HR:106 R 16 O2Sats 100% on RA
WD/WN, comfortable, NAD.
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, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, bilaterally.
Reflexes: 2+ throughout
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Handedness: Right
On discharge:
Neurologically intact
Pertinent Results:
___ Cerebral Angiogram
This diagnostic cerebral angiography confirmed the presence of a
left superior cerebellar artery spontaneous dissection, which
including its second (ambient segment) and first half of the
second (quadrigeminal segment). This is the long dissection
along the superior cerebellar artery and The length of
dissection was measured about 2.5 cm, without focal aneurysmal
formation. We will discuss with the patient regarding different
treatment strategies.
___ CTA head:
Ectasia of the perimesencephalic portion of left superior
cerebellar artery without appreciable intraluminal filling
defect, unchanged from recent cerebral angiogram.
CEREBRAL/RECHECK ___
This diagnostic cerebral angiography showed a stable size and
appearance of previously known left superior cerebellar artery
dissection. No
thromboembolic complication is noted in this diagnostic
cerebellar
angiography. No other vascular abnormality was detected. ___
was consulted for dispo planning.
___ MRI head w/ & w/o contrast
Partially thrombosed dissecting left superior cerebellar artery
aneurysm which
indents the adjacent midbrain-pontine junction, resulting in
mass effect and a
small amount of fluid signal seen within this region.
Medications on Admission:
ASA prn
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth Every 6 hours as needed Disp #*75 Tablet
Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*12
3. Bisacodyl 10 mg PO/PR DAILY Constipation
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 1 tablet(s) by mouth
daily as needed Disp #*30 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours as
needed Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left pontine ICH
Left superior cerebellar artery dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: The patient is a ___ lady with a 2-month history of
headaches, presented with sudden onset of nausea, vomiting and dizziness and
slight tingling and numbness in the right side of the body. Her CT
angiography showed a hyperdense vascular type of lesion in the left
parapontine and CP angle. Her CT angiography showed some vascular
abnormality. She is here for first diagnostic cerebral angiography to
understand the angio architecture of that lesion.
ATTENDING PHYSICIAN: Dr. ___.
ASSISTANT: Dr. ___ and ___, NP.
PROCEDURE PERFORMED: Diagnostic cerebral angiography by catheterization and
injection into the left internal carotid artery, left external carotid artery,
right common carotid artery, left vertebral artery, left vertebral artery spin
angiography and post-processing of the data in a separate workstation under
concurrent physician supervision, we utilized this data for further
interpretation and treatment purposes, and finally right common femoral artery
roadmap angiography.
ANESTHESIA: Moderate conscious sedation was provided by administering divided
doses of Versed and fentanyl during the entire intraservice time of 60
minutes, during which the patient's hemodynamic parameters were continuously
monitored by radiology nurse.
DESCRIPTION OF PROCEDURE: After describing the procedure, rationale, risks,
and benefits of this procedure, the patient was brought to the radiology unit
and was transferred to the radiology table. Under moderate conscious sedation
as described above, at supine position, after prepping and draping bilateral
groin, access to the right common femoral artery was obtained using modified
Seldinger technique. A ___ sheath was inserted into the right common
femoral artery. This was connected to a continuous heparinized saline. We
used a 4 ___ Berenstein 2 catheter over a 0.038-inch Terumo wire for
catheterization and injection into the left internal and external carotid
arteries, right common carotid artery, left vertebral artery. After obtaining
adequate images in AP and lateral and oblique projections, we finally
performed left vertebral artery, spin angiogram and data was post-processed in
a separate workstation under the concurrent physician ___. The 3D
reconstruction data was utilized for further understanding interpretation of
this vascular abnormalities. After obtaining adequate images, the catheter
was removed and after obtaining a right common femoral artery roadmap
angiography, the femoral sheath was removed and hemostasis of the groin was
achieved using 20 minutes manual compression.
FINDINGS: The left common carotid roadmap angiography shows carotid
bifurcation unremarkable. Selective left ICA injection showed very well
opacification of its upper cervical, cavernous and supraclinoid segments along
with finally MCA and ACA branches, without any aneurysm, AVM or other vascular
abnormalities. The capillary and venous phase of this cerebral angiography is
also within normal limits
Selective left external carotid artery angiography shows very well
opacification of its cervical, and finally cranial branches including
occipital, superficial temporal and middle meningeal artery without any
participation into any dural AV fistula or other vascular abnormalities. The
capillary and venous phase of this cerebral angiography is also within normal
limits.
Right common carotid artery roadmap angiography shows carotid bifurcation
unremarkable. There is also very well opacification of its cervical and
intracranial branches including external and internal carotid artery final
branches. The internal carotid artery shows very well opacification of its
upper cervical, petrous, cavernous and supraclinoid segments and finally ACA
and MCA branches, without any aneurysm, AVM or other vascular abnormalities.
The external carotid artery branches also including occipital, superficial
temporal artery and middle meningeal arteries are all within normal limits in
terms of caliber and also shape.
Overall, there is no vascular abnormality in this territory.
Left vertebral artery injection showed very well opacification of its V1-V4
segments along with ___, AICA, superior cerebellar artery and PCA branches.
The left superior cerebellar artery has distracted about 1 cm after
originating from the basilar artery and form a long segment of dissection
including its second (ambient segment) and first half of the second
(quadrigeminal segment.It looks like irregular shape all the way to the third
segment.
No aneurysmal formation or extravasation of the contrast is seen. No other
vascular abnormality is also noted in this cerebral angiography.
The 3D spin angiography of the left vertebral artery injection shows the left
superior artery dissection very well along its second and third segments. No
other vascular abnormality was noted. There is no aneurysmal outpouching is
seen in this angiography.
Finally, the right common femoral artery roadmap angiography showed no
evidence of dissection or vascular injury. The puncture site is proximal to
the bifrontal bifurcation and opposite to the head of the femur.
CONCLUSION:
This diagnostic cerebral angiography confirmed the presence of a left superior
cerebellar artery spontaneous dissection, which including its second (ambient
segment) and first half of the second (quadrigeminal segment). This is the
long dissection along the superior cerebellar artery and The length of
dissection was measured about 2.5 cm, without focal aneurysmal formation. We
will discuss with the patient regarding different treatment strategies.
No procedure-related thromboembolic complication was noted. The patient
remained neurologically intact after this procedure.
Dr. ___ attended and performed this procedure with his fellow
during the entire stages of this procedure.
___, M.D.
Clinical Fellow for ___, M.D.
I, ___, personally attended and performed this procedure with my
fellow, ___, M.D., during the entire stages of this procedure. I
also read and reviewed all images in this exam and personally confirm all key
elements of this dictation and I corrected all errors.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ year old woman with superior cerebellar artery dissection,
evaluate superior cerebellar artery dissection.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered, curved
reformatted and segmented images were generated. This report is based on
interpretation of all of these images.
DOSE: DLP: 2514.48 mGy-cm; CTDI: 232.92 mGy
COMPARISON: Outside hospital head CT dated ___, and bilateral
carotid/cerebral arteriogram dated ___.
FINDINGS:
Head CT: Unchanged or minimally decreased hyperdensity in left
perimesencephalic region corresponding to ectatic vessels seen on CTA. There
is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The
ventricles and sulci are normal in caliber and configuration. No fractures are
identified. A mucous retention cyst is seen within the right maxillary sinus.
Head CTA: The perimesencephalic left superior cerebellar artery is ectatic
beginning approximately 1 cm from its origin off of the distal vertebral
artery and spanning a distance of approximately 2.5 cm without appreciable
intraluminal filling defect. The degree and extent of dilatation is unchanged
from recent cerebral angiogram. No other vascular abnormalities are
appreciated. No evidence of occlusion, aneurysm, or flow limiting stenosis.
Neck CTA: The carotid and vertebral arteries and their major branches are
patent with no evidence of stenoses. There is no evidence of internal carotid
stenosis by NASCET criteria. The lung apices demonstrate mild dependent
atelectasis.
IMPRESSION:
Ectasia of the perimesencephalic portion of left superior cerebellar artery
without appreciable intraluminal filling defect, unchanged from recent
cerebral angiogram.
Radiology Report
CLINICAL HISTORY: Patient is ___ lady who presented with sudden onset
of left-sided headaches and dizziness and numbness in the right side of her
body. Her first diagnostic cerebral angiography confirmed the presence of a
left superior cerebellar artery dissection. This is a second one week
post-onset diagnostic cerebral angiography for checking patient's
angiographic status.
ATTENDING PHYSICIAN: Dr. ___.
ASSISTANT: Dr. ___.
PROCEDURE PERFORMED: Diagnostic cerebral angiography by catheterization and
injection into the left vertebral artery, left vertebral artery spin
angiography and post-processing of the data in a separate workstation under
concurrent physician supervision and utilizing data for further interpretation
and treatment purposes, right common femoral artery roadmap angiography and
hemostasis of the groin using manual compression.
ANESTHESIA: Moderate conscious sedation was provided by administering divided
doses of Versed and fentanyl during the entire intraservice time of 40 minutes
during which the patient's hemodynamic parameters were continuously monitored
by the radiology nurse.
DESCRIPTION OF PROCEDURE: After describing the procedure, risks and benefits
and the rationale, the patient signed a consent form. Under moderate
conscious sedation in supine position, after prepping and draping bilateral
groins, access to the right common femoral artery was obtained using a
modified Seldinger technique and a micropuncture set. A ___ sheath was
inserted into the right common femoral artery, and it was connected to a
continuous heparinized saline. We used a 4 ___ Berenstein catheter over a
0.038-inch Terumo wire and got access into the left vertebral artery, and by
injecting into the left vertebral artery, an AP, lateral and spin angiography
was performed. The data was post-processed in a separate workstation with
concurrent physician supervision and utilizing 3D reconstruction data for
further interpretation and treatment purposes. After obtaining adequate
images, the catheter was removed, and after obtaining a right common femoral
artery roadmap angiography, the hemostasis of the groin was achieved using by
about 17 minutes of manual compression.
This procedure was accomplished uncomplicated, and the patient remained
neurologically intact afterwards.
Dr. ___ attended and performed this procedure with me during the
entire stages of this procedure.
FINDINGS:
The left vertebral artery selective angiography confirmed very well
opacification of the V1-V4 segments along with ICA and superior cerebellar
artery which is in the left side, showed a long segment dissection of its
second and third segments and finally the PCA branches. In comparison to
previous diagnostic cerebral angiography and spin angiography, this dissection
has not got worse and has remained stable in shape and length and appearance.
We are able to see the very distal terminal branches of the superior
cerebellar artery in both sides which means patency of the lumen of this
artery. No procedure-related thromboembolic complication was noted.
The 3D reconstruction data also helped us for further interpretation and
determining the treatment planning.
The right common femoral artery roadmap angiography also showed sizeable
artery with puncture site beyond the bifurcation, across the neck of the
femoral bone.
CONCLUSION:
This diagnostic cerebral angiography showed a stable size and appearance of
previously known left superior cerebellar artery dissection. No
thromboembolic complication is noted in this diagnostic cerebellar
angiography. No other vascular abnormality was detected.
I, Dr. ___, personally attended and performed this procedure with my
fellow during the entire stages of this procedure. I also read and reviewed
all images in this exam and personally agree and confirmed all key elements of
this dictation and corrected all errors.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with L SCA ?dissection; c/o HA, N/V, transient
R hemibody numbness + weakness // L SCA ?dissection; please include T1
sequences
TECHNIQUE: Multiplanar, multisequence MR images of the brain were obtained
before and after the administration of intravenous contrast.
COMPARISON: CT of the head dated ___.
FINDINGS:
Tee left superior cerebellar artery appears aneurysmally dilated. Within this
artery there is a rounded region of curvilinear enhancement with an adjacent
semilunar shaped region of low signal on post-contrast images (101:71) which
is consistent with a partially thrombosed dissecting left superior cerebellar
artery aneurysm. This aneurysm indents the adjacent midbrain-pontine
junction, resulting in mass effect with a small amount of fluid signal seen
within this region.
There is no intracranial hemorrhage. Diffusion weighting imaging does not
demonstrate evidence of acute infarct. The remaining major intracranial
vessels exhibit the expected signal void related to vascular flow. Gray white
matter differentiation is maintained. Ventricles and extra axial CSF spaces
are within normal limits.
There is no abnormal parenchymal, leptomeningeal, or dural focus of
enhancement. The sella turcica, craniocervical junction, and orbits are
unremarkable. The paranasal sinuses and mastoid air cells demonstrate normal
signal.
IMPRESSION:
Partially thrombosed dissecting left superior cerebellar artery aneurysm which
indents the adjacent midbrain-pontine junction, resulting in mass effect and a
small amount of fluid signal seen within this region.
These findings were discussed with ___ by Dr. ___ telephone
at 5:25 on ___, 15 minutes after discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, HEADACHE ABNORMAL HEAD CT.
Diagnosed with INTRACEREBRAL HEMORRHAGE, HEADACHE
temperature: 99.1
heartrate: 106.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 77.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ was evaluated in the ER by Neurosurgery and admitted to
the ICU with a left pontine ICH. She remained intact
neurologically. On ___ she was taken to the Angio suite for a
diagnostic cerebral angiogram which showed a left superior
cerebellar artery dissection. Post-angio she was transferred to
the ICU. She continued ASA 325mg. In the evening she had two
episodes of SVT to the 180s which were likely related to
anxiety.
On ___ she remained stable and was awaiting furhter care
planning. HEr BP goals remained less than 130 systolic and her
neuro exam was stable
On ___ she underwent a CTA which showed stable left superior
cerebellar artery. her blood pressure remained within the
appropriate window and her neurologic exam was stable.
On ___, A physical and occupational therapy consultation was
placed. The patients foley catheter will discontinued.
increased activity. On exam the patient was neurologically
intact.
On ___, The patient was neurologically stable.
On ___, the patient remained stable on neurologic examination.
Her Ativan was changed from IV to PO for anxiety control.
On ___, the patient remained neurologically stable on
examination.
On ___, the patient remained neurologically stable on
examination. She was consented for an angiogram the following
day. She was made NPO after midnigt.
On ___, the patient remained neurologically stable. She
underwent a diagnostic angiogram which showed stable SCA
dissection.
On ___, patient was stable on exam. Blood pressure was
liberalized and she was transferred to the floor. Neuro stroke
was consulted for further management of SCA dissection. On ___
she remained stable and continued to c/o headache.
On ___ she was seen and evaluated and deemed fit for discharge.
Prior to discharge all treatment options were discussed with the
patient including open clipping. Her case was discussed at
length with Neurosurgical experts across the country and after
weighing all risks and benefits of the options, conservative
management was decided to be the best course of action. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transfer for acute leukemia
Major Surgical or Invasive Procedure:
Bone marrow biopsy
Bone marrow biopsy
History of Present Illness:
This is a ___ year old woman with a history of breast cancer s/p
lumpectomy, sentinel node biopsy, XRT on tamoxifen who presents
to OSH with 12 days of sore throat, 2 days of dizziness, who was
found to have a leukocytosis concerning for acute leukemia. She
was transferred to the ___ for further evaluation.
On arrival to the ED, her vitals were Temp: 98.3 HR: 80 BP:
117/66 Resp: 18 O(2)Sat: 95 Normal. She was complaining of
severe
dizziness and the sensation that the room was spinning. She was
vomiting. She was admitted for urgent leukopheresis.
On the floor, she underwent an urgent bone marrow biopsy,
received allopurinol, 2g hydroxyurea x2, and leukopheresis. She
continued to complain of dizziness and nausea, and had a head CT
which was normal.
ROS was notable for loss of appetite, nausea, vomiting, and
dizziness, and was otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
R breast cancer, s/p lumpectomy, sentinel node biopsy, XRT on
tamoxifen.
PAST MEDICAL/SURGICAL HISTORY:
Osteopenia
Social History:
___
Family History:
to be assessed
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.5 BP 122 / 64 78 20 95 Ra
Gen: Vomiting and unfomfortable
HEENT: No conjunctival pallor. No icterus. MMM.
LYMPH: without lymphadenopathy
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: PIV
DISCHARGE PHYSICAL EXAM:
GENERAL: She is afebrile.
HEENT: Moist oral mucosa, no thrush, no oral ulcerative
lesions.
LUNGS: Clear to auscultation.
HEART: Sounds normal.
ABDOMEN: Soft, nontender, no palpable hepatosplenomegaly or
masses.
EXTREMITIES: No leg swelling.
Pertinent Results:
ADMISSION
___ 03:06AM BLOOD WBC-171.7* RBC-2.39* Hgb-8.5* Hct-25.9*
MCV-108* MCH-35.6* MCHC-32.8 RDW-15.6* RDWSD-61.7* Plt Ct-37*
___ 03:06AM BLOOD Neuts-0* Bands-0 Lymphs-5* Monos-7 Eos-0
Baso-0 ___ Myelos-0 Blasts-88* Other-0 AbsNeut-0.00*
AbsLymp-8.59* AbsMono-12.02* AbsEos-0.00* AbsBaso-0.00*
___ 03:06AM BLOOD Hypochr-NORMAL Anisocy-1+*
Poiklo-OCCASIONAL Macrocy-3+* Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 04:29AM BLOOD ___ PTT-33.7 ___
___ 04:29AM BLOOD ___
___ 12:00AM BLOOD WBC-0.2* Lymph-100* Abs ___ CD3%-91
Abs CD3-181* CD4%-73 Abs CD4-146* CD8%-17 Abs CD8-33*
CD4/CD8-4.36*
___ 08:00AM BLOOD Fact V-27* FactVII-64* FacVIII-174
___ 03:06AM BLOOD Glucose-124* UreaN-6 Creat-0.6 Na-136
K-4.3 Cl-99 HCO3-22 AnGap-15
___ 03:06AM BLOOD ALT-268* AST-155* LD(LDH)-1013*
CK(CPK)-81 AlkPhos-99 TotBili-0.4 DirBili-<0.2 IndBili-0.4
___ 03:06AM BLOOD Albumin-3.7 Calcium-8.0* Phos-3.1 Mg-2.1
___ 05:18AM BLOOD VitB12-1839* Folate->20 Hapto-58
___ 10:10AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 10:10AM BLOOD HIV Ab-NEG
___ 10:10AM BLOOD HCV Ab-NEG
PERTINENT IMAGING/RESULTS
___ Cytogenetics Blood
CYTOGENETIC DIAGNOSIS: 46,XX,inv(16)(p13.1q22)[20]
___ Myeloid sequencing
C-kit negative
___ CT head
negative
CXR ___
INDICATION: ___ year old woman with AML with new hypoxemia and
cough// PNA
TECHNIQUE: Frontal radiograph of the chest.
COMPARISON: None.
IMPRESSION:
Left-sided IJ catheter is seen with tip projecting of the
superior SVC.
Opacity at the right lung base could represent infection in the
proper
clinical setting. Alternatively this could represent radiation
changes.
Correlate with timing and location of breast radiation.
Cardiomediastinal silhouette is within normal limits. No
pneumothorax or
pleural effusion.
Linear metallic densities projecting over the right lung base
likely represent fiducial markers, possibly within the right
breast. Clinical correlation recommended.
CT Chest w/o contrast ___
IMPRESSION:
Scattered multifocal ground-glass opacity predominantly within
the right lower
and middle lobes, minimally in the right upper lobe, likely
infectious. Given
neutropenia, atypical organisms should be considered. No lobar
pneumonia.
___ BM biopsy
DIAGNOSIS:
MARKEDLY HYPOCELLULAR BONE MARROW CONSISTENT WITH
CHEMOABLATION; SEE
NOTE.
Note: Only rare blasts and eosinophil precursors are seen on the
aspirate smears. The core biopsy
fragments are markedly hypocellular and do not contain a
discrete blast infiltrate. The findings are in
keeping with chemoablation. Correlation with clinical, flow
cytometry (see separate report
___ and cytogenetics (see separate report ___
findings is recommended.
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-2.1* RBC-2.50* Hgb-7.7* Hct-23.8*
MCV-95 MCH-30.8 MCHC-32.4 RDW-17.2* RDWSD-57.1* Plt ___
___ 12:00AM BLOOD Neuts-32* Bands-1 ___ Monos-35*
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-3* Blasts-1* NRBC-1*
AbsNeut-0.69* AbsLymp-0.57* AbsMono-0.74 AbsEos-0.00*
AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-104* UreaN-8 Creat-0.4 Na-139
K-4.0 Cl-100 HCO3-29 AnGap-10
___ 12:00AM BLOOD ALT-59* AST-46* LD(LDH)-181 AlkPhos-70
TotBili-0.2
___ 12:00AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.0 Mg-2.2
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with acute leukemia, thrombocytopenia, severe
leukocytosis, and dizziness concerning for leukostatis// bleed, leukostatsis
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous 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: Noncontrast head CT from the ___ at 0137.
FINDINGS:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass effect. The ventricles and sulci are normal in size and
configuration. Left basal ganglia calcifications noted incidentally.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality on contrast head CT. Specifically, no
intracranial hemorrhage or large territorial infarct.
Radiology Report
INDICATION: ___ year old woman with acute leukemia needing urgent access, last
plt 22 just got transfusion// please place temp triple lumen access line for
chemotherapy ideally today, if not, first thing tomorrow, ___ aware
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___, attending radiologist, performed
the procedure.
ANESTHESIA: .05 mg of midazolam was administered 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: Versed, Lidocaine
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 52 seconds, 2.52 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.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath.
The Nitinol wire was removed and a short ___ wire was advanced into the IVC.
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. Final spot fluoroscopic
image demonstrating good alignment of the catheter and no kinking. The patient
tolerated the procedure well without immediate complications.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image showing triple
lumen central venous catheter with catheter tip terminating in the distal
superior vena cava.
IMPRESSION:
Successful placement of a temporary triple lumen catheter via the left
internal jugular venous approach. The tip of the catheter terminates in the
distal superior vena cava. The catheter is ready for use.
Radiology Report
INDICATION: ___ year old woman with AML with new hypoxemia and cough// PNA
TECHNIQUE: Frontal radiograph of the chest.
COMPARISON: None.
IMPRESSION:
Left-sided IJ catheter is seen with tip projecting of the superior SVC.
Opacity at the right lung base could represent infection in the proper
clinical setting. Alternatively this could represent radiation changes.
Correlate with timing and location of breast radiation.
Cardiomediastinal silhouette is within normal limits. No pneumothorax or
pleural effusion.
Linear metallic densities projecting over the right lung base likely represent
fiducial markers, possibly within the right breast. Clinical correlation
recommended.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with aml abnormal lft's// eval of abnormal
lft's
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 a hyper echogenic focus along the margin of the
right lobe of the liver measuring 1.1 x 1.1 x 1.2 cm, which may represent
invagination of the intra-abdominal fat versus a hemangioma. The main portal
vein is patent with hepatopetal flow. There is no ascites. Small bilateral
pleural effusions are noted.
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 head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 10.5 cm.
KIDNEYS: The right kidney measures 11.7 cm. The left kidney measures 11.3 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. Simple cyst in the upper pole of the left kidney measures 1.1 x
1.0 x 0.9 cm. Otherwise, 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. 1.2 cm hypoechogenic focus along the margin of the right lobe of the liver,
possibly representing a hemangioma or focal invagination of intra-abdominal
fat. Otherwise, unremarkable liver.
2. Small bilateral pleural effusions.
3. No splenomegaly.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with AML and new ___ swelling// 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 woman with neutropenia and cough// eval for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Parenchymal mass in the right lower lobe has resolved and most likely
represented atelectasis. Left-sided central line projects to the SVC.
Cardiomediastinal silhouette is stable. Surgical clips are seen over the
right lower chest. No pneumothorax is seen. There are no pleural effusions.
Cardiomediastinal silhouette is stable.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with neutropenia, persistent cough and coarse
lung exam// PNA, leukostasis changes
TECHNIQUE: Multi detector axial CT images of the thorax without intravenous
contrast. Coronal and sagittal reformats.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 35.9 cm; CTDIvol = 5.4 mGy (Body) DLP = 188.8
mGy-cm.
Total DLP (Body) = 189 mGy-cm.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
LUNGS AND AIRWAYS: Patchy foci of ground-glass density within the right lower
and middle lobes, minimally in the right upper ___ be
infectious/inflammatory. No lobar pneumonia. Left basal atelectasis. The
tracheobronchial tree is patent.
PLEURA/PERICARDIUM: Trace bilateral pleural effusions. No pericardial
effusion.
MEDIASTINUM: No hilar or mediastinal adenopathy.
HEART AND VESSELS: No cardiomegaly. There is a left-sided central venous
catheter in situ. The aorta and major vessels to the neck are unremarkable.
The main pulmonary trunk is normal in caliber. No evidence of right
ventricular strain.
ESOPHAGUS AND NECK: Unremarkable.
BONES AND SOFT TISSUES: No suspicious osseous or soft tissue lesion.
IMPRESSION:
Scattered multifocal ground-glass opacity predominantly within the right lower
and middle lobes, minimally in the right upper lobe, likely infectious. Given
neutropenia, atypical organisms should be considered. No lobar pneumonia.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Nausea, Transfer
Diagnosed with Acute lymphoblastic leukemia not having achieved remission, Dizziness and giddiness
temperature: 98.3
heartrate: 80.0
resprate: 18.0
o2sat: 95.0
sbp: 117.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old woman with PMH most significant for R
breast cancer s/p lumpectomy and XRT on tamoxifen who presents
with leukocytosis, found to have inversion 16 AML, started on
7+3
# AML with inversion 16
Pt presents with dizziness and nausea and was found to have
leukocytosis intitially to 189k. She underwent urgent
lekopheresis and was initiated on hydroxyurea and allopurinol.
Serologies consistent with hepatitis B vaccination.
Hep C and HIV negative. G6PD negative. She was initiated on 7+3.
She was started on acyclovir and posaconazle prophylaxis. In the
setting of c/f PNA as below, started on cefepime and vanc, vanc
d/c'ed, cefepime stopped I/s/o new rash, held abx for 1 day with
uptredning temperature (no true fevers), so was started on
meropenem for febrile neutropenia coverage. Meropenem continued
until ___ then switched to levofloxacin for planned 7 day
course given prior GGOs seen on imaging. Patient's ANC began to
recover by day 25, discharge ANC 672.
# Hypoxemia, resolved, c/f infiltrate on CXR, cough, resolved.
Suspect pulmonary leukostasis vs PNA. Pt started on cefepime and
vancomycin empirically, vancomycin discintinued. Cough resolved.
Cefepime was stopped I/s/o new rash, held abx for 1 day with
uptrending temperature, so was started on meropenem for febrile
neutropenia coverage. As above transitioned to levofloxacin on
___, with plans to continue for likely 7 days, but to be
discussed in oncology follow-up appointment.
#Nausea
Fairly well controlled with Phenergan earlier in course, had
some acute worsening and was given fosaprepitant and started on
olanzapine BID PRN with improvement.
#Rash
Morbilliform, abdomen and back, possibly related to cefepime
which was stopped, and rash resolved.
# H/o Breast cancer, s/p lumpectomy and radiation. Tamoxifen
held in the setting of 7+3.
# H/o hemorrhoids with rectal bleeding: Applied low dose steroid
cream and lidocaine cream for symptomatic management. Had
intermittent BRB on TP, but otherwise was asymptomatic.
# Elevated transaminases
Hepatitis serologies consistent with vaccination. Suspect
leukemic involvement. Trended down with treatment of leukemia.
# Coagulopathy, resolved
Suspect elevated INR in the setting of poor PO intake, gave some
vitamin K. DIC less likely in setting of nl fibrinogen. Resolved
with vitamin K.
Transitional Issues
===================
[]Tamoxifen held in the setting of 7+3. Likely should continue
to hold while undergoing consolidation therapy.
[]continue levofloxacin for 7 days post discharge (last day
___
# CODE: Full code with limited trial of life sustaining therapy.
# EMERGENCY CONTACT:
Name of health care proxy: ___
Relationship: 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:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ ___ year-old gentleman with a PMH of CAD s/p DES in
___ LAD (___) and hyperlipidemia, now presenting with
numbness and tingling across his left chest and left arm.
Symptoms began this morning at 10 am. He also reports some
discomfort radiating to the back of his shoulder. This feels
different than his prior MI which hurt much worse. He denies any
nausea, vomiting or diaphoresis. He denies any amerliorating or
exacerbating factors, and denies any worsening with exertion. No
shortness of breath, no calf tenderness, or recent travel. No
cough, sore throat or congestion. No focal neuro symptoms, and
no rash. He thinks that his symptoms might be similar to reflux
since it seems to move up his throat, but has no history of
GERD. He took aspirin 325 mg at home prior to presentation. In
the ambulance, he received nitroglycerin without much
improvement of his symptoms.
In the ED, initial vitals were: 97.6 63 124/79 16 97%. Labs were
remarkable for: H/H 13.1/37.5; troponin T < 0.01 (at 18:00),
D-dimer < 150. Patient received famotidine 20 mg PO. EKG was not
logged but reportedly showed NSR, with T wave inversions in III,
which were old. After discussion with the Atrius attending,
patient was admitted for stress-MIBI or exercise stress Echo.
Prior to transfer, vital signs were: 97.7 79 131/77 18 98% RA.
On arrival to the floor, patient is chest pain free. His pain
resolved while in the ED although patient is not sure what made
the difference.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: None. Last glucose ___: 100; ___
Cholesterol 233, but fasting 149. Baseline BP around 110/80.
2. CARDIAC HISTORY: none.
3. OTHER PAST MEDICAL HISTORY:
Depression
Hemorrhoids
Social History:
___
Family History:
Father: ___ disease, Sister: bipolar disorder.
Physical Exam:
Admission Physical Exam:
VS:97.9 118/69 58 16 98% RA
General: well appearing, NAD
HEENT: MMM
Neck: supple, no JVD
CV: RRR, no m/g/r
Lungs: CTAB
Abdomen: soft NT, ND
Ext: no c/c/e
Skin: no rashes or lesions
(unchanged at discharge)
Pertinent Results:
ADMISSION LABS:
___ 06:10PM BLOOD WBC-5.1 RBC-4.34* Hgb-13.1* Hct-37.5*
MCV-86 MCH-30.2 MCHC-35.0 RDW-13.0 Plt ___
___ 06:10PM BLOOD Neuts-65.2 ___ Monos-6.8 Eos-0.7
Baso-0.6
___ 06:10PM BLOOD ___ PTT-34.8 ___
___ 06:10PM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-106 HCO3-24 AnGap-12
CARDIAC LABS:
___ 02:45AM BLOOD CK(CPK)-83
___ 06:10PM BLOOD cTropnT-<0.01
___ 02:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:38AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:02PM BLOOD D-Dimer-<150
CXR ___: Frontal and lateral views of the chest were
obtained. There is minimal left base atelectasis. No focal
consolidation is seen. There is no pleural effusion or
pneumothorax. Slight prominence of the left hilum on the
frontal view without correlates on the lateral view is stable.
The cardiac and mediastinal silhouettes are stable and
unremarkable. On the lateral view, there may be a slight
obscuration of the retrosternal clear space with a 2.5 x 1.8 cm
opacity. However, this appears to be artifactual as on the
second lateral view it is no longer present.
Stress test ___:
INTERPRETATION: This ___ year old man with h/o HLD; s/p LAD stent
in
___ was referred to the lab for evaluation of chest and left
arm pain.
The patient exercised for 9.5 minutes of ___ protocol (~
___ METS),
representing an average exercise tolerance for his age. The test
was
stopped due to fatigue. No chest, neck, back, or arm discomforts
were
reported by the patient throughout the study. There were no
significant
ST segment changes throughout the study. The rhythm was sinus
with no
ectopy throughout the study. Appropriate blood pressure response
to
exercise. Blunted heart rate response to exercise.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Blunted
heart rate response to exercise. Average exercise tolerance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Citalopram 20 mg PO QHS
3. LaMOTrigine 150 mg PO QHS
4. Aspirin EC 325 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Perphenazine 4 mg PO DAILY
7. Simvastatin 40 mg PO QHS
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Citalopram 20 mg PO QHS
4. LaMOTrigine 150 mg PO QHS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Perphenazine 4 mg PO DAILY
7. Simvastatin 40 mg PO QHS
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Clopidogrel 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Chest pain.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
minimal left base atelectasis. No focal consolidation is seen. There is no
pleural effusion or pneumothorax. Slight prominence of the left hilum on the
frontal view without correlates on the lateral view is stable. The cardiac
and mediastinal silhouettes are stable and unremarkable. On the lateral view,
there may be a slight obscuration of the retrosternal clear space with a 2.5 x
1.8 cm opacity. However, this appears to be artifactual as on the second
lateral view it is no longer present.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS, HYPERCHOLESTEROLEMIA
temperature: 97.6
heartrate: 63.0
resprate: 16.0
o2sat: 97.0
sbp: 124.0
dbp: 79.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ year-old gentleman with a PMH of CAD s/p DES
to proximal LAD (___) and hyperlipidemia, admitted with
numbness and tingling across his left chest and left arm.
# Chest numbness/tingling: The patient was admitted with chest
numbness/tingling, responsive to morphine and GERD regimen. ED
testing ruled out pulmonary embolism with low D-dimer and
pneumonia with normal CXR. Though atypical for cardiac chest
pain, the patient was admitted for a stress test in light of his
history of CAD. He had no EKG changes or elevation in cardiac
enzymes. Exercise treadmill test demonstrated a blunted heart
rate response, though was able to exercist to 10.5 mets without
symptoms or EKG changes. The patient was continued on home
aspirin, metoprolol, and simvastatin.
# Hyperlipidemia: Chronic. the patient was continued on home
simvastatin.
# Depression: Chronic. The patient was continued on home
bupropion and citalopram.
TRANSITIONAL ISSUES:
Patient to follow up with his outpatient cardiologist |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Acute Urinary Retention
Heroin/Cocaine Withdrawal
Major Surgical or Invasive Procedure:
___ Catheter placement
History of Present Illness:
Mr. ___ is a ___ with a history of ongoing IVDA, previous
gunshot wound now s/p nephrectomy/CCY/appy, HTN, and mood
disorder NOS presenting with 5 days of urinary retention. Per
his report, he has not voided more than a few drops and notes
dysuria. He has a history of BPH, and gives a history of similar
report ___ years ago in ___ that improved with prescription
of doxazosin. He has not been taking any of his medicine for the
past 5 days, and describes escalating use of IV heroin and
cocaine (mixed) with up to 2g heroin and 1g cocaine daily.
.
Accompanying the retension, he notes subjective fevers and
violent shaking chills for 5 days. His abdomen is diffusely
painful with a constant, sharp, nonradiating pain. Denies
rashes, N/V/D. No nodules on the fingers or toes.
.
He mentions suicidal ideation over the past 5 days, coinciding
with increasing drug use. No active plan, though attempted once
before by cutting the wrist longitudinally.
In the ED, initial VS: 97.4 81 181/90 18 100% RA. His urine
tested positive for opiates and cocaine. A CT abd/pelvis was
unremarkable. Foley placed with 400cc urine output. UA sent
without suggestion of infection. Was then admitted to medicine.
.
On arrival to the medicine floor, his initial vitals were T97.2
BP134/86 P75 RR16 Sat97RA. He is comfortable. Abd pain at ___.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
-Hypertension
-s/p gunshot wound necessitating ex. lap, nephrectomy,
cholecystectomy, and appendectomy
-IVDA
.
PSYCHIATRIC HISTORY:
- Dx: Opiate dependence, cocaine abuse, mood disorder NOS
- Hospitalizations: Multiple, patient not sure of number, most
recently spent a couple days in CSU in ___
- SA/SIB: Per ___ records, SA ___ yrs ago by OD on 20 Klonopin,
SIB of superficial cutting in teenage. Reports intentional
heroin/cocaine OD 2.5 mos ago, required Narcan, in records
reported as accidental.
- Med trials: Wellbutrin, Zyprexa, Clonidine, Trazodone, Celexa,
Seroquel, Gabapentin, Zoloft, Elavil, Vistaril, Depakote -
unsure
if any were helpful, apparently had inadequate trials due to
drug
use and nonadherence
- No outpatient psychiatrist or therapist. Past treatment at
___
Social History:
___
Family History:
Multiple family members with psychiatric disorders and substance
abuse problems.
Physical Exam:
ADMISSION EXAM
VS - T97.2 BP134/86 P75 RR16 Sat97RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI,
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no RRW
HEART - RRR, normal S1 S2, no murmurs were auscultated
ABDOMEN - diffuse discomfort to palpation, soft and no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no osslers or janeways, no spiders, no rashes
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout,
DISCHARGE EXAM
Afebrile, VSS
Gen: AOx3, NAD, no s/s of withdrawal
Lungs: CTAB, crackles at bases cleared with cough
Heart: RRR, no murmurs
Abd: soft, slight TTP in RLQ, no rebound/guarding, +BS
Ext: no edema
Pertinent Results:
ADMISSION LABS
___ 06:30PM BLOOD WBC-5.4 RBC-4.62 Hgb-14.3 Hct-40.6 MCV-88
MCH-31.0 MCHC-35.2* RDW-12.8 Plt ___
___ 06:30PM BLOOD Neuts-52.7 ___ Monos-6.8 Eos-2.8
Baso-1.0
___ 06:30PM BLOOD ___ PTT-31.5 ___
___ 06:30PM BLOOD Glucose-119* UreaN-13 Creat-1.0 Na-138
K-3.3 Cl-101 HCO3-23 AnGap-17
___ 06:30PM BLOOD ALT-20 AST-33 LD(LDH)-250 AlkPhos-59
Amylase-94 TotBili-1.2
___ 06:30PM BLOOD Lipase-32
___ 06:30PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD Calcium-10.0 Phos-3.8 Mg-1.9
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
___ 08:00AM BLOOD WBC-3.9* RBC-4.27* Hgb-13.5* Hct-38.2*
MCV-90 MCH-31.6 MCHC-35.3* RDW-13.0 Plt ___
___ 08:15AM BLOOD Neuts-59.7 ___ Monos-5.0 Eos-3.6
Baso-0.9
___ 08:15AM BLOOD ___ PTT-31.0 ___
___ 08:00AM BLOOD Glucose-106* UreaN-19 Creat-1.1 Na-138
K-4.1 Cl-104 HCO3-27 AnGap-11
___ 08:00AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.9
CT Abd:
IMPRESSION: No CT explanation for patient's pain. Specifically,
no
obstruction as clinically queried.
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal BID (2 times a day) as needed for congestion.
Disp:*2 unit* Refills:*0*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
10. quetiapine 200 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
Disp:*30 packet* Refills:*0*
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing: Please ask pharmacist to
demonstrate inhaler use.
Disp:*1 inhaler* Refills:*0*
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*30 Capsule(s)* Refills:*0*
3. hydrochlorothiazide 12.5 mg Capsule Sig: 0.5 Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
7. quetiapine 100 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*0*
8. doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
Disp:*45 Tablet(s)* Refills:*0*
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
10. fluticasone 50 mcg/Actuation Disk with Device Sig: Two (2)
puffs Inhalation twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute urinary retention
Constipation
Cocaine and Heroin Withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ male with history of chills.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
mild right base atelectasis and mild elevation of the right hemidiaphragm. No
focal consolidation, pleural effusion, or evidence of pneumothorax is seen.
It is also noted in the prior study, again seen is a 1.1-cm nodular density in
the right suprahilar region which could represent confluence of shadows and
possibly converging vascular structures but the possibility of lung nodules
again should be considered. Cardiac and mediastinal silhouettes are stable.
Surgical clips and shrapnel again seen in the upper abdomen.
IMPRESSION: No acute cardiopulmonary process. Again seen nodular opacity in
the right suprahilar region for which further evaluation with chest CT is
again recommended. Right base atelectasis.
Radiology Report
CLINICAL HISTORY: ___ male with multiple abdominal surgeries and
diffuse abdominal pain. The patient has a history of gunshot wound. Evaluate
for obstruction or diverticulitis.
___.
TECHNIQUE: MDCT-acquired axial images from lung bases to the pubic symphysis
were displayed with 5-mm slice thickness with 130 mL Omnipaque intravenous
contrast. Coronal and sagittal reformats were displayed with 5-mm slice
thickness.
CT ABDOMEN: The visualized lung bases are clear aside from mild dependent
bibasilar atelectasis. There is no pleural or pericardial effusion.
The patient is status post remote gunshot wound to the abdomen with bullet
fragments anterior to the aorta and right hepatic lobe, unchanged in
distribution from the prior study.
The liver is normal. There is no intrahepatic bile duct dilation. The
gallbladder is absent. The common bile duct is slightly dilated to 7 mm,
within normal limits in a post-cholecystectomy state. The spleen, pancreas
and bilateral adrenal glands are normal. The patient is status post right
nephrectomy. The left kidney enhances homogenously and excretes contrast
promptly without hydronephrosis. A hypodensity in the left renal inferior
pole is a simple cyst and is unchanged from the prior study. Other left renal
hypodensities are too small to characterize and statistically most likely
represent cysts.
The small and large bowel are normal in course and caliber without
obstruction. There is no free fluid and no free air. The aorta is of normal
caliber throughout. No pathologically enlarged mesenteric or retroperitoneal
lymph nodes are identified.
CT PELVIS: The rectum, sigmoid colon and prostate are normal. A Foley
catheter is in the bladder. Air in the bladder is likely due to Foley
instrumentation. There is no free fluid and no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: Grade 1 retrolisthesis of L5 on S1 is unchanged. No bone
finding suspicious for infection or malignancy is seen.
IMPRESSION: No CT explanation for patient's pain. Specifically, no
obstruction as clinically queried.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CHILLS
Diagnosed with RETENTION URINE UNSPECIFIED, ABDOMINAL PAIN GENERALIZED, CHEST PAIN NOS, DEPRESSIVE DISORDER, SUICIDAL IDEATION
temperature: 97.4
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 181.0
dbp: 90.0
level of pain: 9
level of acuity: 3.0 | This is a ___ yo M with a long psychiatric history as well as
current IV drug abuse who presents with acute urinary retention,
constipation, and thoughts of self harm.
1. Acute urinary retention: The patient said that he had not
urinated x three days, prompting him to present to the emergency
room. His urinary retention was likely precipitated by a drug
binge as well as discontinuing his home Doxazosin. In the ED, a
Foley catheter was placed with return of 400cc of concentrated
urine. On hospital day #1, the patient was given a voiding
trial. After 8 hrs, the patient was able to void ___ of dark
urine. Urine culture was negative. The patient was given some IV
hydration and he continued to have improved urine output. The
patient was kept on his home dose of Doxazosin, and this was
increased from 4mg to 6mg on discharge.
2. Abdominal Pain: After Foley placement, the patient continued
to complain of lower abdominal pain, so a CT abdomen and pelvis
was performed that did not show any obstruction, perforation,
abscess, or other cause of his pain. The patient was
constipated without a bowel movement in 4 days. He was given an
aggressive bowel regimen and passed stool on Day 1. The
patient's abdominal pain improved with his bowel movement and
also after treating his drug withdrawal.
3. Opioid and Cocaine Withdrawal: The patient had injected
cocaine and heroin on the day before admission. On hospital day
1, the patient began experiencing tremors, anxiety, lacrimation,
diaphoresis, and abdominal cramping consistent with withdrawal.
He was placed on ___ scale with Valium, Hydroxyzine, Tylenol,
and Ibuprofen given for symptomatic relief. The patient required
less and less Valium and felt better on day 2.
4. Psychiatric Issues: The patient has a h/o anxiety and
depression. On admission, he said that he had increasing
thoughts of self-harm and that he did not feel safe. The patient
had a sitter overnight and psychiatry evaluated him the next
day. According to psych, they did not feel that he was actively
suicidal. They recommended treating him for withdrawal and
enrolling him in a dual diagnosis program on discharge.
5. Hypertension: continued metoprolol, doxazosin, and HCTZ.
Doxazosin was increased to 6mg.
Transitional Issues: The patient was discharged to a partial
dual diagnosis program, where he will receive substance abuse
counselling as well as psychiatric consultation. The patient was
agreeable to this and optimistic about sobriety. The patient had
a slightly low WBC count on discharge. He does have HepC, and
signs of HepB infection (+HBcAb). With known risk factors, the
patient should have an HIV test done by his PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Rigors/fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ f/o F with PMHx of HTN, HLD, hypothyroidism, OA,
amyloiod
angiopathy, MVP, remote breast CA, as well as massive saddle PE
in early ___ with subsequent readmission for GIB during which
IVC filter was placed and followed by subsequent admission with
small IVH during which a/c was stopped, who was sent in from ___
after having rigors and low grade temperature, now found to have
UTI.
Of note, pt has advanced dementia and is oriented x 1 at
baseline. History was obtained from pt's dtr and pt's caregiver.
Per report, the patient has largely been at her baseline. In
retrospect, her daughter notes that she has possibly been
slightly more agitated over the past few day and was slightly
more tired last night, both of which could have been indicative
of a developing UTI. This morning, she was noted to have rigors
and temp to 100.5. Given flu outbreak at her SNF (she is
currently on ppx Tamiflu), she was sent in for eval pt dtr's
request.
ED Course:
Initial VS: 96.5 102 119/48 22 95% RA
Labs significant for lactate 4.3->2.7. UA with 25 WBCs and few
bacteria. Flu negative.
Imaging: CXR with "Mild pulmonary vascular congestion. No focal
consolidation to suggest pneumonia."
Meds given: vanc, cefepime, NS
VS prior to transfer: 98.0 83 107/57 22 94% RA
On arrival to the floor, the patient is alert and in NAD. She
denies any acute complaints, but her baseline dementia limits
history as above.
ROS: As above. Denies chest pain, shortness of breath, abdominal
discomfort. The remainder of the ROS was largely limited by
patient's mental status.
Past Medical History:
-Hypertensive heart disease
-Hypothyroidism
-Hyperlipidemia
-Osteoarthritis
-Cognitive impairment
-Amyloid angiopathy
-Mitral valve prolaps
-Osteoporosis
-Breast cancer ___, s/p partial mastectomy and radiation
-Saddle PE with readmission for GIB in setting of
anticoagulation
now s/p IVC filter, also subsequently c/b small intraventicular
hemorrhage
-C.diff
Social History:
___
Family History:
Son ___ ___ brain tumor
Father with colon cancer and esophageal cancer, died of an MI.
Mother had ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS - ___ 1656 Temp: 97.8 PO BP: 106/68 R Lying HR: 93 RR:
18
O2 sat: 94% O2 delivery: Ra
GEN - Alert, NAD
HEENT - NC/AT, MMM, face grossly symmetric
NECK - Supple
CV - RRR, ___ systolic murmur heard throughout
RESP - CTA B
BACK - no clear CVAT but pt not very cooperative with sitting
forward for exam
ABD - S/NT, mildly distended, BS present
EXT - No ___ edema or calf tenderness, dressing on L hand c/d/i
SKIN - No apparent rashes
NEURO - Not cooperative with exam but moving all extremities
PSYCH - Calm, appropriate
.
.
DISCHARGE PHYSICAL EXAM
=======================
VS - 24 HR Data (last updated ___ @ 748) - Temp: 97.7 (Tm
98.3), BP: 100/62 (100-105/59-66), HR: 68 (68-77), RR: 18, O2
sat: 94% (92-96), O2 delivery: Ra
GEN - Alert, NAD
HEENT - NC/AT, MMM, face grossly symmetric
CV - RR, ___ systolic murmur, 2+ radial pulses b/l
RESP - CTAB, normal WOB
ABD - S, NT, not distended, BS present
EXT - No ___ edema or calf tenderness, dressing on L hand c/d/i
SKIN - No apparent rashes
NEURO - Awake, alert, makes eye contact, more
interactive/conversant with me today
PSYCH - calm, smiling
Pertinent Results:
===============
ADMISSION LABS:
___ 09:00AM BLOOD WBC-4.6 RBC-4.21 Hgb-12.4 Hct-38.9 MCV-92
MCH-29.5 MCHC-31.9* RDW-16.0* RDWSD-53.8* Plt ___
___ 09:00AM BLOOD Glucose-110* UreaN-35* Creat-1.1 Na-146
K-4.4 Cl-98 HCO3-26 AnGap-22*
___ 09:00AM BLOOD ALT-41* AST-33 AlkPhos-84 TotBili-0.9
___ 09:08AM BLOOD Lactate-4.3*
.
.
===========
Micro:
-___ UCx: mixed bacterial flora (final)
-___ BCx: NGTD
-___ BCx: NGTD
-___ Stool C. diff: negative
.
.
===========
Imaging:
CXR:
FINDINGS: Cardiac silhouette size is mildly enlarged but
similar. The mediastinal and hilar contours are unremarkable.
Mild pulmonary vascular congestion persists. No focal
consolidation, pleural effusion, or pneumothorax is present.
The osseous structures are diffusely demineralized with
unchanged compression deformity of a low thoracic vertebral
body. IVC filter is noted in the upper abdomen.
IMPRESSION: Mild pulmonary vascular congestion. No focal
consolidation to suggest pneumonia.
================
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-3.2* RBC-3.50* Hgb-10.3* Hct-32.4*
MCV-93 MCH-29.4 MCHC-31.8* RDW-16.2* RDWSD-54.4* Plt ___
___ 06:50AM BLOOD Glucose-101* UreaN-30* Creat-0.8 Na-143
K-4.6 Cl-102 HCO3-28 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___)
2. Levothyroxine Sodium 88 mcg PO 4X/WEEK (___)
3. Polyethylene Glycol 17 g PO DAILY
4. Heparin 5000 UNIT SC BID
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. RisperiDONE 0.25 mg PO DAILY
8. Artificial Tears ___ DROP BOTH EYES BID
9. OSELTAMivir 75 mg PO Q24H
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
Last dose on ___
2. Miconazole Powder 2% 1 Appl TP BID
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. RisperiDONE 0.25 mg PO QHS:PRN agitation
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Artificial Tears ___ DROP BOTH EYES BID
7. Docusate Sodium 100 mg PO DAILY:PRN constipation
8. Heparin 5000 UNIT SC BID
9. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___)
10. Levothyroxine Sodium 88 mcg PO 4X/WEEK (___)
11. RisperiDONE 0.25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI w/ acute tox/met encephalopathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fatigue, cough// Evaluate for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size is mildly enlarged but similar. The mediastinal and
hilar contours are unremarkable. Mild pulmonary vascular congestion persists.
No focal consolidation, pleural effusion, or pneumothorax is present. The
osseous structures are diffusely demineralized with unchanged compression
deformity of a low thoracic vertebral body. IVC filter is noted in the upper
abdomen.
IMPRESSION:
Mild pulmonary vascular congestion. No focal consolidation to suggest
pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, ILI
Diagnosed with Urinary tract infection, site not specified, Weakness
temperature: 96.5
heartrate: 102.0
resprate: 22.0
o2sat: 95.0
sbp: 119.0
dbp: 48.0
level of pain: ua
level of acuity: 3.0 | ===================
HOSPITAL COURSE
===================
___ f/o F with PMHx of HTN, HLD, hypothyroidism, OA, amyloiod
angiopathy, MVP, remote breast CA, as well as massive saddle PE
in early ___ with subsequent readmission for GIB during which
IVC filter was placed and followed by subsequent admission with
small IVH during which a/c was stopped, who was sent in from ___
after having rigors and low grade temperature, now presenting
with fever, rigors, and positive UA, concerning for UTI, with
some change in her mental status concerning for encephalopathy.
She is now clinically improved, with no fevers, rigors or other
significant VS abnormalities. And she is at or near her reported
baseline mental status.
# Fever/Chills with concern for
# UTI: Pt presented from ___ with rigors and low grade temp.
While flu was an initial concern given current outbreak at her
SNF, her flu swab was negative (she is on Tamiflu PPx). Given
positive UA and history of recurrent UTI's, UTI seems most
likely source of her symptoms. Most recent urine culture with
e.coli resistance to CTX, cefepime, cipro but sensitive to
Bactrim, zosyn, meropenem, unasyn.
- De-escalated from zosyn to unasyn on ___ given prior urine
sensi's
- urine cx ultimately grew mixed bacterial flora
- given the absence of other localizing signs/symptoms at this
time, still suspect that UTI was the most likely cause of her
presenting symptoms
- plan to treat for 5 days with empiric abx (Day 1 = ___, last
day = ___
- given her seemingly good response to unasyn, will transition
from unasyn to augmentin today, last day of abx will be ___.
- stop oseltamivir
# LACTIC ACIDOSIS: resolved with fluids and empiric abx
# Loose stools
# H/O C.DIFF: In ___ in the setting of abx.
- C. diff was checked and negative on ___
- loose stools likely antibiotic-induced (unasyn is a frequent
culprit)
# BLEPHARITIS: Currently being treated at ___ with artificial
tears.
- continued artificial tears
# DEMENTIA WITH BEHAVIORAL DISTURBANCES: history of sundowning
during prior admissions; has done well during this
hospitalization and did not require any PRNs for agitation or
anxiety
- delirium precautions
- continued Risperdal qAM
- per d/w daughter if sundowns, she generally responds to
Risperdal 0.25mg PO QHS PRN; this was ordered but was never
required during this hospital stay
# PRIOR DVT/PE: Pt with massive saddle PE in early ___ with
subsequent readmission for GIB during which IVC filter was
placed and followed by subsequent admission with small IVH
during which a/c was stopped. No longer on a/c. No concern for
recurrent VTE at this time (no hypoxia, SOB, ___ edema).
- continued ppx HSQ which pt gets at ___
# HTN/HLD: No longer on medications per patient's dtr.
.
.
===================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Nausea/vomiting, failure to thrive
Major Surgical or Invasive Procedure:
___ percutaneous cholecystostomy tube placement
History of Present Illness:
___ w/h/o MI, PVD, mesenteric ischemia s/p SMA bypass, most
recently s/p exlap and SMA thrombectomy POD20, returns to ER
tonight with N/V. No f/c/ns. She states the vomiting started
last
night. She has had some minimal associated discomfort but no
real abdominal pain. No hematochezia/melena. No hematemesis.
Past Medical History:
PMH: mesenteric ischemia; MI early ___, s/p cardiac cath, no
intervention
PSH: SMA thrombectomy ___, Aorto-common hepatic/SMA bypass
w/ dacron graft ___, ___ stenting ___, Ex-lap
and SBR ___, take back for bleeding ___, SMA stenting
___, ___ stenting ___, hysterectomy ___
Social History:
___
Family History:
Brother and mother with DM.
Physical Exam:
Vitals: 98.8 85 107/65 20 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: unlabored
ABD: Soft, nondistended, mild TTP in RUQ around drain, no
rebound or
guarding, normoactive bowel sounds, no palpable masses, midline
incision healing well
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 07:53PM BLOOD WBC-7.4 RBC-3.39* Hgb-10.2* Hct-31.4*
MCV-93 MCH-30.1 MCHC-32.4 RDW-15.0 Plt ___
___ 04:05AM BLOOD WBC-5.4 RBC-2.29* Hgb-6.9* Hct-21.3*
MCV-93 MCH-30.3 MCHC-32.5 RDW-15.0 Plt ___
___ 07:35AM BLOOD WBC-6.0 RBC-2.85* Hgb-8.7* Hct-27.5*
MCV-97 MCH-30.5 MCHC-31.6 RDW-15.7* Plt ___
___ 08:29PM BLOOD ___ PTT-50.2* ___
___ 12:00AM BLOOD ___ PTT-51.1* ___
___ 08:10AM BLOOD ___ PTT-29.9 ___
___ 03:28AM BLOOD ___
___ 06:25AM BLOOD ___
___ 07:35AM BLOOD ___ PTT-34.4 ___
___ 07:53PM BLOOD Glucose-161* UreaN-39* Creat-1.3* Na-139
K-4.1 Cl-100 HCO3-24 AnGap-19
___ 07:35AM BLOOD Glucose-95 UreaN-7 Creat-0.4 Na-140 K-4.1
Cl-104 HCO3-27 AnGap-13
___ 02:50AM BLOOD ALT-12 AST-12 AlkPhos-92 TotBili-0.4
___ 08:10AM BLOOD ALT-14 AST-15 AlkPhos-95 TotBili-0.4
___ 07:35AM BLOOD Calcium-7.6* Phos-4.3 Mg-1.6
___ 08:01PM BLOOD Lactate-2.4*
___ 12:03AM BLOOD Lactate-0.8
___ 07:35AM BLOOD PREALBUMIN-PND
Medications on Admission:
Simvastatin 20mg daily
Aspirin 81mg daily
Coumadin
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
Stop ___
2. Aspirin EC 81 mg PO DAILY
Should be enteric coated aspirin
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Calcium Carbonate Suspension 1250 mg PO TID
5. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
6. Magnesium Oxide 400 mg PO BID
7. Metoclopramide 10 mg PO QIDACHS
8. Neutra-Phos 2 PKT PO TID
9. Pantoprazole 40 mg PO Q24H
10. Simvastatin 20 mg PO DAILY
11. Warfarin 0.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Failure to thrive
Supratherapeutic INR
Sub-acute/Chronic cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Recent ___ clot. Rule out ischemic colitis, arterial clot.
COMPARISON: Prior abdominal/pelvic CTA from ___.
TECHNIQUE: ___ MD CT images were obtained through the abdomen and pelvis
without IV or oral contrast. Sagittal and coronal reformats were generated.
FINDINGS:
Mild bibasilar atelectasis is improved with focal residual area of atelectasis
noted at the right lung base. There is no pleural or pericardial effusion.
CT OF THE ABDOMEN: Evaluation of solid abdominal viscera is limited by lack
of IV contrast. The liver does not demonstrate focal hepatic lesions.
Gallstones are seen within an otherwise unremarkable gallbladder. There is
redemonstration of a 1.8 x 2.2 cm hypodense nodule in the left adrenal gland.
The right adrenal gland, pancreas and spleen are otherwise within normal
limits. Kidneys do not demonstrate hydronephrosis or masses.
The patient is status post supraceliac aortic graft with two limbs, one
coursing to the celiac axis and the other to the SMA. Stents are again seen in
the native superior mesenteric artery and inferior mesenteric artery. Patency
of the graft and vessels cannot be assessed on this non-contrast examination.
Moderate atherosclerotic calcifications are seen in the intra-abdominal aorta,
without aneurysm.
The stomach is fluid-filled. There is no evidence of small bowel obstruction
or bowel wall thickening, although assessment is limited without oral or IV
contrast. Surgical sutures are seen in the left lower quadrant (02:33) with a
focally prominent loop of bowel at the anastamosis, but decreased in size in
the interval. The appendix is not visualized, but there is no evidence of
acute appendicitis. There is no free fluid or free air in the abdomen. Fat
stranding is seen along the anterior abdominal wall (02:35). There is no
mesenteric or retroperitoneal lymph node enlargement by CT size criteria.
Skin staples are noted overlying the midline anterior abdominal wall and left
inguinal region. Subcutaneous fluid collection within the midline anterior
abdominal wall has decreased in size and is compatible with a seroma.
CT OF THE PELVIS: There is a small amount of mildly complex pelvic free fluid
on the right which has decreased in extent compared to the prior exam.
Urinary bladder and terminal ureters are within normal limits. The rectum is
grossly unremarkable. There is no inguinal or pelvic lymph node enlargement
by CT size criteria.
OSSESOUS STRUTURES: No blastic or lytic lesions suspicious for malignancy.
IMPRESSION:
1. Examination is limited by lack of IV contrast. Supraceliac aortic graft to
the celiac and superior mesenteric arteries, as well as the native SMA and ___
stents are redemonstrated, but graft and arterial patency cannot be assessed.
2. No gross bowel abnormality to indicate ischemic bowel, although assessment
again is limited without IV or oral contrast. No bowel obstruction.
3. Decreased amount of mildly complex fluid in the pelvis.
4. Cholelithiasis.
5. Stable left adrenal adenoma.
Radiology Report
INDICATION: Status post ___ thrombectomy on ___, now with nausea,
vomiting.
COMPARISON: CT abdomen and pelvis, ___, CTA abdomen and pelvis,
___.
TECHNIQUE: Axial MDCT images were taken before and after the administration
of 150 cc of Omnipaque intravenous contrast in a multiphasic fashion. Coronal
and sagittal reformats were also examined.
FINDINGS: Emphysematous changes and bibasilar atelectasis are seen. Several
tree in ___ opacities in the left lower lobe remain unchanged compared to the
most recent prior study. The visualized heart and pericardium are
unremarkable.
The liver enhances homogeneously without focal lesions or intrahepatic biliary
ductal dilatation. The gallbladder remains distended with several gallstones
in a dependent position but no adjacent fat stranding or wall edema. The
spleen is homogeneous and normal in size. The pancreas is unremarkable
without focal lesions, peripancreatic stranding, or fluid collection. A
hypodense nodule is again noted within the left adrenal gland. The right
adrenal gland is unremarkable. The kidneys present symmetric nephrograms and
excretion of contrast without solid or cystic lesions.
The stomach and small bowel are unremarkable without any evidence of wall
thickening or obstruction. The colon also maintains a normal caliber without
any evidence of wall thickening. Surgical staples are seen along the anterior
abdominal wall, and a small postoperative seroma is seen posterior to this
surgical defect. There is no abdominal free air or free fluid. There is no
mesenteric or retroperitoneal lymphadenopathy.
A Foley is present within a partly distended bladder. The patient is status
post hysterectomy. A small amount of simple free fluid is present in the
pelvis. There is no pelvic sidewall or inguinal lymphadenopathy.
No suspicious lesion is seen in visualized osseous structures.
CTA: The patient is status post supraceliac aortic graft. Stents in the
native SMA and ___ remain occluded. The native celiac remains stenosed at its
origin, and there is retrograde filling of the left gastric and splenic
arteries. The branches of the supraceliac graft trunk remain patent with
attenuation of the common hepatic artery. The superior mesenteric artery
portion of the graft is widely patent, and again seen is abrupt narrowing of
the SMA distally (3A:63). Note is made of an accessory right renal artery.
The renal arteries remain widely patent.
IMPRESSION: Grossly unchanged appearance of patent supraceliac aortic graft
post-thrombectomy. No signs of bowel ischemia.
Radiology Report
HISTORY: Assess positioning of Dobbhoff tube.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
One frontal view of the abdomen shows a nonobstructive bowel gas pattern.
There is no pneumatosis or free air. There has been interval placement of a
Dobhoff tube with its tip ending in the proximal stomach and pointing
superiorly. The celiac stent is unchanged in position. The lung bases are
clear. There are degenerative changes of the visualized osseous structures.
IMPRESSION:
Interval placement of a Dobhoff tube with its tip ending in the proximal
stomach and pointing superiorly.
Radiology Report
HISTORY: ___ female status post superior mesenteric artery
reconstruction now with ileus. Evaluate for obstruction.
TECHNIQUE: Multi detector CT images were obtained from the lung bases to the
proximal femurs after the administration of intravenous contrast material.
Multiplanar re-formatted images in coronal and sagittal planes are provided.
DLP: 547.94 mGy-cm
COMPARISON: CTA of the abdomen and pelvis dated ___.
FINDINGS:
CT ABDOMEN:
Heart and lungs: There are bilateral pleural effusions which are small, with
adjacent atelectasis which has slightly increased since ___.
Again seen are emphysematous changes in the bases bilaterally and several
___ opacities left lower lobe, which are unchanged. There are no
concerning nodules or mass lesions in the lung bases. The visualized portion
of the heart and pericardium are normal. There is no pericardial effusion.
Liver: The liver is normal in size and homogeneous in enhancement with no
focal lesions. There is no intra or extrahepatic biliary ductal dilatation.
The portal and hepatic veins are patent.
Gallbladder: The gallbladder is distended with a thickened wall and multiple
radiopaque gallstones. The common bile duct is not dilated.
Spleen: The spleen is normal in size and homogeneous in enhancement.
Pancreas: The pancreas is homogeneous in enhancement and does not demonstrate
ductal dilatation or peripancreatic fat stranding.
Adrenals: The right adrenal gland is normal in size and shape. Again seen is
a hypodense lesion left adrenal gland, which is unchanged.
Kidneys: The kidneys are normal in size and display symmetric nephrograms and
contrast excretion. The ureters are normal in caliber along their course to
the bladder. There are no concerning mass lesions in the kidneys. There is
no perinephric abnormality is seen.
Bowels: There is a small hiatal hernia. The stomach contains a nasogastric
tube, and is underdistended, but grossly normal. The small bowel is opacified
with contrast and does not show abnormal dilatation or focal wall thickening.
There is no evidence of small bowel obstruction. The large bowel contains
feces and does not show obstructive mass lesions, diverticulitis, or wall
thickening. There is no intraperitoneal free air.
Lymph nodes: There are a few prominent although nonenlarged mesenteric lymph
nodes, which are likely reactive. There are no pathologically enlarged
retroperitoneal lymph nodes by CT size criteria.
Vessels: There is no aneurysmal dilatation of the abdominal aorta. The
patient is status post supra celiac aortic graft. The stents in the native
SMA and ___ remain occluded. The native celiac artery remains stenotic at its
origin. No suspicious lesions in the visualized osseous structures.
Osseous structures and soft tissues: There has been interval development of a
1.8 x 3.7 x 14 cm organized fluid collection in the anterior abdominal wall,
which likely represents a postop seroma, however overlying infection cannot be
excluded.
Pelvis: The bladder is well visualized and unremarkable. There is a small
amount of free fluid. There are no pathologically enlarged pelvic sidewall or
inguinal lymph nodes CT size criteria.
IMPRESSION:
1. No evidence of small bowel obstruction.
2. Distended gallbladder with wall thickening and multiple radiopaque
gallstones. Recommend correlation with patient's symptoms.
3. Grossly unchanged appearance of patent super celiac artery aortic graft.
4. Interval development of a long anterior abdominal wall fluid collection
which likely represents a postoperative seroma, however overlying infection
cannot be excluded.
Radiology Report
INDICATION: Abdominal pain, nausea, and thickened gallbladder on CT. Assess
for evidence of acute cholecystitis.
COMPARISON: Multiple prior CT abdomen studies dating back through ___.
FINDINGS: The liver echogenicity and echotexture are within normal limits.
No focal liver lesions are identified. There is no intra- or extra-hepatic
biliary duct dilatation. The common duct measures 4 mm. The portal vein is
patent, with normal hepatopetal flow. The gallbladder is markedly distended
and contains sludge and small layering stones. There is circumferential
gallbladder wall thickening and probable gallbladder wall edema, as seen on
several prior CTs dating back through ___. There is minimal
pericholecystic fluid. The pancreas is not well assessed due to overlying
bowel gas.
IMPRESSION: Markedly distended gallbladder containing sludge and small stones
in conjunction with gallbladder wall thickening and minimal pericholecystic
fluid, similar in appearance to several prior CTs dating back through
___. Although the sonographic findings are highly concerning
for acute cholecystitis, the appearance on the prior CTs suggested that this
process may in fact be subacute versus chronic. Further evaluation could be
performed with a HIDA scan, if clinically warranted.
Findings were discussed with Dr. ___ by Dr. ___ at 12:28 a.m. via
telephone on ___, 5 minutes after discovery of the findings.
Radiology Report
HISTORY: ___ woman with cholecystitis. Please perform percutaneous
cholecystostomy.
COMPARISON: Prior ultrasound abdomen from ___, CTA abdomen ___ and CTA ___.
OPERATORS: Dr. ___, radiology attending and Dr ___, abdominal imaging
fellow.
Dr ___ was present in the ultrasound procedure suite for the duration of the
procedure.
PROCEDURE:
After informed consent was signed by the patient, the patient was taken to the
ultrasound suite and placed in a supine position. The time out procedure was
performed per ___ protocol. An entrance site was determined for percutaneous
cholecystostomy tube placement at a right intercostal space laterally. The
patient was prepped and draped in usual sterile fashion. 1% lidocaine was used
for local anesthesia. A 22 gauge needle was used for deep subcapsular local
anesthesia.
Using ultrasound guidance, an 8 ___ ___ catheter was advanced into the
gallbladder via a transhepatic approach, using trocar technique. The position
of the pigtail was confirmed within the gallbladder lumen sonographically.
Approximately 130 cc of tan, purulent bile was aspirated. Approximately 10 cc
of the fluid was sent for culture and Gram stain. The catheter was attached
to a draining bag. Catheter was secured via statlock and adhesive gauze. No
periprocedural complications were encountered. The patient tolerated the
procedure well and was transferred to the medical unit in stable condition.
Moderate sedation was provided by administering divided doses of fentanyl (50
mcg) and Versed (1 mg) throughout the total intra service time of 25 min
during which the patient's hemodynamic parameters were continuously monitored,
by an independant, trained Radiology nurse.
FINDINGS:
Limited ultrasound of the gallbladder was performed prior to the biopsy. The
gallbladder demonstrated distension and wall thickening. Sludge and debris
was identified within the gallbladder. CBD measured 5 mm. No pericholecystic
fluid collections are identified.
IMPRESSION:
Successful ultrasound guided placement of 8 ___ ___ catheter into the
gallbladder, with subsequent aspiration of approximately 130 cc of purulent
bile. Approximately 10 cc of fluid sent for microbiology. Catheter attached
to a draining make and secured via statlock and adhesive gauze. No
periprocedural complications.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 97.8
heartrate: 106.0
resprate: 20.0
o2sat: 99.0
sbp: 93.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | On admission, pt was hydrated and followed with serial labs and
exams. A CTA revealed that her aorto-CHA/SMA bypass was open.
She received 3 units of pRBCs and 1 unit of FFP. Her lactate
normalized and her N/V improved. She did have melenic stool and
was thus started on a PPI. The following day, pt vomited 200cc
of coffee ground emesis. She was given 2 units of pRBCs and 1
unit of FFP. On HD3, pt again had melenic stools. Her Foley
catheter was d/c'd. She was started on Ensure supplements. On
HD4, d/t persistent inability to tolerate po intake, a Dobhoff
was placed and tube feeds started. On HD5, reglan was started
for high TF residuals. On HD6, pt had one episode of emesis. On
HD7, pt's nausea and pain improved. She was given 2 units of
pRBCs. On HD8, pt was tolerating TFs at goal. On HD9, TFs were
decreased due to a high residual. A CT scan was done to look for
a mechanical reason for perisistent nausea and abdominal pain
and demonstrated findings concerning for cholecystitis. On HD10,
after an ultrasound also demonstrated findings consistent with
cholecystitis, pt had a HIDA scan with nonfilling of the
gallbladder. On HD11, a percutaneous cholecystostomy tube was
placed and pt was started on Unasyn. Bile was sent for culture
and subsequently grew Klebsiella pneumoniae. After placement of
the perc chole, TFs were resumed. On HD12, pt again was able to
tolerate TFs at goal. On HD13, TFs were cycled. On HD14, unasyn
was switched to augmentin. On HD15, TFs were halved in an
attempt to increase pt's appetite and po intake. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
phenytoin / Penicillins
Attending: ___.
Chief Complaint:
Knee pain and drainage
Major Surgical or Invasive Procedure:
I+D, washout of left knee
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: 1130 pm
_
________________________________________________________________
PCP: ___ doctor at ___ is Dr. ___
___
.
HPI:
Tragic case of a ___ year old male with parpaplegia and TBI after
being hit by a drunken driveer while jogging in ___. He was
able to live somewhat independently in a wheelchair until ___ when he was hit by a car as he was exiting his car? He then
sustanied a comminuted distal L femur fracture. O He was then
admitted to ___ on ___ as a transfer from ___
___ where he wa admitted with AMS, fever, found to have
e.coli bacteremia, LLE complex hematoma and new R hip effusion
c/b septic arthritis with ongoing fevers and leukocytosis. He
underwent washout of R hip and L knee had a wound vacumn placed
until the day of discharge. He was discharged on merepenem until
___. He went to orthopedic and was found to have
purulent brown drainage from the L knee and was thus referred to
the ED. He was seen in the ED by orthopedics who determined that
he would need washout of his knee in am but admitted to medicine
give recent prolonged medical course.
In ER: (Triage Vitals: 98.7 85 121/69 18 100% ra )
Meds Given: dilaudid,
Fluids given: Radiology Studies:X ray
consults called: orthopedics
.
PAIN SCALE: severe pain in R hip. NO pain in L knee or hip.
He denies, cp, sob, n/v/d or other symptoms but he is a poor
historian and admits to me that he gets his medical history all
mixed up.
.
[X]all other systems negative except as noted above
Past Medical History:
TBI ___ pedestrian struck while jogging ___
pelvic fx s/p fixation
chronic foley
colostomy
L ankle fusion ___
L hamstring to quad transfer ___
L inguinal hernia
parastomal hernia repair ___
HTN
HLD
LLE weakness and decreased sensation
HCV
Multiple non-displaced fractures ___ to ___ MVA
Social History:
___
Family History:
Reviewed. Not pertinent to this hospitalization
Physical Exam:
VITAL SIGNS:
PAIN SCORE ___ R hip
1. VS T 98.1 P 98 BP 122/76 RR 18 O2Sat on __97% on RA
GENERAL: Obese male, laying in bed. He is pleasant and
conversant.
Nourishment: good
Grooming: good
Mentation
2. Eyes:
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[X] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE 3+
RLE edema with fracture, pitting red overlying skin, brown
drainage from medial aspect of knee.
LLE with 2+ DPP pulse. Unable to look at hip secondary to pain
No pain with ranging of R knee.
PICCL
[X] Vascular access [] Peripheral [X] Central site:R PICCL -
site c/d/i
5. Respiratory [ ]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
Well healed midline scar. Colosomty bag in place with brown
stool. No surrounding erythema. Soft abdomen, no rebound or
guarding.
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [ X]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
[ X] Alert and Oriented x 2- thought he was at ___ [ ] Romberg:
Positive/Negative [ X] CN II-XII intact [X ] Normal attention
[ ] FNF/HTS WNL [] Sensation WNL [ ? ] confused - but able to
DOWB but unable to give specific details of his history for
example on which hip he had surgery[ ] Asterixis Present/Absent
[ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[X] Warm with RLE as above.
He has at least two sacral decubiti- L hip and sacrum-
unstageable
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [?] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
12. Genitourinary [] WNL
[ X] Catheter present [] Normal genitalia [ ] Other:
TRACH: []present [X]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[X]present []none [ ]site C/D/
Pertinent Results:
___ 07:04PM LACTATE-1.8
___ 06:45PM GLUCOSE-98 UREA N-14 CREAT-0.5 SODIUM-131*
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-26 ANION GAP-14
___ 06:45PM GLUCOSE-98 UREA N-14 CREAT-0.5 SODIUM-131*
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-26 ANION GAP-14
___ 06:45PM WBC-14.7* RBC-3.32* HGB-9.3* HCT-28.7* MCV-87
MCH-28.1 MCHC-32.5 RDW-15.1
___ 06:45PM NEUTS-81.6* LYMPHS-8.3* MONOS-5.3 EOS-4.1*
BASOS-0.7
___ 06:45PM PLT COUNT-636*
___ 06:45PM ___ PTT-38.1* ___
___ 06:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-LG
___ 06:45PM URINE RBC-3* WBC-170* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1 RENAL EPI-<1
___ 06:45PM URINE AMORPH-RARE
___ 06:45PM URINE MUCOUS-RARE
==================
___: PICC in upper SVC
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 2 TAB PO BID
2. Lisinopril 10 mg PO DAILY
3. Heparin 5000 UNIT SC TID
4. Polyethylene Glycol 17 g PO DAILY constipation
5. Ascorbic Acid ___ mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Fentanyl Patch 12 mcg/h TP Q72H
11. Zinc Sulfate 220 mg PO DAILY
12. Meropenem 500 mg IV Q6H
13. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
14. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
15. OLANZapine 5 mg PO QID:PRN agitation
16. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Ascorbic Acid ___ mg PO BID
3. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
4. Docusate Sodium 100 mg PO BID
5. Fentanyl Patch 25 mcg/h TP Q72H
6. Heparin 5000 UNIT SC TID
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Lisinopril 10 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. OLANZapine 5 mg PO QID:PRN agitation
13. Polyethylene Glycol 17 g PO DAILY constipation
14. Senna 2 TAB PO BID
15. Zinc Sulfate 220 mg PO DAILY
16. Vancomycin 1500 mg IV Q 12H
17. Bengay Cream 1 Appl TP TID:PRN pain
18. ertapenem 1 gram Injection Daily
through ___
19. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic joint, left knee
Pressure ulcers
Traumatic brain injury
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: Left distal femur fracture.
FINDINGS: There is re-demonstration of a widely comminuted distal femur
fracture with no apposition of the fracture fragments. Distal fracture
fragment is posteriorly displaced. Also re-demonstrated is an old fibular
fracture that appears to have healed. The bony detail is obscured by the
overlying cast. The alignment is unchanged and no new fracture is identified.
Soft tissues are unremarkable and no radiopaque foreign body is seen.
IMPRESSION: Re-demonstrated distal femur fracture with no apposition of the
fracture fragments. Unchanged alignment compared to the radiograph of ___.
Radiology Report
REASON FOR EXAMINATION: Evaluation of PICC line placement.
AP radiograph of the chest was reviewed in comparison to ___.
The right PICC line can be seen in the region of the subclavian vein, but the
tip is not clearly seen beyond this point and then appeared to be entering
into the brachiocephalic vein or SVC. The heart size and mediastinum are
stable. Lungs are essentially clear and there is unchanged elevated position
of the right hemidiaphragm. Right and left consolidations seen on the prior
study have resolved in the interim.
The findings were communicated by Dr. ___ and at 01:35 a.m. on ___ to Dr. ___ the phone.
Radiology Report
PICC LINE EXCHANGE / REPOSITIONING
INDICATION: ___ year old man with need for antibiotics and right line that
needs to be exchanged for PICC, getting vanco.
The procedure was explained to the patient. A timeout was performed.
RADIOLOGIST: Dr. ___, ___ fellow and Dr. ___, radiology
resident performed the procedure.
TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was
advanced through the indwelling right arm double lumen PICC line, and
subsequently into the SVC under fluoroscopic guidance. The old PICC line was
then removed and a peel-away sheath was then placed over the guidewire. A new
___ F double lumen PICC line measuring 43 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 guidewire were then removed. The catheter was secured
to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new
___ double lumen PICC line. Final internal length is 43 cm, with the tip
positioned in the SVC. The line is ready to use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Knee pain
Diagnosed with OTHER POST-OP INFECTION, ACCIDENT NOS, URIN TRACT INFECTION NOS
temperature: 98.7
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 69.0
level of pain: 9
level of acuity: 3.0 | ___ with left lower extremity paraplegia, s/p MVA with TBI, e.
coli sepsis with septic hip and knee infection (s/p washout to
right hip and left knee) who was at rehab and presents with
drainage from his left knee concerning of infection.
# Septic joint, left knee
He presented with concern for left knee infection. He was on
meropenem at home. He underwent I+D and washout of an apparently
infected hematoma on his left knee. He was started on vancomycin
and meropenem after the I+D. His labs improved and he remained
afebrile. Orthopedics recommended an above the knee amputation.
The patient refused preferring to attempt to treat with
antibiotics instead. He will receive 6 weeks of vancomycin and
ertapenem from ___, through ___. ID was involved and he
should follow up with Dr. ___ at ___ in ___
- Ertapenem can be substituted for Meropenem 500mg IV q6 if
needed
In regards to his right hip, he has chronic osteoarthritis. The
washout from his prior admission showed no growth. This hip is
similar to his chronic OA hip pain per the orthopedics team that
knows the patient. No aspiration was done of the hip. The
patient did endorse right hip pain but does not that this has
been chronic and is not worse than baseline.
He had an ___ guided PICC placement on the right, with placement
confirmed in the ___ via fluoroscopy
# Pressure ulcers:
The patient has a number of pressure ulcers including sacral and
hip ulcers. Wound care was consulted. He was encouraged to have
good nutrition, frequent position changes (he is noncompliant
with positioning), ulcer friendly mattress and good RN care.
# Hypertension, benign:
He was continued on his home medications.
# Traumatic brain injury:
He was continued on his home medications.
his fentanyl patch was increased to 25mcg q72 on ___ for
ongoing pain. He remains on oral Dilaudid and Tylenol. He is
non-weight bearing to his LLE. He should follow up with
orthopedic surgery |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Lipitor / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
abnormal liver tests
Major Surgical or Invasive Procedure:
ERCP - sphincterotomy
___ guided drain placement
History of Present Illness:
Mr. ___ is a ___ male with the past medical history
diabetes mellitus, hypertension who presented to ___
with dyspnea. He explains that he has felt fatigue and dyspnea
on exertion for about a month. This has been progressively
worsening. ___ night was particularly bad and
he had chills and night sweats. This morning he noted a dark
color to his urine. He denied any abdominal pain, fevers,
chest pain. He has not been eating, because he has not been
feeling well. For these progressively worsening symptoms he
presented to the emergency department at ___. Laboratory
studies at ___ demonstrated a total bilirubin of 4.0,
slightly elevated LFTs, and a right upper quadrant ultrasound
indicated possible gallbladder mass. The patient was
administered Zosyn and referred to ___ for further
evaluation.
In the emergency department here he was again administered
Zosyn, and a CT abdomen demonstrated perforated cholecystitis
with several large fluid collections seen in the right liver
lobe and adjacent porta hepatis tests region with stones within
collections. Probable calculus also seen in the region of the
gallbladder neck/cystic duct. Moderate intrahepatic biliary
ductal dilation.
He was evaluated by the surgical team and felt to have
cholangitis with need for cholecystectomy. He was accepted to
the ___ service, they wrote a note, and they placed orders. The
___ team also communicated with the ED their desire to perform
an ERCP prior to cholecystectomy. Through a misunderstanding,
a bed request was placed for ___ instead of the ___
campus, and the patient ended up on ___. Because ___
does not have a team based on the ___ it is now
logistically difficult for them to manage this patient. We will
accept this patient to the ___ service and complete the
ERCP later today. If, after ERCP, the plan is still for
surgery, he will be transferred back to the ___ team on ___
___.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- HTN
- HLD
- DM: Pt was hosp ___ at ___ with concern for DKA vs
alcoholic ketoacidosis.
- BPH: Patient was hospitalized at ___ MICU ___ for ___
with a creatinine up to 10. This was thought to be from a
combination of new BPH and nephrotoxic medications. Cr improved
over several weeks with Foley placement, hydration, lasix, and
avoidance of ACE-I. Had a recent creatinine of 0.8 on ___ in
___. Patient intermittently straight caths himself at home
and sometimes overnight will leave catheter in place to be able
to sleep through the night.
Social History:
___
Family History:
Father: killed in ___
Mother: died of kidney failure in her early ___
Children in good health
Physical 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, 2 out of 6 systolic 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, surprisingly, 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:
WBC 16.3
Hemoglobin 12.2
___ 14.9
INR 1.4
Glucose 107
Creatinine 1.3
ALT 164
AST 132
Alk phos 213
Total bilirubin 3.1
Lipase 141
Albumin 2.7
Urinalysis with 100 protein, 1000 glucose, trace ketones,
moderate bilirubin, 2 WBCs
Lactate 1.8
# CTA Torso (___): 1. Perforated cholecystitis with several
large fluid collections seen in the right liver lobe and
adjacent porta hepatis region, measuring up to 8.5 cm, with
stones noted within the collections. Probable calculus is also
seen in the region of the gallbladder neck/cystic duct.
2. Mild to moderate intrahepatic biliary ductal dilatation.
3. No evidence of pulmonary embolism or acute aortic abnormality
.
# ERCP (___): no evidence of choledocholithiasis,
sphincterotomy performed, reported placement of metal stent
# ___ drainage (___): 200 cc of purulent fluid was
drained. Limited pre- and intra-procedural grayscale and color
Doppler ultrasound images of the right upper quadrant were
obtained. Images demonstrate a large, lobulated, heterogeneously
hypoechoic fluid collection in the expected location of the
gallbladder, measuring up to 12.8 x 7.5 x 7.5 cm. The
gallbladder is noted at the deep and medial portion of the
collection. The collection and gallbladder were subsequent
targeted for ultrasound-guided aspiration and drain placement.
Postprocedural images demonstrate catheter pigtail coiled in the
___ the collection, with a significant interval decrease
in the size of the collection following aspiration.
IMPRESSION: Successful US-guided placement of an ___
pigtail catheter into the gallbladder fossa collection via a
transhepatic approach. Sample was sent for microbiology
evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ezetimibe 10 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. empagliflozin 25 mg oral DAILY
4. MetFORMIN (Glucophage) 1000 mg PO DAILY
5. CloNIDine 0.1 mg PO BID
6. Pravastatin 40 mg PO QPM
7. Metoprolol Succinate XL 200 mg PO DAILY
8. GlipiZIDE XL 10 mg PO BID
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*24 Tablet Refills:*0
3. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
5. TraMADol 50-100 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. CloNIDine 0.1 mg PO BID
7. empagliflozin 25 mg oral DAILY
8. Ezetimibe 10 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. GlipiZIDE XL 10 mg PO BID
11. MetFORMIN (Glucophage) 1000 mg PO DAILY
12. Metoprolol Succinate XL 200 mg PO DAILY
13. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: History: ___ with likely GB mass who presents with dyspnea// eval
for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 4.2 s, 32.9 cm; CTDIvol = 17.2 mGy (Body) DLP = 564.3
mGy-cm.
3) Spiral Acquisition 6.9 s, 54.1 cm; CTDIvol = 27.5 mGy (Body) DLP =
1,486.8 mGy-cm.
Total DLP (Body) = 2,055 mGy-cm.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Coronary artery calcifications are noted. The heart,
pericardium, and great vessels are otherwise unremarkable. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Mild scarring/atelectasis is seen in the right lower lobe.
Lungs are otherwise clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Evaluation the abdomen is limited by motion.
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is mild to moderate, central
intrahepatic biliary ductal dilatation. The CBD is not well seen.
The gallbladder is perforated (05:31), with several large adjacent fluid
collections noted in the right hepatic lobe communicating with the gallbladder
lumen which measure up to 8.5 x 4.9 cm (05:28). The collections extend
inferior to the liver, with surrounding fat stranding and edema noted in the
mesentery (05:38). A radiodensity in the porta hepatis region (05:29), may
represent an obstructing stone in the cystic duct. Additional radiodense
stones are seen in the aforementioned fluid collections, (for example 05:34).
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral subcentimeter hypoattenuating lesions are too small to characterize,
but likely represent cysts. There is no hydronephrosis or perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. 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. There is no
free intraperitoneal fluid or free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Multiple old right-sided rib fractures are noted. A right
inguinal hernia containing fat is noted.
IMPRESSION:
1. Perforated cholecystitis with several large fluid collections seen in the
right liver lobe and adjacent porta hepatis region, measuring up to 8.5 cm,
with stones noted within the collections. Probable calculus is also seen in
in the region of the gallbladder neck/cystic duct.
2. Mild to moderate intrahepatic biliary ductal dilatation.
3. No evidence of pulmonary embolism or acute aortic abnormality.
Radiology Report
INDICATION: ___ year old man with perforated cholecystitis// Please perform
gall bladder fossa drainage
COMPARISON: CT abdomen and pelvis ___.
PROCEDURE: Ultrasound-guided drainage of gallbladder fossa collection.
OPERATORS: Dr. ___, radiology resident and Dr. ___,
___ radiologist. Dr. ___ supervised the trainee during the
key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated. The blunt trocar was advanced through the collection and into the
gallbladder and a catheter deployed. Fluid was aspirated, however it was
noted that the gallbladder appear completely empty but most of the collection
remained. The catheter was then retracted into the collection and the
collection aspirated completely. The position of the pigtail was confirmed
within the collection via ultrasound.
Approximately 200 cc of purulent 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
2.5 mg Versed and 125 mcg fentanyl throughout the total intra-service time of
57 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited pre- and intra-procedural grayscale and color Doppler ultrasound
images of the right upper quadrant were obtained. Images demonstrate a large,
lobulated, heterogeneously hypoechoic fluid collection in the expected
location of the gallbladder, measuring up to 12.8 x 7.5 x 7.5 cm. The
gallbladder is noted at the deep and medial portion of the collection.
Interval images show decompression of the gallbladder with a persisting
collection between the gallbladder in the liver and within the liver.
Postprocedural images demonstrate catheter pigtail coiled in the ___ the
collection, with a significant interval decrease in the size of the collection
following aspiration and decompression of the gallbladder.
IMPRESSION:
Successful US-guided placement of an ___ pigtail catheter into the
collection within the liver and between the gallbladder and the liver.
Gallbladder was also aspirated to completion. Sample was sent for
microbiology evaluation.
RECOMMENDATION(S): Follow-up with ultrasound if there is continued pain or
concern as the catheter is within the collection which may not still be
communicating with the gallbladder.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with SOB, wheezing// assess for pneumonia
COMPARISON: Chest CT ___
Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
New left basilar opacities are concerning for pneumonia. There is mild
pulmonary vascular congestion. No large pleural effusion or pneumothorax.
Cardiomediastinal silhouette is within normal limits. Multiple chronic
right-sided rib fractures are noted.
IMPRESSION:
New left basilar opacities concerning for lingular or left lower lobe
pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:51 am, 5 minutes after
discovery of the findings.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Dyspnea, unspecified
temperature: 99.0
heartrate: 105.0
resprate: 20.0
o2sat: 98.0
sbp: 157.0
dbp: 90.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT & PLAN: ___ h/o HTN/DM2, presented with fatigue and
dyspnea and found with perforated cholecystitis, cholangitis.
# Cholangitis
# Perforated cholecystitis
Mr. ___ was admitted with WBC 16, transaminitis,
intrahepatic bil dil with evidence of perforated cholecystitis
on Torso CT. The CT scan revealed a large GB fossa fluid
collection. He was initially seen by ACS surgery service - and
ERCP was recommended in case there was CBD stone accounting for
the cholecystitis and possibly cholangitis (given elevated
LFTs). As a result, ERCP was done on ___ - this showed no CBD
stone. He underwent sphincterotomy and placement of metallic
stent to help facilitate passage of any future CBD stone.
Ultimately, to address the fluid collection, Mr. ___
underwent US guided drainage and placement of drain on (___)
into GB fossa. Nearly 200 cc of purulent fluid was removed.
Cultures ultimately grew EColi - pansensitive. He was initially
on IV cipro/flagyl and then transitioned to oral cipro/flagyl.
There were no issues on this regimen.
He was instructed on how to manage a drain. He will be seen
by home ___ and ___ services. He will need the CBD stent pulled
in 4 weeks. He tolerated regular diet. He has a follow up with
Dr. ___ for consideration of CCY (likely in 6 wks
time). He was discharged in good condition. Tramadol PRN was
sufficient to address any pain.
# Hyponatremia: Na 134. Likely overload
- No signs of dehydration. Improved symptomatically from IV
Lasix.
# DM2
empaglifozin, glipizide, and metformin were temporarily held.
He can resume this medication on discharge.
# HTN: Will continue clonidine to avoid rebound hypertension.
He was treated with metoprolol - and added with amlodipine due
to persistent hypertension. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
naproxen
Attending: ___.
Chief Complaint:
Right foot cellulitis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ male with a past medical history
significant for CAD s/p CABG in ___, HLD, type II diabetes c/b
neuropathy and history of diabetic foot infections who presents
from ___ clinic with worsening right foot cellulitis.
The patient had a right trans-metatarsal amputation for
significant right foot infection on ___. The patient
was
discharged on doxycycline, which, per the patient, he completed
last ___. Following the procedure the patient had been
feeling well until ___ when he began to have
diarrhea,
nausea, generalized malaise, right foot pain, and some mild
chills. He had his visiting nurse visit the following day who
undressed his wound and found there to be increasing erythema,
malodor and some discharge. The patient was scheduled for a
follow up with his podiatrist today, who subsequently referred
his to the hospital for admission for IV antibiotic therapy.
In the ED, initial vital signs were within normal limits and
labs
were significant for a Hgb 11.8, CRP 56.8, and no leukocytosis.
Imaging showed postoperative changes of transmetatarsal
amputation and a New lucency at the medial aspect of the second
mid metatarsal which could represent osteomyelitis. He received
one dose of IV Levofloxacin 500mg, Oxycodone 5 mg and IV
MetroNIDAZOLE 500 mg.
Upon transfer to the floor, vital signs were again within
normal
limits and the patient was complaining of worsening right foot
pain, but otherwise had no other concerns.
Past Medical History:
CAD w/ MI ___ s/p CABG at ___.
IDDM - Type 2 - c/b retinopathy and neuropathy A1c 8.0 in
___
Nephrolithiasis s/p lithotripsy
Diabetic foot infections with poor wound healing
-first episode was ___ at ___
-___ episode in ___ which required IV antibiotics and
hyperbaric chamber
Injury to right leg and back after fall at work
Right rotator cuff repair
Retinal reattachment
Discectomy
GI bleed (peptic ulcer disease per notes) ___
R ___ and ___ digital amputations due to OM ___
Social History:
___
Family History:
Mother with CABG x3 in her ___
Sister and maternal aunts with "cardiac problems"
Physical Exam:
ADMISSION EXAM
==============
GENERAL: No acute distress, resting comfortably in bed.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi,
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema, 2+ DP pulses in
b/l
lower extremities. RLE warm, without erythema or edema, mildly
tender to palpation along the posterior calf. Right foot in
dressing w/out erythema or drainage expanding beyond the
bandage.
LLE cool to touch, no edema, erythema, or tenderness. Left foot
without any lesions, ulcers.
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE EXAM
==============
VITAL SIGNS: 98.1 126/82 79 20 95RA
GENERAL: No acute distress, resting comfortably in bed.
HEENT: EOMI
LUNGS: No increased work of breathing
ABDOMEN: Nondistended
EXTREMITIES: No cyanosis, clubbing, or edema. Right foot
bandaged at time of exam.
NEURO: A&Ox3
Pertinent Results:
ADMISSION LABS
==============
___ 11:04AM BLOOD WBC-8.7 RBC-4.87 Hgb-11.8* Hct-39.5*
MCV-81* MCH-24.2* MCHC-29.9* RDW-15.2 RDWSD-44.2 Plt ___
___ 11:04AM BLOOD Plt ___
___ 11:04AM BLOOD Glucose-88 UreaN-20 Creat-1.0 Na-142
K-4.5 Cl-101 HCO3-23 AnGap-18*
___ 11:04AM BLOOD CRP-56.8*
MICRO
=====
___ SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{STAPH AUREUS COAG +, BETA STREPTOCOCCUS GROUP B}; ANAEROBIC
CULTURE-FINAL ___.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{CANCELLED} EMERGENCY WARD
IMAGING
=======
___ R FOOT XR
IMPRESSION:
Postoperative changes of transmetatarsal amputation of the foot.
New lucency at the medial aspect of the second mid metatarsal
which could represent osteomyelitis. Consider MRI for further
characterization.
___ ABIs
IMPRESSION:
1. Ankle-brachial index was not obtained in the right leg due to
overlying
bandage from recent right foot amputation. Right posterior
tibial artery was noncompressible.
2. Triphasic waveforms throughout the left lower extremity with
a toe brachial index of 0.78 consistent with mild arterial
insufficiency in the left lower extremity.
___ MRI R FOOT
IMPRESSION:
Patient is status post transmetatarsal amputation of all 5 toes.
Skin ulceration noted at the distal stump of the first
metatarsal
Osteomyelitis involving the first through third metatarsals.
Partially loculated abscess formation at the distal stump of the
second and third metatarsals.
DISCHARGE LABS
==============
___ 06:40AM BLOOD WBC-6.6 RBC-4.74 Hgb-11.6* Hct-38.0*
MCV-80* MCH-24.5* MCHC-30.5* RDW-15.1 RDWSD-43.9 Plt ___
___ 07:10AM BLOOD Glucose-136* UreaN-16 Creat-0.9 Na-141
K-4.9 Cl-102 HCO3-24 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. FoLIC Acid 1 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. glimepiride 2 mg oral DAILY
6. Invokana (canagliflozin) 100 mg oral DAILY
7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
8. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
2. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth Daily Disp #*6
Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times a day
Disp #*17 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Every six hours as
needed Disp #*12 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. Atorvastatin 20 mg PO QPM
9. FoLIC Acid 1 mg PO DAILY
10. glimepiride 2 mg oral DAILY
11. Invokana (canagliflozin) 100 mg oral DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
Cellulitis
Secondary diagnosis
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with rt foot cellultis// evaluate for ostero
TECHNIQUE: AP, lateral, oblique views of the right foot.
COMPARISON: Foot films from ___.
FINDINGS:
Patient is status post transmetatarsal amputation as seen on prior. Since
prior, the medial margin of the remaining mid right second metatarsal is
relatively lucent. Callus formation seen at the second and third metatarsal
amputation sites. No other sites of interval erosion. Soft tissue swelling
is noted. Vascular calcifications again identified. Posterior and inferior
calcaneal spurs are noted.
IMPRESSION:
Postoperative changes of transmetatarsal amputation of the foot. New lucency
at the medial aspect of the second mid metatarsal which could represent
osteomyelitis. Consider MRI for further characterization.
Radiology Report
EXAMINATION: MRI of the right forefoot with and without contrast.
INDICATION: ___ year old man with right foot cellulitis, CT with question
osteomyelitis, MRI for further investigation.// ___ year old man with right
foot cellulitis, CT with question osteomyelitis, MRI for further
investigation.
TECHNIQUE: Multisequence multiplanar MRI of the right forefoot was performed
before and after the administration of intravenous gadolinium (Gadovist 9 cc).
COMPARISON: Right foot radiographs dated ___. MRI of the right foot
dated ___, performed at an outside institution.
FINDINGS:
The patient is status post transmetatarsal amputation of all 5 toes. There is
abnormal T1 hypointense signal with corresponding hyperintense STIR signal in
the shaft of the remaining third metatarsal bone involving predominantly the
distal aspect but extending to the base. Similar signal is also noted in the
shaft of the second metatarsal bone but to a lesser extent. Post contrast
images demonstrate enhancement of the affected regions. Findings are
compatible with osteomyelitis. Additionally, there is a third focus of
osteomyelitis in the distal portion of the remaining first metatarsal bone.
A skin defect is noted in the distal stump at the level of the first
metatarsal. Soft tissue edema and contrast enhancement is noted in the deep
and superficial soft tissues surrounding the second and third metatarsals.
At the distal stump of the second and third metatarsal, along the plantar
aspect, there is irregularly shaped fluid signal which demonstrates rim
enhancement which appears to have several branches compatible with abscess
formation. The main portion of the abscess measures 0.9 x 0.7 x 1.7 cm. In
addition, fluid is seen extending to the skin surface along the dorsum of the
foot, presumably an additional site of ulceration/fluid collection, best
correlated with physical exam (10:8)
Diffuse fatty atrophy is noted of the intrinsic musculature of the foot.
IMPRESSION:
Status post transmetatarsal amputation of all 5 toes.
Skin ulceration noted at the distal stump of the first metatarsal
Osteomyelitis involving the first through third metatarsals.
Irregularly shaped fluid collection with rim enhancement at the distal stump
of the second and third metatarsals, predominantly plantar, compatible with
abscess. In addition, note is made of a fluid collection extending to the
distal dorsal surface.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:28 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old man with prior PVD, severe diabetes s/p foot
amputation on right, eval for worsening PVD.// ___ year old man with prior PVD,
severe diabetes s/p foot amputation on right, eval for worsening PVD.
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.
COMPARISON: None
FINDINGS:
Right:
Femoral artery: Triphasic waveform
Popliteal artery: Triphasic waveform
Posterior tibial artery: Biphasic waveform
Right ABI (at rest): Not obtained due to overlying bandage from recent right
foot amputation.
The right posterior tibial artery was noncompressible and demonstrates a
biphasic waveform.
Left:
Femoral artery: Triphasic waveform
Popliteal artery: Triphasic waveform
Posterior tibial artery: Triphasic waveform
Dorsalis pedis artery: Triphasic waveform
Left TBI (at rest): 0.78
The left lower extremity vessels were noncompressible.
Pulse volume recordings showed symmetric amplitudes at all levels,
bilaterally.
IMPRESSION:
1. Ankle-brachial index was not obtained in the right leg due to overlying
bandage from recent right foot amputation. Right posterior tibial artery was
noncompressible.
2. Triphasic waveforms throughout the left lower extremity with a toe brachial
index of 0.78 consistent with mild arterial insufficiency in the left lower
extremity.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Foot pain, R Foot swelling, Wound eval
Diagnosed with Cellulitis of right lower limb
temperature: 97.4
heartrate: 94.0
resprate: 18.0
o2sat: 97.0
sbp: 116.0
dbp: 61.0
level of pain: 9
level of acuity: 2.0 | HOSPITAL COURSE
===============
Mr. ___ is a ___ male with a past medical history
significant for CAD s/p CABG in ___, HLD, type II diabetes c/b
neuropathy and history of diabetic foot infections who presented
from ___ clinic with worsening right foot cellulitis.
ACTIVE ISSUES
=============
# Right Foot Cellulitis: S/p right trans-metatarsal amputation
on ___ for significant right foot infection. The patient was
discharged on doxycycline, which he completed approximately one
week prior to this admission. Felt systemically ill over past
week, and surgery site appeared red and macerated per ___.
Improved with 24 hours levo/flagyl (D1 = ___. MRI prelim read
showing osteomyelitis, but per discussion with podiatry this may
be post-surgical change. Will see podiatry in clinic next week,
they will f/u final MRI read. Will continue 10 day course of
antibiotics (last day ___.
CHRONIC ISSUES
==============
# Type 2 Diabetes: Complicated by retinopathy, neuropathy,
Diabetic foot infections w/ most recent surgery for
trans-metatarsal amputation on ___. Lantus 20u QAM and 20u QPM
with sliding scale. Held home diabetes medications Metformin,
Invokana, glimepiride and Trulicity while admitted, restarted on
discharge.
# CAD w/ MI ___ s/p CABG at ___.
- Started ASA 81 (held in distant past due to concern regarding
GI bleed; given multiple contributing mediations at that time,
reasonable to restart ASA for secondary cardioprotection)
- Continue Atorvastatin 20 mg PO QPM
- Continue Metoprolol Succinate XL 100 mg PO DAILY
# Peptic Ulcer Disease
- Continued Pantoprazole, decreased dose from 40 mg PO Q12H to
DAILY (see note for ASA above)
TRANSITIONAL ISSUES
===================
[] Podiatry f/u on ___ at 11:10 AM; they should follow
up final MRI read regarding concern for osteomyelitis
[] Continue levofloxacin and metronidazole for 10 day course
(last day ___
[] Added low dose aspirin for secondary prevention (distant GI
bleed not directly attributable to ASA), and decreased
pantoprazole dose 40 mg PO Q12H to DAILY |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Levofloxacin / lisinopril
Attending: ___.
Chief Complaint:
Neck pain s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old male who suffered a mechanical
fall out of bed the morning of admission where he landed on his
back. He was helped back into bed by his nephew. The patient
was unable to get up due to pain in the right hip. EMS was
initiated. Patient reported right hip pain, mild headache and
midline upper neck pain. Patient denied numbness, weakness or
tingling.
Imaging revealed right inferior pelvic rami fracture and C2
(Type II odontoid)fracture.
Past Medical History:
1. Chronic kidney disease
2. Hypertension,
3. COPD, on home O2 in the past, intubated per family one or ___
years ago for a COPD exacerbation.
4. BPH status post TURP.
5. Primary biliary cirrhosis.
6. GERD
7. History of diastolic heart failure based on TTE in ___.
8. Hyperlipidemia.
9. History of apparent pseudogout
10. History of pericardial effusion and tamponade in ___.
11. Anemia.
12. History of CVA and seizure in ___ with an
incidental 6-mm ___ aneurysm.
Family History:
Non-contributory
Physical Exam:
Per neurosurgery admission/consult note:
O: T:98.2 BP: 152/80 HR: 83 R 18 O2Sats 99 %
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atrumatic
Neck: Midline tenderness upper ___ C-spine
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam,
Orientation: Oriented to person, place, and date.
On discharge:
98.2, 75, 111/59, 16, 95% on room air.
Pertinent Results:
___ 09:20AM BLOOD WBC-8.9 RBC-4.16* Hgb-13.2* Hct-42.5
MCV-102* MCH-31.7 MCHC-31.1 RDW-14.3 Plt ___
___ 09:10PM BLOOD WBC-7.0 RBC-4.25* Hgb-13.6* Hct-43.3
MCV-102* MCH-31.9 MCHC-31.3 RDW-14.4 Plt ___
___ 09:10PM BLOOD Neuts-78.0* Lymphs-12.8* Monos-8.9
Eos-0.1 Baso-0.2
___ 09:10PM BLOOD ___ PTT-54.0* ___
___ 09:20AM BLOOD Glucose-106* UreaN-31* Creat-1.7* Na-136
K-4.3 Cl-101 HCO3-23 AnGap-16
___ 09:10PM BLOOD Glucose-115* UreaN-25* Creat-1.4* Na-137
K-4.1 Cl-103 HCO3-21* ___ CT C-spine w/o contrast
1. Type II odontoid fracture, age indeterminate.
2. Severe multilevel degenerative disc disease.
___ Right femur/pelvis (ap/lat)
1. Irregularity at the right inferior pubic ramus with adjacent
lucency seen raising concern for inferior pubic ramus fracture.
Given this, one wouldsuspect an additional fracture in the right
pubic ring, although one is not definitively identified on this
radiographic study.
2. Knee joint chondrocalcinosis.
___ CXR
Single supine AP portable view of the chest was obtained. The
cardiomediastinal silhouette is stable. The aorta is calcified
and tortuous and the cardiac silhouette is top normal to mildly
enlarged. Slight prominence of the interstitial markings is
stable compared to prior and may be due to chronic lung changes.
There is mild left base atelectasis, although underlying
aspiration is not excluded. Surgical clips are again seen
overlying the left lower hemithorax. No large pleural effusion
or pneumothorax is seen.
___ Thumb left
1. Severe first CMC and radiocarpal DJD.
2. Chondrocalcinosis and scapholunate advanced collapse
consistent with CPPD arthropathy.
___ CT pelvis w/o contrast
Fractures of the right inferior pubic ramus and anterior column
of the right acetabulum. No fracture of the femoral head.
___ C-spine MRI
Preliminary read:
Type 2 odontoid fracture is unchanged in alignment compared to
the CT.
Mildly increased fluid signal along the fracture margins
suggests subacute fracture given sclerosis on CT. There is no
definite ligamentous disruption. Multilevel degenerative
changes described above, similar to prior Preliminary
Reportexamination from ___
Medications on Admission:
Lasix 40 ___, spiriva, albuterol inh, amlodipine 5', ASA81,
citalopram 30', ergocalciferol, fluticasone nasal spray, MVI,
omeprazole 40', ranitidine 150'', ursodiol 300''', zonisamide
300'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Citalopram 30 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Furosemide 40 mg PO MWF
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
breakthrough pain
12. Ranitidine 150 mg PO BID
13. Senna 1 TAB PO HS:PRN constipation
14. Tiotropium Bromide 1 CAP IH DAILY
15. TraMADOL (Ultram) 25 mg PO QID
16. Ursodiol 300 mg PO TID
17. Zonisamide 300 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Type II odontoid fracture
Right pubic rami fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man with fall out of bed felt to have type 2 odontoid
fracture. Additional evaluation of odontoid fracture.
COMPARISON: CT of the cervical spine, ___. MRI cervical spine,
___.
TECHNIQUE: Sagittal T1, T2 and IDEAL with axial T2 and GRE images were
acquired through the cervical spine without intravenous contrast.
FINDINGS:
Exam is moderately degraded by patient motion.
Again seen is a fracture through the base of the odontoid process, similar in
appearance and alignment compared to the prior examination. High T2 signal
structure posterior to the C2 vertebral body likely represents prominent
venous plexus and is unchanged. There is mildly increased STIR signal along
the fracture margins suggesting subacute process given sclerosis on the CT.
No ligamentous disruption or fluid collection is identified within the
confines of the motion degraded examination. The spinal cord appears normal
in signal intensity and morphology in the craniocervical junction is normal as
are the visualized portions of the posterior fossa.
There is multilevel degenerative change with diffuse disk desiccation and
decreased disk height.
At C2-C3, there is a broad-based disc protrusion and ligamentum flavum
thickening mildly narrowing the spinal canal. There is no significant neural
foraminal narrowing.
At C3-C4, there is a broad-based disc protrusion and ligamentum flavum
thickening which moderately narrows the spinal canal. Facet and uncovertebral
joint osteophytes result in mild bilateral neural foraminal narrowing.
At C4-C5, there is a broad-based disc protrusion and ligamentum flavum
thickening resulting in moderate to severe spinal canal narrowing with
remodeling of the spinal cord. Uncovertebral and facet joint osteophytes
result in moderate bilateral neural foraminal narrowing.
At C5-C6, there is a broad-based disc bulge without significant spinal canal
narrowing. Facet and uncovertebral joint osteophytes result in mild bilateral
neural foraminal narrowing.
At C6-C7, facet and uncovertebral joint osteophytes result in moderate to
severe bilateral neural foraminal narrowing. There is no significant
narrowing of the spinal canal.
The C7-T1 level is unremarkable.
Small disc protrusions are noted in the upper thoracic spine at T2-T3 and
T3-T4.
IMPRESSION:
1. Type 2 odontoid fracture is unchanged in alignment compared to the CT.
Mildly increased fluid signal along the fracture margins suggests subacute
fracture given sclerosis on CT. There is no definite ligamentous disruption.
2. Multilevel degenerative changes described above, similar to prior
examination from ___.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FRACTURE OF PUBIS-CLOSED, FX C2 VERTEBRA-CLOSED, FALL FROM BED, HYPERTENSION NOS
temperature: 98.2
heartrate: 83.0
resprate: 18.0
o2sat: 99.0
sbp: 152.0
dbp: 80.0
level of pain: 13
level of acuity: 3.0 | Mr. ___ was admitted to the inpatient ward under the Acute
Care Surgery Team for further management of his right pubic rami
fracture and Type II odontoid fracture. He was seen by
Orthopedics and Neurosurgery/Spine for evaluation of his
injuries. His pubic rami fracture was ___ and he was
allowed to bear weight to his lower extremities as tolerated.
In regards to his odontoid fracture, neurosurgery recommended
that he wear a hard collar (Aspen) at all times. The patient
underwent a MRI for further evaluation of the injury as well.
After more detailed evaluation, it was felt that Mr. ___
injury was ___. He should continue to wear the
cervical collar at all times (other than during hygiene) until
his follow up with Neurosurgery. He also has a follow-up
appointment with ACS and orthopedics.
During his inpatient stay, Mr. ___ pain was controlled
with narcotic and non-narcotic pain medications. He was started
on his home medications during his stay. He tolerated an oral
diet without issue and had no issues voiding. Physical therapy
evaluated Mr. ___ on two occasions and recommended that he
obtain further physical therapy at a rehabilitation facility
upon discharge.
At the time of discharge, Mr. ___ was hemodynamically
stable, afebrile and in no acute distress. Discharge
instructions were provided using a ___ interpreter. His
daughter was updated with the plan and discharge instructions as
well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right Facial Palsy / Right Sensory Changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with no
significant past medical history except for MVA in ___ with
reported left sided weakness who presents to ___ ED today with
right facial palsy and right hemibody weakness and numbness.
Per
her report she had been in her usual state of health last week
on
___ when driving to get lunch. She noted at that time
some
tingling in the mouth and that the food did not taste right on
the right side of her mouth. She then noted that her face was
progressively feeling as if it were numb or tingling and that it
was moving less. She presented to ___ and ___ ___ on
___ where a diagnosis of Right Bells Palsy was made and
the
patient was discharged on a steroid taper as well as Valtrex
___ as intervention. Of note they also diagnosed her with
some
deficit of gag reflex in right which was not in the left, and
trauma was caused to the left ___ on attempts to perform derumen
disimpaction.
The patient then reported because she was feeling as if her
right
hemibody was weak and numb that she contacted ___ again who
directed her to the ED for further evaluation. She also noted
that shortness of breath/dyspnea on exertion was noted shortly
after the onset of her symptoms with increase in this over the
past week.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, vertigo, or tinnitus.
She did endorse some vague non-vertiginous lightheadedness.
Denies difficulties producing or comprehending speech. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough. Denies chest pain or tightness, palpitations. Denies
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:
- MVA ___ w/ reported weakness
Social History:
___
Family History:
- Paternal history of multiple members with blood clots and
heart
disease
- Maternal history of miscarriage x3
Physical Exam:
Admission Exam:
Pain=5(left ___, T=98.5F, HR=76, BP=142/77, RR=16, SaO2=100% RA
General: Awake, cooperative, NAD.
HEENT: Right facial hemiparesis
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR
Abdomen: soft, nontender, abdominal adipose
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Attentive, with good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 3mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation demonstrated inconsistencies including
right>left deficit to temperature, but increased right
sensitivity to pinprick. ___ strength noted bilateral in
masseter.
VII: Clear peripheral nerve deficit with decreased activation
and
strength in right face as well as reported deficit to taste in
the left tongue.
VIII: Hearing decreased to finger-rub in left.
IX, X: Palate elevates symmetrically. Gag reflex absent in
right
throat, but full in left
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing (right
tongue
in cheek demonstrated giveway)
-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
R ___ ___ ___ 5 5 5 5 5
* Right hemibody demonstrated giveway in several distributions
which did not fit any pattern. On first second testing the
patient was full throughout. No circumduction of one arm about
the other was noted.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: Sensation was noted to be decreased to light touch and
temperature in right hemibody splitting the midline, however
pinprick heightened sensation in the right relative to the left.
Abdominal pinprick did not reveal a level, or deficit between
the
hemispheres. No extinction to DSS. Vibration was noted to be
worse in the right distal lower extremity with equal report at
the knees.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Discharge Exam:
T 97.9, BP 113-136/59-75, HR 65-88, RR ___, O2 98-100% on RA
On examination, the patient demonstrates a clear peripheral
cranial nerve 7 deficit with upper and lower distribution of
facial weakness. She also reported loss of taste in the right
tongue relative to the left. Her palate elevated symmetrically,
but the gag reflex was absent in the right and brisk on the
left. She demonstrated inconsistent facial sensory examination,
reporting pinprick was greater in the right face (splitting at
midline) and temperature was greater in the left face. Weakness
in the right hemibody was in no specific pattern and on first
effort was full strengh throughout, no circumduction was seen.
In terms of the numbness, there was deficit to temperature but
increased sensation to pinprick in the right arm which clearly
is an inconsistency. In the abdomen, pinprick was symmetric
throughout without deficit. In the lower extremities, pinprick
was weaker in the ankle of the right lower extremity relative to
the left. Vibration sense in the right distally was reduced,
but symmetric at the knees.
Otherwise, there were no neurological deficits.
Pertinent Results:
___ MR ___ contrast
1. No evidence of hemorrhage, ___ effect, or infarction.
2. No evidence of demyelinating disease.
3. Apparent soft tissue scalp defect midline and posteriorly
which may
represent a scar although direct visualization is recommended.
___ MR ___ contrast
1. Disc protrusion at the C5-C6 level, to the right of midline,
causing
moderate narrowing of the right aspect of the spinal canal and
bilateral
neural foraminal narrowing, right greater than left.
2. No abnormal enhancement or evidence of demyelinating disease.
3. No evidence of spinal cord compression.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ValACYclovir 1000 mg PO Q24H
2. PredniSONE 60 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
Tapered dose - DOWN
2. Artificial Tear Ointment 1 Appl BOTH EYES QHS
RX *artificial tears ointment 1 appl topical at bedtime, to
right ___ Disp #*1 Tube Refills:*1
3. Artificial Tears Preserv. Free 2 DROP BOTH EYES Q2H
RX *peg 400-hypromellose-glycerin [Artificial Tears] 1 %-0.2
%-0.2 % ___ drops topical every hour to right ___ Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Bell's Palsy
C5-6 disc protrusion
s/p right wisdom teeth removal causing loss of gag reflex
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
INDICATION: ___ year old woman with new right gag loss and right hemibody
sensory changes // question of demyelinating disease
TECHNIQUE: Sagittal and axial T1, gradient echo, FLAIR, diffusion, and T1
imaging was performed. After administration of intravenous gadolinium, axial
T1 and sagittal MPRAGE imaging was performed and re-formatted in axial and
coronal orientations
COMPARISON: None.
FINDINGS:
There is no evidence of intracranial hemorrhage or mass effect. The ventricles
and basal cisterns appear normal.
There are normal vascular flow voids. There is no evidence of acute ischemia
based on diffusion-weighted imaging.
There is a developmental venous anomaly within the right parasagittal frontal
lobe. There is otherwise no abnormal brain parenchymal or leptomeningeal
enhancement.
The orbits, skull base, and paranasal sinuses are unremarkable. There is an
apparent soft tissue scalp defect midline and posteriorly which may represent
a scar although direct visualization is recommended.
IMPRESSION:
1. No evidence of hemorrhage, mass effect, or infarction .
2. No evidence of demyelinating disease.
3. Apparent soft tissue scalp defect midline and posteriorly which may
represent a scar although direct visualization is recommended.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST
INDICATION: ___ year old woman with new right gag loss and right hemibody
sensory changes // question of demyelinating disease
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were performed. After administration of
intravenous gadolinium, sagittal and axial T1 weighted imaging was performed.
COMPARISON: None.
FINDINGS:
The vertebral body heights are preserved. The alignment within the cervical
spine is normal. There is T1/T2 hyperintense signal within the left C7
transverse process which suppresses on IDEAL imaging and thus represents an
area of focal fatty marrow.
The cervical spinal cord is normal in signal and morphology. There is no
cerebellar tonsillar ectopia. There is no abnormal cord parenchymal or
leptomeningeal enhancement. There is no evidence of demyelinating disease.
The paraspinal and prevertebral soft tissues appear unremarkable.
At the C2-C3 level, the spinal canal and neural foramina appear normal.
At the C3-C4 level, uncovertebral hypertrophy and bilateral facet osteophytes
cause mild bilateral neural foraminal narrowing. The spinal canal appears
normal.
At the C4-C5 level, there is a tiny posterior disc protrusion without
significant spinal canal narrowing. The neural foramina appear normal.
At the C5-C6 level, there is a posterior disc protrusion, greater on the right
side of the spinal canal, causing moderate narrowing of the right aspect of
the spinal canal and remodeling of the ventral surface of the spinal cord.
Additionally, the disc protrusion extends into the neural foramina, right
greater than left, causing moderate right and mild left neural foraminal
narrowing. There is no associated spinal cord signal abnormality.
At the C6-C7 level, there is a small posterior disk protrusion, slightly left
of midline, without significant spinal canal narrowing. The neural foramina
appear normal.
At the C7-T1 level, the spinal canal and neural foramina appear normal.
IMPRESSION:
1. Disc protrusion at the C5-C6 level, to the right of midline, causing
moderate narrowing of the right aspect of the spinal canal and bilateral
neural foraminal narrowing, right greater than left.
2. No abnormal enhancement or evidence of demyelinating disease.
3. No evidence of spinal cord compression.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Facial numbness, R Ear pain
Diagnosed with SKIN SENSATION DISTURB
temperature: 98.5
heartrate: 76.0
resprate: 16.0
o2sat: 100.0
sbp: 142.0
dbp: 77.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ year old woman who was recently diagnosed
with a right Bell's palsy at ___ and ___ (on prednisone and
valtrex) who presented with continued symptoms as well as new
symptoms of right arm and leg numbness. During neurological
testing in the ED, she noticed that her right side was weaker
than her left; she is right-handed and reports that her right
side is typically her stronger and more coordinated side. She
was noted at the outside facility and in the ED to have a
decreased gag reflex on the right, intact on the left. Due to
these multiple symptoms and exam findings, she was admitted for
further workup.
The patient has right facial weakness in a LMN pattern
(decreased eyebrow raise, ___ closure, nasolabial fold and
smile), decreased taste on the right side, and possible right
___ hyperacusis (although left ___ experienced recent trauma at
outside facility during cerumin disimpaction), all consistent
with a right Bell's palsy. The seventh nerve is inflamed,
possibly from a prior viral infection.
The patient had blurred vision the morning after admission,
likely due to not taping her ___ shut the night previously, as
she had been instructed to do at ___ and ___. She was
provided with ___ drops to use every hour when awake and ___
ointment to use at night, in addition to continued taping of the
right ___ at night. She was instructed to see an ophthalmologist
if her ___ blurriness should recur and persist despite
preventative measures to protect the ___.
Her diminished right gag is most likely due to prior wisdom
teeth removal on the right side.
Her right sided numbness was only present in the arm on exam,
and she had right brachioradialis weakness, consistent with MRI
findings of C5-6 disc protrusion with C6 root impingement. This
disc protrusion is likely a result of her car accident in ___,
after which she states she did not have imaging done. She should
use a soft collar and hard pillow at night to prevent nerve
irritation and worsening of symptoms. Surgery is not needed at
this time.
- Prednisone 60mg daily (continuing outpatient) - will need to
taper by 10 mg daily after 60 mg daily for 7 days
- D/c Valtrex |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / beta blockers / Cephalosporins / I.V. contrast
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with COPD/emphysema on PRN
home
O2 (up to 3L), HFrEF (EF 35-40%), severe MR, CKD, CAD s/p MI and
VF arrest (BMS to RCA), afib on warfarin s/p PPM, history of M.
abscesses on sputum culture s/p abx treatment, and newly
diagnosed likely stage IIIA non-small cell lung cancer squamous
of the LUL, presenting with left sided thoracic pain.
On the day prior to presentation, he had CT-guided placement of
2
markers in his left upper lobe for planned radiation therapy.
Post- procedure CT noted small left pneumothorax.
He began experiencing pain on the day prior to admission after
anesthesia wore off. He states he experiences sharp localized
nonradiating chest pain, worse with deep inspiration felt at the
site of the radial marker placement. He was not experiencing
pain
there prior to the procedure.
He denies fevers, chills, palpitations, dyspnea. No change to
his
chronic cough.
In the ED, initial vitals:
T 96.6 HR 70 BP 111/55 RR 18 O2 Sat 100% RA
- Exam notable for:
RESP: Scattered crackles, Unlabored respiratory effort. Tender
to
palpation over site of radio marker placement.
- Labs notable for:
CBC: WBC normal at 5.8, Hgb 10.5 with MCV 103, Plt 115
Coags: ___ 12.6, INR 1.2
- Imaging notable for:
CXR (two studies one hour apart) showing the fiducial marker and
no evidence of definite pneumothorax. (See imaging section below
for list of CXRs)
EKG: Afib/flutter with V-paced at HR 70, QTc 459 ms
- Pt given:
___ 14:00 PO Acetaminophen 1000 mg
___ 17:54 PO/NG Torsemide 40 mg
___ 17:54 PO/NG Warfarin 2.5 mg
___ 18:43 PO/NG Docusate Sodium 100 mg
___ 20:48 PO Acetaminophen 650 mg
___ 21:26 PO/NG Atorvastatin 40 mg
___ 21:26 PO/NG Famotidine 20 mg
___ 21:26 PO/NG Senna 17.2 mg
Per ___ fellow: exp film reviewed ___ doctor and actually showing
worsening pneumo, recheck expiratory film at midnight or if
increase in pain (note not in chart, only in dashboard. Note
that
the radiology read report does not indicate worsening
pneumothorax)
- Vitals prior to transfer:
T 97.4 HR 76 BP 115/64 RR 18 O2 Sat 100% RA
On the floor, patient is pleasant, jovial and overall looking
well. He is wearing 2L of nasal cannula. He does not have any
wheezing or coughing, just pain in his left chest which is about
___ and nontender to palpation. He also has some shortness of
breath. He does not have any dizziness or lightheadedness. He
reports a history of a clot in his left leg in the past.
He has chronic pain in his bilateral legs. He has had chronic
back pain as well. He does not take NSAIDs. He is hard of
hearing
but has a right hearing aid with him.
Past Medical History:
ATRIAL FIBRILLATION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CONGESTIVE HEART FAILURE
CORONARY ARTERY DISEASE
NEPHROLITHIASIS
EMPHYSEMA
HYPERLIPIDEMIA
ATYPICAL MYCOBACTERIAL INFECTION
H/O MYOCARDIAL INFARCTION
Social History:
___
Family History:
Per prior discharge summary:
Mother died at ___ of tuberculosis
Father died at ___ of ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
T 97.6 BP 100 / 66 HR 72 RR 16 O2 Sat 95 2L NC
General: Elderly, chronically ill gentleman, in no acute
distress.
HEENT: Has hearing impairment (hearing aid in left ear)
Chest: nontender to palpation
CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes.
Abdomen: Soft, non-tender, non-distended.
Ext: Warm, well perfused, 2+ pulses, no edema or tenderness to
palpation.
Skin: Warm, dry, no rashes or notable lesions including absence
of petechiae.
Neuro: CNII-XII intact, moving all extremities spontaneously.
DISCHARGE PHYSICAL EXAM
=======================
General: Elderly, in no acute distress
HEENT: Has hearing impairment (hearing aid in left ear)
Chest: nontender to palpation
CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, breathing
comfortably on room air.
Abdomen: Soft, non-tender, non-distended.
Ext: Warm, well perfused, 2+ pulses, no edema or tenderness to
palpation.
Skin: Warm, dry, no rashes or notable lesions including absence
of petechiae.
Neuro: CN II-XII intact, moving all extremities spontaneously.
Pertinent Results:
LABS
==========
___ 06:00AM BLOOD WBC-5.9 RBC-3.00* Hgb-9.6* Hct-31.4*
MCV-105* MCH-32.0 MCHC-30.6* RDW-18.6* RDWSD-71.7* Plt ___
___ 06:00AM BLOOD ___ PTT-29.8 ___
___ 06:00AM BLOOD Glucose-106* UreaN-37* Creat-2.1* Na-142
K-4.2 Cl-104 HCO3-26 AnGap-12
___ 06:00AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.3
IMAGING
==========
___ CT ___
1. Technically successful CT-guided placement of two fiducial
markers in the left upper lobe lung mass.
2. Small postprocedure left pneumothorax.
CXR
___ 4:23 ___
No definite pneumothorax is seen on the radiograph.
Specifically
the
pneumothorax seen on the CT performed 2 hours prior is not
definitively discerned on the current radiograph.
New fiducial marker seen within the mid left lung. Mild
pulmonary edema.
Diffuse bilateral parenchymal opacities appear grossly unchanged
compared to the prior radiograph.
___ CXR 6:07 ___
No definite pneumothorax. No substantial change in parenchymal
lung findings compared to the prior study.
___ CXR 12:01PM
Comparison to ___. The lung volumes have
decreased.
The diffuse bilateral interstitial opacities are overall stable
in extent and severity. The fiducial marker in the left lung as
well as the left pectoral pacemaker are stable. There is no
evidence for the presence of a pneumothorax. Stable mild
cardiomegaly.
___ CXR 1:20 ___
Unchanged exam compared to 1 hour earlier. No definite
pneumothorax.
___ CXR 1:03 AM
Comparison to ___. Millimetric left pneumothorax
is unchanged. No evidence of tension. Stable appearance of the
lung parenchyma, with known changes and a fiducial marker in the
left lung lesion. Stable position of the left pectoral
pacemaker.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Vitamin D 1000 UNIT PO DAILY
4. Glucosam-Chond-MSM(with boron)
(___) 1 tablet oral DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
7. azelastine 0.15 % (205.5 mcg) nasal BID
8. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Famotidine 20 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. folic acid ___ mcg oral DAILY
13. Torsemide 40 mg PO BID
14. Warfarin 5 mg PO 2X/WEEK (MO,FR)
15. Warfarin 2.5 mg PO 5X/WEEK (___)
16. Trelegy Ellipta (fluticasone-umeclidin-vilanter) 100-62.5-25
mcg inhalation DAILY
17. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN Pain - Severe
18. GuaiFENesin ER 600 mg PO Q12H
19. Ferrous Sulfate 65 mg PO DAILY
20. Cinnamon (cinnamon bark) 1000 mg oral Daily
21. Senna 25.8 mg PO DAILY
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN Pain - Severe
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. azelastine 0.15 % (205.5 mcg) nasal BID
6. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
7. Cinnamon (cinnamon bark) 1000 mg oral Daily
8. Cyanocobalamin 500 mcg PO DAILY
9. Famotidine 20 mg PO DAILY
10. Ferrous Sulfate 65 mg PO DAILY
11. folic acid ___ mcg oral DAILY
12. Glucosam-Chond-MSM(with boron)
(___) 1 tablet oral DAILY
13. GuaiFENesin ER 600 mg PO Q12H
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Potassium Chloride 20 mEq PO DAILY
16. Senna 25.8 mg PO DAILY
17. Torsemide 40 mg PO BID
18. Trelegy Ellipta (fluticasone-umeclidin-vilanter)
100-62.5-25 mcg inhalation DAILY
19. Vitamin D 1000 UNIT PO DAILY
20. Warfarin 5 mg PO 2X/WEEK (MO,FR)
21. Warfarin 2.5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Post-procedure pneumothorax
SECONDARY DIAGNOSIS
===================
Non-small cell lung cancer
Heart failure with reduced injection fraction
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ stage IIIA non-small cell lung cancer squamous of
the LUL 1 day s/p placement of radiologic marker in L lung c/o chest pain at L
lung// ptx, post-procedural complication ptx, post-procedural complication
IMPRESSION:
Comparison to ___. The lung volumes have decreased. The diffuse
bilateral interstitial opacities are overall stable in extent and severity.
The fiducial marker in the left lung as well as the left pectoral pacemaker
are stable. There is no evidence for the presence of a pneumothorax. Stable
mild cardiomegaly.
Radiology Report
EXAMINATION: AP/PA SINGLE VIEW EXPIRATORY CHEST
INDICATION: ___ year old man with fiducial placement y'day, now c/o localized
chest pain// Eval for ptx.
TECHNIQUE: AP upright expiration and lateral view of the chest.
COMPARISON: Multiple prior comparisons, most recent from ___ at
00:16
FINDINGS:
Examination is overall unchanged compared to approximately 1 hour earlier.
Left chest wall cardiac conduction device lead tips terminate in the right
atrium and right ventricle. 2 fiducial markers are noted within the known
left upper lobe pulmonary mass. There are persistent low lung volumes with
diffuse bilateral interstitial opacities, overall stable in extent in
severely. There remains no definite pneumothorax identified. Stable
cardiomegaly.
IMPRESSION:
Unchanged exam compared to 1 hour earlier. No definite pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pneumothorax, mildly increasing over the
last day, ___ s/p CT-guided placement of 2 markers in his left upper lobe//
change in PTX change in PTX
IMPRESSION:
Comparison to ___. Millimetric left pneumothorax is unchanged.
No evidence of tension. Stable appearance of the lung parenchyma, with known
changes and a fiducial marker in the left lung lesion. Stable position of the
left pectoral pacemaker.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Rib pain
Diagnosed with Postprocedural pneumothorax, Oth surgical procedures cause abn react/compl, w/o misadvnt, Chest pain, unspecified
temperature: 96.6
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 55.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ year old male with COPD/emphysema on PRN
home O2 (up to 3L), HFrEF (EF 35-40%), severe MR, CKD, CAD s/p
MI and VF arrest (BMS to RCA), afib on warfarin s/p PPM, and
history of M. abscesses on sputum culture s/p abx treatment, and
newly diagnosed likely stage IIIA non-small cell lung cancer
squamous of the LUL, presenting with left sided thoracic pain
found to have a pneumothorax.
ACUTE/ACTIVE PROBLEMS:
# Chest pain
# Hypoxia- at baseline oxygen requirement
Presented with chest pain in setting of known post procedure
small pneumothorax and was admitted for monitoring. There was no
tension pathology. Initial CXR without clear PTX but subsequent
CXR did show a small millimetric left pneumothorax which
remained stable on serial imaging. ___ reviewed imaging and felt
no intervention was needed. His pain was managed with
acetaminophen.
CHRONIC ISSUES:
#COPD
Has home O2 to be used PRN. On RA to 2L here for comfort with
goal O2>88%.
- Continued home trelegy, fluticasone
#NSCLC/SCC of LUL
S/p flexible bronchoscopy with EBUS-TBNA for lung cancer staging
on ___ with all LN turned back negative for cancer- 11L,
4L, 7, and 4R (stage IIIA based on his last CT/PET). Per recent
radiology note, it is not clear that he has more advanced
cancer. Will follow up with radiation oncology with plans for
cyberknife in ___
# Atrial fibrillation
CHADS2VASC is 3. INR 1.2 on arrival, given 2.5 mg on ___ and 5
mg on ___. He will check his INR at home on ___ and
communicate with clinic for adjustments.
# Anemia
Hgb 10.5, stable from one month ago with Hgb 10 on ___.
#HFrEF
Last TTE in ___ showing mild symmetric LVH with normal
cavity size, mild regional LV systolic dysfunction LVEF 40-45%.
No signs of volume overload on exam.
Continued torsemide 40 mg PO/NG BID, metoprolol succinate 25mg
dialy
#CORONARY ARTERY DISEASE
#HLD
History of MI. Continued Aspirin 81 mg, Atorvastatin 40 mg PO/NG
QPM, metoprolol 25 XL.
#CKD
OMR records of the last ___ years show baseline Cr appears to be
2.2-2.5.Patient's Cr was 1.9 on most recent nephrology visit.
#Allergic rhinitis
Continued azelastine.
#GERD
Continued famotidine 20mg daily
# Insomnia/Anxiety
Recently prescribed Ativan 0.5-1mg PRN for sleep; ok to
continue
TRANSITIONAL ISSUES
[] Recommend PCP follow up to assess for continued improvement
[] If persistent chest pain or O2 requirement, consider repeat
CXR to re-evaluate pneumothorax |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
Arthrocentesis of right hip
History of Present Illness:
___ with h/o DM, HTN, dementia presents from Assisted Living
with R hip/leg pain and inability to walk. The patient also
reports that she fell from a chair onto her R knee - though this
hasn't been confirmed by AL staff. Per ___, outpatient
NP, states that over last ___omplained of R leg pain.
has known OA and uses a walker, however this AM pt was unable to
walk.
In the ER, initial VS 98.0 89 161/96 16 96% on RA. Plain
films of her pelvix, hip, femur, knee, and tib/fib showed no
acute fracture. CT pelvis showed no acute fracture but ? fluid
collection. She was then sent to fluoroscopy where aspiration of
the R hip was performed. Ortho was apparently consulted in the
ER but has not yet seen the patient. Labs remarkable for CRP
54.8 and ESR 40. She was given tylenol and ibuprofen.
Of note, she usually is cared for at ___ and has no records at
___.
Past Medical History:
-DM2
-HTN
-Dementia-alzheimers
-HLD
-Depression
Social History:
___
Family History:
denies any DM, HTN, or early cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.8 154/95 91 20 99RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally,mild expiratory
wheezes, no 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, abdominal fullness over upper abdominal
quadrant.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 ___ 98RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally,mild expiratory
wheezes, no 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, abdominal fullness over upper abdominal
quadrant.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, unable to lift either leg on own power, reports pain with
palpation in numerous locations.
Pertinent Results:
ADMISSION
___ 11:30AM BLOOD WBC-7.5 RBC-3.95* Hgb-12.3 Hct-37.7
MCV-95 MCH-31.2 MCHC-32.7 RDW-13.7 Plt ___
___ 11:30AM BLOOD Glucose-188* UreaN-16 Creat-1.0 Na-140
K-3.7 Cl-101 HCO3-29 AnGap-14
___ 07:00AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9
DISCHARGE
___ 07:30AM BLOOD WBC-9.3 RBC-3.86* Hgb-11.8* Hct-37.0
MCV-96 MCH-30.6 MCHC-31.9 RDW-13.7 Plt ___
___ 07:30AM BLOOD Glucose-187* UreaN-16 Creat-0.9 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
___ 07:30AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
IMAGING:
PLAIN FILMS: Right knee, three views and right tibia and fibula,
two views.
FINDINGS: There is no evidence for fracture, dislocation, bone
destruction,
or joint effusion. The medial compartment of the right knee
appears
moderately narrowed. Small-to-moderate tricompartmental
osteophytes are
present. Patchy vascular calcifications are noted.
IMPRESSION: No evidence of fracture.
CT PELVIS
FINDINGS: No acute fracture or dislocation is detected.
Degenerative
subchondral cystic changes are seen in the right femoral head.
No SI joint or
pubic symphysis diastases is identified. No focal lytic or
sclerotic lesion
concerning for infection or malignancy is detected.
Vascular calcifications are seen in the aorta and iliac
arteries. Sigmoid
diverticulosis is seen. The distal ureters and bladder are
normal. There is
a minimal fat-containing inguinal hernia on the left.
IMPRESSION:
1. No acute fracture or dislocation.
2. Degenerative changes in the right femoral head.
3. Sigmoid diverticulosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Quetiapine Fumarate 25 mg PO BID
2. Sertraline 100 mg PO DAILY
3. Simvastatin 10 mg PO DAILY
4. Acetaminophen ___ mg PO Q8H:PRN pain
5. Aspirin 81 mg PO DAILY
6. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit Oral bid
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Valsartan 320 mg PO DAILY
9. Donepezil 5 mg PO HS
10. GlipiZIDE XL 10 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Artificial Tears ___ DROP BOTH EYES QID
13. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES QID
3. Aspirin 81 mg PO DAILY
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Donepezil 5 mg PO HS
6. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
7. Quetiapine Fumarate 25 mg PO BID
8. Sertraline 100 mg PO DAILY
9. Simvastatin 10 mg PO DAILY
10. Valsartan 320 mg PO DAILY
11. Naproxen 250 mg PO Q8H:PRN pain
12. TraMADOL (Ultram) 25 mg PO Q6H:PRN hip pain
13. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg calcium- 200 unit Oral bid
14. GlipiZIDE XL 10 mg PO DAILY
15. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Osteoarthritis
Secondary dx: Diabetes, Depression
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
RADIOGRAPHS OF THE LEFT KNEE AND TIBIA/FIBULA
HISTORY: Trauma.
COMPARISONS: None.
TECHNIQUE: Right knee, three views and right tibia and fibula, two views.
FINDINGS: There is no evidence for fracture, dislocation, bone destruction,
or joint effusion. The medial compartment of the right knee appears
moderately narrowed. Small-to-moderate tricompartmental osteophytes are
present. Patchy vascular calcifications are noted.
IMPRESSION: No evidence of fracture.
Radiology Report
RADIOGRAPHS OF THE PELVIS AND RIGHT FEMUR
HISTORY: Pain after a fall.
COMPARISONS: None.
TECHNIQUE: Right femur, five views, and AP pelvis.
FINDINGS: The hip joint spaces are mildly narrowed. There is no evidence for
fracture, dislocation, or bone destruction. Patchy vascular calcifications
are present.
IMPRESSION: No evidence of fracture.
Radiology Report
HISTORY: ___ female with right hip pain status post fall, concerning
for pelvic fracture.
COMPARISON: None.
TECHNIQUE: MDCT imaging was obtained through the pelvis without intravenous
contrast. Coronal and sagittal reformats were prepared and reviewed.
FINDINGS: No acute fracture or dislocation is detected. Degenerative
subchondral cystic changes are seen in the right femoral head. No SI joint or
pubic symphysis diastases is identified. No focal lytic or sclerotic lesion
concerning for infection or malignancy is detected.
Vascular calcifications are seen in the aorta and iliac arteries. Sigmoid
diverticulosis is seen. The distal ureters and bladder are normal. There is
a minimal fat-containing inguinal hernia on the left.
IMPRESSION:
1. No acute fracture or dislocation.
2. Degenerative changes in the right femoral head.
3. Sigmoid diverticulosis.
4. Minimal fat containing inguinal hernia on the left.
Radiology Report
STUDY: Right hip joint aspiration under fluoroscopy ___.
CLINICAL HISTORY: ___ woman with dementia and complains of
right-sided hip pain. Patient elevated CRP.
PROCEDURE: Written informed consent was obtained from the patient. Timeout
using three patient identifiers was performed prior to needle entry. The
patient was placed supine on fluoroscopic table. The right hip was prepped
and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize
the anterior soft tissues. Subsequently, an 18-gauge spinal needle was
inserted into the right hip joint under fluoroscopic visualization. ___ cc of
nonpurulent yellowish joint fluid was aspirated. The patient tolerated the
procedure well without any immediate complications.
FINDINGS: The initial radiograph demonstrates no signs for acute fractures or
dislocations or significant degenerative changes. Later images demonstrate the
aspiration needle projecting over the femoral neck.
IMPRESSION:
1. Successful aspiration of ___ cc of nonpurulent yellowish joint fluid from
the right hip.
2. No signs for acute bony injury or significant degenerative changes of the
right hip.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: RIGHT LEG PAIN
Diagnosed with PAIN IN LIMB
temperature: 98.0
heartrate: 89.0
resprate: 16.0
o2sat: 96.0
sbp: 161.0
dbp: 96.0
level of pain: 13
level of acuity: 3.0 | ___ with dementia, HTN, DM presents from assisted living s/p
fall with R leg pain, likely ___ osteoarthritis.
#Leg pain: unclear etiology, possibly muscular pain however had
small effusion present in R hip which did not show evidence of
septic arthritis, gout. Also with elevated ESR and CRP, so
concerned for possible RA or other rheumatologic process,
however no other symptoms. Pain is described in numerous
locations to even light touch, making a joint arthropathy also
less likely. Patient was evaluated by physical therapy who
recommended she go to a rehab facility.
#DM2: oral hypoglycemics were held while in ___ and she was
placed on a Humalog sliding scale. Her home medications were
resumed upon discharge.
#HTN: No acute exacerbation of chronic problem. Patient
continued on home meds while in the hospital.
#Dementia: secondary to alzheimers. Patient was continued on
home medications.
-cont donepezil
-cont seroquel
#Depression: No acute exacerbation of chronic problem. Patient
continued on home meds while in the hospital. |
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
Major Surgical or Invasive Procedure:
L3-L5 Laminectomy with L4-L5 noninstrumented fusion
History of Present Illness:
___ is a ___ man with past medical history of
diastolic heart failure, CAD status post remote history PCI,
hypertension, hyperlipidemia, CKD stage IV with baseline
creatinine 1.8, recent DVT status post 6 months of Xarelto, no
longer anticoagulated), rheumatoid arthritis (leflunomide and
methylprednisolone. Recent admission ___ for weakness
and IPH found on Noncon head CT. He presents today after
evaluation by neurology for gait instability and urinary
incontinence prompted MRI lumbar ___ showing findings
concerning for cord compression. During recent admission, the
patient was evaluated for progressive global weakness,
intraparenchymal hemorrhage, and ? amyloid angiopathy. Given
IPH, his AC for RLE DVT was discontinued given it had been given
for six months. He was seen by neurology on ___ for the
abnormalities noted during his admission; due to exam findings
concerning for myeloneuropathy, he was referred for outpatient
MRI, which showed the concerning findings of subacute L3
compression fractures, severe spinal canal narrowing at L3-L4
crowding the cauda equina. Likely impingement of L5 nerve root.
Evaluated by Ortho ___ who recommended admission, additional
imaging, and NPO for possible intervention.
Past Medical History:
BPH
Gout
arthritis
___ (on Lasix since ___
CAD status post PCI x2 ___ years ago)
HLD
HTN
CKD (stage 4, baseline Cr 1.6)
recent DVT (unclear if provoked, 4 weeks after hospitalization
for PNA ___ on Xarelto)
Rheumatoid arthritis (leflunomide and methylpred)
Social History:
___
Family History:
Brother CAD @ ___
Mother dementia
___ in two bothers
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ 1140 Temp: 97.4 PO BP: 136/76 HR: 74 RR: 18
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 2+ pitting edema to mid shin bilaterally R > L
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, although with some bilateral hearing
impairment, ___ strength upper extremities, ___ strength in RLE
hip flexion, ___ in flexion and extension of toes, ___ LLE in
all
muscle groups
DISCHARGE PHYSICAL EXAM:
Last 24h:
No issues overnight. Awaiting rehab placement
PE:
AVSS
NAD, A&Ox4
nl resp effort
RRR
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Labs:
Pending
Imaging:
None
==================================
Pertinent Results:
___ 09:05AM BLOOD WBC-6.6 RBC-2.46* Hgb-7.5* Hct-24.4*
MCV-99* MCH-30.5 MCHC-30.7* RDW-16.5* RDWSD-59.3* Plt Ct-87*
___ 06:26AM BLOOD WBC-7.5 RBC-2.78* Hgb-8.2* Hct-27.8*
MCV-100* MCH-29.5 MCHC-29.5* RDW-17.0* RDWSD-61.3* Plt Ct-87*
___ 04:36AM BLOOD WBC-12.9*# RBC-3.15* Hgb-9.3* Hct-31.5*
MCV-100* MCH-29.5 MCHC-29.5* RDW-17.0* RDWSD-60.8* Plt ___
___ 07:40AM BLOOD WBC-5.3 RBC-3.14* Hgb-9.3* Hct-30.8*
MCV-98 MCH-29.6 MCHC-30.2* RDW-17.0* RDWSD-60.3* Plt Ct-98*
___ 08:15PM BLOOD WBC-9.1# RBC-3.36* Hgb-10.0* Hct-33.0*
MCV-98 MCH-29.8 MCHC-30.3* RDW-17.1* RDWSD-61.1* Plt ___
___ 08:15PM BLOOD Neuts-87.8* Lymphs-3.9* Monos-6.9
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.98* AbsLymp-0.35*
AbsMono-0.63 AbsEos-0.00* AbsBaso-0.01
___ 09:05AM BLOOD Plt Ct-87*
___ 06:26AM BLOOD Plt Ct-87*
___ 04:36AM BLOOD Plt ___
___ 09:05AM BLOOD Glucose-108* UreaN-62* Creat-2.1* Na-142
K-4.7 Cl-101 HCO3-28 AnGap-13
___ 04:36AM BLOOD Glucose-172* UreaN-56* Creat-2.2* Na-144
K-5.0 Cl-101 HCO3-26 AnGap-17
___ 07:40AM BLOOD Glucose-108* UreaN-57* Creat-2.0* Na-146
K-4.2 Cl-104 HCO3-30 AnGap-12
___ 08:15PM BLOOD Glucose-110* UreaN-58* Creat-1.9* Na-143
K-4.8 Cl-100 HCO3-27 AnGap-16
___ 09:05AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
___ 07:40AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.3
___ 08:15PM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2
___ 08:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 12.5 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Methylprednisolone 6 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
10. Furosemide 40 mg PO DAILY
11. leflunomide 20 mg oral QHS
12. Losartan Potassium 25 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Sodium Chloride Nasal ___ SPRY NU BID:PRN obstruciton
15. traMADol-acetaminophen 37.5-325 mg oral TID
16. Allopurinol ___ mg PO DAILY
17. Magnesium Oxide 400 mg PO DAILY
18. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*90 Capsule Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Do not drive or operate heavy machinery while taking this
medication
RX *oxycodone 5 mg 1 capsule(s) by mouth every ___ hours Disp
#*60 Capsule Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atenolol 12.5 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Furosemide 40 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. leflunomide 20 mg oral QHS
13. Losartan Potassium 25 mg PO DAILY
14. Magnesium Oxide 400 mg PO DAILY
15. Methylprednisolone 6 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Omeprazole 20 mg PO DAILY
18. Pravastatin 40 mg PO QPM
19. Sodium Chloride Nasal ___ SPRY NU BID:PRN obstruciton
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Lumbar spinal stenosis
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 PT21 MR SPINE
INDICATION: ___ year old male presenting with low back pain and right lower
extremity weakness in the setting of known lumbar stenosis on MRI L-spine.
MRI C and T spine given his upper tract signs to rule out concomitant cervical
or thoracic stenosis.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed.
COMPARISON: ___ lumbar spine MRI.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
CERVICAL:
Vertebral body alignment is preserved. Vertebral body heights are preserved.
There is no marrow signal abnormality.
The visualized portion of the spinal cord is preserved in signal and caliber.
There is loss of intervertebral disc height and signal throughout cervical
spine.
Within the limits of this noncontrast study there is no evidence of infection
or neoplasm. There is no prevertebral soft tissue swelling..
At C2-3 there is no vertebral canal or neural foraminal narrowing.
At C3-4 there is disc bulging and uncovertebral osteophytes with moderate
vertebral canal narrowing resulting in cord flattening/remodeling without
definite evidence of abnormal cord signal. There is at least moderate
bilateral neural foraminal narrowing. Nonspecific bilateral facet fluid is
noted.
At C4-5 there is disc bulging and uncovertebral osteophytes with moderate
vertebral canal narrowing and cord flattening/remodeling without evidence of
abnormal cord signal. There is moderate bilateral neural foraminal narrowing.
Nonspecific bilateral facet fluid is noted.
At C5-6 there is disc bulging and uncovertebral osteophytes with mild
vertebral canal narrowing and mild left neural foraminal narrowing.
Nonspecific bilateral facet fluid is noted.
At C6-7 there is disc bulging and ligamentum flavum thickening with mild
vertebral canal narrowing.
At C7-T1 there is no vertebral canal or neural foraminal narrowing.
THORACIC:
Alignment is normal. There is mild diffuse bone marrow signal heterogeneity.
There is loss of intervertebral disc signal throughout the thoracic spine.The
spinal cord appears normal in caliber and configuration. There is no evidence
of vertebral canal or neural foraminal narrowing.
OTHER: The visualized portions of the lungs are grossly preserved. Limited
imaging of lumbar spine on scout imaging again demonstrates patient's known L3
compression deformity. Scout imaging demonstrates minimal maxillary sinus
mucosal thickening.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Multilevel cervical spondylosis as described, most pronounced at C3-C4 and
C4-C5, where there is moderate vertebral canal narrowing with cervical spinal
cord flattening/remodeling without definite evidence of abnormal spinal cord
signal.
3. Mild multilevel thoracic spondylosis as described, with no definite
evidence of thoracic spinal cord lesion compression.
4. Minimal paranasal sinus disease and patient's known L3 compression
deformity partially demonstrated on scout imaging.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old man with lumbar stenosis// evaluation for lumbar
spine instability evaluation for lumbar spine instability
TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine.
COMPARISON: MRI ___.
FINDINGS:
5 non-rib-bearing lumbar vertebral bodies are present. Compression deformity
of L3 appears similar to ___. Remaining vertebral body heights
appear preserved. Mild disc space narrowing of L3-L4 and L5-S1. Mild facet
hypertrophy small multilevel anterior osteophytes. Bones appear osteopenic.
Dense vascular calcifications.
IMPRESSION:
Compression deformity of L3 appears similar.
Radiology Report
EXAMINATION: LUMBAR SINGLE VIEW IN OR
IMPRESSION:
Image from the operating suite shows posterior probe a what appears to be the
L3-L4 level. Further information can be gathered from the operative report.
Radiology Report
INDICATION: ___ year old man with hx dvt in RLE, xarelto stopped d/t brain
microhemorrhage. Needs IVC filter placed prior to OR today.// IVC filter
before OR today
COMPARISON: MRI on ___
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 0 mg of midazolam throughout the total intra-service
time of 30 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.9 min, 50 mGy
PROCEDURE:
1. Right iliac vein and IVC venogram.
2. Infrarenal Denali IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. the right neck was prepped and draped in the usual sterile fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible Right
internal jugular vein was punctured using a 21G micropuncture needle.
Ultrasound images of the access was stored on PACS. A ___ wire was
advanced through the micropuncture sheath into the inferior vena cava. The
micropuncture sheath was exchanged for a 9 ___ Denali IVC filter sheath.
The inner dilator of the sheath was advanced into the right iliac vein. The
wire was removed and a small amount of contrast was injected to confirm
appropriate positioning. An IVC venogram was performed at this time.
Based on the results of the venogram, detailed below, a decision was made to
place a infrarenal, Denali filter. The inner dilator of the sheath was
removed and the vena cava filter was advanced over the wire until the cranial
tip was at the level of the inferior margin of the lower renal vein. The
sheath was then withdrawn until the filter was deployed. The loading device
was then removed through the sheath and a repeat contrast injection was
performed, confirming appropriate filter positioning. The final image was
stored on PACS. Although the filter migrated slightly inferiorly during
placement, the filter remained above the iliac bifurcation in satisfactory
position.
The sheath was removed and pressure was held for 10 minutes,at which point
hemostasis was achieved. A sterile dressing was applied. The patient tolerated
the procedure well and there were no immediate post procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal IVC filter.
IMPRESSION:
Successful deployment of Denali IVC filter.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal MRI, Back pain, Unsteady gait
Diagnosed with Collapsed vertebra, NEC, lumbar region, init, Weakness, Acute embolism and thrombosis of right popliteal vein, Ac emblsm and thombos unsp deep veins of left dist low extrm
temperature: 98.0
heartrate: 77.0
resprate: 18.0
o2sat: 100.0
sbp: 156.0
dbp: 64.0
level of pain: 3
level of acuity: 2.0 | In the ED, initial vitals: T98.0 HR77 BP156/64 RR18 SaO2100% RA
- Exam notable for: ___ Exam ___ hip flexor strength and ___
___ distally on the right side. Multiple upper tract signs as
well with upgoing Babinski, as well as sustained clonus
bilaterally and mild hyperreflexia. midline and R sided lumbar
pain ED exam ___ ___ hip flx, ___ knee flx/ext, ___ foot
dorsi/plantarflx Babinski unclear no saddle anesthesia; rectal
with normal tone and good augmentation, guaiac neg brown stool -
Labs notable for: Cr 1.9 (baseline 1.8) - Imaging notable for:
LENIS 1. Deep venous thrombosis of the distal right popliteal
vein and right peroneal veins. 2. Patent right common femoral
and femoral veins, and right
posterior tibial veins. 3. No evidence of deep venous
thrombosis in the leftlower extremity veins. 4. Significant
right lower extremity subcutaneous edema.
MR THORACIC ___ ___
1. Partially degraded study due to motion artifact.
2. Degenerative changes of the cervical ___ most significant
at
C3-C4 and C4-C5 where there is moderate vertebral canal
narrowing
with mild cord flattening/remodeling without definite evidence
of
abnormal cord signal.
3. No significant abnormality of the thoracic ___.
MR ___ ___
1. A subacute L3 superior and inferior endplate compression
fractures with
minimal 3 mm retropulsion of the inferior endplate.
2. 3 mm retropulsion of the L3 inferior endplate, a disc bulge
and prominent
epidural fat results in severe spinal canal narrowing at L3-L4,
crowding the
cauda equina. In combination with severe facet arthropathy,
there is moderate
left neural foraminal narrowing where a facet osteophyte
remodels the exiting
left L4 nerve root.
3. Degenerative changes at L4-L5 results in moderate spinal
canal narrowing,
with likely impingement of the traversing right L5 nerve root
and contact of
the left L5 nerve root in the subarticular zones. Left facet
synovial cyst
appears to contact the traversing left L5 nerve root.
4. Additional findings as described above.
Upon arrival to the floor, the patient reported he was overall
doing well. He had had chronic lower back pain, which has
improved of late. He previously was having significant R hip
pain as well which has improved in last several weeks. He
endorses some trouble with urinary incontinence if he is unable
to reach the bathroom in time, with some dribbling. Chronic
diarrhea over last several months with multiple BMs per day.
Somewhat improved recently. No CP, SOB, Nausea, vomiting,
constipation, dysuria.
Patient admitted for management of lumbar spinal stenosis.
Orthopedics decided to perform lumbar decompression. IVC filter
placed for chronic DVT. Unable to be anticoagulated due to
amyloid angiopathy in brain and prior intraparenchymal
hemorrhage.
Patient was then admitted to the ___ ___ Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.Hospital course was otherwise unremarkable.On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
He was taken to the OR on ___ for a L3-L5 laminectomy, L4-5
uninstrumented fusion with Dr. ___. He has been doing well
post op and has been cleared for discharge to REHAB.
TRANSITIONAL ISSUES: per Medicine TEAM
=========================
[ ] Consider transitioning atenolol to metoprolol given CKD and
decreased renal clearance. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right thoracoscopy with decortication - ___
History of Present Illness:
Mr. ___ is a ___ year old male with a PMH of LURT (___) with
CKD stage IV of renal allograft on mycophenolate and tacro, a
significant cardiac and vascular history on ASA, and prostate
CA,
who presents today with SOB. Four hours prior to presentation,
Mr. ___ developed acute onset of SOB at rest. No alleviating
factors. Worsened with walking around. Associated with ___
episodes of cough with clear phlegm, weakness and chills. Denies
CP, abd pain, n/v. Denies hemoptysis, leg swelling, recent
travels, surgeries. Pt has history of Afib and DVT and is on
blood thinners. Denies fevers, urinary or bowel symptoms. Of
note, pt recently treated for C diff, and bowel movements have
improved and on active treatment.
Patient recently admitted from ___ for acute on chronic
heart failure complicated by multilobar pneumonia, parapneumonic
effusion, and pericardial effusions. During that course, he was
aggressively diuresed with 200 mg of IV Lasix, and treated with
IV ceftazidime, vancomycin and azithromycin. Of note, patient
had
bilateral pleural effusions with a right chest tube placed from
___ with 2.7 L of serosanguineous fluid drained. Patient
also noted to have a pericardial effusion treated with aspirin
and colchicine.
ED Course notable for:
Initial Vitals in the ED: 98.4 70 165/118 18 93% RA
Exam notable for: Coarse crackles and ? rub on the R lung field,
basilar carackles on left
Relevant labs/imaging:
- CBC: Leukocytosis WBC 14, 82.7% PMN
- BMP: K 5.4, BUN/Cr 49/2.5 -> rpt whole blood K+ refused by
patient
- Trop: 0.02 x2
- Lactate: 1.1
- proBNP: ___
- CXR: There is a moderate, loculated right pleural effusion,
which is increased insize compared to most recent prior study.
- EKG: Sinus rhythm, incomplete left bundle branch block, poor R
wave progression
- CT Chest:
1. Compare to ___, the dependent portion of the
previously seen moderate right pleural effusion has mostly
resolved. A dependent small left pleural effusion is decreased
in
size.
2. A moderate-sized loculated right lateral pleural effusion
persists. A small loculated effusion is also seen in the right
major fissure.
3. Mild pulmonary edema.
4. Severe coronary artery and mitral annular calcifications.
5. Persistent moderate to large pericardial effusion.
Consults:
- Renal Transplant - Admit to ET
- IP - defer to thoracics
- Thoracics - hold apixaban pending drainage planning
- MERIT - continue management of chronic problems, plan to admit
to Medicine pending drainage plan; not on hep gtt until
finalized
plan by Thoracics
Patient Received:
___ 08:12 SC Insulin 24 UNIT
___ 08:12 SC Insulin Not Given per Sliding Scale
___ 08:12 PO/NG Allopurinol ___ mg
___ 08:12 amLODIPine 10 mg
___ 08:12 PO/NG CARVedilol 25 mg
___ 08:12 PO/NG Colchicine .3 mg
___ 08:12 PO/NG HydrALAZINE 37.5 mg
___ 08:12 PO Multivitamins 1 TAB
___ 08:12 PO Mycophenolate Mofetil 250 mg
___ 08:12 PO Pantoprazole 40 mg
___ 08:12 PO Tacrolimus 2 mg
___ 08:12 PO Vancomycin 125 mg
___ 08:12 Torsemide 80 mg
___ 08:12 PO/NG Vancomycin Oral Liquid ___ mg
___ 10:33 IV Heparin
___ 14:52 PO Vancomycin 125 mg
Vitals on Transfer: AF HR 63 BP 128/43 RR 17 O2 99% on 2L
Upon arrival to the floor, pt endorses the above history though
is not really interested in talking. His wife says that he was
in
his usual state of health over the last ___ weeks, though his
dyspneic symptoms would fluctuate (ie sometimes feels great,
sometimes feels like his breathing is labored). Yesterday around
8PM, he had just used the stairs and suddenly stated that his
breathing was too labored and he needed to go to the hospital.
He
denies chest pain or pressure, fever or night sweats. He
endorses
orthopnea, chronic but stable cough and increased abdominal
distension without abdominal pain. He has been taking his
medications regularly and missed only 1 dose of his Torsemide
all
week; he says that his urine output has been the same and has
not
dropped off at all. His diarrhea has also improved dramatically
since starting oral Vancomycin. Denies sick contacts.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronary artery disease (s/p ___ 2 to proximal-LAD ___,
s/p ___ 2 to mid-LAD ___.
- HFpEF
- Afib
3. OTHER PAST MEDICAL HISTORY
Claudication/Aorto iliac occlusive disease (ABI 0.88/0.76).
Morbid obesity.
Obstructive sleep apnea
C diff enterocolitis
Renal artery stenosis
S/p kidney transplant with CKD stage IV transplanted kidney
Klepbsiella UTI
Prostate cancer
Hyperparathyroidism
Social History:
___
Family History:
Father: ___
Mother: ___, ESRD on hemodialysis, CHF, stroke, HTN
Brothers: Lung cancer, CAD, MI
Father: ___, gout
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: AF BP 157/72 HR 75 RR 20 O2 92% on 2L NC
GENERAL: Lying flat in bed on his right side. Flat affect. NAD
HEENT: anicteric sclera, otherwise limited (pt requesting to
sleep)
CARDIAC: RRR, soft systolic murmur at apex
LUNGS: No increased WOB. Decreased breath sounds along the right
base to mid lung field
ABDOMEN: softly distended, non tender
EXTREMITIES: no edema, wwp
NEUROLOGIC: AOx3, facial symmetry, moving all extremities with
purpose
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 503)
Temp: 98.3 (Tm 98.6), BP: 144/59 (130-151/51-68), HR: 59
(59-68), RR: 18 (___), O2 sat: 94% (92-97), O2 delivery: Ra,
Wt: 161.3 lb/73.17 kg
GENERAL: Lying on left side in bed. Appears in NAD. Flat affect.
HEENT: anicteric sclera, otherwise limited
CARDIAC: RRR, soft systolic murmur at apex
LUNGS: No increased WOB. Bilateral decreased breath sounds with
wheezing in right mid lung field.
ABDOMEN: softly distended, non tender
EXTREMITIES: no edema, wwp
NEUROLOGIC: AOx3
Pertinent Results:
ADMISSION LABS:
==============
___ 10:32PM BLOOD WBC-14.1* RBC-3.87* Hgb-10.5* Hct-32.6*
MCV-84 MCH-27.1 MCHC-32.2 RDW-16.7* RDWSD-50.4* Plt ___
___ 10:32PM BLOOD Neuts-82.7* Lymphs-6.7* Monos-7.3 Eos-1.4
Baso-0.6 Im ___ AbsNeut-11.68* AbsLymp-0.95* AbsMono-1.03*
AbsEos-0.20 AbsBaso-0.08
___ 11:22PM BLOOD ___ PTT-52.7* ___
___ 10:32PM BLOOD Glucose-96 UreaN-49* Creat-2.5* Na-138
K-5.4 Cl-102 HCO3-22 AnGap-14
___ 10:32PM BLOOD CK(CPK)-109
___ 10:45AM BLOOD ALT-9 AST-21 LD(LDH)-221 AlkPhos-65
TotBili-0.3
___ 10:32PM BLOOD CK-MB-2 proBNP-5434*
___ 10:32PM BLOOD cTropnT-0.02*
___ 05:45AM BLOOD cTropnT-0.02*
___ 10:32PM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 10:51AM BLOOD %HbA1c-6.9* eAG-151*
___ 05:04AM BLOOD calTIBC-218* Ferritn-633* TRF-168*
___ 12:51AM BLOOD tacroFK-26.3* (note: not a true trough)
MICRO:
======
___ urine culture - Citrobacter koseri
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ blood culture - negative
___ sputum culture - contamination
___ pleural fluid culture -
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ urine culture - negative
___ blood culture - pending
IMAGING AND STUDIES:
==================
___ CXR
There is a moderate, loculated right pleural effusion, which is
increased in
size compared to most recent prior study. There is a small left
pleural
effusion which is also increased in size. There is no focal
consolidation,
although evaluation of the right lung base is limited due to the
presence of
the pleural effusion. No pneumothorax is identified. There is
unchanged
cardiomegaly without overt pulmonary edema. No acute osseous
abnormalities are
identified.
___ CT chest w/o contrast
1. Compared to ___, the dependent portion of the
previously seen
moderate right pleural effusion has mostly resolved. A
dependent small left
pleural effusion is decreased in size.
2. A moderate-sized loculated right lateral pleural effusion is
bigger. A
small loculated effusion is also seen in the right major
fissure.
3. Mild pulmonary edema.
4. Severe coronary artery calcifications.
5. Persistent moderate pericardial effusion.
___ RUQ US
1. Patent hepatic vasculature.
2. Right-sided pleural effusion
___ pleural fluid cytology: negative for malignant cells
___ renal transplant ultrasound:
Elevated resistive indices of the transplant kidney, with
differential which
may include acute tubular necrosis and rejection.
___ CXR:
Comparison to ___. The 2 right-sided chest tubes
are in stable
correct position. Improved ventilation of the left lung with
decrease in
extent of the left retrocardiac atelectasis. Minimal increase
in size of the
pre-existing basal postoperative parenchymal opacities. Mild
cardiomegaly
persists.
___ CXR:
Atelectasis and moderate, probably multilocular right pleural
effusion have
both increased since ___, despite the right apical
thoracostomy tube.
Although there is no right pneumothorax there is more
subcutaneous emphysema
in the right chest wall. Severe cardiomegaly stable. Pulmonary
vasculature
is more engorged and mediastinal veins more dilated indicating
cardiac
decompensation.
___ CXR AP and lateral:
Small right pleural effusion may have increased. No
pneumothorax. Severe
consolidation is still present at the right base. Heart size
stable.
Mediastinal veins are slightly distended, but there is no
pulmonary edema.
___ CXR:
Heart size and mediastinum are stable. Extensive mid and lower
right lung
consolidations are noted. Subcutaneous air within the right
chest wall is
present. Small bilateral pleural effusions are present. Small
right apical
pneumothorax is seen. Overall there is no substantial change
except for
increase in the subcutaneous air within the right chest wall
compared to
previous examination. The other changes minimal interval
increase in still
small left pleural effusion.
___ CXR:
In comparison with study of ___, the cardiomediastinal
silhouette is
stable. There is continued mild elevation of pulmonary venous
pressure.
Increased opacification is again seen at the right mid and lower
lung,
slightly less prominent than on the previous study. Any
residual pneumothorax
is very small. Subcutaneous gas is again seen along the lateral
chest wall.
The left pleural effusion appears more prominent.
___ CXR:
Comparison to ___. The right chest tubes are
removed. The air
collection in the soft tissues has decreased. Stable extent of
the overall
small to moderate right pleural effusion that pre existed.
Stable small left
pleural effusion. Stable mild pulmonary edema and moderate
cardiomegaly. No
evidence of pneumothorax.
___ CXR:
Heart size is enlarged, unchanged. Bilateral pleural effusion
is small.
Right mid and lower lung consolidation are unchanged.
___ CT CHEST
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either
axilla or
thoracic inlet. Gas foci in the right anterior chest wall
related to prior
procedure. New collection in the soft tissues adjacent to the
prior chest 2
site measuring 6.4 x 2.1 cm (302:57). No mild atherosclerotic
calcifications
in the head and neck arteries.
HEART AND VASCULATURE:
The heart is enlarged with a dilated left atrium. Small to
moderate
pericardial effusion, unchanged. Stent in the LAD. Mild
atherosclerotic
calcifications in the aorta, mild in the other coronaries and
none in the
mitral annulus. A pulmonary artery is mildly enlarged measuring
3.2 cm. The
aorta is normal caliber throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Several borderline enlarged
mediastinal lymph
nodes are again noted, unchanged, the largest in the subcarinal
station
measuring 1.2 cm in short axis diameter. No apparent hilar
lymphadenopathy.
PLEURA:
Small bilateral pleural effusions, stable to the left and
smaller to the right
after pleural drainage. There are small pockets of air within
the right sided
pleural space.
LUNGS:
The airways are patent to the subsegmental levels. Moderate
bronchial wall
thickening in the right lower lobe associated to ground-glass
opacities in
this lobe, relatively unchanged from prior. Ground-glass
opacities and mild
interlobular septal thickening are also noted, most prominent in
both upper
lobes, representing mild edema.
CHEST CAGE:
No acute fractures. Old healed fracture in the right posterior
ribs. No
suspicious lytic or sclerotic lesions. Mild dorsal spondylosis.
UPPER ABDOMEN:
The limited sections of the upper abdomen show no significant
abnormal
findings.
IMPRESSION:
Small right-sided pleural effusion with indwelling pockets of
air after
pleural drainage. There is a hematoma in the superficial soft
tissues in the
prior pleural tube tract. Pleural thickening is noted after
VATS
decortication.
Re-demonstration of bronchial wall inflammation in the right
lower lobe.
Mild to moderate pulmonary edema remains.
DISCHARGE LABS:
===============
___ 05:08AM BLOOD WBC-7.6 RBC-3.38* Hgb-9.6* Hct-30.5*
MCV-90 MCH-28.4 MCHC-31.5* RDW-17.6* RDWSD-58.0* Plt ___
___ 05:08AM BLOOD Plt ___
___ 05:08AM BLOOD Glucose-129* UreaN-42* Creat-2.1* Na-142
K-3.9 Cl-100 HCO3-28 AnGap-14
___ 05:08AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.5
___ 05:08AM BLOOD tacroFK-5.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrALAZINE 37.5 mg PO Q8H
2. Tacrolimus 2 mg PO Q12H
3. Glargine 28 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. CARVedilol 25 mg PO BID
10. Colchicine 0.3 mg PO DAILY
11. melatonin 10 mg oral QHS:PRN insomnia
12. Multivitamins 1 TAB PO DAILY
13. Mycophenolate Mofetil 250 mg PO BID
14. Pantoprazole 40 mg PO Q24H
15. Pravastatin 40 mg PO QPM
16. Tamsulosin 0.4 mg PO QHS
17. Torsemide 80 mg PO BID
18. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
19. Vancomycin Oral Liquid ___ mg PO Q6H
20. DICYCLOMine 10 mg PO DAILY:PRN cramps/diarrhea
21. Acyclovir 400 mg PO TID:PRN cold sore
22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Doses
due to finish ___. Sertraline 50 mg PO DAILY
3. CARVedilol 12.5 mg PO BID
4. Glargine 21 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Tacrolimus 2.5 mg PO Q12H
6. Acidophilus Probiotic (acidophilus-pectin, citrus) 100
million cell-10 mg oral DAILY
7. Acyclovir 400 mg PO TID:PRN cold sore
8. Allopurinol ___ mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. Apixaban 2.5 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Calcitriol 0.25 mcg PO DAILY
13. DICYCLOMine 10 mg PO DAILY:PRN cramps/diarrhea
14. Multivitamins 1 TAB PO DAILY
15. Mycophenolate Mofetil 250 mg PO BID
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. Pravastatin 40 mg PO QPM
18. Tamsulosin 0.4 mg PO QHS
19. Torsemide 80 mg PO BID
20. Vancomycin Oral Liquid ___ mg PO Q6H
21. HELD- Pantoprazole 40 mg PO Q24H This medication was held.
Do not restart Pantoprazole until PCP follow up
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Loculated pleural effusion, right
Complicated urinary tract infection
End stage renal disease status post renal transplant
Chronic kidney disease stage IV of graft
Secondary diagnoses:
Atrial fibrillation
Recurrent C difficile infection
Hypertension
Depression
Pericardial effusion
Coronary artery 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: CT CHEST W/O CONTRAST
INDICATION: History: ___ with loculated effusion?// loculated effusion?
TECHNIQUE: Multi-detector helical scanning of the chest was performed without
intravenous iodinated contrast agent and reconstructed as 5 and 1.25 mm thick
axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 38.5 cm; CTDIvol = 18.7 mGy (Body) DLP = 720.6
mGy-cm.
Total DLP (Body) = 721 mGy-cm.
COMPARISON: Chest CT from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. The esophagus is
unremarkable.
UPPER ABDOMEN: The imaged upper abdomen is notable for extensive calcified
atherosclerotic disease.
MEDIASTINUM: Previously noted prominent mediastinal lymph nodes are smaller.
HILA: There is no hilar mass or lymphadenopathy, within the limitations of an
unenhanced study.
HEART and PERICARDIUM: Heart size is normal. Coronary artery and mitral
annular calcifications are severe. A moderate pericardial effusion is
unchanged. The thoracic aorta is normal in caliber. Main pulmonary artery
diameter is within normal limits.
PLEURA: The posterior dependent portion of the previously seen moderate right
pleural effusion has mostly resolved. A moderate sized loculated right lateral
pleural effusion is bigger. A small loculated effusion is also noted along
the right major fissure (4:124). A small dependent left pleural effusion is
decreased in size. No pneumothorax.
LUNG: Diffuse interlobular septal thickening and ground-glass opacities in the
bilateral lower lobes, right greater than left, likely represent pulmonary
edema. Mild subsegmental atelectasis is noted in the right lower lobe. No
suspicious nodules. The airways are patent to the level of the segmental
bronchi bilaterally. Mild diffuse bronchial wall thickening is again noted,
likely related to edema.
CHEST CAGE: No suspicious osseous lesions or acute fracture. Redemonstration
of several chronic right posterolateral lower rib fractures.
IMPRESSION:
1. Compared to ___, the dependent portion of the previously seen
moderate right pleural effusion has mostly resolved. A dependent small left
pleural effusion is decreased in size.
2. A moderate-sized loculated right lateral pleural effusion is bigger. A
small loculated effusion is also seen in the right major fissure.
3. Mild pulmonary edema.
4. Severe coronary artery calcifications.
5. Persistent moderate pericardial effusion.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: evaluate for ascites, e/o cirrhosis, PVT
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Prior ultrasound dated ___.
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. There is no ascites. However, a right-sided pleural
effusion is seen.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 4 mm.
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 12.6 cm.
Kidneys: The right kidney measures 6.9 cm. The left kidney measures 7.2 cm.
No stones, masses, or hydronephrosis are identified in either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 23.7 cm/sec.
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:
1. Patent hepatic vasculature.
2. Right-sided pleural effusion
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p Right VATS washout/decortication, has 2 chest
tubes.// postop
IMPRESSION:
In comparison with the study of ___, there has been a right VATS
procedure with 2 chest tubes in place and possible small apical pneumothorax.
The large loculated pleural effusion has been drained.
Continued substantial enlargement of the cardiac silhouette with some
increasing pulmonary vascular congestion. Opacification at the left base is
consistent with small pleural effusion and volume loss in the lower lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R pleural effusion now s/p VATS with
decortication on ___, with placement of 2 chest tubes// interval change in R
pleural effusion interval change in R pleural effusion
IMPRESSION:
Comparison to ___. The 2 right-sided chest tubes are in stable
correct position. Improved ventilation of the left lung with decrease in
extent of the left retrocardiac atelectasis. Minimal increase in size of the
pre-existing basal postoperative parenchymal opacities. Mild cardiomegaly
persists.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R pleural effusion s/p VATS with
decortication on ___, now with 2 R chest tubes// interval change?
interval change?
IMPRESSION:
Compared to chest radiographs, ___ through ___.
Atelectasis and moderate, probably multilocular right pleural effusion have
both increased since ___, despite the right apical thoracostomy tube.
Although there is no right pneumothorax there is more subcutaneous emphysema
in the right chest wall. Severe cardiomegaly stable. Pulmonary vasculature
is more engorged and mediastinal veins more dilated indicating cardiac
decompensation.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with renal transplant, uptrending Cr// please
eval renal transplant
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Prior ultrasound dated ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. There is a 1.2 x
1.2 x 1.1 cm simple cyst seen in the lower pole of the transplant kidney.
Specifically, the cortex is of normal thickness and echogenicity, pyramids are
normal, there is no urothelial thickening, and renal sinus fat is normal.
There is no hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.87 to 0.96,
suggestive of acute tubular necrosis versus transplant rejection. The main
renal artery shows a normal systolic waveform, with absent diastolic flow,
consistent with high resistance flow. The peak systolic velocity is 78.7.
Vascularity is symmetric throughout transplant. The transplant renal vein is
patent and shows normal waveform.
IMPRESSION:
Elevated resistive indices of the transplant kidney, with differential which
may include acute tubular necrosis and rejection.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R pleural effusion s/p VATS/decortication
with placement of 2 chest tubes, one of which was removed ___// interval
change in pleural effusion? interval change in pleural effusion?
IMPRESSION:
Compared to chest radiographs ___ through ___ at 06:30.
Large region of right lower lung consolidation unchanged. Accompanying
pleural effusion small at most. No pneumothorax. Moderate cardiomegaly
stable. Left lung clear. No appreciable left pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R pleural effusion s/p VATS
withdecortication on ___, 1 R chest tube removed ___ R chest tube self
d/c'd on ___// ?interval change ?interval change
IMPRESSION:
Compared to chest radiographs ___ through ___ one.
Previous pulmonary vascular congestion has improved. Moderate cardiac
enlargement is stable low mediastinal venous engorgement has decreased
Right pleural drainage catheter has been removed and there is no pneumothorax.
Subcutaneous emphysema in the right chest wall is approximately unchanged.
Small right pleural effusion has decreased, but there is still severe
consolidation in the right lower lung, pneumonia until proved otherwise.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ hx CKD s/p LURT w CKD again, CAD s/p DES (asa), afib
(apixaban), HFpEF w recent exac b/l pleural effusions s/p R CT p/w
recurrent, loculated R pleural effusion, s/p R VATS decort, patient self-d/c'd
Chest tube ****to be obtained at 11am****// pneumothorax? ****to be obtained
at 11am**** pneumothorax? ****to be obtained at 11am****
IMPRESSION:
Compared to chest radiographs ___ through ___ at 09:40.
Small right pleural effusion may have increased. No pneumothorax. Severe
consolidation is still present at the right base. Heart size stable.
Mediastinal veins are slightly distended, but there is no pulmonary edema.
Subcutaneous emphysema in the right chest wall is stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ hx CKD s/p LURT w CKD again, CAD s/p DES (asa), afib
(apixaban), HFpEF w recent exac b/l pleural effusions s/p R CT p/w
recurrent, loculated R pleural effusion, s/p R VATS decort// ? pneumothorax ?
hemothorax ? interval change ? pneumothorax ? hemothorax ? interval change
IMPRESSION:
Heart size and mediastinum are stable. Extensive mid and lower right lung
consolidations are noted. Subcutaneous air within the right chest wall is
present. Small bilateral pleural effusions are present. Small right apical
pneumothorax is seen. Overall there is no substantial change except for
increase in the subcutaneous air within the right chest wall compared to
previous examination. The other changes minimal interval increase in still
small left pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R pleural effusion s/p removal of 2 chest
tubes// interval change in pleural effusion
IMPRESSION:
In comparison with study of ___, the cardiomediastinal silhouette is
stable. There is continued mild elevation of pulmonary venous pressure.
Increased opacification is again seen at the right mid and lower lung,
slightly less prominent than on the previous study. Any residual pneumothorax
is very small. Subcutaneous gas is again seen along the lateral chest wall.
The left pleural effusion appears more prominent.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with right pleural effusion s/p removal of 2
chest tubes// interval change? interval change?
IMPRESSION:
Comparison to ___. The right chest tubes are removed. The air
collection in the soft tissues has decreased. Stable extent of the overall
small to moderate right pleural effusion that pre existed. Stable small left
pleural effusion. Stable mild pulmonary edema and moderate cardiomegaly. No
evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R pleural effusion s/p removal of 2 R-sided
chest tubes// interval change in pleural effusion? interval change in
pleural effusion?
IMPRESSION:
Heart size is enlarged, unchanged. Bilateral pleural effusion is small.
Right mid and lower lung consolidation are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with bilateral pleural effusions, new fever//
evidence of consolidation?
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume with stable small bilateral pleural effusions right
greater than left. Cardiomediastinal silhouette is stable. Patchy
parenchymal opacity in the right lung is unchanged. No pneumothorax is seen
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: In summary, Mr. ___ is a ___ y/o male with a PMH of ___
with CKD stage IV of renal allograft on mycophenolateand tacro, significant
vascular disease, AFib on apixaban,history of DVT, recurrent C diff,
pericardial effusion andrecently drained effusions who presents with dyspnea
and is foundto have recurrent right pleural effusion s/p chest tube placement
and removal. He spiked a fever on ___// evidence of consolidation,
atelectasis, PTX? please eval pleural effusions
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 2.2 s, 35.2 cm; CTDIvol = 14.3 mGy (Body) DLP = 504.2
mGy-cm.
Total DLP (Body) = 504 mGy-cm.
COMPARISON: Multiple prior chest CTs, most recently ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. Gas foci in the right anterior chest wall related to prior
procedure. New collection in the soft tissues adjacent to the prior chest 2
site measuring 6.4 x 2.1 cm (302:57). No mild atherosclerotic calcifications
in the head and neck arteries.
HEART AND VASCULATURE:
The heart is enlarged with a dilated left atrium. Small to moderate
pericardial effusion, unchanged. Stent in the LAD. Mild atherosclerotic
calcifications in the aorta, mild in the other coronaries and none in the
mitral annulus. A pulmonary artery is mildly enlarged measuring 3.2 cm. The
aorta is normal caliber throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Several borderline enlarged mediastinal lymph
nodes are again noted, unchanged, the largest in the subcarinal station
measuring 1.2 cm in short axis diameter. No apparent hilar lymphadenopathy.
PLEURA:
Small bilateral pleural effusions, stable to the left and smaller to the right
after pleural drainage. There are small pockets of air within the right sided
pleural space.
LUNGS:
The airways are patent to the subsegmental levels. Moderate bronchial wall
thickening in the right lower lobe associated to ground-glass opacities in
this lobe, relatively unchanged from prior. Ground-glass opacities and mild
interlobular septal thickening are also noted, most prominent in both upper
lobes, representing mild edema.
CHEST CAGE:
No acute fractures. Old healed fracture in the right posterior ribs. No
suspicious lytic or sclerotic lesions. Mild dorsal spondylosis.
UPPER ABDOMEN:
The limited sections of the upper abdomen show no significant abnormal
findings.
IMPRESSION:
Small right-sided pleural effusion with indwelling pockets of air after
pleural drainage. There is a hematoma in the superficial soft tissues in the
prior pleural tube tract. Pleural thickening is noted after VATS
decortication.
Redemonstration of bronchial wall inflammation in the right lower lobe.
Mild to moderate pulmonary edema remains.
NOTIFICATION: The findings were discussed with Dr ___. by ___
___, M.D. on the telephone on ___ at 3:16 pm.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Dyspnea
Diagnosed with Pleural effusion, not elsewhere classified, Dyspnea, unspecified, Type 1 diabetes mellitus without complications, Long term (current) use of insulin
temperature: 98.4
heartrate: 70.0
resprate: 18.0
o2sat: 93.0
sbp: 165.0
dbp: 118.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ y/o male with a PMH of LURT (___) with CKD
stage IV of renal allograft on mycophenolate and tacro,
significant vascular disease, AFib on apixaban, history of DVT,
recurrent C diff, pericardial effusion and recently drained
pleural effusions who presents with dyspnea and is found to have
recurrent right pleural effusion, status post VATS complicated
by bleeding from chest tube site, as well as urinary tract
infection.
ACUTE ISSUES:
=============
# Right loculated pleural effusion:
On presentation the patient had mild orthopnea, required 2L NC,
and was noted to have had 4 lb weight gain since prior visit. Of
note he had a chronic pleural effusion s/p chest tube placement
(___) with 2.7 L of serosanguineous fluid drained. Imaging
on admission showed slight increase in moderate loculated
pleural effusion. He underwent VATS washout and decortication
with Thoracics ___ with placement of 2 chest tubes, one of
which was removed by Thoracics on ___, the second of which was
accidentally pulled out overnight ___. He received
antibiotics, CTX (___) and flagyl (___), which were
stopped ___. Diuretics were titrated based on his volume status
and renal function, as below. His home apixaban was stopped and
he was put on a heparin gtt intraoperatively, but this was held
in the setting of coagulopathic bleeding from chest tube
sites/suture sites on ___. Apixaban resumed prior to d/c. His
supplemental O2 requirement was weaned. He received Acapella and
chest ___. He was evaluated by ___ and rehab was recommended.
# Complicated UTI
Urine culture grew Citrobacter koseri. Though he denied urinary
symptoms and had a bland UA, the decision was made to treat for
UTI given his immunosuppressed status. Following completion of
the antibiotic course as above, he was continued on PO cipro for
a total of 14 days of antibiotics, due to finish ___.
# ESRD s/p LURT ___:
# CKD Stage IV of graft
CKD IV in renal transplant with baseline serum creatinine of 2.5
due to transplant glomerulopathy (biopsy proven ___. Last
admission was uptitrated on tacro due to low troughs. His
torsemide was initially increased from his home dose given his
volume overload on admission, then was held in the setting of
worsening ___, then resumed at home dose of 80 BID upon
discharge. He was continued on tacrolimus and MMF. His
tacrolimus dosing was adjusted as needed with a goal trough of
___. He was discharged on 2.5 mg BID.
# AFib:
s/p DCCV ___ CHADS2 = 5. His home carvedilol was reduced
in the setting of postoperative bradycardia. His home Apixaban
was stopped and heparin gtt was used intraoperatively, though
this was stopped ___ in the setting of coagulopathic bleeding.
At time of discharge, he was continued on apixaban.
# Recurrent C diff:
Last stool sample ___ seen at APG (note in OMR), positive
for C diff. PO vancomycin was continued (___), with the plan
to extend his courses of PO vanc until 2 weeks after completing
antibiotics (___).
# Hypertension:
His home carvedilol was continued at a reduced dose, as above.
His home amlodipine was initially held but restarted prior to
discharge. His home hydralazine was dc'd during this admission.
# Depression
He was evaluated by palliative care during this admission, and
was started on sertraline 50 mg daily. Would likely benefit from
outpatient Pall Care f/u.
CHRONIC ISSUES:
===============
# Pericardial Effusion
S/p high dose aspirin/colchicine until ___ and ___
respectively. He was continued on ASA 81 daily. CT demonstrated
that pericardial effusion was stable.
# Abdominal distension:
The patient complained of abdominal distention on admission,
presumably secondary to volume overload. LFTs were noted to be
normal, and abdominal US did not show ascites and demonstrated
patent hepatic vasculature. He received diuresis as above.
# CAD:
# Bilateral carotid artery disease (80-99% ___, 60-69% LICA):
# Claudication/aortoiliac occlusive disease:
# Recent CVA:
s/p ___ 2 to proximal-LAD ___, s/p ___ 2 to mid-LAD
___. Plavix discontinued in ___. Continued home Aspirin
81 mg QD, Pravastatin 40 mg PO QPM (myalgias with high dose
atorvastatin).
# IDDM:
A1c 6.9% this admission. Dose reduced lantus to 21U qAM (down
from home dose 28U). He received ISS and diabetic diet.
# Hyperparathyroidism:
Continued Calcitriol 0.25 mcg PO QD.
# Gout:
Continued Allopurinol ___ mg QD.
# BPH:
Continued home tamsulosin 0.4 mg QD.
# Insomnia: Held home melatonin. Given ramelteon 8 mg QHS:PRN. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension, fevers
Major Surgical or Invasive Procedure:
intubation
left central venous line placement
arterial line placement
incision and drainage right axillary abscess
History of Present Illness:
History of Present Illness: ___ y/o M with history of
schizoaffective disorder, presented to PCP ___ 1 week history
of developing right axillary abcess, sent to ___. In ___ had I and
D with culture of fluid. Noted to have white count to
cellulitis developing abcess, saw PCP, ___ and D ( cultured)
and basic labs with elevated white count and bandemia. Initial
lactate 3.7, hypernatremic. After vanc/cefepime, Spiked fever to
102.7 got 4L of fluid, became agitated, tachypneic, vomited,
worried about airway tubed with improvement in ABG. More
hypotensive, now s/p 6L now on levo and neo, fent and versed,
turned off propofol given hypotension. Left subclavian line
placed with non contrast CT chest to evaluate for deep space
infection. Small opacity left lingula on CXR after emesis.
On arrival to the MICU pt with bp of ___ systolic on maximum
doses levophed and phyenylephrine.
Review of systems:
(+) Per HPI
(-) Per family, denies night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Recent bilateral axillary rash treated
with nystatin
Past Medical History:
psychoaffective disorder on clozaril requiring weekly blood
draws
ischemic colitis ___ paralytic ileus ___ clozaril
hyperlipidemia
Social History:
___
Family History:
Father CAD, deceased, CAD, mother deceased, Pulmonary
fibrosis,siblings, HTN, hyperlipidemia
Physical Exam:
Admission Exam: Vitals: T: 104.5 BP: 122/81 P:84 R: 29 O2: 93%
General: intubated, sedated
HEENT: Sclera anicteric, MMM, ET, NGT in place. EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Right axilla with warmth,blanching erythema with firm
induration extending to right chest and along right upper arm,
marked.Left axilla with superficial erosions, redness and scale
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No rigidity noted
Pertinent Results:
Admission Labs: ___ 01:17PM ___ PTT-36.4
___
___ 01:17PM PLT SMR-NORMAL PLT COUNT-239
___ 01:17PM NEUTS-66 BANDS-26* LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-2* MYELOS-1*
___ 01:17PM WBC-27.2*# RBC-5.15 HGB-15.1 HCT-45.9 MCV-89
MCH-29.4 MCHC-33.0 RDW-13.6
___ 01:17PM ALBUMIN-4.3
___ 01:17PM ALT(SGPT)-77* AST(SGOT)-33 ALK PHOS-100 TOT
BILI-0.6
___:17PM GLUCOSE-183* UREA N-25* CREAT-2.9*#
SODIUM-130* POTASSIUM-5.2* CHLORIDE-92* TOTAL CO2-24 ANION
GAP-19
___ 01:30PM URINE MUCOUS-FEW
___ 04:49PM LACTATE-2.8*
___ BLOOD CULTURE Blood Culture,
Routine-pending
___ SEROLOGY/BLOOD ASO Screen-FINAL
___ MRSA SCREEN MRSA SCREEN-PENDING
___ ABSCESS GRAM STAIN-FINAL; FLUID
RIGHT AXILLARY ABCESS CULTURE-FINAL {STAPH AUREUS COAG +};
ANAEROBIC CULTURE-PRELIMINARY
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4-6H Dyspnea
2. Clozapine 400 mg PO DAILY
3. Desonide 0.05% Cream 1 Appl TP BID
4. Lithium Carbonate 0 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral Daily
7. Atorvastatin 10 mg PO DAILY
Discharge Medications:
1. Clozapine 325 mg PO QPM
2. Polyethylene Glycol 17 g PO DAILY
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN PARALYSIS
4. Artificial Tears ___ DROP BOTH EYES PRN DRY NESS
5. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral Daily
6. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4-6H Dyspnea
7. Desonide 0.05% Cream 1 Appl TP BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right axillary abscess
MSSA infection
Toxic Shock Syndrome
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
EXAM: Chest, single semi-erect AP portable view.
CLINICAL INFORMATION: ___ male with history of sepsis.
___.
FINDINGS: Single frontal view of the chest was obtained. There are low lung
volumes, which accentuate the bronchovascular markings. Given this, slight
increase in opacity at the right lung base could be due to summation of
shadows, although consolidation cannot be excluded in this setting. Repeat
with better inspiration, PA and lateral views would be helpful for further
evaluation. The left lung is clear. No pleural effusion or pneumothorax.
The cardiac and mediastinal silhouettes are unremarkable.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Status post endotracheal intubation.
COMPARISONS: Earlier radiograph from the same day.
TECHNIQUE: Chest, supine AP portable.
FINDINGS: There has been interval placement of an endotracheal tube that
extends up to the carina. An orogastric tube courses across the left
hemidiaphragm into the stomach, its distal course not visualized. The lung
volumes are low. There is no definite pleural effusion or pneumothorax. The
cardiac, mediastinal and hilar contours appear unchanged. A patchy right
infrahilar opacity appears unchanged and may be due to minor atelectasis.
However, in the left mid to lower lung, there is a vague but new suggested
opacity.
IMPRESSION:
1. Endotracheal tube extending up to the carina. Findings were discussed
with Dr. ___ at the time of this dictation at 6:45 p.m. by telephone. At
that time, the finding of a low endotracheal tube had already been identified
and corrected.
2. Vague new suspected left mid to lower lung opacity raising concern for
atelectasis, pneumonia or aspiration; re-evaluation in short-term follow-up is
recommended.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Sepsis.
COMPARISONS: Earlier on the same evening.
TECHNIQUE: Chest, supine AP portable.
FINDINGS: An endotracheal tube has been retracted slightly and now resides
approximately 5 cm above the carina. There is a new left subclavian central
venous catheter that terminates in the upper superior vena cava. An
orogastric tube again courses through the mediastinum into the left upper
quadrant. The cardiac, mediastinal and hilar contours appear unchanged.
There is no pleural effusion or pneumothorax. Vague left mid lung opacity
suspected on the prior study is less distinct, but there may be a developing
retrocardiac opacity at the medial left lung base, where opacity appears
somewhat denser. Patchy right basilar opacity is likely due to minor
atelectasis and appears unchanged.
IMPRESSION: Status post interval placement of left subclavian central venous
catheter with tip terminating in the superior vena cava. Interval retraction
of endotracheal tube. Suspicion for developing medial left basilar opacity,
for which further attention in follow-up imaging is recommended.
Radiology Report
INDICATION: ___ male with large right axillary abscess with
multiorgan failure, recent admission at ___ for severe ileus with
abdominal distention, evaluate for extensive soft tissue infection/abscess and
elsewhere intra-abdominal infection or perforation.
TECHNIQUE: Non-contrast CT torso was obtained. Multiplanar reformatted
images were obtained and reviewed.
DLP: 1239.37 mGy-cm.
FINDINGS:
CT CHEST: Endotracheal tube is noted. Nasogastric tube courses into the body
of the stomach. A left subclavian central venous catheter terminates in the
upper SVC. Probable hypodense lesion in the inferior right thyroid lobe is
noted.
Small bilateral pleural effusions of low-density are noted with basilar
atelectasis. Right apical subpleural scarring. There is mild underlying
septal edema noted. An underlying infection is not definitively excluded.
Prominent subcarinal lymph nodes measure up to 1.2 cm in short axis which may
be reactive. The extrathoracic soft tissues demonstrate subcutaneous foci of
air within the right axillary soft tissues with a focus of hyperdensity which
may represent underlying hematoma. Fat stranding is also noted within this
region. Heart is normal in size, with trace pericardial effusion.
CT ABDOMEN:
Diffuse hepatic steatosis is noted. Gallbladder, spleen, pancreas, both
adrenal glands are normal. The left kidney demonstrates a partially exophytic
fluid-attenuating low-density lesion, likely a renal cyst (2:80), though
incompletely evaluated without IV contrast. The unopacified bowel is normal.
A few prominent right paraaortic fatty hilum-containing lymph nodes are noted,
but are nonspecific.
Incidental note of a left-sided IVC.
CT PELVIS: The bladder is decompressed with a Foley catheter in place. No
significant lymphadenopathy. The prostate and seminal vesicles are grossly
normal. No free fluid is noted.
BONES: Mild multilevel degenerative disc disease, most prominent at L1-L2 and
L5-S1. No suspicious lytic or blastic lesions identified.
IMPRESSION:
1. Soft tissue stranding, foci of intrinsic air and hyperdense material,
likely small hematoma within the right axillary soft tissues. However,
there is no discrete drainable fluid collection noted.
2. Small bilateral pleural effusions and basilar atelectasis and septal
edema. Prominent mediastinal/subcarinal lymph nodes are noted, which may be
reactive. An underlying infection is not definitively excluded.
3. Normal caliber bowel without evidence of ileus or obstruction.
4. Diffuse hepatic steatosis.
5. Hypodense lesion in the superior pole of the left kidney statistically
most likely represents a renal cyst but is incompletely evaluated.
6. Incidental note of a left-sided SVC.
Radiology Report
PORTABLE AP X-RAY
INDICATION: Patient with severe sepsis, emesis prior to intubation?
COMPARISON: CT scan and chest x-ray of ___.
FINDINGS:
Left lower lobe consolidation is worsening since yesterday and could be
compatible with aspiration and pneumonia. ET tube ends 2 cm above carina.
Left-sided subclavian line ends in upper SVC. The lung volumes are low.
Mediastinal and cardiac contours are mildly enlarged and unchanged. There is
no pneumothorax.
CONCLUSION:
Left lower lobe consolidation is worsening since yesterday, compatible with
aspiration or pneumonia.
Dr. ___ has been verbally contacted for the results.
Radiology Report
CHEST ON ___
HISTORY: Septic shock, question volume overload.
REFERENCE EXAM: ___.
FINDINGS: ET tube is unchanged. NG tube tip is poorly visualized. Lung
volumes are low and there is near-complete opacification of both hemithoraces
likely due to alveolar infiltrate although there could also be an element of
layering effusion. Heart size is mildly enlarged. The overall impression is
that of worsened fluid status. An underlying infectious infiltrate cannot be
totally excluded.
Radiology Report
CHEST ON ___
HISTORY: Sepsis, intubated, hypoxia.
Compared to the study from earlier the same day, there is no significant
interval change. ET tube and left subclavian line are unchanged. Lung volumes
continue to be low. There is pulmonary vascular re-distribution, probable
layering effusions and dense retrocardiac opacity.
Radiology Report
CHEST ON ___
HISTORY: Catheter placement.
FINDINGS: There is a new right IJ line with tip fairly high, probably in the
upper superior vena cava. There is no pneumothorax. ET tube, NG tube and
left subclavian line is unchanged. The line position was discussed with ___
at 8:10 p.m. by phone by Dr. ___.
Radiology Report
CHEST ON ___
HISTORY: Septic shock, on pressors.
FINDINGS: The ET tube, NG tube, left subclavian line, and right IJ line are
unchanged. There is increased bilateral pleural effusions that are layering
posteriorly. There is ill-defined vasculature bilaterally and cardiomegaly,
compatible with CHF. There are alveolar infiltrates bilaterally and dense
retrocardiac opacity. Compared to the prior study, the pulmonary status has
worsened.
Radiology Report
PORTABLE CHEST OF ___
COMPARISON: ___ radiograph.
FINDINGS: Indwelling support and monitoring devices are unchanged in
position. The cardiac silhouette has decreased in size and the vascular
pedicle width has markedly decreased since the prior study. This may reflect
improved volume status of the patient. There remains mild pulmonary vascular
congestion. Bilateral pleural effusions have markedly decreased in size since
the prior study, and there is associated improving aeration at the lung bases
with decreasing bibasilar atelectasis.
Radiology Report
INDICATION: ___ male with florid septic shock, now on CVVH. Evaluate
for volume overload.
COMPARISONS: Multiple prior chest radiographs, most recently of ___.
FINDINGS: Frontal view of the chest was obtained. Endotracheal tube
terminates 4.7 cm above the carina. Nasogastric tube terminates below the
diaphragm. The heart is of top normal size with normal cardiomediastinal
contours. Pulmonary vascular congestion remains without overt pulmonary
edema. Small layering left pleural effusion with bibasilar atelectasis is
similar to ___. No pneumothorax.
IMPRESSION: Stable pulmonary vascular congestion. Small left pleural
effusion with bibasilar atelectasis, similar to prior.
Radiology Report
REASON FOR EXAMINATION: Severe sepsis after PEA arrest.
Portable AP radiograph of the chest was reviewed in comparison to ___.
ET tube, NG tube, right internal jugular line and left subclavian line
appeared to be in unchanged position. Heart size and mediastinum are stable.
Pulmonary edema appears to be slightly more compressed than on the prior
study, associated with bibasilar effusions and bibasilar atelectasis.
Radiology Report
INDICATION: ___ male with PEA arrest, status post CPR. Evaluate for
contusions or interval change.
COMPARISONS: Multiple prior chest radiographs, most recently of ___.
FINDINGS: Frontal view of the chest was obtained. Endotracheal tube
terminates 5.4 cm above the carina. NG tube terminates below the diaphragm.
Right IJ large bore catheter terminates in the upper SVC. Left subclavian
central venous catheter terminates in the mid SVC. Lung volumes are low.
Heart and mediastinal contours are stable. Pulmonary edema appears similar to
prior with small pleural effusions and bibasilar atelectasis. No
pneumothorax.
IMPRESSION: Stable pulmonary edema with bilateral effusions and bibasilar
atelectasis.
Radiology Report
INDICATION: Seizures. Evaluation for acute process.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast.
COMPARISON: None.
FINDINGS: There is no hemorrhage, edema, mass effect, or evidence of
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent and gray-white matter differentiation is
preserved. The calvaria are unremarkable. Fluid within the nasopharynx,
maxillary sinuses, and mastoid air cells is likely related to intubation.
IMPRESSION: No acute intracranial abnormality.
Findings were discussed by Dr. ___ with Dr. ___ by phone at
12:16 p.m. on ___.
Radiology Report
INDICATION: ___ man with severe sepsis, new bradycardia, rising
leukocytosis, concern for occult infection.
COMPARISON: CT chest, abdomen and pelvis without contrast ___.
TECHNIQUE: Axial helical MDCT images were obtained of the abdomen and pelvis
with oral contrast only. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 993.89 mGy-cm.
FINDINGS: There has been increase in bibasilar consolidations. Air
bronchograms are visible within this area of consolidation. There is a stable
small amount of bilateral pleural effusions. The visualized heart and
pericardium are unremarkable in appearance.
CT ABDOMEN: This is a non-contrast study, which limits evaluation of the
intra-abdominal solid organs. Within these limitations, the liver is of low
density signifying fatty infiltration. There are small areas of more defined
hypodensity at the peripheral edge of segment II and IVB signifying more
pronounced fatty change. The gallbladder is unremarkable with no stones or
pericholecystic fluid. The spleen, pancreas, and adrenal glands are
unremarkable. There is a 1.8 cm exophytic left renal upper pole cyst,
otherwise bilateral kidneys are unremarkable.
An NG tube is in place with the tip terminating in the gastric antrum. The
stomach, duodenum, and small bowel are unremarkable in appearance with no
areas of focal wall thickening or obstruction. The large bowel is
unremarkable in appearance. There are scattered prominent periaortic and
portacaval lymph nodes; however, none of these meet CT size criteria for
enlargement. There is no intra-abdominal free air, ascites, fluid collections
or hernias.
CT PELVIS: A Foley is in the bladder along with a small focus of air, which
is otherwise unremarkable in appearance. A rectal tube is in place. There is
a right-sided femoral A-line in place. There is no inguinal or pelvic wall
lymphadenopathy. There is no pelvic free fluid or air.
OSSEOUS STRUCTURES: There are multilevel degenerative changes in the
thoracolumbar spine, most pronounced at L5-S1. There are no focal blastic or
lytic lesions in the visualized osseous structures concerning for malignancy.
IMPRESSION:
1. Interval increase in bibasilar consolidations along with interval
development of air bronchograms along with unchanged bilateral pleural
effusions concerning for infection.
2. No evidence of intra-abdominal abscess or infectious process.
3. Hepatic steatosis.
4. Left upper pole renal cyst.
Results were discussed over the telephone with Dr. ___ on
___ at 4:34PM 45 minutes after discovery.
Radiology Report
INDICATION: ___ male with severe sepsis.
COMPARISONS: Multiple prior chest radiographs, most recently of ___.
FINDINGS: Frontal view of the chest was obtained. Endotracheal tube
terminates 5.8 cm above the carina. An OG tube terminates below the
diaphragm. Right IJ large bore catheter terminates in the lower right IJ or
upper SVC. Left subclavian central catheter terminates in the upper SVC.
Lung volumes remain low. Pulmonary edema is improved, now mild, and small
bilateral pleural effusions with adjacent atelectasis remain. Heart size and
cardiomediastinal contours are stable.
IMPRESSION: Improved pulmonary edema, now mild, with small bilateral pleural
effusions and adjacent atelectasis.
Radiology Report
INDICATION: ___ man with severe septic shock, now with rising total
bili. Rule out biliary pathology.
COMPARISON: CT of the abdomen and pelvis ___.
FINDINGS: The liver is diffusely echogenic, consistent with moderate hepatic
steatosis. There are multiple hypoechoic areas of focal fatty sparing within
the liver. There is a small simple-appearing cyst within the left lobe of the
liver measuring 0.6 x 0.4 x 0.8 cm. No suspicious liver lesions identified.
There is gallbladder wall thickening with areas of comet-tail artifact
compatible with adenomyomatosis. Layering sludge is also seen within the
gallbladder. There is no sign of cholecystitis.
The common bile duct measures 0.4 cm. The intrahepatic biliary tree is
nondilated.
There is no free fluid within the upper abdomen.
The visualized portions of the pancreas appear unremarkable.
IMPRESSION:
1. Diffuse hepatic steatosis.
2. Simple cyst within the left lobe of the liver.
3. Gallbladder adenomyomatosis and sludge. No obstruction of the biliary
tree is identified.
Radiology Report
REASON FOR EXAMINATION: Cough, hypoxic, respiratory failure.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 6 cm above the carina. The NG tube tip is in the stomach.
The left subclavian line tip is at the level of mid SVC. The right internal
jugular line tip is at the level of superior SVC. Heart size and mediastinum
are stable. Left retrocardiac consolidation and mild interstitial pulmonary
edema are unchanged. There is no pneumothorax.
Radiology Report
STUDY: Portable AP chest radiograph.
COMPARISON: Portable AP chest radiograph ___
FINDINGS: Heart size is top normal. The mediastinal and hilar contours are
widened but stable since ___. Right internal jugular line tip
is at the thoracic inlet. There is mild pulmonary vascular congestion, stable
compared to most recent prior. Right base atelectasis is stable.
IMPRESSION: Borderline cardiac decompensation, stable since ___.
Radiology Report
STUDY: AP portable chest radiograph.
COMPARISON: Portable chest radiograph, ___.
INDICATION: New PICC line placement.
FINDINGS: There has been interval placement of a right PICC line with tip
terminating in the region of the cavoatrial junction. There is no pleural
effusion. Right basal atelectasis stable. There is a possible left anterior
pneumothorax. There is mild pulmonary vascular congestion.
IMPRESSION:
1. Possible left anterior pneumothorax. Upright study is recommended for
better evaluation. This finding was called to Dr. ___ by Dr. ___ at 11:09
a.m. 10 minutes after the time of discovery by telephone.
2. PICC line with tip terminating in the region of the cavoatrial junction.
Withdrawal by 1.5 cm may be performed to confirm placement in the lower SVC.
Radiology Report
HISTORY: ___ man, after resolved septic shock, which required five
pressors and steroid on admission. Now extubated and reported bilateral
visual loss. Also has history of psychiatric disease. Assess for evidence of
cerebrovascular accident.
COMPARISON: None.
TECHNIQUE: Non-contrast multiplanar, multisequence images were acquired
through the head. Diffusion-weighted images and ADC map were also obtained
for evaluation.
At the time of the image acquisition, both Dr. ___ (fellow) and Dr.
___ (attending), were at the scanner monitoring the case. After
assessing the non-contrast images, Dr. ___ Dr. ___ the
findings with the primary team, and a joint decision was made that intravenous
contrast was not needed.
FINDINGS: There is a punctate FLAIR, DWI-bright and ADC-dark focus in the
left corona radiata (image 317, series #5), compatible with an acute/subacute
focal ischemic change or restricted diffusion. There is no major vascular
territorial infarct.
The ventricles and sulci are normal in size and symmetric in configuration.
Minimal periventricular white matter T2/FLAIR hyperintensity, nonspecific and
of doubtful clinical significance. There is no evidence of intracranial mass
or hemorrhage. The gray-white matter differentiation is preserved. Major
vascular flow voids are present. The visualized globes are grossly
unremarkable.
There is small amount of fluid layering in the left maxillary sinus and the
left sphenoid sinus. There is bilateral mastoid retained fluid.
IMPRESSION:
1. Focal area of restricted diffusion, suggesting acute/subacute ischemia in
the left corona radiata. Otherwise, no evidence of major territorial infarct.
2. No signal abnormality in the globes, optic nerves, chiasm or tracts, or
the occipital lobes.
Radiology Report
INDICATION: ___ man with recent line placement, concern for
pneumothorax.
COMPARISON: ___ radiograph and CT from ___.
TWO PORTABLE ERECT VIEWS OF THE CHEST: There is no evidence of pneumothorax.
A right-sided internal jugular line is unchanged in correct position. A
right-sided PICC terminates in the mid to low SVC. Previous left-sided
subclavian line has been removed.
There are bibasilar opacities consistent with streaky atelectasis; however,
there is also a slightly asymmetric appearance of pulmonary opacities which
could be related to an atypical infectious process, less likely pulmonary
edema given the configuration.
IMPRESSION: No evidence of pneumothorax. Asymmetric pulmonary opacities on
this radiograph. Suggest continued follow up to evaluate for the possibility
of atypical pneumonia.
Radiology Report
MRA OF THE HEAD AND NECK WITHOUT CONTRAST, ___
INDICATION: New onset of bilateral blindness. Evaluate for vascular
occlusion.
COMPARISON: None. Head MRI performed one day earlier is available for
correlation.
TECHNIQUE: Two-dimensional time-of-flight MRA of the neck and
three-dimensional time-of-flight MRA of the head were obtained without
intravenous contrast. Maximal intensity projection reformatted images of the
neck and head arteries were obtained. No intravenous contrast was
administered due to poor renal function.
FINDINGS:
MRA NECK: The study is mildly limited by motion artifacts. There is no
evidence of a hemodynamically significant stenosis in the cervical common
carotid, internal carotid, or vertebral arteries. The left vertebral artery
is dominant.
HEAD MRA: This study is mildly limited by motion artifacts. The non-dominant
right vertebral artery terminates in the right posterior inferior cerebellar
artery. Otherwise, there is no evidence of a hemodynamically significant
arterial stenosis in the left vertebral artery, basilar artery, and their
major branches, nor in the internal carotid arteries and their major branches.
There is no evidence of an intracranial aneurysm.
IMPRESSION: Slighly motion-limited studies. No evidence of arterial occlusion
or hemodynamically significant arterial stenosis in the neck or intracranial
circulation. The non-dominant right vertebral artery terminates as the
posterior inferior cerebellar artery.
Radiology Report
PORTABLE AP CHEST FILM ___ AT 1614
CLINICAL INDICATION: ___ with chest pain and cough. Assess for
pneumonia.
Comparison is made to the patient's prior study of ___.
Portable semi-erect chest film ___ at 1614 is submitted.
IMPRESSION:
1. Right subclavian PICC line and right internal jugular central line are
unchanged. Lung volumes remain low. No focal airspace consolidation is seen
to suggest pneumonia. No pleural effusions or pneumothorax. The heart
remains enlarged with left ventricular prominence, most likely representing
cardiomegaly, although a pericardial effusion cannot be entirely excluded.
Clinical correlation is advised. Mediastinal contours are unchanged. No
pulmonary edema.
Radiology Report
INDICATION: ___ man with new right PICC.
COMPARISONS: ___.
FINDINGS: Previous internal jugular catheter has been removed. Right PICC
has been replaced with new right PICC terminating in the mid-to-distal SVC.
Lung volumes are low, without focal consolidation, pleural effusion, or
pneumothorax. The heart is normal in size with normal cardiomediastinal
contours.
IMPRESSION: Satisfactory position of the replaced right PICC.
Radiology Report
HISTORY: ___ man with right abdominal pain.
COMPARISON: Abdomen CT ___, and Liver Ultrasound ___.
FINDINGS:
The liver is improved in echogenicity since the prior ultrasound of ___. There is a small round echogenic region in segment V of the
liver which measures 3.2 x 1.6 x 1.5 cm. This structure was not visualized on
the prior abdominal imaging. While this may represent a hemangioma,
ultrasound is unable to characterize. Two tiny simple cysts are also again
noted within the liver.
No biliary dilatation is seen and the common duct measures 0.3 cm. The
gallbladder wall is again noted to be thickened with punctate echogenicities
consistent with adenomamyomatosis. No gallstones are visualized. The
pancreas is unremarkable, but is only partially visualized. The spleen is
enlarged, measuring 14.8 cm. No ascites is seen in the abdomen.
Doppler examination: Color Doppler, and spectral waveform analysis was
performed. The main, right and left portal veins are patent with hepatopetal
flow. Appropriate arterial waveforms are seen in the main, right and left
hepatic arteries. The hepatic veins and IVC are patent.
IMPRESSION:
1. No biliary dilatation. Adenomyomatosis of the gallbladder again noted. No
gallstones and no signs of cholecystitis are visualized.
2. Hepatic steatosis seen on the prior imaging is improved with less
echogenicity of the liver.
3. Small hyperechoic structure in segment V of the liver could represent a
hemangioma but was not visualized on prior imaging. A three-month followup
ultrasound could be performed to assess stability or a multiphase CT or MRI
could be performed for further characterization.
4. Splenomegaly. No ascites identified in the abdomen.
Radiology Report
INDICATION: Right shoulder pain.
COMPARISON: None.
THREE VIEWS RIGHT SHOULDER: There are moderate degenerative changes of the
glenohumeral joint with humeral head osteophyte formation. Acromioclavicular
joint is preserved. There is no fracture or dislocation. No amorphous soft
tissue calcifications. A PICC line is partially visualized. The visualized
right hemithorax is clear.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABSCESS TO LEFT AXILLA
Diagnosed with SEPTICEMIA NOS, CELLULITIS OF ARM, SEPSIS , ACCIDENT NOS, ACUTE RESPIRATORY FAILURE, CONDUCT DISTURBANCE NOS
temperature: 98.3
heartrate: 93.0
resprate: 18.0
o2sat: 96.0
sbp: 123.0
dbp: 81.0
level of pain: 3
level of acuity: 3.0 | This is ___ y/o M with hx of schizoaffective disorder admitted
with R axillary abscess positive for MSSA c/b by toxic shock
syndrome, w/ subsequent hypoxemic respiratory failure requiring
intubation, acute on chronic renal failure w/ anasarca requiring
CVVH tranisitioned to HD, sinus pauses, and bilateral blindness
from ischemic optic neuropathy secondary to hypotension. Upon
transfer to the floor he became progressively agitated,
disoriented, delusional, and delirious. He also developed a line
infection, which was succesfully treated with Vancomycin. His
mental status improved with resolution of his infection, as well
as gradual uptitration of Clozaril. His renal failure recovered
and his dialysis was discontinued. He was found to have anemia
of chronic disease, which was treated with 1U of pRBC.
# Septic Shock: The patient developed refractory septic shock
requiring 5 pressor support and fluid resucitation to 35L. The
source of his sepsis was thought to be his right axillary
abscess. He may have been predisposed to a more severe immune
response on clozaril which causes agranulocytosis and perhaps a
functional neutropenia. CT abdomen/pelvis was unrevealing with
the right axillary absess remaining the most likely source. He
initially received clindamycin, meropenem and vancomycin for
broad spectrum antibiotic coverage and high dose steroids x 3
days for refractory septic shock. MSSA was identified from the
abscess, all other cultures were negative. He was thus started
on a 2 week course of nafcillin from ___. He was
suspected of having a toxic shock syndrome due to the lack of
positive blood cultures and received IVIG, a toxic shock panel,
and PVL testing on the MSSA was performed. He was eventually
weaned down on his pressors and transferred to the floor when he
no longer required pressor support. On the floor he remained
hemodynamically stable with no required interventions. His I&D'd
abscess site in the right axilla remained clean and dry with no
evidence of reaccumulation. On discharge he is afebrile and
normotensive.
# Renal Failure: During the course of his septic shock and
agressive fluid resucitation the patient developed renal
failure. He was started on CVVH with removal of much of the
resucitation fluid. The anasarca he had developed during
resucitation raised initial concern for compartment syndrome,
but evaluation by surgery and orthopedics ruled out compartment
syndrome, and anasarca improved with CVVH. He required
initiation of hemodialysis, which was continued upon his
transfer to the floor. During his time on the floor his kidney
function showed continued improvement with increasing urine
output and downtrending creatinine. He was eventually taken off
of dialysis, with expectation of recovery of normal kidney
function.
# Optic neuropathy: Upon extubation the patient noted bilateral
visual loss. MRI/MRA was unrevealing for an intracranial
etiology. Evaluation by neuro-ophthalmology revealed ischemic
optic neuropathy due to shock as the underlying cause of his
blindness. With this diagnosis the patient is unlikely to
recover meaningful vision, with perhaps the possibility of light
perception in the future. He was registered with the
___ Registry for the Blind, who will
conduct an assessment in the future. Case management was
consulted for the appropriate services at rehab and at home
given his new diagnosis.
# Hypoxemic Respiratory Failure: He was initially intubated for
airway protection after becoming agitated and vomiting. He did
have a lingular opacity on CXR suggesting aspiration. He
developed a hyperchloremic Metabolic and respiratory acidosis in
setting of sepsis, hyperchloremic with NS fluid boluses. He
underwent further fluid resuccitation with Bicarbonate. He
initially required high PEEPs due to abdominal contribution and
was paralyezed due to vent dysynchrony. As his acidosis improved
the paralysis was removed and he was weaned to lower PEEPs and
fi02. He did have a period of fevers with increased ventilatory
support suggesting VAP. Imaging was unrevealing. Antibiotics
were broadened to cefepime and vancomycin, he improved with
narrowing back to nafcillin. He was ultimately extubated, and
upon transfer to the floor required no supplemental oxygen. Upon
discharge he is breathing comfortably with no oxygen
requirement.
# Schizoaffective disorder: At home the patient was on lithium
and clozaril. He was without increased tone on examination and
it was not felt that he had neuroleptic malignant syndrome
contributing to his shock. His Clozaril was gradually resumed,
starting at 50mg BID, as compared to his home dose of 400mg QD.
Initially his total dose was increased by 50mg/day, but upon
consulting psychiatry and discussing with his outpatient
pscyhiatrist it was decided that 25mg/day would be a safer
escalation. Upon further discussion with our inpatient
pscyhiatry service it was decided that 25mg every other day
would be safer. Additionally, his entire dose was moved to QHS.
Unfortunately due to his renal failure he could not resume his
home Lithium. He had increasing agitation during his time on the
floor, with disorientation, delusions, and suicidal ideation.
This was thought to be due to a combination of subtherapeutic
clozaril, d/c of lithium, and delirium. He was started on QHS
haldol, and given PRN haldol for episodes of significant
agitation. However, due to excessive sedation and pt's
complaints of akithesia the QHS haldol was stopped. Notably, the
pt's mental status seemed to improve following the
identification of a presumed line infection on ___ and
subsequent treatment with appropriate antibiotics. He remained
delusional but was much more redirectable and less agitated. It
was thought that some component of his agitation prior to this
was due to delirium in the setting of occult infection. In light
of his intolerance of Haldol, he was trialed on 0.5mg ativan PRN
for agitation, which proved effective and also helped him to
sleep. Upon discharge his mental status has markedly improved.
He is still delusional (per family he is at his baseline), but
not agitated, and able to answer questions and follow commands
appropriately. He is on 325mg of Clozaril, and will require
continued uptitration by 25mg every other day starting on
___ until his home dose of 400mg daily is reached. CBC
with differential should be monitored weekly to evaluate for
agranulocytosis.
# Fever, leukocytosis, ?Line infection: On ___ the patient
had a borderline WBC of 10.7. He had low grade temps to 99.7,
and became markedly diaphoretic. A rectal temperature revealed a
fever to 102. He was cultured from his temporary HD line, his R
AC PICC line, and from his PIV. A urine culture was also
obtained. He was started on vancomycin and cefepime. On ___
his WBC had increased to 11.4. It was presumed that his
infection originated from his HD line or his PICC line. Both of
these were pulled, and tip cultures were obtained which showed
no growth. All blood and urine cultures showed no growth. On
___ he defervesced and his white count returned to within
normal limits. Throughout the remainder of his hospital course
he remained afebrile with a normal white count and no localizing
signs or symptoms of infection. He completed a 10 day course of
vancomycin for a presumed line infection, which ended on
___.
# Vagal episodes: While intubated he had a PEA arrest recovering
with epinephrine. He subsequnently had multiple asystolic
episodes with immediate return to circulation in the setting of
vagal activities such as coughing. Cardiology was consulted and
recommended theophylline which lessened his vagal tone and the
vagal episodes decreased in frequency. The theophylline was
stopped before transfer to the floor. On the floor he required
no interventions and remained in NSR with no episodes of
asystole or arrhythmia.
# Urinary retention: Upon transfer to the floor the patient had
a foley catheter in place in order to monitor UOP closely. As
his renal function improved, the foley was discontinued.
Following discontinuation he had no difficulty urinating but was
incontinent. On ___ he developed urinary retention, with no
urination over the course of ___ hours, and 900cc in his
bladder upon bladder scan. He was straight cathed with succesful
drainage. Throughout the rest of his hospital course he was able
to void spontaneously without difficulty.
# Anemia: The pt had a gradually downtrending Hct upon transfer
to the floor. No obvious source of bleed, and iron studies most
consistent with anemia of chronic disease. On ___ he
experienced dizziness with upright position and had positive
orthostatic vitals with a Hct of 22.7. He was transfused with 1U
of pRBC, with a Hct increase to 24.7 and a decrease in his
symptoms. He will need to be closely monitored for
signs/symptoms of anemia at his rehab facility.
# Abdominal pain, transaminitis: During his MICU course the
patient had a significant transaminitis from shock liver. His
LFTs downtrended to normal upon transfer to the floor. During
his time on the floor he had a mild elevation in his ALT/AST and
Alk phos. A RUQ U/S was performed which was unremarkable. His
coags and albumin were reassuring. His LFTs began to downtrend
without intervention, and his ALT/AST/AlkP/Tbili are
208/30/229/0.6 upon discharge. In the setting of his
transaminitis he also developed diffuse abdominal pain. The pain
was mild and was intermittent. Abdominal exam was consistently
reassuring, and the patient had no hematochezia, melena,
constipation, nausea, or vomiting. His LFTs will need to be
trended at his rehab facility. His abdominal pain symptoms will
need to be monitored.
# Hyperlipidemia: Patient was on a home med of lipitor. However,
PCP recommended holding after elevated LFTs from shock liver.
Atorvastatin was held, LFTs and CKs were trended. Upon discharge
his LFTs were still mildly elevated, and his atorvastatin should
be held until he has outpatient follow up with his PCP.
# COPD: Former smoker, requiring albuterol inhaler prn. He was
given albuterol nebs as needed after transfer to the floor,
which offered symptomatic relief. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Episode of full body stiffening, incontinence, aphasia and
decreased responsiveness at home.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ year old man with history of multiple prior CVAs
with residual right lower extremity weakness and decreased
spontaneous speech output who was brought in by EMS for episode
of full body stiffening, incontinence, aphasia and decreased
responsiveness at home. History obtained by wife as patient
unable to relay detailed/accurate history on assessment.
Per wife, the patient was in his usual state of health up until
1700 this afternoon, when she noticed that while he was talking
to him, he suddenly appeared to have a glazed over appearance as
if he was a man "who could not see." His body then stiffened and
she went to help him (he was standing against the wall at that
time) when she felt his entire body tense. She also noted a
stream of urine down his leg. She helped him to sit down when
she
noticed that he started just repeating the same sentence and not
responding to him. She also thought his right side was weak
again, as it was with his prior stroke ___ months ago. EMS was
called and code stroke was activated in ED once LKW was
confirmed
to be 1700.
Regarding prior pertinent neurological history, per chart review
(wife is poor historian) since his stroke in ___, he has had
residual right lower extremity weakness, dragging the leg. His
wife notes that he is minimally interactive and will only
respond
if asked a question directy. She prepares all his meals for him,
his medications, and helps to bathe him. He is supposed to use a
walker but he is "too stubborn." When asked what he does all
day,
she says "nothing." She has someone come and stay with him while
she is at work. There is suspicion of CADASIL or CAA based on
prior chart review, however he never underwent genetic testing
for CADASIL and his wife today on exam denies hearing the word
before, although per chart review, she has participated in
discussions regarding both potential CADASIL and CAA in the
past.
Review of systems limited to wife, who is poor historian.
No recent fever, chills, change in sleep, stressors, medication
changes. No recent falls. She notes a caveat that her husband is
a man "who does not complain or talk much" though.
Past Medical History:
-stroke x 2 with resultant R sided weakness
-HTN
-elevated A1C
-HLD
-CKD
Social History:
___
Family History:
no reported history of CADASIL, migraines, strokes
Physical Exam:
On Admission (___):
Vitals: HR61 RR19 SBP164/91 SaO2 98 RA
General: Awake, HOB elevated on stretcher, not agitated
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Neurologic:
MS: alert, regards examiner, perseverates over sentence ("I
don't
know" or continuously says his name). Does not follow verbal
commands or mimic. Does keep arm up if lifted while being asked
to keep his arm up (i.e., requires both verbal and mimic
stimuli). Tracks examiner. No evidence of neglect.
CN: right ptosis with symmetric brow raising, right NLFF with
slight delay in activation, tongue appears midline. PERRL 3>2,
EOMI. No saccades.
Motor: Lifts all extremity antigravity with resistance detected
in noxious. R IP with slightly weaker withdrawal to noxious
compared to L IP. Remaining strength exam as assessed by
resistance to noxious appears intact. No adventitious movements.
Reflexes: brisk throughout, plantar response is extensor
bilateral
Sensation: withdraws briskly to noxious in all extremities.
Coord: able to scratch his shins with his toes apparently
accurately and reach up to touch his face apparently
purposefully
with both hands on both sides of face.
On discharge:
Vitals:
98.0 143 / 87 61 18 98 Ra
General: Awake, not agitated
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Neurologic:
MS: alert, follows all simple commands. Has difficulty with
cross
body commands. No evidence of neglect.
CN: right ptosis with symmetric brow raising, right NLFF with
slight delay in activation, tongue appears midline. PERRL 3>2,
EOMI. No saccades.
Motor: Normal tone and bulk. Right drift without pronation.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L ___ 5 ___ 5 5 5 5
R ___ 5 ___ 5 5 5 5
Reflexes: deferred
Sensation: no deficits to gross touch. No extinction.
Coord: FTN intact. Could not understand how to do HTS.
Pertinent Results:
___ 02:07AM BLOOD WBC-6.5 RBC-4.76 Hgb-12.2* Hct-37.7*
MCV-79* MCH-25.6* MCHC-32.4 RDW-14.4 RDWSD-41.2 Plt ___
___ 07:37PM BLOOD WBC-6.7 RBC-5.22 Hgb-13.8 Hct-42.2
MCV-81* MCH-26.4 MCHC-32.7 RDW-14.6 RDWSD-42.6 Plt ___
___ 02:07AM BLOOD Neuts-70.7 ___ Monos-6.3 Eos-0.5*
Baso-0.6 Im ___ AbsNeut-4.63 AbsLymp-1.41 AbsMono-0.41
AbsEos-0.03* AbsBaso-0.04
___ 07:37PM BLOOD Neuts-55.8 ___ Monos-9.2 Eos-1.8
Baso-0.9 Im ___ AbsNeut-3.72 AbsLymp-2.11 AbsMono-0.61
AbsEos-0.12 AbsBaso-0.06
___ 02:07AM BLOOD ___ PTT-29.0 ___
___ 08:20PM BLOOD ___ PTT-27.1 ___
___ 02:07AM BLOOD Glucose-185* UreaN-19 Creat-1.4* Na-142
K-3.4* Cl-105 HCO3-25 AnGap-12
___ 02:07AM BLOOD ALT-12 AST-17 LD(LDH)-217 CK(CPK)-346*
AlkPhos-66 TotBili-0.3
___ 08:20PM BLOOD CK(CPK)-350*
___ 02:07AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:07AM BLOOD Albumin-4.1 Cholest-208*
___ 02:07AM BLOOD %HbA1c-6.1* eAG-128*
___ 02:07AM BLOOD Triglyc-58 HDL-58 CHOL/HD-3.6
LDLcalc-138*
___ 02:07AM BLOOD TSH-0.90
___ 02:07AM BLOOD CRP-0.9
Imaging:
MRI ___
IMPRESSION:
1. No acute intracranial abnormality.
2. Subacute left temporal lobe infarct, unchanged. Old
bilateral thalamic,
cerebellar and pontine infarcts.
3. Extensive microangiopathic changes throughout the bilateral
cerebral
hemispheres and posterior fossa with evidence of
microhemorrhages, unchanged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Doxazosin 4 mg PO HS
4. Vitamin D ___ UNIT PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
8. Multivitamins 1 TAB PO DAILY
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Doxazosin 4 mg PO HS
4. Vitamin D ___ UNIT PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. LevETIRAcetam 750 mg PO BID
2. amLODIPine 10 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Doxazosin 4 mg PO HS
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Seizure
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
EXAMINATION: ED STROKE CTA HEAD AND NECK WITH PERFUSION Q14 CT HEADNECK
INDICATION: Suspected stroke with acute neurological deficit.// Please
exclude ICH, signs of early ischemic stroke, large vessel occlusion, or other
vascular abnormality.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
CT images using the Rapid perfusion sotware were also obtained.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
3) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
4) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,208.6 mGy-cm.
Total DLP (Head) = 4,653 mGy-cm.
COMPARISON: CT of the head from ___ and MR ___ of the brain from ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass effect.
Again seen are areas of confluent periventricular and subcortical hypodensity,
which are nonspecific and possibly a sequela from chronic small vessel
ischemic changes which is more than expected for patient's age.
There is mild-to-moderate generalized parenchymal volume loss with prominence
of the ventricular system and extra-axial CSF spaces. This is more than
expected for patient's age.
They are unchanged old lacunar infarcts in the bilateral thalami, right
greater than left and left caudate.
Unchanged areas of encephalomalacia in the inferior left cerebellar hemisphere
and left temporal lobe, likely a sequela from prior infarction.
Unchanged 4 mm granuloma in the left anterior frontal lobe, possibly a sequela
from prior granulomatous 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 scattered atherosclerotic plaques along the carotid siphons
bilaterally, left greater than right, resulting in less than 50% luminal
narrowing. Along the anterior circulation, there are several areas of vessel
narrowing with what appears poststenotic dilation, especially seen along the
left ICA terminus and distal M1 and proximal M 2 segments (series 4, image
241-243). Additional vessel wall irregularities are seen along the proximal l
right M1 segment (series 4, image 240) and right M2 segment (series 4, image
244-250).
Alternating segments of stenosis, normal vessel caliber and mild dilation
along the V3 and V4 segments of the left vertebral artery with near complete
occlusion at the vertebrobasilar junction. There is an atherosclerotic plaque
in the midportion of the right V4 segment, no significant luminal narrowing.
The basilar artery is normal. There is mild vessel wall irregularity along
both posterior cerebral arteries.
The dural venous sinuses are patent.
CT PERFUSION:
CBF<30% volume: 0 mL
CTA NECK:
There is a bovine type aortic arch. The common carotid and right vertebral
arteries appear unremarkable with no evidence of stenosis or occlusion. There
are mixed atheromatous and atherosclerotic changes at both bifurcations,
resulting in no stenosis on the left and less than 50% stenosis of the
proximal ICA on the right by NASCET criteria. The cervical ICAs are otherwise
unremarkable.
There is complete occlusion of the left vertebral artery at its origin, most
likely chronic in nature. Intermittent opacification of the cervical left
vertebral artery is likely due to vessel reconstitution from muscular
branches.
OTHER:
The visualized portion of the lungs are clear allowing for pleuroparenchymal
scarring and mild atelectasis. The visualized portion of the thyroid gland is
within normal limits. There is no lymphadenopathy by CT size criteria.
IMPRESSION:
1. Chronic left vertebral artery occlusion with reconstitution from muscular
branches.
2. Moderate intra crane atherosclerotic changes involving the cavernous ICAs
bilaterally, the left ICA terminus, bilateral MCAs and bilateral PCAs as well
as the bilateral V4 segments, left greater than right. The findings are
overall similar to prior MRA allowing for technical differences.
3. Less than 50% stenosis of the proximal right cervical ICA by NASCET
criteria.
4. Unchanged confluent periventricular and subcortical hypo density which is
nonspecific but most likely a sequela of chronic small vessel ischemic changes
which is more than expected for patient's age.
5. Unchanged sequela of prior infarction in the left caudate, bilateral
thalami, left temporal load and left cerebellar hemisphere.
6. Mild to moderate diffuse parenchymal volume loss, more than expected for
patient's age.
7. Additional findings described above.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with new aphasia// r/o stroke
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: MRI and MRA of the brain from ___. CT and CTA of the
head from ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction.
Again seen are extensive, predominantly confluent periventricular and deep
white matter T2/FLAIR hyperintensities in the cerebral hemispheres bilaterally
and within the pons, consistent with severe chronic small vessel ischemic
changes.
Multiple small microhemorrhages are seen throughout the cerebral hemispheres,
basal ganglia and within the posterior fossa, suggestive of amyloid
angiopathy.
Sequela of prior infarcts with encephalomalacia are seen in the left temporal
lobe, pons and left cerebellum. There is residual enhancement along the left
temporal lobe infarct, indicating a subacute state. Old lacunar infarcts in
the right middle cerebellar peduncle and bilateral thalami.
There is mild-to-moderate generalized parenchymal atrophy, more than expected
for patient's age. Prominence of the ventricular system and extra-axial CSF
spaces is most likely due to the previously mentioned generalized parenchymal
atrophy.
Major intracranial vessels are patent. Major dural venous sinuses are patent.
The paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Subacute left temporal lobe infarct, unchanged. Old bilateral thalamic,
cerebellar and pontine infarcts.
3. Extensive microangiopathic changes throughout the bilateral cerebral
hemispheres and posterior fossa with evidence of microhemorrhages, unchanged.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Altered mental status, unspecified
temperature: 97.8
heartrate: 61.0
resprate: 18.0
o2sat: 98.0
sbp: 182.0
dbp: 158.0
level of pain: 0
level of acuity: 2.0 | ___ year old man with HTN and multiple past infarcts who
presented
with concern for seizure event vs a vascular event in the
setting
of an acute change in mental status with aphasia, tonic
stiffening and urinary incontinence. The event was followed by
confusion is suspicious for seizure, but given his history he
was
worked up for a vascular event. NIHSS 5 on arrival with exam
notable for significant expressive > conductive aphasia, with
gradual improvement of conductive aphasia within 30 minutes of
arrival. Exam also notable for subtle right ___ weakness compared
to left, although formal testing was limited by conductive
aphasia. Labs notable for PLT 126. Imaging notable for prior MRI
___ which demonstrated close to >50 microbleeds with notable
white matter disease. Patient was started on keppra for seizure
prophylaxis. MRI was unrevealing for an acute infarct. EEG
preliminary read showed diffuse slowing with intermittent front
slowing only. No epileptiform activity, however given high
suspicion for seizure, continued on keppra 750mg BID. Etiology
of microbleeds likely hypertension given basal ganglia and
brainstem involvement.
======================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
latex
Attending: ___.
Chief Complaint:
RLQ pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
Ms. ___ is a ___ you F with no significant PMHx who presents
with 2 days of abdominal pain. She reports that yesterday she
woke up with acute diffuse abdominal pain. It as associated with
nausea, emesis (although forced), and anorexia. Her pain became
worse and localized to the RLQ around 8pm. She
reports it was sharp and constant. At around 1 am she felt a
release of the intense pain and a sense of dissipation. Febrile
102 at home and febrile to 100.7 in the ED. She was also
tachycardic 137, improved to 103 with 2L Bolus.
Past Medical History:
PMHx: none
PSHx: none
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals:99.2, 97, 125/69, 18, 97% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: breathing comfortable on room air
ABD: Soft, nondistended, tender RLQ, focally guarding
Ext: WWP
Discharge Physical Exam:
VS: T: 98.5 PO BP: 114/71 R Lying HR: 77 RR: 16 O2: 98% Ra
GEN: A+Ox3, NAD
HEENT: atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, mildly distended, appropriately tender at incisions.
Incisions with dermabond, wounds well-approximated, no s/s
infection
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
Acute appendicitis with substantial surrounding inflammatory
changes and free fluid which could suggest perforation. Small
volume free fluid in the pelvis is not completely simple and
could represent purulent fluid mixed with ascites. No organized
abscess currently.
LABS:
___ 02:55AM URINE UCG-NEGATIVE
___ 02:55AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:28AM LACTATE-1.3
___ 02:10AM GLUCOSE-129* UREA N-6 CREAT-0.8 SODIUM-135
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-14
___ 02:10AM ALT(SGPT)-14 AST(SGOT)-16 ALK PHOS-39 TOT
BILI-0.9
___ 02:10AM LIPASE-11
___ 02:10AM ALBUMIN-4.5
___ 02:10AM WBC-19.0* RBC-4.32 HGB-12.4 HCT-37.1 MCV-86
MCH-28.7 MCHC-33.4 RDW-12.5 RDWSD-39.0
___ 02:10AM NEUTS-86.8* LYMPHS-6.4* MONOS-6.0 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-16.45* AbsLymp-1.22 AbsMono-1.13*
AbsEos-0.01* AbsBaso-0.02
___ 02:10AM PLT COUNT-237
___ 02:10AM ___ PTT-27.4 ___
Medications on Admission:
OCP, spironolactone 150''
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. GuaiFENesin ER 1200 mg PO Q12H
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Take with food
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
6. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with RLQ abd pain, feverNO_PO
contrast// r/o appy
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 7.0 s, 55.1 cm; CTDIvol = 26.0 mGy (Body) DLP =
1,434.1 mGy-cm.
Total DLP (Body) = 1,449 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is top-normal in size measuring 13.4 cm. No evidence of
focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix measures up to 11 mm with
mucosal hyperemia and substantial surrounding inflammatory changes as well as
small volume free fluid in the right lower quadrant; no organized abscess
(2:70; 601:26).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small volume free fluid in the pelvis measures 32 ___. No organized abscess
currently.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Acute appendicitis with substantial surrounding inflammatory changes and free
fluid which could suggest perforation. Small volume free fluid in the pelvis
is not completely simple and could represent purulent fluid mixed with
ascites. No organized abscess currently.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain, Tachycardia
Diagnosed with Unspecified acute appendicitis, Tachycardia, unspecified, Right lower quadrant pain
temperature: 100.7
heartrate: 137.0
resprate: 16.0
o2sat: 100.0
sbp: 129.0
dbp: 77.0
level of pain: 2
level of acuity: 1.0 | The patient was admitted to the Acute Care Surgery service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute appendicitis WBC
was elevated at 19.0. On POD #1, the patient underwent
laparoscopic appendectomy, which went well without complication
(reader please refer to the Operative Note for details). After a
brief, uneventful stay in the PACU, the patient arrived on the
floor on IV fluids, and acetaminophen, toradol and oxycodone for
pain control. The patient was hemodynamically stable.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
weakness, hyperkalemia, ___, hypercalcemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Metastatic jejunal NET (s/p substantial abdominal
resection for malignant bowel obstruction c/b severe short bowel
syndrome, now on octreotide, everolimus, TPN) who presented from
home with weakness, hyperkalemia, ___, hypercalcemia
As per review of notes, she was started on everolimus in
___
in light of her significant abdominal malignant burden, with
reservation as there was concern that it would not be well
absorbed given short gut, but patient preferred oral regimen to
IV chemotherapy. TPN was continued in light of short gut.
On ___ Gen Med team called regarding hyperkalemia from ___,
tried to ___ patient to ED, but couldn't contact her, so
contacted ___ (who felt that it was due to orange jucie), then
planned to re-draw. On ___, ___ called Dr ___ reported
that patient looked dehydrated due to increased ostomy output,
but wasn't aware of any re-check for K. Accordingly, Dr ___ patient to ___, where her Cr was 3.8 and K 6.1, Calcium
12. She was given IVF and had foley placed. She received
hyperkalemia protocol with glucose/insulin/albuterol.
In the ED, initial vitals: 97.8 100 117/78 14 100% RA. CBC was
normal, CHEM with HCO3 of 12, Cr 3.2, BUN 59, Trop 0.01, Lactate
2.3, VBG 7.29/24, repeat was 7.24/32, UA with few bacteria, 100
Glucose, 30 prot. EKG without peaked t waves but sinus at 99.
Patient was given 2L NS and admitted to medical ward. Stool and
urine studies sent.
Pt reports that she has taken the everolimus for the past month
without serious side effect. She noted that over the past ___
days she has felt very fatigued, has eaten less, and may have
had
slight increase in ostomy output but not significantly. She
noted
that she has urinated less in the same time frame, but it was
not
difficult to void, and she felt that she emptied her bladder
completely. She ntoed that her ostomy output is very thin/watery
at baseline. She noted that she was without fever or chills,
nausea, vomiting, rash, sick contacts. She noted that she had
slight diffuse abdominal pain radiating to the back which was up
to ___ at times. She reported that TPN was held for 2 days in
light of hyperkalemia. She reported that she enjoys drinking OJ
at home.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___:
"- ___: abdominal pain, fever, and chills. CT shows
a
mass in the small bowel. Other testing not entirely documented
(in ___
- ___: s/p resection. Path showed T4N1 well-differentiated
NET of the jejunum. Her chromogranin A was elevated to 117
prior
to resection.
- ___: Imaging showed ___, but
chromogranin
remained elevated
- ___: negative octreotide scan (NV)
- ___: CT Torso showed multiple small mesenteric lymph
nodes
(largest 14mm) and two subcentimeter nodules along the liver
capsule, concerning for recurrent metastatic disease.
- ___: chromogranin 207, serotonin 2379
- ___: Initiated octreotide 20mg IM monthly
- ___: Liver Bx showed metastatic NET, well-differentiated,
Ki67 16.6%
- ___: octreotide 20mg IM
- ___: admitted with nausea, vomiting, discovered to have
sigmoid bowel obstruction.
- ___ ex-lap, SBR, bladder repair
- ___ washout, TAC, SBR, L salpingectomy
- ___: Dotatate scan shows widespread disease in the
abdomen
- ___: octreotide 20mg IM (no dose since ___
PAST MEDICAL HISTORY:
Sarcoidosis (Dx early ___)
HTN
Thyroid nodule
SBO s/p resection (___)
Social History:
___
Family History:
Sister with colon polyps
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.0 PO ___ 18 97 RA
GENERAL: sitting in bed, appears very fatigued, pleasant
EYES: PERRLA, anicteric
HEENT: dry MM, OP clear
NECK: supple
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, no
increased
WOB, speaks in full sentences
CV: RRR no m/r/g, normal distal perfusion, no edema
ABD: SOFT, NT, ND, has midline old vertical scar, has LLQ ostomy
with thin bnrown liquid in bag, ne rebound or guarding, no
epigastric tenderness, hypoactive BS
GENITOURINARY: foley in place with clear yellow urine
EXT: warm, dry, no deformity
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
DISHCARGE PHYSICAL EXAM:
VS: 98.2, 110/60, 77, 20, 98% RA
General: pleasant woman, sitting in bed, NAD
EYES: PERRLA, anicteric
HEENT: dry MM, OP clear
NECK: supple
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, no
increased
WOB, speaks in full sentences
CV: RRR no m/r/g, normal distal perfusion, no edema
ABD: SOFT, NT, ND, has midline old vertical scar, has LLQ ostomy
with thin brown liquid in bag, no rebound or guarding, no
epigastric tenderness, +BS
EXT: warm, dry, no deformity
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
Pertinent Results:
ADMISSION LABS
==============
___ 09:35PM BLOOD WBC-7.8 RBC-3.83* Hgb-11.3 Hct-35.4
MCV-92 MCH-29.5 MCHC-31.9* RDW-13.6 RDWSD-46.0 Plt ___
___ 09:35PM BLOOD Neuts-74.1* Lymphs-13.7* Monos-11.3
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.78 AbsLymp-1.07*
AbsMono-0.88* AbsEos-0.01* AbsBaso-0.02
___ 09:35PM BLOOD Glucose-124* UreaN-59* Creat-3.2*# Na-136
K-5.0 Cl-103 HCO3-12* AnGap-21*
___ 09:35PM BLOOD ALT-58* AST-43* LD(LDH)-228 CK(CPK)-53
AlkPhos-229* TotBili-1.2
___ 09:35PM BLOOD Lipase-138*
___ 09:35PM BLOOD Calcium-10.7* Phos-5.1* Mg-2.2
UricAcd-7.9*
___ 09:43PM BLOOD ___ pO2-105 pCO2-24* pH-7.29*
calTCO2-12* Base XS--12
___ 09:43PM BLOOD Lactate-2.3*
IMPORTANT INTERVAL LABS
==========================
___ 05:00AM BLOOD %HbA1c-6.7* eAG-146*
___ 05:25AM BLOOD T4-5.5 T3-72* calcTBG-1.01 TUptake-0.99
T4Index-5.4 Free T4-0.9*
___ 05:47AM BLOOD T4-4.9 T3-74* Free T4-0.8*
___ 05:25AM BLOOD TSH-0.03*
___ 05:47AM BLOOD TSH-0.23*
___ 05:50AM BLOOD TSH-0.19*
___ 05:25AM BLOOD 25VitD-11*
___ 05:00AM BLOOD Cortsol-14.7
DISCHARGE LABS
===============
___ 05:50AM BLOOD WBC-6.3 RBC-2.43* Hgb-7.1* Hct-22.8*
MCV-94 MCH-29.2 MCHC-31.1* RDW-13.5 RDWSD-46.5* Plt ___
___ 05:50AM BLOOD Glucose-139* UreaN-21* Creat-1.0 Na-141
K-3.9 Cl-110* HCO3-21* AnGap-10
___ 05:50AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9
MICRO
======
___ 2:36 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ C diff: negative
IMAGING
========
CXR
Left-sided PICC line with the tip in the right atrium and should
be pulled
back 1-2 cm. Lungs are clear. Cardiomediastinal and hilar
silhouettes are normal. There is no pneumothorax or pleural
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Everolimus 10 mg PO Q24H
3. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety
4. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
5. Pantoprazole 40 mg PO Q24H
6. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous ONCE
RX *liraglutide [Victoza 2-Pak] 0.6 mg/0.1 mL (18 mg/3 mL) 0.___aily Disp #*1 Syringe Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6HR PRN Disp #*28
Tablet Refills:*0
3. Psyllium Wafer ___ WAF PO BID
4. Vitamin D ___ UNIT PO 1X/WEEK (TH)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth 1x week, ___ Disp #*4 Capsule Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Everolimus 10 mg PO Q24H
7. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety
8. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
9. Pantoprazole 40 mg PO Q24H
10. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
11. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until you follow up with your doctor
12.Maintenance Fluids
ICD 10: ___ Ostomy Malfunction
Rx: 1 Liter Lactate Ringers daily
___ MD: ___
Fax if needed: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Anion gap metabolic acidosis
Hyperkalemia
___ on CKD
Short gut syndrome with high ostomy output
Secondary Diagnosis
====================
Metastatic jejunal neuro endocrine tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: PICC placement?// PICC placement?
TECHNIQUE: AP portable
COMPARISON: ___
IMPRESSION:
Left-sided PICC line with the tip in the right atrium and should be pulled
back 1-2 cm. Lungs are clear. Cardiomediastinal and hilar silhouettes are
normal. There is no pneumothorax or pleural effusion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness, Transfer
Diagnosed with Hypokalemia, Acute kidney failure, unspecified, Weakness
temperature: 97.8
heartrate: 100.0
resprate: 14.0
o2sat: 100.0
sbp: 117.0
dbp: 78.0
level of pain: 5
level of acuity: 3.0 | ___ PMH of Metastatic jejunal NET (s/p mult abdominal resections
for malignant bowel obstruction now w/ end jejunostomy c/b
severe short bowel syndrome, now on depot octreotide,
everolimus, TPN and daily mIVF (1L LR)) who presented from home
with weakness, hyperkalemia, ___, hypercalcemia.
___ on CKD
#Metabolic Acidosis: Patient initially presented with ___ and
___ iso significantly increased ostomy output over past few
months and not receiving TPN at home for the past few days prior
to admission. She was volume resuscitated and ___ and metabolic
acidosis improved. Given short gut also presumed d-lactatic
acidosis contributing. Ervolimus was held during admission and
will restart at discharge.
#High Ostomy output
#Short Gut syndrome
#Nutrition: Her ostomy output remained high during admission
>2.5L a day. Infectious causes were ruled out. She was started
on loperimide, lomotil, tincture of opium, and psyllium wafers.
She was also started on q8hr octreotide. These were all
uptitrated to max doses but there was no reduction in ostomy
output. Prior authorization was sent for patient to be started
on liraglutide GLP-1 for short gut syndrome and high ostomy
output but this was not able to be started while inpatient. She
was continued on TPN while inpatient and max amount of fluid was
added to TPN to help patient keep up with ostomy output. She
will require 1L IV fluids from ___ as an outpatient while ostomy
output remains elevated. She was monitored while inpatient for
stability and Cr was stable with 1L LR a day in addition to TPN.
Her renal function was stable at it's best levels in some time
w/Cr 1.0-1.1 over 48 hours with this regimen.
#Weakness
#Secondary Hypothyroid: No focal weakness on exam, likely due to
hypovlomemia, electrolyte disarray, hypercalcemia and ___. No
infectious etiology was found. Her subjective weakness improved
with fluids. TSH was sent and was found to have low THS and free
T4 suggestive of central hypothyroid vs sick euthyroid vs
octreotide effect. Endocrine was consulted during admission and
will follow up patient as an outpatient for consideration of
starting thyroid replacement therapy.
#NIDDM Type II: New dx of DM Type II with a1c 6.7. Metformin is
contraindicated for her. Prior authorization sent for
liraglutide 0.6mg daily for added benefit of delayed gastric
emptying as above. She will start this as an outpatient.
#Hypovitaminosis D: Vitamin D was found to be low. She was
started on Vitamin D ___ UNIT PO/NG 1X/WEEK (started ___.
#Metastatic jejunal NET (s/p substantial abdominal resection for
malignant bowel obstruction c/b severe short bowel syndrome, now
on octreotide, everolimus, TPN. She was continued on TPN during
admission. She will continue daily TPN at home and daily IVF (1L
LR)
#HTN: Her amlodipine was held during admission. Patient blood
pressure was well controlled without medication so she was not
continued at discharge.
Transitional issues
=====================
#Held medications:
- Amlodipine
[] Has endocrine follow up to check on TFTs - subclinical
hypothyroid vs octreotide effect
[] Vitamin D found to be low, started on 50,000 repletion, dose
given ___. Continue per discretion of PCP
[] Patient will receive 1L LR a day with ___, please assess
ostomy output and if decreasing would consider switching to
every other day fluids or discontinuing if able
[] Monitor Cr as an outpatient, give fluids if Cr increasing or
refer to same day NP visit
[] Prior authorization for liraglutide sent while in hospital.
[] If ostomy output still high, on liraglutide would consider
stopping and starting Teduglutide (Gattex) for high ostomy
output
[] monitor BP if elevated would restart amlodipine
#HCP/Contact: son ___ who is her HCP ___
#Code: Full Confirmed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ventricular Tachycardia
Major Surgical or Invasive Procedure:
Subcutaneous ICD Placement ___
History of Present Illness:
Ms. ___ is a ___ w/ history of murmur ___ LV septal defect
per patient and post-concussive syndrome s/p MVA in ___, who
was in her USOH when she presented to ___ after presyncopal
episode and noted to have wide-complex tachycardia.
On ___, patient was running her usual 2 miles at normal
exertion when she began to feel lightheaded and palpitations.
Putting her head between her knees alleviated the
lightheadedness somewhat, but she remained lightheaded and
dyspneic, with back pain and lower chest/abdominal pain. She
returned to her apartment and lied down on the floor due to
lightheadedness. When standing, she felt very lightheaded and
pre-syncopal She then had 1 episode of nonbloody diarrhea
accompanied by nausea, vomiting, and abdominal pain. She also
noted difficulty hearing and some slurred speech. Her symptoms
persisted, so she presented to CHA.
On presentation to CHA, patient was noted to be in a wide
complex tachycardia. She was given 2mg of Mg IV push without
termination of arrhythmia. She was then sedated with 2mg of
Versed and shocked with 150J using biphasic external
defibrillator. She had prompt return of NSR with improvement in
vitals and symptoms. She was noted to have persistent T wave
inversions in the inferior leads. She also received 150 mg of
amiodarone, 2 L of fluid, and placed on an amiodarone drip
before being transported to ___.
In the ___ ED, she is stable and asymptomatic. She continues
on amiodarone gtt and has been given Tylenol and calcium.
She has a history of presyncopal episodes related to medical
procedures (nevus removal and sutures to finger) and anxiety
(accompanied by tunnel vision). She also had a 20-minute episode
of lightheadedness last week while running.
In the ED initial vitals were: Tmax 97.9 HR 88 BP 120/85 RR 14
SpO2 sat 100
Labs/studies notable for: WBC 19.7 Plt 144 Trop (peak at 1.9 at
CHA) 0.49 then 0.47; electrolytes wnl
CXR: No acute cardiopulmonary process
Patient was given: amiodarone gtt, then stopped after EP was
consulted
Vitals on transfer: Tmax 98.4 HR 84 BP 155/80 RR 19 O2sat 97RA
On the floor, patient is resting comfortably with normal sinus
rhythm on telemetry.
Past Medical History:
1. CARDIAC RISK FACTORS
- none
2. CARDIAC HISTORY
- per patient, possible LV septal defect and childhood murmurs
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- migraines
- asthma
- post-concussive syndrome in ___ following MVA
- Anxiety attacks
- Right foot injury
- Dysplastic nevi
Social History:
___
Family History:
Paternal grandfather with hx. of PPM and LBBB. Maternal uncle
died of sudden cardiac death at ___ years of age. No other
history of sudden death, coronary artery disease, CHF,
arrhythmia. Mom with migraines. Family history of Alzheimer's
disease and non-melanomatous skin cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
============================
VS: Afebrile 114/76 83 18 100% RA
GENERAL: 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: JVP at 12cm at 45 degrees
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/gallops/rubs. 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
===========================
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK: JVP not elevated, supple
CARDIAC: RRR no m/r/g. ICD insertion site TTP, slightly warm, no
erythema or edema, c/d/i
LUNGS: CTAB, nonlabored breathing
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact. ___ strength and sensation intact in
all extremities. negative pronator drift. no CBL signs
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION/PERTINENT LABS
==========================
___ 04:55AM BLOOD WBC-19.7*# RBC-4.08 Hgb-12.5 Hct-37.3
MCV-91 MCH-30.6 MCHC-33.5 RDW-12.8 RDWSD-41.9 Plt ___
___ 04:55AM BLOOD Neuts-79.0* Lymphs-14.2* Monos-5.9
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.52* AbsLymp-2.80
AbsMono-1.15* AbsEos-0.00* AbsBaso-0.04
___ 04:55AM BLOOD ___ PTT-31.3 ___
___ 04:55AM BLOOD Glucose-88 UreaN-18 Creat-0.8 Na-134
K-6.1* Cl-104 HCO3-17* AnGap-19
___ 04:55AM BLOOD cTropnT-0.49*
___ 10:51AM BLOOD cTropnT-0.47*
___ 09:15PM BLOOD CK-MB-3 cTropnT-0.41*
___ 04:55AM BLOOD Calcium-7.5* Phos-3.8 Mg-2.2
DISCHARGE LABS
===================
___ 06:49AM BLOOD WBC-21.8*# RBC-4.40 Hgb-13.6 Hct-40.3
MCV-92 MCH-30.9 MCHC-33.7 RDW-12.6 RDWSD-41.9 Plt ___
___ 06:49AM BLOOD Glucose-94 UreaN-13 Creat-0.6 Na-136
K-4.0 Cl-100 HCO3-20* AnGap-20
___ 03:25AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:49AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
EKG: NSR, right axis, normal intervals, inverted T waves in
inferior leads and in V1, V2.
CXR: No acute cardiopulmonary process.
2D-ECHOCARDIOGRAM
___ The left atrial volume index is normal. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size is normal
with moderate global free wall hypokinesis. Tricuspid annular
plane systolic excursion is depressed (1.4 cm) consistent with
right ventricular systolic dysfunction. 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. There is mild-moderate
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal right ventricular cavity size with moderate
free wall hypokinesis. Mild-moderate trisucpid regurgitation.
Normal biventricular cavity sizes with preserved regional and
global left ventricular systolic function. Mild mitral
regurgitation.
Is there a history to suggest ARVC, RV contusion, or RV
ischemia?
CARDIAC MRI ___
IMPRESSION: Normal rigth venticular cavity size with mild global
free wall hypokinesis and dyskinetic distal basal segment and
mildly
depressed ejection fraction. Fatty replacement of the distal
right ventricularfree wall. Normal left ventricular mass, cavity
size and regional/global systolic function. Moderate mid wall
late gadolinium enhancementin the left ventricular basal septum,
mid inferoseptum, mid
inferior, and apical lateral walls. These findings are
consistent with ARVC/non-ischemic cardiomyopathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrOXYzine 10 mg PO PRN Anxiety
2. Spironolactone 25 mg PO DAILY cystic acne
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID asthma
4. Fexofenadine 60 mg PO QHS
5. Montelukast 10 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB
7. Fluticasone Propionate NASAL 1 SPRY NU PRN congestion
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours Disp #*21 Tablet Refills:*0
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*6 Capsule Refills:*0
3. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*21 Tablet Refills:*0
4. LORazepam 0.5 mg PO DAILY:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet(s) by mouth once per day Disp #*4
Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours Disp #*7
Tablet Refills:*0
6. Sotalol 80 mg PO BID
RX *sotalol 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB
8. Fexofenadine 60 mg PO QHS
9. Fluticasone Propionate NASAL 1 SPRY NU PRN congestion
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID asthma
11. HydrOXYzine 10 mg PO PRN Anxiety
12. Montelukast 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
Ventricular Tachycardia
SECONDARY DIAGNOSIS
===================
Anxiety
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with ventricular arrhythmia// cardiomegally
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and well-aerated lungs without focal consolidation, pleural
effusion, or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: Cardiac MRI:
INDICATION: ___ year old woman with asthma p/w VT while running s/p
defibrillation. Evidence of RV hypokinesis on echo// eval for scar, ARVC, any
other septal abnormalities
TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology.
COMPARISON: None available.
IMPRESSION:
Please note that this report only pertains to extracardiac findings.
There is a trace right-sided pleural effusion. There are no other
extracardiac findings.
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with new Sub Q ICD// Assess SubQ ICD device and
lead position- please make sure to get the Battery in both views Assess
SubQ ICD device and lead position- please make sure to get the Battery in both
views
IMPRESSION:
The patient has received a subcutaneous ICD device. As requested, the battery
is visualized on both the frontal and the lateral view. Both views document
the subcutaneous position of the lead. There is no evidence of pneumothorax.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Tachycardia, Transfer
Diagnosed with Supraventricular tachycardia
temperature: 97.9
heartrate: 88.0
resprate: 14.0
o2sat: 100.0
sbp: 120.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old female with PMHx asthma, anxiety who
presented at OSH for presyncope found to have VT s/p
cardioversion transferred here for further workup. An EKG
revealed right axis deviation with T wave inversions in V1-V2.
Echocardiogram with normal EF, but evidence of moderate RV
hypokinesis. Cardiac MRI revealed fatty infiltration of the RV
wall w/ mild global hypokinesis, as well as late gadolinium
enhancement of the LV mid-wall. These findings were all
consistent with diagnosis of ARVC. Given global involvement,
ablation was not an option. Instead, patient was started on
sotalol 80mg BID, and a subcutaneous ICD was placed. Patient
started on IV vanc after procedure, then transitioned to Keflex
at discharge to complete 3 day antibiotic prophylactic course.
Otherwise patient received home hydroxyzine 10mg for anxiety and
home inhalers, montelukast for asthma. Of note, patient and
family understandably very anxious about this diagnosis.
TRANSITIONAL ISSUES
=====================
[ ] f/u with Dr. ___ on ___
[ ] med changes: new med sotalol 80mg BID
[ ] last day Keflex ___
[ ] f/u CBC at next appointment - WBC 21.8 on day of d/c, likely
stress rxn to ICD placement procedure, but ensure it has come
back down
# CODE: full
# CONTACT: ___ (___) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain with nausea
Major Surgical or Invasive Procedure:
Lap band removal with patch and washout
History of Present Illness:
___ is a ___ year old woman who is status post a
10-cm Allergan band, which was placed on ___. She
presents with just over 24 hours of severe left lower quadrant
pain. It came on suddenly and was not associated with food. She
did have some nausea but no vomiting. She also had a fever to
103
at home. She is having regular bowel movements. She does
remember
three weeks ago having a GI viral illness.
Past Medical History:
ASTHMA
DEPRESSION
DIABETES TYPE II
FATTY LIVER
HEARTBURN
HYPERCHOLESTEROLEMIA
Social History:
___
Family History:
non-contributory
Physical Exam:
+ Febrile in ED now resolved. HR 108 --> 85 AVSST
There is no pallor, no edema, no cyanosis,
no icterus, no lymphadenopathy. Respiratory: Bilateral air
entry is positive, lungs are clear. Cardiovascular: S1 and S2
normal. Abdomen is soft, non-distneded. Port site non-tender
and
unremarkable. ++ tenderness left lower quadrant. Incisions well
healed. No erythema, no drainage, no hernias identified.
Extremities are normal.
Pertinent Results:
___ 10:45PM BLOOD WBC-14.5*# RBC-4.74 Hgb-10.5* Hct-33.4*
MCV-71* MCH-22.2* MCHC-31.5 RDW-15.8* Plt ___
___ 08:18AM BLOOD WBC-6.2 RBC-3.96* Hgb-8.7* Hct-28.3*
MCV-72* MCH-22.0* MCHC-30.7* RDW-15.7* Plt ___
___ 10:45PM BLOOD Glucose-134* UreaN-13 Creat-0.9 Na-134
K-4.1 Cl-98 HCO3-22 AnGap-18
___ 06:51AM BLOOD Glucose-101* UreaN-6 Creat-0.7 Na-138
K-4.0 Cl-106 HCO3-27 AnGap-9
BAS/UGI AIR/SBFT FINDINGS: Initial fluoroscopic scout image
reveales a surgical drain terminating in the left upper
quadrant. Multiple fluoroscopic images were obtained while the
patient ingested water-soluble contrast and thin barium in both
upright and supine positions revealing free passage of contrast
from the esophagus into the stomach and small bowel. There is
no evidence of extraluminal contrast to suggest leak. There is
no evidence of narrowing or stricture.
IMPRESSION: No evidence of stricture or leak.
Radiology Report
INDICATION: Band erosion status post band removal. Rule out leak.
COMPARISON: Upper GI ___. CT abdomen and pelvis ___.
FINDINGS: Initial fluoroscopic scout image reveales a surgical drain
terminating in the left upper quadrant. Multiple fluoroscopic images were
obtained while the patient ingested water-soluble contrast and thin barium in
both upright and supine positions revealing free passage of contrast from the
esophagus into the stomach and small bowel. There is no evidence of
extraluminal contrast to suggest leak. There is no evidence of narrowing or
stricture.
IMPRESSION: No evidence of stricture or leak.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LLQ PAIN
Diagnosed with INFECTION DUE TO GASTRIC BAND PROCEDURE, ABN REACT-SURG PROC NEC, DIABETES UNCOMPL ADULT
temperature: 100.6
heartrate: 108.0
resprate: 16.0
o2sat: 97.0
sbp: 101.0
dbp: 52.0
level of pain: 8
level of acuity: 3.0 | Patient came to the hospital with abdominal pain, nausea, fever
and chills. CT scan suggested that the gastric band had eroded
through the surrounding gastric mucosa, which was likely the
cause of the symptoms patient was having. Patient underwent a
gastric band removal operation, patching, and washout of the
abdominal cavity as determined by Dr. ___ as the way to treat
the symptoms. The patient's symptoms gradually resolved post
operatively and you lab markers improved. Patient demonstrated
that they could tolerate a stage III bariatric diet and it was
determined they met criteria for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
purulent drainage from foley
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o obstructive uropathy (presumably from BPH) and ureteral
stricture with chronic indwelling foley hospitalized
___ for E. coli urosepsis c/b anterior abd wall abscess
with probable fistulous connection to the bladder s/p bilateral
perc neph tubes and 2 week course of meropenem presenting with
report of purulent drainage from foley and urethra since this
morning, no decrease in UOP. Patient A&Ox2 at baseline so
limited history but he denies any f/c, abdominal back or flank
pain, no n/v.
In the ED intial vitals were: 98.8 90 111/67 20 95%. UA grossly
positive. Na 126.
Patient was given vancomycin, zosyn.
On the floor, patient poor historian and only intermittantly
cooperative with questioning with phone interpreter. No active
complaints.
Review of Systems:
(+)
(-) fever, chills, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
dysuria, hematuria.
Past Medical History:
H/O C. diff infection, treated wtih PO flagyl through ___
H/O urosepsis secondary to enterobacter cloaceae, treated with
H/o pyocystitis requiring b/l nephrostomy tubes
IV cefepime through ___
Hypertension
Hyperlipidemia
Depression
TII DM, last A1C 6.1% on ___
Hypothyroidism
Peripheral neuropathy
Dyspepsia
BPH
Perpheral vascular disease
Left foot ulcer wtih dry gangrene
H/O R BKA ___ progressive peripheral vascular disease on ___
H/O left transmetatarsal amputation in ___ in ___
H/O right hip fracture in ___
Social History:
___
___ History:
Diabetes.
Physical Exam:
Physical Exam on Presentation:
Vitals- 98.0, 150/80, 80, 18, 100%/RA
General- Alert, oriented to person and date, only intermittantly
cooperative with exam even with aid of phone interpreter
HEENT- Sclera anicteric
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation anteriorly
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- foley in place. also with bilateral nephrostomy tubes which
are capped and not draining
Ext- right BKA. left foot with unstagable ulcer of heel, lateral
heel, lateral ankle. 8.5x4.5cm ulceration of dorsal left foot
with surrounding erythema and fibrous drainage
Neuro- CNs2-12 intact, motor function grossly normal
Physical Exam on Discharge:
T98.1, BP120/60, HR66, RR16, O2sat:100%RA
exam otherwise unchanged from admission
Pertinent Results:
========================================
Lab Results on Presentation:
========================================
___ 04:15PM BLOOD WBC-10.4 RBC-3.39* Hgb-9.4* Hct-28.9*
MCV-85 MCH-27.6 MCHC-32.4 RDW-14.7 Plt ___
___ 04:15PM BLOOD Neuts-67.8 ___ Monos-4.7 Eos-2.7
Baso-0.3
___ 04:15PM BLOOD ___ PTT-37.1* ___
___ 04:15PM BLOOD Glucose-175* UreaN-29* Creat-0.8 Na-126*
K-4.7 Cl-90* HCO3-22 AnGap-19
___ 04:15PM BLOOD ALT-22 AST-20 AlkPhos-75 TotBili-0.1
___ 04:15PM BLOOD Albumin-3.5
___ 08:00AM BLOOD Calcium-9.6 Phos-4.2# Mg-1.8
___ 04:25PM BLOOD Lactate-1.4
___ 05:35PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 05:35PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:35PM URINE RBC-45* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 05:35PM URINE WBC Clm-MANY
========================================
Imaging:
========================================
Radiology ReportCT CYSTOGRAM (PEL) W/CONTRASTStudy Date of
___ 10:30 AM
IMPRESSION:
1. Moderately good distention of the urinary bladder was
achieved before there
was significant leakage of contrast around the Foley catheter
via a patulous
urethra.
2. There is no evidence of extraluminal contrast or contrast
filling within a
fistulous tract. The prior fluid collection in the anterior
abdomen is
resolved although there is mild thickening of the rectus
abdominis muscle
anterior to the bladder, and slight residual subcutaneous
stranding.
3. Vasculopathy.
Radiology Report ART EXT (REST ONLY) Study Date of ___
1:51 ___
final read pending on discharge
Radiology Report VENOUS DUP EXT UNI (MAP/DVT) LEFT Study Date of
___ 1:52 ___
final read pending on discharge
==========================================
Microbiology:
==========================================
___ BC: NGTD
___ 5:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 4:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:48 am BLOOD CULTURE
Blood Culture, Routine (Pending):
===================================
ECG's
===================================
Cardiovascular Report ECG Study Date of ___ 4:28:26 ___
Sinus rhythm. Borderline short P-R interval. Compared to the
previous tracing of ___ the rate has slowed. There is
variation in precordial lead placement and improvement in the
ST-T wave changes. There is increased limb lead voltage.
Otherwise, no diagnostic interim change.
Cardiovascular Report ECG Study Date of ___ 3:06:46 ___
Sinus or ectopic atrial rhythm. Since the previous tracing the
rate is faster. Precordial R waves are less prominent. Clinical
correlation is suggested.
Cardiovascular Report ECG Study Date of ___ 9:54:04 AM
Sinus rhythm. Short P-R interval. Lateral limb lead T wave
flattening. Since the previous tracing of ___ there is
probably no significant change.
Cardiovascular Report ECG Study Date of ___ 2:22:30 AM
Sinus rhythm. Since the previous tracing the rate is slower.
Lateral
precordial R waves have increased in voltage.
====================================
Lab results at Discharge:
====================================
___ 06:45AM BLOOD WBC-7.9 RBC-2.69* Hgb-7.4* Hct-23.9*
MCV-89 MCH-27.4 MCHC-30.8* RDW-15.1 Plt ___
___ 06:45AM BLOOD Glucose-106* UreaN-24* Creat-0.7 Na-135
K-4.1 Cl-107 HCO3-25 AnGap-7*
___ 06:45AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.6
___ 01:26PM BLOOD ___ pO2-166* pCO2-38 pH-7.41
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 08:10PM BLOOD %HbA1c-7.0* eAG-154*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl ___X/WEEK (MO,WE,SA)
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Escitalopram Oxalate 5 mg PO DAILY
4. Milk of Magnesia 30 mL PO DAILY:PRN constipation
5. Acetaminophen 500 mg PO Q6H:PRN pain
6. Aspirin 81 mg PO DAILY
7. Calcitriol 0.25 mcg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Senna 2 TAB PO DAILY
10. Atorvastatin 20 mg PO DAILY
11. Ranitidine 150 mg PO BID
12. Docusate Sodium 100 mg PO BID
13. Lactulose 30 mL PO BID
14. Fish Oil (Omega 3) 1000 mg PO BID
15. Gabapentin 300 mg PO HS
16. Mirtazapine 30 mg PO HS
17. Tamsulosin 0.4 mg PO HS
18. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Bisacodyl ___X/WEEK (MO,WE,SA)
5. Calcitriol 0.25 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Escitalopram Oxalate 5 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Gabapentin 300 mg PO HS
10. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Mirtazapine 30 mg PO HS
14. Ranitidine 150 mg PO BID
15. Senna 2 TAB PO DAILY
16. Tamsulosin 0.4 mg PO HS
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Lactulose 30 mL PO BID
19. Milk of Magnesia 30 mL PO DAILY:PRN constipation
20. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days
last day of therapy: ___. Avoid direct sun exposure while
taking.
21. Outpatient Lab Work
please draw a Chem-10 on ___ and bring results to the
attention of the on-call physician.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: MRSA UTI
Secondary: Peripheral Vascular Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Recent urosepsis complicated by abdominal wall abscess,
presenting with recurrent frank pyuria, self-resolving. Evaluate for reason
for pyuria, fistulous connection to the abdominal wall?
COMPARISON: CT cystogram ___. CT abdomen and pelvis ___ and
___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the pelvis
before and after infusion of water-soluble contrast into the bladder via Foley
catheter. Approximately 200 mL was instilled before there was a significant
leakage out of the urethra around the Foley catheter. Multiplanar axial,
coronal, and sagittal images were generated.
TOTAL BODY DLP: 704 mGy-cm.
FINDINGS:
CT CYSTOGRAM: The bladder contains a Foley catheter with inflated balloon and
is moderately well distended with water-soluble contrast. There are a few
locules of anti-dependent gas in the bladder lumen. No extraluminal contrast
is detected. No fistulous tract is seen. The previous abdominal wall fluid
collection is resolved, however, there is mild thickening of the rectus
abdominis muscle and slight subcutaneous fat stranding in this region. Of note
the urethra is quite patulous.
The rectum is distended with fecal material. Visualized loops of small and
large bowel are unremarkable without evidence of wall thickening or
obstruction. There is no ascites, ectopic air or abdominal wall hernia
detected. There is no pelvic lymphadenopathy.
The inferior poles of the kidneys are included. Bilateral nephrostomy tubes
are partially visualized with trajectory towards the renal pelvises, however,
the pigtails are not included. Mild peripelvic stranding is similar to prior
studies. The abdominal vasculature is heavily calcified.
OSSEOUS STRUCTURES: Patient is status post ORIF of the right hip. There are
no concerning blastic or lytic lesions detected.
IMPRESSION:
1. Moderately good distention of the urinary bladder was achieved before there
was significant leakage of contrast around the Foley catheter via a patulous
urethra.
2. There is no evidence of extraluminal contrast or contrast filling within a
fistulous tract. The prior fluid collection in the anterior abdomen is
resolved although there is mild thickening of the rectus abdominis muscle
anterior to the bladder, and slight residual subcutaneous stranding.
3. Vasculopathy.
Radiology Report
MEDICAL HISTORY: ___ man with a history of diabetes, hypertension and
hyperlipidemia who previously underwent right below-the-knee amputation. He
presents with non-healing left foot ulcers. Please evaluate arterial status.
TECHNIQUE: Arterial Doppler and pulse volume recordings were obtained of the
left lower extremity.
FINDINGS: The Doppler waveforms at the femoral level were triphasic; however,
they became monophasic at the distal superficial femoral artery. The
popliteal and tibial vessels demonstrated monophasic Doppler waveforms. The
ankle-brachial index is 0.48. Pulse volume recordings were normally phasic at
the low thigh, but there was diminished phasicity at the calf and ankle and a
non-phasic waveform at the metatarsal level.
IMPRESSION: Normal triphasic waveforms at the left femoral artery with
monophasic waveforms below this level. Monophasic metatarsal waveform with
diminished ankle-brachial index to suggest significant ischemia.
Radiology Report
HISTORY: ___ man with diabetes, hypertension, and hyperlipidemia who
previously underwent a right below-knee amputation. He now presents with
non-healing left foot ulcers. Evaluate left lower extremity veins for
possible bypass.
TECHNIQUE: The left greater saphenous vein was visualized using ultrasound
from its origin at the fossa ovalis down to the ankle level.
FINDINGS: The vein was patent with diameters measuring from 3.3 mm proximally
to 2.2 mm distally. There was no thrombus or evidence of reflux.
IMPRESSION: Patent left greater saphenous vein with diameters as noted.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Urinary retention
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.8
heartrate: 90.0
resprate: 20.0
o2sat: 95.0
sbp: 111.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | PRIMARY REASON FOR HOSPITALIZATION: Mr. ___ is a ___ male
with PMH of HTN, T2DM, dyslipidemia and obstructive uropathy who
recently was discharged from the hospital following an admission
for urosepsis requiring bilaterl nephrostomy tubes given bladder
outlet obstruction from pyuria who presents from ECF with
recurrence of pyuria. He was found to have MRSA Bacteruria and
was started on Bactrim, which treats according to sensitivities.
He developed hyperkalemia and was switched to doxycicline, which
is also effective according to sensitivities. He was seen by
vascular surgery for non-healing ulcers as well, and will follow
up with them in clinic.
ACUTE CARE:
# MRSA BACTERURIA: Patient with complicated past urological
history, and presented with purulent drainage from foley. He was
not febrile, normal WBC, lactate normal. Given vanc/zosyn in ED,
cefepime overnight, and started on meropenem for risk for
resistant organisms. Stopped abx because appeared colonized, not
infected, but then grew >100,000CFU MRSA/ml. Also with history
of abscess with fistula to bladder, although this had resolved
on CT cystogram ___. Started on Bactrim DS BID to treat
MRSA UTI. He developed hyperkalemia, attributed to bactrim, and
was switched to doxycycline. He has sources for seeding the
urinary tract via nephrostomy tube and foley, and BC negative.
Urology was consulted and agreed to followup as outpatient while
continuing doxycycline.
#Hyperkalemia: In the course of Mr. ___ hospitalization,
he developed hyperkalemia with ECG changes while on Bactrim. He
was treated with standard acute hyperkalemia therapy, and was
switched to doxycycline.
# Hyponatremia: likely in setting of mild volume depletion.
Improved with volume repletion.
# Ulceration of left foot: patient with history of severe PVD,
s/p right BKA, with multiple unstagable ulcerations of left
foot, large ulcer with purulent drainage. No palpable pulses.
THe wounds are not healing well, but lack signs of infection.
Vascular was consulted. Non-invasive ultrasounds of the left leg
were done and pending on discharge. He will followup with
vascular surgery as an outpatient for evaluation of surgical
intervention. Continued ASA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending: ___
Chief Complaint:
Fatigue, Confusion, Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This patient is a ___ M with hx of early onset Alzheimers,
cerebral amyloid angiopathy and brain bleed ___ years ago who came
to the ED with several days of worsening confusion and dyspnea.
His wife mentioned that his speech became garbled and
nonsensical (although he is confused at baseline, he usually is
able to string sentences together). She also noticed that he
would have periods of increasing work of breathing, inhaling and
exhaling deeply. He was brought to the ED, where his initial
vitals were stable, but repeat vitals revealed a temp of 101.
Notable labs included D-Dimer ___, UA with 21 WBCs, head CT
which showed stable encephalomalacia, and CTA which showed no
evidence of PE. LP attempted but not successful. He was treated
empirically for UTI and meningitis with IV cipro, acyclovir,
ceftriaxone, vancomycin, and Tylenol and transferred to the
floor.
Past Medical History:
- Alzheimers - early onset
- Cerebral Amyloid Angiopathy
- ICH
- OSA on home CPAP
- S/p rod placement in R hip
- Inguinal Hernia Repair ___
Social History:
___
Family History:
Father deceased with a history of MI. Mother deceased with hx of
lipoma. There is no family history of brain tumors or other
known malignancies.
Physical Exam:
ADMISSION:
Vitals: 98.2 | ___ | 78 | 18 | 98
General: alert, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, negative
Kernig/Brudzinski
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, left leg slightly bigger compared to right, although no
erythema or pain to palpation
Neuro: A+Ox1-2 (self, unable to say date, chose hospital on
multiple choice), moderate inattention, CNs2-12 grossly intact,
___ strength bilaterally in all limbs
DISCHARGE:
Vitals: 97.8 | 133/77 | 69 | 18 | 100RA
General: alert, 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, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left leg continues to be slightly bigger compared to
right, although no erythema or pain to palpation
Neuro: A+Ox3 (stable from yesterday), slight inattention,
CNs2-12 grossly intact.
Pertinent Results:
CBC
====
___ 04:45AM BLOOD WBC-5.8 RBC-3.54* Hgb-10.8* Hct-33.5*
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.0 RDWSD-45.0 Plt ___
___ 04:55AM BLOOD WBC-10.8* RBC-3.48* Hgb-10.7* Hct-33.5*
MCV-96 MCH-30.7 MCHC-31.9* RDW-13.2 RDWSD-46.6* Plt ___
___ 10:00AM BLOOD WBC-12.2* RBC-3.75* Hgb-11.5* Hct-36.6*
MCV-98 MCH-30.7 MCHC-31.4* RDW-13.2 RDWSD-47.2* Plt ___
___ 09:40PM BLOOD WBC-12.7*# RBC-3.82* Hgb-11.8* Hct-36.7*
MCV-96 MCH-30.9 MCHC-32.2 RDW-13.2 RDWSD-46.2 Plt ___
DIFF
====
___ 04:45AM BLOOD Neuts-72* Bands-0 ___ Monos-6 Eos-2
Baso-0 ___ Myelos-0 AbsNeut-4.18 AbsLymp-1.16*
AbsMono-0.35 AbsEos-0.12 AbsBaso-0.00*
___ 04:55AM BLOOD Neuts-77* Bands-0 Lymphs-6* Monos-11
Eos-1 Baso-0 Atyps-5* ___ Myelos-0 AbsNeut-8.32*
AbsLymp-1.19* AbsMono-1.19* AbsEos-0.11 AbsBaso-0.00*
___ 10:00AM BLOOD Neuts-71 Bands-7* Lymphs-16* Monos-6
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-9.52* AbsLymp-1.95
AbsMono-0.73 AbsEos-0.00* AbsBaso-0.00*
___ 09:40PM BLOOD Neuts-77* Bands-5 Lymphs-10* Monos-7
Eos-0 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-10.41*
AbsLymp-1.40 AbsMono-0.89* AbsEos-0.00* AbsBaso-0.00*
COAGS
======
___ 04:45AM BLOOD ___ PTT-35.0 ___
___ 04:00PM BLOOD ___ PTT-28.7 ___
___ 09:40PM BLOOD ___ PTT-27.6 ___
BMP
====
___ 04:45AM BLOOD Glucose-112* UreaN-21* Creat-0.9 Na-141
K-3.8 Cl-106 HCO3-24 AnGap-15
___ 04:55AM BLOOD Glucose-137* UreaN-20 Creat-0.9 Na-139
K-3.7 Cl-105 HCO3-25 AnGap-13
___ 10:00AM BLOOD Glucose-118* UreaN-20 Creat-1.0 Na-136
K-3.6 Cl-100 HCO3-23 AnGap-17
___ 09:40PM BLOOD Glucose-138* UreaN-22* Creat-1.1 Na-137
K-3.8 Cl-101 HCO3-24 AnGap-16
LFTs
====
___ 04:45AM BLOOD ALT-64* AST-24 AlkPhos-104 TotBili-0.7
___ 04:55AM BLOOD ALT-81* AST-27 AlkPhos-107 TotBili-1.2
___ 10:00AM BLOOD ALT-129* AST-72* LD(LDH)-252* AlkPhos-104
Amylase-22 TotBili-2.5* DirBili-0.6* IndBili-1.9
___ 10:00AM BLOOD Lipase-21
IRON STUDIES
============
___ 04:45AM BLOOD calTIBC-213* Ferritn-690* TRF-164*
B12
====
___ 10:00AM BLOOD VitB12-515
HAPTOGLOBIN
============
Hapto-337*
D-DIMER
========
___ 09:48PM BLOOD D-Dimer-___*
THYROID
========
___ 10:00AM BLOOD TSH-4.9*
___ 04:55AM BLOOD T4-5.1
HEPATITIS
========
___ 10:00AM BLOOD HBsAg-Negative HBsAb-PND HBcAb-Negative
___ 10:00AM BLOOD HCV Ab-Negative
URINE
=====
___ 10:15PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 10:15PM URINE RBC-3* WBC-12* Bacteri-FEW Yeast-NONE
Epi-0
CT HEAD- ___
============
IMPRESSION:
1. No acute intracranial hemorrhage identified. Unchanged
encephalomalacia in
the left frontal lobe compared to the most recent prior exam
from ___.
2. Chronic small vessel ischemic disease, progressed from the
prior CT from
___.
CT PE- ___
==========
IMPRESSION:
Evaluation is mildly limited by respiratory motion. No evidence
of pulmonary
embolism or acute aortic abnormality.
___- ___
========
FINDINGS:
Non-occlusive thrombus is seen in the left common femoral vein
extending into
the proximal greater saphenous. There is no flow or
compressibility in the
superficial femoral and popliteal arteries suggestive of
occlusive thrombus.
The posterior tibial and peroneal veins appear patent. The
iliac left vein is
not well visualized.
There is normal compressibility, flow, and augmentation of the
right common
femoral, femoral, and popliteal veins. Normal color flow and
compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Occlusive and non-occlusive deep vein thrombus in the left
lower extremity
veins.
RUQ US- ___
===========
IMPRESSION:
1. The hepatic parenchyma appears within normal limits. No
focal liver
lesions.
2. No intra- or extrahepatic biliary duct dilation.
3. Cholelithiasis.
MICRO
======
__________________________________________________________
___ 6:53 am Blood (Toxo) CHEM 63490M ___.
**FINAL REPORT ___
TOXOPLASMA IgG ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
__________________________________________________________
___ 6:53 am Blood (EBV) CHEM 63490M ___.
___ VIRUS VCA-IgG AB (Pending):
___ VIRUS EBNA IgG AB (Pending):
___ VIRUS VCA-IgM AB (Pending):
__________________________________________________________
___ 6:53 am Blood (CMV AB) ___ 63490M ___.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
54 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
If current infection is suspected, submit follow-up serum
in ___
weeks.
__________________________________________________________
___ 6:53 am SEROLOGY/BLOOD CHEM ___ ___.
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
__________________________________________________________
___ 4:55 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:06 am BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:00 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 10:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 11:51 pm
URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Memantine 10 mg PO BID
2. Doxepin HCl 50 mg PO HS
3. Donepezil 10 mg PO QHS
4. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Donepezil 10 mg PO QHS
3. Doxepin HCl 50 mg PO HS
4. Memantine 10 mg PO BID
5. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth AS DIRECTED Disp #*1 Dose Pack Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Complicated urinary tract infection
- Left femoral vein deep venous thrombosis
Secondary Diagnoses:
- Isolated ALT elevation
- Alzheimer's type dementia
- Cerebral Amyloid Angiopathy
- Spinal Stenosis
- Inguinal Hernia Repair ___
- OSA on home CPAP
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with elevated D-dimer // evaluate for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP =
7.6 mGy-cm.
2) Spiral Acquisition 3.4 s, 26.4 cm; CTDIvol = 14.0 mGy (Body) DLP = 369.0
mGy-cm.
Total DLP (Body) = 377 mGy-cm.
COMPARISON: CT torso ___
FINDINGS:
Evaluation is mildly limited by respiratory motion.
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: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild dependent atelectasis bilaterally. Lungs are
otherwise clear without masses or areas of parenchymal opacification. The
airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
Evaluation is mildly limited by respiratory motion. No evidence of pulmonary
embolism or acute aortic abnormality.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with hx of Alzheimers and CAA presenting with
confusion and dyspnea, with elevated D-dimer (>7000) // ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Non-occlusive thrombus is seen in the left common femoral vein extending into
the proximal greater saphenous. There is no flow or compressibility in the
superficial femoral and popliteal arteries suggestive of occlusive thrombus.
The posterior tibial and peroneal veins appear patent. The iliac left vein is
not well visualized.
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Occlusive and non-occlusive deep vein thrombus in the left lower extremity
veins.
NOTIFICATION: The findings were discussed with Dr ___. by
___, M.D. on the telephone on ___ at 2:38 ___, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with AMS and new transaminasemia. // Rule out
biliary pathology. Assess liver echogenicity, portal venous flow and spleen
size.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT from ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 10.9 cm. An incidental note is made of
a 1.4 cm accessory spleen.
KIDNEYS: The right kidney measures 11.4 cm. The 6 mm cyst is noted in the
interpolar to lower pole region. The left kidney measures 11.6 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. The hepatic parenchyma appears within normal limits. No focal liver
lesions.
2. No intra- or extrahepatic biliary duct dilation.
3. Cholelithiasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with h/o cerebral amyloid angiopathy presented
with confusion which was improving today with initiation of abx for UTI. Also
started on lovenox for DVT today, now with worsening confusion and conductive
aphasia // Evidence of acute intracranial 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, 16.6 cm; CTDIvol = 48.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
Hypodensity in the left frontal lobe with associated ex vacuo dilation of the
left lateral ventricle remains stable. There is no new hemorrhage. There is
no evidence of acute infarction, edema, or mass. There is prominence of the
ventricles and sulci suggestive of involutional changes. Periventricular and
subcortical white matter hypodensities are likely the sequela of chronic small
vessel ischemic disease.
There is no evidence of fracture. There is mild mucosal thickening of the
ethmoidal air cells. 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.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Stable left frontal lobe encephalomalacia.
Gender: M
Race: PATIENT DECLINED TO ANSWER
Arrive by WALK IN
Chief complaint: Dyspnea, Confusion
Diagnosed with Altered mental status, unspecified, Dyspnea, unspecified
temperature: 99.0
heartrate: 99.0
resprate: 16.0
o2sat: 99.0
sbp: 104.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Dr. ___ is ___ with hx of early onset Alzheimer-type
dementia, cerebral amyloid angiopathy s/p ICH ___ years ago, who
presented to the ED with ___ days of worsening fatigue,
confusion, and DOE, who was found to have a DVT now on
rivaroxaban, UTI now on Bactrim being discharged at/close to his
baseline mental status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
colchicine
Attending: ___
Chief Complaint:
Dyspnea/palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o STEMI s/p RCA stent in ___, HFpEF, ESRD secondary
to DM s/p LURT in ___ with allograft nephropathy (baseline Cr
2.4-2.6), sarcoidosis, h/o UE DVT (not on AC), presenting with
one week of progressive dyspnea, edema, and weight gain.
He noticed development of peripheral edema and increasing
abdominal girth approximately 1 week ago. Around the same time
the noticed a decrease in his urination (1 gallon/day compared
to
his baseline ___ gallons/day). States that he first started
feeling SOB 2 days ago. He feels SOB with exertion (stairs), but
has not felt SOB at rest. Sleeps on recliner at baseline, has
not
had to sleep more upright or use more pillows. Has also had
several episodes of feeling his heart pounding at rest,
different
than baseline palpitations he has. Since clinic visit 2 months
ago, has gained 25lbs. He denies CP, diaphoresis, dizziness,
fevers, chills, sweats, rhinorrhea, cough, N/V/D/abd pain,
dysuria, rashes. No history of transplant rejection.
In the ED, VS were normal (afebrile, HR 80, BP 134/58, SpO2
96-98% on RA). Exam notable tired appearing man, bibasilar
crackles, 2+ pitting edema of the b/l lower extremities w/o
tenderness or erythema.
Labs in ED notable for:
-Na 145, K4.7, Cl 105, CO2 23, BUN 73, Cr 3.1.
-WBC wnl, H/H 10.9/34.9, plt 170
-pro BNP 5881
-Set 1 trop 0.13, MB 9
-D-dimer 638 (age adjusted normal 590)
-UA bland, UCx pending
CXR notable for mild pulmonary edema, trace right pleural
effusion, opacities at the right heart border c/f asymmetric
alveolar edema vs atelectasis vs infection.
EKG with irregular rhythm with varying P wave morphology, normal
rate, narrow QRS, L axis deviation, TWI in I and L, Q waves in
inferior and lateral leads, poor R-wave progression.
Pt was given 120mg furosemide IV and admitted to medicine for
presumed HF exacerbation.
Past Medical History:
CAD s/p STEMI with stent (___)
___
ESRD s/p LURT in ___, baseline Cr 2.4-2.6
IDDM on U-500 insulin
Sarcoidosis with prior cardiac, lung, eye, and skin involvement.
No symptoms or rheum f/u since 1990s.
RUE DVT of fistula several years ago, not on AC
Obesity
Gout
Palpitation
HTN
PVD
Social History:
___
Family History:
- Maternal grandmother and grandfather with DM
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: T98.2 HR80 BP134/58 RR22 96% RA
GENERAL: Morbidly obese, fatigued but alert, NAD.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: JVD difficult to appreciate given body habitus.
CARDIAC: Irregular rhythm, normal rate. Distant heart sounds,
audible S1 and S2, ? faint systolic murmur at LLSB.
LUNGS: Faint crackles at the bilateral bases. Otherwise clear.
Normal work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, +distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: pitting edema to the bilateral knees, mildly worse
on L>R, no erythema, no tenderness to palpation. warm, well
perfused.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Normal mental status. + bilateral peripheral sensory
deficits in the upper and lower extremities. no gross motor
deficits.
DISCHARGE EXAM:
===============
VITALS: ___ ___ Temp: 98.5 PO BP: 173/67 R Sitting HR: 80
RR: 20 O2 sat: 90% O2 delivery: Ra FSBG: 218
GENERAL: Well-develop, obese male sitting upright on side of
bed.
NAD.
HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Sclera
anicteric.
NECK: Unable to appreciate JVD secondary to body habitus.
CV: RRR, normal S1/S2, no murmurs, rubs, or gallops.
RESP: CTAB, no wheezes, rales, or rhonchi.
ABD: Soft, nontender. Distended, dull to percussion. NABS. No
rebound or guarding.
MSK: 1+ pitting edema to mid shin bilaterally, slightly worse
than baseline per pt
SKIN: No lesions or rashes noted.
NEURO: CNII-XII grossly intact. No focal deficits. Moving all 4
extremities with purpose. Answering all questions appropriately.
Pertinent Results:
ADMISSION LABS
===============
___ 03:15PM BLOOD WBC-6.5 RBC-3.93* Hgb-10.9* Hct-34.9*
MCV-89 MCH-27.7 MCHC-31.2* RDW-13.7 RDWSD-44.6 Plt ___
___ 03:15PM BLOOD Glucose-82 UreaN-73* Creat-3.1* Na-145
K-4.7 Cl-105 HCO3-23 AnGap-17
___ 03:15PM BLOOD CK(CPK)-736*
___ 03:15PM BLOOD CK-MB-9 MB Indx-1.2 proBNP-5881*
___ 06:30AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
___ 03:15PM BLOOD D-Dimer-638*
___ 07:03PM BLOOD tacroFK-12.4
DISCHARGE LABS
===============
___ 05:47AM BLOOD WBC-6.7 RBC-4.01* Hgb-10.9* Hct-35.7*
MCV-89 MCH-27.2 MCHC-30.5* RDW-13.4 RDWSD-43.4 Plt ___
___ 06:30AM BLOOD Neuts-62.0 ___ Monos-8.4 Eos-3.9
Baso-0.5 Im ___ AbsNeut-3.47 AbsLymp-1.37 AbsMono-0.47
AbsEos-0.22 AbsBaso-0.03
___ 05:47AM BLOOD Plt ___
___ 05:47AM BLOOD Glucose-253* UreaN-94* Creat-3.6* Na-140
K-4.8 Cl-96 HCO3-26 AnGap-18
___ 03:15PM BLOOD CK(CPK)-736*
___ 11:49PM BLOOD CK-MB-9 cTropnT-0.11*
___ 05:47AM BLOOD Calcium-9.9 Phos-5.6* Mg-2.3
___ 03:15PM BLOOD D-Dimer-638*
___ 05:47AM BLOOD tacroFK-5.6
IMAGING
===============
Renal Transplant US ___. No hydronephrosis. Unremarkable appearance of the transplant
kidney and urinary bladder.
2. Patent renal transplant vasculature.
TTE ___
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with possible
hypokinesis of the basal inferior wall. The remaining segments
contract normally (LVEF >= 55 %). The right ventricular cavity
is mildly dilated with borderline normal free wall function. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with normal
cavity size and mild regional systolic dysfunction c/w possible
CAD (RCA territory). Mildly dilated right ventricle with low
normal systolic function. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___
pulmonary pressures are higher.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Lorazepam 0.5 mg PO QID:PRN anxiety
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Mycophenolate Mofetil 750 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO BID
8. Tacrolimus 3 mg PO Q12H
9. Furosemide 40 mg PO EVERY OTHER DAY
10. Furosemide 80 mg PO EVERY OTHER DAY
11. Rosuvastatin Calcium 5 mg PO QPM
12. U-500 Conc 36 Units Breakfast
U-500 Conc 36 Units Dinner
Insulin SC Sliding Scale using UNK Insulin
13. Amitriptyline 50 mg PO QHS
14. Clopidogrel 75 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. BuPROPion (Sustained Release) 150 mg PO BID
17. Gabapentin 300 mg PO TID
18. Gabapentin 300 mg PO QHS
Discharge Medications:
1. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*0
2. Glargine 70 Units Breakfast
Glargine 55 Units Bedtime
Humalog 45 Units Breakfast
Humalog 45 Units Lunch
Humalog 45 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 70 Units before BKFT; 55 Units before BED; Disp
#*30 Syringe Refills:*0
RX *insulin lispro [Admelog SoloStar U-100 Insulin] 100 unit/mL
AS DIR 45 units before breafast, lunch and dinner Disp #*30
Syringe Refills:*0
RX *insulin lispro [Admelog SoloStar U-100 Insulin] 100 unit/mL
AS DIR Up to 12 Units QID per sliding scale Disp #*30 Syringe
Refills:*0
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ult-Fine
II] 31 gauge x ___ AS DIR Disp #*90 Syringe Refills:*0
3. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 1 mg 1 capsule(s) by mouth Every 12 hours Disp
#*60 Capsule Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Amitriptyline 50 mg PO QHS
6. Amlodipine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. BuPROPion (Sustained Release) 150 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Gabapentin 300 mg PO TID
12. Gabapentin 300 mg PO QHS
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Lorazepam 0.5 mg PO QID:PRN anxiety
15. Metoprolol Succinate XL 50 mg PO BID
16. Mycophenolate Mofetil 750 mg PO BID
17. Rosuvastatin Calcium 5 mg PO QPM
18.Outpatient Lab Work
Please draw a basic metabolic panel and Tacrolimus level on
___.
Please fax results to ___ (ATTN: Dr. ___
___: 585.6
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
===============
Acute on chronic heart failure with preserved ejection fraction
___ on CKD
Secondary Diagnoses
=================
History of renal transplant
Coronary artery disease
Insulin dependent diabetes mellitus complicated by neuropathy
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S. RIGHT
INDICATION: ___ year old man with renal transplant, admitted for ___ and
volume overload// eval for evidence of rejection, obstruction
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound ___
FINDINGS:
The right transplant renal morphology is normal. The transplant kidney
measures 11.6 cm and length. Specifically, the cortex is of normal thickness
and echogenicity, pyramids are normal, there is no urothelial thickening, and
renal sinus fat is normal. There is no hydronephrosis and no perinephric
fluid collection. The urinary bladder is minimally distended and normal in
appearance.
The resistive index of intrarenal arteries are mildly elevated ranging from
0.74 to 0.80. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 56 cm/sec. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. No hydronephrosis. Unremarkable appearance of the transplant kidney and
urinary bladder.
2. Patent renal transplant vasculature.
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: ___ with history CHF presenting with SoB, heart pounding// ?CHF
TECHNIQUE: Frontal and lateral views of the chest
COMPARISON: ___ chest radiograph
FINDINGS:
The lungs are reasonably well inflated. Asymmetric opacities adjacent to the
right heart border are new. Trace right pleural effusion. No definite left
pleural effusion. No pneumothorax. Moderate cardiomegaly. Mild pulmonary
edema.
IMPRESSION:
Moderate cardiomegaly and mild pulmonary edema and a trace right pleural
effusion. Asymmetric opacities adjacent to the right heart border could
reflect asymmetric alveolar edema, atelectasis, or infection.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Palpitations
Diagnosed with Heart failure, unspecified, Palpitations, Dyspnea, unspecified
temperature: 98.2
heartrate: 80.0
resprate: 22.0
o2sat: 96.0
sbp: 134.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with HFpEF, ESRD s/p LURT in ___ complicated
by allograft nephropathy, DM, and CAD s/p STEMI with RCA stent
in ___ presented with a heart failure exacerbation.
# Acute on chronic HFpEF
Patient presented with dyspnea on exertion and lower extremity
edema consistent with a heart failure exacerbation. He had
reportedly gained approximately 30 pounds in the last month. The
patient confirmed adherence to his diuretic regimen but noted
having ___ food several times in the weeks prior to
presentation, making dietary indiscretion the most likely cause
of his exacerbation. He had a TTE on ___, that showed left
ventricular hypertrophy and mild regional systolic dysfunction
consistent with known CAD in the RCA territory. He was diuresed
with IV lasix until he was closer to euvolemia, at which point
his regimen was switched to PO torsemide. On the day of
discharge, his weight was 313 lbs, his Cr was 3.6, and his
diuretic regimen was torsemide 60mg PO daily.
# ___ on CKD
Creatinine on presentation was 3.1 from a baseline of 2.4-2.5
(history of living unrelated kidney transplant and allograft
nephropathy). Given his overall clinical presentation,
cardiorenal physiology was felt to be the most likely etiology
of his ___. He was aggressively diuresed as above, and on the
day of discharge his Cr was 3.6. His mycophenolate was continued
at his home dose, but his tacrolimus was found to be
supratherapeutic. On the day of discharge, his tacrolimus
regimen was 1mg BID.
# Palpitations
The patient also complained of two episodes of "heart pounding"
that had occurred in the weeks prior to presentation. Per him,
this was different than his known palpitations. An EKG done in
the ED was unremarkable, and continuous telemetry monitoring did
not reveal any abnormalities. The patient did not experience any
episodes while hospitalized.
# IDDM complicated by neuropathy
The patient presented on a home regimen including U500 insulin.
Per hospital protocol, our ___ colleagues were consulted and
recommended switching to a basal-bolus glargine/lantus regimen
while inpatient. Given possible contribution of U500 to edema,
he was recommended to be discharge OFF of U500. His new basal
bolus regimen includes Lantus 70mg qAM, Lantus 55mg qPM, Humalog
45mg w/ meals and a sliding scale. He was also continued on his
home gabapentin initially at a reduced dose due to ___, but okay
to resume home dosing now that Cr stabilized.
Chronic Issues
===============
# CAD s/p PCI to RCA in ___
The patient was continued on his home metoprolol, aspirin, and
clopidogrel. His rosuvastatin was uptitrated to a high intensity
dose (20mg) given his history of STEMI. He also underwent a TTE
that showed mild regional systolic dysfunction consistent with
his known CAD in the RCA territory.
Transitional Issues
===================
[ ] Diuretic regimen - patient discharged on torsemide 60mg PO
daily, however this should be continuously reevaluated in the
outpatient setting to maintain euvolemia.
[ ] Insulin regimen - discharged on new basal-bolus regimen.
Patient was previously on U500 regimen, which can contribute to
hypervolemia.
[ ] Statin - patient was on a low-intensity rosuvastatin dose
despite having a history of STEMI. This was uptitrated while
inpatient.
[ ] Gabapentin dosing - home gabapentin regimen was decreased
while hospitalized given decreasing renal function. Can be
readjusted as outpatient with resolution of ___.
[ ] Physical therapy - the patient conveyed while hospitalized
that he wished to have outpatient physical therapy in order to
regain his independence.
[ ] Please draw labs on ___: BMP and Tacrolimus level
Code: Full (presumed)
Contact: None provided |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Motor vehicle collision
Facial trauma
Major Surgical or Invasive Procedure:
___ - Repair of facial/nasal laceration
History of Present Illness:
Patient is a ___ year old male who presents as trauma following
MVC while intoxicated. Per report, patient was intoxicated
driver who suffered low speed collision vs. cement wall.
Initially taken to OSH where initial GCS 15, however, patient
proceeded to display large volume hematemesis, and thus, was
intubated there due to concern for airway protection. Pan-scan
revealed only nasal bone fractures, no other injuries, and
hematemesis is subsequently felt to have been the result of
bloody run down from his epistaxis. Patient was then
transferred to ___ and admitted to ___ due to intubation.
Plastic surgery is consulted at this time for management of
nasal fracture with overlying complex nasal laceration.
Past Medical History:
HTN, HLD, CAD, CVA
Social History:
___
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
Gen: intubated, sedated
HEENT: There is an inverted U shaped laceration over the right
nasal sidewall, crossing the dorsum and extending over the left
sidewall. This is a superficial laceration involving only skin.
There is no septal hematoma present. There are no other
lacerations or abrasions present on the face or scalp. There is
mild periorbital bruising bilaterally. Midface stable to
palpation with no obvious stepoffs. No hemotympanum. No
obvious intraoral lacerations but difficult to assess due to ET
tube. Unable to perform cranial nerve exam due to sedation.
=================
ON DISCHARGE:
VS: T98.3, HR 102, BP 164/89, RR 18, SaO2 97% RA
GEN: no acute distress
HEENT: Repaired right nasal laceration C/D/I, otherwise NCAT,
EOMI, MMM
CV: RRR
PULM: Easy work of breathing
ABD: Soft, NT, ND
EXT: Warm, well perfused
Pertinent Results:
___ 08:20PM BLOOD WBC-11.8* RBC-4.49* Hgb-14.1 Hct-39.6*
MCV-88 MCH-31.4 MCHC-35.5* RDW-13.5 Plt ___
___ 02:30AM BLOOD WBC-14.9* RBC-4.18* Hgb-12.9* Hct-36.9*
MCV-88 MCH-31.0 MCHC-35.1* RDW-13.2 Plt ___
___ 04:50AM BLOOD WBC-7.3# RBC-3.47* Hgb-11.3* Hct-30.5*
MCV-88 MCH-32.5* MCHC-36.9* RDW-13.0 Plt Ct-96*
___ 08:20PM BLOOD UreaN-13 Creat-0.7
___ 02:30AM BLOOD Glucose-164* UreaN-14 Creat-0.8 Na-141
K-4.2 Cl-105 HCO3-20* AnGap-20
___ 04:50AM BLOOD Glucose-163* UreaN-18 Creat-1.0 Na-138
K-3.3 Cl-102 HCO3-27 AnGap-12
___ 02:30AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.5*
___ 04:50AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.9
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Acetaminophen 650 mg PO Q6H
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink or drive while taking pain medications.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
Take with meals. Stop for loose or watery stools.
9. cefaDROXil 1 gram oral DAILY Duration: 5 (five) Days
RX *cefadroxil 1 gram 1 tablet(s) by mouth DAILY Disp #*5 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
nasal laceration
nasal bone and maxillary sinus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with ETT s/p intubation OSH // trauma, intubated
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Endotracheal tube is present 3.5 cm above the carinal. Nasogastric tube
courses below the diaphragm into the stomach. Lung volumes are low. There is
no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal select is within normal limits. Mild prominence of central
pulmonary vasculature is noted likely due to low lung volumes. No displaced
fractures are identified.
IMPRESSION:
Endotracheal tube and nasogastric tube in appropriate position. Low lung
volumes.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: History: ___ with MVC, intubated, nasal fractures // evaluate
facial fractures, other acute injuries
TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.
Bone and soft tissue reconstructed iamges were generated. Coronal reformatted
images were also obtained
DOSE: DLP: 531.3 mGy-cm; CTDI: 25.8 mGy
COMPARISON: None
FINDINGS:
There are multiple bilateral minimally displaced nasal bone fractures with
overlying soft tissue swelling. A bony fragment is noted inferior to the
right nasal cavity. The bony nasal septum (vomer) is fractured with most
fragments displaced leftward within the nasal cavity. No other fractures are
identified. There are aerosolized secretions within the nasopharynx. Fluid is
in the maxillary sinuses bilaterally. The lamina papyracea appears intact. The
nasal lacrimal canals also are normal in appearance. There is mucosal
thickening within the ethmoid air cells and in the frontal sinuses and fluid
in the sphenoid sinuses.The mastoid air cells and middle ear cavities are
clear. Patient is intubated.
IMPRESSION:
1. Multiple minimally displaced nasal bone fractures with overlying soft
tissue swelling.
2. Fluid and secretions within the nasopharynx, maxillary sinuses and sphenoid
sinuses, likely due to intubation and fractures.
3. Mucosal thickening of the ethmoid and frontal sinuses.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with MVC // interval change
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
ET tube tip is 6.5 cm above the carinal NG tube tip is in the stomach. Heart
size and mediastinum are stable. Minimal bibasal areas of atelectasis are
present
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: INTUBATED MVC
Diagnosed with NASAL BONE FX-OPEN, FX MALAR/MAXILLARY-CLOSE, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ year old male who presents as trauma
following motor vehicle collision against a cement wall while
intoxicated. Per report, patient was intoxicated. He was
intubated at an outside hospital for hematemesis which was later
determined to have been the result of his epistaxis. He was
transferred to ___ and admitted
to the Trauma Surgical ICU due to intubation. After admission,
plastic surgery was consulted for management of nasal fracture
with overlying complex nasal laceration. The laceration was
repaired successfully. The patient was subsequently extubated on
hospital day 2 and subsequently transferred to the floor where
he remained throughout the rest of his hospitalization. He
remained afebrile and hemodynamically stable throughout.
At the time of discharge, he was tolerating a regular diet. His
pain was controlled with oral medications alone. He was voiding
without difficulty and ambulating without assistance. He was see
by social work who counseled him on options for alcohol
cessation; however, the patient refused additional help. He was
given the appropriate discharge instructions and will follow-up
with plastic surgery shortly on ___ for suture
removal and to see Dr. ___ in clinic. He will be discharged on
a few days of Duricef to complete a 1 week course of
antibiotics. He received a tetanus shot while in the ED. |
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:
Upper endoscopic ultrasound on ___
History of Present Illness:
Mr. ___ is a ___ male with HTN, complete
heart block with pacemaker placement in ___, prostate
cancer,
seizure disorder, vascular dementia, prior TIA, who presented to
the ED with abdominal pain. He has had intermittent LLQ
abdominal pain that is worsened by eating for the past few days.
He also reported 1 episode of non-bloody emesis and inability to
eat tolerate much fluid due to increased pain. He had 3
episodes
of diarrhea and had been fatigued. He went to ___
urgent care on ___ for worsening pain, where he had a CT
abdomen/pelvis showing mild intrahepatic bile duct dilation,
unchanged since ___. There he had ALT 201, AST 311, AP 173,
Tbili 1.1, lipase 288, WBC 10.8, Hb 11.9, negative troponin. He
was referred to ED. He also reported intermittent chest
tightness, but was not actively having pain in the ED.
In the ED, he was afebrile with Tmax 98.8, P in ___, BP
125/51-138/60, RR 18, O2 saturation 97-100% on room air. Labs
were notable for ALT 210, AST 231, AP 187, normal total
bilirubin
0.7, lipase 96. He had normal WBC 9.5, Hb 11.6, normal BMP,
negative UA, normal lactate 1.0, negative troponin. He received
IV D5LR 75 cc/hr, ASA 324mg, Ramelteon, Protonix 40mg. Blood
and
urine cultures were collected. Exam was notable for LLQ
tenderness.
He is not a great historian. He said he'd started having
nausea,
vomiting, diarrhea and abdominal pain (center and LLQ) starting
on ___, 2 days ago. He said he'd had the abdominal pain
every
once in a while and would feel "great" for a while then the pain
could come back. When he arrived on the floor, he denied any
abdominal pain, but said he'd had a little overnight. He denied
nausea, vomiting, diarrhea, dyspnea, chest pain, difficulty
urinating. He was eating a regular diet and denied pain after
eating.
I spoke with his daughter ___ by phone who said he had
nausea
and vomiting back in ___ when he'd gotten his pacemaker
placed, but thinks this was a "bug" since other contacts had
similar symptoms. However, he'd been having more frequent and
consistent abdominal pain, nausea, vomiting, and gas in the past
few days.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative. He denied fevers,
chills, numbness, focal weakness, tingling, dyspnea.
Past Medical History:
COMPLETE HEART BLOCK S/P PACEMAKER PLACEMENT (___)
PROSTATE CANCER S/P RADICAL PROSTATECTOMY (___)
HYPERTENSION
SEIZURE DISORDER
HX OF STROKE
VASCULAR DEMENTIA
MEMORY LOSS
VENOUS STASIS
GLAUCOMA
POLYNEUROPATHY
APPENDECTOMY (Age ___
COLONIC POLYPS
GASTROESOPHAGEAL REFLUX
Social History:
___
Family History:
Both parents deceased with no known medical problems. Father
died in his ___ and mother died at ___. Brother with some type
of pancreas problem.
Physical Exam:
Admission exam:
===============
VITALS: Tmax 98.8, P in ___, BP 125/51-138/60, RR 18, O2
saturation 97-100% on room air
GENERAL: Alert and in no apparent distress, sitting in bed
eating
lunch, conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: Heart regular, no murmur, no S3, no S4. 2+ radial pulses
bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, mildly tender to palpation in
center and LLQ. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation, no Foley
MSK: Moves all extremities, no swelling or edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to person/place/month/year, face
symmetric, speech fluent
PSYCH: pleasant, appropriate affect
.
.
Discharge exam:
===============
VS: ___ 0727 Temp: 97.9 PO BP: 146/66 HR: 63 RR: 18 O2 sat:
96% O2 delivery: RA
Gen: NAD sitting up in chair
HEENT: anicteric sclera, MMM
Neck: no JVD
Cards: RR, no m/r/g appreciated, no peripheral edema
Chest: CTAB, normal WOB
Abd: moderate distention, soft, not tender to palpation or
percussion, bowel sounds present
Neuro: awake, alert, conversant with clear speech
Psych: calm, cooperative, pleasant
Pertinent Results:
Admission labs:
===============
___ 01:00PM BLOOD WBC-10.8* RBC-3.64* Hgb-11.9* Hct-36.1*
MCV-99* MCH-32.7* MCHC-33.0 RDW-12.5 RDWSD-45.4 Plt ___
___ 01:00PM BLOOD Neuts-86.9* Lymphs-4.4* Monos-7.9
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.40* AbsLymp-0.48*
AbsMono-0.86* AbsEos-0.00* AbsBaso-0.02
___ 01:00PM BLOOD Glucose-154* UreaN-17 Creat-1.1 Na-137
K-5.1 Cl-100 HCO3-25 AnGap-12
___ 01:00PM BLOOD ALT-201* AST-311* AlkPhos-173*
TotBili-1.1
___ 01:00PM BLOOD Lipase-288*
___ 01:00PM BLOOD cTropnT-<0.01
___ 06:38PM BLOOD cTropnT-<0.01
___ 06:42PM BLOOD Lactate-1.0
.
.
Micro:
======
-___ UCx: no growth (final0
-___ BCx: NGTD
.
.
Imaging:
========
-___ CT abdomen/pelvis with contrast
IMPRESSION:
"1. No acute abdominopelvic process. No CT findings directly
correlating to the reported history of acute left lower quadrant
pain.
2. Mild left lateral lobe intrahepatic bile duct dilation is
unchanged since ___, but appears slightly
progressed since ___. MRCP is recommended to assess for
underlying obstructive lesion or evidence for a chronic process
such as a primary sclerosing cholangitis. Please correlate
with LFTs.
3. New 1.2 cm right adrenal nodule can also be assessed with
MRI.
4. Extensive sigmoid and descending colonic diverticulosis. No
diverticulitis.
5. Small hiatal hernia.
6. Nonobstructing 1.8 x 1.5 cm lipoma within the wall of the
hepatic flexure."
.
-___ CT abdomen w/ & w/o contrast
IMPRESSION:
"1. 1.7 cm right adrenal nodule is not consistent with an
adrenal adenoma but it shows no enhancement. On precontrast
imaging, is difficult to characterize owing to its small size
but it seems to measure slightly above density expected for
simple fluid. This is likely a small pseudocyst of the adrenal,
possibly posttraumatic/post hemorrhagic, doubtful in
significance. Differential may include unusual solid
hypoattenuating hypovascular lesions such is a ganglioneuroma,
however, or might still represent an adenoma with relatively low
level of fat enhancement. Metastatic disease or any other
malignant lesion is highly unlikely. Follow-up CT or MR is
recommended in 6 months to reassess.
2. Mild intrahepatic bile duct dilation in liver segments 2 is
nonspecific. No focal liver lesion is identified."
.
-___ Upper endoscopic ultrasound: normal duct, no stones or
sludge; see report for full details (scanned PDF format, unable
to copy results into notes)
.
.
Discharge labs:
===============
___ 06:35AM BLOOD WBC-6.9 RBC-3.64* Hgb-11.8* Hct-35.1*
MCV-96 MCH-32.4* MCHC-33.6 RDW-12.4 RDWSD-43.8 Plt ___
___ 06:35AM BLOOD Glucose-92 UreaN-17 Creat-1.1 Na-141
K-4.2 Cl-107 HCO3-24 AnGap-10
___ 06:35AM BLOOD ALT-98* AST-37 AlkPhos-221* TotBili-0.4
___ 02:50PM BLOOD Lipase-25
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Phenytoin Sodium Extended 100 mg PO TID
2. Pantoprazole 20 mg PO DAILY
3. aspirin-dipyridamole ___ mg oral Q12H
4. Furosemide 20 mg PO DAILY:PRN Leg swelling
5. Tamsulosin 0.8 mg PO QHS
Discharge Medications:
1. aspirin-dipyridamole ___ mg oral Q12H
2. Furosemide 20 mg PO DAILY:PRN Leg swelling
3. Pantoprazole 20 mg PO DAILY
4. Phenytoin Sodium Extended 100 mg PO TID
5. Tamsulosin 0.8 mg PO QHS
6.Outpatient Physical Therapy
Please evaluate and treat as indicated for impaired balance and
impaired functional mobility.
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea, Vomiting, & Abdominal pain
Transaminitis
Chest pain
Complete heart block s/p PPM
Discharge Condition:
Mental Status: Clear and coherent, but is forgetful.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD WANDW/O C
INDICATION: ___ year old man with HTN, pacemaker, prostate cancer s/p
prostatectomy, vascular dementia, here with abdominal pain, elevated LFTs,
biliary ductal dilatation, found incidentally to have new right adrenal nodule
on CT abd/pelvis on ___// **ADRENAL PROTOCOL** (Spoke with radiologist
about ordering) Does the adrenal nodule look suspicious for malignancy? He
has newly placed pacemaker from ___ and cardiology says not
MRI-conditional.
TECHNIQUE: Multidetector CT of the abdomen was done with IV contrast. IV
contrast was injected and the abdomen was scanned in arterial, portal venous,
and 15 minute delayed post-contrast phases.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: 1041.8 mGy cm
COMPARISON: CT abdomen and pelvis with contrast ___
FINDINGS:
ADRENALS: A right adrenal mass measures 1.7 x 1.5 cm on axial imaging with a
measured density of 23 ___ on noncontrast imaging. This mass measured 32 ___ on
enhanced phase imaging and 29 ___ on 15 minute delayed phase imaging with an
absolute washout of 33 % ((enhanced-delayed)/(enhanced-unenhanced)) and a
relative washout of 9% ((enhanced-delayed)/enhanced). However on none of the
contrast-enhanced series does the relatively low-density lesion show any
definite enhancement.
Left adrenal gland is unremarkable.
LOWER CHEST: Atelectasis is minimal in the lung bases. Electronic lead in the
right heart is partially visualized.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is focal mild dilation of
intrahepatic bile ducts in segment 2 (10:23) as noted previously.
Extrahepatic bile duct is normal caliber. The gallbladder is within normal
limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is small and irregular with linear subcapsular
calcification, likely sequela of prior trauma.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Multiple renal cysts are identified in bilateral kidneys there is no
perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia is noted. Colonic diverticulosis is
noted. Small and large bowel loops are normal caliber. 2.5 cm lipoma in the
wall of the colonic hepatic flexure is unchanged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal wall is within normal limits.
IMPRESSION:
1. 1.7 cm right adrenal nodule is not consistent with an adrenal adenoma but
it shows no enhancement. On precontrast imaging, is difficult to characterize
owing to its small size but it seems to measure slightly above density
expected for simple fluid. This is likely a small pseudocyst of the adrenal,
possibly posttraumatic/post hemorrhagic, doubtful in significance.
Differential may include unusual solid hypoattenuating hypovascular lesions
such is a ganglioneuroma, however, or might still represent an adenoma with
relatively low level of fat enhancement. Metastatic disease or any other
malignant lesion is highly unlikely. Follow-up CT or MR is recommended in 6
months to reassess.
2. Mild intrahepatic bile duct dilation in liver segments 2 is nonspecific.
No focal liver lesion is identified.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal labs
Diagnosed with Epigastric pain, Nonspec elev of levels of transamns & lactic acid dehydrgnse
temperature: 96.3
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 60.0
level of pain: 10
level of acuity: 3.0 | # Abdominal pain
# Transaminitis
# Biliary obstruction
He was reportedly having abdominal pain, nausea, vomiting, prior
to admission. Normal LFTs (AST and ALT in ___ except AP mildly
elevated to 164 on ___, but elevated AST, ALT, alk phos on
___, stable currently. Stable intrahepatic bile duct dilation
on CT abdomen/pelvis compared to ___ scan. ERCP team was
consulted. Unable to have MRCP due to recent pacemaker
placement. ERCP team performed EUS.
- EUS with normal bile duct, no stones, no sludge; no
ERCP/sphincterotomy was needed
- ERCP team recs: possibly was a passed gallstone causing
transient biliary obstruction; nothing further to do as long as
LFTs improving
- LFTs improving since admission
- is currently totally asymptomatic and feeling well, tolerating
regular diet with no abdominal pain, nausea, or other complaints
[] would advise f/u with PCP ___ ___ weeks for repeat LFTs to
ensure fully normalized
.
# Right adrenal nodule: CT abdomen showed new 1.2 cm right
adrenal nodule.
- underwent CT adrenal protocol (___): adrenal nodule is not
particularly worrisome but does require 6-month interval
follow-up
- Radiology read:
"IMPRESSION: 1. 1.7 cm right adrenal nodule is not consistent
with an adrenal adenoma but it shows no enhancement. On
precontrast imaging, is difficult to characterize owing to its
small size but it seems to measure slightly above density
expected for simple fluid. This is likely a small pseudocyst of
the adrenal, possibly posttraumatic/post hemorrhagic, doubtful
in significance. Differential may include unusual solid
hypoattenuating hypovascular lesions such is a ganglioneuroma,
however, or might still represent an adenoma with relatively low
level of fat enhancement. Metastatic disease or any other
malignant lesion is highly unlikely. Follow-up CT or MR is
recommended in 6 months to reassess."
[] CT or MR in 6-months to follow-up right adrenal nodule
.
# Chest pain/tightness
He had reported intermittent chest pain prior to admission
(including when he was here for PPM on ___, when he had 2 neg
troponins), but no active chest pain. He had two negative
troponins here (1 at ___, 1 in ED) and no ongoing/recurrent chest
pain during hospitalization.
.
# Complete heart block s/p recent pacemaker placement: no issues
during hospitalization
[] Routine f/u with cardiology already scheduled
.
# Insomnia
On day of discharge he reported recent severe insomnia
(described as waking up frequently during the night) and
requested "sleeping pills." We educated him on sleep hygiene and
encouraged him to be active during the day and ensure he is
sleeping in a quiet, dark room at night when he returns home. If
that does not improve his insomnia, we encouraged him to
follow-up with his primary care physician for additional
consideration of medical treatment for insomnia.
[] f/u reported insomnia at next PCP ___
.
# Impaired balance & reduced functional mobility
Was evaluated by ___ who advised home with outpatient ___. We
provided patient with Rx for outpatient ___.
[] f/u response to outpatient ___ at next PCP ___
.
=========================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Haldol / Vancomycin / Iodine Containing Agents
Classifier
Attending: ___
Chief Complaint:
elevated LFTs, abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
Liver biopsy ___
History of Present Illness:
___ with a history of autoimmune hepatitis s/p OLT in ___ on
tacro/MMF, borderline personality disorder, and DMII who
presented with abdominal pain and elevated LFTs. She reported
that the day prior to admission, she developed dull,
non-radiating epigastric pain asociated with nausea and bloody
and bilious emesis. She also reported recent EtOH use with ___
drinks the night prior to admission. She was concerned that her
FSBS was high, so she presented to an OSH. While there, she was
noted to have elevated LFTs and mild epigastric pain so she was
transferred to the ___ for further evaluation.
Past Medical History:
- s/p liver transplant at ___ ___ for autoimmune hepatitis,
followed by Dr. ___
- borderline personality disorder
- organic affective syndrome
- history of opiate abuse
- alcohol abuse
- type 2 diabetes mellitus
- hypertension
- post-traumatic stress disorder
- s/p cholecystectomy
- sciatica and chronic low back pain
- Repeated history of threatening to kill herself when told
she's being discharged or when not receiving IV narcotics or
benadryl (See d/c summary dated ___, and multiple other
past d/c summaries, SW and Psych notes ___, etc.)
Social History:
___
Family History:
Mother with diabetes, unknown type.
Physical Exam:
ON ADMISSION:
Vitals- T 97.8, 135/94, 94, 90, 16, 98% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no m/r/g
Abdomen- NABS. Soft, distended. Mild epigastric tenderness. No
rebound or guarding. No organomegaly.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor and sensory function grossly normal
ON DISCHARGE:
VITALS: 98.1, 133/93, 113, 18, 95% RA
PHYSICAL EXAM
General- Alert, oriented, angry, agitated and emotionally
labile. Yelling at times. Not diaphoretic.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple
Lungs- CTAB, no wheezes, rales, ronchi
CV- Regular rate and rhythm, normal S1 + S2, no m/r/g
Abdomen- NABS. Soft, distended. Mild epigastric tenderness,
distractable. No rebound or guarding. No organomegaly.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor and sensory function grossly
normal. No tongue fasciculations.
Pertinent Results:
ON ADMISSION:
___ 04:25AM BLOOD WBC-3.4* RBC-4.39 Hgb-10.6* Hct-32.9*
MCV-75* MCH-24.0* MCHC-32.1 RDW-18.6* Plt ___
___ 04:25AM BLOOD ___ PTT-24.6* ___
___ 04:25AM BLOOD Glucose-185* UreaN-20 Creat-0.8 Na-136
K-4.3 Cl-103 HCO3-24 AnGap-13
___ 04:25AM BLOOD ALT-58* AST-79* AlkPhos-77 TotBili-0.3
___ 04:25AM BLOOD Albumin-3.7
___ 04:51AM BLOOD tacroFK-3.3*
___ 04:29AM BLOOD Lactate-2.0
ON DISCHARGE:
___ 10:20AM BLOOD WBC-3.8* RBC-4.75 Hgb-11.7* Hct-35.7*
MCV-75* MCH-24.6* MCHC-32.8 RDW-18.5* Plt ___
___ 10:20AM BLOOD Glucose-207* UreaN-12 Creat-0.7 Na-136
K-3.8 Cl-98 HCO3-29 AnGap-13
___ 10:20AM BLOOD ALT-37 AST-35 AlkPhos-91 TotBili-0.4
___ 10:20AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.8
___ 08:10AM BLOOD Lipase-43
___ 08:10AM BLOOD tacroFK-LESS THAN
___ 10:20AM BLOOD tacroFK-LESS THAN
___ 04:29AM BLOOD Lactate-2.0
IMAGING
___ Imaging LIVER OR GALLBLADDER US
IMPRESSION:
1. Patent hepatic vasculature. Low resistive indices in the
hepatic arteries. This is a nonspecific finding but has been
described with hepatic artery stenosis. This could be evaluated
with dedicated cross-sectional imaging if clinically indicated.
2. Echogenic liver suggesting a parenchymal abnormality such as
fatty
infiltration although more advance forms of liver disease are
not excluded.
3. The spleen is upper limits of normal in size.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Gabapentin 800 mg PO TID
3. ClonazePAM 1 mg PO TID
4. Propranolol 40 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO TID
6. carisoprodol 350 mg oral TID
7. Mycophenolate Mofetil 500 mg PO BID
8. Tacrolimus 3 mg PO QAM
9. Tacrolimus 2 mg PO QPM
10. TraMADOL (Ultram) 50 mg PO BID:PRN pain
11. Pantoprazole 40 mg PO Q12H
12. Citalopram 20 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Glargine 75 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. ClonazePAM 1 mg PO TID
3. Gabapentin 800 mg PO TID
4. Glargine 75 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 20 mg PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
8. Propranolol 40 mg PO BID
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 3 mg PO QAM
11. Tacrolimus 2 mg PO QPM
12. carisoprodol 350 mg oral TID
13. MetFORMIN (Glucophage) 500 mg PO TID
14. TraMADOL (Ultram) 50 mg PO BID:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
15. Zofran ODT (ondansetron) 4 mg ORAL Q4H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
16. Zolpidem Tartrate 7.5 mg PO HS
RX *zolpidem 5 mg 1.5 tablet(s) by mouth at bedtime Disp #*12
Tablet Refills:*0
17. RISperidone (Disintegrating Tablet) 1 mg PO BID:PRN
agitation/anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Transaminitis
Alcohol abuse
Abdominal Pain
Secondary diagnosis:
Type 2 Diabetes
Borderline personality disorder
Organic affective syndrome
Hypertension
Sciatica and chronic low back pain
Discharge Condition:
Alert and oriented, and coherent.
Ambulatory. Able to walk without assistance.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with elevated LFTs, hx of liver transplant //
inflammation, other acute
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Liver Doppler ultrasound dated ___ and CT abdomen
dated ___.
FINDINGS:
The liver is echogenic. There is no evidence of focal liver lesions or
intrahepatic biliary dilatation. The common bile duct measures up to 1.4 cm,
unchanged from prior. There is no ascites, right pleural effusion or sub- or
___ fluid collections/hematomas.
The spleen measures 12.9 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 43 cm per second. Appropriate
arterial waveforms are seen in the right hepatic artery and the left hepatic
artery however the resistive indices are low with resistive indices of 0.44,
and 0.54, 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:
1. Patent hepatic vasculature. Low resistive indices in the hepatic arteries.
This is a nonspecific finding but has been described with hepatic artery
stenosis. This could be evaluated with dedicated cross-sectional imaging if
clinically indicated.
2. Echogenic liver suggesting a parenchymal abnormality such as fatty
infiltration although more advance forms of liver disease are not excluded.
3. The spleen is upper limits of normal in size.
NOTIFICATION: Change in wet read discussed with Dr. ___ by Dr. ___ at
10:05 on ___
Radiology Report
INDICATION: ___ year old woman with history of AIH, s/p orthotopic liver
transplant now with low Tacrolimus levels and transaminitis. // please do
percutaneous liver biopsy
COMPARISON: Ultrasound performed on ___.
PROCEDURE: Ultrasound-guided non-targeted liver biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist, who was present and supervising throughout the total procedure
time.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the right
hepatic lobe was performed and a suitable approach for non targeted liver
biopsy was determined. No other abnormalities were identified on the limited
imaging.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound
guidance, a 18 gauge core biopsy needle was then advanced into the liver and a
single core biopsy sample was obtained and placed in formalin. The skin was
then cleaned and a dry sterile dressing was applied. There was no immediate
complications.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75mcg fentanyl throughout the total intra-service time of
13minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated non-targeted liver biopsy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, ELEVATED LFT'S
Diagnosed with ABDOMINAL PAIN RUQ, ABN LIVER FUNCTION STUDY, LIVER TRANSPLANT STATUS
temperature: 98.1
heartrate: 94.0
resprate: 18.0
o2sat: 98.0
sbp: 128.0
dbp: 87.0
level of pain: 8
level of acuity: 3.0 | This is a ___ yo woman with a history of autoimmune hepatitis s/p
OLT in ___ on tacro/MMF, borderline personality disorder, and
DMII who presents with elevated LFTs and reported emesis and
abdominal pain, found to have toxic/metabolic liver injury on
liver biopsy in the setting of recent EtOH use.
# Transaminitis - The patient is s/p OLT for autoimmune
hepatitis ___ years ago with ___ steatosis on her biopsy in
___ with stage I fibrosis. She presented this admission with
worsened LFTs in the setting of recent EtOH intake and loc
tacrolimus level. Due to concern for rejection in the setting of
poor medication compliance, she had a liver biopsy on ___,
which showed Stage I fibrosis and evidence of toxic/metabolic
injury but no evidence of rejection recurrence of autoimmune
hepatitis. Her LFTs improved to normal limits by the end of
admission, her physical exam was benign, and she was discharged
stable condition. Of note, patient refused to take her
transplant medications by bargaining for IV narcotics. "If you
don't give me IV pain meds then I'm not taking my transplant
meds. You can tell Dr. ___ throwing my liver away." It
was repeatedly recommended that she comply with her transplant
medications and avoid alcohol to avoid harm to her liver. She
was discharged with instructions to follow up with her liver
clinic.
# Nausea, emesis, abdominal pain - The patient endorsed
epigastric and RUQ pain on admission. RUQ U/S showed an
echogenic liver and no indications of cholecystitis. Her
physical exam was reassuring. She had been drinking alcohol
recently but her lipase was WNL. Suspect gastroparesis from
non-compliance with her insulin versus GERD or gastritis from
recent alcohol use. Malingering for IV pain medications was also
considered. No evidence of GI bleeding or perforation. Benign
abdominal exam, with distractable pain. She was given high dose
pantoprazole and PO pain medications for nausea. No IV narcotics
were given, and strict limits were set. She demanded IV push
zofran only, later switched to oral-dissolving ondansetron. She
was tolerating a PO intake for several days prior to discharge
without any witnessed episodes of vomiting, including a grilled
cheese sandwich and salad.
# Suicidal Ideation: On attempted discharge ___ ___, patient
suddenly expressed suicidality with plan to kill herself by
drinking herself to death if she were discharged. Psych had
already been consulted morning of ___ due to a family member
calling the ___ stating the patient was suicidal. On MA
psych evaluation, patient adamantly denied being suicidal, but
this changed on notification of pending discharge. This is not
the first time she has expressed SI as an instrument to avoid
discharge from the hospital or ED (see multiple prior d/c
summaries, SW notes, psych notes). Psych was reconsulted and by
time of evaluation, it was too late to discharge to shelter
system. Next morning, patient again made statements about
killing herself. Psychiatry evaluated her and determined she
briefly met ___ criteria, but on reevaluation it she was
cleared by Psychiatry and was discharged from the hospital.
# Alcohol abuse - Patient with h/o alcohol abuse and reported
that she had been drinking recently. She was placed on CIWA,
continued on her home clonezepam and did not have significant
withdrawal symptoms while hospitalized here previously.
# Palpitations: She reported having palpitations during this
admission but declined an EKG against medical advice.
# Refusing transplant, BP, insulin medications and diagnostic
testing against medical advice: The patient was continually
refused her medications unless she received IV narcotics, pushes
of IV Zofran, and increased sleep aids. The risks of not taking
her medications were communicated to her multiple times, and the
patient continued to decline her medications.
# DM2 - Home metformin was held and the patient was placed on
fixed dose lantus and humalog sliding scale. She repeatedly
refused to take her diabetes medications unless she was given IV
narcotics. The risks of not taking these medications were
explained to her multiple times during this admission, and she
understands. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cefepime / meropenem / vancomycin / Iodinated Contrast- Oral and
IV Dye / ceftriaxone / ceftazidime
Attending: ___.
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Push Enteroscopy
History of Present Illness:
Mr. ___ is a ___ male with medical history
notable for alcoholic cirrhosis, complicated by portal
hypertension, hepatojejunal varices status post TIPS,
SMV/splenic/TIPS thrombosis on warfarin, status post parallel
TIPS placement and revision ___ and SMV/splenic stents, CAD
status post DES in ___, recent admission for presumed
diverticular v rectal varix bleed, who presents with a 1 day
history of black stools.
He reports a 1 day history of dark stools. He had one episode
earlier in the day and one on arrival to ED. Per ED resident,
maroon/melanotic in color. Denies chest pain. He does have
chronic shortness of breath and chronic abdominal pain which is
unchanged. He additionally had a fall yesterday from standing
height without loss of consciousness or head strike.
ROS negative for fevers chills, changes in vision or hearing,
nausea or vomiting, dysuria, new rashes lesions or wounds.
On arrival to the ED initial vitals stable (T 97.9, heart rate
73, BP 151/84, respiratory rate 17 satting 100% on room air (ED
exam notable for right upper quadrant discomfort to palpation.
Rest of the ED exam otherwise unremarkable.
Initial labs notable for hemoglobin 11.7 (13.1 at last d/c), INR
2.8, ALT/AST 64/55, Lipase 539. CBC, chemistries otherwise
unremarkable. Noncontrast head CT without acute intracranial
process. Right upper quadrant ultrasound with Dopplers
demonstrated patent bilateral TIPS, absence of ascites.
Hepatology was consulted in the ED. Recommended IV
ciprofloxacin
for prophylaxis and admission to ___. He received IV
PPI 40×1, IV morphine 4 mg x 1, IV Ciprofloxacin 400 mg x1
On arrival to the floor he currently feels well.
Past Medical History:
- alcoholic cirrhosis ___ B)
- Necrotizing pancreatitis with pancreatic pseudocyst and
pancreatic insufficiency
- Hepatojejunal varices s/p portal vein/SMV stent, TIPS and
coiling (___)
- portal vein/SMV stent thrombosis (on apixaban)
- CAD s/p MI with BMS placement in ___
- Bipolar disorder
- Hypothyroid
- HTN
- Chronic low back pain
- Diverting hepaticojejunostomy, cholecystectomy and side to
side pancreaticojejunostomy in ___
- recurrent GI bleed
- IDDM
Social History:
___
Family History:
Father died of MI
Physical Exam:
ADMISSION EXAM
==================
VS: Reviewed and stable
GEN: A&Ox3, appropriate mood and affect
HEENT: NC/AT EOMI MMM
NECK: No JVD
CV: RRR
PULSES: 2+ radial
RESP: CTAB
ABD: mildly TTP RUQ
EXT: no lower extremity edema
SKIN: no jaundice
DISCHARGE EXAM
===================
24 HR Data (last updated ___ @ 1306)
Temp: 98.1 (Tm 98.1), BP: 127/86 (106-127/70-86), HR: 65
(56-73), RR: 16 (___), O2 sat: 99% (95-100), O2 delivery: Ra
GEN: Alert, interactive, NAD
HEENT: EOMI, sclera anicteric, MMM
CV: RRR, systolic ejection murmur
RESP: CTAB, unlabored respirations
GI: soft and non tender in all four quadrants, +BS
EXT: no lower extremity edema
SKIN: no jaundice
Pertinent Results:
RELEVANT LABS
==================
___ 07:00AM BLOOD TSH-6.2*
___ 05:50AM BLOOD WBC-3.6* RBC-4.01* Hgb-12.6* Hct-37.7*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.1 RDWSD-45.0 Plt ___
___ 05:50AM BLOOD Glucose-124* UreaN-14 Creat-0.8 Na-140
K-4.9 Cl-97 HCO3-34* AnGap-9*
___ 05:50AM BLOOD ALT-60* AST-44* AlkPhos-78 TotBili-0.4
MICROBIOLOGY
==================
None pending.
RELEVANT STUDIES
==================
___ RUQ U/S:
1. Patent bilateral TIPS.
2. Morphologically cirrhotic liver without focal hepatic
lesions, ascites or splenomegaly.
3. The fullness within the left renal pelvis is not visualized
on current
study suggesting resolution.
___ CT HEAD W/O CONTRAST: No acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Dyspnea
2. ARIPiprazole 15 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. HydrOXYzine 50 mg PO PRN Unknown
6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
7. Ascorbic Acid ___ mg PO BID
8. Aspirin 81 mg PO DAILY
9. Creon 12 6 CAP PO TID W/MEALS
10. Creon 12 1 CAP PO BID:PRN with snacks
11. Divalproex (DELayed Release) 1250 mg PO QPM
12. Ferrous Sulfate 325 mg PO BID
13. Levothyroxine Sodium 300 mcg PO 6X/WEEK (___)
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Loratadine 10 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Pantoprazole 40 mg PO Q12H
18. Rifaximin 550 mg PO BID
19. TraZODone 50 mg PO QHS:PRN insomnia
20. Zinc Sulfate 220 mg PO DAILY
21. Magnesium Oxide 400 mg PO DAILY
22. Metoprolol Succinate XL 25 mg PO DAILY
23. Narcan (naloxone) 4 mg/actuation nasal ONCE:PRN
24. Toujeo SoloStar U-300 Insulin (insulin glargine U-300 conc)
300 unit/mL (1.5 mL) subcutaneous QPM
25. Warfarin 6 mg PO DAILY16
26. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN Dyspnea
3. ARIPiprazole 15 mg PO DAILY
4. Ascorbic Acid ___ mg PO BID
5. Aspirin 81 mg PO DAILY
6. Creon 12 6 CAP PO TID W/MEALS
7. Creon 12 1 CAP PO BID:PRN with snacks
8. Divalproex (DELayed Release) 1250 mg PO QPM
9. Ferrous Sulfate 325 mg PO BID
10. Furosemide 40 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. HydrOXYzine 50 mg PO PRN Unknown
13. Levothyroxine Sodium 300 mcg PO 6X/WEEK (___)
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Loratadine 10 mg PO DAILY
16. Magnesium Oxide 400 mg PO DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Narcan (naloxone) 4 mg/actuation nasal ONCE:PRN
20. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
21. Pantoprazole 40 mg PO Q12H
22. Rifaximin 550 mg PO BID
23. Toujeo SoloStar U-300 Insulin (insulin glargine U-300 conc)
300 unit/mL (1.5 mL) subcutaneous QPM
24. TraZODone 50 mg PO QHS:PRN insomnia
25. Warfarin 6 mg PO DAILY16
26. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
Melena
Alcoholic Cirrhosis
SMV Thrombosis
SECONDARY DIAGNOSES
=====================
Chronic Abdominal Pain
Bipolar Disorder
CAD s/p MI
Type II Diabetes Mellitus
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 hx of TIPs procedure on anticoagulation with GI bleed.//
Portal flows? TIPs flow? Ascites?
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: TIPS ultrasound dated ___.
FINDINGS:
In comparison to the prior exam dated ___ the TIPS 1 is renamed as LT
TIPs on current study and TIPS 2 is renamed RT TIPs.
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified.
There is no ascites.
There is stable splenomegaly, with the spleen measuring 12.7 cm.
There is no intrahepatic biliary dilation. The CHD measures 3 mm.
There is no evidence of stones or gallbladder wall thickening.
Main portal vein: 84.3 cm/sec, previously 130 cm/sec. The main portal vein is
patent with hepatopetal flow.
Left TIPS is patent and demonstrates wall to wall flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Proximal TIPS: 36.7 cm/sec, previously 71 cm/sec
Mid TIPS: 29.9 cm/sec, previously 67 cm/sec
Distal TIPS: 24.3 cm/sec, previously 28 cm/sec
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior portal vein is towards the TIPS. Appropriate flow is seen in
the hepatic veins and IVC.
Right TIPS is patent and demonstrates wall to wall flow.
Portal vein and intra-TIPS velocities are as follows:
Proximal TIPS: 114 cm/sec, previously 155 cm/sec
Mid TIPS: 178 cm/sec, previously 127 cm/sec
Distal TIPS: 62.5 cm/sec, previously 40 cm/sec
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior portal vein is towards the TIPS.
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.
KIDNEYS: The previous fullness within the left renal pelvis is not visualized
on current study.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Patent TIPS x2.
2. Morphologically cirrhotic liver without focal hepatic lesions, ascites or
splenomegaly.
3. The fullness within the left renal pelvis is not visualized on current
study suggesting resolution.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall on anticoagulation.// Intracranial bleed?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Prior exam from ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, 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:
No acute intracranial process.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Melena
Diagnosed with Melena
temperature: 97.9
heartrate: 73.0
resprate: 17.0
o2sat: 100.0
sbp: 151.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man with past medical history of
EtOH cirrhosis complicated by variceal bleeding (___) at the
site of his hepaticojejunostomy (created b/c of remote
necrotizing pancreatitis), s/p TIPS, SMV/splenic/TIPS thrombosis
on warfarin, s/p parallel TIPS placement and revision ___ and
SMV/splenic stents admitted now for 1 day of melenic stools
concerning for UGIB. He was started on IV pantoprazole and
closely monitored for recurrent bleeds. His hemoglobin remained
stable ~11s and he did not require any transfusions. No evidence
of recurrence of melena. Underwent push enteroscopy with no
evidence of bleeding source and no varices seen. Small
non-bleeding erosion at J-J anastomosis was visualized. He was
transitioned back to his home medicines, including PO
pantoprazole and deemed medically cleared for discharge.
TRANSITIONAL ISSUES
=========================
[] Patient was given initial dose of HAV (Havrix) and HBV
(Engerix-B) vaccines before discharge as he was non-immune.
Please administer followup doses per standard protocol
[] Continue to monitor INR closely with outpatient labs
[] Discharge Hb: 12.6
[] Discharge Cr: 0.8
[] Discharge T bili: 0.4
ACTIVE ISSUES
=========================
# Melena
1 day history of melena. Last EGD ___ with single balloon
upper
enteroscopy was normal and no known varices. He was recently
discharged with a hemoglobin of 13.1 and had a hemoglobin on
this admission at 11.7. He was initially started on IV
pantoprazole BID for prophylaxis and his warfarin was held on
admission. He did not have any further episodes of melena or
hematochezia. Underwent push enteroscopy with no evidence of
bleeding source and no varices. Small non-bleeding erosion at
J-J anastomosis was visualized. As his hemoglobin remained
stable in the ___ during this admission, he was re-started on
his home meds, including warfarin and PO pantoprazole. He was
discharged with Hb of 11.7.
#EtOH Cirrhosis
MELD 16. Complicated by Hepatojejunal varices s/p portal
vein/SMV
stent, TIPS and coiling (___), portal vein/SMV stent
thrombosis (on warfarin), Parallel TIPS placement and revision
and SMV/splenic stents ___.
Volume: Continued home Lasix 40mg daily, without any evidence of
ascites on ultrasound
Infection: No history of SBP, received IV ciprofloxacin
transiently in the setting of potential upper GI bleed
Bleeding: as above
Encephalopathy: Continued rifaximin
Nutrition: Continued MVI, Zinc, Ascorbic acid
#SMV thrombosis: Goal INR ___. Warfarin initially held, then
restarted after suspicion for active bleed decreased (stable
H+H). Discharged on home dose of warfarin 6mg with INR of 2.1.
Name of health care proxy: ___
Relationship: mother
Phone number: ___
Code: Full code, presumed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right open ankle fracture after a fall.
Major Surgical or Invasive Procedure:
Right ankle removal of deep implanted hardware, removal of
external fixator under anesthesia, proximal tibial bone graft
harvest, distal tibia open reduction, internal fixation using a
hindfoot nail, distal/tibiotalar arthrodesis.
Anterolateral thigh free flap to close open right ankle wound.
History of Present Illness:
___ w/ hx afib on coumadin presents as transfer from ___
___ for open R ankle fracture. Pt was walking up steps
carrying 2 bags of groceries when she slipped and fell down 6
steps with no headstrike or LOC, but R ankle twisted. Taken to
OSH where she was found to have open R ankle fracture. Given 2g
ancef, attempted reduction under propofol conscious sedation,
and transferred for ortho. INR 2.6 at OSH. Last took coumadin
(2.5mg) yesterday, missed 5mg dose today. At OSH negative head
neck CT. Pt denies any other complaints besides R ankle pain.
Pt lives with her daughter, uses cane for L knee pain but very
active.
Past Medical History:
vertigo, afib, multiple R ankle surgeries w/ skin grafts as
child s/p trauma
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: Tm: 97.9 Tc: 97.2 HR: 87 BP: 133/70 O2sat: 93%RA
Gen: comfortable. NAD. A&Ox3
CV: regular rate and rhythm.
Lungs: CTAB. No respiratory distress. On RA
Abd: soft, non-tender, non-distended.
LLE: incision from donor site c/d/i. No erythema or induration.
RLE: flap site is c/d/i. Good gap refill <2 sec. Strong
dopplerable pulse in ___ the flap. It is still moderately
swollen. JP drain x 1 has thin serosanginous drainage.
Good ___ pulses bilaterally.
Pertinent Results:
___ 05:05AM BLOOD ___
___ 05:10AM BLOOD ___ PTT-36.5 ___
___ 05:45AM BLOOD ___ PTT-67.7* ___
___ 05:05AM BLOOD WBC-9.8 RBC-3.11* Hgb-8.9* Hct-28.7*
MCV-92 MCH-28.6 MCHC-31.0* RDW-14.5 RDWSD-48.6* Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem 240 mg PO QID
2. Digoxin 0.25 mg PO DAILY
3. Warfarin 2.5 mg PO 5X/WEEK (___)
4. Warfarin 5 mg PO 2X/WEEK (MO,TH)
Discharge Medications:
1. Digoxin 0.25 mg PO DAILY
2. Warfarin 2.5 mg PO 5X/WEEK (___)
3. Warfarin 5 mg PO 2X/WEEK (___)
4. Acetaminophen 650 mg PO Q4H
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Docusate Sodium 200 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Ondansetron 8 mg IV Q8H:PRN nausea/vomiting
9. Aspirin 121.5 mg PO DAILY
10. Diltiazem 240 mg PO QID
11. cefaDROXil 500 mg oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right open distal tibia fracture, above a pantalar arthrodesis
with an open wound at fracture site.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old woman s/p surgical fixation R ankle with open wound
// alignment
COMPARISON: FLUOROSCOPY FROM ___
IMPRESSION:
Known open fracture. 4 fixation wires as well as external fixators are
visualized. The alignment appears appropriate.
Radiology Report
INDICATION: ___ year old woman with right ankle fracture // right ___ angiogram
to evaluate vessels prior to flap placement
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating 2 mg of midazolam
throughout the total intra-service time of 1 hr and 5 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. 1 back of FFP was
administered (322 mL)
MEDICATIONS: Midazolam, FFP
CONTRAST: 71 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 18 min, 67 mGy
PROCEDURE:
1. Right lower extremity angiogram.
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.
Using palpatory, ultrasound and fluoroscopic guidance, the left common femoral
artery was punctured using a micropuncture set at the level of the mid femoral
head. A ___ wire was advanced easily under fluoroscopy into the aorta. A
small skin incision was made over the needle and the needle was exchanged for
a 5 ___ sheath which was attached to a continuous heparinized saline side
arm flush.
An Omni flush catheter was advanced over the wire and the ___ wire was
exchanged for a Glidewire. The Glidewire was used to select the left external
iliac artery and the Omniflush catheter was exchanged for a C2 glide catheter.
The C2 glide catheter was advanced into the superficial femoral artery.
FINDINGS:
There is diffuse, moderate atherosclerosis with no evidence of flow limiting
lesion throughout the right lower extremity. The right common femoral artery,
superficial femoral artery, profunda and popliteal arteries are patent. The
anterior tibial and posterior tibial arteries are patent to the foot with a
patent dorsalis pedis artery. The peroneal artery is patent until the level of
the ankle.
IMPRESSION:
Two vessel runoff to the right foot through the anterior tibial and posterior
tibial arteries.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT IN O.R.
INDICATION: ORIF
TECHNIQUE: Screening provided knee operating room without a radiologist
present. Total fluoroscopy time 114.2 seconds.
COMPARISON: ___.
FINDINGS:
Images obtained in the operating room demonstrate placement of intra medullary
rod in the distal right tibia extending across the tibiotalar and subtalar
joint, with interlocking calcaneal screws. There are also interlocking
proximal screws. For details of procedure, please consult the procedure
report. Extensive background hindfoot and midfoot ankylosis. Large lateral
bone fragment the level of the ankle noted.
Radiology Report
INDICATION: Open ankle fracture.
TECHNIQUE: 3 fluoroscopic spot images without the radiologist present.
COMPARISON: None.
FINDINGS:
3 fluoroscopic spot images are provided for localization purposes of the known
open fracture. Evaluation of the fracture is difficult on these images.
There is a known medial malleolar fracture and a displaced lateral malleolar
fracture. There is impaction of the tibia on the talus. 4 fixation wires are
appreciated. There is air in the soft tissues consistent with the known open
fracture. The total fluoroscopic time is 44.0 seconds. For further details
please see the intraoperative note.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Transfer, s/p Fall
Diagnosed with FX MEDIAL MALLEOLUS-OPEN, FALL ON STAIR/STEP NEC
temperature: 97.4
heartrate: 90.0
resprate: 16.0
o2sat: 98.0
sbp: 128.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right ankle irrigation and
debridement and external fixator placement, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications. After her
posttraumatic swelling resolved, the patient was taken to the
operating room on ___ for right ankle irrigation and
debridement, hindfoot fusion nail, and wound vac placement over
medial ankle wound, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications. In order to
address her medial ankle wound, the patient was taken to the
operating room on ___ for anterolateral thigh free flap
placement, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications. For all operations, the patient was given
___ antibiotics and anticoagulation per routine with
a Heparin drip (due to her diagnosis of atrial fibrillation).
After the patient's final operation during this hospitalization,
she was transitioned back to her home Coumadin regimen for
anticoagulation. The patient's home medications were otherwise
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
During her hospitalization, the patient had one episode of chest
tightness for which the primary team immediately responded. The
patient's vital signs were stable and within normal limits
during this isolated episode. She had no other associated
symptoms, as she was breathing comfortably on room air with good
oxygen saturation and no other radiating pain. A 12-lead EKG was
obtained, and it was unchanged from her baseline EKG. Her CBC,
electrolytes were within normal limits and she had negative
troponins. She was noted to be quite anxious and informed the
primary team that she had been very nervous regarding her
surgeries. She was given a single dose of IV lorazepam, to which
she responded quickly. Her chest tightness was completely
resolved and did not return. Her vital signs were monitored
closely for the next few hours, and remained stable within
normal limits. 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
nonweight bearing in the right lower extremity, and will be
discharged on Coumadin for DVT prophylaxis. The patient will
follow up with Drs. ___ per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / Bactrim
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___: Coronary artery bypass grafts x4 (LIMA-LAD, SVG-PDA,
SVG-OM1, SVG-Diag); Endovascular saphenous vein harvest RLE.
History of Present Illness:
Mr. ___ is a ___ male with a history of coronary
artery disease, hyperlipidemia, and hypertension. He presented
to the E with chest pain. He was walking around in his apartment
this morning and he started having left-sided squeezing chest
pain that radiated to his left arm and jaw with some associated
diaphoresis and shortness of breath. He took 2 doses of
sublingual nitroglycerin and his pain resolved after resting. He
presented to his PCP at his already scheduled appointment and
was noted to have new ST depressions on EKG. He was given a full
dose of aspirin at that time and transferred by ambulance to our
facility for evaluation. Upon arrival to the ED, he was chest
pain-free. A cardiac catheterization demonstrated severe left
main coronary artery disease. Cardiac surgery was consulted for
revascularization.
Past Medical History:
Allergic Rhinitis
Asthma
Calcium Pyrophosphate Deposition Disease
Coronary Artery Disease
Depression
GI Bleed
Hyperlipidemia
Hypertension
Osteoarthritis on MTX and prednisone
Psuedogout
PTSD
TMJ
Surgical History:
Removal of parathyroid lesion
Facial reconstruction secondary to trauma
Tonsillectomy
Social History:
___
Family History:
Father ___ CAD/PVD
Maternal Grandfather ___ at age ___ Cancer - Prostate
Maternal Grandmother ___ at age ___ Cancer - Colon;
Diabetes-Adult Onset
Mother Alive ___ CAD/PVD
Paternal Grandfather ___ at age ___ Diabetes-Adult Onset
Paternal Grandmother ___ at age ___ Cancer - Breast;
Diabetes-Adult Onset
Paternal Uncle ___
Sister Alive
Physical Exam:
___ BP: 101/60 HR: 83 RR: 16 O2 sat: 92% O2 delivery:
Ra
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade __none____
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [x] __none___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: cath site Left: 2+
Carotid Bruit: Right: none Left: none
Discharge Exam
Physical Examination:
General: NAD [x]
Neurological: A/O x3 [x] non-focal x[]
HEENT: PEERL []
Cardiovascular: RRR [x]
Respiratory: Dim bibasilar with rales [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] No Edema
Left Upper extremity Warm [x] No Edema
Right Lower extremity Warm [x] tr Edema
Left Lower extremity Warm [x] tr Edema
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage []
Sternum stable [x] Prevena [x]
Lower extremity: Right [x] Left [] CDI []
Pertinent Results:
Transthoracic Echocardiogram ___
The left atrium is elongated. The right atrium is moderately
enlarged. There is no evidence for an atrial septal defect by
2D/color Doppler. There is mild symmetric left ventricular
hypertrophy with a normal
cavity size. There is a small area of regional left ventricular
systolic dysfunction with hypokinesis of the basal and mid
inferior and inferolateral walls (see schematic) and
preserved/normal contractility of the remaining segments. The
visually estimated left ventricular ejection fraction is 50-55%.
There is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Tissue Doppler suggests an
increased left ventricular filling pressure (PCWP greater than
18 mmHg). Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is normal for gender with
a normal ascending aorta diameter for gender. The aortic arch
diameter is normal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is trace aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The pulmonic valve leaflets are not well seen.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and mild regional systolic dysfunction in a
PDA distribution. Increased PCWP. Normal right ventricular
cavity size and systolic function. Mild mitral regurgitation.
Trace aortic regurgitation. Indeterminate pulmonary artery
systolic pressure.
Cardiac Catheterization ___
right dominant; heavily calcified vessels.
LMCA: 90% stenosis in the distal segment extending to the ostium
of the LAD and LCX.
LAD: 80% stenosis in the proximal segment. 50% stenosis in the
proximal segment. 70% stenosis in the mid segment. The ___
Diagonal has a 70% stenosis in the proximal segment.
LCx: mild irregularities. ___ Obtuse Marginal with 100% stenosis
in the proximal segment. ___ Obtuse Marginal with 100% stenosis
in the proximal segment. OM1 and OM2 fill via collaterals.
RCA: 100% stenosis in the mid segment. Distal vessel fills via
left to right and right to right collaterals.
Transesophageal Echocardiogram ___
PRE-OPERATIVE STATE: Sinus rhythm.
Left Atrium ___ Veins: Normal ___ size. No spontaneous
echo contrast is seen in the ___.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Normal interatrial septum. No atrial septal defect by 2D/color
flow Doppler.
Left Ventricle (LV): Normal wall thickness. Normal cavity size.
Mild regional systolic dysfunction (see schematic). Low normal
ejection fraction. Intrinsic LVEF likely lower due to severity
of mitral regurgitation. Grade II diastolic dysfunction.
Right Ventricle (RV): Normal cavity size. Normal free wall
motion.
Aorta: Normal sinus diameter. Normal ascending diameter. Normal
arch diameter. Normal descending aorta diameter. No sinus
atheroma. Simple atheroma of ascending aorta. Simple arch
atheroma. Simple descending
atheroma.
PULMONARY ARTERY: Normal main diameter.
Aortic Valve: Thin/mobile (3) leaflets. Minimal leaflet
calcification. No stenosis. Trace regurgitation. Central jet.
Mitral Valve: Normal leaflets. Mild leaflet calcification. No
systolic prolapse. Mild annular calcification. Moderate [2+]
regurgitation. Eccentric, inferolaterally directed jet.
Pulmonic Valve: Normal leaflets. Trivial regurgitation.
Tricuspid Valve: Normal leaflets. Trace regurgitation. Central
jet.
POST-OP STATE: The TEE was performed at 12:37:00. Atrial paced
rhythm.
Post-op Comments Patient post CABG x5
Support: Vasopressor(s): Phenylephrine.
Left Ventricle: Similar to preoperative findings. Similar
regional function. Global ejection fraction is low normal.
Right Ventricle: No change in systolic function.
Aorta: Intact. No dissection.
Aortic Valve: No change in aortic valve morphology from
preoperative state. No change in aortic regurgitation.
Mitral Valve: No change in mitral valve morphology from
preoperative state. No change in valvular regurgitation from
preoperative state.
Tricuspid Valve: No change in tricuspid valve morphology vs.
preoperative state. No change in regurgitation vs preoperative
state.
Pericardium: No effusion.
Discharge Labs
___ 06:03AM BLOOD WBC-10.2* RBC-2.80* Hgb-7.6* Hct-25.1*
MCV-90 MCH-27.1 MCHC-30.3* RDW-17.4* RDWSD-57.1* Plt ___
___ 04:59AM BLOOD WBC-11.1* RBC-3.02* Hgb-8.1* Hct-26.7*
MCV-88 MCH-26.8 MCHC-30.3* RDW-17.5* RDWSD-54.4* Plt ___
___ 06:03AM BLOOD Glucose-111* UreaN-16 Creat-0.7 Na-136
K-4.3 Cl-99 HCO3-23 AnGap-14
___ 04:59AM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-135
K-3.9 Cl-96 HCO3-25 AnGap-14
___ 05:22AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-133*
K-4.8 Cl-95* HCO3-27 AnGap-11
Medications on Admission:
1. Naloxone Nasal Spray 4 mg IH ONCE MR1 overdose
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain -
Severe
4. BusPIRone 30 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Artificial Tears GEL 1% ___ DROP BOTH EYES Q2H:PRN dry eyes
7. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain
8. Vitamin D ___ UNIT PO DAILY
10. Atorvastatin 80 mg PO QPM
11. FoLIC Acid 1 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Lisinopril 10 mg PO DAILY
15. LORazepam 0.25-0.5 mg PO QHS:PRN anxiety, insomnia
16. Colchicine 0.6 mg PO DAILY
17. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
18. FLUoxetine 40 mg PO DAILY
19. Omeprazole 40 mg PO BID
20. PredniSONE 5 mg PO DAILY
21. Methotrexate 25 mg PO QTHUR
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Calcium Carbonate 500 mg PO Q8H
with meals
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY Duration: 5 Days
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q 4 hours Disp #*30
Capsule Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
8. Senna 17.2 mg PO DAILY
9. Artificial Tears GEL 1% ___ DROP BOTH EYES Q8H dry eyes
10. Metoprolol Tartrate 50 mg PO Q8H
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
12. Aspirin EC 81 mg PO DAILY
13. Atorvastatin 80 mg PO QPM
14. BusPIRone 30 mg PO BID
15. FLUoxetine 40 mg PO DAILY
16. Fluticasone Propionate NASAL ___ SPRY NU DAILY:PRN allergy
17. FoLIC Acid 1 mg PO DAILY
18. LORazepam 0.25-0.5 mg PO QHS:PRN anxiety, insomnia
19. Naloxone Nasal Spray 4 mg IH ONCE MR1 overdose
20. Omeprazole 40 mg PO BID
21. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Severe
22. PredniSONE 5 mg PO DAILY
23. Vitamin D ___ UNIT PO DAILY
24. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you follow in clinic or
restarted by your cardiologist
25. HELD- Methotrexate 25 mg PO QTHUR This medication was held.
Do not restart Methotrexate until you are cleared by the clinic
to restart
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft
Past medical history:
Hyperparathyroidism
Asthma
PTSD
Calcium pyrophosphate deposition disease
h/o UGIB
Chronic facial pain secondary to trauma
Psuedogout
Arthritis on MTX and prednisone
Depression
Removal of parathyroid lesion
Facial reconstruction secondary to trauma
Tonsillectomy
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Trace Edema bilaterally, right thigh ecchymosis
Followup Instructions:
___
Radiology Report
INDICATION: ___ with CAD, HTN, HLD presenting with L sided chest pain //
acute process?
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. Nipple shadows project over the lung bases. There is
the large hiatal hernia with air-fluid level noted. Cardiomediastinal
silhouette is otherwise unremarkable. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p CABG // FAST TRACK EARLY EXTUBATION CARDIAC
SURGERY Contact name: ___: ___
TECHNIQUE: AP chest x-ray
COMPARISON: Multiple priors, most recent chest PA and lateral dated ___
FINDINGS:
Compared to the most recent study 3 days prior of ___, status post
CABG with bilaterally low lung volumes and expected postsurgical changes of
the cardiomediastinal silhouette. No pneumothorax or large pleural effusion.
Mild atelectasis. The endotracheal tube terminates appropriately 3.6 cm above
the carina. Appropriate positioning of bilateral chest tubes. The
mediastinal tube tip terminates at the level of the diaphragm. The right IJ
central venous catheter terminates at the caval atrial junction. The enteric
tube terminates within the esophagus.
IMPRESSION:
1. Status post CABG with expected bilateral low lung volumes. No pneumothorax
or pleural effusion.
2. The enteric tube terminates within the esophagus. Recommend advancement at
least 12 cm.
3. Mediastinal drain tip noted to terminating at the level of the diaphragm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p cabg // s/p mt removal and pleural
tubes on water seal
TECHNIQUE: AP chest x-ray
COMPARISON: Multiple prior studies, most recent ___
FINDINGS:
Bilateral low lung volumes. No pneumothorax or pleural effusions following
chest tubes to water seal. Interval removal of the endotracheal and enteric
tube. Unchanged cardiomediastinal silhouette. Sternotomy wires aligned and
intact. Moderate-sized hiatal hernia.
IMPRESSION:
1. Interval extubation and removal of the enteric tube.
2. No pneumothorax or pleural effusion following chest tube to water seal.
3. Moderate size hiatal hernia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest tube removal // eval for ptx,
effusions, edema
TECHNIQUE: Portable chest AP
COMPARISON: Chest radiograph dated ___
FINDINGS:
In comparison to the radiograph from ___, there are unchanged low lung
volumes. There has been interval removal of the 2 chest tubes. Sternotomy
wires are intact and aligned. No pneumothorax. Unchanged opacification at
the left lung base, consistent with atelectasis. No pulmonary edema. No
pleural effusions. Cardiomediastinal silhouette is unchanged.
IMPRESSION:
1. Interval removal of the 2 chest tubes. No pneumothorax.
2. Unchanged left basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with s/p CABG // eval for effusions, edema
eval for effusions, edema
IMPRESSION:
Comparison to ___. Better visualized is a large hiatal hernia.
Stable correct alignment of the sternal wires. Borderline size of the heart.
A previous parenchymal opacity at the left lung bases has completely resolved.
Lung volumes have returned to normal. No pleural effusion. No pulmonary
edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dizziness
Diagnosed with Acute ischemic heart disease, unspecified
temperature: 96.7
heartrate: 110.0
resprate: 20.0
o2sat: 97.0
sbp: 159.0
dbp: 102.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ presented initially to his PCP with worsening
anginal pain. He was sent to the ED, where EKG on arrival showed
ST depressions in I and aVL and early R wave progression.
Troponins elevated, plateaued at 0.06 on ___. Given his
elevated TIMI score, he had a cardiac catheterization on ___
which showed three vessel disease with 90% Left Main stenosis.
Referred to cardiac surgery for urgent CABG and underwent
appropriate surgical work-up while receiving medical management.
On ___ he was taken to the operating room where he underwent a
coronary artery bypass graft x 4. A PREVENA was placed to aid
with wound healing. Please see operative note for full details.
He tolerated the procedure well and was transferred to the CVICU
in stable condition for recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated later that day. He was weaned from inotropic and
vasopressor support. Beta blocker was initiated and he was
diuresed toward his preoperative weight. He remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. Chest tubes and pacing wires were
removed per cardiac surgery protocol. He did not have adequate
pain control with Dilaudid, therefore, APS consult was called.
His home Oxycodone was resumed and pain control improved. He had
___trial fibrillation on POD 4 which converted to
normal sinus rhythm with increased Lopressor and Magnesium. He
remained in sinus rhythm for the remainder of his hospital stay
and did not meet criteria for anticoagulation. He was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 5 he was ambulating
freely, the wound was healing with Prevena in place (to be
removed POD ___, and pain was controlled with oral
analgesics. He was discharged to ___ in good condition
with appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Sulfa (Sulfonamide Antibiotics) / Prandin / codeine /
epinephrine / glimepiride / morphine / Vicodin / ibuprofen /
Benadryl / Dilaudid / niacin / rosiglitazone / tramadol
Attending: ___
Chief Complaint:
Chest tightness, light headedness, nausea
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ yo F hx of HTN, HLD, DMII, paroxysmal afib sent from ___
office for chest pressure, lightheadedness, and nausea.
Patient reporting ___ months of increasing DOE. Previously
could walk as far as she wanted without stopping. Now only 1
city block. Not improved with albuterol. In this setting had an
exercise stress on ___. Patient developed lightheadedness and
felt that her legs would buckle during test. On EKG had ___epression during exercise in leads II, III, F,
V4-V6.
Patient reports waking up this morning and feeling lightheaded
shortly after getting out of bed. Does not think this was
positional, as no lightheadedness initially on standing. Took
her vitals at that time 160s/60s HR48 glucose in 150s. Shortly
after this she began to feel nauseous and like she needed to
have a bowel movement. Followed by chest tightness / pressure.
Middle of chest to left side of chest. No radiating. No
diaphoresis. Has had episodes of CP like this before at rest
that resolve with nitro. Did not try nitro today. Lasted a few
minutes and resolved spontaneously. Called PCP and while rushing
to get ready for appointment had another episode of chest
tightness. Also resolved in a few moments spontaneously. PCP
sent patient to the ED.
In the ED initial vitals were: 98.2 58 168/69 18 100% RA
EKG: ST depressions in I, II, V4, V5. T wave inversion in aVR,
V1. Unchanged from ___
Labs/studies notable for: Cr 0.7 INR 0.9 hgb 10.1 (stable)
Patient was given: full dose ASA
Vitals on transfer: 98.2 187/53 53 16 100%RA
On the floor patient has very mild sensation of chest
tightness. Otherwise feels well.
Past Medical History:
HTN, HLD, DMII, paroxysmal afib
Social History:
___
Family History:
father and three sisters with MI in ___
Physical Exam:
admission:
GENERAL: WDWN woman 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: No JVD
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:
GENERAL: ___ woman 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: No JVD
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
Pertinent Results:
Coronary Anatomy
The LMCA had no angiographically apparent CAD. The LAD had
moderate calcification and 60-70%
diffuse disease with serial ___ plaques elsewhere. The Cx had
mild luminal irregularities. The RCA
had proximal 50% stenosis.
Interventional Details
Percutaneous Coronary Intervention: A 6 ___ XBLAD3.5 guiding
catheter was used to engage the
LMCA and provided adequate support. A 180 cm Pressure Wire
guidewire was then successfully
delivered across the lesion. The lesion was predilated with a
2.5 mm balloon and then a 3.0 x 26 mm
Resolute stent was then deployed and postdilated with a 3.5 mm
balloon. Final angiography revealed
normal flow, no dissection and 0% residual stenosis in the stent
and 40% stenosis at a distal bifurctation
in the distal LAD.
Impressions:
1. 2 vessel disease with FFR + LAD.
2. Successful PCI of the LAD with DES..
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 12.5 mg PO DAILY
2. Eplerenone 25 mg PO DAILY
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Torsemide 2.5 mg PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. candesartan 32 mg oral Q1H
8. Digoxin 0.125 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Acebutolol 200 mg PO BID
12. LORazepam 0.5 mg PO QHS:PRN sleep
13. Omeprazole 20 mg PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Ferrous Sulfate 325 mg PO DAILY
16. Magnesium Oxide 400 mg PO ONCE
17. Aspirin 81 mg PO DAILY
18. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral QAM
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral QAM
7. candesartan 32 mg oral Q1H
8. Diltiazem Extended-Release 180 mg PO DAILY
9. Eplerenone 25 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. GlipiZIDE XL 12.5 mg PO DAILY
13. Levothyroxine Sodium 88 mcg PO DAILY
14. LORazepam 0.5 mg PO QHS:PRN sleep
15. Magnesium Oxide 400 mg PO ONCE Duration: 1 Dose
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Torsemide 2.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease
Acute coronary syndrome/unstable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest pain // ? acute process
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. Faint platelike lower lung
atelectasis is noted. No signs of pneumonia or edema. The heart and
mediastinal contours appear within normal limits. No hilar congestion or
edema. Bony structures appear intact. No free air below the right
hemidiaphragm.
IMPRESSION:
Platelike lower lung atelectasis, otherwise unremarkable.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.2
heartrate: 58.0
resprate: nan
o2sat: 100.0
sbp: 168.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ ___ year old woman with hypertension, hyperlipidemia,
type 2 diabetes not on insulin, and remote history of paroxysmal
atrial fibrillation, who presented with chest pressure,
lightheadedness, and nausea. She had negative troponins on
admission and her EKG was unchanged from baseline. Of note, she
had an exercise stress test ___ had 2 mm down sloping ST
depression during exercise in leads II, III, F, V4-V6. However,
she has had similar findings on stress tests since ___. But her
symptoms were new/worsened from baseline. She went for cardiac
catheterization on ___, and had 60-70% occlusion in the LAD
and 50% RCA occlusion. She had an LAD DES placed, and Plavix was
added to her regimen. She was already on aspirin and
candesartan, and these were continued. She was not yet started
on a beta-blocker, with recommendation that it be started if
follow up echocardiogram showed decreased ejection fraction.
Digoxin and acebutolol were discontinued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of pancreatitis (___),
choledocholithiasis and cirrhosis ___ autoimmune hepatitis c/b
hepatic encephalopathy, ascites, s/p TIPS recently (___), also
hx of grade I varices per EGD ___, on transplant list
presenting with abd pain, worsening jaundice and worsening
hyperbilirubinemia. Patient endorses nausea and vomiting and
abdominal pain for one day. It is in the RUQ and woke her up
from sleep this AM. Also with nausea and vomitting over the past
___ days. She endorses a poor appetite. Has had some blood in
stool which she attributes to straining without melena.
Otherwise moving her bowels normally. No CP, no SOB, no urinary
problems.
___ was transferred from ___ with Tbili 22.7 (from 8),
Dbili 16.2, Na 122 from 128 BUN 28 Cr 1.1. WBC 11 Plts 70. ALT
377 AST 238
Initial ED vitals were T: 97.8 HR: 70 BP:97/44 RR: 18 99% RA.
Exam was notable for scleral jaundice, abdominal TTp over RLQ,
and heme + brown stool. UA was notable for large bili, otherwise
negative, with lactate 1.7, K+ 5.9, Na 122, with ALT 380 AST 269
Tbili 23.9, lipase wnl at 51, HCT 35.3, INR 1.6. She recieved
ceftriaxone, morphine and zofran. Abdominal US did not visualize
pocket amenable to diagnostic paracentesis with no acute hepatic
findings. Liver was consulted, recommened holding diuretics,
checking cultures and admission to liver for observation.
She was recently admitted ___ to ___ for increasing
abdominal distention felt to be secondary to progression of
liver disease with 6.2 L fluid removed in total by paracentesis
and TIPS performed by ___. There was concern that the liver
capsule may have been punctured during the procedure and she
recieved FFP.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, dysuria, hematuria.
Past Medical History:
Past Medical History: (from chart, reviewed)
1. cirrhosis ___ autoimmune hepatitis
- c/b portal hypertension with ascites
- recently placed on transplant list
- previous hx of grade III varices requiring banding on ___.
Grade I varices on ___ EGD
- h/o encephalopathy
- h/o ascites
2. hx of reactive PPD and prior high risk exposure active MTB:
PPD in past and prior high risk exposure to coworker treated
with only 1 month of INH. Unclear whether ever recieved full
course of treatment for latent TB.
3. choledocholithiasis
4. pancreatitis ___
Social History:
___
Family History:
DM in the family
Physical Exam:
ADMISSION
VS: 98 95/52 76 18 100%ra
GENERAL: Ill appearing female, mild distress from abd pain
HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, dry MM
NECK: supple
LUNGS: Left basilar crackles
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, RUQ tenderness. No ascites
appreciated
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox 2.5 (wrong date in ___, CNs II-XII
grossly intact, moving all extremities. Mild asterixis
DISCHARGE
VS: 97.3 114/73 64 20 100% RA
GENERAL: elderly female, no acute distress
EYES: EOMI, sclerae icteric
ENT: oropharynx clear
NECK: No JVD, no ___
LUNGS: decreased sounds at bases
HEART: Regular, systolic murmur at LUSB, non-radiating
ABDOMEN: Obese, nontender. No ascites appreciated
EXTREMITIES: warm, no edema, 2+ pulses radial and dp
NEURO: alert, CNs II-XII grossly intact, moving all extremities.
Mild asterixis
Pertinent Results:
ADMISSION
___ 09:45PM WBC-9.2# RBC-3.06* HGB-12.2 HCT-35.3*
MCV-115* MCH-40.0* MCHC-34.7 RDW-19.2*
___ 09:45PM NEUTS-83.7* LYMPHS-9.7* MONOS-5.0 EOS-1.4
BASOS-0.2
___ 09:45PM ___ PTT-36.4 ___
___ 09:45PM PLT COUNT-80*#
___ 09:45PM ALBUMIN-3.4*
___ 09:45PM LIPASE-51
___ 09:45PM ALT(SGPT)-380* AST(SGOT)-269* ALK PHOS-242*
TOT BILI-23.9* DIR BILI-14.2* INDIR BIL-9.7
___ 09:45PM GLUCOSE-121* UREA N-29* CREAT-0.8 SODIUM-122*
POTASSIUM-5.9* CHLORIDE-89* TOTAL CO2-22 ANION GAP-17
___ 09:58PM LACTATE-1.7
___ 11:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-4* PH-6.5 LEUK-NEG
___ 11:35PM URINE COLOR-Brown APPEAR-Clear SP ___
DISCHARGE
___:20AM BLOOD WBC-2.7* RBC-2.55* Hgb-9.7* Hct-27.6*
MCV-108* MCH-38.0* MCHC-35.2* RDW-25.2* Plt Ct-32*
___ 07:20AM BLOOD Plt Ct-32*
___ 07:20AM BLOOD Glucose-122* UreaN-15 Creat-0.6 Na-126*
K-5.9* Cl-100 HCO3-19* AnGap-13
___ 07:20AM BLOOD ALT-87* AST-78* AlkPhos-131*
TotBili-26.3*
___ 07:20AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.6* Mg-2.1
LIVER ULTRASOUND ___:
1. Cirrhosis with trace perihepatic ascites.
2. Status post TIPS with wall to wall flow, with velocities
described above, which are similar to the prior exam.
3. Cholelithiasis without evidence for cholecystitis. No
reported sonographic ___ sign.
CT ABD & PELVIS W CONTRAST ___:
1. Patient status post TIPS procedure with 3.5 x 6.7 x 4.7 cm
heterogeneously hypodense, nonenhancing region near the TIPS
shunt. This likely represents a combination of some venous
thrombosis, small bilomas and expected post-TIPS changes.
2. Occlusion of the accessory hepatic vein distal to the TIPS
shunt due to use of a covered stent.
3. Nonocclusive left portal vein thrombus and tiny nonocclusive
thrombus near the portal splenic confluence.
4. No abnormality to correlate with history of rectal bleeding.
No evidence of active contrast extravasation in the
gastrointestinal tract.
5. Sequelae of portal hypertension including splenomegaly and
ascites. Ascites is improved from comparison exam.
6. Mosaic attenuation of the lung bases likely due to small
airways or small vessel disease.
EGD ___: Varices at the upper third of the esophagus
suggestive of "downhill" varices. Erythema with exudate in the
distal esophagus compatible with mild esophagitis. Otherwise
normal EGD to ___ part of the duodenum
COLONOSCOPY ___: Normal colonoscopy to the cecum. Sub-optimal
prep.
CULTURES:
___ CULTURE: no growth
___ CULTURE: pending
___ CULTURE: no growth
___ SWAB: negative
___ CULTURE: no growth
___ CULTURE: no growth
Radiology Report
HISTORY: Autoimmune hepatitis and cirrhosis on transplant list, status post
TIPS procedure. Question acute bleed for hemobilia.
TECHNIQUE: Noncontrast, arterial, portal venous and delayed phase sequences
for sorry series were performed through the abdomen following uneventful
administration of 150 cc Omnipaque IV contrast. Coronal and sagittal
reformats were provided by technologist.
DLP: ___ mGy-cm.
COMPARISON: Multiphasic CT of the liver, ___, TIPS procedure ___, MRI abdomen ___.
FINDINGS:
The lung bases demonstrate heterogeneous density with mild bilateral
atelectasis. No suspicious nodule or mass is seen. Heart size is mildly
enlarged. Normal appearance of the gastroesophageal junction.
The liver demonstrates a nodular, cirrhotic appearance. There is a small to
moderate amount of ascites. The patient is status post TIPS procedure. In
the right hepatic dome there are new areas of heterogeneous for hypodensity
which do not enhance in the region of the TIPS measuring approximately 3.5 x
6.7 x 4.7 cm. There is also new thrombus in the accessory right hepatic vein,
which supplied the systemic side of the TIPS shunt. The TIPS shunt appears
patent. There is also nonocclusive thrombus in the left portal vein, which is
limited to an area within the fissure of the ligament has falciform ligament
and likely due to altered flow dynamics status post TIPS. The hepatic veins
are diminutive in size, likely due to portal systemic shunting. The main
portal vein demonstrates a tiny, nonocclusive thrombus near the portal splenic
confluence. No arterially enhancing liver lesions are identified.
The gallbladder demonstrates gallstones without evidence of acute
cholecystitis. Normal appearance of the pancreas. The spleen remains
enlarged measuring 16.6 cm. Normal appearance of the adrenals and kidneys.
Small and large bowel are unobstructed. No significant rectal varices or
evidence of active contrast extravasation in the GI tract is seen.
Atherosclerotic aortic calcifications are noted without evidence of aneurysm
or dissection.
Degenerative changes of the lumbar spine are noted without acute or suspicious
osseous abnormality.
IMPRESSION:
1. Patient status post TIPS procedure with 3.5 x 6.7 x 4.7 cm heterogeneously
hypodense, nonenhancing region near the TIPS shunt. This likely represents a
combination of some venous thrombosis, small bilomas and expected post-TIPS
changes.
2. Occlusion of the accessory hepatic vein distal to the TIPS shunt due to use
of a covered stent.
3. Nonocclusive left portal vein thrombus and tiny nonocclusive thrombus near
the portal splenic confluence.
4. No abnormality to correlate with history of rectal bleeding. No evidence
of active contrast extravasation in the gastrointestinal tract.
5. Sequelae of portal hypertension including splenomegaly and ascites.
Ascites is improved from comparison exam.
6. Mosaic attenuation of the lung bases likely due to small airways or small
vessel disease.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: LIVER- TRANSFER
Diagnosed with OTH SEQUELA, CHR LIV DIS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.8
heartrate: 70.0
resprate: 18.0
o2sat: 99.0
sbp: 97.0
dbp: 44.0
level of pain: 4
level of acuity: 2.0 | ___ h/o autoimmune hepatitis listed for transplant, hepatic
encephalopathy, ascites, s/p TIPS (___), grade I varices (EGD
___, pancreatitis (___), choledocholithiasis p/w nausea /
vomiting, RUQ abd pain, bloody stool, and hyperbilirubinemia.
# RUQ abdominal pain: She presented with RUQ abdominal pain
radiating to the right chest, which resolved on its own without
intervention. This was likely injury to liver parenchyma related
to her TIPs procedure. CT abdomen showed a 3x7x5cm non-enhancing
lesion surrounding TIPS (biloma vs venous thrombosis). She
refused a paracentesis during this admission, and did not have
evidence of SBP. There was no evidence for cholecystitis on US
and CT. Her Tbili was elevated on admission, however remained
stable. MELD 24. She had EGD ___ without observed bleeding from
common bile duct, and a colonoscopy ___ without evidence of
bleeding. She was treated with a short course of ceftriaxone
(___), albumin infusions, lactulose and rifaximin, and close
monitoring. She did not require surgical or endoscopic
intervention for her abdominal pain, and at the time of
discharge was much improved.
# Autoimmune hepatitis/Cirrhosis: c/b HE, ascites, grade I
varices (per EGD ___. Transplant list. Baseline MELD 24 on
admission from 16 at baseline. Tbili on admission 23 (baseline
8.5). Has been off nadolol due to hx dizziness. She was
continued on azathioprine 100mg daily, lactulose and rifaximin.
Her nadolol was held in the setting of hypotension. Her
prednisone was tapered (15mg at home, decreased by 2.5mg every 4
days). At the time of discharge, her LFTs were elevated but
stable, and her MELD was ___.
# Hypotension: She was found to have secondary adrenal
insufficiency given hyponatremia, hypokalemia, and that she has
been on prednisone x ___ yrs. Her AM cortisol was low (2.6), and
cortisone stimulation test showed an increase in 7.6 to 15.3
(suggesting secondary adrenal insufficiency. Endocrine was
consulted, and recommended a prednisone taper (decreased by
2.5mg every 4 days, recheck cortisol when down to 5mg).
# BRBPR / anemia: Hct ___ from baseline ___. Stool guiac
negative, however her BRBPB was likely ___ hemorrhoidal bleed.
No active bleed seen on CTA abdomen, EGD, or colonoscopy. DIC
labs significant for low fibrinogen 144 and elevated FDP ___,
although LDH 208 wnl. She received a total of 3 units pRBCs
during this admission. Her Hct at the time of discharge was
stable at 27.6.
# Hyponatremia: stable. Likely hypovolemic hyponatremia in the
setting of diuresis, dehydration, and liver disease. FeUrea 27%
on admission, suggests pre-renal. Her diuretics were held, and
she received albumin for resuscitation as needed.
CHRONIC ISSUES
# Hyperkalemia: likely secondary to secondary adrenal
insufficiency. She was treated with prednisone taper, and
kayexalate as needed.
TRANSITIONAL ISSUES
# Patient admitted with abdominal pain, hyperbilirubinemia, and
hyponatremia. Patient underwent CT scan, which showed a possible
biloma or infarction at the site of her recent TIPS. There was
no evidence of infection, and her pain resolved prior to
discharge. Diuretics discontinued. Sodium levels remained
stable. Bilirubin levels also remain elevated, but stable prior
to discharge.
# She had low SBP in the ___. Was seen by Endocrine given
concern for secondary adrenal insuffiency. Her cortisone stim
test showed secondary adrenal insufficiency (intact adrenal
glands with chronic central suppression from prednisone). She
was started on a prednisone taper (10mg on ___ to be decreased
by 2.5mg every 4 days. When she reaches 5 mg daily, she should
have her cortisol level rechecked, and if this is normal, then
her steroid taper may continue. If not, may need referral to
Endocrine as outpatient.
# She will also need close follow-up in Liver Clinic given
persistently elevated bilirubin.
# Please check her sodium and potassium, which were low and high
respectively at the time of discharge. This was likely secondary
to adrenal insufficiency. Her diuretics were held at the time of
discharge.
# She has a chronic anemia, with Hct at discharge 27.6. She
required occasional blood transfusions during this admission. CT
abdomen with contrast and colonoscopy did not find a definitive
source of bleeding
# CODE: Full
# CONTACT: Daughter ___ ___ |
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 pressure and lightheadedness
Major Surgical or Invasive Procedure:
Synchronised cardioversion 200 J
History of Present Illness:
Mr. ___ is a ___ year old man with a history of dyslipidemia,
nephrolithiasis, recent STEMI s/p 2 DES in ___ who presented
today with L chest pain and associated lightheadedness.
Today, was in his usual state of health and while he was
standing when he had left sided upper chest pressure. He took a
baby aspirin. Went away for a couple minutes but came back. Took
another baby aspirin. Later on, developed lightheadedness as
well. While it did not feel like how he felt when he had a heart
attack, he was concerned enough to come to the hospital. Denied:
chest pain, back pain, neck pain, arm pain, headache, vision
changes, diaphoresis, abdominal pain, muscle weakness. Confirms
consistent back pain but has been stable and has known kidney
stone on Flomax.
Recent diagnosis of CAD with inferoposterior STEMI s/p DES to
LCx ___, followed by staged PCI with DES to LAD on ___.
Hospitalized ___ for STEMI c/b cardiogenic shock as well as
acute nephrolithiasis. Discharged on ASA/ticagrelor. Has been
compliant with all medications since discharge.
In the ED,
#initial vitals were:
- HR 146, BP 129/103, RR 18, SpO2 100% on RA
#EKG: Wide-complex tachycardia, LBBB, superior axis, CL 420 ms
interspersed with sinus/fusion beats likely representing VT.
On arrival, was hemodynamically stable but tachycardic.
Cardiolgoy was consulted. Blood pressures dropped to 68/51 and
underwent synchronized cardioversion which was unsuccessful. Was
going to give lidocaine but spontaneously cardioverted. Repeat
EKG revealed sinus rhythm with rates in ___, q waves and twi in
II/III/avF and tall R waves in precordial leads consistent with
prior inferoposterior STEMI. IVF was started and was amiodarone
loaded, sent to the CCU subsequently with vital signs prior to
transfer being 98.7 72 95/67 20 100% RA.
Past Medical History:
1. CARDIAC RISK FACTORS
- Severe hyperlipidemia
2. CARDIAC HISTORY
- STEMI ___: LCx 100% s/p DES, LAD 70% s/p DES, RCA
80-90%
- Echo ___: biplane LVEF = 39%
3. OTHER PAST MEDICAL HISTORY
- Nephrolithiasis
- Extraction of needle in toe
- GERD
- Microscopic hematuria, not yet worked up
- Erectile dysfunction
Social History:
___
Family History:
Mother with lung cancer and stroke, father s/p CABG, borther
with throat cancer obesity and substance abuse, sister with
melanoma and chronic lymphocytic leukemia.
Physical Exam:
Admission exam:
===============
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP at clavicles at 45 degrees
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge exam:
===============
VS: Afebrile 100s-120s/50-60s 60-70s ___ 96% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP at clavicles at 45 degrees
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
Admission labs:
===============
___ 11:35AM BLOOD WBC-9.9 RBC-4.75 Hgb-14.5 Hct-42.7 MCV-90
MCH-30.5 MCHC-34.0 RDW-12.7 RDWSD-41.9 Plt ___
___ 11:35AM BLOOD Neuts-67.5 Lymphs-17.8* Monos-11.6
Eos-2.4 Baso-0.3 Im ___ AbsNeut-6.65* AbsLymp-1.75
AbsMono-1.14* AbsEos-0.24 AbsBaso-0.03
___ 11:35AM BLOOD ___ PTT-34.7 ___
___ 11:35AM BLOOD Plt ___
___ 11:35AM BLOOD Glucose-102* UreaN-9 Creat-1.0 Na-137
K-4.0 Cl-101 HCO3-25 AnGap-15
___ 11:35AM BLOOD CK(CPK)-97
___ 05:01AM BLOOD ALT-21 AST-18 LD(LDH)-355* AlkPhos-94
TotBili-0.5
___ 11:35AM BLOOD CK-MB-2 proBNP-1363*
___ 11:35AM BLOOD cTropnT-0.97*
___ 11:35AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.4
___ 05:00PM BLOOD TSH-4.7*
___ 05:01AM BLOOD Free T4-0.9*
___ 11:47AM BLOOD Lactate-1.7
Micro:
======
none
Studies:
========
CXR ___: No acute pulmonary process identified.
TTE ___: pending final read
Discharge labs:
===============
___ 05:15AM BLOOD WBC-8.4 RBC-3.97* Hgb-12.0* Hct-35.5*
MCV-89 MCH-30.2 MCHC-33.8 RDW-12.7 RDWSD-41.7 Plt ___
___ 05:15AM BLOOD Glucose-94 UreaN-8 Creat-0.9 Na-139 K-4.3
Cl-104 HCO3-22 AnGap-17
___ 05:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QPM
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Simvastatin 10 mg PO QPM
6. Tamsulosin 0.4 mg PO DAILY
7. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
8. pitavastatin 1 mg oral 3X/WEEK
9. LORazepam 1 mg PO Q8H:PRN pain
10. Lidocaine 5% Ointment 1 Appl TP DAILY
Discharge Medications:
1. Amiodarone 400 mg PO TID
2. Amiodarone 200 mg PO DAILY
Please start this dose on ___. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
4. Aspirin 81 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lisinopril 2.5 mg PO DAILY
7. LORazepam 1 mg PO Q8H:PRN back pain
8. Metoprolol Succinate XL 25 mg PO DAILY
9. pitavastatin 1 mg oral 3X/WEEK
10. Tamsulosin 0.4 mg PO QHS
11. TiCAGRELOR 90 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Ventricular tachycardia
SECONDARY:
Coronary Artery Disease
Nephrolithiasis
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: ___ with STEMI 1 wk prior now w/ palpitations, CP concerning for
prior angina.
TECHNIQUE: Frontal view
COMPARISON: ___ chest radiographs
FINDINGS:
Lordotic positioning. Lungs are fully expanded. No CHF, focal infiltrate,
pleural effusion or pneumothorax detected.. Heart size at the upper limits of
normal or slightly enlarged. Aorta calcified and minimally tortuous.
Allowing for this, the mediastinal contour is within normal limits for age.
IMPRESSION:
No acute pulmonary process identified.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Chest pain
Diagnosed with Ventricular tachycardia
temperature: 98.2
heartrate: 146.0
resprate: 18.0
o2sat: 100.0
sbp: 129.0
dbp: 103.0
level of pain: 8
level of acuity: 1.0 | Mr. ___ is a ___ year old man with a history of dyslipidemia,
nephrolithiasis, recent STEMI s/p 2 DES in ___ who presented
today with L chest pain and associated lightheadedness and found
to have sustained monomorphic vtach self resolved and back in
sinus rhythm.
# CORONARIES: STEMI ___: LCx 100% s/p DES, LAD 70% s/p
DES, RCA 80-90% no stent placed
# PUMP: Echo ___: biplane LVEF = 39%
# RHYTHM: sinus rhythm
#Ventricular tachycardia:
Noted to have monomorphic ventricular tachycardia in the ED.
Became hypotensive to SBPs ___ in the setting of sedation for
cardioversion. He subsequently had unsuccessful synchronized
cardioversion. He reverted into sinus rhythm spontaneously
confirmed on EKG. He was started on amiodarone gtt and sent to
CCU. No electrolyte abnormalities and not hypoxic on admission.
No new medications that may cause increased risk for VT.
Etiologies include: cardiac irritation from recent STEMI,
developing scar tissue, re-entrant rhythm from ischemia,
hypothyroidism. Aside from q waves and twi in inferior leads and
tall R waves in precordial leads which are consistent with prior
inferoposterior infarct, no other striking evidence of ischemia.
Cardiac enzymes were trended and troponin was elevated, but
CK-MB remained flat. Therefore, repeat cardiac catheterization
was not pursued. Amiodarone gtt was transitioned to amiodarone
400mg TID, plan for transition to 200mg daily after 1 week. He
had no further events on telemetry. EP was consulted and
recommended no ablation, ICD placement or ___ vest given stable
presentation, self-resolution, stability on amiodarone, and
likely triggered rhythm as opposed to re-entrant circuit.
Baseline TSH 4.7. Baseline LFTs ALT 21, AST 18, Alk phos 94, T
bili 0.5. Will need PFTs as well as outpatient EP follow up.
#CAD | HLD | H/o STEMI:
STEMI ___ LCx 100% s/p DES, LAD 70% s/p DES, RCA 80-90%
no stent placed. Continued aspirin, ticagrelor. Has significant
history of not tolerating many statins. On pitavastatin 3x/week
at home. Continued on ASA and ticagrelor. Pitavastatin was held
given not on formulary. Will require lipid specialist follow up
for statin resistance, as well as general cardiology follow up.
#HFrEF:
EF of 39% in setting of STEMI. Metoprolol was continued
fractionated.
#Flank pain, nephrolithiasis:
1.5 cm stone in R renal pelvis. Continues to have pain. Urology
appointment on outpatient basis still needs to be scheduled.
Continued lidoaine patch, Ativan prn, and Flomax.
============================
TRANSITIONAL ISSUES
============================
[] Discharged on amiodarone 400mg TID, transition to 200mg daily
after 1 week (start on ___
[] EP, cardiology, lipid, and urology follow up needed.
[] Baseline TSH 4.7. Baseline LFTs ALT 21, AST 18, Alk phos 94,
T bili 0.5.
[] Will need ___ PFTs for amiodarone.
# CODE: Full (confirmed)
# CONTACT/HCP: ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nifedipine / Nexium Packet / Aspirin / Bisphosphonates
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o dementia, osteoporosis and SVT presents with LLQ
abdominal pain and altered mental status x3 days. History taken
from home aide as patient unable to give history.
Home aide reports patient had been "slower" on ___ and less
interactive and complaining of general discomfort. Then, the
evening prior to admission, the patient began complaining of
significant LLQ abdominal pain and the patient was brought to
the emergency room.
The patient has had subjective fevers but not chills. No chest
pain but occasional dyspnea. + abdominal pain as above. The
patient is occasionally incontinent of urine and has been having
increased incontinence since the onset of symptoms. No nausea,
vomiting or diarrhea. No decreased PO intake.
In the ED, initial vitals:
98.2 80 125/76 20 97% RA
Labs were significant for
UA: Large Leuks, Many Bacteria, Nitr Positive
140 102 23
-------------<123
4.5 27 0.8
ALT: 13 AP: 84 Tbili: 1.0 Alb: 3.7
AST: 24 LDH: Dbili: TProt:
___: Lip: 17
13.6
16.8>----<243
42.3
N:81.5 L:6.7 M:10.8 E:0.2 Bas:0.4 ___: 0.4 Absneut: 13.73
Abslymp: 1.12 Absmono: 1.81 Abseos: 0.03 Absbaso: 0.07
Imaging showed
___ Chest (Pa & Lat)
FINDINGS:
Lung volume is low. Mild bibasilar opacities likely reflect
atelectasis. No pneumothorax or pleural effusion is identified.
Cardiac silhouette is difficult to assess due to low lung
volumes. No displaced rib fracture is identified.
IMPRESSION:
No radiographic evidence of pneumonia.
In the ED, she received
___ 05:55 IV CeftriaXONE 1 gm
Vitals prior to transfer:
98.5 92 112/66 20 94% RA
Currently, patient is moving around in bed, interactive with
environment but no appropriately answering questions.
Past Medical History:
Hypertension
Glaucoma
h/o falls
Lesion in ___ ventricle of brain (meningioma versus choroid
plexus papilloma)
Hearing loss
Depressive disorder
Anxiety disorder
Osteoporosis
Allergic rhinitis
h/o lichen simplex chronicus
h/o peptic ulcer disease
h/o hypercholesterolemia
aortic insufficiency
h/o compression facture
SVT post-op in ___ (vs possible A-fib)
R femoral neck fracture ___
SURGICAL HISTORY
Open reduction internal fixation and debridement to and
inclusive
of bone of left distal radius fracture ___
Left femur intrameduallary nailing with trochanteric fixation
nail ___
Fixation with short Synthes trochanteric fixation
nail (TFN), 11 x ___ x ___ for right (femoral neck)
intertrochanteric hip fracture ___ ___
Social History:
___
Family History:
Three daughters with breast cancer.
Physical Exam:
ADMISSION
==========
VS: 98.2 115/89 91 18 97
GEN: NAD, moving around in bed
HEENT: Sclerae anicteric, poor dentition
___: RRR II/VI SEM, no elevated JVP
RESP: No increased WOB, bibasilar crackles, no rhonchi
ABD: suprapubic tenderness. No rebound or guarding. + b/l CVAT
EXT: Warm, no edema
Neuro: Moving all 4 extremities. No facial droop.
DISCHARGE
=========
VS: 97.8 | 110/54 | 70 | 18 | 96 RA
GEN: NAD, moving around in bed
HEENT: Sclerae anicteric, poor dentition
___: RRR II/VI SEM, no elevated JVP
RESP: No increased WOB, bibasilar crackles, no rhonchi
ABD: suprapubic tenderness. No rebound or guarding. + left sided
CVAT
EXT: Warm, no edema
Neuro: Moving all 4 extremities. No facial droop.
Pertinent Results:
ON ADMISSION
=============
___ 04:10AM BLOOD WBC-16.8* RBC-4.33 Hgb-13.6 Hct-42.3
MCV-98 MCH-31.4 MCHC-32.2 RDW-12.9 RDWSD-46.1 Plt ___
___ 04:10AM BLOOD Neuts-81.5* Lymphs-6.7* Monos-10.8
Eos-0.2* Baso-0.4 Im ___ AbsNeut-13.73* AbsLymp-1.12*
AbsMono-1.81* AbsEos-0.03* AbsBaso-0.07
___ 04:10AM BLOOD Glucose-123* UreaN-23* Creat-0.8 Na-140
K-4.5 Cl-102 HCO3-27 AnGap-16
___ 04:10AM BLOOD ALT-13 AST-24 AlkPhos-84 TotBili-1.0
___ 04:10AM BLOOD Lipase-17
___ 04:10AM BLOOD Albumin-3.7
___ 04:50AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:50AM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG
___ 04:50AM URINE RBC-5* WBC-58* Bacteri-MANY Yeast-NONE
Epi-9
___ 04:50AM URINE CastHy-8*
___ 04:50AM URINE Mucous-MANY
ON DISCHARGE
=============
___ 05:48AM BLOOD WBC-7.2 RBC-3.79* Hgb-11.8 Hct-36.9
MCV-97 MCH-31.1 MCHC-32.0 RDW-12.6 RDWSD-45.5 Plt ___
___ 05:48AM BLOOD Glucose-90 UreaN-17 Creat-0.6 Na-139
K-3.8 Cl-99 HCO3-31 AnGap-13
MICROBIOLOGY
============
___ 4:50 am URINE Site: NOT SPECIFIED
GRAY TOP HOLD # ___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
========
___ (PA & LAT)
Evaluation of lung bases is limited due to low lung volumes.
The repeat radiograph with improved inspiratory level may be
helpful to more fully evaluate left lower lobe opacities to help
distinguish atelectasis from infectious pneumonia.
___ BILAT, W/AP CHEST
1. Minimally displaced left lateral sixth rib fractures appear
acute to
subacute. Left lateral seventh rib deformity appears subacute to
chronic with probable callus formation.
2. Left lung base opacification is new from the prior study and
likely
represents a combination of pleural effusion and atelectasis.
Superimposed infectious process or aspiration cannot be
excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID before breakfast and dinner
2. raloxifene 60 mg oral DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheeze
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
7. Acetaminophen 1000 mg PO Q8H:PRN pain
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. DULoxetine 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*180 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheeze
3. Docusate Sodium 100 mg PO BID
4. DULoxetine 20 mg PO DAILY
5. Omeprazole 40 mg PO BID before breakfast and dinner
6. Senna 8.6 mg PO BID:PRN constipation
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % place on left lateral chest wall
once a day Disp #*30 Patch Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 14 Doses
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet
Refills:*0
10. Metoprolol Succinate XL 25 mg PO DAILY
11. raloxifene 60 mg oral DAILY
12. Furosemide 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
-Urinary tract infection
-Subacute fractures of left lateral ___ and 7th ribs
-Acute toxic-metabolic encephalopathy
SECONDARY
-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: History: ___ with L flank pain // rib fx or infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Lung volume is low. Mild bibasilar opacities likely reflect atelectasis,
although pneumonia is not fully excluded at the left base. Small left pleural
effusion is noted. Cardiac silhouette is difficult to assess due to low lung
volumes. No displaced rib fracture is identified. Compression deformities of
the spine appear similar to before.
IMPRESSION:
Evaluation of lung bases is limited due to low lung volumes. The repeat
radiograph with improved inspiratory level may be helpful to more fully
evaluate left lower lobe opacities to help distinguish atelectasis from
infectious pneumonia.
Radiology Report
EXAMINATION:
RIB BILAT, W/AP CHEST
INDICATION:
___ year old woman with osteoporosis, no known trauma but pain on palpation in
many regions of the chest. // Evaluate for rib fractures
TECHNIQUE: Rib films
COMPARISON: ___
IMPRESSION:
1. Minimally displaced left lateral sixth rib fractures appear acute to
subacute. Left lateral seventh rib deformity appears subacute to chronic with
probable callus formation.
2. Left lung base opacification is new from the prior study and likely
represents a combination of pleural effusion and atelectasis. Superimposed
infectious process or aspiration cannot be excluded.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, L Flank pain
Diagnosed with Urinary tract infection, site not specified
temperature: 98.2
heartrate: 80.0
resprate: 20.0
o2sat: 97.0
sbp: 125.0
dbp: 76.0
level of pain: 4
level of acuity: 2.0 | Ms. ___ is a ___ year-old lady with a history of dementia, ___,
SVT and HTN who presented with worsening confusion and decreased
activity from her baseline.
#Complicated Urinary Tract Infection: Symptomatic given AMS.
Positive UA and urine culture grew >100 000 CFU of pan-sensitive
E.coli. Given left CVAT, assumed to be pyelonephritis albeit has
alternate reasons for pain in the area (see next, rib
fractures), day 1 is ___. Switched to Bactrim DS bid to
finish 10-day course on ___.
#Rib fractures / Osteoporosis: Patient with history of
osteoporosis and multiple non-traumatic fractures in spine.
Given left chest wall pain and tenderness a rib protocoled chest
X-ray was obtained which showed sub-acute minimally displaced
fractures of the left lateral ___ ribs. Started on standing
acetaminophen 1g q8h and lidocaine 5% patch with some
improvement in pain. No report of recent falls or trauma per
daughter and home health aide.
#Acute toxic metabolic encephalopathy: Initially very confused
and somnolent. After HD#2 on antibiotics, improved to be "50%
below baseline" per home health aide. Some more improvement upon
more aggressive pain management and ambulation. Her risk factors
for prolonged encephalopathy are dementia, language barrier,
decreased mobility from chronic pain.
#Diastolic Heart Failure, not decompensated: Furosemide and
metoprolol were held on admission in setting of active infection
and soft blood pressures. Her metoprolol was restarted as her
infecion abated and BPs were in better ranges. Furosemide as her
CXR showed some increase in left-sided effusion but her BPs
decreased to the low ___. Discharged on decreased furosemide
dose of 10mg daily.
#LLL opacity: To some degree secondary to effusion but X-Ray
cannot exclude consolidation. As she did not have respiratory
symptoms she was not treated as pneumonia.
#Mobility: Evaluated by ___, found to be only ~10% below
baseline. Got 2 sessions of inpatient ___. Given that she has ___
home health aide and her mental status would benefit from going
back home and she can have home ___ she was discharged with ___
for home ___ as she is homebound. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower extremity weakness and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o female with a past medical history of morbid
obestiy, diastolic heart failure, depression, pulmonary
hypertension, essential hypertension, hypothyroidism who
presented to ___ with lower extremity weakness and edema.
Patient is a poor historian and says she has a "hard time
remembering things". Per the patient and records, patient has
had trouble ambulating over the past month. States she has
progressively become more weak and is unable to ambulate like
she used to. Per the notes from her rehab facility, patient has
been having worsening lower extremity edema which is causing
difficulty with ambulation. Patient has been refusing her lasix
because "it causes her to frequently urinate" and they d/c her
foley catheter for a period of time. Patient denied fevers,
chills, SOB, CP, abdominal pain, vision changes, HA,
lightheadedness, syncope. Denies PND, worsening orthopnea.
Denies back pain, bowel incontinence. Endorses diaphoresis,
urinary frequency, pain with urination, decreased PO intake.
Patient extremely depressed but denies SI.
In the ED, initial vitals were: 97.6, 138/87, RR 20, P72. CXR
showed minimal left basilar atelectasis, difficulty study due to
habitus. Cr 1.6. EKG RBBB and Afib. UA positive for nitrites,
trace leukocytes, moderate bacteria. s/p rocephin for possible
UTI given f/c and UA findings. BNP 4340. Patient admitted for
acute on chronic heart failure exacerbation, FTT, and inability
to ambulate.
On the floor, VS 97.8, 147/65, P 64, RR 20, 100% RA. Patient
was emotional and teary eyed. Denied any pain, SOB, N/V,
abdominal pain. Continues to endorse leg weakness.
Past Medical History:
Morbid Obesity
Diastolic CHF
Pulmonary HTN
Essential HTN
Hypothyroidism
Atrial fibrillation
OSA - not on CPAP or BiPAP
OA
Major depression d/o
Social History:
___
Family History:
family history of CHF in father, mother did not have medical
problems, no children
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:97.8 BP:147/65 P:64 R:20 O2:100%
General: bedbound, obese, alert and oriented x3, NAD, teary eye
HEENT: normocephalic, atraumatic, PERRL, EOMI,sclera anicteric,
normal oropharynx
Neck: large neck, no JVD appreciated
CV: RRR, ___ SEM at RUSB, no gallops
Lungs: unable to assess bases due to habitus, clear to
auscultation anteriorly, no crackles or wheezes appreciated
Abdomen: obese, normal bowel sounds, unable to assess for
organomegaly due to habitus and pannus
GU: f/u in place
Ext: pulses - 2+ UE, 2+ RLE, 1+ LLE, anasarca, 3+ ___ pitting
edema
Neuro: II-XII grossly intact, sensation intact in UE and ___,
plantar response is flexor, unable to assess patellar reflex,
___ UE strength, ___ dorsiflexion/plantarflexion
Skin: no ecchymoses, no petechiae, telangiectasias on chest
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.0 | BP ___ | P 48-71 | RR 20 | O2 93% RA
General: Morbidly obese, tearful at times. NAD.
HEENT: Pupils equal and reactive to light, EOM intact.
Oropharynx withour erythema or edema.
Neck: Supple, no cervical lymphadenopathy. Difficult to assess
JVD due to body habitus.
Resp: Clear to auscultation bilaterally.
CV: Irregularly irregular. Normal S1, S2. ___ Midsystolic murmur
loudest at left lower sternal border.
Abdomen: + Bowel sounds, nontender to palpation.
Ext: Radial, DP, ___ pulses 2+. Skin warm and dry. Some increased
size of right arm, does not appear erythematous or hot to the
touch. No pain with palpation.
Neuro: A+Ox3. CN II-XII grossly intact. Upper and lower
extremity strength ___.
Skin: No rashes, bruising or petechiae.
Pertinent Results:
ADMISSION LABS
___ 04:45PM GLUCOSE-136* UREA N-35* CREAT-1.6* SODIUM-135
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
___ 04:45PM proBNP-4340*
___ 04:45PM WBC-9.4 RBC-3.94* HGB-10.6* HCT-32.4* MCV-82
MCH-26.8* MCHC-32.7 RDW-17.1*
___ 04:45PM NEUTS-88.6* LYMPHS-6.7* MONOS-4.1 EOS-0.2
BASOS-0.4
___ 04:45PM PLT COUNT-134*
___ 04:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:45PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-TR
___ 04:45PM URINE RBC-1 WBC-2 BACTERIA-MOD YEAST-NONE
EPI-2
___ 04:45PM URINE HYALINE-21*
URINE CULTURE: E. coli, pansensitive.
BLOOD CULTURES x2: Pending at discharge
DISCHARGE LABS:
___ 07:40AM BLOOD Glucose-151* UreaN-37* Creat-1.7* Na-134
K-3.9 Cl-99 HC___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 225 mcg PO DAILY
2. Furosemide 60 mg PO BID
3. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
On ___
4. Docusate Sodium 100 mg PO TID
5. Amlodipine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD DAILY
To right knee on at 10A and off at 10P
8. Fentanyl Patch 75 mcg/h TP Q72H
9. Potassium Chloride 20 mEq PO DAILY
Hold for K > 5.0
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Lactulose 15 mL PO Q8H:PRN constipation
13. Bisacodyl 10 mg PR HS:PRN constipation
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO TID
4. Fentanyl Patch 75 mcg/h TP Q72H
5. Levothyroxine Sodium 225 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Duration: 7 Days
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Furosemide 60 mg PO DAILY
12. Lactulose 15 mL PO Q8H:PRN constipation
13. Lidocaine 5% Patch 1 PTCH TD DAILY
14. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Inability to Ambulate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath, inability to walk, not taking lasix.
TECHNIQUE: Portable upright AP view of the chest.
COMPARISON: None.
FINDINGS:
Study is limited due to patient rotation. Heart size is likely mildly
enlarged. Mediastinal contours are difficult to assess given patient
rotation. There is no pulmonary vascular congestion. Mild streaky left
basilar opacity likely reflects atelectasis. No focal consolidation, pleural
effusion or pneumothorax is identified. No acute osseous abnormality is seen.
IMPRESSION:
Minimal left basilar atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with SHORTNESS OF BREATH
temperature: 97.6
heartrate: 72.0
resprate: 20.0
o2sat: nan
sbp: 138.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | Patient is a ___ y/o female with a past medical history of morbid
obestiy, diastolic heart failure, depression, pulmonary
hypertension, essential hypertension, hypothyroidism who
presented to ___ with lower extremity weakness and edema.
ACUTE ISSUES
# Lower extremity weakness and edema - Patient complains of
lower extremity weakness and inability to ambulate over the past
month. Difficult to obtain a history from patient as she is a
poor historian. Spoke to nursing facility and they stated her
legs are slightly more swollen compared to baseline, however her
legs are always large and difficult to assess. She is
noncompliant with her lasix 60 mg BID and often refuses her
lasix because "it makes her urinate too frequently". Etiology of
lower extremity edema is multifactorial and is most likely a
combination of morbid obesity, CKD, venous insufficiency, and
nutritional deficiency (patient has had a decreased appetite).
There also seems to be a volitional component to her inability
to ambulate. Patient also stated that she is incontinent even
when off the lasix. Denies back pain, bowel incontinence, has
___ strength in lower extremities. Plantar reflex is flexor
bilaterally. Patient also has "fear" of walking, which may be
contributing to her inability to ambulate. Administered IV lasix
during hospitalization. Wrapped legs with ace wrap and elevated
legs. ___ evaluated patient and recommended mobility training at
rehab. If her difficulty walking continues, she should have a
neurology consult as an outpatient.
# Elevated Creatinine: The patient's admit Cr was 1.5 and
discharge 1.7. It is unclear what her baseline is, but seems to
be 1.2-1.3. Her creatinine increased slightly with IV lasix, and
it is likely that she is not grossly fluid overloaded. The
patient will be discharged on 60mg PO lasix daily. Please check
her Cr in 1 week, and if her Cr is less than 1.5, please
increase the lasix to 60mg BID.
# Acute on chronic diastolic heart failure - Patient does not
have TTE on file or prior labs. BNP 4K on admission. Denies PND,
orthopnea, SOB; however, did have worsening bilateral ___ edema
and abdominal distention.
# Incontinence - Patient had a chronic f/c up until a few weeks
ago. She pulled out her catheter 2x at the nursing facility with
the balloon inflated. Patient saw a urologist (note in chart) on
___. Note states that "the patient urges to urinate, however
because getting out and into bed is so labor intensive, she
chooses to urinate into a diaper". Patient wanted an
anticholinergic to treat this; however, the urologist did not
think it was appropriate (as she also has constipation).
Urologist did not think a f/c was appropriate. A foley catheter
was placed on admission but removed prior to discharge. UA was
notable for nitries and bacteria. Received rocephin in the ED.
UCx grew E.coli, which was pansensitive. She was started on
Bactim x 3 days (___). BCx were negative.
# Thrombocytopenia, abdominal distention, weakness,
telangectasias, morbid obesity -Concern for NASH/cirrhosis given
physical exam findings and morbid obesity. LFTs were obtained
and AST 44, ALT 15, ALP 171, TB 1.4, Albumin 2.6. Did not obtain
RUQ ultrasound or pursue testing during admission; however,
recommend work up as outpatient if clinically indicated.
# Major depression - patient very teary eyed and "without a
home" although she is living at rehab for the time being.
Without SI. Decreased appetite and trouble remembering things
(memory difficulties over past couple of days). Spoke to RN at
nursing facility and patient has been acting out recently.
Patient is not on any psych medications. Psychiatry was
consulted, where patient denied any depression or history of
major depression. Anti-depressant medication not indicated at
this time.
CHRONIC ISSUES
# Hypothyroidism - continued home dose of levothyroxine 225 mcg.
TSH was 3.2. No acute issues.
# Essential HTN - continued home amlodipine 10 mg daily.
Consider change amlodipine to alternative anti-hypertensive
agent given side effect of lower extremity swelling.
# Atrial fibrillation - EKG here in Afib, rate ___. On aspirin
81 mg at home. CHADS2 score is 2. Adjusted stroke risk 4.0% per
year. CHADS2VASC score 4. Based on her risk factors, would
consider changing oral anticoagulation to warfarin if
recommended by outpatient cardiologist. Will discharge patient
home on aspirin 81 mg daily.
# GERD - continued home omeprazole. No acute issues.
TRANSITIONAL ISSUES
- Needs to work with ___ as outpatient
- Please check her Cr in 1 week, and if her Cr is less than 1.5,
please increase the lasix to 60mg BID.
- Please wrap legs in ACE bandages to help with edema |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim DS / Levaquin / Vancomycin Hcl / Dilantin Kapseal /
Keflex / Ciprofloxacin / Baclofen / Detrol / lisinopril /
oxybutynin / Zosyn / cefepime / pistachio / linezolid /
azithromycin / fosfomycin
Attending: ___
Chief Complaint:
Abdominal pain, chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH of polysubstance use disorder, MVC ___ c/b T12
paraplegia, recurrent sacral/trochanteric decubitus ulcers,
neurogenic bladder, recurrent UTIs, obstructive uropathy/CKD,
ileal conduit urinary diversion c/b L anastomotic stricture
requiring L indwelling PCN (___), ESRD on HD who presents w/
LUQ pain found to have urinary tract infection.
He presents with L sided chest/abdominal pain that has been
on/off since his last discharge. Unclear history of
provoking/palliating factors, but deep breaths and movement may
make it worse. Denies f/c at home, SOB, cough, other chest pain,
N/V, his typical UTI sx though difficult to tell iso his
complicated history. has been having loose BMs one per day
Of note patient has had multiple recent admissions for urinary
tract infections. Most recently here from ___ with ___
urine
culture growing pan-sensitive E.coli, urine culture ___ growing
VRE. S/p 2 week course of fosfomycin Q72H, last day ___. In the
past has grown MDR pseudomonas (last ___. Was also admitted
___ with urine growing pan-sensitive klebsiella but he
was treated with IV meropenem for 2 weeks.
In the ED:
- Initial vital signs were notable for: 100.5 ___ 17 99%
RA
- Exam notable for: TTP in L chest wall (reproduces his pain)
without overlying ecchymosis. soft, TTP in LLQ, 1+ ___ worse on
L
than R (chronic per pt)
- Labs were notable for: WBC of 12.2, Hb 7.6, UA with 12 WBCs
and
many bacteria.
- Studies performed include: CXR: No acute cardiopulmonary
process. Patient declined CT A/P.
- Patient was given: Meropenem, oxycodone 60mg for pain
- Consults: Case was discussed with ID and he was transitioned
to
Meropenem
Vitals on transfer: 98.8 67 183/86 14 98% RA
Upon arrival to the floor, patient acting paranoid.
Confrontational with staff and refusing medical
treatment/diagnostic tests. Endorsing auditory hallucinations
and states that he feels mentally unwell. Initially refusing to
stay in room, but later returning to room.
Past Medical History:
PAST MEDICAL HISTORY
====================
- T12 paraplegia s/p spinal fusion/rod placement after car
accident ___ c/b neurogenic bladder
- Neurogenic bladder s/p ileal conduct urinary diversion
(___)
c/b L anastomotic stricture requiring chronic indwelling PCN
___, stent replaced q3months
- Multiple admissions for recurrent UTI/pyelonephritis growing
MDR organisms (E. Coli, K. pneumoniae)
- Recurrent sacral and trochanteric decubitus ulcers s/p
debridement and advancement flaps (most recently ___
- L proximal tibia and fibula fracture ___
- Hx R foot cellulitis with R lateral malleolus pressure ulcer
___, right great to patient amputation ___
- Hx R hip osteomyelitis
- H/o c. diff colitis
- Seizure disorder
- Chronic pain
- DJD shoulders/hips
- GERD
- Anxiety
- Hx substance abuse
- HTN
- Depression
- Anemia of chronic disease
Social History:
___
Family History:
Mother- NHL
Sister- uterine cancer
Father- fungal infection
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: 24 HR Data (last updated ___ @ 1637)
Temp: 99 (Tm 99.9), BP: 182/95 (182-195/85-114), HR: 122
(93-142), RR: 18, O2 sat: 97% (96-99), O2 delivery: Ra
GEN: Sitting up in wheelchair, moderately anxious.
NECK: no JVD
CARD: Tachycardic, regular, S1 + S2 present, SEM loudest at apex
and radiating to L. axilla
RESP: CTAB, no wheezes/crackles, breathing comfortably on RA
ABD: Soft, non-distended, moderate LUQ TTP with guarding
BACK: Left flank PCN in place w/o pain or erythema
GU: L PCN draining yellow urine, RLQ ostomy in place with dark
yellow urine
EXT: WWP, trace ___ edema, rotated (baseline per pt)
SKIN: L dorsal foot wrapped in gauze
NEURO: AOx3, ___ UE strength
DISCHARGE PHYSICAL EXAM:
=========================
Vitals ___ 1130 Temp: 98.2 PO BP: 145/90 R Sitting HR: 86
RR: 18 O2 sat: 97% O2 delivery: Ra
GEN: Sitting in wheelchair, cooperative with exam, not agitated.
CARD: Regular rate and rhythm, no murmurs rubs or gallops
RESP: On room air, no difficulty breathing, lungs clear to
auscultation bilaterally, no crackles, wheezing, or
rhonchi.
ABD: Nondistended, slightly tender to palpation in the left
lower
quadrant, no rebound, no guarding.
GU: L PCN draining yellow urine, RLQ ostomy in place.
EXT: WWP, no ___ edema
NEURO: AOx3
Pertinent Results:
ADMISSION LABS
===============
___ 06:22AM BLOOD WBC-12.2* RBC-2.38* Hgb-7.6* Hct-22.8*
MCV-96 MCH-31.9 MCHC-33.3 RDW-14.4 RDWSD-49.7* Plt ___
___ 06:22AM BLOOD Neuts-69.8 ___ Monos-7.5 Eos-2.5
Baso-0.2 Im ___ AbsNeut-8.52* AbsLymp-2.36 AbsMono-0.92*
AbsEos-0.31 AbsBaso-0.03
___ 06:22AM BLOOD ___ PTT-26.8 ___
___ 06:22AM BLOOD Glucose-115* UreaN-50* Creat-4.7* Na-142
K-4.4 Cl-105 HCO3-19* AnGap-18
___ 06:22AM BLOOD ALT-10 AST-11 AlkPhos-105 TotBili-0.2
___ 06:22AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:22AM BLOOD Albumin-4.4 Calcium-8.3* Phos-3.6 Mg-1.6
___ 10:25AM BLOOD Triglyc-315* HDL-44 CHOL/HD-4.3
LDLcalc-83
___ 06:22AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:22AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 06:22AM BLOOD Lactate-0.8
INTERVAL LABS
=============
___ 06:20AM BLOOD ALT-28 AST-31 LD(LDH)-177 AlkPhos-117
TotBili-<0.2
___ 06:22AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:22AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 10:25AM BLOOD Triglyc-315* HDL-44 CHOL/HD-4.3
LDLcalc-83
___ 06:22AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 03:45PM BLOOD Ethanol-NEG
___ 06:47AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
===============
___ 12:00PM BLOOD WBC-8.7 RBC-2.27* Hgb-7.4* Hct-23.0*
MCV-101* MCH-32.6* MCHC-32.2 RDW-13.7 RDWSD-50.6* Plt ___
___ 12:00PM BLOOD Glucose-133* UreaN-83* Creat-3.7* Na-135
K-5.2 Cl-99 HCO3-21* AnGap-15
___ 12:00PM BLOOD Calcium-8.1* Phos-5.8* Mg-1.8
IMAGING/STUDIES
=================
___ US
1. No sonographic explanation for abdominal pain identified.
Note is made a fluid-filled distended stomach is visualized.
This is not surprising given that the patient reported recently
drinking water just before the exam.
2. Splenic size is within the upper limits of normal. No
splenic abscess is seen.
3. Stable mild right-sided hydronephrosis. Atrophic kidneys
with echogenic
appearance of the renal cortex bilaterally consistent with
underlying medical renal disease.
___ (SUPINE ONLY)
1. No radiographic evidence of small bowel obstruction or
ileus.
2. Large stool burden within the colon.
___ ABD & PELVIS W/O CON
1. No evidence of left upper quadrant pathology. The spleen is
normal in
appearance, allowing for the limitations of a noncontrast study.
2. Large stool burden within the colon. Unremarkable bowel with
no dilatation or wall thickening.
3. Mild fullness of the right renal calyces and right ureter in
a patient
with ileal conduit.
MICROBIOLOGY
==============
_________________________________________________________
___ 3:12 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
GRAM NEGATIVE ROD #2. >100,000 CFU/mL.
__________________________________________________________
___ 10:08 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
FOSFOMYCIN Susceptibility testing requested per ___.
___
___ ON ___ (___).
ZONE SIZE FOR Fosfomycin IS 18MM Zone size determined
using a
method that has not been standardized for this
drug-organism
combination and for which no CLSI or FDA-approved
interpretative
standards exist. Interpretive results for fosfomycin
exist only
for E. coli, for which zone sizes of <16 are classified
as
non-susceptible. Interpret results with caution..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 1:13 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. CloNIDine 0.2 mg PO TID
4. Loratadine 10 mg PO DAILY
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 40 mg PO DAILY
7. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN Pain -
Mild
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Tizanidine 4 mg PO BID
10. Zolpidem Tartrate 10 mg PO QHS
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral QD
12. Ferrous Sulfate 325 mg PO DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
14. ___ (alprostadil) 1,000 mcg urethral unknown
15. amLODIPine 10 mg PO DAILY
16. LevETIRAcetam 500 mg PO Q12H
17. LevETIRAcetam 500 mg PO 3X/WEEK (___)
18. OxyCODONE (Immediate Release) 60 mg PO Q8H:PRN Pain -
Moderate
Discharge Medications:
1. Fosfomycin Tromethamine 3 g PO 1X/WEEK (WE)
Dissolve in ___ oz (90-120 mL) water and take immediately
RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by
mouth once weekly on ___ Disp #*4 Packet Refills:*0
2. OLANZapine 10 mg PO BID
RX *olanzapine 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
PRN Refills:*0
4. Ramelteon 8 mg PO QHS
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
5. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablet by mouth BID PRN Disp
#*120 Tablet Refills:*0
6. amLODIPine 10 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral QD
10. CloNIDine 0.2 mg PO TID
11. Ferrous Sulfate 325 mg PO DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. LevETIRAcetam 500 mg PO Q12H
14. LevETIRAcetam 500 mg PO 3X/WEEK (___) on dialysis days
after dialysis
15. Loratadine 10 mg PO DAILY
16. ___ (alprostadil) 1,000 mcg urethral unknown
17. Nephrocaps 1 CAP PO DAILY
18. Omeprazole 40 mg PO DAILY
19. OxyCODONE (Immediate Release) 60 mg PO Q8H:PRN Pain -
Moderate
20. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN Pain
- Mild
21. sevelamer CARBONATE 800 mg PO TID W/MEALS
22. Tizanidine 4 mg PO BID
23. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
- Psychotic disorder
- Polysubstance use disorder
SECONDARY
=========
- End stage renal disease
- neurogenic bladder
- ileal conduit urinary diversion c/b L anastomotic stricture
requiring indwelling nephrostomy tube
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair but independent with wheelchair
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with fever, leukocytosis, LUQ pain.// Eval for
slenic abscess, hepatobiliary pathology.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Report from the CTA of the abdomen ___ and 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.
CHD: 6 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity. Views of the left upper quadrant demonstrate a
fluid-filled, distended stomach. The patient reported recently consuming a
moderate quantity of water just before the exam.
Spleen length: 12.3 cm
KIDNEYS: The kidneys are atrophic. The renal cortex is diffusely echogenic
bilaterally. Mild right-sided hydronephrosis is re-demonstrated. There is no
evidence of masses, or stones in the kidneys.
Right kidney: 6.7 cm
Left kidney: 7.7 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No sonographic explanation for abdominal pain identified. Note is made a
fluid-filled distended stomach is visualized. This is not surprising given
that the patient reported recently drinking water just before the exam.
2. Splenic size is within the upper limits of normal. No splenic abscess is
seen.
3. Stable mild right-sided hydronephrosis. Atrophic kidneys with echogenic
appearance of the renal cortex bilaterally consistent with underlying medical
renal disease.
Radiology Report
INDICATION: ___ year old man with Recurrent vomiting. LUQ pain.// eval for
ileus
TECHNIQUE: Portable supine abdominal radiograph.
COMPARISON: Abdominal radiographs ___ and ___.
FINDINGS:
There is a left percutaneous nephrostomy tube. There is posterior spinal
fusion hardware in the thoracolumbar spine. Surgical clips are noted in the
right-side of the pelvis.
There is a large stool burden within the colon. There are no abnormally
dilated loops of small or large bowel. There is no evidence of free
intraperitoneal air, although evaluation is limited by supine technique. No
suspicious radiopaque calculi are identified. There are no acute osseous
abnormalities.
IMPRESSION:
1. No radiographic evidence of small bowel obstruction or ileus.
2. Large stool burden within the colon.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: ___ year old man with LUQ pain and vomiting// eval for splenic
pathology eval for bowel pathology
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 54.2 cm; CTDIvol = 14.6 mGy (Body) DLP = 790.5
mGy-cm.
Total DLP (Body) = 790 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
The absence of intravenous contrast administration limits the evaluation of
the intra-abdominal solid organs and the bowel.
Lungs: The visualized lung bases are within normal limits.
Liver: The liver is homogeneous with a smooth contour.
Biliary: There is no intrahepatic or extrahepatic bile duct dilatation. The
gallbladder is unremarkable.
Spleen: The spleen is not enlarged and is homogeneous.
Pancreas: Unremarkable. There is no pancreatic duct dilatation.
Adrenal glands: Unremarkable.
Urinary: Limited examination of the kidneys due to artifact from the
orthopedic hardware.
The kidneys are atrophic. There is an ileal conduit, with mild fullness of the
right calyces. A left percutaneous nephrostomy tube is again seen, with
persistent fullness of the left upper pole calices.
Gastrointestinal: There is a small hiatal hernia. There is a large fecal load
in the colon. There is no evidence of bowel dilatation or obstruction.
Vascular: There are mild atherosclerotic calcifications of the abdominal
aorta.
Lymph nodes: There is no enlarged lymph nodes.
Bone and soft tissues: There is no suspicious bone lesion. Diffusely sclerotic
bone, in keeping with renal osteodystrophy. Unchanged appearance of the bone,
with fracture involving the right femoral neck and dislocation of the left
femur. Stable appearance of the moderate compression fracture of T12 vertebral
body. Orthopedic fusion hardware is seen from T9-L2, unchanged in position.
Stable fat stranding involving the sacrococcygeal region is seen, with no
overt ulceration.
A small right inguinal hernia is seen, containing colon. No complications are
seen.
There is gynecomastia.
IMPRESSION:
1. No evidence of left upper quadrant pathology. The spleen is normal in
appearance, allowing for the limitations of a noncontrast study.
2. Large stool burden within the colon. Unremarkable bowel with no dilatation
or wall thickening.
3. Mild fullness of the right renal calyces and right ureter in a patient
with ileal conduit.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LUQ abd pain
Diagnosed with Unspecified abdominal pain
temperature: 100.5
heartrate: 130.0
resprate: 17.0
o2sat: 99.0
sbp: 180.0
dbp: 100.0
level of pain: 4
level of acuity: 2.0 | PATIENT SUMMARY
==================
___ with a PMH of polysubstance use disorder, MVA ___ c/b T12
paraplegia, recurrent sacral/trochanteric decubitus ulcers,
neurogenic bladder, recurrent UTIs, obstructive uropathy/CKD,
ileal conduit urinary diversion c/b L anastomotic stricture
requiring L indwelling PCN (___), ESRD on HD who presents w/
LUQ pain, found to be febrile with leukocytosis and tachycardia,
initially concerning for UTI.
ACUTE ISSUES
===============
# Leukocytosis
# Fevers
Patient presenting with fevers, leukocytosis and LUQ pain found
to have bacteria and WBCs on UA. Patient has history of
recurrent urinary tract infections in setting of ileal conduit
urinary diversion c/b L anastomotic stricture requiring L
indwelling PCN (___). His recent urine cultures grew
pan-sensitive Klebsiella on ___, pan-sensitive E. Coli on ___,
VRE on ___. He grew MDR pseudomonas in ___. He was most
recently treated with fosfomycin Q72 hours last dose on ___. He
was planning to follow up with ID to discuss suppressive
therapy, but he did not make it to appointment. Case discussed
with ID in ED and they recommended Meropenem given multiple
medication allergies and history of resistant infections in the
past. Urine culture with colonic bacteria (sample likely taken
from ostomy). Discussed revision of L ureteral stenosis w/
urology as frequency of UTIs has increased; however, patient
does not want to pursue any surgical management, therefore
urology signed off. ID consulted and did not feel picture was
c/w UTI. Meropenem was stopped and patient watched off ABx.
Leukocytosis and fevers resolved, but patient again became
febrile and developed leukocytosis on ___, this time with 127
WBC in urine that also grew enterobacter cloacae. Patient was
treated with fosfomycin, and then was started on fosfomycin
prophylactic treatment on ___.
# Bacteruria
Patient chronically colonized, likely due to complex renal
anatomy of ileal conduit and PCN. Patient was started on
fosfomycin prophylaxis this hospitalization, and asymptomatic
bacteruria does not require treatment.
# Paranoia, hallucinations, delusions
Patient endorsing auditory hallucinations. Feeling scared and
unsafe. Initially believing that he was raped while in the
hospital, but later acknowledging that this was a delusion.
Intermittently refusing diagnostic and therapeutic
interventions. Was initially verbally threatening staff with
violence, but has since become more calm and cooperative,
although did have continued issues with behavioral disturbances,
yelling, and cursing.
Urine tox positive for cocaine x2 (although patient denies use).
Searched room given cocaine positivity and threats of violence
to staff, which was very upsetting to the patient. On room
search, found some home medications, but no illicit substances
or weapons. In the week after the room search, patient
voluntarily told his nurse that he had found some of his home
oxycodone in his sock that he had forgotten about. This was
placed in the lock box, and due to concern that the patient was
pocketing his doses of oxycodone while in house, this was
switched to a liquid form.
Patient continued to speak with pressured speech and was
paranoid, at one point claiming to have been raped by staff;
however, later noting that this was "all in my head" and that
his voices had told him this. Patient was treated with
olanzapine, which was titrated to 10 mg PO BID with 5 mg PRN for
breakthrough agitation. On discharge he still reported hearing
voices, however he "realizes these are fake" and thinks that
they have decreased since he started the olanzapine. He was
discharged with home ___ psych nurses as well as olanzapine PO
BID, with the plan to eventually taper as an outpatient at the
discretion of outpatient psychiatry.
# LUQ Pain
# Nausea
# Constipation
Patient reporting LUQ pain on presentation. He declined a CT A/P
in the ED. Pain began after a fall about a month ago, so may be
musculoskeltal in origin. Initial abdominal US was unremarkable:
did not show any evidence of splenic or hepatobiliary pathology.
KUB ___ without evidence of obstruction but did show large
stool burden. Patient eventually underwent CT, which again
showed large stool burden Abdominal pain and tenderness may
therefore be secondary to constipation. Patient was offered
several medications for constipation, but mostly refused. He
states that he refuses bowel regimen because after the car
accident he could no longer feel below the waist, and is
incredibly embarrassed by frequent accidents. He told nursing
that he did manual disempaction every morning. This was not
witnessed by nursing or anyone on staff. He did eventually have
a few large bowel movements that were witnessed by nursing, with
slight resolution of his abdominal pain, and nausea. He
attributes the bowel movements to the liquid form of oxycodone,
and is very resistant to taking the liquid oxycodone. He was
counseled about constipating effect of opiates and need for
bowel regimen, and he was encouraged on discharge to make sure
he has a bowel movement every day. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
L foot pain
Major Surgical or Invasive Procedure:
I+D of left foot (___)
I+D of left foot (___)
Flap closure of left foot (___)
History of Present Illness:
Mr. ___ is a ___ year old M w/ opioid use disorder and
untreated HCV who presents with two days of left foot pain,
swelling, and redness after a plantar wart scraping. A couple
days ago, he was picking at a potential wart under his left
fifth
MTPJ and noticed that his foot began to swell and was painful 2
days ago.
In the ED, he spiked a fever to 101.4, but otherwise VS were
within normal limits. Exam was notable for small amount of
purulent drainage from his L lateral foot. He was minimally
responsive and only arousable to voice, with pinpoint pupils.
X-ray showed no acute fracture or bony destruction of his L
foot.
He was ordered for vanc, Flagyl, and cefepime. Blood and wound
cultures were sent. He was given naloxone with improvement in
his
mental status.
Upon arrival to the floor, the patient continued to be minimally
responsive to questions, though with further questioning was
able
to answer questions and stated that he was tired. He notes IV
heroin use most recently 2 days ago with injection to the right
arm and denies injection to his feet. He typically uses new
needles, denies sharing, uses tap water to draw up, clean
cigarettes as the filter, denies licking the needle, and uses
saline for injection. Other drug use includes marijuana last
night.
He denies N/V, chest pain, SOB.
REVIEW OF SYSTEMS:
==================
10-point ROS otherwise negative.
Past Medical History:
None
Social History:
___
Family History:
Declined to talk about family history.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: Temp: 98.6 HR: 78 BP: 138/68 RR: 18 O2sat: 97% RA
Gen: Minimally responsive. Arousable to voice.
HEENT: NC/AT. EOMI. Pinpoint pupils
Neck: No swelling.
Cor: RRR. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Soft, NT, ND. Striae and excoriations across lower abdomen.
Ext: No edema, cyanosis, or clubbing. On plantar surface of L
lateral foot there is a 1x1cm ulceration with surrounding
erythema extending 10 cm superiorly toward the ankles,
serosanguinous fluid expressed.
Skin: Erythematous mark on R antecubital region that patient
notes is from IV injection. No ___ lesions, ___ nodes, or
splinter hemorrhages inspected.
Neuro: Arousable to voice. Gross sensorimotor intact.
Heme: No petechia. No ecchymosis.
DISCHARGE PHYSICAL EXAM
========================
VITALS: 24 HR Data (last updated ___ @ 343)
Temp: 98.3 (Tm 98.5), BP: 105/64 (100-110/62-66), HR: 55
(51-59), RR: 12 (___), O2 sat: 97% (97-98), O2 delivery: Ra
Gen: Laying in bed.
HEENT: PEERL, non-dilated pupils
CV: RRR. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Soft, NT, ND. Striae and excoriations across lower abdomen.
Ext: No edema, cyanosis, or clubbing. L foot wrapped in gauze,
dressing c/d/I.
Skin: Erythematous mark on R antecubital region that patient
notes is from IV injection. No ___ lesions, ___ nodes, or
splinter hemorrhages appreciated.
Pertinent Results:
ADMISSION LABS
===============
___ 11:23PM BLOOD WBC-10.8* RBC-4.91 Hgb-12.8* Hct-39.8*
MCV-81* MCH-26.1 MCHC-32.2 RDW-13.8 RDWSD-40.2 Plt ___
___ 11:23PM BLOOD Neuts-66.9 ___ Monos-7.8 Eos-1.4
Baso-0.2 Im ___ AbsNeut-7.24* AbsLymp-2.53 AbsMono-0.84*
AbsEos-0.15 AbsBaso-0.02
___ 11:23PM BLOOD Glucose-175* UreaN-17 Creat-0.7 Na-139
K-3.9 Cl-101 HCO3-26 AnGap-12
___ 11:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 11:32PM BLOOD Lactate-1.6
___ 06:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:50AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:50AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 06:50AM URINE Mucous-RARE*
___ 09:52AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG
PERTINENT INTERVAL LABS
========================
___ 10:15AM BLOOD ALT-43* AST-33 LD(LDH)-148 AlkPhos-55
TotBili-0.4
___ 10:15AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
___ 06:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 Iron-60
___ 06:50AM BLOOD calTIBC-234* ___ Ferritn-177
TRF-180*
___ 10:15AM BLOOD CRP-79.2*
___ 05:30AM BLOOD CRP-54.5*
___ 05:25AM BLOOD CRP-17.0*
___ 06:50AM BLOOD CRP-2.9
DISCHARGE LABS - Last labs ___
===============
___ 05:30AM BLOOD WBC-5.9 RBC-4.93 Hgb-13.0* Hct-40.2
MCV-82 MCH-26.4 MCHC-32.3 RDW-14.1 RDWSD-40.4 Plt ___
___ 05:30AM BLOOD Glucose-94 UreaN-28* Creat-1.1 Na-140
K-5.3 Cl-102 HCO3-25 AnGap-13
IMAGING
========
SURGICAL PATHOLOGY REPORT (___)
PATHOLOGIC DIAGNOSIS:
Left foot tissue: Fibroadipose tissue with granulation tissue
and acute and chronic inflammation.
L FOOT X-RAY (___)
IMPRESSION:
No acute fracture or bony destruction.
MICROBIOLOGY
=============
__________________________________________________________
___ 3:38 pm SWAB LEFT FOOT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 2:59 am BLOOD CULTURE Site: ARM
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:15 am FOOT CULTURE Source: Left foot.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
__________________________________________________________
___ 11:23 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*90 Tablet Refills:*1
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*7 Capsule Refills:*0
3. CloNIDine 0.1 mg PO TID
RX *clonidine HCl [Catapres] 0.1 mg 1 tablet(s) by mouth every 8
hours Disp #*45 Tablet Refills:*0
4. Ibuprofen 400-600 mg PO Q6H:PRN Pain - Mild/Fever NOT
relieved by Acetaminophen
RX *ibuprofen [IBU] 400 mg 1 tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocare] 4 % apply patch to affected area at
night Disp #*6 Patch Refills:*0
6. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice daily Disp #*3 Tablet Refills:*0
7.Outpatient Physical Therapy
Please provide crutches to patient
Dx: foot cellulitis and abscess (L03.119)
Px: good
___: 13 months
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Left foot cellulitis
SECONDARY DIAGNOSES
====================
Opioid use disorder
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: History: ___ with left lateral foot gangrene, cellulitis//
Evaluate for underlying fracture
TECHNIQUE: Three views of the left foot
COMPARISON: None.
FINDINGS:
No acute fractures or dislocation are seen. There is a plantar calcaneal
spur. A dorsal osteophyte is noted at the level of the base of the
metatarsals, seen only on lateral projection. Mineralization is normal.
There are no erosions.
IMPRESSION:
No acute fracture or bony destruction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Foot pain, L Foot swelling
Diagnosed with Cellulitis of left lower limb
temperature: 101.4
heartrate: 94.0
resprate: 16.0
o2sat: 100.0
sbp: 143.0
dbp: 78.0
level of pain: 10
level of acuity: 3.0 | SUMMARY
=========
Mr. ___ is a ___ year old M w/a hx of opioid use disorder and
untreated HCV who presented with two days of left foot pain,
swelling, and redness after a plantar wart scraping found to
have L plantar MTPJ cellulitis with abscess.
ACUTE ISSUES
=============
#Acute L plantar cellulitis with abscess
#Fever, leukocytosis, elevated CRP
Presented with left foot pain, erythema, swelling, purulent
discharge, all consistent with cellulitis. No pain with movement
of foot and no joint pain. He went to the OR on ___ for a
debridement with podiatry; no joint involvement, did not probe
to bone so low suspicion for osteomyelitis. He went back to the
OR on ___ for further debridement and wound vac placement.
Finally he went back to the OR on ___ for flap closure. He was
started on vancomycin, cefepime, and flagyl until his cultures
resulted; they showed coag-negative staph and mixed bacterial
flora. He was switched to Bactrim and Keflex for a total of 14
days of antibiotics (___). His blood cultures were
negative.
#Opioid use disorder/IVDU
Patient recently discharged in ___ on methadone. Patient
stated that he had used IV heroin 2 days prior to admission. HIV
negative on last admission. He is known HCV positive, untreated.
He was seen by addiction psychiatry and social work. He was
initiated and continued on methadone 30 mg QD as well as
clonidine 0.1 mg TID. He is setup with Habit ___
clinic. He was provided with a naloxone script at discharge.
#Normocytic Anemia
Thought likely due to anemia of inflammation from his IV drug
use as well as cellulitis, as his iron studies, haptoglobin, LDH
were normal. His Hgb on discharge was 13.0. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old M with a history of hypothyroidism
and reactive airway disease who presents after having an episode
of presyncope, dizziness and urinary incontinence while on the
train, found to be originally in sinus rhythm with one episode
of bradycardia and hypotension in the ED, with resolution upon
administration of atropine.
The patient was in his usual state of health until two weeks
prior to admission when he was scheduled for an outpatient
procedure for the implant of a bone anchored hearing aid. During
the procedure, the patient was put under general anesthesia, and
was noted to have an irregular heart rhythm on telemetry
monitoring, and thus the procedure was aborted. The patient
remained asymptomatic in the following days, and saw his PCP
where his EKG was normal. He was referred to a cardiologist, and
was scheduled for an appointment in early ___.
One week prior to admission, the patient had an episode of
fatigue during a hot day while umpiring a baseball game. He
denies dizziness, presyncope, CO or SOB, and he drank some
Gatorade with resolution of his symptoms. The patient was then
asymptomatic until the day of his admission when he was sitting
on the train. The patient does not recall the event, but per his
girlfriend, he became pale in the face, and he "zoned out." The
patient then recalls coming to covered in sweat, and having had
an episode of urinary incontinence. He does not recall having an
CP, SOB or palpitations during this episode. He was not confused
following the episode, and actually felt back to his baseline
within minutes. In total, the episode lasted ___ seconds.
On presentation to the ED, the patient was asymptomatic and
found to be in sinus rhythm with a rate in the ___. However,
while in the ED he had another similar episode where he began to
feel "not right," describing that he felt lightheaded. At this
point, his EKG showed sinus bradycardia, HR of ___, and his
SBP dropped to the mid to high ___. He was given atropine with
resolution of symptoms, return to normal sinus rhythm with a
rate of 80, and an SBP immediately afterwards of 200mmHg.
Labs/studies notable for: Trop < 0.1, no electrolyte
abnormalities
Vitals on admission: HR 55, BP 131/90, O2 95% RA, RR 17
On arrival to the CCU: The patient was asymptomatic, not
complaining of any CP, SOB, palpitations, dizziness or
lightheadedness
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems: No CP, no dyspnea on exertion, no
paroxysmal nocturnal dyspnea, orthopnea, ankle edema.
On further review of systems, patient does note a 30 pound
unintentional weight loss over the past year. He has had some
myalgias and joint pains over the last month. He denies cough,
hemoptysis, black stools or red stools.
All of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- No Diabetes
- No Hypertension
- No Dyslipidemia
2. CARDIAC HISTORY: No significant cardiac history
3. OTHER PAST MEDICAL HISTORY:
- Hypothyroidism
- Reactive airway disease
Social History:
___
Family History:
Father died from "heart attack" in his sleep at the age of ___,
mother with emphysema.
Physical Exam:
Admission physical exam:
VS: T: 98.0 HR: 55 BP: 130/92 RR: 16 O2 SAT: 95% RA
GENERAL: Well developed, well nourished in NAD speaking in full
sentences and lying comfortably in bed. Oriented x3.
HEENT: Normocephalic atraumatic. Sclera anicteric. Dilated
reactive pupils bilaterally. EOMI. Conjunctiva were pink. No
pallor or cyanosis of the oral mucosa.
NECK: Supple. No jugular venous distention.
CARDIAC: Regular rhythm, bradycardic. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes. Diffuse erythema of
face.
PULSES: Distal pulses palpable and symmetric.
Discharge physical exam:
VS: stable, see flow sheet
Tele: sinus rhythm/sinus arrhythmia with PACs, 49-62,
orthostatics done last night were negative
GENERAL: Well developed, well nourished in NAD speaking in full
sentences and lying comfortably in bed. Oriented x3
HEENT: Normocephalic atraumatic
NECK: Supple. No jugular venous distention
CARDIAC: normal s1,s2, no murmurs
LUNGS: clear bilaterally
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Warm, well perfused. No peripheral edema
SKIN: no open areas Diffuse erythema of face
PULSES: + CSM, + Distal pulses palpable and symmetric
Pertinent Results:
Pertinent labs:
---------------
___ CXR: No acute process
___ 07:00AM BLOOD WBC-7.2 RBC-4.45* Hgb-14.5 Hct-41.0
MCV-92 MCH-32.6* MCHC-35.4 RDW-13.0 RDWSD-44.2 Plt ___
___ 05:43AM BLOOD WBC-10.3* RBC-4.91 Hgb-15.1 Hct-44.5
MCV-91 MCH-30.8 MCHC-33.9 RDW-12.8 RDWSD-42.2 Plt ___
___ 09:15PM BLOOD WBC-13.9* RBC-5.18 Hgb-16.5 Hct-47.3
MCV-91 MCH-31.9 MCHC-34.9 RDW-13.0 RDWSD-42.6 Plt ___
___ 09:15PM BLOOD Neuts-83.1* Lymphs-8.1* Monos-6.6 Eos-1.2
Baso-0.4 Im ___ AbsNeut-11.57* AbsLymp-1.13* AbsMono-0.92*
AbsEos-0.17 AbsBaso-0.06
___ 09:31PM BLOOD ___ PTT-23.3* ___
___ 07:00AM BLOOD Glucose-89 UreaN-16 Creat-0.9 Na-141
K-3.9 Cl-109* HCO3-20* AnGap-12
___ 05:43AM BLOOD Glucose-90 UreaN-18 Creat-0.9 Na-142
K-4.1 Cl-109* HCO3-19* AnGap-14
___ 09:15PM BLOOD Glucose-99 UreaN-21* Creat-1.1 Na-138
K-5.6* Cl-102 HCO3-21* AnGap-15
___ 09:15PM BLOOD ALT-23 AST-34 AlkPhos-65 TotBili-0.5
___ 09:15PM BLOOD Lipase-25
___ 03:35AM BLOOD cTropnT-<0.01
___ 09:15PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.0
___ 05:43AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.1
___ 09:15PM BLOOD Albumin-4.3 Calcium-9.7 Phos-3.5 Mg-2.1
___ 05:43AM BLOOD TSH-3.6
___ 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:32PM BLOOD Lactate-1.6 K-4.8
Pertinent Imaging/Studies:
___ chest Xray:
FINDINGS:
Lungs are moderately well expanded and essentially clear other
than mild
bibasilar atelectasis. Mediastinal contours and hila are
unremarkable.
Slightly prominent cardiac silhouette extension weighted by AP
technique. No pneumothorax or pleural effusion.
IMPRESSION:
No acute process
___ Echo:
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function (LVEF 55%).
No valvular pathology or pathologic flow identified. Mildly
dilated ascending aorta. No structural cardiac cause of syncope
identified.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ years.
EEG: ___ pending final report
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 137 mcg PO DAILY
2. Fenofibrate 145 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Cyanocobalamin Dose is Unknown IM/SC MONTHLY
Discharge Medications:
1. Cyanocobalamin 1 injection IM/SC MONTHLY
2. Fenofibrate 145 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Levothyroxine Sodium 137 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Vagal presyncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with bradycardia// evaluate for intra-thoracic
process
TECHNIQUE: Chest AP
COMPARISON: None
FINDINGS:
Lungs are moderately well expanded and essentially clear other than mild
bibasilar atelectasis. Mediastinal contours and hila are unremarkable.
Slightly prominent cardiac silhouette extension weighted by AP technique. No
pneumothorax or pleural effusion.
IMPRESSION:
No acute process
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Presyncope
Diagnosed with Bradycardia, unspecified
temperature: 97.8
heartrate: 69.0
resprate: 18.0
o2sat: 100.0
sbp: 210.0
dbp: 154.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old M with a history of hypothyroidism
and reactive airway disease who presents after having an episode
of presyncope, dizziness and urinary incontinence while on the
train. In the ED, he had an episode of sinus bradycardia
bradycardia with transient hypotension, which resolved with
administration of atropine.
#Presyncope, vasovagal: In the ED, an ECG demonstrated gradual
sinus slowing with sinus bradycardia as slow as ___ bpm,
associated with hypotension (BP ___ mmHg). This resolved with
the administration of 1mg atropine. An echocardiogram identified
no structural cardiac cause of syncope. His orthostatics were
negative. Neurology was consulted due to symptoms of
unresponsiveness, staring gaze and urinary incontinence, but
they did not suspect a primary neurological event such as
seizure and did not recommend a head CT. The patient was started
on 24 hour EEG that was normal. Lyme serologies were negative.
Given the prominent vasomotor component, a pacemaker was
deferred. He had no events on the telemetry and he was sent home
with a cardiac monitor (Zico patch) and close follow up with his
cardiologist and PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left groin pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ s/p left sigmoid colectomy for recurrent diverticulitis in
___ now presents with 4d history of left groin pain. By
report, he was lifting something heavy and has felt a "knot" in
his groin with no appreciable bulge since. Reports the pain as
different in quality to his previous bouts of diverticulitis.
Has tolerated diet, no nausea/vomiting. Regular BM, no blood in
stools, no diarrhea.
Past Medical History:
PMH: recurrent diverticulitis, prior diverticulitis with ___
drainage, HTN, HLD
PSH: sigmoid colectomy (___), colonic polyp removal, distant
foot surgery
Social History:
___
Family History:
prostate CA - father, DM - father, HTN - father,mother; CAD -
father
Physical ___:
ON ADMISSION:
Temp: 101 HR: 60s BP: 170/100s O2Sat: 100% on RA
Gen: NAD, AAOx3
CV: RRR, no murmurs
Pulm: CTAB
Abd: soft, obese, NT, ND, no rebound, no guarding.
Left groin: mild tenderness to deep palpation, no erythema, no
fluctuance, no lymphadenopaty appreciated, no bulge; + cough
impulse and small hernia appreciated on valsalva
Right groin: no appreciable defect/cough impulse
Lower Extremities: no wounds or injuries, no calf swelling, full
ROM
ON DISCHARGE:
VS: HR 98.1, HR 61, BP 143/70, RR 16, SaO2 99% RA
GEN: no acute distress
CV: RRR
PULM: CTAB
ABD: Soft, nondistended, nontender, mild tenderness to palpation
in left groin.
EXT: Warm, well perfused.
Pertinent Results:
CT ABDOMEN/PELVIS:
Mild acute diverticulitis involving the mid to distal descending
colon. No drainable fluid collection or extraluminal gas.
Findings are less severe as compared to the prior study from ___.
Few prominent left inguinal lymph nodes with slight haziness of
the adjacent fat, nonspecific, but correlate with symptoms that
may relate; query local inflammatory process.
Medications on Admission:
1. Pravastatin 80 mg PO QPM
2. Atenolol 25 mg PO BID
3. Triamterene-HCTZ (37.5/25) 1 CAP PO BID
Discharge Medications:
1. Atenolol 25 mg PO BID
2. Triamterene-HCTZ (37.5/25) 1 CAP PO BID
3. Pravastatin 80 mg PO QPM
4. Acetaminophen 650 mg PO Q4H:PRN pain, fever
Do not exceed 3000 mg daily.
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
Do not drink or drive while taking narcotic pain medications.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
Take for constipation associated with narcotic use. Stop for
loose stools.
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mild diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: +PO contrast; History: ___ with complicated hx of divertic s/p
partial colectomy, here with fever/chills, left lower abd pain+PO contrast //
evaluate for divertic, abscess, fistula
TECHNIQUE: Contrast enhanced MDCT images of the abdomen and pelvis were
obtained following the administration of intravenous contrast. Reformatted
coronal and sagittal images were also obtained.
This study involved 4 CT acquisition phases with dose indices as follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
4) Spiral Acquisition 5.2 s, 57.0 cm; CTDIvol = 16.8 mGy (Body) DLP = 955.7
mGy-cm.
Total DLP (Body) = 971 mGy-cm.
COMPARISON: ___
FINDINGS:
Lung bases: Minimal bilateral dependent atelectasis is seen. There is no
focal consolidation or pleural effusion. No pericardial effusion is seen.
Abdomen/Pelvis: A few scattered millimetric hypodensities in the right lobe
of the liver measure up to 5 mm, too small to further characterize but most
likely representing cysts and stable compared to the prior study.. The spleen
is top-normal in size. The pancreas and adrenal glands are unremarkable. The
kidneys uptake and excrete contrast symmetrically bilaterally. No focal renal
lesion is identified. A small accessory splenule is incidentally noted. The
stomach is relatively collapsed. No bowel obstruction is seen. Patient is
status post partial colectomy, with postsurgical changes seen, including
diastasis of the anterior abdominal wall in the anterior midline of the mid
abdomen, probably about the level of the umbilicus. Focally, there is mild
stranding along the mid to distal descending colon, most consistent with mild
acute diverticulitis. The colon appears collapsed at this level, but does not
appear significantly thickened. No drainable fluid collection or extraluminal
gas is seen.
The bladder is unremarkable. The prostate gland is normal in size. No free
fluid or free air is seen. There are a few prominent left inguinal lymph
nodes with slight haziness of the adjacent fat, correlate with related acute
symptoms.
Osseous structures: No concerning lytic or blastic lesions are seen. Mild
degenerative changes are seen at the lumbosacral junction with disc space
narrowing.
IMPRESSION:
Mild acute diverticulitis involving the mid to distal descending colon. No
drainable fluid collection or extraluminal gas. Findings are less severe as
compared to the prior study from ___.
Few prominent left inguinal lymph nodes with slight haziness of the adjacent
fat,, nonspecific, but correlate with symptoms that may relate; query local
inflammatory process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with DIVERTICULITIS OF COLON
temperature: 98.2
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 186.0
dbp: 107.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a history of
diverticulitis s/p sigmoid diverticulitis who was admitted to
the ___ with left quadrant
abdominal pain. He was observed and treated with antibiotics for
presumed mild diverticulitis as seen on CT scan. He was also
found to have a left groin hernia, reducible, which may have
contributed to his symptoms. His vital signs were monitored
closely and he remained afebrile throughout his hospitalization.
His abdominal pain gradually improved and he was started on a
regular diet, which was well tolerated without abdominal pain.
He was given appropriate discharge and follow-up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toradol / Imitrex / Phenothiazines / Nsaids / Morphine
Attending: ___.
Chief Complaint:
Chest pain, verbal abuse
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with PMH of epilepsy, chronic
back pain on narcotics, and hypotension (?AI on prednisone) who
presented to the ED with chest pain and verbal abuse. Of note,
she is a poor historian.
States she developed substernal chest pressure while packing
her suitcase that lasted 30 minutes and radiated to L shoulder,
associated with nausea which is chronic. No diaphoresis or
palpitations. Reports prior minor MI following husbands death ___
years ago and says she occasionally gets similar pain but
otherwise no cardiac history.
She also reports being under significant financial stress and
unsupportive family members. Today, she was kicked out of the
hotel she has been staying due to inability to pay. She called
her family and they were verbally abusive on the phone and
refusing to help her out. She called multiple hotlines to report
domestic verbal abuse and was instructed to come to BI for
further management.
Also reports skin lesions all over her body from an "untreated
staph infection." Per partners records concern for skin popping
vs. vasculitis and have referred to derm but she has not
followed up. \
In the ED initial vitals were: T 98, HR 56, BP 96/56, RR 18, O2
96% RA
EKG: Low voltages throughout, diffuse TW flattening and
inversions V2-V5. No significant changes from ___
Labs/studies notable for: Negative troponins x2, TSH 2.3, utox
+benzos, barbs, opiates. Serum tox ___.
Patient was given: 2L NS, 32.4 mg phenobarbital, 5mg oxycodone,
home meds
Vitals on transfer: AF, HR 54, BP 120/73, RR 16, O2 99% RA
On the floor she denies any chest pain or shortness of breath.
Reports nausea and back pain from not eating or getting her pain
medications in the ED.
*Of note on review of Partners records has had multiple recent
episodes of being found unresponsive on the street requiring
narcan with skin lesions concerning for skin popping, though
denied any excess narcotic usage. Also ___ review concerning
for multiple providers providing hydromorphone.
Past Medical History:
1. CARDIAC RISK FACTORS
- Reports prior MI in ___, denies any stents
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Past alcoholism
- Epilepsy
- Chronic back pain on narcotics
- Long QT
- ? Adrenal insufficiency, previously on 5mg prednisone
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 97.6 BP 124/66 HR 57 RR 20 O2 SAT 100% RA
GENERAL: Alert, oriented, appears comfortable.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP not elevated
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
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.
SKIN: Scattered unroofed blisters on arms, shins, one on
abdomen. No erythema or drainage
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.1 98 88-107/53-69 51-67 ___
GEN: appears comfortable.
NECK: Supple
CARDIAC: RRR
LUNGS: Resp were unlabored
EXTREMITIES: No c/c/e.
SKIN: Scattered unroofed blisters with surrounding erythema on
arms, shins, one on abdomen, covered with clean dressings
Pertinent Results:
ADMISSION LABS:
===============
___ 11:43PM BLOOD WBC-5.9 RBC-4.00 Hgb-12.6 Hct-37.7 MCV-94
MCH-31.5 MCHC-33.4 RDW-13.7 RDWSD-47.7* Plt ___
___ 11:43PM BLOOD Glucose-68* UreaN-6 Creat-0.6 Na-137
K-4.0 Cl-98 HCO3-28 AnGap-15
___ 11:43PM BLOOD ALT-13 AST-18 AlkPhos-121* TotBili-0.2
___ 11:43PM BLOOD cTropnT-<0.01
___ 06:48AM BLOOD cTropnT-<0.01
___ 11:43PM BLOOD TSH-2.3
___ 06:48AM BLOOD Free T4-0.8*
___ 11:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-POS* Tricycl-NEG
DISCHARGE LABS:
================
___ 07:50AM BLOOD WBC-4.8 RBC-3.51* Hgb-10.6* Hct-33.1*
MCV-94 MCH-30.2 MCHC-32.0 RDW-14.4 RDWSD-49.7* Plt ___
___ 07:50AM BLOOD Glucose-110* UreaN-7 Creat-0.5 Na-143
K-3.5 Cl-107 HCO3-26 AnGap-14
___ 07:50AM BLOOD Mg-2.1
IMAGING/STUDIES:
================
CXR ___:
Retrocardiac left base opacities are nonspecific, may reflect
early infectious process in the appropriate clinical setting.
___ Imaging CARDIAC PERFUSION PHARM
Normal myocardial perfusion. Normal ejection fraction
___ Cardiovascular STRESS TEST
Non-anginal type symptoms with non-specific EKG changes.
Appropriate hemodynamic response to vasodilator stress. Nuclear
report
sent separately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Citalopram 40 mg PO BID
4. Senna 43 mg PO BID
5. Diazepam 5 mg PO Q8H:PRN Anxiety
6. Gabapentin 600 mg PO TID
7. HYDROmorphone (Dilaudid) 8 mg PO Q4H:PRN Pain - Moderate
8. HydrOXYzine 50 mg PO TID:PRN nausea
9. Omeprazole 20 mg PO BID
10. PHENObarbital 32.4 mg PO QID
11. Polyethylene Glycol 17 g PO BID:PRN constipation
Discharge Medications:
1. Mupirocin Ointment 2% 1 Appl TP BID
RX *mupirocin 2 % Apply to affected areas twice a day Refills:*1
2. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Citalopram 40 mg PO BID
5. Diazepam 5 mg PO Q8H:PRN Anxiety
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Gabapentin 600 mg PO TID
8. HydrOXYzine 50 mg PO TID:PRN nausea
9. Omeprazole 20 mg PO BID
10. PHENObarbital 32.4 mg PO QID
11. Polyethylene Glycol 17 g PO BID:PRN constipation
12. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
13. Senna 43 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Non-cardiac chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with CP, hypotension, brady// eval for pna
TECHNIQUE: AP portable chest radiograph
COMPARISON: Chest radiograph dated ___
FINDINGS:
AP portable chest radiograph demonstrates a rotated patient. Heart appears
enlarged without evidence of overt pulmonary edema. Opacities projecting
within the retrocardiac region are nonspecific, may reflect aspiration or
early infectious process. There is no pneumothorax or pleural effusion. Note
is made of partial resection of proximal left clavicle. Lumbar spinal
hardware is partially imaged.
IMPRESSION:
Retrocardiac left base opacities are nonspecific, may reflect early infectious
process in the appropriate clinical setting.
Radiology Report
INDICATION: ___ year old woman with CXR on admission, ? PNA newly febrile//
PNA, interval change
TECHNIQUE: Frontal and lateral chest radiograph
COMPARISON: Radiograph dated ___
FINDINGS:
Frontal and lateral chest radiograph demonstrate a rotated patient. Partial
resection of proximal left clavicle is noted. Heart is enlarged with no
evidence of pulmonary edema. Retrocardiac opacities appear resolved. Linear
opacity within the left lower lung zone reflects atelectasis. Blunting of the
left costophrenic angle may reflect scarring or atelectasis. There is no
pneumothorax or pleural effusion. Spinal hardware is noted.
IMPRESSION:
Resolution of retrocardiac opacity. No new opacity.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, SOCIAL ISSUES
Diagnosed with Chest pain, unspecified
temperature: 98.0
heartrate: 56.0
resprate: 18.0
o2sat: 96.0
sbp: 96.0
dbp: 56.0
level of pain: 9
level of acuity: 3.0 | Information for Outpatient Providers: ___ hx epilepsy, chronic
back pain on narcotics, and hypotension (?AI on prednisone) who
presented with chest pressure in the setting of having to leave
her hotel due to inability to pay. ECG w/o ischemic changes,
cardiac enzymes negative, pharmacological stress test normal.
Had several episodes of hypotension in house and somnolence that
were thought due to overmedication, possibly adrenal
insufficiency which she was diagnosed with recently at ___, but
self discontinued home prednisone prior to admission. Restarted
home prednisone. Cortisol is low, and TSH is inappropriately
normal in setting of low free T4. Dermatology evaluated skin
lesions with biopsy consistent with excoriations. Topical
mupriocin ointment started. Seen by social work with plan to
discharge to shelter in ___ or patient's sister's home in
___, up to the discretion of the patient.
SW put in extensive work to arrange for cab voucher and bus
transportation on the patient's behalf and discharge paperwork
was prepared. However, just prior to discharge patient ELOPED
without being formally discharged. She stated that she was going
to the ___ to pick up prescriptions
from her PCP, but it is not clear why she left prior to
discharge. She then returned after more than an hour, at which
point discharge had been finalized and remained so.
#CHEST PAIN: History is low concern for ischemic etiology of
pain. ECG w/o changes and two sets negative troponins. Notably
not great historian with changing story. Pharmacologic nuclear
stress test negative.
#CHRONIC BACK PAIN: ___ review concerning for possible
multiple prescribers and Partners records with recent admissions
requiring narcan for likely opioid overdose. ___
would only accept if dilaudid decreased to 4mg q4h, dose was
tapered over two days accordingly.
#? ADRENAL INSUFFICIENCY: Reports being put on prednisone 5mg
daily for ? adrenal insufficiency in setting of what sound like
syncopal episodes that were deemed to be potentially orthostatic
in nature. Self-discontinued prednisone 3 days prior to
admission. Given transient episodes of hypotension associated
with somnolence in hospital prednisone was restarted but should
have endocrine follow-up to complete work-up.
#? CENTRAL HYPOTHYROIDISM: Reports that has briefly been on
levothyroxine in the past and requested this visit. TSH 2.3 with
free T4 0.8, c/f central hypothyroidism.
Deferred thyroid replacement inpatient given social situation
and concerns for inadequate follow-up but should have
endocrinology follow-up arranged through PCP
#EPILEPSY: Continued gabapentin 600mg TID and phenobarbital 32.4
mg QID. Neurology evaluated and felt an alternative regiment
might be better and requested outpatient neurology follow-up at
___.
#SKIN LESIONS: Had multiple unroofed blisters on
arms/legs/abdomen on admission. Perseverated heavily on them
during admission and frequently requested antibiotics for her
"staph infection". Review of Partners records showed prior
evaluations felt likely skin popping but concern for vasculitis,
however she did not complete dermatology follow-up. Dermatology
evaluated here, felt likely trauma vs. prurigo nodules but not
vasculitis. Biopsy consistent with excoriations. Started on
mupirocin for impetiginized excoriations.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Simvastatin / Lipitor
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization (___)
EP Study
History of Present Illness:
___ yo M male with h/o CAD s/p CABG in ___, ischemic
cardiomyopathy, AICD in place for frequent PVCs, HTN, HLD, and
DMII presenting with chest pain that woke him up from sleep
around 3am this morning. He reports that he was in his usual
state of health until ___, when he noticed a slight burning
in his chest while snowblowing. He did not think much of it and
it resolved on its own. He was feeling well on ___, but
reports eating may foods that have been known to cause him to
have GERD symptoms. He then woke up around 3am with burning
substernal chest pain that radiated to his jaw and both arms. He
also felt his heart racing. No SOB, no diaporesis.
.
He reports that he took 2 SLNTGs without resolution of his pain.
He also took a variety of antiacids but his pain continued.
After approximately an hour, he decided to call EMS. As per
report, he was in "runs of VT" to the 150s. He was otherwise
stable and mentating appropriately. He received amiodarone 150
mg, aspirin 324 mg, and 100 mcg of fentanyl.
.
In the ED, initial VS: ___, 16, 99%. ECG revealed wide
regular rhythm with rates ranging from 150 - 155 bpm. He
received morphine 8 mg, etomidate 10 mg, fentanyl 50 mcgs, and
ondasetron. He was cardioverted with 200J and converted to sinus
rhythm with resolution of his chest pain. Vitals prior to
transfer: 97.8ax, 138/89, 75, 96%.
.
Upon arrival to the floor, the patient reports feeling well. He
denies current CP, palpitations or SOB. He is currently in NSR
around 65-70 bpms.
.
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.
No orthopnea, no PND, no ___ swelling.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: ___, 1 vessel bypassed
-PERCUTANEOUS CORONARY INTERVENTIONS: No
-PACING/ICD: ___ ___, model V 268 dual-chamber ICD.
Originally placed in ___ for frequent PVCs, replaced in ___.
Most recently interrogated on ___. His device is programmed
with one tachy-protection zone, to treat rates greater than 167
bpm in the VF zone.
-ISCHEMIC CARDIOMYOPATHY (LVEF ~30%)
3. OTHER PAST MEDICAL HISTORY:
-ABDOMINAL AORTIC ANEURYSM - 3.6cm repeat ___
-DIABETES TYPE II, non insulin dependant: RETINOPATHY and
neuropathy
-ERECTILE DYSFUNCTION
-GASTROESOPHAGEAL REFLUX
-GOUT
-HYPERLIPIDEMIA
-HYPERTENSION
-apical aneursym, abnormal ETT Thallium 61/01, ett thal
mod/severe fixed defect in septum, and partially reversible
inferior 442.9
-LEFT BRACHIAL VEIN THROMBOSIS ___ -while off warfarin for
dental
-OSTEOARTHRITIS
-TOBACCO ABUSE
Social History:
___
Family History:
Strong family history of CAD: father, brother and mother.
Physical Exam:
Admission:
VS - 98.2, 151/90, 65, 18, 96% on RA.
GENERAL - well-appearing elderly in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVP 2-3 cm above the clavicle
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, no s3/s4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 1+ 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,
Pertinent Results:
Admission:
___ 05:10AM BLOOD WBC-11.0 RBC-4.86 Hgb-14.5 Hct-42.7
MCV-88 MCH-29.9 MCHC-34.0 RDW-13.9 Plt ___
___ 05:10AM BLOOD Glucose-258* UreaN-33* Creat-1.2 Na-141
K-4.1 Cl-102 HCO3-23 AnGap-20
___ 05:10AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.7
___ 05:10AM BLOOD ___ PTT-30.6 ___
Discharge:
___ 07:00AM BLOOD WBC-12.0*# RBC-4.53* Hgb-13.7* Hct-39.7*
MCV-88 MCH-30.3 MCHC-34.5 RDW-14.0 Plt ___
___ 06:50AM BLOOD ___ PTT-65.7* ___
___ 07:00AM BLOOD Glucose-300* UreaN-31* Creat-1.4* Na-137
K-4.4 Cl-98 HCO3-28 AnGap-15
___ 07:00AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.0
___ 12:28PM BLOOD %HbA1c-7.8* eAG-177*
Cardiac Enzymes:
___ 05:10AM BLOOD CK(CPK)-86 CK-MB-3 cTropnT-0.02*
___ 01:35PM BLOOD CK(CPK)-428* CK-MB-26* MB Indx-6.1*
cTropnT-1.24*
___ 07:30PM BLOOD CK(CPK)-381* CK-MB-22* MB Indx-5.8
cTropnT-1.24*
___ 07:05AM BLOOD CK(CPK)-278 CK-MB-12* MB Indx-4.3
cTropnT-0.94*
Cardiac Catheterization (___)
COMMENTS:
1. Selective coronary angiography in this left dominant system
demonstrated two vessel CAD. The LMCA was heavily calcified
with an ostial 25% stenosis. The LAD was heavily calcified with
diffuse severe calcific disease from the ostium (65%) into the
mid LAD that appears to be a functionally recanalized total
occlusion without a clearly identifiable central lumen ending at
D2 (which itself has a retroflexed origin). A high D1
(functionally a ramus intermedius) with a proximal 40% lesion
followed by a proximal-mid ___ stenosis. The LAD proper is
totally occluded after D2 and S2 (S2 has 40% origin stenosis);
the mid-distal LAD fills by collaterals from D1 and D2. The LCx
has moderate to heavy calcification with an ostial 20% stenosis.
There were small twin OM1s. The proximal AV groove LCx had a
40% spanning stenosis at the origin of a moderate OM2 (which
itself has mild proximal plaque). There is a branching OM3. The
large AV groove LCx supplying an atrial branch, a tortuous large
LPL and modest caliber twin LPDAs. The RCA had a very early
origin conus branch and was heavily calcified. There was diffuse
proximal disease to 60%. There is a mid total occlusion with
distal filling via vasa and right-to-right collaterals supplying
twin acute marginals (with side branches extending towards the
inferior septum) and a modest caliber distal RCA and RPDA.
2. Arterial conduit angiography revealed the SVG-LAD to be stump
occluded which had been previously documented in ___.
3. Limited resting hemodynamics revealed mild systemic arterial
systolic hypertension with an SBP of 141 mmHg.
FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Occluded SVG-LAD.
3. Mild systemic hypertension.
Portable TTE (___)
-The left atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with akinesis of
the septal and apical segements and true apex. There is the
suggestion of an apical left ventricular aneurysm. No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
arch is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral 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 no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
-IMPRESSION: Moderately dilated left ventricle with severely
reduced left ventricular systolic function with regional wall
motion abnormalities as described above. Suggestion of a
dyskinetic apex/apical aneurysm. Increased left ventricular
filling pressure. Mildly dilated aortic root, ascending aorta,
and aortic arch. Mild aortic regurgitation. Mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
Diastolic pulmonary artery hypertension.
-Compared with the report of the prior study (images unavailable
for review) of ___, the left ventricular ejection fraction
appears worse (previously 35-40%, now 30%) and the cavity is now
moderately enlarged; although the wall motion abnormalities are
similar, Optison was not used on the prior study, thus the
difference in global systolic function may represent improved
image quality on the current study rather than an actual change
in function. The suggestion of a dyskinetic apex/apical aneurysm
is now more easily visualized. Increased left ventricular
filling pressure is new. Mild aortic and mitral valve
regurgitation are now present. Moderate pulmonary artery
systolic hypertension is now appreciated; its presence was not
able to be determined previously.
___ DUP EXTEXT BIL (___)
-FINDINGS: Right great saphenous vein was harvested previously;
a patent branch is noted. The left greater saphenous vein is
patent with diameters
ranging from 0.21 to 0.77 in the thigh and 0.21 to 0.30 in the
calf.
1. Right great saphenous vein is harvested.
2. Left great saphenous vein is patent with the measurements as
above.
CXR (___)
The lungs are well inflated and clear bilaterally with no areas
of focal consolidation, pleural effusion or pneumothorax. The
heart is borderline normal in size. The aorta is mildly
tortuous. ICD is seen in place with right atrial and right
ventricular leads in position. Patient is status post median
sternotomy with sternotomy wires seen, unchanged in position.
Epicardial leads are once again noted. Mild multilevel
degenerative changes of the thoracic spine are seen.
Medications on Admission:
-ALPRAZOLAM - 500 MCG TABLET - TAKE ___ BY MOUTH EVERY 6 HOURS
AS NEEDED FOR ANXIETY ATTACK. Pt reports taking ___ month.
-AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth once a day
for suppression of PVC's, clarification requested by Express
Scripts
-GEMFIBROZIL - 600 mg Tablet - 1 Tablet(s) by mouth once a day
triglycerides
-GLYBURIDE - 5 mg Tablet - 3 Tablet(s) by mouth once a day dm
-HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once
a day bp *** Pt reports not taking as prescribed.
-ISOSORBIDE DINITRATE - 20 mg Tablet - 1 Tablet(s) by mouth
three times a day for angina
-LOSARTAN - 100 mg Tablet - 1 Tablet(s) by mouth once a day
bp/cardiomyopathy
-METFORMIN - 1,000 mg Tablet - 1 and ___ Tablet(s) by mouth q
am, 1 qpm dm
-METOPROLOL TARTRATE - 50 mg Tablet - TID as per report from
patient[1 and ___ Tablet(s) by mouth twice a day blood pressure,
correct dose is 75mg twice daily] *** needs to be confirmed
-NITROGLYCERIN - 0.4MG Tablet, Sublingual - UT DICT
-TYLENOL/CODEINE ___ Tablet - TAKE ___ BY MOUTH
EVERY ___ HOURS AS NEEDED. Pt reports he does not taking this
often.
-ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day prevention
-CALCIUM CARBONATE [GAVISCON] - 500 mg Tablet, Chewable - ___
Tablet, Chewable(s) po q6h prn
Discharge Medications:
1. alprazolam 0.5 mg Tablet Sig: 0.5-1.0 Tablet PO every six (6)
hours as needed for Anxiety.
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day.
3. glyburide 5 mg Tablet Sig: Three (3) Tablet PO once a day.
Tablet(s)
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Please do not take this medication until you have your labs
checked on ___ and directed by your PCP or another
physician.
6. metformin 1,000 mg Tablet Sig: ___ Tablets PO twice a day:
Take 1.5 tablets in the morning and 1 tablet in the evening.
Please do not take this medication until you have your labs
checked on ___ and directed by your PCP or another
physician.
.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5m as needed for chest pain: Please take 1 tablet
every 5 minutes x3 and call your doctor.
8. Tylenol-Codeine #3 300-30 mg Tablet Sig: ___ Tablets PO every
___ hours as needed for pain.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 2 tablets twice daily until ___. Then
take 2 tablets once daily until ___. Then take 1 tablet
daily unless otherwise directed.
12. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
13. Outpatient Lab Work
Please obtain a complete metabolic panel (including Na, K, HCO3,
Cl, BUN, Cr, Mg, Phos, Ca) on ___.
Fax results to Dr. ___ at ___.
14. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*125 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Severe coronary artery disease
- Ventricular tachycardia
Secondary
- Non insulin dependant diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
VENOUS MAPPING OF LOWER EXTREMITIES
INDICATION: ___ man with coronary artery disease, being evaluated for
CABG.
TECHNIQUE: Grayscale and Doppler ultrasound images of the lower extremity
superficial venous system were obtained.
FINDINGS: Right great saphenous vein was harvested previously; a patent
branch is noted. The left greater saphenous vein is patent with diameters
ranging from 0.21 to 0.77 in the thigh and 0.21 to 0.30 in the calf.
IMPRESSION:
1. Right great saphenous vein is harvested.
2. Left great saphenous vein is patent with the measurements as above.
Radiology Report
INDICATION: Preoperative evaluation prior to coronary arterial bypass
grafting in a patient with coronary arterial disease, status post previous
bypass graft, more recently with chest pain.
COMPARISON: Chest radiograph from ___
TECHNIQUE: Axial CT images were acquired through the chest without
intravenous contrast. Coronal and sagittal reformatted images were also
reviewed.
CT CHEST WITHOUT CONTRAST: The patient is status post coronary arterial
bypass graft as well as placement of a dual-lead pacer/AICD device. The heart
is notable for extensive coronary arterial calcification. Calcifications are
also present along the interventricular septum and there are faint
calcifications of the aortic valve. The ascending aorta is enlarged,
measuring 4.7 cm in diameter as is the main pulmonary artery, which measures
3.3 cm in diameter. The degree of atherosclerotic calcification in the
ascending aorta is minimal, to the level of the aortic arch, beyond which
there is moderate calcification of the descending thoracic aorta. There is no
hilar, mediastinal or axillary lymphadenopathy by size criteria. The left
lobe of thyroid contains a 12 x 9 mm hypodense nodule.
Central airways are patent, and there is a small area of plugging in a right
lower lobe bronchial (4:193). There is minimal dependent subsegmental
atelectasis as well as a small amount of basal smooth intralobular septal
thickening and ground-glass opacity, suggesting minimal edema. The lungs are
otherwise clear. There is no pleural effusion or pneumothorax.
The study is not tailored for subdiaphragmatic assessment, nevertheless note
is made of a small hiatal hernia. There is no suspicious sclerotic or lytic
osseous lesion.
IMPRESSION:
1. Extensive coronary arterial calcification as above, with minimal
atherosclerotic calcification of the ascending aorta and moderate
atherosclerotic calcification of the descending aorta.
2. Enlarged ascending aorta, measuring 4.7 cm in diameter.
3. Enlarged pulmonary artery, measuring 3.3 cm in diameter and consistent
with pulmonary arterial hypertension.
4. A 12-mm left thyroid nodule. Recommend nonurgent thyroid sonography in
order to further assess this finding.
5. Mild pulmonary edema
Results and recommendations for followup were entered into the Critical
results communication system on ___
Radiology Report
INDICATION: ___ male with history of coronary artery disease, history
of CABG, here for preoperative evaluation.
COMPARISON: PA and lateral chest radiograph ___.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS: The lungs are well inflated and clear bilaterally with no areas of
focal consolidation, pleural effusion or pneumothorax. The heart is
borderline normal in size. The aorta is mildly tortuous. ICD is seen in
place with right atrial and right ventricular leads in position. Patient is
status post median sternotomy with sternotomy wires seen, unchanged in
position. Epicardial leads are once again noted. Mild multilevel
degenerative changes of the thoracic spine are seen.
IMPRESSION: No evidence of infection or malignancy.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with PAROX VENTRIC TACHYCARD, AICD STATUS
temperature: nan
heartrate: 150.0
resprate: 16.0
o2sat: 99.0
sbp: 164.0
dbp: 118.0
level of pain: 8
level of acuity: 1.0 | ___ yo M with CAD s/p CABG in ___, AICD in place, DMII, HTN and
HLD, presenting with chest pain x1 hour. Found to be in VT to
the 150s.
# Tachyarrhythmia
The patient reports waking from sleep with SSCP and
palpitations. He was noted to be in VT by EMS and received
amiodarone 150 in the field. Upon arrival to the ED, was found
to be in a wide complex regular tachycardia and was cardioverted
to NSR. His AICD was last interrogated in ___, with no
noted tachyarrhythmias. The patient's amiodarone dosing was
increased. His AICD was interrogated in house and it should
that his VT sensing function was not turned on, and it was set
to only sense and shock VF. He underwent an EP study, which was
unable to induce VT. He will likely benefit from additional
outpatient EP evaluation. He was noted to have occasional
episodes of ___ beat NSVT on telemetry during which he was
asymptomatic. His amiodarone dose was increased to 400 mg BID
for 1 week, followed by 400 mg daily for 1 week, finally
followed by a maintenance dose of 200 mg daily. This schedule
is subject to change given his cardiac surgery (see below) or
other outpatient follow up.
# Coronary artery disease (s/p CABG in ___
Pt reports experiencing burning, squeezing SSCP in the setting
of V that was not responsive to SLNTG. He remained chest pain
free following his cardioversion. His ECG revealed slight ST
changes, c/w cardioversion. His initial troponin was 0.02,
however this increased to a peak of 1.24. Upon further
questioning, the patient has been experiencing chest
pain/pressure with exertion for approximately the last month.
Given this history, as well as his troponin elevation that was
above what would be expected in a patient with VT s/p
cardioversion, the patient underwent a cardiac catheterization
which revealed surgical proximal LAD-DI and RCA disease. He was
evaluated by cardiac surgery and is to undergo repeat CABG.
# Chronic systolic heart failure
Pt most recent LVEF ~30% as seen on pMIBI in ___. He appeared
euvolemic on exam and did not endorse ___ edema or orthopnea. He
underwent a repeat TTE, which was significant for: an LVEF of
30% as well as the presence of a new apical aneurysm. No clot
was visualized. The possibility of anticoagulation was
discussed but it was felt to be unnecessary.
# Acute kidney injury
The patient's creatinine was noted to rise to 1.4 prior to his
discharge. It was felt to be likely secondary to a prerenal
etiology, likely hypovolemia in the setting of being NPO in the
mornings prior to both his EP study and cardiac cath. His
losartan was held. He was also instructed to not begin taking
his metformin and losartan immediately upon discharge. He was
given a prescription to have his kidney function tested prior to
restarting these medications.
# Hypertension
Was hypertension upon arrival to the ED in the setting of VT.
He remained slightly hypertensive during his hospital stay. He
was continued on his home medications: metoprolol, losartan
(held at points given ___, and HCTZ.
# Hyperlipidemia
Pt reports that he believes he had muscle aches from a statin in
the past, but was not clear on the exact medication. He was
continued on his home gemfibrozil. Pravastatin was added given
his troponin leak and following his catheterization, when it the
significant coronary blockages were noted.
# Non insulin dependant diabetes
The patients oral medications were held while he was in the
hospital. Given his history of allergy to contrast dye, the
patient was premedicated with prednisone, after which the
patient was noted to be hyperglycemia. He was maintained on a
humalog insulin sliding scale.
# Osteoarthritis
Pt reports taking occasional tylenol with codeine for pain. He
remained symptom free during this hospitalization.
======================================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Lisinopril
Attending: ___.
Chief Complaint:
Leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with history of persistent atrial
fibrillation on warfarin, chronic diastolic congestive heart
failure, hypertension, hyperlipidemia who presents with
worsening lower extremity edema.
The patient reports that she has noticed worsened lower
extremity for 1 month. At baseline patient's ability to exert is
limited by her severe arthritis. She is able to walk less than a
block at baseline but over the last couple weeks she has only
been able to walk a few feet before she became dyspneic. She
does not check her weight at home but reports that her urine
output has remained relatively unchanged. She reports that she
has missed several doses of furosemide over the last month,
however she believes that she has taken 90% of the doses. Denies
any recent dietary changes or indiscretion. She reports that her
son noticed that her eye was red on the day prior to
presentation; however no
changes in vision, itching, or discharge. No fevers, chills,
rhinorrhea, congestion. No PND or orthopnea. She reports that
her INR is managed by her PCP but she has not had INR checked
over the last couple weeks.
In the ED initial vitals were: 97.7 73 140/86 18 100% RA
Exam notable for: Per cardiology exam, irregular rhythm, distant
heart sound but no M/R/G. JVP difficult to evaluate due to body
habitus but estimated to be at the angle of jaw sitting at 45°,
lungs with fine bibasilar crackles, abdomen soft nontender, 2+
lower extremity edema up to bilateral thighs.
EKG: Atrial fibrillation at 72 bpm, T-wave inversion in V2, no
other significant ST/T-wave changes.
Imaging: CXR with pulmonary edema
Labs/studies notable for: Cr 1.2->1.1, WBC 5.3 Hb 10.9, plt 121,
INR 9.3, proBNP 2415; UA with hematuria
Patient was given:
___ 03:37 IV Furosemide 40 mg
___ 09:23 PO/NG Losartan Potassium 100 mg
___ 09:23 PO/NG Sertraline 100 mg
___ 10:26 IV Furosemide 60 mg
Vitals on transfer: 98.1 57 139/61 22 98% RA
On the floor, the patient recounts the above history. She
reports that she feels well at present and has no complaints.
She specifically denies any chest pain, palpitations, shortness
of breath at present.
Past Medical History:
1. CARDIAC RISK FACTORS
- Pre-diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- HFpEF (> 55%)
- Persistent atrial fibrillation
- Moderate TR
- Moderate pulmonary hypertension
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- COPD
- Depression/Anxiety
- Frequent UTIs
- Osteoarthritis
Social History:
___
Family History:
Brother with MI at ___ years old
Father, deceased from MI (unknown age)
Mother, deceased at ___, stomach cancer
Physical Exam:
============================
ADMISSION PHYSICAL EXAMINATION
============================
VITALS: 97.8 132/79 63 18 98 RA
GENERAL: AOx3, sitting in bed, in no acute distress
HEENT: PERRL, EOMI, left eye with ectropion and scleral redness.
MMM
NECK: Supple with JVP at angle of jaw at 45 degrees
CARDIAC: Irregularly irregular, no m/r/g, no carotid bruit
LUNGS: Bibasilar crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ peripheral edema bilaterally to the thighs
SKIN: Venous stasis changes on bilateral lower extremities
PULSES: Distal pulses palpable and symmetric
============================
DISCHARGE PHYSICAL EXAMINATION
============================
VITALS:
___ 0711 Temp: 97.7 PO BP: 145/86 HR: 72 RR: 16 O2 sat: 94%
O2 delivery: Ra
___ Total Intake: 1030ml PO Amt: 1030ml
___ Total Output: 2400ml Urine Amt: 2400ml
GENERAL: AOx3, in bed, in no acute distress
HEENT: PERRL, EOMI, MMM
NECK: Body habitus limits exam, JVP continues to appear elevated
CARDIAC: regular, somewhat distant heart sounds, soft systolic
murmur
LUNGS: crackles auscultated bibasilarly
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: gauze wrapping to ___ without ___ warm
extremities
SKIN: Venous stasis changes on bilateral lower extremities with
significant varicose veins and scattered superficial bruising
PULSES: Distal pulses palpable and symmetric. Ulcer left lateral
leg. Onychomycosis.
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 11:37PM BLOOD WBC-5.3 RBC-3.45* Hgb-10.9* Hct-35.2
MCV-102* MCH-31.6 MCHC-31.0* RDW-15.4 RDWSD-56.1* Plt ___
___ 11:37PM BLOOD ___ PTT-52.8* ___
___ 11:37PM BLOOD Glucose-134* UreaN-39* Creat-1.2* Na-143
K-4.7 Cl-103 HCO3-24 AnGap-16
___ 08:09AM BLOOD ALT-10 AST-22 AlkPhos-105 TotBili-0.9
___ 11:37PM BLOOD proBNP-2415*
___ 08:09AM BLOOD cTropnT-0.02*
___ 05:10PM BLOOD cTropnT-<0.01
___ 05:10PM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
RELEVANT LABS:
==============
___ 11:37PM BLOOD proBNP-2415*
___ 08:09AM BLOOD cTropnT-0.02*
___ 05:10PM BLOOD cTropnT-<0.01
___ 08:09AM BLOOD VitB12-185* Folate-7
___ 08:09AM BLOOD TSH-3.3
___ 08:00AM BLOOD Glucose-88 UreaN-80* Creat-2.9* Na-139
K-3.3* Cl-92* HCO3-28 AnGap-19*
MICROBIOLOGY:
=============
___ urine culture: negative
===========================
REPORTS AND IMAGING STUDIES
===========================
___ Chest Xray
IMPRESSION:
1. Moderate enlargement of cardiac silhouette is increased from
___. Differential includes 19 decompensated heart
failure or pericardial effusion. Please correlate with clinical
status.
2. Mild pulmonary vascular congestion without pulmonary
interstitial edema.
3. No focal consolidations.
___ TRANSTHORACIC ECHOCARDIOGRAM
The left atrium moderately dilated. The right atrium is markedly
dilated. The estimated right atrial pressure is at least 15
mmHg. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
imaging quality, regional wall motion cannot be determined.
There is right ventricular depressed free wall contractility.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The right ventricular
cavity is dilated with free wall hypokinesis. [In the setting of
severe tricuspid regurgitation, intrinsic right ventricular
systolic is more depressed.] 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 mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened and fail to fully
coapt. Severe [4+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. [In the setting of
at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
dilation with depressed free wall contractility. Severe
tricuspid regurgitation. At least mild pulmonary artery systolic
hypertension. Normal left ventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the severity of tricuspid regurgitation has increased and the
estimated PA systolic pressure is now lower. The decrease in
estimated PA systolic pressure may reflect worsening right
ventricular systolic function.
___ Transesophageal Echocardiogram Report
CONCLUSION:
There is moderate/severe spontaneous echo contrast in the body
of the left atrium and in the left atrial appendage. The left
atial appendage ejection velocity is depressed. There is no
evidence for an atrial septal
defect by 2D/color Doppler. Global left ventricular systolic
function is normal. There is beat-to-beat variability in the
left ventricular contractility due to the irregular rhythm. No
ventricular septal defect is seen. Dilated right ventricular
cavity with borderline normal free wall motion. Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There are simple atheroma
in the ascending aorta. There are simple atheroma in the
descending aorta. No aortic dissection is seen. 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 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 valve leaflets are mildly thickened
with leaflets that fail to fully coapt. No mass/vegetation are
seen
on the tricuspid valve. No abscess is seen. There is severe [4+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is moderately elevated. In the setting of at least
moderate to severe
tricuspid regurgitation, the pulmonary artery systolic pressure
may be UNDERestimated. There is no pericardial effusion.
IMPRESSION: Good image quality. Severe tricuspid regurgitation
due to non-coaptation of leaflets. Right ventricular dilation
with borderline normal function. Normal global left ventricular
systolic function with beatto-beat variability in ejection
fraction. At least moderate pulmonary hypertension (may be
underestimated in setting of tricuspid regurgitation). Simple
atheroma in the ascending and descending thoracic aorta. Mild
pulmonary artery systolic hypertension.
RENAL U.S.Study Date of ___
Normal renal ultrasound. No hydronephrosis. No evidence of
renal artery
stenosis.
Transthoracic Echocardiogram Report
___
There is normal left ventricular wall thickness with a normal
cavity size. Global left ventricular systolic function is
normal. Moderately dilated right ventricular cavity. Tricuspid
annular plane systolic excursion (TAPSE) is normal. Intrinsic
right ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There is abnormal
interventricular septal motion c/w right ventricular
volume>pressure overload. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral leaflets are mildly thickened
with no mitral valve prolapse. There is mild pulmonic
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is moderate to severe [3+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension.
IMPRESSION: Adequate image quality. Dilated right ventricle with
moderate to severe tricuspid regurgitation and moderate
pulmonary hypertension.
Compared with the prior TTE of (images reviewed) of ___
the volume overload/septal shift is less pronounced and the
spectral doppler profile of the tricuspid regurgitation is more
parabolic all consistent with a reduction in tricuspid
regurgitation/rv afterload. There still is 3+ TR however.
Pulmonary pressures are higher. Right ventricular systolic
function is improved.
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-4.9 RBC-3.56* Hgb-11.2 Hct-35.6
MCV-100* MCH-31.5 MCHC-31.5* RDW-14.4 RDWSD-51.8* Plt ___
___ 08:10AM BLOOD ___ PTT-35.2 ___
___ 08:10AM BLOOD Glucose-119* UreaN-38* Creat-1.0 Na-143
K-3.5 Cl-97 HCO3-30 AnGap-16
___ 08:10AM BLOOD Mg-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Furosemide 60 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Sertraline 100 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. Warfarin 2.5 mg PO 1X/WEEK (___)
9. Warfarin 5 mg PO 6X/WEEK (___)
Discharge Medications:
1. Torsemide 20 mg PO DAILY
2. Warfarin 2 mg PO DAILY16
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Sertraline 100 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. HELD- Losartan Potassium 100 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until discussed with
your outpatient physicians.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Acute exacerbation of heart failure with preserved ejection
fraction, tricuspid regurgitation, acute kidney injury
===================
SECONDARY DIAGNOSES
===================
atrial fibrillation, hypertension, hyperlipidemia, chronic
obstructive pulmonary disorder, 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 RADIOGRAPHS
INDICATION: History: ___ with wheezing h/o chf.// wheezing
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recent from ___.
FINDINGS:
Moderate enlargement of the cardiac silhouette is increased. No focal
consolidations are seen. There are probable small bilateral pleural
effusions. No pneumothorax. There is mild pulmonary vascular congestion
without pulmonary interstitial edema.
IMPRESSION:
1. Moderate enlargement of cardiac silhouette is increased from ___. Differential includes 19 decompensated heart failure or pericardial
effusion. Please correlate with clinical status.
2. Mild pulmonary vascular congestion without pulmonary interstitial edema.
3. No focal consolidations.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with h/o HFpEF, TR, who was admitted with CHF
exacerbation. Now with new ___ rising despite holding diuresis.// evaluate for
obstruction
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 9.7 cm. The left kidney measures 10.4 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.74-0.82. The resistive indices on the
left range from 0.77-0.82. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 50
centimeters/second. The peak systolic velocity on the left is 31
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is mildly distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No hydronephrosis. No evidence of renal artery
stenosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Leg swelling
Diagnosed with Other specified soft tissue disorders
temperature: 97.7
heartrate: 73.0
resprate: 18.0
o2sat: 100.0
sbp: 140.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | =================
SUMMARY STATEMENT
=================
Ms. ___ is a ___ year old woman with history of persistent
atrial fibrillation on warfarin, diastolic congestive heart
failure, hypertension, hyperlipidemia, who presented with
worsening lower extremity edema, diagnosed with a heart failure
exacerbation. This admission she was initially actively diuresed
with IV lasix 60 prn. She later developed ___ thought to be ATN
in the setting of ___ and relative hypotension. She was
managed supportively and renal function was improving by
discharge. She was also evaluated by the structural heart team
regarding potential intervention for her severe TR, with plan to
follow up with structural heart as an outpatient.
=============
ACUTE ISSUES:
=============
# Acute on chronic diastolic congestive heart failure:
She presented with worsened lower extremity edema and weight
gain (200.4 lbs on admission, from 187 lbs in cardiology clinic
___. She was volume overloaded with elevated BNP, overall
consistent with heart failure exacerbation. The precipitant of
her heart failure exacerbation was unclear, although she did
miss several doses of furosemide in the last month. No clear
dietary indiscretions. No evidence of infection. TTE this
admission showed worsening severe TR. She was initially diuresed
with 60mg IV Lasix prn; she was briefly transitioned to 120 PO
torsemide BID but subsequently developed ___ as below. She was
restarted on torsemide 20 mg PO daily and diuresed well; she
was discharged on torsemide 20mg daily.
# Severe TR:
She was found to have severe TR on TTE this admission, which
improved somewhat with optimization of her volume status. She
was seen by the structural heart team for consideration of
percutaneous intervention. She should follow up with structural
heart as an outpatient.
# Persistent atrial fibrillation:
Patient noted to have supratherapeutic INR of 9.3 on admission
for unclear reasons, though she had not had her INR checked for
2 weeks prior to admission. There was no indication for reversal
given INR not above 10 and no evidence of active bleed. She was
restarted on warfarin 2 mg on discharge. She had asymptomatic
bradycardia, so her metoprolol succinate was reduced to 25 mg
daily on discharge.
# ___:
Baseline Cr 0.9-1.0. She developed a marked ___ this admission,
with creatinine peaking at 2.9. This was thought to be likely
ATN in the setting of relative hypotension and ___.
Renal was consulted. Diuretics were held and she did receive
gentle fluids with improvement in her creatinine. Her renal
function recovered to baseline by discharge, and she was
restarted on torsemide 20mg. Discharge creatinine (___): 1.0.
Losartan was held on discharge for her resolving ___ she was
also normotensive off of losartan, but can restart as
outpatient.
===============
CHRONIC ISSUES:
===============
# Macrocytic anemia:
# Vit B12 deficiency:
She was found to have a macrocytic anemia with vitamin B12 <200,
which is highly suggestive of deficiency. She received IM B12
this admission. Transitional issue to order MMA, homocysteine
level, and IF antibodies as an outaptient; she has no clear risk
factors for dietary deficiency or malabsorption.
# HLD:
Continued simvastatin.
# COPD:
Continued Advair, albuterol PRN
# Depression:
Continued sertraline.
===================
TRANSITIONAL ISSUES
===================
[] Discharge weight (___): 75.7 kg / 166.89 lb
[] Discharge creatinine (___): 1.0
[] Patient was started on torsemide 20 mg as an inpatient and
was net negative, despite being on PO Lasix 60mg at home and
developing HF exacerbation. Unclear whether torsemide 20 mg will
be optimal dose home diuretic for the patient. Please draw
repeat chem-10 on ___ or ___ to monitor for possible ___
secondary to ___. Also monitor the patient's volume
status, daily weights, and respiratory status to manage ongoing
titration of her diuretics.
[] Patient was supratherapeutic on INR to >9 at admission.
Warfarin was held for most of her admission, before being
restarted on ___. She will be discharged on planned warfarin 2
mg daily, but will likely need further dose titration. Please
draw repeat INR by ___ at latest to assess status of
anticoagulation.
[] Losartan was held at discharge given recovering ___ and near
normal blood pressures. Her blood pressure has been controlled
off of the losartan. Depending on repeat chem-10 drawn on ___ or
___, can restart losartan at a lower dose if patient continues
to have stable Cr.
[] Patient noted to have hematuria on admission urinalysis in
setting of supratherapeutic INR. Consider repeat U/A and
hematuria workup as outpatient.
[] Consider ordering MMA, homocysteine and IF antibodies, given
her B12 deficiency. She needs continued B12 therapy.
[] Monitor HR for metoprolol titration.
[] Should follow up with structural heart as an outpatient
regarding her severe TR. Likely needs a pre-op dental evaluation
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with a history of cholangiocarcinoma C1D17
gemcitibine/cisplatin, s/p metal biliary stenting ___, who
presents with fever. Since his last chemo 1 week ago he has had
worsening fatigue and feeling more short of breath. Today he had
a fever to 102.5. No headache, sore throat, cough, CP, abdominal
pain, nausea, diarrhea, dysuria or rash. He took 1g Tylenol at
3pm with improvement. He was referred to the ED for further
evaluation.
In the ED, initial VS: 98.6 76 115/57 20 100%. Labs revealed
normal lactate, alk phos elevated to 347, but stable from prior.
No leukocytosis. Urinalysis with 16 WBC, but no leuk est, nit,
or clinical symptoms of infection. CXR without evidence of
infection. 1 blood culture sent. The patient was started on
vancomycin and unasyn, and admitted to OMED for further
management. VS prior to transfer: 98.7 78 121/64 15 99% RA.
On the floor, the patient complains of ongoing fatigue. He
states that he has had chills off and on for the past month. He
does endorse intermittent shortness of breath, especially when
climbing to the top of a flight of stairs (also new over the
past month). He denies cough, chest pain, abdominal pain,
nausea, diarrhea, or rash.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: Presented with painless jaundice associated with
epgiastrice fullness, heartburn and 10lb weight loss x 1 month.
-___: CT and MRCP (___) showed biliary dilatation,
CBD mass extending to bilateral hepatic
duct. In addition, there was concern for right liver lobe lesion
suspicious for metastasis, and prominent porta hepatis
lymphadenopathy.
-___: Underwent ERCP with sphincterotomy, CBD stenting and
PD stenting. Brushings were positive for adenocarcinoma, c/w
pancreatobiliary origen.
-___: Metal stent placed and mass unresectable based on
intraop eval with metastatic adenocarcinoma involving one lymph
node. Intraop ultrasound showed deep right lobe mass causing the
biliary dilatation and extending into the caudate lobe but not
obviously involving the left lobe
-___: Initiation of treatment held d/t elevated bili
-___: ERCP done, each stent was cannulated with a balloon
and
copious debris and stone fragments were extracted from each
stent
with balloon sweeps
-___: Initiated Gem/Cis
PAST MEDICAL HISTORY:
-HTN
-Hyperlipidemia
-DM2 (diet controlled)
-s/p lumbar discectomy
Social History:
___
Family History:
mother with colon CA at ___
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.2 BP: 122/80 HR: 74 RR: 20 02 sat: 100%RA
GENERAL: Pleasant man in no acute distress
HEENT: EOMI, PERRL, MMM, oropharynx clear
NECK: No lymphadenopathy or thyromegaly
CARDIAC: Normal s1, s2, no MRG
LUNG: CTAB
ABDOMEN: Soft, non-tender, non-distended; liver edge palpated
just below costal margin
EXTREMITIES: non-edematous
PULSES: DP pulses 2+
NEURO: CN II-XII intact; strength ___ in upper and lower
extremities
SKIN: No rash
DISCHARGE EXAM:
Vitals: Tm 98.3, Tc 98.2, 110/56, 77, 18, 99% RA, Am glucose 87
GENERAL: Pleasant man in no acute distress
HEENT: EOMI, PERRL, MMM, oropharynx clear
NECK: No lymphadenopathy or thyromegaly
CARDIAC: Normal s1, s2, no MRG
LUNG: CTAB
ABDOMEN: Soft, non-tender, non-distended; liver edge palpated
just below costal margin
EXTREMITIES: non-edematous
PULSES: DP pulses 2+
NEURO: CN II-XII intact; strength ___ in upper and lower
extremities
SKIN: No rash
Pertinent Results:
ADMISSION LABS:
___ 06:52PM BLOOD WBC-6.8 RBC-2.80* Hgb-8.9* Hct-26.7*
MCV-95 MCH-31.7 MCHC-33.2 RDW-14.9 Plt ___
___ 06:52PM BLOOD Neuts-76.4* Lymphs-13.6* Monos-9.4
Eos-0.3 Baso-0.2
___ 06:52PM BLOOD ___ PTT-30.3 ___
___ 06:52PM BLOOD Glucose-234* UreaN-13 Creat-0.8 Na-134
K-3.8 Cl-98 HCO3-29 AnGap-11
___ 06:52PM BLOOD ALT-23 AST-27 AlkPhos-347* TotBili-0.7
___ 06:52PM BLOOD Lipase-45
___ 06:52PM BLOOD Albumin-3.3*
___ 07:01PM BLOOD Lactate-1.9
___ 09:55PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:55PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
___ 09:55PM URINE RBC-2 WBC-16* Bacteri-FEW Yeast-NONE
Epi-0
___ 09:55PM URINE CastGr-3* CastHy-10*
PERTINENT LABS
Anemia Work-Up:
___ 06:00AM BLOOD WBC-6.5 RBC-2.54* Hgb-7.9* Hct-23.9*
MCV-94 MCH-31.2 MCHC-33.2 RDW-15.8* Plt ___
___ 06:00AM BLOOD Ret Aut-6.1*
___ 06:00AM BLOOD ALT-19 AST-17 LD(LDH)-91* AlkPhos-313*
TotBili-0.9
___ 06:00AM BLOOD Calcium-10.0 Phos-2.4* Mg-1.8 Iron-17*
___ 06:00AM BLOOD calTIBC-192* Hapto-297* Ferritn-686*
TRF-148*
Hypercalcemia Work-Up:
___ 06:15AM BLOOD Calcium-11.1* Phos-3.4 Mg-2.0
___ 12:11PM BLOOD PTH-60
___ 04:14PM BLOOD freeCa-1.31
DISCHARGE LABS
___ 06:30AM BLOOD WBC-4.5 RBC-2.74* Hgb-8.5* Hct-26.7*
MCV-98 MCH-31.0 MCHC-31.7 RDW-16.0* Plt ___
___ 06:30AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-141 K-4.3
Cl-109* HCO3-24 AnGap-12
___ 06:00AM BLOOD ALT-18 AST-21 AlkPhos-289* TotBili-0.6
___ 06:30AM BLOOD Calcium-10.0 Phos-3.1 Mg-2.1
MICROBIOLOGY:
___ 6:52 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STREPTOCOCCUS PNEUMONIAE.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
12:45PM.
GRAM POSITIVE COCCI IN CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
IMAGING
CXR ___: No signs of pneumonia or other acute intrathoracic
process
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
2. Ursodiol 300 mg PO BID
Discharge Medications:
1. Outpatient Lab Work
ICD-9 code: 156.1
Please check calcium and CBC
results to: Dr. ___ fax ___, Dr. ___
___ fax ___
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Ursodiol 300 mg PO BID
4. Cefpodoxime Proxetil 400 mg PO Q12H
please continue through ___
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Streptococcus Pneumoniae bacteremia
-Hypercalcemia, possibly primary hyperparathyroidism
-Relative anemia and leukopenia, without evidence of bleed,
likely from infection
SECONDARY:
-Cholangiocarcinoma
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: Cholangiocarcinoma, fever, on chemotherapy, question
pneumonia.
FINDINGS: PA and lateral views of the chest were provided demonstrating no
focal consolidation, effusion or pneumothorax. The cardiomediastinal
silhouette is normal. Bony structures are intact. There is no free air below
the right hemidiaphragm. DISH-related changes of the mid T-spine noted.
IMPRESSION: No signs of pneumonia or other acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, CHEMO
Diagnosed with FEVER, UNSPECIFIED
temperature: 98.6
heartrate: 76.0
resprate: 20.0
o2sat: 100.0
sbp: 115.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | ___ year old man with a history of cholangiocarcinoma C1D18
gemcitibine/cisplatin, s/p metal biliary stent clean out
___, admitted with fever, mild dyspnea on exertion, and
fatigue, found to have bacteremia.
ACTIVE DIAGNOSES:
# Streptococcus Pneumoniae Bacteremia: Blood cultures returned
positive on ___. Given pt's history of cholangiocarcinoma he is
at risk of bacteremia simply from translocation of bacteria at
site of tumor. Remainder of the patient's infectious workup was
unremarkable: UA without UTI, CXR without evidence of pneumonia.
He was initially treated with vancomycin and Zosyn but Zosyn was
stopped on ___ since gram stain revealed GPCs. Antibiotics were
narrowed to Ceftriaxone on ___. As he remained afebrile, he was
transitioned to cefpodoxime to complete a total of 14 days of
antibiotics (last day ___.
#. Anemia: The patient hemoglobin dropped acutely from 8.9 to
7.9 the morning following admission. He did not report a history
of blood loss. He was guaiac negative. Anemia work-up revealed a
reticulocytosis and iron deficiency. The patient was unsure of
his most recent colonoscopy but indicated it has been many years
since his last colonoscopy. Colon cancer screening should be
reviewed and colonoscopy should be considered as an outpatient.
The patient's hemoglobin subsequently rose and was 8.5 on day of
discharge.
# Hypercalcemia: Peaked at 11, with albumin of 3.3. PTH level of
60. In hypercalcemia of malignancy expect PTHrP production and
subsequent PTH repression. Current clinical picture may be
consistent with primary hyperparathyroidism with some
suppression of otherwise elevated PTH by low grade PTHrP
production. Ca improved with fluids. This should be trended in
outpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Penicillins
Attending: ___.
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
===================================================
MEDICINE NIGHTFLOAT ADMISSION NOTE
Date of admission: ___
====================================================
PCP: ___: dyspnea
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ year old woman with PMH mediastinal cyst s/p
excision ___, recent pleural effusion and pericardial
effusion
x 2 months who follows with ___ thoracic surgery who presents
with 3 days of worsening pleuritic left sided chest pain
associated with DOE.
In the ED, initial VS were: 97.5 86 124/81 20 100% RA.
Labs showed: BNP 240, lactate 1.8.
Imaging showed: left basilar opacity which may be due to an
effusion and atelectasis, new compared to ___. No
pneumothorax.
EKG: sinus rhythm, T wave flattening throughout pre-cordial
leads.
Received: 1L IVF, 2 mg IV morphine, 4 mg IV Zofran, 30 mg IV
Ketorolac.
Thoracic surgery was consulted who felt that left sided chest
pain did not appear to be related to right-sided VATS surgery 2
months ago. Felt that symptoms were more likely
pleurisy/pleuritis. Of note, patient was worked up several years
ago for similar complaints of chest pain, syncope, autonomic
dysfunction. A TTE was recently recommended but not yet
scheduled.
Thoracic recommended NSAIDS and tylenol for pain. Did not
recommend thoracentesis as effusion was small. Recommended
admission to medicine for syncope work up versus discharge home
with pain medication and close cardiology follow up.
___ was consulted and plan was to admit to cards and
start 15 mg meloxicam. 0.6 colchine BID if fails, and add
prednisone.
Transfer VS were: 97.8 101 132/78 16 99% RA.
On arrival to the floor, patient reports that she had a deeper
chest pain caused by the mediastinal cyst. After surgery she had
some residual pain but this improved to baseline. She had some
numbness and pain along the skin on the right upper breast which
was felt to be due to the procedure she had and nerves affected
during the surgery. She was started on gabapentin for this pain
which helped somewhat.
She was feeling fine when she had a syncopal event on ___ where
she "face planted." She reports feeling lightheaded before hand
and seeing "stars" before she passed out. Denied pain leading up
to this episode. Was seen in urgent care where syncope was
attributed to new gabapentin medication plus dilaudid and
possible dehydration/decreased PO intake.
Several days later she started having left sided chest pain. She
felt like the pain was related to the fall she had on that side
of her body when she had the syncopal episode.
For her pain she has had multiple chest CTs per patient, without
contrast and 2 with contrast. No PE was seen on the CT-A scans.
A
left sided pleural effusion and pericardial effusion were seen
on
chest CT originally which then resolved on the chest CT done
___. New CXR today shows left sided opacity and bedside
ultrasound showed pericardial effusion and left pleural effusion
small.
She reports that the pain is on the left side of the chest on
the
lower part of chest and upper abdominal area. Also radiates
around the side to the back. Worse with inspiration and says
that
she feels she can't get a deep breath and this makes her feel
SOB. The pain is also worsened with any exertion. It hurts more
when she lays down and improves with sitting up.
She reports that she is having episodes of feeling very hot and
flushed when normally she is very cold. This has been happening
for a little while now. She never took her temperature before.
On
admission to the floor her temperature is ___. She has had hot
flashes in the past but says the heat she has been feeling at
home felt different to her. She never thought to check her
temperature during those times though.
Per thoracics notes:
She is s/p resection of mediastinal cyst on
___. She reports a syncopal event on ___ which caused
her to fall while walking in her yard which is at a slant and
landing on her left chest. She reports left-sided chest pain
beginning ___ (8 days after fall). She has since has a CT-PE
study which was negative for PE, designated rib films which did
not demonstrate fractures. She was recently seen in the Thoracic
surgery clinic on ___ and subsequently underwent a CTA study
which was also negative for PE. Each of these studies
demonstrated a small left lower lobe effusion of varying degrees
and resolving pericardial effusion.
REVIEW OF SYSTEMS:
(+)PER HPI
Did a full ROS. No weight loss/gain, headaches, scleritis, eye
pain, change in vision, hearing changes, sore throat, swollen
lymph nodes, cough, abdominal pain, N/V/D/C, joint swelling,
muscle aches, weakness.
Past Medical History:
Anxiety
Herpes Simplex II
GERD
C-sections x 3
Inguinal hernia repair
Right video-assisted thoracoscopic surgery robotic assisted
pericardial cyst excision
Social History:
___
Family History:
Mother and multiple other family members on
maternal side of family with hypothyroidism. No autoimmune
history otherwise.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 102.1 122/81 105 18 100% on RA PULSUS: 16
GENERAL: NAD, flushed cheeks, shallow breathing
HEENT: AT/NC, ___, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
Chest: very tender to minimal palpation over LUQ and lower left
chest about ___ or 6th rib downwards. Tender over left
mid-axilla
as well.
ABDOMEN: nondistended, unable to assess LUQ fully due to
exquisite tenderness with minimal palpation, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
98.1 BP 112/78 HR88 RR18 SatO2 98%Ra
GENERAL: sitting in bed at 45 degree angle
HEENT: ___
Neck: JVD does not decrease with inspiration (+Kussmal).
LUNGS: CTAB
HEART: Normal S1, S2; no murmurs, rubs, gallops
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: some trace edema bilaterally, pulses 2+, warm to
touch
Pertinent Results:
ADMISSION LABS:
Tropx3
CRP: 265.6
ESR: 51
___ 02:00PM BLOOD WBC-9.1 RBC-4.26 Hgb-12.4 Hct-39.0 MCV-92
MCH-29.1 MCHC-31.8* RDW-14.6 RDWSD-49.4* Plt ___
___ 02:00PM BLOOD Neuts-74.1* Lymphs-13.7* Monos-11.0
Eos-0.7* Baso-0.1 Im ___ AbsNeut-6.74* AbsLymp-1.25
AbsMono-1.00* AbsEos-0.06 AbsBaso-0.01
___ 02:00PM BLOOD ___ PTT-26.1 ___
___ 02:00PM BLOOD Glucose-110* UreaN-9 Creat-0.9 Na-139
K-3.9 Cl-98 HCO3-25 AnGap-16
___ 02:00PM BLOOD ALT-13 AST-11 AlkPhos-97 TotBili-0.4
___ 02:00PM BLOOD cTropnT-<0.01 proBNP-240*
___ 07:45AM BLOOD CRP-265.6*
___ 02:09PM BLOOD Lactate-1.8
HOSPITAL COURSE IMAGING:
CXR ___:
The lung volume is small, exaggerating bronchovascular markings
and with
secondary left basilar atelectasis. No focal consolidation to
suggest
pneumonia. The pulmonary vasculature is unremarkable. There is
small left pleural effusion, new compared ___. There
is presumed left compressive atelectasis. There is no pleural
effusion on the right. No pneumothorax. No acute osseous
abnormalities.
IMPRESSION: Left basilar opacity which may be due to an effusion
and atelectasis, new compared to ___. No
pneumothorax.
ECHO ___:
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. IVC dilated (>2.1cm) with <50% decrease with
sniff (estimated RA pressure (>=15 mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mildly depressed LVEF. No resting or Valsalva inducible LVOT
gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Cannot assess RV
systolic function. Abnormal septal motion/position. Prominent
moderator band/trabeculations are noted in the RV apex.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+)
MR.
___ VALVE: Normal tricuspid valve leaflets. Mild to
moderate [___] TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PS.
PERICARDIUM: Effusion echo dense, c/w blood, inflammation or
other cellular elements. The pericardium may be thickened.
Significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, c/w impaired ventricular
filling. Echo findings are suggestive but not diagnostic of
constriction.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Conclusions
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed (LVEF= 45-50 %). There is no left
ventricular outflow obstruction at rest or with Valsalva. There
is abnormal septal motion/position. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. The pericardium may be thickened. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. The echo findings are suggestive but not
diagnostic of pericardial constriction.
IMPRESSION: Echodense pericardial effusion vs. thickened
pericardium with abnormal septal bounce and respiratory
variation in septal motion, dilated IVC as well as variation in
mitral and tricuspid inflow velocities suggestive of pericardial
constriction. Mild mitral regurgitation. If clinically
indicated, a cardiac MRI may be indicated.
REPEAT ECHO on ___:
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PERICARDIUM: Very small pericardial effusion. Effusion
circumferential. No RA or RV diastolic collapse.
Conclusions
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a very small pericardial effusion. The effusion appears
circumferential. No right atrial or right ventricular diastolic
collapse is seen.
IMPRESSION: Very small circumferential pericardial effusion with
borderline exaggeration in mitral and tricuspid valve inflow but
without abnormal septal motion of constriction. No evidence of
tamponade.
Compared with the prior study (images reviewed) of ___ the
septal motion is normal. As before if concern for constrictive
physiology remains cardiac MRI may be helpful clinically. The
pericardial effusion is unchnaged.
CARDIAC MRI Pending
DISCHARGE LABS:
CRP: 198.0
___ 04:55PM BLOOD WBC-5.1 RBC-3.66* Hgb-11.1* Hct-33.7*
MCV-92 MCH-30.3 MCHC-32.9 RDW-14.6 RDWSD-49.6* Plt ___
___ 04:55PM BLOOD Plt ___
___ 04:55PM BLOOD Glucose-140* UreaN-12 Creat-0.8 Na-143
K-3.8 Cl-102 HCO3-27 AnGap-14
___ 07:50AM BLOOD CK(CPK)-28*
___ 04:55PM BLOOD CRP-198.0*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 20 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Gabapentin 100 mg PO BID
4. Gabapentin 200 mg PO QHS
5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
6. LORazepam 0.5 mg PO DAILY:PRN anxiety
7. Omeprazole 20 mg PO Q12H:PRN heartburn
Discharge Medications:
1. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 capsule(s) by mouth daily Disp #*90
Capsule Refills:*1
2. Ibuprofen 800 mg PO TID
RX *ibuprofen 800 mg as dir tablet(s) by mouth as dir Disp #*135
Tablet Refills:*1
3. FLUoxetine 20 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. Gabapentin 200 mg PO QHS
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. LORazepam 0.5 mg PO DAILY:PRN anxiety
8. Omeprazole 20 mg PO Q12H:PRN heartburn
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp
#*180 Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Constrictive effusive pericarditis
Discharge Condition:
Mental status: clear and coherent
Ambulatory status: independent
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with ___ Pleural effusion, worsening pleuritic chest pain x
2//evaluate for pneumothorax or pleural effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT dated ___ and chest radiograph dated ___.
FINDINGS:
The lung volume is small, exaggerating bronchovascular markings and with
secondary left basilar atelectasis. No focal consolidation to suggest
pneumonia. The pulmonary vasculature is unremarkable. There is small left
pleural effusion, new compared ___. There is presumed left
compressive atelectasis. There is no pleural effusion on the right. No
pneumothorax. No acute osseous abnormalities.
IMPRESSION:
Left basilar opacity which may be due to an effusion and atelectasis, new
compared to ___. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman with pericardial constriction + pericardial
effusion.Further categorize pericardial constriction.
TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology.
COMPARISON: CT angio of the chest dated ___
IMPRESSION:
Please note that this report only pertains to extracardiac findings.
Small volume left pleural effusion, also noted on the recent chest CT dated ___. No additional extracardiac findings seen on this exam.
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea on exertion
Diagnosed with Disease of pericardium, unspecified
temperature: 97.5
heartrate: 86.0
resprate: 20.0
o2sat: 100.0
sbp: 124.0
dbp: 81.0
level of pain: 8
level of acuity: 3.0 | ___ year old woman with PMH mediastinal cyst s/p excision
___, recent pleural effusion and pericardial effusion x 2
months, and morbid obesity who who presented with worsening
pleuritic left sided chest pain associated with DOE, syncope x2,
who was found to have evidence of pericardial constriction and
pericardial effusion on ultrasound. Patient's heart rate was not
increased during her hospital stay, which was reassuring.
We started treatment with high dose ibuprofen q6-8hours and
daily colchicine, with some decrease in severity of patient's
symptoms and improvement of constriction evidenced on repeat
echo.
We performed a cardiac MRI and a repeat echo before patient was
discharged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain
Necrosis of vaginal/cervical tissue with supra-infection
History of stage IIB squamous cell carcinoma of the cervix
status post chemoradiation
Major Surgical or Invasive Procedure:
Exam under anesthesia, hysteroscopy, dilation and curettage,
vaginal/cervical biopsies
History of Present Illness:
Ms. ___ is a ___ year old woman with history of cervical
cancer s/p chemoradiation (last in ___ and Crohn's disease
who presented with acute on chronic lower abdominal and pelvic
pain. Patient was recently seen in the ED on ___ and then
re-presented on ___ for ongoing abdominal pain which
was attributed to her Crohn's disease. She was discharged on
prednisone and scheduled to start humira as an outpatient, but
had yet to start.
Recently, patient reported that her pain had been present since
___, but worsening. The pain was described as ___ sharp
lower abdominal pain that radiated to the back, worse with
movement improved with Percocet, acetaminophen and ibuprofen. No
fevers, chills, or night sweats. Of note, on the morning of ___,
patient had a CT abd/pelvis w/ no evidence of recurrence or
signs of Crohn's complications, but did show an enlarged uterus
w/ fluid and air in uterine cavity.
Of note, she was recently diagnosed with a UTI on ___, on
levofloxacin. She reported dysuria, but no hematuria, no flank
pain. She also reported malodorous discharge for unknown amount
of time. Sexually active w 1 partner, denied use condoms. Noted
that she is menopausal.
In the ED, initial vital signs were:
- Initial Vitals/Trigger: 7 96.5 117 143/86 20 100% RA.
- Exam: Tearful, lower abdominal tenderness most prominent in
the suprapubic region, no CVA tenderness bilaterally
- Labs were notable for WBC 14.2, microcytic anemia H/H
10.3/32.9, plts 336, normal chem 10 including Cr 0.7, lactate
1.2, UA with no bacteria, 10 WBC, mod leuks, mod blood, 40
ketones, 30 protein
- Studies performed
___
CT A/P that showed:
1. Status post ileocecectomy and for inflammatory bowel disease
is no evidence of local recurrence or signs of a complication of
Crohn's disease
2. Enlarged uterus a with the fluid and air with the in the
uterine cavity.
- Patient was given: 4mg IV morphine x3, 4mg IV zofran
- Vitals on transfer:
98.5 91 150/91 18 99% RA
Past Medical History:
Past Medical History:
1. Beta thalassemia.
2. Wisdom tooth extraction in the past.
3. Asymptomatic nephrolithiasis.
4. Crohn's disease
5. Cervical Cancer s/p chemo and brachytherapy
Past Surgical History:
___: Laparoscopic Ileocecectomy
Social History:
___
Family History:
Mother with breast cancer at age ___. One maternal cousin with
uterine cancer. Another maternal cousin had atypical cervical
cells, not requiring major surgery, radiation or chemotherapy.
Physical Exam:
===========================
Physical Exam on Admission:
===========================
Vitals-98.4 156 / 88 99 22 100 RA
GENERAL: AOx3, groaning in pain, teary eyed
HEENT: Pupils 2-3 mm, equal, round, and reactive bilaterally,
extraocular muscles intact. Sclera anicteric. Moist mucous
membranes, Oropharynx is clear..
CARDIAC: Regular rhythm, normal rate, no murmurs
LUNGS: Clear to auscultation bilaterally No wheezes, rhonchi
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mildly tender to
deep palpation in all four quadrants. No guarding, no rebound.
EXTREMITIES: No lower ext edema, 2+ DP bilaterally
NEUROLOGIC: CN2-12 grossly intact. non-focal.
===========================
Physical Exam on Transfer:
===========================
Vitals: Tm 99.4 144-156/84-66, RR 20 100% on RA
GENERAL: AOx3, groaning in pain, teary eyed
HEENT: Pupils 2-3 mm, equal, round, and reactive bilaterally,
extraocular muscles intact. Sclera anicteric. Moist mucous
membranes, Oropharynx is clear..
CARDIAC: Regular rhythm, normal rate, no murmurs
LUNGS: Clear to auscultation bilaterally No wheezes, rhonchi
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mildly tender to
deep palpation in all four quadrants. No guarding, no rebound.
EXTREMITIES: No lower ext edema, 2+ DP bilaterally
NEUROLOGIC: CN2-12 grossly intact. non-focal.
===========================
Physical exam on discharge:
===========================
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, nondistended, minimally tender in b/l LQ, no
rebound/guarding
___: nontender, nonedematous, no inguinal LAD
Pertinent Results:
============================
Labs:
============================
___ 12:45PM BLOOD WBC-14.2* RBC-4.39 Hgb-10.3* Hct-32.9*
MCV-75* MCH-23.5* MCHC-31.3* RDW-16.6* RDWSD-44.8 Plt ___
___ 12:45PM BLOOD Plt ___
___ 12:45PM BLOOD Glucose-163* UreaN-15 Creat-0.7 Na-135
K-3.8 Cl-96 HCO3-22 AnGap-21*
___ 12:45PM BLOOD ALT-<5 AST-13 LD(LDH)-207 AlkPhos-84
TotBili-0.3
___ 12:45PM BLOOD Albumin-4.2
___ 12:45PM BLOOD CRP-177.8*
___ 07:25AM BLOOD WBC-11.7* RBC-4.11 Hgb-9.5* Hct-30.4*
MCV-74* MCH-23.1* MCHC-31.3* RDW-16.1* RDWSD-43.4 Plt ___
___ 07:25AM BLOOD Glucose-120* UreaN-7 Creat-0.6 Na-136
K-3.5 Cl-98 HCO3-27 AnGap-15
___ 07:25AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9
___ 06:05AM BLOOD WBC-9.8 RBC-3.67* Hgb-8.3* Hct-27.1*
MCV-74* MCH-22.6* MCHC-30.6* RDW-16.3* RDWSD-43.2 Plt ___
___ 08:56AM BLOOD WBC-10.5* RBC-3.85* Hgb-8.8* Hct-28.8*
MCV-75* MCH-22.9* MCHC-30.6* RDW-16.2* RDWSD-44.1 Plt ___
___ 06:05AM BLOOD Neuts-79.3* Lymphs-11.4* Monos-7.2
Eos-1.1 Baso-0.2 Im ___ AbsNeut-7.79* AbsLymp-1.12*
AbsMono-0.71 AbsEos-0.11 AbsBaso-0.02
___ 08:56AM BLOOD Neuts-83.0* Lymphs-10.2* Monos-4.7*
Eos-0.9* Baso-0.4 Im ___ AbsNeut-8.68* AbsLymp-1.07*
AbsMono-0.49 AbsEos-0.09 AbsBaso-0.04
___ 06:05AM BLOOD Glucose-91 UreaN-11 Creat-0.7 Na-138
K-4.2 Cl-100 HCO3-31 AnGap-11
___ 09:06AM BLOOD Glucose-84 UreaN-13 Creat-0.6 Na-138
K-3.5 Cl-99 HCO3-28 AnGap-15
___ 09:06AM BLOOD ALT-<5 AST-12 AlkPhos-66 TotBili-0.2
___ 06:05AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.7
___ 09:06AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.4 Mg-1.5*
___ 05:55AM BLOOD WBC-10.5* RBC-3.86* Hgb-8.8* Hct-29.0*
MCV-75* MCH-22.8* MCHC-30.3* RDW-16.1* RDWSD-43.6 Plt ___
___ 06:06AM BLOOD WBC-10.7* RBC-4.10 Hgb-9.3* Hct-30.6*
MCV-75* MCH-22.7* MCHC-30.4* RDW-15.9* RDWSD-42.9 Plt ___
___ 05:55AM BLOOD Neuts-83.6* Lymphs-9.3* Monos-5.3
Eos-0.9* Baso-0.3 Im ___ AbsNeut-8.81* AbsLymp-0.98*
AbsMono-0.56 AbsEos-0.10 AbsBaso-0.03
___ 06:06AM BLOOD Neuts-82.3* Lymphs-10.5* Monos-5.1
Eos-1.0 Baso-0.4 Im ___ AbsNeut-8.84* AbsLymp-1.13*
AbsMono-0.55 AbsEos-0.11 AbsBaso-0.04
___ 05:55AM BLOOD Glucose-91 UreaN-8 Creat-0.6 Na-137 K-4.2
Cl-99 HCO3-31 AnGap-11
___ 06:06AM BLOOD Glucose-86 UreaN-11 Creat-0.6 Na-138
K-4.5 Cl-96 HCO3-29 AnGap-18
___ 05:55AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.4
___ 06:06AM BLOOD Calcium-9.6 Phos-3.8 Mg-1.9
___ 05:55AM BLOOD FSH-62*
___ 05:55AM BLOOD Estradl-<5
============================
Microbiology:
============================
URINE CULTURE (Final ___: <10,000 organisms/ml.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final ___:
Negative for Chlamydia trachomatis by PANTHER System,
APTIMA COMBO 2
Assay.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION (Final ___:
Negative for Neisseria gonorrhoeae by PANTHER System,
APTIMA COMBO 2
Assay.
Blood Culture, Routine (Final ___: NO GROWTH
=============================
Imaging:
=============================
___ CT Abdomen Pelvis:
1. Unchanged appearance of the uterus from 3 days prior. There
is again a
moderate amount of air and debris within the uterine cavity.
Findings are
nonspecific but infection or malignancy cannot be excluded.
Thickening of the right adrenal gland appears unchanged from
___.
2. No evidence of small or large bowel inflammation.
3. Indeterminate hypodensities in the right kidney measure up to
1.1 cm.
Nonemergent renal ultrasound is recommended for further
assessment.
___ CT Abdomen Pelvis:
IMPRESSION:
1. Status post ileocecectomy and for inflammatory bowel disease
is no evidence
of local recurrence or signs of a complication of Crohn's
disease
2. Enlarged uterus a with the fluid and air with the in the
uterine cavity.
This may be post instrumentation in the past with known cervical
ca. However
correlation with an history physical findings to exclude
infection or tumor
necrosis should be made.
___ MRI Pelvis
IMPRESSION:
1. No signs for avascular necrosis or insufficiency fractures.
2. Degenerative changes of the inferior left sacroiliac joint
and left pubic symphysis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 15 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Budesonide 9 mg PO BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
do not take more than 4000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*1
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
do not drink alcohol or drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*25 Tablet Refills:*0
3. PredniSONE 15 mg PO DAILY
___: 15mg/day
___: 10mg/day
___: 5mg/day
___: discontinue med
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Vitamin D 1000 UNIT PO DAILY
5. Levofloxacin 750 mg PO Q24H Duration: 14 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
6. MetroNIDAZOLE 500 mg PO Q8H
Take with food to avoid GI upset.
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours.
Disp #*42 Tablet Refills:*0
7. Budesonide 9 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Necrosis of vaginal/cervical tissue with supra-infection
Recurrence of cervical cancer
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 crohns s/p surgey but with worsening
symptoms and prior studies showing worsening disease now with severe abd pain
// ? of worsening crohns disease
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
neutral density oral contrast (VoLumen) was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 5.8 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 28.0 s, 0.2 cm; CTDIvol = 295.2 mGy (Body) DLP =
59.0 mGy-cm.
3) Spiral Acquisition 7.4 s, 48.1 cm; CTDIvol = 7.1 mGy (Body) DLP = 337.5
mGy-cm.
Total DLP (Body) = 398 mGy-cm.
COMPARISON: ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal solid renal lesions or hydronephrosis. The
subcentimeter hypodensity in the upper pole, again seen with no interval
change, likely cyst. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Post ileocecal ectomy with no
abnormality seen in the neo terminal ileum and ileocolonic anastomosis. There
is no mesenteric stranding or extraluminal fluid collection. There is no
abnormal bowel wall thickening or enhancement. The colon and rectum are
within normal limits. The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is fluid present within the uterus an air-fluid
levels. Patient with known cervical CA. Has the there been a recent
intervention?
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Status post ileocecectomy and for inflammatory bowel disease is no evidence
of local recurrence or signs of a complication of Crohn's disease
2. Enlarged uterus a with the fluid and air with the in the uterine cavity.
This may be post instrumentation in the past with known cervical ca. However
correlation with an history physical findings to exclude infection or tumor
necrosis should be made.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ year old woman with hx of crohns now s/p EUA, hysteroscopy, D
C, vaginal/cervical bx for necrosis of vaginal/cervical tissue with
superimposed infection, now with worsening clinical picture and increased
pain. // ? coexisting colitis and pelvic etiology, pyometria? abdominopelvic
abscesses
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 27.9 s, 0.2 cm; CTDIvol = 476.4 mGy (Body) DLP =
95.3 mGy-cm.
3) Spiral Acquisition 4.7 s, 52.1 cm; CTDIvol = 9.2 mGy (Body) DLP = 474.1
mGy-cm.
Total DLP (Body) = 571 mGy-cm.
COMPARISON: CT ___.
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. A
hypodensity in segment 4 likely represents focal fat. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: Thickening of the right adrenal gland is unchanged from ___.
The left adrenal gland is unremarkable.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Hypodensities in the upper and lower pole the right kidney are indeterminate
in density and measure up to 1.1 cm. No focal lesions are seen in the left
kidney.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The patient is
status post ileocecectomy. Previously seen thickening and hyperemia of the
neoterminal ileum is not apparent on today's examination. Otherwise, the
colon and rectum are within normal limits. The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Bilateral the essure devices are noted. The uterine
cavity contains a moderate amount of and air and fluid attenuation debris,
although assessment is limited on CT.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Unchanged appearance of the uterus from 3 days prior. There is again a
moderate amount of air and debris within the uterine cavity. Findings are
nonspecific but infection or malignancy cannot be excluded. Thickening of the
right adrenal gland appears unchanged from ___.
2. No evidence of small or large bowel inflammation.
3. Indeterminate hypodensities in the right kidney measure up to 1.1 cm.
Nonemergent renal ultrasound is recommended for further assessment.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Lower back pain
Diagnosed with Unspecified abdominal pain
temperature: 96.5
heartrate: 117.0
resprate: 20.0
o2sat: 100.0
sbp: 143.0
dbp: 86.0
level of pain: 7
level of acuity: 3.0 | ___ with h/o Crohns disease s/p ileocecectomy ___ and
cervical cancer s/p chemoradiation who re-presents with
persistent abdominal pain c/f supra-infected necrotic tumor.
#) Acute on chronic abdominal pain
Patient presented with sharp, band like lower abdominal pain
radiating to the back. Her history is notable for cervical
cancer s/p radiation therapy. PET CT ___ showed an overall
stable mildly avid cervical mass. She has undergone
ileocecectomy for her Crohn's disease and is currently on
prednisone 15mg for a flair which occurred ___.
She was admitted to the GI service on ___. In the ED, she was
started on IV ceftriaxone x24 hours for a known UTI. She was
switched to levofloxacin on ___. Workup of her abdominal pain
including abdominal CT on ___ showed no signs of colitis/Crohns
flair however did show enlarged uterus with fluid and air in the
uterine cavity. Patient was evaluated and there was concern for
supra-infected necrotic tumor and she was transferred to the
gynecology oncology service. She had EUA, biopsies, hysteroscopy
and D&C on ___.
#) Cervical/vaginal necrosis with suprainfection
She underwent exam under anesthesia, vaginal and cervical
biopsies, hysteroscopy and dilatation and curettage on ___. This
revealed agglutination of her upper vagina and fibrosis and
thickening of the upper vaginal walls. There was foul-smelling
white discharge with sloughing of necrotic tissue at the upper
vagina and cervix. Hysteroscopically, there was dense fibrotic
tissue within the endometrial cavity with no normal-appearing
endometrium. The left tubal ostia was potentially visualized. On
rectovaginal exam, there was thickening and fibrosis of the
parametria bilaterally, but no nodularity.
Post-operatively, she was kept on IV flagyl and levofloxacin for
24 hours. She was transitioned to PO flagyl and levofloxacin on
___. Her WBC continued to downtrend from admission 14.2 -->
10.5. Her pain was controlled with PO Tylenol around the clock
and oxycodone prn.
On POD#2, patient began complaining of increased pelvic pain
radiating to her back. She was switched to IV levofloxacin and
flagyl. A repeat CT abdomen/pelvis showed "unchanged appearance
of the uterus from 3 days prior, moderate amount of air and
debris within the uterine cavity; no evidence of small or large
bowel inflammation." Given the change in her clinical status,
Infectious Disease was consulted for management of antibiotics.
ID noted that patient is immunosuppressed on tapered steroids
without significant white blood cell count or fevers. They
suggested 14 day course of augmentin for coverage of her
superinfected debris and UTI.
Her pain regimen was changed to scheduled PO Tylenol, dilaudid
4mg q4 hours and dilaudid PCA for breakthrough pain with mild
relief of symptoms. Chronic pain was consulted on POD#4 for pain
control recommendations. They recommended discontinuation of the
PCA due to minimal use by patient, starting gabapentin and
continuing opioids with dilaudid 4mg q4 PRN.
#) Cervical Cancer
Pathology results from ___ showed necroinflammatory debris with
bacterial overgrowth, invasive squamous cell
carcinoma-moderately differentiated of the vaginal biopsy and
invasive scc-focus too small to grade of cervical biopsy. Ms.
___ was informed of the pathology results which were
concerning for recurrence of disease. She was offered the option
to continue inpatient management and have PET CT to assess for
metastatic spread vs. discharge home with oral pain regimen and
outpatient CT. Patient elected to continue workup on an
outpatient basis and PET CT was scheduled for ___.
#) Crohn's
For her Crohn's, GI continued to follow and recommended
discontinuing humira and a prednisone taper by lowering her dose
to 15mg and then lower it from there by 5mg/every 5 days to
limit wound healing issues and in the setting of her infection.
She was continued on her home dose of budesonide.
#) For her Beta thalassemia, her hemoglobin was at baseline and
stable through the course of her admission.
By hospital day #5, her WBC was stable, she was tolerating a
regular diet, voiding spontaneously, ambulating independently,
and pain was controlled with oral medications. She was then
discharged home in stable condition with outpatient follow-up
scheduled. |
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:
___ y/o M with h/o morbid obesity and family history of early CAD
who presented to the ED with ___ weeks of worsening burping,
bloating and chest pain radiating to his shoulder. He states
that he feels L chest radiating to his shoulder, crampy in
nature, that comes on intermittently associated when he feels
like he needs to burp, relieved afterwards that occurs when he
goes up a flight of stairs. He reports these symptoms sometimes
come on after eating and last a few hours. He states he has not
been active recently. His pain is not associated with nausea,
vomiting, or diaphoresis. States he has been noticing dyspnea as
well that will occur intermittently, sometimes at rest when he
is laying down. Denies orthopnea, PND, or snoring at night. He
also has been having L arm pain intermittently, believes he may
be sleeping on it. Also states he has been having memory issues
starting last week such that he cannot remember his boss's name.
He denies any fevers, chills, cough, sore throat, abdominal
pain, diarrhea, constipation, dysuria.
In the ED initial vitals were: 98 84 143/81 18 100% RA
Labs/studies notable for: trop negx2. Chem panel wnl. WBC: 3.7.
D-dimer 210.
CXR with no acute process.
CTA head/neck wnl.
Patient was given: ASA 243mg x2
In the ED, he had two negative troponins and nuclear stress test
which revealed partially reversible large moderate severity
perfusion defect in RCA distribution. Cardiology consulted and
recommending cardiac cath tomorrow.
Neuro also consulted for poor memory, and deemed poor memory may
be secondary to attention.
Vitals on transfer: 98.1 62 102/64 16 98% RA
On the floor, Patient is chest pain free. States the last time
he had chest pain was earlier this morning when he was moving
around, but resolved very shortly.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
History of peptic ulcer disease, H. pylori infection, s/p
Prevpac
anxiety
depression
morbid obesity.
Social History:
___
Family History:
Mom died of brain tumor at age ___. Dad died of a heart attack at
age ___. He has one brother and one sister with no medical
problems. No family history of type 2 diabetes or colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.3 127/75 75 18 97% RA
Weight: 186.9kg
GENERAL: Obese black male in no acute distress.
HEENT: PERRL. EOMI. MMM
NECK: Supple. JVP not elevated at 45 degrees
CARDIAC: RRR. No mrg.
LUNGS: Unlabored breathing. Distant breath sounds due to girth
ABDOMEN: +BS. Soft, non-tender, non-distended. No hepatomegaly.
No splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
GENERAL: no acute distress, NAD
HEENT: EOMI
NECK: no JVD
CARDIAC: RRR, nl S1 S2, no murmurs/rubs/gallops
LUNGS: clear to auscultation bilaterally
ABDOMEN: soft, NT, ND, NABS
EXT: WWP
SKIN: no rash
NEURO: moving all extremities spontaneously, CN2-12 grossly
intact
Pertinent Results:
ADMISSION LABS:
___ 12:00PM BLOOD WBC-3.7* RBC-5.06 Hgb-14.8 Hct-46.8
MCV-93 MCH-29.2 MCHC-31.6* RDW-14.4 RDWSD-48.3* Plt ___
___ 12:00PM BLOOD Neuts-58.8 ___ Monos-8.2 Eos-3.0
Baso-0.3 Im ___ AbsNeut-2.16 AbsLymp-1.07* AbsMono-0.30
AbsEos-0.11 AbsBaso-0.01
___ 12:55PM BLOOD ___ PTT-31.9 ___
___ 12:00PM BLOOD UreaN-14 Creat-1.2 Na-145 K-5.1 Cl-105
HCO3-26 AnGap-19
___ 12:00PM BLOOD ALT-20 AST-18 CK(CPK)-228 AlkPhos-81
TotBili-0.6
___ 12:55PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.4 Mg-2.0
UricAcd-9.5* Cholest-162
PERTINENT INTERVAL LABS:
___ 07:09PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD VitB12-530
___ 01:16PM BLOOD D-Dimer-210
___ 12:00PM BLOOD %HbA1c-5.0 eAG-97
___ 12:00PM BLOOD Triglyc-121 HDL-36 CHOL/HD-4.5
LDLcalc-102
___ 04:30AM BLOOD TSH-2.7
___ 12:00PM BLOOD 25VitD-11*
___ 12:00PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 12:00PM BLOOD HCV Ab-Negative
___ 12:00PM BLOOD METHYLMALONIC ACID-Test
DISCHARGE LABS:
___ 06:46AM BLOOD WBC-4.1 RBC-4.82 Hgb-14.1 Hct-44.2 MCV-92
MCH-29.3 MCHC-31.9* RDW-14.2 RDWSD-48.0* Plt ___
___ 06:46AM BLOOD Glucose-101* UreaN-14 Creat-1.1 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
___ 12:55PM BLOOD ALT-20 AST-19 AlkPhos-79 TotBili-0.5
___ 06:46AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0
MICROBIOLOGY: N/A
IMAGING/STUDIES:
MRI BRAIN ___
There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. There is no parenchymal signal abnormality. There is
no focus of slow diffusion. Principal intracranial vascular flow
voids are preserved. The ventricles and sulci are
age-appropriate. The ethmoid air cells are partially opacified
and there is a mucous retention cyst in the right maxillary
sinus, unchanged. The orbits are grossly unremarkable.
IMPRESSION: Unremarkable noncontrast enhanced brain MRI, except
for chronic sinus disease as described.
CARDIAC CATH ___
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
STRESS MIBI ___. Probable partially reversible, large, moderate severity
perfusion defect involving the RCA territory in the setting of
significant attenuation.
2. Normal left ventricular cavity size and systolic function.
CTA HEAD AND NECK ___. No acute intracranial abnormality.
2. Patent intracranial arterial vasculature without significant
stenosis,
occlusion, or dissection.
3. Neck CTA is severely limited by body habitus, however the
common carotid arteries and distal branches appear grossly
patent. The proximal vertebral arteries are not well assessed,
however appear grossly patent distally. No frank evidence for
occlusion.
4. The adenoids and palatine tonsils are prominent, without
focal mass lesion. Clinical correlation is recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. flaxseed oil 1,000 mg oral DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth every day Disp #*30
Capsule Refills:*0
3. flaxseed oil 1,000 mg oral DAILY
4. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Non-ischemic chest pain
#obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with 1 week of SOB chest pain chest pain, assess for
PNA/pulm edema/cardiomegaly
TECHNIQUE: AP and lateral view of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are low. The lungs are clear without consolidation, effusion, or
edema. The cardiomediastinal silhouette is within normal limits given low
lung volumes. No acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: Intermittent slurred speech and memory difficulties. Evaluate
for bleed or vascular abnormality.
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 6.5 s, 0.5 cm; CTDIvol = 106.2 mGy (Head) DLP =
53.1 mGy-cm.
3) Spiral Acquisition 5.1 s, 40.1 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,282.1 mGy-cm.
Total DLP (Head) = 2,232 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation of the upper chest and lower cervical vasculature is severely
limited by body habitus and photon starvation.
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration. A small
frontal dural calcification is noted (5:282).
There is a moderate mucous retention cyst in the right maxillary sinus. There
is trace background mucosal wall thickening in the bilateral maxillary sinuses
as well as opacification of a few bilateral ethmoid air cells and trace
mucosal wall thickening of the sphenoid sinuses. The visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are
otherwise clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear patent without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The great vessel origins and proximal vertebral and common carotid arteries
are not well assessed due to body habitus. The proximal common carotid
arteries appear grossly patent. The proximal vertebral arteries are difficult
to assess. However, the distal vertebral arteries appear grossly patent. The
carotid bifurcations are grossly patent and there is no internal carotid
artery stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are grossly clear given limitations. The
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. The adenoids and palatine tonsils are
prominent, without focal mass lesion.
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent intracranial arterial vasculature without significant stenosis,
occlusion, or dissection.
3. Neck CTA is severely limited by body habitus, however the common carotid
arteries and distal branches appear grossly patent. The proximal vertebral
arteries are not well assessed, however appear grossly patent distally. No
frank evidence for occlusion.
4. The adenoids and palatine tonsils are prominent, without focal mass lesion.
Clinical correlation is recommended.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD.
INDICATION: ___ y/o M with h/o morbid obesity and family history of early CAD
who chest pain radiating to his shoulder. Chest pain ruled out for cardiac
cause by clean cardiac cath. Also had several discrete episodes of several
minutes of aphagia. Also feeling more confused recently and unable to recall
normal things.// evidence of lesions
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ head and neck CTA.
FINDINGS:
There is no evidence of hemorrhage, edema, mass, mass effect, or infarction.
There is no parenchymal signal abnormality. There is no focus of slow
diffusion. Principal intracranial vascular flow voids are preserved. The
ventricles and sulci are normal in size and configuration. The ethmoid air
cells are partially opacified and there is a mucous retention cyst in the
right maxillary sinus, unchanged. The orbits are grossly unremarkable.
IMPRESSION:
1. There is no evidence of acute intracranial process or hemorrhage.
2. Chronic sinus disease as described.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: MULTIPLE COMPLAINTS
Diagnosed with Other chest pain
temperature: 98.0
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 143.0
dbp: 81.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ with PMH of morbid obesity and family
history of early CAD who presented with bloating and chest pain
x1-2 weeks, evaluated with p-MIBI c/f reversible RCA lesion,
then subsequently cardiac catheterization which showed normal
coronary arteries. His chest pain symptoms were thought to be
related to dyspepsia and he was started on omeprazole. The
patient also reported transient aphasic episodes prior to
admission. He was evaluated by neurology, found to have negative
CTA head/neck, TTE w/o thrombus and negative MRI brain. He was
discharged on ASA81mg daily and will follow up as outpatient for
EEG to rule out seizure.
# CHEST PAIN: Patient presented with 2 weeks of exertional chest
discomfort associated with symptoms of burping/belching. His
cardiac enzymes were negative x2 in the ED. ECG was w/o changes.
Patient underwent pMIBI in the ED which showed possible reversal
defect in RCA territory. He underwent cardiac cath which showed
no coronary disease. His symptoms were thought to be related to
GERD vs. dyspepsia. He was started on omeprazole 20mg daily and
should f/u with PCP as outpatient for further evaluation. The
patient has already been treated with triple antibiotic therapy
for H pylori. Can consider testing for eradication as
outpatient.
# APHASIC EPISODES: Patient reported several episodes of
forgetfulness and 3 discreet episodes of aphasia in the weeks
prior to presentation. He was evlauted with CTA head and neck
which was negative. He was evaluated by neurology who
recommended w/u with MRI brain (which was preliminary negative),
TTE which showed no evidence of thrombus. Telemetry showed no
evidence of AF. He will f/u with neurology as outpatient for EEG
to evaluate for possible seizure and for further evaluation. Lab
work-up including TSH, B12 and MMA was within normal limits. The
patient was started on aspirin 81mg daily.
# THROMBOCYTOPENIA: plts slightly low during admission, in 130s,
remained stable. Consider repeat CBC as outpatient for further
evaluation.
Transitional Issues:
- Cardiac cath showed no vessel blockage. Trop was negative and
no changes on EKG. We did not start the patient on statin
because his ASCVD risk score was calculated approximately 3%.
Would however recommended continued counseling about weight
loss, healthy diet and exercise.
- Noted to have low platelets while hospitalized to 128 of
unclear etiology. Consider repeat CBC after discharge for
further evaluation.
- Started on omeprazole 20mg daily as suspect pain sensation GI
in origin. Patient w/history of ulcers s/p treatment for H
pylori. Consider repeat H pylori testing to ensure eradiation,
consider further GI referral
- Patient should follow up with neurology after discharge for
further work-up of his aphasic episodes. Should have routine EEG
after 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:
SOB
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
___ w/PMHx of ESRD secondary to DM s/p renal tx in ___ with
failure now on home HD 4x/week, DM, PVD, HTN, CHF, h/o PNA
presenting with acute onset shortness of breath this AM. The
patient's wife called EMS, as the patient was requiring more
than his baseline 2 L nasal cannula, with saturations reportedly
in the ___. On arrival, the patient had increased work of
breathing with saturations in the ___. He was placed on 6 L
nasal cannula with improvement in his saturations to the low
___. He was then placed on NRB, sats in ___ on arrival. In ED,
patient was febrile to ___, and received vanc/zosyn. CXR with
severe pulm edema, with BNP above assay. Patient was due for HD
today, so Dialysis consulted, and patient had ___ off. Patient
placed on bipap, which he did not tolerate, and so was
transitioned to face tent.
Per EMS, en route patient intermittently with A. fib with RVR.
Of note, patient with altered mental status per his wife, which
is something that happens with infections.
In the ED, initial vitals were: 104.6 ___ 24 97%
bipap
- Exam notable for: crackles in LLL, diminished in right base
- Labs notable for: ABC 12.1, Hgb 7.9 (baseline ___, BNP
>70000, Trop 0.21->0.26 CKMB 103/2. Lactate 1.7.
- Imaging: CXR with pulmonary edema, unable to rule out
infectious process.
Patient was given:
09:53 IV Piperacillin-Tazobactam 4.5 g ___
___ 10:24 IV Vancomycin 1000 mg ___
___ 10:43 IV Acetaminophen IV 1000 mg ___
___ 11:22 IV Fentanyl Citrate 25 mcg ___
___ 17:17 IV Morphine Sulfate 2 mg ___
___ 17:54 IV Morphine Sulfate 2 mg ___
___ 20:29 PO/NG OxyCODONE (Immediate Release) 5 mg
___
___ 20:29 PO/NG Acetaminophen 650 mg ___
On the floor, patient endorses shortness of breath that is
stable. Endorses cough that is intermittent, no sputum
production. He has been having chills for about 3 days. "Pain
all over" which is normal for him. No chest pain, chest
pressure.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-HTN
-HL
-HFpEF
-DM2
-ESRD s/p kidney transplant in ___, failed, on HD since ___
via LUE AVF (___)
-PAD w/ multiple stents in legs
-L foot ââ¬â multiple I&Ds, multiple toe amputations, then
transmetatarsal amputation ___
-diabetic retinopathy c/b R eye blindness
-Colon cancer s/p right hemicolectomy ___
-Skin SCC in situ sternum s/p Moh's excision
-Hypothyroidism
- Moh's excision SCC in situ sternum
Social History:
___
Family History:
diabetes in mother with related renal disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
Vital Signs: 98.2 101 / 71 91 20 95% 4L NC
General: Alert, oriented, no acute distress. AAOxperson and
place, and year.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: bilateral crackles in lower fields
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 1+ pitting edema bilaterally. Venous stasis changes. Left
foot amputation, dry dressing, no erythema or tenderness on left
leg or thigh
Neuro: non focal. AAOxperson and place and year, but month
___
DISCHARGE PHYSICAL EXAM:
======================
Vitals: 99.9 127 / 71 87 20 93 3L
Daily weight: 97.07 kg -> 99.79 kg -> not recorded x 2 -> 84.2
kg -> 85.6 kg
General: AAOx3, chronically ill appearing man in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: anterior exam clear, crackles at bases, decreased BS RLL
similar to prior
Abdomen: Soft, non-tender, distended, no g/r/r
Ext: Lower extremities with no edema, s/p left TMA
Skin: Venous stasis changes in bilateral lower extremities with
numerous excoriations present. Right toes with multiple
ulcerations and darkening of skin but no warmth or drainage.
Left TMA dressing c/d/i.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:31AM BLOOD WBC-12.1* RBC-3.85* Hgb-7.9* Hct-26.3*
MCV-68* MCH-20.5* MCHC-30.0* RDW-18.3* RDWSD-43.8 Plt ___
___ 09:31AM BLOOD Neuts-85.0* Lymphs-6.2* Monos-6.2 Eos-1.7
Baso-0.2 NRBC-0.2* Im ___ AbsNeut-10.26*# AbsLymp-0.75*
AbsMono-0.75 AbsEos-0.20 AbsBaso-0.03
___ 09:31AM BLOOD ___ PTT-27.2 ___
___ 09:31AM BLOOD Glucose-261* UreaN-73* Creat-5.5* Na-129*
K-4.4 Cl-84* HCO3-26 AnGap-23*
___ 09:31AM BLOOD ALT-21 AST-22 AlkPhos-565* TotBili-0.7
___ 09:31AM BLOOD CK-MB-2 proBNP->70000*
___ 09:31AM BLOOD cTropnT-0.21*
___ 02:35PM BLOOD CK-MB-2
___ 02:35PM BLOOD cTropnT-0.26*
___ 06:40AM BLOOD CK-MB-2 cTropnT-0.24*
___ 04:40PM BLOOD cTropnT-0.23*
___ 09:31AM BLOOD Albumin-3.4* Calcium-9.3 Phos-3.9 Mg-2.2
___ 09:35AM BLOOD ___ pO2-29* pCO2-57* pH-7.34*
calTCO2-32* Base XS-1
___ 09:45AM BLOOD Type-ART pO2-158* pCO2-49* pH-7.38
calTCO2-30 Base XS-3
___ 09:35AM BLOOD Lactate-1.7 K-4.4
___ 03:35PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE LABS:
===============
___ 06:12AM BLOOD WBC-17.8* RBC-3.68* Hgb-7.5* Hct-24.8*
MCV-67* MCH-20.4* MCHC-30.2* RDW-18.3* RDWSD-42.5 Plt ___
___ 06:12AM BLOOD Neuts-82.4* Lymphs-9.3* Monos-4.9*
Eos-2.4 Baso-0.3 NRBC-0.2* Im ___ AbsNeut-14.65*
AbsLymp-1.66 AbsMono-0.88* AbsEos-0.43 AbsBaso-0.05
___ 06:12AM BLOOD Glucose-171* UreaN-57* Creat-5.7* Na-137
K-5.0 Cl-93* HCO3-27 AnGap-22*
___ 06:12AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.4
___ 06:05PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative IgM HAV-Negative
___ 06:05PM BLOOD HCV Ab-Negative
___ 06:05PM BLOOD COPPER (SERUM)- normal, 145
___ 06:05PM BLOOD ZINC-PND
___ 08:50PM URINE Color-DkAmb Appear-Cloudy Sp ___
___ 08:50PM URINE Blood-LG Nitrite-NEG Protein-600
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 08:50PM URINE RBC-43* WBC-35* Bacteri-MOD Yeast-NONE
Epi-0
MICROBIOLOGY:
=============
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE URINE CULTURE-negative
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ 1:15 pm SWAB Source: left TMA wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
YEAST, PRESUMPTIVELY NOT C. ALBICANS. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ BLOOD CULTURE Blood Culture, Routine-negative
___ BLOOD CULTURE Blood Culture, Routine-negative
___ BLOOD CULTURE Blood Culture, Routine-negative
___ BLOOD CULTURE Blood Culture, Routine-negative
___ BLOOD CULTURE Blood Culture, Routine-negative
___ BLOOD CULTURE Blood Culture, Routine-negative
___ 9:57 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___ 23:44.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
IMAGING:
=======
CHEST (PORTABLE AP)Study Date of ___ 9:28 AM
IMPRESSION:
Moderate pulmonary edema. Slightly more focal opacity in the
left mid lung
with sparing of the left costophrenic angle could also reflect
pulmonary
edema, but superimposed infection cannot be excluded in the
right clinical
setting.
CHEST (PORTABLE AP)Study Date of ___ 9:25 AM
Heart size is normal.
Extensive parenchyma opacities are similar to previous
examination, with
minimal improvement.
TTE ___:
The left atrium is moderately dilated. The left atrial volume
index is moderately increased. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF =
75%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: no vegetations seen
U/S LUE Fistula ___:
IMPRESSION:
No evidence of clot. Patent left upper extremity AV fistula,
but aneurysmal
cephalic vein outflow noted
CXR ___:
IMPRESSION:
No significant interval change since the prior examination with
persisting
severe pulmonary edema and a moderate right pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 200 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN BREAKTHROUGH
PAIN
9. PredniSONE 5 mg PO DAILY
10. Tacrolimus 2 mg PO Q12H
11. Vitamin D 1000 UNIT PO DAILY
12. Acetaminophen 650 mg PO Q8H
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID constipation
16. alfuzosin 10 mg oral DAILY
17. Tamsulosin 0.4 mg PO QHS
18. Zinc Sulfate 220 mg PO DAILY
19. sevelamer CARBONATE 800 mg PO TID W/MEALS
20. Pravastatin 10 mg PO QPM
21. DIALYVITE 800 (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
22. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
23. Calcium Acetate 1334 mg PO TID W/MEALS
Discharge Medications:
1. Ampicillin-Sulbactam 3 g IV Q24H
2. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp < 90, hr < 60
3. Nephrocaps 1 CAP PO DAILY
4. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
5. Acetaminophen 1000 mg PO Q8H
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
7. Acyclovir 200 mg PO Q12H
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 10 mg PR QHS:PRN constipation
10. Calcium Acetate 1334 mg PO TID W/MEALS
11. DIALYVITE 800 (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
12. Docusate Sodium 100 mg PO BID
13. FoLIC Acid 1 mg PO DAILY
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Omeprazole 20 mg PO DAILY
17. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN BREAKTHROUGH
PAIN
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Pravastatin 10 mg PO QPM
20. PredniSONE 5 mg PO DAILY
21. Senna 8.6 mg PO BID constipation
22. sevelamer CARBONATE 800 mg PO TID W/MEALS
23. Tamsulosin 0.4 mg PO QHS
24. Vitamin D 1000 UNIT PO DAILY
25. Zinc Sulfate 220 mg PO DAILY
26. HELD- alfuzosin 10 mg oral DAILY This medication was held.
Do not restart alfuzosin until your blood pressure improves, and
okay'd by your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Hypoxic respiratory failure
Volume overload
Sepsis
Enterococcus bacteremia
Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSIS:
===================
End stage renal disease
Encephalopathy
Decubitus ulcer
Anemia of chronic disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ w/dyspnea, crackles in left base and diminished in right,
febrile, please eval for PNA // ___ w/dyspnea, crackles in left base and
diminished in right, febrile, please eval for PNA
TECHNIQUE: Portable semi-erect frontal chest radiograph.
COMPARISON: Chest radiographs from ___.
FINDINGS:
Portable semi-erect frontal chest radiograph again demonstrates mild
cardiomegaly and moderate pulmonary edema, with slightly improved aeration of
the right mid to low lung compared to ___. Slightly more focal
opacity in the left mid lung with sparing of the left costophrenic angle could
also represent pulmonary edema, but superimposed infection cannot be excluded
in the right clinical setting. There are bilateral pleural effusions,
moderate to large on the right and trace the small on the left. No
pneumothorax is visualized.
IMPRESSION:
Moderate pulmonary edema. Slightly more focal opacity in the left mid lung
with sparing of the left costophrenic angle could also reflect pulmonary
edema, but superimposed infection cannot be excluded in the right clinical
setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ESRD on HD, CHF p/w SOB ___ volume overload,
also with sepsis c/f aspiration PNA // ? improvement of pulm edema ?
improvement of pulm edema
IMPRESSION:
Heart size, mediastinal contours and mild vascular congestion are stable. No
acute pulmonary findings are present
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with esrd, chf, new hypoxia and RVR after
dialysis today // eval for PNA, flash pulm edema eval for PNA, flash
pulm edema
IMPRESSION:
Comparison with the study of ___, there is little change in the
enlargement of the cardiac silhouette, significant pulmonary edema, and
prominent right effusion with compressive atelectasis at the base.
Radiology Report
EXAMINATION: ___ AVF/DUPLEX HEMO/DIAL ACCESS LEFT
INDICATION: ___ year old man with enterococcal bacteremia, was on home hd //
eval for clot which may be nidus of infection
TECHNIQUE: Gray scale and color images were obtained of the left upper
extremity hemodialysis access
COMPARISON: None
FINDINGS:
There is a patent left brachial artery stent at the arterial inflow. The
draining cephalic vein is patent without any evidence of clot, however is
noted to be aneurysmal and large with a maximum diameter of 2.5 cm.
IMPRESSION:
No evidence of clot. Patent left upper extremity AV fistula, but aneurysmal
cephalic vein outflow noted
Radiology Report
INDICATION: ___ year old man with sudden SOB // volume overload, opacity
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Re- demonstrated is severe pulmonary edema as well as a moderate right pleural
effusion, unchanged. The size and appearance of the cardiomediastinal
silhouette is enlarged but unchanged. No pneumothorax identified.
IMPRESSION:
No significant interval change since the prior examination with persisting
severe pulmonary edema and a moderate right pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Altered mental status
Diagnosed with Heart failure, unspecified
temperature: 100.4
heartrate: 110.0
resprate: 20.0
o2sat: 96.0
sbp: 121.0
dbp: 59.0
level of pain: unable
level of acuity: 2.0 | ___ w/PMHx of ESRD secondary to DM s/p renal tx in ___ with
failure now on home HD 4x/week, DM, PVD, HTN, CHF, h/o PNA
presenting with acute onset shortness of breath, likely from
volume overload and infection.
# Hypoxic respiratory failure: DDx = volume overload vs HCAP vs
aspiration PNA vs PE. Pt on home O2 3L at night. Patient
presented with worsening shortness of breath, lower extremity
edema, BNP>70,000, CXR with moderate pulmonary edema and
improvement in respiratory status after HD (3.5 L removed). This
was all together consistent with volume overload due to
inadequate home HD leading to flash pulmonary edema in this pt
with ESRD and CHF. The pt was also febrile to 104.6 with
leukocytosis to 12 and clinical concern for aspiration,
suggesting infection. CXR showed a focal opacity in left mid
lung which could reflect HCAP given recent hospitalization for
PNA vs aspiration PNA. Also contributing to his respiratory
failure was Afib with RVR likely triggered by either overload or
infection. Continued MWF HD while inpatient. Vanc/Zosyn (___) narrowed to unasyn (___) given Enterococcus bacteremia
based on ID recommendations. On discharge, down to 3L NC.
# Sepsis: Pt with pan-sensitive Enterococcus bacteremia.
Possible sources include skin infection especially decubitus
ulcer vs self-accessing AVF at home vs open foot wound s/p
amputation. Also possible but less likely is HCAP vs aspiration
PNA. Blood cultures showed pan-sensitive Enterococcus.
Vanc/Zosyn (___) narrowed to unasyn. Wound nurse consulted
for care of decub ulcer and numerous excoriations on
extremities. TTE limited but negative for vegetations.
Ultrasound of fistula showed no clot. ID followed for antibiotic
guidance and recommended 2 week course. On ___ narrowed to
ampicillin but white count rising so unasyn resumed. Continue
unasyn through ___.
# Afib with RVR: Patient with HR as high as 140s in ED, likely
in setting of volume overload vs infection. Rate controlled
after HD, although still in fib. Previously not on home beta
blockade. Pt has been on Plavix in the past for lower extremity
arterial stents given hx PAD. However, not currently
anticoagulated because of prior bleeding during home HD
sessions. Review of OMR notes suggests pt prefers not to be on
anticoagulation as it would limit his ability to perform HD at
home. Started Metoprolol 6.25 q6h for rate control. Continued
home ASA 81.
# Encephalopathy: Per wife, patient becomes altered when he is
infected. A&Ox3 on most evaluations, although intermittently
inattentive to interview. Likely toxic encephalopathy in setting
of infection. No headache, visual changes, neck stiffness.
Continued Abx as above.
# Elevated Troponin: Patient with Troponin 0.21->0.26->0.24,
flat CKMB. EKG stable from prior with LBBB and repolarization
abnormalities although no ST changes. Likely in setting of
demand given Afib w RVR and ESRD, and not plaque rupture given
lack of chest pain or EKG changes. Continued ASA, and started
metoprolol 6.25 q6h as above.
# Left open transmetatarsal amputation wound:
# Skin excoriations:
# Decub ulcer:
# Macerations between toes
Patient followed by vascular surgery and wound care. On
examination on admission, no evidence of infection. Treated with
antibiotics per above.
# ESRD/HD s/p failed renal transplant: 4x/week at home,
converted to MWF inpatient, per renal. Patient anuric. Continued
Sevelamer, prednisone. Started nephrocaps. Tacrolimus stopped as
graft no longer functioning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ is a ___ with a history of ventricular arrhythmia
s/p ablation and PPM/ICD, iCMP (EF 25% ___, afib with
bradycardia (on warfarin), CAD s/p PCI x2 (most recently ___
on aspirin and Plavix who presents with dyspnea, ___ edema, and
report of melena. He presented to ___ because he had felt
increasingly SOB in the last week, most pronounced over the past
2 days where he felt SOB with any activity or even with talking.
He has history of CHF but no known history of hospitalization
for CHF exacerbation. He is on 80 mg daily of Lasix but in the
past week had been increased to 120 mg due to increased ___
edema.
He had also had one episode where he noted melena in his
underwear on ___. He had otherwise been having brown BMs and
reports no BM since ___. He has no history of GI bleeding in
the past. On arrival at ___, his initial Hgb was 6.6 with INR
> 9. He was also found to have BNP 4317, Cr 3.5 from baseline ~
1.7, trop negative x1. He was given 1 U pRBC and vitamin K and
transferred to ___. Also had bilateral LENIs that were
negative.
On arrival to ___, he was found to have Hgb 6.7, INR 8. BNP was
similarly elevated at 4260. He was given another 1U pRBC, 4 U
Kcentra, and 40 mg IV Lasix to which he put out 400 cc urine. In
the ED he was noted to have Guaiac positive stool.
In ED initial VS: 0 97.6 70 112/56 19 97% RA
Patient was given:
___ 14:53 IV Furosemide 40 mg
___ 14:53 IV Pantoprazole 40 mg
___ 15:55 IV Kcentra 4 Units
Imaging notable for:
CXR: Cardiomegaly and moderate right pleural effusion and
suspected small left pleural effusion. Vascular congestion
without overt edema.
Seen by GI with plan to scope in AM
VS prior to transfer: 0 97.6 50 127/51 24 96% Nasal Cannula
On arrival to the MICU, he reports somewhat improved breathing
but still dyspneic. No othropnea or PND. No CP, palpitations, or
lightheadedness. No abd pain, n/v/d. No fevers.
Past Medical History:
1. Recurrent ventricular tachycardia, status post ablation.
2. Post-infarction cardiomyopathy, status post ICD.
3. Chronic atrial fibrillation with a slow ventricular
response.
4. Coronary artery disease, status post inferior myocardial
infarction.
5. Hypertension
6. Hyperlipidemia
7. Psoriasis
8. Hx of fractured collar bone following syncopal episode
9. Gout
10. Seasonal allergies
11. Remote circumcision
Social History:
___
Family History:
Mother had an MI at age ___, she died at age ___. Brother Died at
age ___ from an MI. Another brother with Type 1 DM. He died at
age ___ from complications of his diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: see metavision
GENERAL: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated to jaw at 45 degrees, no LAD
LUNGS: crackles at bases, dyspneic while talking
CV: bradycardic, regular, ___ systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, 1+ edema
NEURO: alert and oriented x4, MAE
DISCHARGE PHYSICAL EXAM:
- VITALS: 97.7 115 / 53 50 20 95 RA
- WEIGHT: 74.6kg
- WEIGHT ON ADMISSION: 82.5kg
- TELEMETRY: paced, PVCs
GENERAL: well appearing, NAD, alert and interactive
SKIN: Diffuse echymoses on forearms
HEENT: JVP 9cm
LUNGS: CTAB
HEART: RRR, bradycardic, IV/XI holosystolic harsh murmur
ABDOMEN: Soft, NT, ND
EXT: trace ___ edema, WWP
Pertinent Results:
ADMISSION LABS
==============
___ 01:41PM BLOOD WBC-9.7 RBC-3.48* Hgb-6.7*# Hct-24*#
MCV-69*# MCH-19.3*# MCHC-27.9*# RDW-19.8* RDWSD-47.8* Plt ___
___ 01:41PM BLOOD Neuts-75.3* Lymphs-14.0* Monos-8.9
Eos-0.9* Baso-0.2 NRBC-0.3* Im ___ AbsNeut-7.28*
AbsLymp-1.35 AbsMono-0.86* AbsEos-0.09 AbsBaso-0.02
___ 01:41PM BLOOD ___ PTT-43.9* ___
___ 01:41PM BLOOD Glucose-100 UreaN-95* Creat-3.5* Na-135
K-5.1 Cl-95* HCO3-23 AnGap-22*
___ 01:41PM BLOOD CK(CPK)-24*
___ 01:41PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-4260*
PERTINENT LABS
==============
___ 01:41PM BLOOD WBC-9.7 RBC-3.48* Hgb-6.7*# Hct-24*#
MCV-69*# MCH-19.3*# MCHC-27.9*# RDW-19.8* RDWSD-47.8* Plt ___
___ 10:04PM BLOOD WBC-10.2* RBC-3.87* Hgb-8.1* Hct-27.8*
MCV-72* MCH-20.9* MCHC-29.1* RDW-21.6* RDWSD-54.4* Plt ___
___ 01:41PM BLOOD ___ PTT-43.9* ___
___ 04:29PM BLOOD ___
___ 01:41PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-4260*
___ 05:35AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0 Iron-33*
___ 04:48AM BLOOD Albumin-3.2* Calcium-8.2* Phos-6.3*
Mg-3.1* UricAcd-10.7*
___ 05:35AM BLOOD calTIBC-381 Ferritn-56 TRF-293
___ 04:48AM BLOOD TSH-5.4*
___ 06:10AM BLOOD T4-7.9
DISCHARGE LABS
==============
___ 07:04AM BLOOD WBC-7.1 RBC-3.89* Hgb-8.2* Hct-29.8*
MCV-77* MCH-21.1* MCHC-27.5* RDW-25.0* RDWSD-67.0* Plt ___
___ 07:04AM BLOOD Glucose-82 UreaN-48* Creat-1.7* Na-138
K-3.9 Cl-96 HCO3-30 AnGap-16
___ 07:04AM BLOOD ALT-44* AST-80* AlkPhos-205* TotBili-1.1
MICROBIOLOGY
============
___ BLOOD CULTURE Blood Culture, Routine-no
growth
___ BLOOD CULTURE Blood Culture, Routine-no
growth
___ URINE URINE CULTURE-no growth
IMAGING
=======
___ TTE:
Left Atrium - Long Axis Dimension: *7.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *9.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1
cm
Left Ventricle - Diastolic Dimension: *6.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Left Ventricle - Stroke Volume: 60 ml/beat
Left Ventricle - Cardiac Output: 2.98 L/min
Left Ventricle - Cardiac Index: *1.55 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *13 < 13
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: 2.9 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 19
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 2.60
Mitral Valve - E Wave deceleration time: 165 ms 140-250 ms
TR Gradient (+ RA = PASP): *53 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Marked ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing wire is seen in the RA and extending into the
RV. Normal interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Mild regional LV systolic dysfunction. No LV
mass/thrombus. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity.
Normal RV systolic function. Paradoxic septal motion consistent
with conduction abnormality/ventricular pacing.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
___ (4+) MR.
___ VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Moderate to ___ [3+] TR. Moderate PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is mild regional left ventricular systolic dysfunction
with inferior akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is mildly dilated with normal free wall contractility.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. ___ (4+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
___ [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___, LV
and RV are now dilated. The degree of MR and TR seen have
significantly increased.. Overall LVEF has increased.
EGD ___:
Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Mucosa: Patchy erythema and friability of the mucosa with no
bleeding were noted in the antrum. These findings are compatible
with gastritis. Cold forceps biopsies were performed for
histology at the stomach.
Other Atrophic appearing rugae.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Normal mucosa in the esophagus
Normal mucosa in the duodenum
Erythema and friability in the antrum compatible with gastritis
(biopsy)
Atrophic appearing rugae.
Otherwise normal EGD to third part of the duodenum
- Tissue biopsy:
Gastric antrum, mucosal biopsies:
- Antral mucosa with reactive gastropathy and focal surface
erosion/active inflammation.
- Immunostain for Helicobacter species is in progress and the
results will be reported in a revised
report.
CXR ___:
Substantial cardiomegaly is unchanged in the short period of
time. Pacemaker defibrillator lead terminates in expected
location of right ventricle. There is right pleural effusion,
moderate. There is substantial vascular congestion but no overt
pulmonary edema.
Radiology Report
INDICATION: ___ with sob, GI bleed getting blood transfusion// ?
effusions/pulm edema
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
There are bilateral pleural effusions, there is a moderate right pleural
effusion. Suspected left pleural effusion as well though left costophrenic
angle is obscured by overlying cardiac pacer. Superiorly, the lungs are clear
without consolidation though notable for vascular congestion without overt
edema. There is a least moderate enlargement of the cardiac silhouette.
Multiple old posterior left rib fractures are noted.
IMPRESSION:
Cardiomegaly and moderate right pleural effusion and suspected small left
pleural effusion. Vascular congestion without overt edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF s/p diuresis// please eval for pulm
edema please eval for pulm edema
IMPRESSION:
Substantial cardiomegaly is unchanged in the short period of time. Pacemaker
defibrillator lead terminates in expected location of right ventricle. There
is right pleural effusion, moderate. There is substantial vascular congestion
but no overt pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.6
heartrate: 70.0
resprate: 19.0
o2sat: 97.0
sbp: 112.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | ___ with a history of ventricular arrhythmia s/p ablation and
PPM/ICD, iCMP (EF 25% ___, afib with bradycardia (on
warfarin), CAD s/p PCI x2 (most recently ___ on aspirin and
Plavix who presents with acute anemia and melena in setting of
INR >___/b decompensated heart failure
after pRBC infusion, subsequently diuresed to dry weight and
discharged to rehab.
# CORONARIES: RCA: Proximal 30% disease mid vessel, mid vessel
40% stenosis, distal 70% stenosis, 70% stenosis at the origin of
large PL. RCA stent placed.
# PUMP: EF 40%
# RHYTHM: A. fib/V paced |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with T2 transitional cell
carcinoma with neoadjuvant chemotherapy followed by robotic
cystectomy and intracorporeal neobladder made out of ileum,
recent massive PE ___ on lovenox c/b left paraspinal
hematoma found on ___ who presents with worsening back
pain.
He was recently discharged from ___ with on ___. He had
been admitted to the urology service on ___ for management of
back pain from a left paraspinal hematoma which occurred in the
setting of therapeutic anticoagulation for his pulmonary
embolism. A factor Xa level was checked and was consistent with
supratherapeutic anticoagulation. Lovenox dose was decreased to
90mg BID, and a repeat Xa level was ok.
He states that he has had back pain persistently since his
recent admission but that it got much worse over the last
several days. His last enoxaparin dose was ___ evening. He
also relates that he has experienced light headedness but no
episodes of syncope. He does endorse easy fatigability but no
shortness of breath, no chest pain.
Past Medical History:
Urothelial Ca:
- On ___, C1D1 ddMVAC
- On ___, C2D1 ddMVAC
- On ___, underwent cystoprostatectomy ___ LN and no
evidence of residual disease in the bladder
s/p tonsillectomy
h/o shingles
h/o alcoholism, abstinent for ___ years
h/o polyp on colonoscopy ___
Social History:
___
Family History:
father died of head and neck cancer.
mother alive at ___ with DM
Physical Exam:
ADMISSION:
Vitals: T:98.2 BP 106/68: P:84 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
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
BACK: no paraspinal or supraspinal tenderness
DISCHARGE:
VS: 97.9 130/60 HR68 16 97% 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,
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
BACK: no paraspinal or supraspinal tenderness
NEURO: ___ ___ strength; sensation intact
Pertinent Results:
ADMISSION LABS:
---------------
___ 09:13PM BLOOD WBC-3.3* RBC-3.00* Hgb-7.7* Hct-24.4*
MCV-81* MCH-25.7* MCHC-31.6* RDW-16.8* RDWSD-50.0* Plt ___
___ 09:37AM BLOOD Glucose-169* UreaN-47* Creat-1.7* Na-130*
K-4.0 Cl-96 HCO3-17* AnGap-21*
___ 11:23AM BLOOD ___ PTT-27.4 ___
DISCHARGE LABS:
---------------
___ 12:45PM BLOOD WBC-6.7 RBC-3.39* Hgb-9.3* Hct-28.8*
MCV-85 MCH-27.4 MCHC-32.3 RDW-17.2* RDWSD-53.4* Plt ___
___ 12:45PM BLOOD Glucose-103* UreaN-27* Creat-1.3* Na-138
K-4.7 Cl-109* HCO3-17* AnGap-17
MICRO:
------
Blood Culture, Routine (Final ___:
KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
--------
Non-con CT abdomen pelvis ___
1. Enlarging bilateral paraspinal muscle hematomas with
hematocrit levels.
2. Mild bilateral hydronephrosis is minimally increased from
prior.
3. Nonspecific increased stranding around small bowel
anastomosis in the right
lower quadrant.
4. Evidence of anemia.
5. Multiple simple pelvic fluid collections, likely lymphoceles
or seromas,
similar or decreased in size compared to the previous CT.
Non-con CT abdomen pelvis ___
1. Bilateral paraspinal muscle hematomas are slightly smaller
compared to ___.
2. Previous mild bilateral hydronephrosis are improved, and mild
fullness of renal collecting system remains.
3. Multiple simple pelvic fluid collections are similar or
slightly larger
than before, and consistent with lymphocele or seromas.
Bilateral ___ U/S ___
1. New Partial non-occlusive thrombus in the left proximal
superficial
femoral vein
2. No evidence of acute deep venous thrombosis in the right
lower extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 90 mg SC Q12H
2. Acetaminophen 325 mg PO Q4H
3. Diazepam 2 mg PO Q6H:PRN muscle pain
4. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN moderate to severe
pain
Discharge Medications:
1. Apixaban 5 mg PO BID
2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN moderate to severe
pain
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Docusate Sodium 100 mg PO TID
5. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
6. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*2
7. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
primary: bilateral paraspinal hematomas; acute kidney injury;
GNR bacteremia
secondary: recent history of pulmonary embolus; transitional
cell carcinoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with previous paraspinal hematoma with back pain
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 915 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Right lower lobe peripheral opacity is decreasing in size.
Atelectasis at the left base, lingula and right middle lobe is mild. Heart
size is normal without pericardial effusion. Hyperdensity of the cardiac
myocardium relative to blood pool suggests anemia.
ABDOMEN: Within the limitations of a study obtained without IV contrast. The
liver, gallbladder, pancreas, spleen, and adrenal glands are grossly normal.
The kidneys show mild hydronephrosis bilaterally. The ureters are normal in
caliber. 4 mm hyperdense focus in the upper pole the right kidney is most
likely a hemorrhagic cyst. The ureters are normal in caliber.
The stomach, small and large bowel are normal in caliber without obstruction.
There is a mild amount of stranding surrounding the small bowel anastomosis in
the right lower quadrant which is nonspecific (2:68). The appendix is normal.
There is no mesenteric or retroperitoneal lymphadenopathy. There is no free
air or free fluid. Abdominal aorta is caliber, with mild atherosclerotic
disease demonstrated.
PELVIS: The neo-bladder appears unchanged and unremarkable. There are
numerous postsurgical changes in the pelvis with scattered surgical clips
especially along the right pelvic wall. Multiple simple appearing fluid
collections in the left pelvis are again seen including a 6.4 x 5.4 cm left
pelvic wall fluid collection (2:70) which is unchanged. 4 x 2.8 cm fluid
collection along the anterior aspect of the psoas is smaller, previously 4.2 x
3.8 cm (2:65).
BONES: There is no worrisome bony lesion. There is unchanged heterotopic bone
formation adjacent to the right femoral head (2:79). Again there are
degenerative changes in the lower lumbar spine with mild rightward curvature
and disc height loss at L5-S1 with associated disc vacuum phenomenon and
endplate sclerosis.
SOFT TISSUES: Again there are mixed density collections in the paraspinal
muscles bilaterally, increased in size from previous CT with hematocrit levels
internally. On the left, the collection measures 3.8 x 3.7 x 14 cm (TRV x AP
x CC), previously 3.2 x 3.1 x 11.8 cm. On the right, the collection measures
4.7 x 3.5 x 13.7 cm (TRV x AP x CC), previously 2.1 x 1.9 x 2.6 cm. No new
collection is detected.
IMPRESSION:
1. Enlarging bilateral paraspinal muscle hematomas with hematocrit levels.
2. Mild bilateral hydronephrosis is minimally increased from prior.
3. Nonspecific increased stranding around small bowel anastomosis in the right
lower quadrant.
4. Evidence of anemia.
5. Multiple simple pelvic fluid collections, likely lymphoceles or seromas,
similar or decreased in size compared to the previous CT.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with known DVT and pulmonary embolism // ?
persistent DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: ___ bilateral lower extremity ultrasound, CT abdomen
pelvis ___
FINDINGS:
The left common femoral vein demonstrates normal compression and wall-to-wall
color flow however very sluggish flow is seen within the left common femoral
vein particularly at the junction with the greater saphenous vein. Blunted
waveforms within the left common femoral vein compared to the contralateral
side likely reflects upstream compression of the left external iliac vein by
known pelvic fluid collections, better seen on previous CT. No residual
thrombus is clearly noted within the left common femoral, left profunda
femoris, or greater saphenous veins.
There is normal compressibility, flow, and augmentation of the right common
femoral, bilateral femoral, and bilateral popliteal veins. Normal color flow
and compressibility are demonstrated in the posterior tibial and peroneal
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins. Previously seen thrombus is no longer visualized.
2. Markedly sluggish flow within the left common femoral vein may be a
precursor to the formation of deep venous thrombosis.
3. Blunted waveforms within the left common femoral vein likely reflect
upstream compression of the left external iliac vein by the presence of known
pelvic fluid collections, better assessed on recent CT.
Radiology Report
INDICATION: ___ year old man with bilateral paraspinal hematomas // evaluate
for progression of hematomas and hydronephrosis.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer
Radiograph 3) CT Localizer Radiograph 4) Spiral Acquisition 5.1 s, 60.6 cm;
CTDIvol = 11.1 mGy (Body) DLP = 618.7 mGy-cm. Total DLP (Body) = 619 mGy-cm.
COMPARISON: CT abdomen and pelvis without contrast ___
FINDINGS:
LOWER CHEST: Dense right lower lobe peripheral opacity is similar to before.
Relative hypodensity of blood pool against the cardiac myocardium is
suggestive of anemia.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Previously seen mild bilateral hydronephrosis have been improved and there
remains mild fullness of renal collecting systems. 4 mm hyperdense focus in
the upper pole of the right kidney is unchanged and likely a hemorrhagic cyst.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: Patient is status post cystectomy and creation of neobladder. Trace
free fluid is noted in the pelvis. Several round cystic lesions are again
noted along the pelvic wall which may represent seroma or lymphocele. Largest
lesion measures 7.2 x 7.0 cm, larger than before (previously 5.9 x 5.8 cm).
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Heterotopic bone formation is again noted anterior to right proximal femur.
SOFT TISSUES: Hematoma in the right paraspinal muscles measures 3.0 x 3.3 x
11.5 cm (03:41), smaller than before (previously 3.7 x 3.6 x 13.2 cm).
Hematoma in the left paraspinal muscles measures 3.1 x 4.3 x 7.8 cm, also
smaller than before (previously 2.9 x 4.1 X 9.1 cm).
IMPRESSION:
1. Bilateral paraspinal muscle hematomas are slightly smaller compared to
___.
2. Previous mild bilateral hydronephrosis are improved, and mild fullness of
renal collecting system remains.
3. Multiple simple pelvic fluid collections are similar or slightly larger
than before, and consistent with lymphocele or seromas.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with hx of dvt with leg swelling // ?clot
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is apparent intraluminal echogenic material in the left proximal
superficial femoral vein with partial color flow and non-compressibility,
consistent with a partial thrombus.
Otherwise, there is normal compressibility, flow, and augmentation of the
bilateral common femoral, deep 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:
1. New Partial non-occlusive thrombus in the left proximal superficial
femoral vein
2. No evidence of acute deep venous thrombosis in the right lower extremity
veins.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 6PM, 5 hours after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with Nontraumatic hematoma of soft tissue
temperature: 96.8
heartrate: 128.0
resprate: 18.0
o2sat: 100.0
sbp: 96.0
dbp: 48.0
level of pain: 4
level of acuity: 2.0 | Key Information for Outpatient Providers:Mr. ___ is a ___
year old male with transitional cell cancer s/p cystectomy and
with PE history on Lovenox c/b paraspinal hematoma who presented
with recurrent back pain.
#Paraspinal Hematoma: He was diagnosed with submassive PE on
___ and initially started on lovenox at 1mg/kg BID. Later
that month he presented with severe back pain and was found to
have bialteral paraspinal hematomas. Lovenox was decreased to
1.5mg/kg daily, which he continued to take until he presented
again with severe lower back pain on ___. On admission,
repeat imaging notable for enlarging bilateral paraspinal muscle
hematomas (approximately 4 x 4 x 15 cm each) with resultant
anemia and ___. He was given blood products (3 units pRBCs) and
all AC was initially held. Upon stabilization, he was started on
apixiban gradually to a dose of 5mg BID with no loading dose. He
tolerated this medication well with no further bleeding
complications.
#PE/DVT: As above, submassive PE on ___ with recurrent
bleeding on lovenox. He was started on apixiban 5mg BID with no
loading dose. He tolerated this medication well. H/H stable at
discharge. He underwent repeat ___ U/S prior to discharge, which
noted small superficial thrombus but no deep vein thromboses.
Therefore, no indication for IVC filter. Patient tolerated six
minute walk test with no desaturation on RA prior to discharge.
___: Cr of 1.7 on admission from baseline of 1. Etiologies
include hypovolemia versus bilateral compression of ureters from
bilateral hematomas (although less likely). Alternatively, may
have had an element of rhabdomyolysis from compression from
hematomas, however, CK not measured on arrival. Urine lytes NOT
consistent with intrinsic renal dysfunction and patient improved
over hospitalization with gentle PO and IVF hydration. Final Cr
of 1.2 down from 1.7 upon admission.
#Bacteremia: His course was also complicated by pan-sensitive
klebsiella bacteremia with likely source from neobladder. He was
initially treated with IV antibiotics and transitioned to 500 mg
PO ciprofloxacin without complication. His two week course of
antibiotics completes on ___.
TRANSITIONAL ISSUES
- Discharged on apixiban 5mg BID (2.5mg pills); monitor closely
for signs of bleeding and dose adjust as needed for renal
function.
- Will need to complete 14 day course of PO 500mg BID cipro for
GNR bacteremia ENDS: ___.
-Please follow up creatinine: Slightly above baseline on
discharge
#CODE STATUS: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of metastatic lung cancer and
hypertension who started coughing and subsequently became
unresponsive on ___. The patient was given mouth-to-mouth by
family but police came fairly quickly and shocked once in the
field for presumed VFIB; patient became asystolic then developed
ROSC with initial rapid AFIB and one round of epinephrine.
Intubated in field by EMS. Loaded with amiodarone. Was taken to
___. Initial EKG at OSH w/ 2-3mm ST depressions in V2-V4
with some concave ST elevations in aVR. At OSH, crit noted at
18, given one unit PRBCs. Central line placed (RIJ), got
norepinephrine transiently, propofol, amiodarone, blood, 4L NS.
Started cooling process and transferred to ___.
.
In the ED, initially woken up here and had eye movements,
positive gag, non purposeful movements but unable to follow
commands. Was resedated with fent/versed. His vent settings were
Vol/AC FiO2:100% PEEP:5 RR:14 Vt:500. Had BRB on exam. ST
depressions remain but somewhat improved on arrival to ___. NG
lavage was negative. He was transfused not given units of pRBCs
with goal per GI of >30. He was seen by GI who thought Ddx
included ischemic colitis or ischemic gastritis event as a
result of CV collapse vs primary GI bleeding process. Cardiology
fellow spoke with Dr. ___ the patient who agrees
that he should have left heart cath at some point but no
indication at this time. CTA showed no PE, no blush from
possible GI bleed. He was noted to have a left lung mass from
likely prior lung malignancy, a 4.1 cm infrarenal abdominal
aortic aneurysm, sclerotic foci within the bones and a small
left sided pleural effusion. CT Head was performed with no read
at time of transfer. Labs were notable for Hct of 25.3, WBC of
0.8, lactate of 2.8, trop of 0.2, Cr of 0.9 and unremarkable
LFTs. Admitted to MICU for further management.
Past Medical History:
- Metastatic Squamous Lung Cancer on nevilabine Cycle 2
- HTN
- Coronary disease s/p bypass surgery
- Gout
- Hypercholesterolemia
Social History:
___
Family History:
Unremarkable
Physical Exam:
INITIAL PHYSICAL EXAM:
General- intubated sedated
HEENT- pupils 3mm, reactive, symmetric bilateral
Neck- soft, supple, no JVD noted
CV- nl s1 + s2, rrr, no murmurs
Lungs- anterior exam ctab
Abdomen- soft non tender
GU- foley in place
Ext- cold, has pulses
Neuro- RASS, gait deferred
.
DISCHARGE PHYSICAL EXAM
Vitals- T 98.0 BP 140-150/60s P ___ R 18 O2Sat 95% RA
General- NAD, follows commands and responds with one-word
answers
HEENT- Sclera anicteric, MMM
Neck- supple
Lungs- diffuse upper airway rhonchi anteriorly
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- AOx1
Pertinent Results:
INITIAL LABS
___ 03:00AM BLOOD WBC-0.8* RBC-2.54* Hgb-8.1* Hct-25.3*
MCV-100* MCH-32.0 MCHC-32.1 RDW-16.5* Plt ___
___ 03:00AM BLOOD Neuts-57.2 ___ Monos-4.1 Eos-0.3
Baso-1.1
___ 03:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-2+
Target-OCCASIONAL Schisto-1+ Burr-2+ Stipple-1+ Tear Dr-1+
Acantho-1+
___ 05:08AM BLOOD ___ PTT-32.3 ___
___ 05:08AM BLOOD Ret Aut-0.5*
___ 01:40AM BLOOD Glucose-162* UreaN-19 Creat-0.9 Na-133
K-5.2* Cl-101 HCO3-21* AnGap-16
___ 01:40AM BLOOD ALT-28 AST-57* AlkPhos-68 TotBili-0.6
___ 01:40AM BLOOD cTropnT-0.20*
___ 01:40AM BLOOD Albumin-3.8 Calcium-7.5* Phos-4.0 Mg-1.6
___ 05:27AM BLOOD Type-ART Temp-34.2 pO2-417* pCO2-36
pH-7.40 calTCO2-23 Base XS--1 Intubat-INTUBATED
___ 01:58AM BLOOD Lactate-2.8*
___ 05:27AM BLOOD O2 Sat-100
___ 06:00PM BLOOD freeCa-1.03*
___ 01:40AM URINE Color-Straw Appear-Clear Sp ___
___ 01:40AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:40AM URINE RBC-41* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
___ 01:40AM URINE CastHy-3*
___ 11:57 am BLOOD CULTURE Source: Line-RIJ.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:12 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
MORAXELLA CATARRHALIS. HEAVY GROWTH.
IMAGING/STUDIES
___ Cardiac Echo
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size is normal with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets are mildly thickened (?#).There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal regional and low normal
global biventricular systolic functino. No definite valvular
dysfunction identified. Mildly dilated ascending aorta.
___ CT Abdomen/Pelvis
IMPRESSION:
1. No pulmonary emboli to the segmental level.
2. A mass in the left lung likely represents the patient's
known metastatic lung cancer. Small left pleural effusion. The
endotracheal tube ends 4 cm above the carina.
3. A saccular aneurysm in the ascending aorta, a fusiform
aneurysm of the infrarenal aorta, a saccular aneurysm of the
infrarenal aorta and a fusiform aneurysmal dissection of the
common left iliac artery have appearances suggesting chronicity;
advise correlation with prior outside imaging for assessment of
stability or change.
4. A lytic lesion in the T3 vertebral body likely represents
metastasis.
___ CTA Chest
IMPRESSION:
1. No pulmonary emboli to the segmental level.
2. A mass in the left lung likely represents the patient's
known metastatic lung cancer. Small left pleural effusion. The
endotracheal tube ends 4 cm above the carina.
3. A saccular aneurysm in the ascending aorta, a fusiform
aneurysm of the infrarenal aorta, a saccular aneurysm of the
infrarenal aorta and a fusiform aneurysmal dissection of the
common left iliac artery have appearances suggesting chronicity;
advise correlation with prior outside imaging for assessment of
stability or change.
4. A lytic lesion in the T3 vertebral body likely represents
metastasis.
___ CT Head
IMPRESSION: New evidence of infarction, hemorrhage or mass
effect. Extensive
paranasal sinus disease.
___ CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Minimal right and moderate left pleural effusion,
associated with substantial atelectasis at the left lung base.
The well ventilated areas of the lungs are unchanged and
unremarkable. The monitoring and support devices are constant.
Mild cardiomegaly continues to be present. No pneumothorax.
___ EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of a slow background frequency with generalized
occipitally maximal periodic epileptiform discharges (GPEDs)
that developed as the study continued. There is no organized
electrical activity to indicate an electrographic seizure. In
comparison to the prior day as record this reflects a higher
likelihood for seizure in the setting of a moderate to severe
encephalopathy.
___ EKG
Atrial fibrillation with a rapid ventricular response.
Non-specific ST-T wave changes which are rate-related. No
previous tracing available for comparison
___ EKG
Sinus rhythm. Non-specific ST-T wave changes. Compared to
tracing #1 atrial fibrillation has resolved.
___ EKG
Sinus rhythm with premature atrial contractions with aberrant
conduction.
Non-specific ST-T wave changes. Compared to the previous tracing
of ___ ectopy and aberrant conduction are new.
DISCHARGE LABS
___ 05:54AM BLOOD WBC-11.3* RBC-2.94* Hgb-9.3* Hct-28.8*
MCV-98 MCH-31.5 MCHC-32.1 RDW-17.6* Plt ___
___ 05:54AM BLOOD Plt ___
___ 05:54AM BLOOD Glucose-115* UreaN-7 Creat-0.7 Na-136
K-3.5 Cl-99 HCO3-29 AnGap-12
___ 02:22PM BLOOD CK(CPK)-122
___ 02:22PM BLOOD CK-MB-18* MB Indx-14.8* cTropnT-0.12*
___ 05:54AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.8
___ 01:55PM BLOOD Type-ART Rates-/___ Tidal V-800 PEEP-5
FiO2-40 pO2-104 pCO2-43 pH-7.29* calTCO2-22 Base XS--5
___ 09:57AM BLOOD Lactate-1.0
___ 09:57AM BLOOD freeCa-1.04*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO HS:PRN insomnia
2. Simvastatin 20 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Senna 2 TAB PO BID:PRN constipation
5. Aspirin 81 mg PO DAILY
6. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Senna 2 TAB PO BID:PRN constipation
2. Simvastatin 20 mg PO DAILY
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. LeVETiracetam 1000 mg PO BID
7. Pantoprazole 40 mg PO Q12H
8. Acetaminophen 1000 mg PO Q8H:PRN fever
9. Atenolol 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
1. Ventricular Fibrillation Arrest s/p cooling protocol
2. Bright Red Blood Per Rectum
3. Moraxella Pneumonia
4. Anemia
Secondary Diagnosis
1. Metastatic Lung Cancer
2. Coronary Artery Disease
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
___ ___ ___ 81 [E]
Date: ___ Ref Dr: ___ MCGILLVRAY
CHEST (PORTABLE AP)
Final:
HISTORY: Cardiac arrest and metastatic lung cancer. Evaluation of ET tube
placement.
COMPARISON: Outside hospital chest radiograph performed ___.
FINDINGS: Portable supine frontal view of the chest. The study is limited due
to patient positioning. A nasogastric tube terminates in the stomach. The
endotracheal tube terminates 5.5 cm above the carina. There are midline
sternotomy wires. There is a left pleural effusion above a severely elevated
left hemidiaphragm. A right internal jugular line ends in the mid SVC. Left
posterior rib fractures are healed; the nondisplaced lateral fractures shown
on the subsequent torso CT are not visible on this conventional . The heart
size is normal.
IMPRESSION: Moderate left pleural effusion, left lower lobe atelectasis,
elevated left hemidiaphragm, chronicity indeterminate.
Radiology Report
HISTORY: Altered mental status status post cardiac arrest and cooling.
TECHNIQUE: Multi detector CT scan through the head without the administration
of IV contrast. Coronal, sagittal and thin section bone algorithm
reconstructed images were obtained.
DLP: 1282.15 mGy-cm. CTDIvol: 59.65 mGy.
COMPARISON: None.
FINDINGS: The study is somewhat limited by motion artifact. There is no
evidence of hemorrhage edema, mass, mass effect or infarction. Prominence of
ventricles and sulci likely represents age-related atrophy. Periventricular
white matter hypodensities likely represent the sequela of chronic small
vessel ischemic disease. There are calcifications in the basal ganglia
bilaterally. There is preservation of gray-white differentiation. The basal
cisterns are preserved.
There is evidence of prior paranasal sinus surgery. There are extensive
aerosolized secretions nearly filling the right ethmoid air cells, maxillary
sinuses and sphenoid sinuses. The mastoid air cells are clear. There is
calcification in the cavernous portions of the internal carotid arteries.
IMPRESSION: New evidence of infarction, hemorrhage or mass effect. Extensive
paranasal sinus disease.
Radiology Report
HISTORY: Status post cardiac arrest. Metastatic lung cancer. Evaluation for
pulmonary emboli.
TECHNIQUE: Multi detector CT scan through the abdomen and pelvis was
performed without the administration of IV contrast. Subsequently 150 cc
Omnipaque intravenous contrast was injected and a repeat scan of the chest,
abdomen and pelvis was performed. Three minute delay scan through the abdomen
and pelvis was also obtained. Coronal and sagittal reformatted images were
obtained.
DLP: 4312.75 mGy.
COMPARISON: None.
FINDINGS:
Vascular:
There are no filling defects in the pulmonary arteries to the subsegmental
level to indicate pulmonary emboli.
The ascending aorta has a focal saccular aneurysm or pseudoaneurysm which
contains wall calcification which is likely indicative of chronicity (4:45).
A calcified fusiform infrarenal abdominal aortic aneurysm measures 4.4 cm
(4:345). Immediately superior is a smaller saccular dilation (505:41).
The left common iliac artery contains an aneurysmal nonpropagated dissection
measuring up to 2.3 cm (504:31) which shows wall calcification.
Chest:
The thyroid is normal. An endotracheal tube ends 5 cm above the carina.
There is bibasilar atelectasis. A mass in the left lower lung likely
represents the patient's known lung cancer. There is a non-hemorrhagic left
pleural effusion. The heart size is normal. There is no pericardial
effusion. The airways are patent to the segmental level. No axillary,
mediastinal or hilar lymphadenopathy is identified.
Abdomen:
The liver enhances homogeneously without focal lesions. The portal vein is
patent. Mild periportal edema and promienece of the SVC is likely due to
fluid resuscitation. The pancreas contains a calcification, likely from an
episode of prior pancreatitis. The spleen and right adrenal gland are
unremarkable. The left adrenal gland is thickened. The kidneys enhance
symmetrically without focal lesions or evidence of hydronephrosis.
A nasogastric tube ends in the stomach. The small and large bowel are
unremarkable without evidence of wall thickening or obstruction. The appendix
is seen in the right lower quadrant and appears normal.
There is no free air, free fluid or abdominal lymphadenopathy.
Pelvis:
The bladder is decompressed and contains a Foley catheter. A locule of air in
the bladder is likely related to instrumentation. There is no free air, free
fluid or lymphadenopathy in the pelvis. There is a tiny fat containing
umbilical hernia. There is a rectal temperature probe.
Osseous structures:
There are marked degenerative changes of the thoracic and lumbar spine. A
lytic lesion in the T3 vertebral body likely relates to the patient's known
metastatic disease. There is marked loss of vertebral body height of the L5
vertebral body.
IMPRESSION:
1. No pulmonary emboli to the segmental level.
2. A mass in the left lung likely represents the patient's known metastatic
lung cancer. Small left pleural effusion. The endotracheal tube ends 4 cm
above the carina.
3. A saccular aneurysm in the ascending aorta, a fusiform aneurysm of the
infrarenal aorta, a saccular aneurysm of the infrarenal aorta and a fusiform
aneurysmal dissection of the common left iliac artery have appearances
suggesting chronicity; advise correlation with prior outside imaging for
assessment of stability or change.
4. A lytic lesion in the T3 vertebral body likely represents metastasis.
Comment: Findings discussed with Dr. ___ by ___ at the time of discovery.
Final findings discussed with ___ by ___ at 10:13.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Cardiac arrest, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Minimal right and moderate left pleural effusion, associated with
substantial atelectasis at the left lung base. The well ventilated areas of
the lungs are unchanged and unremarkable. The monitoring and support devices
are constant. Mild cardiomegaly continues to be present. No pneumothorax.
Radiology Report
In comparison with the earlier study of this date, there has been placement of
a right subclavian PICC line that extends to the mid portion of the SVC,
little change.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Endotracheal tube placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the monitoring and support
devices are in unchanged position, with exception of a removal of a right
internal jugular vein catheter. The position of the endotracheal tube is
constant with the tube projecting approximately 3.5 cm above the carina.
Moderate cardiomegaly, left pleural effusion, left and right basal atelectasis
and mild fluid overload persist.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with cardiac arrest after
intubation.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 5.4 cm above the carina. The right PICC line tip is at the
level of cavoatrial junction. Heart size and mediastinum are grossly
unchanged. Left pleural effusion is noted as well as bibasal atelectasis,
both unchanged since the prior study. There is no evidence of pulmonary
edema. There is no evidence of pneumothorax.
Radiology Report
INDICATION: ___ man with metastatic lung cancer, CAD status post
CABG, admitted status post V-fib arrest, complicated by Moraxella pneumonia on
treatment. Speech and swallow evaluation.
COMPARISON: None available.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS: Barium passes freely through the oropharynx and esophagus without
evidence of obstruction. Silent aspiration was noted with thin consistency
barium and deep penetration was noted with nectar-consistency barium. For
details, please refer to the speech and swallow division note in OMR.
IMPRESSION:
1. Silent aspiration with thin-consistency barium.
2. Deep penetration with nectar-consistency barium.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: EU CRITICAL/S/P CARDIAC ARREST
Diagnosed with GASTROINTEST HEMORR NOS, MAL NEO BRONCH/LUNG NOS, CARDIAC ARREST, CAD UNSPEC VESSEL, NATIVE OR GRAFT, AORTOCORONARY BYPASS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is an ___ with metatstatic lung cancer admitted
after VFIB cardiac arrest with concurrent GI bleed.
.
ACUTE ISSUES
# S/p Cardiac Arrest: The patient presented with EKG changes
consistent with cardiac ischemia and an elevated troponin
suggesting possible underlying cardiac etiology of cardiac
arrest. It was unclear whether this was a type I versus type II
MI in setting of GI bleed. The patient was initiated on a
cooling protocol and was successfully extubated on ___.
Patient was clinically stable and transferred to inpatient ward
for further medical management.
.
#Encephalopathy: In the MICU, the patient was started on
leviteracetam after rewarming for periodic occipital discharges
noted on EEG. The patient's mental status improved over the
course of the hospitalization and was AOx2-3 upon discharge. He
was continued on leviteracetam at discharge.
.
# Moraxella PNA: Patient was thought to be febrile during the
cooling protocol. CXR revealed substantial atelectasis at the
left lung base with a stable pleural effusion. Patient was
started on vancomycin/cefepime after gram stain of sputum on
___ was positive for gram negative diplicocci and culture grew
moraxella catarrhalis. Coverage was narrowed to azithromycin
for 5-day course (d1 = ___ which was completed prior to
discharge.
.
# Goals of care: Patient was DNR/DNI at time of transfer to
floor and it was decided that care should not be re-esculated to
the unit. On the floor, it was confirmed with the patient's
family that he was DNR/DNI and should he clinically
deterioriate, the focus of his care would be on comfort measures
only. A discussion was had about the patient's end-of-life care
given his metastatic lung cancer and cardiac disease. The family
elected to consider hospice once patient was transitioned to
SNF.
.
# GI Bleed: Patient presented with likely LGIB given low
hematocrit and bright red blood on rectal exam (NG lavage is
negative). Patient was evaluated by GI who recommended PPI IV
and serial hematocrit monitoring. The patient's hematocrit
stablized without invasive intervention.
.
CHRONIC ISSUES
# CAD: Patient with history of remote CABG. No recent angina or
other cardiac symptoms. Aspirin was initially held and then
restarted once stabilized. Simvastatin was initially held and
then also restarted on the general medicine floor.
.
# Metastatic lung cancer: Patient has known metastatic lung
cancer. His oncologist Dr. ___ at ___ was
notified of the ___ hospital admission.
.
TRANSITIONAL ISSUES
-Speech and Swallow Evaluation Recommendations
1. PO diet: nectar thick liquids and soft solids
2. PO meds: whole if small or cut if larger in puree
3. Oral Care: TID
4. Aspiration precautions including:
- 1:1 supervision/assist with all POs
- sit fully upright for all POs
- feed only when awake/alert/attentive
- small single bites/sips
- alternate every few bites with a sip
5. Pt will need repeat videoswallow prior to advancement back to
thin liquids given silent aspiration today
-Patient can consider outpatient evaluation for hospice services |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS ___:
Mr. ___ is a ___ man with a history of hypertension, who
presents for evaluation of syncope. Earlier today, he had just
completed his usual workout, and walked 2 miles on the treadmill
at the gym. He was sitting on a bench after, then got up to
leave. After walking ___ yards, he felt very dizzy, and passed
out. The next thing he remembers is waking up in the ambulance.
No confusion from that point on. Denies any lower extremity
swelling or pain, history of thromboembolism, other recent
trauma immobility or surgery, cough, hemoptysis. He denies any
chest pain or shortness of breath prior to the syncope. He
struck his face when he syncopized. His only other pain
complaint is his right knee where he is a small abrasion. Right
now his dizziness is completely resolved. No prior episodes.
Of note, last night, he felt palpitations around midnight that
lasted for a few hours, then resolved. No chest pain or
pressure. No palpitations during the syncopal episode or
currently.
- In the ED, initial vitals: 98 58 143/85 20 100% RA
- Labs were significant for trop<0.01
- Imaging showed CT head & C-spine with no acute fracture. CXR
no acute process. No right knee fracture
- In the ED, pt received:
IM Tetanus-DiphTox-Acellular Pertuss (Adacel) .5 mL
___ 11:20 PO Thiamine 100 mg
___ 11:20 PO Multivitamins 1 TAB
___ 11:20 PO FoLIC Acid 1 mg
___ 17:09 PO Aspirin 324 mg
- He was evaluated by trauma surgery, who noted an abrasion
over his left forehead & malar eminence. Recommended Spine
evaluation
- Spine saw the patient, and cleared patient -- no need for MRI
or C- collar. Recommended syncope workup.
- Vitals prior to transfer: 98.1 65 160/85 14 96% RA
Currently, he feels great. He has a mild headache, but no
facial pain or knee pain. He feels at his baseline.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- HTN
- GERD
- heart murmur
- prostate cancer s/p therapy ___ years ago
Social History:
___
Family History:
FAMILY HISTORY: Father with MI at early age (___)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 PO 186 / 93 L Lying 73 20 95 Ra
GEN: well appearing, non toxic, sitting in bed, NAD
HEENT: large ecchymoses over left eye, PERRL, mmm
NECK: no JVD, supple
PULM: normal work of breathing on room air, lungs clear
bilaterally
CAR: rrr, ___ systolic murmur loudest at LUSB nonradiating to
carotids
ABD: soft, NT/ND, normal bs
EXTREM: warm, 2+ DP pulses, no edema
NEURO: CN II-XII intact, A&Ox3, ___ strength in b/l UE & ___,
sensation intact
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS: 157/72 69 94%RA
GEN: well appearing, non toxic, sitting in bed, NAD
HEENT: large ecchymoses over left eye, PERRL, mmm
NECK: no JVD, supple
PULM: normal work of breathing on room air, lungs clear
bilaterally
CAR: rrr, ___ systolic murmur loudest at LUSB nonradiating to
carotids
ABD: soft, NT/ND, normal bs
EXTREM: warm, 2+ DP pulses, no edema
NEURO: CN II-XII intact, A&Ox3, ___ strength in b/l UE & ___,
sensation intact
Pertinent Results:
ADMISSION LABS:
___ 09:45AM BLOOD WBC-5.2 RBC-5.36 Hgb-16.9 Hct-47.6 MCV-89
MCH-31.5 MCHC-35.5 RDW-12.6 RDWSD-41.1 Plt ___
___ 09:45AM BLOOD Neuts-70.3 Lymphs-17.7* Monos-9.6 Eos-1.0
Baso-0.8 Im ___ AbsNeut-3.66 AbsLymp-0.92* AbsMono-0.50
AbsEos-0.05 AbsBaso-0.04
___ 09:45AM BLOOD ___ PTT-24.7* ___
___ 09:45AM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-135
K-5.3* Cl-100 HCO3-24 AnGap-16
___ 09:45AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD cTropnT-<0.01
___ 09:45AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.9
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-4.8 RBC-5.23 Hgb-16.8 Hct-46.5 MCV-89
MCH-32.1* MCHC-36.1 RDW-12.8 RDWSD-41.8 Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-131* UreaN-17 Creat-1.0 Na-136
K-3.8 Cl-98 HCO3-24 AnGap-18
___ 07:35AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.0
IMAGING:
CT C-SPINE ___ IMPRESSION:
1. No acute fracture.
2. Mild anterolisthesis of C3 on C4 and C4 on C5, likely
degenerative, however no prior exams are available for
comparison. Consider further evaluation with MRI if there is
clinical concern for ligamentous injury.
CT HEAD ___ IMPRESSION:
1. No acute fracture or acute intracranial hemorrhage.
2. Soft tissue swelling around the lateral aspect of the left
orbit.
CHEST XRAY ___ IMPRESSION:
No acute cardiopulmonary process.
XRAY KNEE ___ IMPRESSION:
No acute fracture or dislocation. Degenerative changes.
MICROBIOLOGY: UCx pending
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ranitidine 150 mg PO BID
2. amLODIPine 5 mg PO DAILY
3. Lisinopril 20 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atenolol 50 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. Atenolol 25 mg PO QHS
9. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Bacitracin Ointment 1 Appl TP QID:PRN scar
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Lisinopril 20 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Ranitidine 150 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
orthostatic hypotension
Secondary diagnosis:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with syncope and facial trauma// fx? sdh? ptx?
TECHNIQUE: Three views of the right knee
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. There are moderate osteoarthritic
changes including narrowing of the medial joint compartment and
tricompartmental spurring. Minimal to no suprapatellar joint effusion is
seen.
IMPRESSION:
No acute fracture or dislocation. Degenerative changes.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with syncope and facial trauma// fx? sdh? ptx?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
The cardiac silhouette is borderline to mildly enlarged. Mediastinal contours
unremarkable. No pulmonary edema is seen. No displaced fracture is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with syncope and facial trauma// fx? sdh? ptx?
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, 17.3 cm; CTDIvol = 46.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territory infarction, hemorrhage, edema,
or mass-effect. There is prominence of the ventricles and sulci suggestive of
age-related involutional changes.
There is mild soft tissue swelling along the lateral aspect of the left orbit.
No underlying fracture is seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute fracture or acute intracranial hemorrhage.
2. Soft tissue swelling around the lateral aspect of the left orbit.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with syncope and facial trauma// fx? sdh? ptx?
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.9 s, 23.3 cm; CTDIvol = 32.5 mGy (Body) DLP = 755.9
mGy-cm.
Total DLP (Body) = 756 mGy-cm.
COMPARISON: None.
FINDINGS:
There is mild anterolisthesis of C3 on C4 and C4 on C5, likely degenerative
however no prior exams are available for comparison. No fractures are
identified. There is multilevel degenerative changes of the cervical spine.
These appear worse at the C5-C6 and C6-C7 levels, where there is disc height
loss. A disc bulge at the C5-C6 level causes mild spinal canal narrowing.
Facet hypertrophy and uncovertebral osteophytes at the C3-C4 level cause
moderate to severe left-sided neural foraminal narrowing. Facet hypertrophy
and uncovertebral osteophytes at the C4-C5 level cause mild right-sided neural
foraminal narrowing. There is no prevertebral edema.
Calcifications are noted in the posterior right thyroid lobe without evidence
of discrete nodularity.
IMPRESSION:
1. No acute fracture.
2. Mild anterolisthesis of C3 on C4 and C4 on C5, likely degenerative, however
no prior exams are available for comparison. Consider further evaluation with
MRI if there is clinical concern for ligamentous injury.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse, Abrasion of other part of head, initial encounter, Fall on same level, unspecified, initial encounter
temperature: 98.0
heartrate: 58.0
resprate: 20.0
o2sat: 100.0
sbp: 143.0
dbp: 85.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ male with a history of hypertension
who presents for evaluation of syncope.
#Syncope: Pt was transported to the ED after he stood up from a
bench after going to the gym, felt dizzy, and fell. This was
most likely due to orthostatic hypotension. His orthostatic BPs
on hospital day 1 were 160/80 (lying) --> 118/70 (standing). He
was given 1L intravenous fluids, and his orthostatic BPs were
reassessed: 152/78 HR=77 --> 157/72 HR=69. His negative head CT
was also reassuring against a neurologic etiology of his
symptoms. He did note palpatations the night before this event,
though he did not note any palpitations at the time of or just
prior to falling. He was kept on telemetry overnight with no
significant events or arrhythmias. He does have a soft, ___
systolic murmur on exam, though unlikely that this fall was due
to severe aortic stenosis given and overall soft murmur without
significant history of AS. Very low suspicion of PE given that
pt does not smoke and has not had significant prolonged period
of immobilization. He was monitored overnight with fluids and
had no subsequent syncopal events while hospitalized. On day of
discharge he was ambulatory, with VSS.
Patient discharged after discussion with outpatient cardiology
team to reach out for ___ Heart on ___ at 1pm.
We stopped his amlodipine and atenolol 25mg QHS for reassessment
with his cardiologist and to be restarted if needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status / Hypotension
Major Surgical or Invasive Procedure:
- R radial line (___)
- L radial line (___)
- Intubated ___ (for EGD)
- Extubated ___
- EGD ___
History of Present Illness:
Mrs ___ is an ___ year old female with a history of HTN and CAD
s/p stent who was found down and altered by her family in the
afternoon of ___. In the preceding days leading up to the
sentinel event, MRs ___ was experiencing abdominal pain with
diarrhea and nausea, but otherwise had no antecedent deviations
from her usual health. Her daughter reports having normal phone
conversation with Mrs ___ at 1350 on ___, however, when she
arrived at her home by 1420 she found Mrs ___ sitting
inattentive in her chair, not moving and unresponsive to
commands. Not moving any extremities, and was slurring her
words. Daughter thought she was having a stroke and called EMS.
Initially brought to ___ where she was reportedly
confused and minimally reponsive. Systolic BPs in the ___. Found
to be hypoglycemic in the mid ___ and subsequently treated with
1 amp D50. Also treated with an amp of bicarb for hyperkalemia,
value unknown. CT head and neck reportedly normal without
intracranial process. Prior to transfer she received a single
dose of flgayl. Got 1L NS at OSH. Prior to transfer, she was
found to be in AFIB/RVR with rates to the 190s. Started on a
diltiazem drip and sent by EMS to ___. In the amblance,
patient's HR dropped to ___ and she became hypotensive. Dilt
drip stopped and bolused with ~ 1L of fluid.
Upon arrival to the ___ ED, initialy vitals were 97.8 70 85/50
24. She was confused, lethargic, and not appropriately
responsive. Patient appeared in mixed cardiogenic/septic shock.
EKG with new precordial TWI but bedside U/S with good squeeze
and w/o WMI. Patient complained of abdominal pain which led to a
CT abdomen which did not find any abdominal pathology, but did
identify an intra-aortic mural thrombus. Patient was intubated,
lined with a right IJ, given 2L NS, started on levophed and
started on vancomycin/cefepime. Vascular surgery consulted for
aortic thrombus.
Labs were notable for marked leukocytosis, metabolic acidosis,
initial lactate of 9, elevated Trop/CK, BNP greater than assay,
and labs concerning for DIC. U/A w/ evidence of infection
On transfer, vitals were: 97.8 55 121/72 18 100%
On arrival to the MICU, patient is intubated and sedated, unable
to obtain further direct history
REVIEW OF SYSTEMS:
(+) Per HPI but unable to obtain further given
intubation/sedation
Past Medical History:
CAD s/p stent > ___ years ago
HTN
Anxiety
No recent hospitalizations or surgeries
History of UTIs (last > ___ year)
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
================================
Vitals: T: 98.4 124/67 70 100% FiO2 0.5 PEEP 5
GENERAL: Obtunded, unresponsive, not withdrawing to painful
stimuli
HEENT: Sclera anicteric, mouth extremely dry, no oral
ulcerations oropharynx clear. ET tube in place at 22.
NECK: supple, JVP markedly distended with plump EJ/IJ. No LAD
LUNGS: Fair air movemnt b/l with mechanical ventilation sounds,
no wheezes, rales, rhonchi.
CV: Irregular, slow, normal S1 S2, II/VI ejection murmur. No
clicks, gallops or rubs. Unable to ___ DP pulses, radial
pulses 2+ b/l.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Legs/arms warms, but feet cold. no clubbing, cyanosis. 2+
___ edema b/l to mid thighs.
SKIN: Hematomas with faint oozing at IV sites. Blueish
discoloration of palmar surface of hands. Question petechiae vs
senile purpura on back. Mottled appearance of b/l feet.
NEURO: AAOx0. Obtunded.
.
.
Discharge Exam
Vitals- T 97.7 HR 91-114 BP 91-117/40-50s RR 22 SpO2 95% on
RA
General: frail woman in bed with NG tube, alert, responsive,
HEENT: dry MM
Lungs: clear inspiratory sounds w. transmitted upper airway
sounds on exhalation
CV: RRR, 2+ systolic murmur best heard at apex
Abdomen: soft, nontender throughout, +BS
Ext: 2+ pitting to knee, improved from prior
Neuro: grossly intact
Right DP Pulse: NEG Right ___ pulse: Doppler
Left DP and ___ pulses by Doppler.
Wound Assessment:
Location: coccyx/Proximal
Type: sDTI
___ : 2x 0.5cm,
Wound Bed:deep purple, nonblanchable
Exudate:none
Odor:none
Wound Edges:intact
Periwound Tissue:pink, blanchable
Wound Pain: denies
Wound Assessment:
Location:Coccxy/Distal
Type:Pr U, unstageable
Size: 1x0.5cm
Wound Bed:90% yellow/10%pink
Exudate:none
Odor:none
Wound Edges:irregular
Periwound Tissue: pink, blanchable
Wound Assessment:
Location: Right Lateral Heel
Type:Pr U
Size: 1x 0.5 cm
Wound Bed:red, blanchable
Exudate:none
Odor:none
Wound Edges:intact
Periwound Tissue:pink, blanchable
Wound Assessment:
Location:Left Heel
Type:sDTI
Size: 2x 0.5cm
Wound Bed:deep purple,nonblanchable
Exudate:none
Odor:none
Wound Edges:irregular
Periwound Tissue:pink, blanchable
Of note: pt has stable eschar on Left second toe approx. 05x
0.5cm. Would leave OTA. No s/s of infection.
Pertinent Results:
ADMISSION LABS:
=============================
___ 09:45PM BLOOD WBC-20.8* RBC-3.69* Hgb-11.4 Hct-38.0
MCV-103* MCH-30.9 MCHC-30.0* RDW-18.6* RDWSD-69.9* Plt Ct-52*
___ 09:45PM BLOOD Neuts-86.9* Lymphs-4.8* Monos-7.7
Eos-0.0* Baso-0.1 NRBC-0.8* Im ___ AbsNeut-18.07*
AbsLymp-0.99* AbsMono-1.59* AbsEos-0.00* AbsBaso-0.03
___ 09:45PM BLOOD ___ PTT-45.8* ___
___ 09:45PM BLOOD Plt Smr-VERY LOW Plt Ct-52*
___ 02:58AM BLOOD FDP-80-160*
___ 09:45PM BLOOD Fibrino-69*
___ 09:45PM BLOOD Glucose-96 UreaN-79* Creat-2.3* Na-144
K-5.0 Cl-109* HCO3-10* AnGap-30*
___ 09:45PM BLOOD ALT-789* AST-1690* LD(LDH)-3284*
CK(CPK)-1120* AlkPhos-128* TotBili-2.0*
___ 09:45PM BLOOD Lipase-115*
___ 09:45PM BLOOD CK-MB-33* MB Indx-2.9 proBNP-GREATER TH
___ 09:45PM BLOOD cTropnT-0.12*
___ 09:45PM BLOOD Albumin-2.9* Calcium-8.1* Phos-7.0*
Mg-2.2
___ 12:28AM BLOOD Type-ART pO2-375* pCO2-32* pH-7.19*
calTCO2-13* Base XS--14
___ 09:45PM BLOOD Lactate-9.1*
___ 12:28AM BLOOD O2 Sat-98
.
MICROBIOLOGY:
=======================
___ Blood Culture NGTD
___ C. difficile DNA amplification assay (Final
___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ urine culture
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ Blood cultures: NGTD
IMAGING/STUDIES:
======================
___ - CXR
ET tube in appropriate position. Enteric tube tip at the GE
junction and
should be advanced. Left basilar opacity likely due to effusion
with adjacent atelectasis noting that infection is not excluded.
Probable small right effusion. Vascular
congestion without overt edema.
___ - CTA Chest / Abdomen
1. Irregular thrombus is identified at the posterior aortic
arch extending to
the ascending thoracic aorta at mid thoracic level. Finding
likely represents
acute or subacute thrombus.
2. Infrarenal fusiform abdominal aortic aneurysm with maximal
with eccentric
mural thrombus which appears chronic.
3. Eccentric mural thrombus in the right internal iliac artery.
4. Large splenic infarct.
5. Small subsegmental pulmonary emboli in bilateral lower lobes.
6. Small to moderate bilateral pleural effusions are not
hemorrhagic.
Minimal pulmonary edema.
7. Heterogeneous enhancement of liver and hyperenhancement of
bilateral
adrenal glands may reflect hypoperfusion syndrome.
8. Bilateral adrenal nodules.
9. ET tube terminates 2 cm above carina. Consider pulling back
by 1 cm. A
transesophageal tube terminates at GE junction. Consider
advancing by 10 cm.
___: TTE
EF41%. Severe mitral regurgitation with leaflet thickening and
mild rheumatic deformity of the posterior leaflet. Left
ventrcular cavity dilation with mild-moderate global
hypokinesis. Moderate pulmonary artery hypertension. Right
ventricular cavirty dilation with mild free wall hypokinesis.
Mild aortic regurgitation.
___: RUQ US
1. Patent hepatic vasculature.
2. Mildly 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 Head Non Con
1. No hemorrhage.
2. Right thalamic lacunar infarct.
___: Renal US
A symmetrical vascularization of both kidneys and the somewhat
limited Doppler
study. No hydronephrosis..
___: TTE
EF30-35%. Dilated, moderately depressed left ventricular
systolic function with severe mitral regurgitation. Mildly
dilated, hypokinetic right ventricle with moderate to severe
tricuspid regurgitation. Borderline pulmonary artery systolic
hypertension.
___: KUB
Nonspecific bowel gas pattern without evidence of ileus,
obstruction, bowel
ischemia, or perforation.
___: CT Chest
1. Bilateral small to moderate-sized effusions right greater the
left with
associated compressive atelectasis. More focal patchy areas of
consolidation
seen within the left upper and lower lobes may represent
underlying airspace
disease. Ground-glass opacities within the right lower lobe and
middle lobe
are nonspecific.
2. Previously-seen irregularly-shaped thrombus within the aortic
arch and
descending thoracic aorta is not well evaluated on this
examination.
___: CT Abdomen/Pelvis
1. Moderate amount of ascites and diffuse anasarca may be
related to volume
resuscitation and third spacing.
2. Short segment of bowel wall thickening in the proximal
descending colon and
splenic flexure may represent ischemia in the setting of DIC and
shock,
however, evaluation is limited.
3. Bilateral delayed contrast excretion from the kidneys likely
represents
acute on chronic kidney injury with probable ATN. More focal
areas of
wedge-shaped hypo attenuation may also represent a combination
of chronic and
possible acute infarcts.
4. Previously seen splenic infarct is better evaluated on prior
imaging.
___ CXR
Right internal jugular line tip is at the level of cavoatrial
junction. Heart size and mediastinum are overall unchanged but
there is interval substantial improvement of pulmonary edema.
Bilateral pleural effusions are large. There is no appreciable
pneumothorax.
Hilar enlargement is bilateral and reflect pulmonary artery
dilatation
bilaterally.
___ CXR
Slight interval improvement in bilateral pleural effusions.
Persistent left lower lobe atelectasis.
___ CXR
As compared to ___, there are new bilateral
pleural effusions, left more than right, with subsequent areas
of atelectasis. Decreased lung volumes with signs of mild
pulmonary edema. Moderate cardiomegaly. In the interval, the
patient has been extubated, the right internal jugular vein
catheter and nasogastric tube remain in place. No evidence of
pneumothorax.
___ ART EXT (rest)
Multilevel disease below the femoral arteries bilaterally, right
worse than left.
___ CXR
In the setting of mild pulmonary edema it is it is difficult to
detect early pneumonia but consolidation is probably present in
the right upper lobe and perhaps at the left lung base as well.
Moderate right pleural effusion and moderate cardiomegaly is
stable.
Right PIC line ends in the low SVC. Esophageal drainage tube
ends in the
stomach.
___ CXR
Compared to ___ radiograph, feeding tube has been
withdrawn with tip now at approximately the thoracoabdominal
junction level. This could be advanced several cm for standard
positioning. Persistent cardiomegaly accompanied by pulmonary
vascular congestion and mild edema. The moderate right and
small left pleural effusions are present with adjacent bibasilar
atelectasis and or consolidation.
___ CXR
Image number 3 shows the top of catheter securely positioned in
the distal
parts of the stomach. No complications, notably no
pneumothorax.
DISCHARGE LABS:
=======================
___ 05:30AM BLOOD WBC-10.0 RBC-2.60* Hgb-7.7* Hct-25.8*
MCV-99* MCH-29.6 MCHC-29.8* RDW-19.9* RDWSD-70.1* Plt ___
___ 05:48AM BLOOD Neuts-89.5* Lymphs-5.1* Monos-2.7*
Eos-0.9* Baso-0.2 NRBC-0.7* Im ___ AbsNeut-14.71*
AbsLymp-0.83* AbsMono-0.45 AbsEos-0.14 AbsBaso-0.03
___ 02:02AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL Bite-OCCASIONAL
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-158* UreaN-65* Creat-1.3* Na-139
K-4.3 Cl-94* HCO3-34* AnGap-15
___ 09:00AM BLOOD ALT-52* AST-28 LD(LDH)-469* AlkPhos-75
TotBili-0.8
___ 05:30AM BLOOD Calcium-7.9* Phos-4.4 Mg-2.5
___ 06:00AM BLOOD VitB12-936*
___ 05:03AM BLOOD 25VitD-28*
___ 05:30AM BLOOD Digoxin-1.8
___ 05:46AM BLOOD Digoxin-2.3*
___ 05:51AM BLOOD Digoxin-2.9*
___ 06:38AM BLOOD freeCa-0.96*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO DAILY
4. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Simvastatin 20 mg PO QPM
2. Acetaminophen (Liquid) 650 mg PO Q6H
3. Amiodarone 200 mg PO DAILY
4. Calcium Carbonate Suspension 1250 mg PO QID
5. Chloraseptic Throat Spray 1 SPRY PO Q3H:PRN throat irritation
6. Digoxin 0.125 mg PO EVERY OTHER DAY
7. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
8. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN rectal
pain
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. LOPERamide 2 mg PO QID:PRN loose stools
13. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
14. Senna 8.6 mg PO BID:PRN constipation
15. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
17. Torsemide 60 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Disseminated intravascular coagulation
Mixed Cardiogenic/Septic Shock
Oliguric Renal Failure
GI Bleed
Shock liver
Respiratory Failure
Atrial Fibrillation
Toxic metabolic encephalopathy
Urinary Tract Infection
Hospital Acquired Pneumonia
Non ST Elevation Myocardial infarction
Heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hypotension // eval RIJ placement
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ 22:00
FINDINGS:
ET tube terminates 17 mm above the carina. Right internal jugular venous
catheter terminates in low SVC. Transesophageal tube terminates in the
stomach. Severely enlarged cardiac silhouette is similar to 3 hr prior.
Retrocardiac left lung base opacity is persistent.
IMPRESSION:
Right internal jugular venous catheter terminates in low SVC.
ET tube terminates 17 mm above the carina. Consider pulling back by 2 cm.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___, MODS/urosepsis with renal failure, shock liver, DIC.
Possible underlying heart failure contributing to mixed septic/cardiac shock.
? ___. Please eval hepatic vasculature with doppler.
TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: CTA torso of ___.
FINDINGS:
Liver: The hepatic parenchyma is mildly echogenic. No focal liver lesions
are identified. There is no ascites.
Incidental note is made of bilateral pleural effusions.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 4 mm.
Gallbladder: The gallbladder is surgically absent.
Pancreas: Imaged portion of the pancreas appears within normal limits, with
portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 7.8 cm.
Kidneys: The right kidney measures 8.2 cm. The left kidney measures 8.3 cm.
Single images of the bilateral kidneys demonstrates no gross abnormalities.
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:
1. Patent hepatic vasculature.
2. Mildly 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.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with history of acute change in mental status,
sepsis, and DIC evaluate for intracranial bleed, stroke.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 10.0 s, 18.0 cm; CTDIvol = 45.8 mGy (Head) DLP = 824.4 mGy-cm.
Total DLP (Head) = 838 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, edema, or mass. There is a focal
hypodensity in the right thalamus consistent with lacunar infarct. No other
infarct is identified. There are extensive calcifications of the vertebral
artery and bilateral carotid arteries. The ventricles and sulci are normal in
size and configuration. There is no evidence of fracture. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No hemorrhage.
2. Right thalamic lacunar infarct.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with bilateral subsegmental pulmonary emboli.
// ? 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 and femoral veins. Normal flow, compression and augmentation is seen
in the left popliteal vein. The left posterior tibial veins demonstrate
vascular flow.
Occlusive thrombus is seen within the right popliteal vein. This vein does
not compress and does not demonstrate vascular flow. Deep vein thrombosis is
also seen within the right posterior tibial veins. Note is made that the
peroneal veins could not be identified bilaterally.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
Deep vein thrombosis seen in the right popliteal vein in also in the right
posterior tibial veins. Note is made that the peroneal veins are not
visualized bilaterally.
NOTIFICATION: Findings of right leg DVT were conveyed by telephone to Dr.
___ at 15:21 on ___ approximately 15 min after
discovery.
Radiology Report
EXAMINATION: RENAL U.S.with DOPPLER
INDICATION: ___ year old woman with shock, DIC, thrombosis, oliguric ATN // ?
renal vascularture thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT ___.
FINDINGS:
The right kidney measures 9.9 cm. The left kidney measures 9.4 cm. There is no
hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
DOPPLER: Color flow on pulse Doppler assessment both kidneys was performed
but was limited by a continuous respiratory motion. However, there is
relatively symmetrical vascularization in both kidneys. Arterial waveforms
show relatively normal acceleration times bilaterally with symmetric
appearance in the right and left kidney. Venous drainage is also normal.
The bladder is empty with Foley catheter in place.
IMPRESSION:
A symmetrical vascularization of both kidneys and the somewhat limited Doppler
study. No hydronephrosis..
Radiology Report
INDICATION: ___ year old woman with shock, DIC, ___, shock liver and now
worsening pressor support and rising lactate // ? ischemic gut
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
Chest CTA ___
FINDINGS:
Bilateral perihilar parenchymal opacities consistent with pulmonary edema are
decreased, improved since ___. ET tube terminates 26 mm above the carina.
Right internal jugular venous catheter terminates in the low SVC.
Transesophageal tube terminates within the stomach. Persistent moderate
cardiomegaly is unchanged since ___. No evidence of pleural effusion or
pneumothorax. Cardiomediastinal borders and hilar structures are normal.
IMPRESSION:
Pulmonary edema is improved since ___. ET tube terminating 26 mm above the
carina. Consider pulling back 1-2 cm.
Radiology Report
INDICATION: ___ year old woman with shock, DIC, ___, shock liver and Now
worsening pressor support and rising lactate // ? signs if obstuctruction /
ileus, or ischemic gut
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: CT chest and abdomen/pelvis dated ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Bowel gas
pattern is nonspecific, but nonobstructive. There is no evidence of
pneumatosis or pneumoperitoneum. The distal end of an enteric feeding tube
projects over the expected location of the gastric body. The distal end of a
temperature probe is seen projecting over the midline inferior pelvis. There
is lumbar scoliosis with associated degenerative changes. Osseous structures
are otherwise grossly unremarkable.
IMPRESSION:
Nonspecific bowel gas pattern without evidence of ileus, obstruction, bowel
ischemia, or perforation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with respiratory decompensation. Possible CHF
and new hypoxemia. // please assess interval change
IMPRESSION:
Since ___, the endotracheal tube has been advanced, now
terminating within 1.5 cm of the carina. This could be withdrawn a few cm for
standard positioning. Stable cardiac enlargement accompanied by pulmonary
vascular congestion and mild perihilar edema. Small right and small to
moderate left pleural effusions with adjacent bibasilar atelectasis.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman with mixed septic/cardiogenic shock. DIC, shock
liver, ___ on CKD. Now with worsening hemodynamics, pulmonary edema. Poor
stool output // eval of pulmonary infiltrate, ? obstruction or impaction.
Evolution of infarcts.
TECHNIQUE: 5 mm axial images were obtained from the lung bases through the
greater trochanters with out intravenous contrast and with oral contrast.
Coronal and sagittal formats.
DOSE: Total DLP = 945 mGy-cm2
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
For detailed evaluation of the lungs please refer to report from dedicated CT
thorax performed the same date. There are bilateral small pleural effusions
with compressive atelectasis.
There is a small hiatal hernia which is filled with oral contrast. Evaluation
of the abdominal solid organs and intravenous contrast. Within this
limitation, the liver and pancreas are unremarkable. The area of previously
seen splenic infarct is difficult to evaluate on this noncontrast exam. The
spleen has a mottled appearance consistent with known infarct. The adrenal
glands are not well seen.
There is a delayed renal contrast excretion bilaterally from intravenous
contrast administered on ___. There is suggestion of
wedge-shaped hypodensities bilaterally within the left upper pole and right
lower pole which may be related to phase of contrast or represent ATN versus
infarcts. There are additional areas of cortical scarring and defects, likely
chronic/old infarcts.
Oral contrast of different phases likely some related to prior imaging is seen
in the large and small bowel. There is colonic diverticulosis without
evidence of diverticulitis. There is suggestion of a small segment of bowel
wall thickening within the splenic flexure and proximal descending colon,
which may be secondary to ischemia, however evaluation is limited. The
remaining bowel is unremarkable.
There is a moderate amount of ascites. No evidence of free air.
There is extensive atherosclerotic calcification of the abdominal aorta and
its major branches. There is focal infrarenal aortic aneurysm measuring 3.3 x
2.8 cm (series 3, image 70).
Calcification seen in the uterus may be related to vascular calcifications
versus fibroids. A Foley catheter within the decompressed bladder. There is
nondependent air in the anterior bladder likely from instrumentation.
There is diffuse large amount of anasarca.
No suspicious osteolytic or osteoblastic bone lesions. Multilevel
degenerative changes are seen throughout the lumbar spine. Degenerative
changes are also noted at the bilateral sacroiliac joints and bilateral hip
joints.
IMPRESSION:
1. Moderate amount of ascites and diffuse anasarca may be related to volume
resuscitation and third spacing.
2. Short segment of bowel wall thickening in the proximal descending colon and
splenic flexure may represent ischemia in the setting of DIC and shock,
however, evaluation is limited by lack of distension.
3. Bilateral delayed contrast excretion from the kidneys likely represents
acute on chronic kidney injury with probable ATN. More focal areas of
wedge-shaped hypo attenuation may also represent a combination of chronic and
possible acute infarcts.
4. Previously seen splenic infarct is better evaluated on prior imaging.
Radiology Report
INDICATION: ___ year old woman with mixed shock, DIC, renal failure distended
abdomen // ? ileus or obstruction
TECHNIQUE: Two views of the abdomen
COMPARISON: Abdominal radiograph ___
FINDINGS:
When compared to chest radiograph performed the same day there has been
interval retraction of the endotracheal tube which now lies approximately 3 cm
above the level the carina. There is a right IJ central catheter likely
terminating the right atrium. The enteric tube is seen terminating in the
body of the stomach. There are bibasilar opacities seen left worse than right
and left mid lung opacity better evaluated on the chest radiograph.
Multiple distended loops of likely small and large bowel are seen the abdomen,
new compared to prior study, measuring up to approximately 10 cm. No evidence
of free air. There is a Foley catheter seen overlying the bladder. Contrast
is seen within loops of bowel overlying the pelvis.
IMPRESSION:
Dilated loops of likely colon in the abdomen, new from prior study, likely
represents ileus.
Multiple focal lung opacities.
Radiology Report
EXAMINATION: CT chest without contrast
INDICATION: ___ woman with mixed aseptic/cardiogenic shock, DIC,
shock liver, a KI on chronic kidney disease now with worsening hemodynamics
and pulmonary edema. Poor stool output. Evaluate for pulmonary infiltrates,
question obstruction or impaction. Evolution of infarcts.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
without intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 925.9 mGy-cm
COMPARISON: CTA chest ___
FINDINGS:
The esophagus is dilated and filled with oral contrast throughout. The
endotracheal tube terminates approximately 2.3 cm above the level of the
carina. There is enteric tube within the esophagus that terminates in the body
of the stomach.
No pericardial effusion. Extensive coronary artery calcifications are seen.
There is a central venous catheter that terminates at the cavoatrial junction.
There is a three vessel aortic arch. The aorta is normal in course and
caliber with out definite aneurysmal dilatation, however, evaluation of the
thoracic aorta is better made on prior CTA performed ___ where a
large irregularly-shaped thrombus was seen extending from the aortic arch
through the descending thoracic aorta, not as well evaluated on this
examination. Moderate vascular calcification of the aortic arch, descending
thoracic aorta common origin of the great vessels.
No pneumothorax. There are bilateral small to moderate pleural effusions
right greater than left with associated compressive atelectasis in the lower
lobes. There is slightly more patchy consolidation within the superior left
lower lobe and posterior left upper lobe which could reflect pneumonia.
Ground-glass opacities within the right lower and middle lobe are mild and
possibly from edema or infection. The central tracheobronchial tree is
patent.
Limited evaluation of the thyroid gland is grossly unremarkable. No definite
mediastinal or axillary lymphadenopathy by CT size criteria.
Evaluation for hilar lymphadenopathy is limited secondary to lack of
intravenous contrast.
No suspicious osteolytic or osteoblastic bone lesions. Multilevel
degenerative changes are seen throughout the thoracic and lumbar spine. There
is mild retrolisthesis of L1 respect to L2 and a grade 1 anterolisthesis of L4
respect L5.
IMPRESSION:
1. Bilateral small to moderate pleural effusions right greater the left with
associated compressive atelectasis. More patchy areas of consolidation within
the left upper and lower lobes may represent pneumonia as may the mild
ground-glass opacities within the right lower and middle lobes, though these
latter opacities could be edema.
2. Previously-seen irregularly-shaped thrombus within the aortic arch and
descending thoracic aorta is not well evaluated on this examination.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with DIC s/p recent extubation // ? pulm edema
or PNA ? pulm edema or PNA
COMPARISON: ___
IMPRESSION:
Right internal jugular line tip is at the level of cavoatrial junction. Heart
size and mediastinum are overall unchanged but there is interval substantial
improvement of pulmonary edema. Bilateral pleural effusions are large. There
is no appreciable pneumothorax.
Hilar enlargement is bilateral and reflect pulmonary artery dilatation
bilaterally.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubation for EGD // ETT placement
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The patient is intubated with an endotracheal tube terminating 3.5 cm above
the level the carina. A right internal jugular catheter terminates in the mid
SVC. A nasogastric tube terminates below the left hemidiaphragm. Lung
volumes are unchanged compared to the prior study. There is persistent left
lower lobe atelectasis versus consolidation. The bilateral pleural effusions
have decreased in size. No consolidation or pneumothorax seen. Persistent
prominence of the bilateral hila likely reflect pulmonary arterial
enlargement.
IMPRESSION:
Slight interval improvement in bilateral pleural effusions. Persistent left
lower lobe atelectasis.
Radiology Report
EXAMINATION: Oropharyngeal swallowing video fluoroscopy.
INDICATION: ___ year old woman with DIC multiorgan failure and dysphagia //
?swallow eval, failed bedside
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 02:35 min.
COMPARISON: None.
FINDINGS:
There is incomplete initiation of every attempt to swallow with aspiration of
teaspoon thin liquids and ___ teaspoon of barium pudding. There was
inability to clear the aspirated material. There was a significant amount of
residual barium contrast pooling within the vallecula, which the patient was
similarly unable to clear.
IMPRESSION:
Incomplete initiation of swallows with gross aspiration of thin liquids and
barium pudding in addition to significant pooling within the vallecula.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with recent ICU admission for
cardiogenic/septic shock now tachypnic with faint wheezing. // please
evaluate for pulm edema. please evaluate for pulm edema.
IMPRESSION:
As compared to ___, there are new bilateral pleural effusions,
left more than right, with subsequent areas of atelectasis. Decreased lung
volumes with signs of mild pulmonary edema. Moderate cardiomegaly. In the
interval, the patient has been extubated, the right internal jugular vein
catheter and nasogastric tube remain in place. No evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with recent resp distresss s/p videofluoro
study // ? aspiration ? aspiration
COMPARISON: ___
IMPRESSION:
NG tube tip is in the stomach. Bilateral pleural effusions are extensive.
Bibasal consolidations are unchanged. There is no evidence of pulmonary
edema. Overall no substantial change since previous examination noted on the
current study.
Radiology Report
INDICATION: PICC placement // ___ yo F DIC multiorgan failure, midline in
place, unable to be advanced
COMPARISON: Chest radiograph of ___.
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow, ___
___ (resident), 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: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
CONTRAST: 8 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 4.2 min, 8 mGy
PROCEDURE: 1. Right brachial, axillary, and subclavian venogram.
2. Replacement of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced.
The wire was unable to be passed centrally. The wire was withdrawn and a
right brachial, axillary, and subclavian venogram was performed through the
existing catheter, demonstrating central occlusion of the vessel of the
catheter was in. A proximal collateral was identified. The catheter was
slightly withdrawn and a double angled glidewire was advanced through the
collateral centrally into the SVC. The glidewire was exchanged for the PICC
Nitinol wire using a Kumpe catheter. The Kumpe was exchanged for a peel-away
sheath over the guidewire. The guidewire was then advanced into the superior
vena cava. A double lumen PIC line measuring 41 cm in length was then placed
through the peel-away sheath with its tip positioned in the distal SVC under
fluoroscopic guidance. Position of the catheter was confirmed by a
fluoroscopic spot film of the chest. The peel-away sheath and guidewire were
then removed. The catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the midline replaced with a
new double lumen PIC line with tip in the lower SVC.
IMPRESSION:
Successful placement of a 41 cm right arm approach double lumen PowerPICC with
tip in the lower SVC. The line is ready to use.
Radiology Report
INDICATION: ___ year old woman with DIC and prolonged ICU stay for sepsis now
with right lower extremity is cool with no Doppler on DP pulse // evidence of
clot/ischemia, evaluate bilateral extremities,
TECHNIQUE: Non-invasive evaluation of the arterial system in the lower
extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
COMPARISON: None
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the right femoral
and superficial femoral arteries. Monophasic Doppler waveforms are seen in
the popliteal and posterior tibial arteries. Absent waveforms are identified
in the dorsalis pedis and digital arteries.
The right ABI could not be measured due to non-compressible vessels.
On the left side, triphasic Doppler waveforms are seen in the right femoral
and superficial femoral arteries. Monophasic Doppler waveforms are seen in
the popliteal, posterior tibial, and dorsalis pedis arteries. Absent waveform
is identified in the digital artery.
The left ABI could not be measured due to non-compressible vessels.
Pulse volume recordings showed damped amplitudes bilaterally, at all levels,
right greater than left.
IMPRESSION:
Multilevel disease below the femoral arteries bilaterally, right worse than
left.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p multiorgan failure DIC with new cough,
known pulmonary edema // interval changes
IMPRESSION:
As compared to ___ chest radiograph, pulmonary vascular
congestion is now accompanied by mild perihilar edema. This is asymmetrically
distributed, right greater than left, and the possibility of other
superimposed process in the right lung such as infection is not excluded.
Moderate to large right pleural effusion and small to moderate left pleural
effusions are again demonstrated with adjacent bibasilar atelectasis and or
consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with DIC, tube feeds, failed swallow study, now
with hypotesnion // ?interval change ?aspiration ?interval change
?aspiration
COMPARISON: Radiographs ___ through ___.
IMPRESSION:
In the setting of mild pulmonary edema it is it is difficult to detect early
pneumonia but consolidation is probably present in the right upper lobe and
perhaps at the left lung base as well. Moderate right pleural effusion and
moderate cardiomegaly is stable.
Right PIC line ends in the low SVC. Esophageal drainage tube ends in the
stomach.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old woman s/p DIC, HCAP // 2 step for NG tube placement
2 step for NG tube placement
COMPARISON: ___
IMPRESSION:
Double the tube is demonstrated on the second radiograph to be within the
stomach. Right PICC line tip is at the cavoatrial junction. Substantial
interval improvement in pulmonary edema is demonstrated. Bilateral pleural
effusions are moderate associated with bilateral consolidations and
cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with a history of CAD who was transfered to ___ for
management of multi organ system failure in the setting of mixed cardiogenic
and septic shock; hospital course complicated by DIC, NSTEMI, oliguric renal
failure, shock liver, GI bleed now with HCAP/Aspiration PNA. // Eval for
interval change
IMPRESSION:
Compared to ___ radiograph, feeding tube has been withdrawn with
tip now at approximately the thoracoabdominal junction level. This could be
advanced several cm for standard positioning. Persistent cardiomegaly
accompanied by pulmonary vascular congestion and mild edema. The moderate
right and small left pleural effusions are present with adjacent bibasilar
atelectasis and or consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with complex history transferred to MICU
overnight with respiratory distress // evaluate for pulmonary edema
IMPRESSION:
Compared to previous radiograph from a few hr earlier, a feeding tube has been
advanced into the proximal stomach. Stable cardiomegaly accompanied by a
improved pulmonary vascular congestion and apparent decrease in size of
moderate right and small to moderate left pleural effusions with persistent
adjacent bibasilar atelectasis or consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dobhoff in placement advanced 3cm. Assess
location // Dobhoff advanced 3cm
IMPRESSION:
Since a recent radiograph from approximately 2 hr earlier, a feeding tube has
been advanced slightly further in the body of the stomach. No other relevant
changes since the recent exam.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with DIC and resp distress on HCAP treatment
with NG tube placement // evaluation of NG tube location evaluation of NG
tube location
COMPARISON: ___ obtained at 07:39
IMPRESSION:
Type of catheter is at the gastroesophageal junction. Right PICC line tip is
at the cavoatrial junction. Pulmonary edema is substantial associated with
bilateral pleural effusions. Cardiomegaly is substantial, unchanged.
RECOMMENDATION(S): NG tube should be advanced at least 10 15 cm to secure it
position within the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with resp failure, new NG tube // ? position
of NG ? position of NG
TECHNIQUE: Prior study obtained the same day at 15:09
IMPRESSION:
Duct cough tube tip is in the stomach. Right PICC line tip is at the
cavoatrial junction. Pulmonary edema is still present associated with large
bilateral pleural effusions.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS
INDICATION: ___ year old woman with dysphagia and new NG // NGplacement , 2
studies NG PLACEMENT 3 STUDIES
IMPRESSION:
Image number 3 shows the top of catheter securely positioned in the distal
parts of the stomach. No complications, notably no pneumothorax.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Altered mental status, Hypotension
Diagnosed with ATHEROSCLEROSIS NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, ACIDOSIS, LIVER DISORDERS NEC
temperature: 97.8
heartrate: 70.0
resprate: 24.0
o2sat: 95.0
sbp: 85.0
dbp: 50.0
level of pain: 0
level of acuity: 1.0 | PATIENT
Mrs ___ is an ___ with a history of CAD who was transfered to
___ for management of multi organ system failure in the
setting of mized cardiogenic and septic shock; hospital course
complicated by DIC, NSTEMI, oliguric renal failure, shock liver,
and academia. Floor course complicated by HCAP and dysphagia,
discharged on tube feeds.
.
.
# Mixed Cardiogenic/Septic Shock: Patient presented to ___
w/multiorgan dysfunction. She was found to have elements of
septic shock as well as cardiogenic shock. At the time of
admission, she was intubated and had a internal jugular line
placed to provide medications. Her initial lactate was 4, and
she had acidosis to 7.19. She had minimal urine output. She was
started on broad spectrum antibiotics - initially
Vancomycin/Cefepime on ___ and transitioned to
Vancomycin/Zosyn for broader coverage including anaerobes. A TTE
was performed and showed severely depressed ejection fraction
with significant valvular disease. Due to tachycardia she was
initially started on phenylephrine, although due to severe
peripheral vascular disease this was transitioned to levophed
after the patient received amiodarone loading for her atrial
fibrillation. Given the cardiogenic component, dobutamine was
started on ___. The patient's lactate improved to 1.3 and
her CVO2s which had initially been in the ___, improved to the
___. Given elements of volume overload diuresis was attempted
beginning on ___. The patient was minimally responsive to
increasing doses of lasix and thus was switched to a bumetanide
gtt on ___. Swan-Ganz catheter was considered given
patient's mixed pixture, but family refused placement. An
albumin challenge along with lasix was also attempted, and
minimally successful. At this point, it was felt that patient
was intravascularly dry and diuresis was abandoned, with patient
instead maintained with colloids, albumin and PRBCs as needed.
Patient's pressor requirements were able to be downtitrated over
the next several days and she eventually was able to maintain
adequate blood pressures without pressor support by ___. In
the setting of sedation/elective intubated for EGD, patient
briefly required pressor support, but she was again able to be
quickly weaned on ___. It was felt that a significant
component of Mrs ___ shock was from myocardial stunning of
sepsis.
.
# Oliguric Renal Failure: Patient w/renal failure at admission
that was felt to be likely ___ acute on chronic renal disease,
as patient had been hypotensive with SBPs in the ___ at OSH for
a significant period of time. Renal dopplers indicative of
medical renal disease that is likely chronic, and the acute
insults of mixed shock likely caused a temporary ATN picture for
the patient that transiently recovered with improved perfusion.
Patient's baseline creatinine/GFR was unknown, but presented at
2.6. This value increased to 3.8 and patient was near-anuric for
the first several days of hospital course. Renal was consulted
for CRRT. However, patient was able to maintain electrolyte
balance, and despite exceedingly low bicarbonate levels from
metabolic acidosis, was able to maintain a near-normal pH from
respiratory compensation. Patient became increasingly volume
overloaded with volume resuscitation, but it did not become a
limiting factor for her lung mechanics. Patient began to have a
marked increase in urine output by ___ and her creatinine
began to fall by ___. She developed a post-ATN diuresis with
an inability to excrete free water and she subsequently became
hyponatremic. She occasionally received boluses of hypertonic
saline but as her renal function improved, her UOP normalized
and she became eunatremic by ___. By the time of her transfer
out of the ICU, Mrs ___ was able to maintain a daily I/O
balance, but she remained significantly volume overloaded.
Creatinine at the time of transfer to the floor was 1.3 and
continued to downtrend. Ct 1.3 on discharge and will be
rechecked on ___ after discharge. Baseline Ct 0.9-1.0.
.
# DIC: Patient w/DIC as evidenced by elevated PTT,
thrombocytopenia, hemolysis, low fibrinogen. Initially she
required cryoprecipitate, but by treating her underlying shock
the DIC slowly resolved. Due to a hypercoaguable state she had
multiple infarcts including DVTs, pulmonary embolisms, splenic
infarcts and mural thrombus in the aorta. She was started on a
heparin gtt for this. Because of coagulopathy, her heparin was
monitored via Xa levels with correlation to her PTTs. As her
liver function and coagulopathy normalized, PTT ranges
normalized and were followed. Patient's fibrinogen normalized by
___ and remained greater than 200 for the remainder of her
hospitalization. She was maintained on the heparin drip given
her significant arterial and venous thromboembolic burden
(although no distal occlusions were noted). The drip was
suspended temporarily in the setting of a GI bleed, but was
restarted after her hematocrits stabilized. Patient was
converted to warfarin before being discharged.
.
# GI Bleed: Patient was noted to have falling hematocrit in the
setting of large melenic stools by ___. Started on IV PPI BID.
CT abdomen/pelvis demonstrated wall thickening of the splenic
flexure suggestive of ischemic colitis. Lactate, however, was
normal. Patient required intermittent PRBC transfusions to
maintain an adequate hematocrit. GI was consulted, who performed
an upper endoscopy on ___ which demonstrated erythema and
erosions in the stomach compatible with gastritis. Heparin drip
(for DIC, as above) was suspended temporarily until serial
hematocrits stabilized. In the setting of DIC, VTE, and arterial
thrombosis, patient was started on warfarin prior to discharge.
In total patient required one transfusion of PRBCs.
.
# Shock Liver: Likely there was a precipitating event that led
to hypotension, whether this was mixed shock -
sepsis/cardiogenic or a specific arrhythmia that precipitated
transient loss of blood pressure, the patient experienced
classic shock liver with a rapid rise in LFTs, and a slow
recovery with improved perfusion. No specific intrahepatic
etiology was found for her transaminitis. TBili and LFts
gradually downtitrated while ___ gradually improved,
suggestive of an improvement in synthetic and excretory function
of the liver. Values were near-normal by the time of transfer
out of the ICU.
.
# Respiratory Failure: Patient intubated on arrival to the
hospital. She was generally able to be kept on pressure support
but at times required a rate. After admission given the poor
prognosis, patient switched to DNR/DNI in event of need for
re-intubation. Patient was able to breathe sufficiently on
pressure support for the early period of her hospital course to
compensate for her metabolic acidosis. She later required CMV
support. As patient's organ system and mental status improved,
she began to pass her RSBI/SBTs. Mental status proved to be a
barrier for several days, but patient was eventually extubated
on ___. Patient was subsequently able to maintain adequate
oxygenation with minimal support (2L NC). Patient was electively
intubated for an upper endoscopy, but was quickly extubated on
___ without difficulty.
On the medical floor, patient was intermittently tachypneic to
RR ___ with hypoxia that resolved with repositioning and
oxygen. On ___, she became tachypneic to RR ___ with SpO2 ___.
Her CXR was notable for a new RLL infiltrate and possible
mucous plugging. She was transferred to the intensive care unit
for possible need for bipap. Patient had been requiring 35% face
tent intermittently on floor past few days. Patient did not
require CPAP or bipap, was weaned to nasal cannula and was
called back out to the floor. She was weaned from 4L to room
air and continued to do well from a respiratory standpoint.
# Atrial Fibrillation: Patient w/afib at baseline. Agents such
as levophed and dobutamine along with overall illness
precipitated Afib w/RVR. Patient received her first amiodarone
load on ___ with good response in heart rates. She also would
transiently switch into normal sinus rhythm. Patient became
increasingly hard to rate control over subsequent days. She more
frequently broke into RVR, requiring several re-loads of
amiodarone. As her pressors were weaned, her rates slowed, but
she remained in the persistent arrhythmia. She was eventually
started on digoxin for further rate control. On the medical
floor, cardiology was consulted and recommended discontinued of
digoxin and addition of metoprolol This was done with
continuation of amiodarone; however, patients rate was poorly
controlled and she was intermittently hypotensive. Metoprolol
was discontinued and digoxin restarted with good rate control.
.
#Dilated cardiomyopathy: During hospitalization, TTE notable for
depressed EF and severe TR and MR ___ above), initially in the
ICU with mixed cardiogenic and septic shock. On transfer to the
floor, she was volume overloaded with significant peripheral and
pulmonary edema. She was evaluated by cardiology and initially
on a Lasix gtt which was discontinued due to hypotension. She
was then diuresed with IV Lasix boluses. She was then started
on torsemide 60 mg daily. Cardiology recommended the addition of
captopril 6.25 TID, but this was deferred in the setting of SBP
85-100s. As new cardiomyopathy could be secondary to cardiac
stunning in the setting of shock, a repeat TTE should be
performed 1 month following discharge. She will also follow up
with cardiology after discharge.
.
# Altered Mental Status: Patient initially had a significant
altered mental status, felt to be secondary to toxic-metabolic
encephalopathy from multi-system organ failure, infectious from
patient UTI, and primary neurologic from DIC-related thalamic
CVA. As patient's acute illness resolved, her mental status
improved and she was able to be extubated. However, she
experienced significant hyperactive delirium post-extubation.
Family initially refused the use of antipsychotics, but
eventually consented to their use. With appropriate medical
management, patient delirium improved, but did not entirely
resolve prior to her transfer from the ICU.
.
# Urinary Tract Infection: Patient presented with sepsis as
above, with the urinary tract as the presumed source given a
dirty U/A. Patient was treated with vancomycin and zosyn as
above. When transferred to the floor, on ___, patient had
pyuria with positive urine culture. She concurrently had HCAP
and was being treated with broad spectrum antibiotics.
.
# Thalamic Stroke: Patient with thalamic stroke in setting of
DIC.
.
# NSTEMI: Patient had a type II NSTEMI in setting of demand
ischemia from her hypotensive episode. Serial cardiac biomarkers
were trended to peak and fall. Given the lack of convincing EKG
changes, it was felt that her changes stemmed from demand in the
setting of hypotension. Serial TTEs demonstrated a decreased EF
40% to 30% with 4+ MR and 3+ TR. As mentioned above, a third TTE
will by done by cardiology upon discharge. Given her
cardiomyopathy, patient was started on statin prior to
discharge. Beta blocker was held in setting of poor rate control
and hypotension.
.
#Hypernatremia: Patient intermittently hypernatremic in the ICU
and the floor which improved with 200 cc-250 cc free water
flushes with tube feeds.
.
#Dysphagia: On transfer to the floor, patient noted to be
choking on jello. She underwent bedside swallow evaluation and
video oropharyngeal swallow evaluation which showed severe
oropharyngeal dysphagia characterized by difficulty with oral
and pharyngeal initiation of bolus, delayed swallow trigger, and
significant pharyngeal weakness with poor bolus propulsion. This
results in penetration of nectar-thick liquids and pureed solids
with subsequent aspiration of nectar. Based on this exam,
patient was thereafter kept on strict NPO with all
nutrition/hydration/meds via non-oral means. Patient was
evaluated by GI for PEG placement who deferred placement during
hospitalization given concurrent active cardiopulmonary disease.
Patient failed bedside swallow on ___ (day of discharge)
and will need a video swallow study in one month.
.
#HCAP: On ___, patient was hypotensive to SBP 80-90s. She was
given gentle IVF boluses with good response in BP. Patient
found to have UTI (see above) as well as new RUL infiltrate.
Patient started on vancomycin, cefepime, and flagyl for broad
spectrum coverage for HCAP vs. aspiration pneumonia. Patient
improved and flagyl and vancomycin were discontinued. Cefepime
completed for a seven day course.
.
#Cool Right lower extremity
Patient with non-dopplerable right DP oulse concerning for
ischemia, evaluated by Vascular surgery in the ICU and then
again on the medical floor for cold and mottle appearance. Given
that patient had DIC, this was thought to be an arterial clot.
ABI showed R>L multilevel disease below the femoral arteries.
Per Vascular surgery, there was no need for surgical
intervention and heparin gtt was continued. Her exam improved
with right foot becoming warmer.
#Diarrhea: Patient with loose stools after being transferred
from the ICU w/ rectal tube removed. Cdiff was negative.
Diarrhea thought to occurring in the setting of tube feeds. Her
tube feeds were thickened with banana flakes and loperamide
added with improvement.
.
#Wound care: Patient with coccygeal pressure ulcer and several
dry arterial ulcers on bl feet. Patient evaluated by wound care
with recommendations as below.
#Hypocalcemia: Patient with low ionized calcium w/ PTH
appropriately elevated, thought secondary to poor intake vs.
occurring s/p shock Pt would benefit from IV repletion but
unable to do so given potential adverse reaction with digoxin.
Patient was started on calcium carbonate QID with monitoring of
daily ionized calcium levels.
#Goals of care: Team met with patients two daughters and
granddaughter to discuss GOC and code status. Per daughter and
HCP, patient would want all measures performed including CPR and
intubation.
TRANSITIONAL ISSUES:
-Amiodarone- patient was loaded with 10 grams, patient should
start 200mg amiodarone on ___
-Anticoagulation- patient will be discharged on warfarin for
treatment of PEs and DVTs in context of DIC (3 mo) and atrial
fibrillation (ongoing). INR at time of discharge 4.0 with plan
to hold Coumadin on day of discharge. Next INR to be checked on
___ and Coumadin should be restarted appropriately.
-Volume status: patient started on torsemide 60 mg daily for net
volume even daily. Held on discharge for ___- should be
restarted when Creatinine 1.0
-Nutrition: patient with impaired swallowing on both bedside and
video swallow study. Patient is NPO and is being discharged to
rehab with NG tube in place. Patient failed bedside swallow on
___. Video swallow study should be repeated to assess for any
regain in function within one month of discharge. If not,
discussion regarding PEG placement will need to be undertaken.
-Patient will follow up with cardiology for repeat TTE to assess
EF and valvular disease. Further medical management of NSTEMI
with ACE inhibitor and/or beta blocker could be considered.
- if patients creatinine improves to baseline of 1.0 and blood
pressures are stable with systolics >90 please consider starting
2.5mg of lisinopril daily
-Patient on Lexapro on admission. This was held on discharge
due to risk for QTc prolongation in context of amiodarone use.
Please re-evaluate mood and treat as needed.
- Please check daily digoxin levels and hold digoxin for
supratherapeutic levels
- Please check Chem-7 to monitor Creatinine. Patient discharged
with Cr 1.3 with baseline being 0.9-1.0. Patient has had
fluctuating creatinine likely pre-renal etiology. Holding
diuretics and giving patient 250cc of normal saline can correct
kidney injury.
- Patient using humidified face mask at night and intermittently
throughout the day
- Patient will occasionally desat, she needs repositioning as
well and placement of pulse oximetry placed on forehead. She can
intermittently require ___ of supplemental O2 that can be
weaned.
- Daily mouth care
-Wound care to feet (embolic disease from DIC and coccygeal
pressure ulcer:
Pressure relief per pressure ulcer guidelines
Support surface: Atmos Air
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times
Waffle Boots
If OOB, limit sit time to one hour at a time and
Sit on a pressure redistribution cushion-Standard Air ( x )
Elevate ___ while sitting.
Moisturize B/L ___ and feet, intact tissue BID with Sooth and
Cool
Topical Therapy: Leave eschared ulcers intact
Leave left heel ulcer intact, pressure redistribution
Left Heel: Cleanse with wound cleanser. Cover with Adaptic,
gauze then wrap with Kling. Change once daily.
# Contact: Deb Sanbary (HP) ___ Alt ___
___
# Code: Full (confirmed with HCP) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ y/o RHW with a history of HTN, pacemaker for
"flat line", and deafness who presented to the ED as a transfer
from ___ for "AMS". History gathered from Son as the patient
herself does not recall what had occurred today. Per the son,
the patient has been having multiple events over the past 8
months with another event today. The son describes these events
(which have occurred about ___ times before today) as a period
in which the patients speech gets slurred, her speech becomes
confused, she gets a little agitated, she repeats things
frequently and then does not remember the events. These episodes
last about ___ min and in each case she had returned to
baseline. The son says she went to go see an internist, and
cardiologist for this and that everything was fine and that she
had a neurology appointment but that it was canceled by the
patient. Today the son says that she usually wakes up around 6
am but when he called there was no answer. His brother in law
went to go
check up on her and found her asleep. When she finally woke up
she was noted to have slurred speech and she fell when she tried
to get out of bed hitting the side of her face on the dresser.
The son arrived about 30 min later and found her confused,
calling him by the wrong name, and saying to him to go to work
and other things that just did not make sense. She was seen at
___ and ___ transferred here for neuro eval. Here she was
seen with family at bedside and per there report was back to
baseline except she is a little more sleepy then usual. She is
unable to tell what had occurred today or why she is here.
On neuro ROS, the pt denies headache, loss change to vision,
dysarthria, dysphagia, vertigo. Denies difficulties producing
speech. Denies focal weakness, numbness, paraesthesia. On
general review of systems, the pt denies recent fever or chills.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting or abdominal
pain. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
Arrythmia s/p pacemaker (by ekg likely just an IED)
Social History:
___
Family History:
No seizures.
Physical Exam:
Physical Exam:
Vitals: 98.1 90 136/62 20 99% 2L
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM. poor dentition
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, holosystolic murmur at LLSB
Abdomen: soft, NT/ND.
Extremities: Left hand erythema, no pain to palpation or
movement.
Skin: no rashes.
Neurologic:
-Mental Status: Alert, oriented to person, place and time
(except
she initially si ad it was ___. Language is fluent with intact
repetition and comprehension. There were no paraphasic errors.
Pt. was able to name ___ card items and read ___ card
sentences. Able to follow both midline and appendicular
commands.
Current knowledge demonstrated with knowledge of the president.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. VFF to confrontation as best I
can tell, had a hard time following directions given her.
Funduscopic 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 increased in ___. No pronator drift
bilaterally. No tremor, asterixis noted.
Strength appreciated as full b/l in upper and lower ext.
-Sensory: No deficits to light touch, pinprick. Perhaps a little
vibration loss at the toes b/l L3 in one hour or 1
episode >5 min
_
_
________________________________________________________________
Discharge Exam: Unchanged from admission exam. Mental status
appropriate.
Pertinent Results:
___ 07:15AM BLOOD WBC-7.8 RBC-3.84* Hgb-11.9* Hct-36.2
MCV-94 MCH-31.0 MCHC-32.9 RDW-12.8 Plt ___
___ 07:15AM BLOOD Glucose-90 UreaN-16 Creat-0.7 Na-136
K-4.0 Cl-102 HCO3-24 AnGap-14
___ 07:15AM BLOOD ALT-11 AST-19 AlkPhos-52 TotBili-0.6
___ 01:35PM BLOOD Cholest-164
___ 07:15AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.9
___ 03:55PM BLOOD %HbA1c-5.5 eAG-111
___ 01:35PM BLOOD Triglyc-91 HDL-75 CHOL/HD-2.2 LDLcalc-71
___ 07:15AM BLOOD TSH-0.74
___ 07:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CXR: AP portable upright chest radiograph obtained. Abandoned
pacer
leads are noted in the left chest wall extending into the heart.
A right
chest wall pacer is also seen with lead tips extending into the
expected
location of the right atrium and right ventricle. The heart is
top normal in size. There is no focal consolidation, effusion,
or definite signs of CHF. No pneumothorax is seen. Mediastinal
contour is unremarkable. Bony
structures appear grossly intact with chronic deformity of the
left mid
clavicular shaft. Degenerative changes at the right AC joint
noted.
EEG: Final report pending.
Medications on Admission:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Keppra 250 mg Tablet Sig: One (1) Tablet PO twice a day:
please take 1 tab twice a day for one week, then take 2 tabs
twice a day from then on.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Altered mental status, question pneumonia.
FINDINGS: AP portable upright chest radiograph obtained. Abandoned pacer
leads are noted in the left chest wall extending into the heart. A right
chest wall pacer is also seen with lead tips extending into the expected
location of the right atrium and right ventricle. The heart is top normal in
size. There is no focal consolidation, effusion, or definite signs of CHF.
No pneumothorax is seen. Mediastinal contour is unremarkable. Bony
structures appear grossly intact with chronic deformity of the left mid
clavicular shaft. Degenerative changes at the right AC joint noted.
IMPRESSION: No definite signs of acute intrathoracic process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CONFUSION
Diagnosed with ALTERED MENTAL STATUS , HYPERTENSION NOS, CARDIAC PACEMAKER STATUS
temperature: 98.1
heartrate: 90.0
resprate: 20.0
o2sat: 99.0
sbp: 136.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Ms ___ was admitted for paroxsymal episodes of confusion,
slurred speech, and nonsensical speech that lasted ___ minutes
concerning for seizure activity.
Neuro: We were unable to get an MRI due to her pacemaker. EEG
was performed and initial report showed no epileptiform
activity, final report pending. Despite the normal routine EEG,
given the high clinical suspicion for seizures based on history,
confirmed with family during hospitalization, the decision was
made to initate Keppra at 250mg bid with a goal to increase to
500mg bid. Seizure precautions, including driving restrictions
per MA law until 6 months seizure free, was reviewed. Her exam
was stable throughout.
Cardiovascular: Hemodynamically stable throughout admission
Respiratory: Stable on room air throughout admission
Infectious Disease: CXR and basic labs unremarkable, afebrile
throughout with no signs/symptoms of infection.
Physical therapy: Evaluation performed to assess for safe
discharge home- patient was cleared by ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PCP: ___, MD
CC: ___
Major ___ or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ is a lovely ___ year old man with history of mycobacterium
szulgai cavitary infection, aspergillus lung infection, chronic
kidney disease and Sjogren's syndrome who is presenting with
fever, ___ and weakness.
___ reports that overall he has been doing well until about 3
days ago when he began feeling weak, run down and with poor
appetite. He reports that he is too weak to walk much and he can
only walk to and from the bathroom but he feels weak and is
worried he will fall even with use of walker. He has had poor
appetite and is not eating much, he reports a 6lb weight loss
over the last month. He continued to worsen over the next couple
days with development of ___ productive of yellow-white sputum
and increased shortness of breath. He has had no hemoptysis. He
reports a runny nose and congestion but no sore throat or muscle
aches. He reports a deep, "lung" pain when he coughs and never
has chest pain without coughing. He denies pleuritic type chest
pain. He had 1 fever this afternoon which lasted about 2 hours,
reaching 101 so he decided to seek care in the emergency
department.
In the ED, initial vitals were: 8 98.4 88 110/52 24 99% RA. His
exam was similar to prior exams and he appeared well. His labs
were largely stable with a Hb slightly lower than normal. CXR
was similar to prior with improvement in infiltrate at left
lower lung field. He was admitted to medicine for failure to
thrive.
On the floor, ___ is comfortable and in good humor. He
reports ongoing ___ productive of yellow sputum as described
above and chest pain with coughing which he describes as "lung"
pain with coughing. He has no other complaints and while he
feels crummy he is doing well.
Review of systems:
(+) Per HPI, also reports burning with urination though he says
this is ongoing for months
(-) Denies chills, night sweats, recent weight gain. Denies
headache, sinus tenderness. Denies chest tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Otherwise ROS is
negative.
Past Medical History:
History of left upper lobe aspergilloma.
History of positive PPD with history of previously treated TB.
History of Sjogren's syndrome. Followed in Rheumatology.
History of slowly progressive renal insufficiency/Stage IV CKD
(baseline Cr 2) Followed in ___. The patient has
deferred a renal biopsy to date and ___ clinic notes indicate
lower utility of biopsy sicne renal scarring would probably not
disclose etiology of disease
Mycobacterium Szulgai infection diagnosed ___
Anemia of chronic disease
Social History:
___
Family History:
Aunt with PTB
Sister with leukemia
Brother had liver cancer
Father died of heart disease
Physical Exam:
PHYSICAL EXAM:
Vitals: 99.0 PO 105 / 62 70 18 99 RA
Pain Scale: ___
General: Patient appears chronically ill but overall well. He is
extremely pleasant, enjoyable to talk to, fully alert, oriented
and in no acute distress. He appears cachectic with significant
muscle loss, ___ protuberances, temporal wasting and loss of
supraclavicular, intercostal fat
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP low, no LAD appreciated
Lungs: Rales and decreased BS on L >R, diminished air movement
bilaterally
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Cachectic
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
Pertinent Results:
Admission Labs:
___ 07:29PM BLOOD WBC-15.4* RBC-2.61* Hgb-8.0* Hct-26.2*
MCV-100* MCH-30.7 MCHC-30.5* RDW-13.5 RDWSD-49.3* Plt ___
___ 07:29PM BLOOD Neuts-78.8* Lymphs-7.8* Monos-12.1
Eos-0.5* Baso-0.3 Im ___ AbsNeut-12.16* AbsLymp-1.20
AbsMono-1.86* AbsEos-0.08 AbsBaso-0.04
___ 07:29PM BLOOD Glucose-142* UreaN-55* Creat-2.2* Na-134
K-4.2 Cl-99 HCO3-18* AnGap-21*
___ 07:29PM BLOOD cTropnT-<0.01
___ 07:29PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.1
___ 07:47PM BLOOD Lactate-2.3*
Imaging:
CXR: Re-demonstrated extensive left lung cavitation with
increase lucency compared to the prior study. Persistent but
apparent decrease in size left base opacity.
CT ___
IMPRESSION:
1. Interval enlargement of left upper lobe and lower lobe
cavitary lesions
since ___, reflecting known Aspergillus infection,
with new
superimposed consolidations across the remaining left upper and
lower lobe
parenchyma.
2. Unchanged peribronchial nodules, mild inflammation, and
bronchiectasis
across the right upper lobe.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Azithromycin 250 mg PO Q24H
4. Ethambutol HCl 1000 mg PO DAILY
5. Ketoconazole 2% 1 Appl TP BID
6. Moxifloxacin 400 mg oral DAILY
7. Miconazole 2% Cream 1 Appl TP BID between toes
8. Linezolid ___ mg PO DAILY
9. Voriconazole 200 mg PO Q12H
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
4. Aspirin 81 mg PO DAILY
5. Azithromycin 250 mg PO Q24H
6. Ethambutol HCl 1000 mg PO DAILY
7. Ketoconazole 2% 1 Appl TP BID
8. Miconazole 2% Cream 1 Appl TP BID between toes
9. Moxifloxacin 400 mg oral DAILY
10. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 %
ophthalmic Q4H:PRN
11. Voriconazole 200 mg PO Q12H
12.Nutritional supplements
Nepro 1can TID x30 days
Dispense #90
Diagnosis: Severe malnutrition ICD 10:E46
Discharge Disposition:
Home
Discharge Diagnosis:
mycobacterium ___ cavitary lung infection
aspergillus
possible influenza
anemia
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 weakness// eval for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest CT from ___ and chest radiograph from ___
FINDINGS:
Extensive left lung cavitation is re-demonstrated increase lucency as compared
to the prior chest radiograph. There is persistent left base opacity which
appears slightly decreased compared to the prior radiograph. There may be a
left pleural effusion. Evidence of bronchiectatic changes are again seen in
the right lung.
Cardiac and mediastinal silhouettes are grossly stable.
IMPRESSION:
Re-demonstrated extensive left lung cavitation with increase lucency compared
to the prior study. Persistent but apparent decrease in size left base
opacity.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with known LUL cavitary lesion, aspergillosis and
NTM// Eval for pneumonia superimposed on chronic aspergillosis and NTM. Eval
for improvement of chronic disease
TECHNIQUE: Axial CT images of the chest were obtained without the use of IV
contrast. Coronal and sagittal reformats were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 39.9 cm; CTDIvol = 5.5 mGy (Body) DLP = 216.0
mGy-cm.
Total DLP (Body) = 216 mGy-cm.
COMPARISON: Chest CTA from ___ and ___.
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There are no enlarged axillary or
supraclavicular lymph nodes. Included views of the thyroid are within normal
limits. The chest wall musculature is atrophic.
UPPER ABDOMEN: The patient is post cholecystectomy. The upper abdomen appears
grossly normal, within limits of noncontrast evaluation.
MEDIASTINUM: An 8 mm prevascular lymph node is unchanged (series 3, image 24),
remaining under CT criteria for adenopathy.
HILA: There is no hilar lymphadenopathy.
HEART and PERICARDIUM: The heart size is normal. There is no pericardial
effusion. Moderate calcifications are demonstrated along the LAD (series 3,
image 34).
LUNG AND PLEURA: Known left upper lobe and left lower lobe cavitary lesions
have enlarged since the ___ CT examination. The left upper lobe
cavitary lesion measures approximately 5.7 x 5.4 x 8.1 cm (series 3, image 15,
series 6, image 47). The dominant left lower lobe cavitary lesion measures
12.3 x 8.0 x 15.2 cm (series 3, image 28). Adjacent consolidations within the
left upper and lower lobes have also markedly worsened, particularly at the
left lung base and lingula (series 3, image 41, 37, 30). Multiple
subcentimeter nodules with adjacent ___ opacities and mild
bronchiectasis along the right upper lobe are minimally changed since the
___ examination (series 5, image 109).
CHEST CAGE: There are no osseous lesions concerning for malignancy or
infection.
IMPRESSION:
1. Interval enlargement of left upper lobe and lower lobe cavitary lesions
since ___, reflecting known Aspergillus infection, with new
superimposed consolidations across the remaining left upper and lower lobe
parenchyma.
2. Unchanged peribronchial nodules, mild inflammation, and bronchiectasis
across the right upper lobe.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:16 am, 10 minutes after
discovery of the findings.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Chest pain, Cough, Dyspnea
Diagnosed with Shortness of breath, Dyspnea, unspecified
temperature: 98.4
heartrate: 88.0
resprate: 24.0
o2sat: 99.0
sbp: 110.0
dbp: 52.0
level of pain: 8
level of acuity: 2.0 | ___ year old man with history of mycobacterium szulgai cavitary
infection s/p 12 months of treatment, aspergillus lung infection
currently being treated and followed by ID, chronic kidney
disease and Sjogren's syndrome who is presented with fever,
___ and weakness and found to have worsening of his underlying
lung disease.
# Fever
# ___ with sputum production
# Pneumonia-mycobacterium and aspergillus
Known well to ID and pulmonary and presented at Pulmonary
consult last ___. Briefly, his ID history is as follows, he
has a history of cavitary Tb which was treated, then found to
have for M. szulgai in ___ and he started Rifampin,
Ethambutol, Moxifloxacin and Azithromycin on ___, AFB
culture positive again on ___ and he was restarted his 4 drug
M. s___ regimen in ___, admitted ___ where BAL
cultures grew Aspergillus fumigatus and he was started on
voriconazole for chronic cavitary aspergillosis. Given drug
interactions between rifampin and voriconazole, rifampin was
initially switched to linezolid but he did not tolerate this due
to depressive symptoms and it was discontinued. He remains on
voriconazole for chronic cavitary aspergillosis and a
combination of azithromycin/ethambutol/moxifloxacin for his
pulmonary NTM. Per last ID note, anticipated course of treatment
duration of ___ months for chronic cavitary aspergillosis and ~
12 months for NTM infection. The patient underwent a repeat CT
scan which showed worsening of disease. He was seen by the
inpatient ID and pulmonary services. He had sputum samples, both
expectorated and induced which were non-diagnostic. The patent
refused a flu swab and was started on empiric Tamiflu and will
complete a 5 day course. He was seen by RT and was given
instruction on the acapella valve. Bronchoscopy was discussed
but it was decided that the patient should be considered for
surgical resection. He was seen by Dr. ___ thoracic
surgery who felt the patient may be a candidate for
pneumonectomy. He will follow up with Dr. ___ in clinic early
next week to discuss surgical options.
No changes were made to the patient's home antibiotic regimen.
-F/u with ID ___
-F/u with Thoracic (Dr. ___ ___ will be called on ___ by Dr.
___ office to set up appointment.
#Severe Malnutrition
The patient has significant weight loss in the setting of his
illness. His appetite was good in the hospital and he was
completing meals.He was seen by nutrition who recommended ___
small meals/day with 3 cans of nepro supplements.
# Pre-diabetes
During prior hospitalizations he required insulin. Last A1c 6.0.
Glucose was monitored but insulin was not started.
# Acute on chronic anemia of chronic disease:
Chronic Baseline H/H around ___, admitted with Hb of 8.0 and
with large MCV of 100. During last admission and during
admission in ___ he had drops in Hb during acute
illness. Suspect current anemia is related to infection and
decreased BM production. Iron students 3 months ago with anemia
of chronic disease. He was transfused 1 unit PRBCS with
improvement in his anemia and his dyspnea on exertion.
# CKD, stage IV
Chronic, stable admitted at baseline Cr |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
seafood
Attending: ___.
Chief Complaint:
___ weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a pleasant ___ w/ colorectal ca s/p sigmoid
colectomy w/ recurrent, metastatic pulmonary disease, s/p
FOLFOX,
w/ cerebellar mets s/p Suboccipital craniectomy for debulking of
left cerebellar tumor ___, who p/w progressive ___ weakness,
b/l feet paresthesias, who was referred in by her ___ for
worsening HA, fever ___.
The ED notes that the pt noted worsening HA over the past 3
days,
___ weakness, intermittent subjective fevers, up to ___. HA is
constant, associated w/ mild photophobia, no neck stiffness or
vision changes.
In ED, she was noted to be afebrile. MRI C/T/L spine revealed
intradural extramedullary lesion at T4 with spinal cord edema.
NSGY recommend Dexamethasone 6mg IV followed by 4mg Q6 with
taper
to 2mg BID w/ cord edema. In light of disease burden, they did
not recommend NSGY. She received 1L NS and 4 mg Morphine IV. HR
110-129 and BP 109/73 and O2 sats hovered in the mid 80% on 2L
NC.
On my evaluation, the patient was minimally conversant, and in
mid sentence, frequently would roll her eyes back. The son and
husband, both named ___, noted that this just started to occur.
The patient was not able to give me much of a history as she was
extremely slow to respond, making eye contact only transiently,
and then would roll her eyes backwards and then lose her train
of
though. When I asked her who her oncologist is, she answered
___. I asked her this question multiple times and she repeated
___. Her son and husband noted this is an acute change and she
is not normally confused at baseline. Her only complaint at this
time is pain in her feet b/l. She denied any neck pain or
headache. She was unable to provide me much more history.
I discussed the case w/ Dr. ___ noted the patient had
been refusing treatment for her cancer for a long time and lost
to follow up despite repeated attempts. Due to her extremely
poor
physical condition, chemotherapy is no longer an option.
The patient, her husband and son and I had a long discussion
about her current condition. Patient initially wanted
"everything" to keep her alive, but then after informing her
that
her advanced disease has progressed to a point of no return, and
that chemo is no longer an option, they all agreed that she has
"suffered enough," and they wanted to focus on making her
comfortable. ___, her son, only wish was to see her "smile,"
and
"comfortable." Her husband ___ agreed w/ CMO and his only
request at this time is that she have a private room in our
attempt to focus on her comfort. ___'s only request right now is
to "go home."
Past Medical History:
PMH: HTN, hypothyroidism, polymyositis, ILD
Metastatic rectosigmoid
adenocarcinoma s/p ileostomy and adjuvant chemotherapy
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: HR ST 130s, SBP 110s, O2 sat 88% on 2L NC --> 93%
on
3L
General: cachectic elderly female in bed, resting in bed
comfortably, makes eye contact but does not maintain
appropriately, speaks only in several word sentences before
becoming withdrawn
HEENT: MMD
CV: +tachycardia, + parasternal heave, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Speech is at times incomprehensible, at times fluent,
she
is oriented x 3, strength is 3+/5 b/l UE, strength 4+/5 on
plantar and dorsiflexion but she is unable to lift legs off
table
and unable to bend knees, she has a hard time following commands
and is very slow to respond to questions and unable to complete
sentences, at times eyes roll backward but no myoclonic activity
notable
DISCHARGE PHYSICAL EXAM
=======================
not performed per CMO
Pertinent Results:
ADMISSION LABS
==============
___ 03:04PM BLOOD WBC-11.1* RBC-4.77 Hgb-14.4 Hct-42.6
MCV-89 MCH-30.2 MCHC-33.8 RDW-14.0 RDWSD-45.4 Plt ___
___ 03:04PM BLOOD Neuts-73.1* Lymphs-15.7* Monos-9.9
Eos-0.4* Baso-0.4 Im ___ AbsNeut-8.10* AbsLymp-1.74
AbsMono-1.10* AbsEos-0.04 AbsBaso-0.04
___ 03:04PM BLOOD Glucose-150* UreaN-11 Creat-0.6 Na-128*
K-5.1 Cl-86* HCO3-26 AnGap-21*
___ 03:04PM BLOOD ALT-12 AST-41* AlkPhos-140* TotBili-0.7
___ 03:04PM BLOOD Albumin-3.8
___ 03:18PM BLOOD Lactate-1.6 Na-130*
IMAGING
========
MRI C,T,L SPINE W/ AND W/O CONTRAST ___
1. 6 x 12 mm enhancing intramedullary lesion at T4-5 with
associated cord
edema extending approximately from T2 to T7. In the setting of
widespread
metastatic disease, this most likely represents metastasis.
2. Numerous osseous metastases as described without definite
evidence of
extension into the epidural space.
3. Numerous bilateral pulmonary metastases.
4. Mild degenerative changes without evidence of spinal canal
narrowing or
high grade neural foraminal narrowing.
CT HEAD W/O CONTRAST ___
1. No emergent intracranial process.
2. Intracranial metastases were better evaluated on prior MRI.
DISCHARGE LABS
==============
none per CMO
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Mycophenolate Mofetil 1000 mg PO BID
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID:PRN Constipation
9. Famotidine 20 mg PO BID
10. Heparin 5000 UNIT SC BID
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
13. Scopolamine Patch 1 PTCH TD ONCE:PRN nausea
14. Senna 8.6 mg PO BID:PRN costipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice per day Disp
#*60 Tablet Refills:*0
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
Do not exceed 6 tablets/day
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. Famotidine 20 mg PO BID
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Mycophenolate Mofetil 1000 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
11. Scopolamine Patch 1 PTCH TD ONCE:PRN nausea
12. Senna 8.6 mg PO BID:PRN costipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Metastatic Colorectal Cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: ___ woman with mestatic rectal cancer, back pain,
bilateral ___ weakness
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of 7 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: None.
FINDINGS:
The vertebral body heights and alignment are preserved. There are numerous
bony metastases, many of which demonstrate very low signal on T1 and T2
weighted images, consistent with a sclerotic lesions. The most prominent bony
metastases are seen in the T2, T3, T6, T11, L1, L2, L3 vertebral bodies and
throughout the visualized portions of the sacrum and ilium. There is no
enhancing soft tissue mass in the epidural space. There is no evidence of
cord compression.
At approximately T4-T5 there is an enhancing nodule in the anterior aspect of
the spinal canal on the postcontrast sagittal T1 weighted images measuring 6 x
12 mm (series 14, image 7). On the corresponding sagittal T2 weighted images,
there is no evidence of mass effect on the thecal sac or the spinal cord at
this level (no compression or displacement). There is however focal expansion
of the spinal cord with T2 heterogeneous signal and edema that extends from
approximately T2 to T7, consistent with an intramedullary lesion (series 13,
image 8). The remaining spinal cord is normal in caliber and signal
intensity. Conus medullaris terminates at L1-2 and the cauda equina are
within normal limits.
Multilevel degenerative changes are mild and there is no evidence of disc
herniation. Disc bulging at L4-5 and L5-S1 levels results an mild neural
foraminal narrowing bilaterally. There is no spinal canal narrowing or
high-grade neural foraminal narrowing. A small perineural cyst is noted in
the left neural foramen at T1-T2 (series 9, image 22).
There are innumerable pulmonary metastases.
Please refer to recent brain MRI of ___ for full description of
postsurgical changes in the cerebellum and additional brain metastases that
are not evaluated on the current examination.
IMPRESSION:
1. 6 x 12 mm enhancing intramedullary lesion at T4-5 with associated cord
edema extending approximately from T2 to T7. In the setting of widespread
metastatic disease, this most likely represents metastasis.
2. Numerous osseous metastases as described without definite evidence of
extension into the epidural space.
3. Numerous bilateral pulmonary metastases.
4. Mild degenerative changes without evidence of spinal canal narrowing or
high grade neural foraminal narrowing.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with rectal cancer metastatic to lungs/brain, p/w headache
and report of fever this morning to 105 // any acute cardiopulmonary process?
and acute
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___, MR head ___
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, or edema.
Intracranial metastases were better evaluated on prior MRI. The ventricles
and sulci are normal in size and configuration.
Left cerebellar postoperative changes and widened CSF space are similar to
prior. There is no evidence of fracture. Left suboccipital craniectomy is
again noted. 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 emergent intracranial process.
2. Intracranial metastases were better evaluated on prior MRI.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with Weakness
temperature: 37.7
heartrate: 129.0
resprate: 16.0
o2sat: 92.0
sbp: 103.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | ___ w/ colorectal ca s/p sigmoid colectomy w/ recurrent,
metastatic pulmonary disease, s/p FOLFOX, w/ cerebellar mets s/p
Suboccipital craniectomy for debulking of left cerebellar tumor
___, who p/w progressive ___ weakness, b/l feet paresthesias,
who was referred in by her ___ for worsening HA, fever ___. Her
spine MRI revealed intramedullary spinal mets w/ cord edema, as
well as innumerable lung and bone metastases, with decision made
by patient and family to transition care to CMO.
# GOC, CMO - Admitting hospitalist and outpatient oncologist
spent > 90 minutes total w/ family and the patient discussing
goals of care, and they all agreed that at this juncture,
considering her disease has progressed to the point of no return
and chemotherapy would be of no benefit, focus will shift
towards making her comfortable. Continued on home oxycodone.
Patient set up for home hospice.
# Spinal Cord Edema - evaluated by NSGY in ED, recommended
dexamethasone to decrease edema, no operation indicated given
poor prognosis. Discharged on dexamethasone 4mg BID. Per
patient's wish, had appointment set up as outpatient with
radiation oncology to discuss palliative radiation for possible
relief ___ weakness and pain.
TRANSITIONAL ISSUES
===================
SPINAL CORD EDEMA
[ ] started on dexamethasone 4mg BID for spinal cord edema per
NSGY recs
[ ] set up as outpatient with radiation oncology on ___ to
discuss palliative radiation
CMO
[ ] patient set up for home hospice, outpatient oncologist aware
CODE STATUS: DNR/DNI, CMO |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
simvastatin / lisinopril / Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ discharged from ___ on ___ after resection of
gastric adenocarcinoma on ___ now presents from rehab with
abdominal pain. Pain started last night and gradually became
more
severe throughout day. Sharp, ___ focused in the LLQ. She
reports 3 episodes of vomiting. Last BM this AM, normal in
caliber. Patient has been tolerating a regular diet for approx
one week.
Past Medical History:
PMH: Invasive signet ring cell type gastric adenocarcinoma,
Colonic adenoma in ___, Hyperlipidemia
PSH:
- ___ - Wedge excision of posterior wall of stomach tumor
with serosal preservation and fiducial placement
- TAH/BSO
Social History:
___
Family History:
No family history of GI disease or cancer
Physical Exam:
Discharge Exam:
VITALS: Temp: 98.0 HR: 75 BP: 138/79 Resp: 18 O(2)Sat: 98
GEN: NAD, Alert, Cooperative
CV: RRR, No, R/G/M
RESP: CTAB
ABD: Soft, Non-distended, mild tenderness in LLQ with no
guarding and no rebound. Well healing midline laparotomy
incision.
EXT: no edema, moving appropriately
NEURO: no focal deficits
Pertinent Results:
___ 07:25AM BLOOD WBC-5.0# RBC-4.44 Hgb-9.8* Hct-33.1*
MCV-75* MCH-22.0* MCHC-29.5* RDW-23.8* Plt ___
___ 04:51PM BLOOD WBC-13.0*# RBC-5.46*# Hgb-11.5*#
Hct-39.2# MCV-72* MCH-21.1* MCHC-29.4* RDW-24.1* Plt ___
___ 07:25AM BLOOD Glucose-119* UreaN-4* Creat-0.7 Na-142
K-3.6 Cl-110* HCO3-25 AnGap-11
___ 04:51PM BLOOD Glucose-124* UreaN-13 Creat-0.7 Na-138
K-4.2 Cl-100 HCO3-24 AnGap-18
___ 04:51PM BLOOD ALT-15 AST-40 AlkPhos-88 TotBili-0.4
___ 04:51PM BLOOD Lipase-242*
___ 04:56PM BLOOD Lactate-1.9
___ CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
High grade small bowel obstruction with sharp transition point
in the upper central abdomen, likely secondary to an adhesion.
___ Portable AXR
IMPRESSION:
1. No significant interval change in multiple loops of dilated
small bowel consistent with a small-bowel obstruction. No free
air.
Medications on Admission:
1. Acetaminophen 650 mg PO TID pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Acetaminophen 650 mg PO TID
3. Ferrous Sulfate 325 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
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
SUPINE AND UPRIGHT ABDOMINAL PLAIN FILM ___ AT ___
CLINICAL INDICATION: ___ with small-bowel obstruction. Assess for
interval change.
Comparison is made to the patient's scout images from an abdominal CT scan
___ at 2057.
Supine portable and left lateral decubitus images of the abdomen and pelvis
are submitted.
The distal end of the nasogastric tube is seen projecting over the stomach.
There are scattered surgical clips in the left upper abdomen. There continue
to be multiple dilated loops of small bowel overlying the upper pelvis and
left lower quadrant. These are likely not significantly changed since
___ and are consistent with a small-bowel obstruction. No free air is
seen.
IMPRESSION:
1. No significant interval change in multiple loops of dilated small bowel
consistent with a small-bowel obstruction. No free air.
Gender: F
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Abd pain, Vomiting
Diagnosed with INTESTINAL OBSTRUCT NOS, MALIG NEOPL STOMACH NOS
temperature: 99.5
heartrate: 97.0
resprate: 20.0
o2sat: 97.0
sbp: 154.0
dbp: 79.0
level of pain: 10
level of acuity: 2.0 | Mrs. ___ is a ___ pleasant female who was admitted admitted to
___ on the ___ from her rehab
facility for abdominal pain and symptoms of partial small-bowel
obstruction. Her ___ CT demonstrated a transition between
dilated and nondilated ileum in the anterior hypogastrium
roughly at the location of the inferior extent of her midline
incision. Her abdominal pain improved with nasogastric
drainage, IV fluids, and pain control. Her abdominal distention
decreased during her admission. She did not had any fevers or
chills throughout her admission.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, and actively
participated in the plan of care.
At the time of discharge, 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 was discharged to her rehab facility.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. She has a follow-up appointment with Dr.
___ on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Transient left visual loss.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old man with no significant past medical
history who presented with left eye visual symptoms.
He states that he was in his usual state of health this morning,
and went to work as usual. He then went to the gym, as he does
every day. He did a class called "body pump" which consisted of
lifting weights. He then took a shower, got in his car and
started driving home. As he was driving, he noticed some dimming
of the vision in his left eye, similar but not the same to
floaters that he has had in the past. He is convinced that the
symptoms were in the left eye, not the left visual field. He
then continued to drive home for 45 minutes without issue. When
he pulled in to his driveway, he noticed that the lights at his
house were dimmer out of his left eye. He did cover each eye
separately and says that there wasn't as much light getting in
to his left eye. He also saw a translucent disc in the
___ his vision, just in the left eye. At this point,
he decided to come in to the ED for evaluation. He had no eye
pain, headache, or any other neurological symptoms at this
point.
While in the ED, he was evaluated by ophthalmology, who
performed a dilated slit lamp exam. Prior to dilation, pupils
were noted to be equal and reactive, 4-->2mm. Visual acuity was
___ ___. IOP was normal bilaterally. No significant cataract
was noted. Corneas and anterior chambers were unremarkable.
Fundoscopic exam revealed normal retinas, and sharp discs with
no disc pallor or edema. Arteries and veins were unremarkable.
On visual field exam, the resident noted a subtle lower temporal
deficit in the right eye only and so neurology was called.
On neuro ROS, he denies headache, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- BPH
- HTN
- Insomnia
- "Freckle" on retina, not sure which eye, that has been
followed by his eye doctor and was apparently not concerning
Social History:
___
Family History:
Mom with retinal detachment and MI. No history of stroke or
other neurologic disease such as MS or brain tumors. Father with
a history of cancer in his eye (possibly melanoma), passed away
from COPD. No history of autoimmune disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: 98.8 88 157/90 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
Abdomen: soft, NT/ND
Extremities: No edema, well perfused.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Naming intact. Reading intact. Speech was not dysarthric. Able
to follow both midline and appendicular commands. Pt was 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: Pupils 7mm bilaterally, minimally reactive s/p dilation. VFF
to confrontation. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI with fatiguable end-gaze nystagmus ___ beats.
Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Not tested.
PHYSICAL EXAM ON DISCHARGE:
Vitals: 98.2 85 141/82 14 99% ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted
Neck: Supple, trachea midline
Pulmonary: No SOB
Cardiac: WWP
Abdomen: soft, NT/ND
Extremities: No c/c/e
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to the exam. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Speech was not dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils ___ bilaterally. VFF to confrontation.
Fundoscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI with fatiguable end-gaze nystagmus ___ beats.
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.
Slight right hand intention tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Not tested.
-DTRs: Not tested.
-Coordination: No dysmetria on FNF.
-Gait: Not tested.
Pertinent Results:
Laboratory
___ 01:15AM BLOOD WBC-7.6 RBC-4.45* Hgb-14.8 Hct-41.3
MCV-93 MCH-33.2* MCHC-35.8* RDW-12.9 Plt ___
___ 01:15AM BLOOD Neuts-69.7 ___ Monos-7.0 Eos-1.9
Baso-0.4
___ 01:15AM BLOOD Glucose-103* UreaN-25* Creat-0.9 Na-140
K-3.8 Cl-104 HCO3-24 AnGap-16
___ 05:35AM BLOOD ALT-28 AST-30 LD(LDH)-187 AlkPhos-46
TotBili-0.7
___ 01:15AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.2
___ 01:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:15AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 01:15AM URINE RBC-<1 WBC-6* Bacteri-FEW Yeast-NONE
Epi-0
___ 01:15AM URINE CastHy-1*
___ 01:15AM URINE Mucous-RARE
___ 05:35AM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.6 Mg-2.2
Cholest-183
___ 05:35AM BLOOD %HbA1c-5.4 eAG-108
___ 05:35AM BLOOD Triglyc-54 HDL-73 CHOL/HD-2.5 LDLcalc-99
___ 05:35AM BLOOD TSH-1.7
Imaging
CTA Head & Neck (___): Preliminary Read
1. No evidence of acute intracranial hemorrhage or mass effect.
2. No evidence of hemodynamically significant stenosis,
aneurysm, or pathologic large vessel occlusion within the
vasculature of the head and neck.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetronidAZOLE Topical 1 % Gel Dose is Unknown TP Frequency
is Unknown
2. Tamsulosin 0.4 mg PO HS BPH
3. Vitamin D Dose is Unknown PO Frequency is Unknown
4. melatonin 5 mg oral QHS Insomnia
5. Multivitamins Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Tamsulosin 0.4 mg PO HS BPH
2. melatonin 5 mg oral QHS Insomnia
3. MetronidAZOLE Topical 1 % Gel 0 Appl TP Frequency is Unknown
4. Multivitamins 1 TAB PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Monocular visual impairment, most likely due to cataracts
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
INDICATION: History: ___ with dizziness, decreased vision. concerned for
embolic event to the retinal artery causing TIA // evidence of storke, clot
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of intravenous contrast
material. Images were processed on a separate workstation with display of
curved reformats, 3D volume rendered images, and maximum intensity projection
images.
DOSE: DLP: 2533.25 mGy-cm; CTDI: 140.34 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect, or midline
shift. The ventricles and basal cisterns appear normal.
There is no evidence of pathologic large vessel occlusion, hemodynamically
significant stenosis, or dissection within the vasculature of the neck. The
vertebral arteries are codominant. There is no evidence of aneurysm, vascular
malformation, or hemodynamically significant stenosis within the intracranial
vasculature.
The lung apices are unremarkable. The major glandular and muscular structures
throughout the neck appear normal.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
2. No evidence of hemodynamically significant stenosis, aneurysm, or
pathologic large vessel occlusion within the vasculature of the head and neck.
3. This report is provided without 3D and curved reformats. When these images
are available, and if additional information is obtained, then an addendum may
be given to this report.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Vision changes
Diagnosed with VISUAL DISTURBANCES NEC
temperature: 98.8
heartrate: 88.0
resprate: 16.0
o2sat: 100.0
sbp: 157.0
dbp: 90.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ male with no significant past
medical history who presented with transient left eye visual
loss. At the time of presentation, he reported visual problems
in the his left eye but denied associated pain, paresthesias or
weakness. He was seen by ophthalmology in the ED who reported no
acute intraocular process, noting that Mr. ___ has mild
bilateral cataracts. He also had a CT Head & Neck in the ED
which, on preliminary read, showed no stenosis, occlusion or
aneurysm. His visual impairment improved in the ED and continued
to improve on the floor. All of his labs were within normal
limits, including his HbA1c (5.4%), TSH (1.7) and LDL (99).
Given a lack of risk factors and his monocular visual impairment
is not consistent with TIA or Amaurosis Fugax. It is likely that
this monocular problem might be related to a worsening of his
preexisting cataracts. Mr. ___ was discharged home and
advised to follow up with an ophthalmologist. This plan was
also discussed with his PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye / Motrin / sulfa / Penicillins
/ aspirin / ibuprofen / ergocalciferol (vitamin D2) /
nitroglycerin / Lasix / cefotaxime
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with history of morbid obesity,DM ___ yrs on
Metformin) and COPD, ___ presenting with abdominal pain and
neutrophilia concerning for SBP.
The patient states that her pain developed this morning. She
states it feels similar to last time when she had ascites, and
states that it is somewhat different in the fact that it is
constant. She also endorses nausea and vomiting and inability to
tolerate PO over the last few months, with associated 100 lb
weight loss over the last year. She denies any black or bloody
stools. She denies any fevers or chills.
The patient initially presented to ___ where she had
a CT scan which showed mild ascites and was started on a
cefotaxime for presumed SBP. She was transferred to ___
because her hepatologist is Dr. ___ here at ___. She last saw
Dr. ___ in ___ and has not seen her since due to
transportation issues.
Of note, the patient initially presented with new onset ascites
to ___ on ___ (SAAG > 1.1). Abdominal US
was suggestive of cirrhosis. She subsequently had a liver biopsy
in ___ which showed Liver, needle core biopsy: Moderate
macrovesicular steatosis involving approximately 40% of the
core biopsy, mild septal and lobular mixed inflammation, rare
foci of ballooning degeneration, trichrome stain demonstrates
cirrhosis with a prominent sinusoidal component.
During her last visit with Dr. ___ on ___, they discussed her
recently diagnosed NASH cirrhosis. At that time, Dr. ___
her to be completely compensated. She had no h/o SBP or GI bleed
at that time. The patient reports that she had an
EGD/Colonoscopy but this does not exist in our system. The note
from Dr. ___ that the patient was to have an EGD as an
outpatient at the end of ___ but it appears this did not
happen.
In the ED initial vitals: 97.5 90 107/65 20 98% Nasal Cannula
- Exam notable for: PE diffuse lower abdominal tender to
palpation
- Imaging notable for:
-Bedside US without tappable ascites.
-OSH CT showing mild ascites but no acute process
-___ RUQUS
1. No evidence of portal vein thrombosis.
2. Coarsened and nodular echotexture of the liver consistent
with cirrhosis without focal liver mass. Possible trace
perihepatic free fluid. No other ascites identified. Relatively
unchanged splenomegaly.
- Labs notable for plt 90, Tbili 0.9, ALT 53, AST 90, AP 117,
Chem 7 wnl, UA unremarkable. OSH labs: WBC 6.9, TBili .7, AST
82, ALT 43, Cr .7
- Patient was given: cefotaxime at the OSH, Morphine 4 mg IV,
Zofran 4 mg IV, and 6 units of insulin.
- Vitals prior to transfer: 97.5 88 100/60 16 96% 2L NC
On arrival to the floor, the patient continues to complain of
abdominal pain described above. She reports that she has had
normal BM's even one hour ago. She reports that she hasn't eaten
anything since one day prior to admission. She also reports
chronic b/l calf pain and worsening shortness of breath
currently, but reports that she has not had any of her inhalers
yet today. Additionally, she reports that she has a diffuse rash
that developed on arrival to ___.
Past Medical History:
-___ Cirrhosis: diagnosed on liver biopsy, seen previously by
Dr. ___ (on Metformin)
-morbid obesity
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission:
VITAL SIGNS 97.4 PO 125 / 72 92 20 96 2l
GENERAL: Morbidly obese, lying comfortably in bed, wide awake
HEENT: MMM, no scleral icterus
CARDIAC: RRR, no m/r/g
PULMONARY: CTAB, no w/r/r
ABDOMEN: NOrmal BS. Tender to palpation to moderate pressure in
epigastrium and Right quadrants.
EXTREMITIES Trace peripheral edema b/l. L Calf tender to
palpation
SKIN - Diffuse erythematous macular rash on abdomen, pruritic
NEUROLOGIC - AOx3. Grossly intact neuro exam. CN2-12 grossly
intact. Gait deferred
PSYCHIATRIC - Mood and affect appropriate
Discharge:
VS: 97.4 PO 101 / 57 85 18 94 ra
FSBG 258, 270, 316, 252
GENERAL: Morbidly obese, lying comfortably in bed, wide awake
HEENT: MMM, no scleral icterus
CARDIAC: RRR, no m/r/g
PULMONARY: clear to auscultation bilaterally, decreased breath
sounds at the bases
ABDOMEN: soft, distended, ___ to palpation
EXTREMITIES: Warm, well perfused, trace edema bilaterally
NEUROLOGIC: AOx3. Grossly intact neuro exam. CN2-12 grossly
intact.
PSYCHIATRIC: Mood and affect appropriate
Pertinent Results:
Admission:
___ 06:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN->12 PH-6.0
LEUK-MOD
___ 06:30PM URINE RBC-2 WBC-9* BACTERIA-FEW YEAST-NONE
EPI-6
___ 06:30PM URINE MUCOUS-RARE
___ 10:57AM URINE HOURS-RANDOM
___ 10:57AM URINE UHOLD-HOLD
___ 10:57AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-SM
___ 10:57AM URINE RBC-6* WBC-6* BACTERIA-FEW YEAST-NONE
EPI-7
___ 10:57AM URINE HYALINE-1*
___ 10:57AM URINE MUCOUS-RARE
___ 10:50AM ___ PTT-34.0 ___
___ 10:40AM GLUCOSE-322* UREA N-14 CREAT-0.6 SODIUM-134
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-27 ANION GAP-17
___ 10:40AM estGFR-Using this
___ 10:40AM ALT(SGPT)-53* AST(SGOT)-90* ALK PHOS-117* TOT
BILI-0.9
___ 10:40AM LIPASE-35
___ 10:40AM cTropnT-<0.01
___ 10:40AM ALBUMIN-3.9
___ 10:40AM WBC-6.8 RBC-4.86 HGB-14.4 HCT-45.1* MCV-93
MCH-29.6 MCHC-31.9* RDW-13.6 RDWSD-46.1
___ 10:40AM NEUTS-86.3* LYMPHS-7.2* MONOS-5.5 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-5.85 AbsLymp-0.49* AbsMono-0.37
AbsEos-0.03* AbsBaso-0.02
___ 10:40AM PLT SMR-LOW PLT COUNT-90*
Discharge:
___ 07:00AM BLOOD WBC-3.9* RBC-4.70 Hgb-14.1 Hct-43.7
MCV-93 MCH-30.0 MCHC-32.3 RDW-13.6 RDWSD-46.6* Plt Ct-85*
___ 07:00AM BLOOD Neuts-61.2 ___ Monos-8.1 Eos-2.5
Baso-0.3 Im ___ AbsNeut-2.41 AbsLymp-1.08* AbsMono-0.32
AbsEos-0.10 AbsBaso-0.01
___ 07:00AM BLOOD Plt Ct-85*
___ 07:00AM BLOOD ___ PTT-31.9 ___
___ 07:00AM BLOOD Glucose-241* UreaN-14 Creat-0.5 Na-139
K-3.4 Cl-96 HCO3-27 AnGap-19
___ 07:00AM BLOOD ALT-41* AST-34 LD(LDH)-171 AlkPhos-110*
TotBili-0.6
___ 06:17AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
___ 06:04AM BLOOD %HbA1c-10.9* eAG-266*
Imaging:
RUQ ultrasound ___
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Splenomegaly and small volume ascites.
CXR ___
IMPRESSION:
No free air
Lower extremity dopplers
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. Nonvisualization of the bilateral posterior tibial and
peroneal veins.
Abdominal Ultrasound ___
1. Cirrhotic liver, without evidence of focal lesion.
2. Splenomegaly and small volume ascites.
Micro:
___ BCx pending x2
___: UCx negative x2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 50 mg PO DAILY
2. LORazepam 0.5 mg PO DAILY:PRN travel, anxiety
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. OxyCODONE (Immediate Release) 10 mg PO Q4-6 HR PRN Pain -
Severe
5. Vitamin E 800 UNIT PO DAILY
6. GlipiZIDE 10 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
11. Ursodiol 500 mg PO BID
Discharge Medications:
1. BD Ultra-Fine Nano Pen Needles (pen needle, diabetic) 32
gauge x ___ miscellaneous ASDIR
RX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needles] 32
gauge X ___ Use for insulin administration qAC and qHS Disp
#*200 Strip Refills:*0
2. Glargine 15 Units Breakfast
Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 14
Units QID per sliding scale Disp #*2 Syringe Refills:*2
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. LORazepam 0.5 mg PO DAILY:PRN travel, anxiety
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. OxyCODONE (Immediate Release) 10 mg PO Q4-6 HR PRN Pain -
Severe
9. Spironolactone 50 mg PO DAILY
10. Ursodiol 500 mg PO BID
11. Vitamin E 800 UNIT PO DAILY
12. HELD- GlipiZIDE 10 mg PO DAILY This medication was held. Do
not restart GlipiZIDE. Talk to your ___ doctors about your
___ medications.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Poorly controlled Diabetes Mellitus Type 2
- Hyperglycemia
- Abdominal Pain
Secondary Diagnosis:
- ___ cirrhosis
- History of ascites
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 cirrhosis presenting with abdominal pain //
?pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
Cardiac silhouette size is mildly enlarged. Mediastinal contours are grossly
unremarkable. No overt pulmonary edema is seen. Evidence of DISH is seen
along the thoracic spine.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with cirrhosis and abdominal pain // ?portal venous
thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___
FINDINGS:
LIVER: The liver is coarsened in echotexture. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. Possible trace perihepatic free
fluid versus artifact is noted. No other ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 7 mm.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 17.8 cm (previously 17-cm on ___. Small perisplenic varices noted.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No evidence of portal vein thrombosis.
2. Coarsened echotexture of the liver consistent with cirrhosis without focal
liver mass identified. Possible trace perihepatic free fluid. No other
ascites identified. Relatively unchanged splenomegaly.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old woman with NASH cirrhosis p/w diffuse abdominal pain,
concern for peritonitis- want to rule out perf. // evidence of free air or
bowel obstruction
TECHNIQUE: Abdomen two views
COMPARISON: Chest x-ray ___
FINDINGS:
Mild gastric distention with air-fluid level. Lucency seen on the decubitus
radiograph may represent prominent peritoneal fat or small volume
pneumoperitoneum. Upright abdominal radiograph recommended to exclude free
air. Surgical clips right upper quadrant. No small or large bowel
dilatation. Degenerative changes spine.
IMPRESSION:
Lucency seen on the decubitus radiograph may represent prominent peritoneal
fat or small volume pneumoperitoneum. Upright abdominal or chest radiograph
recommended to exclude free air.
NOTIFICATION: The findings were discussed with ___ M.D. by ___
___, M.D. on the telephone on ___ at 7:29 ___, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with h/o immobility due to morbid obesity, p/w
worsening dyspnea and b/l calf pain evaluate for evidence of dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. The posterior tibial and
peroneal veins are not identified in either calf.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Nonvisualization of the bilateral posterior tibial and peroneal veins.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with new onset abdominal pain with ?peritonitic
signs, now w/ concern for possible free air in abdomen. // evidence of free
air below the diaphragm
TECHNIQUE: Chest two views
COMPARISON: Abdomen radiographs ___, chest radiograph ___
FINDINGS:
No free peritoneal air. Stable chest radiograph from earlier today.
IMPRESSION:
No free air
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with NASH cirrhosis and abdominal
pain/swelling, limited RUQUS showing little fluid but now concern for more
distention so we want another evaluation for ascites. // evaluation of level
of ascites, liver contour
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver gallbladder ultrasound ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is small volume
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 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, measuring 17.0 cm.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Splenomegaly and small volume ascites.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Right lower quadrant pain, Left lower quadrant pain
temperature: 97.5
heartrate: 90.0
resprate: 20.0
o2sat: 98.0
sbp: 107.0
dbp: 65.0
level of pain: 4
level of acuity: 3.0 | ___ F h/o NASH cirrhosis, ascites in the past, recently
compensated, who presented with diffuse lower abdominal pain and
neutrophilia.
#Abdominal pain: CT at OSH showed mild ascites but no other
acute process. Otherwise her labs to date are unrevealing for
any other intra-abdominal problem. Small amount of ascites on
OSH CT so SBP was considered, especially given neutrophilia on
___ with diff. Received one dose of cefotaxime at the OSH. On
presentation, patient was mildly tender to palpation but no
peritonitic signs as previously report by OSH physicians,
completely ___ on L side. Unclear etiology given normal BM
and otherwise normal CT. Empricially started antibiotics for
SBP, now discontinued. Need to avoid cephalosporins given rash
with cefotaxime. Lipase normal. Etiology of her abdominal pain
unknown, but improved with simethicone and conversative
measures. Gallbladder disease difficult to exclude as RUQ
ultrasound limited by patient's body habitus. Repeat abdominal
ultrasound showed small amount of perihepatic ascites but
otherwise unrevealing. Patient's pain improved on hospital day
#2 without intervention.
# Chronic COPD: Patient noted to be wheezy on physical exam.
Given h/o COPD, she was continued on albuterol, Advair, and
duonebs.
#Recent weight loss: unclear history but patient reports current
weight is 260 and was previously almost 400 about a year ago.
She relates it to poor appetite since cirrhosis diagnosis and
she was told her malignancy workup was negative in the past, but
we did not have records for review. Denied any other
constitutional symptoms.
#B/l Leg pain: likely chronic in nature, but given worsening
shortness of breath would consider DVT/PE and LENIs negative for
PE though could not visualize posterior tibial or peroneal
veins. Evaluated by ___ and will have home ___ visits on
discharge.
# Rash: Erythematous abdominal rash after cefotaxime at OSH.
Patient likely allergic to cephalosporins. Given sarna and
cetirizine for relief.
# ASCITES: h/o admission for ascites in the past, maintained on
spironolactone.
# CIRRHOSIS: ___ NASH. H/o ascites in the past. Continued home
vitamin E.
# NIDDM: Held home metformin and glipizide. Had persistently
elevated sugars to the 200s, increased home lantus to 15 units
BID with ISS. ___ consulted and recommended outpatient
follow-up.
TRANSITIONAL ISSUES
====================
- Home glipizide discontinued upon discharge as insulin regimen
uptitrated per ___ recommendations
- Discharged on glargine 15 units qAM and 18 units qPM with
sliding scale
- Given poorly controlled diabetes, recommend PCP referral to
___ tighter glucose control
- Patient reports a significant weight loss over the last year;
please ensure that the patient is up-to-date on cancer screening |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bilateral elbow pain
Major Surgical or Invasive Procedure:
___: right elbow open reduction, internal fixation with
radial head replacement, coronoid process fixation
History of Present Illness:
___ year old male RHD with no pmhx presents with right elbow
fx/dislocation (terrible triad) s/p fall off bicycle
(unhelmeted) this am landing directly his left side. Noted
immediate pain and deformity to the right elbow. +Head scrape,
no LOC. No associated injuries per report. Denies
numbness/tingling/weakness in right arm/hand. Denies pain of the
clavicle, shoulder, or wrist.
Past Medical History:
L elbow I&D s/p superficial wound that became infected s/p
bicycle fall 6 months prior
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD, comfortable
AVSS
RUE:
-splint in place, intact
-mild edema in right hand, no ecchymosis or erythema
-Full painless ROM at shoulder, wrist, hand
-Ax/AIN/PIN/ulnar fire, SILT ax/m/r/u
-2+ radial/ulna pulses
LUE:
-no edema, ecchymosis, deformity
-NTTP arm, forearm
-full painless ROM at shoulder, elbow, wrist, hand
-Ax/AIN/PIN/ulnar fire, SILT ax/m/r/u
-2+ radial/ulna pulses
Pertinent Results:
See OMR for pertinent results
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*1
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*100 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
-right radial head fracture, ulnar coronoid process fracture,
lateral collateral ligament tear with elbow dislocation
-left nondisplaced radial head fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS RIGHT
INDICATION: ___ man with right elbow fracture, dislocation, evaluate
for interval reduction.
TECHNIQUE: Single lateral view of the right elbow.
COMPARISON: Earlier same-day elbow radiographs ___ at 10:03.
FINDINGS:
Overlying casting material is new. Re-identified are comminuted fractures of
the proximal radius and ulna, specifically involving the radial head and neck
as well as the ulnar coronoid process. No definite distal humeral fracture is
seen. There is persistent anterior dislocation of the distal humerus at the
elbow joint. Comminuted fracture fragment involving the majority of the
radial head is again seen displaced into the joint just distal to and slightly
posterior to the displaced distal humerus. Multiple smaller comminuted
fracture fragments are again seen anterior to the joint. Elbow effusion is
not as well seen given obscuration by overlying casting material.
IMPRESSION:
Persistent dislocation despite reduction attempt.
Radiology Report
INDICATION: ___ with elbow dislocation s/p reduction// confirm placement
post reduction
COMPARISON: Prior radiographs performed earlier today.
FINDINGS:
Single lateral view of the right elbow provided. Alignment is restored at the
right elbow. An overlying plaster splint is noted. Irregularity at the
radial head is consistent with known fracture.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with pre-op//evaluate for pre-op eval per ortho
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
INDICATION: ___ year old man with right elbow fracture,dislocation// Evaluate
for right elbow injury
TECHNIQUE: Multiplanar CT images were obtained in standard and bone
algorithm. Reformatted views or obtained and reviewed.
DOSE: Not available
COMPARISON: Right elbow radiographs from ___ at 13:08.
FINDINGS:
Right elbow: Evaluation is mildly limited due to patient positioning. On the
scout film, cortical irregularity of the mid right ulnar shaft is not included
CT field-of-view, incompletely assessed on this study (2:1). Redemonstrated
is an acute fracture dislocation involving the right elbow. The olecranon is
posteriorly dislocated relative to the distal humerus. A comminuted fracture
involving the coronoid process of the proximal ulna demonstrates a 2.4 cm
posteriorly and inferiorly displaced fragment. There is an extensively
comminuted fracture involving the radial head, which is inferiorly dislocated
relative to the humerus. Multiple tiny osseous fragments are present, several
just anterior to the distal humerus are without clear donor site, possibly
related to the comminuted radial head fracture although it is difficult to
exclude a distal humerus injury.
Chest: Other than mild dependent atelectasis, the visualized lungs are clear.
No rib fracture or pneumothorax in the visualized field. A 6 mm right lower
lobe subpleural pulmonary nodule is of doubtful clinical significance in a
patient of this age. No pleural effusion.
Abdomen: The stomach is mildly distended with heterogeneous material
presumably representing ingested food. Visualized loops of small and large
bowel demonstrate normal caliber and wall thickness. The liver, gallbladder,
spleen, pancreas, bilateral kidneys and bilateral adrenal glands are
unremarkable within the limits of this noncontrast examination.
IMPRESSION:
1. Fracture dislocation involving right elbow with comminuted displaced
fractures of the coronoid process and radial head.
2. Multiple tiny osseous fragments are present, several just anterior to the
distal humerus are without clear donor site, possibly related to the
comminuted radial head fracture although it is difficult to exclude a distal
humerus injury.
3. Cortical irregularity of the right ulnar midshaft on scout view,
incompletely assessed. Dedicated imaging of this region could evaluate for
additional fracture if clinical concern.
Radiology Report
INDICATION: History: ___ with right elbow dislocation with left elbow pain as
well// eval for fracture
TECHNIQUE: Three views of the left elbow
COMPARISON: None.
FINDINGS:
There is a nondisplaced fracture of the radial head. Anterior and posterior
elbow joint effusions are seen. No dislocation is seen.
IMPRESSION:
Nondisplaced radial head fracture with associated anterior and posterior elbow
joint effusions.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS RIGHT PORT
INDICATION: RT ELBOW FX.ORIF
TECHNIQUE: Intraoperative images.
COMPARISON: CT from ___.
FINDINGS:
Intraoperative images were obtained without a radiologist present.
IMPRESSION:
Please refer to dedicated surgical note performed on same day for details of
the procedure.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS RIGHT
INDICATION: s/p elbow fx surgery// assess for elbow dislocation assess
for elbow dislocation
TECHNIQUE: Right elbow, two views
COMPARISON: CT from ___.
FINDINGS:
Patient is status post ORIF of a right elbow fracture dislocation, overall in
improved anatomic alignment. Please note that the overlying cast obscures
fine bony detail. There is no definite evidence of a dislocation on the
lateral view.
IMPRESSION:
No definite evidence of dislocation on the lateral views. Frontal views are
obscured by the overlying cast and the elbow is not well evaluated.
If there is further clinical concern, a dedicated radiograph with the cast
removed can be performed for further evaluation.
Radiology Report
INDICATION: ___ year old man with right elbow terrible triad, s/p ORIF//
confirm elbow is located, hardware intact
TECHNIQUE: AP and lateral views of the right elbow
COMPARISON: ___
FINDINGS:
Again, patient is status post ORIF of right elbow fracture dislocation in
anatomic alignment on the lateral view, the AP view slightly suboptimal.. No
new fractures identified. Overlying cast obscures fine bony detail.
IMPRESSION:
Overlying cast obscures fine bony detail. Status post ORIF of right elbow
fracture dislocation. AP view slightly suboptimal, but anatomic alignment is
seen on the lateral view. If anything, alignment appears slightly improved
compared to the prior study.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ man with right elbow visible deformity after fall.
TECHNIQUE: 2 views right elbow.
COMPARISON: None.
FINDINGS:
There is a comminuted, intra-articular fracture-dislocation of the right
elbow. Specifically, there is a comminuted fracture through the radial neck
extending into and involving the radial head. There is a curvilinear 15 mm
fracture fragment, likely from the radial head/neck, seen just lateral to the
major transverse radial neck fracture line. Displaced fracture fragment
involving the majority of the radial head is posteriorly displaced and
rotated, seen just distal to the articular surface of the distal humerus,
likely within the joint. Additionally, there is a comminuted fracture of the
ulnar coronoid process. Multiple small comminuted fracture fragments are seen
anterior to the joint. The distal humerus is displaced anteriorly. There is
an elbow effusion. No definite fracture involving the humerus is seen. No
worrisome focal osseous lesions. No periostitis. No concerning soft tissue
calcification or unexpected radiopaque foreign body.
IMPRESSION:
Comminuted, intra-articular fracture-dislocation of the right elbow involving
the proximal radial head/neck and ulnar coronoid process. Comminuted fracture
fragment from the radial is likely displaced into the joint. No definite
fracture of the distal humerus. Further details, as above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Bicycle accident
Diagnosed with Nondisp fx of head of right radius, init for clos fx, Pedl cyc driver injured in nonclsn trnsp acc nontraf, init
temperature: 96.4
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 122.0
dbp: 80.0
level of pain: 9
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 elbow fracture/dislocation and left radial head
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for ORIF of
right elbow, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with OT who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the let and right upper extremity, and will
be discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Methotrexate / Novocain / epinephrine / lisinopril / Norvasc /
Procardia / labetalol / chlorthalidone / Augmentin / Pneumovax
23 / Arava / spironolactone / diltiazem / GABA supplement /
hydralazine
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ old woman with confirmed white coat hypertension as well
as essential HTN, mild dyslipidemia, RA and history of SVT
presents with hypertensive urgency.
She has an extensive history of HTN which has been difficult to
manage due to labile blood pressures. She had 24 hr ambulatory
BP
monitoring in ___ with mean 24h BP = 126/61, nadir
nighttime
DBP 41 mmHg while on a very similar medication regimen as now
(Coreg in AM was recently bumped up to 50 mg). She was last seen
in Dr. ___ ___. At that time she was feeling well,
but upon initial BP check she was 215/100 mmHg, but this
rapidly
came down to 160/90 with reassurance. She admitted to anxiety,
but mostly directed at her blood pressures themselves rather
than
anything else in her life. She was started on escitalopram for
anxiety which she has been taking but doesn't like. She has also
started meditating and doing Tia Chi every ___ for
relaxation. She asked Dr. ___ she could take Lasix
QOD rather than daily to which he agreed.
___ prior to admission, she woke up with a slight heaviness in
her head, but felt otherwise well. For the first time, she
skipped her Lasix in AM but took the rest of her AM med's. She
meditated in AM and her headache felt slightly worse. Worsened
still after her Tia Chi, when she was home alone. She became
nervous that her headache may be related to her blood pressure,
either high or low. She felt fatigued, but denied chest pain,
shortness of breath, blurry vision, or weakness. Headache was
bilateral frontal and throbbing in quality w/o N/V. She became
very anxious and decided that she should go to the ER to have
her
BP checked. She was BIBA to ___.
In the ED, initial VS were: 97.0 70 ___ RA
Exam notable for: neuro exam wnl PERRL
ECG: NSR
Labs showed: Na: 133, Cr 1.2 (baseline 1.2)
Imaging showed:
NCHCT
1. No acute intracranial abnormality.
2. Mild paranasal sinus disease
Consults: None
Patient received: Carvedilol 25 mg, Lisinopril 20 mg (home meds)
Transfer VS were: 97.4 65 164/82 17 96% RA
Discussion initiated in ED due to known white coat HTN with
nocturnal hypotension diagnosed with recent ambulatory blood
pressure monitoring and patients blood pressure down to 160/80
on
home meds. Despite recent Dr. ___ from ___
recommending no titration of anti-hypertensives due to average
SBP of 134 w/ nocturnal dips, the emergency attending insisted
upon admission.
On arrival to the floor, patient reports that she was quite
anxious in the ED, but headache has resolved. No symptoms. She
is
very concerned that her blood pressure could be dangerous.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
HTN with strong white coat phenomenon
HLD
pSVT
RA
Social History:
___
Family History:
No FH of sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.4 PO 201 / 85 (180/80 in R arm on manual recheck) 76 18
96
GENERAL: NAD, slightly anxious appearing.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 97.7 PO BP: 169/77 HR: 61 RR: 18 O2 sat: 93%
O2 delivery: Ra
GENERAL: NAD, anxious affect
HEENT: atraumatic, normocephalic, anicteric sclera, moist mucous
membranes
NECK: supple
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 03:33PM GLUCOSE-114* UREA N-17 CREAT-1.2* SODIUM-133*
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-20* ANION GAP-14
___ 03:33PM cTropnT-<0.01
___ 03:33PM CK-MB-1
___ 03:33PM WBC-5.0 RBC-4.51 HGB-13.2 HCT-37.9 MCV-84
MCH-29.3 MCHC-34.8 RDW-13.1 RDWSD-39.8
___ 03:33PM NEUTS-71.0 LYMPHS-15.4* MONOS-8.2 EOS-4.2
BASOS-0.8 IM ___ AbsNeut-3.54 AbsLymp-0.77* AbsMono-0.41
AbsEos-0.21 AbsBaso-0.04
___ 03:19PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
DISCHARGE LABS:
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Carvedilol 50 mg PO QAM
3. Carvedilol 25 mg PO QPM
4. Lisinopril 20 mg PO BID
5. Humira (adalimumab) 40 mg/0.8 mL subcutaneous Unknown
6. Escitalopram Oxalate 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
Discharge Medications:
1. Carvedilol 50 mg PO QAM
2. Carvedilol 25 mg PO QPM
3. Escitalopram Oxalate 10 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Humira (adalimumab) 40 mg/0.8 mL subcutaneous Unknown
6. Lisinopril 20 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with hypertension to 200s/100s, and new ___
headache- occipital and on sides// assess for head bleed/stroke
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 14.0 s, 15.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: MR head from ___. CT head from ___.
FINDINGS:
There is no evidence of large territorial infarction,hemorrhage,edema,or
mass-effect. There is prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of acute fracture. There is mild-to-moderate mucosal
thickening of the ethmoid air cells. The visualized portion of the mastoid
air cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild paranasal sinus disease.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Headache, Hypertension
Diagnosed with Essential (primary) hypertension
temperature: 97.0
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 231.0
dbp: 94.0
level of pain: 0
level of acuity: 3.0 | ___ old woman with confirmed white coat hypertension,
essential HTN, mild dyslipidemia, RA and history of SVT
presented with hypertensive urgency with BP to 210/100 with mild
headache. |